Interview with a Physical Therapist
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Show notes:
Interdisciplinary collaboration is SO important in primary care. It’s a tragedy when we’re each rockstars in our own bubble of a profession, but aren’t collaborating or communicating enough to fully understand what each profession actually does.
I’m absolutely obsessed with physical therapy, and it’s a HUGE key to success for patients with musculoskeletal complaints in primary care-- but I didn’t really see how it worked on the other side until I was a patient myself.
What NPs Need to Know About Physical Therapy
In this week’s video, I’m interviewing Stephanie who’s been a physical therapist for 10 years, and we’re answering questions from the email list about physical therapy. We cover:
✅ What physical therapy is and how they can help patients
✅ Who’s a good candidate (or not) and what patients should go that aren’t being referred
✅ The role of imaging before sending to physical therapy
✅ How to manage cost/time/insurance concerns patients have
✅ What we can do in primary care to counsel patients and prepare them to set them up for success with a physical therapist so they can finally feel better
If you liked this post, also check out:
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WEBVTT
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Hey there, welcome to the Real World NP podcast. I'm Liz Rohr, family nurse practitioner, educator,
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and founder of Real World NP, an educational company for nurse practitioners in primary
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care. I'm on a mission to equip and guide new nurse practitioners so that they can
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feel confident, capable, and take the best care of their patients. If you're looking for clinical
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pearls and practice tips without the fluff, you're in the right place. Make sure you subscribe and
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leave a review so you won't miss an episode. Plus you'll find links to all the episodes with
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extra goodies over at realworldnp.com slash podcast. Oh my goodness, I am so excited to
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share this week's video with you. I just can't even describe how excited I am. In this week's
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video, I did an interview with a physical therapist. She's actually my personal physical
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therapist after I had an injury last year, and she's amazing. She is so full of pearls of
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practice, so full of wisdom, just so smart. I got to ask her all the questions. The theme
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of our interview is, what would you like a primary care provider to know? I took some
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questions from the audience. If you are on the email list, you will have the opportunity to submit
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your own questions for upcoming interviews if you're not already on the list. But we talked
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about a whole bunch of things. Red flags, not to miss, when to refer to physical therapy,
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who would benefit from physical therapy that we might not think about, what to expect,
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how to counsel patients. Oh my gosh, just so many good things. Addressing the topic of
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access to physical therapy related to funds and all of that stuff. I really hope you enjoy
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it. It is so much fun to record. Please let us know what questions you have. I would love to have
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Stephanie back on. Again, she's just the best, but I hope you enjoy this interview. If you have
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not grabbed the ultimate resource guide for the new NP, before you check out the rest of this
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video, head over to realworldnp.com slash guide. You'll get these videos sent straight to your
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inbox every week with notes from me, patient stories, and bonuses that I really just don't
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share anywhere else, including the opportunity to submit questions to upcoming specialists on
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channel. Without further ado, here is our interview. Thank you for being here. Would
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you like to introduce yourself? Thank you so much for having me. Hi, everyone. My name is
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Stephanie Burns. I'm a doctor of physical therapy, and I've been practicing about 10 years.
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I mainly work in the orthopedic outpatient setting. Awesome. Awesome. I love working
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with you so much, and you know so much information. I have so many questions. We'll
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get to the framing question. How would you describe physical therapy? I think the context
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of the situation is that I feel very well-versed in physical therapy, especially since working
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with you personally, learning more and more about what physical therapy is and what it does
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and all of that. I think that sometimes the nurse practitioners who are new are not as
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familiar with physical therapy and what you do. There are a lot of things to clarify. Maybe
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to start from there so that they feel more comfortable sending referrals to you and knowing
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when to refer to you. Yeah, that's a great question. Honestly, the profession of physical
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therapy has changed over the years. It started as a bachelor's, it morphed into a master's,
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and now there's no schools out there that even have a master's program. You have to
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have a doctoral degree. Really, what the idea is is that we're all movement scientists.
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We really did have a bad reputation. We had a reputation of being people who were helping
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patients after surgery. That was our main job. Because of that, we pushed a lot of people.
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We pushed them and it was painful. I think a lot of that was just the best evidence-based
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practice back then was if you didn't have the range of motion, to push the range of motion,
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to make the range of motion. There are some cases where you do have to do that, but they are so
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minimal. There are very, very few cases where you really have to push through that pain.
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The evidence behind that has just changed drastically and the profession has changed
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drastically. We don't work under a physician or a nurse practitioner. We work autonomously.
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We really have learned how to work best with the patient as an individual.
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That means basically that one size doesn't fit all. We can't just push everyone and get the
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same range of motion for everyone and get the same strength for everyone. It's just really
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important to really hone in on what that individual's goal is and what the practitioner
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wants us to, as a team, what we're all trying to achieve from it. Do it in a way that's actually
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pretty comfortable for the patient. It's not painful. It's about optimizing movement.
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That's a really great question because I think that comes up for me a bit.
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Is physical therapy supposed to hurt? I think that I've had some patients come back
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with various experiences being like, it was too painful. Then some people saying,
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their physical therapist said to them, I never want you to leave in more pain than when you
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started. What is the general consensus on that from your perspective or does it really patient
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to patient vary? Well, it's difficult because pain is difficult to define. Pain comes from
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each individual's experience with pain. If you ever notice pediatrics, a child's pain is going
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to seem like the end of the world. It's because they've never experienced anything before.
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Everything is just really dramatized. For instance, if you work with some of the elderly
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population, they can have a fracture and be like, fine, no big deal. Now, of course,
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that's categorizing. Not everyone is like that, but the more experience we have with pain,
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the less we are afraid of it. So much of physical therapy, at least in the outpatient
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world, is learning how to get over the fear of movement. Sometimes there's a psychological
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pain involved. Sometimes there's a trauma involved. Sometimes there's something like
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abuse, but sometimes it could just be a car accident too. All of these things create a
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psychological trauma that really can affect our ability to move and to feel okay. If we don't
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feel safe, then our pain is going to be worse. It's really the physical therapist's job to make
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you feel like you're in a safe environment and make you really be able to feel like you can
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communicate. If you can't communicate to your PT that you don't feel comfortable, that this
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is too much, it shouldn't be the PT saying back to you, well, this is what we have to
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do. They should really be able to hear that and be able to say, okay, I understand that I'm
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not physically asking you to do too much, but that doesn't matter because it feels like it's
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too much for you as the patient. Because of that, we have to back down and we have to
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say, okay, let's break it down. Let's just do this in steps. It's not a big deal if it's
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too much for you, but the PT has to work with you with that. That's the whole idea of
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individualized treatment for each person out there. I'm just laughing, Stephanie thinking
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about us working together and I did this really tiny baby move. I had a back injury last year
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and I did this tiny little baby move and I was like, does this supposed to hurt this much?
