On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Sandy Hilton, David Butler and Bronnie Thompson on the show to discuss persistent pain during COVID-19. 

In this episode, we discuss:

-Shifting current healthcare curriculum to better educate clinicians on persistent pain

-Can passive modalities empower people to pursue more active treatment options?

-How to create more SIMS during the COVID-19 pandemic

-Can telehealth appointments adequately address persistent pain?

-And so much more!

Resources:

International Association for the Study of Pain Website

Factfulness Book

David Butler Twitter

Sandy Hilton Twitter

Bronnie Thompson Twitter

A big thank you to Net Health for sponsoring this episode!  Learn more about Four Ways That Outpatient Therapy Providers Can Increase Patient Engagement in 2020!

For more information Bronnie:

I trained as an occupational therapist, and graduated in 1984. Since then I’ve continued study at postgraduate level and my papers have included business skills, ergonomics, mental health therapies, and psychology. I completed by Masters in Psychology in 1999, and started my PhD in 2007. I’ve now finished my thesis (yay!) and can call myself Dr, or as my kids call me, Dr Mum.

I have a passion to help people experiencing chronic health problems achieve their potential. I have worked in the field of chronic pain management, helping people develop ‘self management’ skills for 20 years. Many of the skills are directly applicable to people with other health conditions.

My way of working: collaboratively – all people have limitations and vulnerabilities – as well as strengths and potential. I use a cognitive and behavioural approach – therapy isn’t helpful unless there are visible changes! I don’t use this approach exclusively, because it is necessary to ‘borrow’ at times from other approaches, but I encourage ongoing evaluation of everything that is put forward as ‘therapy’. I’m especially drawn to what’s known as third wave CBT, things like mindfulness, ACT (Acceptance and Commitment Therapy) and occupation.

I’m also an educator. I take this role very seriously – it is as important to health care as research and clinical skill. I offer an active knowledge of the latest research, integrated with current clinical practice, and communicated to clinicians working directly with people experiencing chronic ill health. I’m a Senior Lecturer in the Department of Orthopaedic surgery & Musculoskeletal Medicine at the University of Otago Christchurch Health Sciences.

I also offer courses, training and supervision for therapists working with people experiencing chronic ill health.

For more information Sandy:

Sandy graduated from Pacific University (Oregon) in 1988 with a Master of Science in Physical Therapy and a Doctor of Physical Therapy degree from Des Moines University in December 2013. She has worked in multiple settings across the US with neurologic and orthopaedic emphasis combining these with a focus in pelvic rehabilitation for pain and dysfunction since 1995. Sandy teaches Health Professionals and Community Education classes on returning to function following back and pelvic pain, has assisted with Myofascial Release education, and co-teaches Advanced Level Male Pelvic Floor Evaluation and Treatment. Sandy’s clinical interest is chronic pain with a particular interest in complex pelvic pain disorders for men and women. Sandy is the co-host of Pain Science and Sensibility, a podcast on the application of research into the clinic.

For more information on David:

Understanding and Explaining Pain are David’s passions, and he has a reputation for being able to talk about pain sciences in a way that everyone can understand. David is a physiotherapist, an educationalist, researcher and clinician. He pioneered the establishment of NOI in the early 1990’s. David is an Adjunct Associate Professor at the University of South Australia and an honoured lifetime member of the Australian Physiotherapy Association.

Among many publications, his texts include Mobilisation of the Nervous System 1991 The Sensitive Nervous System (2000), and with Lorimer Moseley –  Explain Pain (2003, 2013), The Graded Motor Imagery Handbook (2012), The Explain Pain Handbook: Protectometer (2015) and in 2017, Explain Pain Supercharged. His doctoral studies and current focus are around adult conceptual change, the linguistics of pain and pain story telling. Food, wine and fishing are also research interests.

Read the full transcript below:

Karen Litzy (00:00:23):

Hello everyone. And thank you for joining us today for this webinar. For those of you who are here live, you got to hear a little bit of pre-conversation which is great. And of course in that pre-conversation we were talking about all the things happening in the world today, specifically here in the United States with a lot of unrest and protests for very, very good reasons, in my opinion. And so we just want to acknowledge that and that we see it and that we are trying to learn, and we are doing our best to be allies to our fellow healthcare workers and citizens across the country and across the world for all of the other countries who have been showing solidarity. So I'm Karen Litzy, I'm going to be sort of moderating this panel of minds and I'm going to now go round and just have each of them say a little bit about themselves. So Sandy I’ll start with you.

Sandy Hilton:

Okay. Hi, I'm Sandy Hilton. I'm a physiotherapist here in Chicago, Illinois with Sarah Haag. We have entropy physiotherapy and our clinic is predominantly working with pain. It's like a hundred percent of my case load is people in pain and about 80% of that is pelvic pain in particular. But I still see, you know, the rest of humans.

David Butler (00:01:49):

Hi, I'm David Butler from Adelaide Australia. I'm a physio, although I'm completely a professional and I believe everybody has the exact same role in treating pain. I'm trying to hire, but I can't retire. And then in world, our changing knowledge and our changing potential just keeps me, keeps me on track. So yeah, any sort of pain I'm happy to talk about.

Bronnie Thompson (00:02:16):

I’m Bronnie Thompson, I'm an occupational therapist by original training with some psychology thrown in, and I'm an educator and clinician as well, but a teeny tiny bit of research, but not much. And I'm a painiac and quite proud of it actually.

Karen Litzy:

Excellent. So again, everyone, like I said, if you have questions as we go along, please feel free to put them in the Q and a part. And I will be looking at that as we're going through now, like I said, we've got some questions ahead of time, but before we get to some of the questions that some of the listeners and viewers have wanted to ask, I also want to just quickly acknowledge that we've got a bit of a mixed audience, so we've got healthcare practitioners and clinicians and we've also got people living with pain.

Karen Litzy (00:03:11):

And so as a clinician for me, it's a great opportunity. I think to address people in pain who maybe don't have the access or the ability to kind of get this information that's in their town or where they're living. So I am really, I'm really looking forward to this discussion, especially for those people that are watching that are living with persistent pain. So the first question I'm going to ask is and I'll ask this of all of you. If you were to give a piece of advice to a new professional or a healthcare professional that is sort of newly working with people with persistent pain, what would that piece of advice be?

Sandy Hilton (00:04:11):

I'm in Chicago. I'm just going to take it. I really like to stress, especially to students that, you know, we get this concept that the longer you've been in the field, the better you are at it. And, I think that maybe we make different mistakes, but everyone is learning this. And there's so much about pain that we're learning. And so if you're just starting in, I don't know that you might have an easier time because you have less bad habits to get rid of and can start with some of the better newer research and avoid some of the mistakes we made.

Bronnie Thompson (00:04:50):

So she's doing the popcorn approach. She looks at me. And so I think my advice would be, listen, listen very carefully to what people tell you and trust that they're telling you your experience. Don't try and read stuff into it, just listen and reflect, show that you're listening by reflecting what you've heard. So you can give that you've understood one another, because it's really easy to come out of school with all of this knowledge packed up and your brain thinking, Oh, I've got to do an info dump just like that. And it's not that great for the person, stop and listen.

David Butler (00:05:37):

They are lovely comments. I'd add. I would welcome anybody to the most new and exciting area of health. And there is a true pain revolution out there. And I would say to anybody, when you come in to just lift your expectation of outcome or what, might've been five or 10 years ago, because the clinical trials and our knowledge of the potential for humans to change is just increasing so dramatically. And I say, now we can say think treatment, not necessarily management because for many people recovery or some form of recovery is on the cards and what's leading the charge is the talking and the movement therapies. It's not the drug therapies for chronic pain. And, I just like to reflect as an older therapist now, patients who maybe 10, 15 years ago with maybe complex post pain surgery or Phantom limbs or complex regional pain syndrome would have thought, and I can't really help here. Now we welcome them through the door and you can get such pleasure, pleasure from treating these people no matter how long they've had the problem.

