Healthy Wealthy & Smart

Healthy Wealthy & Smart: Where Healthcare Meets Business. The Healthy Wealthy & Smart podcast, hosted by world-renowned physical therapist Dr. Karen Litzy, offers a wealth of knowledge and expertise to help healthcare and fitness professionals take their careers to the next level. With its perfect blend of clinical skills and business acumen, this podcast is a one-stop-shop for anyone looking to gain a competitive edge in today's rapidly evolving healthcare landscape. Dr. Litzy's dynamic approach to hosting combines practical clinical insights with expert business advice, making the Healthy Wealthy & Smart podcast the go-to resource for ambitious professionals seeking to excel in their fields. Each episode features a thought-provoking conversation with a leading industry expert, offering listeners unique insights and actionable strategies to optimize their practices and boost their bottom line. Whether you're a seasoned healthcare professional looking to expand your skill set, or an up-and-coming fitness expert seeking to establish your brand, the Healthy Wealthy & Smart podcast has something for everyone. From expert advice on marketing and branding to in-depth discussions on the latest clinical research and techniques, this podcast is your essential guide to achieving success in today's competitive healthcare landscape. So if you're ready to take your career to the next level, tune in to the Healthy Wealthy & Smart podcast with Dr. Karen Litzy and discover the insights, strategies, and inspiration you need to thrive in today's fast-paced world of healthcare and fitness.
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Now displaying: 2019
Dec 30, 2019

Happy holidays to the Healthy, Wealthy and Smart family! This is a special episode where all the amazing women behind the show come together to discuss 2019 and what’s to come in 2020. Thank you for supporting us and we hope to continue to provide great conversations in the new year!

In this episode, we discuss:

-Why you should enlist a team to help grow your business

-How to gracefully ride the ebbs and flows of entrepreneurship

-Prioritizing your mental health to avoid burnout

-New year intentions from the team

-And so much more!



A big thank you to Net Health for sponsoring this episode!

Check out Optima’s Top Trends For Outpatient Therapy In 2020!


For more information on Jenna:

Jenna Kantor, PT, DPT, is a bubbly and energetic woman who was born and raised in Petaluma, California. She trained intensively at Petaluma City Ballet, Houston Ballet, BalletMet, Central Pennsylvania Youth Ballet, RDA Choreography Conference, and Regional Dance America. Over time, the injuries added up and she knew she would not have a lasting career in ballet. This lead her to the University of California, Irvine, where she discovered a passion for musical theatre.

Upon graduating, Jenna Kantor worked professionally in musical theatre for 15+ years then found herself ready to move onto a new chapter in her life. Jenna was teaching ballet to kids ages 4 through 17 and group fitness classes to adults. Through teaching, she discovered she had a deep interest in the human body and a desire to help others on a higher level. She was fortunate to get accepted into the DPT program at Columbia.

During her education, she co-founded Fairytale Physical Therapy which brings musical theatre shows to children in hospitals, started a podcast titled Physiotherapy Performance Perspectives, was the NYPTA SSIG Advocacy Chair, was part of the NYC Conclave 2017 committee, and co-founded the NYPTA SSIG. In 2017, Jenna was the NYPTA Public Policy Student Liaison, a candidate for the APTASA Communications Chair, won the APTA PPS Business Concept Contest, and made the top 40 List for an Up and Coming Physical Therapy with UpDoc Media.

Jenna Kantor currently holds the position of the NYPTA Social Media Committee, APTA PPS Key Contact, and NYPTA Legislative Task Force. She provides complimentary, regularly online content that advocates for the physical therapy profession. Jenna runs her own private practice, Jenna Kantor Physical Therapy, PLLC, and an online course for performing artists called Powerful Performer that will launch late 2019.

Jenna continues to perform in musical theatre and lives in Queens, New York with her husband and two cats.


For more information on Julie:

Dr. Julie Sias, PT, DPT is the Producer of the Healthy, Wealthy and Smart Podcast. Julie received her Doctor of Physical Therapy degree from Chapman University. Julie loves to gain new insights and inspiration from the guests of the show in order to enhance her physical therapy private practice in Newport Beach, California.

For more information on Lex:

Alexis Lancaster is a student intern on the Healthy Wealthy and Smart podcast. She earned her Bachelor of Science degree in Biology, a Graduate Certificate in Healthcare Advocacy and Navigation, and is currently in her final year of the Doctor of Physical Therapy program at Utica College in Utica, NY. Lex would love to begin her career as a traveling physical therapist and hopes to eventually settle down in New Hampshire, where she aspires to open her own gym-based clinic and become a professor at a local college. She loves working with the pediatric population and has a passion for prevention and wellness across the lifespan. Lex also enjoys hiking, CrossFit, photography, traveling, and spending time with her close family and friends. She recently started her own graphic design business and would love to work with you if you have any design needs. Visit to connect with Lex.

For more information on Shannon:

Dr 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:

Karen Litzy:                   00:00:07           Hey everybody. Welcome to the last live podcast of 2019 I am your host, Karen. Let's see, and today's episode is brought to you by Optima, a net health company. Optima therapy for outpatient is a software solution enabling therapists and staff to do their jobs efficiently and accurately. Their software provides anytime, anywhere access to documentation, even while disconnected, which is huge, and workflows that streamline patient care and save valuable time. You can check out Optima's new on demand video to learn what's in store for outpatient therapy practices in 2020 with some of the biggest industry trends along with tips and best practices to successfully navigate these changes.

Karen Litzy:                   00:01:14           Learn about these trends for the new year at and we will of course have a link to this in the show notes under today's episode. And I also want to thank net health not only for today, but for being such an amazing sponsor to this podcast. We couldn't do what we do every week without their help. So a huge thanks to net health. So definitely check them out. And notice I said we now it's because of course I cannot do this podcast alone by any means. And today I am so excited to have the powerhouse team behind this podcast for amazing physical therapy entrepreneurs for strong, amazing women who help bring this podcast to life every single week. So in this episode, I'm happy to have on doctors. So they're all doctors, Julie Sias, Jenna Kantor, Shannon Sepulveda, and Lex Lancaster. And what we did was I had a conversation with Jenna and Julia.

Karen Litzy:                   00:02:18           You'll hear that in the first half of the podcast. And then in the second half of the podcast with Lex and Shannon and we talked about what our sort of our year in review, what 2019 did for us as people and as women and as entrepreneurs and physical therapists. And one theme that came across was that we're all doing things that make us happy and that in 2020 we want to continue that and we want to sort of construct the life that we want to see us leading. So that's in our personal lives and also in our life as physical therapists. So the amazing thing is Lex, Jenna and Julie are new grad physical therapists. Jenna and Julie have started their own practices. Lex has her own business outside of physical therapy, helping people with websites and graphics. Shannon, has an amazing practice in Bozeman, Montana.

Karen Litzy:                   00:03:20           She has started her practice about two years ago. It has grown exponentially. So she talks about how she did that. And it's amazing. We talk about what I have coming up in 2020 including an online course to help all those physical therapists or occupational therapists out there who want to start their own practice in a way that feels good to them in a way that's going to make them happy, bring them joy. And also the most important thing as physical therapists is our job is to get people better. And in our conversations in this podcast, we talk about how what we do as individuals not only affects us, but it's exponential. It affects everyone around us, our communities, our friends, our families, and of course the patients that we serve. And we're so grateful to that. And of course, as the host of the podcast and creator of the podcast, I just want to thank all of these women because without them I wouldn't be able to do this.

Karen Litzy:                   00:04:14           There's no way I can do this on my own. Like one of my guests said, Stephanie Nickolich and we mentioned this in the podcast is if you try and do it all, it'll keep you small. And when I was trying to do it all with this podcast, it was keeping me small. I wasn't able to upcycle this as much as I have with the help of these four women. So I just want to tell all of them and I say it in the podcast as well as that I appreciate them. I think they're amazing and I wouldn't be able to do what I do without them. And I just want them to know that my gratitude for this past year of 2019 is so immense and looking forward into 2020. I'm so excited to see what we all come up with. So I hope you guys really take in this episode because I think it's really special and of course to the audience thank you so much for another great year of listening and interacting with the podcast and being able to meet so many listeners all over the world has been a real joy to me in this past year. So everyone, thank you so much. Have a very, very happy new year and we'll be back with brand new episodes in 2020.

Karen Litzy:                   00:05:24           Hey Jenna and Julie, welcome to the podcast. Welcome back to the podcast. Since you've both been on several times. The reason being is because we all work together on the podcast to make it what it is. So well, welcome, welcome. So we're wrapping things up for 2019 and I thought, well, what better way to do that then with the people who make this podcast happen every year and who I'm eternally grateful for and appreciate so much for all of your hard work and your dedication and your fun and your being you. So, thank you guys for everything that you do. And now let's talk about 2019. Right? So we have January, 2019 to now. So a lot of things have happened within that year. So Jenna, we'll start with you. What are some highlights for you that's happened over the past year that you can kind of share with all the listeners?

Jenna Kantor:                00:06:34           Why hello listeners! Good, good evening and sun salutations. For me, I started my own practice literally on January 1st and we were driving back and I got my first patient that day. So literally my practice started this year. That was a big one for me. I also very quickly left all my PRN for those who don't know, that's working as needed, like a substitute teacher at a bunch of mills and I very quickly left all of them and I have been working for myself and it was the best decision I ever made. I have that musical theater background, which I'm sure listeners are quite familiar with, but if you don't know not, you know, and I was really not meant as a physical therapist to be sitting in one spot from nine to five. I really am not built that way and I love that I can make my own schedule, my own life and not feel like I'm really stuck in a location. It's a very, very big deal for me. That was something that was very concerned about as a performer. So I'm grateful to have made that move for myself.

Karen Litzy:                   00:07:49           Awesome. And Julie, how about you? So what's happened from January till now?

Julie Sias:                      00:07:54           So having been kind of mentored by Karen for the past three years, it was nice cause I also actually started my own practice and Karen was helping me along the way and everything. And January 1st yes, had my first patient and everything and it's been going really well, I haven't left my PRN jobs, but I do manage my concierge outpatient practice. And then I also see kiddos as like a consultation kind of gig. And then I work at a skilled nursing facility, PRN right now to supplement all that. But it's been a really exciting year because I finally have had a lot of control over all of my hours and it's been nice being out of school as a new grad.

Karen Litzy:                   00:08:44           Yeah. And Julie, when did you graduate? What was your graduation?

Julie Sias:                      00:08:49           So I graduated in the summer last year and then I took the licensing exam in November.

Karen Litzy:                   00:08:56           Right, cause you had to wait that extra long time to take your licensing exam.

Julie Sias:                      00:09:01           Yeah, so that was when I was just like a licensed applicant in California and I was working at the skilled nursing facility that I did a clinical rotation at. And then after I finally got my license, I was able to do all the paperwork to get a corporation and everything.

Karen Litzy:                   00:09:16           Right, right. And Jenna, when did you graduate?

Jenna Kantor:                00:09:19           That is so cool, Julie. I graduated in May 2018, took my boards in August and then I had a baby. No idea. I felt like, I think it was the rule of threes and I didn't have a three so I made up one.

Karen Litzy:                   00:09:48           That's so funny. Can you imagine now people probably be like, Oh my God, if they get like just a little clip.

Julie Sias:                      00:09:54           That's Jenna's one liner for the episode. We should make a graphic. I had a baby.

Karen Litzy:                   00:10:06           So great that the two of you were able to have a good idea of what you wanted to do and then we're able to execute on that and take action on that because it's certainly not an easy thing to do, especially when you've just graduated and you're trying to, you know, sort of make your Mark and kind of find your way. So to be able to know that before you even graduated I think is is amazing. And do you have any advice? Let's say there are some new grads listening or some students who are getting ready to graduate on what they can do to get some clarity around maybe where they would want to start their career at. And I'll have either one of you can jump in. Julie, do you want to jump in?

Julie Sias:                      00:10:56           Yeah, I'm ready to rock. So it was good to have accountability from you Karen because I kept telling you every year that I was going to do this. So then when it finally came to the time I couldn't really back down. So that was good. Cause then I had told everybody so if I ended up backing down that wasn't really going to look very good. And then I was also really clear with how I wanted my life to be. And going this route is definitely more of like a, it's tough, it's been tough kind of cause it's feast or famine sometimes and that's kind of like the ugly side of being an entrepreneur. But I have to like pause and just be grateful when I think about like my day and I just go, you know what, this is actually my ideal day. I got to go for a walk in the morning.

Julie Sias:                      00:11:54           I saw two patients. Maybe it's not like whether I want to be for like a full time job eventually, but I just have to like take a second and just be grateful. So it's good to have a clear vision about what you want your days to look like and then just know that when you put in the hard work eventually it will pay off.

Jenna Kantor:                00:12:41           Yes.  Amen, this is Jenna. I could not agree with you more. I think that is such a good point with any new practice owner is to stop and essentially smell the roses because it's easy to be, Oh my God, this is where I'm at. Oh my gosh. You know, living sometimes paycheck by paycheck and yes, you're not going to be rolling in the dough right away. It takes time. It takes patience, it takes persistence, all that stuff. But exactly what you said I think is a great way to approach it. I think a big thing, well there's a lot of big things for somebody. Big things when you graduate and you're trying to find a job, but there really is, from what I have seen, I know there's always an exception to the rule. There's really no help with the idea of graduating and getting a job from your school. They are focusing on teaching you what you need to know. You've got to pass those boards, boom, bada Bing. So if you're not going to continue and try to teach at the school that you were just at, you're not going to really get that guidance. The big thing now unfortunately as most of the jobs are at mills, there are places where people don't want to work for a long period of time. That's why they're always hiring. It just is what it is. And you could have this idea similar to me where you want to work with performing artists or say you want to work with tennis players. Say you want to work with geriatric patients only, but not by the hair of the chinny chin, Medicare, chin.  So you have a different vision on how you want to treat your patients. It's not easy to fully see that through when you graduate because you see this number of what you owe.

Jenna Kantor:                00:13:50           So you're in this like fantasy world. You're in school, you're learning like, Oh that's what I'm going to do. You graduate, you see your debt, that number and that number changes everything for everyone you've finished. You're like I need to get a job now. And it's just ah, and then you start work and then I've heard from some people, cause I spoke to a lot of new grads since then, I'm coming to me and I've only been out for a year and four months, you know, since taking the boards and then coming to me, just so fearful of

Jenna Kantor:                00:14:26           what if I quit? And that makes me look like a bad physical therapist. I always say the same thing. I don't care if it's your fourth, your fifth or 10th job that you're quitting. This is your life. None of us are living your life. So you got to make sure you are happy every time. You may get promises that, that they may not keep. And you need to keep track of that so you're not putting it on yourself. When you're not enjoying the job and you feel like you need to suck it up, you're not supposed to suck up life you’re supposed to enjoy life. You can't find that working for someone. You might be happy working at a mill. I'm not saying you wouldn't be, you wouldn't be, but most people aren't, unfortunately. So you're going to go through a journey most likely, unfortunately as a new grad of really having a hard time finding that fully right place for you to work long term.

Karen Litzy:                   00:15:14           And I usually tell people to kind of when you're trying to figure out, well what do I want to do or where might I fit? I usually have people do a couple of different exercises and I mentioned this on the podcast before, but one is like, just make three columns. I'm a big column person, right? So you make three columns in the first, just put like what you love to do and the second column is what you're good at because they could be two different things. Just cause you'd love to do something doesn't mean you're good at it. Like I love to do graphics doesn't mean I'm good at it, but I love to do it but I'm not good at it. And then the third is what will someone pay you for? So if you can kind of find a through line there, I think it helps you to sort of drill into maybe what are your strengths, what are you good at? What do you love? What will someone pay you for? So I always say like, I'm really good at crocheting. I really love crocheting, but no one's going to pay me for it. So it's a hobby. See the difference, right? So you want to make sure that

Karen Litzy:                   00:16:30           you're excluding your hobbies as being your full time job. But you know, for me, I some examples of what I'm good. Like I love curiosity, I love asking questions. I love, you know, networking and being with people and meeting new people. Those are things I really love and those are also things I'm good at. And so I was able to parlay that into a podcast and then parlay that into, through the podcasts and through networking into public speaking and into being asked to different conferences and stuff like that. So just know that not everything has to come from one singular job. You know like, and I think we can all say that here cause we've all got a couple of different things in the fire, stokes in the fire. Is that how you say it? I'm not really sure.

Karen Litzy:                   00:17:22           At any rate I would say to new grads is to certainly find the job that's going to put food on your table and feed your family and feed yourself and feed your pets and feed your kids and feed whoever else is depending on you. But don't discount that this one thing is the only thing you're allowed to do. You're allowed to do a whole bunch of other stuff, you have to give yourself that permission to do that and then you never know where that's going to lead you. Because if I only stuck just to patient care, well I wouldn't have this podcast and I wouldn't be going all over the world speaking and I wouldn't be asked to coordinate social media for conferences around the world. I mean just wouldn't be a thing. But instead I just decided to do what I love and do it well and get paid for it. It's awesome.

Julie Sias:                      00:18:28           Actually I have like a counter to that and that sometimes it's also good not to do what you love as a job cause it can be something that is your me time sort of thing. Oh that's like another counter to that. I was thinking about that maybe if you monetize something, it takes away the fun from it and then it becomes something where like I have to do this to make money versus I get to do this because I want to do it.

Karen Litzy:                   00:18:59           Right. And I think when you reach that point,

Jenna Kantor:                00:19:03           Yeah, I agree. Cut the cord if you don't like it's for me with performing I did. That was before me professionally for many years in musical theater. And I started to, I got into an eating disorder and I had to take a backstep cause it felt like a nine to five job going to these different States and I started doing community theater again to refine and which I did. And then I started working professionally again. So really was just, I realized I was just working at the wrong places. It's not that they were bad places, just not right for me. So yeah, I definitely agree with it's just assigned to cut the cord

Karen Litzy:                   00:19:41           Like Julie said, when you get to that point where I love doing this thing, but now it feels like a chore. I think you have to really do some self reflection and kind of see like, boy this is not, maybe, maybe I made a misstep here, so I need to take a step back and reexamine what I'm doing and let it go. Or you can see are there ways that I can make it even better if I give up some of the controls. Hmm, nice. Right? So I felt what Julie just said is what I felt about the podcast a couple of years ago. This very podcast, I was like, Aw man, I have to do another podcast. But then, and I was like pissed about it cause I was like, Oh, but I have to do this and this and this and Oh now I have to make time for this.

Karen Litzy:                   00:20:37           And I thought, all right, let me take a step back and kind of re-examine what I'm doing here. Cause there's gotta be a way that I can make this better and that I can make it bigger. And the thing for me was asking for help. So once I ask for help and let the control go, now all of a sudden it's, you know, more enjoyable and it's something that I continue to be very proud of, but that I'm not like, Oh no, not again, damn you podcast. You know, so it's instead of cutting the cord, I just tried, I took a step back and tried to look at ways that I can improve upon it and the improvement came with bringing people on board. So that's, you know, another all very valid kind of ways to look at things.

Julie Sias:                      00:21:49           Yeah. Another way to look at it too is that when you were under a lot of pressure, that allowed you to kind of be more creative too, to look for solutions and sometimes you go in directions that you wouldn't have thought you were going to go just because you were under that pressure and boom. That's where sometimes magic happens too.

Karen Litzy:                   00:22:09           That's right. Yeah. I think what Ryan Estis who was on the podcast a couple of weeks ago, what did he say? Like, when you're comfortable it breeds laziness or something like that, I'm really butchering his statement. I was like, boy, I really butchered that one up pretty well. But I remember when you said that, I was like, yes, that's so true. And yeah, it was something to the effect of like if he was looking at it from the point of view of an entrepreneur, that when you get to the level where you know you're consistently making money and you're consistently successful and then does that then breed complacency and does that take away your creativity a little bit?

Julie Sias:                      00:22:58           Yeah. That's not really the magic zone for growing.

Karen Litzy:                   00:23:01           Right, right, right. Yeah. And that's when you need some outside eyes to kind of take a look and see, and like Steve Anderson said last week, what is the role of a coach? And he said to give you those external eyes and ears that opens you up to things that you're just not seeing. And that's for everyone.

Julie Sias:                      00:23:27           Yeah. I actually have a perfect example of this and it was when I was just graduated and I was a licensed applicant and I had gone to all of my clinicals and asked for a job because I needed to make money while I was studying for the boards and stuff. And so ended calling Karen up and I was just like, you know, this one job offer, I got sure, like I'll have guaranteed money and guaranteed hours and stuff, but I just, it's not sitting with me well, I didn't really enjoy that experience as much as I could have. And then you were just like, Oh well maybe that's not the right fit for you. And then I got really creative and asked for referral for another clinic and ended up getting a job that better suited me at that time. So it was kind of nice having you there cause I was in the trenches like, Oh I need to make money right now. And you were just like, no, just take a step back. And then I had all these other opportunities present themselves.

Karen Litzy:                   00:24:24           Right. Right. And Jenna, that's kind of what you were saying. Right. When you graduate, like you said, all you're seeing is like, I've got debt, I need to make money. So you just take what you can. And so, you know, we don't always want to take just what we can, but you know, we want in an ideal world, we want to take what fits from all perspectives, what fits for the employer, what fits for you as a potential employee, what fits for you, whether you want to be an entrepreneur or you know, a part time entrepreneur, full time, whatever. But I think as a healthcare provider, if you find that job that fits, it just allows you to help more people.

Karen Litzy:                   00:25:19           Right? And in the end, we're in the business of making people better. And if you're not in the job that allows you to do that or you're not in the head space that allows you to do that, then the people who ultimately suffer are not you. I mean, you do a little bit, but it's the people that we’re out there to help. We're there to help people. That's what our job title is. And so if you can't, you're not in a good head space to do that or in a good physical space to do that. Then I think it becomes very difficult. Like Julie said, well, I had a great day. I was able to do the things I want to do that keep me sane. So that when you show up for your patients, your clients, you're showing up fully for them. That's where I think the PT profession can Excel for sure.

Jenna Kantor:                00:26:24           When I was filling in for PRN work, I would come in energized, positive. I would walk in and go, let's do some physical therapy. We're going to heal. And like people loved me, or at least I believe they did. I had the patients even though I was a substitute teacher, which is how I introduce myself.

Jenna Kantor:                00:26:45           Like I really bonded with these people, you know, and I have that energy, but Oh yeah. If I had one full day or Oh my gosh, forgot it, two or three, Oh, can maybe have at once. Oh my God. Full days in a row, I would need days to recover, days to recover. Like I was like, I was gone, I was gone. I was like sleeping, like just feeling so tired throughout the day and it really made it so apparent to me that everyone else is doing this six days a week, maybe five, you know, I don't know, depending on there schedule, but I was just, Oh my God, I can't, you know, hence here we are a private practice owners on this call. Yeah, exactly.

Karen Litzy:                                           Now let's talk about what's in store for 2020 new decade. New year.

Jenna Kantor:                00:27:44           It's my birthday. I'm turning 40 years old. That means I'm going to be so mature. February 16th. I like flowers, see's candies and cats and Disney for anyone who wants to know. Yeah, we're getting a dog. But like I'm more of a cat person so, but it has to be cute cats cause there are those presents. But 2020 is going to be awesome. I'm sorry, I just jumped in. But I'm theater people love talking about themselves being the center of attention. It's great. So I am so excited about fairytale physical therapy. For those who don't know, Fairytale Physical therapy is where we bring musical theater shows to children in hospitals and teach choreography that’s secretly composed of therapeutic exercises. This whole past year we've been working on paperwork back and forth with the lawyers to get it done right.

Jenna Kantor:                00:28:42           And we're like almost there every time. Like people ask, it was just us liberal almost there. Right now we're trying to get the right legal name because it's not as simple as you would think. So we're trying to figure out that legal name where they're not straying too far from what we are. And so that's going to exciting. And then for me, I am doing a lot of one-on-one beta tests with performers, for one course an online course for performers to essentially, those are going to be mini courses like say you have, hip tendonitis. All right? Now the majority of non-union musical theater performers do not have health insurance. And if they do, they have extremely high deductibles. So they usually just don't get help. So this is creating a wellness program that will be on that boundary of like, Oh my God, you doing like physical therapy stuff, but y'all do.

Jenna Kantor:                00:29:42           It's about the patients. So I'm creating this for them. The people who don't have that access, they don't have the money, they don't have all that, where it's a program and right now I'm just testing it on people cause it's physical therapy. You have to test on people and see if it works, if they stick with it. And so that's really cool. So I'm literally doing it, I'm doing three different types of injuries, right? No, five injuries right now. And taking different people. They're essentially like patients where I'm talking to them every week and like upping the game and figuring out symptoms. So that's great. Move that over. Now I'm also starting next week, just walking into the new year one on one work with physical therapists who want to work with dancers and figuring out what they want to know to make them the confident, accessible and go to dance PT in their area.

Jenna Kantor:                00:30:35           So I am working with now five, it was originally three 50 minutes ago, became five. I'm working with five and figuring out what they learned and basically giving, creating a course from this. So I'm very excited about two things cause it's where I want my energy to go. I love doing, like we were saying, find what you like doing. I like doing the creation of online stuff. And I've just encountered so many people with limited access to performing arts, physical therapists who specifically know that. And if they do know that our hearts, they don't have the insurance. You know, there's a lot, a lot of people in this world who don't get it. So I'm very excited to be bringing that help to performers at large. Whether it be giving that education to physical therapists or providing a program to them directly so that is exciting!

Julie Sias:                      00:31:36           Jenna, I was like, I'm going to bring like some California chill into the conversation because when I think about 2020 it's more just like, okay, I got my income streams and their proportioned a certain way. I want my business to grow more than the other ones and slowly phase those out. So that's like my intention for 2020 but then every other intention has nothing to do with physical therapy.

Karen Litzy:                   00:32:12           I love it. That's good.

Julie Sias:                      00:32:16           I’ve just been spending too much time thinking about physical therapy this year too much time, so next year I'm just thinking about more time with family, more time exploring hobbies and stuff. Maybe then I'll feel refreshed and have some inspiration to do more online type services and stuff like that, but just going into 2020, I have I don't want to say low expectations, but just I don't want to set too many things, just see where it goes.

Karen Litzy:                   00:32:40           You have sort of more relaxed expectations, so not that they're low. I think phasing out your PRN jobs and increasing your income that’s a big job. And it's awesome. So I think that's a great thing to focus on. That'd be fabulous.

Julie Sias:                                              Karen, you haven't told us about your 2020.

Karen Litzy:                   00:34:09           Why I am going to do nothing? No, I'm just kidding. I'm just stepping back and I'm going to live the life of Riley for the whole year. No, no, no. I am going to continue obviously with my concierge practice because I love it. I would like to take on another independent contractor onto the practice as well. Just to, even if it's just one or two patients a week, you know, just something to kind of help offset the amount of time I'm spending with patients, which I love. But, it's a lot. So oftentimes I get caught up working in the business instead of on the business. So that's something that I'd like to kind of get a better balance of. And I am also in the final stages of putting together an online program. I know I said I was going to do this year, and I did it because I was too fearful and just was too afraid of like, no one's gonna buy it. I'm going to look so stupid. And with that, you know, it's clear that has been holding me back. But I've been working with Adrian Miranda also. So he helped me with some videos and worked with Joe Tata, to help me come up with a great plan. And I've been working with copywriters throughout the year and some business coaches. And so I have a program that I was calling strictly business mastermind, but now I think we're might change it to the private practice mastermind, but that might be changed. I think someone else has a name that's pretty similar.

Jenna Kantor:                00:35:20           You could do PP mastermind, so you could say pee pee like professionally, which would be funny. He'd be mad.

Karen Litzy:                                           Oh boy. I didn't even think of that. Now that private practice mastermind PPM, I may need to rethink this. But we're hoping for like an end of January launch and it's not just me, there's myself, there's lawyers, there's accountants, there's PR professionals, marketing professionals, investment professionals, you know, investment 101 for entrepreneurs kind of thing. Got other successful physical therapists are going to come in and that's just the six week part of the course. So six modules over three months, but then it's a year long program. So each month I have new mentors coming into the group to talk about whatever the group is looking for. Whether that be, you know, practice succession or tax stuff, student loan stuff, whatever.

Karen Litzy:                   00:36:38           So we'll have monthly webinars for the whole year. And then the best part is I'm doing the Marie Forleo model. So Marie Forleo started a B school, which is an online kind of business school, like abbreviated business school that she started several years ago. And once you purchase it once, that's it. So if we do it again and there are things added to it, you're always in the Facebook group. You don't get shut out of the Facebook group after a year. You don't have to pay for upgrades and all that kind of bullshit cause I think that's so stupid. So I'm going with the Marie Forleo model and it seemed to serve her well since she's made millions and millions of dollars and she's just helped so many people. And I think they just know that like, Hey, this is the deal. And so once you buy the program, once you're in it for life and you'll get the benefits of that for as long as you need or want said benefits.

Karen Litzy:                   00:37:41           So I love it. I kind of liked that model. I just think it's, I dunno, it just fits my personality a little bit better, you know? So, we'll come up with a name, and then we'll unroll it hopefully at the end of January.

Jenna Kantor:                                        Karen Litzy’s LIT program. Karen Litzy’s Master class cause you could do lit in LITzy. So that'll be like the fire. Oh, I see what you mean. That's a topless pizza delivery man. I dunno. I just, I was thinking lit. That's red fire color and nothing. What else is fire color? Oh, pepperoni. And then I went to pizza and that's where we got.

Karen Litzy:                                           Well, I thought it was because I am from the pizza capital of the world, which I guess would make sense. That would be amazing. I love that. Yeah. Yeah. Old forge, Pennsylvania. Plug for my hometown, pizza capital of the world. But yeah, so, but that's pretty much. And then, I also am going to take a vacation.

Julie Sias:                                              Where are you going?

Karen Litzy:                   00:39:08           I don't care, but I'm doing it. I don't know where I'm going yet,

Julie Sias:                                              You should go to Hawaii.

Karen Litzy:                                           I love Hawaii. It's so nice.

Jenna Kantor:                                        This morning you, I don't know what it is, but one, I have a friend that's gone on vacation that is when I decided to contact you. So it's not on purpose. It's just so when I'm contacting you I'll be like, wait a second. She's probably obvious. She's in Hawaii. She's in Hawaii.

Karen Litzy:                                           So we'll see. I don't know, but 2020. I am definitely, cause I have not had like proper vacation in a long time. So my goal, one of my biggest goals, and this is not PT related, kind of like what Julie said, but is take a vacation and love that with Brett. He just doesn't know it yet.

Karen Litzy:                   00:40:03           We just have to be after June. He worked for a state Senator in New York, so he's in session until in Albany, you know, you gotta, you gotta do what you gotta do. And then the other thing that I want to do, and Jenna can probably help me with this, is get a little more involved on the legislative side of things.

Jenna Kantor:                                        Love that stuff, man. You want, it's that be the change you want to see in the world.

Karen Litzy:                   00:40:50           That's another thing that I'd like to do, whether it's PT related or not PT related, but just try and push for things that I believe in that should be happening.

Jenna Kantor:                                        So I think this has been the best podcast ever. I think for all of us were overjoyed to have us have cats. Julie, where's your pet?

Julie Sias:                                              She's outside.

Jenna Kantor:                                        There's that dog, a dog and two cats walk into a bar. Thank you so much for having us on Karen.

Karen Litzy:                                           Yeah, this was great. And I'm just so happy to wrap up the year and I'm looking forward to lots of great stuff from everyone and with the podcasts and just kind of keep moving forward and trying to innovate and do some fun stuff. So that's the goal and I thank both of you. So Jenna, Julie, thank you again. Like I said in the beginning, I appreciate you guys so much for all of your hard work and help and making the podcast much better than it ever was. So thank you so much. And everyone we're going to take a quick break to hear from our sponsor and we'll be right back.

Karen Litzy:                   00:42:20           This episode is brought to you by Optima, a net health company. Optima therapy for outpatient is a software solution enabling therapists and staff to do their jobs efficiently and accurately. Their software provides anytime, anywhere access to documentation, even while disconnected and workflows that streamline patient care and save valuable time. You can check out, optimize new on demand video to learn what's in store for outpatient therapy practices in 2020 with some of the biggest industry trends along with tips and best practices to successfully navigate these changes. Learn about these trends for the new year at

Karen Litzy:                   00:43:00           Hey Lex and Shannon, welcome to the podcast for our year end wrap up our year in review. So thank you so much for coming on and being on the other end of things for Shannon and the other end of things for Lex too. So thanks so much. So I spoke with Jenna and Julie the other day and now I have you guys here and I'll say the same thing to you guys that I said to them is that I'm so thankful and appreciative of both of you for being part of the podcast and really elevating it to a new level this year. Cause I really do feel like without your help and without your contributions that it just wouldn't have been what it was. So I just want to thank both of you and know that I appreciate both of you for your work in front and behind the scenes. So thank you so much. And now let's talk about 2019 because now is the time of year that everyone looks back on the year. So I'll ask the same question of both of you.

Karen Litzy:                   00:44:14           Where were you at January of 2019 versus kind of where you are now. So Lex, why don't I have you start kind of what big things happened in your year? Where are you now? So it's way different than where you were in January.

Lex Lancaster:               00:44:32           Yeah. It's pretty crazy to be honest. I was thinking about it last night. This time last year, I was preparing for my last clinical physical therapy school, so I was actually going to New Hampshire. Mmm. I was going to be in an outpatient clinic for 13 weeks. I was super excited because it was my last one, but I was also getting that full 13 weeks in outpatient clinics. I was like my powerful clinical, so super pumped. So I finished that and then I went to graduation and I actually got engaged on white coat night. So that was really, it was awesome. Kyle did a really good job. And then I graduated PT school, it was so awesome. I was so happy. And then the NPTE came around and that was a different experience altogether. I will say that I underestimated that completely. Just the preparation for it as a whole, but then I passed. So that was great. And then now, so I had this dream of being a travel PT.

Lex Lancaster:               00:45:42           So, this past year, you know, I decided I was going to explore that. So right after I passed the NPTE, I accepted a contract with my fiance in Alaska. So we moved 3,500 miles away from home to an Island of 1200 people in Alaska. So now we're in Ketchikan where it's like the rain capital of the world. So I don't look at rain as like, let's keep me inside anymore. It's okay. It's always raining. It's never not raining. And it's pretty dark here. It's pitch black still right now. So we're currently in Alaska and an outpatient clinic. And to be honest, it's been a whirlwind transitioning from student to kind of a PT, but you're just studying for your exam to a full blown PT. It's been hard just because I didn't expect it. You know, I've done clinicals, I'm like, Oh, it's no big deal. It's totally different when you're the person. So I've spent a lot of time in the last 13 weeks just kind of getting used to that and getting the groove and I’m excited. I'm excited to see what the next year will bring because this year was just really, really awesome and I'm really excited for, you know, to see what's next.

Karen Litzy:                   00:46:52           And you also, not to, I don't want to leave this out, but you also have an entrepreneurial streak in you. You have a company that you started this year as well. Am I correct?

Lex Lancaster:               00:47:05           Yeah, yeah. And I shouldn't, you're right. So I guess I initially launched it in like the end of 2018 but this past year has just skyrocketed. I just went from, I mean, I guess word of mouth is kind of the way that it really worked out. And I get to design websites and graphics and I am a virtual assistant, so I get to work with people all over the country and all different professions. I have so much fun doing that and I started it in PT school as I admit. I used to do it when I was bored in class. And then, you know, it got to the point where that was how I took study breaks. So that was the way I decompressed and I found that that was a big stress reliever for me.

Lex Lancaster:               00:47:56           So I explored that option and then I was kind of talking to Shante, movement Maestro and she was like, you know, you could really do something with this because I approached her at RockTape course and I was like, Hey, do you need an assistant? And that was right after I started working for you Karen. So like I was feeling pretty good. I was like, this is fun. I love doing this. And then I decided to do the whole web design business too and big changes for that coming next year. So yeah, it's been, it's been really, really cool. I've learned a lot about a lot of different people and I get to explore that all the time and I love it.

Karen Litzy:                                           Yeah, I think that's great. What would you say to a physical therapy student right now? Who is set to graduate in, whether it be, maybe they're graduating now or maybe it's spring of 2020 given the huge changes that happened in your life over the past year. What would you say to them as they prepare to graduate or maybe they just graduated?

Lex Lancaster:               00:48:48           A couple things I would say I would say really explore your mental health. I think that I didn't take that route when, as I was graduating, preparing for the NPTE and I feel like I truly drained myself to the point where if I could go back, I would invest in, you know, even a coach just to get me out of that sympathetic drive because I feel like my life just kind of, I just devoted all of my time and energy to the NPTE and it really did drain me. And, it was just a lot to manage. So let's say explore your mental health, get that in check and you know, really be prepared to learn a lot and find yourself in whether you're in your last clinical or just starting your job, you know, if you're the smartest person in the room, try not, you know, try not to be that.

Lex Lancaster:               00:49:50           Like there's always something to learn and it's hard to go back to be in the clinic and be by yourself and not have someone to bounce ideas off of that's in your room. Like your CI. It's hard. And I truthfully would say get involved in Twitter. I've found that I've met the most incredible PTs on Twitter and I get so much good advice from them and I'm able to contact, you know, people have specialties that come into the clinic and I'm just like, wow, they could use some opinions on, you know, the vascular aspect and I'll find somebody on Twitter and they are more than willing to help me. I would say just reach out if you have any questions about patients because there are so many PTs on Twitter and social media in general that would help you. So I would say just keep your network huge.

Karen Litzy:                   00:50:36           That's great advice. And you know, I feel like this, the first time I heard someone say take care of your mental health. I mean Shannon, like we've been the NPTE or the boards and on through to our career. Have you ever gotten that? I never got that advice to kind of take care of your mental health. I think it's great.

Shannon Sepulveda:      00:51:00           Yeah. I mean I think it's super important. I mean, one thing like when I was a runner and an athlete and so I always made sure that like I worked out every day cause that really helped. But I remember like, just wait until you take your specialized board exam because then you don't get your results for three months. So it's like three months of like, okay, like is it June yet? You know? And so you don't even like, and like when I took my women's health board exams also I was postpartum so that like added a whole new mental health aspect to it. But I mean I studied for, you know, probably six months, probably pretty intensely for three months. And then you take the exam and it's very similar to the NPTE where you're like, I don't know if I pass this because the questions are similar where you're just like, ah, yeah, I don't really know.

Shannon Sepulveda:      00:51:55           And then you have to wait three months to know if you pass. And so that's really hard.

Lex Lancaster:                                       I'll say a week was really hard. So I give you a lot of credit. Yeah, I know it was a hard, and you walk out and you're like, then I have never felt like I have completely bombed a test, but I feel like I just bombed that and then everyone's like, don't worry, this is normal.

Shannon Sepulveda:                              Oh, it was sort of like, even with like my women's health exam and then I was like, I think I failed that. And then I ended up getting like in the top 10 or 25 it was something like I did really well on it, but I thought I failed it.

Lex Lancaster:                                       It's so odd that our brains do that, that all we remember all of the negative questions. We forget how many good ones there were and then we just kind of wrap around that.

Karen Litzy:                   00:52:51           Yeah. And that's life, right? That's why people always say to like, keep a gratitude journal at night. So then you remember the good things that happen to you every day and you don't get wrapped up in the negative because I think that's, like you said, it's kind of where our brains tend to go. We remember those negative aspects before we'll remember the positive ones. It is amazing.

Shannon Sepulveda:      00:53:15           Yeah. It's the same thing with patients. Like who do you go home and think about the one patient that didn't get better, not the six that you made better.

Karen Litzy:                   00:53:27           Totally. And now, Shannon, speaking of changing lives, so going from January till now, what's been going on? What were your highs and lows and just so everyone knows, I mean they can go on the website, but you're a business owner. You're in Bozeman, Montana. And one of the only women health specialists in the state of Montana?

Shannon Sepulveda:      00:53:53           I'm the only one that's taking the board exam. A couple women in Montana who have done the Herman and Wallace pelvic floor and they're super highly trained and there's other people in Bozeman that are women's health physical therapists, but I'm the only one that's taken the plunge to take the exam. But yeah, so 2018 so I know, I was thinking about this question. So I've been in my own practice for a little over two years. And so I was thinking, I'm like, where was I in January? And so since I take insurance, January is always like dead pretty much, but December is always nuts. I think I was still building my business like last January. I didn't really like have a full schedule. I had been in business for a little over a year.

Shannon Sepulveda:      00:54:45           I changed my last name when I left my old clinic, just kind of to make a clean break with insurance and everything. And so I was still trying to get like name recognition and I do women's health also getting into like the Perinatal community in Montana. And so this year I'm finally like, like doctors know who I am and patients come in, they're like, I got referred by, you're like so-and-so. They said you're awesome. And so I'm getting like all of these women, especially postpartum women, that's generally who I see, who were like, Hey, so and so like saw you, you changed their lives and I'm here. And so I would say like probably well over 50% if not 80% of my patients are direct access word of mouth. And I'm just like, Oh, this is so nice because I don't have to like network anymore.

Shannon Sepulveda:      00:55:49           I don't have to like spend my nights at like local networking events and which I was doing just to get some name recognition and now I feel like I can, I don't want to like totally rely on word of mouth. I still think I need to get out into the community but it's really nice just to like check my phone. I do online scheduling and be like someone's requesting an appointment and another person's requesting an appointment and know that like the patients are coming without me having to like really go out and spend a lot of time, which, and I think doing that really helped me now. I think I had to do that but now it's nice where like it's almost like an exponential growth cause moms tend to talk, which is really nice. And so the word of mouth has gotten really great for me.

Karen Litzy:                   00:56:37           That's awesome. And you know, I think you bring up a really good point that you were in business for a year and you had a patient flow but it wasn't like you were overwhelmed and you know, you didn't have this full, full schedule. And I think for people starting out in business that is so important to realize that you don't start your business and in two months, it's rare it could happen. Yes. You're not usually on a full schedule within a month or two.

Shannon Sepulveda:      00:57:09           No. And I think what was really important was like the time that I wasn't seeing patients, like I took that time to either like have lunch with somebody, like have lunch with a prenatal yoga instructor or like have lunch with, you know, really anybody, a doula and midwife, like whatever. And so I really like had a lot of lunches and coffees just to like meet people. So when I wasn't seeing patients, I was trying to meet people in the community. And I feel like those like one-on-one rather than like the big networking events were really important. And I sent like, it was great for me too because like I want to know who to send to for prenatal and postnatal yoga and I want to know who the good doulas are and who the good midwives and OBs are because I send people their way and who the good like trainers are that understand pregnancy and postpartum because I'm not a trainer. Like I get people to not pee their pants so they can go to the gym and see the trainer.

Karen Litzy:                   00:58:10           Correct. It could be your slogan. And you know something that would work.

Shannon Sepulveda:      00:58:19           Yeah, it was funny cause Shayla, the one that I did the podcast on with the hats she wanted, I got a bunch of my hats embroidered and she wanted me to put on the back leak-free thanks to my PT and I was like, that's awesome. You know, I don't know if people will wear that, but that's a really good slogan.

Karen Litzy:                   00:58:39           That's great. I mean, you're really good at what you do. No, I mean that's great because what do people want? They don't, like you said, like I get them to not pee their pants so they can do other things. It's that simple. You don't have to overcomplicate things. Yeah, but I love that you're still kind of doing business. I call it like business generating activities, you’re not getting paid for it, but it's business generating activities, so it's still like a moneymaking activity. And you're right, the bigger, like Lex said, the bigger network you have, whether that be virtual in your case, because your business is in Bozeman, the bigger network you have a Bozeman, the more people are going to come your way. And so you did all of that work and now you're really starting to see the benefits of it and it's really exciting.

Shannon Sepulveda:      00:59:28           Yeah.

Karen Litzy:                   00:59:29           It's also good that you know the cycles of your business. So you know there's going to be really bit busy but January, not so much. You'd be like, okay, so January I'm going to set aside this time to do X, Y, and Z for my business. And if you know that those are the ebbs and flows because every business has an ebb and flow, then you know you can rely on that. And like I remember for me, my downtime is now around Christmas, new years, not a lot of people around. So that this would be the time where I would take a vacation or I would work on business plans for next year or I would, you know, just get things together. So, so to speak. So I think it's great that you brought up all those points. And Shannon, what would you tell a new business owner, regardless of what kind of PT business you have, whether it's a cash based business or your insurance or a hybrid, what have you learned that you're like, Oh man, I would tell everyone this.

Shannon Sepulveda:      01:00:29           Yeah, I've learned that if you're good at what you do and you get patients better, they will tell other people. And so I don't want to say think of every patient as a referral source, cause that sounds like you're, you know, it sounds like you're categorizing them. But think of every patient as like, this person is very important. It's very important for me to get them better because that's what I do and what I'm good at. But it's also very important for my business because if you get them better and you treat them well with respect and you do everything, they're going to tell other people, especially in a small town. And so like I am very, like sometimes I come home and like after seeing like patients for an hour, so like I see like seven patients and that's a big day for me.

Shannon Sepulveda:      01:01:22           And I am just like compassion fatigue is like full on set in because like I am so engaged for that period of time and with my population it's really important because it's really important for, they just need someone to listen to them. But if you think of every patient that way, it pays back. And every word that you use with the patient is very important. Because they come from like sometimes doctors that say things that I wouldn't necessarily say to a patient and they come in with, you know, thought viruses. Thank you Lorimer Mosley and you know, just talking to them but being really compassionate, you know, with all for your patients. Yes. Really in the end. And sometimes it's hard at like four o'clock at the end of the day, but it's really important.

Karen Litzy:                   01:02:16           Yeah. And I always think of your patients instead of like you said, referral source, cause that is a little, that's, I don't know how to like how would you, I described them as ambassadors.

Karen Litzy:                   01:02:30           So they become ambassadors for my practice. And that's the way that I don't treat them as a referral source. I treat them as an ambassador. So someone who chose because of the care you gave to them, you know, I would love for you to see this friend of mine or my daughter or my cousin or my, you know, X, Y, Z person, my coworker. Because like you said, you're listening to them, you're treating them with respect and kindness and compassion. And so to reduce that to a referral source is, I don't know, I agree with you. I like to use ambassador because they're new, that they want to be part of what you're doing. You pulling them in and saying, Hey, I'll give you a free X, Y, Z. If you refer me to five of your friends.

Shannon Sepulveda:      01:03:24           But because they're choosing to represent you and they're so excited to tell people like that's what is so awesome about what I do is like, like I'll see people and be like, thank you so much for referring your friend. They're like, Oh my gosh, I am telling everybody because like we don't have to pee our pants anymore and we don't have to have painful sex anymore and this is just so great. And I'm like, yeah, it's great.

Karen Litzy:                                           And Lex, you'll get more of that as you practice more, you know, you'll get people coming to the clinic you're in specifically to see you, which you might've already gotten so far is you're in this small town, right?

Lex Lancaster:               01:04:07           Yeah. I actually wanted to say that because you used a word Shannon, you said, or a phrase, compassion fatigue. And I find that as a new grad, I'm learning how, cause that's me every day I do that. And you know, my patients come in and on the Island we don't, there's not a lot of doctors. The practitioners here, you know, they have to go down to Washington to see a specialist. So oftentimes people will come in with, you know, a lot of comorbid conditions and we have to sift through all of that and make sure they've seen the correct people. So there's nothing I love more than getting on the phone with four doctors for one patient. So, and I've found that like, that's caring about them and I'm like, Hey, look, I'm going to reach out to your doctor. And they love that. And, but I do find at the end of the day that I'm exhausted. And so I'm trying to find that balance where I'm giving, giving, giving, but also saving a little bit for myself at the end of the day. But yeah, there's been patients that are like that, Karen, they just, they're like, Oh, I've told my friend. And then that friend comes in and then they come see me and it's just like, this is amazing. And that's why I could see why having your own business, why that's so important. Because that word of mouth aspect, you really can't replace that.           

Karen Litzy:                   01:05:24           Yeah. Yeah. And you know, I think most PTs have that kind of compassion fatigue. And one thing that has helped me is, I remember it was at, Oh, I dunno, it might've been Jason silvernail might've mentioned it on Twitter. I'm not a hundred percent sure, but I remember. So I think it was him saying that the thing that helped him the most and he's in the army, the thing that helped him the most is, is finally realizing that somewhat he is not responsible for a patient's outcome, that the patient's responsible for their outcome. So and that's hard because you're investing your time and your compassion and your emotions into this patient and your skills. But once I realized once I was able to kind of separate myself from like I am not the fixer, I'm there to guide and to coach and to diagnose and treat but not to fix and can separate the fact that I'm not responsible for this person's outcomes, that the person needs to embody that.

Karen Litzy:                   01:06:32           Then the compassion fatigue is less, it's still there because we're all humans, but it's much, much less. And when you instill that into your patients, it's really fun. Like I had a patient who had chronic neck pain for five plus years and came in and he had stopped running, working out, doing this, doing good, going to CrossFit, doing everything. And I said, well, why, why, why do you think that is? And I understand I was the same way. And so we got him back to doing things and I would see him once a week, once every other week now, just once a month. And he's like, yeah, so I had like a week. I was like, I really didn't have any pain. He's like, and you know, it's because he's like, I work out like almost every day now. He's like, so you're here but it's not like what you're doing to me. He's like, I'm working out and that's what's making me feel better. I'm like, yeah, exactly. He was like, what? You gave me permission to work out again? I was like, yeah, I can do this. And I was like, I was like, you got like, that's exactly what you hope to hear is like, yeah, got it. It clicked. And you can tell it like clicked for him at some point that week. Like, I'm helping myself get better. Oh, I see how it works. Got it.

Shannon Sepulveda:      01:07:51           Yeah. And that's, I think really like, it's hard. Like I try really hard not to make my patients dependent on me. Like I try really hard. I was like, my job is to empower you to get yourself better. Like I give you the tools to get yourself better and I don't tend to do a lot of like if someone's in like acute pain, I'll do some manual therapy, but I don't tend to do a lot of manual therapy because aye I can see like sometimes they'll become dependent and my job is to be like, no, you can do this. Like you, you can do this. It's all you.

Karen Litzy:                   01:08:29           Yeah. And all the research that like Lex, I feel like, and I don't know Shannon, you could probably agree with me here, but I feel like Lex and like you guys and your new grads, like you guys are starting out on like second base. I started out, I didn't even start out in the dugout. Like when I started, I feel like I started out in like the showers. Like I didn't even get to the dug out yet.

Karen Litzy:                   01:08:50           You know, with all of this sort of patient forward care and you know, the science behind pain and all this stuff that's this new research that has come out in the last 10 to 15 years. I feel like as a physical therapist it really gives us a headstart if you're keeping up with it. So like you're light years ahead of where I was.

Lex Lancaster:               01:09:14           And I would say a lot of it too is because of people that share things. Because you know, even like on social media, you see something and someone shares, whether it's at a snippet of an article or something, you're like, where did they see that? And then you go read that and you're like, Oh wow, that was awesome. So you know, people post the books that Lorimer Moseley's books and you know, you see those posts, you're like, Oh, I should read that. And you read it and you just gain all this knowledge. And like I said, I feel like a lot of it is dependent on people that share things. So, you know, all the podcasts that are out, especially, I mean, especially yours, Karen, to be honest, I'll say, I look at all yours and I'm like, Oh my God, that's so amazing. So yeah, I feel like we do have an advantage, I would say, especially with the pain science literature, new curriculums like that, that like just the education piece that I give for pain, people just are like, Oh, okay. And then it's like immediate buy-in and it's so easy to just get people to, like you said, get ready to help themselves

Lex Lancaster:               01:10:13           We're very ahead of the pain science literature.

Karen Litzy:                   01:10:19           I know I looked back and I'm like, Oh man, I'm grateful. I'm so grateful. I'm better with these people.

Shannon Sepulveda:      01:10:22           Oh yeah. I mean, I graduated in 2011 and there was nothing really, Oh yeah. I mean, well, in my PT education there was, yeah. I started learning some stuff after that, but there was nothing in my PT education about pain sciences and that was like, so I would have had like didactic until about 2010 early, you know, so I know it's like 10 years ago.

Karen Litzy:                   01:10:59           I know. And like David Butler first published on sort of pain science stuff in 1996. Wow. You guys look it up. It was 96 or 97. And so, you know, we have, they say research to practice takes like 15 years.

Shannon Sepulveda:      01:11:18           There it is. There it is.

Karen Litzy:                   01:11:20           It's amazing. It's astounding to me. And, I find that if you stay engaged as a newer grad, that you really do have such an advantage, and advantage with your patients and I hope that people really no that and can appreciate that. Then new, newer ish grads can really appreciate how lucky they are coming up. As far as information, the information pipeline is so much easier. Now. I won't even tell you, like I had to do the Dewey decimals system. I'm so old.

Shannon Sepulveda:      01:11:56           We were cleaning my house and I had all of my PT books and like my husband, so he works for the US geological survey and he has a PhD and I had all my PT books, what are you doing with these? I was like, he's like, have you looked at these in 10 years? And I was like, no. And he's like, everything's online now Shannon, you can get rid of these. Yeah, yeah. And like everything.

Karen Litzy:                                           I got rid of my mind a couple of years ago. I'm like, what did I doing? And even if it's all these journals, like physical journals in my apartment, I'm limited space here in New York. I'm like, I gotta get rid of these journals. They're taking too much space.

Karen Litzy:                   01:12:52           So let's talk about what's coming up in 2020. So what are you looking forward to? Do you have any goals or expectations or plans, whether Lex, I'm assuming you're going to get married.

Lex Lancaster:               01:13:07           Yeah. So we finally set a date. The wedding has been interesting. So I didn't really want a wedding just because it is, it's overwhelming. It's a lot of stuff to plan. But then, you know, family, they're like, Oh, well you're the only girl. You really should do it. So we set a date for October 17th of next year, so we're going to get married in New York. I've done minimal stuff. I've gotten the venue, really making very slow progress.

Lex Lancaster:               01:13:36           So working on that and then you know, for 2020, you know, I'm really looking at bringing, I just applied for a trade name for my business so I could take my name off it and just make it a new name. So I'm really excited to launch that eventually once I get that all set in stone and really trying to bump that side gig up just because I have found the value in the last couple months of doing things you like to do more often. So Kyle and I were actually talking the other day and you know, we're seeing the value of providers that have their cash based or insurance businesses and these small towns in their hometown. And we're seeing the value here. Like you get to know people, you get to know doctors. I love travel PT, I do, but I'm very far from home so I'm hoping I get closer back to home and we kind of want to land in a spot where we can kind of start our own thing.

Lex Lancaster:               01:14:34           We were those people like we care, we want to reach out to people out. People know us back home. And we really wanted to start our own thing. So we're trying to get back toward, well and try to do that just because I see people, you know, as they have their own business, they make so many decisions that they get to see patients when they want to see for how long they want to see them. And sometimes, you know, I'm very jealous of that right now. You know, there are patients that I'd love to spend an hour and a half way, then I just can't. And so I think that's a major goal right now. It's just to get to that spot. And I understand as a new grad it's very hard. Yeah. I mean, I don't, and Julie did it, so I should probably reach out to her because, you know, everyone says like, it's really hard to do a business on your own as a new grad.

Lex Lancaster:               01:15:21           I should reach out to her because that's what we want to do. And you know, we understand that will probably be hard, especially with student loans and whatnot, but at the same rate, like we're trying to define, you know, what's your happiness worth? And we just kind of find that right now the quality of care that we want to provide is sometimes limited by you know, whether it's because of insurance, a lot of dancers and we're finding it hard to justify their care even though they need it with insurance and people can't afford to do X, Y, and Z out of pocket. So we're trying to find, navigate all of that. So, I dunno, trying to, that's a goal just to get to a place where we can build our own, you know, set of patients.

Karen Litzy:                   01:16:04           Awesome. And you're in upstate New York?

Lex Lancaster:               01:16:08           That's where I'm originally from, but we're probably going to end up back in New Hampshire. Yeah, we both really love it there. And I don't think my parents will be in New York forever, so I think we're just going to go back to New Hampshire area. So we're close to Boston.

Karen Litzy:                   01:16:23           Yeah, I think that's a great goal. And you should definitely talk to Julie about that. And the good thing is you have each other to give each other support. You and Kyle have each other so you can, you have that support from each other. And I think being able to do that with the two of you I think would be really exciting.

Karen Litzy:                   01:16:42           If you build up your side gig, then you can slowly build up your practice. You know, you just to know where you have those income streams coming from. But I think that's cool.

Lex Lancaster:               01:16:52           I'll say after reading Danny McTay’s book, it kind of gave us both a little hope of just that you can do it. It's just you have to decide if you're going to burn the ship or do it as a side gig for a little bit. And I think we're more or less thinking side gig for a little bit, even if it's just something, something to let us treat, you know, the high level athletes that we can't justify insurance-based for right now.

Karen Litzy:                   01:17:18           Yeah. Basically. Yeah. You should talk to Julie cause that's what she's doing. She's sort of building it up slowly. We talked about it for this podcast. So. Perfect. And how about you Shannon? What's coming up for 2020?

Shannon Sepulveda:      01:17:31           I was thinking about this, I'm like, what are my goals? So business is really good, which is awesome. I think one of my goals I need to try. So I really don't want to hire anybody. I do all my own billing, all my own scheduling. I see my patients. I need to try to figure out time management a little more. Because like I'll be in like I take Fridays off and I'm with my daughter and sometimes my son has off kindergarten on Fridays and I'll be like in the target parking lot. And now they know when I stopped the car and I like sit in the parking lot space, I'm like checking my email. They're like, mommy, don't check your email. We need to go into the store. And I'm like, like accepting patient appointments or just like, you know, I need to try to figure out how to do that because I want to do everything.

Shannon Sepulveda:      01:18:26           But for myself. And so it may just be like saying no, it may just be having a wait list and trying to figure out like the feast or famine of owning your own business, like these ebbs and flows where like this month is like just absolutely nuts. Like I had five people call me in the last week trying to get in before their deductible resets. And so like I have like, I'm taking next week off and I'm not seeing anybody but like the 30th and the 31st, I think I'm like seven patients a day or something like that. 31st I have patients to like five 30 on new year's Eve because like, they're like, Oh please. And I'm like, okay, okay. You know, and because I know January is going to be really slow. And it's really hard. I'm staying up till 11 o'clock at night to finish my notes. And so I think either I just have to accept that that's the way it's going to be or do a little bit more time management.