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And you were like, you were so nice about it. It was just super weak. You're customizing
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things and we're like, we're just not going to do that exercise because you're too scared,
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basically. I still appreciate that about you and I think that sometimes patients will have
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a frustrating experience where they'll come back and feel like they didn't have that
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relationship with their physical therapist. That can be really hard. I think that brings
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up one thing that you and I have talked about a lot is about using physical therapy
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handouts and what is the difference between physical therapy diagnosis and management
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versus medicine diagnosis and management, if you want to speak to that.
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So I can share from my perspective, nurse practitioners will say things like,
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oh, you have a back pain and you have back pain and it's going down your legs.
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And then so we're like, okay, here's a sheet of exercises and you can go do that.
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So back pain is a good one. Another good one is like shoulder, like a rotator cuff injury.
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So I think the biggest issue I've seen with it is that there are phases of physical therapy.
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So there's that fear phase, right? You have to kind of like relax the patient.
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And one thing I just want to touch on is that can be, some of the physical
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therapy environments that are out there, like people that are treating more than one patient
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at a time, like an open gym environment, or just kind of like, you don't really feel
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like you're getting that attention that you need. Make sure that it's a good fit for you.
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I just want to say that because really one-to-one physical therapy, one-to-one
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treatment with any practitioner is really, for me, I think that's the most helpful aspect.
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Yeah.
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But sorry, back to your other question. With the handouts, like there are phases of healing.
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And so the first thing is, you know, kind of calming that patient down,
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reducing some of that pain, get them to really not like tense, protect and avoid,
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because that's what they want to do. But in some of the language that we use,
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make sure you don't sleep on your stomach, or you don't lift anything over 10 pounds,
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or you really don't want to lift your child from the ground. That type of language can really
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encourage fear in our movements. And instead, it's a little bit just as much as sometimes we
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have to sit and breathe with things that are emotionally uncomfortable. We have to kind of
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sit and breathe and relax and try to move as normal as possible, even when physical things
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are uncomfortable. So instead of that like tense, protect and avoid, you kind of want to think
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of it more of like relax, breathe, and move as normal as possible.
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Yeah. Yeah. And then one of the things that you and I talked about how like with nurse
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practitioners, the more of the challenge for us, it lies in the diagnosis.
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And then once we get to the diagnosis, our treatments are very algorithmic. So step one,
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two, three, and four, or is it like it sounds like with physical therapy,
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it's actually quite the opposite? It's more like psychotherapy.
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There is a big emotional component I can attest to it.
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There is, but there's also like a problem solving component to it.
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So kind of like we're talking about those phases. So like that first phase is that relaxation,
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the next phase for one individual might be to strengthen, and then the third phase maybe
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to stretch. And the problem with some of those handouts is they cover all the phases
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immediately. And that's where people get a little confused or maybe not the best,
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most efficient results from it, because some work and some don't. And because of that,
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they get frustrated. Definitely. Yeah. And I've found, at least I know in our work,
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and it sounds like it's been like that for other patients too, is kind of like,
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if I'm having this pain, my body is very different than somebody else's. And so my
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greatest laborum is not doing anything on the left side, compared to like the other
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muscles. Right. And so it sounds like it's also very much like the game is kind of in
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figuring out the right treatment for that person. Does that sound right to you?
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Yeah. Like from a diagnosis standpoint, the words of like rotator cuff care or shoulder
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impingement or tendonitis, tendinosis, tendinopathy, they all kind of mean the
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same thing. Like, okay, so before you all hate me for that, what that means is that yes,
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of course, from a medical standpoint, something is different happening onto the tissue,
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right? We understand that we understand the structure that involved is different.
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But from a treatment standpoint, it may not change it at all. So one of the biggest take
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homes that I learned in physical therapy school is we treat the person and we treat the
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impairment, but we don't treat the diagnosis. So again, like diagnosing something, sure,
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you know, we know that like, if they kind of move like this, they're going to have a
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rotator cuff issue or if they have issues with their back that are very directional
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preference based, okay, maybe it's more of a disc herniation. But for a treatment,
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there is no diagnosis equals ABC treatment. And I think a lot of patients want that,
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of course, who wouldn't want that, right? A little filing cabinet would go in, here you go,
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perfect. That would be great. And that's where it comes into similar more like psychotherapy
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than it does with, with medicine, because there is no like pill that fixed it, right?
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It's about listening to the patient, about hearing the patient about understanding their
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fears of movement, and then really trying to, you know, get to the bottom of it,
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because you can, I mean, there are so many more minutes in the day than just the 30 minutes or
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60 minutes you have with the PT. There's not even so much about doing your exercises.
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I know I'm going to get a lot of things for that, too. But we want you to do your
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exercises. However, even more importantly than that, we want you to change how you move.
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Right. So if let's let's go back to that emotional metaphor. If I was struggling with
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something emotionally, and I take five minutes or 30 minutes out of my day to meditate,
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right, it's better than nothing. But what if I just try to like have a mindful attitude
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throughout my entire day, right, that's going to make a bigger change than just that 30
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minutes when I have all these other minutes in the day, not being mindful. So that's that's
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stronger. It's absolutely better than nothing, of course, but throughout the day, and really
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being mindful of like, every time you lift your arm to get dressed or to reach, you know,
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are you hiking that shoulder every time you move your back? Are you doing something kind of,
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and what you're working on and what they're working on it are two different things because
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they come from two different places and two different compensatory patterns that have been
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Right, right. So I have questions here from our audience. Is there something that often you get
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like referred to you, that's quote unquote referred too late, like something that would
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be you would prefer that they get referred sooner they could advise patients of when
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they're making their decision whether or not to go to PT like is there any are there any
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situations where you see you'd wish they went sooner or that you see that are too late?
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Yeah, um, anything that's chronic, I would say is too late. No. Sorry. Yeah. What I mean by that
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is a lot of times, patients can go to a practitioner and they can say, Yeah, I've
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had this knee pain, but I've had it for 10 years. And in my experience, that's not the
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person that's going to be like, Oh, let's do a knee replacement and spend 10 years.
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But no one's ever asked, did you ever have PT because sometimes they hadn't. So when people
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have surgery before PT, it could be a personal preference where someone just didn't didn't want
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to go through that they just wanted to get the surgery first. But there's so much benefit
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at least trying it. I recently just had a patient who had a C6, C7 neck herniation,
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and he was in he couldn't even lay on the table. This guy was in a very, very acute,
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severe situation. And the referring provider was very much like, you can try PT, but
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good luck, you're going to need surgery, right? So he really wanted to do a cervical
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fusion for it. And as we know, you kind of need all of that mobility. When you take a
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piece of the spine, it doesn't just affect that piece affects above and below and kind of all
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the way down the chain. So we want to avoid that as much as we can, because there really
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are some some downsides to it, especially if you're on the younger side. And this guy came
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in and definitely was not my easiest patient that we figured it out and we problem solved.
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He's absolutely fine. He has no symptoms.
