Healthy Wealthy & Smart

On this week's episode of the Healthy, Wealthy and Smart Podcast, I welcome Leda McDaniel on the show to share her experience with persistent pain. Leda McDaniel is a Physical Therapist in Atlanta, GA. As a physical therapy student, Leda published a book that chronicled aspects of her three-year battle with chronic knee pain and ultimately led her down a path of discovery on her way to healing with a holistic approach. In this episode, we discuss: -Leda's experiences with Complex Regional Pain Syndrome (CRPS) and how it impacted her life -Pain neuroscience education and a holistic approach to treatment for CRPS -How Leda's approach to patient care has shifted to a biopsychosocial framework -The importance of listening to the patient's story and being a voice of hope -And so much more! Resources: Sapiens Moves Website Email: LedaMcDaniel1@gmail.com Painful Yarns Book Moments from a Year of Healing: A Book of Memories and Essays Leda McDaniel Facebook Sapiens Moves Instagram The Outcomes Summit: use code LITZY For more information on Leda: Leda McDaniel is a Physical Therapist in Atlanta, GA. She earned her Doctorate of Physical Therapy from Ohio University and holds a B.A. in psychology from Trinity University, in San Antonio, Texas where she also played Basketball and ran Track and Cross Country for the NCAA Division III School. As a physical therapy student, Leda published a book that chronicled aspects of her three-year battle with chronic knee pain and ultimately led her down a path of discovery on her way to healing with a holistic approach. It was this experience that motivated her to become a physical therapist in order to help others recover from chronic pain. Her book is entitled: "Moments From a Year of Healing: A Book of Memories and Essays" and can be found on Amazon: https://www.amazon.com/dp/B07CWGH7X6/ref=sr_1_1?s=digital-text&ie=UTF8&qid=1525656733&sr=1-1&keywords=moments+from+a+year+of+healing Leda's Professional Blog: https://sapiensmoves.wordpress.com/ Read the full transcript below: Karen Litzy: 00:01 Hi Leda welcome to the podcast. I'm happy to have you on and a big congratulations to you for being a new physical therapy graduate. So welcome to the field. And you know, longtime listeners of this podcast will know that I often have people on the podcast who have struggled through persistent pain, who maybe are still having persistent pain issues and you are one of those people. So what I would love for you to do is just let the audience know who you are and tell your story and then we'll take it from there. So I will throw it over to you. Leda McDaniel: Thank you. Yeah, so I just recently graduated from physical therapy school and I'm entering my clinical practice as a physical therapist. So I'm in Atlanta, Georgia and I'll be starting residency at Emory university for Orthopedic Physical Therapy in August. Leda McDaniel: 01:03 So I'm really excited about that. A little bit about what got me into this field and interested in being a physical therapist. I had an ACL injury that I suffered in my mid twenties, tore my ACL playing soccer and then I had surgery, reconstructive surgery, to repair that ACL. And the recovery from the surgery didn't quite go as planned, so I had had a prior ACL surgery, so it kind of knew what to expect. What's this time it was not quite so good and it was a little bit different and challenging in that the physical therapist I was working with kept pushing me to strengthen my muscles and try to get my range of motion back and all those things that I was familiar with, but I knew it wasn't really responding as you might expect it would after surgery. So I had this chronic pain and inflammation that developed over the next six months to a year. Leda McDaniel: 02:04 And both my physical therapist that I was working with at the time, and then, a handful of orthopedic doctors, including the surgeon who did the surgery, they were a little bit puzzled as to what was going on because I had a repeat MRI. They couldn't find any structural issues. At the time I was really focused on that idea of well I still have pain, what is wrong structurally? And I just had this feeling that something is wrong. It didn't feel right. It was always painful and it was always swollen and I really couldn't it over the hump to the extent that I was even limping when I was walking about a year after surgery. So I continued to try to rehab and over the next additional year and two years out of ACL surgery I had a second surgery. Leda McDaniel: 03:00 The idea that they clean out some of the scar tissue in there. It's the joint capsule is scarred up a little bit and try to get things work in a little bit better or feeling a little better after that surgery. Again, that kind of made my situation worse and I developed this mirror pain cause I knew I was hypersensitive at that point and had after that diagnosis of complex regional pain syndrome and just really severe nerve pain to the extent that not only was it painful to walk, but I really couldn't walk and I couldn't put pressure on that knee. I couldn't touch the knee without it being painful. And kind of just spiraled into it's really bad situation where I was pretty disabled. I wasn't able to work at the time. And in that time period had gone back to school for physical therapy because I'm flattered by this injury and wanting to help other people regain their health. Leda McDaniel: 03:59 I had some really excellent physical therapists along the way who really try their best to work with me even though things weren't going in an ideal direction. So, anyway, so I had to take time off school. I couldn't work. All of this really pursuing or being fixated on this idea of what structure is injured. And it really, the course of my injury and health didn't really change until my perspective or kind of switched my focus to more of a treating pain based on what were currently understanding is more of a progressive approach to chronic pain, which is pain neuroscience education where we're understanding that there are many components to pain not just structural ones and a lot of these inputs can contribute to these situations where you have this over sensitivity or hypersensitivity. Leda McDaniel: 05:05 And that's kind of the place I found myself in. So I really started to self treat based on some of those principles and try to reduce the sensitivity that built up within my nervous system. And over the course of about a year, I was able to turn things around and get back to the point where I was walking. I was back to school, working, functioning in society like I wanted to and my pain levels were significantly decreased. And gradually, gradually got to the point where I was pain free. Karen Litzy: And can you talk about what specifically you did during this time in order to treat the pain? Obviously not treat the structural issues, but to treat the pain just so the listeners have an idea of what you did. Leda McDaniel: Sure, absolutely. So it's not a quick fix approach by any means, and it's not a singular approach by any means. Leda McDaniel: 06:08 So I really had the perspective of creating as many positive inputs to my life as possible. And I was really diligent about addressing all the different components as we know, pain really has this bio, psycho social, construct. And so I really wanted to have positive inputs physically, mentally, and emotionally and socially. So physically, I was eating a really nutrient dense diet, so lots of full foods, real foods, fruits, vegetables, bone broths, collagen stocks, things like that. So really preparing foods from scratch and eating a lot of nutrient dense foods. I was meditating to decrease my sympathetic activation or over sensitivity work on the mental component. I was doing a psychological therapy at the time. So cognitive behavioral therapy to try to just that psychological component. I was using visualization to try to incorporate the lowest level input that I could to that system and really start preparing for movement in a joint that couldn't really take movement in the beginning, but trying to retrain my brain to prime it for the movements I want it to be able to do. Leda McDaniel: 07:42 So I did a lot of visualization on walking, moving my knee. When I got a little bit better, I would visualize myself doing higher level athletic activities such as running or jumping or those sorts of things. Karen Litzy: 09:44 So over the year plus time that you started incorporating all of these different kinds of inputs into your system, did you start doing everything all at once or did you sort of slowly pepper things in? Leda McDaniel: Yeah, so there was definitely kind of a gradual addition of different components. As I learned more, I was trying to incorporate different types of movement to try to make a difference. So, for example, I'd started a mindfulness based stress reduction meditation course online. That was free. Because I had found out about that and that helped quite a bit. But I gradually added other things in. And one of the things I wanted to mention as well is I was doing, it's hard to mention every single treatment I was doing cause I was really trying to address all these little pieces and I think addressing all those little things really made the difference to turn the tide. Leda McDaniel: 11:07 So one of the other important things that I was doing not overly relying on but definitely helped me get out of the most acute and serious pain so that my nervous system could reorganize was pharmacological treatment. So I was taking so medications to get me out of pain. And I think that as an adjunct treatment to the other things I was doing, it was actually really important. So you have these periods of not being in such severe pain that I had the ability to you some of these other treatments. Karen Litzy: Yeah, and I mean I don't think that there's anything wrong with pharmacological interventions, especially for people with CRPS. I mean this is really painful and I think that you're right, you kind of need the medications as a bit of a reprieve for your systems so that you can get to all this other stuff. Karen Litzy: 12:08 Now the question is, is are you now on the same medications that you were on in the sort of height of this pain process? Leda McDaniel: I am not. So I was pretty resistant to taking medication in the beginning. And I really used it for the smallest duration that I could to get me out of that really severe pain. Once I was on my way with this combination of lifestyle factors and I'd really seen the pain decrease to the extent that I could walk without being in pain, or I could touch my knee without having a severe pain reaction, I really started to taper off these medications with the guidance of the prescribing physician. Karen Litzy: Right. So I think for listeners is just important to remember that if you have pain, we're not saying do all of this other stuff and don't go a pharmacological route because sometimes that's necessary, but you have to make sure that you go that pharmacological route with your physician and that when you're ready to kind of taper down that you do that also under the guidance of your physician. Leda McDaniel: 13:31 Absolutely. That's a great point. I think also it's important to mention that, and this has been mentioned by others in the field that are doing this work, really trying to get patients to take an active role in their treatment. So just taking medication but not doing these other active components such as meditation, the prescribed loading if that's appropriate. And really addressing lifestyle factors and taking ownership of those in addition to these more passive treatments I think is really important. Karen Litzy: Yeah, and I think when you're talking about people with persistent pain issues like CRPS, you kind of, I think it's okay to have that combination of active and passive treatments. But yes, the patient has to know that they're not coming to the healthcare practitioner to be fixed, but instead they're coming to be guided and that they need to, like you said, take an active role because all of this, you know, nutrient dense diet, meditation, psychological therapy, visualization, progressive loading, exposure training. Karen Litzy: 14:49 So exposure to movement, exposure to activities that maybe you have fear avoidance behaviors around. All of this requires active work from the patient, active work from you. Right? And if you're not doing that as the patient, I think that you're not giving yourself an advantage. Would you agree? Leda McDaniel: Yeah, absolutely. Well said, Karen. Karen Litzy: Yeah. And so let's talk about timeframe here. So obviously changing your diet. We know that diet does have a huge ramifications to overall health, the psychological training, the meditation, the gradual loading, exercise, movement, visualization. This all takes time. So people will probably be thinking how many hours a day were you working on this stuff? Leda McDaniel: Well, for better or worse, I wasn't able to work or go to school at the time. And so really regaining my health over this year period, I actually deferred a year from physical therapy school. Leda McDaniel: 16:00 I had started and completed my first semester, but then wasn't able to continue sequentially, but my program allowed me to defer a year. So for that year my fulltime job was getting back to health and I really took that seriously as a full time job. So, a majority of my time was spent trying to create these positive inputs. I was doing a lot of reading and trying to learn as much as I could about pain and physical therapy related things, because that's developed into one of my passions and I really felt like it was important to maintain this engagement in intellectual pursuits as well, so that I could have some connection and some purpose to my future, even though I wasn't actively in school at the time or actively working at the time. So really to answer your question I was working on this pretty diligently. Karen Litzy: And what was, and maybe you didn't have one, I don't know, but did you have this sort of Aha moment at any point? So from the first surgery to where you are now, can you say there was one point where you reached this crescendo and then things started to fall in place? Leda McDaniel: 17:24 Yeah. Thinking back, I think, I can't pinpoint a specific time point that I would say generally it was about the time when I was forced to take a break from school. So it was almost at the lowest point where I wasn't able to walk on my leg, wasn't able to touch my knee because a sensitivity pain had gotten so bad that it really taken me out of a normal functioning, productive life. And somewhere around that point I was researching and reading as much as I could on my own. And I really stumbled upon this pain neuroscience education approach and some of the work of Lorimer Moseley and Butler and Lowe. And this idea that the pain that I was experiencing didn't necessarily have a structural cause. And to me that was the time period when I really changed my approach from this fixation on trying to find a healthcare practitioner who would tell me what is structurally wrong and how can we fix it to an approach of my nervous system. Leda McDaniel: 18:42 My brain is just creating this maladaptive signaling, maladaptive pain response and I really need to target my nervous system sensitivity versus trying to pinpoint what is wrong structurally for me, that seems like the turning point, where I was able to really start making gains and gradually progressed back to health. Karen Litzy: Yeah. So it was kind of the light bulb went off and you said to yourself, I think there's another way. And was there any one piece of reading book article that you can say, you know something, this really helped me to understand what's going on? Leda McDaniel: 19:30 Yeah. I think as somebody who's interested in health at the time, but you didn't have a great grasp on some of the biology and physiology surrounding pain systems and the nervous system one book that really helped me understand these things and I would recommend to clinicians and patients who are wanting kind of an easy buy in to these sorts of principles is Lorimer Mosley's book painful yarns. He tell stories to communicate these principles of how pain systems work in our bodies. And really does a lovely job making these principles accessible to people who might not have the scientific background to understand because pain is complex. These systems are complex. But listening to these stories, I think it makes it really understandable. Karen Litzy: Yeah. A little bit more digestible for folks. I often tell my patients to get that book because it really is a patient forward book because of the stories and the metaphor that he uses throughout the book to make you say, Huh, okay. Karen Litzy: 20:51 I think I'm starting to understand this a little bit. Because for the average person, maybe they don't need to get too into the weeds as to the chemical reactions happening in the brain and within the body in the spinal cord and why these persistent pain issues can arise and kind of take hold in the body. But we certainly can give patients stories and metaphors to help them have a better understanding of maybe what's happening and to decrease the fear around what's happening within their bodies. And I think painful yarns does a great job at that. Karen Litzy: And all right, so you are diagnosed with CRPS you dive in, you start treating yourself. Were you still seeing a physical therapist over this year? Or were you really just at this point working on all of the components you mentioned above on your own? Leda McDaniel: 21:51 I had actually stopped seeing a physical therapist because as I was learning more, I was seeking a clinician who had some of these approaches in their toolbox. For example, the graded motor imagery. And I really unfortunately couldn't find one in my geographic area. And so I was actually doing these treatments, kind of self treating at that time, hoping that eventually I could work with a PT for some of the loading components. But knowing that at that point I just couldn't tolerate the exercise based physical therapy. Karen Litzy: Right. And now were you ambulatory at this time? Were you using an assistive device were you in a wheelchair. How were you getting around? Leda McDaniel: So after that second surgery I was using crutches for about nine or 10 months. And really non weight bearing. I couldn't put weight on my leg so I didn't go to a wheelchair. Leda McDaniel: 22:55 Partly probably out of stubbornness. But yeah, I was using an axillary crutches to get around everywhere. Karen Litzy: Okay. Well that is not easy as we've all had patients who've been on crutches for like six to eight weeks and they seem to just be completely spent. I can't even imagine for 10 months. But I mean good on you for keeping up and I'm assuming you started seeing progress, which is why you kept with all of this stuff. Right? So how long into this year and a half or a year plus did you start to see changes within your pain? Leda McDaniel: I would say probably within, it took probably three, four months of diligently committing to these practices before I really saw some noticeable change. Which was really hard. But at the same time I think is an important thing to communicate where these changes and the sensitivity that's been built up in your nervous system, it does take time. Leda McDaniel: 24:10 It does take some patience and some persistence and I would really encourage patients and clinicians alike to have this longterm perspective of if we can introduce these positive things just to kind of have trust and just kind of have faith that they're going to make a difference, that they are making a difference on some level, but that noticeable changes might take awhile to manifest. Karen Litzy: Yeah, I agree. I think it is very important when you have patients with persistent pain to be very honest with them and make sure that you're giving them some realistic timelines. Because let's face it, we're human beings and we get frustrated, right? We want things to happen sooner rather than later. Especially when you're in pain and especially if you're suffering. I mean you just can't imagine doing this for another month or week or even day for some people. But I think being honest and giving realistic feedback is very important because that also helps you to mitigate your expectations, which is important, especially when you have such a serious pain complications as CRPS. And now, how has this experience influenced the way you will now treat as a physical therapist? Leda McDaniel: 25:48 I think ultimately while there are a lot of things that I think it adds to my ability to treat patients as a clinician, maybe the first thing is to have a little bit more empathy and compassion for what these patients are going through. Having had this experience, I think I understand what the chronic pain journey and struggle looks like, but also what it feels like to be in that. And I think it helps me relate with my patients a little bit better. So that I'm not just talking at them, but I'm really able to kind of imagine what impact it's having on their life and to try to communicate accordingly and really, really develop some good therapeutic alliance with these patients. I think the other thing that it allows me to do as a clinician is kind of as we were talking about, have a little bit more patience and approach these patients in a little him more of a calm manner. Leda McDaniel: 27:01 I think in realizing that it's going to take time to see changes, but that doesn't mean that it's not worthwhile to work with these individuals on improving their function but also on improving their pain. And really promoting this expectation that recovery from pain is possible or could be possible, but that's more of a longterm goal for these individuals than some of the patients that we work with who are in an acute injury or an acute pain situation. Karen Litzy: Yeah. So it's really providing hope to the patient, allowing them to even visualize themselves pain free. Cause oftentimes if you're years into a painful experience, sometimes you can't even picture your life without it. So I think it's really important to give that hope to patients. And another thing that you had mentioned in some of the pre-podcast writing is that allowing the patients to tell their stories. Karen Litzy: 28:16 So just like today having you tell the story, it can be very powerful way for you to continue with your recovery and for others to learn from. So as clinicians, we have to allow these patients to tell their story and also noting that that story may not all come out at one visit. Leda McDaniel: Yeah, good point. I think there's just like in any physical therapy session or clinician patient relationship, depending on the personality of the patient and the clinician, there's just a natural unfolding of developing trust and developing an ability to communicate between the two people where you really can't force that story out of the patient and you really can't force that trust or rapport but I think as you're intentional about listening to your patients and understanding where they're coming from and how their injury is affecting their life, personally I think over the course of a few treatments or however long it takes to naturally work itself out, you really can develop a close alliance and improve your ability to the effect that patients' health in a positive way and garner some positive outcomes from your treatments. Karen Litzy: 29:48 Yeah. And I think the other thing that's important to mention is sometimes patients aren't ever pain free. And that's okay. Sometimes patients aren't pain free, but they're doing all the things in their life they want to do. You know, they're working towards the things they want to do. Or maybe they went from taking four pain pills a day to a half of one a day. So they may still have pain. And I think as physical therapists, it's sometimes a little difficult because we want to fix people, right? We want to make people 100% healthy, but it's okay if the patient continues to have some level of pain that they're coping and they're living the life that they want to live. So I think as new graduates, if I could give a little piece of advice to all of you guys, it's to not take on your patients outcomes as your own, but to really, like you said, have empathy, sympathy, step into their shoes and understand that hey, maybe they're not pain free, but they can do everything they want to do. And that's okay. They can live with that. Leda McDaniel: 31:00 Yeah, that's a great point. There are different markers or ways that we can see positive change in physical therapy and decreasing pain is one, but improvements in function are another one and absolutely mentioning if we can reduce medication use that can have positive implications of a person's experience and their overall health as well. So I think all of those things are great. Great things to think about. Karen Litzy: Yeah, absolutely. And now, you know, is there anything that we missed? Anything and we're going to, I'm going to get to your book in a second, but is there anything that we missed about your story? Any piece of advice that you know, maybe you would like to give to clinicians as someone who's gone through it? Leda McDaniel: 31:52 I think the first thing that comes to mind is as clinicians, sometimes faced with individuals with longer lasting pain or sometimes pain that doesn't quite match a structural issue or a clear PT diagnosis or medical diagnosis. Sometimes the inclination is to get uncomfortable and maybe distrust the patient or the cognitive dissonance that you're feeling into more of a situation. What I would really ask you as clinicians to first off, no matter what, no matter how uncomfortable this makes you or how puzzled you might be as far as what's going on, I would just ask that you really trust what your patient's telling you. Trust their story, trust their experience. And if it takes a few visits to kind of reconcile what they're communicating with, maybe what is going on, whether it's a sensitization or a longer lasting pain that's manifesting in some other way, I would really ask that you treat them as if what they're telling you is the absolute truth. Leda McDaniel: 33:19 And give that a chance to really play out before making assumptions about a malingering or a psychological primary component to what they're telling you. I think in a lot of cases that's too soon of an attribution from clinicians who are uncertain about what's going on. Karen Litzy: Excellent advice. And you know, at the end of each podcast I usually ask someone, hey, what advice would you give to yourself as a new graduate right out of PT School? But since you literally are a new graduate right out of PT School, it doesn't seem like the right question to ask. But what I will ask is this, knowing where you are now in your recovery and in your life, what advice would you give to yourself during the height of your pain experience? So if you could go back in time knowing where you are now, what advice would you give to yourself then? Leda McDaniel: Oh yeah, that is a great question. I think what I would tell myself is, and I did this a little bit, but I think I would try to encourage myself further, is to keep an open mind about what is possible for your improvements in health and for the body's ability to really heal and recover given the appropriate inputs. Karen Litzy: 35:01 Excellent advice. Thank you so much. And now if people wanted to know more about your story and dig a little bit deeper into your year of healing, they could read your book Moments from a Year of Healing a book of memoirs and essays. And where can people find that? Leda McDaniel: Yes, so my book is available online. It's available from Amazon, both in a print paperback version and also as an Ebook, supported by kindle. So they can search for the title of the book, Moments from a year of healing, a book of memories and essays or search for my name as the author. And I believe either way they should be able to access that. Karen Litzy: Awesome. And what if people have questions for you? Are they want to talk to you a little bit more? Where can they find you? Leda McDaniel: Sure. My email is LedaMcDaniel1@gmail.com and I'm happy to open conversations and really talk to patients or clinicians who are wanting additional resources or just wanting to hear more about my story. Yeah, I think that would be great. Karen Litzy: Well, thank you so much for coming on and sharing your story. And again, congratulations on being a new physical therapist. Good luck in your orthopedic residency at Emery. And I am very certain that any patient that works with you will be very lucky to have you. So thank you so much for being on the program. Everyone 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!

LIVE on the Sport Physiotherapy Canada Facebook Page, I welcome Dr. Christian Barton on the show to preview his lecture for the Third World Congress of Sports Physical Therapy in Vancouver, Canada. Dr Christian Barton is a physiotherapist who graduated with first class Honours from Charles Sturt University in 2005, and completed his PhD focusing on Patellofemoral Pain, Biomechanics and Foot Orthoses in 2010. Dr Barton's broad research disciplines are biomechanics, running-related injury, knee pathology, tendinopathy, and rehabilitation, with a particular focus on research translation. Dr Barton has published over 40 papers in Sports Medicine, Rehabilitation and Biomechanics journals, and he is an Associate Editor for the British Journal of Sports Medicine. In this episode, we discuss: -The inspiration behind TREK Education -Different mediums that facilitate knowledge translation from researchers to clinicians and patients -Common misconceptions around running and injury prevention -The good and bad surrounding social media and knowledge translation -And so much more! Resources: Third World Congress of Sports Physical Therapy Christian Barton Twitter La Trobe University Sport and Exercise Medicine Research Blog Switch TREK Facebook Group Made to Stick TREK Education Website For more information on Christian: Dr. Christian Barton, APAM, is both a researcher and clinician treating sports and musculoskeletal patients in Melbourne. He is a postdoctoral research fellow and the Communications Manager at the La Trobe Sport and Exercise Medicine Research Centre. Christian's research is focussed on the knee, running injuries and knowledge translation including the use of digital technologies. He has written and contributed to a multitude of peer-reviewed publications and is a regular invited speaker both in Australia and internationally. He also runs courses on patellofermoral pain and running injury management in Australia, the United Kingdom and Scandinavia. He is on the board of the Victorian branch of the Musculoskeletal Physiotherapy Association, and a guest lecturer at La Trobe University and the University of Melbourne. Christian is currently studying a Master of Communication, focussing on journalism innovation. He is an Associate Editor and Deputy Social Media Editor at the British Journal of Sports Medicine, as well as Associate Editor at Physical Therapy in Sport. Read the full transcript below: Karen Litzy: 00:00 Hey everybody, welcome to our live broadcast. I'm just going to take a look quickly on my phone to make sure that we are in fact live, which I think we are. Yes. Great. All right, so we're live, which is awesome. All right, so thanks to people who are already on and thank you to my guest, Christian Barton, coming all the way in from Australia. So it is my times as you're watching this. It's 9:30 New York time. So Christian, what time is it in Australia right now? Christian Barton: 00:37 11:30 in the morning. That's quite a nice time to do this. Karen Litzy: 00:43 Yeah. So we're doing this over two different days, so Tuesday for me and Wednesday for you. So crazy. But anyway, thanks for taking the time out to come on to chat with us. So for all the people who are on right now and for as we go through, if you have questions, you can type them in the comments, we can see them and we'll be able to address them as we go along. But before we get started, Christian, what I would love for you to do is just to tell the viewers and the listeners a little bit more about you and how you got to where you are now. Christian Barton: 01:18 Yeah, sure. So I'm a physiotherapist by background have been for nearly 15 years now. So it's getting on. I've always had an interest in research and clinical practice and continuing to try and juggle the two. And that probably started from the very beginning. I finished my undergrad course and well tried to find a position to do some research assistant work on clinical trials and things like that. And quickly my mentors taught me to do your PhD and actually started that about a year and a half out. And so I did that quite early in my career and probably since then I've been probably a mix of half, half clinic and research. So along the way, probably as I've gone through more recently doing more and more research because it gets harder to keep the research, you can do bigger picture things, which is something I've become really passionate about and I'll talk more about later. Christian Barton: 02:05 And so currently I work three main roles. One is my own clinic in Melbourne, which is a sports and an injury clinic. And we work one day a week there and then also work at the Trobe university three days a week. And my main research focus areas around there it's translation and implementation. And then the past couple of years have been doing one day a week with a surgical group. So the Department of Surgery, it's in Newton's hospital in Melbourne and there big project or area of research is around preventing inappropriate surgery. So that aligns very well with what I do of trying to optimize what we do as therapists to prevent unnecessary or inappropriate surgery as we go along. Karen Litzy: 02:44 Yes. Fantastic. Busy weeks. You have busy weeks. Christian Barton: 02:48 Yeah, I work alongside the three kids at home and yet it's not, not the easiest to juggle at times, but it's certainly all things that I enjoy. Karen Litzy: 02:55 Yeah, that's amazing. And every time all the interviews ever had with all of the speakers who are coming to Vancouver in October, all do so much. But we didn't do one time is just have an interview on how you manage your time. But that's for another interview. But I think people would really enjoy that. So now let's talk a little bit more about physiotherapy. So why this field? Christian Barton: 03:23 Yeah, I think as a kid I was always active, playing a lot of sports and had a few injuries myself. And I think I always valued the physios guidance about getting back from some of those injuries. So that got me interested in the field and then you go to university, you actually realize physio has a lot more than just train sports injuries. And you need to have to think about pulmonary rehab and cardiac rehab and you're electrical physio. There's a whole range in spectrum that we through. But I think pretty quickly when I come out I would want it to go back to musculoskeletal and sports. And so we went back down that path. And I think what I enjoy about being a physio therapist is just keeping people active. That's your more sedentary person, where you're trying to motivate them through lifestyle changes to get active and manage their persistent knee pain or back pain or whether it's a really elite sports person. I really enjoy trying to get people to achieve their physical activity goals essentially is what I'm enjoying. Karen Litzy: 04:18 Awesome. And now I can see more and more people joining you. Again, if you're joining, please write like where you're watching from and if you have any questions, put them in the comments because we'll be talked with, you know, so now let's, you had mentioned this earlier, talking about kind of what you do, part of what you do and you're involved in several knowledge translation initiatives. One of them being the trek group, which I remember I guess it was last year after sports congress and we all changed our social media to the trek elephants logo, which was really great. So this is a nonprofit initiative created to enhance knowledge translation to healthcare professionals, but also to patients and general public. So can you tell us a little bit more about trek and how it all started? Christian Barton: 05:13 Yeah, sure. Also I think my research journeys being quite interesting. When I first started off doing research, I was in a gait clinic doing biomechanics research and I've always found that side of our practice really interesting. And you do this real integral research and you spend a long time for assessing data and finally end up with maybe a couple of things that you can share in the community and they share them. And then I started doing more clinical based research and trials. Firstly looking at biomechanics and then did you that exercise interventions. Very early on I actually worked on a lot of systematic reviews and my passion for doing that was, well we have all this great body of research, we need to bring it together so we can disseminate a little bit better. And then I actually did a project in London where it was actually looking at clinical reasoning of physical therapists and how they integrate evidence into their practice. Christian Barton: 05:59 And what I discovered really quickly is not only were people not using evidence based practice all that often when I actually talked to them about patellofemoral pain, which I'd spent the best part of seven or eight years researching, they've never read any of my papers, never read any of my research. And so it sort of made me reflect a little bit and go, well, why am I doing all this research? And it's not actually being translated into practice. And so I started to have a bit of a flipping all I did and instead of spending time in the lab alongside doing clinical trials, I started to focus a bit more time on actually getting information out there. And so have a good friend of mine, Michael Ratliffe who's based in Denmark and we often catch up and catch up at conferences. Christian Barton: 06:40 And actually one of the first times we spent a lot of time together was when I went to a Danish conference a number of years ago. It was actually after that conference, I was sitting down both quite frustrated, having a couple of Belgium beers talking about this problem and the acronym trek come up with just on a random occurrence sitting his kitchen table. I still remember it. It was like, how do we do this? We'd probably need to brand it with already and get people behind a movement and something happening. So trek stands for translating research evidence and knowledge. So it fits really nicely with that. It actually has more meetings in that. And if you look at English language for trek, it means a long and arduous journey, which I think an old translation very much use when you try and actually make change. And then it also fits with Christian Barton: 07:22 probably one of my favorite books I've ever read, which is called switch, which is how to make change when change is hard. I highly recommend people read this book. It changed my life. And it's a really simple analogy. You have a rider sitting on an elephant and you need to get to a destination. So there's three main parts to that. The rider needs to know where to go. The elephant needs to be motivated because it doesn't matter if the writer tells them how often to go. It's not going to go anywhere to be big beast. Right? Christian Barton: 07:48 We also need an appropriate pathway to get there. So if you picture yourself as an elephant rider on an elephant and an elephant in the middle of the jungle, we want to get to the beach. There's no path to get to the beach and it doesn't matter, you're not going to get there. So the concept of trek is that we have clinicians, we have patients searching for health information who are all motivated to learn more and to do better. They don't really know where to find that information and they certainly don't know appropriate path to get there. So the idea of trek is to try and improve that. So that sort of started as an idea about how we do this. And then we've, I guess talking and trying to work with lots of people. It's been set up as a not for profit. Christian Barton: 08:25 So it's not meant to be owned by anyone. No one's meant to profit from it. It's trying to bring everyone together and break down the silos of competition between universities because universities don't like to talk to each other and help each other because they're in competition for the same grants and that they might be buried. The knowledge translation. So it's been really important to me from the beginning that yes, we'll try here where I work supports it. But it's not meant to be owned by the tribe. It's not meant to be by myself. It's meant to be everyone seeing. And it comes from a socialist I guess, concept called connective action where we actually, it's basically a meeting which we connect people with the same ideas. And then I did a communications degree and was focusing on journalism and multimedia and social media and writing a whole bunch of stuff around that. Christian Barton: 09:10 And I thought, well, this is a nice platform to use. I think about not just mainstream media, but also social media or whatever people turn. And then our favorite thing, doctor Google, where most people turn to health information. And when you start looking at doctor Google, it's a pretty broken system with a lot of misinformation. And so the concept and my hope is that in time, this trek movement or trek concept could maybe be something that we can't take over with Dr Google, but we can certainly contribute to the information that people find on doctor Google. And so it's getting people around the world to contribute information but create it in an engaging format that will actually get people to rate it and use it. We know there's lots of barriers to reading research for clinicians, understanding your research their reading, but also it's time. Christian Barton: 09:53 And if you can consume the same information sitting on a train, listening to a podcast or looking at a brief video or infographic that maybe gives you the key information from some research and you can trust that source, that it's not biased, it doesn't have an agenda, then that means you can be confident that you can bring that into clinical practice. And for a consumer or a patient that gets that information, they can maybe make health decisions based on that as well. So that was kind of the origins of the project and it's still growing and developing. A lot of people were helped along the way and hopefully we'll get more as well. Karen Litzy: 10:24 And what has been, so this sort of launched last year, right? Like officially launched. So what metrics have you found from launching last year to where you are now? Christian Barton: 10:39 Yeah, so what I did is actually was lucky enough to get a small grant from the Australian physio association to build a platform to improve physiotherapists knowledge of exercise prescription. And so we did a study last year where we basically built a website, which is exercise.trekeducation.org and before we gave access to everybody, we made them do a test, which is about 20 minutes. And so I have this great data for grants. It's linked with your physios. You've still need to sit down and write up and we see big variations of knowledge of exercise prescription. And we kind of expected, our hope was that we could then test the evaluate, right? This website helped to improve people's knowledge. Now out of 1,600, I think about a hundred filled in that follow up survey or questionnaire rate. But it was at least as the grant gave us the funding to build a platform. Christian Barton: 11:26 And it's a multisite platform. So since this time we've built a website now for many patellofemoral pain, which is a big area of mine for clinicians. We've actually just finishing up a low back pain site and a knee osteoarthritis sites. So by the time the conference is around, we will have launched them and be available and working with some other researchers to make a shoulder side. So think of all the big musculoskeletal conditions with variables. And we've also been developing platforms, consumer patients as well. And so we have one which a PhD student in new idea, Olivia or Silva has been working with me for the last two years and we did a super little trial looking to see how beneficial that might be by itself. And then in conjunction with physiotherapy intervention. And certainly the website by itself is incredibly helpful for improving patient's knowledge and self management strategies, their confidence in doing things. Christian Barton: 12:17 And it seems to lead to reasonable clinical outcomes as well by itself, but probably better