Healthy Wealthy & Smart

The perfect combination of healthcare and business! At Healthy Wealthy & Smart, we interview THE top experts in the fields of medicine, physical therapy, fitness and entrepreneurship to allow you to increase your health, increase your wealth and live your best life.
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Now displaying: November, 2019
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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