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Didn't even take that long. It's probably like three months.
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You know, so it's, it's just always worth that shot. In my opinion, obviously, I'm
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a PP, I'm going to advocate for it. I mean, what do you have to lose?
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Right. Well, I guess I think that's like, that's one of my kind of like pet peeves is
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this misunderstanding interdisciplinary misunderstanding, because all algorithmically,
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like I said, like if we have a diagnosis, I talked about orthopedic hacks in primary care,
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which is basically like NSAIDs physical therapy injections and surgery. That's the pathway for
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most orthopedic injuries. I agree with that. Very oversimplified. But like, yeah, I think
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that because our physical therapy is not in our diagnostic in our in our toolkit, it's
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doing it. And so it's like, Oh, well, what I can do is refer you for an injection or
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do the medicine. Right. And I think that because people in the medical on the medical side,
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like don't fully understand what physical therapy can do, then it's overpassed. Right.
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And like, I think one of this, like, I just have so many things that I just like want to
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share. It's like the things that I've learned from you. I feel like, I don't know. It's
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like, I just want to like download my brain onto people who are like, you know, like,
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because I guess like from that example, like what so I guess if you can like, kind of walk us
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through, if there's a kind of like, if you can give like a zoomed out perspective of what
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what you would do for a person like that, like, what are it like, do you know what I mean,
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how do you boil down what you did for that person? So that like, demonstrate how physical
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therapy helps, right? Like, was it strengthening? Was it mobility? Was it like, I can, I can
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talk about my situation and what I've learned, but I don't want to, I want you to explain.
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Yeah. It's a great question. Great question. And this is just a case, right? So it's just
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one person. Exactly. So he responded, I don't know if you're familiar with like Mackenzie
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based physical therapy. So Mackenzie is a man who was in Australia, who came up, it was
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kind of a funny story. So there was a table, a physical therapy table that was like
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an angle versus flat. And he told the patient, oh, you know, go lay down, I'll be with you in
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a minute. And they were there for back pain, low back pain. And they laid down on their stomach.
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And they weren't supposed to, they're supposed to lay on their back. But what
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happened was this patient was better when they got up. And it gave him, I think it was
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Robin Mackenzie, but it gave him an entire new perception of like, wait a minute. So
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the disc is protruded posteriorly. What if we move posteriorly to make it glide anteriorly?
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And that's what we call a directional preference. So in this particular case,
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you know, that particular man on the table, you know, he responded well to like extension
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because we were gliding the disc more anteriorly by moving posteriorly. And you can also,
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you get some people, it's a little bit less common to have someone with an anteriorly
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translated disc, but sometimes like gymnasts or skaters or dancers, people who go into extension
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a lot will have that. And then they're going to respond to flexion or another group that tends
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to respond to flexion would be more your people with like spinal stenosis because they
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need the canal to be open. And so we're going to get more of that opening with flexion.
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One of the things that can be deceiving, which is kind of tied back to that handout
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question you had is that when you see back pain, a lot of times on that handout is
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go into a ball, bring your knees to your chest, right? So why does that help? It does help.
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But only temporarily and actually can not all the time, but can do more damage.
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So if you're going anteriorly, right, you're going to open up that vertebral space
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and you're going to allow that disc and that nerve to breathe. However,
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it's also going to, because it has more space now, it's going to slide out in that direction.
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So when you close it back down, now the disc is living more so out here and pinching on that
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nerve even more, right? So if we close it down, that hurts, right? It's uncomfortable.
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It's painful. So immediately we think, Oh, don't do it. Kind of, right? Maybe don't do it
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so much load or so much gravity. What if we did it in like a gravity minimized position,
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like that guy on the table. And then so ending up, you know, kind of bringing your yourself
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backwards. And then, so now your vertebral space is going this way and you're kind of pushing
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that disc back into place. And now it's more centered. And what you have to do now is you
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have to stabilize it to stay there. So the ligaments around here, they've been kind of
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stretched out because things aren't in the position. The muscles are probably a little
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atrophied. That's probably how you got there in the first place. And then you have to,
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you have to get it to stay there. But if you try to stabilize it there the whole time
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without putting the disc back into place, that's like not really going to be effective.
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Totally. So it's like a combination of assessing what the issue is, whether it's
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spine or shoulder and like identifying what is too loose and what is not strong enough
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and what is light. And I think like one pearl, I just like, I feel like I have to gush it out.
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It's one of the things you talked about with me was like, people talk about, I think I see
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these things on like health, pop health things everywhere too, of like stretch this muscle
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every day. Right. And it's like, this muscle is always tightening people. But do you want
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to talk about like what muscle tightness is? I know we have some other like referral
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related questions, but what would you say to somebody who's like, oh, my back is always
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so tight, I just need to stretch it? Yeah. Well, let me just wrap up that previous question.
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So the, because the guy was a neck patient, I didn't answer any questions about that,
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but there are also directional preferences for the neck. And a big one is kind of posture,
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because when we tend to sit, we kind of do this, right? So our neck is really forward.
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And then that's how we screw, you're laughing because I'm telling you about this.
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You're like, I'm going to sit up close later.
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I promised I'd do my exercises.
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But if you kind of tuck that chin in, you pull it back, you know, it's not about squishing,
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right? Cause you can hear that in my voice, it kind of, is that awkward?
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But if you elongate, like you have like a string in the back of your head and you're
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kind of being pulled up and back, that opens up some space, also pushes that disc back in.
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So we did a lot of different variations of that for him. We kind of tuck the chin,
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the first one didn't work. We did a little bit of like a lateral component because he had a
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lateral component with the disc. We kind of tech the chin and did the chin tuck because that
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created a little bit of different force that was very helpful for him. And then we just
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progressed it. So you kind of find the biggest thing is find the thing that works.
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And if you can't ask someone else, because there is something that does work.
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Yeah. And like how beautiful of an example to share with people, because like to see behind
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the scenes of what actually happens in physical therapy, to know that like you can help somebody
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with that severe problem through movement alone. I mean, the person has to come to
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appointments they have to do, they have to participate, right? They have to sustain the
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things that you practice together, but that is so impactful. And he was, he was a great
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patient. You know, he was super on top of everything we talked about. So that's, it
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really does make a big difference when you kind of implement everything that we ask you to.
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Yeah, totally. But yeah, do you want to share, I guess like about muscle tightness?
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Oh, yeah. So I think one of the biggest misconceptions that can be out there is,
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is what is tightness? So let's take a runner. That's a pretty standard example. So an
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IT band, right? Everyone gets like a tight IT band. So IT band, kind of that lateral
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aspect of your leg from your hip down to your knee, right? So if you're running,
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and this tightens up, people are like, oh, I just, I foam roll it. Sure, great. That
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makes sense. It's going to release it. But my question is, well, why does it get tight?
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You know, what, what are we missing? Because if you keep running and it gets tight,
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and then you keep foam rolling, and then it gets loose, and then you keep running,
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gets tight, and you keep foam rolling, gets loose. What are you, what are you really solving?