outcomes if we combine it with physio. And we haven't done what to evaluation yet, but we're hoping that we can start to do that more and more as we go along. And most importantly, just have some quality resources that are free. You don't have to pay for it, just there, you can use them. And it's been nice to see the exercise site. And certainly the one with the value at the moment. There's plans to do this as well, but they've been embedded into teaching curriculum as well, which has been really good. So University here at La Trobe is using them, but other universities around the world have also used bits and pieces of content and that's the idea of it is to write and use it all way pointless multiple people around the world creating the same content when we could work, maybe be better together. Karen Litzy: 13:06 No, that makes a lot of sense. And now you're sort of like you said in the beginning, sort of doing a little bit of both your research and clinician. So why are we, in your opinion, why is it so important to bridge that gap between research and clinical practice? Christian Barton: 13:23 Yeah, I think from, if I put not my research hat that my clinician hat on and I think about our physiotherapy profession, I think we have some amazing physios around. We do really, really good job. We have others who are very good physios that are working really hard to continue to improve knowledge. We have a lot of practice that I would also consider as pretty low value care and sometimes iatrogenic care where actually maybe delivering health education and information is actually detrimental to the patient. And so I think collectively we need to work really hard to establish our brand better and better because we can do better. And a big part of that is actually making sure that what we do know to be beneficial for patients all around the world is actually disseminated into the hands of people who can use it. And that's a big part of that is physios and other health professionals. So that's the big passion for trying to change it. And I see in my clinic second and third opinions and sometimes it's just the patient hasn't been motivated, haven't done the things that I need to do that have actually been given really good guidance. But equally we see cases where they've seen multiple health professionals and just the treatments and information being given is just not aligned with what we know of contemporary knowledge around evidence about what should help that person Karen Litzy: 14:36 As physio therapists, what do you think we're doing really well and were doing right and what do you think we need a little bit of hopefully they're not doing wrong. But what they just need a little boost. Christian Barton: 14:57 Yeah, it's a good good question. I think in the most part physio practice and physical therapy practice is moving towards more active management and there's lots of debates on Twitter and social media and people argue about the value or lack of value, whichever side to sit on about manual therapy and things like that. But I think overall we are moving to more active management approaches. We are moving more towards managing the pain science side of things and educating patients better about that. And I think that's probably what we're not doing very well is building that brand of what we deliver. And as a couple of hours to that one is I guess getting collective way across the board that we're all on the same page and delivering similar high value interventions. And what that means is some patients will go to see for therapists or physiotherapists, then they maybe get delivered a lot of electrotherapy or something else and they don't get better in a long time. And then they go back to their doctor or their surgeon and say, oh, I did PT, I did physio. It didn't help. Karen Litzy: 15:54 Yeah, yeah. Failed PT. Christian Barton: 15:57 It failed. And I think that's something that drives me a little crazy is you don't fail that profession, you fail an intervention. It's a lot of inappropriate surgeries and other treatments. I think collectively we need to be more on the same page, but that's something the knowledge translation probably helps with a lot. The other part that I think we do very, very poorly and actually worked with Rob Brightly, he's going to be presenting the conference and that is collecting outcome measures. So we don't actually measure what we do very well. We occasionally measured them and this is the same around the world for compensable patients because we're forced to. But if you were to audit most people's clinical practice and say, can you show me that what you do is truly valuable, it's worth something. Christian Barton: 16:48 Most physio practices won't be able to. And I reflect on myself and I can't do this very well. So we need to get better at measuring the value of what we do. So we can take that information to funders and say, hey, we are actually worth something in what we do is worth something. And so I think that's a cultural thing and it's a systems thing and I think it's something we collectively maybe need to work pretty hard to, to try and change. And certainly locally I'm trying to work with the Australian physio association here and it started to come up with some processes that you can, we might do that and knowledge translation. One of the projects I've enjoyed the most here in Australia is a program called GLA:D. I'm going to talk to Ewa recently and that will be certainly discussed at the conference in the biggest strengths of GLA:D isn't it aligns with clinical practice guidelines. Christian Barton: 17:34 That's education and exercise. So I'll bring that standard up across the board. So first to trust that when they send someone to the program they will get exercise with education and it also raises the outcomes related to that as well. So it can turn around and we have some great data in Australia which were yet to publish, but it certainly shows from now data that not only does pain improve, which is something that may or may not be the most often, but also changes things like medication and also changes things like surgical intention. So people may believe I need surgery or going down the line to surgery. Am I saying certainly in Australia that less people are desiring that. But we look at that in GLA:D that's great here. But the rest of physio practice so you have nothing to contemplate. Suddenly we need to work. You don't run out. Karen Litzy: 18:19 Yeah. And I know the APTA here in the United States does have an outcomes registry that they started I think maybe a couple of years ago, maybe two years ago is starting to collect that data so that we can take it at least here in the US to insurance companies to show that what we do is valuable and that what we do should be reimbursed. Christian Barton: 18:42 Do people contribute to it, do the people actually give data? Karen Litzy: 18:51 I don't know the answer to that question cause it is voluntary. So I don't know the answer to that question at the moment. But I would assume some people do, but do the 300,000 physical therapists that work in the United States? No, but hopefully it's something that will grow over maybe the next, I mean it's slow. Right? So it may take like a decade plus to kind of, if we're being realistic. Right? If someone were to audit my books so to speak, I dunno. I can certainly show that. I don't know. I don't know. That's something I need to get better at, so I'm calling myself out, I guess. And it's something that I certainly need to do better at myself. Karen Litzy: 19:52 So let's talk about your experience as a researcher. So we'll move from kind of the clinical dissemination to do you have any tips for, let's say, new and upcoming researchers or even physio therapy students who maybe want to go into the research track to kind of help maximize their potential for reach and for knowledge dissemination? So, you are the researcher, you're doing great work and then what? It doesn't get to where it needs to go. So what tips would you give to people to help with that dissemination? Christian Barton: 20:37 Yeah, sure. So we put together a paper, which was just recently published in BJSM, trying to remember the exact title, but it's time. I think it's something along the lines of it's time for a place, publish or perish. We've got vanished. Yeah. So we have this in research that if you don't publish your work, then obviously there's no record of you doing it. But also you can't give credibility to your work in peer review processes. Very important to doing that. When we go for job promotions and we got the scholarship, for example, to do a PhD or whatever it might be, they're a competitive process and people look at metrics and one of the key metrics is really simple is how many papers have you published? What journals are they publishing? So it's really hard to get away from that. But ultimately, as we've discussed, that doesn't put the knowledge into the end users hands. Christian Barton: 21:23 And what happens is we end up with commercial companies selling pharmaceuticals and nutraceuticals and surgical interventions. That can be, I guess maximize money. And even pay teams event and for that matter. And so therefore the researchers, good knowledge doesn't get there. And maybe in health information that if news information gets cut through to clinicians and to patients, so you simply have to allocate some time to do it and you have to be quite aware and understanding that that might mean that you take a little bit of a heat on your academic gap or from a publication perspective because when they have so much time in the day. So that's a thing. It's just having that expectation that you can't do it all. That's really important. Spending some time on it. But in saying that it's not a ton of extra time to, after you publish a great RCT that was part of a PhD or whatever it might be, to spend some time with your media team at the university, put out a press release about that RCT and what the implications might be, which there may be ways from a radio interview or getting picked up in papers. Christian Barton: 22:27 And so that's not a lot of extra work on top of maybe two or three years of the study even. Right. I think linking in with me, your teams at different universities is a really good starting point if you can. Then we have the social media world, and the social media world as a challenging one because there's a lot of strong and loud voices on there. Some of them are good, strong amount, Sometimes there's misinformation from those strong loud voices. And so you're going into competition for the microphone essentially on social media to do that. And you can get on and you can have debates and arguments and discussions and conversations about your research that you've done. But ultimately the people who disseminating, interpret that are the ones with the loudest voice and that's kind of, you can lose your information, which is a bit of a frustrating thing. Christian Barton: 23:12 So yeah, so people get very frustrated about that when they've spent two or three years doing some research and then it gets misinterpreted by someone on social media who's got the microphone. So there's a few options around that. I think one of them is either creating a skill yourself or working with someone who has the skills to create knowledge translation resources. So we know from research that we've done and certainly evaluation of this is that the general consumer and that consumer can be the coalition or it can be the patient won't engage with your article, but they are likely to engage with your article but they are likely to engage with an infographic or an animation video. And so spending some time and effort on creating those types of resources to summarize your research findings is probably time and money well spent. So I'd strongly encourage people to price some emphasis on that. Christian Barton: 24:04 And then you've got an asset on social media, and if you already have a big following on social media, you have to be the one that shares that asset because you've created the asset. So you've controlled the narrative of what goes into that asset and the key messages. You can then leverage the people. We do have a market friend and hopefully they can then share for you, et Cetera. We help with so you can spend your time arguing with the people, misinterpreting your work on Twitter or you can spend your time maybe creating some of resources. And I guess the concept of trek is to try and create resources with those types of things can be embedded into a web page. So if you've done research on my back pain and it's game changing research, then those knowledge translation resources can be put onto a platform on trek. Karen Litzy: 24:50 Yeah. Great Advice. Anything else? So we've got getting to know the media team at your university to release a press release, which is huge because that can lead to other opportunities. And knowing how to either get your original research onto an infographic or an info video or a podcast, and then use that as your vehicle via social media, attaching that to some social media influencers, if you will in order to kind of get that out there. But I definitely think that's much better advice than banging your head against the wall and arguing with loud voices. Christian Barton: 25:34 Yeah, exactly. Probably the other advice, if you go back a step in terms of designing search, it's probably really important and this hasn't been done well, but you engage the end user from the beginning. So going back a step and when you're designing your clinical trial, no good designing an intervention that no patient is going to engage or to use. So you might design an exercise program that you think is amazing and it's fantastic, but actually when the patients in the trial do it because they in a clinical trial, but then you go into the real world, It's too challenging for them to do. It's just too difficult. And therefore you're going to get criticized for your intervention that isn't clinically applicable. You want to cop that criticism in that design phase and people say, this is not clinically applicable. This won't work. Because then you've got time to redevelop on it and evaluating it and then realizing it won't cut through. So that's, yeah, I will probably important thing to think about. So when we talk about engaging the end user, particularly patients as the end user, but also clinicians as well, and getting their input because they're all going to be the ones delivering yet. And just to some extent, funders, they're a little harder to talk to. Karen Litzy: 26:45 Yeah. Yeah. A little bit easier to get in with the patients or your fellow colleagues, hopefully. And now earlier you had mentioned that you have done research into topics such as patellofemoral pain. We also know that you do research in running injuries, obviously knowledge translation. So let's talk about kind of some common misconceptions around, we'll take running injury prevention and management, right. Cause these misconceptions come about because of poor dissemination of information I think is one aspect of it. So what would you say are some common misconceptions around running and injury prevention? Christian Barton: 27:32 Yeah. So we can go into lots of areas here. Karen Litzy: 27:35 No, it's a lot of branches. Christian Barton: 27:37 Yeah. So let's stick to running because it's a popular thing again. Everyone likes to manage runners and treat runners and not a lot of people like to run themselves. We actually put an infographic series out on our trek website. So James Alexander who is a master student environment moment putting together a series and we have the graphics and there's a few key ones for running injury prevention. One being stretching helps. And so that's something that has long been ingrained in people's beliefs that why you're getting injured is that you haven't stretched enough then stretching doesn't actually help us prevent injury. So it's not that it's a bad thing necessarily, although there is some evidence that stretching might impair muscle function, might actually reduce your ability to have muscle function but certainly it doesn't prevent injury. Christian Barton: 28:31 So focusing on that as the problem is probably not the answer. Footwear often gets blamed for injuries, prevention and also as though the key focus. Now typically most of the times if you changed before where yes, it could definitely cause the injury drastic change, but a lot of times it's not the fault of a footwear. Someone buys a new pair of shoes, but they also decide they want to get fit and lose weight at the same time. And they go out and they overload and they train too much. Karen Litzy: 29:01 Yeah. So those things kind of do overlap cause you get motivated, you go out and buy the new shoes and then you blame the shoes and not so much the amount of load that you just put through your body that you haven't put through your body in months or years. Christian Barton: 29:14 Exactly. This is not the shoes that are important because they will moderate where the loads go can to some extent. But I think we get very obsessed and part of that comes back to who controls information that gets out there. And it's shoe companies, right? They sell shoes. There's all these motion control technology that shock absorption technologies. And so that's a big marketing campaign and that changes what people buy. And what I will say, it's a big problem. People have that answer. And then we have big pushes about minimalist shoes and they're the answer to everything. And in reality it's probably going to be very variable across different people in it. People with running shoes, all their life will be taken into women's shoe. That's a big change. So that will probably injure them. So yeah, might help. They need, they might get some acuities buying. Christian Barton: 29:59 It might help their heel pain or forefoot stress fracture. So again, just that big emphasis on footwear and often because it's a commercial and marketable thing is offering the way what happens? I always love the example of Australia by a guy called cliff young. So some people are watching may know him, but those who don't, he actually run the first ever Sydney to Melbourne ultra marathon. So that's 800 kilometers or so. And one of our quite a few hours now, cause John did most of his training in numbers. He used to run two or three hours on his farm every day chasing sheep in Gum boots. So Wellington boots, clearly he didn't have any significant injuries. Right. And I have some great footage that I take when I teach my running course. That's some great footage of me doing that. And that's not to say everyone should go out and run in gumboots. Christian Barton: 30:46 But certainly for him he was doing it his whole life. So he's adapted to doing that. And if you're adapted to doing something, don't change it, right? Maybe maybe you might modify footwear to reduce the weight because that we know that helps with performance, but beyond that we don't really have a lot of good evidence that changes footwear will help with injury or performance or anything like that. So my philosophy mostly before where it ain't broke, don't fix it. But there are some nuances around some biomechanical considerations depending on what you want to try and change. But that's probably a couple of the key points of stretching and in footwear and the importance we place on them. I think it's probably more important to get our training loads right. And probably also thinking about, and these are my biases and there's not strong science on this, but doing a resistance training program might be more beneficial for preventing injury. We could do more loading with our muscles and tissues without that impact. And so that's possibly beneficial. And we do see some evidence that may be doing a resistance training program helps with performance as well. And most people get down because they're trying to run personal best times or beat their friends or whatever it might be. So rather than smashing yourself more and more on the training track, maybe get in the gym and do some resistance training would be my advice. Karen Litzy: 31:57 Great. All right. Now, we're gonna shift gears just a little bit here. So the next question is what is or are the most common question or questions, I'll put an s on there that you get asked. And this could be by researchers, clinicians, patients, maybe you've got one for each. I don't know. What are the most common questions you get asked? Christian Barton: 32:28 Yeah, so I'll start with researchers. So academics, you sort of touched on this a little bit before, but it's often around how to dedicate time and make knowledge translation, but not just that. So creating the resources we've talked about before, but how to navigate media or platforms like Twitter, like you get on Twitter and someone's attacking your research and let me see, interpret it. Or you get on Twitter and you put something out there and someone gets offended and that's a problem as well. And so it's actually, it's very difficult on social media because when you're typing things and writing things in, emotion gets taken out of things and people interpret emotions. So you might write something that has really no emotion attached to it, just a simple statement, right? But someone who thinks that you might be attacking them, we'll take that as an attack and then that creates a problem. Christian Barton: 33:19 All the time. And I know that I offend people at times because they tell me that I've offended them and that's what I really appreciate it at least it gives me a chance to reassure and go look. It's not meant to be offensive when used social media is a positive way of translating knowledge and then other people probably get offended and just don't talk to me anymore. Yeah, I think I've been blocked a couple of times. Christian Barton: 33:51 So my advice usually to people about Twitter is I think it's immediate that you can get a really good understanding about how part of the world is thinking. It's only a small part of the world. And then I think it's important to understand that that's the case. You're only getting a snapshot of some people and often it's people who have louder voices and want to go on talking, but it does give you some insight into that. And I think for me that frame some of my research questions and maybe modify as and move it and helps me narrow it down. It gives me a media where I can use assets that we've created to put them in hands of people who will disseminate them. So I think that's really, so sharing a good infographic or podcasts or video on that platform is one of the influential people there who hopefully then share your message. So I think it's important to have some presence there for that reason, but don't get emotional about it. If you feel like you're engaging in a circular conversation, you probably are engaging in circular conversation. You just stop, don't keep going. Karen Litzy: 34:48 Pull yourself out of it. Like I think often times what I see in those circular conversations is like somebody, it just seems like one of the parties within that conversation wants to win more than the other one. Or are they both really, really want to win. And so it's just like, I'm going to get the last word. No, you're going to know I am. No, I am. It goes back and forth and you just like, Christian Barton: 35:14 My advice in those situations, for someone who feels like they're in a circle of conversation, they're beating your head against the brick wall. Just step back for a little bit and just think why is this happening? Why is what I believe or what I think not being interpreted the same way. Right. And it might be that actually you discover your own biases and it might be that. And that's a good reflective thing. It's ok to change you mind and beliefs. That's a good thing. That's a positive thing. Or it might be that actually you don't have as much supporting evidence for what you believe in. And maybe that's because you need to do some better quality research to test your biases and maybe you discovered that actually you were wrong, or maybe you test your biases properly and you discover I was on the right track, so that's good. Yeah. You usually have to prove myself wrong more than I proved myself. Right. That's a good thing. Yeah. Or actually worse what's happening, it comes back to that communications is you're not disseminating your messages very well. So you're actually not providing an adequate messenger. You can sit back and think about that and don't keep argue with that person. You think about some strategies to disseminate and put together a podcast or a video, or write a blog about the topic that has really good details where you've got more than a couple of hundred characters. Karen Litzy: 36:30 Yeah, that is really useful. So, and sometimes in these kind of conversations, if you will, sometimes you can also just take the person and send them a direct message where you can write a novel if you want to do as a direct message. And I find that when you do that and you kind of can explain yourself a little bit better, it helps to kind of foster better communication and a better conversation. And oftentimes when it's in private, people are different. Christian Barton: 37:07 Yeah, that's great. And, taking the conversation off the social media platform is often a really good strategy too. Navigate and get over those miscommunications that can happen. Yeah. Karen Litzy: 37:17 Yeah, I've done that before. Christian Barton: 37:20 That's really spread enemies. Right. And then probably the other advice I'll give to people when I've actually put a tweet about this I think earlier this year or late last year. It's just, I'll refer to them as trolls and I'll call them trolls in until they show their face. People who are on there who don't have a public face. So it's social media. So for me you should have the transparent profile and the reasons for that is you want to know where people come from and where their beliefs come from so you can understand their point of view. And if you can understand that point of view, it makes it a little bit easier to have discussions with. But there's probably people on Twitter who just set up their identify profiles just to kind of attack and stir the pot and it's just not worth engaging with those people's I used to try and have their fun with them and make a few jokes and I've done that a few times. If you'd be probably saying that like, so that's also a time wasting. So it's kind of entertaining, but it's also time wasting as well. So I think when you identify, communicates, asking you persistent questions and almost feels like you're having circular conversations just block that person. There's no, you don't know what their alterior motive is. You don't know what their conflicts of interest are. You don't know where they're coming from. Karen Litzy: 38:28 Well, you don't even know who they are. Christian Barton: 38:31 Exactly. And so I don't think we should engage with those people. That's my first way. Most people won't like hearing that and they just keep creating new profiles. Right. Well that's okay. I never used to block anyone until six months ago, are quite a few people in racing time for that very reason. In short, if you get it, get into social media and you kind of, so you can learn from it and focus more on giving some quality content and having meaningful discussions rather than arguing. Yeah. Karen Litzy: 39:01 Yeah. That's sort the idea of social media, especially when you're a professional, you want to be a professional because you're a professional and so, and the point of social media is to be social. Christian Barton: 39:20 Yep. I like that. Karen Litzy: 39:21 You know, it's not to go on there and be antisocial and argumentative. You're there to be socially it's fine to debate. It's fine to disagree. But some of the things that people hear this all the time that you see on social media, you would never see that kind of an argument with people face to face. It just wouldn't happen. You know? So you have to remember to keep this social in the social media and not be like a maniac. Christian Barton: 39:52 I like that phrase. Keep the social in social media. Karen Litzy: 39:54 Yeah. So if you could recommend one must read book or article, what would it be? Christian Barton: 40:02 Yeah, so I mentioned earlier about with the trek origins and the concept around that. So switch is probably my book. I think it's influenced my life the most from many respects. I think I gave a really brief, probably poor synopsis of it. It is the elephant, the rider and getting to the destination. But it just changes the way you think. And when you're trying to make a change, it gives you nice, simple way for you where your barriers are. So is it people don't know what they need to do? Is it about the emotion and motivation? There's lots of great analogies that examples within that that I think will kind of really inspire you to think about the rest of your work. Not just research it, it's not just clinical practice but how to change relationships with different people and things like that. So I think it's a really good book to read. I'll give you a second one as well. John Rockwood. Yeah, no, he's translation and dissemination is a book called made to stick and that's basically made to stick. So it's around how to make your messages stick. So that's a really nice book as well. So if you're trying to communicate more clearly, that will hopefully give you plenty of ideas and concepts to look out for. That'd be my to go or recommendations. Karen Litzy: 41:12 Perfect. All right, now let's get to the conference. It is October 4th and fifth in Vancouver of this year, October 4th and fifth of this year. And can you give us a little bit of a sneak peek about what you'll be speaking about at the Third World Congress? Christian Barton: 41:32 Yeah, sure. So we've got a couple of presentations. One is actually in the session review, which I'm really looking forward to discussing with yourself and all around knowledge translation. And one of the things I want to talk about in that is how healthcare disinformation develops and spreads? Cause I think it's important we understand the mechanisms of that. And that also allows us an opportunity to understand how we can spread good information because we understand how, how can this disinformation grows and spreads. And hopefully that gives us some insight into how we can grow and spread the good quality information. And so we'll go through some of that and break down some of the things we've talked about around using I guess digital assets for knowledge translation in. One of the things I've actually really looking forward to talking a little bit more about is some of the outcomes from the research we've been doing, particularly around patients and finding them and what we can achieve through a good quality website. Christian Barton: 42:23 So we have a review at the moment, which is under peer review looking at patellofemoral literature and it doesn't just do a systematic review of patient education. It also looks at online information sources. Basically when we look at all of those is the vast majority of conflicts of interest, often financial conflicts of interest. There's a lot of missing information on there. And so for the person navigating that, that's really challenging for them. And we've done a lot of qualitative work with people with the patellofemoral pain. And then part of the new ways work I talked about before, we actually did reasonably if we needed to clinical trial where for a period of that trial all they had was a website that we developed for them. And we put multimedia and engaging resources with quality information and accurate information, simple exercise program that they could do. Christian Barton: 43:12 And so we're still pouring through the results and we'll have it done before the conference and I can see from the preliminary stuff was actually do really well by themselves with quality information. And certainly that then makes your life easier as a physio cause you don't have to fill in as many gaps. I can focus on adequate exercise prescription or clarifying some information and things like that. So it makes us more efficient. So yeah, really looking forward to talking about that in our session. And then the second session I'll be talking on is around exercise prescription and I think the title is beyond three sets of 10. And so I mentioned at the beginning my research started in the biomechanics lab and I used to think biomechanics, were the be all end all and I've probably changed my opinion on that over the years and very subtly, very slowly and I still think biomechanics matter, and exercise prescription around that can be important, but equally education alongside your exercise prescription to address things like Kinesiophobia and pain related fear or something that we find is a really important factor in managing people's pain. Christian Barton: 44:19 So yeah, a huge barrier to actually getting engagement, but even getting, they might do exercise but they won't get as much out of it if you haven't tackled those fears and beliefs. We'll talk some of the research we've done in that space recently around how that can guide exercise prescription and some processes around that. And then I've had some fun almost on the other end of the spectrum where we've actually just got people in the gym and focus more on physiological responses and we just smashed it in with strength and power. And one in physical therapy in sport, which is just a feasibility study. Probably 10 people, people who we just put through a resistance training program of strength and power and the reason we did this study is when you look at all the patellofemoral literature, no one has done a program of adequate intensity of progression and duration. Christian Barton: 45:10 You would actually see any meaningful changes in strength and power despite the fact that a lot of them say that they do strength from your title when you actually look at their protocols are not true strength protocols. So we decided to just put great people through this program and just smashed them in to do. And they did better than I thought they would do. I was actually surprised. And so we'll talk about some of the findings and implications of that and how to put that into your clinical practice. And I think the whole idea for me is we have these programs that physios focus on around motor control and they often low dose exercise. Don't know what the education part alongside that done very well around pain, weighted fear and even exercises to tackle that. And simple great exposure. But equally we don't get the end stage stuff done very well. Actual really good progressive resistance training. Yeah. I think we get the middle part done well, but we kind of miss those two elements that's trying to bring all that together. So I'm looking forward to that where it's not just three sets of 10 of hip abduction and knee extensions. Karen Litzy: 46:11 Yeah, no, that sounds great. And, and I know that anyway, they'll probably be a lively discussion around that topic. I know here in the US, if people are using their insurance, they're often cut off before we would ever even remotely get that. Let's get you in the gym and really do it, you know, let's really kind of work and like you said, like smash it out, get them stronger, get them confidence and, and it's unfortunate, but that's the system that we have to play in and yeah. Christian Barton: 46:44 Well, we can put a link up to the paper on the Facebook group. It's actually open access at the moment? It's appendix of all the exercises. I think they're really simple exercises which was kind of cool about. So we just, we really just pushed it straight away and we only went for 12 weeks. And that was purely from a feasibility perspective of yeah, it just costs money to do these projects over a long period of time. Yeah. But my bargain is that if we kept going and with the clinical hat on, they continue to improve, at least in terms of function. A whole different kettle of fish, but they can do more exercises, more progressive. We make it, the more they can do and wherever their pain usually reduces. But wherever it gets to the point where they're happy or not, at the conference we'll talk about that. Karen Litzy: 47:29 Yeah. Sounds great. I look forward to it. And are there any presentations at the conference that you're particularly looking forward to? Christian Barton: 47:38 Yeah. So I think, and not just because I'm talking to you now, but looking forward to our presentation, not just from me talking but also hearing from yourself and rod and I, I think one of the things I've appreciated about knowledge translation and using social media experts, there's no person in the world that knows everything you guys had it through. Then over the years I've actually learned quite a bit from yourself with the podcasts and stuff you do and really enjoy some of yours. And I think I like the process and approach you've taken and I think you've been quite inspirational about how you can actually find a model where you can spend time doing it, which is really cool. I'm so looking forward to hearing more about that and maybe you have some good tips for me, but also Rob Whitely presenting in the same session. Christian Barton: 48:22 I really like the way rob thinks, he thinks very differently to most people. He's got my favorite Twitter profile picture that I've seen so enough. Those are not from Australia where I quite understand it, but there's a picture of a kid with his head down looking asleep. We've got ex Prime Minister Tony Abbott talking at the same time. So it's quite a funny picture. But he's, yeah, he's a bit eccentric, but also very clever for instance. The whole conference is really good with lots of, I think clinically focused presentations because everyone presenting going through it has a really strong clinical focus here in what they do. I think that's a real strength of it. The Saturday morning there'll be a couple of really good workshops I was looking at it yesterday and trying to work out knowing that you would ask this question where I want to go. Christian Barton: 49:13 And you've got that and it's allowing presentation with Ewa Roos, Christine, both of which have a huge respect for and I've learned a ton about exercise. And so I'm looking to that and saying what other things I could learn from my clinical practice. But at the same time, talk to you about upper limb, the same stuff. Now I see a few cases in shoulders. I don't see as many as Rollin, so it'd be great to learn some things from them, but also I liked to take knowledge from other areas and see how I can apply that to lower limb in my research and yeah. One interesting to do that, but I reckon I'm going to have an apology to those guys for saying that I won't be able to make both. I'll have to make sure I send someone along. Karen Litzy: 49:55 It's going to be hard to choose, but you know, you'd take someone over, you have to divide and conquer. Exactly. You know, can you send someone with that? Yep. Need a team. Yeah, yeah, yeah. Over a beer or wine Karen Litzy: 50:32 No, for me, like a small little glass of beer. That's right. Yeah. Thanks. Yeah, that's true. That's true. And you know, look at sports congress. This past year I did not have the flu. So drinking those like small little ones kept me awake. Christian Barton: 50:49 Good, good, good. Karen Litzy: 50:51 I found like this sweet spot. Well Christian, thanks so much for coming on and giving your time. Thanks everyone for coming on and listening. And Christian, where can people get in touch with you? Where can they find you? They have questions or they want to give you some unsolicited feedback or arguing. Christian Barton: 51:26 Very happy, very happy with any feedback or questions. Probably easiest way to engage is probably on Twitter. So do you use Twitter a little bit for that? We also have a Facebook group for the trek exercise group. So if you look that up, I might put a link to that as well. So it's trek exercise group. And so that's not a bad medium to kind of start to engage with the trek initiative. And we'll actually use that to launch the back pain and also arthritis websites and I can put some links on there to the top from a website which we set up. And actually the other thing on that note, and I might put this on the Facebook page here as we have a course for anyone who's interested, it's a free online course learning how to critique randomized controlled trials. Christian Barton: 52:14 So basically it takes you through some modules about how you go back to taking them. Before that we kind of get your knowledge and confidence on your capacity to do that. Do the course and then you could take a few articles and then at the end of it there's a followup test to see how you go. There are actually some prizes as well. So at this point in time we've had I think over a hundred people sign up to this. But only around about 20 finished. Yeah, there are two $500 prize as far as with Australian dollar prize. So at the moment those 20 people will have finished it or, and we've a one in 10 chance we'd pop your dollars. Say I would suggest that you jump on board and have it for learning, but chances to win a prize Karen Litzy: 52:51 This is 500 Australian dollars or US dollars. Christian Barton: 52:56 It's about $350 US. So it's not as lucrative. It's not a small amount. So this is actually part of the, the trek project in collaboration at the University of Melbourne who established this. And so that's the sort of stuff that we're trying to do with trek is to put these types of resources out there and Yep. So hopefully we can get a few people on board back. Karen Litzy: 53:21 Yeah. So you will try and put all the links. I'll find the links to books and everything that you had mentioned. Switch and make a stick and trek and we'll put them all in the comments here under this video. So that way people can click to them, and join the trek group and figure out how to get in touch with if you have any questions. So everyone, thanks for listening, Christian. Thank you so much. This was great, and I look forward to seeing you in Vancouver. 