Karen Litzy:                   01:19:26           Or even sounds like maybe just setting your boundaries or boundaries for yourself and something that you're comfortable with. I think that that is something I will say that really helped me is saying, you know, listen, the last patient I'm going to see at night is seven o'clock at night. Like I'm not going to go later than that or I'm going to take at least one day off. Yeah. It may not be, may not be a Saturday or Sunday, but I'm going to take one day off during the week and this past what I've done is that I'm going to take five hours or four hour chunk of time and have that just dealing with business kind of stuff. You not teaching care. So I think if you look at your schedule and kind of set your boundaries, then I think you'll find that your time management just flows within that. Or you can get a virtual assistant.

Shannon Sepulveda:      01:20:19           I know I could do that. Yeah. It's funny cause like for some reason my boundaries…

Karen Litzy:                   01:20:24           Cause you're like me Shannon. I'm the same way. Like, I love to like keep everything close to me, but the moment you can like let just one little bit go.

Karen Litzy:                   01:20:46           You'll be like, what the hell was I thinking? What would be the sooner? But you have to do it on your own timeline and when you feel like you can, you can let go of that. A little bit of control. Like I let go of like a smidge at a time. Yeah. And then for me it was easier then.

Shannon Sepulveda:      01:21:03           It's really interesting because I think about, I'm like, okay, as a business owner it is not worth my time to spend. Like I tried to keep my Mondays as admin days like that is not worth my time to do. It's worth my time to pay someone to do the admin stuff, but I keep holding it in.

Karen Litzy:                   01:21:20           Yeah. Yeah. That's a good way to look at it. If you have whatever your fee is, let's say your fee is, I don't know, I’m going to make this up $200 an hour.

Karen Litzy:                   01:21:31           Right. The task you're doing as an admin at $200 an hour task, $25 an hour task, or maybe it's a $20 an hour task. So, and when you look at it that way, it's like what am I doing? Like I could pay someone to do four hours of work and what I get paid in one hour. Do you know what I mean? So when you look at it that way, the financial offset makes a lot of sense because your time is money. And like you said that that four hours could be an hour that you get to spend with your kids having lunch. So it doesn't necessarily mean it has to be with your business, but or it could mean that's your time for, you can go to the gym or you can do X, Y and you can meet with a doctor or doula or whatever. So you know like that is $200 an hour time spent when you're having lunch with like a possible referral source doing like weird admin stuff that you don't need to do is not $200 an hour work.

Karen Litzy:                   01:22:35           That's what I did and just really like looked at everything, wrote down everything I do and you can attach sort of a monetary value to it. And then once it's down on paper you're like, Oh my God, okay.

Shannon Sepulveda:      01:22:52           I know, I know and I haven't like it's interesting cause I hadn't gotten to that point until this December because like I'm still growing and so that's one of the things that I think I'm going to need to think about like, and I'm just going to see how like the ebbs and flows, like if it is still as nuts as it is right now, then like I got the, because the worst is, and honestly like the billing's not that hard. It's verifying the insurance benefits. And sometimes I can do it online and it's really easy. And then sometimes the online just tells me what their deductible is, not how much they've met. And so then I'm on hold with blue cross blue shield for like an hour while I'm trying to do other notes.

Karen Litzy:                   01:23:40           And what you'll find is like you will grow, maybe not exponentially, but you will grow bringing help on, you know, I did an interview with this woman Stephanie Nicholitch, she's like a high performance coach and she said, you're trying to do it all. Keeps you small. Yeah. And, it's true, but you have to feel ready for it. So it's in your time and you'll know.

Shannon Sepulveda:                              Yeah, I think I'll know. And the other thing is like one day, the other Monday I just like sat in front of my computer and I did my QuickBooks and my billing and I came home and I was like, I don't even feel like I've worked today. Yeah. He's like, I hadn't seen patient, I hadn't had that compassion fatigue. So some of it's like, can I actually handle that many patients? You know, can I give good care when I see my caseload.

Karen Litzy:                   01:24:26           Yeah. And these are the growing pains that you have to deal with and it's a good growing pains, growing pains. So hopefully you'll continue with those growing pains. We hear it out in 2020. I think you will. Thank you. I want to thank you guys because like I said, if you do it all, it'll keep you small. There's no way I could do everything that is required of this podcast to keep it of good quality and to have good guests and good interviews and good graphics and good everything and make the guests feel like we're on their side, you know, and that there putting their best foot forward on the podcast. And I think that's what both of you and Julie and Jenna do is creates a good experience, really positive experience for the people who are on it.

Karen Litzy:                   01:25:28           Like Shannon, we were saying like, people bought those hats and Carol and which I think is amazing. But you just never know how far the podcast is going to go. And you know, yesterday I was with some friends and we were talking about the podcasts and what's it on and you know, it's on Spotify and it's on, well iTunes is no longer a thing. So now it's just Apple podcasts and I looked up under medicine and it's like 52 out of all podcasts. For this fully female run podcasts. That is pretty good I think. Awesome. Yeah, it was really cool to see.

Shannon Sepulveda:                              One of my PT friends in Bozeman. He like just moved to Bozeman a couple of years ago and he referred a patient to me and this was about a year ago and I called him and he was like, yeah, I was like listening to healthy, wealthy, smart. And you were on it. And I was like, Oh my gosh, she's in Bozeman. You were like randomly listening to the podcast and then you were like happy that it wasn't because I was in Bozeman, you were listening to it. He's like, no. And I was like, wow, that was awesome. It was a great moment.

Karen Litzy:                   01:26:38           Yeah. And never know who's out there listening and you never know where, again, the podcast becomes a referral generator. We can call a referral generating. This we could say generates referrals, but it does and you never know who's listening and where it's going to kind of take you. So I think that's so good to hear. And like I was talking with a coach that I had on a couple of years ago and she's like, Oh yeah, I got two clients from you. And she referred one of her clients to be on my podcast, the one who was talking about poop. She ended up getting like three clients from being a guest. Whoa. All right. So I was like, Oh, that makes me feel so good that that's the case. So, you know, keep up the hard work and you know how much that I am thankful and appreciate it and wish both of you have very happy 2020 new decade so thanks again so much. And everyone out there listening. Thank you so much for listening all year and we all wish you a very happy new year and hopefully stay healthy, wealthy, and smart.

Karen Litzy:                   01:27:58           And again, a big thanks to Jenna, Julie, Shannon and Lex for all of their work all year. And of course a big thanks to net health. This episode is brought to you by Optima net health company Optima therapy for outpatient is a software solution enabling therapists and staff to do their jobs efficiently and accurately. Their software provides anytime, anywhere access to documentation, even while disconnected and workflows that streamline patient care and save valuable time. Check out their new on demand video to learn what's in store for outpatient therapy in 2020 you can go to


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Dec 23, 2019

On this episode of the Healthy Wealthy and Smart Podcast, I welcome Dr. Sarah Haag on the show to discuss pelvic health for the non-pelvic health PT.  Sarah has pursued an interest in treating the spine, pelvis with a specialization in women’s and men’s health.  Sarah looks at education, and a better understanding of the latest evidence in the field of physical therapy, as the best way to help people learn about their conditions, and to help people learn to take care of themselves throughout the life span.

In this episode, we discuss:

-Intake questionnaires to screen the pelvic floor for patients with low back pain

-Pelvic health red flags

-How to address pelvic floor health with a conservative population

-Assessing the pelvic floor muscles without doing an internal exam

-And so much more!


Oswestry Low Back Pain Disability Questionnaire:

Sarah Haag Twitter

Entropy Physio Website

Home Health Section Urinary Incontinence Toolkit

Rehab Therapy Operational Best Practices Forum

For more information on Sarah:

Sarah graduated from Marquette University in 2002 with a Master’s of Physical Therapy. Sarah has pursued an interest in treating the spine, pelvis with a specialization in women’s and men’s health. Over the years, Sarah has seized every opportunity available to her in order to further her understanding of the human body, and the various ways it can seem to fall apart in order to sympathetically and efficiently facilitate a return to optimal function. Sarah was awarded the Certificate of Achievement in Pelvic Physical Therapy (CAPP) from the Section on Women’s Health. She went on to get her Doctorate of Physical Therapy and Masters of Science in Women’s Health from Rosalind Franklin University in 2008. In 2009 she was awarded a Board Certification as a specialist in women’s health (WCS). Sarah also completed a Certification in Mechanical Diagnosis Therapy from the Mckenzie Institute in 2010.  Sarah has completed a 200 hour Yoga Instructor Training Program, and is now a  Registered Yoga Teacher.

Sarah looks at education, and a better understanding of the latest evidence in the field of physical therapy, as the best way to help people learn about their conditions, and to help people learn to take care of themselves throughout the life span.

Read the full transcript below:

Karen Litzy:                   00:01                Sarah, I was going to say doctor Sarah, hey, it just feels weird because we’ve known each other forever. But Sarah, thank you so much for coming on the podcast to talk about pelvic health for the non-pelvic health PT. So there are a lot of physical therapists who I think are interested in pelvic health, but maybe they don’t want to like dive in literally and figuratively. So what we’re going to do today is talk about how we as physical therapists can treat people with pelvic conditions, with pelvic issues without necessarily doing internal work. What are the functions of the pelvis, really important for bowel and bladder health, right?

Sarah Haag:                  00:49                I mean, it is very important for survival, sex, very important for quality of life and propagation of the species. So these are all things that matter. But also when people come in with low back pain, when people come in with hip pain, I always find it very interesting that people say, but I don’t do the pelvis. You know, the pelvic floor is only a musculoskeletal structure. We’re not trained in most programs to palpate or to touch. It’s just skeletal muscle. That’s all we’re assessing for really as pelvic floor PT’s. So I just think it’s interesting. It’s like a blurry void when you’re looking at a body diagram.  Oh, there’s your knee. So it’s really important I think to understand what’s there and you don’t have to go there, but you have to know what’s there and know that some people need help there and help them find the help.

Karen Litzy:                   01:34                So if someone, let’s take this person that has low back pain because that’s a diagnosis that we can all agree that we see on a regular basis. So what are a couple of questions you can ask during your initial evaluation?

Sarah Haag:                                          So the subjective part of the initial evaluation that perhaps a lot of people are missing or that can take in that pelvic area. There’s a couple of ways that you can kind of like cheat your way in where you don’t even have to think about what to ask to begin with. If you have a red flag questionnaire, there is a bowel and bladder question on there. So, it’s really interesting because people will sometimes circle yes on those and then never discuss it. Like, wait a second, we asked the question, they said yes, it’s a thing.

Sarah Haag:                  02:22                So there’s your in, it was like, I noticed you, you marked yes on the bowel and bladder changes. Can you tell me a little bit more about that? Most of the time it is not truly a red flag. Most of the time it is not a sign they need to be referred to a physician.  Most of the time it’s like no one’s ever asked me that. Yeah. Stuff is different. There’s your in. And then also if you use the classic Oswestry. So it was modified I think in 2001 or 2002 to take off a sex questionnaire. The second question of the questionnaire and it was revalidated and all of those things, but if you use the original, it’s pretty awesome because now they’re like, Huh, nobody’s asked me about sex. And then you’d be like, ah, I see that this is an issue.

Sarah Haag:                  03:06                One of my favorite Twitter stories is I get a direct message from someone asking me about a patient who was having pain with intercourse and I was like, thanks for reaching out. Absolutely. Can you tell me more about when they’re having trouble and where it hurts? Would you like to know where it hurt their knees in one particular position? And I said, fantastic. You can help with that. So, so it’s not always, it might be a sex problem, but it’s not necessarily that problem. So we have to not be shy about asking those. Low back pain is the most expensive health care problem we have in terms of multibillion dollar, probably millions and millions worldwide. And so of course addressing back pain, we’re still working on the best way to do that.

Sarah Haag:                  03:52                But there’s a high prevalence of urinary incontinence and people who have low back pain. So if you’re seeing people who have low back pain and after, if anyone else went to the pregnancy talk this morning, after vaginal deliveries, the prevalence of incontinence goes ways up, goes way up. So if you’re seeing someone with back pain, if someone has had babies, all you can eat what you can do. So we were like, well I see this in your history cause that’s pertinent history for back pain. Correct. And then it’s like, Hey, I noticed this, any issues with this? And here’s the reason I’m asking because you can’t just go, do you pee your pants? Because people like, do I smell like what happened? Like, so if you’re just like, you know, there is a really high prevalence and the nerves in your back go to your pelvis and all of these things.

Sarah Haag:                  04:32                So I’d be really curious to know are you having any issues in this area? Cause there’s help if you are. And then kind of go from there.

Karen Litzy:                                           And I want to backtrack for just a second. When you were talking about red flags and said some are truly red flags and some aren’t. So just so that we’re all on the same page, what would be those truly red flags?

Sarah Haag:                                          Truly in the pelvic world or in the entire rest of your body world is any unintentional weight loss or weight gain, 10 or 15 pounds over a short period of time. Also like fever, like temperature issues, loss of appetite when you have those other constitutional symptoms that go along with it. So just having some quirkiness with your bowel and bladder, it’s really no reason to panic. But if you have also a fever and also a recent traumatic event, no, no, we want to just make sure everything’s okay.

Sarah Haag:                  05:26                And the cool thing is that if you go to the doctor, it’s like you don’t have a UTI. Everything else is looking fine. Awesome. Then I can help with that. But the red flags, there’s been a couple of great papers that have come out where it’s like, it’s not like if you have pain at night, freak out. No, no. If you have pain at night but also a sudden bowel and bladder change and also, okay, now we need to check in for it. But don’t panic if it’s the only one.

Karen Litzy:                                           And now let’s say you’re using these questionnaires and someone puts on bowel, bladder or someone circles sex as something that they’re having difficulty with. And I love this question because this was something that was brought up last year at CSM. So there was a physical therapist there who said, well, I live in the south and these are not easy questions to ask because people are more conservative or they don’t want to talk openly about their bowel and bladder issues or about sex with their partners.

Karen Litzy:                   06:28                And so what do you say to those people? Those therapists that, are dealing with a population that’s maybe much more conservative and they’re not sure how to approach those subject matters.

Sarah Haag:                                          I always say just always with kindness and with a good intention and with a good explanation. So you can’t not do it because it’s awkward for you. You should be asking for a medical reason, right? So quality of life is in our wheelhouse, right? Like we’re doing all sorts of quality of life questionnaires. Pee in your pants is a huge detriment for your quality of life in many cases, not being able to have sex can impact your relationship with your partner, your feelings of ability to even have a partner, having babies. All of these things that end up being huge stresses, which is gonna make a lot of other things not as good either.

Sarah Haag:                  07:28                Just start simple if you’re asking questions. So if someone comes in with like straight forward knee pain, I’m like, how sex, no, that’s not how, that’s not where we go with that. But if someone’s coming in with low back or pelvic issues, the way I usually approach it is to bring it up anatomically. So this is the anatomy. This is what we’re doing. These are where the muscles go. Most people don’t think about them. And when they’re, if they’re having issues like incontinence or have had babies, those pelvic floor muscles are muscles. Like everything else. We’re going to work in PT. So I’m going to ask you some questions and I try to do it in a spot where you have some privacy. I know some PT places you’re like in the middle of a gym.

Sarah Haag:                  08:06                If you can find a quiet corner, do everything you can to put them at ease. But just to be like this is why I’m asking. And if you can see that resistance be like all right, like it’s not necessarily the number one priority for this treatment anyway, but if those things happen to be issues there is help, it can get better and you just let me know if you have any questions. Cause not everybody wants to talk about it and it’s not my job to convince you to deal with it. It’s my job to help you if you want help.

Karen Litzy:                                           And if you’re a physical therapist that isn’t specializing in pelvic health, it’s a little bit different. Cause if you’re specializing in pelvic health and people are going to you because you specialize in pelvic health it’s way easier, you know, these questions are going to come up.  But for those of us who don’t specialize in pelvic health, then those questions can be a little bit more sensitive. So I just want you to make that distinction there for people.

Sarah Haag:                  08:48                Yeah. And also if you’re going to ask if you’re going to take that step and be like, all right, I’m going to ask about the incontinence. I mean cause sometimes you’re in situations where it is an obvious issue. Other times it’s like, well, based on their history they’re actually at risk for it. Then you can talk prevention, which has always been kind of fun. But just if they give you some information, especially if you got up the guts to ask them, then please, please do something with it. Don’t just be like, oh yeah, so great incontinence noted in the chart. I’ll put it on the diagnosis list, like how the plan and there are some things you can do without doing a pelvic floor exam that can make amazing changes.

Karen Litzy:                   09:49                How can you evaluate pelvic floor muscles without having to go internally? I think that’s a question everybody wants to know.

Sarah Haag:                                          Great question. I’ll be honest, some people don’t want you to touch him there like full stop. And so I will actually give people, I would say it’s kind of like a choose your own adventure. So we can actually, we can all check our own pelvic floor muscles right here. And I would basically talk you through it. You would tell me what you felt. I keep an eye on everything else to see what else you were doing. But it would be very honest that my assessment is going to be, I believe you, it seems you’re doing it correctly. Right? But I have to believe you, but you can actually palpate externally. As a clinician you can actually do it and you can do it in sidelying.

Sarah Haag:                  10:33                You can do it in hooklying and some people will do it in prone. I’m not a super big fan cause I can’t see their faces. And also it can be kind of a vulnerable position. Basically if you just palpate, if you find the ischial tuberosity, you know about where the anal sphincters are. Okay. There’s normal human variation. So I always say move slow and make sure you’re asking for feedback. But you know, mid line is where the sphincters are going to be. We’re not going midline. So you just kind of find that ischial tuberosity and palpate your way around to the medial part of it. And that’s where the pelvic floor attaches. So then you can kind of talk them through, like I’d like you to squeeze and there’s a bunch of different cues.

Sarah Haag:                  11:22                One of the most common cues, especially for the back end, is to like squeeze. Like you don’t want to pass gas and that’s awesome. But if you’re a main problem with urinary incontinence, that’s the back side, back side, not the front side. So how do we get it up there? So another cue that has been found to be very helpful, it’s only been studied in men, but it is, shorten your penis. But what’s interesting is ladies, I know we don’t have them, right? Imagine that feeling, right? So like just imagine like pulling in, right? It totally changed where hopefully if this is a class, it would have asked where did you feel it? But like it, it changes it from the back and biases it towards the front of it. So find a cue that gets them to go, oh my God, I felt something.

Sarah Haag:                  12:07                You’re like, awesome. So if you’re doing a Kegel and like this happens, you’re probably not doing it right. If that’s happening, you’re probably not doing right. But if like I’m Kegeling now and then I let go, you shouldn’t have seen me get taller or tensor or breathe funny. It should be very sneaky. So as you’re palpating on the medial side of the ischial tuberosities your feeling for those muscles to contract. So it’s kind of like a gentle bulge and you can totally feel this on yourself here if you’re comfy or somewhere else. But when you feel it, it’s almost like when you’re feeling like if you have your biceps slightly bent and you kind of like contract and you feel at tensioning and like a little bit of a bulge, that’s what you’re feeling for.

Sarah Haag:                  12:51                Okay but it can always be tricky cause I use the word bulge. Some people will have people push down. So we should also be able to like relax your pelvic floor and push down, like having a bowel movement. That shouldn’t happen when you’re trying to contract. So like when I say bulge, you should feel like a gathering of the muscle. That’s what you’re feeling. If you feel your fingers get pushed down in a way they’re doing the opposite of a contraction. So there they’re relaxing.  It would kind of depend on what they were doing and the cues you were giving. So it could just be like, I’m pushing down like doing a Valsalva. But it is basically a lengthening into the pelvic floor. I don’t know if it’s always a relaxation, so to speak.

Karen Litzy:                   13:33                It’s kind of lengthening. And what is the difference between that Valsalva or lengthening and that small bulge? Like why is that significant?

Sarah Haag:                                          When you feel it, you’ll know it’s significant because if they’re pushing down in a way that’s not a contraction. So if you’re going for strengthening or more closure to hold things in, yeah, you want that kind of like tensioning and bulge. But if you’re actually the problems, constipation, I can’t get things out, you want them to be able to relax and link them.

Karen Litzy:                                           Got It. Okay. All right. So now we know how we can kind of feel our pelvic floor muscles without having to do an internal exam. So once you figure out, and kind of what you said sort of leads right into the next question is if you have someone that’s coming in with incontinence and you are looking for that sort of tightening or gathering up of the muscle, which I think that’s a nice cue for people to understand because bulge can sometimes be a little confusing for people, but I liked the cue you’re feeling the gathering of that musculature.

Karen Litzy:                   14:45                Is that something that you are then going to add into a home exercise program or like once you find that the pelvic floor muscles working or it’s not working, what next? What do you do?

Sarah Haag:                                          Well, so I’ll be honest. It’s always I like him and people are brave enough and the patients were brave enough to be like, sure you can have a feel like let’s figure this muscle thing out. I usually try it in a normal active kid in a normal setting. So not a public one. No pelvic settings are normal too. But in like just a normal like say outpatient therapy, be it or orthopedics or neuro, I would actually have them ask more questions about incontinence before even checking the pelvic floor muscles. Because the different types of incontinence are going to kind of tell you a little bit more about what you should do.

Sarah Haag:                  15:35                So some people have incontinence when they tried to go from sit to stand or when they cough or when they go running. So I want to know a little bit more about when is it happening because if it’s only ever when you’re putting your key in the front door or when you’re running into the bathroom, that’s more urgent continence. Would pelvic floor muscle exercises help? Maybe, but also probably looking at their overall bladder health, which is where a voiding log would come in very handy. And actually a shout out to the home health section and they have an incontinence urinary incontinence toolkit. It’s free for members for sure, but I think it might be free for everyone.

Sarah Haag:                  16:15                So it’s a pdf that actually talks you through the different types of incontinence because the most common form of incontinence urge incontinence, which is you’re an urge incontinence is proceeded by a strong urge to go. So this is one of those things where, so there’s a bathroom at the end of the hall. So if you’re like, I’m totally fine, but then your eyes wander, you’re like, oh, I could go and I didn’t have to go. And then I would get up to go and I got to the bathroom and all of a sudden it’s like, oh, where did that come from? Like all of a sudden it felt like your kidneys did a big dump, but they don’t, that’s not how kidneys work.

Sarah Haag:                  16:59                It’s just how it feels to you. So what that really is, is your detrusor muscle kind of going, I’m so excited. I imagine a puppy, like have you ever like gone to let a puppy out the door? Like, so they’re like, hey, I want to go out and you get up and you make a move for that door. And they’re like so excited. Your bladder is like that sometimes. So that’s more of a behavioral thing because what would you do with the puppy who’s now like, wait, every time I do this, she lets me out. Pretty soon you’re letting that puppy out every 10 minutes because yeah, because that’s what the puppy trains you to do. So that’s kind of more of a behavioral thing. And so that’s proceeded by a strong urge. So it’s not just when you’re going to the bathroom, but if you get a strong, unexpected urge and leak, and that’s usually a lot of people also experience some urgency and frequency.

Karen Litzy:                                           So if you feel like you’re not getting to the bathroom in time, what would be a really logical plan to that?

Sarah Haag:                  17:52                You’d go more often, you’re like, Ooh, maybe I need to not wait so long. But the thing is that then you’re training yourself to go more often, your bladder is perfectly capable of holding more that kind of sensitivity and those signals you’re interpreting or like, ah, no, I should go now. And then pretty soon you’re that person who can’t make it through a movie. You’re that person who can’t make it past a bathroom without needing to go. And you’re the person that no one wants to go on a road trip with because you’re stopping every like hour on the hour and every rest stop. But now is that because your brain is interpreting this as such? I know that there’s a physical manifestation obviously, but is that like have you trained your brain and to feel that way to interpret that as such? I would say yes because most of the time, even if it wasn’t intentional, like it’s kind of like a slippery slope. It’s like I almost didn’t make it that one time. I’m going to plan ahead. And then what starts to happen, especially if you’re like, all right,

Sarah Haag:                  18:54                your bladder is filling up. You kind of feel like you need to go and you go to the bathroom and it came out and it’s like, all right, so that was nice and normal. But then imagine that time where you’re like, hold on, I almost didn’t make it, but you were stretched this much. You’re going to start going when the bladder stretches this much. And then pretty soon if you let it so you’re like, Ooh, now I’m going down here. Now I need to go sooner. And this is one way you can tell this is happening. And it can happen sometimes without ending up with a diagnosis of urgency, frequency or incontinence. But where you get to the bathroom and you feel like you’ve got a goal, but then nothing happened. Goals, like it’s the smallest tinkle and you’re like, I thought it wasn’t gonna make it, but that’s ah, that’s all that’s in there. And so that was like big urge little output. That’s kind of a mismatch. And that’ll happen sometimes.

Sarah Haag:                  19:48                But like if you’re paying less than that, that’s not much more than your poster board then a nice healthy post void residual. So you don’t have to empty at that point if you’re bladder’s saying, empty me now. And that’s all that’s in there. Yeah. So it’s kind of like you’re the sensitivity of your bladder has turned way up. Just like how we would compare that to the pain. So the sensitivity is turned way up so that it takes less of a stimulus in the bladder itself to trigger that feeling of you have to go, even though the bladder is barely full.

Sarah Haag:                                          And there’s actually some interesting conversations with urgency and frequency in that feeling of extreme urge, can that be considered a pain? And so it’s kind of interesting conversation because there is normal, there is a normal sensitivity of normal urge, but when that urge becomes pathological, yeah.

Sarah Haag:                  20:47                Too bothersome. Does that crossover into it? Distressing emotional experience? I would think so. Like can you imagine if you’re like on a train or something like that and you have to really, really, you have, you’re having that urge. I mean, that’s very distressing dressing. That’s very distressing. That’s like you’re suffering. So if you have someone like that what do we have them do? So they keep a diary, which you can get on the home health section and we’ll have a link to that in the show notes. You basically ask them to keep track of things for a couple of days. I tend to keep it simple with what are you drinking and when and when, when are you going to the bathroom? If people are willing to measure, that’s the best, but not many people are willing to measure.

Sarah Haag:                  21:37                So what I try to have them do is to kind of come up with their own plan. And I tell them this is not an exact science because you’re not measuring, but that’s okay because if you have a strong urge, which is kind of a lot, but you have like a little tinkle, that’s kind of a mismatch. If that only happens after your third Mimosa, okay, that might actually be like a normal bladder thing. Do you know what I mean? So we kind of look at things that they’re bringing in that may or may not be irritating to them. We look at are they getting enough fluid and bladder loves, loves water. But the first thing most people cut out if they’re having urgency, frequency or incontinence is water is they cut out their water. It’ll almost always backfires.

Sarah Haag:                  22:19                So don’t do that anyone watching. It also makes you constipated, which you can increase your urgency and frequency. So, so yeah, so surprise. Everything needs to work well to work well. Okay. But yeah, so you kind of look at that and I just look for patterns and then I have people try to change one thing at a time. If all you’re drinking his coffee all day, but actually you have good data, good parts of your day and bad parts of the day. Is it the coffee? Because if you’re drinking coffee all day, you’re probably not going to be very nice to me if I say, how about you stopped drinking coffee? Um, emotional response up. So you just kind of look at it. It’s like, Oh, when does this happen? What do we need to change? And it can really help you narrow down. Is it really urge incontinence? Is it actually just frequency and they’re not leaking like they thought they were or you know, is this primarily a stress incontinence issue?

Karen Litzy:                                           Well, so it sounds to me like there’s not a lot of hands on work there.

Sarah Haag:                                          No, no, it’s more behavioral.

Susan:                          23:27                Do you ever use pelvic tilting to get the posterior versus anterior pelvic floor?

Sarah Haag:                                          So that’s a neat work with from Paul Hodges Group. So however you’re sitting, most of us are Slouchy, just do a pelvic floor contraction, however your brain tells you to do that, do it and just feel where you feel it. But then if you get yourself in a situation where you like get more of that Lumbar Lordosis, and so like you stick your tail out, you get more lumber lordosis and then you do the exact same thing. So you’re not changing your cue. For most people it’s cuts to the front. And it’s kind of neat because one of the things, one of my pet peeves is when we were talking about earlier is my pelvic floor therapist get tunnel vision and are just doing pelvic floor exercises, but not reintegrating it into how they’re, they’re using their body.

Sarah Haag:                  24:18                So if you have a runner who’s a chronic but Tucker and she’s leaking out of the front, obviously, how would it feel if you like got those glutes back a little bit? Because you can’t run and Kegel at the same time. You can’t, you can try. It’s not going to go well. And certainly not for like a 5K and let alone not a marathon. So changing how that is biased because most of us don’t think about the pelvic floor until you have a problem, right? But they’ve been working, right? They’ve been doing their thing. You’re using them when you walk up those stairs you’re using them when you’re getting up off the floor. So they do something, the key goal is like your bicep curl. You want a stronger bicep, you’re going to do some curls, you want a stronger pelvic floor, you’re going to have to do some pelvic floor exercises.

Sarah Haag:                  25:07                But that’s not your management plan. You kind of want to, someone said it yesterday, kind of like the core muscles are there like automatic, like when you get ready to do something you don’t think, okay transversus were good. Like it just all happens and you want to kind of get the pelvic floor back into that system and make sure it’s strong enough and coordinated enough to do its part. So you don’t think about it.

Dave:                            25:37                So along those lines then, would you say that if somebody is more lordotic, they’re more likely to engage the anterior floor and then flat back more of the posterior floor?

Sarah Haag:                  25:47                That tends to be what they’re finding on like EMG studies and what I will see clinically with people if they do a ginormous buttock. It’s really interesting if you’re like, how’s your breathing when you do that and, and how good is your squat, let’s say when you do that. And it’s like, Eh, it is what it is. I’m like, okay, so what if we do kind of take it into where some people, especially if they’ve been told by other practitioners to like watch your Lordosis, it’s kind of huge. Which isn’t really a thing. But you know, they kind of, they’re kind of like going in there, they’re like, I’m so scared but it kind of feels good and then you have them do that movement or try that exercise. Usually they’re like, that was way easier than I thought it was going to be.

Sarah Haag:                  26:30                But again, if it’s not working, then we try something else cause everyone’s anatomy is different. Sometimes if they have a lumbar issue, getting into the ideal position for their pelvic floor, may or may not be easy for them, at least at first. But I think you need to play around with how it feels and how it’s functioning as opposed to, I mean, I’ve been guilty of it in my career of like, ah, you need more or less of what you’re doing with your spine and were just different. So it’s where it works best is where it should be.

Jamie:                          27:03                So for a lot of the outpatient conditions and orthopedic setting, there’s still an emphasis on giving some kind of qualitative documentation to the muscle contraction, whether it’s a manual muscle test or something like that for payment purposes. So what are some strategies or tips for clinicians to be able to take that palpation externally and then relate that into their strengthening documentation?

Sarah Haag:                  27:29                So if you’re just checking externally, like just palpating outside, it’s like a plus minus like, Yup, I felt it. Uh, they couldn’t find it. So kind of plus minus, cause you can’t give it more than that. We also have to remember, so when I write about pelvic floor strength in my documentation, I have a number I can put and you can grade it. You have to do that internally, which is why if you’re like, ah, we need to know more, refer him to a friend or go to the training. But I usually give a lot more information. So like, all right, so they, you know, they had like a three out of four, three out of five squeeze. The relaxation was not very coordinated and kind of slow, but then their subsequent contractions were five out of five.

Sarah Haag:                  28:09                All right. Do you know what I mean? We have to, because of payment and insurance and all of those things, we have to write something down. So what I do is I write down what I find and I’m happy to talk about it. So if you want to deny it, I can talk vagina all day with you. And I have, and their questions usually get shorter and shorter. Um, because really they’re asking for information that isn’t necessarily the most helpful. So if you’re checking an externally plus minus, but also I’ve had people who five out of five but still incontinent,

Sarah Haag:                  28:41                So then they’re like, well they’re not weak but you put down, you’re going to do strengthening. I’m like, well yeah, because it’s more of a strengthening, not just a strengthening with a functional goal attached to that, if that makes sense. So sometimes it’s more words, but don’t be shy about one. Well, first of all, please be honest, be as accurate as you can be, but also don’t be shy about doing the best care and be willing to stand up for it. If it gets denied. It’s not cause you gave crappy care likely. I mean, do you know what I mean? I’m like, I dunno how long you practice, hopefully. Good. But if you get denied, it’s not necessarily key because you gave bad care or even did a bad note. It’s because they decided they weren’t going to pay based on something. Hopefully logical that you can talk about. You can always appeal. So don’t let payments scare you away from giving the best care.

Sarah Haag:                  29:36                Sorry. Another soapbox of mine.  So that was urge incontinence. Stress Incontinence.

Karen Litzy:                                           So let’s talk about that because I think that gets the more airtime, so to speak. So that’s when you see the crossfitters are the weightlifters or there’s a great gymnast pitcher yesterday going backwards where you there backwards over the pommel horse, not the pommel horse. It’s the worse just a horse. A spurt. Like it was, yeah. And you’re just like, that could be photo shopped, but also it probably isn’t. Yeah. Or like we’ve all seen like the crossfit videos where women are peeing and then everyone high fives them because they worked so hard that they peed, which, you know, not normal. We know that that’s been addressed by a lot of a pelvic health physical therapists.

Karen Litzy:                   30:32                So I would like to know first I think we just gave the definition of stress incontinence, but I’ll have you give the definition quickly. But then I’d like to go back to something that the question that Dave had asked about the positioning and how that works within weightlifting or within, you know, waited or loaded movements. But go ahead and give the definition of stress incontinence first.

Sarah Haag:                                          So stress incontinence is basically when there’s an increase in intrabdominal pressure that is greater than the closure of pressure of the urethra. And you have some sphincters as well as the pelvic floor helping keep all of that closed. But if you increase the pressure enough on the insides, and that’s why you hear, and again, it’s primarily women, but also a lot of men after prostate surgery, they cough and you get a spurt or you know, you jump and you feel it come out.

Sarah Haag:                  31:21                Those are usually because the closer pressure has gone down or the intra abdominal pressure has gone up.

Karen Litzy:                                           Okay, great. So now what does that look like? For the average physical therapist who’s not a pelvic health therapist. And let’s say they are seeing someone for hip pain and you ask them, are you ever incontinent? Or if they are, you know, heavy lifters are, they are adding load and they say, oh yeah, but that’s normal. Or they have low back pain and they say, yeah, but that’s normal. Everybody does it at my crossfit box or whatever at my gym. So how do you then, if you’re not you, you are someone who’s not a pelvic health therapist, how do you address that?

Sarah Haag:                                          Well, first of all, what all of us should know while incontinence is super common, it is not normal.

Sarah Haag:                  32:16                Not ever being dry is normal. So we need to get away from this idea that like, well, everyone’s doing it. It’s like does that make you want to do it? Like I feel like, no, I feel like no is the answer. So first of all, just, and sometimes they don’t know that. Like, I know that in some like young girl gymnastic teams, like the color of their leotards are chosen to like, not show the pee because they’re incontinent that young. Yeah. And I see a lot of women as adults sometimes before they’ve had babies sometimes after, right? So like what’s the, what came first? But they’ve had lifelong issues with what’s essentially public flourish. She’s with incontinence, sometimes pain with intercourse, all of those things. Competitive gymnasts, competitive cheerleaders. Dancers tend to be probably the biggest, runners or another group.

Sarah Haag:                  33:12                There’s been some studies, there’s one study and I cannot recall it. I mean, it’s probably like 15 years old now. We’re 100% of this division one female track team reported urinary symptoms. 100%. Like every girl. So common. Heck yeah. Normal. So many girls. Yeah. So the biggest thing if you’re not a pelvic floor therapist is to check out their function. So if they can identify when they’re having issues, it’s when I get to this particular weight or it’s when I get to mile 17. Okay. And I usually throw in, like if I ran 17 miles, I’m not really sure what my body would do. Like I dunno, but it still shouldn’t leak. But if you can find out where that breakdown in the coordination in the endurance and the strength and whatever it is happens and look at what’s happening there.

Sarah Haag:                  34:04                Because if you can run 17 miles or you can lift 200 pounds without leaking, but then you do, you’re not, you’re not weak. Right? Like if you can do all of that, something’s happening there to make this happen. Cause if you can lift 200 pounds in that league, something’s working, it’s just not still working when you try to live 210. Okay. So let, let’s look at what’s changing or number of repetitions. Right? That’s what you’re looking at.

Sarah Haag:                  34:52                So if you collapse your chest and which I would probably do after running 17 miles and I’m like this. And now what happens when I collapse what happens to my bottom half when I collapsed my shoulders? Well my butt just tucked. Cause I’m just trying to get through now. The funny thing is the breathing is also harder. So while I’m doing this as kind of a mechanism to keep going, it’s harder to breathe because nothing’s working diaphragm to have a full excursion, right? Yeah. So, so I like to look at if you’re running fine for 17 miles, I want to see you at mile 16. I want to see what’s changing over that mile. I want to see what you looked through my team. And can you, when you start to get to that point, can you make an effort to change something?

Sarah Haag:                  35:32                Do you notice a change in your breathing when you’re lifting 210 instead of 200 and kind of look at it from that way cause you’re not going to kegel why you do that. What do you mean? Oh well say to like precontract and prime and all these things and, and that’s fine, but it’s like if we go back to the running, you’re not kegeling and all that time your pelvic floor after like 30 seconds is like, dude, you don’t want me to get that tired. Like it’s going to be like, we’re going to stop that now. So yeah. So the way I would approach that, if you’re not me, yes and not going to do a vaginal exam, is you look at their performance. So if they said, I have knee pain when I do this, when I go from 200 to 210, they’re my squat.

Sarah Haag:                  36:13                How they do, they’re looking at the mechanics. You would look at what’s happening, what is different? Cause you know, the joint can do it, you know, the muscles can do it. What’s changing. And you would address that. So it’s really no different if they can tell when they’re leaking, you’re just looking what can, what are the things that can change it? Usually the tail lift and looking at their breathing or two really easy ways to go about it.

Karen Litzy:                                           Okay. All right. That’s great. And, and, and that goes with that. Does that also work with, let’s say instead of you’re not a runner weightlifter, but you’re like a new mom or something like that and you’re okay, but then by the end of the day after you’ve been maybe lifting the baby or you know, doing whatever you’re doing it, it doesn’t necessarily have to be sport related is what I’m saying.

Sarah Haag:                  37:06                I think about like function, but definitely, I mean, you asked about, but no, just everyday if getting out of a chair makes you leak, that’s, but then it’s basically a squat. So you are, you’re looking at the activity that they’re having difficulty with and making small changes got in most cases.

Karen Litzy:                                           So I think the biggest takeaway here for me is that not everything is solved by doing a kegel.

Sarah Haag:                                          I think a lot of non pelvic health PT’s may have that, that misconception that if someone has incontinence, well Kegel time. Right? And that’s all you gotta do. That’s what most people do. If they go to the doctor and they mentioned it’s like, ah, you know, that’s pretty normal. It’s not, it’s common. And then they’ll be like, do some kegels and, and a lot of women and men don’t know how to do them.

Sarah Haag:                  37:53                So then they’re just, I’m squeezing stuff and it didn’t work. And it’s like, Oh, before we get too far, can we check and see how you’re doing them? And I think that’s kind of a beautiful segway. So let’s say you have your new mom or you have your athlete or whatever and you are, you’ve tried some stuff, right? Cause none of this is life or death, right? I mean it’s fine to try some things. So already not doing anything about it. So trying to change up a couple of things is perfectly within your purview, especially again, you’re seeing them for hip or low back. It all, it’s all together. You’re good. But if it’s not changing, if it’s not getting better, if when you ask them, you know, can you contract your pelvic floor, what do you feel? They’re like, I got no idea.

Sarah Haag:                  38:33                And they’re like, but please also don’t touch me there. Or are you touching there and you’re like, yeah, I don’t feel anything either. And I’ve used all my cards but I don’t know what to do. That’s when you refer. Because just like any other things, somebody coming to see you as a physical therapist, you’re going to do some things. And if those things are not working or they’re getting worse, you’re going to try something different. Or call the doctor or refer to a friend. Right? So if you change some things and you’re like, I’m amazing, they’re all better. Awesome. Do they need to go to pelvic floor therapy? I’d say no if their incontinence resolves or their pain resolves. But sometimes with especially we see it a lot more in I would say the more active athletic population is a pelvic floor that’s more like this.

Sarah Haag:                  39:19                So it’s like tight and there’s a hundred people call it hypertonic or high tone or short pelvic floor and all these things and basically in my brain, the way I categorize it is like you should be able to contract your pelvic floor and you should be able to let it go. And we can all get better at that. But if you’re like, I’m here, how good is my contraction going to be? Because I’m not showing you my pelvic floor. Like it’s not going to, it’s going to taste like it’s going to not move very much. But if you get them to relax more or they’re like, oh, I didn’t know that was there, that’s better. Then you all of a sudden you have a good contraction.

Karen Litzy:                                           How do they relax? Do you just say relax?

Sarah Haag:                  40:01                Before somebody tells him to relax, the worst thing to do is be like, can you just relax? So I try to have them feel the difference between contracting and not contracting. Because what will happen and people use what the traps all the time is like. So like, ah, so much tension. All right. Again, telling you to relax your shoulders. Things I didn’t think of that. But if you squeeze and let go like as a little bit of like, Oh, I feel that, oh, oh there’s some more space there. So I start with that. Okay. The pelvic floor. But again, if they’re like, I just don’t know, that’s something that is so easy to feel with a vaginal or rectal exam. So that’s where it’s like, ah, you’re having some trouble. I would recommend, would you see my friend for one visit have this exam, they’re checking out your muscles and just see if he can feel that relaxation and then come up with like cueing or a plan that works for them.

Sarah Haag:                  40:54                Cause it’s not just about like slacking everything out. It’s really feeling that that relaxation, that lengthening of the muscles there and being intentional about it. You don’t want to lie there would hope like maybe it’ll let go at some point.

Audience member:                               So you talked about kegeling and what about dosage or prescription and quality versus quantity and how you prescribe that to your patient.

Sarah Haag:                                          There is no hard and fast rule as to like how many, how much. So that’s where, again, I would have them do some and see how the coordination goes. Cause if they’re otherwise neurologically intact and they’re kind of getting it, how many do they need to do?

Sarah Haag:                  41:57                I would say it’s not unreasonable to go kind of basic strength and conditioning principles of, you know, like I know eight to 12 reps three times a day. That’s an okay starting point. And actually, I don’t know if you know this, so I’m writing a book on incontinence and the PT people have it, but it’s the editor just asked me, she’s like, well, since we don’t have like a hard and fast number, do we, should we put that in there? And I said, I think we do. So that’s a good starting point. Not everyone would be able to do that right off the bat, but also some people be able to do that and they’re not getting better. So it’s kind of like let’s start here and see what happens. And then you can kind of titrate it up and down. If I do an exam on somebody and they can’t contract for 10 seconds, they can only contract for five, I’m not going to have them contract for 10 seconds at home. I would probably honestly in that case, have them go, I need you to make sure you can feel the good contraction. So you actually also asked about quantity and quality. I want quality, because all of us can do 100 crappy ones. I’m not sure how much it would help. So really looking to be like, okay, so I feel that contraction and I’m breathing

Sarah Haag:                  43:10                and I usually actually have stopped counting seconds. I’ve had people go by breath, so if you, let’s do it. We’re going to squeeze our pelvic floors and you’re just going to keep squeezing as you breathe in and breathe out normally. Nothing, nothing fancy. And then keep squeezing while you breathe in and breathe out and let go. And what I hope you felt was a squeeze to start with maintaining the squeeze. Some people will feel kind of like a little, a little wave as they breathe, which is not unusual. But then when you stop the breathing and you let go, you should feel that let go. So if you didn’t feel that, let go. I usually say that’s one of two things without feeling right. I can’t tell without feeling is that you got tired and you lost it or you forgot to let go.

Sarah Haag:                  43:51                So that’s okay. Have a wiggle reset and try again. Because if you’re not feeling the contraction, what are you doing? Like you might as well take a walk because then you’ll actually be using your pelvic floor. I like going with the breath because a lot of people like to hold their breath when they’re like, they’ll do like they’ll just suck at it and it, you’ll feel a lift, but it’s just a vacuum. It’s not really your muscles doing their thing. So by doing the breathing, if you breathe in and out twice nice and slow, it’s 10 seconds. You don’t have to count. So if I have you do four of those, you just have to like count on fingers, two breaths come and arrest for two breaths. So much easier to keep track of. And then people actually do them. Cause if I could tell them to do ten second holds, one, two, three, four, five, six, nine, done. And that’s not really helpful either. So like the too slow breaths. Now you’re breathing and don’t have to count and you’re going to stay honest.

Audience member:       44:57                So trying to bring this into the neuro world for someone who’s post stroke and has stress incontinence or they’ve had neural damage of some sort and have stress incontinence, Are there any PNF techniques where you can incorporate the pelvic floor to help with that?

Sarah Haag:                                          I haven’t had PNF stuff since college. And I’m old. So what I would say is, is if I’m recalling that they go through movement patterns and as you’re doing those things, there are things will be happening on the pelvic floor. It seems to make sense. What specifically, I don’t know, but if you’re kind of working more with that tone in general, I’ve only had a couple of patients come see me like post CVA and feeling their pelvic floors is amazing because while it makes perfect sense that one side might be like hypertonic are nonfunctioning until you feel it.

Sarah Haag:                  45:49                It’s like, wow, that’s so cool. Like once I totally normal springy, they can contract and relax the other side just like they’re, they’re hemiparetic arm. It’s cool. With stuff like CVA or neurological involvement, you really want to make sure you’re on board with the physicians and you know that bladder function is still intact because depending on where the stroke is and what exactly happened or where the spinal cord injury is, you don’t want to mess around with screwing up the bladder or the kidneys. So if they’re not going to the bathroom or they’re only leaking during transfers, that could be stress incontinence or it could be overflow incontinence because their bladder is so distended with the effort. So that’s something you would really want to make sure you talk with their nurse or their attending physician and make sure, so how are things working?

Sarah Haag:                  46:38                Because the other thing we need to remember is a lot of things we’re still working on people who have had neurological insults, right? So once you’re like, okay, bladder is relaxing as it fills, contracting, as it empties, it’s emptied fine. We’re not worried about this being overflow incontinence. I would actually start to incorporate stuff like blow before you go. Where you’re managing it the same way you would for someone not having a stroke, but half of that, the beam continent and actually going to the bathroom it seems, I can make it sound very simple, but I have a slide and of course that I teach where it has all the like the tracks up to the brain and all the tracks who, the spinal cord to the bladder. But we got the sphincters, we got the detrusor, all of this stuff just happens.

Sarah Haag:                  47:25                And when I click the slide from this beautiful simple picture, it’s just font about this big, explaining all of the complex things that are happening so far as we know. So again, as long as they’re, bladder is functioning on that basic level where it knows when to empty and it can empty, I would treat him like a anyone else and not assume that it’s just because of a high tone pelvic floor on that one side. That’s the issue. But if you get that person and you do your PNF, please tell me what happens. And if it changes their incontinence, I would really like to know.

Karen Litzy:                                           And when you’re looking at the bladder function, that is something the physician is doing through an ultrasound, is that how that works? How did they do that?

Sarah Haag:                                          They can do it through an ultrasound so that that they are, they can look mostly at like post void residual.

Sarah Haag:                  48:12                But then also there’s a test called neuro dynamics. And this is a test that involves, a catheter and there you’re a threat. And then a probe and another orifice down there to help measure for intra abdominal pressure. And it’s kind of a neat test. If someone wanted to do it on me for free, I would probably do it. But they’re also looking at an EMG the whole time. So they start to fill up your bladder was sailing so you know how much is in there and you’re awake for this test because they go tell us when you, when you feel the first urge to go and they mark where that is. And so you can see how much fluid is in there. And I’m like, tell us when you get like the, I should go to the bathroom now urge. And they mark that and then they’re like, okay, tell us when you can’t take it anymore.

Sarah Haag:                  49:00                And they mark that. So then they know how much your bladder can truly hold. But also looking at what’s your detrusor doing, which is the smooth muscle around your bladder, what’s happening to your pelvic floor, where is the weakness? And usually when they’re full, sometimes they’ll have people cough to see if anything leaks or if any sphincters happen or sphincters what they’re up to. But it’s, it’s involved. But there’s a lot of good information. And interesting side note is that if you do so, that’s really I think really helpful for like a neurologic population just to make sure. I did have one patient I was lucky enough to work with a PT who became a physiatrist who specialized in neurogenic bowel and bladder and she let me come down to watch  urodynamics of one of my patients who was really against cathing.

Sarah Haag:                  49:46                He didn’t want to cath. So she came down, she brought him down to the urodynamics and as it and cause he’s like, I am voiding 400 to 600 milliliters every time I have a bowel movement. And like that’s pretty good. I mean like most are four to 600 CCS and turns out it was only under very high pressure. He was already getting reflects into his kidneys and after he voided four to 600 CC’s, he still had four to 600 left, which is too much. So even though he was having some output, that was the test that really made it clear to him like, oh, it’s coming out, but it’s not healthy. Like I need to cath.

Jamie:                          50:41                What are some of the considerations that you might go through in your thought process when you’re dealing with a male versus a female pelvic pain or incontinence issue?

Sarah Haag:                  50:53                That’s a lot. I could talk for days on that. Well I’m not sure. When you’re talking about considerations. We need to take into consideration our patient preference and what they’re comfortable with. We can tell when our patients are uncomfortable or we should be able to but then kind of try to work out, they might not want to talk to me about this, but who can I get that they would, cause a lot of people would assume that men aren’t really comfortable talking to females. But a lot of the men who come to see me, just want help, and we’ve had several male students come through and you know, they run into like women not wanting a male therapist to do it.

Sarah Haag:                  51:36                It’s just finding that, right? Just like any other body part, finding the right person to help. But then if we go to, you know, bringing up those subjects, I don’t know that in my brain it’s so, so different. Male to female, you’re going to take into consideration their history for sure. I feel happy saying that because now with we have kind of like a gender spectrum, right? We have people who, who have transitioned in varying degrees and we have people who haven’t transitioned but totally identify with the gender. They weren’t assigned at birth and all of these things. So basically I take it functional. So can you just walk me through the issues you’re having, your questions, concerns when it’s a problem, if anything makes it better, does anything in particular make it worse? And then we problem solve from there?

Sarah Haag:                  52:26                So I guess I didn’t really have a good, a good answer, man. Male to female. Their situations are usually different, but it’s kind of different across one gender or the other. Anyway. Is that kind of answer it? Yeah. Great question.

Karen Litzy:                                           Well, thank you so much. Thank you. I think we covered a lot and I thank you guys for being here and I hope that you guys got a lot out of this and can kind of take this back to your patients now. So last question that I ask everyone and it’s so knowing where you are now in your life and your career, what advice would you give to yourself as a new Grad?

Sarah Haag:                                          Ask more questions. To be honest on, I came out of school pretty much like, like the teachers know best and what I learned is right.

Sarah Haag:                  53:16                And then when you get into the real world, I ended up thinking I was not very good at my job for awhile because like you would do what you were taught to do but it wouldn’t work. And then, you know, some things happen and I got older and more comfortable and when you start asking questions you realize there isn’t one answer. So if you start asking those questions, you’re part of, you’re part of the solution. By kind of pushing those boundaries and not like, I wish I would’ve just asked more questions sooner. I’d be so much smarter than I am now.

Karen Litzy:                                           Where can people find you on social media if they want to get in touch with you?

Sarah Haag:                                          Sarah Haig, PT on Twitter, you can find me on my website, and um, I mean Facebook, Sarah Hague.

Sarah Haag:                  54:07                I don’t know what my picture looks like right now, but I’m friends with Karen, so if it says I’m friends with Karen, that’s probably me.

Karen Litzy:                                           Awesome. And just so that everyone knows a lot of this stuff that Sarah spoke about, we will have links to it. We’ll have links to the home health section. We’ll have links to the testing, the urogenic testing. Is that neurodynamic testing? You could just send me a link or something about it. So we’ll have it all in the show notes. Thanks everyone for watching the live. We appreciate it and everybody, thanks for listening. Have a great couple of days. Stay healthy, wealthy, and smart.

Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitterinstagram  and facebook to stay updated on all of the latest!  Show your support for the show by leaving a rating and review on iTunes!

Dec 16, 2019

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Steve Anderson on the show to discuss leadership coaching. Steve is an Executive Coach with Orange Dot Coaching and the host of the Podcast, Profiles in Leadership.  He is a former Board of Trustee for The Foundation for Physical Therapy and was the President of The Private Practice Section of APTA for 6 years between 2002-2008. 

In this episode, we discuss:

-Why you should invest in a coach

-The importance of outside perspective when you’re pursuing excellence

-How to be open-minded and gracefully accept constructive criticism

-Redefining your daily operations with purpose and vision

-And so much more!


Steve Anderson Twitter

Steve Anderson Facebook

Steve Anderson LinkedIn

Orange Dot Coaching Website

Episode 197: The Graham Sessions with Steve Anderson

Profiles in Leadership Podcast

Optima: A New Health Company


A big thank you to Net Health for sponsoring this episode! 


For more information on Steve:

Steve Anderson is the ex-CEO of Therapeutic Associates which is a physical therapy company that consists of 90 outpatient clinics in Washington, Oregon and Idaho and a major hospital contract in Southern California.  He currently is an Executive Coach with Orange Dot Coaching and the host of the Podcast, Profiles in Leadership.  He is a former Board of Trustee for The Foundation for Physical Therapy and was the President of The Private Practice Section of APTA for 6 years between 2002-2008.  He was awarded the most prestigious award the Section gives out annually to a physical therapist, the Robert G. Dicus Service Award in 2010.   Steve received the APTA Leadership Advocacy Award in 2006 for his efforts in Washington D.C. and Washington State in the legislative arena.  In 2012 Steve received the Distinguished Alumnus Award from Northwestern University Physical Therapy School.   In 2016 Steve was awarded Physical Therapist of the Year by PTWA, APTA’s Washington State Chapter.  

Currently Dr. Anderson works with business executives and their teams to improve their leadership skills and coaches them to improve communication skills and working together better as a team.  He lives on Hood Canal in Washington state near Seattle with his wife Sharon.

Read the full transcript below:

Karen Litzy:                   00:00                Hey Steve, welcome back to the podcast. I am happy to have you on. So thanks for joining me today.

Steve Anderson:            00:07                Well, thank you Karen. I'm very happy to be on and I'm looking forward to our discussion.

Karen Litzy:                   00:13                Yeah. So last time you were on, we talked about Graham sessions and we'll have a link to that in the show notes to this podcast so people can kind of go back and learn more about that. But today we're going to be talking about the importance of having a coach. And first I'll swing it over to you if you want to kind of describe what you do as a coach and maybe what is your definition of a coach because there's a lot of coaches out there.

Steve Anderson:            00:45                Okay. So what I am is I'm an executive coach and so that means that I deal mostly with leadership training and communication skills and things like that. So what I do specifically is I work with people that are running companies, CEO types, and executives that are in leadership roles. And so helping them develop their leadership and communication skills. But then I also like to work with teams. And so I have clients that I work with, the CEO and their executive staff on how they can communicate together and how they can work better as a team when they're trying to run their business and grow their business and so on. So that's pretty much what I do. You know, but the definition of a coach is just somebody to help you, you know, figure out.

Steve Anderson:            01:40                I think what happens is we are in a very complex world and in our businesses and so on that they get very complex. I think a coach can help you simplify, look at things and simplified a little bit, help you kind of get out of your overwhelming rut, so to speak, and how you can start to look at things that are the smaller pieces and put that together and then just learn how to communicate with others and grow your business. And in a sense that doesn't seem so overwhelming or overpowering. I see a lot of my clients in that mode of, they're just, they're just overwhelmed and they've just got so much to do and so many things to look at that they don't really know what the next step is.

Karen Litzy:                   02:27                Yeah, I hear you there. I definitely feel like that on almost a daily basis. Now before we kind of go into a little bit more about coaching, just so the audience gets to kind of understand where you're coming from. So you are a physical therapist and you owned a multisite practice, but let me ask you this. You could have retired and just kind of spent the rest of your retirement hanging out and you know, relaxing. So why make that shift to being a coach?

Steve Anderson:            03:04                Sure. So I was a physical therapist and came up through a company called therapeutic associates where I started out as a staff therapist and then I became a clinic director and eventually became the CEO of that company. And it had a very unique ownership structure in the sense that every director of every clinic in that company is an owner in the company. So I was certainly not the only owner in the company. I was one of many owners in the company. And so when I retired, you know, I retired fairly young, I guess when you look at what age people retire these days. And so I thought, well, you know, what do I want to do from here? I don't feel like I'm ready to just do nothing. And so I kinda did the soul search and say, what are things that I really like to do?

Steve Anderson:            03:54                And when it comes right down to it, what I really liked to do is I just really liked to grow leaders and work with people as they're going through their journey. And so, I went and got certified in a program called insights discovery, which is a communication system or style and started reaching out to people and I've got some clients and worked with them and learned, you know, how to improve and get better at what I was doing. And so now I do it on, you know, certainly a part time basis. I'm not doing this full time by any means, but it brings me joy. It feels like I have a purpose and it's something that I just really look forward to doing.

Karen Litzy:                   04:39                I think that's such a great transition from the work you were doing as a physical therapist to the work that you're now doing as a coach. And for me, it gives a lot to think about because oftentimes, especially as a physical therapist, I know I felt this way when I graduated from college was, okay, I'm going to start working for a company and then I'm going to work there until I retire. And then that's it. So oftentimes, you know, it's hard for us to think far ahead, but being able to hear stories like yours I think can inspire a lot of people to say, Hey, wait a second. Like there's more to retirement or there's more to when, maybe whenever it is, you feel like your clinical work as a physical therapist is maybe run its course that you can use your physical therapy degree and you can use information, you can seek out new information in order to start a whole new career, but you're still firmly rooted in the physical therapy world.

Steve Anderson:            05:43                Right. I think you bring up a really great point in the sense that, you know, you don't, when you come out of school and you start your profession, start your career, you know, you can't see often that thing that you want to do. In other words, it's hard to visualize what exactly I want to do and what exactly I want to be. And I see new professionals coming out kind of tortured with that a little bit. Like they wanted to do something but they can't see it other than just the day to day. You know, we're working with the patient. So I can just share my journey a little bit in the sense that, you know, I was an orthopedic physical therapist and I worked hard at being good at that skill and then I became a director and I realized that I really liked working with the team and working with people and people don't always, they think I'm just messing with them when I say this, but I was kind of a reluctant leader. I didn't go in thinking that this is what I want to do, this is how it's going to look. And, I just kind of evolved into that leadership role. And then as I took steps going through my career, all of a sudden I was voted to the CEO of a very large company at 41 years old. And to be honest with you, I was scared shitless.