Karen Litzy (00:06:48):

Great. And, I would echo what Bronnie said is, you know, really listen and also believe, you know, they're giving you their experience. So try and take your bias out of it and believe what they're telling you and try not to talk them out of it because you see this quite a bit of, Oh, I have pain with this. And well, do you really have pain with that? Or is your pain really that much? And as the patient, it's very frustrating to have someone try and tell you what your pain is. So I'm looking at it from the person who has lived with the really chronic and at times debilitating neck pain is just listen, which is good. Believe them, and try not to talk people out of their experiences because it's very frustrating and it's very sort of dehumanizing for the patient, you know?

Karen Litzy (00:07:54):

And when I look back at when I first met David and went up to him at an APTA event and said, would you like to be on my podcast? And he said, yeah, sure, but I'm going to New York. I said, Oh, well, that's great. Cause that's where I live. And so then he met me at my, where I was working at the time and spent two hours with me. And I just, after that felt like, Whoa, like this is the first time that someone really listened and didn't interrupt and believed what I was saying and really set me on a path that just changed my life. Like, I don't know where I would be, had I not had that encounter with David. I think it was like 2011 or 2012. And so I always reflect on that and try and be that person, because I know what it felt like.

Karen Litzy (00:08:45):

And then when someone does come in and, and gives you their full attention and their time and their understanding, and then says, well, challenges your beliefs in a positive way, it was something for me that, you know, and I've talked about it many times that just completely changed my pain and my life. And so, you know, try and be that person is what I would say to people.

Bronnie Thompson:

It's like, we've got to remember that people with pain and I live with fibromyalgia, those of you that don't know that's my reality, it's our experience and what it's like to live without pain. You know, what it feels like to know the things that sit at off things that settle it down and our relationship to it, to that pain and conditions. We come in with a whole lot of knowledge about other people and what we've seen. So we are experts and a whole lot of stuff, but what we're not experiencing as this person's life, their experience via what they're wanting from us even, what's important to them. And that's where when we meet and we can kind of share the hidden paradigms things that we don't know about each other, then we've got a chance to make a huge change and that as we know, I just feel so good about what I do. I just love it. I'm such a pain geek.

Sandy Hilton (00:10:09):

And I think the pain science or the science of pain really gives as a clinician, a lot of comfort to the listen to them, believe them, you don't have to prove it. You don't have to go. And like they say, I hurt here. You don't have to go poke it to reproduce the symptoms to believe it. And that's how I was taught of you have to reproduce the symptoms so that you can document that it's true. And it was like, that's a giant piece of unnecessary that we don't even have to do anymore, which really saves us a lot of time, not to mention establishing that trust and not being one more person. That's poked them in the sore spot. But, that's the thing that I was taught in school.

Bronnie Thompson (00:10:58):

So the question is, do you think that all chronic pain patients were not treated particularly when they were having the first or second episodes of their acute pain or are they in any way destined to become chronic pain patients? Well, my story is I hurt my back. I was what, 21, 22, doing a tango with the patient and a doorway patient was bigger than me. I landed on the floor on my back and I had all the best evidence based treatment at the time, maybe not, maybe not all the ultrasound, but you know, they didn't lie. They're really and relax a bit.

Bronnie Thompson (00:11:48):

But I didn't recover. I was then seeing the Auckland regional pain Center with amazing dr. Mike Butler, who is a rheumatologist and founded, and basically was one of the first in this initiations of bringing the international association for the study of pain to New Zealand, good friend of Patrick Wall knew her stuff very well. Gave me the book the challenge of pain to read. So essentially an explain pain paradigm back in the eighties, I know pain pretty well. My pain has not gone away. So there are some people who will not have a complete recovery of all of their pain, but because none of our treatments provide a hundred percent abolition of pain and actually I'm comfortable with it. I live with the pain and it gives me some stuff that some other people don't have access to. I know what it's like to have every bit of my body feeling really rotten.

Bronnie Thompson (00:12:53):

At the same time. I'm not limited by my pain. And I think sometimes we look at pain removal is that end goal. But I think our end goal is to help people live full, productive, satisfying, joyful and enriched lives. And some people will bring the pain along with them and many people won’t have to and that's amazing. Let's let the person make that decision about what is the most important outcome. But yeah, sometimes we can do all the right things, but if you have a spinal cord injury and you've got a smashed up spine, probability is that at the moment, our technology doesn't give us a solution. We can help, but we can't always take it all away.

Karen Litzy:

David, what are your thoughts on that, that sort of movement from acute pain to chronic pain? You know, what are your feelings on that is, is like you said, are you destined to have it are I know, cause I get this question a lot from people like, well, you know, it started out with like an ankle sprain or it started out with a knee sprain and now it's turned into this. So did I do something wrong or was something not done?

David Butler (00:14:12):

I think you’re not destined to have it, but I think our treatment or therapies and the politics of treating acute pain probably gets in the way. And I also think if someone's hurt their back or any part of their body bad enough to see a health professional, the data is that 50 or 60 or 70% will have a recurrence in the following year. Now most health professionals think a recurrence is a reinjury, but if they really explored what happened, that reoccurance probably happened at a time when they would look at down and flat the immune system's a bit out of balance and they might've just done something simple, lifted up and picked something we would now from pain science, reconceptualize that as well, that's quite good. It's your body testing yourself out like a fire alarm with all the stuff you've been through in the past. It's no wonder your brain. Wouldn't want to play it again to check out how your systems are working, but that just simple piece of knowledge and usually should check to make sure nothing serious has gone on because you check and you can normally say, well, that should ease in a couple of days. That's an example of a little bit of knowledge dampening down. They don't have to go through the old acute process again of more, x-rays more tests, more power.

David Butler (00:15:31):

I think if that's correct, that observation was seen for many years, it could save governments Billions.

Bronnie Thompson (00:15:37):

Oh, absolutely. We've got a great thing. The language we use don't we, is it an injury or is it just a cranky body?

David Butler (00:15:46):

That whole linguistics? And for me and my treatment, you're now a physio by trade. I feel it says important to help someone change the story, to have a story, to take their experience out into society and let it go. That to me is as important as having healthy movement, although they obviously like go together.

Sandy Hilton (00:16:07):

I was gonna say that the saving of money for systems, for sure, but also the saving of time for people and the saving in our healthcare system. Every test you go do is going to cost you a lot of money. And, that time that it takes to get it in a time away from work and family and the concern of what the test results will be. If we can divert them wisely to not do that when it's not really indicated, that's just so good.

Bronnie Thompson:

Yeah. And then I also for, you know, I've had a test now I'm going to wait for the results and now I'm going to wait for what are they going to do as a result of those results? And then, Oh, it's the same. And it just feels very demoralizing to people. And I think that's something we need to think about with make the decision about when and we to stop doing investigations often. That's the sense of the clinician worrying that something, are they going to sue me? It’s not a good way to practice.

Karen Litzy:

Yeah. here's another, we'll do this from Louise. She says, picking up on something David had said earlier, how do we move towards being more, a professional? How do we move the pain industry toward this goal? Excellent question Louise.

David Butler (00:17:51):

There's a lot of answers to it, but a couple would be, I think you just got a quite badly out there would know sports trainers who could deliver an equally good management strategy to some physios, to some doctors, et cetera, right? This pain thing is across all spectrums, which is why the national pain society meetings are so good. And why everybody there is usually humbled and talks to all the other professionals because they realize the thing we're dealing with is quite hard. And we need all the help that that's a weekend get, but it ultimately comes back to provision of pain education throughout all the professions and that pain education should be similar amongst all the professions it's not happening yet. We've tried pushing it, but it's not out there. And it's incredible considering the cost of pain is to the world is higher than cancer and lung diseases together.

Karen Litzy (00:18:51):

Yeah. The burden of care is trillions of dollars across the world. And, you know, even in the United States, I think the burden of care of back pain is third behind heart disease, diabetes. And then it was like all cancers put together, which, you know, and then it was back pain. So, and, and even I was in Sri Lanka a couple of years ago and I did a talk on pain and I wanted to know what the burden of disease of back pain was in Sri Lanka. And it was number two. So it's not like this is unusual even across different, completely different cultural and socioeconomic countries. And, you know, David kind of what you said, picks up on a question that we got from Pete Moore. And he said, why isn't it mandatory that pain self management and coaching skills isn't taught in medical schools? Is it because there isn't expertise to teach it? Well, I mean, David's right here. He's semi retired.