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, I welcome Dr.Tami Struessel and Colleen Rapp on the show to discuss holistic physical therapy. Tami is an Assistant Professor in the Doctor of Physical Therapy Program at the University of Colorado Anschutz Medical Campus and treats patients in an outpatient clinic. Colleen Rapp has worked as a journeyman and press operator at The Denver Post for more than 30 years. Decades of physically demanding work plagued Colleen with back and shoulder injuries as well as significant chronic pain, ultimately requiring surgery. In 2014, she turned to physical therapist and University of Colorado faculty member Tami Struessel, PT, DPT, OCS, MTC for care. In this episode, we discuss: -The key elements that allowed Tami and Colleen to develop a strong therapeutic alliance -The importance of a holistic treatment approach to physical therapy care -How Tami's treatment approaches have shifted to be more patient centered -How physical therapy has changed all aspects of Colleen's life -And so much more! Resources: Colleen Rapp Twitter Colleen Rapp Facebook Physio Pro Website University of Colorado Tami Struessel Clinical Outcomes Summit: use the discount LITZY Benefit Concert for CU PT Scholarship More information on CU Giving Scholarship Program For more information on Tami: Tami began with Physio pro in 2018, and enjoys working with patients after all types of injuries and surgeries. She is an Assistant Professor in the Doctor of Physical Therapy Program at the University of Colorado Anschutz Medical Campus, and has been awarded Bachelor's, Master's and Doctoral degrees in Physical Therapy. Clinically, she has been recognized since 2003 as an Orthopedic Clinical Specialist (OCS) through the American Board of Physical Therapy Specialists and since 1999 as a Certified Manual Therapist (MTC) through the University of St. Augustine. She is a past recipient of the American Physical Therapy Association-Colorado Chapter Physical Therapist of the Year, and teaches, and researches in the areas of clinical reasoning, orthopedic physical therapy practice, and practice management. She is a member and past president of the Colorado State Physical Therapy Board through the Colorado Department of Regulatory Agencies (DORA). Outside of work, she spends as much time with her family in the mountains as possible, enjoying cycling, hiking, skiing, snowshoeing and mountain music festivals. She has 2 adorable dogs, Daisy a boxer/great dane mix, and retired seeing eye dog Donovan, a yellow lab. For more information on Colleen: Life-Changing Experience with Physical Therapist Inspires Patient to Give Back Colleen Rapp has worked as a journeyman and press operator at The Denver Post for more than 30 years. Colleen noted, "I'm very proud to be a woman working in a 'man's world' where the work is difficult, but rewarding." Decades of physically demanding work plagued her with back and shoulder injuries as well as significant chronic pain, ultimately requiring surgery. In 2014, she turned to physical therapist and University of Colorado faculty member Tami Struessel, PT, DPT, OCS, MTC for care. After being introduced to and working with Tami at Physio Pro Physical Therapy in Denver, Colleen's outlook on maintaining a healthy lifestyle began to shift. Colleen reflected, "Life-changing care, to me, is defined as care that influences great changes in self." From the beginning, Tami approached Colleen's treatment from the whole-person perspective. "In addition to my treatment, Tami showed me online anatomy classes so I could learn muscle groups and have a better understanding of my body," she said. Additionally, Tami introduced her to things like a calming application, in efforts to reduce stress. Tami said, "Colleen is one of those patients who truly embraces the idea of becoming stronger and healthier, and is a huge believer in physical therapy." "For years, I viewed my work as my exercise," she said. Through the help of Tami, Colleen lost 30 pounds, has better eating habits and consistently exercises 5-6 days a week. "Tami has taught me the concept of working smarter, not harder," said Colleen. "I feel like a whole new person thanks to my care, and it has led to a newfound appreciation for exercise and for keeping my body strong," Colleen added. "Tami really wants to see her patients succeed, it matters to her." Admittedly, Colleen wasn't fully aware of physical therapy and its importance when she was first referred. From learning movement, stability and range of motion among other things, she realized there were many elements of physical therapy beyond what she initially thought. "I realized that physical therapy was the most important thing in between the points of injury and health," she said. While every day presents challenges to stay on a good path of nutrition, exercise and the willingness to strengthen her physical fitness, Colleen is greatly appreciative of Tami's influence and care in her life. "Through her hard work, Colleen has transformed herself into a much healthier and more resilient person," said Tami. "To me, that is what being a physical therapist is all about!" Colleen's experience and Tami's impact was so life-changing that Colleen felt inclined to give back. With Tami being a Professor for the CU Physical Therapy Program, Colleen felt the best way to honor her was to support funding for student scholarships. Colleen initiated a fundraising campaign for the Physical Therapy Student Scholarship Endowment, supporting future leaders in physical therapy. "I not only personally donated, but I've run multiple online auctions where I have sold sports and music memorabilia," she said. Colleen is not only motivated to improve herself and her quality of life, but ensuring the availability of funds to help the next generation of physical therapists impact their own patients. CU Program Director Margaret Schenkman, PT, PhD, FAPTA has led the charge behind student scholarships since the inception of the CU PT Scholarship & Endowment Board in 2012. Colleen noted, "Margaret supported my efforts to give back and help the students. She reached out to me with so much kindness." "I know that my efforts will impact a student's life just like Dr. Struessel has impacted mine," added Colleen. "She's far more than my physical therapist." Read the full transcript below: Karen Litzy: 00:01 Hi Tami and Colleen, welcome to the podcast. I'm so excited to have both of you on. As I said before we went on the air, this is a first time I've had a physical therapist and a patient on at the same time. So I'm excited for the listeners to learn from both of you. So welcome. Welcome to the podcast. All right, so Colleen, let's start with you. So, why did you seek out a physical therapist? Colleen Rapp: 00:32 Well I was working and I hurt my back and I went to a doctor and basically he had me go to physical therapy, which I had gone before maybe like a couple of weeks. So I wasn't really familiar with physical therapy, but I had hurt my back really bad. So I knew it was going to be a long road and I was kind of nervous at first. And so he recommended me to go to low high physical therapy. And that's where I met Tami. Karen Litzy: 01:02 And so I know you said you didn't know a lot about physical therapy, but once you were referred to physical therapy, did you look anything up? Did you have any expectations? Colleen Rapp: 01:13 I really didn't have many expectations because I'm working with a lot of people that have gotten hurt in my job, I'm a pressman of the Denver Post. It wasn't a very good report from the people because they just didn't get a lot out of it. So it was kinda like, oh, I'm going to physical therapy, what a drag. And that's kind of what I was looking at. So I didn't really know a lot about it, so I just kind of walked in there and had to go basically. Karen Litzy: 01:45 Okay. And so Tami, let's talk about kind of that first visit. Did you know any of this before Colleen came in to see you or did she say, Oh, I'm just here because the doctor told me to. Tami Struessel: 01:57 Well, this particular clinic, sees a fair number of people who are press operators at the Denver Post where where Colleen works. And, so I had seen, you know, a few people here and there. So I knew a little bit about the job. I knew it was a pretty physical job that they had a fairly high injury rate. I evaluated her and, you know, found out that she had had a long a history of being very healthy in her job until she hurt her back and that she was, you know, she was in a lot of pain and I'm having a really hard time getting back to work. And so that's where we started. Karen Litzy: 02:45 And it's kind of look at this as like a mini case study right now. Right. So Colleen she comes in with low back pain, injured at work calling. Were you unable to work at the time? Colleen Rapp: 03:01 Yes, I was taking off work. I could barely walk. So I was taking off work. I couldn't even go down to modified duty. I was at home. Karen Litzy: 03:10 Okay. So Tami kind of walk us through your evaluation, meaning when she came in, what kind of questions did you ask for this subjective? And then what did you look at for the objective part of the eval? Tami Struessel: 03:36 She'd had a long history of working in a very physical job and the vast majority of people that do the job or are men and that she had been very successful and really loved her job and worked hard at it and was very proud of it. And I think she's still very proud of it. Tami Struessel: 03:58 And I think I asked probably fairly typical questions about the mechanism of injury, how she was injured and you know, what kinds of, you know, what kinds of things she was not able to do and what kinds of things she could still do. And then did a full lumbar and hip examination, which I always do. You know, kind of head to toe but focused on those areas. Karen Litzy: 04:31 After that evaluation, Colleen, what did you feel after that first visit when you left? Did you feel like, oh I think I'm in good hands here? Or were you like, oh maybe this might work but I'm not sure. Colleen Rapp: 04:46 No, I definitely at first knew I was in good hands with the way Tami treated me when I came in. I think she knew I was a little nervous and so she kind of, you know, kind of joked with me and she kind of liked explained things to me and then she examined me. But through the examination it was very comfortable. So I was like, oh okay, this isn't so bad. You know, you have to feel comfortable at first and get that report and then you're just not like shaking going, oh my gosh, where am I at? And so I think after like 20 minutes of that and just talking to her, cause the first session was an hour and after her examination she sat with me for about like 10 minutes and explained everything to me about, not exactly what was wrong with me because she doesn't really believe in that she believes in, you know, the fact that I need to know to listen and not concentrate on that. So she kind of just explained to me about, that we were going to work together. I was going to see her twice a week in that we were just going to get me better and get me stronger and made me feel really comfortable. And that was the first step of like just being a good experience. Karen Litzy: 06:03 And you know, before we went on the air, I've talked about this idea of a therapeutic relationship. And I think Colleen, you just really described a really great first step in achieving a therapeutic relationship. So Tami, did you have a sense when Colleen left that A she is going to be coming back and B she was probably going to be pretty invested in this. Tami Struessel: 06:36 I mean, I guess there's always a possibility that you don't connect with people and that they, you know, they choose not to come back. But I didn't get that sense from her. I think, from the very beginning she was very interested and I think because she does like her job a lot and, really wanted to get back to it. Just in general she was invested and I think one of the things she talked about is, as most people do, to know the thing that was wrong with her back. And I'm pretty averse to the, you know, biological approach model and explaining all of the anatomy and everything. Tami Struessel: 07:27 Because I've been doing this now for 28 years, so, I used to do a lot of that. And I realize now that that's just not healthy. And she, she actually, you know, she embraced that. And she already said that that clearly is kind of a core principle for me that, you know, I'm not gonna, I'm not gonna, you know, get that model out and say, here's the thing that's wrong with your back. And, you know, unfortunately sometimes, you know, depending on who she's talked to, whether that's coworkers or that's the nurse at work or that's one of the workers comp physicians or something like that. I think she got a little bit of that. And I tried to divert away from that mindset and that she's really been very receptive. She doesn't ask me very much anymore exactly what you know about my disk or about my, you know, I mean, we talked a little bit about your SI joint but we try not to focus too much on it. Karen Litzy: 08:32 Right. And so Colleen from a patient standpoint, what Tami was saying, is it just for your clarity, so a lot in the physical therapy world, we used to rely on the sort of biomedical model where you know there is an issue with the tissue A plus B equals C. So this hurts and this tissue is quote damaged. This is why you have pain. Now pain, we know is much more complex and we use what's called a bio psycho social model of care, which is, yes there is the bio part is still in there, but we also want to take into consideration that there are psychological aspects to pain and social aspects to pain. So Colleen, my question for you is, did you feel like not focusing solely on the biomedical part of it or just on the tissue part of it was helpful for you in your recovery? Colleen Rapp: 09:34 Yes, because it made me realize that I needed to just work and get better instead of like, oh, this is what happened to me, this is what I have and if I knew, I think I probably would have been scared, you know, or like, Oh, poor me or this or that. And I didn't want to get into that, that view point. I wanted to kind of just say, okay, all right, I got somebody that just basically let's do this. Let's get working, let's get me back to work. I'll work with you. You work with me, I'll teach you things and do the best for me. And I needed to listen and I needed to do those things. And that attitude gave me the will to do that and not focus on the other stuff. And that helped. It really did. If you get your mind focusing on what is wrong it doesn't really help. You got to kind of move on and try to do the things you need to do to get better. Karen Litzy: 10:32 Yeah. I think that's great advice for anyone. Instead of dwelling on what's wrong, let's start dwelling on what's right and what you can do to improve your function and to improve your life. Two very, very different ways of looking at things. And from a patient standpoint. I think that's great to hear. Now, Tami, you were saying before we went on that, okay, the back thing was a couple of years ago, but then there were also some other things. So Colleen is a bit of a repeat offender, no offense Colleen. But again, I think that shows the strength of the relationship. And now I don't know what the laws are in Colorado, but do you have direct access there? Tami Struessel: Yeah, we have a 100% direct access. Karen Litzy: Lucky. So, Colleen, when you were injured, let's say subsequently after the back, you had gone to see Tami for other things. Did you know just to go straight to her or do you still have to go through a system? Colleen Rapp: 11:32 When I went I hurt my shoulder, I basically asked my doctor if I could see her and I told my doctor that I was comfortable with her and the success that I had with her, with my serious back injury and that I really felt comfortable with her and he was okay with that. Tami Struessel: 11:54 These were work related injuries. So there's always going be a claims process and a physician, now take a little bit of a step back after we finished treatment related to her back. We did do some training sessions to really get her beyond, you know, kind of basic back to work and those kinds of things and work a lot on fitness and exercise and those kinds of things, which was fairly new for her. I mean, not that she didn't exercise before, but I think she can probably talk about like what her fitness routine was like. Colleen Rapp: 12:43 Okay. So I think that the most important thing that we're kidding here and I have to kind of come on and for 33 years I worked at the post and I'd never really had an injury and like little things until like five years ago when I hurt my back and that it just seemed like, the last few years with the, you know, staff decrease in everything, we might work a little bit harder or faster and stuff. And I think things have gotten a little bit to where I had had like three injuries and so that's really cool cause Tami actually working with her has reminded me to always make sure that I work smarter than harder and got me back to where no matter what my position is, my work or my life or anything, I always have to be smart and I always have to take care of myself first and you know, be careful what I do and think about what I do. Cause it's the job I do is very dangerous and it is really scary. And, this whole PT thing is really important because it did change everything that I do at my job and it has made it so much safer for me. Karen Litzy: 14:04 So Colleen, I'm going to ask out of pure ignorance here, what exactly does your job entail? Colleen Rapp: 14:21 I actually worked on a five story press. Like on TV where the paper's coming on a conveyor and yeah that's what I worked on. They're a little bit more fancier but they're a little bit bigger. Now there are about five stories high. They're really long. I'm really not sure how long they are, but I do like 600 steps a day. I lift 50 pounds, I push a 1500 pound rolls. I do a lot of climbing. I do a lot of everything. It's eight hours, 10 hours, sometimes 12 hours of just physical work. Karen Litzy: 14:56 Okay. Wow. So that's a lot. So now Tami, as Colleen is coming to you for various injuries. You obviously have this in mind. So my question for you, and this might be some good advice for other physical therapists who might be listening, is how did you take into account her job and the requirements of her job when it came to exercise prescription and things like that. And then, and now I understand why you moved onto the fitness part of things because you know, you hear a lot like, well, insurance cut me off so all we could do or just these little exercises or I only saw the patient for six weeks when in reality, we know they need a lot more to stay healthy and to not reinjure themselves. So what advice would you have for therapists who need to take into account the person's very physical job? Tami Struessel: 16:02 Yeah, so I think there's probably two components of that. So, one is definitely, the work itself and, you know, if I was having her do basic, you know, transverse abdominal contractions and, and those kinds of things, it was just never going to be, you know, to a point where she was able to, you know, get strong enough to actually physically do her job before. And I knew she was able to do it before so she would be able to. So there was definitely, I believe in Colleen could tell you this. I believe in hard exercise. I think sometimes we don't push people enough and some of it does have to do with, there's times where we have a very short, you know, we see somebody for three weeks and, you know, how much can you do from a fitness standpoint. Tami Struessel: 16:55 But we were lucky. We got to see Colleen for longer. And so I had her work hard, as far as kind of general exercise and fitness and getting stronger. There was a time in my career where I would go out and visit the patient and see what their job was and those days are mostly gone, honestly. We get video, you know, off of people's phones. And so I had a pretty good idea of what the work was. But, several times Colleen, brought in, you know, we've talked about it and she's brought in video of, you know, the types of work that she needs to do. And then we would go through things like, you know, so what of your job duties do you think is the hardest or most trickiest? Because she would have to get into like, you know, awkward positions or I think I remember trying to work with her on like what her foot position was or something. She's like, you realize I'm standing on this little bitty platform that I can't really move off of. And I was like, oh, well maybe we need to re rethink that. So I don't know if Colleen you want to talk more about that asset Colleen Rapp: 18:10 There's sometimes where like I'm standing on a platform and there's like a drop on either side of me and I have to reach up and lift up probably about a 45 pounds piece of press. It's called a bar and turn it around and position it in a different way without falling. And it's really crazy because on this precept, the press, there's an air connection to it. So once you take it off where it goes, it pulls you back. And so you have to be pretty strong and you have to be pretty smart or you know, you're in trouble. You can drop it, break your toe or something. So I think we worked on that and that was the most important thing that I think while we're on the subject is the greatest thing about Tami was, is that she saw that I needed to stay strong. When you injure yourself, I think that you have to learn that it's not over. Colleen Rapp: 19:11 As soon as you walk out at therapy, you have to stay strong. You have to keep on doing your job and you have to do the things that are going to make you able to do that and not keep getting hurt. So would this keep working together? I learned all kinds of stuff. I learned how to, you know, just talking with her, she would say, well, can't you move the press down a little bit so you're not, your arms aren't up so high or can you just position yourself or can you not twist? Then, it just all made sense to me and I always say that you can walk up some stairs and you come up really fast. This for example, but if you walk up the stairs right, sounds weird. But if you walk them up right, you can do a whole bunch of them and you're not hurting yourself. But if you don't do things right, the repetition does wear on you. So my period of time with Tami and learning all these things and doing the things that I needed to learn just totally, it was life changing for me. Karen Litzy: 20:12 That's amazing. Tami what a great job. And if I can go back to kind of just reiterate what you had said before. So when you're working with someone who may be has a complicated job situation, not everyone sits at a desk for, you know, eight to 10 hours a day. Not everyone does that. I love the advice of asking the patients to take video of what they need to do. And then the question that you asked, well what are the things that you know are most problematic for you? What are the trickiest things you need to do at your job? Because if you can get the things that are the hardest things to do, I would imagine that working on those and getting some confidence and to be able to do those really difficult parts of the job, then you can get down to like some of the easier work after. Tami Struessel: 21:04 Definitely. Yeah. I mean, and some things are not modifiable. I mean, when you're a large piece of equipment. But what I found with Colleen is she was so familiar with the job and what she had to do that, you know, both we could work together to find alternative ways or alternative positions. I'm like, is there any way you could step up or, you know, do something so that you're not reaching so high or, you know, whatever. And many times she was like, Oh, actually, I've never really thought about doing it that way. I'll try. And, often she was successful with that. And the other aspect was that she had such seniority that she is able to, she has such seniority that she's able to bid on shifts that are a little bit healthier for her in general now. We can talk about things like sleep and diet and stress reduction and weight loss and all these things are a result of her really embracing the idea of, you know, she wanted to continue to work. She knew that she wasn't probably going to be able to, if she didn't really change her lifestyle. And to her credit, she absolutely did. And I repeatedly tell her she's the one that put in the hard work cause I can do all of these same things with somebody else and if they don't take it seriously and they don't really embrace it, then it doesn't matter. Colleen Rapp: 22:42 I think that that's the greatest thing about this is Tami taught me it's not the exercise it's eating well, nutrition, losing weight, sleeping good, using your environment. I was hiking today and I was thinking about, you know, about what the most important thing about, you know, physical therapy and everything was, and I always think that some people that are really working out and stuff, they have to use weights and they have to do things and they think they're so strong and they still do things wrong. And I was hiking and I was like, I use my environment to make myself better every day because of Tami care. By the way, I walked, at work, the way I move and the way I eat, the way I sleep, the way I think because actually, injuries and especially a couple injuries, you know, I just got out of one injury and got hurt again and that was totally mentally hard on me and all this connects to the patient and that's what a patient goes through. Colleen Rapp: 23:58 So when you can correlate all this in your life as a whole body and like Tami teaches, it's amazing. It is. I truly believe that physical therapy is the most important thing between the point of injury and health. And if you keep on going, I'm going to be walking when I'm 62 and I want to be doing a whole bunch of things and it has just changed my life. Karen Litzy: 24:23 I think this is such a great example, Tami, of being a physical therapist, treating at the top of your license and really, really incorporating lifestyle change into your practice. You know, it sounds to me like you're more than I see someone for a bout a therapy they're discharged, Versus giving them a lot of skills and tools to not just take care of that bum knee or the painful shoulder, low back pain, but rather let's look at this person as a whole. Let's take a holistic view of this person. So you know, you said you've been Karen Litzy: 25:23 practicing for 28 years. I've been practicing for like 20, so I can certainly attest that my views have completely changed from when I first started. So I'm not going to assume that yours have or haven't, but if they have changed, where was it in your career where you feel like you had a major shift? Like I can say I know exactly when I had sort of this major shift in treatment paradigm. Did you have that major shift or was it just as more research came out, you just started incorporating all of this? Or were you doing it from the beginning. Tami Struessel: 26:03 I would say that I don't know that I had a shift. I'm fortunate enough to teach at the University of Colorado and so I'm around really smart people all the time and I don't want to minimize how that is so important including people that practice in all different areas. And so I've learned a lot from, you know, from our neuro folks, from our cardiopulm folks, from other, you know, musculoskeletal people. I guess, you know, there was a shift at some point, and I don't even remember, I think I might've gone to a course where the emphasis is like, you know, your orthopedic people have neurological systems. I would say that's probably, if I had to have a point of shifting that was like, oh, of course, you know, if I'm not addressing that, then, you know, then I'm missing the boat. Tami Struessel: 27:06 That was a while ago. But, I would say from a language standpoint, you know, therapeutic neuroscience education and motivational interviewing and some of the things that, you know, I think probably took the first of those about maybe four or five years ago. So, I was never a big, well, I can't say never, but I think I figured out that, you know, just pulling out the spine model and scaring people to death was probably not a good idea a long time ago. But I do think that that, you know, I think we all have learned that probably some of the language that we use is not helpful. I don't know if I had a Aha moment or it's just, I think I've always been very open and from my first outpatient job, I remember I did inpatient for a couple of years and then, I worked at a clinic where the people had continuing education lists that were just enormous and that had a big impact on me. I specifically remember thinking, you know, wow, these people really are invested in learning and learning from each other as well. I think that was instilled in me very, very early in my career and it's continued with me. I have a pretty long continuing education list because I've, you know, been able to glean something from every single thing that I've gone to. Karen Litzy: 28:40 Yeah. That's amazing. And Colleen, as the patient, do you get a sense of that, this sort of lifelong learner in Tami? Colleen Rapp: Oh, yeah. I think Tami inspires me. I mean, I kind of look at her like, who else could you be in your profession? I meen, you teach, you practice, you govern, you everything, you know, I mean it's so inspirational. I have to tell you one thing that she did for me that was kind of relative for this. Not only did she teach me about my health and help me see my things, I kind of like, I'm in a world where the press room so I'm not like very, I'm educated, I'm smart, but I'm smart and the things that I know, and she introduced me to classes online where I could learn about anatomy. And so I took them and it was amazing. She taught me how to be a better person in a whole bunch of ways and being able to go into a doctor's office and know what my quads were and kind of explain things a little bit more and understand what we were doing and what was firing and actually all the way around. It's really incredible. So yeah, I think very highly of her. I think that she totally is a true inspiration. And a gift for her profession. Karen Litzy: 30:12 Sounds that way to me. That's for sure. And it also sounds that, you know, from the patient's standpoint, and I think this is so important, it's something that we hear so much about is that through education she was able to empower you to take control of your own health. You were partners in your care versus her just telling you what to do. And you did it without knowing why or what behind it. And, like you said, really inspired you to reach for more. And if every physical therapist can do that with every patient, then I think that would be such a boon to the profession. Colleen Rapp: 30:52 Oh, definitely. It would, it would kind of, yeah. I mean, you guys, you guys are really important and you guys change lives, but you know, it's hard because not everybody's accessible to that. So, but in this story, I was and it's changed me. I've lost like I think, tell me what, like 35-40 pounds and I exercise like, yeah, like three or four times a week. And I'm just overall a better person. And, it's just a wonderful thing. I'm very, and as, you know, it's in me now and it's not just physical therapy. It's life. It brought life back in me. I can say it that way. Tami Struessel: 31:44 You already said, well, you know, I was hiking today and, you know, I mean we're fortunate enough to live in one of the most beautiful places on earth. Colleen has taken full advantage of that. You know, I think there was a time where she would come home from work and was tired and he wouldn't do a whole lot. And now she's really, she's really a drank the Koolaid of being an active person. I think she exercises, but she's also just a more active person in general and thinks about activity and exercise differently. And, she embraces that and embraces making some lifestyle changes that has made all the difference. Karen Litzy: 32:36 And you know, before we kind of wrap up here, I just have one more question for each of you. They're going to be slightly different, but Colleen, I'll start with you and you've kind of, I think might've already answered this question sort of throughout, but as a patient, how has physical therapy changed your life? And part two of that, what advice would you give to someone who's on the fence about physical therapy? Colleen Rapp: 33:10 I think physical therapy changed my life because I've learned that the most important thing is mobility and stability and so movement. I was always thought that to be a strong person, I had to go out and, you know, get a trainer and do 50 pushups and 30 squats and walk home, couldn't breathe, you know, and what I learned through physical therapy is that the exercises that you get are, are really important to learn how to balance. The simplest things can impact you in a certain way. And the other thing is that I had to embrace it because if I embraced it and learned how to do the things Tami taught me, not on any of the exercises, but if my leg hurt and how to take my leg, or I said, or something I could achieve to be better and to stay better and not be a person that was going to a year from now say, oh my shoulder still hurts or my back still hurts. Colleen Rapp: 34:20 And that's what I worked every day for is finally instead of, you know, I finally found something that like physical therapy that just had an impact to me. And it's very important and it's very important if you do those things, you'll be successful. And that's the way I believe. I think that to tell somebody is to give it a chance. Because I work with so many people that don't, they automatically say, I want to have surgery, I don't want to go to physical therapy. And, I think you get into that stuff where they just assume that it's a waste of time. But I think if you would just give it a chance and just see and, and give it, you know, give it a try and listen, I think you'll learn that it's gonna Change Your Life. Like it did mine. Karen Litzy: 35:11 Incredible. And Tami, this is a question that I ask a lot of my physical therapy colleagues that come on the program and that's given what you know now where you are in your life and your career, what advice would you give to yourself as a new Grad right out of PT School? Tami Struessel: 35:38 Wow. That seems like a long time ago. You know what I think, it might be similar and actually I give this advice to my new grads that I teach. And that is that first of all that your first job or two is so formative and so select wisely, you know, look for places where you have a sense that the culture is good, that there is a lifelong learning mindset. I want to be sure that my patients that have come to see me, if I'm on vacation for a week, then they can go to somebody else and I know that they're going to get really good care. And then just that lifelong learning for yourself. You know, if you get stagnant and, you know, kind of bored, maybe you need to kind of figure out what you might be able to do to kind of spark that again. Tami Struessel: 36:45 There was a time where I decided that I wanted to pursue teaching and I really sought out that opportunity and that's been extremely enriching for me as well. So I'm really fortunate there, but I also don't want to, you know, teach and not treat patients. As long as my body can hold up. I want to, I want to keep doing that because it gives me all kinds of great stories for a class. And it's also fun. I think I was born to be a physical therapist, so, I know I made the right choice a long time ago and it still is really a terrific profession. Karen Litzy: 37:32 Amazing. And Colleen, can you tell us a little bit more about your student scholarship fund and what you have coming up? Colleen Rapp: Well, Tami changed my life so much that I wanted to do something in return. And so I found out this scholarship fund at her school didn't get a lot of funding, so I worked like a year and sold, sports memorabilia and I basically sold concert tickets and all kinds of stuff and I put all the proceeds for a year to the fund. And so the year was up and I kind of wanted to do something. I was like, well, this was really good. I want to do something like really crazy fun, you know, go out with, you know, happy, you know. So I decided to arrange a concert on September 5th, and it's going to have a pretty good artist in Denver. Her name is Hazel Miller and all the proceeds will go to the scholarship fund. They will be donated. So I'm kind of excited about it. Karen Litzy: 38:37 That's incredible. And what a great way to kind of pay it forward. And then just to be clear, this is a scholarship fund at the University of Colorado. Tami Struessel: 38:48 The doctor physical therapy, specific student scholarship fund. Karen Litzy: 38:54 Awesome. Well, I mean, Colleen, what a great way to give back to the profession and to the future of the profession. So, and I'm sure those at the University of Colorado are very thankful for all of your help and enthusiasm in getting the word out about physical therapy. I know. I am. So Colleen, thank you for coming on and sharing your story. And Tami, thank you for coming on and sharing your story. In the way that you've worked with Colleen, and I think that you're giving a lot of therapists, especially newer grads or students, a nice glimpse into really how we can move beyond just take an injury and rehab it to take an injury and change a lifestyle. Tami Struessel: 39:42 Yeah. Thank you so much, Karen. That's what I'm practicing at the top of your license, as you said before, you know that's where you can really feel good every day about inspiring people and getting people to make lifestyle changes, like Colleen made, so that they can be a better, stronger, more resilient person. That's what it's all about. Karen Litzy: 40:08 Amazing. Well, thank you both ladies, for coming onto the podcast today and to everyone listening, thank you 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!

LIVE on the Sport Physiotherapy Canada Facebook Page, I welcome Dr. Lars Engebretsen on the show to preview his lecture for the Third World Congress of Sports Physical Therapy in Vancouver, Canada. Lars Engebretsen is a professor and consultant at the Orthopedic Clinic, University of Oslo Medical School and professor and co-chair of the Oslo Sports Trauma Research Center. In this episode, we discuss: -Dr. Engebretsen's career shift from being reactive to proactive in injury treatment -The importance of a team approach for injury prevention in sport -Programs that focus on translating injury prevention research to coaches and trainers -How to develop your research portfolio -What Dr. Engebretsen is looking forward to at the Third World Congress of Sports Physical Therapy -And so much more! Resources: Third World Congress of Sports Physical Therapy Oslo Sports Trauma Research Center Lars Engebretsen Twitter For more information on Lars: Dr. Lars Engebretsen is a professor and consultant at the Orthopedic Clinic, University of Oslo Medical School and professor and co-chair of the Oslo Sports Trauma Research Center. He is also a consultant and former Chief Doctor for the Norwegian Federation of Sports, and headed the medical service at the Norwegian Olympic Center until the autumn of 2011. In 2007 he was appointed Head of Science and Research for the International Olympic Comittee (IOC). Lars Engebretsen is a specialist in Orthopaedic and general surgery and authorized as Sports Medicine Physician (Idrettslege NIMF) by the Norwegian Society of Sports Medicine. He serves as chief team physician for the Norwegian Olympic teams. The main area of research is resurfacing techniques of cartilage injuries, combined and complex knee ligament injuries and prevention techniques of sports injuries. He is currently the President of ESSKA (European Society of Sports Traumatology, Knee Surgery and Arthroscopy). He is the Associate editor and Editor in chief for the new IOC-BJSM journal: Injury Prevention and Health Protection. In addition, he serves on several major sports journal editorial boards and has published more than 200 papers and book chapters. Read the full transcript below: Karen Litzy: 00:01 Hey everybody, welcome. Happy Saturday to everyone. For those of you who are on the Facebook page right now, welcome. I'm just going to check and make sure it's on. Yes. So we are live, which is awesome. As you know, we've been doing live interviews with speakers from the Third World Congress of sports physical therapy. And for those of you who, if you're on this page, I hope you know when it's going to be, but it's October 4th and fifth in Vancouver, Canada. And today I have the distinct pleasure and honor to be talking with Professor Lars Engebresten. So, professor, welcome. Thank you so much. And as we said before, I've been practicing that name for at least a week, so. All right. Chris Napier, welcome. We said welcome, to you, thanks Chris for being on. It's a little bit early. They're over in Vancouver. So professor, before we get started, can you please tell the audience and tell us a little bit more about you, your career trajectory, and what you're up to? Lars Engebresten: 01:17 Yeah, I'm a professor at the University of Oslo Department of Orthopedic Surgery. And then I work, at the Olympic Center of Norway getting gold medals for Norway. And then I do work at the Olso sport Trauma Research Center, which I run together with Rollbar. And then I am a professor at the medical school and I work every other week for a couple of days in the Olympic national committee. So I have a very good combination or clinical practice. I still operate and I see patients quite a bit every week and research. I have many PhDs working on projects that I would say coordinated by myself. Karen Litzy: 02:02 That's an amazing amount of work to do. It's like five jobs all rolled into one and I'm sure, although this is not what we're going to be talking about today, but maybe another time we'll have you talk about your time management skills. I mean, how you get all of that done because that's an amazing amount of work to fit in. But let's dive right into, since you just mentioned that you're still doing clinical work and research, so how being that clinician scientist, how important is that to merge your clinical work with your research work? Lars Engebresten: 02:38 Well, you know, I think I found out very early in my career in orthopedics how important researchers, I was actually, you could tell this story I was doing in clinic as a resident, up in Trondheim where I did my residency and next door to me was one of the professors. And I had many patients with anterior knee pain. And I would ask him, what do you actually do with those patients? Cause they now see him a little bit strange now on them and then suddenly I operate and all that. So I said, yeah, what kind of operation do you actually do? And then it sounded, you see, I do a Mickey operation, like, elevating the tibial tubercle to reduce the load on the Patella site. And I said, oh, that's strange. How are they doing? And he said, oh, they all do very well. Lars Engebresten: 03:35 And then I actually looked up 50 of those patients. I am in the hospital and then sure enough about one third did pretty well. One third was about the same and one third was much worse. Then I realized, you know, you can't really trust the old professors. You have to in the areas where there are some doubts here and there and what to do, you have to do research in those areas there. There's no way you can be a clinician in your university clinic without, doing that kind of research. So since that time, which was a long, long time ago, I've actually been doing all kinds. So both clinical and basic science research Karen Litzy: 04:18 How does one inform the other? So how does clinical inform research and research informed clinical for you? Lars Engebresten: 04:28 Well, for me it's been like a, you know, I see patients, I follow a various teams. I'd done all kinds of soccer teams, handball teams, ice hockey teams and so forth. I see the issues, what kind of problems do patients have. And I see what we have to, give them in the form of various therapies or various surgeries. And I realized that we aren't really perfect. That there is a lot of research that remains to be done actually. So that's a general in general speaking the way, I've found out that this is something I have to do. And, when I was young I was doing all kinds of sports myself. And I also realized that, you know, when you got the injured really, we really didn't have that much of a argument for getting people back. And that was a long, long time ago. And now we're better, we aren't getting better, but, we still have a way to go. So the last, I would say, 30 years I've been working on the three different research areas. So I've been working on a cartilage issues, a ligament issues, and then later on the prevention of injuries issues. Karen Litzy: 05:48 And you know, since you mentioned the injury prevention issues, let's dive right into that now. So, you've been involved in conducting a number of studies regarding, sports injury prevention. So what would you say are some of the common misconceptions around injury prevention? Lars Engebresten: 06:10 Right. It's very difficult to get people really interested in that area because, you know, it doesn't really pay much on an individual basis. It does pay back to society because you get less injuries by doing it, but to the individual doctor or Physio, it is a difficult because of the payment schedule in these cases. In my case it was actually more specific at what made me change my attitude to this. So I was doing, all kinds of basic science and also can you go studies in the ligaments and tendons and then, you'll see them and they are very good. They were supposed to win the gold medal. Actually in Sydney. The star player had an ACL eight months at a time. And, which was a major issue of course. Lars Engebresten: 07:17 And we operated on her and the most successful and she came back, Nora did not win the gold medal. Olympian bronze medal and she didn't really perform the way she was supposed to. And I realized then actually, that, you know, what we were doing was not really that great. I realized that she was on track for getting osteoarthritis pretty early after the surgery. And I realized, Oh, all my efforts in the, you know, ligament, design and, new ways of doing the surgery and stuff wasn't that great because I thought, you know, I should spend more time on how can I prevent these types of injuries at the same time as I treat them later on. But I kind of refocused towards prevention all these injuries after that incident. Karen Litzy: 08:25 So getting back to this injury prevention, so based on our current knowledge of injury prevention in sports, what would be your recommendation or go to strategy intervention for injury prevention? So for example, is it exercise? Is it load management? Is it education? Lars Engebresten: 09:05 The most important thing is to look upon this as a team effort. There's no way you as one person, I would be able to make a huge difference in this area because prevention is all the aspects that you mentioned. And therefore, you know, in our case, you know, also sports trauma research center, we are a quite a few people working in this field and there's no way that not one of us could make a big difference. Yeah. It's all about the team effort. Because you have to do research, just