Karen Litzy:                   07:03                I mean, I would be.

Steve Anderson:            07:06                Yeah, I was excited to be in this position, but I'm like, Oh my gosh, I mean, you talk about imposter syndrome and I was like, what do I do now? Everyone thinks I'm going to have the answers. So at that point I didn't really know what coaching was or what coaching services wasn't. As a matter of fact, it was fairly a new concept to have a coach. And so I didn't have an opportunity to reach out to one and I didn't really know what to do. And so when I look back on that time, gosh, I could've really used a good coach. And so what I did was I looked for other ways to try and improve my position or my skills. And so I took a few college level or I mean graduate level MBA courses and they were okay, but they weren't really, you know, just resonating with me too much.

Steve Anderson:            08:01                And so then I eventually found this group called Vistage and you may have heard of that, but that's an international group where they have CEOs that work together usually 12 to 15 in a group. They meet on a monthly basis and they basically just learn from each other and help solve each other's problems. And so it's like a group coaching, so set up and I was in that for seven and a half years and really, really learned a lot from that because I had, you know, peers to bounce things off or like could get vulnerable with you. Got to know him really well. And, I think when you can trust somebody and work with someone to get to that level of vulnerability, I think that's where the learning really takes place.

Karen Litzy:                   08:50                And that group that was multidisciplinary group, that wasn't just specifically for therapists or even just for health care, is that correct?

Steve Anderson:            08:58                Exactly. In fact, I was the only CEO in that group from healthcare. And then they make sure that there's no competitors or you're not competing with anybody in that group. And so you start out kind of with people you don't know. And over a period of time you start to know and trust each other. And, and over a longer period of time you can really, you know, really get down to things that you have a tough time talking to most people about because you've really gotten to know these people. So I look at that as kind of a coaching relationship and the fact that my clients that I work with now, once they get to know me and once they trust me, you know, they can tell me the thing that they're afraid of or they can tell me the things that they don't know, without looking weak to the people they lead or without, you know, being their fear of, you know, people thinking maybe they don't really know what they're doing, but they can share that with the coach. And then we can get down to the real nitty gritty of that and what that means and how to work through that.

Karen Litzy:                   10:08                And it sounds like you were able to take what you learned there and combine it with what you learned through your career and then the extra courses taken after retirement to kind of hone your individual coaching skills in order to better grow your clients.

Steve Anderson:            10:30                Right. And I think the emphasis on that scenario you just discussed was the experience. I think the experience you can't buy experience, you can't, you know, like when I look back on mistakes I made when I had less experience, you know, I wish I could go back and do those again cause I think I would do them a lot better. But yet that's how you learn. So hopefully a coach has the experience to help you, say this happened to me and this is how I went through it. And, and this is how I can see you maybe, you know, getting there. I do question or scratch my head sometimes when I see, cause I do see business coaches that have never run a business.

Steve Anderson:            11:18                So that always kind of makes me feel like, well, you know, I want somebody who's been in the trenches. I want somebody who has worked through this before and can help me see some ways through it as opposed to someone who's just read a lot of books and knows all the catch phrases and the authors and so on. But I think the experience is the key there. And if we look at it from the clinical side, you know, if on the clinical side as a physical therapist, we probably refer to it more as a mentor, maybe then a coach. But same thing there. You want somebody who has experience and who has seen, you know, tens of thousands of patients and has that experience that you don't have that can help you maybe see through some things from their experience. And to me that's what makes it a really good mentor and a really good coach.

Karen Litzy:                   12:12                Yeah, I would agree with that. 100%. And you're right, there's nothing worse than seeing coaches advertise their services and they've had a business for less than a year. So, let's talk about pros and cons of having a coach. Let's get practical here. So what are the pros? So if someone's out there looking for a coach and they're on the fence, what are some pros to having a coach?

Steve Anderson:            12:43                Well, again, I think I said a little bit earlier, but I think a good coach can help you simplify what you're trying to accomplish. You know, I think a good coach can look at a complex situation and help you make it simpler. You know, coaches can be your external eyes and ears and provide a more accurate picture of your reality and recognize fundamentals that you have and that you can improve on. And then just breaking down some actions that you do to make them more practical. To me, one of the things that I work a lot with my clients with is it seems so simple, but communicating with others is so powerful. And if you really know how you communicate yourself or what motivates you and how you come across, and then you really get to know the people that you're communicating with and what resonates with them, then you construct your language and you construct your behavior in a way that connects with them.

Steve Anderson:            13:51                Because I can think that maybe my approach is I totally get it and I totally understand what I'm saying and I can look at the person across from me and they're looking at me like, you know, so I'm not connecting with them. So I have to know how to communicate that. And, you know, as we talk about it here, it seems simple, but I think there's a real skill to that. And I think there's a real ability to kind of craft your message in a way that connects with people.

Karen Litzy:                   14:26                Yeah. And I think whenever you talk about relationships, whether it be a personal relationship, a business relationship, the thing that tends to break it down more than anything else is lack of clear communication. Right?

Steve Anderson:            14:47                I was just going to say, and it's like if you look at your family or you look at your people in your business, I've always believed that you don't treat everybody the same. I mean, you have to be fair, but when we're talking about communication, in other words, the way that I would approach one employee could be very different than another depending on who they are, and you know, how they communicate. And so I think a really good leader is able to go in and out of these different styles, I guess, of communication that resonate with that person. And it's not the same for everybody.

Karen Litzy:                   15:29                Yeah. And it's funny, I was just about to bring that up because I was going to ask you a question of, let's say we'll take a scenario here. You're the CEO of your physical therapy business and you've got two people working in your front desk and you've got four physical therapists, and let's say you, I don't know, you notice that you have an unusually high cancellation rate with your patients unusually high. And so you kind of want to get to the bottom of it. So how you would speak perhaps to the people working at your front desk may be a little different than how you would speak to the therapist because they have different roles in your business, right?

Steve Anderson:            16:18                Absolutely. You have a different message for them. And, even when you look at your four physical therapists, let's say, out of those four physical therapists, you have an analytical person who thinks in very analytical terms. Well then the way to approach that would be to talk about the cancellations and no shows from a data perspective. You know, here's the numbers. Here's what it used to be. Here's what we want it to be here. You know, so you talk in very analytical ways. You may have someone else that has a real, you know, that they have more, they have a real caring about people in their feelings approach. And so you might talk to them about that situation and don't talk about analytics, but you might talk about, look at what our patients are missing. Look what we're not, we're not reaching their potential. We're not, you know, touching their hearts, you know, or whatever. So you talk more in those terms and then, other people, you will have different approaches. So I think that you have to know your people well enough to know that sitting in a meeting with six people, I'm giving the exact same message and expecting all of them to embrace it and have it resonate with them all at the same time is probably unlikely.

Karen Litzy:                   17:35                Gosh, it's so much more complicated than it seems at the surface, isn't it?

Steve Anderson:            17:40                Well, it is, but I think that that's what most of us feel. And that's where I think a coach can come in and say, okay, it’s complicated, but we can make it simple. It's a step by step, day by day thing that we can break down. And then it's just like anything else, once you understand kind of the process, then it's practice and you just practice and you practice and you get better and you make some mistakes and yet you do some gaps. And yet, you know, you put your foot in your mouth. Sometimes you learn from that. And over time that's where experience starts to build and improve.

Karen Litzy:                   18:17                Yeah, I guess it is. Once you have that framework, can it become sort of a plug and play kind of practice thing?

Steve Anderson:            18:28                It's good to break it down as simple as possible, but you're also dealing with humans. So just when you think that you just wouldn't, you'd think you've got it figured out. Someone will throw you a curve ball that you didn't see coming and so then you're going to have to, you know, readjust. But, it can be done much better than I think most people do it as just a general statement. You know, there's a great if I can put a plug in for this, a great Ted talk by Gawande, who most of us know who to go on deals and the title of the Ted talk is want to get good at something, get a coach. And he goes through the scenario of how, you know, he is a surgeon was thinking that he was doing pretty well and he improved and he improved.

Steve Anderson:            19:20                And then he got to a point where he just couldn't, he felt like he'd hit his limit. He just wasn't improving much after that. So his question was, well, is this as good as it gets? Is this how I'm going to be? And I'm pretty happy with that, but you know, does that mean this is where I'm at? And then he decided to go back to Harvard medical school and hire a retired professor who was a surgeon and had him come in and watch one of his surgeries. And as he's doing the surgery, he says, Oh man, I'm killing this. This is going so well and I probably just wasted the guy's time and the guys and my money. Cause what's he going to tell me? This was going great. And then the guy came back with a whole two full pages of things that he could work on.

Steve Anderson:            20:09                And he was kind of taken aback from it at first. But then he started doing that and he said, and I broke through that limit. I mean, he said, I'm a way better surgeon now. My infection rates are down, my outcomes are better. You know, and that just proved to him that anyone has a coach. And then he looks at the sports world and says, why is it that the number one tennis player in the world and the number one golfer in the world, they still have coaches. If they're the best, why would they have a coach? Well, because they need that extra eyes and that extra set of ears and so on to kind of help them break through the next level and the patients. And so I do think that that all of us could benefit from a coach or on the clinical side, a mentor. And I just think it's a really good way to spend your time and money to get to the next level.

Karen Litzy:                   21:01                Yeah. And, I love that you brought up that Ted talk. I'm familiar with that Ted talk. And you're right, it just shows that even when you think you're at the top of your game, to have that external eyes and ears on you because you don't know what you don't know. And so to have someone there to point that out in a constructive way and in a way that is going to make you improve, I think is the key. I think opposite, but as the person. So if I'm looking for a coach, I need to be mentally prepared for that person to maybe tell me things that are going to make me feel uncomfortable or that might hurt my feelings. I say that in quotes. But I think you have to be mentally prepared for change. Would you agree with that? As far as the people that you have coached in the past.

Steve Anderson:            21:55                So, yes, you're exactly right. You know, as people that educate and all different ways, we know that the person who's going to learn something has to be in a position that they're ready to learn. In other words, they have to be open to the fact that they have to look at themselves and be willing to realize that there's things to learn and they need to be open to suggestion. And so, yes, I have had some clients where, you know, they kind of thought they were just doing really great and, you know, our discussions were more like them reaffirming, you know, that they did it right and that this is how it should be and whatever. And you're kinda on the other end of the lines, like, I'm okay, so then why am I on this call?

Steve Anderson:            22:49                You know, so it's almost like they're using you to reaffirm to themselves how great they are. That has happened. But, it's rare. It doesn't usually happen. Usually the people that I work with are people that want to work with me because they want to get to the next level. They know that they and I don't really have any clients that are horrible at this. You know, it's kinda like Gawande said is it's people that are really functioning at very high levels but just want to get to the next level. And so, I think the people that are really bad at it are so bad that they don't even recognize that they need a coach or they can improve. I think the people that are the best clients are the ones that are functioning at a very high level. But no, they could maybe just get a little bit further, a little bit higher, if they had a boost or if they had somebody that could help them get there.

Karen Litzy:                   23:48                Yeah. That makes a lot of sense. And now we spoke about the pros. Let's talk about the cons. So I think maybe we might've just said one con that if you're not ready for a coach, then it might not work out so well for you. And that's coming from the person who's seeking. Right. So, yeah, I think you have to be really ready for it. And if you're not, then maybe it's not the right time, but are there any other potential cons that you can see?

Steve Anderson:            24:19                Well, I think that, you know, the, the obvious one is it costs money, you know, and it takes time. You know, so, the way that I would answer that is yes. But then also, you know, look at how much money PT’s spend on con ed and going to conferences and things like that. That takes a lot of money and a lot of time too. So it is just a priority. And, you know, I believe that the return on investment, so to speak, is very high in coaching. Because you really are getting that one-on-one approach. So, and then the other mistake that I see people make sometimes is, you know, I work with a client for awhile and then they kind of say, Oh, okay, this is great. Let's stop now and I'm going to go work on this stuff and then I'll get back to you when I've had time to work on it, practice it.

Steve Anderson:            25:15                And, I think that that's okay. But I do think that sometimes, just having a person continually working with you, even if it’s a lesser frequent time interval, I think it is good to reinforce that because it's hard to just take all this information and then drop everything and then just work on that without step-by-step approaches along the way. You know, it's kinda like I would make a reference to working with a patient that if you gave them a whole bunch of exercises and then say, okay, when you get all these exercises perfected, then come back and we'll go to the next one. Well, you can imagine what those exercises look like without some coaching along the way. If you returned in three months and said, okay, let's look at the exercises, you likely wouldn't even be able to recognize cause they changed them or they haven't done them. Right. And then they kind of, you know, one thing leads to another.

Karen Litzy:                   26:12                Right. Or because they don't have the accountability, they don't do them at all.

Steve Anderson:            26:17                Yeah, that's true.

Karen Litzy:                   26:18                Right. So I think that's the other part of the coach.

Steve Anderson:            26:22                Coaches will help you, you know, be responsible to help you, or be accountable is probably a better word.

Karen Litzy:                   26:32                Yeah, absolutely. Cause I know like I have certainly done continuing education courses and things like that and you learn so much and you're all gung ho. Then a couple of weeks later you're like, what? I haven't been doing everything that I learned at that course or I haven't been as diligent let's say.

Steve Anderson:            26:58                Yeah, exactly. Right. And, I think the other thing that's kind of scary when you start any new thing is that you've probably heard of the J curve. You know, whenever we change behaviors or we try and improve on something, we kind of go in this J curve, which is, if you can imagine what a J looks like, a capital J,  you start at a certain level and you dip down into the bottom of the J because you often sometimes get worse before you get better. And so it's that struggling time and that fumbling time and you just can't quite, you know, get it then, then you kind of come up on the other side of the right side of the J and then you reach a higher level. And so some people are unwilling or don't want to get into the bottom, bottom end of the J because it's frustrating. Sometimes you struggle and so, I mean some people would just rather, you know, go with the mediocrity and just keep going solid without the struggle. But sometimes you need to jump off the cliff and then get down into that lower J curve a little bit before you can really improve.

Karen Litzy:                   28:09                And I think it's also sometimes if you've had this level of success, let's say the, you know, high level executives or entrepreneurs who have multiple six figure businesses, you know, they have this certain level of success and I think you can get a little complacent and you can think to yourself, well, I am doing well, I'm already successful. What do I need a coach to help me get more? Like I'm there already. I've made it. So what do you say to that kind of comment?

Steve Anderson:            28:41                Well, it just depends on what you want to do. You know, earlier in my career there was this Harvard business review article that was kinda, I used it as my management Bible cause it was, it just resonated with me so much. And the story was about the owner of Johnsonville sausage. This was in the day of Johnsonville sausage was only a Wisconsin company. And people who's constantly knew about it, but no one else knew about it. And he described how he was making ridiculous amount of money. He was really successful. He was just, you know, kinda on the top of everything, but he couldn't leave the factory without people calling them all the time. He was working horrendous hours, you know, all these things were happening. And so on the outside you would look at him and say, wow, he's so successful.

Steve Anderson:            29:37                And then he went through this whole series of changing how he did things. Then in the title of the article is how I let my employees lead. And he grew leaders within the company and they took on the security responsibility and accountability. And so, you know, the end of the story is, is that now Johnsonville sausages, there across the country and probably international, he works less hours, makes more money and is happier and he's ever been. So, you know, I sometimes, as you said earlier, we can't always see what the other side looks like, but we just have to realize that there could be a better way. And then there could be a bigger prize at the end if you’re just willing to go down that road.

Karen Litzy:                   30:22                And I don't know many people who would argue against that. I think it's right. I mean that seems like it makes a lot of sense why to have working a little bit smarter, maybe still working hard but at least working smarter and making a better impact on the world, making a better impact with your patients. You know, being able to grow your business or your practice and seeing more patients help more people. So I think that another misconception when it comes to I really need a coach is that the coach is just for you and that no one else is going to benefit from it. Right. But that's not true, is it? And on that note, we're going to take a quick break to hear from our sponsor and be right back.

Karen Litzy:                   31:13                Are you interested in a free opportunity to check in with the latest thoughts of other rehab leaders? Well, I've got one for you. There's a new online rehab therapy community designed for the intersection of the clinical and business sides of rehab. It's the rehab therapy operational best practices forum, catchy name, right? It's all about habits and initiatives that juice up your attendance, revenue, workflows, documentation, compliance, efficiency and engagement while allowing your provider teams to keep their eye on the prize. There are patients and outcomes. I personally believe that a better connected rehab therapy profession has the power to help more people jump in, subscribe and join the conversation. Today. You can find the rehab therapy operational best practices forum @

Steve Anderson:            32:06                It's certainly not true that your influence and who you work with and who you touch on a daily basis will greatly, you know, benefit from you being better at your job. And a lot of times it comes down to just helping you see, helping you find ways to resonate with what you're doing. I'll give you another personal example. So do you know who Seth Goden is? He's kind of a marketing guru guy. And, so, you know, I was in my CEO position and I'm overwhelmed like everybody else and there's so much to do and whatever. And so people used to always ask me, well, what do you do as a CEO? And I would always hesitate because it was like a kind of, what do I do? I answer emails, I talk on the phone, I go to meetings, I go, boy, is that, how boring does that sound?

Steve Anderson:            33:04                You know? And so I happened to be hearing Seth godin and going at this lecture and he said that you have to find a way to even identify within yourself, what do I do and why do I do it? And he gave out some, some ideas and it really resonated with me and I got excited about. So I went home and I worked at it. And so now people say, when I was a CEO, they'd say, well, what do you do as CEO. And I go, I'm an ambassador for my company. I'm a storyteller and I grow leaders and that sounds a lot better.

Karen Litzy:                   33:42                That sounds so much better than I go to meetings and answer emails.

Steve Anderson:            33:48                Exactly. And so you know, so now when I'm doing, I'm sitting there trying to get through my emails. I say, okay, what am I doing? Oh, okay, this email was because I'm being an ambassador for my company. Or this email was cause I'm helping this leader grow. This phone call was for this. And so now those things seem to have more meaning and more purpose. And it just changes my mindset. And so I think that's what a good coach can help you see sometimes.

Karen Litzy:                   34:18                Yeah. What a wonderful example. And I often wonder that I would even say to my patients sometimes who are like executives and CEOs, I was like, well, what do you do all day? And they're like, what do you mean? I'm like, you get into work. And then what happens? And it's amazing how many people are like, I dunno, I mean I go to meetings and I answer emails and I'm on the phone quite a bit, like telling me what they're physically doing at their job versus what is the meaning behind the job. And I think that's the distinction that you just made there very well.

Steve Anderson:            34:56                Yeah. And I'll give you another example. On the other end of the spectrum, I talked at a PT school once, gave a lecture and a young man came up to me and said, God, I was really impressed with what you were saying and it was a talk on leadership and I was really impressed with it and it seems like you really know what you're doing. And he goes, could I come and just shadow you for a couple of days? And I said, you mean just my CEO job? And he goes, he goes, yeah, I'd love to just follow you and see what you're doing. Whatever. I said, Oh yeah, you're going to be bored to death. I mean, what am I going to be able to show you? I mean, you know, I'm sitting at a desk, I'm doing that. He says, why? And he wouldn't drop it.

Steve Anderson:            35:37                So I thought, well, what the heck? So here, this a PT student came and shadowed me for a day and a half and he went to meetings with me and he sat there when I was on the phone and he watched me get caught up. I mean, it was just, you know, he just hung out with me. And when he left he said, Oh, this was really great. I'm kind of thinking, God, I hope I didn't bore him to death. And I got an email from him about six years later and he said, Hey, you remember me, I followed you in whatever. And he says, I just wanted you to know that that day and a half set me on my course roots and my career and now I'm doing this and now I'm doing that. And so it had a huge impact on him. It was very gratifying and it made me feel really good, but I had no idea. So through his eyes, he saw things that I, you know, thought was mundane and day to day, but he saw things that he remembered and helped him, you know, find the career position that he wants. So that was a good story.

Karen Litzy:                   36:38                Yeah. That's great. Yeah. And again, like you said, it's that external eyes and ears, you know, we often don't see what others see and you never know who's looking. You never know who's listening and you never know who's watching.

Steve Anderson:            36:50                Right.

Karen Litzy:                   36:51                So what great examples.

Steve Anderson:            36:56                Yeah. And that's another great point is when you are in a leadership role, people are looking and watching and everything you do and everything you say, matter. And, you shouldn't take it lightly. You shouldn't be afraid of it, but you should realize that you probably have a lot more influence than you realize. And so recognizing that and being aware of that and trying to make that message better, benefits everyone in life.

Karen Litzy:                   37:26                Yeah, totally. And now before we kind of wrap things up here, I have a question that I ask everyone and that's knowing where you are now in your life and in your career. What advice would you give to yourself as a new grad right out of physical therapy school? So pretend you're coaching yourself back in the day.

Steve Anderson:            37:52                You know, I told this story earlier because I remember it like it was yesterday and I came out of school. I wanted to be, this good, you know, manual physical therapist as I could possibly be. And so I was doing a lot of extra study and study group work and so on. And I can remember driving home from one of those sessions, I was probably about two or probably two years out of school. And I remember almost becoming overwhelmed with how can I possibly be as good as I want to be, an understand all this information and hone my skills and see the diagnosis and so on, how I was just overwhelmed with it. And, so I look back and I got through it somehow, but I would have loved to have had a coach then or a mentor that said, no, you're doing exactly what you should do.

Steve Anderson:            38:52                You're working on your craft, you're putting in the time and effort and then you just have to go step by step, day by day. As I said earlier, because I would never imagined I would someday be the CEO of a large private practice physical therapy company. It just had never entered my mind at that stage in my career. So instead of being overwhelmed with, you know, this knowledge I have to get in whatever, I just need to start my journey, keep going and keep, keep moving and putting in the time and effort and where I end up in or I evolve into, I may not be able to predict, but I just know, I just know it's going to be something exciting and fun. And as long as I make the right decisions along that journey, I can reach a level I would have never imagined I could reach. And I do see that in new professionals today and they're struggling with that, you know, a few years out of school. And so my advice to them as it would have been to myself is just keep moving forward, step by step. Take some risks, find some things that resonate and excites you and don't be afraid to try them and see where it leads.

Karen Litzy:                   40:15                Great advice. And now before we go, let's first talk about your podcast and then where people can find you. So talk about the podcast.

Steve Anderson:            40:27                Okay. Well, I just want to say on this podcast, how inspirational and how helpful you were to me. Because as you probably remember, I thought, well, maybe I should do a podcast and I believe I called you and asked you some questions and I had not a clue how to start it and what to do. And, I really, I commend you and thank you very much for helping me answer some of those early questions and so on. So my podcast is called profiles in leadership and I just try and focus on leaders and then how they lead and just learn something from discussions with each one of them. I've been doing it about a year and a half now, a little bit longer. It's great. I mean, I've gotten some really fun, fun interviews, some inside the professional physical therapy profession and some are outside. I'm doing more outside the profession lately, which is fun. And, again, people ask me, why do you do the podcast? And, I say, because I learned something every time I do one, you know, every time I talk to somebody, I've been around a long time and with my experience, I still learn something every time. So it's like that, that gets me in the jazz and I'm inspired by that. So that's why I keep doing.

Karen Litzy:                   41:58                Yeah. And I also heard you say several times that it's fun, so why wouldn't you want to do something that's fun?

Steve Anderson:            42:04                Exactly. And, and you improve. I mean, I heard somebody might've been Joe Rogan who said, you know, if you think I have a good podcast, you should listen to my first few.

Karen Litzy:                   42:15                Oh my God.

Steve Anderson:            42:16                I think we all start at a certain level and if you're not improving, then you probably need to get out.

Karen Litzy:                   42:23                Yeah, probably

Steve Anderson:            42:26                I'm doing it. I think mine are much better than my first ones were. So, you know, that keeps me going too in the sense that I, you know, we all like to get better. We all like self-mastery. If we're not improving, we're probably not not having fun.

Karen Litzy:                   42:42                Yeah. I mean, like I look back at like the first couple of interviews that I did and it was like a straight up boring interview for a job that was not good. It was like, I was not showing my personality. It was very much like, so Steve, tell me about your job and what you do. And it was so, Oh my gosh. Yeah, it was not good. But you know, you got to start, like you said, you got to start somewhere. And I just took courses on public speaking and improv courses in order to help me improve because I knew where my limitations were and what needed to be done. But yeah, I can totally relate to that. The first couple are no good, not good, and it's not because the guests weren't great. It was because of me.

Steve Anderson:            43:33                Well, but look at the risk you took. I mean, to me that's how you reach a higher level of excellence is you're willing to take the risk. You are vulnerable. You were willing to be on camera and on audio and stick your neck out there and, you know, struggle through it a little bit and you improved. And then now you're, you know, you should be very happy with where you're at now because you do a wonderful job. So that's to me what it takes. And if we relate it back to coaching, it's the same thing. It's yeah, I need to take a risk. You need to be vulnerable. You need to realize that, you know, with work time and effort and practice, you're going to get better. And that's what it's all about.

Karen Litzy:                   44:19                Absolutely. Very well said. And where can people find you, find more about you and find more about your coaching business?

Steve Anderson:            44:27                Sure. So, my podcast it's on all of the podcast platforms, but, probably the easiest way to find it is through iTunes. You just search for profiles with leadership, with Steve Anderson. I did some as I did with you early on. I was doing the videos. And so, I do have the video gallery. You can search YouTube for profiles in leadership with Steve Anderson and then also all my podcasts and all the videos that I've done are on my coaching website, which is and that's orange, the word dot And you can see my services there for coaching. And then if you go to click on the media center, that's where the podcast and the videos are stored.

Karen Litzy:                   45:18                Perfect. And just so everyone knows, we will have all of that information on the show notes at So one click, we'll get to all of Steve's information. So Steve, thanks so much for taking the time out today and coming on the podcast. I appreciate it. I appreciate you. So thanks so much.

Steve Anderson:            45:37                Well, thank you Karen. And again, I just thank you for your early mentorship to me when I was trying to figure this all out and I haven’t forgotten that and I'm very appreciative that you're willing to help me.

Karen Litzy:                   45:50                Anytime, anytime. You are quite welcome and everyone else, thanks so much for tuning in. Have a great couple of days and stay healthy, wealthy, and smart.


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Dec 9, 2019

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Ryan Estis on the show to discuss excellence in business. Ryan Estis has more than 20 years of experience as a top-performing sales professional and leader. As the former chief strategy officer for the McCann Worldgroup advertising agency, he brings a fresh perspective to business events. As a keynote speaker, Ryan is known for his innovative ideas on leading change, improving sales effectiveness and preparing for the future of work.

In this episode, we discuss:

-Three actionable tips to constantly reinvent your business

-How to stay relevant and achieve excellence with changing customer expectations

-Four key practices you should adopt to thrive and avoid stagnation

-Why you need to reframe problems in order to produce lifetime customers

-And so much more!


Ryan Estis Website

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For more information on Ryan:

Ryan Estis has more than 20 years of experience as a top-performing sales professional and leader. As the former chief strategy officer for the McCann Worldgroup advertising agency, he brings a fresh perspective to business events. As a keynote speaker, Ryan is known for his innovative ideas on leading change, improving sales effectiveness and preparing for the future of work. He was recently recognized as one of “the best keynote speakers ever heard” by Meetings & Conventions magazine alongside Tony Robbins, Bill Gates, Colin Powell and Mike Ditka.

Ryan delivers keynote speeches, courses and online learning with an emphasis on actionable content designed to elevate business performance. His curriculum emphasizes emerging trends influencing leadership effectiveness, sales performance and customer experience. Ryan helps participants prepare to thrive in today’s ultra-competitive, hyper-connected business environment.

Ryan supports the world’s leading brands, including AT&T, Motorola, MasterCard, Adobe, MassMutual, the National Basketball Association, the Mayo Clinic, Honeywell, Thomson Reuters, Ernst & Young, Lowes and Prudential.

Ryan and his team publish original research featuring client case studies to expand the live event experience. He is also the author of a popular blog on business performance. His writing has been featured in Inc., Forbes, Entrepreneur, FastCompany, SmartBrief, Business News Network, Crain’s Business, and Yahoo Business.


Read the full transcript below:

Karen Litzy:                   00:01                Hi Ryan, welcome to the podcast. I'm excited to have you on. So thank you so much for joining me.

Ryan Estis:                    00:07                Thanks Karen. It’s great to be here.

Karen Litzy:                   00:09                Yes. And so like I mentioned in the introduction, Ryan was one of the keynote speakers this year at the private practice section annual meeting in Orlando, Florida. And I really loved the keynote, which is why I reached out to you. I took action now like you suggested and we'll get into that as part of my tan plan. We'll get into that a little later. I reached out to you via social media. And so here we are, but I have to say I really enjoyed the keynote and yeah, and it took a really like emotional interesting turn in the middle and I feel like in speaking with other participants that was unexpected and welcomed and really got people to sort of grab onto your words and take it to the end. So well done from a speech blueprint standpoint.

Ryan Estis:                    01:06                Well I appreciate it, you know, and I think an experience like that a little more emotional resonance is a good thing because I think that helps. Helps the tan plan, which I know we're going to talk about get a lot of attention. So that's always the goal.

Karen Litzy:                   01:20                Yeah, it was great. So thanks so much for that. But now let's let the listeners who weren't at PPS get a little bit more information from you. A little taste of that keynote. And one of the things that you know we were kind of talking about before we went on the air is at the private practice section. There are a lot of small business owners, a lot of entrepreneurs and a lot of my audience are yes, maybe work in healthcare but are also entrepreneurs. And we were talking about kind of customer expectations and how those expectations has changed over maybe the past couple of years. You probably have better research than I do on this, but can you talk a little bit about customer expectations and how they are kind of changing the small business or entrepreneurial landscape?

Ryan Estis:                    02:09                Right. Well, customer expectations are skyrocketing. They're changing fast because the world around us is changing so fast. I mean, I'm actually sitting at home right now and you know, when we get off this podcast I can turn to my lap and say, Alexa, paper towels and then an hour paper towels are at my front door. And that experience and experiences like those are elevating my expectations of everything. So as a consumer, I have a whole new set of standards with respect to customization, personalization of efficiency, expertise, sense of urgency and how I spend my time. And for those small business owners and entrepreneurs that are astute, aware of that and have evolving their customer experience to meet customers where they are, the future looks pretty bright.

Karen Litzy:                   03:03                And let's say, okay, we'll take me as an example. So I'm a small business owner and I really liked the way my business is running. I'm successful, I've been in business for 10 years. If it ain't broke, why fix it? So what kind of advice would you give to me?

Ryan Estis:                    03:23                I'd have some real thoughts about that. I would say if it ain't broke, it's the perfect time to break it because success breeds complacency. And complacency is the ultimate recipe for disruption. And the reality is for so many small businesses and small business owners, they don't change until there's a crisis, or they're experiencing some significant pain. And so, at that threshold, it's too late and you're on the verge of losing market share and getting commoditized, having your margin squeeze. And I know this from personal experience, if you remember from the keynote, my opening story was about exiting the advertising agency I worked for. And the reality of that situation is we had just deep pockets of resistance to change. You know, we wanted to kind of continue to do what we've always done, follow the playbook. And when the world around you changes and the marketplace changes, that's just such a recipe for disruption. And so having lived through that, I vowed personally, I am never going to experience that pain again. So the mindset of a small business owner today has to be continuous reinvention. Change is no longer an event. It's simply a way of existing. If you want to reign, remain relevant, thrive into the future.

Karen Litzy:                   04:51                And can you give some examples of maybe what you do with your own business to constantly reinvent? Because I feel like we can say you need to constantly reinvent and I feel listeners out there going, okay, great. Well what does that mean?

Ryan Estis:                    05:07                Yeah, yeah. So I'll get real, real specifics. Because here's the reality. If things are going pretty well and like the scenario you outlined, I had my business for 10 years, it's going well and I'm just going to continue to do what I'm doing. I don't see a real need or I have an appetite for change. And when things are going well that's true because change is uncomfortable. But, I've forced myself to get uncomfortable because that's where I'm evolving, stretched and growing. So we'll see a few things that I do. Three things, three very specific actionable tips. I am always in my business conducting what I refer to as three little experiments. I could be experimenting with my marketing on partnership, new software and the goal of the experiment isn't necessarily to have wild success.

Ryan Estis:                    06:03                The goal of the experiment is to learn and iterate forwards. So I'm trying new things that I think could help our business. And a part of that is it puts me in a position where I'm expanding my knowledge, acquiring new skills, getting education feedback, and then pantsing the business forward. So I would say some successes iterative, but you want to get out of your comfort zone and into the learning lane. So we have three very specific experiments that we're running in our business right now and there are tasks and we're getting feedback and evolving as a result. So that's one thing that I do. A second thing that I just really encourage or recommend is that in addition to working in your business, like you do, like probably a lot of your listeners do, and I do as a practitioner and a small business owner, you have to make time to work on yourself and on your business.

Ryan Estis:                    06:59                So for me, we just came out of a two and a half day meeting that I refer to as our 2020 growth summit. So this is literally shutting down emails, shutting down the phones, two and a half days with my team and some of our partners. There were eight of us attending in a room for two days with a very buttoned up agenda talking about the future of our organization. And you know, we're tearing apart the business and challenging ourselves to think about growth into the future. What are our priorities, budget assessment, looking back, looking forward recommendations, competitive intelligence, I mean all of it. So you know, that type of time kind of out of the business to working on that I think is imperative to having kind of a good solid plan and direction ahead. So that's a second recommendation is make you know, take time out to strategically work on your business.

Ryan Estis:                    08:03                Well, the third recommendation I have, and this is something I may have talked about it in the keynote, but I'm a big fan for small business owners of having what I refer to as a personal board of directors. And I have eight people that I've invited formerly this, that on my board of directors. And I invited people that I had a relationship with. I have a lot of trust and respect for their opinion or what they were doing say in their specific area of expertise. And the invitations were fairly informal, but what it's done is it's given me access to these eight people who have competency and skills perhaps to shore up some of my gaps. And I am able at inflection points when facing a critical decision or a juncture or I'm considering making an investment.

Ryan Estis:                    08:58                I had a group of people that, you know, I can reach out to and schedule a time with to use as a sounding board. And I think entrepreneurship at times can be very isolating. And you know, you feel you can get to a point where you feel like you're making decisions in a vacuum. And having an advisory board is moonshine option and valuable part of my growth, particularly over the course of the last couple of years. So those are three very kind of tactical things that I think everybody listening to can think about as it relates to their own business.

Karen Litzy:                   09:29                And, all of those three examples are things that are pretty doable for everyone. You know, it's not like there are things that are so outrageous. Like when you say three little experiments, you mean small, not like I'm going to restructure my entire business, but you know, you constantly throughout the year are doing this. Do you say I'm gonna do three little experiments a year or is it like every quarter or six months?

Ryan Estis:                    10:00                No, these are good questions. I would say I'm always running three experiments simultaneously. So let's say we're working on a marketing project that's a bit of an outlier, an experiment, something we wanted to do, try it. Sponsorship around some of our content branded content. And I'm not sure where this is going to go or if it's realistic. And so what we're testing this, I've reserved a little bit of budget, a little bit of investment, a little bit of capital. We're going to go down this path and then evaluate it. But through this process we'll learn things, we'll uncover things, we'll get customer feedback. We're working with, you know, our marketing partner. And so it's those, they're small tasks that, you know, if there's traction and the evaluation is, yeah, this is beneficial and we could build it then, you know, that we may expand an experiment.

Ryan Estis:                    10:57                So, that's the idea. They're small because I'm a big believer in that. Success is iiterative, you know, you want to be doing little things. There’s been a thought about that. It's like the minimum viable effort. There's BJ Fogg, he wrote a book about tiny habits and small changes and his ideas that to create these, he's a professor at Stanford. And his idea is that you create a new habit, you need to simplify the behavior and then make the change so tiny, so little, so ridiculous that it's just something that's easy to do. So no, you don't want to and you want to take calculated risks, you know, not something that's going to jeopardize your core business. So that's when I think of three little experiments and then you build on those things based on your expanded knowledge, experience, exposure, you know, you can start to iterate your business forward.

Karen Litzy:                   11:59                Yeah, that makes a lot of sense. So like in my world, in the physical therapy world, for me, I can think of changes that I made over the last year. And we're joking before going on air, like I went into these changes with like white knuckles. Like I did not want to let go of the things that I was doing because like you said, it's very uncomfortable so that it works. So for me in the healthcare world, something that was, it was just simply switching my electronic medical records from one company to another and it was very uncomfortable. But now that I've been doing it for, I don't know, eight months or so or nine months, I think to myself, this is so much better. What was I thinking before? Things are better. My patients are getting reminders that they have appointments, the platform's easy, or I can do it on my phone. I don't need a computer. So you know, that's an example of something small and at least in the healthcare world that you can do. And like you said, I was getting feedback from my patients and they were like, I love this new system. This is great. I love getting these reminders. I love that I can pay through the system. So it worked.

Ryan Estis:                    13:14                It works. But I also think it illustrates a very, very relevant point to our conversation that, you know, it's the psychology of change, right? So our brains are wired for safety and survival, not innovation and change, the mechanism in our psychology is trying to keep us safe and alerting us when danger is near. And that's trying to keep us away from these unknown elements. And that was pretty useful in times where there were reptiles running around trying to meet us. But in the modern day society, when you're running a small business, you have to condition yourself to navigate those feelings. So the discomfort, the uncertainty, the trepidation, the anxiousness that you felt upon making this change, that's a sign that you're in the learning lane, that you're expanding, you're growing, you need to kind of learn to welcome a little bit of that tension because that discomfort means you're on the cusp of a breakthrough and you broke through in an area of your business that elevated the client experience that's better for you, that's better for your team. And you just had to navigate that tension inside yourself. And you know what, it's like a muscle cause the next time then you invest in new software or taking intelligent risks or conduct an experiment, you'll recognize that tension of assignment. Yep. I'm in that. I'm in the learning, I call it the learning lane of your comfort zone and into the learning layer. And that's where growth happens.

Karen Litzy:                   14:51                And it's not easy, but it's not easy and it's a little scary. But you know, I guess I love the third point you made kind of having a personal board of directors and I guess I do have this without even kind of categorizing it as such, but I do kind of run things by people and it's interesting even when you run things by this group of, let's say you have eight people to shore up your ideas with, what do you do when they come back to you with feedback that doesn't align with what your thoughts are?

Ryan Estis:                    14:52                Yeah. So ultimately I would say I'm the decision driver, but if I'm out of my comfort zone or I'm entering unchartered territory, then it's useful to gain some outside perspective. And so I'm taking their advice under advising and helping it shape my decision.

Ryan Estis:                    16:04                So if I get feedback or advice or counsel that's counter to what I anticipated and my own opinion, then that means I'm probably going to have to do a better, more thorough job of convincing myself that I was right in the first place. And, then taking that step forward. The other thing about the advisory board, I would just also recommend is I hand selected these people for their particular skill or competency. So I have a technology entrepreneur that's an expert at scaling a business. I have a good friend who owns a research business that's complimentary to mine and he built and scaled that business and sold it. And so he has a lot of expertise that's related to my business. We partner together, but I value the way he ran his business and the organization he'd built.

Ryan Estis:                    16:56                I have my business manager who's known me for 20 years and is a good friend. And I also have my life coaches and spiritual advisors. So, my point in kind of sharing some of that context is, you know, I reach out to the people that I think would have relevant context based on the decision I'm navigating. So, if it's a financial decision, I'll probably reach out to my good friend who's worked in finance on wall street for 20 years and say, I'm thinking about borrowing money to do this and what's your perspective and how does this look good? And these are the terms. And so I have kind of carefully vetted these people based on their experience, exposure and the competency and thinking they could bring to support mine, if that makes sense.

Karen Litzy:                   17:43                That makes perfect sense. And did you do any sort of like self evaluation to see really where your gaps are, whether conscious or unconscious gaps?

Ryan Estis:                    17:54                Yeah, I've gone through coaching programs and have done some assessment work and then I also just recognize, you know, after having been in this business for a decade now, what some of the things that I'm really good at, some of the things that, you know, I'm not strong in. And so I just, I think in this kind of point on the journey, I have some exposure, I have some exposure to that. And some of it's based on my previous experience too. You know, I'm not a finance expert. I've never scaled the business and sold one. And you know, I'm not a technology expert. I've never launched an app. So these are things I'm like, Oh, these are things that, you know, as I move forward and navigate these waters, you know, it'd be good to have people that occasionally can jump in the boat and row with me and that elevates my confidence too.

Karen Litzy:                   18:47                Sure, sure. Yeah. And I'm sure it gives you more confidence in your decisions. And you know, I'm thinking of those like brand new entrepreneurs who feel like completely overwhelmed with absolutely everything. What advice would you give to them to kind of really hone in on what their zone of geniuses or greatnesses if you will, and then what may be they need to fill in the gaps?

Ryan Estis:                    19:12                Yeah. You know, a new honor, first of all, new entrepreneurship is overwhelming. So the best advice I have is be patient with yourself and be honest with yourself and you know, because everyone talks about entrepreneurship and freelancing and the gig economy. And you know, I guess when I quit my job, people thought I was crazy and I don't know, we weren't, entrepreneurship is so celebrated in our culture today and it's really happened in the last 10 years. You know, we've got magazines like fast company and we're putting, you know, these YouTube millionaires on the cover of ink. And I don't know, I think there's all this pressure to succeed and scale and get and just I would say just remember, focus on the next most important thing.

Ryan Estis:                    20:09                Build what you'd want and make and you know, achieve some semblance of success before you move onto the next thing. Focus is so critical for an early stage entrepreneur. It's so easy to get distracted and trying to do seventeens that we try and do 17 things at once. Well, and then you want to be networking. So you're meeting with people in a coffee shop that did it before you and you're just slow down, focus, get the next thing right, be patient, success of build. So that kind of perspective I think is so important.

Karen Litzy:                   20:47                Awesome. Thank you for that advice. That was great. I'm trying to take notes as quickly as I can here, but I'm going to have to go back and listen to this again. Now, you know, before you said you were kind of built to survive, you know, our nervous systems are built as human beings for us to survive. But something that you had mentioned in the keynote was, yeah, it's great to survive, but we also need to adapt and thrive. And you had sort of four keys to this breakthrough for poor performance are four keys to really help us adapt and thrive. So, can you kind of go through those for the listener?

Ryan Estis:                    21:27                I can. So the first one is very related to kind of where we started, which is about change. And the first one's initiate continuous reinvention. So you want to be an agent of change. You want to look at change in challenge through the lens of opportunity. And you want to be invested in this idea of successes that are rid of them to constantly be conducting experiments. And really I'm going to disrupt myself before the marketplace or competition does it for me. So stay in the learning lane, push yourself, get uncomfortable. That's the first one. The second one is really about customer experience, the idea of brand, the customer experience. We're in the experience and kind of, we touched based on how fast customer expectations are changing. The actionable recommendation around that as audit your own customer experience.

Ryan Estis:                    22:20                Look at every customer touch point your app online, offline, and look for opportunities to elevate it and add more value and make the experience better for your customers, meet customers where they are. Then the third one was it's related, but it's really about kind of, you know, the internal operation of your business, which was be a culture champion. I think culture is a catalyst for, you know, employee engagement, discretionary effort and contribution and culture is merely a reflection around how you lead. So think about purpose, vision, values, why are you doing what it is you're doing and what are the people who join you on this journey? Gonna get out of it. And employee experience and customer experience will always be directly correlated. And then the last one was take action. Now you talked about a Tan plan pan is, that's the acronym.

Ryan Estis:                    23:16                Take action now. And it's that, you know, great leaders, entrepreneurs, small business owners, they have a healthy action orientation so they don't get paralyzed. They're able to make decisions. The idea that you take in new information and then you immediately take action on those ideas, right? So, just like this, your listening to this podcast, you invest 30 minutes, 45 minutes or reading a new book, it's then taking a pause after you've taken that information in and say, what can I decide and commit to doing and doing differently that's going to create some momentum or advanced my clots. And that's, you know, really successful people they have, they're hungry for information, but then they back it up with action orientation. And those were the four tips.

Karen Litzy:                   24:04                Great tips. And I want to go back briefly to where you have branding the customer experience or patient experience in the healthcare world. Often times people use the B word, I call the B word branding to be all encompassing, right? Like you just have to, Oh, you just did your work in your branding, or B, be a better brand. But

Ryan Estis:                    24:32                Yeah, that's not really it.

Karen Litzy:                   24:34                It's sort of this term, you know?

Ryan Estis:                    24:37                Yeah. I have an ad agency background, so I'd probably throw that word out too much. I liked how you call it, the B word that's actually good for me. But let me clarify. So I guess a more specific way to describe what I mean by brand. It's establishing an identity, standards of excellence right away you go to market, tell your story, engage customers, deliver service, follow up and follow through that differentiates you from the competition. And that delivers value or resonates in a compelling way with customers, right? It's how you do things and if that, you know, look every touch point with the customers and opportunity to add value in advance or relationship. And it's just imperative in the experience economy that we're carefully thinking about that and looking for ways to elevate.

Karen Litzy:                   25:36                Yeah, and I love the example that you use. Where were you at? A Ritz Carlton or something. Is that where you were? So if you want to like briefly tell that story because I think, you know, when people hear Ritz Carlton, I mean, I know the first thing I think of is expensive, very elevated sense of customer service and is the same thing with like, a St. Regis. And you know, this is what I want to do real quick. I'm going to tell a story about my stay at st Regis and then we can contrast to your stay at a Ritz Carlton, which I would say are on par, right? So I was at a st Regis, I went out, it was like in a very warm part of the country and in the middle of the summer, came back, the air conditioner in the room, not only broke, but flooded the room and like you walked in and it was steamy and it smelled and it was like the carpet was all like squishy with water.

Karen Litzy:                   26:46                So we called down and said, Hey, you know, our air conditioner broke, there's water everywhere. And you know this just like one in the morning, I realize it's like the seed team on but still, so the guy knocks on the door with a mop and a bucket and I was like, Oh no buddy, you're going to need more than that. Like this is not good. So we have to call back down. Say, yeah, no, like we can't actually stay in the room. It's really bad. So someone came up, knocked on the door, handed me a key and said, you're in room three 47 and walked away. I was like, boy that wasn't very st Regis of them was it? And then the next morning I went to the front desk and I was like, well maybe cause everybody was like real tired and like I was with my boyfriend at the time. We just wanted acknowledgement and maybe like have breakfast on us, have a drink at the bar. I went back down and said, yeah, my room flooded last night and they just came up and handed us a key and now we're in this room. The girls like, yep. Got it.

Karen Litzy:                   27:46                And that was my experience. So I wrote a letter and what the st Regis did is probably more along the lines of your experience at the Ritz Carlton. I wrote a letter, I didn't make a big deal while I was there. Wrote a letter, said what happened to general manager, came back and he said, thank you so much for not ranting and raving and making a big deal of things. Any weekend you want. No blackouts. It's on me. So we took him back and they gave us a whole redo. And now I'm like, I would stay at a st Regis again in a heartbeat. They were fantastic

Ryan Estis:                    28:25                There and that's the ultimate lesson for any entrepreneur. It's the last sentence. You just say, cause here, here's the key. And it's similar to my Ritz Carlton experience and their philosophy is that problems are our best opportunities in business to deepen a relationship and that. So it's a real reframing of the problem, opportunity and customer relationship. It's so interesting. The best customer service stories always start out with a problem. My room got flooded, I lost my Ray-Bans in the Bay and was, you know, frustrated. And then some heroes steps in and resolves the problem beyond our wildest expectations. And it deepens our affinity, loyalty and evangelism for that particular brand. And so it's just, it's important to remember, it's never the problem, it's the way it gets resolved that people remember. And that ultimately shapes how they feel about doing business with you and Ritz Carlton leaving keys like PR.

Ryan Estis:                    29:38                It's almost celebrated. We have a guest that has a problem. Here's our moment to shine, to be magic, to create that wonderful, memorable feeling. And you know, so often I think in business and small businesses, you know, we get aggravated, Oh, customer's upset. Oh there's a complaint. And just next time that happens, pause and say, how can we turn this problem into an experience that creates a customer for life? And you'll reframe it. And you know, it's just interesting it's when problems come up for me. Now I have some of my, God, there it is. Now we've got a real opera, a magic moment as arrived.

Karen Litzy:                   30:16                Yeah.

Ryan Estis:                    30:17                How are we going to raise, how are we going to respond?

Karen Litzy:                   30:20                Exactly. And, you know, for the listeners who weren't at PPS, and you correct me if I'm wrong, but you were like paddle boarding and the Bay, you lost your sunglasses. And like some guy that worked at the Ritz Carlton went snorkeling down and got them for you and returned them to you. And you were like, what in the hell?

Ryan Estis:                    30:40                Yeah. And keep in mind, I never said, Hey, I mean I lost it. It was my fault.

Karen Litzy:                   30:47                Yeah.

Ryan Estis:                    30:48                And he just overheard me talking about it. I never, you know, I never went and said, Hey, this happened to me, you know, so it was just totally my thing. And the fact that they picked up on that and did what they did. And I was just, you know, I was dumbfounded and the more I researched and unpacked it and learned and actually spent some time with one of the executives at Ritz Carlton that runs a leadership Academy, you learn how based in their culture that is, right. So it's their values, it's their service standards. I mean, one of the great things at Ritz Carlton is that, you know, they have these very simple standards for how they greet and interact with guests. And part of what's great about that is that it creates consistency across all Ritz Carlton properties, right? So there's a way they greet and interact with the guests and they train on that, not what I mean by brand and things standard of excellence that's repeatable, that differentiates them, that resonates with the customer. So it's just a great takeaway from that is do you have standards? You know, you say customer service excellence that may mean something very different to me than it does to you. And that's my point is you don't leave customer experience up to the subjective interpretation of each individual. You standardize it, create protocol around it, process discipline around it so you can deliver a world class experience every single time. That's the idea.

Karen Litzy:                   32:20                Yeah. So really get specific.

Ryan Estis:                    32:23                Yeah, get specific.

Karen Litzy:                   32:25                Yeah. Yeah, that makes perfect sense. All right, so before we wrap things up here, I just have a couple more questions, but first one is, is there anything we missed? Any key takeaways that you want the audience to get?

Ryan Estis:                    32:41                You know, I think to just, you know, and this isn't new, but I think really spending some time as a small business owner, looking out, being forward thinking, you know, spending a little time, this is a great time of year to do it. We're coming up on the end of the year and I know it's an exercise I'm going through. I'm asking myself, you know, why am I doing this, first of all, and then what do I really want this to be a few months from now, but even five or 10 years from now? And some of that forward thinking and visioning and purpose, solidification. It helps reconnect me to why I got into this in the first place. Why it still matters to me. And the solidification and the articulation of that can really be beneficial to a culture and connecting your people to it and being able with clarity to say, this is where we're going, this is what we're building and this is why we're doing it. This is the impact that it's having. And I think for your listeners in your industry, some of that work could be, so useful and so, so meaningful. So I would think that's another, you know, Simon Sinek did the great Ted talk. He wrote the book and starts with why. And I think that's true.

Karen Litzy:                   33:55                Awesome. Well, thank you for that. And then the last question, I probably should have prefaced this question, but I forgot. So here we go. It's a question that I kind of ask everyone at the end of the interview. And that's knowing where you are now in your business and in your life. What advice would you give to yourself straight out of college?

Ryan Estis:                    34:19                Yeah, I would say, relax, have fun and enjoy the ride because it goes by pretty quick and you know, if it's not something that is going to matter five years from now, don't give it more than five minutes of your time and attention. I think for a lot of, you know, achievement oriented, entrepreneurial type a people, which I am one of, we can tend to get perfectionist and stress about the details and kind of, you know, that creates low grade anxiety and overwhelm when things go wrong. And it's just, as I've gotten a little older and wiser, I think just relaxed and letting some of that stuff go and really making sure that, you know, yeah, hard work is great and building something that you care about and are proud of matters, but just really make sure that you're enjoying the moments and the journey your on, you know, while you're moving through it.

Ryan Estis:                    35:14                I think that's just so critical. I think we project outward and delay our happiness until, you know, I call it the if when happiness travel, if my business gets to this point, you know that then I'll take a vacation or once I get here, then I'll finally be happy. That's a real, a real miss. And so I let some time go by. I think it's certain phases of early phases, my career and my life where I would have been a little more relaxed about things and that's important.

Karen Litzy:                   35:46                Yeah. I know I'm guilty of everything you just said for sure. And now totally guilty. Oh 100% guilty of everything that you just said. And I'm trying to work through that myself. So that's wonderful advice. Now, where can people find you if they want more information and they want to connect with you? They want to hear you speak, all that fun stuff.

Ryan Estis:                    36:11                So I would say that the website's a great place. We do a weekly newsletter called prepare for impact. It comes out every Sunday and it's just kind of a couple of actionable tips to help you get ready to be the best version of who you are and the week ahead. And then social media. LinkedIn, I'm pretty active on Instagram. We have a company Facebook page, pretty pretty active YouTube channel. So all of the social properties. But I'd love to connect with any of your listeners. This was a lot of fun.

Karen Litzy:                   36:45                Fabulous. Thank you so much for coming on. I really appreciate it. And do you have anything coming up? Anything in the works

Ryan Estis:                    36:55                And I do. So, you know, we're working on a book.

Karen Litzy:                   37:02                Yes.

Ryan Estis:                    37:04                I think we're at the point now that we're at the point now where I think it's actually gonna be a pretty good book and it's about sales, service and leadership. I think it'd be very relevant to the, you know, small business owners and practitioners listening and that'll be out sometime next year. So for anybody listening that's interested in, you know, if they subscribe to the newsletter and stuff, we'll be sure and do promotion on it.

Karen Litzy:                   37:32                Awesome. Well, thank you so much for taking the time out and coming on. I appreciate it.

Ryan Estis:                    37:36                Yeah. Thanks for having me.

Karen Litzy:                   37:38                And everyone, thanks so much for listening. Have a great couple of days and stay healthy, wealthy, and smart.


Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram  and facebook to stay updated on all of the latest!  Show your support for the show by leaving a rating and review on iTunes!

Dec 2, 2019

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Dr. Elaine Lonnemann on the show to discuss the impacts of being diagnosed with degenerative disc disease.  Elaine Lonnemann has served the public clinically as a Physical Therapist for over 30 years practicing in a variety of settings in Tennessee, Florida, Kentucky and Indiana. Her early clinical interests in treating patients with low back pain evolved into a clinical academic career with a focus on best practice in orthopaedics, teaching and leadership. She lives in Southern Indiana and is the mother of four boys with her partner and husband Paul Lonnemann who is also a Physical Therapist.

In this episode, we discuss:

-The American Academy of Orthopedic Manual Physical Therapists position on the opioid crisis

-Patient health outcomes following the diagnosis of degenerative disc disease

-The use of Clinical Practice Guidelines for low back pain in physical therapy practice

-Pain science education and the treatment of low back pain

-And so much more!



Elaine Lonnemann Twitter

AAOMPT Website

AAOMPT Position Statements

Battie et al. 2019: Degenerative Disc Disease: What is in a Name?

JOSPT CPG: Low back pain   


For more information on Elaine:

Dr. Elaine Lonnemann received a BS degree in PT from the University of Louisville in 1989, a MSPT from the University of St. Augustine (1996) and DPT (2004). She is the program director of the transitional Doctor of Physical Therapy program for the University of St. Augustine. She has served in several positions for the University of St. Augustine for Health Sciences since joining in 1998 including teaching in the online and continuing professional education divisions. Her responsibilities include oversight of the transitional DPT program as well as the orthopaedic and manual physical therapy residency and fellowship. She is a board-certified clinical specialist in Orthopedics, Certified Manual Physical Therapist and a Fellow of the American Academy of Orthopedic Manual Physical Therapists (AAOMPT). Her clinical experience have been in private practice, home health, outpatient practice, and as Chief PT of outpatient services in a level II trauma center at a university hospital.

Dr. Lonnemann was an associate professor for Bellarmine University in Louisville KY and taught in the first professional program for fifteen years. She has presented nationally and internationally on the topics of spinal thrust manipulation, low back pain guidelines and leadership. She authored textbook chapters in orthopaedic physical therapy and has published in the areas of spine morphology and joint manipulation. She is passionate about leadership, postprofessional physical therapy education, manual physical therapy and integrating pain and movement sciences in the clinical management of clients. She is the current President of AAOMPT and has served two terms as Secretary and Chair of the AAOMPT International Federation of Manual Physical Therapists Educational Standards and International Monitoring Committee, member of the OMPT Description of Advanced Specialty Practice Task Force and committee member and author for the 2018 revision of the Manipulation Education Manual. She received the AAOMPT Mennell Service Award and the 2017 President Joseph and Maureen McGowan Prize for Faculty Development from Bellarmine University which provided the opportunity to study the history of manual therapy at Oxford University.


Read the full transcript below:

Karen Litzy:                   00:01                Hello, Dr. Elaine Lonnemann, welcome to the podcast. I'm happy to have you on.

Elaine Lonnemann:       00:06                Thanks. I appreciate being here.

Karen Litzy:                   00:08                Okay, so today we're going to be talking about degenerative disc disease. But first I would love for you to talk about what it is, why it exists and what do all those letters in AAOMPT stand for?

Elaine Lonnemann:       00:27                Absolutely. So AAOMPT stands for the American Academy of orthopedic manual physical therapists and it's an organization, it's an association that started in 1991 basically because some individuals felt like we needed a group that could present scholarly works that could meet, have conferences and also test clinicians based on international manual therapy standards. And so that group, several individuals got together and that's how it started in Michigan actually. So that now we have representing 3000 physical therapists.

Karen Litzy:                   01:12                That's a lot of therapists. And how long have you been part of the organization?

Elaine Lonnemann:       01:19                I've been a member since actually 1994. So quite a lot of time. I was a resident and fellow in training and became a member of really when it was beginning. So I've been involved as a member and more recently as an officer.

Karen Litzy:                   01:37                Awesome. That's great. So now let's talk about AAOMPT position on DDD or degenerative disc disease, which is something that I think is a very commonly diagnosed. I think it makes people nervous when they hear it because they hear the word disease. So can you talk a little bit about degenerative disc disease and the position AAOMPT has on that?