David Butler (00:19:58):

Why isn’t that mandatory? That's a big, big question. I would say that the change is happening. Change is happening. I would say that at least half of the lectures or talks I give now are to medical professionals and out of my own profession or even more than half. So yeah, change is happening, but it's incredibly slow. It needs a bloody revolution, quite frankly. A complete reframing of the problem and awareness that this problem that we can do something about it and awareness that there's so much research about it let's just get out and do it now.

Sandy Hilton (00:20:40):

The international association for the study of pains curriculum and interdisciplinary curriculum would be a nice place to start. And I know some schools here in the States are using it in different disciplines to try and get at least a baseline.

Bronnie Thompson:

The way we do it as the core for the post grad program, that I am the academic coordinator for it. Doesn't that sound like a tiny, tiny faculty. But anyway the other thing that we know is that looking at the number of hours of pain, education, Elizabeth, Shipton, who's just about completed. If she hasn't already completed her PhD, looking at medical education and the amount, the number of hours of pain, it's something like 20 over an entire education for six to six or more years. In fact, veterinarians get more time learning about pain then we do then doctors medical practitioners do, which suggests something kind of weird going on there.

Bronnie Thompson (00:21:50):

So I think that's one of the reasons that it's seen as a not a sexy thing to know about and pain is seen as a sign of, or a symptom of something else. So if we treat that something else in pain will just disappear, but people carry the meaning and interpretation in their understanding with them forever. We don't unlearn that stuff. So it makes it very difficult, I think for clinicians to know what to do. Because they're also thinking of pain is the sign of something else not is a problem in its own, right? Persistent pain is a really a problem in its own right.

Karen Litzy (00:22:29):

Yeah. And wouldn't it be nice if we were all on the same page or in the same book? I wouldn't even say the same chapter, but maybe in the same book, across different healthcare practitioners, whether that be the nurse, the nurse practitioner, the clinical nurse specialist, the physician, the psychologist, the therapist, physical therapist, it would be so nice if we were all at least in the same book, because then when your patient goes to all these people and they hear a million different things, it's really confusing. I think it's very, very difficult for them to get a good grasp on their pain. If they're told by one practitioner, Oh, see, on this MRI, it's that little part of your disc. And that's what it is. So we just have to take that disc out or put it back in or give a shot to this.

Karen Litzy (00:23:25):

And, and then you go to someone else and they say, well, you know, you've had this pain for a couple of years, so, you know, it may not be what's on your scan. And then the patient's like, who am I supposed to believe? What am I going to do? And, and you don't blame the patient for that. I mean, that's, you'd feel this that's the way I, you know, I had herniated discs and I say, you just get a couple of epidurals and the pain goes away and then it didn't. And I was like, Oh, okay, now there's so my head, I was thinking, well, now there's really something wrong.

Sandy Hilton:

That's the problem. Because yeah, if you think it's the thing you did that helped you or didn't help you, then you lose that internal control.

Karen Litzy (00:24:13):

Yeah, yeah. Yeah. So I think, I think it's a great question and, and hopefully that's a big shift, but maybe it'll start to turn with the help of like the international association for the study of pain and some curriculum that can maybe be slowly entered or David can just go teach it virtually from different medical schools, just throwing it out. There is no pressure, no pressure. Okay. Speaking of modalities, we had a question. This is from someone with pain and it's what can be the appropriate regimen for usefulness of tens, for acute and chronic cervical and lumbar pain of nerve origin. So Bronnie, I know that you had said you had a little bit of input on this area, so why don't we start with you? And then we'll kind of go around the horn, if you will.

Bronnie Thompson (00:25:24):

I think of it in a similar way to any, any treatment, really, you need to try it and see whether it fits in your life. So if you are happy and tens feels good and you can carry it with you and you can tuck it in your pocket and you can do what you want to do. Why not just is, I would say the same about a drug. If you try a drug and it helps you and it feels good and you can cut the side effects, there's nothing wrong with it. Cause we're not the person living life. It's more to think about it in a population. How effective does this? And my experience with tens is that for some people it does help and it gives a bit of medium, like a couple of hours relief, but often it doesn't give long sustained relief and you have to carry this thing around. That's prone to breaking down and running out of batteries, right when you need it. So to me, it's agency, but then I put the person who's got the pain and the driving seat at all times to say, how would this fit in your life? Do you think you want to try this one out? It's noninvasive it's side effects. Some people don't like the experience and sometimes the sticky pads are a bit yuck on your skin, but you know, that's more bad. So yeah, that's my, my take on it.

David Butler (00:26:44):

I haven't used it for 40 years after the second world war. When you start to stop, when they, I was friendly with the guy who invented it and I'm thinking it'd be happy pet we'll would be happy to, with these comments that I agree with what Bonnie said. Absolutely. I would also say that, hi, wow, you have got something there which can change your pain by scrambling some of the impulses coming in. You can change it, let's add some other things which can change the impulses coming in or going out as well. So let's use that. Let's get you building something, maybe something repetitive or something contextual or something as well. So you you've shown change you're on the track. So I would use it as a big positive to push them on keep using it, but on the biggest things.

Sandy Hilton (00:27:32):

Yeah, the advantage is it's. So it's gotten so inexpensive. So for something that has minimal to no side effects and has the potential of helping them to move again, which I think is always the thing that we're aiming for. It's not very expensive. But now like several hundred dollars, right? You can order it online. Now you don't even need a prescription or approval or anything like that.

Karen Litzy (00:27:59):

Yeah. Yeah. That's true. And something that I think is also important is, you know, you'll have people say, Oh, those passive modalities, that's passive. You know, I had a conversation with Laura Rathbone Muirs. Is that how you say the last name? I think that's right. Laura. And we were talking about this sort of passive versus active therapies and, you know, her take on, it was more from that if they're doing these passive modalities, they're giving away their control. And, she said something that really struck and, kind of what the three of you have just reinforced is that no, they still have that locus of control. Cause they're making that conscious effort, that conscious choice to try this, even though it's a passive modality, they still made the choice to use it.

Karen Litzy (00:29:03):

And I think that coupled with what David said, Hey, this made a difference. Maybe there's some other things that can make a difference that I think that I don't think they're losing that locus of control, or I don't think that they're losing they're reliant on passivity, right.

Sandy Hilton:

When they have their own unit and they're not coming into the clinic to have it put on you. And you lie there on the bed while you do it.

Bronnie Thompson:

It's something that you have out in the world. It's not different to sticking a cold compress on your forehead when you're feeling a bit sick, you know, we did it. That's just another thing that we can do. So I see it as a really not a bad thing. And it is in the context, you know, if you can do stuff while you've got it on, then it's the hold up problem, as long as you like.

Karen Litzy:

Great, great. Yeah. As long as you like it. Exactly. Yep. Okay. so we've got another question that we got ahead of time and then there's some questions in the queue. So one of the questions that we got ahead of time was how do we explain pain responses like McKenzie central sensitization phenomenon in modern pain science understanding.

David Butler (00:30:35):

I'd answer that broadly by saying that the definition that we've used and shared with the public in the clinical sense is that we humans hurt when our brains weigh the world. And judge consciously subconsciously that there's more danger out there than safety. We hurt equally. We don't hurt when there's more safety out there, then danger. So somebody who's in a clinic and is bending in any way and it eases pain. There will never be one reason for it. So it might just be, that might just be the clinic. It might be the receptionist. It might be all adding up. It might be the movement. They might've done one movement. And so, Oh, I can do that. And then all safety away, we go again, the next movement helps within that mix. There may be something structural. You've done to tissues in the back and elsewhere that might have eased the nociceptors that barrage up. But by answer will always be that when pain changes, it's multiple things are coming together, contributing to them. And they'll never never just be related to nociception.

Sandy Hilton (00:31:49):

I have to say this to say, I am not McKenzie certified. So this is my interpretation of that. I like the concept of you can do a movement. That's going to help you feel better. And we're going to teach you how to do that throughout the day. Maybe as a little buffer to give you more room, to challenge yourself a little more knowing that you'll have a recovery. And I just pick that part and use that.