figure out whether your program is working. Secondly, you have to make people do it. And third, you have to look at results of it. And that really demands a manpower, budgets, long term studies in this area. Lars Engebresten: 10:13 We've done a lot on randomized control studies showing the effect of these programs, but we still don't have perfect compliance, you know. What we have found out lately is that, we are changing our approach and it can be towards instead of travel around I get a mixture of some of this to athletes and stuff. We actually tried to teach the coaches in Norway anyway. The coach educational programs are now filming this prevention programs we have. So it's all about, I think parents and coaches, then the doctor or the physio doing it. So we have to be able to relate all the knowledge we have and to be able to implement it. And that is the biggest challenge at the moment. Karen Litzy: 11:17 Yeah, that makes a lot of sense. Changing people's behaviors is not easy. Lars Engebresten: 11:25 It's not, but you know, at least where I live and I'm sure also in the US, we have been able to stop people from smoking. Very, very few smokers left here. So we should be able to, you know, instigate the system where, if you are young and you're doing a sport, part of your sport is the prevention part. Karen Litzy: 11:50 Yeah. And, and I think that that's great example that yes. Smoking, when I first moved to New York City, so many people smoke. Now it's a rarity mainly because of good outreach campaigns, via media and things like that. And sometimes they think that's where, injury prevention and sports injury prevention is just not getting its fair air time, I guess. Right. So when you look at mainstream media and news and things like that, they focus on the injury. So the professional player who gets injured or the collegiate player that gets injured, this is the injury. This is the surgery versus look at all the people who haven't gotten injured and why is that? Lars Engebresten: 12:33 Hmm. Yeah. You know, there are some good examples. For example, hamstring injuries, we have a pretty good way of reducing and reducing those by maybe as much as 75%. And even in the premier league in England, the best, very best teams, you don't really do those exercises. And it's really, really crazy cause the number one injury, keeping people out of premier league soccer is actually hamstrings, it's a very strange thing that I've not able to, and I think that's all about, you know, the coaches being involved and understanding how important is this. Karen Litzy: 13:15 Yeah. And are you doing things in Norway? I know you said that now you're getting more coaches to come to lectures and things like that. So if there are people listening from other parts of the world, what sort of system are you using to get those coaches in? Lars Engebresten: 13:32 Well, there, you know, almost every country has some sort of cultures of education and it's like level one, two and three and so forth. And, now we have introduced international programs, you know, all those levels. That's part of some sort of daily education is about prevention. And I think that's I must add a key in this area. We have shown that we are able to reduce the number of serious knee injuries for example by more than 50% in some sports that are really prone to those type of injuries. Team handball is a very good example. Basketball could be another one. So I think that education day is very, very important. But as I said, we are trying out new ways of getting compliance improved cause that's still an issue. Karen Litzy: 14:30 You can have a great injury prevention program but if nobody does it. Lars Engebresten: 14:36 Hmm. I know, you know what we are trying to do is to teach the parents. If you have a daughter, 12, 13, and 14 year old and if she plays soccer or team handball, the chance of having a serious knee injuries are very high and you can really take out insurance by doing a these kinds of exercises at the same time that you are training. So maybe spend 10, 15 minutes, three times a week on this that would be able to reduce the percentage risk for having an injury like that. Karen Litzy: 15:13 Yeah, I mean from the standpoint of the clinician and the researcher just makes so much sense. We just have to get the coaches and the players and the parents and team organizations in schools and things like that on board. And I would assume that takes time and some effort and the incentives. Lars Engebresten: 15:35 I think that in the US you have all the sports in schools, right? Whereas in the rest of the world, for the most part the sports are outside schools and community teams and stuff like that where it is a little bit more difficult to get this through. So there should be good chances in the US and Canada as well. Karen Litzy: 16:01 Alright, well hopefully people listening to this will kind of take this to heart and go to their local high schools and middle schools and try and educate those coaches and parents. All right. Now you already touched upon this I think a particular patient case that you personally treated that caused you to reevaluate your whole treatment paradigms. And I feel like you touched upon that a little bit already. Do you want to expand on that at all? Lars Engebresten: 16:31 Yeah, in a sense that, for me personally, it really changed me from, you know, doing surgery four times a week, four days a week, to spending more work in the research lab, trying to design exercises to help in preventing these kind of injuries. We have done a lot of work on looking at why are they happening and how are they happening. And our team here in Oslo has relatively good knowledge in this area and that has helped us in designing programs. It's taken a long time and takes your way from the OR and into a different environment and that has really put the major change in my medical activities. Karen Litzy: 17:24 And are you happy with that change? Lars Engebresten: 17:30 I am, I'm going to a meeting, for example now in a couple of weeks and I'm preparing for it in Pittsburgh on the ACL, various kinds of injuries. And that just tells you here all these, experts from around the world. They still attending as still the same question comes up. And again, there hasn't been a huge development, I would say, when it comes to serious knee injuries in the results of the treatment we have. So there, you know, the area that I'm interested in, this prevention area probably have still a lot to contribute to the field because you would, the surgeons haven't really caught on, at least not on the measure where of them. I would say in this, even though if you guys have done it, the physios have done it. The big story is still lagging behind a little bit. Karen Litzy: 18:36 Yeah. And it's to me, what it sounds like I'm hearing from you, is it sort of forces you to be instead of a reactive doctor, a more proactive physician. Lars Engebresten: 18:47 Absolutely. That's a good point. That's a difficult change. Karen Litzy: 18:54 Yeah. Especially because you had a lot of training, but it's still, I mean, it's still all medicine and in the end it's helping the patient, which is the most important thing. That's why we do what we do. Right. As we said in the beginning, you're also a researcher. You have an impressive publication record, hundreds of peer reviewed articles. So if you kind of take a look back at all of those articles that you published, which one of your research projects or papers is most meaningful to you? So maybe it doesn't have the highest altmetrics score, but which one to you is like most meaningful? Lars Engebresten: 19:40 For me that's very difficult to say actually because you know, not because I have some many, but more so because I have various fields and I've been very heavily involved in, there were some really important ones in a mechanism and I was working in the lab and then taken lab or to the OR. But I think that, overall the most important one is probably the one we did on, prevention of ACL injuries and team handball and follow, this for 10 years. I mean, you could see, you know, when we went in there actively and we were able to reduce number injuries and then we kind of stepped out and let the players do themselves, ramp back up, all the injuries. And then we really, reinforced our efforts and all of a sudden we were able to really reduced the number of injuries again and just shows us that if you really, put your mind to it, you can really achieve something. So that's probably the most important paper to come up with. Then again, you know, this is all about a team, a group, a team thing. It's not something I've done myself. Yeah. I've been part of the whole team, so really that's probably the most important. Karen Litzy: 21:00 Nice. And then what advice would you have for young researchers who are trying to develop their publication portfolio? Lars Engebresten: 21:10 Yeah, I keep telling my coworkers in the hospital, that's not the university that although it is great to have patients and to treat them and see that they're doing fine. Still if you've been doing that for 10 years, you kind of get bored after a while if you don't really progress and develop yourself. So you have to be able to do some sort of research during your clinical work as well. I'm really trying to tell them some examples here and there, why I did this and that. And then it is absolutely possible to combine a missing clinical practice with some sort of research at least if you're able to work as a team. So you still as you know, have other orthopedic surgeons or in my case physios and trainers that you work with, which will enable you to do much more then you can do only by yourself. I think their whole, the most important advice is to, you know, if you look at your 10 last patients and you see and you really look, take a close look at them, then you realize that, you know, there are many things you don't really know. So there many things that needs to be researched. I had one young person come up to me a while ago saying that he was discouraged because there's nothing more left to research. That's all wrong. Karen Litzy: 22:51 Yeah, everything's been done? Lars Engebresten: 22:54 Everything has been done and you know, that is absolutely wrong there's so much left to do. So there's work for everyone. Karen Litzy: 23:07 Yeah, I would think there would be. And now let's talk about what you're going to be speaking about at the Third World Congress on Sports physical therapy. So can you give us a little sneak peek as to what you're going to be speaking about? Lars Engebresten: 23:20 Yeah, I see from the program that I'm going to talk about ACL or ligament injuries and a surgical treatment versus non surgical treatment. And that's something that we have been working on for awhile in Norway and also with other groups, where we have lots of research have been showing that in Norway we actually do about 50% of our ACL patients are having ACL surgery. The reason is that, you know, people that are not doing pivoting activities or pivoting sports they are completely able to continue what they're doing without having a reconstruction, things like that. The key there is of course, range of motion proprioception and strengths. And, if you are able to do that, then you can do well without having an ACL reconstruction. And even if you have an ACL reconstruction, if you don't do those kind of rehab are, you'll never be successful. That's probably what I would be talking about and some of the results we have from our area in the room. Karen Litzy: 24:39 Sounds great. I look forward to it. And I think it is amazing that it's only 50% of people in Norway. I feel like in the US it's much higher. You probably know the figures better than I do. But just from an anecdotal standpoint, it seems like the moment someone has an ACL tear, they're having surgery regardless. Lars Engebresten: 24:57 Yeah. I'll let you know. The point is nobody knows that in the US because you don't really, you know, how the numbers on people and not having a ACL injuries. It's very interesting because I been working with China actually on developing an ACL program for them. And you know, they have thousands of ACL injuries, but I have no clue on how many actually, because I think they have mostly injuries and China is not really being operated on, at least not until now. But you are right in your part of the world. If you have an ACL injury, you will be operated on automatically almost. And the same goes for central southern Europe. It's the same thing. And in Scandinavia, Sweden, Finland, Denmark, Norway. We're trending to operate only on the ones with the pivoting work and the rest we don't do so in Norway we have about 4,000 ACLs a year. You know, 2000 see surgery. Karen Litzy: 26:14 Right. We'll see what happens as time goes on and people start to realize that maybe there are some other options. But I'm definitely looking forward to that talk in Vancouver. And are there any talks that you're looking forward to or people that you're looking forward to seeing? Lars Engebresten: 26:32 Yeah, you know, I look forward to see some of the PT work on the new ways of getting people proprioceptively sound new ways, testing people for it, in sport, things like that. That is really something that interests me. Karen Litzy: 26:50 Well, I have to say, I want to thank you so much for taking time out today. Is there anything we didn't cover that you have like a burning desire to talk about before we end? Lars Engebresten: 27:00 No. I look forward to come to Vancouver. It's a wonderful city. I was there during the Olympic Games in Vancouver, and Whistler and also down in Vancouver and it was a beautiful area. Karen Litzy: 27:16 Yeah, me too. The only time I've been to Vancouver was when I went to whistler to ski. I was only in Vancouver for as long as it took me to get off the plane, get into a car and drive up to whistler. So I'm definitely looking forward to spending a little more time there. But thank you, professor so much for taking the time out and speaking to everyone and Chris and everyone else that's watching. And Mario gave a thumbs up. Mario Bozenie, thanks so much for tuning in and hopefully we will see you all in Vancouver October 4th and fifth so thanks so much. Lars Engebresten: 27:50 Thank you. Thanks for listening and subscribing to the podcast! 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On this episode of the Healthy Wealthy and Smart Podcast, Shannon Sepulveda guest hosts and interviews Tamara Rial on hypopressive exercise. Tamara Rial is the creator and co-founder of Low Pressure Fitness which is an exercise training program based on hypopressive, myofascial & neurodynamic techniques. In this episode, we discuss: -What are hypopressive exercises? -Patient populations that would benefit from hypopressive exercises -The latest research on the mechanisms and effects of hypopressive exercise -Common criticisms of hypopressive exercise -And so much more! Resources: Shannon Sepulveda Website Shannon Sepulveda Facebook Tamara Rial Website Herman and Wallace Website Pelvic Guru Website Tamara Rial Instagram Hypopressive Guru Instagram Email: rialtamara@gmail.com The Outcomes Summit:Use the discount code LITZY For more information on Tamara: Tamara Rial earned dual bachelor degrees in exercise science and physical education, a masters degree in exercise science and a doctorate with international distinction from the University of Vigo (Spain). Her dissertation focused on the effects of hypopressive exercise on women's health. She is also a certified specialist in special populations (CSPS). She is the creator and co-founder of Low Pressure Fitness which is an exercise training program based on hypopressive, myofascial & neurodynamic techniques. In 2016, this program was awarded the best exercise program by AGAXEDE, a leading sports management association in Galicia, Spain. Dr. Rial is the creative director and professional educator for Low Pressure Fitness. At present, over 2000 health and fitness professionals from around the world are certified Low Pressure Fitness trainers. Dr. Rial is a professor of pelvic floor rehabilitation in the masters Degree at Fundació Universitaria del Bages in Barcelona, Spain. She is the author of several scientific articles and books about hypopressive exercise. She has also published numerous articles and videos about pelvic floor fitness, hypopressive exercise and women's health. She is an internationally recognized speaker and has presented at conferences throughout Argentina, Canada, Mexico, Portugal and Spain. As an established researcher and practitioner, she continues to collaborate with colleagues at universities and health care settings to explore the effects of hypopressive exercise on health and wellbeing. She lives with her husband and two dogs in the United States and Spain. Dr. Rial is available for consulting, speaking and freelance writing in Spanish, Galician, English and Portugues. For more information on Shannon: Shannon Sepulveda, DPT, M.Ed., CSCS, WCS is the owner and Physical Therapist at Shannon Sepulveda, DPT, PLLC. She is an Orthopedic and Women's Health Physical Therapist and is currently the only Board-Certified Women's Health Physical Therapist (WCS) in Montana. Shannon received her undergraduate degree from Dartmouth College, Masters in Education from Harvard University (M.Ed.) and Doctorate of Physical Therapy (DPT) from the University of Montana. She is also a Certified Strength and Conditioning Specialist (CSCS). She has been a practicing Physical Therapist in Bozeman, Montana for over 6 years. In her free time, she enjoys running, biking, skiing, hunting and spending time with her husband, son and daughter. Read the full transcript below: Shannon Sepulveda: 00:00 Hello and welcome to the healthy wealthy and smart podcast. I'm your guest host Shannon Sepulveda and I am here with Tamara Rial. Hi Tamara. Can you tell us a bit about who you are and what you do? Tamara Rial: Well, we're going to introduce a little bit how we met because Shannon came to our hypopressive course that we hosted in Portland with Bobby Grew, right. So I like to call myself a hypopressive expert. I been studying and practicing and teaching this technique for over 10 years and I did my PhD based on hypopressive and its effect on urinary incontinence. And then I began teaching this technique to professionals as also to practitioners. And well, I happened to live in Spain also almost all my life and they do my work there. And also I have been a professor in the University of Vigo in Spain. Tamara Rial: 01:13 But two years ago I came to United States because I married my husband who happens to be American and we moved into New Jersey and that's where I currently live. Shannon Sepulveda: Well, can you tell us a bit about what hypopressives are and what low pressure fitness is because I would assume the majority of the audience has no idea what that is. I think some of us pelvic health PTs know and some other people in the world, but it's all the rage in Spain. So tell us about what it is. Tamara Rial: Yeah, I understand because there's this word hypopressive and some people kind of listen to this word for the first time. So if we look at the etymology of hyper pressure, really what it means, a hypo pressive, it's Hypo. Less pressure pressure of course. So it's an exercise that reduces pressure. Tamara Rial: 02:16 It's specifically a intraabdominal pressure intrabdominal pressure and intrathoracic pressure. So normally we call the hyper pressive exercise as a form of exercising with different postural cues and different poses throughout and a specific mechanism of breathing. And the general name of these exercises was named after that reduction in pressure that we have observed after doing these poses, combined with this specific hypopressive breathing technique. So yes, I know that sometimes it's quite hard to understand, but they name and especially in some countries are for those people who are not familiar with it pelvic PT area. But, it will be the name given to a form of exercise. Shannon Sepulveda: So can you talk a bit about what you mean by poses and then what you mean about the breathing technique? Tamara Rial: Well hypopressive exercises are also known as the hypopressive technique as I said, as a form of exercise that is mainly postural and breathing driven. Tamara Rial: 03:42 So I also like to say that it's a mind body kind of technique because it is based on low intensity poses that can resemble a little bit of the kind of poses we were doing pilates exercise or when in Yoga many yoga instructors will find that many of those poses and breathing techniques are very similar of the ones they also practice. So the postural technique of hypopressive is basically one that aims to do a postural correction, a postural correction in a more body awareness. Like how is our spine, how do we activate our pelvic girdle, how do we activate our pelvic, abdominal muscles or shoulder girdle? So we would focus a lot of body awareness as I said, and on posture reeducation, making the person aware of how they stabilize their spine, how they stabilize their body. Tamara Rial: 04:54 And from there we would progress the exercise from a more static poses. And then from there going to a dynamic postural position, and then the breathing exercise is mainly the technique made up of lateral costal breathing that is also practicing in pilates and also by a form of exercise that is also called the Ooda bandha technique. So this is a Pranayama, yoga Pranayama that we use in hypopressive and we call it the hypopressive breathing. So it's a very noticeable and visible technique. But you, because when you practice it, you see how they add them in draws in and the thorax expands and sometimes people confuse it with a hollowing, abdominal vacuum hollowing. Because when you're doing abdominal hollowing, you see how they belly button draws in and there is actual a little scoop in your abdomen, right? Tamara Rial: 06:10 But really when you're doing abdominal back q or a do the Anna Vanda or hypopressive breathing technique, what is happening is that you're actually opening your rib cage throughout a breath holding maneuvers. So that means you expel all the air or you expel the current volume of air you have in your lungs. And then after that you open your rib cage. And that will lead to a observable and very noticeable draw in of your abdomen. It is going to be even more noticeable that the actual abdominal Holloway maneuver. Why? Because their rib cage opens and lifts and that's gonna draw in the abdomen and in and create this vacuum that we call in yoga with the Yana Veranda, which is a Prana Yama. They are yoga teachers in some practitioners may be also aware of. And the combination of this type of breathing in a sequence with different poses that they instruct are not normally a progressive. The person through these form of exercise, the low pressure fitness technique. Shannon Sepulveda: 07:31 That's awesome. So let's talk about who can benefit from this form of exercise because I think that it's become really popular in the pelvic organ prolapse community and the urinary incontinence community. But then we also had a bodybuilder in our class because she needs to learn these poses for her bodybuilding. And we also learned about other types of athletes in particular in Spain that use this technique to help with their sport. So could you talk about like who can benefit from this? Tamara Rial: 08:03 Right. That's a great question. Well, hypopressives at the beginning where as you a correctly said, we're especially aimed for the post natal woman. And so specially after giving birth woman began to have some urinary incontinence and many women develop some type of prolapse and also they want to rehab there mommy tummy. So the application of this type of exercises that reduce their waistline and also reduce pressure, especially at the first weeks after giving birth where especially in France and in Belgium, the exercise that they were doing and performing and in France and in Spain, these exercise became to get a more popular and I think almost all a postnatal woman do this kind of routine and pelvic floor physical therapist and also midwives and duolas recommending and teach this kind of exercises in the postnatal phase. Tamara Rial: 09:18 So that's why I think it got very popular. But it's true that many other people and at the beginning I wasn't very aware of it because I also began focusing a lot in urinary incontinence because I thought that we're dealing with pressure, right? So this thought of I want to reduce pressure so it will benefit those women or those people who have some type of issue related with increase or dynamic pressure. So the one that always can come to mind or what stress urinary incontinence and pelvic organ prolapse. But there are other pressure issues that can go that people can deal around. And in the woman's health community we are very aware of constipation because it could also lead to constipation in the way we breathe and we push when we go to the bathroom can also lead to some symptoms. Tamara Rial: 10:23 So we've seen that people who a incorporate hypopressive breathing and also hypopressive technique from a regular basics and have constipation issues can benefit. And also there has been some research done on pelvic who suffer nonspecific, lower back pain and who have shown good results doing a basic series of exercises because many people ask what are the exercises? Are they're doing a lot of a complex exercise or are they doing dynamic? No, the basic routine. For example, in the course we learned the basic normal static exercises and in the easiest vacuum, that means a vacuum that is performed with a low breathe breath holdings only between 6-10 seconds. And also very easy poses that almost anybody can do in a standing position in a sitting and a kneeling. So really you don't have to be at gym to perform it and even our elderly in our and people with any type of a movement issues or even people who are in wheelchairs can also perform it because really the exercise is very easy. Tamara Rial: 11:52 It's basically controlling your breathing and control your pose. So it's specifically, we began to see that not only the woman's health, a community could benefit from hypopressive, but also people suffering, as I said, with a constipation, low back pain. And then there has been an increasing application of this type of training from an aesthetic point of view. Why? Because doing this type of exercise, the transverse abdominis muscle gets quite activated and when you see the abdominal vacuum maneuver, you can see that really the transverse and all the abdominal muscles have this corset effect. There's a visible waistline reduction so that waistline reduction is visible during the exercise. But after two or three months of continuous practice, that means doing two or three sessions of 30 minutes over a period of three months. You can observe a statistical reduction. Tamara Rial: 13:07 Yeah, significant statistical reduction in waistline, we're talking about between two centimeters of average or 2.5 between 3.5 right? So that will be the average waistline reduction. So for people who really want to reduce their waistline because they want to look better or they're doing a competition for bodybuilding for example, they are really want to find exercise that can achieve a waistline reduction without only thinking. Of course we all have to think about our food intake and our caloric expenditure. But when all those variables are taken into account and you also want to want to work on your natural corset that means your abdominal muscles. We all know that we have to train our core, but we can train our core in different ways. And one way that we have seen that also can be an alternative to normal or traditional core training methods is also the stomach vacuum or the abdominal vacuum or the hypopressive technique. Tamara Rial: 14:27 In fact, it's funny to observe that in the body building community they have a pose that they execute. That is called the stomach vacuum pose. And this stomach vacuum pose was a popularized by Arnold Schwarzenegger in 1970. There are many, there are some pictures of him that if you go to the Internet and you put an Internet Stomach vacuum pose, you can really see how he had a pose I think he's the king of the stomach vacuum pose. And he really popularized it because when he would go on stage, he will want to show his serratus. So a way to show the great development or the mass development of his serratus would be going into a big rib cage expansion, lifting his arms behind his head and just pulling in his stomach throughout this abdominal vacuum technique that is really hypopressives. Tamara Rial: 15:29 So he even wrote in his bodybuilding, he wrote that he usually trained this technique to achieve a waistline reduction. And if you see his body, it was amazing. He really had a very thin waistline and a big thorax. And now bodybuilder nowadays they're there. Well at least what they are seen as they're getting, they're having trouble in and getting a great lat spread and a great big thorax and in comparison have a very, very thin waistline. So that's why now we're recovering a little bit. This knowledge that he brought us in the 70's it seemed that now more bodybuilders are being aware of doing this type of a stomach vacuum exercises. And even in Spain, the Federation of bodybuilding has a included the stomach vacuum pose again as compulsory for the male competition, which is kind of cool. Tamara Rial: 16:34 And that's why I think it was two years ago. And we begin to see a great demand of body builders to come to our classes to learn, only from aesthetic purpose is to learn the technique because it's not easy. It's not easy to be onstage, hold your breath, be smiling, and at the same time hold your breath for 10 seconds when you're already very tired and open, open your ribs and show that stomach vacuum so you really have to train it. And in our bodybuilders, that came to the course. She is amazing. Of course she was absolutely gorgeous, but she wanted to work a little bit more on her stomach vacuum pose. Shannon Sepulveda: 17:20 Yeah, yeah, yeah. She told me that, that maybe the difference, like it like she's like, I need to learn this. And I was like, wow, that's, I didn't even think about that. And then when you showed us the pictures of Arnold Schwarzenegger I was like, oh yeah. I mean I remember seeing them as a kid, but I was like, oh, it totally is a stomach vacuum. And so I think it's really fun when you have all of people from different Shannon Sepulveda: 17:50 backgrounds in the courses because it's just fun to talk to them and pick their brains and see like why they're here. So I thought that was, that was really cool. Tamara Rial: And how different people from different areas, from fitness professionals for women's health, from even massage therapists, it can have a common link. There was also the course, we had a several yoga instructors because I guess it also makes sense to incorporate a technique that has so much in common with already yoga. Shannon Sepulveda: Yeah. Can you tell us a bit about your research and your education and your PhD work? Tamara Rial: Okay. Yes. So as I said I was Spanish and I think some of our listeners have noticed that I have a little accent. Well say. I've grew up in Spain. I did my education, all of it over there. Tamara Rial: 18:54 I also did a semester in the University of Porto, part of my PhD and they laboratory of CNN, Tropo Matree with the professor. But my main focus was always a pilates, and some type of mind exercise. Mind body exercises a woman's health. So I began to get interested in this because I've seen at least in his Spain, it wasn't a woman's health wasn't a topic that was taught so much in the physical education and fitness community. We were talking about the benefits of exercise for health, but we were looking so much of the benefits of exercise also for Woman's health and how some type of techniques and pelvic floor muscle training could also benefit a lot. Mainly females and males who have some type of dysfunction. Tamara Rial: 20:00 And we really had to bring this knowledge into the physical education to the exercise science community and into the gyms. And I also think into the woman's community because sometimes there's that, well I really think there's this feel like great taboo talking about women's health issues. So maybe it will be easier if we begin to talk about it in a easy way from the gyms and bring this topic into the fitness instructors. So they would bring more awareness and also the coaches into the sports community and that way make aware to our woman and our males that there is option to, and there's options to take care of your pelvic floor and your health with exercising correct movements and how just by breathing you can affect immensely your pelvic floor health because we are not aware of how we breath, how we are standing now. Tamara Rial: 21:06 Now our listeners they're maybe they're sitting in the car they're walking, but are we taking our time? Are we looking in was and are we feeling our brand that we fit in our body? So all those things I thought we, I had to bring it into the fitness community. And that's why I really wanted to focus on how some type of mind body techniques could impact urinary incontinence. And at that time hypothesis was not a very famous thing in Spain. I think it was not famous. Nothing. Maybe some pelvic floor PTs who had been taught in France. Know a little bit about it, but really it wasn't a big thing. So I learned about it from Marcel Frey, who was one of the main people and teachers who begin to get interested in this topic. So I thought, why don't I do a research study on this on urinary incontinence? Tamara Rial: 22:12 And I remember at the beginning it was hard because imagine telling your doctoral advisor that you want to do a study on woman that's kind of, okay, I'm focusing on women and then say I want to focus urinary incontinence. So I'm getting more specific. And then I say, I'm going to assess the effects of hypopressive exercise. When I said this word, he was like, what is this? And we went into the literature and there was nothing in the literature, nothing at that time. And right now there's still nothing. Okay. But at that time there was negative and it was kind of hard because what is the basis? There is almost no basis. And I know, I know I took a risk, but I began to apply it on myself and I begin to apply on some practitioners and I saw results very quickly and they were telling me even after three sessions that they already were feeling a decrease in their ordinary symptoms and they were, I was even shocked because I like time. Tamara Rial: 23:25 I didn't believe it. I was still one, I was one of the skeptic that's a little bit the reason why I said I want to study this to prove it's not working, but when people begin to already tell me, you know, I feel great and I begin to see how women were enthusiastic about it. I said, okay. I really had to give it a chance and that's how I got paid. I'm really passionate now about it and people say, you're very passionate. Why? I think that people who I work with made me passionate because whenever I see that somebody can benefit from what I'm teaching, that makes me happy. And that makes me really think that maybe I'm, if I'm making somebody better, I'm helping in some sort of way, I think that's how I've been driven to keep on in this path. Tamara Rial: 24:19 And also because I want it to make it more on evidence based or a technique that would have more support. Because at the beginning I would hear people say, hypopressives does this, or hypopressives does this, but there was no, there was no basis behind that. Even sometimes the physiological description of the exercise was wrong and people were very assertive. Like people would say, it does this to the body or you can achieve this, whatever. But what is the research like? What is the, what is the, even the physiological mechanism, which explains that. And, and there was very contradictory explanations in the literature because I guess nobody has really wanted dive into it and study to show that maybe it's correct or not as correct because I even at the beginning thought that maybe intraabdominal pressure doesn't increase or maybe decrease. Tamara Rial: 25:29 We still don't know. We still don't know what has happened at the thoracic level so we cannot just assume things if you really don't study it. I think that was the big mistake with hypopressives. People got excited and they began to say, there's no thing called hypopressives. It's fantastic and blah blah blah, but you cannot put something out in the market and say it is great without really having to first apply it with real people as it in a clinical way and then begin to do some short term studies or some physiological studies. That means, for example, if you argue that there is a decrease in pelvic pressure, you have to assess it. You cannot say it without even assessing, maybe not 200 people, but at least a group of people. And then from there, which we would have to see if there is some type of chronic effects. Tamara Rial: 26:39 We still don't have a research that really shows many claims that people say. So those are lacking in the literature. So we always have to be cautious and see, you know, we don't know. We don't know. People are getting some good benefits and they're claiming that they're feeling better. For example, they're feeling more posture rehabilitation or they feel there breathing capacity has increased. But that's anecdotal evidence and we have to prove that with more randomized trials. Right. So, that's a little bit how I started and I got interested in it and I'm still working with it and teaching. I came to United States and I did my first courses through Herman and Wallace, pelvic rehabilitation institute, and also through pelvic guru that we're the first people who trusted me in United States. Tamara Rial: 27:52 And they led their hand and they began also to hear from some pelvic floor practitioners who in United States who were already working with this. And I guess there was a little bit of spread of the word and that's why I think in the United States some people began to get interested in it and now let's just see how it works and hopefully more universities can open new lines of research on this topic because I think women's health and pelvic health, although if we focus a lot on urinary incontinence in pelvic organ, there are many other issue that have not been so much address like a hypertonicity, a topic for dysfunctions, pelvic pain. So there is still a lot of research that we can do. And I think also the area of alternative movement exercises, for example, Yoga and even pilates, there should be more, more interested in it because our woman and our people, our population, we need to move, we need to do exercise. Tamara Rial: 29:13 And we really, when there is a public condition, many women are afraid of moving and doing exercise. And I don't think it's good to tell a woman or to tell a postnatal mom, you know, you have to be careful, don't lift weights or don't do this exercise or don't do curl ups. So are I feel that sometimes we're frightening too much are woman and there and instead of going to the gym or maybe sometimes you can have a leakage and you say, Oh, I'm a little embarrassed because I'm leaking during my crossfit activity, but I love going to crossfit. So maybe I can also compliment my activity with other more pelvic floor friendly programs or with some programs that kind of counterbalance that high intensity activity. I kind of, I sometimes say that a low pressure of hypopressives are the best friends of high impact activities because we have the metabolic benefits of a high intensity interval training, which has a great background of research that shows that is one of the best type of training for many metabolic conditions for our cardiovascular health. So we want people and we need people to be doing their physical exercise. And on that note, we're going to take a quick break to hear from our sponsor and we'll be right back. Shannon Sepulveda: 31:36 Okay, so we learned about some awesome new research in the course. So can you share that with us? Tamara Rial: Yes. Well, we still didn't know until some weeks ago what was happening in the diaphragm. Because it's true that when you do the abdominal breathing maneuver, the hypopressives maneuver, you're actually opening your rib cage in, you're holding your breath. So it was hypothesized that because you're using your inspiratory muscles to hold and expand your rib cage, that diaphragm what is happening it raises up, right? So imagine when you breathe in your diaphragm goes down, contracts and lowers the position and also the pelvic floor because the movement of the breathing and the synergy or the diaphrgm the pelvic floor diaphragm is synergistically, right? So then when you exhale, the diaphragm raises up and also the pelvic floor contracts and raises. Tamara Rial: 32:38 So when you're doing this hypopressive maneuver, what has happened is they're opening your rib cage in your allowing to your Diaphragm to raise up a little bit more. So that means that it achieves a little bit of higher position than when you're only exhaling because it's kind of a stretch of the diaphragm. But the question was, well, but what happens? Because we have some studies that have shown through ultrasounds and MRIs that when you're doing this hypopressive breathing, there is a pelvic lift, right? There's a raise of the pelvic floor and also the bladder and the uterus. So this is something you can actually see. And in the course we also see it in ultrasound measurements, but it's difficult to have an ultrasound measurement of the diaphragm and also it's difficult to see the pressure in your esophagus or in your abdomen. Tamara Rial: 33:40 Because that would have to be through a more difficult assessment that normally in the pelvic settings we don't have have. So normally if we want to assess in a pelvic floor or physical therapist setting the pressure, we can use intrarectal devices or intra vaginal devices. And that way when we're doing different types of maneuvers, we can assess what's happening, right? So when you're doing the maneuver, what happens with hypopressive is there's going to be a decrease of intrarectal pressure intracolon and also vagina, right? If you performing the exercise with the correct form, and I always like to say and this and make it a specific, that it's not something that you can achieve the first day of practice. You have to know how to correctly perform the technique as well as we teach how to correctly perform up pelvic floor muscle contraction to enable the pelvic floor muscle to really lift and contract and not to, for example, Bulge. Tamara Rial: 34:51 That can happen if the technique is not correctly performed or if they breathing phase doesn't accompany the contraction. So in the same way, when we're doing a hypopressive maneuver, what would happen is that we would exhale first and then after that exhalation we would hold their breath and we would only perform a voluntary muscle contraction of our rib cage muscles. So the question is the diaphragm what happens is a very relaxed is a very contracted, is it not? So Trista sin, which is my colleague and one of my friends who have, I been working also very closely and she teaches courses over there in Canada, she actually flew to Vancouver because there's a research group there who's going to access actually with the group of people who are going to do hypopressives and I can't recall right now his name, but he's a phd candidate who is a looking forward to do his phd on the effects of a hypopressive technique on the EMG activation of the diaphragm and also into the pressure management, intrathoracic pressure. Tamara Rial: 36:29 So we won't call it the pilot testing and because Trista is a very good practitioner, she already knows how to do the technique and I know that not everybody wants to introduce a catheter, it's not one of those research that a everybody would want to do. So she did it. And, we have the preliminary results that I can, I can read you some of them. And she also did different poses. So she did the analysis in the standing pose, which was more easier to assess also in kneeling. Because you don't have to move your face or you're not on a board where sometimes you can change the position of the catheter. Tamara Rial: 37:32 Yeah. And, also supine was an easy pose. So that's the assessment and there actually was electromyographic activity shown in the diaphragm from which would make sense because the diaphragm cannot relax. So there's a quite of lengthen in an activity going on even if you're doing the breath holding maneuver. So I guess that when they results on the group, they're going to test on the trial. We will get to know more of really what happens, not when you're doing