Elaine Lonnemann:       02:03                Yeah, so our position is we just oppose the use of that term. It's commonly used as you said, and it's really used to diagnose an age related condition. And that age-related condition shouldn't be considered a disease. It shouldn't be considered degenerative. So it happens whenever on imaging you see changes in the shape or the size of the disks in the spinal column. So that's how it's identified. And, you know, we know several things that nearly everyone's discs change over time. And the interesting thing about that is that not everyone feels pain even when they have those changes in their discs. So, that's why we oppose it or one of the reasons.

Karen Litzy:                   02:52                And you know, like we said, it is so highly diagnosed and when people hear that disease, they think of something that like cancer is a disease or Parkinson's is a disease or a syndrome. But I think it's kind of scary terminology and words matter. So what does AAOMPT feel should be a better descriptor?

Elaine Lonnemann:       03:19                Well, you know, I don't know that we have a descriptor in terms of a substitute, but I think, you know, patients really have the right to accurate healthcare information. And when, like you said, when they are given that diagnosis, you know, not only disease, disease puts a lot of fear in their mind, but degenerative, I mean they start to lose hope because they degenerative just sounds like, you know, they're gone down a pathway, you know, if it is just described as mechanical back pain or radiating back pain, you know, and our healthcare system really looks at trying to find a tissue or a pathoanatomic cause for low back pain. And the research clearly indicates that and has over time that it's very difficult to find a specific cause for low back pain. So we really need to move away from that model.

Elaine Lonnemann:       04:16                And, you know, the other part of that is the patients lose fear, they lose hope. And they also began to believe they can't manage their own pain. So they lose self efficacy. And we know how important that is for our patients. And I think that's the one thing I love about our profession is that we really help patients manage and control their symptoms, their condition, and improve their function. And, whenever they're given that label, it really it can misguide them, you know, because they lose hope. And then they might start choosing, you know, riskier treatment options.

Karen Litzy:                   04:53                Surgeries, medications, even less invasive procedures, things like that that maybe may not be necessary. But like you said, if you're the patient getting this diagnosis of degenerative disc disease, it can maybe feel like you're at the end of your rope and you don't have much more to go.

Elaine Lonnemann:       05:16                That's right. And patients need to know that their situation is real, that the findings that they have, because most people are diagnosed after they've had imaging. And so I think it's really important that we emphasize, yes, those findings are real, but this isn't a disease and this can be managed. And you know, the other thing is that oftentimes those imaging findings stay, but their pain goes away after they're treated. So, you know, that helps to give them some hope. I recently had a student who was 26 years old who came up to me and said, you know, I'm really concerned. I went to see a healthcare provider and because I was having some back pain and they diagnosed me with degenerative disc disease, what am I going to do? And then she just went in, almost fell apart because she said, you know, I love to run.

Elaine Lonnemann:       06:06                I don't, you know, I don't know what I should do. Can I continue to exercise? And I'm thinking about getting an epidural injections because I don't want this to progress. And so I had to kind of step back for a minute and say, okay, it just explained to me why you went, you know, tell me about your pain cause you're not going to, she told me, I'm not even in pain now. She said she had had pain for a week and then went in. Because her sister had structural scoliosis, so she was fearful even though that was at 16, she was fearful that she might have a condition that would be a problem. And now she's fearful because she's been labeled as having degenerative disc disease. So, you know, it really took a while to counsel her and you know, to again, affirm these findings are real, there are changes in our discs but these are normal changes that occur with aging and they shouldn't be considered degenerative. The studies indicate that, you know, there's oftentimes when those findings are present, they don't correlate with the exact clinical presentation of the patient. And that's what we want to get. That's the message we want to get up.

Karen Litzy:                   07:16                And as physical therapists we can certainly relay that message to our patients. But if the patient hears that from the physician first, it makes it a little bit more difficult. Our job becomes a little bit more difficult because now it makes it seem like we're giving two different diagnoses. Maybe it starts with us as individuals, but how can we as the physical therapist who is maybe seeing this patient after they were given that diagnosis from the doctor communicate to the physicians or you know, cause this is a medical system wide use of terminology and it really needs to change from top to bottom. And I feel like sometimes yeah we're that point of entry but oftentimes where people are coming to see us after they get that diagnosis. So how do we as a profession advocate for this change to the greater health care system?

Elaine Lonnemann:       08:22                Well I think we definitely need to partner with our medical colleagues with APTA and we are already partners but definitely get the word out that you know, this type of diagnosis really does misinformed patients. There is research and AAOMPT has developed a white paper that explains the research related to how this misinformation can potentially guide their treatment or lead them to choose, like you said, riskier treatment options. And you know, one of those, obviously the opioid epidemic is something that we have to think about. And not to say that it's going to lead them directly into that path, but it does. There has been some research that indicates that, you know, the healthcare costs are driven because we aren't following the practice clinical practice guidelines for back pain. So I think the biggest message that needs to come out is we need to follow those clinical practice guidelines.

Elaine Lonnemann:       09:22                And I just heard Tony Toledo, do you have his keynote presentation at the interprofessional collaborative spine conference? And there were physical therapists and physicians and chiropractors all together in a room and you know, it was a great opportunity to meet, you know, as partners with them and you know, what can we do for the greater good of our patients? And I think the biggest, yeah, and he actually presented some of the challenges and what can we do from here forward really to improve this situation. And you know, he was talking to all of this. It wasn't just physical therapists, but one of the things that he did address was the continuity of care. And he said it's really important that patients don't wait, that we get them in early and not that every patient would and I don't want to, I don't, I want to make sure this is clear.

Elaine Lonnemann:       10:12                Not every patient who has low back pain needs to be seen by a healthcare provider, whether it be a physical therapist or other conservative type of clinician. Sometimes that pain will go away, but if it's very intense and if it doesn't go away, then they should seek care and it should be early. So talking about the continuity of care, you know, in terms of who sees the patient first and whoever does it should follow the clinical practice guidelines that recognize, you know, with some time with some activity, with some coaching, a reassurance and a comprehensive medical exam that really does rule out a systemic cause or something more sinister because that's the other thing. Patients are fearful. My 26 year old student was fearful that this was something sinister. So I think that is a really important message to get out that comprehensive physical exam can really help to rule out some of the medical disorders that, you know, are uncommon in low back pain, but that our patients are concerned about.

Elaine Lonnemann:       11:21                So, continuity of care was one thing he mentioned. Oh, and the other thing he mentioned is variation in care. Of course, you know, it's a big problem because you know, whatever healthcare provider you see with low back pain, there's a ton of variation in how the providers performing interventions. So, you know, he highlighted that and I couldn't agree more but one of the things that he mentioned and you know, of course president of the Academy of orthopedic manual therapy, you know, so one would think I'm going to mention manual therapy, but really it's because that is part of the clinic, one of the recommendations of the clinical practice guidelines, is manual therapy for back pain. And again, not every patient needs it, but he mentioned, you know, manipulation, mobilization, those are forms of manual therapy along with exercise. And so I think that following the clinical practice guidelines, trying to reduce our variation in care and also recognizing that, you know, as physical therapists, we need to refer on or we need to know when not to treat and when we do need to treat consistently and follow those guidelines.

Elaine Lonnemann:       12:36                So that's probably a long answer to your question, but as far as the message that needs to get out, I really just think highlighting those things are important.

Karen Litzy:                   12:45                No, and I don't think that was a long answer at all. I think that was a very good comprehensive answer. And you know, we're talking about clinical practice guidelines. Where can people find these clinical practice guidelines? I know the orthopedic section of the APTA has clinical practice guidelines on their website. Are there other places where people can search for these guidelines? Because oftentimes we talk about clinical practice guidelines, but people are like, I don't have any idea where to find them. I don't know where to look.

Elaine Lonnemann:       13:21                Well, so that's a good, good point. In terms of looking at websites, you know, I think the orthopedic Academy, their clinical practice guidelines follow the majority of practice guidelines that are out there. The American family practice group also has clinical guidelines. Ciao, published a group of guidelines and they're all fairly consistent. In turn there are some variations and you know, sometimes people ask what, well, why are there, you know, so many variations. And part of it's because the different groups, there might be some bias in those. Just if you break them down and look at the commonalities, you know, again, at least for back pain, I think those are the things that you have to look at. So I know APTA has some links. And now that you mentioned it, we will put links on our website as well to the clinical practice guidelines that are out there. And we'll have a a link to this white paper as well that the Alicia Emerson led that charge along with Gail dial and, and Dan Roan and other Jason's silver. Now other a PTA members amped members that, um, we're working in this area.

Karen Litzy:                   14:38                Yeah. Because I think it's, there is a breakdown from, so you graduate with your PT degree, you start working and if you don't keep, you don't know where to look. You're, you're kind of just sort of floating along using maybe what you learned in school, which is great because hopefully you won't kill anybody or do major harm to somebody. But I think when it comes to diving deeper into treatment paradigms, these clinical practice guidelines, people have to be proactive about that. And so knowing where to look and knowing where to find them is great. Um, and I also want to touch back on the variation of care. And when you're talking about variation of care, are you talking between physical therapists themselves or between a PT versus a doctor versus a chiropractor? Uh, manual therapist versus non-manual therapist? I mean I think there is a lot of variation to care and that can also be quite confusing to the patient. So I don't know in that keynote if he sort of touched on what he meant by variation of care.

Elaine Lonnemann:       15:50                Yeah. He met within physical therapists and or within profession and, and really looking at, you know, and all the individuals in the room, many of us are providing very similar [inaudible] at least are able to provide similar treatment options. And so his, his point was that, you know, we really should be looking at more consistent care model following the practice guidelines and not, um, varying to other types of, of treatment approaches that may not have the evidence and, and so variation and care, but also that evidence, um, the care that is supported by the evidence

Karen Litzy:                   16:28                of course. And you know, that brings me to, this is going slightly off topic, but, well, no, not really. It's still on topic. It, it reminds me of a, a post that I saw in a Facebook group, a physical therapist, and it was a newer ish grad, maybe out a year or two. And he said something to the effect, I'm paraphrasing. Um, when we advertise to the public about what we do as physical therapists, you know, everyone tends to say, you know, we're evidence-based profession. You said, shouldn't the consumer already know that? And how important is it? Like, don't you just have to do what the patient wants? Because all we're worried about is our job is to make a person feel better. So what does it really matter what you use to get them there? Meaning does it matter if you use something that's evidence-based or not?

Elaine Lonnemann:       17:28                Well, and I think, you know, part of that is patient education and having a relationship with your patient so that they do trust you. So you have, you know, I think they have to be able to trust you and you have to develop that therapeutic Alliance with them too. Help them understand that, you know, these are treatment options and it should be patient centered. You know, we want to be patient centered and we want to help them understand that, that these are the best approaches and it's not a one size fits all. I mean there are some outliers, but the extreme variation that has been shown is the problem. It's not the occasional patient who, well yeah, sure. Maybe that PA it's more patient centered to do a different approach, but there's extreme variation.

Elaine Lonnemann:       18:16                And I think even if we just reduce that by 50%, I think it would have a huge impact on care and the research that's coming out of university of Pittsburgh that I'm not involved with this, so I'm just, I'm just reading and trying to do the same thing, everyone else's. But there's some big research that's coming out to talk about that will speak to, you know, following the guidelines when there is variation of care or if there is a variation of care. Okay. Yeah. What's different?

Karen Litzy:                   18:51                Yeah. And I know there was a study that came out a couple of weeks ago that showed that, you know, with different diagnoses, less than half of physical therapists actually follow best evidence to treat.

Elaine Lonnemann:       19:08                Yup. And the thing that you mentioned before too is how do we avoid that? I think as you mentioned, a PTA or being a member of the American physical therapy association really helps. It's made to streamline my direction of understanding so I can go to PT in motion. I can look at, you know, there's a lot of great white papers that they have position statements, you know, on the opioid epidemic. There's just a ton of great resources there. And it was another thing that I would emphasize for clinicians.

Karen Litzy:                   19:43                Yeah. Because you know, in the end, you want to treat people using best evidence, you know, and I think it was Jason Silvernail in a comment said something. Again, I'm paraphrasing, but something to the effect of why would I waste my time doing something that I know doesn't have evidence behind it, when I could be spending that time, precious time with our patients. Sometimes you get an hour, sometimes a half an hour, sometimes 15 minutes, right? So why would you waste that precious time on something that you know, doesn't have the evidence behind it when instead you can be doing something that has been shown to help and that goes back to, and then you'll hear the argument against that was like, well, the patient really wanted it. So that's how I'm developing my therapeutic Alliance.

Elaine Lonnemann:       20:39                Yeah. But I would still argue against that.

Karen Litzy:                   20:43                And that's where like you said, patient education comes in, you want to explain to the patient, Hey listen, I understand that you like treatment X, Y, Z, but right now we know that treatment ABC is more appropriate for you given where you're at. And explain to them why. And I've done that plenty of times and patients are like, okay, so right.

Elaine Lonnemann:       21:04                And then there's an opportunity to negotiate, you know, let's just try this. If it doesn't work, you know, this seems to be more effective than, and it is more efficient. And like Jason said, why, why would you waste your time and their time? You know? And that's what I tell the patient, I respect your time and this is what we understand and this is what we know at this point and is best care. So, you know, if you're willing to go along with me on this, you know, I think we can try it out. And if it doesn't work, you can fire me. You can find another physical therapist or, you know, I'll find you someone that it works, you know, or the treatment, you know. So yeah, I think you have to be really,

Karen Litzy:                   21:45                And I think, like we said in the beginning and going back to degenerative disc disease, words matter, right? And how you explain things matter.

Elaine Lonnemann:       21:55                Yes. Well and Michelle just published a systematic review in spine, she looked at the term degenerative disc disease and the name of the article is what's in a name. And, also found that there's so much variation in what, you know, healthcare providers are calling degenerative disc disease and you know, in summary found that it's just, it's inconclusive and there's not evidence to support this as a disease and there's so much variation in it that they also recommend not using it as a term.

Karen Litzy:                   22:37                And so from what we talked about from a sort of 30,000 foot view as to what associations can do to kind of help clean up terminology, this kind of medical terminology and that may, like you said, partnering with our physician colleagues partnering with maybe our chiropractic colleagues to kind of change the narrative. But what can, for all the listeners out there, let's say you're an individual therapist, what can you do to kind of help change the narrative around that term degenerative disc disease? So your patient comes into you, they're fraught with worry, what can you do?

Elaine Lonnemann:       23:19                Okay. You know, I think the biggest thing is to get our patients as our advocates. And so taking the time to educate them about it and say, yes, you know, this is real. Your changes are real. This isn't a disease. And to help them to understand that and then give them the tools, you know, say, Hey, you know, when you go back to your physician or your other provider, whoever referred, or maybe they didn't refer, you know, get the word out to these medical providers, get the word out too, you know, senators, legislators and because they're speaking to them as well and support, you know, this aspect of, you know, whether it's conservative care, you know, and also having pamphlets or educational materials, you know, that really do talk about, you know, if you are referred to a physical therapist first, that there's, I believe it's an 89 point something percent less likelihood for that patient to be prescribed opiates in the following year.

Elaine Lonnemann:       24:23                And that's a huge statistic, you know, and everybody's concerned about the opioid epidemic right now. So, you know, following practice guidelines and physical therapists should be considered, you know, first primary contact providers, then we can do a comprehensive medical exam, we can screen, we know when not to treat, we know when to refer on. And following those guidelines I think is the other part of what I educate my patients about. So I would say, you know, these are the guidelines and having this material. So if you're interested in sharing this with other people and you know, there are certain patients that are more vocal than others and whenever I hit those patients, I really get them and hit them hard and say, you know, help share this information. If you found this valuable, please advocate for not only yourself but for the next person that comes down the road. So they don't have to worry that there are 26 year old now and they have, you know, this label.

Karen Litzy:                   25:28                Yeah. He had this quote unquote disease. That is not all right. So is there anything else that from your perspective or for AAOMPT's perspective that we missed that you're like, you know, I really want, whether it be other physical therapists or healthcare providers, even the general public to know.

Elaine Lonnemann:       25:52                You know, I think it's important that I'm clear on this. I'm not saying that imaging isn't useful. Because you know, I've talked to us a little bit on the downside of it, you know, but in the absence of trauma or any other systemic medical concern, imaging studies aren't necessary for, you know, low back pain, a comprehensive medical exam is. So I think that's something that I would like to emphasize, but there are times when imaging is necessary and I don't want to come across as saying that, you know, we're downplaying it all the time because sometimes it certainly is necessary. But I think that, you know, the biggest thing that people don't understand is that these are common age related changes in the spine. They don't correlate with symptoms. You know, that's hard for the patients to understand and providers because we are so focused on finding, you know, some type of pain generating tissue as the cause, you know, so sometimes I'll share stories too with patients and say, you know, because they've now got this disease, they've got imaging, they've got findings and you have to kind of talk them off the ledge to a certain extent.

Elaine Lonnemann:       27:14                And I say, you know, if I had a group of 20 year olds, 120 year olds in a group, and then I have a group of 80 year olds, 180 year olds on, on the other side of the room and none of them have back pain. Now they may, probably 90% of us have back pain at some point in our life. But at this point in this room, none of them have back pain. But then if I sent them all into the MRI or imaging room, then 37% of those 20 year olds would come back with degenerative changes in there. There's fine or changes by positive findings and if you then look at the 80 year old group who then goes in and has the MRI, that number goes up to 96% so that kind of gives them a little bit of a balance. So I guess that's the other thing I would share, you know, just that these findings on imaging don't necessarily have to lead individuals to go down a path for riskier treatment options.

Karen Litzy:                   28:15                I think that's a great statistic. And thanks for sharing that because now that's something that if there are any therapists listening, they can kind of use those statistics to say, Hey, listen this is common as you get older. And I think, you know, the downfall that I can see from having this conversation with the patient is then the patient's saying, do you think it's all in my head?

Elaine Lonnemann:       28:40                Right. And that's what I emphasize. Yeah.

Karen Litzy:                   28:42                Oh, real. Yeah. That's why I'm glad that you said like, listen, your pain is here. It's real. You're experiencing this. This is not made up. But let's see if we can, like you said, follow these guidelines get you to move, do exercise, feel more comfortable in your body in order to help reduce your symptoms, reduce the pain. Cause I know, I mean when in my early days of explaining things like that to patients, I've had someone say so it's all in my head and I was like, Oh, that is not what I meant. I definitely screwed that up. And with experience you learn, right? You learn how to do that better. You learn how to relate to the patient. And the best thing to do, like you said, is to use stories and to use statistics and to use metaphors and things like that so that people can kind of understand where you're coming from. But yeah, that's the only downfall that I could think of. That devil's advocate here. Right?

Elaine Lonnemann:       29:41                Absolutely. Yeah. And I think as physical therapists we have to kind of get outside of ourselves. Yes, we know that pain is, you know, it may begin in the brain and the synapses and all of that, but do we really have to say that specifically to the patient? Can't we just say, you know, it's a normal, natural physiological response. You've had it, what you have is real and it's impacted by a lot of things. That's a complex issue. But what you have is real. And I have never argued, that was probably some of the best advice I learned in my fellowship training when the patient has pain. And this was way back when before a lot of the pain science research has come out. But when the patient says they have pain is their pain, that is what they have, you don't argue with them about that. You know, regardless of what type of physiological response you're seeing, what they have is real. And so, yeah, I do hear what you're saying about the downside of it. Yeah. They do have physiological changes, but pain is a complex matter.

Karen Litzy:                   30:43                Well, thank you for all of that info. And I think that this will definitely give therapists something to think about. It'll give therapists a great way to move forward with treatment. People now know how to access the clinical practice guidelines. And that leads me to the last question for you and that is knowing where you are now in your practice and in your life, what advice would you give to yourself as a new grad, fresh out of physical therapy school?

Elaine Lonnemann:       31:16                I would probably recommend to take more time to reflect on my patients. Not necessarily bringing them home, but to take a little more time to reflect on the things that they said personally related to their care. And also reflect on outcomes to a greater degree.

Karen Litzy:                   31:44                Great advice. I always say that I would like to go back to my patients in my early days and just, you're like, I'm sorry.

Karen Litzy:                   31:57                I mean, you know, I was doing the best I could with the information at the time. But you know, of course as you gain more knowledge, you gain more experience. You look back on things and you're like, Oh man, I could've done that better. But that is part of that reflection process. So you look back on patients and you reflect and you think, Hmm, you know, maybe I could've done X, Y and Z. So then the next patient comes along and you do better. So I think that's great advice. I love it. And yeah, where can people find more information about AAOMPT and more information about you if they have questions or anything like that?

Elaine Lonnemann:       32:30                Oh, absolutely. So, the AAOMPT website is and you can certainly email me. I'm happy to answer any questions or talk to you more about, the Academy of orthopedic manual physical therapy, APTA, where to find guidelines, research on low back pain. It's just something I'm very passionate about and always enjoy talking about and working with patients with as well.

Karen Litzy:                                           Awesome. Well thank you so much and thank you for coming on sharing all this info. I appreciate it. Everyone else, thank you so much for tuning in. Have a great couple of days and stay healthy, wealthy, and smart.

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!

Nov 25, 2019

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Eva Norman on the show to discuss her cash based physical therapy business.  Eva Norman, PT, DPT, CEEAA is the President and founder of Live Your Life Physical Therapy, LLC, 100% of cash-based business since 2013. It is the first mobile medical wellness practice in the country run by an inter-professional team of physical therapists, occupational therapists, speech language pathologists, personal trainers, acupuncturists, massage therapists, health coaches and dietitians dedicated to optimizing health by transforming lifestyles through innovative wellness, fitness, rehabilitative and preventative services. The company’s success can be attributed to standardizing an approach to develop a life-long client, transforming lifestyles through care collaboration, and mentoring and investing in their employees.

In this episode, we discuss:

-The shocking story behind how Eva was introduced to physical therapy as a teen

-How to attract and maintain patient flow with a mobile cash practice

-The benefits of virtual assistants for the operational side of business

-The importance of maintaining a connection with your network

-And so much more!


Live Your Life PT Website

Live Your Life PT Twitter

Live Your Life PT Facebook

Live Your Life PT Instagram

Eva Norman LinkedIn

APTA Private Practice Section

For more information on Eva:

Eva Norman, PT, DPT, CEEAA has been practicing physical therapy for nearly 20 years.  She received her B.S., M.S. and Doctor of Physical Therapy degree from Thomas Jefferson University in Philadelphia, PA. Through the years, Dr. Norman has practiced in different practice settings with patients of all ages with various diagnoses. Early on in her career she developed a strong interest in geriatric rehabilitation. To expand her skill set over the years she has taken numerous continuing education courses and also worked in the areas of neurology, orthopedics and cardiopulmonary rehabilitation. In 2013, she became a Certified Exercise Expert for the Aging Adult.

Dr. Norman, an active member of the American Physical Therapy Association since 1994, has served in numerous roles. She is currently serving as the MN Physical Therapy Association’s (MNPTA) Federal Affairs Liaison, MNPTA Delegate, and PT Political Action Committee Trustee Chair. She is a member of the private practice, home health, geriatric, health policy and neurology sections.

In January 2013, Eva founded Live Your Life Physical Therapy, LLC in response to her passionate desire to offer to her clients, patients, and the public, services both in home and the community that could help them to experience health, wellness, and a more active lifestyle throughout their life spans, through the creative applications of preventative and rehabilitative physical therapy, occupational therapy, speech therapy, personal training, acupuncture, massage, health coaching & dietary services.

Read the full transcript below:

Karen Litzy:                   00:01                Hi Eva, welcome to the podcast. I'm so excited to talk to you today. As a lot of people may not be familiar with your story quite yet, but those of my listeners who are know that we have a lot to talk about and we could've gone in a million different directions here from advocacy to APTA membership to the PT pac. I mean on and on and on. But what I really want to know, I'm being selfish here, would I really want to talk about is your business, so live your life, physical therapy. It's a really interesting business model, I think. I think and I hope that a lot of physical therapists will trend into your business model at some point. But before we get to that, can you tell us the story behind it? What is the why behind the company?

Eva Norman:                 00:57                Yeah, it's quite a long story, Karen. But yeah, that definitely will help you understand why the model is the way it is. So when I was 13 years old, I was involved in a hit and run accident. And actually this was actually the weekend before I was going to go trial. I was headed to nationals or I was trialing for the Olympics and swimming. And so it was pretty life changing. My coach said, don't just go do something fun. And so, ya know, I just don't really have the best balance and obviously hindsight's always 20, 20, I don't know what crops go roller skating with my girlfriend, but I did. And so I was literally going across this crosswalk and the 72 year old man who wasn't wearing his glasses that day and drinking, unfortunately instead of hitting the brakes at the accelerator right at the left side of my body, I'm pretty much fractured all my major bones in my left leg that I honestly referred to myself as road kill, to be honest, for a long time.

Eva Norman:                 01:56                And it was very, very traumatic. I was rushed to the hospital where I was told that we needed to amputate within 72 hours. Cause that's all of my ability that we had the femoral artery. There was just, I mean, just a really weak thready pulse. And I come from a family of healthcare professionals. My father's a physician and my mom's a surgical nurse and my team took me home. They told the doctor that they would respectfully disagreed with his conclusion, obviously the diagnostics that had been made and they were going to take me home and have me heal there. So, which is pretty, I know, right. And I just remember being hooked up to morphine and thinking like in shock, of course I'm still in shock, but I trusted my father, but I just remember thinking, okay, how's this going to go?

Eva Norman:                 02:47                And I remember the doctor saying, you realize you're leaving the hospital AMA. And my father's like, I perfectly understand that and I work here. So yes. And so they took me home, they converted our living room into a hospital. And, I was going to the hospital for outpatients though. So the one thing my father did ask, the surgeon is to order outpatient physical therapy because at the time, sadly, there wasn't home care for kids. And even today, as we all know, there's very limited. And so I went to outpatients. You're not even going to believe this, but I had anywhere from two to three times a week at non-weightbearing for nearly four months. This was years and years ago. And so, my parents essentially the range of motion through stretching do it, just retrograde massage, acupuncture, and honestly, incredible nutrition.

Eva Norman:                 03:49                So during this time, actually I got very depressed. As a matter of fact, I tried to commit suicide during this time. And so it was really dark hours, I'd have to say during my life. And I got really depressed when my father came home to tell us that our insurance had exhausted. And so you can imagine having two to three times a week of therapy for that long period of time. No wonder we reached our annual cut so quickly. And so, my dad asked the hospital if they could see me privately and they said, no, we don't do private pay. And, then my dad was like, well, do you know any other providers in the area that could do this? And they're like, no, we don't know anybody.

Eva Norman:                 04:34                So of course my dad literally opens up the yellow pages. Remember back in the day we had yellow pages and just calling anyone and everybody and couldn't find anybody. I mean he researched high and low. They couldn't find anyone outside of where we were from. We're actually from a little town called holiday for Pennsylvania and couldn't find anybody. And so he took the director of the rehab program there at the hospital to breakfast one day. And he asked her if she would consider coming. And the reason is because, you know, people have often asked me like, who is your physical therapist? To be honest, I don't remember. I still don't, it's very foggy. And I've actually looked into this that it was multiple people, but the person I did remember was Jean. So she was the director of the program. I'm not going to share her last name.

Eva Norman:                 05:22                Jean, if you're listening to this, hopefully someday you'll listen to this cause God knows you've heard my story before. But she is very modest and she's okay with me calling her Jean. But anyhow, I would love to share her name. I was interviewed and she said now just by first name and I'm like, okay, I want to share that because a lot of people want to know who she is. And so the person that I remember is her, cause I connected with her, she was in PR. She was honestly, my cheerleader walked in always the high fives would always give me hugs and I left. And so my dad took her to breakfast and begged her truly to come over and she said to my dad, you know, you realize I haven't touched a patient for two years.

Eva Norman:                 06:04                Like, why would you ask me? I'm like, the last person you would see your daughter, you know, and my dad's like, but she loves you. She's connected with you. And she thinks that physical therapy, you're the person she remembers. And so she just come over, you know, I don't know, just talk to her. I'm just worried. And, of course my dad shared with her about the fact that I was so depressed and so I think that's really what motivated to come over. And I don't really know that she knew what she was getting herself into, but that day was honestly very transformative. And I use that word there because it truly was, she gave me hope that day. I might get emotional here cause it is very emotional for me. But she came in and it's just this holistic approach that she had.

Eva Norman:                 06:49                The first thing she saw me, she said it was just this picture of depression. And she came over and gave me a hug and I honestly didn't want to let go. And, she's like, you know, she said to me, she goes, when was the last time you saw your friends? I'm like, it's been months and you know, it's been four months. My mom has me on isolation here. Essentially you're donning gloved right now because my mom's still afraid of infection. And she goes, no, I'm just, yeah. And she turned and looked at my mom's, of course, my parents are sitting there in the room and she said, you know, she needs social interaction. She needs people in her life and you know, is there any way, I mean, her friends could come over and gown and glove like I am.

Eva Norman:                 07:27                And it was at that moment, I think the light bulb went off in my mom's head. Like, what have I done? You know? And so my mom, my mom is like, you know, of course she's like, you know what, I'm going to call your best friend's parents today. We'll have them over for dinner. And of course, my mom's solution, everything was always food. So I had this big dinner that she, of course, Christmas staying for. And then the next thing you know, Jean asks me, she's like, your dad tells me you're not doing your schoolwork. And you know, it's all about like, you know, she's like, you love to read. Your dad says you don't even want to read anymore. And I said, Jean it's the concussion. Cause that's something I forgot to mention earlier that I had sustained a concussion.

Eva Norman:                 08:04                I'm having a hard time focusing. I'm still seeing double, you know, I'm just having a hard time concentrating and she goes, but you have the TV on. I said, I can listen. I just can't read. I just am having a really hard time with that. And she goes, well have you been doing your exercises? I think she assumed that the PT that I worked with gave you exercises and like no one's ever addressed it. No one's ever assessed it. I don't think anybody even knows that add one, except for the doctor that told me I had one. She goes, Oh my gosh. Then you could just tell by the look of her face. She was just livid. Like, gosh, how are we not addressed that? And she turns to my dad's, she goes books on tape. Remember back in the day we handle, yes. You know, that will be a great solution.

Eva Norman:                 08:45                You know, she's like, go. And of course my dad's like, Oh, library down the street, I will get every book imaginable. Great idea. So moving forward. Then the next thing she says, she's like, she's like, now I understand why I haven't been to church and do you actually went to our church? And she's like, I understand your mother doesn't want you leaving this house, literally these four walls. And because she's so afraid that you're going to, you know, obviously end up with an infection. And she said, but you know, I know sister's been calling here a lot and we've been praying for you. Like, I haven't wanted her to come over. And, you know, and it was just an, and I just remember at that moment, I mean, my parents had asked the same question and I finally admitted, I said, you know, I just feel like a failure.

Eva Norman:                 09:25                You know, they had just, you know, four months ago, they had this pep rally for me cause I was heading to nationals or I was going to try nationals again. And you know, I was just so happy about that. And I just honestly felt like I failed my town and my failed my school and who had, okay, there's so much time into me, like coming in, rooting me on everywhere, honestly. And, and so and she goes, no one cares about that. All right, let me be happy that your alive. And an amazing family. And she obviously was telling me everything, but you know, obviously I should be thinking, but I mean, that's really what it was, honestly eating away at me. And so, and I said, you know what, and she made me realize that that's just, that's not important.

Eva Norman:                 10:07                Right? And she goes, well, would you welcome communion? I mean, is that something important? And I honestly broke down at that moment because, you know, I really thought God had abandoned me. Just for her, just to even offer that. And so I welcomed it and she's like, well, you know, sister and I were going to have dinner tonight, so how about she come over tonight as well? So like I said, that day was just amazing for me. And so just knowing that sister would come over with really miss a lot. And so as you can tell, I mean, just even just with these few little things I have shared, I mean, it was just such a holistic approach. She hasn't even touched me yet, but yet cared about, social, my emotional wellbeing. And so then this next piece she was like, okay, today for therapy we're going to take a shower.

Eva Norman:                 10:54                Cause clearly we need one. And so she's asking me about like, where do you shower? I said, well, my mom washes my hair in the sink and then, you know, I sponge bathe in the bathroom, so where's your shower? And I go, well there's one in the basement. Went upstairs, but I can't do steps. And as she goes, why can't you do steps? And I said, well, my leg is just very unstable. And so, it obviously is very painful still. And, and she said, well, why couldn't you go up on your bottom? And I said, well, I don't know how to do that. Can I do that? I remember my dad, like I just remember he was interjecting was like, wait a minute, does this say for her? And she's not allowed to anyway. She's like, absolutely. And of course rolling her eyes again.

Eva Norman:                 11:32                How is it, my staff is not addressed this right? So don't we see that a lot in home care? Clinics don't even ask you like how many steps you have or where your bathroom is and so forth. So Jean shows me how to get up there. She has, my mom had her wrapped my leg, literally had my first shower on the second floor, I mean, in four months. Oh my God. And then I get into my bed for the first time in four months. And so now I'm just crying uncontrollably. I'm just so happy. And it truly, I honestly have hope for the first time. And,I remember her really close to me on the bed and she literally grabs me and like my two arms pretty firmly. And she looks at me like really close and she's like, yeah, Eva do you trust me?

Eva Norman:                 12:16                I go, Jean, I love you. Like, and I'm sorry and I'm going to get emotional right now. I'm like, of course I trust you. And she said like, why don't we have you back? She's like, well, we're not done yet. We haven't done exercise yet today. But she's like, I will be back. She's like, I want you to know is that you will walk some day. Do you believe me when I say that? Yes, I do. And this was, I mean, of course I've been told by, I mean we had had numerous specialists now, you know, had okay examined me and it was like conclusive apparently according to them. It wasn't scary. Oh, it was. And so that day was the start of a whole new life for me. And, I mean literally eight months later.

Eva Norman:                 13:03                Tell them this is the day I was walking with no deficits like in or anything, it really was amazing. He was coming anywhere from two to three times a week. But who did she bring along the way? She brought an OT. She brought a speech therapy because of my concussion, I also ended up with you have ADHD as a result. And I also worked with a dietician to work on my nutrition. I had massage because I had a lot of pain on my leg. Chris, I had mentioned it's an acupuncture earlier. So good luck even today at live your life. I was just thinking that is all said and done. My mom made. So I made two promises, went to my mom. Okay. My mom promised God that if I lived that we would give back. And so from that day, like literally my mom had me volunteering at every PT location, whether it was adult day program, LPP, clinic, you name it.

Eva Norman:                 14:06                I was there when I applied to PT school. I had 3,600 hours of volunteer hours. And that was all with my mom. And, then of course today you could see why it means so much to me to give back to them that I love so much and I'm obviously long story how I got into government affairs, but I think that honesty is the best way that I feel like I have to give back. And then, with regards to the promise that I made my father, my father made me promise it some day I would have a business where I could help others in similar situations. So it's very personal to me and obviously it's kinda been like this healthcare ministry in a sense to me. I'm very spiritual but it's just also just become this. Yeah, just something that I'm just so passionate about.

Eva Norman:                 14:50                And so I started out, so the company started with just physical therapy initially. It's because I would do what I knew best and what I felt comfortable with. And just so you know, by the way, Jean is still my life helped me get into PT school, had my first clinical with her. And the time I graduated, she has seven like thriving clinics all over Pennsylvania. I mean she's doing as she's teaching the last that she sold her businesses now teaching on a penny towards retirement but still doing amazing. And so now I feel like I'm somewhat following in her footsteps and so like it took a while though cause people always ask, they're like this is somebody that you obviously had this promise to make and cause I was afraid of failure to be honest.

Eva Norman:                 15:48                And it sadly took this horrible job to finally take the plunge to be honest. That's usually how it works though, right? And so, I'll never forget the day that then I left that job, which honestly was great day, but my husband said, you know, good for you because this is literally how the company started. And so we go to Buka is you know how they have like the table nets that are just, you know, okay you could with crayons, right. All over and so forth. And we wrote my business plan downstairs just on crayons and stuff. He wrote like generic little business plan but then coming up with the name. Right. So how did we come up with live your life? So I mean we had another sheet, all these words that were meaningful to us, right as a couple.

Eva Norman:                 16:35                We had thought of that cause we don't, we talked about the business for so long and Dan was so supportive of this and so, and I remember like, I mean they're literally words live like these words are everywhere, you know, in physical therapy. And I mean there's was just like live, well I remember there's all these different like verses, you know that I envisioned it so forth. And I'm not even kidding you, but I have to share this. Cause people always ask like, how did you finally come up with that? So we're sitting there and you know, there's music always jam and right. And sure enough, Rihanna comes on the side, live your life. And I'm like, and I literally called Paul walk at that moment, he was like business lawyer. I’m like file it right now.

Eva Norman:                 17:16                Like file it right now. We're not changing our buys like you know, and so we filed literally that day. So it's just such a great name. As we're putting the business plan together, of course this is something I had thought about for quite some time, but the common thread, cause I had been doing home care now at that point. I'm sorry for how many years I been doing at point 10 years. Yeah. At that point. That was almost seven years ago. January 2013. Yeah, I would say essentially open our door I think. But at that point, what I was most frustrated is with the, the noncommunicable diseases, right. From an unhealthy lifestyle. Such like retention, that diabetes, obesity of your RDCs, you know Karen, stroke, cancer, some of the things that truly, I mean that are honestly draining our healthcare system and we're going bankrupt as a result.

Eva Norman:                 18:21                And I'm like, so much of this can be prevented. And I'm so sick of seeing the vicious cycle again and again, repeat patients over and over and over again. I meant seeing them, you know, or it's the pneumonia with the hip fracture on and on and the multiple falls. So it's just this just crazy. I'm like, gosh, we had to do better. And I've always had such a passion for prevention, hence my background where I kind of brought in right. You know, just that holistic approach and just going well beyond just rehab. And so like every patient just prior to this was always going home with some type of what I would call a wellness program. And so I knew I wanted to go in that niche, but I wasn't sure kind of, you know, who to target. Right. And I should start small initially, but you know, I dunno, can I never go small?

Eva Norman:                 19:12                What are those things where you just go big or go right, So yeah, let's do the whole spectrum. Since my head said safe and they're like, okay, how about it? Because this all happened to me at 13 we go 13 end of life. Perfect. Let's start there. And it truly is 13 end of life by the way. Still today. So, okay, so that's our target market and then, okay, so who, and what are we going to target? I'm like everything, everything, every noncommunicable diseases, things that we can prevent, those are going to be, those are going to be like their target things. And so of course they started doing research throughout Minnesota to see where, what towns do we target. I mean it was amazing.

Eva Norman:                 19:53                I found out that like the city of Minnetonka has the most falls than any other city, which is not far from here. And I found that out by looking at the emergency room statistics, you know, so just started targeting like different cities based on, you know, some of that I'd been doing and done that was out there obviously for anyone to find. And so then I'm like, okay. And of course it was just me initially. Right. And I was thankful that I was doing my, it’s called a certified exercise expert for the aging adults certification around that same time. And, my lab partner happened to be a PT that wanted to go to cash based business. So it was like my first hire. It was great. And so because I quickly knew right away that I needed to have a backup cause I'm like, I'm never going to be going on vacation, you know?

Eva Norman:                 20:43                Okay. Right. And how am I going to be able to, you know, continue to grow and he was willing to be that back up who were great by the way. He is now these actually now in Chicago, and doing amazing things with his cash based business but regardless. So we started small, but then I was able to, through those connections and through the certification I was able to identify like all their physical therapists that kind of wanted to start cash based businesses. So targeted them. And then I started teaching at the different universities to connect with other professors, not necessarily wanting to hire students that the professors, because a lot of times they're paying for a part time work. Right. And I thought, yeah, let's target health and wellness professionals. So it was great to kind of, that's how it started and got made.

Eva Norman:                 21:36                So by the end of year one we had four PTs, one personal trainer and a dietician. And so, and it's not that I didn't want to, you know, third discipline, it's just that we couldn't find the right people. Right. That one perhaps like to be out in the community. But also that one to go you mentioned kind of area, right? Because it was NC state. I mean that was, you know, almost seven years ago. So back well defining terms in the house delegates.

Eva Norman:                 22:12                For OT and speech was difficult, but sure enough, a connecting. Like I said, it's all been through relationships to be honest. Everyone that I have hired, it's literally a friend. I know someone for your mom that will work well with you and I'll see. It's been great. I was just thinking about that as earlier today. Kind of, you know, just start team. We were just thinking, because I'm planning our Christmas party right now. Like, you know, there's eight individuals that have been with me since the beginning. There's 25 of us now, so seven PTs. We have one OT, one speech therapist, five personal trainers or massage therapists, a health coach, a dietician in for admin staff and myself. So 15 of those individuals are employees and 10 are contractors.

Karen Litzy:                   23:10                And so if we can just talk, I love the fact that you said you kind of did your research into different towns and tried to see what each one of those towns really needed. So when you are seeing your clients, you had mentioned your cash based, do you take any insurance at all? And so when you’re seeing patients more towards the end of their life, you know, a lot of them are Medicare beneficiaries and we had a little chat about this before we went on the air. So, and this is, I'm sure you get this question a lot. How are you seeing those people?

Eva Norman:                 23:45                Absolutely. Thank you for the question. So end of life would be a lot of patients that are receiving hospice care. So when I can think of end of life, unfortunately a lot of the hospice is in the area only. We'll cover two, maybe three visits at the most of physical therapy so that we have great relationships with all the hospice here in the twin cities. So they'll refer us. Cause a lot of times, you know, people are like, I don't want mom in bed. You know, I don't want her last days to be that. She loves to walk. She loves to, you know, go downstairs and spend time with the grandkids or whatever.

Eva Norman:                 24:33                So I want you to keep doing that. But I want a professional to help her do that safely. And given her medical, you know, history, you know, her medical complexities, right. Obviously. So, so they hire us. But of course sometimes it's not just physical therapy they may want, sometimes it's just, you know, sometimes they may want a massage because it's just soothing and comforting and so forth. Because they have, a lot of times they have pain and so forth. But sometimes, you know, they'll stop eating and they'll hire even our speech language pathologist to figure out, like, is there something that we could do perhaps to help stimulate the taste buds or give her perhaps mechanical soft diet or something as different type of diet perhaps to help her with eating.

Eva Norman:                 25:20                And then sometimes even to our dietician will get hired as well to pick up, how can we get enough calories? We have, and I'm really happy to say this, we have had 15 at this point, 15 clients outlive hospice due to our wellness program. Yeah. Remarkable. And so, Oh, how does it work? Right? Like how do people get into our system and how do we figure out. These are the disciplines that you need it. So, absolutely. So they'll call, they'll call, they'll call 'em. You know, we can call a number. So my admin by the way, are all virtual. They're all virtual assistants.

Eva Norman:                 26:06                So I have one person that literally takes the calls. So there is a series of questions that they get asked and we've actually created an algorithm. So based on how their answers are, you are headed, you know, you're obviously recommended certain different services. Now of course my admin isn't clinical so they don't make ultimate decisions, but they can kind of help start that conversation of where, you know, what they're thinking that perhaps they could benefit from. And so I take that algorithm, the results of that, and then I set up a telehealth free consultation. We do 30 minute free consultation because typically, I mean they have some questions and of course because it's cash, they should. And I open that conversation to like as many family members as they want. You'd be amazed. Like I'm, sometimes I have like the whole family because the family's paying this for mom.

Eva Norman:                 26:57                Or, you know, the son that's in New York. And then, another cousin that's really involved in Texas or whatever is, you know, is on the phone is on this call. So, that's why we've started to do tele-health, calls. They want to see who I am and obviously want to meet their therapist. And that's like a great opportunity to explain, okay, so according to our algorithm, these are the services that we feel that you would benefit from. So I kind of explain what those services exactly will do for them. And then prior to that conversation, I'm also packaging something for them, you know, depending on what we think would work best for that individual given what I already know about them, I try to package some things so that they know what it's going to cost them.

Eva Norman:                 27:43                They don't have to, there's no, we don't have any contracts or commitments they have to make, you know, it's obviously up to them. They can start in whenever they'd like and see us as frequently or not as frequently as they'd like. So it's really up to them. We make our recommendations, but ultimately they make the final decision. And we based that after assessments. Cause a lot of times like I'll give them kind of a ballpark of what I think it could be just based on, you know, other experiences with similar cases, you know, it's really going to come down to really determine what would be best.  We always think that way. And then at that point is really when we finalize the numbers as far as what that looks like.

Eva Norman:                 28:28                And they obviously will make some times their decision as far as what they want to do. But oftentimes they do want to meet. Like who would be the dietician, just want to see if that's a good fit for mom or dad, et cetera. But it's interesting how it's usually the sons and daughters that are hiring us. And you know, we do 13 to end of life, but I'd say the majority of our clients are over the age of 65 so the majority, but yet we have the full, we do like, I mean actually my youngest right now I do, I do have a 10 year old gymnast right now that's actually a professional gymnast that is trying for Olympics. So injury-free they’re amazing. And our oldest right now is 103 and on hospice, you know, people here in Minnesota live a long time. Amen. I'm going to have a hundred year olds for that matter. We have about 15 clients that are over the age of 90 right now.

Karen Litzy:                   29:42                So that's amazing. I mean I really liked this business model and I am a huge proponent of physical therapy being the forefront of wellness care because we're educated for it. We understand co-morbidities, we understand surgical procedures, past medical histories and how best to formulate a good plan of wellness for people. And I really, really feel that, you know, what you're doing in Minnesota is certainly something that can be replicated across the country. I mean, I always tell people like, Eva has a home care business in Minnesota. I mean, it's fricking cold there and there's no way. Like if she could do it, like anybody could do it. Everyone always asks, well, I don't know. I live here. Would I be able to do it? I'm like, let me tell you, yes, yes you can. You absolutely can. It just takes a little bit more work, you know, and it's a different mindset, right? Because you're all of a sudden going from in a clinic where people are just coming in one after the other to now you have to make up your schedule. You have to fill that schedule. It's not as, it's not like, I don't know about your practice, but I know with mine, like I got six new patients in the past week. Week and a half. That's a lot. You know, now in a regular clinic that might be like a day, but when you're going out to people's homes and they're paying you cash, that's a lot of new patients. So how do you guys deal with, you know, your new patient flow?

Eva Norman:                 31:09                Absolutely. Great question. And so, I have to tell you this year, this time of year, so it's fall and spring are our busiest times and I'll tell you kind of why. First of all, right now they're getting ready to head South for the winter. So they're trying to get themselves as strong as possible before the holidays because they want to go to Florida, Arizona or Texas don't make sense. And then in the spring it's those that had been sedentary on the couch all winter long and suddenly they come out in the spring and sure enough things are not working the way they hope to right. Because they haven't been moving. So that's where high season. So right now it's if a 10 grit, good question to ask. Cause we do have a waiting list. It's it honestly. But what happens with the waiting list? Cause I don't think that's good customer service.

Eva Norman:                 31:58                I ended up out in the fields. And so that's because a lot of times people ask me like, when do you add more PTs? Like when do you decide like you need to hire that next person. So when I get to the point where like three quarters of my week, I'm literally spending in the field, it's time to hire. And even just one week of that is like enough for me to say yes, it's time to hire an as a matter of fact work. We have a full time position right now. And I actually, I'm out now part time, but still I would say, but that's still a lot and I've been consistently that now for a while. So, yeah, we're actually down to final interviews. So I hope to have someone hopefully by next year. But that's kinda how we make that decision.

Eva Norman:                 32:43                Before, it used to be like three months consistently, but now I've known that if it stays that busy, especially this time of year, it generally stays the same. Oh, and I haven't really had anyone that I've been able to, like I've had to like, you know, go from full time to part time because essentially once we have them, I keep them busy. And that's one thing too. I should probably share what's also help at this model is that it's kind of a level playing field. There's no, I mean I have the bottom up management style. Like everyone has a voice here and so everyone contributes. Everybody has a project and so perhaps developing a wellness program around what they're passionate about. So we have probably about seven projects going on right now and so just the individuals that not everybody has to do it.

Eva Norman:                 33:33                But right now there's seven individuals that are developing programs around one is looking at cancer. One is looking at diabetes right now. One is looking specifically at dementia. One is looking at dementia, the other one's Parkinson's. And then we are looking at cardiac disease. Develop your like a cardiac rehab program for the community. Like for people they can't get to like the actual, you know, hospital for their cardiac rehab. And I think there's one other ends. Oh, concussions one on concussions. Huge. So those are kind of, I think that was seven. Does that sound like seven. But those are currently actively being utilized and we have multiple disciplines working on one project. So like for example, for like the dementia program, we have a personal trainer, we have an acupuncturist and a physical therapist working on that specific program.

Eva Norman:                 34:28                And so they meet regularly on their own time, might be doing their own zoom meetings as well and meeting so that's sometimes we'll fill in the gaps when we have ebbs and flows. Cause as we all know in cash base world, it ebbs and flows. So that fills in their gaps. And so they know that they're always going to be full. So when they have downtime, they work on their projects, they'll work on research, they'll meet everybody, also has a mentor that which they're required to meet with regularly. So they might meet with their mentor. And also everybody is required to be a part of the professional association and in their professional association. So that might mean, you know, doing committee work might be on their downtime or you might have been asked to put a presentation together.

Eva Norman:                 35:12                So they might be working on that. And you know, well up our time in so many different ways so it stays busy. So I share that because a lot of people say, well, what, what happens when there's downtime? So, but you know, all of that helps the business that leads to employee retention, professional growth in the course of the growth of the company. Which has been really one of the, I'd have to, one of the number one reasons why I think it's led to our success and our growth is because, we do empower them to essentially become these young entrepreneurs, right? And so many of them, you know, want to. So, so lot of times we do lose staff because what happens is they learn how to run their business and they go start their business. But I see that as success.

Eva Norman:                 35:57                They don't compete with us. As a matter of fact, they end up taking their own little niche and they refer and we refer back and forth, which is awesome. So, really it is hard though. That's so much time and energy into them and to see them as always are, don't get me wrong, but you know, it's always great when I go to conferences and I see, you know, my young, you know my employees, my young mentees, you know, they're doing amazing things. So it's always, feels great to see that. So, but yeah, so hopefully so back to you. I mean, I'm sorry that's like, but in a lot of different directions there, but, as far as you know, we have one of actually answering your question a little bit more specific.

Eva Norman:                 36:43                So we have this waiting list. But like I said, we have a dedicated, it actually monitors our schedules. You know, each professional actually has their own schedule and essentially schedules themselves. But when I say one, like if we see gaps, because they'll put, you know, if they want more patients, obviously you know, they'll put it on their schedules. Like I can take three X week. So she'll monitor that so that she knows of people in as people. And we broke up into four quadrants so for those who don't know cities, we essentially break it up into four quadrants. I'm down a new four 35 w and so we just try to keep people into your graphic areas so they're not driving all over because that's a real pain in the ass right when the snow comes down.

Eva Norman:                 37:33                Probably a good hour one way. Although you might be traveling that some days, you know, seriously someday. And it has been pretty bad. Like last winter was horrible. It would take you an hour to drive just 10 miles, which is horrible as well. So, she's great about, you know, in keeping me up to date too. So her and I kind of work together as far as making sure that we keep people busy and so forth. So we might need to be reading perhaps referral sources. Oh, some people were starting, you don't, perhaps numbers are lowering in some people's schedules and so forth. But I mean, generally to be honest, they stay so busy. Yeah, I can't say that we've ever had a point where I had to be worried.

Eva Norman:                 38:24                Like I always feel like there's more than enough that we can do and so on the projects too, our business and they get incentivized to bring in business so we bonus them and so forth. So, you know, people are, we really truly work very collaborative and well together to grow the business. As a matter of fact, one thing I should've mentioned earlier with this interprofessional team that we have established kind of, okay, how do we decide when disciplines come in? Like I need to have packaged something together for someone, you know, PT health coach or I'm sorry, PT, dietician. I think I mentioned speech therapist earlier with an hospice patient. So we meet once a week through zoom and we actually have a care conference while we go through some of these cases where we'll problem solve, you know, when can we bring in the next system?

Eva Norman:                 39:09                Cause sometimes we don't want to throw everybody all, first of all they're paying cash for that. But also it may not be the best, you know, obviously may not be the best approach. And so we talk through that, you know, as far as who would be best right now, you know, and so forth. Like we just, I have a lady right now that the doctor's recommending like steroid injections for her back, you know, and of course we hear that all the time. And so, okay. So my acupuncturist gets on, she's like, tell her all about me. I'm like, Oh, I already have, you know. And I'm like thinking you might be the next thing because she's ready to like literally go with the steroid injection and possibly an opioid because she is so much pain. But let's have you come in.

Eva Norman:                 39:46                And so, you know, we look at you, you know, sometimes one discipline may merge quickly just because of something like that coming up. So, you know, but again, we constantly communicate, we're taking notes, we share kind of even, you know, our notes that we take from care conferences. Sometimes I always say we need to eliminate sometimes let it marinate in the brain to see, okay, well Whoa, would work best perhaps or these patients, sometimes we need to really think that through. And depending on what's going on and perhaps finances to it and also the support or lack of support that they may be having. You know, and I think on, I'm very ethical to like, that's the other thing too, like if we feel that they can get a service covered elsewhere, we will share that with them. And we also try to help them figure out ways that they can get this covered. You know, there's a lot of associations out there. I don't know if you guys are aware that, you know, like for example, for a stroke, the national stroke association, both your local and national, they sometimes will have stipends out there for wellness dollars that you can actually apply for. So Parkinson's has done that stroke muscular dystrophy.

Eva Norman:                 40:53                Most of them are multiples, so we'll have them tap into those resources. If you're a veteran, sometimes the VA has, well, you know, dollars set aside for that. We've found, we actually worked with a purple heart recently that was given 30 wellness visits being purple hearts and purple hearts out there. Take note that you might have a great deal with your wellness. And then all set. I'm just thinking there's also been just even private insurance plans too that sometimes have dollars for memberships and so forth. We've been able to negotiate with them to get them to use those dollars for our services. So, which has been great. So a lot of times just picking the phone and asking that question, is this possible? So, and you know, they're, you know, they're frequently trying to reduce costs, right? They don't want them in the hospitals. So they obviously appreciate what we're trying to do.

Karen Litzy:                   41:44                That's great advice. I'm really glad that you brought that up. That there are resources out there that we can have our patients, we can help our patients tap into for financial resources. I think that's really important. Good, good, good. Very good. And now you had mentioned earlier that all of your assistants are virtual assistants. Where do you find your virtual assistants? Because I know that's a question that comes up all the time.

Eva Norman:                 42:12                So, okay. So my virtual assistants are all, let's see, they're either in school or their moms. And they work out of their homes. And so I know that there's been, I've heard that there's virtual assistants that you can get abroad and so forth and things like that. You know, I actually just recently looked into that and she even had an interview ironically today with a woman in the Philippines, which it could be very cost effective. And I was just thinking more for just, there's just a lot of busy work behind the scenes, you know, of course with many different businesses I could save a lot of time and they're very efficient and I was just surprised like how fast they type and put spreadsheets together or actually can update some of our reports and things and wow.

Eva Norman:                 42:57                This I think good. So, I dunno, it was actually, and she's very cost effective. So thinking about and haven't taken the plunge yet, but just like I said, learned about it recently and interviewed her today, but how do I find them? As I mentioned earlier that really works for us has come to me kind of handpicked from friends or they've reached out, you know, and they reached out because they heard about our company. And I have to tell you, even one of them is a previous clients, you know, that, you know, needed a job and you know, and it honestly was just the right time, you know, it was one of those things where it was, it was truly wonderful. She call it the right time because I couldn't believe that day I shouldn't say I was desperate, but I was at the point where like I wasn't finding what I was looking for and she literally, I could check off all the check boxes with her and I trusted her and I knew her. She was a client of mine and no longer a client of mine. So, and I knew she had a really strong work ethic and the hours would work perfect with her schedule. So, it just worked out.

Karen Litzy:                   44:04                I think it's great cause I think a lot of physical therapists don't think about using a virtual assistant and it can be an economical way to get stuff done. So I think it's great that, you know, we kind of have that conversation around that virtual assistant and how yes, they can answer your phones or yes they can. Do you know, things like that that you would think that no, it has to be in your clinic, but if you don't have a brick and mortar clinic, then you really have to get creative and that's obviously what you've done at live your life PT. Now, is there anything else that you have found in the building up of this company that you would say to someone, boy, if you have the chance to do this to help your company, I would do it. Does that make sense?

Eva Norman:                 44:59                Yes. Ah, goodness. Great question. Yeah, so you know, well, I should take you back to, you know, and also just some. Yeah, it definitely. I would say the one thing that I wish I would have done from the beginning that has helped so much since I started the business. So this would be for the new business owners I'm joining and I have to put in a plug here for the private practice section. I joined the private practice session a year into my business and I wish I had joined them prior to that would've been great cause then I, through that network of individuals, I actually ended up with two tremendous mentors that have helped me so much. When I first started out, I didn't really have a whole lot of money for all, you know, contract develop. I mean I had a lawyer and so forth, but I couldn't afford necessarily to have him generating all these contracts for me week after week after week.

Eva Norman:                 46:01                Cause I would just, you know, I ended up meeting a lot of contracts initially but was really great. Is that I found some tremendous mentors. And I'll name them Sandy Norby, Mark Anderson and Tim shell. I thank you. Thank you. Thank you for listening to this podcast. You guys seriously helped me. Tremendous. I mean save me thousands and thousands of dollars, just sharing what you already had. And just getting me going and just also giving me the confidence and I wish I had had that. I mean, I wish I had met them prior to starting the business, you know, cause then it would've been so hard because I think I was trying to reinvent the wheel and little did I know, like there was all these people that could help me, so I can't stress enough doing that. But then now, once I started the business as far as kind of what I would recommend is, you know, the Rolodex that I have.

Eva Norman:                 46:59                So one thing that I have to tell you, this phone has 7,000 contacts right now. Yes. I know guys. If you can too. All right. 7,000 and I'm not kidding you. And so I have organized it all beautifully. So I mean, anyone that I need, I literally put a profile together in their context. I labeled them based on her state, they're like their profession and how they can potentially help me. And so that has been huge. So because I mean, I go to so many conferences all over the country. I meet so many people and I'll just do that for PT. I do it for other professions that has been my saving grace. I've been able to find quality staff as a result. I've been introduced to, you know, perhaps, you know, corporations that I wouldn't normally have conversations with thanks to those connections.