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I mean, people kind of do that. They're like, oh, well, this is just what I have to do.
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They think it's like their body is like, oh, my body is just this way.
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Yep. Yep. They absolutely do. And if you got to go beyond that, you really have to
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go beyond that. And again, if you don't have a PT that doesn't go beyond that, find a new one,
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because that's, that's not great practice. You don't want to just be chasing symptoms.
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You always really want to be getting to the root of the cause. So this is a little bit of
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statement. It's not true for everyone, but sometimes with runners, what actually is the
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issue is a weak glute med. So our glute med is also on the lateral aspect of our hip,
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and glute med tends to get pretty atrophied. And not, not even so much that it doesn't exist
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in a strength way, but we don't tend to have that neural connection to it anymore. We lose
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that neural plasticity. So it takes a little bit of time to turn back on. It kind of went
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muscle that went to sleep. It's dormant. So we can, we can make it back up. And that's great.
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But that's what people don't realize is, Oh, well, if I just do this exercise, it'll wake
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back up. Maybe, but if you're not taught how to do that exercise, you're not taught
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where you should feel it. You're not asking yourself what is the intention of this exercise
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and where should I feel it? You're probably not getting that result. In fact, you may still
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be using your IT band. Because that glute med has shut off, right? That, that has a responsibility
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in the body. So if it's not working, something else has to absorb its job. Right? So we have
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this force that the glute med is supposed to absorb and supposed to distribute and it's not
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doing it. So who is going to do it? And this is why I said it's a little bit of a blanket
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term because that may not be IT band for some people that may be low back, that may be
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piriformis, that may be, so it, you know, it, it, it's different for different people
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and it can be different based off of your activity. But people tend to just kind of like
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lengthen the glute med. So let's say we did that, right? We have no, I'm sorry, lengthen
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the IT band. I misspoke there. Let's say we did that. So say we have no glute med
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and we stretch out the IT band. Well, what support do we have for our body while we're
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running? We don't have anything now. It's causing, it's giving stability where something
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else is weak, basically. Right. Well, it's, it's overworking, right? It's doing its job
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plus the glutes med job. And so what happens is it gets tight, it gets tired. It's like,
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look, I'm done. Like get someone else to do the job. So if you don't, so that's why,
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you know, people say, oh, you know, stretch, stretch, stretch, stretching is great,
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but strengthen first. And I don't mean like, you know, in your day, I mean, in your phases
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of therapy, strengthen first, because if you really focus on that glute med strength and the
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neuroplasticity and the connection with the brain and then translate that to running and
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you can really feel that glute med activate while you're running, which is kind of hard,
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but super important. Then the IT band barely even have to stretch it because it's not tight.
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Right. And I feel like that's one of the things you and I talked about in terms of
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the chronic knee pain too. Cause it's like, I think that nurse practitioners get frustrated
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for on patient, for patients behalf because there's so much pain chronically for so long.
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And it's kind of hard to tell that to a person with chronic knee pain,
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go to physical therapy, it's going to help you without being really comfortable talking about
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why. So I think that's like one of the reasons I'm so grateful you're talking about all this.
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Cause I think that even if our job as nurse practitioners is not to identify glute medius,
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right? Like you, we can still understand how this whole thing works. So that when we work
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for a patient, Hey, you have chronic knee pain, physical therapy is actually really going
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to help you because it's building up the muscles that are supporting the joint so that
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the joint isn't doing all the work in a similar way. Right. If I'm saying that right,
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similarly to the IT band is overworking your knee, physical joint is overworking. So when
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you do physical therapy, maybe it's uncomfortable because you're, you're strengthening muscles,
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but eventually all of your muscles in your thigh and your hip and all of that
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are going to alleviate that pressure, which ultimately in the long run is going
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to be helpful. Like you said, like it's not like you have to go to physical therapy forever.
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You learn and you understand what you need to do. And then if you get new pains and
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place, you can see PT again. Right. So from, from a PT perspective, that would be amazing
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if that was explained that way to a patient, because sometimes what happens is they let's say,
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let's take me away, for example. Right. So they have this chronic knee pain and then they
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come in for an X ray. That's kind of the standard protocol and in the orthopedic world.
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So they get their X ray and it has osteoarthritis and they say, well,
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what is arthritis? Right. And then the practitioner explains, well, it's
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of the joint. They hear the word degeneration, which is breaking down, which is damage,
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which is irreversible. And all of those words kind of where we're talking about before,
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they create fear and they create loss of hope because they're like, well,
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what can I do about that? I have to get the surgery. Right. So what we, but we know
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that people who have arthritis, there are people that don't have pain, right? So we
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X rayed a bunch of asymptomatic people. There are many things that are still positive,
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quote unquote, in their X ray. So whether it's a degenerative disc disease or it's,
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you know, more like that degenerative osteoarthritis, that doesn't necessarily
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mean that person has pain. Yeah. So where the pain really comes in,
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it's, it's physics. It's, it's the forces that are being put on the joints because the muscles
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around it are not supporting it. Yeah. So if, if pain was explained like that from day one,
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from the, from the first person that that patient had interaction with, it's like, look,
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pain just means that there's one area of your body absorbing more force than another,
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very simply put. And, and PT is that person who will teach you how to distribute those
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differently. Yeah. Yeah. And I think like, too, like it's so holistic and it's so like for just
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as another example, like I love giving examples for NPs, but like I, I've had neck pain and,
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and what we've been doing together, you and me is rotator cuff. It's like,
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yeah, we're doing my shoulder and my back because what's happening is that my trapezius,
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my like upper traps are doing all the work because of my baby little back muscles
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that aren't doing what they're supposed to do. Right. But for me, I'm like, oh, I just have
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neck pain. Maybe I'll just stretch where it's really tight. Like, no, actually you're going
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to build up the other muscles so that that muscle will relax by itself. And then my neck
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feels better. So that goes along with that. Like that's your chronic tightness there.
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Right. So what did you want to naturally do? You want to stretch it out now? Is that bad?
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No, it's not. It feels good. It's great, but that's not the solution, right? That
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was really providing more support so that the upper trap didn't have to do everything.
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Right. Work so hard. Absolutely. Yeah. Give it a break.
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With imaging though, one of the questions that we got was about what imaging,
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like, so if somebody is going to refer, so say somebody has a patient in front of them,
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chronic knee pain do, and it's the first time they're seeing a provider say like,
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I was diagnosed a long time ago. My first thought is like, you only need to do physical
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therapy first. And like, by the way, for people who are watching, I hope this is getting a
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bigger, clearer picture for you because I have to sell people on physical therapy, not for
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my benefit, not for financial gain selling, but for them to buy into why physical therapy is
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so important. So hopefully that is meeting here, but having that conversation with a
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patient, I feel very confident saying to them, physical therapy will be helpful for you.