actually that technique, but what would happen, what chronic effects would have your intercostal, your breathing muscles. And also your Diaphragm from when you're doing this kind of vacuum technique and also what happens into the pressures. So we would be able to show that there is a reduction, the reduction of thoracic pressure and intrabdominal pressure, which is kind of cool. Tamara Rial: 38:40 It's pretty cool because at least now you can say that it makes sense to call it hypopressives. So, well, that's the thing. And also when you're doing hypopressives, the thing is that you're lifting your rib cage and you're using your breathing muscles. So for example, they, SCM muscle increases his electromyographic activity because it's all it has, it enables their rib cage to lift, right? So whenever you're doing a hypopressive, you will really actually see the lift of the rib cage and also the widening of your intercostal rib cages. All the rib cage actually open. So also this serratus is a muscle that is also going to increase as is electromyographic activity. Right. And there has been another group from Brazil that actually did not a chronic study, but they did an acute study that they assessed the electromyographic activity of the abdominal muscles, so transverse, Oblique and internal oblique. Tamara Rial: 40:01 They did it through superficial electromyographic activity and it was with some female practitioners. They were healthy. There were no pelvic floor dysfunction. Just testing when you're doing the vacuum, what actually happens in the core muscles because some people think that when you're doing a hypopressive, maybe there's a high electromyographic activity, but really you're not doing an active contraction. For example, if you do a a crunch exercise or you actually contract forcefully your abdomen, you will have a very high electromyographic activity, but because what you're doing is just having a stabilizing pose that makes your spine grow and you're actually doing a low intensity postural activity and you're opening your rib cage in your muscles. There's not going to be such a high activity. There is an increase of activity but not so much on the rectus abdominis and the external oblique as much as there is in the transfers and in the obliques. So that's why it's especially indicated for people who need a rehabilitation of their deep inner unit and not so much of the outer unit. So especially in the first rehab phases for example, for those with lumbar pain and want to achieve Tamara Rial: 41:34 a greater mind body connection of your deep core muscles or we want to a connect that transverse and the pelvic floor. This could be a technique that we could use for example. So especially more indicated for our deep system. And then from there we can build on a more dynamic exercise that will recruit the larger muscles and the larger dynamic muscles. Shannon Sepulveda: Cool. That's awesome. Thank you so much for that explanation of the new cutting edge research. I think that's awesome. In my experience, it seems like there's a little bit of controversy surrounding hypopressives and low pressure fitness where some women's health people are like, yes. And some women's health People are like, no. And in my opinion, not that it means anything, but my opinion about something like this is if it works for somebody and there's no harm in it, then why then what's the problem? Shannon Sepulveda: 42:41 Because it's not like we're causing any harm with any of this. And so if it's a tool in your toolbox and it works for certain women, what's the harm? Yeah. Because really there is none. And so why not try it? But I just wanted to get your thoughts on, you know, what's going on in the, I mean, I feel like hypopressives are so hot right now. It's Kinda like diastasis is just so hot right now and it's the new buzz word I think in women's health, physical therapy. So, but there's been, you know, people are like, if people don't, I don't really know. But what's your take on all of that? Tamara Rial: There has actually been all a lot of controversy and even a lot of controversy in the scientific literature because I think it was last year there has been a discussion paper published by Carrie Bowen, a researcher from Spain, on hypopressives saying that there wasn't enough evidence to support that hyporessives could be an alternative exercise for women with pelvic organ prolapse. Tamara Rial: 43:54 So they based their discussion paper and their results on the articles that our group has published it on this topic. So I wrote a letter to the editor and it was published on the British journalist sports medicine blog. It's available and they had also a reply. So it's kind of funny when you get to have these replies. So there has been a lot of controversy even in this field because as I said before, it's true that there has not been a lot of research and there are studies that have been publishing from the Brazilian groups. They have done some studies on woman with prolapse. We can find a on pub med with the word hypopressive but my argument and my counter argument in the letter and the response to the letter to the editor that is available as you said in British Journal of sports medicine, you can read it is that the thing is when we are applying a technique and especially a technique as hypopressives, that is first difficult to teach, difficult to a specially properly perform if there's not a good instruction and supervision. Tamara Rial: 45:25 That means that first we have to assess if the person is correctly performing the exercise as well as anything as well as pelvic floor muscle training. We will teach first how to do a optimal pelvic floor muscle contraction before beginning the trial. We have to perform or assure that the person who is really doing that vacuum is actually doing a vacuum and if the form is correct that means does that person do a vacuum that is really lowering the pressure. Is that person really in the correct positioning or does that person need a little bit more of supervision of somebody who really knows how to correct and see if the pose is correct? Is the breathing so in the description and they papers and you can read the paper. They don't describe the exercise as a form of different postural exercises. Tamara Rial: 46:25 They only described that they performed on a technique where there is an abdominal contraction a transverse abdominal contraction. But that is that you don't really know. They have been doing the whole series of exercise as this has been described in the literature because hyporpressives are currently describe the technique as a postural base and a breathing base. So that was my critique that you're basing your argument on the low number of research that is still available and on research that doesn't describe quite maybe let's use the word accurately as all their manuals and other professionals and other also because we can see other research common from other groups that are already doing and describing the technique. And this happens a lot in exercise science and physical therapy. Whenever we're using exercise that involve a lot of supervision and technical instructions, we have to be very clear and describing that technique. Tamara Rial: 47:37 That means how many repetitions did you do, how many rest breaks, how many seconds did you rest between exercise and exercise? Because we know that changing one little variable can change the whole exercise. And, even when it comes to breathing exercise, we have to very accurate accurately describe the time that means, for example, you're breathing in how many seconds you're breathing out, what way you're really now doing a four, six inhalation, or you're breathing out doing a a more relaxed maneuver. Are you for example, doing a more intercostal breathing? Or are you doing a more diaphragmatic breathing using, you know, there's so many different aspects that if we really don't describe how is that technique, it's gonna be more difficult to replicate that and more. And it's going to create even more controversy between the readers or the listeners because we really don't know what the technique is about. Tamara Rial: 48:49 And many times we see a video on youtube. This is the worst thing to learn from youtube. I know that we all go to youtube many of our listeners are now, many people that are doing it, but you can see the person do the exercise. But how did you know if you're really doing what that person is doing it maybe you are contracting or you're trying to pull your shoulder up or it's Kinda hard and I would never I love watching those youtube videos and there are some yoga professionals that do amazing exercises, but it will be very hard for me to know if I'm doing the exercise correct if I don't have somebody that is telling me I think, I think you're doing the pose or even when I'm instructing pelvic floor muscle training, we really have to have somebody that is supervising that technique and giving us advice to progress in the technique. Tamara Rial: 49:56 So I think this has been the first controversy, the lack of research and the claims of some Gurus and like they is the best exercise for the pelvic floor. Well that's a huge claim. You can never do the say that and, or some people will have, I have also claim a hypopressives if you do hypopressive's is much better than Kegal Well, no, no, no, you can never have those because that's going to go against you and, and that's why maybe I think there has been such a bad reputation and also because maybe there has been a lot of marketing towards that waistline reduction. So if people say you're selling it as a tool that is only aesthetic, but it kind of sounds like a selling thing, right? Where we want to sell a product only because it Kinda is new, but why, what is it, how is it an other profession? Tamara Rial: 51:07 Is it professionally driven, technique driven, and that has been the big, I think, huge controversy in the literature and also between practitioners. Right. And I think also another controversy that I see from my point of view is, is that one of people trying to learn, learn it from professionals who learn it from youtube. If I'm not sure about it and I would rather not do it or if you really want to practice it. I always advise people even to exercise under the guidance of professionals and I know that sometimes hiring up a personal training or higher, you know, going to a physical therapist once in awhile people can say it's a waste of time. I think I'm good on my own. But no, even, even us as professionals, we should be instructed on the care of over there people because the eye of a professional is better than your own eyes and we need that supervision. Tamara Rial: 52:20 We need to a planification and we also need an assessment. So maybe when you're under the guidance of a pelvic floor physical therapist or a instructor, they would assess you and say, you know, maybe we should do other exercise or we should begin with this. But then progressed to other phases and talking about progression, the idea that hypopressives would be like the magic pill. No, I don't. I think that that's a very wrong message to tell our people because there's nothing that is magic pill there. It's a tool in your toolbox. So it can be something that you can do to help you in some part of your life, but then you're going to progress and then you're going to do more things. Because for example, hypopressive is a good maybe reputative tool kind of. Yeah, kind of reputation tool. Tamara Rial: 53:20 But I won't think that I'm going to get better improvements in my cardiovascular health doing hypopressives, for example, I'm not going to lose weight doing hypopressives it's not an aerobic driven kind of tool. So if you're beginning to sell a technique as something that is the best for everything, or maybe that thing of a reduces waists. So people say it's because it's because you're losing weight. No, no, no, it's maybe because you're getting a better posture so then you don't have such a bulge in your abdomen. We all know it. Right? If you have bad posture, your abdomen is going to bulge more so by again having a better posture or by having a better breathing habit, you're going to help you to have a better abdominal appearance. Right. And then if you tone your inner unit, that will also help, but we will never, never achieve a waistline reduction or a better appearance without a loss of weight because you almost don't use a lot of energy. Tamara Rial: 54:33 In fact the heart rate will even decrease a little so, so not not increase. Interesting. So we still have to do cardiovascular work. We can then counterbalance our running. Shannon Sepulveda: I know. I was like I love to run and I was like okay, 20 minutes a day, 10 or 20 minutes a day. Like I can do this. And it actually felt really good because I'm so tight for running and I just like them. Then it was actually pretty awesome doing it in the class. Tamara Rial: Yeah. And many, many people who perform running or other type of high intensity activities or aerobic cardiovascular training, they use what he'd do this training, they could operate it after. So as a way of cool down. Yeah. So it's a set of doing other type of exercise or we can incorporate it into our cooling down or even our stretching because many poses are like our stretching houses lying on the floor, stretching and our arms stretching our legs. Tamara Rial: 55:41 So we just incorporate it and it's 10 minutes. You don't need much, you really don't need much. 10 minutes for those that need other 15 maybe 50 minutes and, and I think everybody can find 15 minutes in their day to have sum up some sort of mind, body practice. We really need it nowadays with so much going on. Social media. Shannon Sepulveda: Yeah. Well, it actually, it was interesting, I was thinking about why it felt so good and why say I would stick to something like that instead of yoga. I've tried yoga before and I wasn't too into it. I think it's because never in my life have I stretched that area. Like it's so hard to stretch your thoracic area, right? Like I couldn't, there's no way. Or like even my rectus, right, your front abdominal muscles. Like it's, unless, I mean you could do up dog to stretch, but it's really hard to lengthen and stretch all of that. So it was like the first time in my life where like those muscles stretch and it feel really good. Tamara Rial: 56:39 Because we're stretching from the inside. You've seen our breath instead of pressing it down, we're pulling it inwards. So that's why maybe this sensation is different. I think also the concentration on the breathing in that now it gives you a kind of mindful sensation. So for many people, they only do it as a mindful practice. They're pressing because they're so focused in on their breathing. It takes you out of your daily worries. Shannon Sepulveda: I think that's what I found too because it gave me something to like focus on, like I had an objective so I wasn't thinking about anything else because it's hard to do. And so it's also like a new challenge. Tamara Rial: Yes. Yeah. So it was really great. And to challenge your breath Holding and to only think as well as we count, we always tell people sometimes when they're breathing to count breath up to one, two, three. Tamara Rial: 57:41 So whenever you're counting, you're mindful in your present. And also we're gonna add they've beneficial effects of having us slow paced breathing. That's to add down train our nervous system. So we're also going to help us if we want to just do a mindful or a relaxation kind of technique. Shannon Sepulveda: Well thank you so much for coming on the podcast. And so where can we find you? Email social media courses and you teach people like where can people find you if that. Tamara Rial: Thank you. My name is Tamara Rial So my website is tamararial.com but I'm very active in Instagram, so you can find me as Dr.tamararial and I also have another, another Instagram account that is a specific only, only for hypopressive that is called hypopressiveguru because I also teach other women's health programs, not only hypopressives. Tamara Rial: 58:53 So I focus also on the female athlete. Pelvic friendly exercises, so, so you can see all my programs and courses on my website, although in my social media, especially on Instagram and know the courses I'm hosting in United States are throughout Herman and Wallance and also pelvic guru. So if we'd go to the websites we would see their announce all the hypopressive or low pressure courses. And I think contact email is rialtamara@gmail.com. Shannon Sepulveda: Great. Well thank you so much. We really appreciate it. Thanks for listening and subscribing to the podcast! 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LIVE from the APTA NEXT Conference in Chicago, I welcome Duane Scotti on the show to discuss gymnastics medicine. Dr. Duane Scotti is a physical therapist, educator, researcher and founder of Spark Physical Therapy. He is considered a leader in the fields of rehab, sports medicine, performing arts medicine, and human performance optimization. With years of experience as a physical therapist, runner, and dance instructor in combination with his strength and conditioning background, Duane has been working with many patients to improve all aspects of human performance. In this episode, we discuss: -The most common injuries in the youth gymnastic population -Differential diagnosis for low back pain -Key features of a rehabilitation program following an ankle sprain -How to enhance communication between athlete, coach and clinician -And so much more! Resources: Duane Scotti Twitter Duane Scotti Instagram Spark Physical Therapy Facebook Spark Physical Therapy Website For more information on Duane: Dr. Duane Scotti is a physical therapist, educator, researcher and founder of Spark Physical Therapy. He is considered a leader in the fields of rehab, sports medicine, performing arts medicine, and human performance optimization. With years of experience as a physical therapist, runner, and dance instructor in combination with his strength and conditioning background, Duane has been working with many patients to improve all aspects of human performance. Duane is currently the founder of Spark Physical Therapy, providing prehab, rehab, and performance optimization services either onsite or in the comfort of your home within the Cheshire/Wallingford CT region. He also is a clinical assistant professor in the Department of Physical Therapy at Quinnipiac University responsible for coordinating and teaching musculoskeletal examination, intervention, and advanced manual therapy within the orthopedic curriculum. Duane received his Bachelor of Health Science degree and Master of Physical Therapy degree from Quinnipiac University in 2001 and 2003. He then went on to receive a clinical Doctor of Physical Therapy and a Ph.D. in Physical Therapy from Nova Southeastern University in 2017. Duane is a board-certified Orthopaedic Clinical Specialist, Certified Mulligan Practitioner, certified in dry needling and has advanced training in spinal manipulation, dance medicine, gymnastics medicine, and rehabilitation for runners. Duane has been in clinical practice working with orthopedic, sports, and performing arts populations since 2003. He has strong clinical and research agendas in screening, injury prevention, and rehabilitation for runners, dancers, and gymnasts. Duane uses an integrative model of manual therapy including manipulation, mobilization, and soft tissue treatment including dry needling and the Graston technique for the management of musculoskeletal dysfunction. Duane is a physical therapy advocate and is actively engaged with the American Physical Therapy Association and serves as Vice President of the Connecticut Physical Therapy Association. Read the full transcript below: Karen Litzy: 00:00 Hey everybody. Welcome back to the podcast. I'm coming to you live from Chicago, Illinois at the APTA Next conference. And I have the great pleasure to welcome back to the podcast. Dr. Duane Scotti physical therapists. And today we're going to be talking about gymnastics medicine. So Duane, welcome back. Duane Scotti: 00:19 Thanks for having me Karen. It's good to be back Karen Litzy: 00:21 And I have to tell you, gymnastics is something near and dear to my heart. I was a gymnast for many, many years as a child. And luckily I didn't have any major injuries, but what we're going to be talking about today are kind of the most common injuries you might see in a gymnast. And this is something that Duane is so passionate about. These are the people he sees. So if you're a physical therapist out there, and maybe you have the off chance that you might see one of these young athletes, I think this'll be really helpful for you to give us your insight. So Duane, tell us what are the three most common injuries one might see in a gymnast? Duane Scotti: 01:02 Well, I think first off is I definitely do have a passion for this area. Like you state because I have a daughter who's a gymnast. So that is one of the things that I kind of in my career from a clinical standpoint, kind of focused a little bit more in this area is spinning off of like dance medicine and got into the realm of helping gymnasts out because I did see there was a need in the local club in our region. So in terms of the most common injuries I would say, you know, definitely low back pain, in gymnasts and specifically extension based low back pain. So because of all of the kind of back bends you think about, they do like bridges, back walkovers, back handsprings all of those, especially in the young developing gymnast. So usually the smaller ones like the level fours and fives, they're doing a lot of those skills. A lot of times you'll tend to see that occur as well as a lot of the compressive loads that happen especially during your floor passes in gymnastics, there's a lot of compressive loads as well as shear loads that get transmitted to the spine. Karen Litzy: 02:11 And can you kind of briefly tell us what exactly you mean by when you say a compressive load and can you give an example of when a compressive load might happen and a shear load? Same thing. Duane Scotti: 02:23 So it's really the compressive load is if you think of landing, right, so you're landing, your body weight is coming down. So we know that actually landing, you know, there are some studies that look at between 12 to 17% of your body weight is actually, or times your body weight is actually being loaded through the spine. So that's that compressive load as opposed to like a shear load, which would be something like if you think of doing that back bend or that bridge where you're getting one bone kind of shearing on the other. And in the young developing gymnast who is still growing, that can be problematic. And then that's where we start see things such as stress fractures. So that's kind of really the most you know, important thing. And the thing that I tried to intervene and educate because a lot of times most gymnasts have the perception that maybe back pain is normal with gymnastics due to the training and it's going to happen. But being a young gymnast with their bones developing, if they develop that stress fracture that could be detrimental to their long-term health if it goes undiagnosed. Karen Litzy: 03:28 Oh that was my next question. So let's talk about differential diagnosis of that stress fracture. Cause I think that's really important to think about. And I would imagine that a lot of therapists aren't thinking stress fracture when they're thinking of a young girl or a young boy. Most of the time we think stress fractures in our older adults with osteoporosis, osteopenia. So how do you differentially diagnosed that stress fracture from other causes of back pain? Duane Scotti: 03:59 Yeah, so the stress fractures are, they call spondylolysis and it is really diagnosed based upon the history. So kind of taking a report, is that something that typically it can occur acutely from like a specific landing where they felt an acute kind of sudden onset of back pain, but usually it is something that's developing over time and it's not getting better with rest and it continues to get worse over time. And then there are some things on the physical exam that we can evaluate whether they have pain usually commonly with extension. So they're, you know, doing a standing extension test or a stork test standing on one leg, bending back. You can look at the irritability based upon if they have pain with that or if they don't have pain with like a press up on their stomach, then I feel pretty confident that this person doesn't have a stress fracture, that it is more muscular. Duane Scotti: 04:50 But you always have to kind of make sure and rule that out and then looking at confirming that. So you, you know, you send them to a specialist, a spine specialist. It's not going to show up on x-ray unless it's chronic by that point that they'll see the callus formation on x-ray. But it's really an MRI or a bone scan. And a lot of times, you know, if it is kind of consistent with the history, then even the specialist may not even recommend an MRI just because it's sometimes not necessary. So sometimes it just requires that kind of protection phase and avoiding the extension based activities. And then that allows that to heal. Karen Litzy: 05:26 And how long is that protection phase? Duane Scotti: 05:29 So it's around, you know, everyone's different but around six weeks. So that's the most common timeframe you'll see. And there are some that recommend bracing. So they call that like the, the Boston braces, the Bob braces where they will brace them. So that athlete is actually preventing any back bending at all. So they're not going into any extension and forces them. So it's a hard kind of turtle shell brace. And they'll wear that for six weeks to really make sure that it heals up. Cause some of these young kids don't even realize and they don't understand the severity of it. I actually just had a girl recently who, you know, tried not bracing at first and then wasn't getting better and now she's braced and it will allow things to heal. Karen Litzy: 06:10 Mm, Nice. And my next question was actually going to be how do you communicate this to a young boy, a young girl, young gymnast, that it is of utmost importance to not move into these motions. And then I'm sure you're reinforcing that with parents, guardians, coaches, etc. So talk to us a little bit about the communication that needs to happen around this. A child with a stress fracture. Duane Scotti: 06:38 So I'm lucky in the fact that I'm on site, so I have these relationships with the coaches already. So I'm seeing a lot of the gymnast actually within the gym and I have those relationships with the coaches as well as with the patients. I see the parents are always there during the evaluation. After every visit, I'm always communicating, you know, even if they're not there for the visit, we do the visits in the gym and then I communicate all my findings on each day with them. That being said, it gets challenging, especially during competition season. So this is where the difficulty comes in. And I think it is a very important role we play as healthcare providers where sometimes we have to be the bad guys because we're looking out for their health. So I had a girl this year before regionals, it was, you know, big competition for her and we have to make that decision and there are tough decisions and if things are sounding and going down that route that you think stress fracture, then it's like you have to take care of your long-term health. Duane Scotti: 07:36 And it's, you know, one of the hardest conversations, honestly, I've had, I go, you know, home at night thinking about these decisions. I have these long conversations with their parents and, but in the, you know, in the long run, when I reflect back, I'm like, okay, this was the right decision because you know, I don't want this, you know, female to have persistent low back pain for the rest of her life and she wants to have kids one day and grandkids and be able to move later in life. So you know, you want to make sure that you're thinking for their long term health. Karen Litzy: 08:04 Yeah, I think that's very well said. And you know, I used to work at the lion king in New York and I remember it was like their last performance at the new Amsterdam theater before they moved to the Minskoff. And one of the young simbas was limping around, limping around. So they brought him in and he was not fit to dance that day. And so I had to make the professional decision to call in stage management, call parents, call tutors, call everyone around this huge production of he can't go out and dance because I'm looking out for the longterm house. So it is a lot of tears, which I'm sure you can attest to, but you're right, it's being a good health care professional. It's not about just that moment. It's looking out for these young kids. Duane Scotti: 08:53 And you know, I definitely pride myself on, you know, getting the recovery for injuries as quick as possible so they can get back out there doing what they love, being able to compete. So when something like that happens, you know, you almost feel like, oh, was I a failure or in, you know, but you have to think about the bigger picture and their long-term health versus that short term gain. Karen Litzy: 09:14 Yeah. That's when you take yourself out of it, right. As the therapist, as we should all be doing, we check our ego at the door. It is not us. Sometimes things happen. Timing sometimes sucks and we have to make decisions based on what's in front of us. And I think if you're making what you feel is the best decision at the time for the health of that patient, then it's the right decision. And all right, so outside of stress fractures in the low back, what are there other common types of low back pain? Is it muscular and mechanical, low back pain. And what do you then do for those gymnasts? Duane Scotti: 09:54 So very good. Mainly there's not a huge amount of mechanical low back pain that I tend to see when we think of disk related low back pain, sometimes some facet joint. But these kids are a lot younger so it is usually muscular in nature. I kind of see that common pattern, but it is usually due to an underlying instability in the lumbar spine. But honestly more importantly that I'm seeing is the contributing factors. So specifically looking at hip flexibility, so limited hip flexibility specifically the hip flexors, is going to cause more lumbar extension as well as kind of a weakness or inactivation of the glutes. So these girls are doing these leaps and they're doing these movements where they are extending their hip but they're really not turning on their glutes and their using, you know, if they do have flexibility issues. So I found, you know, addressing those issues. Number one from a treatment standpoint is going to be helpful in the long run, but also for Prehab standpoint. So in prevention. And that's what I kind of do in the gym with all these girls is take them through a full screening help to identify those risk factors and then get them on plans to address the soft tissue care because they are doing a lot of strength and conditioning their front of their hips get really tight and that causes that excessive shearing in the lumbar spine. Karen Litzy: 11:13 Great. So I think for me a big take home here is when you're looking at these young kids, you're not, they're not just tiny adults and so we're not necessarily looking for disc issues, but rather we really need to look above and below to kind of see, well is the back pain, this muscular back pain a result of compensation from other parts? Right? Duane Scotti: 11:36 Absolutely. Yes, definitely. And then even the core stability aspects of most of these gymnasts, like super strong, but sometimes there's still these little muscle imbalances that you can find with like a good examination that they're not using the muscles you think they're utilizing. And a lot of, you know, even physicians and you know, these athletes will go to a, you know, a pediatrician or primary care provider or an Ortho and then you're like, oh well there look at them. They're Jacked, you know, like you've seen gymnasts there, Jacked, like really, really good conditions. Yeah. So they, they're like, oh, there's no way they could be weak. But no, like when you actually watch them move and you watch their movement patterns, then you pick up on some of these weaknesses and then you know, having them get into, when they're doing their extra, it's like, okay, well where are you feeling this and this. I go, if they're not feeling they're glutes at all. They're like all of their feelings and their hamstrings. So I find a lot of that they're kind of using your hamstrings to extend their hip joint and not using their glute. So you kind of work on correcting some of those kinds of muscle imbalances. Karen Litzy: 12:34 Perfect. All right, so let's move off of low back pain. What's another common injury that you see in your gymnasts? Duane Scotti: 12:44 So definitely you know, the most in terms of the research is ankle and foot are kind of the most common region or you know, area to be injured. And most of that is due to traumatic ankle sprains. So they get their classic inversion ankle sprain while they're beam landing from a pass on the floor, dismount off bars, everything vault like you name it, you know, an ankle sprain can happen. And it usually happens in practice. Not so much in competition. We know that the majority of gymnastics related injuries happen during practice. So I do see a lot of ankle sprains. I do a lot of triaging, especially because I'm onsite. So I need to make that clinical decision on, you know, do we send them out for a radiograph? So utilize the Ottawa ankle rules, and seeing, you know, if they can't put weight on it, then they're definitely getting a radiograph. If they're having pain and they have that bony tenderness, then sending them out for a radiograph. And again, this is where I see us as physical therapists being able to make an impact in our communities in being that point person and make that decision so the athlete goes to the proper place versus just putting ice on it and then going home. And then, you know, so I've been able to kind of streamline that process for a lot of the athletes that I see. Karen Litzy: 13:56 Fabulous. And I don't think we need to go into the ins and outs of ankle sprain rehab. But have you found amongst this population, what is one thing you can tell another therapist if you do nothing else to rehab these gymnasts after ankle sprain, you must, must, must include this in your program. Duane Scotti: 14:20 Can I say two things? So first is one thing that I see overlooked a lot is mobility issues. So a lot of people have the assumption that you sprained your ankle, you have a loose ankle and we need just stabilization, stabilization. And that is important. Don't get me wrong. And kind of proper stabilization going from your balance activities proprioception to plyometrics. Definitely necessary need to do the plyometric training with your gymnast before you release them to do gymnastics training. But also checking for mobility issues, specifically lack of Dorsiflexion during like a weight bearing dorsiflexion test. And I've seen that where there's, you know, asymmetries on both sides and that's going to be important because when these gymnast land from their floor passes a lot of them, sometimes land short and if they land short, that requires more Dorsi flexion motion. So that can in turn cause you know more limitations of Dorsiflexion, anterior ankle pain. So you really want to make sure you normalize the joint mechanics and the talocrural joint and do your manipulation mobilization techniques to kind of restore that. So that's one thing. And then, especially if someone's been immobilized. So if there are mobilized in the walking boot or in an air cast, a lot of times you'll find stiffness in those joints as well as the distal tibiofibular joint. Karen Litzy: 15:35 Perfect. Thank you. That is great. I would have thought your firsthand, so we would have been propioception exercises, which are important, but I'm glad that you brought up the mobility stuff. Great. All right, let's talk about one more common injury that you see in this population. Duane Scotti: 15:51 So this is more your kind of growth plate injuries. So the kind of growing gymnast as they're growing, they go through that growth spurt. So commonly in the younger gymnasts, so like the nine 10 year olds, you're going to see like the Seavers, so they're going to have heel pain. The calcaneal apophysis and then as they get a little older, usually around 12 ish, you're going to start to see knee pain. So whether or not it's Sinding-Larsen-Johansson Syndrome, which is the inferior pole of the Patella or the more common one that everyone knows about osgood schlatters which is at the tibial tubercle. So you will tend to see these kind of growing pains if you will. The big thing is to educate the parents, the gymnast, and there are things that they could be doing at this time. Duane Scotti: 16:38 They don't just need to train through pain and usually it relates to soft tissue flexibility. So for Seavers, it's really the calf, the Achilles, make sure they're on a good mobility flexibility program for those structures. And then for the knee, a lot of rectus tightness I tend to see, so working on some of the flexibility mobility during this time period and watching load management, so maybe not doing their rigorous training and if they're going through that kind of gross spurt and they have some pain and now let's say like summer conditioning starting, then they might need, be able to kind of do a modified practice, especially when it comes to the jumping and the plyometric training. So they're not doing because we know that's what really caused it. And that's why the incidence is so high in gymnast is because they're going through this rapid growing and they do a lot of jumping, a lot of contraction of the Achilles and contraction of the quads. So that's why you tend to see pains in both the ankle and the knee area. Karen Litzy: 17:35 Perfect. Yeah, I had a patient a couple of months ago Seavers disease, she was nine and she was a gymnast. And what was really interesting is I would have her, because I needed to see how she jumped and how she landed. And I don't know if this contributed to it or not. In my line of thinking, I felt like maybe it did, but when she landed she tended to land in a very valgus position of her knees. And I don't know, can that, so looking at the biomechanics of the landing, can that help in the treatment of Seavers disease? Cause then we kind of worked on that so that she wasn't landing in quite such a valgus position. So that in my line of thinking was that if we can help to normalize her landing a little bit more, that she'd be able to more effectively use her calf muscle in order to land instead of being at this very sort of sharp valgus angle. Duane Scotti: 18:33 Yes. I think that's definitely important. And then even I guess going one step further than that is looking sagittal plane and with ankle Dorsi flexion. So if they're limited there because their Achilles is tight and their gastric is tight, I see that even more so. But maybe like you said, if even if they're weak hip muscles, so your abductors external rotators are weak and they're going into that dynamic Valgus, you know, could that be a contributing factor to different mechanics going down at the ankle? Possibly. Karen Litzy: Interesting. Yeah. There's so much to think about with these gymnast's that you would not think about in your ordinary population. Duane Scotti: Right, right. No, absolutely. And it is as you said that they have such high levels of training, you know, the girls I see, you know, once they get up to level six and above, they're in the gym for 24, you know, 25 hours a week. Duane Scotti: 19:21 So it's a lot of training. The only get like two weeks off a year. So it's like at the end of the season befor summer starts and then before a fall starts. So it's a lot of training, a lot of wear and tear on their bodies. And that's why it's so important to be able to pick up on, you know, contributing factors. Cause every gymnast is different too. So someone's going to have maybe a tightness in the front of their hips. Someone's gonna have some tight calves, so I'm just going to have maybe week shoulder muscles and they're starting to get shoulder pain with bars or tight lats. So that's a common thing where they're limited with overhead mobility with reaching. So you kind of need to identify what each one does. And that's what I like to do is to get them on like a customized kind of program and it's like, okay, here are your like top five exercises you should be doing before practice every single day. Duane Scotti: 20:03 So as opposed to just like chatting with your friends, like, let's prime the body, let's get, you know, warmed up. If it's rolling the front of your hips, doing some glute activation exercises, make sure they're turned on before practice starts. That's what they need to be doing. Karen Litzy: And you know, I was just going to ask you, what advice would you give to, let's say, any physical therapists out there listening to healthcare practitioner who maybe doesn't have the amount of experience you have with the gymnastic population, but like I said, maybe they've got a gymnast coming in and I feel like you just kinda answered that. Do you want to add anything to it? What advice you would give to that PT? Duane Scotti: 20:48 Don't be afraid to reach out and talk with the coaches. I think a lot of the gymnastics world and culture, I tend to see a little bit of kind of medical professionals on one side, coaches on the other. The coaches think that the medical professionals don't understand their sport and vice versa. The medical professionals think that the sport is just bad for them and they shouldn't be doing it almost that it's too much and it's not good for their bodies. So I think we need to kind of meet in the middle and actually communicate and have these conversations and you know, try to meet in the middle. And that's what I tend to do with the coaches and cause they, I could see where their mindset is. And I, you know, with my years of experience coming from the kind of clinical mindset and injury side, and I've shifted a little bit in some of my thought processes as well. Being able to actually be on site and see some of the training that they do and to see some of the practices. Duane Scotti: 21:32 So just don't be afraid to communicate and I guess reach across the aisle and be able to say, okay, this is what I'm finding, and even just letting them know that, hey, this is pretty irritable right now, but it's a minor problem, but if she can do a modified practice today and tomorrow and then she has off on Sunday, that will give her three days of this kind of protected rest phase and the next week she'll be able to do full practices to have you kind of frame it like that. Then the coaches are like, okay, I could, I could deal with that. Versus the coaches being like, no, they can't modify practice right now. We have a competition in two weeks. But if you've kind of framed it that way and say like, Hey, if we just allow these couple of days and then next week they're going to be able to have full practice without limiting themselves at all, then they're more likely to kind of go with your recommendations versus, you know, everyone being on kind of different sides. Karen Litzy: 22:20 Perfect. I think that's great advice. Communication is vital and everything we do with our patients from all the different stakeholders that are involved to the patient themselves, to parents and caregivers and to each other. So I think that's great advice. Thank you so much. And I have one last question for you and it's the one that I ask everyone and that's knowing where you are now in your life and in your practice. What advice would you give to yourself as a new Grad right out of physical therapy school? Duane Scotti: 22:51 So this is a tough question because I hear this all the time because I listened to all your podcasts and you would think I would have the answer right off the top of my head. But I would probably say, there's a couple things is one, just not be afraid to fail. Failure is good because we learn from that and then don't abandon certain techniques or philosophies early on if you're not getting it right. Continue to learn and grow, evolve. And that's how we all get better in what we do. Karen Litzy: 23:22 I think that's wonderful advice. That's perfect. Resonates with me. Very much so. Thank you, Duane, for coming back on the podcast again and educating us all around gymnastics medicine, so thank you. Duane Scotti: 23:32 Awesome. Thank you for having me. This has been great. Karen Litzy: 23:35 My pleasure. And everyone out there listening. Thanks so much. 