Eva Norman:                 47:51                And so it's almost like, I mean, that's probably been the easiest marketing that I've had. And so, and it's amazing how I'll call up someone five years after the fact that I met them and they'll just remember just based on the little conversation that I wrote, like a little, you know, the little notes that I had. They're like, Oh yeah, I do remember you. You had that cash based business in Minnesota. How's that going? I'm like, Oh my gosh, you do remember me? And so, it's great cause then we'll jump into the conversation and suddenly we're doing business together. So that has helped a lot. And as a matter of fact, sometimes they become even clients themselves. And so, yeah, developing your Rolodex but really organizing it well so that you don't forget those conversations. Use that notes section and write down what that conversation entailed, how you think that person could help you in the future or today, that kind of thing.

Eva Norman:                 48:41                So that has helped. The honest thing I have to say to, you know, I'll put in a little plug cause as far as the marketing, you probably want to know too, you know, we don't do a whole lot. I'd have to say our website is one of the main things. But the other thing is, I joined BNI about five years ago. I don't know if you've heard of it. It's business network. At the time, I was the only physical therapist I've aligned to the United Minnesota, which I was really surprised cause when I read kind of what you know I was doing for other PTs across the country, I thought, well this is really hard to believe. And now of course there are more of, it's interesting how a lot of private practice section members have joined because I've also shared this with others.

Eva Norman:                 49:25                And that has also been a great network of individuals kind of outside of my profession, but be able to connect to like other dieticians, other massage therapists and have been able to also, get business that way and just develop those relationships. So I guess what I'm trying to say is don't be afraid to like join like, you know, organizations like that or the rotary club, things like that. Potentially you can develop relationships outside of your usual comfort zone to meet, you know, people out there that can connect you to perhaps people that can afford your business or connect you to those that do. So. Yeah. So I would say that that would be huge. And I wish someone would've told me that like until you know, two years my business that I started.

Karen Litzy:                   50:09                I mean what great advice and you know, what's the saying like your net worth is your network or your network makes up your net worth or something to that effect. And, that's essentially what, like you said, developing this Rolodex. I love the tips on adding notes into that. I'm going to remember that cause I don't do that and it's a great idea. A friend of mine that I used to play softball with asked me to join his BNI, which I think he's like doing a presentation in a couple of weeks. I'm going to try and catch it, but all amazing advice. And you know, I wanna thank you for being so open and honest about your story. I did not know any of that and that was very, gosh, I can't believe it if I'm being honest what an amazing journey you've had. And especially like, you'd never know it being as every time I see you at a conference, you're out dancing till two in the morning. So how is this possible?

Eva Norman:                 51:18                Oh, he's asked me like where does that come from? I'm like, well there's a story behind it. So yeah, I mean I deeply love it and I owe my life to it. So I mean I really can say that I owe my life to physical therapy.

Karen Litzy:                   51:28                Oh, what an amazing story. And the practice is great now. Where can people find more information about you and about the practice?

Eva Norman:                 51:37                Absolutely. So our website is a great place. But we're also on all the various social media facebook, Twitter, Pinterest, Instagram, LinkedIn, YouTube, well, a lot of different forms of social media. Let me think if anything else. No. And, and our website too, we actually have a weekly blog. And if there's anyone out there, by the way, that wants to be a guest blogger, please reach out to us. We're always looking for people to be a guest blogger for us, so we'd love that.

Karen Litzy:                   52:18                Awesome. And, you know, just for everyone listening, if you go to under this episode, we'll have all the links to the website and all the various social media handles and things like that. So, one click, we'll get you to live your life PT, to learn a little bit more about the model and hopefully more PTs can kind of step into this world. And now I feel like I have such a better understanding about what you do and so much more appreciation for what you're doing in Minnesota. I think it's great. So thanks so much, Eva, for coming on.

Eva Norman:                 52:56                Karen, thanks for having me.

Karen Litzy:                   52:57                And everyone, thank you so much for listening. Have a great couple of days and stay healthy, wealthy, and smart.


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Nov 18, 2019

LIVE from the Annual Private Practice Section Meeting in Orlando, Florida, I welcome Lynn Steffes on the show to discuss physical therapy consulting.  Lynn Steffes, PT, DPT is President/Consultant of Steffes & Associates a rehabilitation consulting serviced based in Wisconsin. She provides consulting services to rehab providers nation-wide.

In this episode, we discuss:

-How Lynn’s career evolved from treating clinician to consultant

-Common consultation inquiries and solutions regarding private practice

-Health and wellness advocacy within physical therapy

-The importance of building a strong network of experts within your field

-And so much more!



BrainyEX Website

Steffes and Associates Consulting Group 


For more information on Lynn:

Lynn Steffes, PT, DPT is President/Consultant of Steffes & Associates a rehabilitation consulting serviced based in Wisconsin. She provides consulting services to rehab providers nation-wide. Ms. Steffes’ is a 1981 graduate of Northwestern University. She is Network Administrator for a group of 50+ private practice clinics where her primary responsibilities include marketing, payer and provider relations and contract management. She currently serves as the state-wide Reimbursement Specialist for the Wisconsin & Florida Physical Therapy Assns.

In addition to her work as consultant, Ms. Steffes works as an adjunct faculty member in the physical therapy program at the University of Wisconsin, LaCrosse Physical Therapy Program, teaching professional referral relations, marketing and peer review. Lynn has addressed private practices, hospital systems, professional associations and therapy networks in forty states regarding Business Aspects of Physical Therapy. Ms. Steffes is active in her profession as a member of the American Physical Therapy Association (APTA) and the Private Practice Section of APTA. She chairs the PPS Task Force for Educational Outreach, is a member of the Impact Editorial Board & the PPS Educational Institute. She is also active in the Wisconsin Chapter of APTA – serving as the Chapter’s Reimbursement Specialist, and on the WI Medicaid Committee.


Read the full transcript below:

Karen Litzy:                   00:01                Hey everyone, welcome to the podcast. I am coming to you live from the private practice annual private practice section annual meeting in Orlando, Florida. And I have the distinct honor and privilege to be sitting here with Lynn Steffe's. And I know I have a lot of questions for her and we're going to get to a lot. But first, Lynn, can you just give the listeners a little bit more about where you are now with your business and what you're doing.

Lynn Steffes:                                         So thank you so much for having me, Karen. This is really fun and it's especially fun because it's absolutely gorgeous. So we're sitting outside and we have, I know I'm from Milwaukee and we have six inches of snow on the ground, so I am loving this, but, awesome opportunity to communicate with a lot of PT. So I actually, I feel like I kind of do a variety of things, but I have a singular mission and vision for that, which I do.

Lynn Steffes:                 00:53                And it's all really surrounding, the promotion of physical therapy as an important health care provider and service, not only in rehabilitation and healing of people, but actually in lifestyle medicine, being healthy. You have a dentist, you have a doctor, you have maybe an accountant or a massage therapist while you need a PT. And that's kind of me. So I promote physical therapy to all kinds of people. I teach at the university level, which I love. I speak all over the country. So I’ve had the privilege of speaking in 43 States, believe it or not. I do a lot of webinars, I do a lot of consulting and I work with practices as small as a guy where his mom does the billing when she feels like it. And I, by the way, don't recommend that.

Lynn Steffes:                 01:43                And then I also work with systems as large as Mayo clinic. So I have kind of a variety. And obviously when you graduated from physical therapy school, you were treating patients. And I know a lot of listeners here that are physical therapists. They graduate from PT school, they're seeing patients. And oftentimes, I know this is the way I felt when I graduated as well. This is what I'm just going to be doing. I'm going to be treating patients until I retire. I didn't have the foresight, I didn't have the knowledge to say, wait, there are other things I can do.

Karen Litzy:                                           So how did you go from treating patients to where you are now and at what point in your career did that shift happen?

Lynn Steffes:                 02:26                Wow, I wish I had some big strategic plan to share with you that I had like this vision, but I really didn't. When I graduated, I really did pediatric physical therapy. I graduated and worked for a private practice and I worked as a contract therapist in a school district and then moved on to a rehab facility and then opened outpatient pediatric clinics in a couple States. And I kind of, I love being a therapist. I always say, you know, I could still be a physical therapist if anyone would take me, but it's been awhile. But as I was treating, I was seeing all these opportunities for physical therapy and kind of just, getting more and more experience opening businesses. And it was weird because I actually worked in a private practice and I love treating people and I love managing, I loved, but really everything I was doing, but there was just a lot of it.

Lynn Steffes:                 03:20                And I think I started developing a little bit of an entrepreneurial, just like the sense that maybe I want to do some stuff on my own. I actually left the practice and interviewed with someone to become a pool therapist. And it was a PT I knew. And after I got done talking about everything I'd done, she was like, wow, Lynn. She was like, I can definitely sell you as a pool therapist, but I could, I'd love to sell you as a consultant. And I said, really? And she said, yeah. And I said, is there any reason I can't sell myself as a consultant? And she said, absolutely not. And that was kind of like this big aha moment for me. And I actually thought I would just like do a little bit of consulting until I found someplace I wanted to work and then I'd just take a job. I always assumed I wanted a job. And so I started consulting and it kind of became quickly a multiplier. And then I started thinking, well, I gotta look for a job. And I said to my husband, I gotta start looking for a job. And he said, I'm pretty sure you have a job. And it's consulting. And it's so funny because that was a long time ago, over 20 years ago. And I still love it.

Karen Litzy:                   04:27                And isn't it amazing that so often it takes that person outside of ourselves, even maybe outside your family or even personal friend group to say, what are you doing? Like you can do this. So what's interesting is you needed that person to give you the push. And now in your work you're giving other people the push.

Lynn Steffes:                 04:48                You know, I feel, I do, I feel super excited when I meet clinicians. And some of them are very young and some are also people who are kind of getting to a point in their career where they're looking for something else. I feel super excited when they want to do consulting. Number one. I think there's so much work to be done in, I don't feel like a sense of competition. I'm just like thrilled that people are getting into promoting what we do and being a multiplier. I think of a consultant as a multiplier. I think like if a practice comes to me and they wanted to start, for example, you know, a running program, Oh my God, I've already worked with seven practices that have started running programs. Somebody comes to me and they want to revise their compensation plan. I can, you know, it's like I kind of become a repository for everybody's experience. I would say I'm a kid in a candy store and as I travel I like gather up wonderful people and just a lot of cool stuff that people do.

Karen Litzy:                   05:52                And so what would you say are the people coming to you for your work as a consultant? What are the most common things that you are seeing that people are like, Hey, we really need help with this?

Lynn Steffes:                 06:04                Well, I feel like everybody needs help with revenue and so anything to do with like marketing promotion, they need help with payer contracting and dealing with third party payers who seem to want to put up roadblocks all the time. And I just have, I have a unique, you know, perspective on that and I've worked with third party payers and I feel like I just am marketing to third party payers. I feel like people come when they look at, you know, how are we going to grow and how are we going to grow in the revenue? And I tap on the shoulder also and go, Hey, yet look at your expenses too. I feel like that's a big thing. I also think compliance, I think we're so burdened and so I try to work with people on what they need to do, but I do it in a different way than a lot of people. I think a lot of people are like into what I call the scary complaints. Like, Oh, you're going to get in trouble. And I do mention that, but I also look at people and I say, you know what, you need to communicate your value in a better way. And if we did that, we'd be in better shape. So that's kind of a variety. Starting cash programs is super fun.

Karen Litzy:                   07:16                And do you mean cash programs within a traditional therapy clinics? So for people listening, there are a traditional clinics, I guess we can categorize them as such that are, they take your insurance. So if you call up a clinic and you say, I have blue cross blue shield, do they take it? Yes. Great. So when you say you help with cash programs, is that within a traditional clinic or within like an out of network or do you help establish a cash practice?

Lynn Steffes:                 07:45                Both. So I feel like there are people who do, they're excellent young therapists, consultants who have developed cash based programs and who, that's all they really talk about. And so I definitely work with a lot of hybrid practices. So practices that have one foot on the dock where you know, the third party payment environment is and one foot in cash base and they're developing other programs. Sometimes I'm working with people that are all cash. Sometimes I refer them to people that are focused on all cash. I also think like, I think we've kind of only just begun in the services we're providing that would just third party payer covered is so limited for PT and there's so much we can do if we just are willing to collect money.

Karen Litzy:                   08:33                And, you know, I think in a traditional therapy setting, I think because physical therapy is always associated with the healthcare system, with the physician, we used to always need a physician referral. So the public's expectation is we take insurance because no one would ever go to a massage therapist, a personal trainer, Pilates or yoga and expect them to be covered by their insurance.

Lynn Steffes:                 08:56                I completely agree. But I have this thought. First of all, I'm just going to say out loud and I hope it’s not offending anyone, but I don't like dentists because I just don't like people messing around in my mouth. But I think dentists have figured it out. They have 100%. I feel like physical therapy as a profession has to grow up to be more like the dental profession. I mean, you know, a hundred years ago, dentists, like basically you saw them when you had to have a tooth knocked out and they were kind of that provider of last resort. They, they really were, a last resort kind of provider. And they have evolved being an amazing healthcare provider. They do prevention, they do treatment, they have specialties, they do cosmetics, they do performance. So there's so many things that are parallel, and I don't know about you, but when I go to the dentist, when I walk in and have something done, they tell me, well, this is what your insurance covers and this is not.

Karen Litzy:                   09:49                Yeah. And I don't have any dental coverage, but guess what I still do every year I go to the dentist. And PT is, so some of it is the consumer mentality. Like I paid a premium, it should cover PT, I don't doubt that. But a lot of people have dental insurance and they still pay for other things. I think some of it is awesome.

Lynn Steffes:                 10:11                It's a mindset shift that we have to have. We have to say this is what your plan covers and these are other services that would benefit you that we recommend. So a lot of times that I'm promoting a program, like for example, the annual PT physical or I'm very interested in lifestyle medicine and brain health and the kind of things people go, well, which insurances cover it? And it's like, okay, that shouldn't be your first question. The first question should be, would this bring value to my patients and my community? And if it does, is there something that's paid that's an inappropriate question but not like who's going to cover in it and if it's not covered.

Lynn Steffes:                 10:44                So some of the mentality shift is our own paradigm. So yeah, and I think there does need to be that shift of this is my expertise, this is what I offer looking around in my community. Would they benefit from XYZ program, a program on brain health, which I know, you have, right? So is this something my community would like because it's not about us. We have to be worried about the end user, which is our client, our patient, however you want to, whatever kind of word you want to put for them. But I do think that from a profession wide standpoint, that that needs to shift. And I think if it can shift, I think you're right, you'd be seeing a lot more hybrid practices where yeah, maybe you take insurance, but you have a brain health, you have a vestibular program, you have a wellness program that can happen. And I think that's where, I mean I totally think there is a 100% place for all cash or all third party. But I think we all kind of went in with more of a hybrid idea.

Lynn Steffes:                 11:54                We would be able to leverage what insurance pays for our patients. And honestly, a lot of people don't want to do insurance cause they say, well it limits the number of visits. Well guess what? If it limits the number of visits, you still can do cash outside of that. You know what I mean? Like I'm always like, why can't we see that? And so it's interesting that I study like dental marketing and dental operations as a way of just having insight into a different provider even though they're not my favorite healthcare provider. So yeah, I think it's really interesting.

Karen Litzy:                   12:28                And what advice would you have for someone listening who maybe wants to start shifting their practice? Going from being a treating physician, from being a treating physical therapist or physician or nurse practitioner or even a dentist. So how could they go from a full time treatment to consulting? Like, do you have to take extra classes? Do you need certifications? Do you, you know, all that kind of real practical stuff.

Lynn Steffes:                 13:00                All right. So really good question. Well, I think first it's a self examination of like what are you good at, passionate about, interested in, and a willingness to share. And, you know, when I first became a consultant I thought I had to know everything and I just realized I just have to like know enough and I have to know, I have to ask you questions so that I can learn what you need and then partner with you to create that to happen. So as a consultant, I did go take additional courses. I took courses through the small business administration through our local college. We have a local women's college that has a business and evening business series. I did some of that. I talked to other consultants and actually I find that, you know, sometimes people come to me and they'll say they want to be a consultant and then I'll have a conversation with them and I'm kind of like, Hmm, okay.

Lynn Steffes:                 13:48                There's a couple of things you need to do, and you need to listen. I feel like that's hard. I think some people think they just want to tell people what to do, but you kinda gotta listen to what they want and be able to do some diagnostics. I think, getting hands on experience, as much book knowledge and classes as you take in all of that, unless you can relate to somebody's problems and say, yeah, I was kind of bad at that and I learned how to do it. Or, this is where I was and here are the steps. I just feel like that that would be a struggle. So I think getting hands on experience. If you're working in a facility or practice, Hey, volunteer to run a project, get on a committee, take the lead, asked to be involved in interviews, asked to be the marketing person, asked to work with your billing and payment, get involved in the association because I've gotten a ton of contacts and I also, like, I always say it like if I'm the smartest person I talked to all day, that's not good.

Lynn Steffes:                 14:48                So I know so many people that are so smart, I feel like I can pick up the phone and call them. So they're multipliers for what I'm able to help people with. I think there are steps in a big thing is hands-on, firsthand experience. Another thing is goal lists. Go take some extra classes, do some reading, but work with experienced people and kind of stick your neck out. I've been consulting for over 20 years and people will call me and say, Hey listen, I got this project, do you do this? And I'm like, you know, yeah, I guess I do, but I haven't done it before but it sounds like fun and if I'm in too deep I just call people.

Karen Litzy:                   15:27                Yeah. That's great. So kind of look for those mentors or friends or like you said, colleagues, people in, I mean we're here at PPS, so it might be people at PPS, it might be your neighbor, it might be, I always say to like, don't overlook your family and your friends because there's a wealth of knowledge there as well. I always tend to look out and I'm like, Oh, what about the person right in front of me who knows how to do X, Y, Z, why am I not asking them?

Lynn Steffes:                 15:51                Well, it's funny because I was working with a practice that wanted to work with more personal injury attorneys and those kinds of patients. That was something they were interested in doing. And I'm very skilled practitioner in working on spine and cervical issues. I thought, you know, this is a good fit. And he's like, I just don't know how to do it. And so I was like, okay, I know of someone who knows, you know, was an injury attorney who I respected and I just contacted her and I paid her for a couple hours and I interviewed her and spend time with her. Just going through like, what did you want? What's important? All kinds of stuff. What about communications? What is, you know, what would discourage you from using a provider? How do you decide who's a prefered? And it was weird because as soon as the interview was done, it wasn't cheap, but it was so worth it. And she kind of said to me, she goes, you know, I need some good PTs. The more I ask, the more I talked to you, the more I realized like, I know what I need and I don't know if I know who it is. And so it's funny that you know, there are a lot of resources out there.

Karen Litzy:                   16:55                Yeah. And so from what I'm hearing is one, don't be shy, can't be shy. Don't be shy too. Don't worry if you don't know everything right now because you can learn it in a short amount of time. And this sounds so crazy coming from me as I'm interviewing you, but I love the idea of interviewing people, but I didn't, I don't know why I never even thought of that before to say why don't really know this, but I know this person does. So let's have a formal interview. Not just like a one or two emails, but really take, like you said, take the time, pay for the time if you need to so that you can really understand what that person needs to help your upcoming client like as you can. I guess you can always do the research so we don't just have to stick to things that we think we know we can expand.

Lynn Steffes:                 17:45                Well, and I think as a PT, I remember as a young PT had a patient once that had a child with osteogenesis imperfecta and I'd never seen it before. I was getting a referral for it and I was like, okay, I don't know what I'm doing. So I just like went on the web and look for a PT that treated that. I found someone out at NIH, national Institute of health. I sent her an email and we set up a call and I went through everything. She sent me her protocols. It was like, and I just realized PTs are such incredibly generous people. A lot of people are generous. PTs are exceptionally generous with that. And that kind of taught me like, Hey, don't be afraid to admit you don't know. I have worked with or had exposure to people have worked with consultants who kind of know what all is.

Lynn Steffes:                 18:35                And at some level people are like, Oh, we're really excited about them. But it doesn't create long term relationships if you don't say, Hey, that's a good question, let's figure it out. You know? So I don't know. I don't have all the answers, but I sure love the questions. You know, I love that. Love it. That should be like my motto for life. I don't really have any answers, but I love to have lots of answers. But I think what struck me from what you just said, is that we can use our skills as physical therapists. We know how to research, we know how to look up diagnoses and treatments and protocols so we can take those skills and transfer them into consultancy skills. Oh my God. So what I have as a process, when I work with practices, I call differential diagnosis.

Lynn Steffes:                 19:27                For your practice. And I basically do diagnostics and then I have a hypothesis and then I write a plan. Then I work on implementing the plan and then we stop and measure and we figure out what's working and what isn't. And of course there are plans just like there are a few, if you treat a lot of knees, you have certain plans you use that usually work. And so over time you kind of accumulate solutions. But I still customize. I think some people like the canned solutions and it probably is more cost effective, but I still like working one on one.

Karen Litzy:                                           I think this is great. Thank you so much. I'm like learning so much here. It seems like your career keeps evolving. Do you have anything coming up that's kind of different than what you're doing?

Lynn Steffes:                 20:15                Wow, that's a really good question. First of all, thank you for giving me opportunity to talk about this stuff, but so I have a really big birthday coming next week and I don't need to share the number but it's a pretty big one and a lot of my friends are retiring and I'm always kind of like, what am I going to do next? I'm still, I don't know, I don't know, I just the way I am, but I have been working in the area of brain health for awhile and, and have a signature turnkey brain health program and I have two. I have one thing I want to do with that program and that is to very specifically, instead of just going into the PT market with it, I want to actually start approaching active senior centers and working with their activity people and their exercise and fitness people.

Lynn Steffes:                 21:07                Because I think the active senior centers have all the tools. They have all the mechanism, they have this captive audience but they don't connect the dots, which is how cognition and wellness fit. So that's something fun I want to do with brainiacs. And then the other thing is I really want to continue to push lifestyle medicine and PT and I want to connect with other like-minded PTs. There was a young PT that I'm kind of that's just starting out. I want to mentor her. She is very interested in lifestyle medicine and exercise and how it relates specifically to anxiety and depression. I feel like we have so many opportunities we haven't even tried to do. And so this year I came out early to go to lifestyle medicine conference, which was next, which was early. Yeah, it was on the front end. So how perfect. But next year I want to be talking at it.

Karen Litzy:                   21:52                Perfect. We'll get that pitch in there and talk at it. That's awesome. And I have one more question that I ask everyone, but before we get to that, if you can talk a little bit more about just the basics of the foundations of the brainiacs program, just because you'd mentioned it and I just want people to understand what that is.

Lynn Steffes:                 22:21                Sure. So I have always, you know, as a peds therapist and adult neuro therapists, I've always been into brain neurology and the flexibility and the adaptability and really the plasticity of the human brain. And I've seen back in the day when we didn't think anything could change after childhood, I saw it could. And so I was always kind of like, yeah, we don't know everything. And now we know much more. But unfortunately my parents both passed from Alzheimer's disease. And so when that happens, when you have two parents diagnosed, it kind of scares you. And so I started doing research on brain health and what the literature showed and it's very clear that, you know, prevention, mitigation, and cognitive fitness and health is not just a learning and study and you know, read a book to us to do code. It really is a physiological thing. And exercise probably has the strongest evidence. And so I started a turnkey program and with the basis of it BrainyEx.

Lynn Steffes:                 23:24                And prescribed exercise at a certain level of walk around. The block is nice, but it doesn't really do the whole job. And so how to prescribe and train someone to, you know, extra as at a proper level. And then I also added health and wellness education that's evidenced based too, it's nutrition, sleep hygiene, stress management, activity management, socialization. And so PTs, we're constantly doing patient education where we're like perfectly suited to do 100% instead of having people come and sit in a class, I'm like, okay, let's work out and teach. And so it's been pretty fun. I have clinics in 13 States doing it now, which I love.

Karen Litzy:                   24:01                Yeah, that's awesome. We'll have a link to that on the website at if people want to find out more information because people aren't getting any younger in this country. And so it's really important and you're right, PT's I think are ideally positioned to be the ones to work with that population. So excellent program. Now, the question that I ask everyone, this is the last question. I probably should have prefaced this to you beforehand, but knowing where you are now in your business and in your life, what advice would you give to yourself as a new grad out of PT school?

Lynn Steffes:                 24:42                That is such a good question. I honestly, it's weird because I don't think my expectations were high enough as a new grad. I get that. And I think similar to what you said, that everybody graduates from PT school and you kind of think you're going to be a PT and I love being a PT and PT is such an incredible profession, but I never dreamed I would be traveling across the country writing chapters to books, developing my own programs, having an opportunity to speak in front of hundreds of PTs teaching at the university. I never thought of all the possibilities. So I guess as a PT I would say like open your eyes and look not only for what you can do one on one with patients, which is incredibly important, but look for opportunities that multiply our profession. And I think I would've told myself earlier on, like I feel like I started early doing it, but I still think I could have even had the vision earlier and you know, and just ask people for help. I love it when people come to me and say, this is something I want to do. Will you help me? I feel like it's an honor, you know?

Karen Litzy:                   25:59                Great, great advice. So great advice for all those students in school and just graduating from PT school or really any programs. So thanks so much. Where can people find you?

Lynn Steffes:                 26:09                So I have a website, and I also have a website for my brain health program, You can always find me at all the meetings.

Karen Litzy:                   26:29                Very true. So Lynn, thank you so much. And just so everyone knows, we'll have links to everything in the show notes for this podcast on the website So Lynn, thank you so much for taking the time out at a PPS and enjoying sitting outside in Orlando before both of us have to go back to our cold places. At least New York doesn't have snow yet.

Lynn Steffes:                                         Yeah, we have snow. Hopefully it'll build. Thank you, Karen. You do a great job of, I think sharing a lot of good information and talking to people who are thought leaders and people who have different ideas. And I think that's pretty important.

Karen Litzy:                                           Thank you so much. And everyone listening, thanks so much for listening. Have a great couple of days and stay healthy, wealthy, and smart.


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Nov 11, 2019

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Shelly Prosko on the show to discuss compassion in healthcare. Shelly is a physiotherapist, yoga therapist, educator and pioneer of PhysioYoga with over 20 years of experience integrating yoga into rehabilitation with a focus on helping people suffering from persistent pain, pelvic health conditions and professional burnout. She guest lectures at yoga and physiotherapy programs, presents at medical and yoga therapy conferences globally, provides mentorship to health providers, and offers onsite and online continuing education courses for yoga and health professionals. Shelly is a Pain Care U Yoga Trainer and maintains a clinical practice in Sylvan Lake, Canada. She is co-editor of the book Yoga and Science in Pain Care: Treating the Person in Pain.

In this episode, we discuss:

-Can compassion be trained?

-The six elements of Halifax’s model of enactive compassion

-Empathic distress, compassion fatigue and burnout among healthcare practitioners

-The five facets of comprehensive compassionate pain care

-And so much more!



Shelly Prosko Twitter 

Shelly Prosko Instagram 

Prosko PhysioYoga Therapy Facebook

Shelly Prosko Youtube

Shelly Prosko Vimeo

Physio Yoga Website

Yoga and Science in Pain Care: Treating the Person in Pain


For more information on Shelly:

Shelly Prosko, PT, C-IAYT, CPI, is a Canadian physiotherapist, yoga therapist, author, speaker and educator dedicated to empowering individuals to create and sustain meaningful lives by teaching and advocating for the integration of yoga into modern healthcare. She is a respected pioneer of PhysioYoga, a combination of physiotherapy and yoga.

Shelly guest lectures at medical colleges, teaches at yoga therapy schools and yoga teacher trainings, speaks internationally at yoga therapy and medical conferences, contributes to academic research, provides mentorship to healthcare professionals and offers onsite and online continuing education courses for yoga and healthcare professionals on topics surrounding chronic pain, pelvic health, compassion and professional burnout. Her courses and retreats are highly sought after and have been well received by many physiotherapists, yoga professionals and other healthcare providers. She is a Pain Care Yoga Trainer and has contributed to book chapters and is co-editor and co-author of the textbook Yoga and Science in Pain Care: Treating the Person in Pain by Singing Dragon Publishers.

Shelly is a University of Saskatchewan graduate and has extensive training in yoga therapy and numerous specialty areas with over 20 years of experience integrating yoga therapy into rehabilitation and wellness care. She considers herself a lifelong student and emphasizes the immense value gained from clinical experience and learning from her patients, the professionals she teaches and the colleagues with which she collaborates. She maintains a clinical practice in Sylvan Lake, Canada and mentors professionals who are interested in pursuing this integrative path.

In addition to her many skills as a healthcare practitioner, Shelly is also an accomplished figure skater and has traveled the world with many professional ice shows. She is passionate about music, dance and spending quality time with family and friends. Shelly believes that meaningful connections, spending time in nature and sharing joy can be powerful contributors to healing and well-being.

Please visit for more info and resources.


Read the full transcript below:

Karen Litzy:                   00:01                Hey Shelly, welcome to the podcast. I am excited to have you on. This is going to be fun today.

Shelly Prosko:               00:07                Thank you for having me. Really excited to talk about this.

Karen Litzy:                   00:11                So I spoke to your coauthor Neil a couple of weeks ago, talking about your book, yoga science and yoga and science and pain care, treating the person in pain. And I'm really excited to dig into sort of your writing within this book because you are writing about compassion. So before we get into the nitty gritty, what is compassion? How do you define it?

Shelly Prosko:               00:41                So believe it or not, there actually is not one agreed upon definition. So that's the first thing is some people describe it as a trait. Others say it's more of an emotion. Some people say it's like a motivation or behavior. But the definition that I use in my chapter is the one that is kind of the working definition that the leading compassion researchers use in the Oxford handbook of compassion science. So that's kind of like the compendium, the Bible of all the thought leaders and researchers around compassion. So that definition, the working definition there is basically compassion is first and foremost. You have to be able to recognize that someone is suffering or struggling or in need. And then the second component is then we have to have the motivation to want to do something about it to alleviate or to help. So basically recognizing the suffering with the motivation to relieve and that is not just us and someone else that's also within ourselves. So compassion also includes the self compassion piece and that is I think really important for us to keep in mind.

Karen Litzy:                   01:56                Yeah, I was going to say, and would you say that having compassion for yourself allows you to be more compassionate towards others? Do you feel like it's a prerequisite for compassion as a healthcare provider?

Shelly Prosko:               02:13                That's a really good question. From my perspective, I think it helps. The more self-compassion we have, the more compassionate we can be for others. But the research is kind of right now from what I've been reading, actually, I just listened to a recent podcast a couple of days ago and with a couple of the leading researchers. And there still is no really solid evidence that increasing self-compassion translates to increased compassion for others or that increasing compassion for others translates to increased self-compassion. That said, there is some research that shows cultivating self-compassion does seem to help increase compassion for others. So we have a bit of research that says that. And my own personal view would be yes, I don't know if it's a prerequisite, but I have noticed in my own self without making this like a therapy session, I have noticed that I scored quite low on self-compassion and I have traditionally been quite, you know, self critical and hard on myself. But as I've learned more about this stuff and practicing self compassion, what that is and, and exploring it and experiencing it, I feel like I overall am just understanding more of what compassion is. And I feel like maybe I'm, you know, more compassionate. It could be just age and stuff too and experience, but that'd be my answer to that.

Karen Litzy:                   03:46                And why is compassion important in the care of people in pain? So how does it benefit me as a healthcare provider to understand compassion? When I'm working with people in pain.

Shelly Prosko:               04:02                Yeah. So I just want to be clear that sometimes people equate, you know, just being compassionate, they just equate that to being kind, you know, and it's just should be common sense and just don't be a jerk. You know, a lot of people just say, well just, it's not that hard. But, you know, there it is a little more nuanced than that. And just going back to your question on, you know, what are some of the benefits if we actually look at the, the deeper layers of compassion and which I can get into a little bit there later, but the components that go into offering compassion and also self compassion towards, you know, yourself. Lot of the research shows, I mean, stuff that we're not probably really surprised at. Like it can increase quality of care for our patients, increase patient outcomes, increase patient satisfaction, increase therapeutic Alliance, and increased patient self care.

Shelly Prosko:               05:04                So I want to just briefly talk about this cause I think it's really important and we don't think about this part of compassion, but there's this one study that I talk about in the book chapter and it was an entire year long. It was in an integrative rehab hospital and it showed there was a hundred women who are living with chronic pain and it showed that it was only once these women actually experienced what it was like to be loved, cared for, to be seen, to be heard. In other words, to have actually to receive compassionate care. Only then could they take active steps towards their own self care, which I think is really important in pain care because so often we talk about how important it is for our patients to play an active role in their pain care. We're always talking about that.

Shelly Prosko:               05:55                The literature says that we're trying to help our patients make healthier choices, et cetera. And now we have some research that says, well, you know what, if we provide this very in depth, nuanced, compassionate care, it looks like people that are patients are then more likely to, you know, better make better choices. And it's neat. Some of the women, what they were saying, things like they felt worthy, they felt loved and yeah, worthy enough to be cared for. And I just think all of that is so fascinating. So those are some of the, you know, the benefits to providing compassionate care, but there's also benefits to us as the healthcare provider. So what some of the research is showing is that it can actually help protect against burnout.

Shelly Prosko:               06:51                We can dive into that a little bit later too in some of the myths, you know, around too much compassion. But, you know and also just overall the positive health outcomes are increased in us as the health care provider and even things like reduced anxiety, depression, even stuff like reduced medical costs and errors and malpractice claims. Like this is just what all the research is saying. But then I think the other part of it that I do want to really highlight is the self compassion piece. So there is benefit for the person in pain to practice self compassion is what some of the research is showing us now and there is also benefit for us as the healthcare provider to practice self compassion. And again some of that for us as a healthcare provider is like reducing burnout, reducing excessive empathy, which they're calling, you know, empathic distress or empathy key things like that.

Shelly Prosko:               07:49                It helping us improve our emotional resiliency and like we said, potentially even increased concern for others, but in the patient, and this is what I thought was so fascinating as of now, I think there's only about five or six studies out there, but they do show that people in pain that either have higher self compassion or some of the studies actually show people in pain. Doing these self compassion practices actually can show reduced pain severity, reduced anger, reduced psychological distress or things like depression, anxiety and even increased pain acceptance. You know, we know there's some benefits. Especially with the ACT, acceptance commitment therapy research, we're starting to see how that's important and, you know, there's even some links to reduce pain catastrophization and rumination and decreased fear avoidance behaviors. And it's just really fascinating. And I think, just the last bit here on that, on that question is increased self-compassion has been shown to reduce our own self criticism and increase our motivation to actually change our behaviors.

Karen Litzy:                   09:02                We're just talking today, Nisha mind who's a psychiatrist. And we were just saying, man, how hard it is to change behaviors for human beings. Cause she was talking, she has a dog. And how with a dog, you know, you can change behaviors by motivating them through food. So they have these incentives or incentivize through food. Humans, it's a little bit harder how difficult it is to change behavior in a human being. So now if compassion and practicing self-compassion can help with behavior change, how do we change compassion? I mean, how do we train compassion? Can we train it?

Shelly Prosko:               09:47                Yeah. So the literature says yes, it is trainable and we have quite a bit now and there's different programs and different styles. And I think, you know, there's a lot of different models and I think probably just to make it easiest for us here as I'll talk through this one model that I really like. It's Joan Halifax and she's an anthropologist and a meditation teacher and a few other things. But she has a really nice model of inactive compassion. And what she talks about is, you know how I said the definition of compassion was in recognizing the suffering first and then having the motivation to alleviate it. She actually goes beyond this and she says that definition's a little bit limiting because compassion is actually more of a dynamic emergent process. So it's more of a wisdom that emerges within the context of the environment that we're in, which makes sense.

Shelly Prosko:               10:53                If you know anything about systems theory or emergent theory and you know, so if we're in a room together with our patient, you've got the patient not person in everything, they're dynamic, you know, evolving system right there in that moment. And then there's us, we're also a dynamic, evolving system that we come together in the context of the environment. And that even changes the dynamic or influences. So compassion can emerge from that interaction, from a series of elements that are actually non compassionate in and of themselves. So we can train and these six elements, and again, this is Halifax's model, but we can train these six elements and it saw like you just train one and then you train the other. It's not linear there, you know, it's like I said, an interdependent integrative process. But I think it's just really fascinating because this is something accessible and tangible.

Shelly Prosko:               11:53                And in the book I go obviously into depth and I'll just try to keep this short. But the first element is the attentive domain. So that's just being fully and wholeheartedly a hundred percent present and you can, we can cultivate our focus or concentration ended up and our attention through a whole host of different ways. Whether it's different mindfulness practices or focused concentrative activities. So that's a whole other way to cultivate that. So just by cultivating and practicing the attention is one way to help the process of compassion. And then the second one is the affective domain. So that is being aware of our emotions and we have a lot of research that shows the more aware we are of our emotions, the more aware we can be of others.

Shelly Prosko:               12:52                And then we also have research that shows some interoceptive awareness practices, believe it or not because of the way something with the insular cortex, you know, we don't know if it's that more information is being sent to the insular cortex or it's just changing the way the brain is interpreting this. But when we do enter in an interoceptive awareness practices, it seems that that increases our ability to be more in touch with our own emotions, which is super cool. So an Interoceptive awareness practice might be like a body scan. So you're taking yourself, we're guiding a patient through, you know, a two minute, you know, scan of the body and inside and what are inside physiological state is like, it could be even, you know, a breath awareness practice.

Shelly Prosko:               13:47                And just knowing how that feels inside the body. And then the third element is intention. So in yoga, that of course, you know, that's my framework, how I frame a lot of things. But in yoga, there's a saying, you know, where your intention goes, the energy follows. So, from a science perspective, when you can actually focus and concentrate on something that you really put, have an attention to it that can affect the outcome. So for example, the intention when you're working with someone might be first and foremost my intention is to care for myself first. Secondly, to then care for the person in front of me. And then you may just want to keep that in mind throughout the whole session. And your intention may be something really specific. Like, I am here to serve, you know, when you sort of keep repeating that to yourself, I'm here to serve, I'm here to serve and my intention setting can be super powerful.

Shelly Prosko:               14:54                I don't know if you've done any intention setting before, but you just set an intention. It doesn't even have to be related to our professional career here. Just even personally, you go into a room or a setting where you're feeling like you don't really want to be there, et cetera. Maybe a family Christmas dinner. And if you go in with this intention, okay, I'm just going to focus on, and you could say anything, I just want to be present or I'm just gonna focus on being kind to myself. And you just focused on that one intention. It's like a theme. So that's the third element. So remember, all of these are now together. They start to accumulate into gaining more insight into the person's suffering in front of you, which then can lead us to have a more compassionate response.

Shelly Prosko:               15:40                Then the fourth element is insight. And that's basically just the idea that these first three components together and practice can lead to that deeper insight into what that person is, you know, is really going through. And then the other part to that insight, I just want to add, cause I think it's so fascinating once we start gaining deeper insight into all this stuff, we do start to understand that there's something called therapeutic humility, which is this idea that, you know, we can't control the outcome. So we do the best that we can. We gain as much information as we can. We be the best people we can be and we help the person as much as we can. And then we detach from outcome and we can pay lip service to that and we can all understand that. But when it comes down to it, I think a lot of us are attached.

Shelly Prosko:               16:38                And we're invested in making sure that the outcome is a certain way. So we could talk about that for a long time. But this is huge in part of the compassionate response is this idea to have this insight that we have to have this humility that we're not the almighty savior and we can't control. And then the last two are embodied and engaged. And so the embodied domain is really this idea that we are fully, fully present. So kind of similar to the first one, but this one is more that we are dividing our attention. Meaning we yes, we have to listen fully and be fully present for the person in front of us. But we also have to stay within our body and not detach from what we're experiencing and disassociate. So we have this idea that we can still feel if our breath is tightening or if there's tension in our body and that can give us a lot of information as well.

Shelly Prosko:               17:37                That's really important. So that's part of the compassionate process. And then the last one, the engaged domain that's really compassion in action. So that's your compassionate. And I think for here, this one, I think the biggest take home message for me has been, it's obviously informed by everything I just said. And it's different depending on the context. So there's no, well there's no GoTo, this is the strategy or this is my response or this is what I say, you know, when my friend is struggling and where someone's giving you some bad news and there's no really go to response, you can have some ideas of course, and then some things maybe that aren't, we want to stay away from saying, but it's really important to understand that compassion is this wisdom that emerges in that situation and the engaged part might be not saying anything or not doing anything. It could be just holding space. And so I hope that helps you and the listeners sort of get a deeper appreciation for this process and that we can train it and that it takes time and it can be extremely helpful for both the person in pain.

Karen Litzy:                   19:01                Yeah, I think that's great. And thank you so much for going into a little more detail there on that model. I think it makes it a little more concrete for myself and certainly hopefully for the listeners as well. And now I think something that people may misunderstand or misconstrue is the idea of compassion and empathy as being the same. So my question is there a difference between compassion and empathy? And if so, can you kind of give us the similarities or differences there?

Shelly Prosko:               19:39                Yeah. So just like compassion, empathy does not have one agreed upon definition either. So this makes it challenging to talk about this stuff because you know, people have different ideas as to what these things are. So some, you know, of what I've read about empathy, it depends if we're talking about cognitive empathy or emotional empathy, behavioral empathy. So that makes it a bit tricky. But I'm going to stick with the empathy that I find most people resonate with and that is more that the empathy where it's our capacity to be able to share the feelings of another person. So what it's like to be in the other person's shoes, right? To resonate with their experience, even to share that emotional experience. So if we use that definition, then we know we can see that empathy is really more of a competency.

Shelly Prosko:               20:43                It can be a motivating force for compassion. But what the literature shows is that empathy is neither sufficient nor required for compassion. And you think about that for a moment. It makes sense because we can have empathy for someone. So we may emote, be able to, you know, really understand and emotionally share that same experience or share that same feeling because we've had a similar experience. The response may not necessarily be a compassionate one and there's lots of different reasons as to why we would or wouldn't. I go into a little bit of that in the book, but just I think, I hope that makes sense to everybody. How you could still have this empathy but maybe not provide of a very compassionate response. The other part of that is you don't necessarily have to even have empathy in order to provide a compassionate response. And I think that's actually quite hopeful. And you know, cause I think even talking to some of my colleagues who some people may feel that they're not as empathetic or they've been told that they don't have, what you don't understand.

Shelly Prosko:               22:05                And, you know, the good news is you may not be really empathetic or you may not consider yourself an empath, but you can still have a compassionate response. And I think if you go back to the Halifax model of all of those elements, you know, that help us provide a compassionate response. Empathy can be part of that. Like you say, it can be a motivating factor, but not, no, not the only factor in it. Certainly, it could still be lacking. You could still be compassionate.

Karen Litzy:                   22:40                That is hopeful for people who may be feel like they're not as empathic as they would like to be. But like you said, that Halifax model is this sort of emergent model by having all of these different inputs go into the system and have, you know, an emergence of compassion from you. So it's not like all of those parts need to be equal.

Shelly Prosko:               23:03                Right? And empathy. Like I said, empathy can be good. Of course. You know, just think of a time when you shared someone's experience feeling, you know, or their experience. You've had a similar experience that may help us give us an idea. But we also have to, I think this is interesting too. We also have to look at the fact that sometimes if we have empathy and we can really share that feeling if we're not careful and if we're not in this more clear kind of state. We may actually start to look at our experience and what we went through and put on someone else, like almost feeling that, well, this is how I felt. So they must feel that too. And there's something that Paul bloom, he's a psychologist at Yale, he calls it empathy arrogance or the arrogance of empathy.

Shelly Prosko:               23:56                And it's just fascinating. Some of his work and you know, this really made sense to me when he talks about the fact that can we truly, truly have empathy, you know, on that deep level of what it means. Because that means that we want really understand and share 100% with that person is going through. And we can't do that really, if you think about it. And it could be, you know, someone may be that we've had a similar experience, or it could be, think of yourself as a healthcare provider. Look at all the patients we have. I'm coming to see us who are very, very different from us. Different things have happened to them, different socio economic status, people who are maybe vulnerable populations marginalized. And if we're in a position of privilege, how can we truly empathize with some of the issues and the things that they're going through that may affect their esteem? So that's kind of a tangent, but I think why I brought that up. I think it's important is because it's just this idea that we can still be really, really compassionate and we can train for these compassionate responses even if maybe we can't fully empathize. So I think that was the point of me bringing that up.

Karen Litzy:                   25:22                Yeah. And I think in my mind, it kind of takes a load off of me as the healthcare provider. You know, that you don't have to have experienced what your patient has experienced in order to provide compassionate care in order to have that therapeutic relationship in order to help that patient in some point of their recovery. So I think it takes a little bit of the pressure off of the healthcare provider, which may in turn help us to be better providers. So we don't have that pressure, like you said, that pressure on us for outcomes because perhaps, you know, you don't want to think, well, because I never experienced it that I can't help this person right now, I'm away or I'm not the right person for you, or something like that. So I think it's an important distinction. And now in the book, in your chapter you sort of have this model of comprehensive, compassionate pain care five sort of points to that. So can you speak about that model of compassionate pain care?

Shelly Prosko:               26:42                Yeah, so really just looking at all the different orientations of compassion. So Paul Gilbert, this is based on Paul Gilbert's work, he's another compassion researcher in the UK. And he talks about the orientations which is giving compassion and then obviously we also receive it. And then the third orientation is the self-compassion within us. So the five components that I see when you look at the full comprehensive, compassionate pain care. The first one is of course what we've talked about here, the health care provider providing compassion. And then the second component is the health care practitioner and the person in pain, cultivating or practicing self-compassion. Oh, that's within each of us. And then the third one is also close family and friends, cultivating compassion towards self and others, including the person in pain. And then the fourth is that we want to make sure that the values of the healthcare organization, including its leaders are in line with compassionate care.

Shelly Prosko:               27:54                So this includes a commitment to providing and supporting an environment where compassion can be cultivated by both the healthcare provider and the person who, and I think that's, you know, just really important to include in a comprehensive model here because it's not just about the healthcare provider and the person. And then the very last point is just the community at large. You know, I think it's important to have overall public awareness and understanding, you know, surrounding the importance and the health benefits and practices of compassion. And then of course, that includes the person in pain. So that's a little lofty and I don't have a task force or a plan or not this, you know, right now I'm focusing on those first two and I'm doing a lot of different things and this is going to be my life's work, Karen.

Shelly Prosko:               28:47                Like I really believe in this stuff. And, I think increasing pain literacy and increasing compassion literacy are two things that, you know, I'm in it for the long run and so how that looks on how we increase pain literacy and compassion literacy in, you know, interest in the general public and in healthcare organizations. I mean, that's a huge topic. But, you know, there are some different things that I've been involved and just with, not necessarily with compassion per se, but just increasing pain that I've seen, you know, our health care community and yoga therapy community. So yeah, to me it's got to be comprehensive like that.

Karen Litzy:                   29:42                That's the way you're gonna make, I think a worldwide impact, certainly on those living in pain when we know, at least here in the United States, and I think this is probably can kind of be generalized to other parts of the world. But here in the United States, the burden of care for just low back pain and neck pain is number, I think three or four behind heart disease, like diabetes. So we're talking about pain as being one of the largest burden of care in the United States. And I would argue probably across the world. I don't know that it's that much different or there's that much difference from other parts of the world. I don't know what it's like in Canada, but I mean it's a lot of money. It's a lot of time. It's a lot of resources. It's a lot of relationships. It's a lot of people in pain contributing to that burden, behind those big numbers of trillions of dollars. They're individual people. And so if adding something like compassionate pain care can help make even the tiniest dent in that, then I think it's, I don't think it's a lofty goal. I think it's just a goal.

Shelly Prosko:               30:58                Yeah. I'm glad you say that and you put that into perspective, which I appreciate and yeah, and I think that, you know, just overall this compassion what we've been talking about here, like I think it's the foundation of pain care or is this foundation of health care. You know, you can't really argue with that. And, I don't think anybody would argue with that. But what I think we just don't quite understand is that we may have good intentions and we may think that intuitively, yes we are compassionate people, but the research shows that it can be lacking in certain areas of the world and certain regions, healthcare regions. And also there are fears and blocks and resistances to compassion. Like there are actually reasons why we may not offer a compassionate response. And, you know, some of those reasons are the organizational barriers or different social pressures.

Shelly Prosko:               32:05                But some of them may also be certain beliefs that we have that compassion may not be the best response for this person. Maybe we have a deep seated belief that the person needs something different. You know, there's a lot to this, but there are different obstacles. And also just our own health. I didn't really talk about this in here, but you know, we might be overwhelmed by stress in our lives or we may have some unmanaged personal distress and we have research that shows we don't need research to tell us this, I don't think, but we do have research that shows when our own physiological state is not regulated. When we're in a state of flight or stress or a sense of anxiety, things like that. Neuro, biologically we are not set to provide a compassionate response.

Karen Litzy:                   32:59                Go figure. Yeah, that makes a lot of sense. All right, what would you love for the listeners to take away from this discussion and then we'll get into where people can find you in the book and all that other stuff, but, what would be your big takeaway when it comes to compassion and care?

Shelly Prosko:               33:25                I think the biggest takeaway that I would like people to understand is that being compassion is not just about being nice or kind or a good person, so that we could still be all those things, but we actually may still be lacking in that compassionate wisdom. So if you can just think of it more than that and that we could, Oh, maybe get a little bit more skilled at developing this compassionate wisdom. And I guess this is more than one takeaway, but that would be the one. And then just knowing that there are these benefits, both the people in pain and also for us as the practitioner for our own health and yes, for burnout and things like that.

Karen Litzy:                   34:18                Now where can people find more information about you, what you're doing and where the book is?

Shelly Prosko:               34:24                So my website's probably the easiest, kind of the one stop shop. So it's like Canada. And you know, if you want to sign up for my newsletter from there, it's on my blog. And then that keeps you up to date. Cause I do online courses, webinars, onsite courses, lots of videos, YouTube, you know, all kinds of different resources and things. So, and then the social media links are all on my website.

Karen Litzy:                   34:54                Yeah. And we'll have all of that to up on the podcast under this episode at so people can one click and get right to you.

Shelly Prosko:               35:04                Okay. Yeah. And then the book, the co-editors, you've already mentioned Neil Pierson and then Marlisa Sullivan is the other co-editor. And we do have some other authors who are contributing or who have contributed to the book. And you can find that book. I mean it's just Google yoga and science in pain care, treating the person in pain. It's on Amazon, Barnes, Nobles, you know where books are sold.

Karen Litzy:                   35:25                I can say I have not read all the chapters, but I have read several of them and I 100% recommend this for healthcare practitioners or not even healthcare practitioners. Really anyone. Because I just find that for me, it's helping me to kind of look inward a little bit more what I'm doing and not doing and what I can improve upon. And a lot of good reminders of pain science and, and things that I can thentalk about with my patients. I think in a way that, that they're understanding and integrating yoga and integrating compassion, integrating breathing and things like that into my treatment. So I'm finding it very helpful from a practice point.

Shelly Prosko:               36:22                Exactly. That's great. Yeah. That was our hope. You know, our hope was that healthcare providers, regardless if they wanted to go deep into, you know, the yoga therapy and bring yoga into their practice or not, you know, we wanted this to be helpful for, you know, people who, you know, just might be informed by some of these teachings. And of course informed by the science and in mind with what the contemporary science is telling us around patients.

Karen Litzy:                   37:05                Yeah, exactly. And it's also nice because it's not like, it's not super heavy. It's not like you're like, Ooh, boy, like I need five hours to read two pages. You know what I mean? Cause it's written in simple language, which is very nice versus so you're taking all these studies that are very scientific and able to simplify them and distill it down into something that's very easy to read. And I think that's why it sticks. So well done for you guys on that. You can find the book at any bookseller and we will have links to it on our website. And Shelly, thank you so much for coming on. I mean this is great and hopefully it allows people to at least look into compassion training, at least start incorporating this with clients and with your patients. So thank you so much for coming on. I appreciate it.

Shelly Prosko:               38:02                Thank you. Thanks so much for having me. I'm just so, so, so grateful.

Karen Litzy:                   38:06                Yeah. Pleasure, pleasure. And everyone, thanks so much for listening. Have a great couple of days and stay healthy, wealthy, and smart.


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Nov 4, 2019

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Nicole Stout on the show to discuss cancer rehabilitation and survivorship care.  Dr. Nicole L. Stout is a renowned health care researcher, consultant, educator, and advocate.  She is research assistant professor in the School of Medicine, Department of Hematology/Oncology at West Virginia University Cancer Institute. Dr. Stout is an internationally recognized expert and leader in the field of cancer rehabilitation and survivorship care.


In this episode, we discuss:

-Functional morbidity in cancer survivors and the role of rehabilitation

-Evidence for rehabilitation and exercise interventions to support individuals with cancer

-Physical therapy clinical, research and education needs to develop survivorship care models

-Why every clinician should be familiar with survivorship care

-And so much more!



Nicole Stout Twitter

Nicole Stout LinkedIn

Academy of Oncologic Physical Therapy 

2nd International Conference on Physical Therapy in Oncology (ICPTO)

American Congress of Rehabilitation Medicine

American Cancer Society

Nicole Stout Research Gate   



For more information on Nicole:

Nicole L. Stout DPT, CLT-LANA, FAPTA

Dr. Nicole L. Stout is a renowned health care researcher, consultant, educator, and advocate.  She is research assistant professor in the School of Medicine, Department of Hematology/Oncology at West Virginia University Cancer Institute. 


Dr. Stout is an internationally recognized expert and leader in the field of cancer rehabilitation and survivorship care. She has given over 300 lectures nationally and internationally, authored and co-authored over 60 peer-review and invited publications, several book chapters, and is the co-author of the book 100 Questions and Answers about Lymphedema. Her research publications have been foundational in developing the Prospective Surveillance Model for cancer rehabilitation.


Dr. Stout is the recipient of numerous research and publication awards. She has received service awards from the National Institutes of Health Clinical Center, the Navy Surgeon General, and the Oncology Section of the American Physical Therapy Association. She is a Fellow of the American Physical Therapy Association and was recently awarded the 2020 John H. P. Maley Lecture for the American Physical Therapy Association.


She holds appointments on the American Congress of Rehabilitation Medicine’s Cancer Rehabilitation Research and Outcomes Taskforce, the WHO Technical Workgroup for the development of Cancer Rehabilitation guidelines, the American College of Sports Medicine President’s Taskforce on Exercise Oncology, and also chairs the Oncology Specialty Council of the American Board of Physical Therapy Specialties. She is a federal appointee and co-chair of the Veterans Administration Musculoskeletal Rehabilitation Research and Development Service Merit Review Board. Dr. Stout is a past member of the American Physical Therapy Association Board of Directors.


Dr. Stout received her Bachelor of Science degree from Slippery Rock University of Pennsylvania in 1994, a Master of Physical Therapy degree from Chatham University in 1998 and a clinical Doctorate in Physical Therapy from Massachusetts General Hospital Institute of Health Professions in 2013. She has a post graduate certificate in Health Policy from the George Washington University School of Public Health.


Read the full transcript below:

Karen Litzy:                   00:01                Hey Dr. Nicole Stout, welcome to the podcast. I am so excited to have you on today. So today we're going to be talking about for all the listeners, cancer, survivorship and morbidity burden among growing populations, probably around the world, certainly in the United States. But Nicole, before we even get to all of those sort of big topics, can you define for the listeners what cancer survivorship is?

Nicole Stout:                                         Yeah, thanks Karen. That's a great question to start off with. And it's a little bit of a Pandora's box right now. So we've historically defined cancer survivors as anyone from the point of their cancer diagnosis, really through the remaining lifespan that that individual has. So we consider a survivor from point of diagnosis and you know, it's sort of different or it's kind of different than what the word expresses.

Nicole Stout:                 01:06                The word survivor, I think in some kind of patient means they're done with treatment, they've survived. And you know, we've seen a bit of pushback in the last few years around people who don't necessarily identify with the word survivor. So if we go back to 2006, there was a very important report that the Institute of medicine released called lost in transition from cancer patient to survivor. And this is where the term came from. Basically that IM report was critical because it said, Hey, medical community, you're doing a great job of treating cancer, that disease, but you're doing a terrible job of helping these people transition back to their life when they're done with treatment. They have a lot of functional morbidities, physical, cognitive, sexual, not managing those things. So this term survivorship was put forward. The idea of managing people to become survivors was put forward.

Nicole Stout:                 02:05                And what's been very exciting is to see the evolution of emphasis and focus on better managing the human being that goes through the disease treatment in addition to managing the disease. But we've come so far with treatments and in some regard, some people who have advanced cancers for example, will be on cancer treatments for the rest of their life. And you know, I participate in a lot of social media groups and I hear these people say, I'm not a survivor and I'm never going to be one. Eventually I'm going to die from my cancer. I know that. And it's a matter of time. And so they don't identify with the word survivor or survivorship. So, you know, we're sort of moving away from that a bit and we're talking for now without individuals who are living with and beyond cancer. And I like to use that terminology. Even though survivorship is prevalent in the literature and prevalent in, you know, our conversations and in oncology circles is how we describe it. But I think we're trying to be more sensitive to the much, much broader population of individuals who are going through cancer treatments today.

Karen Litzy:                   03:19                Yeah. And I liked that phrase, living with and beyond cancer, it seems a little more inclusive to me. Is that why you prefer that phrase?

Nicole Stout:                 03:29                I do. I think that encompasses anyone who ever had a cancer type know who is in treatment, who is a, what we call an ed has completed treatment and has no evidence of disease. And it's also those individuals who may be in palliative care, who are progressing towards end of life, who are still being treated or managed in various ways. So I think it is more encompassing and reflective really of the broad, broad scope of this population.

Karen Litzy:                   04:04                Yes. Because I think oftentimes, and myself included, people think you either have cancer or you don't. After you've gone through treatment, you don't have it in you're a survivor. So you forget about that population of people, like you said, who have cancers that they'll be in treatment for the rest of their lives.

Nicole Stout:                 04:26                Yeah. And that that is actually a growing population with more sophisticated treatment technologies and changes that we've seen around the immunological therapies, the hormonal therapy treatments. Many of these targeted agents as we've come to so call them. And we are seeing individuals live much, much longer with disease, with stable disease, we're able to stabilize it. And so therefore what they would have died from in six months or a year, they're now surviving. I have years on continued temporization treatments. And so how would we describe those individuals? And yeah, let me make sure that the supportive care needs of those people are met and identified and met. It is a very broad population. So I think sometimes we say survivorship and it is not nearly as homogenous as, you know, that group of you either have cancer or you don't. You've been treated and you're finished. Now some people, for some folks that is the case. But for many, there's this very gray area that is the remainder of them.