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They're going to go, you're going to go in for a physical therapy evaluation and you're going to
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set up a plan going forward of weekly or twice a week for a set amount of time, weeks or months,
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making even an estimate of how long it's going to be. And that is going to ultimately help you.
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So that's, that's my feel if you have any addendums for that. The other part of it is
384
00:34:51.719 --> 00:34:56.480
the question that people have is do they need imaging first? Like, so is that like how you
385
00:34:56.480 --> 00:35:02.100
would, before a patient gets to you, what do you wish they kind of knew and did in the
386
00:35:02.100 --> 00:35:07.680
text of how to explain it? And then also in imaging? Yeah. So, I mean, of course everyone's
387
00:35:07.680 --> 00:35:14.780
a little bit different, but if there are red flags, imaging is important, right? So diagnosis
388
00:35:14.780 --> 00:35:20.560
dependent, right? Like, so it is Asia or yeah. Or, or how did they, why are they there? Were
389
00:35:20.560 --> 00:35:24.720
they, was there trauma? You know, was there a fall? Was it a car accident? Things like
390
00:35:24.720 --> 00:35:31.880
that. They need to be imaged, right? Cause we don't want to be doing anything with a
391
00:35:31.880 --> 00:35:37.260
outside of a fracture. It could be, you're not really going to see it in x-ray anyways,
392
00:35:38.560 --> 00:35:44.520
right? So, so we don't even generally have any of that information and knowing that we
393
00:35:44.520 --> 00:35:49.600
don't treat based off of diagnosis, we treat based off of impairment. And just to clarify,
394
00:35:49.820 --> 00:35:54.620
what is an impairment? It's the thing that the patient can't do. So did they lose range
395
00:35:54.620 --> 00:36:00.360
of motion? Did they lose joint mobility? Did they lose strength? Pain? Is this an
396
00:36:00.360 --> 00:36:06.780
impairment? Fear of movement is an impairment. That's, that's what we treat. So really
397
00:36:06.780 --> 00:36:13.700
imaging isn't, isn't necessary. Now there are times where we want images because we're,
398
00:36:13.700 --> 00:36:17.900
we're stumped, right? We're kind of just like, you know, maybe, maybe if we could,
399
00:36:17.980 --> 00:36:23.320
like a glut meat tear, I would say that's a very, very underdiagnosed overlooked
400
00:36:24.540 --> 00:36:28.760
diagnosis. You know, you hear hip bursitis a lot, you hear a little back pain a lot,
401
00:36:28.760 --> 00:36:32.960
but we talked about, you know, how important that glute meat is to support the back, support
402
00:36:32.960 --> 00:36:37.100
the hip, support the knee even. And a lot of times, especially in folks who are a little
403
00:36:37.100 --> 00:36:42.140
bit older, it's porn. Oh, I think I had a family member like that actually. Yeah,
404
00:36:42.440 --> 00:36:47.660
that sounds familiar. Yeah. Yeah. And that, that's one thing I would, I always want like
405
00:36:47.660 --> 00:36:53.240
an image for because it's such a frustrating diagnosis because you go back and forth a lot.
406
00:36:53.420 --> 00:36:57.400
You're like, is this coming from the back? Is this coming from the hip? Because without
407
00:36:57.400 --> 00:37:01.440
the glute meat, it's kind of coming from both, right? Cause it really needs that support.
408
00:37:02.780 --> 00:37:09.480
But that's not something we expect a patient to have coming in. We don't, we don't mind that
409
00:37:09.480 --> 00:37:13.140
they don't have that. It doesn't really affect anything. The only time we really
410
00:37:13.140 --> 00:37:17.920
want imaging is if we're stumped. And the best way to do that is just to have,
411
00:37:17.960 --> 00:37:23.220
if we can have open communication with the nurse practitioner or the doctor or the orthopedic,
412
00:37:23.220 --> 00:37:29.560
whoever was the referring provider for the patient, if we could just have open communication and send
413
00:37:29.560 --> 00:37:34.340
you guys an email, I mean, sometimes emails are really hard to find or really hard to obtain.
414
00:37:34.640 --> 00:37:40.380
And so if we could send you an email, A, giving you a patient update status, right? And B,
415
00:37:40.540 --> 00:37:44.460
maybe like opening that door for communication, saying like, Hey, you know, this isn't,
416
00:37:45.080 --> 00:37:50.320
what we're doing isn't working. You know, what, maybe they do need an injection because
417
00:37:50.320 --> 00:37:55.400
pain is such a barrier. Maybe they really, you know, maybe they do need an image. These
418
00:37:55.400 --> 00:38:00.560
things aren't unnecessary, but sometimes they're over prescribed. Yeah. And I was
419
00:38:00.560 --> 00:38:04.420
going to say in my own personal practice, like I usually tell patients aside from those like
420
00:38:04.420 --> 00:38:09.060
red flags, like diagnosis dependent red flags and like trauma and acute injuries,
421
00:38:09.500 --> 00:38:12.580
just to clarify for new nurse practitioners, those are what we're talking about.
422
00:38:12.760 --> 00:38:18.540
But also like if I've cleared those, I say it's always worth it to see a physical
423
00:38:18.540 --> 00:38:23.940
therapist because in my experience, they always tell me I can't work with this patient. They need
424
00:38:23.940 --> 00:38:28.480
an MRI or they should see orthopedics next. Like they will let me know, or they'll be like,
425
00:38:28.480 --> 00:38:31.060
you know what, they're in too much pain to participate. Can you give them some pain
426
00:38:31.060 --> 00:38:35.880
medication or something like that? Like usually, is that typically your experience as well? Like
427
00:38:35.880 --> 00:38:40.000
I love, I feel like I can trust a physical therapist with that. I mean, I have, I've
428
00:38:40.000 --> 00:38:45.700
worked with better and not as stellar ones, but the ones that I really trust, like I'm like,
429
00:38:45.700 --> 00:38:50.200
I set it up for the patient of what to expect and then they let me know how it's going.
430
00:38:50.860 --> 00:38:55.400
Yeah. I mean, the better communication you can have with your physical therapist, the more,
431
00:38:56.820 --> 00:39:00.820
the more comfortable you're going to feel sending your patient to one.
432
00:39:01.060 --> 00:39:05.280
If you have that relationship with a PT, doesn't have to be just one, can be a whole
433
00:39:05.280 --> 00:39:10.280
network of them, you know, to choose from. And then, you know, you also get kind of
434
00:39:10.280 --> 00:39:14.640
a feel for people's styles of how they do things. And you may be able to say, oh yeah,
435
00:39:14.640 --> 00:39:18.920
this patient, I kind of recommend them to that person because they're more, they kind of pushed
436
00:39:18.920 --> 00:39:21.980
you a little bit more. They're going to get you back to, you know, playing soccer and this
437
00:39:21.980 --> 00:39:26.500
patient, oh, they're really good when people are scared and things like that. So yeah,
438
00:39:26.500 --> 00:39:30.700
I think the biggest thing is, you know, try to create that relationship with the PT
439
00:39:30.700 --> 00:39:35.620
because to tell you right now, like we want it. Yeah. You know, I so appreciate you saying
440
00:39:35.620 --> 00:39:40.220
that. I feel like I stay all the time, cold calling for specialists of any kind for
441
00:39:40.220 --> 00:39:43.200
nurse practitioners to develop relationships with the people that they refer to because
442
00:39:43.200 --> 00:39:47.600
they want it. And I appreciate saying that because it's like, you're trying to do your job.
