Healthy Wealthy & Smart

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

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

In this episode, we discuss:

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

-How to gracefully ride the ebbs and flows of entrepreneurship

-Prioritizing your mental health to avoid burnout

-New year intentions from the team

-And so much more!



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

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


For more information on Jenna:

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

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

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

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

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


For more information on Julie:

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

For more information on Lex:

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

For more information on Shannon:

Dr Shannon Sepulveda, DPT, M.Ed., CSCS, WCS is the owner and Physical Therapist at Shannon Sepulveda, DPT, PLLC. She is an Orthopedic and Women’s Health Physical Therapist and is currently the only Board-Certified Women’s Health Physical Therapist (WCS) in Montana. Shannon received her undergraduate degree from Dartmouth College, Masters in Education from Harvard University (M.Ed.) and Doctorate of Physical Therapy (DPT) from the University of Montana. She is also a Certified Strength and Conditioning Specialist (CSCS). She has been a practicing Physical Therapist in Bozeman, Montana for over 6 years. In her free time, she enjoys running, biking, skiing, hunting and spending time with her husband, son and daughter.


Read the full transcript below:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Julie Sias:                                              Where are you going?

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

Julie Sias:                                              You should go to Hawaii.

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

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

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

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

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

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

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

Julie Sias:                                              She's outside.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Shannon Sepulveda:      00:59:28           Yeah.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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Dec 23, 2019

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

In this episode, we discuss:

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

-Pelvic health red flags

-How to address pelvic floor health with a conservative population

-Assessing the pelvic floor muscles without doing an internal exam

-And so much more!


Oswestry Low Back Pain Disability Questionnaire:

Sarah Haag Twitter

Entropy Physio Website

Home Health Section Urinary Incontinence Toolkit

Rehab Therapy Operational Best Practices Forum

For more information on Sarah:

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

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

Read the full transcript below:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Dec 16, 2019

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

In this episode, we discuss:

-Why you should invest in a coach

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

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

-Redefining your daily operations with purpose and vision

-And so much more!


Steve Anderson Twitter

Steve Anderson Facebook

Steve Anderson LinkedIn

Orange Dot Coaching Website

Episode 197: The Graham Sessions with Steve Anderson

Profiles in Leadership Podcast

Optima: A New Health Company


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


For more information on Steve:

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

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

Read the full transcript below:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Steve Anderson:            36:50                Right.

Karen Litzy:                   36:51                So what great examples.

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

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

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

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

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

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

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

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

Karen Litzy:                   42:15                Oh my God.

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

Karen Litzy:                   42:23                Yeah, probably

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

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

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

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

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

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

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

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


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Dec 9, 2019

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

In this episode, we discuss:

-Three actionable tips to constantly reinvent your business

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

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

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

-And so much more!


Ryan Estis Website

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For more information on Ryan:

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

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

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

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


Read the full transcript below:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Karen Litzy:                   30:16                Yeah.

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

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

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

Karen Litzy:                   30:47                Yeah.

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

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

Ryan Estis:                    32:23                Yeah, get specific.

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

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

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

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

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

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

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

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

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

Karen Litzy:                   37:02                Yes.

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

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

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

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


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

Dec 2, 2019

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

In this episode, we discuss:

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

-Patient health outcomes following the diagnosis of degenerative disc disease

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

-Pain science education and the treatment of low back pain

-And so much more!



Elaine Lonnemann Twitter

AAOMPT Website

AAOMPT Position Statements

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

JOSPT CPG: Low back pain   


For more information on Elaine:

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

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


Read the full transcript below:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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