Karen Litzy:                   05:39                Yeah. And I think saying living with cancer treatment or living through cancer treatment and beyond is just a little more sensitive to the person. Like you said, the person behind the cancer. Because oftentimes when you read articles or even whether it's in a scientific journal or mainstream media and you think about cancer, they are always talking in percentages and numbers but not in the person. And so this kind of brings it down to the personal level. Now you mentioned it a couple of times, as we were talking here about different morbidities related to cancer or cancer treatment. So can you talk a little bit about what people undergoing treatments or maybe have completed their treatments might be experiencing?

Nicole Stout:                 06:37                Yeah, that's a huge topic. We could spend hours just talking about that. But first of all, just in general, when we say morbidity, we're talking about the complications and the side effects that impact an individual's ability to function. So we're talking about functional morbidity. And the good news, the good news is this. The good news is we have a growing population of individuals who are living with and far beyond their cancer diagnosis. We talk about the population of cancer survivors growing. And you know, we look back to like the 1970s, all types of cancers. We were looking at about somewhere between a 40 and 50% survival rate to five years. So we have, and today we have dramatically driven that number much, much higher when we look across all cancers. That number today is around 70%. But when you drill into some of the more commonly diagnosed cancers like breast and prostate, those survival numbers to five years or even higher, upwards of 90% plus.

Nicole Stout:                 07:47                So the good news is more people are being treated and getting to that side of your Mark of survival with no evidence of disease. And that tells us a story that they're more likely to live the rest of their lifespan, but they are living with significant functional morbidity. And so the side effects of cancer treatments are things that we absolutely anticipate. We know that when people go through different types of chemotherapies or mental therapies, radiation therapy, you named the therapy, they are going to be side effects that negatively impact their function. The issue is how severe is the impact? How disabling does it become and does it persist? So multisystem impacts from these interventions. Chemotherapy is a multi, it's a systemic approach to managing disease burden. And unfortunately chemo is not selective. It doesn't go into your body and say, Hey, here's a cancer cell and there's a cancer cell and it wipes out rapidly dividing cells.

Nicole Stout:                 08:54                So is the systemic impact to the body. Your immune system is suppressed, you know, your blood counts drop, you become anemic, you become fatigued. Some chemotherapeutic agents cause cardiac complications and cardiotoxicities some chemotherapeutic agents we know are highly neurotoxic and cause peripheral neuropathies. None of these. And there's a spectrum, right, of the severity of that toxicity that people experience. And so some of those are mild, some of those are more severe. That it is the majority of patients going through treatment will experience at least one or more many experience, more than at least one about 60% experience, at least at one or more functional morbidity. And so when I talk about function, I want to say just sort of as a caveat, I always say I talk about Function with a capital F, meaning that it's not just the physical function. You know, I think in physical therapy we think about movement and mobility and gait and balance and you know, activities. But there's cognitive functioning as well. There's sexual functioning, there's being able to assume your psych.

Karen Litzy:                   10:10                Yes.

Nicole Stout:                 10:10                Social and psychological functioning and all of that, assuming your roles and your daily life. So we have to think very broadly, but when we talk about the morbidity burden, it's very real associated with cancer treatments in the short term. So while people are going through treatment, we expect to see it. But here's the trick. When treatments are done and withdrawal, people do recover to a very high degree. They regain their strength and mobility. But many of them suffer with persistent morbidity. And that disables many from going back to work or resuming their prior roles. And again, those can be across systems. And they can be encompassing of the physical, the cognitive, et cetera.

Karen Litzy:                   10:55                And that gives me a lot to think about as a physical therapist. So if I might be seeing a patient too, let's say they have completed their chemotherapy, radiation, whatever their treatment was a year ago as the physical therapist, it sort of behooves me to ask these questions of them. So even though I may have a patient who's recovering from breast cancer that's coming to see me for knee pain, but these are things that if you are the treating healthcare provider, you have to have in your head and kind of ask these questions of them, of those different systems. Right?

Nicole Stout:                 11:41                Absolutely. And that's actually a great and very critical point to make for physical therapists. And you know, even more broadly, occupational therapist, speech and language, all of our rehab cohort, you know, you said one year after treatment that the thing about cancer treatments, and I refer to them as the gift that keeps on giving because even though an individual finishes treatments, the treatments are oftentimes not done with them. Radiation therapy is a great example. We see individuals have side effects of radiation therapy in the acute timeframe, of course that we can see for example with chest wall radiation and breast cancer, we can see changes to the lung tissue, the bone and the cardiac function even years beyond the completion of treatment in five years, 10 years. So it behooves us to think about the history of cancer but not just did it have a history of cancer and concerned about recurrence of disease with what I'm seeing in my assessment.

Nicole Stout:                 12:41                That's one little piece of it. But the bigger question is, is the impairment that I'm seeing in this patient in front of me somehow related to their cancer treatments? Quite possibly, I would say yes. And if it is, are there things that I need to know about cancer and its treatments so that I can optimally manage this patient? And I would say yes to that as well. It's funny because in, I've been a PT for over 20 years now. I've worked in cancer for the majority of that time. Almost 19 of those 20 plus years have been exclusively cancer. And I still today have physical therapists say to me, I don't really see cancer patients in my practice. And my response to them is they see you every day. They see you everyday. Someone who has had a history of breast cancer with radiation therapy to the chest wall on the left side 10 years ago.

Nicole Stout:                 13:38                And you're seeing them as they are deconditioned, they may have dyspnea, they're now having some cardiac complications that can absolutely be related to radiation cardiotoxicity. You're seeing someone's three years out from prostate cancer treatment who is now having some balance deficits and issues, has had a fall at home for example, do a close assessment of their sensation, because they probably have residual peripheral neuropathy directly related to their neurotoxic chemotherapeutic agents. So we know that many of these side effects persist and can cause what we call these late effects, which are the downstream side effects that patients will experience. And a lot of it is musculoskeletal, neurological as well. You know, there are changes that can happen with regard to sensation, cognition, memory, those types of things also can persist for, can come on more substantially later after the completion of treatment.

Nicole Stout:                 14:43                So there are functional needs someone's going through treatment, but those needs may be, they may be less, they actually may be more in some folks as they age. Because by the way, there's that pesky thing called aging. I'm done with cancer treatments five years, 10 years later. But you know, you've also aged whole cluster of what are the co-morbidities that we're facing that this individual is facing. You know, what type of lifestyle behaviors are they choosing. So really looking at that from that very encompassing perspective and in the short and the long term, not negating that history of cancer, even though it was, you know, five or seven years ago.

Karen Litzy:                   15:26                Yeah. And you know, you kind of answered the question I was going to ask and that's as a physical therapist, why should we care? Well, I think you answered that one very well, but let's talk about the evidence for rehabilitation. And exercise interventions for these individuals with cancer. What does the evidence tell us?

Nicole Stout:                 15:43                Yeah. And so when you asked why should we care, not just to alleviate their morbidity and to give a good quality of life and better function, but there are big, big issues that these folks face that caused downstream medical and healthcare utilization than escalate costs, pain medications, imaging, additional hospitalizations. So we should care from an individual perspective. I want my individual patient to be functioning. We should also care from a system and a societal perspective that we can help to alleviate that burden. So the exercise or the evidence, boy, where do I start? The good news is, as I said, multi-system impact for many of the cancer treatment interventions. And that's everything from surgery through hormonal treatments, including everything in between. But the goodness is there is evidence to demonstrate the benefits of rehabilitation intervention for nearly any patient with any disease type across the continuum of cancer care.

Nicole Stout:                 16:50                From the point of diagnosis through end of life, there's evidence to support our interventions. And you know, I always say that about cancer oncologist everywhere. Cancer does not discriminate based on body region. It does not discriminate based on system impact. It doesn't discriminate based on race, based on gender. Everybody is at risk for having a cancer diagnosis. Now you know, there are some nuances there that level of risks. So we have to be thinking about that evidence very broadly. And so if we start at the beginning, at the point of diagnosis, there are some populations for whom a prehabilitation exercise intervention is highly recommended. We have seen over the last decade, the idea and concept of prehab is, you know, many times we make a diagnosis for a patient with cancer and it is not emergent to treat them. Now some types, it is some types of leukemias.

Nicole Stout:                 17:49                We immediately begin treatment like the sun doesn't set, we treat them. But for a number of populations, there's testing, there's workups that are done. There's lab work, there's imaging and that can take several weeks. And so in populations like lung and colorectal, we had started to see these prehabilitation exercise programs put into place and there's a nice body of literature that has grown and has strengthened demonstrating the benefit of therapeutic exercise, aerobic conditioning, moderate intensity supervised over the course of about two to three weeks. What it does is it prepares them to enter, whether it's surgery or chemotherapy. First it prepares them to enter. They are cancer care continuum in a much better physical performance status. Really the exciting thing in lung cancer with the pre habilitation exercise that we've seen some evidence, the lung cancer population in general, many of them are not in good physical performance status when they're diagnosed.

Nicole Stout:                 18:52                And some of them by virtue of that are not candidates for surgery. They're not candidates for the ideal regimen of chemotherapy because of their performance status. And we're starting to see evidence that that prehabilitation exercise intervention can actually convert someone for being a non surgical candidate to the surgical candidate. And that is, that's where we need to really be looking longer term and saying, does the rehab intervention improve survival in that population? The question is not, you know, something that we haven't answered yet but not far from being plausible. So that's evidence sort of from the point of diagnosis. We also have a large body of evidence around that post usually surgery is the first stop for some, for most folks and that perioperative time period. And it just makes sense. You know, the PT, the rehab consults, for especially our head and neck population, we talk about oropharyngeal, laryngeal parasite as we sort of put those into the head and neck population.

Nicole Stout:                 19:56                Immediate referral for speech and language pathology should be done in that patient population. Immediate referral for PT or OT console for upper quadrant for cervical mobility, first those things should be standards that should become standards of care. The evidence is building in that regard. And then as patients move through treatment, the chemotherapy, radiation therapy, sometimes chemo, radiotherapy combined, is sometimes the next stop. And around that time period the exercise literature supports intervention during chemotherapy, the conditioning to help to mitigate fatigue, moderate intensity, low intensity exercise for individuals to alleviate distress, anxiety, depression. So exercise prescription is something that we're really starting to see more focused on. The American college of sports medicine just released new guidelines last week, providing some very specific evidence around exercise prescription. So we're getting to the point where we can actually prescribe exercise for targeted impairments that individuals are experiencing during cancer treatments.

Nicole Stout:                 21:17                There's strong evidence around fatigue management exercise.  To moderate and low intensity for fatigue management. There's strong evidence around lymphedema using exercise to help for women who have, especially in the breast cancer population. There's strong evidence also around using weight bearing exercise to mitigate bone density loss that happens with many of the hormonal agents. So I know I'm sort of picking and choosing out of the air here, but in general, what do people experience when they go through cancer treatments? Debilitating fatigue is probably one of the most prevalent impairments across all cancer types. There's also so deconditioning that comes along with that and you know, that's a starting place for exercise interventions and you know, half the battle I feel with the rehabilitation intervention. And I feel like my role sometimes as the PT on the team, half of the battle is engaging the patient repeatedly in a conversation about enabling them because as they go through treatment, they feel terrible.

Nicole Stout:                 22:30                You're sick. They're fragile, they're medically complex, right? Their blood counts drop, okay, let's maybe low. So there's risks and you know, it's sort of like the docs will say things like, well, you know, I guess you can exercise but don't overdo it. And that's almost worse than saying don't exercise. And so sometimes it's just, you know, our role in rehab is so critical during that time period of treatment to see them in a repeated fashion. And by that I don't mean, you know, two, two times a week for the duration of their cancer treatment. But you know, maybe it's a monthly basis, maybe it's every other month, maybe it's every three months as they're going through treatment for those check-ins. Re-assessing how their function has changed. Giving them guidance and support and enabling them.

Karen Litzy:                   23:23                Yeah. And it reminds me of some of the work that I do with patients who have chronic pain is that it's not like you said, two times a week for six weeks. It's checking in, it's helping to build their self efficacy so that they can do yeah. And they can do more for themselves.

Nicole Stout:                 23:47                And within their own bodies and giving them permission to do it. Cause like you just said, well you can work out but not too hard. Well like, yeah, that saying, well that's confusing and sometimes our patients need permission to feel more confident with their bodies. I had a patient say something to me once and I will never forget it and I use it in all of my talks and it's always sort of at the core in my mind. And she said to me, you know, the medical oncologists, they may have saved my life that you gave me my life back and if I'm going to survive cancer, what is it worth if I can't have my life back, at least to some degree to do things that I love to do. That just really hits at the heart of why rehabilitation is so critical for these individuals.

Nicole Stout:                 24:39                Because yeah, that treatments that we have now, I mean, we're detecting cancers earlier. The treatments are so much more sophisticated. Many people will go on and live their full lifespan and die from something else and however, it's not good enough anymore for us to say. He said, I have cancer. You should be happy to be alive. You know, even if you're suffering with pain or lymphedema or conflict fatigue or neuropathies and, or cognitive dysfunctions and you're frustrated because you can't think straight and you don't have good short term memory. It's not good enough for us to say you should just live with those things and be happy to be alive. Not when we have the evidence like we do around rehabilitation interventions. And I mean, I could go on about the evidence. We could get into specific impairments, pelvic floor, for example, returning people to continent.

Nicole Stout:                 25:32                Again, that's a place where prehab and then following them through the continuum of care. Makes sense. And you know, we in PT and in rehab has to get out of this episodic care mindset when we're working with patients who have cancer. So that's really where we went and we develop the prospective surveillance model. Way back in the early two thousands when I went to work at the Naval hospital in Charleston, Garvey and Cindy falls there, had developed this protocol for a research study and I went in and this prospective surveillance model said, Hey, we know people going through cancer treatment are gonna experience just awful side effects that are going to negatively impact their function. And if we know that ahead of time, why aren't we using rehab prospectively to help to identify the changes, manage them early when they're less intense and can be managed more conservatively.

Nicole Stout:                 26:28                So we ran those studies over the course of the next 10 years and published extensively on this concept of prospective surveillance, which is start with rehab at the point of diagnosis, assess function at baseline, know what's normal, follow that patient then at punctuated intervals, throughout treatment, one month after they start treatment, they're going to have had surgery or they're going to have started treatment. They're going to start to decline. See them at that one month period, reassess baseline and identify clinically meaningful change. Everything might look great and then you say, good, I'll see you in three months. And then we follow them on an every three month basis after that for the first year, every six months, then up to two years and you're only out to buy. And what we found was that I do think that we indeed identified impairments early because for most people it's not if they occur, it's when, when is it going to happen?

Nicole Stout:                 27:23                So we're able to identify them early. We can treat them much more conservatively when the impairment is less severe rather than waiting for severe, debilitating fatigue or a big fat swollen leg, and trying to fix or rehabilitate, right? We have to be much more proactive and we have the tools to be able to do that. We have the clinical measurement tools, we have the problem solving skills as rehab providers. What we have got to change is our perspective on an episode of care. This really is a more consultative role for rehabilitation and I think that's great. I think it's a great place for us to think about moving to as a profession. Consultation in that, like you said, sometimes you just see the patient, we tweak a little bit on their program and you coached them a little bit and talk about some of the behaviors they want to move towards and talk about. You're going to get there and you enable need and then I'll see you in three months. But sooner if anything goes wrong, you know?

Karen Litzy:                   28:21                And now this brings up to me an interesting question for you. So this, you said back in the early two thousands, this work was done on this, prospective surveillance. So now it is 2019 so you know where I'm going with this, right? So, as rehabilitation professionals, where are we? Are we doing this? Has this been put into mainstream practice? And if not, what do we need to do as the rehabilitation professions?

Nicole Stout:                 29:00                Yeah. So my heart is really as a researcher and it takes time. It takes time to do good studies. So that protocol kicked off in 2000. We didn't publish really our first remarkable studies until 2008 so it took us that eight years to enroll enough patients, analyze the data, come up with a full data set. You know, we completed our enrollment, we had the full data set. So in 2008 we published the first article from that prospective surveillance trial and then we published many, many more that the first was lymphedema, we published on shoulder morbidity, we published on fatigue and it was sort of this cascade after that, you know, once we had the data collected. So I'll start by saying it takes a long time to do good quality research. So really I sort of start the clock around 2008 and we've all heard the adage it takes 17 years for something to go from, you know, the research being published to actually implementing it in practice.

Nicole Stout:                 30:08                So I looked around at my research, okay, I'm out waiting 17 years. How did the escalate the timeline to get this into practice? And, I encourage individuals who do publish, to think about how you advocate for your research. And so where are we right now as a profession? Well for the first few years it was challenging to get people around their head around this concept of prospective surveillance. We had some uptake in some larger cancer centers who said, this makes sense, let's implement and put a physical therapist in the cancer center, which I think is an ideal situation. It's hard to do though because again, in hospital systems we're in our cost centers and you know, the rehabilitation department, you have to have her referral to PT. I mean, we've got to find ways to overcome all of those barriers.

Nicole Stout:                 31:03                So, I would say one moment that was a real catapult for us was in 2010, the American cancer society had identified the evidence around prospective surveillance and they said, do you think that this is ready for sort of an expert review panel? And I said, hell yeah. And so I got to work collaboratively with them and some other colleagues in putting together an expert consensus panel on prospective surveillance. We ended up after a two day symposium look, did the research, worked in groups and teams for about another year and publish 16 articles that came out in a supplement to cancer in 2012. And that I feel like was a bit more of a pivotal moment for us. You know, these research studies were great, but to pull all of that together with a group of experts in a consensus forum and say, this is a model that we need to think about for cancer patients because if we start at the beginning, not just with physical function, but if we start at the beginning with things like assessing someone's cognition, assessing their family status, assessing their financial status, assessing their nutrition status, and we follow them prospectively, all of those things are going to take a negative hit at some point during cancer treatments.

Nicole Stout:                 32:21                So I think prospective surveillance lends itself to a much larger cancer supportive care model, which is how I have been describing it. And it is my intent to really focus on how we can study that model and look at better avenues for implementation in this new position that I'm in now at West Virginia university. This is my goal, which is amazing. Now how, so, you know, if we look toward the future and hopefully what you will be able to achieve in your colleagues across the medical spectrum, what are there policies that need to change that will impact the future of cancer survivorship or the future of living with cancer and beyond? Yeah, so the good news to that is there are a lot of things we can impact because we've laid this foundation of the evidence. We have laid this foundation of expert consensus and there's been a lot between that 2012 and today, more and more providers in rehabilitation services are becoming aware and engaging in cancer.

Nicole Stout:                 33:36                You know, it's not something we prevalently teach in our curriculum in PT school. Think about how you learned about cancer. You learned about cancer in the negative. You learned all of the contraindications to your modalities and exercise and cancer was always one of them, right? You would say in your practical, okay, ultrasound, great, don't do it over the eyes. Don't do it on a pregnant uterus and cancer. So we find it in the negative for so many years. We have generations of therapists out there who love cancer and negative that never learned about the interventions to help to impact improve someone's function going through cancer treatment. So we're seeing that change and it's changing in how do we know it's changing? Individuals are engaging in cancer rehabilitation networks. We're seeing far more publications. We've published on this. A couple of years ago we did a billion metric analysis of the cancer rehabilitation literature and we've seen this tremendous upswing in the evidence base and an increase in volume.

Nicole Stout:                 34:39                We're also seeing more therapists move towards specialty practice and evidence of that is what we have seen culminate in the last year with the first ever deployment of the oncology board specialty certification exam. We had 68 people pass the first exam. So we now have a growing conduct contingency and it will continue to go of therapists who are oncologic clinical specialists, which is fantastic. So we are positioning ourselves, we are moving forward. But when you ask where do we go in the future, I really think of three things. Number one is impacting policy, like you said, second is impacting education. And third really is impacting research. And so I think where do we need to move to in the future? We're starting to see the clinical practitioners really grow. We're starting to see residency programs develop. So from that perspective of the clinical focus, there's evidence, there are pathways that's developing.

Nicole Stout:                 35:41                We have to start thinking about how do we embed this better into our curriculum. And this was last January in PTJ, the January issue of physical therapy journal. I coauthored a commentary article with Dr Laura Gillcrest, Dr Caringness and Dr Julie silver and Dr Catherine Alfano. We were all putting forward commentary on a recent national Academy of science, engineering and medicine report about longterm survivorship for cancer. And basically that report said rehabilitation should be utilized throughout the continuum of care, cancer care in order to contribute to that are longterm outcomes. And if that not doing so, not including rehabilitation during cancer treatment is almost negligence based on the breadth and depth of the literature that we have. So that was a pretty strong statement in that workshop document. So those are the types of things. Recommendations from the national academies will help us change policies.

Nicole Stout:                 36:48                And by policies, I mean, you know, it's not just how do we get paid for what we do, but also policies around, standards, policies that our accreditation bodies use to designate cancer centers. In fact we are seeing, I think they were just released today, the commission on cancer, which accredits probably 95%, I think it is, of cancer centers around the country. So they're a big gorilla, their standards for an accredited comprehensive cancer center and include a standard for rehabilitation care services. It used to just be a criteria that you had to have a referral source to rehabilitation. But in 2020, the new standards that will come out from the commission on cancer actually has a rehabilitation care service standard. So it's been elevated. That's going to be critical for us because it will require your cancer committee in your hospital to identify policies and procedures for rehabilitation practices in oncology.

Nicole Stout:                 37:56                So, you know, this is a place where we've got to start to see uptake in from our rehabilitation directors or administrators in large healthcare systems. The PTA, you know, we were really gonna need to see them start to put forward recommendations. How do we do this to practice? What is the best practice? What are some tools and tool kits that we can rule out. So those things, those policy changes are drivers for us. The education piece, I've spoken to a bit, I think embedding more education into curriculum for the entry level PT. And I think it's critical. You know, we get so bogged down in, well, you know, the capte requirements are, but they are in our curriculum's already too tight and it's a bit of a red herring argument because I see places around the country who have champions for oncology rehab who has put it into the curriculum.

Nicole Stout:                 38:51                It just takes someone to understand what is the best practice look like for an educational model and how do we implement it. So places like Oakland university in Michigan, Emory in Atlanta is working right now on elective modules. So there are some real novel ways that these are being incorporated into PT curriculum. And the third area that I think of for the future is research. And you know, as I said, wow, we've seen an explosion in research in the last decade. It's phenomenal. A greater volume. A lot of that has focused on intervention. It's been within some very specific populations like breast and prostate. There is a lot of breast and prostate, understandably. But we need to look at going beyond. We really should be thinking about how do we look at populations with regard to our rehab interventions of cohort studies, large population studies, and we've got to start thinking a little bit beyond end points.

Nicole Stout:                 39:54                Like function, function is important, don't get me wrong, it's the core of what we do. But if we improve function through rehab intervention, does it change the downstream utilization of healthcare services? Does it mitigate costs? Do we see them spend less time in the hospital? Did they have less than, do they adhere to their chemotherapy better? Do they have less severe toxicities? Do they have better overall survival? So they've got to think about some different end points and take a bit of a health services research approach. I think in oncology rehabilitation going forward. That's what I would love to see as the future and really at the core, the change in clinical practice so that we are a proactive consultative risk stratifying, triaging, screening, and proactively assessing profession when it comes to dealing with oncology.

Karen Litzy:                   40:52                Yeah. And, and you really teed it up for me to ask you this last question here. My question is what advice would you give to your everyday clinician working, whether that be an inpatient or outpatient to allow them to begin to think differently about cancer?

Nicole Stout:                 41:19                And that's critical because the fact of the matter is we look at places like Johns Hopkins and university of Penn and MD Anderson and those are like the preeminent cancer centers in the country. The truth of the matter is the majority of people get treated for cancer and community hospitals right down the street from where you live and in outpatient, freestanding oncology clinics. So the likelihood that you're going to see them is very high. So it is important for, as I said, the general therapist. It's also important for specialty practice therapists to improve their knowledge base in cancer. So how do you do that? There are some great resources. I'm always going to point to the APTA oncologic Academy for physical therapy. We're now an Academy. We used to be the section, I still call it the section.

Nicole Stout:                 42:13                But we have an Academy for oncologic physical therapy and there are phenomenal resources there. They do continuing education programs. They provide fact sheets. They often have great evidence base that you can access to understand what are the measurement tools they should be using, what are the questions I should be asking someone. I feel there are also some, you know, continuing education courses focused specifically on the general therapist and I teach one of them. So there's my bias opinion and my disclosure there with great seminars, but I tell people that in the beginning of the course, one of the first things I say is my goal is not to spend two days with you to get you to become an expert in cancer rehab. My goal is to change the way you think about every single patient that you see regardless of the diagnosis, regardless of the setting that you are in.

Nicole Stout:                 43:05                If they had a history of cancer, what questions do you need to ask? What might you be seeing in your intake that is indicative of side effects of disease treatment, late effects or even metastatic process. The other flip side of that that we haven't talked about and certainly helped me to delve into is that as primary providers, as frontline providers as we are in rehab, right? The direct access. Now, how many of us ask, about screening, cancer screening? How many of us ask questions? How many of us even know what the screening guidelines are for cervical cancer, for breast cancer, for prostate cancer, new screening guidelines for lung cancer. Again, I think that's a great way for physical therapy professionals to brush up in their knowledge base and to start to have these conversations. I'm not going to be the one to order a low dose CT scan for my patient who's at risk for lung cancer, but I might be the person to plant the seed with them and to incite a behavior change if no one else on their medical team has talked to them about it or if they're hesitant about it.

Nicole Stout:                 44:12                Colorectal cancer screening as well. So all of those, we should take responsibility to have those conversations. And that is 100% of the patients that we see to ask those questions. So I think we need to sort of self-assess and say, how can I do this? Knowing that we had, we have 17 million individuals in the United States right now that we call cancer survivors. We are expecting that number to double, double by 20, 40 just because of the growing population, first of all. And because of the escalating rates of survivors, because we're treating the disease so much better. So there are going to be far more of them with the aging population and far more needs for us to meet. So yeah, therapists should be asking themselves, what are the resources out there? There are a lot of places now hospitals, health systems do cancer rehabilitation programs.

Nicole Stout:                 45:10                They're doing continuing education courses and they're doing conferences as well. So take a look at some of the, I know Mary free bed, rehabilitation center up in Michigan, Brooks rehabilitation hospital down in Jacksonville, Florida, Marion joy, Northwestern. Many of these rehab hospitals are looking at doing one day, two day symposium open, you know, for folks to attend. So many hospitals as well are doing these cancer rehabilitation one day symposium and NYU is doing one next year, university of Miami. There's also an on pitch this because it's fantastic. And the ICPTO, which is the international conference in oncology, physical therapy, physical therapy oncology. I see PTO, it will be in Copenhagen in may of 2020. That's not a terrible place to go. This is the second that we, the second conference that we've done, the first conference we had over 280 participants from over 25 different countries around, well just physical therapists just in oncology.

Nicole Stout:                 46:17                It was just amazing. It gave me tingles to be in that room. And so we're hoping to have an even bigger groups. So those are just, you know, again, sort of a snippet of some resources that I can provide. But looking at each of those, I think you can delve deeper into the resources that they have and have them have available within the APTA within the Academy and within some of those other ACRM is another one. The American Congress for rehab medicine has a cancer networking group and that's a beautiful place to go because it is interdisciplinary PT, OT, speech. You have behavioral psychologists, you have interventionalists, you have lifestyle medicine, desire, interest. It's really great. And they have continuous track of cancer rehabilitation content at their conferences. Unfortunately their conferences in early November. So it's coming up quickly, but every year it's in the fall. Next year it will be in Atlanta. So you know, another great place to look for. How do I start to build my knowledge base in this area?

Karen Litzy:                   47:30                Yeah, this is great. Thank you so much for all of those resources and we will put as many of those up in the show notes at Quick question on some of those resources. When you were talking about the different screening tools, can you find those screening tools under the APTA's oncologic PT?

Nicole Stout:                 47:50                So if you're talking about the Academy for oncologic physical therapy, the hotly debated title. Yes, there are. So screening tools for identifying functional morbidity. Yes. So the course that was the evidence database to guide effectiveness, the edge test scores for oncology has published over 25 systematic reviews and have looked at measurement tools with by disease type within different measurement domains. So for example, you can find how do I measure functional mobility in colorectal cancer? How do I measure best measure lymph edema in head, neck cancer? So it's broken down by disease type and then domain of measurement. So that's there. It's an annotated bibliography on their website. So they give you a nice little simple compendium. But for the larger screening population screening guidelines, many of those are American cancer society and the us health prevention preventive task force. Those are, you know, large scale guidelines that are developed and put forward for screening for disease.

Karen Litzy:                   49:02                Yeah, perfect. Perfect. Well that's great. That is a lot of resources for people. So hopefully any rehab professional listening can, if you have no familiarity with any of this information, would you say where's the first place they should go?

Nicole Stout:                 49:21                Well, the first place, that's a great question. And I can help you put some seminal articles up there too. I think there are one and the open access articles. Julie silver wrote a fantastic article in 2013, about impairment driven as a rehabilitation. I feel like it's foundational. It's a great starting place for someone to get their head around all of the stuff involved with cancer treatment and the functional morbidity. And then I think the PTs for PTC oncology Academy is a great place. But also if you're an OT or speechie, you can join the Academy of oncology, PT, you can be an affiliate member, you can get access to our journal and our resources.

Karen Litzy:                   50:06                Oh, that's cool. Good to know. That's very good to know. And you know, I think as from what I've got out of this conversation, because I am not embedded in with the oncological Academy but what I am have come to realize through this conversation is that regardless of your setting, you may in your career encounter a patient that has had cancer or is going through cancer treatment and regardless of whether you're in sports, PT, orthopedics, neurological pediatrics, odds are you're going to treat someone at some point with a cancer diagnosis present or past. And to understand the basics of how that might affect overall systems is incredibly important regardless of whether you work at Sloan Kettering full time within specifically cancer population or you are the physical therapist for the New York Knicks, you know, you may encounter this population.

Nicole Stout:                 51:32                Yeah, that's really a beautiful summary. Karen, I appreciate the way you articulated that because I like to say oncology is everywhere and that's exactly it. It doesn't matter the setting you're in, it doesn't matter what specialty you practice. It doesn't matter geographically where you live. It does not matter, you know, age, gender, et cetera is, it's there, it is everywhere. Multi-system impact across body systems. So I think that's it. And across the lifespan. So I think it's beautifully summed up with that. You just said that, that's how we think about it. Oncologists everywhere. So every patient that you see there is either the risk of them having a cancer diagnosis in the future. So are you talking about the screening guidelines for the chances they'd had a diagnosis in the past and then asking yourself, is that impacting what I'm seeing here in front of me? There's so much we can spend an hour talking about pediatric oncology right now we're talking about red flags, you know, but look around many of the continuing education consortia around the country, med bridge. You know, many of those have a variety of content or are in process of building content for continuing education always look at the references. CSN is a great place to go to get a ton of oncology resources.

Karen Litzy:                   53:00                Got it. And that is coming up in February over Valentine's day weekend in Denver, Colorado. So if you're a physical therapist or not, maybe you just want to go and hang out with 13,000 other PTs. You can go to Denver and you look at the oncology track for CSM.

Nicole Stout:                 53:20                Definitely bring your sweetheart, make a ski weekend, I guess with the ecology content. Yep, definitely.

Karen Litzy:                   53:32                Excellent. All right, so before we wrap it up, I asked the same question to everyone and that's knowing where you are now in your career, in your life. What advice would you give yourself as a new grad out of PT school? So this is the advice you would give to you.

Nicole Stout:                 53:48                The advice I would give to me, it's funny. People would say, if you look back, what would you change? And I always say not a damn thing. I guess my advice to myself is what I hold close to my heart and what I convey to others is go for it. Don't be hesitant to take on something new or different because the new and different is what is going to expose you to a pathway you never would have imagined. I never would have imagined coming out of school that I would be doing oncology work. I was worried about in PT school. I didn't know that this career pathway could exist. I didn't know a clinical research pathway was something that I could even pursue. And as the opportunity came up, if I would've been hesitant, if I wouldn't have been interested in taking the risks, so go for it. Don't be afraid to take a risk. And sometimes that means moving to a different city, that might mean taking a pay cut. You know, a lot of times if we chase the things we love, we're not necessarily chasing the money along with it. I think if we chase a big paying salary, sometimes miss things above, so go for it and be open to try and taking those different pathways.

Karen Litzy:                   55:02                Yeah, great advice. And now where can people find you if they have questions or they want to talk about oncology physical therapy?

Nicole Stout:                 55:12                Oh, you can find me on Twitter, on social media outlet. I really used to try to engage professionally. So it's @NicoleStoutPT. And you know, you can certainly find me there. My Facebook accounts were private. That's where like family and friends stuff. But definitely access and hit me up on Twitter or LinkedIn yet. Another great place. I post a lot of our research articles there. I'm on LinkedIn, so you can certainly connect with me there. Or just email me and always see how many times you can just cold call or cold email. It's some of the most engaging conversations I'll get on the phone with anyone. I will fly anywhere to talk about kids or rehabilitation and you know, some of the best conversations that started with, Hey, I don't want to bother you, but you have some time to talk and I'm happy, you know, to start a conversation via email. So more than happy to engage.

Karen Litzy:                   56:09                Perfect. And Nicole, thank you so much for a really great talk and I think that you have given the listeners a lot to think about and also a lot to look up into research and hopefully spark someone out there to, this might be the path I would like to take. So thank you so much.

Nicole Stout:                 56:24                Well, I thank you for the opportunity. I'm just grateful for everything that you've done to put PT on such a stage and I'm really excited to have been a part of that, so thank you.

Karen Litzy:                                           Thank you so much. And everyone out there listening, thanks for listening. Have a great couple of days and stay healthy, wealthy, and smart.



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Oct 28, 2019

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Neil Pearson on the show to discuss therapeutic yoga in pain care.  Neil Pearson is a physiotherapist, and Clinical Assistant Professor at the University of British Columbia. He is a yoga teacher, a yoga therapist and creator of the Pain Care Yoga training programs for health professionals and yoga therapists.

In this episode, we discuss:

-The components of yoga practice that benefit people with persistent pain

-Yoga therapy as a pain education agent

-The Pancha Maya Kosha Model of yoga and the biopsychosocial model of healthcare

-Yoga and Science in Pain Care: Treating the Person in Pain

-And so much more!


Pain Care U Twitter

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Pain Care U Website

Yoga and Science in Pain Care: Treating the Person in Pain


For more information on Neil:

Neil Pearson, PT, MSc(RHBS), BA-BPHE, C-IAYT, ERYT500

Neil Pearson is a physiotherapist, and Clinical Assistant Professor at University of British Columbia. He is a yoga teacher, a yoga therapist and creator of the Pain Care Yoga training programs for health professionals and yoga therapists. Neil is founding chair of the Physiotherapy Pain Science Division in Canada, recipient of the Canadian Pain Society's Excellence in Interprofessional Pain Education award, faculty in yoga therapist training programs and an author. Neil develops innovative resources, collaborates in research and serves as a mentor for health professionals and yoga practitioners seeking to enhance their therapeutic expertise. He is co-editor of ‘Yoga and Science in Pain Care: Treating the Person in Pain,’ available Aug 2019.


Read the full transcript below:

Karen Litzy:                   00:01                Hey Neil, welcome to the podcast. I'm happy to have you on to talk about yoga and science in pain care, which is a title of your new book. And we will talk about the book throughout the podcast, but I'm excited to learn more about yoga and how yoga can work with people in pain. So welcome back to the podcast.

Neil Pearson:                00:24                Thanks so much Karen. I can't remember how long it's been since we've been here but it’s wonderful to be back.

Karen Litzy:                   00:29                Yeah, I think it's been awhile. I don't know either, but I think it's been a long time, but I'm excited today to talk about yoga and how yoga can be an agent for people in pain. So as a lot of the listeners know, I had a long history of chronic neck pain, so this is something that really interests me, but I will kind of pass it along to you. So how does yoga help as a pain education agent?

Neil Pearson:                01:00                Okay. So, maybe I'll start at a bit of a different place, but coming to there, so I guess part of my excitement around this, you know, we've got this new textbook out, it's called yoga and science in pain care. And really what it's trying to do is, is teach health care people about yoga and yoga research and how it can help but also some of the research behind that in terms of why it would work. And also it's sort of tried to go the other way as well as to teach yoga people about pain and about the lived experience of pain. So with the textbook, we're trying to hit both sides, right? Because we really see this as being something that needs to be integrated. And I think we sort of hit a really nice time with this because there's such interest in non-pharmacological pain management now.

Neil Pearson:                01:54                Everyone’s starting to recognize that the long-term management of pain or the care of people in pain has lots to do with what the individual does for themselves. Not completely as self-help kind of work, but more as what the person does for themselves under the guidance of people like us as physical therapists and under the guidance of people like the yoga therapists. So that sort of, the sort of broader where this is coming from. And then if we look at sort of how it can help, we can start by looking at some of the research and I guess probably in terms of pain management and pain care the simple thing to do to start with when we say we have now have formal analysis and systematic reviews that show that yoga therapy has been shown to be effective.

Neil Pearson:                02:45                That helping people to have less pain, to improve both perception of ability but also measured function and also improved quality of life. Those three things really are the three keys that people want. When we have ongoing pain, we want to have less pain, better ease of movement, and better quality of life. And the research is showing positive findings there. And it's showing positive findings in quite a varied group. So, there's a lot of research on low back pain. I mean, that's the one that has the most research. So much so that the, you know, the American medical association now has a yoga as one of the suggested treatments for people who have ongoing low back pain. But it also shows benefits for people who have rheumatoid arthritis, osteoarthritis, fibromyalgia, a whiplash associated disorder and a irritable bowel syndrome as well.

Neil Pearson:                03:43                So there's this growing body of evidence saying that when people have these conditions that they can find benefit from them. And of course, like any area of research, we'd have to say, you know, it doesn't say that it's gonna work for everyone. It just says that if you take a lot of people and you give it to them, there will be some benefit with using yogas. The therapy people always want to know, well, is the yoga therapy better than physical therapy or is it better than going to the gym? Is it better for other movement practices? And we don't have that research yet. The effects sizes of some of the research when people are going through using yoga therapy for pain management are higher than the effect sizes of movement on their own and comparable to the effect sizes. You see when you do research looking at cognitive behavioral therapy plus movement therapy for people with chronic pain, which makes a lot of sense because yoga therapy really does cover a lot of the aspects of the person. And so your listeners may be thinking yoga for people with pain. That sounds actually pretty ridiculous because whenever I see pictures of people doing yoga, there's no way that that's what people in pain are going to do,

Karen Litzy:                   05:00                Right? Cause they're always in these positions where even if I don't have pain, I think to myself, how in the heck am I supposed to get into that position?

Neil Pearson:                05:10                Well, exactly right. And, and it sort of the other question that often sounds ridiculous to the person who has ongoing pain is like, aren't you listening to me? I told you that movement hurts and you're telling me you want me to move as a way to get better. But movement is the problem. And so it's interesting that the practices of yoga can help people to find new ways to move with more ease. But also, the practice of yoga, we need to recognize really are so vast. We're talking about, if we sort of overviewed yoga, yoga is about learning how to relate to yourself in new ways, how to live in a world in new ways. It is about movement with the postures and it is about doing breathing techniques. And then there are awareness techniques which are akin to mindfulness, but they're a little different.

Neil Pearson:                06:10                And then there are also within yoga there are meditation techniques as well. So it really covers a broad, broad spectrum of interventions. And if we go to the literature again around chronic pain and chronic pain care, we see that mindfulness techniques and meditation are showing positive benefits. Movement is showing positive benefits. Gaining knowledge is showing positive benefits, acceptance, commitment therapy, cognitive behavioral therapy. All these things show benefit for people with chronic pain. And there are aspects of those all within yoga sort of as this package. And the idea would be that we could, with the person who has ongoing pain, the yoga therapist would be able to do an assessment to see how the pain has changed the person or influenced sort of all the aspects of their existence. And then try to find how we could use different techniques of yoga to help.

Neil Pearson:                07:08                So for instance, if a person was, let's take a common example, like the person who has chronic low back pain, but we know that with chronical back pain, often there's anxiety. Often there's grief. Well, there are aspects of yoga that we could use to address the grief or the anxiety. Often when we have ongoing pain, we have the sense of loss of self competence or self efficacy and we could use certain aspects of yoga to address those. Our body tends to get stiff or some muscles, you know, are gripping all the time. And within yoga we can do things to help to release muscles that are gripping or learn how to reengage muscles that seem to be inhibited. And so it's the practice of yoga would be to or yoga therapy would be to go through it and see how this individual is impacted and then see how we could use the different aspects within yoga to put together a plan to address a lot of the changes that are related to ongoing pain.

Karen Litzy:                   08:12                Yeah. So I think what you're describing may be a little different than what a lot of, perhaps the listeners are seeing. Meaning yoga is more than just handstands on Instagram and you know, doing these impossible moves and making them look so easy because I think that's what a lot of people associate yoga with. And so what we're talking about here is not just going to a yoga class or not just putting something fun up on Instagram, but the yoga therapist being very intentional in their prescription, the type of yoga therapy they feel this person needs. So it's individualized based on a proper evaluation.

Neil Pearson:                09:02                Oh, exactly. Yeah. Although the one difference in yoga therapy is that yoga therapy is not diagnostic, right? So the yoga therapist isn't a trained health care professional. So what the yoga therapist is doing is it's actually applying yoga, getting the person to do different aspects of yoga, like meditation or awareness or breathing or movements. And then seeing how the person is limited in that and then working with them to find a way so that they can do that particular technique to help them to change ease of movement of life pain.

Karen Litzy:                   09:40                Got it. Yeah. And there was, you know, something, we spoke about this a little bit before we went on the air, but there was a sentence within the book, the yoga and science and pain care that I had never heard of this saying before. I mean I'm not immersed in the yoga world, but it's the sentence is expanding our view and even altering our perspective to a Pancha Maya Kosha perspective enhances our understanding that pain physiology is studying the person as much as our biology. So can you talk about that for a little bit because I kind of liked that saying so you could expand on that.

Neil Pearson:                10:25                Yeah. So there's sort of the two parts of it is that that studying physiology is about starting the person, not just the biology, but then there's also this Pancha Maya Kosha which all start with that within healthcare we talked about the bio-psychosocial or bio-psychosocial spiritual model, which is intended to be an integrated view of the person that everything biological is going to affect everything psychological, it's going to affect everything social is going to affect the person who has spiritual manner and it's all working together as an integrated unit. So within yoga, the philosophy and the view of yoga is that there are different aspects of the individual, so the individual is integrated and whole, but we can look at the individual from different aspects to understand them better. And so I'm this pantry, my kosher view looks at the individual from a physical perspective, from a more energetic perspective, being Pancha is one of the things they're talking about, which really is life force.

Neil Pearson:                11:31                And then it really relates a lot to breath as well. But then there's within yoga to SIM Phi, we could say we look at they often call it the lower mind, but it's really getting at the automatic aspects of the human, all that stuff that runs automatically. And then there's above that or you know, I guess above it. There's this other aspect of us that this about us thinking about what we're thinking and it's about us regulating thoughts and emotions and breath and all that stuff. And then the other aspect of us is more the aspect of his that has more to do with spirit and connectedness to the world and everything. And so yoga already looks at the person from that kind of perspective. And with the idea that any change in one aspect of the individual is going to have an effect on the other aspects of the individual.

Neil Pearson:                12:25                So if you have a little back pain, it's going to change the way you breathe. It's going to change the automatic functioning of the body. It's going to change the way you think and emote and it will change your connection with yourself, your community. And that then you'll also have as part of its core belief system is that if a person that had low back pain, you could help the person with low back pain by going through any one of those aspects of the person so that you could help the person by affecting the physical body, by working on breath, by working on the automatic system, by working on thoughts and emotions or community that all those, everything interacts. And so that you could, you know, work at it through any of those aspects of your existence.

Karen Litzy:                   13:08                Got it. And as someone who has had chronic neck pain for many years, it is very true that the physical pain certainly affects so much else that is happening in your life. It affects your thoughts, it affects your emotions, it affects your relationships, it affects the way you hold your body, the way you relate to your body, the way you see your body. So now I feel like I have a much better idea as to what that sentence means and how yoga can help the individual relate to all of that and kind of put it all together. Cause sometimes when you're in it, you don't see it. Know what I mean? Like you don't see that you're not relating to your body, you don't see that you're moving differently, you don't see that you're breathing differently, you're clenching, you're holding, you just, you don't realize it because it's just the way you are as a result of the pain.

Neil Pearson:                14:10                It's so true. And I think one of the key things about what you just said is that the experience of pain often disconnects us from awareness of ourself even so much so that we know now from the science side that sometimes when there's ongoing pain that a person will have a hard time actually feeling the non pain sensations of their physical body. So you know, imagine a person with a low back pain and we asked them to take their attention to the rollback and tell us what they feel there. And typically what a person would do is tell us about their back pain. And then of course I get really sort of funny reaction to people when I say, okay, you told me about your pain. What I want you to do is take your attention back there and tell me the non pain sensations you can feel on your low back.

Neil Pearson:                15:02                Which a lot of people, you know, really don't get that. And I say, okay, well you know, just right now take your attention to the feeling of your hands. Your hands are resting. Can you feel your fingers? Can you feel the temperature of your skin in your hands? Can you feel the angle of the knuckles? You probably can feel a whole lot of non pins sensations there and say if you had low back pain, I'd probably say, okay, now take your attention to your upper back, your mid back and notice the non pain sensations. They're just sort of exploring. Scan around. Okay, now what I want you to do is go down to your low back. No, just the pain. Sort of acknowledge it. Now what I'd like you to do is see if you can feel non pain sensations in that same area.

Neil Pearson:                15:41                So maybe you need to try to look under the pain or around it or through it. I feel that and it's amazing that some people will say, you know, I really don't experience anything right now except the pain. All I feel there is pain. I can feel my mid back, I can feel my upper back, but my low back, it's pain. That's all there is. And then other people will say, I can sort of feel it, but it feels like it's murky or muddy or hard to feel. And then, you know, we don't often get it with low back pain, but say what was your hand where the pain was? Well often people when they start to do this say, you know, my hand doesn't feel this right shape or size. It feels like it's too big or it feels like it's too small. It feels distorted.

Neil Pearson:                16:24                And so it's really interesting is that the practices of yoga specifically get people to take their attention to their physical self to try to reconnect to those sensations. And this is always part of yoga, but in Western science we're finally understanding this. It's really only been in the last five or 10 years where we've paid attention to the distortions of body awareness and body image that are common when pain persists. And, of course this becomes really fascinating to me because the next part is, as a research guy, I get stuck in because I know clinically when a person tells me that, that when I get the person start to work on finding those subtle non pains and sensations of their physical body, that when the person starts to be able to feel those sensations, that there's an associated decrease in their pain.

Neil Pearson:                17:20                And then the more the person is able to feel the subtle non-painful sensations of self, the more the pain diminishes. But I can't give you any good scientific explanation for that. You know, we see it clinically, but we can't fully explain it in some sort of, you know, central nervous system or insular cortex or any of those things. We just can't explain it. But to me, that's part of the interesting thing about both the practice of yoga is that it's driven by experience. And yet what the science is now doing is showing is that there's science that says that, you know, the experience of yoga aren't just all in your head. They're actually real measurable changes in the humans biology and physiology.

Karen Litzy:                   18:08                Yeah, it's really interesting. And I wonder now you have me wondering, well why do people experience that decrease of pain when they start, you know, looking at the painful areas more than just painful. I mean, are they making changes in the sensory cortex? Is it affecting that idea of smudging that maybe they have a clearer outline of what that body part is now in the brain? And that can lead to changes? I don't know, but it's really an interesting concept.

Neil Pearson:                18:45                Well, and the thing about that too is that as we start to study more our sense of our physiological state, we start to realize that body awareness and aspect of it is, or a big aspect of is happening, sort of outside the sensory cortex. It's happening more in the insular cortex. And so I know in the last year I saw one research study that was saying that they couldn't find any smudging and people who had altered body awareness, but they were looking at the sensory motor cortex and didn't look at the insular cortex. And so it's another area as the research goes on, is maybe that smudging is happening in a different place or that alteration of brain activity is happening in a different place than we thought, but certainly the person that is experiencing it and if the person is experiencing it, we hope we can be able to find, you know, the correlate in the brain activity.

Neil Pearson:                19:45                Of course our, you know, our sciences far beyond or far behind, the experience that the human has, which really gets back to that other aspect of what you're saying is that that statement is when we study physiology, we hope that by studying physiology and pain physiology, that what we start to do is understand the human more rather than, maybe I'll say it this way often when I go to pain society conferences, there's a lot of biochemistry people there and they're talking about their research and at the end of it, they nearly always say, so what the science says is that here's this target for pain care, for pain intervention. And what they're talking about is that, we could give a chemical to the person to target this thing, this gene or this ion channel or whatever it is to change the person's experience of pain. And of course, my question always when I'm there is, so is there anything that the human could do to change that

Karen Litzy:                   20:48                Outside of something pharmacological?

Neil Pearson:                20:50                Well, exactly right. And it would make sense if, if we're getting good effects from different treatments. Like yoga therapy that obviously they must be affecting these same biochemical and genetic and epigenetic things within the human. But they're doing them through the person's own, you know, we can say through their own medicine cabinet.

Karen Litzy:                   21:13                Right. That medicine cabinet in the brain that David Butler talks about.

Neil Pearson:                21:17                Yeah. Yeah. And I think we can expand it into the human right. Because there's a, you know, especially even with the endorphins, cause there seem to be receptors for those all over the body.

Karen Litzy:                   21:29                Or even, you know, up and coming research into the microbiome and things like that. I think is also an interesting study in pain and how can we alter our diets or can we alter what we put in our system to change the pain experience?

Neil Pearson:                21:55                Oh, absolutely. And I think this, you know, when we get to nutrition, the book actually has a chapter on nutrition. And, one of the things that we find one scan clinically is that some people change their diet a lot and really have very little change in their pain or their quality of life. Other people change their diet even just a small amount and get a massive change. And this, once again is part of the thing that is the complexity of pain care is that, we, you know, as an organism, we are a whole bunch of systems together and sometimes you can change one system a little bit and it really, really changes the organism or the person and others times you change that system a ton and you get very, very little change in the human. And that's one scan, part of the trouble of pain care. But part of the advantage of approaches like yoga therapy is because they're sort of okay with that idea is that everyone's fully individual and we don't have everyone should change their diet this way, or everyone should move their back this way, or everyone should, you know, stand this way or, right, right. It's not a linear model at all.

Karen Litzy:                   23:11                Yeah. No, definitely not. And then when you think about pain and you think about it as an experience, and if we're going off of all the different inputs that can be put into the body, that can have impact over one's pain experience, and you think of all the different ways you can alter those inputs, all of a sudden treating the person with persistent pain goes way beyond just movement. Right? It goes into all of those myriad of inputs that you have ability to alter, whether that be as the yoga therapist, a physical therapist, or let's not forget the person experiencing the pain themselves.

Neil Pearson:                23:54                Oh, it's so true. Yeah. And with that last comment, you made, the person experiencing pain, the one thing we were really happy that we did within this book was that's her first chapter. So Julietta Belton wrote the first chapter on the lived experience of pain because we wanted to bring it back to, you know, this is why we're doing this work. It's not, you know, it's not that we're all just trying to understand pain. We're trying to help people. But back to movement, one of the things I think is that physical therapists and yoga therapists, anyone who's doing movement therapy, I think one of the really important things that we can do is start to shift our view of movements as though we can use movement for more than helping a person to be flexible, helping the person to be stronger.

Neil Pearson:                24:39                And within yoga therapy, we often do this. We'll say, you know, when you're in this yoga posture, it's not just affecting you on the physical level. It's affecting you on every level. And so we can actually use some of the yoga postures to help with other issues related to pain such as, so I was thinking about, so,one when we do a seated forward bend. So maybe if you have back pain, it's really hard to do it, but you still can get in that kind of position where you're sitting on the floor. Legs were straight or bent in front of you and your trying to reach down towards your knees, your shins, your feet, wherever you get to. The metaphor here is of learning how to let go so you can move forward.

Neil Pearson:                25:29                And so, we can use a lot of the different yoga postures like that is that we're thinking. So here's a person who is stuck, right? The person is, you know, maybe it's letting go of the need to have a definitive diagnosis because a lot of times that happens and sometimes to be able to, we see the person clinically that, you know, when we're in this multidisciplinary pain management setting, we say, you know, it seems to be this, one of the big things that stuck for this person, they're stuck believing that they need that to be able to move forward. And so we can use movement or postures to try to address other issues like that. Or as maybe another one that makes a little bit more, is more clear. Often we feel a sense of fragility when we have especially low back pain, pelvic pain.

Neil Pearson:                26:19                So if we can get you to come into one of the standing warrior postures, when people, the majority of people in a warrior posture, I'm standing with your arms reaching up or out to the sides. There is a sense of strength and stability and connectedness when you do this. And the really nice thing is we could do those postures from a seated position and people still feel that same kind of thing. And so the idea is could we use movement to effect the person on a psycho-emotional level as well? Could we make that out? One of our goals is this person who doesn't feel strong, feels unstable, feels fragile. Could we use movements not just create physical strength, but to address the other changes that are happening to the person? I think so.

Karen Litzy:                                           Yeah. I think so too. And I love that yoga has got that part and I hope that other movement practitioners start to think, well, you don't need yoga to do that.

Neil Pearson:                27:16                Right? You can use any, you know, think of any movement that we do and how it makes us feel. Could we address it that way. And then the one other thing that movement has tried to address in one of the chapters in the book is the idea of using movements or yoga therapy as an educational agent. So I know your listeners all know about explain pain and that wonderful work there. And what we're doing with explained pain really is it starts with a cognitive behavioral therapy, right? We're changing auditions to change their behavior. And so for a lot of the people that we work with, they may not have learned how to learn by sitting and listening or reading a book. They may have learned how to learn by doing. And so one of the things we're playing around with is the idea of when a person has ongoing pain, could we get the person to move in a way that could sort of, when the person moves that way they feel an increased sense of ease or they get some increased movements. And then you use that change from the movement as the educational agent.

Karen Litzy:                   28:21                Saying like, look at what your body can do. Yeah, same thing.

Neil Pearson:                28:26                Yeah. Well you can start with, wow, that's awesome. Your pain changed, right? Because that's one of the core messages of explained pain is that right? Changeable. So instead of telling the person that pain is changeable and explaining it to them, if you can get the person to do something and at the end of it, they have less pain or more ease of movement to say, look, it changed. And of course the next step is, and you did it. And so I would then jump into, let's look for all the other things that you could do to actually change this, which is saying to the person your pain is changeable. And you have some influence in it, which is part of what we're trying to do with pain.

Karen Litzy:                   29:09                Yup. Yeah. It's like giving them the keys to the car.

Neil Pearson:                29:13                Exactly.

Karen Litzy:                   29:13                Right. And having them be in the driver's seat versus feeling like they're the passenger and the pain is in the driver's seat.

Neil Pearson:                29:24                Oh yeah. That's a really great way of saying it. And I think clinically what we want to do is both with people we, you know, we want to find a way to integrate these things, but I really, really believe that there's a lot of the people we work with would understand pain better if we got them to experience it. Experience what we're trying to tell them.

Karen Litzy:                   29:47                Yeah. And we know experiential learning for a lot of people is something that sticks.

Neil Pearson:                29:54                Exactly. Yeah. And I think that's the thing is that there were a whole bunch of people that when we explained pain, it changes their cognition, but it immediately they get it, they understand it. It's powerful enough to change their behavior. But then there's other people then some of the research shows this now is that some people have this sort of partial reconceptualization of pain. They understand everything you told them, but they don't apply it to themselves. And so what you're going to need to do at that point is get the person to have the physical experience that matches up with the cognitive experience. And I guess what I'm saying is that what we could do is use the movement practices of yoga or any kind of moving practice for some individuals as the educational agent first and then, I think we need to start to play with that because some people just don't learn well when we talked to them, at least not as well as they do with the physical experience of it.

Karen Litzy:                   30:58                Yeah. And I think as the therapist that you can kind of get a sense of this after one or two visits that okay. It seems like they understood, but yet they're not able to apply this to themselves or are they kind of come back to you with the same, I don't want to say the same complaints cause that's not right. But with the same maybe problem solving outlook that they did before when you know, you've kind of spoken about pain and maybe how pain works, let's say from explaining pain and they're still coming back to you with this same idea. The same. I did this so I must have done something wrong. And that's why it hurts because I keep doing this to myself.

Neil Pearson:                31:55                Exactly right. There was something in what you said too that made me think that it's possible that that person coming back,  doesn't have the coping strategies that match up with the new information that they learned. So the person's, you know, coped by being saved, being tough and just sucking up and gritting your teeth and pushing through it or coped by fear avoidance. And so we've given them this new information, but the person that hasn't, when the pain worsens, they go back to the coping strategies that don't match up with the new paradigm.

Karen Litzy:                   32:29                Right. Yeah. And that was really hard for me to do as well. So what would happen, and I'll give an example of what that means. I think you correct me if I'm wrong, but I used to get a lot of neck pain in my sleep so I'd wake up and kind of feel a pop and then wouldn't be able to move. And what my original coping strategy was hi, I have to call off work today because I need to stay in bed. So I would stay in bed. I used ice, I would use heat but I wouldn't move and that did not do well for me cause like it would help in the short term maybe that day. And then I'd be able to get back into things the next day. But I was still in an awful lot of pain. I mean, maybe I was a nine out of 10 and then I was at seven out of 10 but the seven out of 10 I could function. You know what I mean?

Neil Pearson:                33:24                Yeah, absolutely.

Karen Litzy:                   33:25                Until I started going through explain pain and moving more. So now if I wake up and I feel that pain, my first thought is not, Oh, I better lay in bed. It's okay, let me get up, let me start stretching, let me start moving, let me go to the gym and at least get on a bike. And now, because that's sort of my new shift in thinking that maybe the pain will last only one or two days and not forever. Because before it was this high level of pain with a higher spike. And now it's just little to no pain with a spike or a flare up, if you will, a couple times a year. But knowing the moment I feel that, that I get my butt to the gym and I realized that movement is the thing that helps and that I shouldn't be fearful of that. So for me, that was the input into my system that helped and everyone is different of course, but I think that's a real life example of what you just said.