443
00:39:48.020 --> 00:39:51.640
And like we sometimes they feel like they're bothering and it's like, no, they're at,
444
00:39:51.700 --> 00:39:54.480
you're actually helping make sure that the appropriate patients are going to the right
445
00:39:54.480 --> 00:39:58.400
place, right? Like we, you don't want to send you things that you don't have the ability
446
00:39:58.400 --> 00:40:04.140
to see or because they are not appropriate, right? Yeah. So there are definitely things that
447
00:40:04.140 --> 00:40:08.900
like are outside of people's skillsets. You know, not every patient sees pelvic floor,
448
00:40:08.900 --> 00:40:14.280
not, sorry, not patient, not every physical therapist. She's patients, but pelvic floor
449
00:40:14.280 --> 00:40:20.320
dysfunction or TMJ or a hand issue. So absolutely, you know, knowing what their
450
00:40:20.320 --> 00:40:25.900
specialties are and, and if you don't ask, like we would love to talk to you.
451
00:40:25.900 --> 00:40:34.360
Yeah, they're not scary. They get so scared. I'm looking at the questions that were
452
00:40:34.360 --> 00:40:39.560
submitted. So are there any red flags that you see that get missed by a provider that referred
453
00:40:39.560 --> 00:40:50.420
them or is it not, not too bad? So I worked, I think, which probably like when I worked in
454
00:40:50.420 --> 00:40:56.420
like Somerville and Cambridge and things like that, and I can't tell you why this location
455
00:40:56.420 --> 00:41:01.640
was like this more so than others, I'm not really sure. But there's a high percentage
456
00:41:01.640 --> 00:41:07.980
of patients that are hypermobile and that is a diagnosis. I feel like that's
457
00:41:09.320 --> 00:41:12.840
really underdiagnosed unless someone's coming from Children's Hospital, you know,
458
00:41:12.840 --> 00:41:16.780
where they're kind of getting it as a kid and they, and there's times where I've
459
00:41:16.780 --> 00:41:23.780
diagnosed people with EDS and I'm like, yeah, Ehlers-Danlos syndrome. Exactly. And I'm
460
00:41:23.780 --> 00:41:27.460
like, you know, you really got to talk to your doctor about this or, you know, there's a
461
00:41:27.460 --> 00:41:35.820
Boston that I'll send them to or it's, it's a, I see, I don't have a percentage per se,
462
00:41:35.880 --> 00:41:39.200
but I would honestly probably guess maybe more than 50% of my patients
463
00:41:39.980 --> 00:41:48.100
have this. And, and so what is hypermobility, right? So the way we diagnose it or kind of
464
00:41:48.100 --> 00:41:53.650
can say that someone has it or not is just based off of the Byton scale. And if you're
465
00:41:53.650 --> 00:42:00.970
familiar with that, it, it's just nine tests. So the first thing is, is your hands. So can
466
00:42:00.970 --> 00:42:09.010
you reach like your, your thumb down to your wrist? No. Okay. But you'll see like something,
467
00:42:09.270 --> 00:42:12.890
you know, this is like an, the old word would have been like double jointed, right?
468
00:42:13.070 --> 00:42:17.270
And so you'll see people like, they can do that. I can do some of them. So like
469
00:42:17.270 --> 00:42:22.030
the pinky is next. So if you can bend your pinky back beyond 90 degrees.
470
00:42:24.290 --> 00:42:31.290
So you're, you're at like 88 degrees over there. Just about there, but you can see how that's
471
00:42:31.290 --> 00:42:37.430
obviously more than 90, right? Or this one doesn't go as far, but still more than 90.
472
00:42:37.910 --> 00:42:42.670
So that's, so it's one, two, three, four. Okay. So each side of the body counts as a
473
00:42:42.670 --> 00:42:47.610
different number. The next thing is elbow hyperextension. I don't really have that,
474
00:42:47.610 --> 00:42:52.010
but you're looking for more than 10 degrees of, of hyperextension. And you really want
475
00:42:52.010 --> 00:42:56.110
to measure that passively because actively they'll just kind of stop here. And so you
476
00:42:56.110 --> 00:43:02.510
really want to get that full hyperextension. So that's five, six. And then the knees. So
477
00:43:02.510 --> 00:43:07.710
you're looking at either standing or supine hyperextension of the knees. Same thing
478
00:43:07.710 --> 00:43:14.870
that 10 degrees. And then if they can or could as a child, like palm the ground
479
00:43:15.370 --> 00:43:19.390
with their knees straight. So like bending forward, reaching their palms on the ground,
480
00:43:19.390 --> 00:43:23.050
other fingertips has to be like a flat palm and their knees have to stay straight.
481
00:43:24.210 --> 00:43:30.310
So if you have more than four of those be positive tests, it's considered classified
482
00:43:30.310 --> 00:43:36.590
as hypermobile. And that can really change diagnosis. So, you know, people who are
483
00:43:36.590 --> 00:43:40.610
hypermobile, there's been strong links with anxiety even, right? So these people are
484
00:43:40.610 --> 00:43:46.730
going to have possibly a more, a higher fear of movement. There's been strong links with
485
00:43:46.730 --> 00:43:53.570
lack of proprioception. So one of the things that's like another criteria that fits into this
486
00:43:53.570 --> 00:43:58.790
is do you trip a lot? Are you clumsy? Do you drop things? And so from your standpoint,
487
00:43:58.790 --> 00:44:02.490
you may think of those questions as like a neurological concern, right? Like they're,
488
00:44:02.690 --> 00:44:05.990
they're developing some sort of neurological disease and you're like, oh, that's not good.
489
00:44:06.350 --> 00:44:09.830
But what if they've just been like that their whole life? Like the person and
490
00:44:09.830 --> 00:44:14.950
kind of like, like, you know, I clipped my shoulder like on doorways a lot.
491
00:44:16.270 --> 00:44:19.930
Like, oh, and the thing is that you don't know where you are in space.
492
00:44:19.970 --> 00:44:23.770
So interesting. I feel like I sort of meet criteria for this.
493
00:44:24.910 --> 00:44:28.650
I think you do absolutely. I think we tested that. Yeah.
494
00:44:29.170 --> 00:44:32.330
My neck is a little hypermobile. I'm definitely clumsy. Definitely clumsy.