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, Jenna Kantor guests hosts and interviews Megan Sliski and James Nowak on the New York Physical Therapy Association Student Special Interest Group. Megan is the NYPTA SSIG President, National Student Conclave Project Committee Chair and NYPTA Central District Conclave Committee Chair. James is the NYPTA SSIG Vice President. In this episode, we discuss: -The roles and responsibilities of the President and Vice President of the NYPTA SSIG -A few of the highlights and accomplishments of the SSIG this term -What Megan and James look forward to in their future leadership roles -And so much more! Resources: NYPTA SSIG Website Megan Sliski Twitter James Nowak Twitter For more information on Megan: Favorite PT Resource: PT Now School: Utica College: DPT 2020; Utica College: Health Studies, Healthcare Ethics "I'm excited to see the team grow & work together to create opportunities for DPT/PTA students around New York." For more information on James: Favorite PT Resource: New Grad PT School: Utica College: DPT 2021; Utica College: Health Studies "I'm so excited to be a part of a growing team that has the opportunity to truly enhance the student physical therapy experience in New York State." 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 here with healthy, wealthy and smart. And I'm here to interview Megan Sliski and James Nowak. First of all, thank you so much for coming on and agreeing to speak about drum roll please. The student's special interest group. You're here in New York and you two are a power duo and Megan here is the president and James is the vice president and you're halfway through now. Is that where you're at? About halfway through. So I would love for those who don't know, when people say, what does this SSIG do? That's the student special interest group. Could you start from the elections? Don't worry about taking me through the whole year. I'll ask you questions as we go through. So you got elected. What happens next? I'm going to hand it to Megan and then when you need help you can pass it over to James. Megan Sliski: 00:57 So when we first got elected, Jenna, a lot of it was just trying to figure out what the dynamic of the new team was going to be and how we were going to encompass the goals of the SSIG into the individuals that we were introducing into the SSIG. And so the beginning of the term involved a lot of transitioning and a lot of, of trying to make sense of, you know, what we were going to do and how we were going to progress forward. And the SSIG being just only in its infancy, only two years old at this point. You know, we had a lot to consider. We had to, to figure out, you know, what had worked the previous year, what hadn't worked, how are we going to move forward? How are we going to make this organization successful? How are we going to pair with the NYPTA and, and really make this an organization that was going to succeed. Megan Sliski: 01:44 And so at the beginning we really focused on trying to get to know each officer individually as well as trying to get to know the positions individually. And so the nominating committee chair from last year did a wonderful job slating candidates. And we were very fortunate that the candidates that we had were so wonderful and that all of the individuals who are elected were just so great for their positions. And you know, we're really lucky for that. And so what we did was move forward. We got to know the individuals on an individual basis and we figured out how we were going to make the organization work for us. That being said, you know, there were times where there were hurdles, but when aren't there hurdles will a new organization, especially when the organizations only in it's second year. And we were fortunate enough that, you know, James and I actually go to the same school. Megan Sliski: 02:32 And so we were able to meet almost weekly to talk about some of the challenges we were having in some of the successes and how we were going to make sure that the successes continued. But at the same time, how are we going to approach the challenges that we were having? Again, with it being a new organization. And I happen to think that we're very lucky that James and I went to the same school because in the second year of this organization, we were able to work through some things that were a bit challenging that we hadn't maybe thought about before, that maybe weren't issues the year before. And I think that we've been very lucky so far with the caliber of people that we've had and the team that we've had. And I think that the rest of the year it's going to be so wonderful. I love that. Jenna Kantor: So, James, for you, when you got elected, what happened? Was there a meeting? Was there, I mean, you already knew Megan, I'm assuming. I would love to know. James Nowak: 03:26 It's actually a really funny story. So I'm wrapping up in my first year of DPT school and I remember, It's the fall with heavy musculoskeletal stuff. And then this girl by the name of Megan comes in and does a little introduction on this state organization, state student special interest group called the NYPTA SSIG. And immediately within, probably within a couple of minutes of her presenting it, I said, oh my God, this like, like this is for me, this is what I want to be a part of. And at the time, I probably saw Megan around a little bit, but I had never talked to her. And I gathered up the courage and I introduced myself and I said, you know, this right here is something I want to be a part of. James Nowak: 04:13 I want to make a difference, not only at my school, but on the state level I want to interact with students and professionals both throughout the state, you know. And so I said, I went up to her and I said, how do I get involved? And then she kind of talked me through the election process and how that was gonna be coming up. She did a little presentation right before elections ran. And so from there I decided to apply. And thankfully I got slated. Luckily, luckily enough, I got elected as the vice president. And I was very, very thankful for that. And I think my process after that really my first initial thought was, okay, so now I'm a part of the state organizations, such a phenomenal opportunity. I wanna be able to work with students throughout the state. James Nowak: 04:58 I'm here in central New York. You know, if you think of a map of New York state, you put a dot right in the middle. That's where I am. And I'm going to get to work with people who are all the way down south in the city and all the way up towards Canada. And getting to being able to really get the wealth of knowledge and experience from them. It was very exciting to me. I hadn't had the opportunity to interact with the students yet. So I think my first thing was really getting to know my team, you know, getting to know the people who were elected. So initially it was phone calls, just to get to know them. Eventually as the year turned to the start of our term. James Nowak: 05:41 We had a nice transitional meeting, so we had a transitional meaning from our board from the previous year and the people who are elected for this year that we're currently in. And that it wasn't just a phone call on the phone, it was face to face through the computer. Really, it's almost like Skype, but they use, it's a platform called goto meetings that we use. And I got to see the past president of the SSIG and I got to see all the people that I was working with throughout the year and it was such a unique opportunity to be able to interact on that level. Even though I'm sitting in my apartment in Utica, New York, I got to talk with students who were from, you know, places like Columbia all the way down in the city. And that was such a unique opportunity. Jenna Kantor: 06:25 I love that. So for you, James, what have you been doing? Cause you look over all the regional reps. So for those who don't know, I was part of the SSIG, so I'll educate you guys on this. So there are regions within New York in which there is a student that represents several schools and we'll handle the communications with several schools because New York is huge and we have a lot of schools here. So when you're working with the regional reps, how often do you meet and how do you run those meetings? James Nowak: 07:00 So I think that's a great question Jenna. As of right now, we try and meet on a monthly basis. And with that being said, coming up towards our midterm here where, you know, something we really put at the forefront is getting immediate feedback on things and we're going to get feedback from students and see is that something that's working? Is this something that's not working? You know? So that's something we're going to see. But as of right now, that's kinda how we do things and enables us to really, on a monthly basis be able to say, okay, so these are the things we're working on. How can we contribute? How can the representatives throughout the state really add various ideas to your advocacy dinner? Let's say for example, that you're planning, you know, how can we bolster this? How can we support you to make this a reality? Jenna Kantor: 08:11 I love that. I love that. So they're not thrown to the wolves. Megan, for you, we went a little bit backwards because I jumped to the interactions with the regional reps. You're working with the board. So I always forget because there's the main board and then there's the extension people. What are the terms? The advisors and the advisory panel. I should know this because I was on the advisory panel but, but so in these meetings with the advocacy chair, somebody who's in charge of volunteering and somebody who's in charge of events. What do you guys discuss or what even did you guys discuss and how was it passed along to James to be passed along to the regional reps? I mean just throwing out 5 million ideas. Megan Sliski: 08:56 So I think that that was something that was a challenge last year. We were trying to work through how do we communicate from the executive board and advisory panel to the Board of Representatives. And that's something that James and I did not take very lightly this year. We worked very hard to figure out how we were going to communicate with the board representatives. The Board of Representatives and the liaisons are our main contact with the schools. And without them, our structure falls apart. We need them, we need the communication with them. They need to know what's going on. And so the way that we worked through this was yes, we had our executive board meetings where the executive board talked with the advisory panel and we figured out the plans for everything and we figured out, you know, what we were going to do for the rest of the term or even for just the upcoming months. Megan Sliski: 09:53 Not even extending until the end of the term and just focusing on the now. So we would talk through that. But what we added this year, Jenna, that I think you'd be very happy to hear is that the board of Representatives were invited to every single executive board meeting. And so not only do they know what's going on at the executive board meetings, they have active voices in what's going on at the executive board meetings. So the board of reps have become this voice for us, the voice of we know what's going on in this region, we understand our schools, we can give you the information that you need to help the SSIG be successful right now in these regions, in these schools. And I think that that was what was crucial and that's what we added in, that's really been beneficial to our organization is that we've been able to encompass all of our officers and we've been able to involve all of those officers in the decisions and we've been able to hear all the different perspectives and I think that's been great. Jenna Kantor: 10:55 How did you narrow down exactly what you were going to be doing this year, Aka advocacy dinners or even conclaves? Megan Sliski: We haven't actually, we haven't narrowed that down and I think that maybe that's one of our strengths is that we're trying to figure things out as we go. I talked earlier in the podcast about how this organization is in its infancy and how we don't actually know exactly where it's going. And I think maybe that's the best part of this organization right now is that we don't know. You know, so we've thrown off ideas, we've talked, we figured out what everyone's strengths are. We figured out where we can go with the ideas that we have. And from that we've decided that, you know, we have a very strong advocacy chair who's really great at working with the student assembly and working with you as the past advocacy chair. Megan Sliski: 11:47 She's had wonderful mentorships. Which I can say for a lot of our officers, actually all of our officers, they've had wonderful mentorship to be able to guide them to what we've done now. I think that talking about the strength and talking about, you know, what succeeded last year, you know, what we can do better from last year. We had such a strong board last year and they left us with such monumentous advice and you guys were so wonderful in guiding us to where we needed to be for the next year. And we've taken that and we've run with it, you know, and everyday we may not have the answer to what we're doing tomorrow, but I think that right now the plans that we have in place are wonderful and I think they're great for enhancing the student experience. Megan Sliski: 12:36 And I think that as the term continues, we're just going to keep coming up with more ideas and we're just going to be able to keep invigorating students to be able to get involved with the special interest group. And personally, that's what I love about it. I think that every day we just grow more and more as an organization and I love that. Jenna Kantor: So what have you guys accomplished this year so far? You share some and you share some split the mic. Megan Sliski: So I'll start. I don't want to sell so much of James' thunder, but I think so far one of the wonderful things that we've come up with is that we've voted in the establishment of an advocacy task force. And we've also voted in the establishment of a service task force. Megan Sliski: 13:21 The advocacy task force is going to promote legislation nationally and statewide to help students become more informed on the issues that really pertain to us as physical therapists and physical therapist assistants. And the service committee, the service Task Force, I'm sorry I should use the right language, is going to really focus on helping our service chair with implementing a really great day of service project. Something that we really hold to high standards in New York state. And I am so excited to see what they accomplish. So I'll give the mic to James and I'll let him talk about more of our successes. James Nowak: 13:55 Well, without further ado, so I think really two things stand out to me early on. One first is it's really a continuation of last year and it's really implementing the advocacy dinners. We've really tried to put a focus on students networking not only with themselves but with professionals as well too, to really advocate for our profession out always. PTs with PTAs as well with one common goal of, educating folks, educating just our regular public along with educating our legislators. You know, that's put a focus on is initially, you know, extending that to things such as lobby day. And really just letting students know that, hey, this is something, you know, your classroom education has relied on. It's very important, but you also should be concerned about some of the legislative issues that are going on cause it's really going to impact your future. James Nowak: 14:48 So we've already had a couple of advocacy dinners. We've had some standout speakers such as former NYPTA president, Dr. Patrick VanBeveren. He gave a phenomenal presentation at Utica College. And really I want to say with that is a huge shout out, not only to our advocacy chair Liping Li for, for really making these things happen, but also, our regional representatives, down to the liaisons at each individual school. Really Planning and being our boots on the ground. We're making these things happen. They did a phenomenal job. And I would say our second accomplishment of this year, which I really feel strongly about is connecting with the NYPTA and specifically the NYPTA districts. Something we've really made a push for is to start to really try in and promote similar events, you know, and get students involved in mingling with the professionals in their various regions. We had our regional representatives actually reach out to the district chairs and the NYPTA and really trying to foster that relationship. So then you know, in the future we have that great connection with professionals who are in the field, and that will really provide students with phenomenal networking opportunities that they might not be able to get at their individual programs, but they can receive that from us. Jenna Kantor: 16:16 I freaking love that. Okay. So I am going to move you both forward into the future. The future of when your term ends. What are you going to miss most? Megan Sliski: 16:36 I think what I'm going to miss the most is being able to inspire the students in New York from my leadership position as the president. I'm going to miss talking with them on a weekly basis and you know, hearing their thoughts and hearing their opinions on how we're going to better things for the physical therapy profession in New York state. But I say I'm going to miss that. Although I have a feeling that those relationships aren't going anywhere and I have a feeling that knowing myself, I'm still going to be reaching out and talking to all of those individuals I think I'm going to miss inspiring the team. I think I'm going to miss the SSIG. This being my second year involved I think the SSIG has really given me an opportunity to grow and I think it's helped me realize who I am as a person and who I want to be as a professional. And although I'm eternally grateful to the SSIG for what it's given me in my role as a graduate student, I'm gonna miss that. I think I'm gonna Really Miss Interacting with the people that I've met, but I also know that that's not the end of what I plan to do. And although it'll be a little bit of a bittersweet ending, I'm excited for what comes after the SSIG for me. James Nowak: 17:58 Just got to wipe away my tears after that one. I don't know how I'm going to follow that. What I think really going off what Megan was saying, our organization, one of the things were really true is we try and do is deliver the experiences to students throughout the state. And that I think I would miss a lot is hearing feedback from schools saying, did you know, did you like this? You know, and stuff like that. And really being able to implement things that, you know, and give students the experiences that they might not be necessarily getting in the classroom directly. But I think just Kinda like what Megan was saying, working with the team, you know, when you're in an organization like this and you're able to network with students throughout the state, you really do build close bonds, you know, and there's something about that atmosphere of, you know, coming together, collaborating, sort of to deliver those experiences and really make a difference. You know, what we're doing here is we are inspiring and we are educating the future professionals of our field and to really be at the forefront of that is something that I think I'd miss greatly. Megan Sliski: 19:09 I want to comment James on what you just said. So I happen to think that our dynamic duo of leading a team isn't quite over yet. And so our sounding all somber here and sad about leaving, I have a feeling that James and I are going to continue our little teamwork and leading teams and things are just going to get a little bit better. So look out for the dynamic duo. Jenna Kantor: I love it. Well, thank you so much dynamic duo for coming on. Take care everyone. Thanks for tuning in. 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 Graham Sessions 2019 in Austin, Texas, Jenna Kantor guests hosts and interviews Lisa VanHoose, Monique Caruth and Kitiboni Adderley on their reflections from the conference. In this episode, we discuss: -The question that brought to light an uncomfortable conversation -How individuals with different backgrounds can have different perspectives -How the physical therapy profession can grow in their inclusion and diversity efforts -And so much more! Resources: Lisa VanHoose Twitter Monique Caruth Twitter Fyzio 4 You Website Kitiboni Adderley Twitter Handling Your Health Wellness and Rehab Website The Outcomes Summit: use the discount code LITZY For more information on Lisa: Lisa VanHoose, PhD, MPH, PT, CLT, CES, CKTP has practiced oncologic physical therapy since 1996. She serves as an Assistant Professor in the Physical Therapy Department at University of Central Arkansas. As a NIH and industry funded researcher, Dr. VanHoose investigates the effectiveness of various physical therapy interventions and socioecological models of secondary lymphedema. Dr. VanHoose served as the 2012-2016 President of the Oncology Section of the American Physical Therapy Association. For more information on Monique: Dr. Monique J. Caruth, DPT, is a three-time graduate of Howard University in Washington D.C. and has been a licensed and practicing physiotherapist in the state of Maryland for 10 years. She has worked in multiple settings such as acute hospital care, skilled nursing facilities, outpatient rehabilitation and home-health. She maintains membership with the American Physical Therapy Association, she is a member of the Public Relations Committee of the Home Health Section of the APTA and is the current Southern District Chair of the Maryland APTA Board Of Directors. For more information on Kitiboni: Kitiboni (Kiti) Adderley is the Owner & Senior Physical Therapist of Handling Your Health Wellness & Rehab. Kiti graduated from the University of the West Indies School of Physical Therapy, Jamaica, in 2000 and obtained her Doctorate of Physical Therapy from Utica College, Utica, New York, in 2017. Over the last 10 years, Kiti has been involved in an intensive study and mentorship of Oncology Rehabilitation and more specifically, Breast Cancer Rehab where her focus has been on limiting the side effects of cancer treatment including lymphedema, and improving the quality of life of cancer survivors. She has been a Certified Lymphedema Therapist since 2004. She is also a Certified Mastectomy Breast Prosthesis and Bra Fitter and Custom Compression Garment Fitter. 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. And here I am at the Graham sessions in 2019 here. Where are we? We're in Austin, Texas. Yes, I'm with at least. And we're at the Driscoll. Yes. At the Driscoll. Yes. I'm here with Kiti Adderley, Monique Caruth and Lisa VanHoose. Thank you so much for being here, you guys. So I have decided I want to really talk about what went on today, what went on today in Graham sessions where we were not necessarily hurt as individuals. And I would like to really hit on this point. So actually Lisa, I'm going to start by handing the mic to you because you did go up and you spoke on a point. So I would love for you to talk about that. And then Monique, definitely please share afterwards and then I would love for you to share your insight on that as well. All right, here we go. Awesome. Lisa VanHoose: 00:52 So first of all, thank you so much for giving us this opportunity just to kind of reflect on today's activities. And so, I did ask a question this morning about the differences in the response to the opioid crisis versus the crack cocaine crisis. And I was asking one of our speakers who is quite knowledgeable in healthcare systems to get his perspective on that. And he basically said, that's not really my area. Right. And then gave a very generic answer and as I said earlier to people, I'm totally okay with you saying you don't know. But I think you also have to make sure that that person that you're speaking to knows that I still value your question and maybe even give some ideas of maybe who to talk to and this person would have had those resources. But, I guess it was quite evident to a lot of people in the room that they felt like I had been blown off. Lisa VanHoose: 01:48 So yes. So that was an interesting happenings today. Jenna Kantor: And actually bouncing off that, would you mind sharing how this has actually been a common occurrence for you? You kind of said like you've dealt with something like this before. Would you mind educating the listeners about your history and how this has happened in your past? Lisa VanHoose: I think, anytime, you know, not just within the PT profession but also just in society as general when we need to have conversations about the effects of racism. Both at a personal and systemic level, it's an uncomfortable conversation. And so I find that people try to bail out or they try to ignore the question or they blow the question off and ultimately it's just, we're not willing to have those crucial conversations and I think they almost try to minimize it. Right. Lisa VanHoose: 02:41 And I don't know if that comes from a place of, they're uncomfortable with the conversation or maybe they just feel like the conversations not worth their time. But, I can just tell you as just a African American woman in the US, this is a common occurrence. As an African American PT, I will admit it happens a lot within the profession. But I do think that there are those like you and like Karen and others that are willing to kind of move into that space because that's the only way we're going to make it better. Jenna Kantor: Thank you. Thank you for giving me that insight. Especially so because people don't see us right now, so, so they can really get a fuller picture of it. And now, Monique, would you mind sharing when you went up and spoke, how that experience was for you, what you were talking about and how you felt the issue that you are bringing up was acknowledged? Monique Caruth: 03:37 Well, as Lisa said, we're kind of used to talking and it going through one ear and out the next day and our issues not really being addressed. I think it comes from a point where a lot of Caucasians think that if you try to bring it up, they would be blamed for what was done 400 years ago, 300 years ago. So it comes from a place of guilt. They don't want to be seen as they have an advantage. And I think as blacks we had a role to play in it by saying, oh, you're white and you're privileged. So you had an advantage, which structurally there is an advantage. There is structural advantages as I was discussing with Lisa and Kiti last night that as an immigrant, even though I'm black, they're more benefits that I've received being here than someone who was born maybe in Washington DC or inner city Chicago or maybe even, Flint, Michigan. Monique Caruth: 04:51 I can drink clean water, I can open my tap and drink. What I don't have to worry about, you know, drinking led or anything like that. I can leave home with my windows open, my doors open and feel safe that my neighbors will be looking out for me and stuff that I can walk my neighborhood. So there are privileged even though I'm black, that some people that can afford and would I be ashamed of being in that position? No, acknowledge it. And even with an all black community, there are a lot of us, we may not have been born in a world of wealth. I wasn't, my parents sacrificed a lot to get me where I am today, but not because I have somewhat made it means that I have to ignore the other people that have struggled. Monique Caruth: 05:43 And this is a problem that I'm noticing in a lot of black communities, like when someone makes it or they become successful, Aka Ben Carson, Dr Ben Carson, we feel that if I can make it, why can't you? And because some of those people were not afforded the same privileges that you were afforded, and it's kinda not fair to make that statement that if I made it. So can you, and you can't tell people that you worked your butt off and pull yourself up by your bootstraps when you were afforded welfare stuff. Your, you know, your mom benefited from stuff. I was afforded scholarship so that I don't have to have $200,000 in debt. So I could afford to purchase a home after I graduated and all that stuff because I was not in debt. Monique Caruth: 06:47 And a lot of people do not have that luxury. So I can tell people if I can do it, you can do it too. I have to try to find ways to address their concerns and see how I can better help them to move forward and live better. And the problem within our profession is that many in leadership, even though they see themselves as making it, they don't want to have acknowledge that not everyone comes from the same place. It's not a level playing field. And they try to dismiss those by saying, Oh, if I can make it, everybody else can as well. Jenna Kantor: Thank you. Well said. Well said. Kiti. would you mind sharing in light of what everybody said, some of your thoughts on this matter? Kitiboni Adderley: 07:30 While it was interesting to watch the conversation, listen to the conversation today. I have a unique perspective in that I don't practice in the United States. I don't live in United States, but I frequently here taking part in education, but also watching the growth and development of the physical therapy profession. So I'm from The Bahamas and it's predominantly African descent population. Right? And so some of the issues that people of color in the United States deal with, we don't really deal with those in terms of that limitations and privileges. And you know, it's more of a socioeconomic for us. And once you can afford it, then you go and do. And, and I think we're pretty fortunate if we talk about while across the board that most people can afford some form of education and get it. Kitiboni Adderley: 08:30 So I'm in a unique position because I look African American, it was, I don't open my mouth. You don't know. And so I'm privy to some conversations on both sides of the role, you know, and if people are probably, so what do you think about this and how do you feel about that and how does it bother you? And you know, so while I'm not the typical African American and they see them start to take a step back and it sort of gives you the understanding that they don't truly understand that every person of color does not have the same story. And so you can approach us expecting us to have the same story. Right? Cause your three x three women of color here, one's born and bred African American ones born and bred Trinidad and transplanted United States and one's born and bred, still working in The Bahamas and the Caribbean. Kitiboni Adderley: 09:17 Good. So we all have different perspectives that we all come from different backgrounds and different experiences. But it was interesting and when Lisa asked a question and you know like, you know, people say you will, you know you need to bring it up if we don't talk about these things enough. And it's almost like, okay, you bring up the conversation. So the balls in play, it's tossed from one play at an accident and be like, Oh shit, we can handle, listen to bar this draft again. And so the conversation shuts down and you're like, but you didn't answer the question and you're like, you know, well, yeah, okay, well we'll throw the ball up in the air. And at another time, and I think this is where the frustration comes in for people of color that live in United States because you want us to have these conversations were given quote unquote, the opportunity to ask questions or have these discussions and the discussions come up and at the end of it it's like, okay, we just gave you the opportunity to discuss where do we go from here? Kitiboni Adderley: 10:14 What's done, what's the recourse, what's our next step? What's our plan of action? And when we talk about inclusion and diversity, if you're not going to take it to the next step, if you're not going to have a call to action, then what's the point? And this is why probably people of color don't come back out again because what's it's a bit, it's a bit annoying. It's like frustration because you stand there, you're waiting for a response. And I was like, oh, well, you know, this isn't my field and I appreciate the honesty, but then let's address this at some point we have to address this. So do we need another meeting just to address this? Do we have to have, you know, just, let's pick the topic and work on it. So like I said, it was a very unique perspective. Kitiboni Adderley: 10:57 I sort of like watching the response of the other people in the room and see how they respond to it, but the conversation needs to keep going for those of us who can tolerate it or have the patience to deal with it at this given time. And, it was a great experience. It was a good experience. Jenna Kantor: I love it. So I would have just one more question for each of you and it's what would you recommend we do as a profession, both individually and as a collective in order to grow in this manner? Monique Caruth: 11:37 Well, piggy backing off of what Kiti mentioned, I was sort of blown away too when he said that that's not his field because he's a reporter, he does documentary stuff all you was asking was one opinion you want asking for, you know, an analysis or anything. It was just an opinion and he refused to give that. And his excuse was, I don't know much about it and what was, it wasn't surprising but no one else in the crowd said well we then address her concern and immediately he was, she didn't put it in a way that made it seem or the crack epidemic was black and the opioid crisis as white. He was the one who drew it up cause I was actually praising her for how skillfully she worded it. I'm learning a lot of tack from obviously Lisa I'm not that tactful and my family tells me I need to be tactful, but it's that no one else said, okay, let's discuss it. Monique Caruth: 12:51 Really. Why, why is APTA making such a big push choose PT. Now. Versus in the 80s when the crack and the crack epidemic was destroying an entire city because DC was known for being chocolate city on the crack epidemic, wiped it out and it got judge all. Alright, it rebuilt it. But now again, it's trying to find like I went to Howard University, you know, I could walk around shore Howard and I'm like, am I in Georgetown? Because you don't recognize, you know, the people live in that. It has driven out a lot of blacks that were living in drug pocket. You know, it's now predominantly, young white lobbyist living in the area. So if we don't have the support of our colleagues, how can we address inclusion? How can we address equity if they're not willing to put themselves out there to say, Hey Lisa, I got your back. Monique Caruth: 14:05 We need to talk about this. We need to discuss it. Let's have a discussion. Your question was not answered. It wasn't even to say that it was acknowledged with a dignified response because we're spending millions of dollars under choose PT campaign. Why is it because the surgeon general is saying, oh there needs to be another alternative because Congress is trying to pass bills to lower the opioid crisis. Why? If you asking people to choose PT what makes it different? Okay. Even with the Medicaid population, the majority of people who receive Medicaid are black and brown. Are we fighting to get make that people have medicaid coverage or other stuff. Or are we fighting running down Cigna and blue cross blue shield and Humana and all those other types of insurances? Because we think the money is in these insurances. When they could dictate whatever they want, then you could provide a service and say you're providing quality service. Monique Caruth: 15:14 But if they say, oh, we're just gonna reimburse you $60 we are getting $60 and people on our income. So people complain on Twitter and on social media about, you know, insurance stuff. But if I see a medicaid patient in Maryland, I am guaranteed $89 and that person has the treatment. They're being seen, they're getting better. It's guaranteed money. But a lot of people don't want to treat the Medicaid population because they think they're getting blacks or Hispanics. And I hear complaints like I don't really want to treat that population because we are going to have no shows and cancellations and all that stuff, which is bs. It's excuses. And we have to do better as a profession to acknowledge or biases and work on ways to help work with the population that we serve. Because let's face it, America is not going to remain white? It's gonna get mixed. We're going to have some more chocolate chips in the cookies. Okay. All right. It's going to be more than two chocolate chips in the whole cookie next time. Jenna Kantor: 16:33 Before I pass it to you, Kiti, I really like where you're going with this, Monique, and I think it's important to acknowledge why, which I didn't at the beginning. Why, why, why we're tapping on this one incident and really diving in and it's because what I learned today from my friends is that this is a common occurrence in the physical therapy industry. It's not just it and it's not just within our industry. It's what you guys deal with regularly. And if we are talking about our patients providing better patient care, we need to really, really be fully honest with where we are at. Even as they are speaking, I'm constantly asking myself, what are my things that I'm holding within me where I'm making assumptions about individuals? There's always room for growth. So please as you continue to listen to Kiti speak next, just keep letting this be an opportunity to reflect and grow. Kitiboni Adderley: 17:50 Okay, so I recognize that incident was uncomfortable. It was an uncomfortable conversation to have and it's okay to have uncomfortable conversations. As physical therapists, we have uncomfortable conversations with our patients all the time. We have uncomfortable conversations with our colleagues and we have to call them out on some mal action or when they call us out on something that need to do. And because the conversation is uncomfortable, it doesn't mean that we don't have it. We probably need to talk about it more. And so if there's anything that I want to say, I think we need to have more of these conversations and have them until they no longer become uncomfortable until we could actually sit down with, well no, I shouldn't say anybody but, but the people of influence, cause this is what it's really about. We were sitting with very influential people today and all of us there, I'm sure where people of influence and you know, this is what we need, this is what we need to use. And don't be afraid to have the conversation. As uncomfortable as it may make you feel. Why are we having this conversation? We want inclusion, we want diversity, we want a better profession. And those are the goals of the conversation. We shouldn't shy away from it. Jenna Kantor: Thank you. I'm gonna hand this over to Lisa for one last one last thing. Lisa VanHoose: 18:43 So I just want to talk about the fact that part of the conversation was this dodging right? Of a need to kind of have this very authentic and deep conversation. The other part of today's events that I'm still processing is this conversation about the need for changed to be incremental, right? Comfortable. And for those of us that are marginalized to understand that the majority feels like there has been significant change and that was communicated to me in some side conversations and I was challenged by one person that was like, well, I think you have this bias and you're not recognizing the change that has occurred and how that this is awesome that we're even in a place to have this, that we're having this conversation today. Lisa VanHoose: 19:46 You know, that you need to acknowledge that success that we've made. And so I do agree that, you know, what all work is good work and I will applaud you for what has been done today. But I also would say to people who feel that way, step back and say, okay, if the PT profession has not really changed as demographics in the last 30 years, and if you were an African American and Hispanic and Asian American, an Asian Pacific islander or someone of multiracial descent would you be okay with that? Saying that, you know what, I started applying to PT school when I was in my twenties and I'm finally maybe gonna get in my fifties and sixties. How would that feel? Right? That wasted life because you're waiting on this incremental change. And I think if we could just be empathetic and put ourselves in the other person's shoes and say, would I be okay with waiting 30 years for a change? Lisa VanHoose: 20:53 Would I be all right with that? But I often feel like when it is not your tribe that has to wait, you okay with telling somebody else to wait? Right? And so, I want to read this quote from Martin Luther King and it was from the letters from Barringham where he criticized white moderates and he said that a white moderate is someone who constantly says to you, I agree with your goal, with the goal that you seek, but I cannot agree with your methods of direct action. Who believes that he can set the time table for another man's freedom. Such a person according to King is someone who lives by a mythical concept of time and is constantly advising the Negro to wait for a more convenient season. And that's how I felt like today's conversation from some, not all was going. King also talked about the fact that that shallow understanding from people of goodwill is more frustrating than the absolute misunderstanding from people of ill will. Luke warm acceptance is much more bewildering than outright rejection. And I say that all the time because I would prefer that you be very honest with me and say, I don't really care about diversity and inclusion, but don't act like you're my ally. But then when it's time to have a hard conversation, you say, I can't do that. I'm like, choose a side, pick a side. There is no Switzerland. There is no inbetween. Jenna Kantor: 22:25 Thank you so much you guys. I'm so grateful to be having this conversation to finish it with a great Martin Luther King quote, which is absolutely incredible. I'm just full of gratitude, so thank you. I'm really looking forward to this coming out and people getting to share this joy of learning and growth that you have just shared with me right now. Lisa VanHoose: And thank you for being an ally. We really appreciate that. So we're not, I just want people to know, we're not saying that the African American or the immigrant experience is different from the Caucasian experience. I think we all have this commonality of being othered at one time or another, but yes, with being a white female LGBTQ, I think the complexities of who we are as a human, there's always going to be a time where you're an n of one or maybe of two and you get that feeling that, Ooh, am I supposed to be here? But I think what we're talking about is being empathetic and if we're going to talk about being physical therapists, being practitioners and compassionate, and we're going to provide this patient centered care, how can you tell me you're going to provide patient centered care when you can't even have a conversation with me as a colleague, right. When you can't even see me. So I just want the audience to know, that we're not coming from a place of being victims were coming from a place of really wanting to have collaborative conversations. Monique Caruth: 23:59 I like to view my colleagues as family members. There are times, as much as I love my family, my mom and my dad and my sisters and my brothers in law, there are times we will sit and have some of the most uncomfortable conversations, but at the end of it it's out of love. It's all for us to grow as a family. And Yeah, you may not talk to the person for like a day or two, but you're like, shit, you know, that's my sister, that's my brother in law. You know, I have to love him. But you know, you try to hear their perspective, you try to make sure they hear your perspective and you come out on common ground so that the family can grow. And we don't treat this profession as a family, the ones who are marginalized are treated as step children. Monique Caruth: 24:57 And that's a bad thing because stepchildren usually revolt. And when they revolt, the ones who are comfortable with incremental change and are afraid of chasing the shiny new object. Because when I heard that comment today, I felt like the shiny new object was diversity, equity and inclusion that people were trying to avoid without saying it outright. And, someone who feels like they have been marginalized. It was like a low blow. So I, for one, appreciate people like you, Ann Wendel, Jerry Durham, Karen Litzy, and stuff. Who Have Sean Hagy and others, Dee Conetti, Sherry Teague reached out to us and say, how can we help? And you need people like that to be on your side. Martin Luther King needed white people. Okay. Rosa parks needed white people. Harriet Tubman needed white people to get where they're, even Mohammed Ali needed white people to be as successful as he is. We all need each other. If we are saying championing better together, how can you be better together if you're not willing to hear the reasons why you feel marginalized or victimized, it's not going to work. Stop turning around slogans or bumper stickers and start working on fixing the broken system that we have. That's all I'm asking for and we got to start working as a family, as uncomfortable as it may be. All right, we'll get over it and you're going to like and appreciate each other for it later on. Jenna Kantor: 26:44 Thank you guys for tuning in everyone, take care. 