Neil Pearson:                34:27                Yeah. And I think it's great one because what you've said is that what you've found is that you can change the pain and the ease of movement through movements, but also I think what you're saying as well is there's somehow there's a different relationship with your different perspective on it. You're understanding it in a different way.

Karen Litzy:                   34:48                Yeah. It's less as this sort of monstrous threat that's going to take over my life for the next couple of weeks, days, months versus now. It's like a little annoyance that I know I have the coping skills and the mechanisms at my disposal that I can make a change for myself versus going to a doctor for a quick fix of a pain medication or something, which is what I used to do.

Neil Pearson:                35:22                Yeah. Well and what I'd say is, well as within yoga and yoga therapy is that a yoga therapy will offer you more on expanding a number of coping strategies or alternatives. We often think of as making people more flexible in their body, but it actually makes us more flexible in how we adapt or modify things when pain persists. So, you know, you wake up in the middle of the night, maybe one of the things is that I'm laying there and actually taking your attention to the pain and exploring the pain. Actually spending some time doing that or the practice of noticing what's happening to your breath. So now or changing your breath or noticing what's happening in your body tension or changing your body tension too. Within yoga there's many, many different ways that you can try to impact things. We often say we want to do practices that have to do with awareness because awareness practices in and of themselves can be a beneficial when we have ongoing pain.

Neil Pearson:                36:28                And then there are other practices that are about regulation. So, you know, getting you to breathe in a certain way or hold your body in a certain way or move your body in a certain way or think a certain way. So with the awareness you can have awareness of your breath or your body or your thoughts or your emotions or your energy or the pain. And the same thing with regulation. You can regulate any of those and start to see what happens when you do either of these things. But then the one other bit you said too was about discernment is what you've learned. You've, you know, you've changed your view of you. You're now when you feel the pain, you can discern more about when the pain is like this, I need to do this. And when the pain’s like this, I need to do this. And, I think that's another positive that people can get or the practices of yoga therapy is that you start to actually understand your pain better, right? Be able to discern different aspects of it or different strategies that you need to do at different times where often when we have chronic pain, it's almost like we lose coping, right?

Karen Litzy:                   37:37                Oh, there's no question. You lose everything. You lose all perspective on yourself as a human being, you know? I mean, even as someone like me who is, I was a physical therapist when I first had all of this pain and you just completely, everything I learned as a PT flew out my brain. It was gone because all you want is for the pain not to be there. And the reason you want the pain not to be there is because you want to have a life with more choices and more possibilities. Whereas when people are in pain, their choices are you get up, you go to work and you come home. If you can even make it to work, those are your choices. That's all you have. You know, have kids, maybe it's struggled to take care of your kids or suffer through taking care of X, Y, Z. Right? Versus when you don't have pain, your options are, I can get up, I can go to the gym, but I can go to work or I can go to the gym, meet up with friends, go on vacation, you know, clean my apartment, go play sports. So all of a sudden you have a life of very little choice and possibilities to an opening of your choices and possibilities. And it's just because you don't have that pain anymore.

Neil Pearson:                38:53                Right. And I think that's one of the beauties of the practices that allow us to start to explore are there things that we actually can do for ourselves to try to change this? Or are there things that people can help guide us to be able to do that? Because I think when we're in that huge pain, what we're looking for is, you know, the thing that will just stop it, of course. And you know, we're living in society where the approach mostly is to look externally. And then one of the troubles that people have sometimes when they start to hear about yoga therapy and sort of the self care part is just this idea that it's almost like it's all up to me, right? You're telling me it's all up to me and what we want to say is no, that that doesn't really work well or we want to do is say, what you need is the expertise of a PT or a yoga therapist or an OT who can help to guide you and be there and you know, cheerlead you and coach you and help you through this.

Neil Pearson:                39:53                Because this is really, really hard stuff. You know, learning the techniques of yoga, if people really immerse themselves in it, they'll typically say, this is hard to do. Well, it's way harder to do when you're in pain. Right?

Karen Litzy:                   40:09                Right. And you don't want to think like, Oh, I have one more thing I need to do now. I need to do this. I've got all this pain, now I need to do this.

Neil Pearson:                40:17                Yeah, yeah, true.

Karen Litzy:                   40:19                But yeah, when you position yourself as the guide, you know, I've been reading this book by Donald Miller called the StoryBrand. And in it he talks about the guide who would be, in this case, the yoga therapists and physical therapists and thinking of them as like the Yoda and the student or the hero, he calls them the hero of the story, which would be our patients would be the heroes of our stories are like the Luke Skywalker's. So they're coming to you for guidance, you're helping them, you're giving them the tools, the confidence, in this case, the movement, the education that they need to go out and be the hero of their lives.

Karen Litzy:                   41:00                So it's not like, Oh, one more thing I have to do. If we can reframe that for those people in pain, it's more like let us guide you so that you have so much to do.

Neil Pearson:                41:13                Absolutely. And you know, there's one other piece that I just want to tack on the end because I'm sure you have some people here listening who have ongoing pain is that one of the really difficult things, and I know some, there's been some blogs talking about this recently that has importance is when we work with an individual who has ongoing pain, actually don't know what the outcome is going to be. I think we can be pretty certain that we can help people to be able to move with more ease and to have some less pain and to, you know, get quality of life. But somehow we need to say to people that, you know, when you do these things, you might be the person who says, you know, the pain is mostly gone and I really can do most of what I could do before.

Neil Pearson:                41:56                Or he might be the person who says, well, you know, the pain is better, but it's still there. But what you've been able to do is show me how to get back to allowing my life. You know, the pain is less, but I'd be able to get back. And then there's this other group that will say, you know, it doesn't seem like the pain really is changed at all, but you know, if we've been successful with them, the person will say that, you know, even though the pain is there, you've helped me figure out how to live and have pain. Right. And I think that's one of the struggles that people have when they hear us talking about pain management, is the struggle between you're looking for wanting so much the thing that will stop all the pain. But then not really recognize where maybe recognizing the ideas that for some people that's not the outcome.

Karen Litzy:                   42:50                Right. Yeah. And I try and, you know, and that comes, I think as the therapist, I think that comes, that's something that I think experience helps a lot. The experience of the therapist helps a lot because you kind of have a little more confidence to say to the patient, Hey listen, the goal here is to get you doing the things you want to be doing. You may still have pain doing them, but you can do everything you need to do. Would you be okay if you had a small amount of pain and were still able to do everything you want to do? Cause our goal here is not complete elimination of pain or, I mean, yeah, I guess that is the ultimate goal, but being realistic, we have to tell the patient, Hey listen, this may not happen. What if I told you you could do everything you wanted to do and the pain might be there if doesn't really, you're not suffering. It doesn't bother you that much. Would you be okay with that? And that's a hard conversation to have.

Neil Pearson:                43:51                Yeah. Well, you know, in the yoga world is it's somewhat easier because anyone who's a yoga therapist has, I mean that's what we've learned. That's really what yoga says is that we will have pain, we will have suffering in life. And the whole practice of yoga and yoga therapy is to actually learn how to live with it and decrease it. But it's not, you know, it doesn't have the goal of saying there's going to be none.

Karen Litzy:                   44:21                Yeah. And I think that that's important. It's important to tell patients. And that's the one thing, this is a total rant on my part, so apologize ahead of time. But you know, when you see websites and they're like eliminate your back pain by reading this free resource, well, that drives me bananas and it drives me crazy as a person who did have chronic pain for many years, you're searching for that thing and if someone puts it out there and then you read it and you're like, my pain is the same, I would be like, screw you. It didn't help my pain. It's like a crappy thing to do to someone because I feel like you're praying on very vulnerable people by doing that. And I think that's why.

Neil Pearson:                45:08                Yeah, I agree all the way. I mean, it's just not truth. It's a marketing stick.

Karen Litzy:                   45:14                Right.

Neil Pearson:                45:15                I'm like you, it enrages me. It's hard not to be the police though, right? You want to jump on and say, what are you saying then? And we know that, you know, within our professions, really within all the healing professionals or helping professions, there are people who unfortunately use language like that. Hopefully at some point we will be more compassionate.

Karen Litzy:                   45:40                Yes. Yes. I hope so because, Oh man, that is something that just drives me crazy. But I digress. Let's get back to the book. What do you hope people take away from the book after reading it?

Neil Pearson:                46:05                Well, I guess the biggest thing that I want people to take away with is this idea that yoga therapy is something we should consider as a one of the paths when people have ongoing pain. Overall, that's what I want people to do. You know, we don't think that yoga therapy is the answer. But we see it as something that can be integrated within our Western medical world with people with chronic pain and so integrated into that system. But also it allows more access because people usually can get to yoga therapy for less of a cost than they could to medical practitioners. So it's more just to see it as you know, as we've talked about, there's this view of what yoga is. Well, yoga is something different from that. And it actually does make sense as one path to consider when we're working towards recovery when pain persists.

Karen Litzy:                   47:01                Absolutely. And now before we end, I have one more question for you. And that's knowing where you are now in your life and in your career. What advice would you give to your younger self?

Neil Pearson:                47:16                Oh, wow. You know, after I graduated as a physical therapist, I spent the first four and a half years working in hospitals and worked, trauma, ICU. And I worked in a neonatal ICU and cardiac care and all these things. And, the thing that if I were to go back to that spot, I would say, Hey, you're doing the right thing. It's funny because a lot of my colleagues were working, you know, we're stepping right into private practices. And by being in that situation, what I not only did I started working as a physical therapist with this umbrella of protection because there were all these other people who are also working with the same patients in the hospital. But I learned such a humanistic view of what I was doing.

Neil Pearson:                48:10                I guess that's because a lot of the stuff we were doing in the hospital had to do with life and death. Now when you're working in a trauma ICU with neonates and so I think you know, cause I know there was a lot of pressure I wanted to work in, you know, sports medicine and in private practice. There was pressure not to be in the hospital. So I guess I'd go back and say you're doing the right thing cause it really helped me to see the person more than the low back or the shoulder or the knee.

Karen Litzy:                   48:50                Yeah. You know, I worked in a hospital first as well when I first graduated from PT school.

Neil Pearson:                49:00                There are some advantages to that.

Karen Litzy:                   49:04                Yeah. Oh yeah, absolutely. I think it like really increases your empathy and your communication skills. Cause you're like you said you're dealing with pretty sick people. And I wouldn't have traded that for the world. All right, so now where can people find the book?

Neil Pearson:                49:28                Well the books on Amazon. Awesome. So that's probably the easiest place to find it.

Karen Litzy:                   49:34                Yes. So we'll put the link in the show notes. So if people want to go to, they can just click on this episode and go straight to the book.

Neil Pearson:                49:47                Great. And if people want to learn anything more about the other things that I work on. My website is I'll share that as well with you on there. You can learn about the pain care yoga training that I do and I have a distance professional mentorship that I do for health care professionals as well.

Karen Litzy:                   50:11                Nice. That's awesome. And because you're up in Canada, right?

Neil Pearson:                50:16                Yeah, that's right. If you're in Vancouver and you drove East of it four and a half hours over a couple of mountain ranges, I'm in the Okanogan Valley of British Columbia.

Karen Litzy:                   50:26                Got it. Kind of. It is so big. Well Neil, thank you so much for coming on. This was a great conversation. I think it's going to give people a lot to think about when they're working with those patients in pain. So thank you so much. And everyone, thanks so much for listening. Have a great couple of days and stay healthy, wealthy, and smart.



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Oct 21, 2019

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Keats Snideman on the show to discuss the non-traditional path to physical therapy school.  Keats Snideman is a results-driven Rehab and fitness professional with over 20 years in the Fitness/Athletic Performance and bodywork industry and most recently the field of physical therapy.

In this episode, we discuss:

-How Keats’ background in health and wellness enhanced his learning in PT school

-The personal and professional pros and cons of being a non-traditional PT student

-The benefits of diversity within a PT cohort

-Time and resource management to avoid burnout

-And so much more!



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Reality Based Fitness Website



For more information on Keats:

Hello, my name is Keats Snideman and I am a results-driven Rehab and fitness professional with over 20 years in the Fitness/Athletic Performance and bodywork industry and most recently the field of physical therapy. My educational background includes a doctorate in physical therapy from Northern Arizona University (PHX Biomedical campus) and a B.Sc in Kinesiology from Arizona State University. Other certifications and titles held include: Certified Strength & Conditioning Coach (CSCS), Certified Orthopedic Manual Therapist (COMT, through OPTIM Manual Therapy), a Strong First Gyra (SFG) Level 1 Kettlebell instructor, a certified Kettlebell Functional Movement Screen Specialist (CK-FMS), a certified neuromuscular therapist (CNMT), and a licensed massage therapist (LMT) in the state of Arizona.


Read the full transcript below:

Karen Litzy:                   00:01                Hi Keats, welcome to the podcast. I'm happy to have you on. So today we're going to be talking about the non traditional path to physical therapy school. And the way we're kind of defining this nontraditional path would be you didn't graduate from high school, go to undergrad and right into physical therapy school. So there was some time off in which you had a completely different career. Well, yeah, a different career and then decided to go into physical therapy school a little later in life. And I use that in quotes when I say that. So what I would love for you to do Keats is can you kind of tell your story to the audience so they get to know you a little bit more?

Keats Snideman:           00:45                Yeah, absolutely. So like a lot of PTs, I have a fitness background, I ran some college track, got into working out and decided to become a personal trainer. This was like mid nineties, so quite, quite a long time ago. And that sort of led me down a little bit into the sort of functional fitness was kind of becoming a thing kind of in the 90s. And people who are beginning to use that word function a lot.  I have a twin brother also in the fitness world and we got exposed to a gentleman named Paul Chek. He's the guy who kind of popularized the Swiss ball, the physio ball doing the weight training on it, standing on it, doing all that crazy stuff. This was in like 97 to 99. And Paul Chek was also very rehab oriented, not a physical therapist himself, but started opening my eyes to sort of the world of sort of biomechanics and you know, it's sort of high level physiology, and started reading, you know, more technical sort of physical therapy type books and it really interested me and I was like, wow, there's more there than just being a personal trainer.

Keats Snideman:           02:00                So I sort of made a decision at that point that I wanted to go on and get, I think it was a masters degree. Most of the programs at that time.  But then life happens. Got married, had our first child. I had my own business and eventually I went back to school to finish my bachelor's degree at Arizona state university. And really had the idea of going kind of into PT school pretty quickly after that. Had another child, open up a different location for my business. And time just goes by, you know, very, very quickly. And the next thing I knew it was 2012, 13. I was like, if I don't go to school now, I'm never gonna do it. But all the time through that I ended up getting a massage certification or I got in the early two thousands.

Keats Snideman:           02:47                So I started putting my hands on clients who needed it. I started getting some soft tissue clients and basically really trying to find out, you know, what's the best way to use that tool? Cause I wasn't really like a massage person per se. I kind of came into the sort of the manual therapy body work world as more of a fitness person. How could I get somebody out of pain is pretty much the number one thing why people were seeing me so that I could get them more active to get them more mobile, that really fits in to what a lot of physical therapy does. Sort of our modern understanding of pain as it's changing that the therapy is just sort of a, you know, like a brief reset to try to then help, you know, we get that window of opportunity to try to make a change.

Keats Snideman:           03:43                And so that, you know, that finally allowed me to make the decision to go to school because I want to be able to do more than just what a massage therapist can do. And more, you know, I wanted to be able to do, if I want to do a joint mobilization or manipulation like a chiropractor could do, you can't do that as a massage therapist. And so that was the final decision. I closed up my shop, I went back to school, I bit the bullet. It was a very challenging road, but even with the family and everything and I got through it, finished a few years ago and here I am.

Karen Litzy:                   04:18                And I mean that's quite a story and we'll get into some of your words of wisdom and advice for other people who might be in the situation where they have a family, they have children, they don't know if they can do this because it is very time consuming. But before we get to that, I would love to know if you could name a couple of your top struggles during PT school that you were obviously able to overcome. Cause you did graduate, you're now a physical therapist. So give us some of your struggles and what you did to help get over them.

Keats Snideman:           04:53                Absolutely. So I would say the first thing that was really, really the hardest for me and my program was at Northern Arizona university. And we were the first class to be sort of accelerated instead of a three year program. It was a two and a half year program. So we didn't get really a lot of breaks. So the coursework I think was condensed a little bit more. And so that meant a little bit higher level of information that we were obtaining. So that first semester was a bit like hazing for me. I've constantly been learning and taking continuing education courses my whole career as a massage therapist, personal trainer, strength coach. But I wasn't quite prepared for the onslaught, sort of the drinking from a fire hose type of thing, if you will, that that first semester did.

Keats Snideman:           05:42                And I end up getting a C I think in pathophysiology, which was, it was like in memorizing a thousand PowerPoint slides and two every two weeks. It was brutal. And that put me in academic probation. You can't get a C in PT school. I mean, are you going to get many of them C B’s and above? And so that was, you know, I was worried, I thought, man, am I gonna flunk out? You know, I just started after all this, you know, what am I going to tell my family? This is terrible, but I got through it. The rest of my grades were actually quite good after that. But if you haven't been sort of in the academic setting for a while, you've really got to kind of give yourself a little bit of an adjustment time and not be so hard on yourself to the expectations for like getting these great grades needs to be tempered because it's intense.

Keats Snideman:           06:35                Obviously you went through it. The amount of information that a physical therapy student will be exposed to is pretty insane. I know medical doctors get a tremendously crazy amount of sort of, you're sort of a general as first, but I think PTs have gotta be some of the broadest sort of scope practitioners out there and me, it was sort of like med school light, you know, a lot of our classes are actually with PAs because we were actually kind of getting sort of the university of Arizona medical curriculum that was given to the PAs at NAU and we were sort of teamed up there with them and some of the occupational therapists as well. So that was my biggest struggle was just the amount of information was just overwhelming. But once I kinda settled in and really focused more on comprehension and learning instead of just getting good grades, I've never been a grade person. I couldn't really care less, unfortunately you need to get good enough grades to pass and then not get kicked out of the program. But I've always been about, I want to understand. So I think if someone who hasn't been in school in awhile, kind of a non traditional student like myself, you've gotta be easy on yourself and you've got to give yourself time to adapt and to adjust to that, just that amazing, wildly overwhelming amount of information that you can get, especially in that first semester, that first year.

Karen Litzy:                   08:07                And how did you balance the amount of information, the studying the comprehension. And I liked the fact that you said you're there to learn and comprehend, not just memorize, but that was in PowerPoint slides which I think is great advice for anyone. But how did you balance this with a wife and two kids?

Keats Snideman:           08:27                It wasn't easy. I wouldn't really say that you can, it's not balanced and you know, the family has to be on board. Obviously my kids are a little bit older. My wife obviously she knew how much this meant to me, so she was very supportive. I wasn't able to be as involved with my kids and their sports and stuff. So there's definitely sacrifices. You can't pass PT school. Even if you're just a single younger person who doesn't have any problems, your life will not be balanced if you are in any doctoral program, especially one like physical therapy. So I wouldn't say I really balanced it, but when I had the time and I needed, because you can't just study, study, study, study, you will literally burn yourself out and there comes to a point, kind of like a sponge that's just saturated with water.

Keats Snideman:           09:15                It won't take any more. It just doesn't work. So you have to give yourself little breaks more frequently. And for me, you know, I grew up sort of this ADD never got diagnosed until I was an adult. That's even more important cause I think my executive functioning skills burn out very, very quickly. So I do very well with like the Pomodoro technique where I do like 25 minutes and then take a five minute break or maybe that's 15 minutes, right? Things like that where you do like little mini sprints rather than a marathon of learning. So you give yourself time to get into what's called like a diffuse mode of sort of learning where you have the focus mode, where you're really putting a lot of effort, but then you gotta just walk away, go for a walk, juggle play ping pong. We played a lot of ping pong. If you have a ping pong table and you're like, that really got me through school. I love ping pong. I love it. I have a thing on the table in my house. And just doing something completely different. I'm very much into exercise activities, sprinting, little mini workouts, little mini resets. I feel that helped get me through it. You can't just sit there for hours upon hours and hours. You will just literally just be wasted time.

Karen Litzy:                   10:35                Yeah, that is wonderful advice and I think that carries over nicely even when you start working as a therapist as well. Great advice. Now let's talk about some of the positives of going back to school as a nontraditional student.

Keats Snideman:           10:58                Yeah. Well for me, there's a lot of positives because I had already been working with people for so long as a personal trainer, a strength coach and a massage therapist and sort of a hybrid of all those kind of at the same time that I've been dealing with people for so long. And a lot of these young millennials that are just, you know, like you talked about more traditional which is definitely a good way to do it. Don't get me wrong, I kind of wish I had done that, but they don't have sort of the life experience and the ability to deal, I think with a lot of the psychological and more of the interpersonal issues that will come up when you're dealing with people in pain and dealing. Like once you lived a little bit longer, I feel like you just get it a little bit more. A lot of people in PT, at least sort of in traditional outpatient or even acute, they're a little bit older and I feel like you can relate to them a little bit better.

Keats Snideman:           11:51                And it helps me to think about something like soft skills that the professors would talk about and I'd be like, wow, I guess I'm kind of lucky in that respect because I'm older. I kind of already have had to develop those over the years. Those interpersonal communication skills and they would tell, you know, my classmates, these younger sort of millennials that it doesn't really matter what you get. Like, yeah, you got to pass the boards, you gotta pass this, you gotta be smart. But you know, being first in your class, like it doesn't mean you're necessarily gonna be the best therapist. And nobody's going to ask you, Hey, Karen, you know, can you tell me what you got on your NPT boards, et cetera? Oh no, that's too low. I want to work with this person over here.

Keats Snideman:           12:36                Or Hey, what'd you get in your patho though? First? Because it doesn't matter, right? You've got to get through it. You can always, you don't need to memorize everything, just you need to know it enough to pass the test. But the most important thing in physical therapy is your ability to empathize, to be empathetic and to deal with another human being that you're dealing with. And I felt like as an older student that was something I kind of already had. So that was like a big plus I think. And when I'm working with my a little bit older clients and patients, I think that helps. So that's a big plus that you can't really get except through time and going through all those different sort of client and patient interactions over the years that will sort of, you know, cause you have these fits sometimes with clients, they don't work well. You don't always buttheads so you develop a certain amount of grit that I think as a bit of an older student you don't have to develop as much as the newer, younger ones.

Karen Litzy:                   13:45                I think that’s a huge positive. I mean experience counts. Experience counts. What other positives did you find even maybe as you were going through the program or looking back on it now?

Keats Snideman:           14:03                Well for me with my background and there were other students in there that were like in their thirties. There was one other guy in his forties, you know, it was like the real grandpa. He, you know, he was a little younger than me. But my background was in fitness and in massage. So I had already kind of educated myself a lot on anatomy and physiology. Since we had this sort of medical curriculum. We spent like six weeks or something on the organs and the guts and I didn't really know that too well, so that was pretty hard. But the rest of this stuff sort of with my background wasn't too hard in terms of it's like I felt like I had already prepared myself for that. Contrary to popular belief, you go to PT school more to learn about differential diagnosis and how to not really hurt somebody, you know, it's more like med school light than it is about, like, I'm going to become sort of a mild personal trainer. Like you don't spend a ton of time on the ins and outs of exercises.

Keats Snideman:           14:57                They sort of say, well you're going to get that in your rotations. So a lot of people who are more non traditional that had come maybe from like insurance or a different world, they didn't have a much of an exercise background as me. They were really looking for that in school and we didn't get that as much. It's not really what it's about. You get that more on your rotation. So I felt like my previous background had made up for that gap that we weren't going to get in school. I had already sort of gone through the sort of the painstaking self studied it just really sort of figure out like you know, which exercises are appropriate for all the different muscle groups and movements and doing sort of like a needs analysis for the sport or the activity.

Keats Snideman:           15:52                Cause that's not really what you're getting in PT school. And I think people don't always understand that they think they're going to learn like everything about exercise. And that's kind of not what it's about. It's more like I keep saying sort of like this being sort of a primary care provider light. You know, and now most States have direct access. So, you know, like taking blood pressures, understanding cardiovascular concerns, understanding pharmacology and like the basics of like protecting, these are real things that are very important that that's what I got out of PT school the most was sort of that thing being sort of, I'm trying marry care provider and the exercise stuff is sort of secondary.

Karen Litzy:                   16:40                Yeah. So because you had had this other career before you came into PT school, you were able to kind of be on top of your game I guess. And like you said, you were able to fill in some of those gaps in PT school with what'd you already knew. So that is obviously a huge positive. Any other positives that maybe if someone out there is thinking, Hmm, maybe I want to go into PT school, but I'm like over 40 or I'm over 30 or 35, you know, or I'm married, I have kids. Were there any other positives that maybe not even related to physical therapy but maybe spilled over into your home life or your personal life?

Keats Snideman:           17:19                Well I think it was good for my teenage boys to see that even as an older adult that, you know, the amount of effort they saw, how much I was putting into it, how much it meant to me to just to show them that if you put in the work at any age, like you can still do some pretty cool things. And, you know, you can teach an old dog new tricks. I mean, I think the younger brain learns a little quicker. I don't think there's a lot of debate about that. You can still do it. So for me, I think the positive was it gave me a sense of belief that if I'm really determined that I can find a way. So gave me like a new level of confidence in myself that I have the grit that I have, that I had to take the GRE three times.

Keats Snideman:           18:09                And for those who don't know, that's the graduate record examination that's put on by the people who create the SAT. So it's sort of a SAT for college grads and I hadn't done like high school math, since like 80s and early nineties. So, you know, I did well on those other parts, but I just couldn't remember like basic stuff. I had to get the book. So it gave me sort of a new level of confidence that, you know what, even when things are really tough and you feel like you can't get through, like you can and you know, and you just got to kind of plow through it, like the time will go by anyway. And you just gotta figure it out. How can you work with yourself? To try to, you know, accomplish the goal as challenging as PT school at any age.

Keats Snideman:           18:54                It's challenging but definitely harder if you have a family you've been out of sort of that test taking mode. I used a lot of like some of these other like apps where it sort of makes you keep doing the ones that you're not good at. Cause you do have to memorize some stuff for the test. Let's face it. But if you take the time and you're just, you don't be so hard on yourself, you can get through it, you will get through it.

Karen Litzy:                   19:25                Absolutely. And now again, the question I ask everyone on the show is, and I feel like you kind of just answered it, but I'm going to ask the question anyway because maybe you have a different answer, but what advice would you give to yourself, your pre PT self knowing where you are now in your life and in your business and in your work? What advice would you give to your pre physical therapy school self?

Keats Snideman:           19:54                Well I think I was very hard on myself for like initially doing poorly in that first semester especially in that pathophysiology class. But I really thought that I could get through it easier. You know, I just thought like, Oh, this, you know, this is going to be good. I've already sort of learned a lot on my own. I sort of underestimated. So I scheduled my sort of personal training and my sort of my whole clientele in a way that was not realistic. So, you know, working I think is good if you can do it, but giving yourself sort of the permission to say no to certain things that this is an important commitment. And that, you know, not to beat myself up that I'm not earning as much as I could potentially earn by working more because this is an important goal and I need to focus, you need to get it done.

Keats Snideman:           20:56                There'll be plenty of time to work after, but I did work throughout my whole schooling. I was trying to bring in a couple thousand dollars a month, you know, for my own clientele. And I did, but that was about probably about a third of what I had originally sort of thought I could do. So I did have to take out a little more loans than I wanted to, but once I sort of realized that it's okay, that sort of like lowered that stress levels for myself, that just is a huge commitment that I've put on myself that I can do, I could commit to all these different elements. And there's only so much time in a day. Like, you know, there's only so much energy you have, you know, sort of like money in a bank. You don't have the, we call it like units of energy.

Keats Snideman:           21:40                I don't have a hundred units of energy for school and a hundred units of energy for my family and a hundred and some energy for my clients. I have a hundred units total and that's what I sort of figured out. So I would give myself the advice then manage your units, you know, manage your physical and emotional capital because there's only so much and you just have to be realistic. And I just, I was not realistic with myself with what I thought I could do versus the reality. And once I sort of kind of had that sort of come to Jesus moment, I was better cause I was okay with it.

Karen Litzy:                   22:13                Well I think that's great advice. So giving yourself permission to prioritize things in your life and doing it all to 100 percent. Excellent advice. Now is there anything else that you wanted to let the listeners know before we sign off about being that nontraditional student in physical therapy school?

Keats Snideman:           22:34                I think we need more non traditional students. I mean I think it only helps the programs. I think if any of my classmates that are listening to this, hopefully they are, they can agree. I think a lot of people appreciated me in the class because I would ask the questions. I find if I didn't, interesting kind of being with sort of this younger generation, it's like they're just programmed and it's kind of like robots that just like get the information, figure out how to you know, memorize it, regurgitate it on a test, move on. And it's more about like passing and getting to the next level than it is about mastery and comprehension and not a lot like questions are asked about things that I thought maybe that the teachers explained that were confusing. So I would ask the questions, I'd be like, well what about this and what about that?

Keats Snideman:           23:32                And because I'd been in the real world for longer. So I think having that older student and maybe some people thought it was a little bit annoying and that's okay. I'm okay. To me, I’m that guy, because I think it was helpful for the betterment of the class. And when you have somebody who's lived a little bit longer, like you just don't care as much. You just, if something's important to ask, it's important. Like you don't have to go, Oh, I'm not going to ask cause I don't want to like offend anybody or you know what I'm saying? So like having those little more seasoned, non traditional students, I think it spices things up a little bit. And I felt that I kind of provided that for my class and it really sort of, it kinda helps sort of broaden the curriculum by bringing in more real life experience of working with people.

Keats Snideman:           24:25                Not that I was a physical therapist, but I was working with people in pain, working with people who had weakness and you know, fitness issues, which is what we do a lot in PT regardless of your setting. So that's my advice is that if you’re really, really passionate about helping people in that domain, that we need more nontraditional, a little bit older students in these programs because it really helps to just sort of broaden the scope because of what we can bring with our experience as everybody else in the class. Everyone has their own experiences. Even, I mean young, middle age, older, it's all good. Like to have a variety instead of just everybody being the same. Like I'm all about diversity and I think we should just embrace more diversity. And like I saw something on the news, I think it was the other week on CBS or something and it was some guy like he was like a car mechanic and he went back to school like in his late fifties and he got his medical degree that just like, I love it. That's stuff just like juices me up and he's bringing all his experience to that program. That must have been really neat for the other students.

Karen Litzy:                   25:37                Yeah, I could not agree with you more. And now where can people find you if they want to chat about your experiences or if they have any questions for you?

Keats Snideman:           25:47                Yeah, I'm a pretty Googleable guy. I've got a couple of websites that are sort of in shambles right now, but if you just Google my name, Keats Snideman, I'm on Facebook, I'm on Twitter and Instagram. I think it's a @coachKeats and then I think it's Keith Snideman is what I'm on for Instagram. I'm trying to figure out this whole social media thing. For my own business. I do a combination of PR and work and then just my own, I'm too much of an entrepreneur to work full time for anybody else. But if anybody wants to email me, it's I love helping people who are non traditional to sort of, you know, make the decision. I mean it's not for everybody, but if you're on the fence, I talked to people frequently who sort of find out about me and I would love to talk to you about it.

Karen Litzy:                   26:43                Awesome. Absolutely, all of that information will be in the show notes for this episode at so that people can one click and get to you in any way possible. Perfect. We'll have it all there. So Keith, thank you so much for taking the time out while you're here in New York, dropping your son off at NYU.

Keats Snideman:           27:01                I know. Crazy. Yeah, it's been a blast. I'm so glad we got to meet up today. I've always wanted to, you know, talk to some other PTs when I come out here and I'm just, yeah, I'm very, very glad that I was able to get on your show. I've been a big time fan of your podcast when I was a student. I'd share it with my fellow classmates. Your doing an amazing job of just getting amazing people and concepts out into the world.

Karen Litzy:                   27:26                Well, thank you very much. And, I again, thank you for taking the time today and everyone else have a great couple of days and stay healthy, wealthy and smart.


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Oct 14, 2019

On this week’s episode of the Healthy, Wealthy and Smart Podcast, Jenna Kantor guests hosts and interviews Cameron Massumi on new graduate engagement within the American Physical Therapy Association. Cameron Massumi, SPT is the president of APTA's Student Assembly Board of Directors.

In this episode, we discuss:

-Cameron’s passion for new graduate engagement within APTA

-Inclusion and diversity within APTA

-How to engage in networking events

-Ways you can get involved within your professional organization

-And so much more!



Cameron Massumi Twitter                                                                Outcomes Summit: Use the code LITZY for discount    

For more information on Cameron:

My name is Cameron Massumi, and I am the President of the Student Assembly Board of Directors. I believe that APTA serves an integral role in ensuring the future of our profession through advocacy, public awareness campaigns, and the sharing of a unified vision. However, there is, unfortunately, a marked decline in membership as students graduate from PT school and become active clinicians. It is my goal to stop this from happening and hopefully bring new graduates back into the APTA. My strong background in sales and marketing as well as my leadership experiences prior to entering PT school will allow me to bring a unique skill set to the Board of Directors. I

will use these skills as well as my connections to ensure membership and engagement increase so our profession can continue to grow and become stronger. My vision is that through my leadership the student assembly can help promote awareness of the profession, increase diversity, and boost member retention. As a profession we need to collaborate, innovate, and strive for excellence. APTA is the best tool to ensure the success of our profession so that we can #MoveForward, so let’s get together and create some real change. After all, we’re #BetterTogether!


For more information on Jenna:

Jenna Kantor (co-founder) is a bubbly and energetic girl who was born and raised in Petaluma, California. Growing up, she trained and performed ballet throughout the United States. After earning a BA in Dance and Drama at the University of California, Irvine, she worked professionally in musical theatre for 15+ years with tours, regional theatres, & overseas ( until she found herself ready to move onto a new chapter in her life – a career in Physical Therapy. Jenna is currently in her 3rd year at Columbia University’s Physical Therapy Program. She is also a co-founder of the podcast, “Physiotherapy Performance Perspectives,” has an evidence-based monthly youtube series titled “Injury Prevention for Dancers,” is a NY SSIG Co-Founder, NYPTA Student Conclave 2017 Development Team, works with the NYPTA Greater New York Legislative Task Force and is the NYPTA Public Policy Committee Student Liaison. Jenna aspires to be a physical therapist for amateur and professional performers to help ensure long, healthy careers. To learn more, please check out her website:


Read the full transcript below:

Jenna Kantor:                00:00                Hello, this is Jenna Kantor with healthy, wealthy and smart. I'm here with Cameron Massumi who is currently the APTA student assembly president, all those things, however you prefer to pronounce it. First of all, Cameron thank you so much for coming on. First of all, it is a joy to interview this gentleman before we go into our topic on new grads. Cameron is one of those rare bulls who has massive stamina where he ran twice to become part of the student assembly. And that alone just shows that if you've seen the movie Rudy where he never gives up on his dream, Cameron, you definitely exemplify that. So thank you for being a person with the stamina to run again. And very, very well represent students at large.

Cameron Massumi:       00:49                Oh, thank you for that Jenna. I have to say that I wouldn't say it's a stamina aspect more than it's just perseverance. I think you really learn from your experiences. I did run twice the first time I was unsuccessful. But I'd say that I gained a lot of knowledge from that. You know, you learn a lot about who you are. You really take the time to do some introspection and see what are the areas that you're most passionate about and you find ways to stay motivated and stay involved. I was thankful to the previous board. The students tell me they really helped me find an area in which I could contribute. And so I was a member of the professional advocacy committee and did some work on playing national advocacy centers and then did what I could to stay involved and really kind of figuring out what I would like to work on the next time around when I applied.

Jenna Kantor:                01:41                I love that. I love that. All right. Let's now jump into the new Grad stuff now. Why are we talking about new grads? Cause right now you're currently a student. I actually am a new Grad. I'm experiencing what we are going to be discussing. So why do you specifically have a passion for new grads and have some futuristic plans for that, which we will get into in a bit, but why specifically new grads?

Cameron Massumi:       02:03                Sure. I think the best way to address this is looking at friends and connections that I've made. I think APTA does a phenomenal job of first of all engaging students and finding a platform for them to have their voices heard and for them to be able to network with other individuals. You know, firsthand that we can make some great lasting friendships. But what the APTA I think struggles that a little bit is retaining some of that engagement when it comes to new grads. We have no secret that we have a decline in our member basis as people transition from students to working professionals. There's a positive in that the trend is moving forward as we are retaining more and more. I think early career started years has incentivized the ability for the association to retain members.

Cameron Massumi:       02:51                I think the fact that with our rebranding that we're currently going through as an association, we're finding what matters to its members and really utilizing that to make the association more applicable and more exciting for demonstrating value to members. For me as a person that's about to embark on my own career, transitioning from the role of student to professional it's how do I find a way to stay engaged and how do I find a way to contribute to not only association but my profession. One of the things that most of the feedback that I get from a lot of my friends having graduated is they feel that they're going from a space where they have an existing platform to, you know, share their views and their desires within the profession to one where they don't. So this is a passion project of mine and something that I'm really looking forward to contributing on. And I think APTA's done a commendable job in engaging student voice and looking for collaboration on this. Individually myself, I'm looking at utilizing my state chapter to help with this. But also really pulling students and seeing what we can get collaboratively and seeing where that goes.

Jenna Kantor:                04:17                I love that. So regarding new grads, how do they have a voice right now?

Cameron Massumi:       04:23                Ah, it's interesting question. I think that ultimately it comes down to you finding your voice. You can use social media. It's a very powerful tool. You can use open floors within APTA. We just had our house of delegates and there's plenty of opportunities for members to get involved there. You can become an active member in your delegation. You can seek leadership opportunities within your chapter, within sections, academies or even at national office. I think that there is a plethora of opportunities for people to utilize. But it ultimately, it comes down to you what level of motivation that the individual has.

Jenna Kantor:                05:02                I want to dive a little bit deeper onto the negative specifically for us as new grads and anybody who's listening, not you, you're not a new graduate currently a student. But for being a new Grad, there is definitely a dropoff. There are these opportunities but a lot of it has to do with after five years of experience, doors really do open for getting to apply for some greater leadership positions. And even that when you go, well for me, I specifically experienced this in my state, there is still a level of trust, meaning distrust for me being a new face and energetic face, a creative face, not somebody who's been around to learn the ways of how that specific area wants it to run. So would you mind speaking on that? Where is there a voice for somebody who is still waiting to be trusted?

Cameron Massumi:       05:53                Sure. Tough question. Thank you for that. I'd say a lot of that really just comes down to you as an a association, as a profession or as a whole what we are doing to uplift and support individuals. There was a good bit of discussion at house of delegates and at next about diversity, equity and inclusion and for our student assembly meeting at next conference we had a round table and we invited some key panelists as well as students to share their insight and experiences on the topics. And it's interesting because when it became apparent really quickly is how diversity was highlighted almost exclusively at equity and inclusion. I think that as we try to shine more light to that and looking at what equity really means and inclusion and equity, meaning truly leveling the playing field and supporting people and giving them all the tools they need to have equal opportunities. It's not just saying here go, we're really building up individuals and letting them get to a place where they can create change and they can make their mark. And inclusivity is just ensuring that we're doing that with everybody and we're bringing them to that point.

Jenna Kantor:                07:29                I just want to express my appreciation for this. With the diversity, equity inclusion coming up in these conversations at this conference, at the house of delegates. It's great, although we do not have a game plan at this moment, which is very clear in this conversation. It's good that it's being brought up on the national level, not just at the state level. I definitely personally represent this being a person with a personality that is out of the norm. Now, if I went to musical theater people, I'm in the norm. My personality blends in and actually Cameron, you would stand out. So I do appreciate that it's beyond just the color of your skin. So I appreciate that the equity and inclusion is also being included in this whole picture with the actual definitions to provide the opportunity that people, so desire.

Cameron Massumi:       08:23                So the quote about diversity is being asked to the party and inclusion is being asked to dance. And I think that's a pretty powerful statement if you really break it down and you know, I commend APTA for their effort in or renewed effort in ensuring that we move forward with this as a profession. But it's really interesting. You know I see a very diverse group of people that come to these conferences and in my program back at Virginia, I see a vast diversity within our student population. Inclusion is one of those ones that's a little bit harder to utilize. Because you can't really force somebody to do something. You have to elevate them and promote a way in which they can take that opportunity to really get their voice out there and heard. And, and I think that we're moving in the right direction and it's exciting times and I can't wait to see where it goes.

Jenna Kantor:                09:24                Yeah, yeah, for sure. I think I really liked that you gave that definition. It was worth the wait. It was worth it. So for me, I was just at house of delegates to share a little bit and I'm new. It was my first time at house of delegates. So as a new Grad I went there and I was not voted in as a delegate, an elected delegate. But I was an alternate delegate and with that I was able to attend and sit in the gallery, which is in the very back in order to just listen and learn, which is very valuable during the breaks I am very extroverted.

Jenna Kantor:                10:05                And where for you Cameron, I mean you are present so people want to talk to you. You have that. It's amazing for me. I want to meet people. So I did find regarding specifically inclusion, which is why I wanted to, I was like oh I thought of this. I'm like, oh this'll be a great one with Cameron cause this is where your passion lies. I found myself in the room, you know when you see two people bonding that, oh they know who I am so I'm going to stand on the side and wait until you know you're kind of like smiling awkwardly on the side, you know, so I can get in the conversation and maybe have some bonding time. I think maybe one time, the whole time was it actually successful with me standing on the side because people were so focused in on their individual conversations.

Jenna Kantor:                10:46                So I did not get any networking at all in at house of delegates, which was a shame. And, as you are saying right now about that, inclusion is hard because you can't force anybody. I think what I experienced would be a perfect example of a very, very eager beaver wanting to meet people. Cause that's the thing. You need to meet people. You need to gain that trust and you develop those relationships. And I'm not important enough. That's what I'm assuming where they would go, oh wait, Jenna's here, let's include give eye contact, equal eye contact in the conversation where you can somehow become a part of it even as the new person. So I really like how you're bringing that up, the individual. What are ways that we as the APTA team members where we could start thinking outside of the box outside of our own world to maybe pay attention to when we are actively being exclusionary because of the own world that we live in.

Cameron Massumi:       11:46                Well first I like to say I'm sorry that you were made to feel that way. The House of Delegates is definitely crazy, especially this year when we had over 70 motions to get through. So you have a shorter amount of time and always so much to really get some of those meaty discussions out of the way that can present quite a problem to be able to communicate and network, I guess.

Jenna Kantor:                12:09                Oh, for sure. But these are half hour breaks.

Cameron Massumi:       12:12                Well my suggestion, I mean this really goes down to what are you doing to engage in conversation. You know, I recommend that if it's something that you're passionate about to find alternative means of starting dialogue, you know, it's fine to use the tact where you're kind of standing by respectfully and waiting, but there are other times where it may be more appropriate to interrupt but to you know, find a way to segway into the conversation and say, you know, I was just standing by and I really heard you discussing this. You know, it's actually something that I'm really passionate about. Would you mind if I shared my input? Or you know, maybe ahead of time, reach out and say, Hey, I know I'm a member of your delegation or I am a constituent and this is a passion area of mine I'd love to be involved in discussing this.

Cameron Massumi:       13:10                There's all sorts of different ways that you can approach individuals and it's going to vary based on your personality and the personality of who you're trying to reach out to. So that's where I'd say it took to really start and just find ways to do it. I mean, I'm a very extroverted person. I have no problem really walking up and saying, hey, you know, I would love to engage in some dialogue, but there's other people that are more timid and you just have to find different ways of doing it. I don't think that it is plausible to really expect people to just notice you at all times and be like, Hey, like I see you over there, come on in. And I don't think that that is an issue with inclusivity, more so than the fact that there's just a lot of things going on. So, it's important for people to take more active roles to get involved with things that they're passionate about.

Jenna Kantor:                14:09                This is really helpful. I mean and you make a very good point here Cameron, on just like seeing the real big picture of like the barriers, even though we may be all be in the same room of just the chaos that goes on in the rooms. And this isn't just like one thing. I mean we have these annual wonderful events, CSM, NEXT, we have the national student conclave. We had these other events which are also other opportunities and then of course the local opportunities as well. So for you, what are your future plans that you want to explore with the new grads? Because I remember us talking at Graham sessions, I believe. No, Federal Advocacy Forum. We're like plugging all these places everywhere, by the way, attend all these things at the federal advocacy forum. And you were talking about your passions, some things that you might want to develop one day for new grads. Would you mind starting to go into that?

Cameron Massumi:       15:04                I'm sure I don't have any true plans at this point. All I know is that I feel that the new Grad, early career professionals population is kind of a lost area. And what I mean by that is that there's no formal engagement targeting that group. And that's unfortunate in my mind. So I'd really like to see more active participation engagements available for that demographic. And currently myself, you know, I'm looking to kind of transition from the current role that I'm in and to more of one focused on my local chapter level for a little bit as I also work to you know, further my own practicing career and then really just find a final way to increase involvement and engagement with that population. So there's a good number of early career professionals that I'm friends with that live in my home state. So I would just want to collaborate with them and see what we can get off the ground going.

Jenna Kantor:                16:13                I love that. And for those who don't know, Cameron’s a champ.  I cannot express enough how this is somebody you do want to meet. You do want to have in your life in some capacity because of just he is a person who really speaks his truth but really from the heart and has so much love for others and seeing everybody really have the ideal professional career that they so desire. And we had a great bonding moment at federal advocacy forum talking about this and though I have most definitely put you in the hot seat, but for reasons to really help identify that there is and what you just said, there is a gap on the support that's available right now. It's not the APTA is ignoring it, they see it, but it's still there. It's one thing to see it and then figure out exactly how can action be taken. That would be exactly what people need. It's definitely been discussed. So I really appreciate and I'm honestly happy and excited for people in your area to be getting your wisdom and you even just like figuring out what you can do. That's very powerful. So just honestly, thank you for that.

Cameron Massumi:       17:25                Oh, thank you Jenna. I'm just one person, you know, and I'll speak in, like you said, from the heart, and these are just my own thoughts, but I really think that that the heart of it is collaborative efforts. You know, people from various backgrounds are gonna be able to come together and really problem solve a lot. And then as far as APTA goes, I think that they do a terrific job of acknowledging areas for improvement. And they are really actively trying to pursue avenues in which they can rectify some things and improve existing methods. I don't think that they do a bad job by any means with early career professionals, but I just don't think that it's where it needs to. I don't think that where it currently is where it needs to be. But you know, everything's a learning process and as we continue to grow as a profession, things will inevitably improve.

Jenna Kantor:                18:18                Oh, for sure. I was looking at things like that as opportunities. I'm like, oh look, we have more opportunities. And I think, it is really good at looking at things as opportunities and you have to look at it in a positive light. So for anybody who might be listening and being like, ah, you know, waiting for us to say something bad. Like what is it going to, how in this particular conversation right now where we're really trying to reach out and pull in the new Grad audience, like, is it gonna do us any good to sit here and bad mouth or to actually acknowledge what the APTA is doing and how they're regularly acknowledging things. So that way it gives you a rightful reason to hope and believe in an organization that has the power to make a huge difference. They have a huge audience.

Jenna Kantor:                19:02                They have a huge following. Even if right now in June 2019 just for when this goes forward, and time passes, there's one third of the population. There's no denying. Even for nonmembers they have a huge, huge audience. So it is very important. Even if you don't currently believe are not currently a member which join if you're not currently a member, you cannot deny the outreach that they have. So what is very good news? You want to hear that they're talking about it. You want to hear that it's on their mind. You want to hear that they're seeing the opportunities and are trying their best to explore it to the right thing because you know, as soon as they take action on it, they got to stick with it to see if it works, you know, and get that feedback. Well Cameron, thank you so much for coming on here. Thank you for dedicating this time. You've been in meetings this whole time and I was able to fortunately schedule you here at NEXT 2019 and I could not appreciate it enough. Do you have any final words you would like to say? You're like Mic drop to people who are new Grad physical therapists or even soon to be.

Cameron Massumi:       20:14                Thank you Jenna for the opportunity. I think the biggest thing is just be an advocate for the profession and for yourself in whatever capacity that is. The APTA provides a lot of platforms for you to be able to get involved, for you to be able to get your voice out there and heard, support your PAC. You know, that's how we get things done legislatively. How we improve things regulatory too. As an example from a student perspective, you know, lots of lobbying has allowed for legislation to be enacted to help with student loan forgiveness. That's massive. You know, that helps not only students, but early career professionals and we're relieving a lot of their financial burden. Stuff like that is really powerful. Don't underestimate your voice. You have much more volume, your actions and your voice speak volumes and just find a way to get involved.

Jenna Kantor:                                        I love it. Thank you so much.


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Oct 7, 2019

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Dr. Michelle Collie on the show to discuss the importance of outcomes and how they can make a difference in your practice. Michelle became the owner of Performance Physical Therapy. Under Michelle’s leadership, Performance has grown to a practice with 13 locations in Rhode Island and Massachusetts and over 200 employees.  

In this episode, we discuss:

  • What is the definition of outcomes as it relates to physical therapy.
  • How to use patient outcomes and business outcomes to drive your business forward
  • Using outcomes data to increase your referrals
  • A sneak peek into Michelle’s keynote speech at The Outcomes Summit
  • And so much more!




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For More on Dr. Collie:


Born and raised on a sheep farm in New Zealand, Dr Michelle Collie spent her childhood years training pet sheep, riding motorbikes, and eating enough lamb to last a lifetime. She earned her bachelor’s degree in Physiotherapy from the University of Otago in 1994 then moved to Rhode Island due to the United States Physical Therapy shortage. In 2003 while pursuing a Master of Science and Doctorate of Physical Therapy from Massachusetts General Hospital’s Institute of Health Care Professionals, Michelle became the owner of Performance Physical Therapy. Under Michelle’s leadership, Performance has grown to a practice with 13 locations in Rhode Island and Massachusetts and over 200 employees.  

Michelle is an APTA member and serves as the chair of the private practice PR and Marketing committee. Performance Physical Therapy has received a number of awards over the years for its business success and philanthropy, the highlight being the recipient of the 2014 Jane L Snyder, Private Practice of the Year. She is a board-certified Orthopedic Clinical Specialist


Read the full transcript below:


Karen:                         00:00   Hey Michelle, welcome back to the cloud cast. I'm happy to have you back.

Michelle:                      00:04               It's great to be here. Karen, thank you for having me.

Karen:                         00:07               Of course. So today we're going to talk about outcomes, specifically outcomes within your clinic and with your patients. But I think before we get into the meat of this talk, I would love to hear from you what your definition of outcomes is.

Michelle:                      00:24               Well, um, hopefully I'm not quoted by the Webster dictionary or anyone else out there, but for me in my practice is a physical therapist. To me, outcomes of the results that are numbers and they could mean practice management outcomes such as how many patients we see visits in an episode in here. They could be outcomes related to patient satisfaction such as your net promoter score or how many Google reviews did you get. Or they could also be clinical outcomes based on such things as the specific clinical outcomes means, Mitt measures that we use, whether it's related to the Oswestry or a disability scales. So those are just examples of some of the outcomes. But I think outcomes are like the results, tangible numbers of behind them. So you can actually give some, um, objective measures behind what these outcomes are.

Karen:                         01:19               Right. And you S uh, I like that you kind of put those outcomes into different categories because when I hear outcomes I just get incredibly overwhelmed and think, well there's, there could be so many. Right? So thanks. No. So now we kind of have a defined how do we measure outcomes within our practice? And maybe you can give some examples of what you guys do, but is there, do you have any standardized ways that you are measuring these different outcomes?

Michelle:                      01:50               So again, we can classify it into different ways and I will bring out one, one methodology actually is when it comes to practice management outcomes, that's something you hear often, especially with the benchmarking program that happens through the private practice section. We start looking at outcomes and using numbers to benchmark against each other. And those are things such as, um, how many, how many visits in an episode of care or how much revenue do you gain per patient visit? So these are things that are very much financial and operational defined and how you figure out business wise how well you're doing. So that's one side I'm going to flip to the other side, which I think is much more exciting to talk about for most people and that's actually our clinical outcomes. How good a job or how well are we doing when it comes to treating our patients?

Michelle:                      02:47               And there's such a drive now to looking at our outcomes as far as our clinical outcomes and what does that truly mean? Does that mean that my practice or Misa physical therapists get someone better and less visits or at least amount of time or with more intervention or different combination when, how much better do we get someone? So the outcomes to me relate around time, which could also be actual number of visits or encounters and also is how much bitter someone gets. If I'm treating a runner and they, our goal is, Hey, I want to run a marathon in four hours, am I being sucks? Can I get them back to being able to do that? And can I do that just as well as not just the next physical therapist, but other fitness, health care provider, whoever that is. And how can these outcomes?

Michelle:                      03:42               So how do measuring outcomes help to drive your practice? So I guess this is a really, what you're counting down to was the why. Why bother doing this? And so yeah, this is getting to the why, which is the most fundamental part is by measuring our outcomes and helps us differentiate. Now when we can differentiate ourselves, it makes it easier to do marketing and that marketing can, it can impact us in different ways. We can use it to market to get more patients. We can use it to negotiate, which is marketing messaging with a payer, whether that's an insurance company or whether someone's paying cash for services that we now have outcomes, which is data to help him messaging and differentiate, here's what I can do or my practice can do. Um, so I think there's many different levels, um, that it relates to, but it's all comes back to marketing and messaging and being able to differentiate and communicate to the consumer and will the payer about what our services can provide.

Michelle:                      04:54               And can you give an example of how you, you and your practice might use your outcomes to market and you can choose if you want to market to a payer market to the general public, I'll let you choose. So we've done a whole bunch of things that our practice and hit a lot of success. Um, one is marketing and this is probably the easiest one for people to understand marketing to physicians. So with the data that we have, I can go to a physician [inaudible] physician group and say, Hey, here are end results. If you, when you refer a patient to us, we're going to get them this much theatre and here's what the national benchmarks are. So we're actually proving to you that we're going to get the results that you want and guess what? I can and we're actually gonna do it at least visits and what the national standards are.

Michelle:                      05:51               Now I can compare as cells to um, we, I compare as to practice nationally or regionally or even over time. Look, we put these new systems in place or we started try needling or using this new blood flow restrictive therapy or whatever modalities or treatment methodologies we're using and say, because of this, now we're now we have the data to show how much better we're getting patients. And then for us it's actually really helped to Provo provide actually data to referral sources and they can actually say, Oh, so we're going to seam patients to you because you're actually going to provide solutions and get our patients better. It's not just about the fact that Oh, you've got more clinics or you are open on Saturday mornings and no one else is, or you had fancy equipment. I mean these are true differentiators, not just things we can do to make ourselves look better.

Michelle:                      06:50               I think that's the big thing. I think, you know, years ago I always used to think that marketing and promoting your practice was just simply about relationships. And if people like you, they'll send you patients and patients like you, they'll come back to see you and all those. Although those things are true too a little bit when you've actually got the data behind you and really meant, helps you tell a story and say, Hey, this is why we should be treating your patients or to the general public. This is why you should be coming to physical therapy to help with your back pain or your ankle sprain or your pelvic health problem or your dizziness. You've got the numbers to show that we will get you better.

Karen:                         07:31               Yeah, and I think it's great to use numbers because these are our facts, right? You're not fudging these numbers. This is the actual data that is coming out of your clinic. So I think it's great to be able to then instead of just have the data and say, Oh great, look what we did. But you want to use those outcomes in order to market your clinic.

Michelle:                      07:56               Exactly. And I think the other nice side about it as when you're using the data to market, it actually changes the culture within your clinic and within your practice.

Karen:                         08:07               That was literally my next question was how did outcomes affect that people working day to day in your practice?

Michelle:                      08:13               Yeah, well I think it's really helped to make us practice and every visit make all of our clinicians and their patient care coordinators and our assistance and our exercise specialists realize, yes, we're very concerned about customer service and giving, um, you know, having beautiful clinics and all of these other aspects. But at the end of the day, we need to make sure that every moment we're spending with patients is designed to get them back to be doing the things they want to do in this got a show in the data. Yeah. And I think it's helped to really drive our clinic and the kind of care that we're providing. So it's not just about, Oh, I'll collect the data and now I'm going to get paid more by an insurance company. Or now people are going to come and see us or doctors or refer. It actually drives the culture within a clinic to ensure that you, I always feel like we've got rid of complacency which can sometimes creep and practices. Yeah. And how do,

Karen:                         09:14               how do you use this, the outcomes data to kind of align with your vision or the or the mission of your practice? What would you say to other clinicians when it comes to aligning the data with the mission and vision?

Michelle:                      09:30               Well, I think that's really a great point you bring up because people often say, well how do you know what to measure and why are you doing this? And I think it always starts with your strategic plan and figuring out, first of all, what is your purpose? Which is like your greater good. Why do you, why you in practice and what's it all about? And then thinking, okay, well then what's their, what's their mission, what are EMV values? And once you figured those things out, then you can challenge yourself and say, well how am I going to prove it and how am I going to measure it? So that when someone says to me, Oh, your purpose is about having a healthy, fulfilling the film happy community, and you're helping your community to be in that way, how are you going to truly measure that?

Michelle:                      10:13               That's what you're doing? So I think you have to start with that strategic over powering, look at your vision, your mission, your values and names going on. How am I going to measure that and not the other way round. Mmm. We see like, yes, we're going to look after our community and then we're going to use innovative results given here and now it's like, well, how are we going to prove that? I'm like, the only way you can prove that you're getting results driven, innovative care is by showing the data because otherwise it's just talk [inaudible].

Karen:                         10:48               Yeah, yeah. No, that's great. As you're saying this, I'm thinking about my mission for my company and like, Hmm, yeah, okay,

Michelle:                      10:59               how am I going to measure this now? And it's not, you're not going to come up with it overnight and there's no perfect way to do it because this is quite a new area for physical therapists or we're only just part of this evolving healthcare environment where payments changing and with payment changes the messaging of how we're promoting what we do, but it is turning into much more a shift away from fee for service and much more to say like we're paying for the outcomes or the experience, not how many visits or how many units of charge per visit or how many visits and an episodic here we should be advocating improving our stamps for our outcomes. Neat. Good. The only way we can do that as some health, pulling out what clinical outcomes and how we're gonna measure those and basic jet.