495
00:44:34.990 --> 00:44:39.350
That's so interesting. So you probably are just treating them a little differently,
496
00:44:39.350 --> 00:44:47.210
just being more mindful. Yeah. 100% for them, it's posture. It's posture because
497
00:44:47.210 --> 00:44:52.790
so let's say they stand with that genuine recurvatum in their knees, that hyper extension,
498
00:44:53.090 --> 00:44:58.590
right? What's going to happen to their low back? It's going to increase the lumbar lord
499
00:44:58.590 --> 00:45:04.770
doses, right? So I've had people come in, you know, 10 plus years of back pain,
500
00:45:04.770 --> 00:45:08.890
watch them stand, they hyper extend their knees, they have that increased lord
501
00:45:08.890 --> 00:45:14.070
doses. I say soften your knees, I tape them in a softened knee position so they can't move.
502
00:45:14.730 --> 00:45:21.330
And they come in, their vaccines gone. So great. So it's such an easy fix. And I just
503
00:45:21.330 --> 00:45:24.810
feel like, like that's, that's gotta be in people's radars a little bit more to have
504
00:45:24.810 --> 00:45:29.590
that like hypermobility scan, because it does lead to a lot of different things. And it
505
00:45:29.590 --> 00:45:33.910
means someone has like Ehlers-Danlos syndrome, or they could have pot syndrome, or even like
506
00:45:33.910 --> 00:45:39.590
our fans, you know, they have cardiac issues, there's other systemic things that could be
507
00:45:39.590 --> 00:45:45.090
going on as well that need to get ruled in and out. Totally. That's so, that's so
508
00:45:45.090 --> 00:45:48.810
interesting. One of the questions was about being able to read physical therapy notes.
509
00:45:48.810 --> 00:45:54.850
And for me, I glaze over and I'm just like, it's going well. I signed it and it's in
510
00:45:54.850 --> 00:45:58.990
their chart. Like I don't really know how to read physical therapy notes. I don't know why.
511
00:45:59.010 --> 00:46:02.030
Like I can't even think of the examples. I just remember reading and it looks very
512
00:46:02.030 --> 00:46:06.210
different from the way that we write our notes. And so I just was like, therapy's going well,
513
00:46:06.410 --> 00:46:15.410
I think. Just like maybe bad. Yeah, no, it's, we know what happens. You know, generally we
514
00:46:15.410 --> 00:46:19.150
only sign notes for Medicare. We send notes out to be signed for Medicare patients
515
00:46:19.150 --> 00:46:25.650
anyways, just because that's an insurance requirement. But there is, there's a
516
00:46:25.650 --> 00:46:30.430
Massachusetts requirement that every 30 days, a physical therapist has to do a progress
517
00:46:31.630 --> 00:46:37.010
and most EMRs will just send that to the referring provider, like in a fax or an email
518
00:46:37.010 --> 00:46:40.650
or whatever. So that's, that's why you get our notes a lot of the time. Oh, I was wondering,
519
00:46:40.850 --> 00:46:46.270
I was like, I wrote a prescription. I don't know why. Like, why are you talking to me?
520
00:46:46.470 --> 00:46:50.390
Go away. But I just was like, I didn't understand the signature part. I thought
521
00:46:50.390 --> 00:46:57.650
always being an inconvenience that I wasn't sending stuff in the first place, but I
522
00:46:57.650 --> 00:47:03.870
signed the initial evaluation, every progress note, which is every 30 days in the discharge
523
00:47:03.870 --> 00:47:11.530
note has to be signed or the insurance company doesn't reimburse us. Which that's a whole
524
00:47:11.530 --> 00:47:16.790
different soapbox, but there's no other insurance company that does require that.
525
00:47:17.190 --> 00:47:20.930
But Massachusetts law does require that we send the progress note. Now that progress note
526
00:47:20.930 --> 00:47:25.110
does not have to be signed if it's not Medicare, but we, we do have to send it
527
00:47:25.110 --> 00:47:29.570
I see. I like hearing, I like hearing it. I just don't know how to interpret it.
528
00:47:30.210 --> 00:47:34.430
Yeah. So, so basically it's, it's subjective is the first part, right? So it's like, what,
529
00:47:34.650 --> 00:47:39.550
how does the patient feel things are going? So that's, that's good or bad, you know,
530
00:47:40.850 --> 00:47:44.590
the object of stuff, I think would be the hardest because it's all just numbers
531
00:47:44.590 --> 00:47:48.850
and you're like, what, what, you don't know what the normal, the normative value is.
532
00:47:49.170 --> 00:47:53.450
So it's like, oh, they have, you know, 55 degrees of flexion. Like, well, what are
533
00:47:53.450 --> 00:47:58.170
you supposed to have? You know, that doesn't tell me anything. So I can, I can definitely
534
00:47:58.170 --> 00:48:02.750
understand that. I think if you read any part of it, read the assessment because that's,
535
00:48:02.750 --> 00:48:06.230
that should be written in like plain English. That's just kind of like, you know,
536
00:48:06.310 --> 00:48:10.630
patient presents with this. They could do this. They now can do this. They're still
537
00:48:10.630 --> 00:48:16.290
working on this. They would still benefit from PT is generally like the formula for that
538
00:48:16.290 --> 00:48:20.630
aspect. Yeah. And I usually, I feel like too, when I've seen them and I do appreciate
539
00:48:20.630 --> 00:48:24.510
seeing them, like the part that I understand, but it's usually like, what are the goals? And
540
00:48:24.510 --> 00:48:28.610
it's like, to be pain free by the, like, there's usually some sort of like metric goal of like,
541
00:48:28.690 --> 00:48:32.650
they want to be without pain during certain activities, like that kind of thing. Yeah.
542
00:48:33.190 --> 00:48:36.190
Yeah. I usually just say like, do you need more physical therapy? I'll write more.
543
00:48:37.890 --> 00:48:43.810
Yeah, you do. I think one of the other questions that really came up a lot was about,
544
00:48:44.450 --> 00:48:47.770
I think the main challenge that I see in primary care, aside from like kind of like
545
00:48:47.770 --> 00:48:51.290
convincing patients. And again, I say that in quotes because I'm not, I'm not coming from
546
00:48:51.290 --> 00:48:55.450
a nefarious place. I'm coming from like a connecting them to understanding what exactly
547
00:48:55.450 --> 00:49:00.190
the benefit is. Right? Like it's, it's not, I have no agenda as I can to help them. Right.
548
00:49:00.310 --> 00:49:04.070
But sometimes you have to get people's buy-in and you have to explain, like,
549
00:49:04.370 --> 00:49:09.050
what are their objections? And usually the main objections are, is this going to help me?