Bronnie Thompson:

I heard the story of how it all came about and it, and it's you know, it's an observation that sometimes movement in one direction bigger than another. And that's cool. It's like, you're all saying, let's make this little envelope a little bigger and play with those movements because we're beasts of movement.

Bronnie Thompson (00:32:50):

We just forget that sometimes we think we've got to do it one way. And you know, I can't tell my plumbers who crawl under houses. Look, you've got to carry things the way, you know, the proper safe handling thing. And I wasn't, I was the same safe handling advisors like me. But you know, there's so many ways that we can do movements and why can't we celebrate that? And the explanation, sometimes we come up with really interesting hypotheses that don't stand the test of time. And I suspect it might be some of the things that have happened with the McKenzie approach. It's same time. What McKenzie did that very few people were doing at the time was saying, you can do something for yourself that as we are the gold ones, that's what changed.

David Butler (00:33:40):

Bronnie, what's really helped us to start the shift away from poking the sore bit, come on, do it yourself. And, and I always give great credit to Robin McKenzie for that shift in life.

Sandy Hilton (00:33:53):

Yeah. And an expectation that it's going to get better. Right.

David Butler (00:34:00):

You think that’s showing something in the clinic that helps. Wow. Let's ride let's rock.

Karen Litzy (00:34:07):

Yeah. And oftentimes I think patients are surprised. Do you ever notice that Sandy, like, or David, or, you know, when you're working with patients, they're like, Oh, Oh, that does feel better. And they're just sort of taken aback by, Oh, wait a second. That does feel better and it's okay. I can do it. Yeah. And then you give them the permission to do so. And like you said, is it's certainly not one single thing that makes the change. But I think everything that you guys just said are probably the tip of the iceberg of all of the events surrounding that day, that time, that movement, that can make a change in that person. And I think that's really important to remember. That's what I sort of picked up from the three of you.

Bronnie Thompson:

But the stories like that kind of convenient ways of, for us to think that we know what we're doing, but actually within what this person by what this person feels and how they experience it. And the context we provide us safety, security. And I'm going to look after you, that's, you know, changes, motivations about how important something is and how confident you are that you can do it. We can provide the rationale important part. The person ultimately drives that. So we can also provide that sense of safety and that I'm here. I'm going to hang around while you do this stuff. Let's play with it. Let's experiment. And if we can take that experiment, sort of notion of playing with different movements in, we've got a lot more opportunity for people in the real world to take that with them. We can't do that. Or forgive people are prescribed. You will do this movement. And this way perfectly I salute, but the old back schools, Oh, I know scary, And they did get people seeing the other people were moving. And that's a good thing that we can take from it. It's always good and not so good about every approach.

Karen Litzy (00:35:11):

Now I have a question for David and then out to the group, but you know, we've been talking about Sims and dims and safeties and dangers. And so for people who maybe have no idea what we're talking about, when we're talking about Sims and dims, can you give a quick overview of what the Sims and dims, what that is so that people understand that jargon that we're using?

David Butler (00:36:40):

Okay, it's a model we use. There's lots of other similar models out there. So basically based on neuro tag theory, the notion of a network that there's danger danger in me networks out there, and there's safety in me networks, rather simple, structured thinking here, and we've looked at these this has emerged due to the awareness, the pain science that we have a network in our brain. But me as an old therapist, when the brain mapping world came in and we realized, hang on pain, isn't just a little nest up there. There could be thousands of areas of the brain ignited indeed the whole body ignited in a pain experience. And one of the most liberating bits of information for me and my whole professional career, because what it meant was that many things influence a pain experience and a stress experience, move experience lab experience, and many things can be brought in to actually try and change it.

David Butler (00:37:39):

And all of a sudden means that everything matters. So this is where dims danger in me, safety sims in me, it was just a way to collect them. So an example of a dim with categorize them could be things you hear, see, smell, taste, and touch. So for one person, it could be the smell of something burning or looking at something or hearing something noise. The things you do could be a dim. It could be just doing nothing, but then there's Sims, gradually exercising, gradual exposure seems in things you hear, see, smell, taste, and touch could be going out. One of my most common exercises I now give somebody is to go down to our local market and find four different smells, four different things to taste, four different things to touch. And then they'll say, why should I do that? Because you can sculpt new safety pathways in your brain, which will flatten out some of them, some of the pathways they're linked to pain and it comes to of the things you say important.

David Butler (00:38:37):

You know, I can't, I'm stuffed, I'm finished. I got mom's knees. We try and change that language too. I can, I will. I've got new flight plans. I can see the future, the people you meet, the places you're with. So it's a way of categorizing all those things in life into either danger or safety, we try for therapy, we try and remove the dangerous. It is often via education. What does that mean? And we try and help them find safety and health professionals out there are good at finding danger, but we're not used to getting out there and finding those liberating safety things. And of course the DIMS SIMS thing. It's also closely linked in, we believe to immune balance. So the more dims you have, the more inflammatory broad immune system, the more sims you have, you move more towards the analgesics or the safety. And so it's the way to collect them. It's a way to collect as we try and unpack and unpack a patient's story listing to it within to unpack it and then to re-pack it again with them in a different way. Did that make sense?

Karen Litzy (00:39:49):

Absolutely. Yes. I think that made very good sense. And I believe you, there is a question on it, but I believe you answered it in that explanation. It says, have you had patients that cannot find Sims or it's difficult to identify and if so, how can you teach them what a SIM is? But I think you just answered that question in that explanation.

David Butler (00:40:11):

Once they get it. They're on their way. And we send people on SIM hunting homework. So for example, the same might be places you go, okay, if you can get out, just walk in the park or walk somewhere, then power up the SIM by feeling the grass, touching the box, spelling something. And we pair it up by letting them know that if you do that, your immune system gets such a healthy blast, that it can also help dampen down some of the pain response.

Bronnie Thompson (00:40:39):

And with regard to our current situation, sort of around the world COVID-19 and all the subsequent stuff. And also the situations in the U S at the moment, is it any wonder that lots of people are feeling quite sore because we’re eating this barrage of messages to us. And so I would argue that at the moment it might be worthwhile if you're a bit vulnerable to getting fired up with the stuff said, it's a good idea to ration, how much time you're spend looking at the stuff, not to remain ignorant, but to balance it with those other things that feel good, that make you feel treasured and loved and committed. And for me, it's often spending some time in my studio, walking the dog, going outside, doing something in nature. And there is some really good research showing that if you're out in the green world nature, that there is something that our body's really relish, kind of makes sense to me.

Sandy Hilton (00:41:42):

So taking that concept into what's going on right now, there's been a challenge clinically of the things that helped people balance that out, got taken away from them. Yeah. So it was a complicated it still is. It was a complicated thing where it wasn't your choice to stop going to the swimming pool because it made you happy and it gave you exercise and balance this out. Someone closed the pool and told you, you couldn't go. And so there's all different layers of loss in that and lost expectations and loss of empowerment and all of these things. So we have had to help people rediscover things that they could access that could be those positives. And that's been hard and really working my muscles of how to help people find joy or pleasure or happiness or safety in an unsafe environment to really get that on a micro level when you've lost the things that used to be there. And, it's been like a lot, but you can do it. It just takes concentration.

David Butler (00:42:57):

An important thing. That's so important. I think a question for therapists health professionals should be a sane question should be, you know, what's your worldview at the moment. And I would ask that, and it's usually not good, but I chat and have a chat. And actually I'd like to take people through some graphs that the world is not as bad as it really is. And if you look at I've been reading a book by Hans Rosling called factfulness. And really over time, our world is getting better. There's less childhood diseases, a whole range of things, getting better, bad, and bad things, getting better. This is a hiccup. This, for example, I had a musician recently and I had a graph I could show her that say that there's now 22,000 playable guitars to a million people in the world. But 12 years ago, there was only 5,000. All right, this is just one little thing. All right, cool. There's a lot of stats that show that our world is improving, you know, children dying, amount of science, a whole range of things. And this hiccup we have that I'm hopeful humanity can get, can get through, but just a little message I pass on is therapy.

Bronnie Thompson (00:44:13):

Even though we can't do stuff, we can't access places. What can't be taken away as our memory of being there. So it's really easy to take a moment to back a memory that feels good to say, actually, you can't take that one away from me. I might not be physically getting there, but I can remember it, feel those same feelings. And then being mindful.