Karen:                         11:50               Yeah. And how do your outcomes from clinic aligned with

Michelle:                      11:54               your vision and your mission? Like what is the mission of your clinic and how do you, how do your outcomes revolve around that? The way our mission is about providing innovative, results-driven, physical therapy services for a community. And the way that we measure the outcomes is that our goal is to get, use the hashtag better, faster. So we're all about getting people better, more better, and doing it in the least number of visits we possibly can. Now it's interesting because there's many practices out there, and I'm often challenged by this and this is where I butt heads with media, other people in private practice and like, but we get paid per visit. Why would you want to see people enlist visits? And I've had some really fun heated debates with some colleagues and peers over this Mike. But if we can do it and least visits, isn't that the right thing to do?

Michelle:                      12:45               And then doesn't then allow us to advocate and, and, and prove ourselves and our value. And they're like, what? How can you afford to do that? Because you're basically sacrificing money because you're going to do it and least visits. So it's been a fun debate to have because we've had it now for many years. And I think the ties of changing, because I've been now in a position to actually go to payers and insurance companies and actually hit the data and say, look, we are doing at least visits. So let's talk about how we do some cost sharings. Let's talk about different ways to reimburse because we're doing it and at least visits and uncles to go to the outcomes to show that we're getting people just as bitter or more. That's really poor English with that. So I came up here. Yeah, that's okay. We get the gist of it.

Michelle:                      13:35               So one of your outcome measures might be how many visits are in an episode of care? So we had the keys that we use, we use visits in an episode of care and the other one we use is the clinical more clinical um, change. So traditionally we've used photo focused on therapeutic outcomes of your system. Um, which has been great because that will, that will differentiate patients based on payer, um, diagnosis, body part, all of these things. So we can say, Hey, for a bag spine or all the Pedic on Euro or upper extremity, here's how, here's the change that we're getting in function and we can actually beat back and compare ourselves to other practices both in our region and nationally as well. You can do, it's an interesting time because now with MIPS and again I realized the assaults and people out there who don't know if MIPS are going to happen and we still don't have a lot of final rules, but again, we're still in with Mets. We're still using different, um, standardized clinical outcome tools that we're all very familiar with and I'm looking at opportunities to benchmark not just against it within their own practices, but between each other's practices as well.

Karen:                         14:54               Yeah, I think that's great. I love looking at it that way of, of figuring out your mission and then how are you going to measure it and then taking those measurements and using it for a whole bunch of different things.

Michelle:                      15:07               Well, I think that to me that's been the most interesting thing in our practice. It's, we've got this mission and a vision, which is what you have to start with. And your purpose. We've created the tools to measure it well. We've figured out what tools and how to measure it and it's, it's really helped evolve the culture of that practice. It's helped us with how we onboard our staff. It's helped us with how we recruit new people. It's helped us when we take on students. So it's had a big impact on every part of their practice. And, um, rather than just, you know, how just rather than just how we treat a patient, an everything embodied bodied, everything.

Karen:                         15:47               That's awesome. And now you had mentioned photo and coming up in October, October 23rd to the 25th, and Knoxville, Tennessee is the outcomes summit. Uh, and you are one of the keynote speakers. So can you give us just a little sneak peek, a little taste of what your keynote speech is going to be about?

Michelle:                      16:07               Well, so the keynote speak is all about on marketing with outcomes data, helping people understand the value, um, for outcomes data. When marketing your practice, I'll use my personal story because I think it helps to show that I'm, you know, really at the end of the day, just a little farm girl from a very remote part of the world. And um, so if, if I can use data to Mark it with anybody can, and I also like to talk a lot about the fear because I think there's a lot of fear out there. PTs are often scared. One of my deck data doesn't show what I want it to show.

Karen:                         16:44               Right? Then what happens

Michelle:                      16:46               then what happens? So yeah, that's like the million dollar question. And then what happens is people run away from fear and then they don't do it and so they're not moving forward. So I definitely had plenty of fears when I first started put up though the date and say what a for not as good as we think we are. Well, I find it interesting that it's really abandoned teach and if you're following what your purpose and your mission is and the results are going to happen because this changes all of the messaging and it impacts your entire culture. But I think it's a journey of how to address the fear of what if my data isn't as good as what I think it can be. Because when it comes to marketing, yeah, I can have beautiful brushers and amazing weird site. I can be open all different hours and think those things are going to differentiate me and they will a little bit.

Michelle:                      17:37               But at the end of the day, I do think it comes back to data is the real differentiator and if you want to get serious about marketing and messaging what your practice does, and I think this goes, now I'm going to get on a, and this goes for our app proficiency as a whole and list were privy. At least we're proving that we really are the base caregivers for muscular skeletal and your a muscular disorders and diseases. Then we, you know, we're still lists, we're just not doing a good job, but at the moment like how do we differentiate ourselves from the other healthcare providers and fitness people out there who also say we'll take care of someone's back pain or help them get trained for a five K. so again, we have to, as a profession, as a whole, use that data and be comfortable using it to prove proven value.

Karen:                         18:31               I love it and it sounds like it's going to be a great talk. So all of the people who are going to the outcomes, the clinical outcomes summit are in for real treat. Um, so that's awesome. Now, uh, before we, and here I have a one more question and that's what advice would you give to yourself as a new graduate? Fresh out of PT school. So that farm girl from New Zealand, she just graduated from PT school. What advice, knowing where you are now in your life and career, would you give yourself back then?

Michelle:                      19:11               Oh my God, it's so much advice I would give. I think it would be about the key advice I would say is that your, we all have fear. We're all nervous of things. Whether it's, Oh, I'm going to make a mistake when I treat a patient or I'm going to have a practice that's not successful, or I'm going to open my mouth and sound like an idiot, but we're all gonna do it in. That's fine. And the only way to conquer those fears is just push through it and just keep, keep moving forward. So I think it would just be letting myself know at that shy Tinder age in my early twenties that, um, all the challenges that I had, just the same of everyone else's. And so yeah, just put on your big girl panties. They would say base the fears and move forward. Sorry.

Karen:                         19:57               Great advice. And now where can people find you, whether it be on social media and or your clinic?

Michelle:                      20:04               Um, so we have a multi clinic practice based out of Rhode Island with some clinics in Massachusetts as well. So performance is our website and all their social media handles all reflect their performance. P So, um, feel free to check out her website and we are you on Instagram, Facebook, Twitter, all of those, all of those places.

Karen:                         20:30               Awesome. Well, Michelle, thank you so much for coming back onto the podcast. I appreciate it. You gave me a lot to think about, so thanks so much. Thanks very much, Karen and everyone, thanks so much for tuning in. Have a great couple of days and stay healthy, wealthy, and smart.


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Sep 30, 2019

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Dr. Stephanie Gray on the show to discuss bone health.  Dr. Stephanie Gray, DNP, MS, ARNP, ANP-C, GNP-C, ABAAHP, FAARFM, is a functional medicine provider who helps men and women build sustainable and optimal health and longevity so that they can focus on what matters most to them. She is co-founder of Your Longevity Blueprint nutraceuticals with her husband, Eric. They own the Integrative Health and Hormone Clinic in Hiawatha, Iowa.

In this episode, we discuss:

-What is functional medicine and integrative medicine?

-Hormones that impact your bone density as you age and how to find your deficiencies

-The difference between natural and synthetic hormones

-Your Longevity Blueprint: a guide to mastering each of your body systems

-And so much more!



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Stephanie Gray, DNP, MS, ARNP, ANP-C, GNP-C, ABAAHP, FAARFM, is a functional medicine provider who helps men and women build sustainable and optimal health and longevity so that they can focus on what matters most to them! She has been working as a nurse practitioner since 2009. She completed her doctorate focusing on estrogen metabolism from the University of Iowa in 2011. Additionally, she has a Masters in Metabolic Nutritional Medicine from the University of South Florida’s Medical School. Her expertise lies within integrative, anti-aging, and functional medicine. She is arguably one of the midwest's’ most credentialed female healthcare providers combining many certifications and trainings. She completed an Advanced fellowship in Anti-Aging Regenerative and Functional medicine in 2013. She became the first BioTe certified provider in Iowa to administer hormone pellets also in 2013. She is the author of the FNP Mastery App and an Amazon best-selling author of her book Your Longevity Blueprint. She is co-founder of Your Longevity Blueprint nutraceuticals with her husband, Eric. They own the Integrative Health and Hormone Clinic in Hiawatha, Iowa.


Read the full transcript below:

Karen Litzy:                   00:01                Hi, Dr. Stephanie Gray. Welcome to the podcast. I'm happy to finally have you on. This is taken forever between the two of our schedules.

Stephanie Gray:            00:09                Thank you for having me on. I'm excited to speak with you today.

Karen Litzy:                   00:12                Yeah, I'm very excited. And we had met, Gosh, last year, maybe

Stephanie Gray:            00:17                October.

Karen Litzy:                   00:18                Yeah, October of last year. Holy Cow. Yes. Well, I'm very excited to have you on because when we met at unfair advantage and I remember hearing your story and hearing you speak and I thought I need to talk to this woman because I think she's doing some really great work, so I'm happy to have you on and share all about what you're doing. We'll talk about your book, the longevity blueprint in a little bit, but first, can you let the audience know a little bit about your journey from your BS to your MS in nursing to doctorate to all these certifications and how that happened in the why behind it?

Stephanie Gray:            00:58                Sure. Well, maybe the short version is that I was born and raised in the Midwest and I grew up in a very healthy family and I wasn't quite sure what I wanted to do with my life as many people are I’m sure. My parents always took us to see a chiropractor, not a regular doctor. They were self employed, had a really high deductible. So they wanted to keep us healthy and growing up, I wanted to get into medicine. I kind of grew up wanting to be a doctor. I'd play with my doctor Kit, but I didn't necessarily want to prescribe drugs. And so I thought, well maybe I'll go into nursing. Right? So I went through the nursing program at University of Iowa and I love nurses, man, they're so important. We have a shortage, we need more nurses. But I thought I wanted to have more autonomy and more independence and I wanted to still be able to diagnose and treat patients.

Stephanie Gray:            01:43                And so I did continue on to become a nurse practitioner and I ended up going through the master's and then the doctorate program. And I still was a little unsatisfied. I felt like, man, there's gotta be more to life than prescribing medications. Right? Nursing is a more holistic approach in general. And that's why I'm biased to nurse practitioners as primary care providers because I think they do provide a more holistic approach. I wanted some additional trainings so that I could incorporate nutrition, that I would have some credentials behind recommending things other than drugs. So I did also then pursue a master's in metabolic nutritional medicine, which taught me a lot about, you know, using supplements and herbs and whatnot, which I heavily applied in my practice. And then I also did complete the advanced fellowship in anti-aging, regenerative and functional medicine which helped me tremendously. I learned a lot about use of bioidentical hormones as well. And I really just became on fire for integrative and functional medicine and thought, this is it. This is what, especially my community in Iowa needs, because there weren't a lot of providers offering this sort of care. So that's, I guess that's kind of my story.

Karen Litzy:                   02:50                Well, that's a great story. I love it. Now you mentioned functional medicine and Integrative Medicine. Can you kind of help us out and talk about what those branches of medicine are?

Stephanie Gray:            03:01                Sure. So integrative medicine combines or integrates conventional medicine with natural, uneven, complimentary forms of medicine. It's not, I'll say functional medicine also really more works to get to the root cause of the problem. That's kind of more of the definition of functional medicine. And I use both in my practice. I use functional medicine to kind of discover the why, but I also use integrative medicine because there is a time and place for medication use. Sometimes patients do need antibiotics or surgery. I've had to partake in them myself. But I want to provide my patients with the best of all worlds combined. So do I think chiropractic is important? Yes. Acupuncture? Yes. Use of supplements. Yes. Medications, all of the above. I think the major difference in the analogy I use with my patients that I did not create a colleague, Patrick, he mentions conventional medicine as being more of the fire department approach. Right? We need conventional medicine. If you have a big bad ugly tumor or whatnot, you need the fire department to put that out to remove it. But conventional medicines tools are drugs and surgery. Functional medicine is a little different. We described that in my practice as being more of like a carpenter approach and that's what I describe in my book. Really helping to repair and rebuild the body, figure out why the fire happened in the first place and try to get to that root cause of the problem, not just provide a bandaid approach.

Karen Litzy:                   04:16                Right. And that's a great analogy. Thank you for that. That’s definitely clear. It makes functional and integrative medicine a little bit clearer for everyone. Hopefully. So now I mentioned the book longevity blueprint and again we'll talk about that a little bit later, but there's a chapter in the book, Chapter Four where you discuss the importance of fixing nutritional deficiencies and specifically when it comes to our bones. So as mainly women, we all know as we get older and as we go through menopause, our hormones change and bone density can change along with that. So what nutrients I guess are specifically important for our bones?

Stephanie Gray:            05:09                So I'll discuss several nutrients. So many women think calcium is a number one most important nutrient for their bones. And the truth is that your bones need a lot more than calcium. So vitamin D, magnesium, vitamin K2 and strontium are all nutrients that I recommend to my patients. I mentioned vitamin D in several different chapters of my book and that as many people know, helps your body absorb calcium and phosphorus from the foods you eat. And it helps with bone remodeling. Maybe I don't know how deep we should get into that. Maybe you shouldn't, but without enough magnesium though calcium can also collect in the wrong places in soft tissues and cause arthritis. And so magnesium is just as important as calcium. There have been several studies of women with Osteopenia or osteoporosis showing they're actually not deficient in calcium deficient, they’re deficient in magnesium yet.

Stephanie Gray:            05:58                What's the number one most prescribed supplement? Menopausal woman. Again, it's calcium. I personally have had a kidney stone and they are not fun. So calcium can not only gain weight, it can cause bone spurs, but it can cause kidney stones. It can calcify our arteries. We don't want it getting absorbed in to the wrong places of our body. And that's where vitamin K2 comes in also. So vitaminK is really overlooked nutrient. It's one of the four fat soluble nutrients. So it really helps prevent calcium from accumulating in our vessels. And it can even, some people believe can help remove dangerous calcifications too. We know that low levels of k2 can directly be related to poor bone mineral density. So I like analogy.

Stephanie Gray:            06:45                So here's another analogy on what vitamin K2 really does, and vitamin D. So vitamin D is the doorman that opens the door for calcium to enter the bloodstream. But once it's in the bloodstream, it could go anywhere. So I think if K2 is being that usher that's going to direct the calcium from the lobby, if we think of a hotel or whatnot, directing him to the appropriate seat in our bone matrix. So do we need vitamin D? Yes. Do we need magnesium? Yes. We also need vitaminK2. So there are different sort or different types of vitamin K. So vitaminK is broken down to K1 and K2. So if you are purchasing a supplement, if it just says vitaminK , you don't necessarily know what you're getting.

Stephanie Gray:            07:26                You want to make sure that the label is really differentiating if specifying what is in that product. So vitamin K1 isn't as much needed to be supplemented. It's the deficiency is pretty rare. It's found in leafy Greens. Hopefully you're all getting your leafy Greens. But vitamin K2 comes from very specific foods and also bacterial synthesis. So think of it. Think of yourself as you know, if you don't have a healthy gut, unfortunately your body's not going to be able to convert. K1 to K2 in the gut if you've taken antibiotics, whatnot, if you have a lot of food sensitivities and gut inflammation. And so you really want to think about consuming foods with K2 and possibly supplementing in that as well. So vitamin K2 comes from fermented soybeans, which many of us probably are not consuming and also from the fat milk and organs of grass fed animals.

Stephanie Gray:            08:16                So things like egg yolk, butter, and even liver with why we're coming, we're becoming more vitamin K deficient is that you are where you're what you eat, eat. So if you've heard of what Michael Poland has said, and I think that's really true with K2. So when we removed animals from the pasture, right? If we don't eat animals that are eating greens, they're not getting the K2 themselves and then we're not getting it from our products. So you want to make sure you are eating grass fed animals and think of wild game. Wild game is really what's can usually consuming the ingredients. So try to consume more pheasant, duck rabbit, venison, elk, or wild Turkey. I mean these are things that we don't all have access to, but that would actually help increase our K2 levels. So if you can't get some of those foods into your diet, then you could consider supplementing that.

Stephanie Gray:            09:06                It could literally again consume the fermented soy beans. But MK7 has a pretty long half life, longer than MK4. So I recommend my patients take MK7, MK4 is actually extracted from a tobacco plant, which I don't like either, sometimes will come from fermented soybeans, geranium or chickpea. And the source that we use for our production is chickpea. It has a longer half life, so a single daily dose can provide longer protection. So many of my patients, we're putting on 45 90 or even 180 micrograms of MK7 per day. It's great to incorporate foods that have, you know, consumed grass Greens. You hit the chlorophyll to get the vitamin K and to have a great healthy gut that convert can indicate too, but if you can't, and supplementing with MK7 is what I recommend.

Karen Litzy:                   09:56                Yeah. And, just so people know, are you doing blood tests on people to find these levels? I just want to point that out so that people listening are like, well, I'm just going to go buy all this stuff, but you have to go and be evaluated first.

Stephanie Gray:            10:15                Yeah. So in my book in chapter four I talk about, well, every chapter of the book discusses a functional medicine testing option that's available. And chapter four is all about examining micronutrient deficiencies. Which even my patients who eat organic, who grow their own food in their backyard are still nutritionally deficient because our food sources are just not as nutrient dense as they used to be. I mean, the magnesium content in our foods has been on a decline since the 1950s. It keeps going down and down and down, which is very sad. But because of that, we can see that evidenced on a test that we run on our patients. So one of the first tests for my patients with osteoporosis or Penia that we would run is this nutritional analysis, which is looking at vitamin, mineral, amino acid, antioxidant, and even Omega levels. And if you have the access to a functional medicine practitioner, definitely I would recommend getting this test because then you don't have to guess how much magnesium, how much do I need? It's better to really get the test to see what you need.

Karen Litzy:                   11:12                Right. Yeah, no, that makes a lot of sense. And I just wanted to point that out to people so that they know. I guess also, are there any dangers of taking these vitamins if you don't need them?

Stephanie Gray:            11:28                So vitaminK to a high dose just can cause blood thinning. So if patients are taking anticoagulants, if they're on medications like Warfarin, you know, Coumadin, then this could potentiate those effects at really high dosages. So if you're listening to this and you want to take some K2, you probably need it. But talk to your doctor or nurse just so that they know so that they can monitor your levels. So that would the biggest, biggest side effects.

Stephanie Gray:            12:04                The last nutrient for bone mineral density that I recommend to my patients is strontium. This was one of the first minerals that I really learned about for bone density. So I heavily used it initially even before I learned about the importance of K2. There have been randomized double blind placebo controlled clinical trials showing that strontium in a dose of about one gram per day could be equally as effective as a lot of the bisphosphonate medications without getting those nasty side effects. But I have seen this be effective in my patients too. Granted, I'm recommending they take minerals, optimize their hormones, reduce their stress, exercise, right? So all of those interventions are going to have an additive effect for improving bone density. But strontium can be very, very helpful for bone density as well.

Karen Litzy:                   12:48                Nice. All right, so we have vitamin D, vitaminK2, strontium and magnesium.

Stephanie Gray:            12:56                And then calcium of course calcium. I don't put calcium on the top of the list, but yes.

Karen Litzy:                   13:01                But it's there. Okay. All right. Now you mentioned hormones for a quick second there, but is there value in optimizing hormones for bone density?

Stephanie Gray:            13:13                You Bet. So about 25 well, I think it's 27% of women over 50 can have osteoporosis, right? Like a fourth of those patients of that population, which is pretty scary. Yeah. And I'll go 40% have osteopenia. There's also, I'm referencing women over 50 so what's the other common dominator for women over 50 usually you're going through menopause around that declining and this, the danger here is that this can increase risk for fractures. Of course, Osteoporosis Foundation says at 24% of those with hip fractures die within a year. That's, that's terrible. Very cool. So absolutely, I run a hormone clinic and I strongly believe that improving estrogen, progesterone, and even testosterone levels in women can help with bone density. And I can talk a little, I can go into depth with each of those hormones.

Karen Litzy:                   14:06                Yeah, I think I would like a little bit more in depth conversation on that and also the difference between synthetic and natural hormones.

Stephanie Gray:            14:15                Sure, sure. So maybe first we'll talk a little bit about estrogen. So estrogen literally helps with a proper bone remodeling process. Progesterone helps promote osteoblastic activity. So osteoblast help build your bones while osteoclast break it down, right? So progesterone is going to help with the bone builders and testosterone has been proven to actually stimulate new bone growth and inhibit or block the osteoclastic that breaking down activity. Progesterone, I've even been heard called one time I heard it called a bone trophic hormone. Like it literally seems to promote bone formation, which is wonderful. So it's one of the first hormones I'll start my patients on even before their menopausal many peri-menopausal or younger are taking progesterone. And when I mentioned testosterone for women, some women kind of look at me sideways like, well I don't want to grow a beard or I don't think I need to.

Stephanie Gray:            15:12                But actually it's extremely important if you even think of how testosterone helps with muscle mass, it can help strengthen the patient also, right? To improve balance, to minimize falls. Testosterone is great for many reasons. In my book I actually mentioned a study. I feel so strongly about how important testosterone can help really because of the study, because I've seen this, testosterone has shown an 8.3% improvement in bone mineral density, which is like unheard of. It's just dramatic. I've had patients who have received hormone replacement therapy, not overnight, but over a year, go from having osteoporosis, Osteopenia to even having normal bone density because after a year, their bones are improving and that is amazing. But conventional medicine, many times putting patients on drugs, we're just hoping that they don't have a decline. We're just hoping that they stabilize, not that they actually build bone density and hormones can really help do that.

Stephanie Gray:            16:08                But in reference to your other question, anytime we talk about hormones, the cancer word is going to come up. So that's where I can differentiate between the synthetics and the naturals. And in my book in chapter six actually show the molecular structure of synthetic hormones like I synthetic progestin and natural progesterone aesthetic is faster on molecule and natural testosterone cause the hormones really need to fit like a key fitting in a key hole, right? And that's what the molecular structure of natural or bioidentical hormones are. I mean, they should fit like a key fitting in and thus caused your side effects. So most of the studies that showed hormones cause cancer were studies like the women's health initiative study, which was done on a lot of women, but they use synthetic horse urine and they use Premarin.

Stephanie Gray:            16:54                That's literally what Premarin stands for, pregnant Mare's urine. So naturally I try to not replicate what was done in that study with my patients. I don't want to use synthetic hormones. I don't want to use oral estrogen either. That means estrogen taken by mouth in a pill form, right? Which is going to have to be cleared through the gut and the liver. So who was trained through, I should say in addition to the fellowship program that I went through was bio t, they're a hormone pellet company. They're the biggest hormone pellet company in the nation who very well trained their providers and their practitioners and they keep us up to date on all the current research and what's happening in Europe as well with hormones. And so they strongly believe that hormone is given an appellate version, which is an actual subcutaneous little implant that we put under the fatty tissue, kind of in the lower back.

Stephanie Gray:            17:44                Upper bottom area is by far the safest. And that's what we're going for with our patients, right? We want to improve on density. We want them feeling better. We want to give them the safest version of the safest dosage. And so pellet therapy specifically is what can improve bone density the most. But again, we're using natural hormones that are plant-based, not synthetic. They should bind to your hormone receptors appropriately. And therefore the risks of, you know, what were shown in the women's health initiative study just can't be compared to what practitioners like myself use. Cause we're using natural hormones, not the synthetics and not by mouth.

Karen Litzy:                   18:19                And so what are the side effects or the downside of using these natural hormones versus a synthetic?

Stephanie Gray:            18:26                Sure. So all of us are already making, well we should be making hormones, right? Which when we grow up we go through adolescence, our hormones peak and then in our twenties and thirties and forties and 50s we start seeing this decline. So really if hormones are dosed appropriately, patients shouldn't have side effects. However, if you think of younger women when they're cycling, sometimes before bleeding they may have some fluid retention or a little bit of breast tenderness or whatnot. And sometimes those symptoms can reoccur as we give patients hormones. The goal is that those would be very short lived. They wouldn't last once we refined the dose. But too much of estrogen can definitely cause fluid retention, breast tenderness, potentially some weight gain. Too much testosterone could cause acne, oily skin, hair growth. Too much. Progesterone can make you feel a little tired. Most menopausal women need help sleeping. So they like that effect, kind of calms them down. Or if women are real PMSing they need or have anxiety, they need some progesterone to calm them down. But we don't want to overdose patients. Right? We don't want to get them to high levels of the hormones, but we want to give them high enough levels that will protect their bones, that will help them sleep. Right. That will provide benefit.

Karen Litzy:                   19:34                Are there instances of cancer with the natural hormones?

Stephanie Gray:            19:41                So there are always instances of cancer? I can't say definitively that. No, I've never seen it. I'd never had a patient ever have cancer. But from my experience, they're very rare. And Bio T are great to have as a resource because they track all of that. I mean, they're tracking all these hundreds and hundreds of thousands of patients with pellets and they're tracking the rights and if they confidently say the rates are extremely low.

Karen Litzy:                   20:07                Well, you know, cause we wanna give the listeners sort of like a balanced view of everything. So we want to give the, you know, as you know, and I'm sure this is the exact questions that your patients probably ask you.

Stephanie Gray:            20:23                Yes.

Karen Litzy:                   20:25                Or hopefully that's what they ask you. Let's put it that way, So now talking about these hormones, how would one know if they are low on these hormones?

Stephanie Gray:            20:37                Good question. Really get tested. Does every postmenopause woman with osteoporosis need testosterone? No, I can't say that I'm speaking to what has helped my patients. But the beauty of functional integrated medicine is that we personalize treatment, right? We test hormone levels to see what our patients need and we test them at the beginning of therapy and through the therapy and annually, right. To make sure we're not under or overdosing our patients. So, I recommend that women, even young women, and I should say men too, but we're kind of speaking to women today, get their hormone levels tested in their twenties, thirties, forties. Right? So they can get a baseline. They can track changes. So they start to feel different, start to feel something has gone awry, we can compare to see where their hormones were before. I think that's really important. But basic blood tests can tell you where your hormone levels are.

Stephanie Gray:            21:27                And now that's for postmenopausal women and for men. Now if you're younger, another test that I utilize in my practice is saliva hormone testing. So for younger women whose hormones fluctuate, whose hormones fluctuate on a daily basis, many times I'll have them spit into a tube every couple of days over the course of a month so we can really see what's happening. Maybe they're getting headaches for population or maybe they're getting headaches before bleeding or having pms or whatnot. If we can correlate their labs with their symptoms, then we know exactly what's happening, which hormones fluctuation is triggering that, and then we can intervene appropriately. So that's the beauty of testing and not guessing. Really being able to examine on paper what's happening and match it with what the patient's plan.

Karen Litzy:                   22:09                And with osteoporosis or Osteopenia, let's say you are getting tested when you're younger to find out, you know, what are you deficient in vitamin or mineral wise and where are your hormones levels at? Can you through this process help to let's say ward off osteoporosis or Osteopenia even if it's a genetic thing within your family.

Stephanie Gray:            22:40                I guess the easy answer there would be sure. That would be the goal of course. So we want to ward off all chronic disease.

Karen Litzy:                   22:47                Yeah, exactly.

Stephanie Gray:            22:49                I'm sure there could be some rare genetic disorder. I'm not aware of that. Maybe, you know, we couldn't influence, but yes, that would absolutely be the goal is intervene soon. Absolutely.

Karen Litzy:                   23:03                Got It. And is there anything else when you're seeing patients coming to you with Osteopenia, osteoporosis, anything else that you're looking at or any other treatments that you may suggest? So that if anyone is listening to this, and let's say they are concerned that maybe they have osteoporosis or Osteopenia or they are post-menopausal or reaching that post-menopausal phase and they want to go to their doctor and they want to ask them about these tests, is there anything else aside from what we've already talked about that you would suggest?

Stephanie Gray:            23:37                Oh, all kinds of things. So I'm back to the micronutrient deficiency possibility. Well, especially if that occurs, we're going to be looking at diet with the patient, right? I had a young woman my age who was drinking like six or seven cups of coffee per day. And I said, you know, that's just basically leaching minerals from your bones, right? It's a diuretic. It's essentially robbing you of all important nutrients, even nutrients you're supplementing with. So you still need to examine diet with all of our patients and make sure that we're eating well. Right? And not just drinking tons of carbonated beverages or caffeine or whatnot. So definitely looking at diet is important. Sometimes we do look at heavy metal toxicity with our patients, with these patients specifically. I don't want to say it's rare, but it's much more common and more easy to treat the patients, you know, by fixing the nutritional deficiencies and the hormones.

Stephanie Gray:            24:32                But there are times where it is really important to look at heavy metals as well. And then I definitely always ask my patients about their stress, right? So if they have low hormone levels, that's part of that's natural, right? Your hormones are going to decline as you age, but you're super stressed out. Stress is your body's biggest hormone, hijacker stresses not helping your situation or your bombs. So we do need to think about lifestyle and really getting stressed under control, deep breathing, Yoga, meditation, and then examine if they're doing weight bearing activity as well. Yeah, of course. Needs to start really young, right? You build your phone mineral density in your 20s. So know that needs to start at a very young age. But I do want to make sure my patients are exercising as well.

Karen Litzy:                   25:20                Awesome. Well, I think that gives us a really nice holistic view of kind of looking at Osteopenia and osteoporosis from sort of bridging the gap really between that functional medicine and traditional medicine. As a physical therapist, I often get patients referred to me for osteoporosis to do those exactly what you said, those weight bearing exercises, stress reduction, things like that. And so it's good to know that as a physical therapist that we can team up with other healthcare professionals with our patient's wellbeing at the center.

Stephanie Gray:            25:54                Absolutely, I would say that that's also a belief for functional medicine, that we need interdisciplinary care for our patients. You know, I don't have time during my visits to teach patients exercise for strength and balance. We have our own strengths, but we can work together as a team and really have a multidisciplinary approach for our patients, which is going to provide them with better outcomes.

Karen Litzy:                   26:17                Yeah, no question. I agree 100%. And now we had mentioned the book a little bit, it's called the longevity blueprint, can you tell the listeners a little bit more about the book and where they can find it?

Stephanie Gray:            26:30                Maybe I'll go off on a little tangent here and just say why I wrote the book first. I think sometimes patients or consumers may think, oh, so-and-so just wrote a book, but she doesn't know because she hasn't experienced such and such or whatnot. And I'm definitely a provider who has gone through my own health challenges, unfortunately. But fortunately I've used them to my advantage to write this book. So I personally, I've struggled with a lot of things. The most challenging really was fast heart rate or a tachnocardic episodes, which, landed me at Mayo Clinic actually, well, firstly to be in the emergency room, but I eventually landed me at Mayo and conventional medicine's approach to my issue was to take a medication to control my heart rate. And although that could have worked and could have helped, I thought I need to figure out what's happening to me.

Stephanie Gray:            27:25                I needed to figure out why my body's gonna ride, right, why my heart is racing like this. And so around the same time, my husband is actually our office manager at our clinic. We have integrated health clinic in Iowa and he said, you know, you should really use this to try to streamline the process as far as what we recommend to our patients. Can you outline all of what we offer? Because sometimes patients would come see a functional medicine practitioner who only offered gut health or only offered hormone health or detoxing or whatnot. And we really offered the whole Shebang. And so he said, why don't we try to create some sort of analogy to outline all of what we can offer patients really to provide them hope. And so I created this blueprint outlining a functional medicine and all the different principles of what we can offer patients with every organ system of the body.

Stephanie Gray:            28:14                And then I kind of laced through my personal story as well as far as what I had to utilize to regain back my health. And so what I'm doing with the book is I'm trying to at least create this analogy between how we maintain our homes and the compare that to our body, right? So with our home, we have, well I have hair in my drain, right? I don't want hair clogging my drain. You probably mow your lawn. If you have a lawn, you probably change the furnace filters on your home right there. Just things you'd have, you know, you have to do to maintain your home. But we don't always know how to maintain our body. We don't know how to rebuild our body if we're sick or build that health period. And so I'm taking a room in each of our homes, right?

Stephanie Gray:            28:55                And I'm comparing that to an organ system in the body. So chapter one is all about gut health because I believe that gut is the most important piece of our health, most important organ system that we have. And I'm comparing that to the foundation of the home. You have to have the strong foundation upon which to build good health. So then I go chapter by chapter. I'm comparing, you know, organ system. So we were talking a lot about chapter four today and chapter six, chapter six I'm comparing the heating and cooling in your home, right? And you don't want to be too cold, you want to be too hot, you have to have a good thermostat there. But I'm comparing that to the endocrine system in the body. And so I try to help patients rebuild their body, rebuild every organ system using functional medicine principles. So I talk about the tests that are important. I talk about the nutrients that are important and offer patients resources as well.

Karen Litzy:                   29:42                That's awesome and that's really great for patients. And just so everyone knows, we'll have a link to the book in the show notes over at So if you're interested and you can go over, click a link and it'll take you right to Stephanie's books, you can read more about it and see if it's for you. And now, Stephanie, I ask everyone this question at the end of the podcast and that is knowing where you are now in your life and in your business, what advice would you give to yourself and in your case, since you have a plethora of degrees, let's say right after your bachelor degree, after you graduated with that bachelor's in nursing.

Stephanie Gray:            30:26                Okay, so that's tough. I think what part of what I've learned through my health situation, I had to change my diet and nutrition and what not, but I also had to reduce stress big time. And so I think one I really recommend to all, well everyone but including the youth, I wish I would have as happy I as I am to be where I am and to have the knowledge I have so that I can ultimately help others. My health suffered along the way and so I could have, you know, done this over a longer period of time and instead of jamming it into fewer years, I think the advice to myself would be to physically set time in my calendar to deep breathe. Deep breathing has been extremely important to me to calm my nervous system. I'm obviously a fast talker and I needed to set aside time for my body to just mend and relax, rest and digest. So I think that's what my advice would be to take time for myself. As hard as it would've been, it probably would've been very difficult for me to do yoga. I probably couldn't have sat still, but I needed it. Yeah. That's probably the advice to just slow down, breathe slowly, take time.

Karen Litzy:                   31:39                Yeah. And that's great advice and it's advice that I give to a good majority of my patients as well. And so now is there anything else, I know that you had mentioned that you have an offer for listeners. Do you want to share that now?

Stephanie Gray:            31:54                Sure. So if you're hearing about functional medicine for the first time today, I'd highly recommend you check out my book just because I think that it could provide you hope or hope for a loved one. I think many patients are just so dissatisfied, they keep going to the doctor, they keep being told that everything's normal and they know they don't feel normal and they know there are answers out there and there's a good potential that a functional medicine provider could help you. So I would definitely recommend grab a copy of my book, which is loaded with resources but also look for a functional medicine practitioner in your area. So the code on our website that can be used to purchase the book, although it's available at Barnes and noble and Amazon and everywhere books are sold is So if you use the code healthy10, you can get 10% off order on the book or any of the supplements like vitamin K2 or anything you feel like you need. But after, you know, when you think of a home being built, there's always a contractor overseeing that process. And, that's what the last chapter of my book is about. Finding your contractor to help you personally as a community build your health. The book can help, but you do need a guide. You need a contractor.

Karen Litzy:                   33:01                Well thank you so much. This was great. I love learning different ways to kind of keep myself healthy and as I get older and I start, I mean I think I have a little while left, but kind of entering the phase of my life where a lot of this stuff is going to be very pertinent to me. So I thank you for sharing it all.

Stephanie Gray:            33:25                Well, thank you for having me on. I hope this helps many of your viewers

Karen Litzy:                   33:28                And I think it will. Thank you so much Stephanie and everyone out there listening. Thanks so much. Have a great couple of days and stay healthy, wealthy, and smart.


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Sep 19, 2019

LIVE on the Sport Physiotherapy Canada Facebook Page, I welcome Alex Hutchinson on the show to discuss sports journalism.  Alex Hutchinson is National Magazine Award-winning journalist who writes about the science of endurance for Runner’s World and Outside, and frequently contributes to other publications such as the New York Times and the New Yorker. A former long-distance runner for the Canadian national team, he holds a master’s in journalism from Columbia and a Ph.D. in physics from Cambridge, and he did his post-doctoral research with the National Security Agency.

In this episode, we discuss:

-How to disseminate findings from complex research studies to a layman audience

-Attention grabbing headlines that commit to a point of view

-Endure: Mind, Body, and the Curiously Elastic Limits of Human Performance

-What Alex is looking forward to from the Third World Congress of Sports Physical Therapy

-And so much more!


Third World Congress of Sports Physical Therapy

Alex Hutchinson Twitter



Alex Hutchinson Website


For more information on Alex:

I’m an author and journalist in Toronto. My primary focus these days is the science of endurance and fitness, which I cover for Outside (where I’m a contributing editor and write the Sweat Science column), The Globe and Mail (where I write the Jockology column), and Canadian Running magazine. I’ve also covered technology for Popular Mechanics (where I earned a National Magazine Award for my energy reporting) and adventure travel for the New York Times, and was a Runner’s World columnist from 2012 to 2017.

My latest book, published in February 2018, is an exploration of the science (and mysteries) of endurance. It’s called ENDURE: Mind, Body, and the Curiously Elastic Limits of Human Performance. Before that, I wrote a practical guide to the science of fitness, called Which Comes First, Cardio or Weights? Fitness Myths, Training Truths, and Other Surprising Discoveries from the Science of Exercise, which was published in 2011. I also wrote Big Ideas: 100 Modern Inventions That Have Transformed Our World, in 2009.

I actually started out as a physicist, with a Ph.D. from the University of Cambridge then a few years as a postdoctoral researcher with the U.S. National Security Agency, working on quantum computing and nanomechanics. During that time, I competed as a middle- and long-distance runner for the Canadian national team, mostly as a miler but also dabbling in cross-country and even a bit of mountain running. I still run most days, enjoy the rigors of hard training, and occasionally race. But I hate to think how I’d do on an undergraduate physics exam.


Read the full transcript below:

Karen Litzy:                   00:00                Hey everybody. Welcome to the Third World Congress of sports physical therapy Facebook page. And I am your host, Karen Litzy. And we have been doing several of these interviews over the past couple of months in support of the Third World Congress of sports physical therapy. And today we have writer, journalist, author, athlete, Alex Hutchinson who is part of the Third World Congress. He's going to be a part of an informal Q and A and also doing a talk with Greg Lehman, who's already been on. So Alex, welcome to Facebook live.

Alex Hutchinson:           00:37                Thanks very much, Karen. It's great to be here.

Karen Litzy:                   00:39                All right, so for those people who maybe aren't as familiar with you, can you tell us a little bit more about yourself?

Alex Hutchinson:           00:46                Yeah, I mean, I guess when people ask what I do, I say I'm a freelance journalist, but if you kind of drill down a little bit, my subspecialty is like, I'm a sports science journalist or even an endurance sports science journalist, which isn't really a job, but it's effectively what I do. So I write for, for outside magazine and a few other places. There's Canadian running magazine and a newspaper in Canada called the globe and Mail, but mainly outside magazine about the science of Endurance sports, sports more generally, adventure, fitness, health, all those sorts of things. A fairly, fairly broad stuff that interests me, I try and look at the science angle of it. And so that means talking to a lot of athletes and sometimes I talk to coaches, but mostly I talk to researchers who are trying to use, you know, research studies, peer reviewed, you know, placebo-controlled, blinded studies to answer questions that a lot of us have when we exercise, you know, what workout should I do or how should I refuel or these sorts of things.

Karen Litzy:                   01:48                Alright, so you're taking, which I think is great. You're taking the research and you're able to disseminate that out into, if you will, the layman's audience.

Alex Hutchinson:           01:57                Yeah, that's the goal. Yeah. And, it's interesting cause I come from a running background. I was a competitive runner. And I was a, a guy interested in science, but there wasn't no, when I was competing in the sort of nineties and early two thousands, it to me at least, it seemed, it wasn't very easy, I didn't even know that there were, you know, thousands of researchers around the world trying to answer these sorts of questions. And I think for me it was in the middle two thousands I started seeing some columns in the New York Times from Gina Kolata. And then from Gretchen Reynolds.  Gina Kolata had a column called personal best where she was like looking into the myth that lactic acid causes fatigue. And this was maybe around 2005 and I was like, Holy Mackerel.

Alex Hutchinson:           02:37                And she was interviewing scientists who are asking these questions. And I thought there are scientists who care about lactic acid so that kind of started me on the path of thinking that, realizing there's a body of research out there that wasn't reaching interested lay people like myself. So I started pursuing that. And I think today there's a lot more. Like there were a lot of avenues through which exercise science reaches the lay people. I feel like I'm one of those channels, but it's definitely, there's a lot more options for people now, including directly from scientists themselves in places like Twitter.

Karen Litzy:                   03:13                Exactly. And I think that's where I, you know, in the late nineties, mid two thousands, social media certainly wasn't as robust as it is now. And now you have scientists and researchers being encouraged to get onto these platforms and disseminate some of their information, whether it be through tweets or infographics, podcasts, Facebook lives, things like this. So I think the leap from relatively nothing, you know, meaning researchers kind of doing their research but not having perhaps the means to get it out to a wider audience outside of a journal that not every lay person who reads, you know, having such great avenues to disseminate this information. Do you feel like it's made a difference in the general public?

Alex Hutchinson:           04:00                I think it has. It's hard to really evaluate this stuff, but my sense is there's a higher level of literacy or sort of awareness of issues, you know, things like how to fuel that's maybe not just drawn from, I heard it from a guy at the gym or I heard it from my coach who heard it from his coach who is taught by, you know, some guy in 1830 that this is how it works. I mean, I would almost say that we've gone from a place of scarcity to a place of excess that now it's not like you can't find information. Now there's these fire hoses of information just drenching you with 20 different theories. All of which seemed to be supported by scientists about how you should eat, how you should exercise, how you should move, and all these sorts of things.

Alex Hutchinson:           04:45                So I started writing about sports science, let's say 15 years ago or a little less than that. And at that point it was like, let's get the information out there. People don't realize that there's information now. It's like there's all this information, let's curate the information. Let's try and provide people with some judgements about what's reliable and what's not. Why we think that some sources of information are better than others. How each person can evaluate for themselves, whether this is trustworthy. You know, and this is obviously not an easy or there's not like one answer to this study's right and this study's wrong, but, yeah, I feel like my role has shifted a little bit from get the information out there to, okay, maybe I can be a trustworthy source of curation where I'm giving people the information, not necessarily telling them what to think, but saying, here's the evidence. Now you may choose to think this evidence isn't convincing enough for you to switch to the, you know, the Aldana Diet or you may not, but here's, here's what the evidence says it exists.

Karen Litzy:                   05:45                Yeah, and that's a great lead into my next question is when we look at quote unquote fake news and we can categorize that as misinformation or disinformation. So misinformation being like you're putting something out there and you think it's good, but you just don't know that the information is bad versus disinformation, which is, I guess we can categorize more as propaganda. So you know, the information's not correct, but you're pushing it out there anyway. So I think it's important to me. Both of those are fake news, but it's important to make that distinction. So as a journalist, how do you navigate this and how important is it for you to get that right?

Alex Hutchinson:           06:27                Yeah, yeah, yeah. Well, getting it right is important to me and I'm glad you made that distinction because I think that's an important one because you know, fake news in the politicized sense is another way of saying propaganda. And I think that's mostly not what we're dealing with in the exercise or the health space. I mean there, there is actually, I mean, you know, let me take that back a little bit there. There are people who are just selling things to make money who are just, they don't really care whether it's true. They're putting steroids into their stimulants, into their strength supplements because they just want people to feel a boost and they're just flat out lying so those people are bad and they're also not that hard to spot if truth be told, if you're critical, what's tougher is the, you know, what you call misinformation rather than disinformation, which is people honestly believe this.

Alex Hutchinson:           07:20                Like, I tried this diet, it works for me, and therefore everyone should be doing it. And I read this study that shows that people who do this diet, you know, increase their levels of some inflammatory marker and that proves, that confirms my belief. And therefore I'm going to become an evangelist for this. And I'm going to say that everyone who disagrees with me has been paid off by big industry and blah, blah, blah. And sometimes it's not quite that. I mean, I'm caricaturing it, but people don't have strong beliefs that don't have as strong beliefs about, you know, controversies in particle physics cause we don't have personal experience in particle physics when you're talking about health and exercise and eating and things like that. We all have our, we have our experiences. And so we map that on top of whatever evidence we're experiencing, and I include myself in this, you know, my experiences play into what science, scientific research finds plausible.

Alex Hutchinson:           08:12                So that creates a different dynamic. So to answer your actual question, how do I navigate this? Imperfectly like every other human, but my goal in what I write, what I try and do is if I'm writing about a study, this article from my perspective as the one in which I'm able to serve, take the key graph from that study, cut and paste it into my article and then describe what the study was. Here's what they did, here's what they found.

Alex Hutchinson:           08:46                I'll take it a step further than that because my role is to interpret. I'll say, here's what I think this means, but I want to make sure I can give enough information to someone who doesn't think that's what it means is also can also see, well that's what the evidence was. And it's like, well no, I don't agree that that should change my behavior or whatever, but I'm giving them, I want to give people enough information so they understand what the study did and what it found. And then the meaning, if I've given people enough information, they don't have to rely on me telling them that this is what it means even though I am going to tell them what I think it means.

Karen Litzy:                   09:16                If you were to give tips to let's say the layman person, say it's like my mom or you know, your friend who knows nothing about science, he doesn't have a phd in physics, and we'll get back to that with you in a second. But what tips can you give to the lay person on how to spot this misinformation, because the thing is when you look at a lot of articles, they're always citing this study, that study, this study.

Alex Hutchinson:           09:47                Yeah. It used to be like, show me the peer reviewed evidence. But yeah, I've slowly realized, you know, and understood that there is a peer reviewed study for everything. And you know, 10 years ago I used to get, I'd see a study saying, you know, hey the, you know, the fruit of this plant, if you take it's going to increase your endurance by 2%. It's like, well if they have a placebo controlled, double blinded study published in a peer reviewed journal, it must be true. I'll write about it. And then, you know, I never did hear about that extractive of such and such a plant. Again, like no one, it never turned out to be a thing. And I sort of finally understand, you know, started to understood the bigger systemic problems, which is that if you have, you know, thousands of Grad students across the country looking for a master's thesis that can be done in six months or an experiment, they can be done in six months.

Alex Hutchinson:           10:33                They're testing all sorts of things. And if it's not interesting, they don't publish it. And if it happens by chance to produce a positive result, then they publish it in a journal. So we get this sort of, there's always public positive studies about everything. What I was saying, which is that just the mere presence of a study isn't enough. So there is no simple template. But I would say there are some guidelines like follow the money. If someone's trying to sell you something, it’s obvious, but it's surprising what a good rule of thumb that is. And it's why we see so much information about pills and technology.

Alex Hutchinson:           11:20                And so little information about, you know, another study showing that sleep is good for you, getting some exercise is good for you because it's very hard to monetize that. And so there's lessons. I don't mean to sound like a patsy or like someone who's, you know, pump promoting my own way of seeing things. But I think there are some sources that are more sort of authoritative than others. And frankly, the mainstream media still does a pretty good job relative to the average blog. Now there are some great blogs out there and you know, and I will say, I started out in this, I set up my own blog on wordpress and I blogged there for five years, just analyzing studies. And then runner's world asked me to bring the blog onto their site and then it got moved outside.

Alex Hutchinson:           12:08                So it's not that there aren't good blogs and you can maybe get a sense of what people's agendas are and what their backgrounds are. But, you know, if I knew that, I know in this highly politicized world, I know that this may be a controversial thing to say, but if I see something in New York Times, I'm more likely to believe it than if I see it on, you know, Joe's whole health blog and I read the New York Times and I get frustrated frequently and I say that now they're getting this wrong. And this is not a full picture of this. Nobody's perfect. But I think that people with credentials and getting through some of those gatekeepers is one way of filtering out some of the absolute crap that you see out there.

Karen Litzy:                   12:53                Perfect. Yeah, I think those are very easy tips that people can kind of follow. So sort of follow the money, see who's commissioned said RCT, systematic review. And, oftentimes, especially on blogs, it can be a little tricky because some of them may write a blog and be like, oh, this is really good. But then when you look down, it's like the blog is sponsored by so-and-so,

Alex Hutchinson:           13:18                And that's the reputable people who are acknowledging who's sponsoring them. Then there's the people who are getting free gear, free product or money straight up, but they're not, you know, like there's levels of influence and the people who are disclosing that at least they're disclosing it. But nonetheless, it's, you know, one of the things that I think people often kind of misjudge is when, when someone says that follow, you know, follow the money and the financial influences, finances can influence someone. That doesn't mean that the people who are passing on this message or corrupted or that it's disinformation as you would say that they're deliberately, yeah. I mean, lots of researchers who I really highly respect do excellent research funded by industry. And I think that there's any important information that comes from that research, but I also think that the questions that get asked in industry funded research are different than the questions that you might ask if you just had you know, a free pot of money that wasn't tied to any strings.

Alex Hutchinson:           14:16                If you want to, you know, not to pick on anybody, but if you want to know which proteins are best for building strength and if the dairy industry is going to fund a whole bunch of studies on dairy protein, then you're going to have this excellent body of research that shows that dairy protein is good for building muscle. That doesn't mean it's wrong, it just means that we haven't studied what, you know, vegetable proteins or other forms of meat. There's been less emphasis on those proteins so you get a distorted view of what's good or bad without anybody doing anything wrong. It's just that money does influence the way we ask questions and the answers we get.

Karen Litzy:                   14:53                Great. Thank you. Now I had just mentioned about having a phd in physics. That is obviously not me. How did you end up doing your phd in physics and how does this help you when it comes to writing your articles or writing these reviews of RCTs or systematic reviews?

Alex Hutchinson:           15:14                Well, I should first say that if anyone's interested in becoming a science journalist, I wouldn't necessarily recommend doing a phd in physics. It's not the linear path or you know, the path of least resistance. I honestly didn't know what I wanted to do when I grew up. Some advice I got, which I think was good advice to some extent was, you know, if you don't know what you want to do, do something hard because at least you'll prove to people that you can, you know, solve problems and there'll be some transferability of that training. And I think that was true to some extent. And I, you know, so I did physics in Undergrad. I still didn't know what the heck I wanted to do. And I had an opportunity to go do a phd in England, which seemed like a big adventure.

Alex Hutchinson:           15:50                So I went and did a phd there, PhDs there are actually a lot shorter than they are in North America. It's just over three years for my phd. So it wasn't, it wasn't like this sort of, you know, spent my entire twenties on this. Physics was fun, but it just, I could see that the other people in my lab were more passionate about it than I was, that they were, they were just interested. They were passionate about it. And I thought, man, I want to, I want to find something that I'm passionate about. So I ended up in my late twenties saying, okay, well it's been a slice, but I'm going to try something else. And, you know, fortunately I guessed right. And journalism turned out to be fun. Fun for me. I don't write, you know, especially these days if I'm writing about exercise and it's not like I need to know Newton's laws or anything like that or you know, apply the principle of general relativity to exercise.

Alex Hutchinson:           16:35                So there's not a lot of like direct pay off. But I would say that having a scientific training has helped me be willing to speak to scientists and not be intimidated by paper. You know, Journal articles that look very complex and you know, I have the confidence to know that, okay, I don't have a clue what this journal article is saying, but I know if I slow down, if I read it a few times and if I call it the scientist and say, can you explain this to me? I'm not worried. Well, I mean, I don't like looking stupid, but I'm over the idea is like, it's okay. I can call up the scientist. I know enough about scientific papers to know that probably the guy in the office next door to whoever wrote this paper doesn't understand this paper. You know, science is very specialized and so it's okay to just say, explain to me, explain it to me again. Okay. This time, pretend I'm, you know, your 90 year old grandfather and explain it again. And so that allows me, or has helped me write about areas even when I'm not familiar with them and not be intimidated by numbers and graphs and things like that.

Karen Litzy:                   17:36                All right. And I would also imagine that going through Phd training yourself, you understand how articles are written, you kind of can look at the design, and you can look at the methods and have a little bit more, I guess confidence in how this study was maybe put together. Versus no training at all.

Alex Hutchinson:           18:03                You've seen how the sausage is made and so you understand the compromise that get made. I will say that it was surprising to me how different the physics processes to the sort of the sports science world in terms of just the factors that are there that are relevant in physics. You’re never dealing with people. And with the sample recruitment and things like that. An Electron is an electron, you know, for the most part. You know, and this is an important to understand is physics aside by looking a lot of studies, I started to see the patterns and started to understand what the functions were, started to understand how to read a paper relatively quickly. How did you know it? For me to find stories, I ended up looking at a lot of journal articles and I can't read every one of them in depth in order to find the ones I wanna write about.

Alex Hutchinson:           18:52                So I have to find ways of, you know, everyone knows you. Yeah, you can read the abstract, but you're not going to get the full picture. You know, you start to learn just by experience, by doing it. That, okay, if I read the introduction, that's where the first three paragraphs are where they're going to give me the context. Because often a study seems very specific and you're like, I don't know what you're talking about. And then they'll give two paragraphs where they're just like, since the 1950s, scientists have been wondering about x, Y, and zed. And then you can go to the conclusions and then, you know, depending on how deep you want to get, you understand where, which part of every paper is written with a specific format and you can figure out where to go with a little experience. And it doesn't require a physics phd or it requires just getting, getting familiar with that particular, you know, subject area.

Karen Litzy:                   19:35                Nice. And now, you know, we talked earlier about how, you know, information from researchers went from like a little drip to a fire hose and as far as getting information out to the general public, so because there is so much information available, how do you approach designing your article titles and headlines to ensure you grab attention for the reader. So I think that's a great question directed at the researchers who are maybe thinking of doing a press release or things like that to help promote their article.

Alex Hutchinson:           20:10                Yeah. This is a really interesting question. This isn't one where my thinking has shifted over the last, let's say, decade. So I started out, you know, in print journalism, writing for newspapers and magazines. I still do that, but one of the things in from when you're writing for a newspaper magazine is you don't have control over your headlines. You write the article, the editor writes the headline. And so my experience in that world was always one of frustration being like, I wrote this very carefully nuanced, balanced article. And then the headline is, you know, do this and you'll live till you're a hundred or whatever. It's like, no, that's not what I was saying. It's terrible. And so I got into this sort of reflects of habit you know, just apologizing for the headlines. Like, Oh, you know, when I talked to researchers, I'm so sorry about the headline.

Alex Hutchinson:           20:59                You know, I'm very sophisticated, but you know, that this silly editor wrote the headline and a couple of things help to sort of shift my views a little bit on that. One is the shift to online meant that newspapers and journalists now have a very, very clear idea of who clicks on what. So you understand what it is that gets people's attention. And the second thing is that, you know, when I started my own blog, and then even now, when I blog, I don't have full control of my headlines, but when I was on wordpress, I wrote my own headlines. And when I now as a blogger, I suggest headlines. And so I don't have control, but I am given more input than I used to be on how this article should be conveyed.

Alex Hutchinson:           21:40                And one thing that's really clear is that, what people say they want and what people will do is different. And so I remember looking at when the global mail is the Big News newspaper in Canada. I remember when it first started showing its top 10 most clicked articles. You know, in the transition to digital on its website. And of course, everyone says, I hate clickbait. I want to have sophisticated, nuanced conversations. And then the top 10 articles clicked would all be something to do with Brittany Spears or whatever. You know, this was 10 years ago. And it's like, so people click on, people do respond to clickbait and click bait it's bad. But you know, I sometimes I want like sometimes give talks to scientists about science communication and I'll give some contrast between here's the journal article, you know, here's my headline and the journal article will be something that's so careful that you're not even, it definitely doesn't tell you what the article's going to say.

Alex Hutchinson:           22:36                You're not even entirely sure what the subject is. You know, like an investigation of factors contributing to potentially mitigating the effects of certain exercise modalities. And you're like, I don't know. I don't know what that's about. No one clicks on it. And so it's like that sort of, if a tree falls in the forest, if you write a perfectly balanced nuanced article and nobody reads it, have you actually contributed to science communication? And so one of the things that I found in with headlines that I'd complain about is I would complain about a headline that someone had written for my article and then, and I try to think why am I complaining about this? And it's like, well it's sort of coming out and saying what I was hinting at, I was hinting at, I didn't want to come out and say, you know, overweight people should exercise more or whatever.

Alex Hutchinson:           23:22                Cause that's horrible. No one would say that. But if you sort of read what the evidence that I was shaping my article to be, it'd be like, if you're not getting results from your exercise, maybe you're just not exercising hard enough. I was like, well maybe I need to own the messages. You know, if the headlines to me seems objectionable, maybe it's my article is objectionable and I've tiptoed around it, but I need to think carefully. And if someone reads my article, you know, an intelligent person reads my article and says this in sum it up in seven words, this is what it is, then I need to maybe be comfortable with having that as the headline, even if it's an oversimplification, because the headline is never going to convey everything, all the nuances. There's always caveats, there's always subtleties.

Alex Hutchinson:           24:04                You can't convey those in seven words. That's what the article is for. So I've become much more of a defender, not of clickbait, not of like leading people in with misleading things. But if ultimately the bottom line of your article is whether it's a academic article or a press article is, you know, this kind of weight workout doesn't work and you should be okay with a headline that says that. And yes, people will say, but you forgot this. And then you can say, well, no, that's in the article, but I can't convey all the caveats in the headline. So anyway, that's my, that's my sort of halfhearted defense of attention grabbing headlines in a way.

Karen Litzy:                   24:37                Yeah. And if you don't have the attention grabbing headline, like you said, then people aren't going to want to dive into the article. So I was, you know, looking up some of the headlines from and the first one that pops up is how heat therapy could boost your performance. And you read that and you're like I would want to find out what that means.

Alex Hutchinson:           25:02                And they put some weasel words in there. It's not like heat therapy will change your life. It's how it could boost your performance. And so, and I'm there, it's interesting, I've got conversations with my editor and they, you know, they don't like question headlines. They don't want to be as like, is this the next, you know, a miracle drugs? And then it turns out the answer is no. It's like they feel that's deceptive to the reader. They want declarative headlines that say something. It’s an interesting balance but outside has been, they've had some headlines which were a little, you know, there was one a while ago about trail maintenance and it was like the headline was trail runners are lazy parasites or something like that. And that was basically, that was what the article said. It was an opinion piece by a mountain biker. They got a ton of flack for that and they got a bunch of people who are very, very, you know, I'm never gonna read outside again. It's like, dude, relax. But I understand, but I understand, you know, cause it is a balance there. They want to be noticed and I want my articles to be noticed, but I don't want to do it in a deceptive way.

Karen Litzy:                   26:07      &nb