550
00:49:09.090 --> 00:49:12.450
How does this help me? Right. And so that's what the purpose of our talking is so that we
551
00:49:12.450 --> 00:49:16.510
can fully understand, I mean, we can't fully understand it in like a half an hour, but you
552
00:49:16.510 --> 00:49:21.370
better understand what the process is and how it actually believe with gusto that is going to
553
00:49:21.370 --> 00:49:27.470
help. Right. And then number two and three are about cost and about time. And it's either cost
554
00:49:27.470 --> 00:49:30.950
because they don't have insurance or their insurance in Massachusetts. There's a plan
555
00:49:30.950 --> 00:49:36.110
that only covers 60 visits per year for any condition. I don't know if that's been
556
00:49:36.110 --> 00:49:39.830
updated, but there's some other ones that will cover, like for me personally, I had a back
557
00:49:39.830 --> 00:49:47.090
injury being covered for I think 60 days only. And then the other part of it is copays, right?
558
00:49:47.150 --> 00:49:50.370
So like, is there copay too high? Those are the main like objections. And so when it comes to
559
00:49:50.370 --> 00:49:53.890
like selling a patient on it, it's kind of like addressing those things. But what's the,
560
00:49:53.990 --> 00:49:57.390
do you have any thoughts about that? Cause I know that we were both frustrated with the
561
00:49:57.390 --> 00:50:01.770
state of insurance access and physical therapy access. So what are your thoughts about that?
562
00:50:02.570 --> 00:50:12.930
Yeah, it's hard. I disagree with how insurances deal with that because I mean, every insurance
563
00:50:12.930 --> 00:50:20.370
is different. Of course. I know there, it has since changed, but there was an insurance that
564
00:50:20.370 --> 00:50:28.530
said 30 days actually. It's like, you get 30 days to fix the condition and it's per condition
565
00:50:28.530 --> 00:50:37.670
per lifetime. Really? So if you had an ICD-10 code of NIOA, right? You got 30 days in your
566
00:50:37.670 --> 00:50:46.170
entire life to fix it. It's wild. So then they changed it to 60 days. And I think they've
567
00:50:46.170 --> 00:50:51.230
since changed it to 60 visits in a year, which is much better. 60 visits is a lot.
568
00:50:52.230 --> 00:50:56.430
Generally you should be seen for under 20. You know, it should be, if it's really
569
00:50:56.430 --> 00:51:01.330
straightforward, like an ankle sprain or things like that, you know, 12 visits or so is like
570
00:51:01.330 --> 00:51:06.970
two to three months is really enough. Or if someone has, especially anything with like
571
00:51:06.970 --> 00:51:12.690
healing from a fracture, those are pretty straightforward. Post-op is generally going
572
00:51:12.690 --> 00:51:17.670
to be about four months. Unless it's ACL, it's going to be about six months.
573
00:51:18.350 --> 00:51:22.490
Oh my gosh. I love hearing this because like, from my perspective, like that is so
574
00:51:22.490 --> 00:51:28.070
disparate from insurance. And also it's nice to hear that like, I think it's also important
575
00:51:28.070 --> 00:51:32.370
for us to know as nurse practitioners, how to set patients up for success. Yeah. So
576
00:51:32.370 --> 00:51:35.550
then step aside, but like even in that communication piece, like this is going,
577
00:51:35.670 --> 00:51:39.870
like when you and I first met with my back, you were like, Ooh, 60 days is not that long.
578
00:51:40.270 --> 00:51:44.150
And I, in my perspective, I was like, Oh, really? It's going to take a long time,
579
00:51:44.150 --> 00:51:47.950
but that's nice to know. I know about an ACL tear, but like, I didn't know about
580
00:51:47.950 --> 00:51:53.910
four months and that's helpful to know. Yeah. Usually like that 16 week. And this is again,
581
00:51:54.050 --> 00:52:00.110
kind of categorizing, but if you look at pretty much any post-op rehabilitation protocol
582
00:52:00.110 --> 00:52:05.350
around that four months, Mark, they're starting to do like sport activity, right? And a lot
583
00:52:05.350 --> 00:52:09.870
of, not all, some insurances don't even cover it. If you're only working on sport activity.
584
00:52:11.330 --> 00:52:16.690
Sometimes that can be a little bit tricky to, you kind of have to be
585
00:52:16.690 --> 00:52:21.010
creative with how you write things. So it's just a conversation that you want to have with
586
00:52:21.010 --> 00:52:26.590
your patient too. Like sometimes I'll see people have like a $75 copay and I'll be like, you know,
587
00:52:26.730 --> 00:52:30.730
can you be here twice a week or do you want to just do once a week or do you want to
588
00:52:30.730 --> 00:52:37.030
do once every other week? It's our job to work with you to figure it out. So if you
589
00:52:37.030 --> 00:52:42.310
only get six visits, but it's your job to know your benefit though, right? So to know
590
00:52:42.310 --> 00:52:48.890
come in and kind of discuss the concerns that you have. Most people are going to try to see you
591
00:52:48.890 --> 00:52:53.950
twice a week, right? Because it takes that repetition to really build it. There's, I think
592
00:52:53.950 --> 00:52:57.590
there's a study out there. It says it's a little vague. It says between like 300 and
593
00:52:57.590 --> 00:53:04.150
600 repetitions are really needed to not learn a new skill, but just actually build that
594
00:53:04.650 --> 00:53:08.990
neuroplasticity of a muscle firing rate. So that's, that's a lot. And then if you're
595
00:53:08.990 --> 00:53:14.550
doing, if it's in the beginning and you're not really getting that feedback often enough to
596
00:53:14.550 --> 00:53:19.210
know that you're firing it correctly, then you're firing it incorrectly and then you're
597
00:53:19.210 --> 00:53:22.830
kind of wasting your time. And so that's why we try to say twice a week, at least in the
598
00:53:22.830 --> 00:53:27.050
beginning. And then maybe once a week after you feel more comfortable and you're working
599
00:53:27.050 --> 00:53:32.470
on more of the strengthening aspect, but we can move, we're very flexible in that. And if
600
00:53:32.470 --> 00:53:36.170
they're not, then you have to think about, you know, do they want your
601
00:53:38.030 --> 00:53:42.090
fee or do they want to help you? So you gotta be careful with that.
602
00:53:49.630 --> 00:53:54.870
That's our episode for today. Thank you so much for listening. Make sure you subscribe,
603
00:53:55.210 --> 00:54:00.670
leave a review and tell all your NP friends. So together we can help as many nurse practitioners
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00:54:00.670 --> 00:54:05.550
as possible, give the best care to their patients. If you haven't gotten your copy of
605
00:54:05.550 --> 00:54:11.490
Ultimate Resource Guide for the new NP, head over to realworldnp.com slash guide.
606
00:54:11.910 --> 00:54:16.550
You'll get these episodes sent straight to your inbox every week with notes from me,
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00:54:16.870 --> 00:54:20.750
patient stories and extra bonuses. I really just don't share anywhere else.
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00:54:21.110 --> 00:54:24.090
Thank you so much again for listening. Take care and talk soon.
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