Sandy Hilton:

This is funny because if you look at Bronnie's background, that's one of the memories I've been using. When I lost the lakefront, I was like, okay, I'm just going to sit there and pretend that I'm not at that beach by that pier. So it's, it's fabulous. And even pictures or recordings of things that you've done before is like, okay, now there is still good stuff. I might not have it right here, but they're still good stuff. So that's really funny. As soon as I saw the picture, I'm like, yeah. And gratitude and just, yeah.

Bronnie Thompson (00:45:05):

The other thing as well, we've always got something that we can be grateful for all that. It might feel trite, you know, I'm living in winter, but I've got a roof over my head. I can have a damn fine cup of coffee and probably a nice craft. I'll at the end of the day, these are things that I can do and can have any way. So we can create the sense of safety insecurity inside ourselves without necessarily having to experience it.

David Butler (00:45:38):

Right. Just a quick comment. I would share that with patients who can't get out are saying the things you do when you're still can be as important as the things you do when you move. Right? So let's explore. If you can't do things, you can still really work you yourself with the things you do. And you're still calm. The introspection reading, thinking, contemplation memory enhancement, go through the photo album, et cetera. And I'd also like to always say to someone to link that in that is a very, very healthy thing to do to your neuro immune complex.

Karen Litzy (00:46:13):

And that sort of brings, I think we answered this question. This was from a woman who is living with chronic pain and at high risk with COVID-19. So how do we get past the fear of going out where people are crowding areas to get the exercise we need to maintain our fitness and muscle tone to reduce our pain. She said, even though I'm doing exercises and stretching, I've lost the ability to walk unaided on uneven grounds through weeks of lockdown. And the hydrotherapy pool is closed. She said, she knows, I need to get out and walk more, but shopping centers, which are the best place to find level floors are out. And a lot of places that she used to go are now very crowded because people are, don't have the access to gyms and things like that. Are health professionals able to suggest options when she lives in a hilly area with only a few but all uneven footpaths or sidewalks. And she has a small house.

Sandy Hilton (00:47:18):

That's the kind of thing that we've been doing since it's like, okay, let's problem solve this out. Because yeah, you have your carefully set way to get through this and then it's disrupted.

Bronnie Thompson:

Yeah, boy, I like having lots of options for movement opportunities. So we don't think of my exercise, but we think of how can I have some movement today and bring that sense of, we are alike to be like, if I can imagine I'm walking along the beach while I'm standing and doing something and, you know, doing the dishes or watching TV or something that still can bring some of those same neuro tags it's same illusion, imaginary stuff activating in my brain. And that is a really, really important thing because we can't always the weather can be horrible, especially if you're in Christchurch and you can't go out for a walk.

Bronnie Thompson (00:48:27):

Yeah. But you know, we can think novelty is really good. So maybe this is a really neat opportunity to try some play. And I've been watching some of the stuff that our two chiropractor friends do with you put, let's put, at least try some obstacle courses and the house so that it's not we're not thinking of it as exercise. And I've got, do three sets of 10, please physios change that. Let's do something that feels like a bit of fun. There's some very cool inside activities that are supposed to be for kids. I haven't grown up yet. I'm still a baby.

Sandy Hilton (00:49:16):

Yeah. A lot of balance and things like that you inside that would help when you have your paths back outside. Yeah, yeah.

Karen Litzy:

Yeah. Great. And then sticking with since we're talking about this time of COVID where some places are still in lockdown, some places are opening up. Bronnie and David are in an area of the world where they have very, very few cases, very, very few cases, Sandy and I are in a part of the world where we have a lot more than one. So what a lot of practitioners have had to do is we've had to move to tele-health. And so one of the questions David Pulter, I believe, as I hope I'm saying his name correctly is do we perceive that our ability to be empathetic and offer effective pain education is somehow diminished by a tele-health consult. So are we missing that? Not being in person.

Sandy Hilton:

I have found it equally possible in person or telehealth cause you're still making that connection. We do miss stuff. We can't read the microexpressions in people as easily. So we as therapists have to work harder, but for the person on the other end, think about what the alternative is.

Sandy Hilton (00:50:46):

And it's been really cool for the people with pelvic pain, that every single time they've gone to a physio it's been painful. And on tele-health it's the first time she has been able to talk to someone about all of her bits and pieces without being afraid that it's going to hurt because there was no way to see somebody inside somebody's home.

Bronnie Thompson:

You get to know something more about me. I've met more pets than ever thought. It was wonderful. This is a privilege that occupational therapists have had for a long time. And I'm so pleased that other other clinicians are getting that same opportunity, because we know so much more about a person when we can see the environment that they live with. That's just fantastic, but it's harder.

David Butler (00:51:39):

I find I've come back into clinical practice. I thought I was going to retire because I wanted to go, but also doing it. I was hopeless at first, but I'm really enjoying it. And I actually believe, I actually believe for the kind of therapies we're doing it's equal or better than face to face. Ideally, I think I'd like to have one face to face or maybe two but then to continue on with the tele health, particularly for people are in rural areas and it's almost no this kind of therapy was coming anyway, but the COVID has hastened it. So I found myself getting anecdotally here a much more emotional, closer, quicker link to patients by the screen. They were in a safe place. They're in their house. That's number one. They're not in a clinic you're there. And you can actually look at that face in the screen, as we're doing now, I'm looking at your faces, maybe one or two feet away, and I'm just keep looking at you.

David Butler (00:52:46):

And there's this connection, which is there. And there's also these other elements it brings in like, you start at 10 o'clock and you finish at 10:45. So there's open and closure, which isn't really there in some of the, in some of the clinics, the difficulty I'm having with it though is I was never in face-to-face practice a very good note taker. I used to make notes at the end. I was talking too much, but what you have to do here, my suggestion with face to face is you really need to plan and make your notes straight after. What did I tell that one on the screen, last clinical context, to sort of remind you of all the little juicy bits that we've got in the interaction. So it's really, for me, it's coming back to curriculum and mind you, I'm glad I'm not doing dry needling or just manipulating it with the talking therapy, but my suggestion is to have the habit curriculum.

David Butler (00:53:44):

So I've got my key target concepts. I know that I've addressed them in that particular session in the next session. I know I've gone back and I've done teach them the self reflection as well. Then to come back to see if I can get it all, or if I've translated my knowledge into something functional or some change. So I'm really, I'm really loving it. And I think there's something rather new and special with this, with this interaction. But maybe that's just me as a physio who sort of used to the more physical stuff. Maybe this is something more natural to the psychologist, its perhaps, but I'm with it.

Bronnie Thompson (00:54:22):

I’ve been doing the group stuff. And I found that has been, I've seen, I like it because they don't have to go and travel someplace. It does mean that we can offer it to people who otherwise can't get here. You know, they can't seek people, especially rural parts of New Zealand, low broadband is not that great in many parts as well. So it gets that it's an opportunity. I'd like to see the availability of it as an option. So we can use like we do with our therapies, we pick and choose the right approach or the right piece at the right time and the right place that doesn't have to be one or the other, like you said, you could see him a couple of times in person and then a couple tele-health and then maybe they come back again and then you do mix and match.

Karen Litzy:

We have time for one more question here, maybe two. So David, this was one you might be able to answer it really quickly. As a practitioner, what is the utility of straight leg raise slump and prone knee bend test and the assessment of chronic back pain. Is it still relevant?

David Butler (00:55:38):

Oh gosh. Oh gosh. I'm going to dodge that question and would say it, it would depend on the client who comes in so I think those neurodynamic tests, which I still do. I think the main principle from them is you're testing movement. You're not testing a damaged tissue and anytime you're doing a physical examination, the deeper thing is the patient is testing you. You're not testing them. So what that patient, what that patient offers back in terms of movement or pain responses or whatever, depends on so many things. I might however, have a client and they are out there who do have maybe a specific stickiness or something or something catchy, whatever that may well, the scar around it might well be polarized by action, where I might spend a little bit more time taking a closer look at it. Now that might be relevant. Someone might have, for example, someone might come out of hospital and have had a needle next to the IV drip, next to their musculocutaneous or radial sensory nerve there where it's really worthwhile. Let's explore all the tissues here and see that that nerve can move or slide or glide. But in the second case, I'd made a clinical decision that we probably have issues out in the tissues, which are with a closer evaluation. That's a really broad answer.