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 on the Sport Physiotherapy Canada Facebook Page, I welcome Greg Lehman on the show to preview his lecture for the Third World Congress of Sports Physical Therapy in Vancouver, Canada. Greg is a physiotherapist, chiropractor and strength and conditioning specialist treating musculoskeletal disorders within a biopsychosocial model. He currently teaches two 2-day continuing education courses to health and fitness professionals throughout the world. Reconciling Biomechanics with Pain Science and Running Resiliency have been taught more than 60 times in more than 40 locations worldwide. In this episode, we discuss: -Common misconceptions surrounding the source of pain -Do biomechanics matter? -Promoting movement optimism in your treatment framework -What Greg is looking forward to at the Third World Congress of Sports Physical Therapy -And so much more! Resources: Greg Lehman Website Greg Lehman Twitter Third World Congress of Sports Physical Therapy David Butler Sensitive Nervous System Alex Hutchinson Endure For more information on Greg: Prior to my clinical career I was fortunate enough to receive a Natural Sciences and Engineering Research Council MSc graduate scholarship that permitted me to be one of only two yearly students to train with Professor Stuart McGill in his Occupational Biomechanics Laboratory subsequently publishing more than 20 peer reviewed papers in the manual therapy and exercise biomechanics field. I was an assistant professor at the Canadian Memorial Chiropractic College teaching a graduate level course in Spine Biomechanics and Instrumentation as well conducting more than 20 research experiments while supervising more than 50 students. I have lectured on a number of topics on reconciling treatment biomechanics with pain science, running injuries, golf biomechanics, occupational low back injuries and therapeutic neuroscience. While I have a strong biomechanics background I was introduced to the field of neuroscience and the importance of psychosocial risk factors in pain and injury management almost two decades ago. I believe successful injury management and prevention can use simple techniques that still address the multifactorial and complex nature of musculoskeletal disorders. I am active on social media and consider the discussion and dissemination of knowledge an important component of responsible practice. Further in depth bio and history of my education, works and publications. Read the full transcript below: Karen Litzy: 00:00 Hey everybody, welcome to the live interview tonight with Doctor Greg Lehman. And we have a lot to cover tonight. So for everyone that is on watching, oh good. And we're on. Awesome. Just wanted to make sure, for everyone that's on watching and kind of throughout the interview, if you have any comments or you have any questions or you want to put Greg on the spot, feel free to do so. We can see your comments as they come up. Greg, if you can't see them, just know I'll kind of let you know. But one thing we do want to know is if you're watching, say hi and let us know where you're watching from. And that way when you start asking questions, at least I'll have a better, kind of know who you are a little bit. Now before we get to the meat of the interview, I just want to remind everyone that if you are watching this, this is not on my page and it's not on Greg's page, but instead we are on the Facebook page for the Third World Congress in Sports Physical Therapy and that is going to be taking place on October 4th and fifth in Vancouver, Canada. Karen Litzy: 01:20 So hopefully we're going to be doing more of these throughout the year talking to a lot of the presenters and Greg is one of the presenters at the congress. So that's why he's here. Greg Lehman: 01:31 Not just me every time Karen Litzy: 01:35 Although I have to say, I bet people would really enjoy that. Greg Lehman: 01:39 Yeah, I'll fill in for whatever speaker it is and I'll just learn their stuff and then pretend like I know Karen Litzy: 01:46 Okay. So I'd like to see you fill in for Sarah Haag. Greg Lehman: 01:50 Done. I'll shake my pelvis. Karen Litzy: 01:53 Pelvic health and stuff like that. That would be amazing. I would actually wouldn't mind seeing that. Now before we get started, Greg, can you talk a little bit more about yourself, just kind of give the listeners, the viewers here a little bit more of a background on you so that they know where you're coming from, if they are in fact not familiar with you. Greg Lehman: 02:13 Okay. Well, leading into that, I'm a generalist. I'm not a specialist. I have a background in kinesiology and then a master's in spine biomechanics and I was really into spine biomechanics for a long time. But you know, I became not, sorry, I was going to say dissolutioned. That's a little too strong. I've always been skeptical, skeptical of everything that I've known, and that's probably why I got accepted to my master's in biomechanics because they liked the questions I asked. And then my research there was in mainly exercise, like EMG and manual therapy, what manual therapy does. And I was pretty lucky because I was with Stuart McGill and two chiros named Kim Ross and Dave Breznik, who I always have to mention. And I should give a big shout out to Stu because he took on Kim Ross Dave Breznik who were chiros at the time and they did like amazing research that challenged so much of what we know about, you know, spine manipulation. Greg Lehman: 03:19 And they also challenged me to think about what I thought about low back pain at the time. So my master's was really helpful for me because it challenged so much of what I thought. And so that's when I was first introduced to the bio psycho social, not actually first, cause I used to read John Sarno when I was like 19 years old. I was a bit of a nerd when I was a kid. But definitely the occupational biomechanics at Waterloo, even though they love biomechanics, even back then they knew that psychosocial factors were important for your pain and injury. And then I went to chiro school, actually I went to, that's like in quotes. I like was registered, but I didn't go to class, but I had a research program and they were awesome. They funded me to do more biomechanical research. Then I was in practice for a long time and then I went back to physio school and then I was in practice for a long time and didn't do a lot of research. And then I just started teaching with John Sarno who's running the conference with the running clinic and they were great. And at the same time I also started teaching my course which is about biomechanics and pain science. How do we like bring them together? And you've hosted me. Karen Litzy: 04:38 I've taken that course. Yes. Greg Lehman: 04:41 For you is like an echo chamber. Just it was confirmation bias. Yeah, yeah, yeah. We know this shit, Greg. But thanks for confirming what I already know. And my course does that a lot, which I don't mind. So that's me. There you go. That was fun. Karen Litzy: 04:56 Excellent. Very good. And, you know, just as a side note that I spoke to John Sarno a couple of years, like when I was in the middle of like all my neck pain, I reached out to him via email and he said, you need to call me. Greg Lehman: 05:11 Oh, interesting. Karen Litzy: 05:12 So I called him and I spoke to him. I never saw him but I spoke to him and he was like, you're a young chickadee. I was like, what? And like crying and all this neck pain. I'm like, who is this guy? And he said, well, just get my book. Read it. If it doesn't work, come in and see me. Greg Lehman: 05:30 Yeah, that's funny. I had a patient, he was very famous, very rich, and he bought like a hundred of his books and gave them out to his friends. He thought it was amazing. Sarno was interesting because and this happens, this is the issue with biomechanics sometimes is he had physios working with him for a long time and then he realized that doing physical medicine conflicted with the message he was giving about where pain came from, meaning like predominantly emotional, I'm probably bastardizing my sense in a long time since I thought about them. And so, which is funny that he had the problem that I had for a long time and so many of us do where we think it's bio-psychosocial, but often our biomechanical ideas will conflict with their psychosocial. So we have to be careful in how we navigate all the multidimensional nature of pain. Karen Litzy: 06:26 I think that's the important part is that it's multidimensional and that you can't have that pendulum swing too far in either direction. And you know, now that we're on the topic of pain, let's go in a little bit deeper, so what would you say are the biggest misconceptions or common misconceptions around pain and it's, I'll put this in quotes, sources, quote unquote sources. Greg Lehman: 06:53 Yeah. The biggest one. And I really like to focus on this because it helps me in practice, it's this idea that, and I like this cause it's how our practice is that we don't always need to fix people, right? And I kind of mean, I don't just mean that in the biomechanical way. And I would have meant that in the biomechanical way five years ago where I would have said, well, you don't have to fix that posture. You don't have to fix that strength or that weakness or we don't fix strength. We're gonna have to fix that weakness or tightness. And I believe that although I do think strength and weakness and range of motion can be relevant sometimes, but I also don't think we need to always fix catastrophizing and depression and anxiety and worry, and so that criticism goes both ways. Greg Lehman: 07:53 It started out for biomechanical with me, but I would also say psycho social and we see that in the literature where people recover and they still have these, you know, mediators of disability and pain. It could be high catastrophizing but they still do really well because maybe they built up their self efficacy and they got a little bit of control and they were able to do something and something to control their pain or do something that they loved or they had some sort of hope. And so that's the biggest one, that idea of like fixing and if you want to be more technical or mechanical, it's the same idea. Like I don't think you have to get rid of nociception. So like your tissue irritation stuff, you can have shit going on in the tissues, but it's how you kind of respond to that stuff. That's exciting. Karen Litzy: 08:45 Well why would want to get rid of nociception. Greg Lehman: 08:49 Yeah. Well I mean I don't, well I know what you mean. Like, we don't, you don't want to, cause when you sit down you want to get an ass ulcer. Right. You definitely want to move around. So, but that now we get into crazy stuff with that. Karen Litzy: 09:03 Well do you mean the sensitivity around it? Greg Lehman: 09:05 Yeah, it'd be like you definitely don't want like a raging disc herniation that's pressing on a nerve root and you have chemical inflammation, things like that. It's worthwhile getting rid of. But you know, other things, you know, you can have tendinosis and a muscle strain and it can definitely hurt. But it's the idea that sometimes maybe what our rehab does is helps us cope with those, with those things, right? That's at a peripheral level and more central level. You can have anxiety and worry and those might magnify your pain response, but you can also cope with them as well. And so I love that message because I think it's just positive. Like people think I'm so messed up, I got scoliosis, I'll never got pain. And I'm like, dude, like it might contribute. I don't think the research actually supports that. Perhaps. Perhaps it does, but you can have that and still be doing awesome. Karen Litzy: 10:00 Right. So just cause you have chronic, let's say persistent pain or you've had pain for x amount of time, it doesn't mean that that should be the thing that defines what you do or defines whether you're happy or sad or anxious but that it's a part of your life that perhaps you can cope with or like in my case I had many years of chronic pain. Now I have pain every once in awhile. But there are times where it's more severe than I would like it to be. And there are times when I want to fix it or I need to fix it. And then there are other times where I feel like I can cope with it and it's not horrible. Karen Litzy: 10:45 I think it's context dependent. So like I had pain last year, like pretty severe for like a week or so, and I knew that in another couple of days I had to get on a flight to go to Sri Lanka. And so I needed it. So what I did for myself was I decided to get medication to help bring those pain levels down and that's what I needed at the time. But I felt so guilty about it. I would like say is this the bio psycho social way? Is this the way I should be handling this? Greg Lehman: 11:20 I would think so. I'm going to mansplain you for a second. Cause I'm guessing that you knew that this was just a flare it was going to go away and that you've managed it before, but you're just giving yourself a break for a few days. Yeah. I don't think there's anything wrong with taking Tylenol for a few days. I've talked off topic, but it's how you do manual therapy, I don't do a lot of manual therapy, but I don't begrudge people that do. And it's, especially at an athlete level, I brought this up with some of the people who are going to be at the congress and I'm like, I find it ironic that all of us who teach a running course, none of us really teach manual therapy at our running courses and no one would ever say that manual therapy is a strongly evidence based, you know, modality for running injury. Greg Lehman: 12:16 It's not, we would all talk about load management and exercise and blah, blah, blah, blah, blah, all of these things. Yet when you're a physio or a chiro training like elite athletes and you're working with them the day before their competition, what are you doing? You're probably doing some manual therapy. And so I just found that ironic that we do that, that when we're traveling with the team, I don't travel with teams, but I do have athletes come to see me the day before an event or I've been working with them for months and here I am doing what people would call low value care. But I'm like, no, sometimes it's a bandaid, but sometimes bandaids help and that's the only solution. Well, the solution that works then. Karen Litzy: 13:08 Well again, it's context dependent, right? So if, and I saw this conversation on Twitter about, you know, what are we doing race day and race day yeah you probably are doing some sort of manual therapy. Greg Lehman: 13:30 You're treating that little niggle and this things tight and sore and you treat and people feel better. And if fatigue is psychobiological, which it is, then our intervention is probably psychobiological and it could certainly be more psycho based. Yeah. Karen Litzy: 13:48 Right, right. It's still real. And you know, in the context of athletes and being, this is the Third World Congress in Sports Physical Therapy. So there'll be a lot of, we can assume, I don't know, physios there that probably work with an athletic population. And so I think it's important to bring that up. All right. I digress. Greg Lehman: 14:14 I did, you were the professional. Karen Litzy: 14:20 So one common misconception is that we don't have to fix everything and not just the biological part, but the psychosocial part as well. Is there any other, maybe one other common misconception around pain and its sources that you hear a lot or you see a lot? Greg Lehman: 14:40 I mean if I had to say anything, it's like it's the relationship between bio motor abilities, which would be like strength and flexibility and pain. I think that it's over sold. You know, I don't think posture is relevant. I don't think strength or motor control is irrelevant. I just think it gets over done in that, that to me is that kinesio pathological model, which I have a big issue with, which would be like your knee goes into Valgus, you're going to pay for it later and you're going to get knee pain or hip pain. And, I'm like, well if your knee hurts and it goes into Valgus it's certainly a reasonable option to avoid that for a little bit. And then you might recover cause it's an avoidance strategy and build yourself back up and you'll do great. But I think what often happens is we then say, well, you went into valgus and it hurt, therefore valgus is inherently wrong and we need to make rules for everyone on how they should function. I hardly saw you when we were in Denver together, but I gave that whole, I forgot about that. We just saw each other, sorry, I was with Betty the whole time. I couldn't hang out with you guys. And so that I gave that example of limping, like when you sprain your ankle. Karen Litzy: 16:06 That example was great. Greg Lehman: 16:08 Yeah. You sprained your ankle and it feels better to limp. That's totally reasonable. But no one would then conclude that we all should be limping. That that's the right way to move. When I see like people I really respect, like Shirley Sahrmann or Jill Cook who will, you know, say avoid hip abduction, right? It's so horrible on the tendon, on the outside of the hip or is so bad on the knee. And I'm like, yeah, it's reasonable for symptom modification but I don't want to make a general rule and that happens too much and then we're too quick to be like, well just cause someone got better with exercises that try to change those movement patterns. That doesn't mean that's why that treatment was successful. Often those rehab programs that try to change movement patterns are like amazingly comprehensive and excellent rehab programs. And then you have like awesome therapists like you know, Stuart McGill or Shirley Sahrmann who just like build in this graded self efficacy and pump them up and they tell them you can do whatever you like. Let's just change your movement patterns and start doing this stuff you love again, may have nothing to do with the movements. It's just like the person was like, wow, I'm awesome, you're awesome. Let's do it. Karen Litzy: 17:26 I think you can't sort of parcel out one part of that complete treatment program and say this is the thing that worked. This is why this worked. I mean, you can't do that. I think that's impossible. Greg Lehman: 17:37 No. And it's certainly the same with the people who I really love, like Peter O'Sullivan and that whole group when they help people, like I don't really agree. I'm such a jerk. I don't always agree with their mechanisms because when I see Pete treat, he's just so confident. It's like, you can do this, you can do this and bend over and do this and do this. And like, and I would never practice that way. I just couldn't pull it off. But I can imagine how much he helps people. That's actually why I really respect him. What he does really well. When he tests RCTs, he doesn't test himself. He trains people and other people do it. So, I actually shouldn't, I'm not knocking his research. I can't get to his style because he's so confident. It's absolutely really honorable what he does where he's like, I'm not going to be the dude that's in the RCT and train people and then we'll do the studies on them, which is just, that's nice science. Karen Litzy: 18:34 Yeah, for sure. And all of those people you mentioned also have great reputations. People are referred to them when nothing else works. And so as the patient, you're like, well I know this person's the expert. Karen Litzy: 18:49 Right. So I think in the patient mind they're thinking, if anyone can fix me, yeah, it's going to be this person. And I think that that also plays into it. Greg Lehman: 19:00 I just opened my own little clinic out of my house. We have like a little gym. It used to be a workshop and now it's a clinic gym and I have nothing on the walls. And I'm like, how can I placebo the hell out of this? So that's my answer. I like art. I want to put up like, no, I should put up like placebo shit. Like what was like going to make me look amazing? Karen Litzy: 19:25 Yeah. Well you can put up like awards you've gotten put up your degrees. People will be like, look at how many degrees he has. Look at all of his qualifications. He must be amazing. Greg Lehman: 19:37 Yeah. Maybe, I don't know. Karen Litzy: 19:41 You see that a lot in the US like when you walk into an office, the degrees and the licenses and certifications, right? Greg Lehman: 19:46 All that weekend certifications, all that nonsense. After I teach, I always tell everyone, like, whenever you want me to write on your certificate, I will write levels six fascial blaster done, master Fascia blaster. I don't care. It's all bullshit. Karen Litzy: 20:03 Biomechanics. Does it matter? Greg Lehman: 20:07 Since the sport conference let's start. They definitely matter for performance. We got to listen to our coaches and the physios. But biomechanics and technique matter for performance. So if you want to tell someone to sit up straight, yeah, it's totally reasonable to do that if you're thinking how they're going to function 30 years from now. So that's great advice. And then, it's like a question of when they matter after that. And so I kind of Parse it into a few different areas of when they matter. The big one for me is like what's more important, is it's not how you move, it's that you're prepared to do what you're doing. So make the mechanics and the loads on the person matter. Greg Lehman: 20:59 But it's the movement preparation. So my pithy expression is preparation trumps quality, right? Something like that. And then the other way or the other area where they matter is this symptom modifications. So if it hurts to do something, like if you're a runner and your knees hurt and you heel strike and you have a long stride, it's totally reasonable to shorten your stride, maybe changed your foot strike, although that's debatable, but it could serve it is certainly is an option. And if it feels better, keep running like that. So the mechanics there help but it doesn't prove, you know, the thesis that there's a right way of running. It's just that you're running differently cause another run or you're going to be like stop forefoot striking and actually lengthen your stride. I've done that plenty of times. So you're just symptom modifying. Greg Lehman: 21:45 So mechanics help a ton for symptom modification. And then you know there's probably under high high loads, there's probably better ways for your tissue to tolerate strain. You know, like if you're landing and cutting you can go into valgus but you probably don't want to go into Valgus if your knee's not flexed. Right. So high loads where the tissue gets overloaded matters. And then after that with that principal there, it gets more difficult because you start thinking of the spine and you're like, okay, is there a better way for the spine to tolerate loads? And that's where we have been debating biomechanical principles here because certainly the bio does drive nociception sometimes. And so those are the big areas for me where biomechanics matters. Sorry I went over that fast. Karen Litzy: 22:39 I think that makes perfect sense. And I mean, I don't know if you saw this since you are probably more into tumbling and gymnastics than I am. I haven't seen this yet. But did you see yesterday a gymnast broke both of her legs or something. Greg Lehman: 23:01 I saw that by accident. I won't see it again. Karen Litzy: 23:02 But I don't know what happened there. Greg Lehman: 23:07 I think it may have been in a double Arabian or a double front tack and she landed and then hyper extended. And what freaked me out a little, only saw it once and I'm not gonna see it again, is I don't think she landed with straight knees. They were like bent and then they went into extension like, which freaks me out because my daughter's learning front and I'm doing them with her front tuck step outs, and you kind of land on that one leg and it's straight ish. And I was worried of extending. Karen Litzy: 23:46 Yeah. I mean I haven't seen the footage of that, so I was just wondering if that would be a time when biomechanics mattered or just an accident. Greg Lehman: 23:55 It certainly did. But here's the problem with all the biomechanics mattering stuff, is it the mechanics mattered and caused the injury. It's just whether you can prevent it. Yeah. It's like so many ACLs. Someone might cut 10,000 times with their knee in valgus. Well, that's proof of principle, that they're safe and then they do it one way that's slightly different and then they tear their ACL. But it doesn't mean that the way they were doing it before was unsafe because they could have had less valgus pattern before and then they could have done that too. Like, yeah, I don't know. It's difficult. Karen Litzy: 24:34 Yeah, and I think when you're talking about injury prevention, I mean that's a whole other conversation. But I think that so many factors go into that as well. It's sleep, it's nutrition. It's what did you do the day before or was the beginning of the game, the end of the game? Are you fatigued? Are you not? I mean, so much can go into that. So yeah, you can cut 10,000 times and one time you have an injury. It doesn't mean that the way you did it was incorrect. It doesn't mean that the preparation leading up to it, it could have been that day. It could have been what you did the night before. I mean, so many factors and elements that go into something, some sort of accident or injury like that, which is why injury prevention programs are difficult. Greg Lehman: 25:25 Yeah. And, and we see them running, you know, like we've been saying the same thing for years. So you don't have training errors, which just means don't do too much too soon. And then you try to nail it down in the research and you say, well, what's too much and what's too soon? And then there's no real good research on that, right? Because there's so many different variables that influence that. So my joke tonight, we're arguing not we were talking on Twitter about this. I'm like, well, we can probably all agree when it's like just looks ridiculously like too much too soon. And that's the pornography test, right? Which is your old Supreme Court justice is either pornography or obscenity and they're like, I can't define pornography, but I know when I see it. And so when a movement pattern or a training load is pornographic than maybe you avoid it or depending on your personality. Karen Litzy: 26:17 Right. Well, you mean it just gets a point where it's so obscene. Greg Lehman: 26:20 It's so obscene. You say, ah, that's probably some of them. But it has to be that and who knows? That's the worst part is there's probably people who can handle that obscenity. And I stopped this analogy because I dunno, they're built for it. They prepared to handle. Karen Litzy: 26:41 All right. Let's talk about being a movement optimist. Yes. So for those of people watching and listening that aren't familiar with this, can you talk about it a little bit more and how this came about? Greg Lehman: 27:02 Well, I mean, I have already, I've already said all the good stuff I've run out of material. Karen Litzy: 27:08 I can't, I can't even believe for a second. That's true. You're not like your greatest hits album. Greg Lehman: 27:18 I was in Denmark and they gave me this little bobble head that you've pressed the top of and the whole thing like bounces. And it's funny, I was in Scandinavia three or four years ago and they gave me the same thing. It's like this thing that I would get there, but it's called a hop to mist. I loved it. My kids have it anyways, so what it means is like we need to stop vilifying like certain movements. You know, like when you look at someone's skateboarding, their knees are going to cave in and it's amazing and it's a successful movement pattern. If you rock climb and you were just at a birthday party. Karen Litzy: 28:01 I was at a rock climbing birthday party yesterday for my 10 year old niece. Greg Lehman: 28:05 Well, I doubt they were doing it, but there's something called a drop knee, which is what I do on a climb is, is you can do it. I'm not doing it. You put your foot up behind you almost and drop your knee down into valgus and then stand up on that and you go into that. Karen Litzy: 28:24 There are actually some more like real climbers there and they were doing that. There are a couple of people doing that move. Cause I remember my friend that I was with was like, oh my God, look at that person's knee. How is she doing that? Greg Lehman: 28:37 Yeah. And so Alex Honnold is a famous rock climber. They just won the Oscar for Free Solo Yosemite without a rope. But I have sometimes he's in another documentary about Yosemite. I've filmed it when he's in it because he sits like me. He's like super hunched forward with the super forward head posture. And here he is climbing, you know, these massive granite walls and that's a movement optimists, it says you can do all these weird funny things with your body and still be fantastic. You can be a paralympian where you're missing a limb than have induced, you know, assymmetry that you can have scoliosis and make it to the Olympics. You can have scoliosis and lift five times your body weight. And so that's the optimism. It's this revolt a bit against the kinesio pathological model, which to me is certainly has value. Greg Lehman: 29:39 It's certainly has treatment efficacy because I like the treatments that are associated with it, but the fundamental ideas behind it that there's like bad ways to move or better ways to move for injury and pain, that's what I would challenge. I'd be like, let's be more optimistic about how we move, you know, we don't have to always fix these things right now is go and anytime someone like me talks and says to people, all you can move this way, you always want to look for exceptions, right? When you're in practice, like, when should I, you know, disregard what I think, like when you know, when is how someone moves. Like when is that important? You know that and that'll help him be a better clinician. I think. I always challenge challenging whatever you think is true. It makes it difficult. Karen Litzy: 30:40 Yeah. But I think having that as a clinician, having that sense of doubt is not a bad thing. Greg Lehman: 30:48 Yeah. I mean, I'm going to want to agree with you. Sorry. It was like, why am I listening to this guy? It's like, but then there's those clinicians that get people better by sheer force of personality. They have that utmost belief in what they do, even when they may be full of shit. And so that's how it was hard. Karen Litzy: 31:16 I have a great example of that, I'm not going to go into it right now. Greg Lehman: 31:25 Now you also have to wake up in the morning and be happy with yourself, so. Karen Litzy: 31:29 This'll be an easy one for you. What is the most common question you get asked by other physio therapists? If you could say whether it's maybe they private message you or at your courses or lectures. What is the most common question that other physios or healthcare providers ask you? Greg Lehman: 31:59 Oh, that's funny. I didn't read this one before, but a few things. But usually it's like what's the paper that you mentioned? And then I have to like come up with a name and I usually know it, but the bigger one is this is what I do with people. This is not what you talked about, but tell me why it's helping them. That's, what I get a lot, they want validation and then they want to like, you know, tell me their theories of things, but really tell me they want me to tell them why it's great. It's like what the mechanism is. Karen Litzy: 32:47 That's why it's okay. Looking for just your confirmation. Greg Lehman: 32:54 Confirmation and then like, and then trying to like find out why it works. Like they want me to do the research behind it, I'm going to go. Okay. So what do you say? I mean it depends. Like I probably do like the motivational interviewing thing where I roll a bit with towards distance and I just probably, it's pretty bad, but I probably just read say are actually depends if I've met them before, I'll just talk about the general things that help pain and I'll say maybe it's working this way, but I don't, that's all I do if I think they're totally off base. I don't think I ever really say that. I don't know if I've ever done that. Karen Litzy: 33:49 Now, and you kind of alluded to this in your answer there, but if you could recommend one must read book or article, what would it be? And if you want to say one book and one article, but just one. Greg Lehman: 34:06 Yeah. You know what I'd go old sounds funny saying old school, but I would read David Butler's the sensitive nervous system. So good. Yeah, it is. Cause it's not only good in like a pain, but if when you read that he's just throwing out little ideas all the time. Like it would be nice for me to reread and just pull out his anecdotes and like little things that he says to do because there's things that I do and I thought, oh, this is kind of neat. And I thought I'd discovered them myself. I thought I'd, you know, you know, found it myself and then I'm realizing here at, he said it 20 years ago or something like that. Yeah, yeah, yeah. That, and then like his former partner would been Louie Gifford and I've only read parts of his books, but I've read some of his other writings and I like his stuff too. But David Butler's the central nervous system, which is just, and it's what, 15 years old, but it's still plenty accurate. Karen Litzy: 35:07 Yeah. Yeah. And for people who are listening or watching, I can plug that into the comment section, when this is done. All right, so let's move on to the conference. October 4th and fifth in Vancouver, the Third World Congress is sports physical therapy. So can you give us a little bit of a glimpse into what you're going to be talking about? Greg Lehman: 35:32 Not really. I am talking with Alex Hutchinson who's kind of a friend of mine here in Toronto, like the same kind of know those same people. Karen Litzy: 35:46 You run in the same crowd. Greg Lehman: 35:53 Like, you know, like we rock climb together. We've been to some similar weddings. I've known Alex for awhile and I love his stuff and I always pump up his stuff in my courses. That's what's funny. And then when they put him with me, I was like, this is awesome. Because I always talk about the psychobiological model of fatigue, which is that fatigue is kind of a nice analog for pain. That it's not just purely physiology, that there's a psychology component to fatigue. And I'm like, Whoa, we should talk about this because look how this area of function relates to pain. But so we're talking together on like this massive nebulous talk topic of pain science and athletes. Karen Litzy: 36:44 Yeah. Yeah. That's a heavy one. I listening to his book Endure right now. Greg Lehman: 36:48 Yeah. See I like the breath holding stuff in there. Karen Litzy: 36:55 That's the chapter I'm on now, which I can't even fathom. Greg Lehman: 37:13 So go, go online and find David Blaine's breath holding stuff. He needs to have the breath holding record. He did. But he could also do like eight minutes without that. I used to hold my breath in church all the time to pass the time. But breath holdings interesting because if you just hold your breath right now, you might make it 30 seconds, but you can train yourself to make it for four minutes. And so within like a few days if not an hour. So it means your physiological reaction to try to breathe is way over cooked. And that often happens with persistent pain. We do this protective response. So I've been talking about breath holding for years and then Alex's book came out and I'm like perfect. Now I can refer people to that way better down. But so like finding analogs between weird things about pain and then interesting things about performance or breath holding is really nice. Greg Lehman: 38:04 So we've been talking, we were probably going to go rock climbing and then we're going to try to maybe come up with something that parallels each other. I will probably, I'm guessing talk about like how we, I like doing something really practical, like instead of saying this, which might have a negative connotation to some patients, like set them up to have some, you know, less than good expectations say this instead. So, you know, like the diet stuff, don't eat this, eat this. Well it would be the same idea with explaining common running injuries. Which we'll probably talk about, cause Alex's a runner and I'm a slow runner. So mine will probably be something like that. Just met her way to phrase things. And because everyone always says to me like, okay, well what the hell do I do then if I don't tell them that they have SI joint pain cause it's out of place than what the hell do I say? No, no, not yet. Yeah, I think. And then that's really fun and it's a nice end. We'll have time to talk about it too because there'll be a lot of wisdom in the room and hopefully we'll maybe pull that out. Karen Litzy: 39:22 Yeah, that sounds great. And I really appreciate those kinds of conversations because then I know that I can kind of take that and use that with my patient population on Monday. Or Tuesday, whatever day. But you know, the next day in clinic. Greg Lehman: 39:38 That's the idea. I don't want to hammer people with research. I know I won't do that. That's for sure. That's easy. I could do that. And it'll be entertaining by your life. Go. Well I got some more research, but it'll probably be more practical. Right. And we're real, more practical story. Karen Litzy: 39:52 Nice. And I look forward to, you know, the two of you speaking together, I think we'll be entertaining and educational and I look forward to that kind of play that you guys will most likely have off of each other. I'm reading his book and you brought the bread holding, which is exactly where I am. And it reminded like in the breath holding chapter, you know, he said like the people who had like, who broke these records or who could really hold their breath the longest are the people who knew that someone was there to pull them up if they needed it. Yeah. And so when I think about that as it compares to pain, like especially persistent pain, I wonder if you knew like you had an out, would that pain still be as persistent? So that's what got me thinking listening to this chapter was like, hmm, if you knew your pain had a safety net, how would that change your view of your pain? Greg Lehman: 41:03 Oh, that's interesting. No, and I think what you're talking about has actually more ramifications for the negative aspects, right? Because most people think, oh, this will pass, but there's some that think that this won't pass. And Yeah. And that's why there is no optimism. And that's of building that where, there's no reason for them to think that it will change. And that's kind of what we have to do is build that model that there's a possibility for change. Karen Litzy: 41:35 Yeah. And before we're going to wrap things up in a second, but Kate Pratt said, well, I find one of the greatest sources of misinformation to patients about pain and biomechanics is their MD/ortho. As PTs we hopefully consistently educate our patients. Do you think it's possible to educate MD's or orthos regarding pain and how would you begin to approach such a scenario? So I think she means as the individual clinician with, you know, the referring physician or the physician who's seeing that patient. Greg Lehman: 42:11 Yeah. I mean in general, I think that's a problem across the board of all professions. How we change our colleagues, view the docs, like our colleagues. And I'm not really sure cause you would assume that has to happen at a school level, right at the training there and at a conference level. So it's really conferences in schools who are open to, you know, providing the different messages there. But I would say, and we've talked a lot about this is when you do have patients who have these beliefs from their doctors or other healthcare providers, which is super common, there are routes that you can, you know, still address those beliefs without throwing the doctor under the bus and that's what you have to figure out. So often it's more like acknowledging yeah, that's, you know, you have hip pain because he has OA or something you can say that's part of it. Greg Lehman: 43:15 This is the my optimism approach. Yeah. The hip OA is part of your hip pain, but you can still do great even though you have those changes on the scan. And that often really helps, especially with when physios and like we're navigating referral sources. And it's so funny that you bring, I just got, I just like 10 minutes ago before we started, I got a referral from a sport MD who was in the course. I taught with JFS school. On running five years ago and said, are you seeing patients? And like it was so funny that she was in the course because you don't normally see MDs. Yeah. You know, taking courses with the PTs. Great to do that. And so that's how we have to change. You use it somehow get into that educational system. Karen Litzy: 44:01 Yeah, I agree. And from a one on one. I think it's difficult. I mean Karen Litzy: 44:11 What I've done once that worked with the referring physician was, you know, I said, hey, you know, we're doing this, this, this and this, but I found this article, do you want to take a look and let me know what you think? Cause I'm thinking of incorporating it. And it was like an, I don't know, I think it was an article, Moseley or Peter O'sullivan. And so I sent them that and then he was like, oh yeah, that's really interesting. Yeah, definitely start doing that. So that's a way you can kind of maybe start. Greg Lehman: 44:44 Yeah. O he or she just rolled with your resistance maybe. No, I totally agree. Yeah. I think we're good. Karen Litzy: 45:00 It's so hard, but it's a way to be diplomatic. It's a way to say, you know, I don't know. Greg Lehman: 45:08 I really liked that you just sold a good treatment plan and then you gave them other research behind it. That's nice. Yeah. That's probably better than saying you're an idiot. Karen Litzy: 45:20 Yeah. Well, yeah. But I mean I also find that like I had one doctor that came back to him and he's also a good friend of mine. He was like, that's really interesting. Like we need to talk more about it. Oh, that's cool. Which is awesome, you know? But he's also a friend began, you know, we played softball together. So it's like the different opinions. Karen Litzy: 46:01 Chris Johnson said to say thanks for carving out the time you need to stop picking your eye. Always exercise diplomacy and avoid creating a disconnect. It doesn't accomplish anything. And that's in regards to Kate's question that we just tried to answer. Like I'm bringing a course to New York City and we're going to have like a free two hour preview of it and just invite doctors. Greg Lehman: 46:44 Wow. Karen Litzy: 46:45 That's, you know, one way to do it if you want to get them involved in the educational process with Physios, which I think is great. Greg Lehman: 46:52 One of my best course ever in Toronto here was, we had three physiatrists that came and they were fantastic. That's awesome. Go into this stuff. It was a bit, some of it seemed a bit new, but they're open and like, and then the email to everyone after and they share their experiences. I love when you have multi disciplinary people at the course. There are some, I mean I'm not throwing MDs under the bus. They certainly, it's so hard. I have a friend who was an MD and he's like the best motivational interviewer. He was so good. Like he knew this thing is that as patients had to do, but you know, in Canada you only have eight minutes with them. Yeah. And there or whatever. Anyways, so I'm off topic. Karen Litzy: 47:42 So let's wrap things up here. Are there any presentations you're looking forward to seeing at the conference? Greg Lehman: 47:48 Rob Whiteley. Yeah. I really like is like career and that the stuff he's done and what he's doing there, you know. I'm a socialist I like exercise for everybody and I like the name to change things. But I have trouble like arguing with exercise. It's amazing. It's jam packed like there, there's so many. So that's one of the reasons I wanted to go cause you know, I would have, it'd be nice to go to that conference as well. Karen Litzy: 49:22 Well, I am looking forward to your talk with Alex. I will obviously finish his book within the next week, so that's very exciting. And I've already taken your class and read your free resource. So I feel like I'm like ready for it. Greg Lehman: 49:39 I'll bring something new. Karen Litzy: 49:42 I'll come armed with lots of questions. All right. So before we hop off, where can people find you? Greg Lehman: 49:49 Just my website I guess, which is Greglehman.ca. Which I hardly do anything on and then Twitter, same thing. Twitter is my favorite. I like the discussions on Twitter, even cultivate them, trying to keep them polite and nice and you know. So Facebook, Nah, it's for the trolls. Karen Litzy: 50:15 I think. Yeah, I guess it depends anyway. Again, a whole other conversation. Yes. Greg Lehman: 50:21 No, I'm doing a big thing on Facebook right now. I shouldn't say that. Greg Lehman: 50:29 Yeah. Cause we have like a podcast with me and Oh, I have a podcast, I guess. Never. It's, well it's Adam, it's Meakins podcast, but I'm the cohost so I guess is mine. I don't know. When do you get part of that? I've done three with them. I'm just baggage. I'm a carry on. Karen Litzy: 50:52 Yeah. I think, I think you need, you need a little bit more. I don't think that three really qualifies as like a permanent cohost. Greg Lehman: 51:01 Oh yeah, yeah. I don't think I want that. Karen Litzy: 51:03 No, no, no. You're still like a guest cohost, give it a couple more and then I think you're in. Greg Lehman: 51:08 Okay. Well we're doing like a thing on neurodynamics like their dynamic techniques. And so I wanted to poll people and see what people thought. You know, I was curious what people thought, what the hell we were doing when we do them for that. Karen Litzy: 51:27 I use them, I use them. And oftentimes in people who are a little fearful of movement. Greg Lehman: 51:33 Yeah. So what does that tell you what you're doing? Or you really like manipulating the nerve to, you know, feed them more oxygen or something. Getting someone moving again? Karen Litzy: 51:45 I think you're getting someone moving again, I think you're taking them to a place where they can stay within a relative comfort zone and you can kind of see, I think what I use it is because you can see some changes pretty quickly. And so I think patients then get a little more confident that they can move because they can see those changes pretty quickly. So that's why I like to use them is to give people some hope. Greg Lehman: 52:15 It's a modification. Karen Litzy: 52:18 So that's why I use them, but I use them quite a bit just because I think, I think that they work very well. The only time I don't use them was really with like one person who said I was doing all these nerve glides and now it made my arm so much worse. Greg Lehman: 52:37 It's like everything. Karen Litzy: 52:38 You know, but I don't know how many, what they were doing, why they were doing them, what explanation they were given. I have no idea that I just sort of held off for a little bit and had the move a different way. But yeah. So that's why I use them. Karen Litzy: 52:59 So if no one else has any questions. So Agnes said that she'll play softball with me in Vancouver. Greg Lehman: 53:08 Tell her I'm going trampolining and rock climbing. Karen Litzy: 53:15 I would go trampolining but I really just like bungee trampoline. Greg Lehman: 53:19 Let's do stuff. Karen Litzy: 53:20 Well you're attached to a bungee and then you obviously go down and then you can go up and flip like two, three times in the air and come back down again. You can't twist, but I did do a double layout. Yeah, it was pretty cool. But yeah, I would definitely play softball. I will bring my glove and I can do some trampolining. I wouldn't have done it 10 years ago or five years ago because of my neck, but now I can do it. Yeah, totally can. Karen Litzy: 54:14 Just so people know when Greg and I were at the align conference a couple of weeks ago in Denver, Colorado and he had his daughter Betty with him cause it was her birthday weekend and she was his personal photographer just so that it made him look better than everyone else because he had personal Paparazzi. And she was just super adorable and doing back walkovers and she probably would've done a lot more, but we were at a conference on the first day. Karen Litzy: 55:21 She was very sweet and that's who we're talking about. All right. And I'm going to edit all of this out before I put it out on a podcast. Thank you everyone so much for listening and sorry for rambling at the end. If no one else has any questions, I just want to thank you all for listening and make sure you go and click on the link on this Facebook page. Should take you to the website for the Third World Conference in sports physical therapy. Again, it's October 4th and fifth, and Vancouver. Greg is speaking with Alex Hutchinson and I think that's going to be a highlight of the conference. You don't want to miss it. So Greg, thanks so much for hopping on the call and sorry for the technical difficulties. Thank you so much and we'll try and put all the information that we spoke about in the comments section here. So thanks everybody. And Greg, thanks again. 