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Healthy Wealthy & Smart

The Healthy Wealthy & Smart podcast with Dr. Karen Litzy features top experts in health, wellness and business with a particular focus on physical therapy. We take evidence based medicine and break it down making it easier to understand and immediately apply to your life. At Healthy Wealthy & Smart our goal is simple: to provide you with the best information to live a healthy and pain free life!
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Now displaying: July, 2019
Jul 29, 2019

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!

 

Jul 22, 2019

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.

 

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Jul 15, 2019

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.

 

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Jul 11, 2019

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.

 

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Jul 8, 2019

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.

 

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