Karen Litzy (00:57:11):

I think it's a tough question to answer because it, sorry, got a cat behind me. I felt my chair moving and I was like, what's going on? Just a large cat. So last question. So how to manage tele-health when the patients may be kind of embarrassed of their house or context or spaces or family it's very common in low socioeconomic patients. So they may not want to turn on their camera.

Sandy Hilton:

Yeah. I've had that shaking well, and I've had people in their car or very clearly like I'm kind of angled cause there's a lot going on in my house and I don't have a green screen. So where it's like, and there's just a wall behind me and it's one of the reasons like I'll talk to him ahead of time of if I'm in the clinic, it's clearly the clinic, but I'll tell them I'm at my house.

Sandy Hilton (00:58:12):

Cause of COVID. So, you know, no judgment, you're going to see a wall and probably a cat and just kind of be up front in the beginning of this as a thing, I've had people that start with the phone on or turn it off or whatever, you just, you roll with it. But I have those conversations ahead of time, before we even do the call.

Bronnie Thompson:

It's about creating a safe space for people. You know, if somebody feels, you know, was not having the video, it won't be that long before. I hope we've got some rapport and it feels better. I'm just, I'm doing a bit of a chuckle because the reason I've got my green screen behind me as my silversmith studio, which has an absolute shambles because it's a creative space. So I'm just disguising it because it's works.

David Butler (00:59:07):

There is something about delivering a story of some talking in the patient's room and there's cupboard doors open and you're looking in their cupboard at the same time. And you know, looking at that, then I just look at that thing. We’re safe here.

Karen Litzy (00:59:26):

Well, listen, this has been an hour. Thank you so much. I just want to ask one more question or not even a question, more like a statement from all of you that, what would you like the people who are listening and they're, like I said, there were clinicians, there were non-clinicians on here. And I think from the comments that we're seeing in the chat is very valuable and very helpful. So what do you want to leave people with?

Sandy Hilton:

I'm gonna echo how I started. We're learning more every single week. I'd say, day but I'm not reading that often. So even if you've gone or you've treated someone and you couldn't quite figure out a way to help them, don't give up because there's more information and more understanding and more ways to get to this all the time. And I don't think you're stuck if you hurt.

David Butler (01:00:26):

I'd like to mirror those comments, explore the power of tele health, lift your expectations of outcome for those patients, people who are suffering and in pain, who are listening for those who are getting into pain treatment there's a science revolution and a real power in that revolution behind what you do. So just go for it.

Bronnie Thompson (01:00:52):

I think don't be hung up on with the pain changes or not, be hung up on does this person connect with me. We create trust. Am I listening? Can I be a witness? Can I be there for you? Because out of that will come this other stuff. There are some people whose pain doesn't get better. It doesn't go away. And that's a reality, but it doesn't mean that you have to be imprisoned or trapped by your pain. That means you develop a different relationship with your pain. And I think that's a lot of what we are doing is creating this chance to have some wiggle room, to begin to live life. That's what I'm looking for.

Karen Litzy (01:01:53):

Beautiful. Well, you guys thank you so much. And for everyone that is here listening, I just want to say thank you so much for giving up an hour of your time. I know that time is valuable, so I just want to thank you all and to Bronnie and to David and to Sandy. Thank you. Thank you. Thank you. And kind of on the fly. So I just want to thank you so much and to everyone. I guess the thing that I would leave people with is, if you're a clinician or if you are a patient, the best thing that you can do, if you are in pain is reach out to someone who might be able to help you, find a mentor, find a clinician, ask around Google, do whatever you can try and find someone who like Bronnie and David and Sandy I'll echo everything. You said that number one first and foremost, you connect with and that you feel safe with. You want them to be your super SIM, you know, like Sandy's my super SIM.

Karen Litzy (01:02:48):

So you want them to be your super SIM. And, if you can find that person, that clinician just know that that there can be help, you know, whether you're struggling as the clinician to understand your patients or your the patient struggling to find the clinician, I think help is out there. You just have to make sure that you be proactive and search for it. Cause usually they're not going to come knock on your door. So everybody thank you so much for showing up. Thank you, everyone who is on the call and to everyone who is watching this on the playback I hope you enjoyed it. If you have any questions, you can find us we're on social media and various websites and things like that. So we're not hard to find.

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 Apple Podcasts

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Eric Miller on the show to discuss how to maximize the value of your physical therapy practice.  Eric Miller has been in the financial planning industry for over 20 years. He is the Co-Owner of Econologics Financial Advisors and the Chief Financial Advisor. He has a degree from Capital University and is a Registered Financial Consultant® and licensed insurance agent. He takes pride in helping practice owners become the financial heroes of their own stories and has taken this passion to over 600 families in the past decade.

In this episode, we discuss:

-How to maximize the value of your practice

-The business systems that add the most value and are most attractive to potential buyers

-Financial considerations when planning your exit strategy

-Simple strategies to minimize your tax bill every year

-And so much more!

Resources:

Econologics Financial Advisors Website

Econologics Financial Advisors Youtube

Eric Miller LinkedIn

Econologics Financial Advisors Facebook

A big thank you to Net Health for sponsoring this episode!  Learn more about the Redoc Patient Portal here.  

For more information Eric:

Eric Miller has been in the financial planning industry for over 20 years. He is the Co-Owner of Econologics Financial Advisors and the Chief Financial Advisor. He has a degree from Capital University and is a Registered Financial Consultant® and licensed insurance agent. He takes pride in helping practice owners become the financial heroes of their own stories and has taken this passion to over 600 families in the past decade. During this time, he’s had over 15,000 conversations with practice owners regarding money, investing, practice expansion, practice transitions, taxes, asset protection, estate planning, and helping them shape their financial attitude toward abundance. Econologics Financial Advisors is an Inc. 5000 honoree for 2019 as one of the fastest growing companies in the US.

Read the full transcript below:

Karen Litzy (00:01):

Hey, Eric, welcome to the podcast. I am happy to have you on.

Eric Miller (00:05):

Well, thanks, Karen. I'm really excited to be here. Yeah.

Karen Litzy (00:08):

Before we get into our talk on, you know, how to maximize the value of our practice, in your bio, I read that you're a registered financial consultant. So can you explain to the listeners what that is and maybe how that differs from a financial advisor, an accountant? What is the differentiation there?

Eric Miller (00:31):

No problem there. So I think when people hear that I'm a financial advisor, I mean, people kind of have the same impression that all financial advisors are alike, so to speak. And that's not always the case. You know, there's some financial advisors that specialize in working with you know, ministers and teachers and all different kinds of professions. I just happened to work with private practice owners. Now, as far as am I licensed to do what I do in the financial world, there's something called being a fiduciary. And when you're a fiduciary, that basically means that you have to do what's in the best interest of your client, not all financial advisors adhere to that standard. What's called a registered investment advisor and we're held to that standard under the SEC guidelines. And then as a registered financial consultants, it's a designation that I picked up along the way. And it just basically, you know, there's certain criteria that you have to use to be able to get to that designation that's system.

Karen Litzy (01:41):

Got it. Yeah. So, you know, we were talking before we went on and it's kind of like if you're in the physical therapy world, which I am, and you go on to become, you know, like a clinical specialist in orthopedics or a clinical specialist and in pediatrics, it's like going on for a little bit extra education and certification and what you do is that right? Okay. That's exactly correct. Perfect. Perfect. All right. So now let's get into the meat of this interview. So today we're going to be talking about how to maximize the value of your practice, perhaps plan for an exit of that eventually. And we're going to weave in some critical tax strategies that you might be able to use to save you money. So no one likes to leave money on the table. No one likes to feel like a dope because they didn't know what they were doing. So, let's start with maximizing the value of your practice. So first, what does that even mean?