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 Kelly Duggan on the show to discuss her hybrid physical therapy business model. Kelly is the creator and owner of Physical Therapy U, a successful insurance based PT clinic in Bridgewater Massachusetts. PTU is focused on changing the healthcare experience for their community with a focus on youth athletes. In this episode, we discuss: -How Kelly's hybrid practice has married quality patient care with financial freedom -Marketing strategies that have exponentially grown Kelly's practice -Top key performance indicators Kelly tracks to ensure her clinic meets its mission -Why your life vision should align with your daily life -And so much more! Resources: PTU Clinic Instagram PTU Clinic Website PTU Clinic Facebook Strive Labs Email: PTUclinic@gmail.com For more information on Kelly: Kelly J. Duggan is a physical therapist with over a decade of experience in both inpatient and outpatient settings. Kelly is the creator and owner of Physical Therapy U, a successful insurance based PT clinic in Bridgewater Massachusetts. PTU is focused on changing the healthcare experience for their community with a focus on youth athletes. Physical Therapy U is a hybrid clinic offering PT, massage and sports/fitness trainings. Kelly uses this hybrid approach to combat the typical decline in revenue that most insurance based outpatient clinics (that aren't tied to a hospital) experience over time. Kelly is also a proud wife and mom of her three young children. Kelly has worked hard to show that although the timing doesn't feel "perfect", you can open a clinic at any time of life. Physical Therapy U was created during the 3 months after her third child's birth, while she also had her 1.5 year old and 3 year old home with her. Kelly encourages others to go after their dreams and although being in the spotlight causes significant anxiety, she continues to push herself forward so that others can see what is possible. In just three short years Kelly has successfully tripled her small business from a 1200SF space to a 4500SF space without the need of tripling her patient visits. Kelly enjoys sharing her highs and lows with others so that they can learn the best techniques even faster than she did. Physical Therapy U continues to grow and evolve and Kelly welcomes any and all advice for the future success of her business. Read the full transcript below: Karen Litzy: 00:01 Hey Kelly, welcome to the podcast. I'm happy to have you on. Welcome. Kelly Duggan: 00:06 Thank you so much for having me. Excited to be here. Karen Litzy: 00:09 And today we're going to talk about your business, the growth of your business. I would say the very fast growth of your business over the past three years. So PTU opened its doors three years ago. It was you and your sister working 10 hours a week. And now let's fast forward to three years. You have 17 employees, four PTs, one PTA. I mean that's a huge growth in three years. So I'm really excited for you to come on and let the listeners know how you did it. So let's first talk about how you started. So take it away. Kelly Duggan: 00:49 Yeah. So how we started, I was actually nine months pregnant and trying to decide which direction I was going to go with things. I had always been an employee that worked like around 30 hours a week and I would have one day off with my other kids. And when we got pregnant with our third, we realized that financially that was not going to be an option anymore. I needed to work full time. So I started looking at different options to do that, who I would work for, what I would want to do. I've always really enjoyed, the program development and the marketing aspect of physical therapy. For me, you know, I've always needed a creative outlet and that was kind of my outlet in physical therapy. But where I was and kind of what I was looking into, that wasn't going to be an option. Kelly Duggan: 01:43 So it kept getting thrown around. Like what about your own place? What about your own place? And so finally, as the pregnancy progressed, I sort of started looking into it. So what do you, what do you do when you first start looking into stuff? You start googling it. So that's where this all came from, is kind of a few Google searches of like, how's this going to work? And, what I did at the time, was reached out to a few other people that were in my situation, parents of multiple kids that own their own practice to see because for me, that was the big hangup of, you know, this is going to take a lot of time away from my family. Am I going to be okay with that? And how, you know, how is that gonna work with my family and work with myself or my kids in the future. Kelly Duggan: 02:31 So I reached out to a few other moms of multiple kids who had opened their own practices. And, you know, I got some feedback that I liked. I got some feedback that I didn't like and, you know, I kind of just hung on to the words of advice from the people that said, go for it. And Yeah, I think my son was like one month old when we finally committed and I said, you know what, I'm just going to do this. And I think, and I always laugh about this, but I think that I was so massively pregnant and then postpartum that my husband was just like, yeah, whatever you want to do, whatever that sounds great. Whatever we have to do, we'll find the money and just kind of like on board. So yeah, we started out really small. Kelly Duggan: 03:20 I found a clinic that allowed me to do a one year lease because for me, I was just preparing for, well, if it doesn't go well, what are my options? I'll always have my license. So, you know, where could I work if this doesn't go well and it doesn't build and it doesn't grow, like I want it to grow. So I found a clinic that did a one year lease. I looked at all the bare minimums of what do I need to make at the bare minimum. And I just laid it all out. You know, I always say I'm not a huge numbers person, but I think owning your own practice turns you into one. So now I'm like all about the numbers and that's, you know, my mom took this photo of me sitting at my laptop. Kelly Duggan: 04:05 Like, I dunno what I was doing either making the website or trying to crunch the numbers and I've got a coffee in one hand, one hands on the mouse and somehow I'm like balancing my newborn like on me. And it was just like very kind of how my life was at that moment. And for me it was if I want to do what I'm really passionate about in PT, which is marketing program development in sports, then I have to create it myself because it's not there. The option is not there for me. So it's just figuring out what I had to do to do it myself. Karen Litzy: 04:58 And I mean to do this massively pregnant and then with a newborn, I mean that is ballsy. Like that is no joke. I mean, I don't have children, so I don't know what those first months are like, but I mean, and this was your third. It's not like it was your first, you had two other children. I mean what a leap. Kelly Duggan: It was. And again, it was just kind of like, all right, it's go big or go home. Like if we're going to do this and I'm very much a determined person. If something is not there that I want, I'm going to create it or make it or somehow make it happen. And this was an opportunity for more time with my family in the long run. So in order for me to have more autonomy in the long run, it had to be done and it had to be created and it was, you know, it was for me and it was for my family and it was kind of like that, you know, you see like the parent lift a car off their kid, you hear those stories of was that sort of situation, it was like, okay, here's this person with no business background, who hates numbers. Kelly Duggan: 06:01 Who is going to like create this massive thing because I have to, that was the option, so it had to be done, you know? Karen Litzy: Yeah. And so that's when you started three years ago. So let's fast forward now to today where like I said earlier, 17 employees four PTs, one PTA. So can you break down for the listeners how you did that because that is massive growth and Kudos to you. Kelly Duggan: Thank you, so it's funny because I didn't plan it that way. It's not like I was like, you know what, my three year plan is this and my five year plan, 10 year plan says this again, I was very naive going into it. So I thought this is my plan and this is where I'll be, you know, three years from now if it's successful, I'll just stay in that same location. Kelly Duggan: 07:00 So we opened our doors in May and in September I looked at my sister, I'm like, well, this isn't going to work. You know, we were in a 1200 square foot space, you know, it took about a month and a half, but we went from no patients to I had a full schedule and I was prepared on the opposite end of that. Like I was prepared for all right, maybe I'll have three days or whatever it is. But we scaled really quickly. So starting in September, I started looking for additional staff and it took me until January to actually hire someone. So I would say anybody that's kind of in this position is just make sure you're preparing ahead of time for if it does go well. Cause I did not. And so I hired someone in January and then I hired my second person in February and that's when I said, okay, I'm not even gonna make it to a year in this location. Kelly Duggan: 07:56 Like we need to expand. So it was probably March so not even one year in where I started looking into what is this location need to look like in order for it to be a success because the demand was there and I didn't want to not provide the same service for more people. Like, you know, you see clinics that ended up getting stacked in their booking. People on top of the next person is just crazy and busy. And I didn't want to do that. I wanted to still be able to provide the same level of service just for more people. So that meant expanding. So I started looking at additional locations and how that was going to work and started hiring and scaling is the big word that we used, but we scaled up from March when I started looking to the following March when we moved into our new location. Kelly Duggan: 08:57 It was just kind of a slow scale and I was lucky enough to find a team of people that understood the importance of where we were going. And they were willing to adjust their hours as needed, but also work anywhere between like 28 and 40 hours as needed as we scaled. So for me, you know, I don't like to use the term, I was lucky because I busted my ass for everything that I've done. But in the sense of hiring people, in a kind of a team and a family that understood the importance of that, I was lucky. I mean these, these people kind of worked as hard as I did to get us to where we need to be. So that was good because you don't always find that in employees, you know? Karen Litzy: 09:44 Yeah. For sure. And now let's back up for a second. How did you go from zero patients to a full schedule? Cause that's what everybody wants to know. How do I get more patients on my schedule? How do we let people know we're here and we're ready to help? Kelly Duggan: 10:03 So. MMM. Yeah, you know, I hustled basically. So in whatever that term means to you, you know, like the older generation are horrified by the use of that term. But, I worked really, really hard. And I just networked and got my face everywhere. And you know, it, I think we've talked about this before, but I feel really uncomfortable when I'm talking in group settings or in front of people Karen Litzy: 10:34 I know, but I don't get it. Kelly Duggan: 10:38 Thank you. The Facebook lives, but again, it was there was a need to do, I knew that if I wanted to grow my practice, people had to know who I was. And I had to be seen as kind of an authority in the PT World, in my community. So in order to do that, you have to put yourself in front of people. So I was putting myself in networking groups, putting myself in business associations, talking, volunteering to talk, I'm doing all these live videos and posting it to different groups and doing all these things that are way outside of my comfort zone because I knew that people had to recognize me and my brand as, you know, as healers. So, on top of that we did like a lot of online marketing or I always say we, but I did a ton of online marketing. Kelly Duggan: 11:29 As well as, I did some print ads, not a lot because they're so expensive. But what I did do, which I tell everyone to do, cause it's such a good idea, is I think it's everyday direct mailers is what it's called for the post office where you can either create a postcard or a letter and you can map out on the US Postal Service website, who you want to get your letter. And so within like a three mile radius of my clinic, I sent out a postcard, which one side had who we were and what we did and the services we offered. And then on the other side I did a baseball schedule. Right. Or you do a football schedule or basketball or whatever. Because for me, like when I get mail, if it's junk, I throw it out unless it has a sports schedule on it. Kelly Duggan: 12:24 And then it's on my fridge. And then I don't even know who these people are and they're on my fridge, the entire sports schedule because it's the sports schedule. So I put it up there. So to put the sports schedule or whatever that is, you know, in your community, it goes right on people's fridges. And then every day they were opening the fridge and they see your logo and they see whatever it is you put on there. And that helped. And I did have a lot of patients that came to me because they got the flyers and they're like, oh yeah, you're on my fridge. Karen Litzy: Yeah, because don't they say it takes like x amount of touch points before some of them will decide to pull the trigger and make a purchase. Kelly Duggan: So I did a ton of marketing, you know, and even, you know, the patients that we did have asking them, but I don't want to use this as like a copout as to why we scaled so quickly. Kelly Duggan: 13:16 But you know, I also take insurance, so that obviously is a lot easier than convincing people, you know, over your cash rate. But in the beginning I wasn't contracted with every insurance, so I was actually seeing, you know, a handful of patients that were paying my out of pocket rates because I wasn't contracted with their insurance yet. So that was kind of cool. Karen Litzy: Yeah. So you had a little bit of a hybrid in the beginning and then, and now, do you take all insurances in your area or just a couple? Kelly Duggan: I take most insurances there. Again, from the business side of things, there are a couple of insurances that financially, we wouldn't just lose money, but I'd lose like a lot of money. So we can't take every insurance, but we do take most and then we do offer our cash rate or a prompt pay rate if people don't want to use their insurance or some people don't even want to use their insurance benefit. Kelly Duggan: 14:21 So, even though they have an insurance that we would contract with, they choose to still pay us a cash rate and then you know, we have additional services since moving into our larger location that cause again, PT insurance, it doesn't, unless your really savvy is the word I'll use, it doesn't make good money. We basically we paid the bills and that's how we get by. But if we want to make additional incomes of that, you know, my employees can get raises and we can buy new fun equipment. We had to take on all these additional ancillary services in the new location. Karen Litzy: 15:02 Okay. So what are these ancillary services? Because this is something that I think we really want to touch upon because listen, not everyone has a cash based service. I would say the majority of people by and large do not. Yeah. And that most physical therapy offices around this country take insurance. And like you said, sometimes the insurance does not reimburse a lot. I know New York state, it's very, very low. So what ancillary services have you added? So again, kind of make that hybrid practice. Kelly Duggan: 15:40 Yeah. So in our previous location, which was really small, what we did, and it was a much smaller scale, but we would hold classes every now and then, so we'd have, you know, a yoga class or a strength and conditioning class or something so every now and then we could get a little bump of money, in our new location, which is 4,500 square feet. We're able to add in a lot more. Kelly Duggan: 16:10 So we're looking to make it a little more consistent, but we've had yoga. I hired, so I didn't like rent out, but I hired two massage therapists, and they work on kind of like a per diem rate. So they're not there all the time, but you know, when they have clients. So we've built up and that's really been a huge compliment to our physical therapy services, not only for our patients, but for our therapists in kind of taking the load off of not having to do as much manual because if people are getting massages with it, it just helps that much more and then people are carrying over better. And, so that's been a benefit all around financially and for our patients. And for our therapists. We hired massage therapists. Kelly Duggan: 17:11 I had massage therapists and I have a program that we call the elevation programs so that, we all know that insurance doesn't cover everything, right for physical therapy. They don't really cover the sport based stuff or transitioning someone back to crossfit or whatever it is. It's not always covered within their plan. And then, you know, there also insurances that cut you off after 60 visits or at 90 days. So what we did was kind of bridged the gap between physical therapy and a patient's return to sport or return to their full activity. So we created something called like an elevation plan where people can purchase it on a monthly basis, you know, similar to how you would purchase a gym membership. And the elevation plans include, you know, PT visits, massages and an exercise prescription by a personal trainer, which one of our rehab aids is a personal trainer. Kelly Duggan: 18:21 So we utilize her and kind of kick people off with this really great program. And it's really meant to be a transitional program. So people will do it for a month or two, and then they have the confidence in order to get back to sport or gym or whatever it is they wanted to do. And maybe they're like getting back to, but maybe they're starting it for the first time. So we have yoga, we have the elevation plan, we have massage, and we do like sport performance clinics. So, you know, sometimes we do two hour ones. We just had a dance one for our dancers. Sometimes we do, you know, like a six week program for our youth athletes. We really focused on, at the new location, kind of like, my big thing was, okay, you know, I love to work with athletes. Kelly Duggan: 19:15 I think it's an underserved population. The youth athlete, I think we get lost in the shuffle. So that was for us kind of a big part of what we're trying to do with PTU. So we have all these programs for our youth, for flexibility, coordination, the things that the coaches can't necessarily allocate time for in their practices. We again, are just trying to bridge the gap and support where there is a need. So we created all these programs. So all of that is additional money that helps to run our insurance based practice. Karen Litzy: 19:54 Right. Fabulous. And I love the sports performance for our kids because you're right, that is not something that is widely used. You know, kids they go to their practice, they do their sport, and then that's it. And I mean, I see a lot of kids in my practice having very adult injuries, ACL injuries, you know, knee pain, a torn labrum. So things like that. So I think what a great idea. And then that's also great for your marketing. Right? Karen Litzy: 20:37 It's also great for your marketing because then you have the kids coming in, the parents know you're there. So if something happens to anyone in the family, they're going to come to you because they already know you, like you and trust you. Kelly Duggan: 20:53 Yeah, absolutely. I think, you know, with having like kind of the youth athlete as your main population, you know, they can't drive themselves. So someone has to bring them, whether it's a parent or an aunt or you know, and then they're exposed to your facility and exposed to what you do. And, I think once they see that you're providing something different, that's of quality and the services, the customer service there, it just spreads like wildfire. Karen Litzy: 21:28 Yeah. Fabulous. And now so we spoke about what you did to get patients in the beginning, how you've expanded and how you've expanded so quickly, which is all awesome. Now can you tell us, were there any mistakes, any pitfalls along the way that you can share? Kelly Duggan: 21:50 I mean, there's always, pitfalls. I'm trying to think of something. Karen Litzy: 22:00 Yeah. Like if there's something that you're like, oh man, if only I knew I would not have done it this way. Kelly Duggan: 22:10 Yeah. Well, you know, a lot of pitfalls that were kind of, if I had known I probably would have done differently. The billing aspect of things in the beginning we outsourced, which was fine because again, it wasn't like I was learning so much at the time anyways. It's not like I could learn another skill of the billing side of things. So I outsourced. But we lost a lot of money in outsourcing. And I think not only did we lose a lot of money, but I think there was a lot of opportunity for me to have learned more about why we bill and what we bill and that aspect of things that I just wasn't paying attention to for the first year and a half. I was just kind of filling out and assuming that everything was fine and coming back on in it and it was fine. Kelly Duggan: 23:10 It was just once we decided to take on billing and hire someone, the learning curve there of what we're billing, how much we're billing, why we're billing it, what we get paid. I learned a lot in those first like six months of bringing on billing that in hindsight probably should have just figured out like how I could have done that earlier on. Because once we took it on and we started learning more about what you know, actually pays and what doesn't pay, we were able to make some adjustments in what we do to make more money through insurance. So that was definitely kind of a big eyeopener for me switching from outsourcing billing to taking it on. Karen Litzy: 24:01 Great. Yeah. Know your billing know where your money's coming from, where it's going and why some things are being paid and others are not. And I mean the list can go on and on. Right, Karen Litzy: 24:14 That's great advice for people who are wanting to start their own practice, especially in an insurance based practice. Kelly Duggan: 24:24 Yeah. And a lot of those outsourcing companies, they will train you, you know, that's an option. I just kept saying, Eh, I'm like, like this one more thing I don't need to know. And it was like once I learned it, I'm like, wait, what was I doing? Why did I not want to know any of this is so important. Making more money. Karen Litzy: 24:42 Right. And now what are the things that you look at now? So in business, you know, we talk about key performance indicators. So what are let's say for you and your business, what are the three most important KPIs that you look at? Kelly Duggan: 25:08 Yeah, we look at cost per visit. So obviously you're looking at what you make per visit cause that's important for me. I'm looking at cost per visit and obviously I want that to be lower than what we make per visit because my overhead is so high, our cost per visit is a bit higher. Which is why in going to the new location and tripling in size. It's funny cause a lot of like insurance based PT clinic owners were like, no, like that doesn't like, you can't do that, it's not gonna work. Insurance doesn't pay enough money for that model to work. That's why people don't do it. And I just kept going back to like, yeah, but it's a service to our patients. It's exactly what they need and somehow we're gonna figure out how to make it work because it's what people want and it's going to just provide so much for them. Kelly Duggan: 26:12 So a huge one for me is cost per visit cause it's high. But we want it to be below what we make per visit. So I'm looking at cost per visit and then I'm looking at how can I make that lower? I pay attention a lot to like how many elevation plans were selling in a month, how many massages we're selling in a month. Because again, that is going to bring down that cost per visit for me so I focus a lot on there. I used to focus on, you know, the average amount of visits we were getting out of people. But over time it's been similar over time, so it's not like I'm like, you know, worried about it. But there are certain key performance indicators that I don't know how I want to say this without sounding like, I don't want my therapist to be aware that all right we need every patient to have 12 visits because that's what we need financially. Kelly Duggan: 27:26 You know, you don't want someone's treatment to be affected by the bottom line. So I track it, but that's not something I share with my employees or even try and like, oh, we got to get that to, you know, 13 visits or 14 visits because I mean, it's a wonderful thing if you can get somebody better within four visits or six visits, cause then they're gonna, you know, talk about, Oh my God, I felt better in six visits. So you don't want to focus on those numbers. So I think, you know, you do see that number of listed a lot when people are talking about key performance indicators and how many visits you're getting out of your plan of care. But I think going into it and focusing on that number is not a good thing for us as PTs. Karen Litzy: 28:15 Right. Yeah. And, also it then puts these perhaps unrealistic what's the word? When they have to meet a quota, is that a thing? Like PTs have to meet a quota or something like that? Yeah, some clinics. It incentivizes the wrong thing, right? I think what you're doing is you're incentivizing patient care. Versus incentivizing patient visits. Those are two very different things. More visits doesn't equate better care. It just equates more visits. Kelly Duggan: 28:59 Yup. Exactly. Exactly. And we've talked a lot about in talking to my coworkers and stuff of, all right, well, what do we have to do? How many visits do we need to do? And how many massage appointments do we need? How many elevation plans do we need so that we continue to deliver the level of care that we're delivering. I don't want to change my business model to seeing a patient every half hour, or, you know, forcing that sort of way to hit our bottom line. I'd rather have it, well, you know, can we get more people in? Can we do performance clinic? Can we, you know, add in yoga again, like how can we add additional services? Because you hate to really like turn into a mill to hit your numbers, you know? So for us, we need to encourage more people to, you know, sign up for massage or maybe we need another deal because we're getting close to that number of we're not gonna, you know, make our minimum requirements and we don't want to change our model. We don't want to change the level of care we're able to provide to people. So I think that therapists knowing that they are getting so much better with like, mmm, you know, wanting to do these additional programs and wanting our patients to do these additional programs. So it's been good in that sense. You know, and I've heard from other business owners and other PTs that they'll get a bonus if they hit their productivity. Karen Litzy: 30:42 That's terrible. Kelly Duggan: 30:46 That's not what we want to do at all. You know, it's like, it's just, again, it's the quality of care and it's then the PTs just thinking about their numbers and not, am I getting people better? Karen Litzy: 30:58 Exactly. And then, you have PTs saying, oh, I can work through lunch or I'll stay later, or I'll come in earlier because they're just so focused. I mean, let's be honest, a lot of PTs are type A, right, so focused on hitting this arbitrary number to get a bonus. Right? So let's say they get $1,000 bonus. Well, right, that thousand dollar bonus down to all the times coming in early and lunches that you worked through, guess what, that thousand dollar, $2,000 bonus that it doesn't equate to what you're making per hour. Right. And then it just, I think it's a great way to burn out your therapists. And I'm not sure, is the care better? Is it not better? I don't know that I can't say, but I think it's, like we said, just incentivizing the wrong thing. So glad you brought that up. Is there any other big KPI that you look at regularly and that forces you to maybe change the way your business is being run? Kelly Duggan: 32:17 Not really. I mean, I look at a lot of stuff just to monitor for myself. You know, I look at average codes for treatment, you know, and are we in line with the national average. You know, how can we make that in line with the national average while still providing the quality care that we're providing. I mean there's nothing that I, again, it's a lot of stuff that I look at kind of the behind the scenes stuff, but nothing that I would want my therapist too be concerned with I guess. Karen Litzy: 32:59 Yeah. And what about cancellations? No shows? Yeah. It's always one that everybody always touted as being one, but I dunno. Kelly Duggan: 33:10 We track that and if it starts to get higher than like, you know, a certain number, we were like, okay, what's happening? But we have things in place that, kind of limit the amount of cancels and no shows. You know, we do our reminder calls. We, you know, people that are dropping off, patients that drop off. We use like an automated email system we use. We're integrated with strive, so we use strive, but I know some people use infusion soft. Karen Litzy: 33:45 Infusion soft is very expensive. Kelly Duggan: 33:48 Yeah. I love strive. It's really user friendly. And the customer service has been awesome and you don't have to like build your own sort of stuff. It's, you know, you create your own content and all of that, but you don't have to like be a computer genius to use it. Karen Litzy: 34:12 And is that strive labs through web PT? Kelly Duggan: 34:16 We were using them before they were integrated with web PT and they do work with, you know, if you don't use webPT, I believe, you know, but I do use webPT. Karen Litzy: 34:28 Cool. Very cool. And so we talked about where you came from, where you're at, what you're looking at, how you're growing. So now where do you see yourself going in the next three years? Kelly Duggan: 34:43 Yeah, so, you know, I'm always thinking about that. But you know, one of my biggest struggles I would say right now is because we're so busy as just like, how do I get through the day? How do I get through the day? And I would say a couple of weeks ago, I'm like, what am I doing? Like all of my energy is focused on how am I getting through today and this week? And I'm not thinking of kind of the long term. And every time we have either a student or someone interviewed, they're like, what's the longterm plan for PTU? I'm like, well, you know, I don't really know.You know, people ask, because for me it was, I opened PTU because I wanted that creative outlet. You know, I wanted to support our athletes, but I wanted autonomy and I wanted time with my family. And I'm starting to get that so I don't want to, you know, it's not in the cards for the next three years to expand to another location. Kelly Duggan: 35:42 It's just to get this PTU central location successful in the insurance world. And, you know, I'd like to be able to give everybody raises. And all of that. So I want the next three years is figuring out how do we make this insurance hybrid model, successful so that we can, you know, give people raises and continue to treat at the level that we're treating. And you know, so that I can get the time that I wanted with my family. And then if we're able to do all of that in three to five years, maybe, you know, I've talked about adding on a second location, but I don't even want to think about it because I'm, again, like you mentioned, a lot of PTs are type A, I'm so type a that if I decide that I want to have a second location, I can't say, well, I'm going to do it in five years. Kelly Duggan: 36:39 Like it'll be here in six months. Like that's just how like I work. So I just, I want to keep putting that off. And for right now it's just PTU. It's our central location. I want it to be, you know, successful. And when I say successful, you know, I don't want to sugar coat it. I want it to be lucrative. I want it to be a business that makes money. Karen Litzy: Of course you got, why wouldn't you and what other business world outside of like PT, the healing world do people say I really hope it's successful. Like of course yeah I still want to make money though. Yeah! That's why you started your own business for some freedom, for stability to be with your family, to help the people in your community and to make money. You didn't start a business to not make money. Karen Litzy: 37:32 He didn't start a non for profit, which is a totally different world. So like if you opened up a clothing store, you wouldn't be like, man I just, I just hope I can make money one day. Kelly Duggan: Yeah. It's funny cause it's the PT struggle, you know, it's like I want to support my patients. But you know, you have to put on that business owner hat and be like, well we need to make money to support our patients. Karen Litzy: So that's right. It's your responsibility to make money so that you can be present in your neighborhood and that you can be present in your community and help people. Because if you didn't make any money, you'd have to close your doors and all those people who depend on you, what do they do then? Kelly Duggan: Yeah, exactly. So in three years, you know, I want, you know, hopefully two more PTs is like the goal, you know, and I'd like to have that within the next year. And I want one of those PTs to take over the performance side of things because I feel like that's one area that we can continue to grow and we could have, you know, we could constantly be hosting some sort of sport related supportive group or clinic or camp or whatever. But I don't have time to plan all that. So I want to hire, I want one of my PTs to kind of take over the performance side of things. Karen Litzy: 38:49 Very smart. Well, it sounds like you have a good plan in place and I love the fact that you said, you know, I just want to make this into a well oiled machine. This is what I want. And that's amazing because not everything, like you said, not everything has to be scaled to infinity. I mean, knowing where you are in life and knowing what you want and knowing how you want to live your life and if you can achieve that Karen Litzy: 39:20 Achieve those goals within the parameters that you have. It just has to be, like you said, little tweaks here and there. I think that's amazing. So congratulations on such a huge, huge change in three years. Kelly Duggan: 39:34 Thank you. Thank you. And I want to actually bring that up. I want to say something to that because, I think again, PTs as kind of type A, and especially PTs coming out of school, we are so on this really, really like fast train of trying to be successful and achieve our goals. And, for PTs a lot of people are so focused on their career and their career ladder in their career growth. And I just want to say a reminder to people to kind of pull yourself away from that for a second and just think like, what do I want out of my life? What are my life goals, right? Is it that I want to travel more? Is it that I want to have a lot of money? Kelly Duggan: 40:25 Is it that I want more time with my family? Whatever it is for you. Think about that for, you know, a few minutes and then think about, okay, so how does PT fit into that? And not the opposite way of like, let me like reach the top of this career ladder and then like, well, is PT my life? Or like where am I now? So just pull yourself away from that and think of, you know, like for me it was and it might take a life event for you to figure out that. Like for me it was having my third kid and like, wait a minute, what the hell am I doing here? And it was okay, I want more time with my family. How do I do that? How does PT fit into that? And I just want to encourage more people to do that. Cause I think as type a people, we get so obsessed with climbing this kind of career ladder that, you know, we can get lost in it. Karen Litzy: 41:19 And great advice. And I am in this, speaker's group, which is really a bit of an entrepreneurial group as well. And the woman who runs it Trisha Brook, at one of our first sessions, she had us write out kind of what do you want your legacy to be? And that's if you think about that you're doing exactly what you just said. You know, you're putting forth what do you want your legacy in this world to be? Right? And it sounds like for you it was too, you know, be with your family to have an influence over your children and to have that be such a great legacy. Have your children, your family, be your legacy, have the community that you're in, be your legacy. But what I didn't hear from you, and correct me if I'm wrong, but what I didn't hear from you is for PTU to be your legacy. Karen Litzy: 42:21 Right. It was, I want to make a change in my community and my family and that's the legacy. PTU is part of the way I do that. But it's not everything. Excellent advice. And now I feel like I'm going to ask you this last question, but you might have just answered it. But the question is, given where you are now life, career, what advice would you give yourself as a new grad out of PT School? Kelly Duggan: 42:57 That's it. Don't fall for the trap. Kelly Duggan: 43:12 Don't fall for the kind of trap of just trying to, you know what, nevermind, I wouldn't say that. Because I feel like all of that got me to where I am right now. You know, the struggle of how do I get high around the career ladder and how do I do all of this. And, so I guess what would I say to myself straight out of PT School is take jobs that you have fun at. If it's not fun at the end of the day, if you didn't laugh, if you didn't enjoy yourself, get out of that situation sooner than later. I think I held on to certain things knowing that they were good for my career and I should have let go of them sooner. Karen Litzy: 44:08 Excellent advice. Couldn't agree more. And now where can people find you and the clinic if they want more info or they want to talk shop with you. Kelly Duggan: 44:17 So I'm on my website is PTUclinic.com. The email is PTUclinic@gmail.com. I'm on Facebook, I'm on Linkedin. I'm not on there too often, but I'm on Facebook pretty regularly and my clinic is on Instagram. So any of those realms reach out if it's something that you're thinking of doing. I love talking with people that are thinking about opening their own clinic. I love to just encourage it, I think, you know, if it's something that you want to do then to go out and do it and yeah, reach out to me. I'd love to be of any help if that's what you're looking for. Karen Litzy: 44:57 Awesome. Well thank you so much, Kelly, for coming on and sharing your entrepreneurial journey. I think you gave a lot of people a lot of help today, so thank you so much. Kelly Duggan: 45:07 Thank you so much for having me. Really appreciate the opportunity to talk about it and I hope we encourage some people today. Karen Litzy: 45:15 Yeah, I hope so too. Thanks so much. And everyone out there listening. 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! 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