Eric Miller (02:42):

That's a great place to start because I think people automatically assume that when I say maximizing your practice value, it's just about money, right? It's just about, Oh, the, you know, what's the enterprise value of my business. And then that leads into, Oh my gosh, he's going to talk about like profit and loss and EBITDA and all these really technical terms. But in my viewpoint maximizing practice value. Isn't just about money. It's about the other parts of owning a business that you get value for like time, right? Like you would want to build a business that gives you a lot of time. You'd want to build a business that gives you great relationships with either your employees or recognition from your community. So when I say, if you're trying to maximize the value of your practice, it's not just about the money.

Eric Miller (03:31):

It's about all of those other things, because you know, you look at it, most people that own a private practice that is your largest investment. You know, it's like the thing that provides the most cash flow to your household, and it is an investment and anybody that's owned a business for any period of time knows that it's something that you have to care for. And that you have to make sure that you're treating like an investment and putting in the time and the money to make sure that you get the most value out of it. That's our definition for that.

Karen Litzy (04:04):

Yeah, absolutely. So how can we as practice owners then maximize the value of our practice. If let's say in the event, we want to sell it, we want to exit our practice in whatever way we want that exit to happen.

Eric Miller (04:21):

There's definitely some key areas like, yeah, you have to kind of assume the viewpoint of a buyer. Like if I'm going to buy your practice, Karen, like what are some of the things that I would like to see in place that would allow me to give you, you know, top dollar for it. And I think number one is your personnel organized? Okay, do you have organized personnel? Do people have job descriptions? Do they know what they're doing? Do they know who to report to? So, you know, I think that that is that's key because obviously if you have people in your organization that are aligned and are all kind of working together, you know, you're going to have a really powerful organization. If you can do that, if you don't, then you're going to have, you know, this scattered business that everyone's kind of doing their own thing and that's not good.

Eric Miller (05:13):

So that's certainly one thing. And then of course, just having good stable systems that are built in your business so that there's procedures that people have, that they can follow. You know, there should be an organization chart somewhere where people know like who's in charge of what I think that's going to all add value to your business. Certainly if you look at like the facility, what's the facility look like, is it in good shape? You know, do you have, if you lease the building, do you have a good lease on it? You know, is there new carpeting is, I mean, is it a nice place where people feel safe to come to, you know, certainly a buyer's going to think about that. And then I think from an income standpoint, obviously you have to be solvent.

Eric Miller (05:57):

You certainly don't want to have a lot of, you know, outstanding accounts receivable out there. You want to make sure your books are up to date and current, you don't owe any back taxes on the practice. You have multiple income streams in the business that you like multiple services that you provide because no one wants to be reliant upon one of anything. So I think those are all, some really key areas that if you can get those things in shape and you can get them systematized, you're really going to have something that someone else would want and they would value. And they're going to pay you a much higher amount for that.

Karen Litzy (06:33):

Yeah, that makes sense. So what I'm hearing is you really want to have an organization that's sort of a well oiled machine where people know why they're coming to work. They know what they're doing once they get there and reasonably happy at their jobs, if not very happy at their job.

Eric Miller (06:52):

Yeah. And I think that you're exactly right. And I think the key as the person that's in charge of it is that you have to know what your role is in that business. So I think a lot of people that are in private practice, and maybe you can attest to this when you first started out, you're just trying to make things happen and go, right. And, you know, as you go on, you kind of realize, look, I'm not just a practitioner, I'm also an owner and I'm an executive and those are completely different roles. And I think over time, if you can really make sure that you understand that those three roles are separate and that you have to make sure you master them to that degree, or at least hire someone that can do those things, that that's really going to create you a valuable practice, you know?

Karen Litzy (07:41):

And I mean, when you first start out, like I work with a lot of like first time entrepreneurs, you are the owner, the therapist, the executive, the marketer, the pay, you know, you're everything, right? So, so let's say you have a practice like that, where maybe you are a single owner practice, right. Or maybe you have one person part time person. So you don't have this sort of robust, huge practice. Can you sell that?

Eric Miller (08:12):

Well, you can, you can sell anything. It's just as a matter of how much you're going to get for it. So, again, looking from the buyer's perspective, he wants to buy something. That's not dependent upon one person. He wants something that's going to be basically, he can assume that there's free cashflow there. That is going to be worthwhile to him as an investment. So if you have like a single doctor practice or you're a single practitioner, I mean, you can certainly sell it. It's just not going to go for a very high, multiple, see, most of the practices that we're talking about, you know, are going to sell for maybe like a one to two times earnings. Whereas if you get a bigger organization that has, you know, seven, eight, nine, 12, 20 PTs on staff, there's executives in the office, it's going to go for a much higher, multiple could go as high as eight to 10 of your earnings. So it is, it is that kind of a game, but that's, you know, that's the journey.

Karen Litzy (09:08):

Right? And, you know, you had said you want to have a lot of systems in place, in your opinion, what are the most valuable or most important systems to have in place within your business? Looking at it from a value standpoint?

Eric Miller (09:23):

I think definitely having a good financial system is really key because look at what, you know, a lot of businesses, business owners, don't like to confront the finance part of their business, and that's why they don't have much in reserves. And, you know, they're always kind of struggling for, gosh, I can't make payroll this week. And it's just a constant battle when you don't have good financial systems in place, because they're just, they're not paying attention to their money lines. And unfortunately, when it comes to your practice, that that is the most important thing is keeping that practice solvent, which means that there's more money coming in than what's going out. So that personally, I think that's the most important. Some people would say a marketing system is really key because let's face it. If you don't have more patients coming in and buyers definitely going to want to see that he's going to want to see that you are, you have a system in place where you're constantly getting new patients in the door. Right. And then, you know, I think a good quality control system is, is really, really key. Because if people aren't, you know, getting better and you don't diagnose that quickly of, you know, why aren't people getting better because that's what you do as a physical therapist, your job is to get people pain-free, you know, or reduce their pain. So I think that's a pretty key area too.

Karen Litzy (10:42):

Nice. Yeah. I just had this conversation about the importance of a financial system. Cause I sort of switched my financial system within my practice around, over the last couple of years and it's made such a huge difference. You know, I started looking at the financial system in percentages sort of going off of Mike McCollough, the book profit first. And so, yeah. So how much stays in the business? How much goes to me as an owner, how much goes to taxes? How much goes to profit, how much goes, and then making sure that when that money comes in, it is automatically divided up into those percentages and it's made a huge difference.

Eric Miller (11:22):

That's so awesome to hear it, does it because you've instilled control over your money right now. Right. And when you look at like what's a barrier for a lot of practice owners is that they don't feel like they have control over their money. Right. And, when you start putting in good control, it's kind of like when you're adjusting somebody or you're getting someone to feel better, right. You have to kind of put control in on that person. Like, I need you to do this and move here and do that. It's the same thing with your money. You have to kind of allocate it so that you know, your expenses are you channel your money to places where it needs to go to handle whatever expense that would be. Certainly, you know, you're yourself. I think, you know, is the most important person that you need to pay first.

Karen Litzy (12:07):

Well, that's what profit first says. No, it's true. Like, and once I started doing that, it made everything just lighter. So now like quarterly taxes are coming up September 15th or depending on when this airs that might've just been that September 15th date. And I remember like years ago, I'd be like, Oh my gosh, I don't know how, how do I not have them now? I'm like, Oh, totally fine, my money's where it's supposed to be. I am good. Like, this is exactly where it needs to be.

Eric Miller (12:43):

That actually is kind of like an underlying goal and purpose that I have is I, you know, people always ask like, what's the product of a financial advisor and people think it's, you know, Hey, you know, you made me 20 or 30% or you know, helped me save in taxes. Not really, you know, I like people to feel relaxed about their financial condition and just what you explained to me right there. You're definitely much more relaxed about your condition now because you have control over it and it doesn't control you. That's really awesome.

Karen Litzy (13:13):

Yeah. And it's a little stressful at first because it's different and it's a change. So I always tell people if you're starting out now start off this way. And Holy cow you'll be so much easier. Everything is just, I feel so much easier. Yeah, just a sense of ease that I now know, like, yes, I have money set aside for this. It's already paid, like it's basically already paid for.

Eric Miller (13:39):

That's it that's right. But it also does another thing too. It does make you look at and say, you know what, maybe I'm not making enough money in my business because I can't cover some of these other things. And I think that's the most important thing that people have to realize. And I'll go off on a little tangent here, but there's really two basic rules of, for me, income and expenses. The first one is that just get used to the fact that your business will try to spend every dollar that it makes. And then some, and, and that's not just for a business, that's like a government or any household or organization just, it's just going to try to spend every dollar that it makes. And then some, but at the same time, it will also make the exact amount of money.

Eric Miller (14:25):

It thinks it needs to make to survive. So when I say that, people are like, what does that mean? I'm like, well, look, you know, if you know that you have expenses coming up, somehow miraculously, the business does make enough to cover it. Doesn't it? It's just like, it's just, that's the way it is. So the trick to it is simply to make sure that your reserves and your profit and your taxes are just part of what the business thinks it needs to make to survive. And if you can get that in as what you said as part of that profit first book, I think that's what he's talking about is that it sets the right income target for what the business really needs to make, because that's the biggest outpoint that I usually see with, with practice owners is that I'll ask them, Hey, what's your income target? They'll say, well, you know, I need to make $30,000 a month to pay my bills. And I'm like, well, no, that's not what you need. You actually need 45. If you want to include your profits and building up reserves and paying your taxes that they're operating on a wrong income target. So I think that's really key is to make sure you're operating on the right number.

Karen Litzy (15:30):

Right. So don't underestimate it completely because I think oftentimes people will just look at, well, this is my rent. These are my utilities. This is my payroll. If you're paying people and these are, you know, overhead costs that maybe we have to pay, you know, phone bills, things like that. And that's it. And they're like, okay, so that's all I have to make.

Eric Miller (15:55):

That's right. And that's where their demand for income is. But, and if, but if they put in, Hey, I need another $10,000 a month for myself. I need another 5,000 for taxes. I need another because I want to make sure I have reserves. So if I have to shut down for another month, I can handle that. Right. You start putting all those things in. Now the number changes from Oh, 35, I need to make 50. Oh, right. Okay. Well, that's fine. How many more patients do I need to see a week? Right. To be able to make that number, it just gets them, you know, being a problem solver now, as opposed to like, I can't do anything about it kind of mode.

Karen Litzy (16:32):

Yeah. And I do that. Like people always ask me, well, how many patients, you know, do you usually see a week? And I said, well, it's not, how many do I usually see it's this is what I need to see to make X amount of money per week. So that I know per month, this is what I'm making. And my costs are a little bit lower because I have a mobile practice. So I'm not paying a lease on a brick and mortar facility, but I still have to pay my own rent for my apartment. And I still got to eat. You know, these are all the things that you have to put in. So it's not just, what does the business need, especially if you're a solo preneur, what do you need to survive?

Eric Miller (17:12):

Yeah. And I think this is where a lot of people, yeah. A lot, a lot of practice owners and entrepreneurs gets, think that their business is more important than their household. And you know, I'm under the, you know, our philosophy, our viewpoint is that your household is like a parent company. Okay. You think about this, you look at all the big corporations out there and you know, people have opinions of them, but they do understand money pretty well. And they certainly understand that let's take Facebook. For example, Facebook owns, I don't know if you do this, like 83 other companies and they're the parent company to all of those other companies, but everything flows to the parent company. Okay. We're your households, no different, you know, you own, you have a, let's say you own a house, a business, maybe a piece of real estate 401k plan, the bank account. Right. Those are all assets of the household. So you really, you know, once you start treating your household, like the parent company, then you set up the system so that, you know, your household you're meeting the goals and purposes of the household people. I think they don't do that. They don't take care of themselves like they should.

Karen Litzy (18:19):

Yeah, no, I think that's great advice. Thank you for that. Alright. So we've got those financial marketing quality control systems, obviously three very important systems and we can go on and on and systems. That's a whole other conversation. So we will take those and people can run with them as, as sort of prioritizing their systems. So now we've got, we've got all of our systems in place. We've especially our financial system. So how do we plan? Let's say we're getting towards the end of our treating career, whatever your clinical career, whenever that may come. And it may come at different times for different people. How do we efficiently plan for an exit? What do we do?

Eric Miller (19:05):

As far as like getting the business ready to exit out.

Karen Litzy (19:09):

Yeah. Like let's say, let's say you're getting ready to kind of exit out of your business. Now we know that maybe you can try and sell it. Or what if you're just like, this is the business is done. You're just done. What do you do?

Eric Miller (19:24):

Yeah. Well, I mean, I think the first thing you gotta realize, you gotta look at your own financial readiness. Like, can you afford it? You know? I mean, I think a lot of people, they get into a position where they're tired, they get exhausted, right. Because they've been doing things for themselves or I'm sorry, just for the business. And then they just get burnt out, you know? Well, you know, burnout, you know, what burnout is, it has nothing to do with that. It's just that you don't have a bright enough future in front of you. That's what burnout comes from. Right. And I can see why a lot of practice owners getting that conditions. Like I just keep doing the same thing every day and I can't see a bright future for me, so I might as well just sell the thing. Okay.

Eric Miller (20:06):

So the first thing that I do is just, I try to rehabilitate, like, do you remember why you decided that you wanted to be a business owner? Do you remember like what the purpose was? And if you can revitalize that, I think you can get that person back on track, but look at the end of the day, if you don't want to do it anymore and you want to sell your business, then you know, certainly, you know, hiring a broker can help. Certainly finding someone or just finding another PT that, you know, in the area that would be willing to take, you know you know, sell, you can sell the business to, for Goodwill or it's not going to be very high price, but certainly you can find someone that would be willing to buy practice for some costs. Right. That may just not be very much. Right.

Karen Litzy (20:52):

And then what, if you were ready to just wrap it up, you don't want to sell it. Are there things that one needs to think about as they wind it down?

Eric Miller (21:02):

You mean just like, just close it down?

Karen Litzy (21:04):

You're closing it down. You're moving on to greener pastures, if you will. So you decided to close it down. Are there any financial considerations that one has to think about in that scenario?

Eric Miller (21:16):

Well, you know, certainly look at how much money that you make from your business. Even, you know, money that through the cashflow that you make, it's sometimes a lot more significant than what people think. And certainly you can own the business. You can just, I mean, if you're a physical therapist, you can just go work for somebody else if you want to. But you know, I think people just have to realize that, that their business does provide them a pretty good living and they just have to analyze that and say, do I have enough to replace that? Or can I go to work for somebody else and replace that income? You know, it's certainly not a good thing to do. You know, there's seven different ways to exit out of business. And that's one of them just shutting it down. It's probably the most, it's the worst way to do it, but I know that it does happen.

Karen Litzy (22:05):

Yeah. Yeah. What are the other ways you could just name them? We don't have to go into detail.

Eric Miller (22:13):

So you can die with your boots on, you can close it down. You can sell to an associate. Okay. You can sell to a competitor. Okay. You can sell to private equity. Okay. You can gift the practice to somebody else. Okay. Or you can have your employees buy it through, what's called a Aesop plan. Those are the seven ways that you can exit out of your practice. Okay. Great. What happens with most practice owners is they either sell to an associate to a private equity group, the size of the practice.

Karen Litzy (22:54):

Yeah. Yeah. And so now let's talk about taxes.

Eric Miller (23:03):

Yes. So, Oh, taxes. Hey guys, when you could see your eyes got big.

Karen Litzy (23:07):

Who likes to pay taxes, right. Nobody likes to do it, but we all do it because we need, we need the services that they provide. Right. So let's talk about some tax strategies that might be able to save us some time.

Eric Miller (23:21):

Yeah. Yeah. I think the first thing on taxes is that you have to realize that your accountant may or may not understand the tax code completely. And it sounds really weird because everyone assumes that they have an accountant, Hey, he's going to try to minimize my taxes. That's not really what their goal is. Their goal is to make sure that you are compliant, that you file your taxes on time. They're not necessarily doing tax planning for you. They're not trying to minimize your taxes. Okay. So I think that's the first thing is that you really have to make sure you're working with an accountant that has the viewpoint that I want to try to minimize this tax bill as much as I can, because it won't happen by itself. You have to be proactive. You cannot take a passive role in minimizing your taxes, or you're just going to end up paying the most.

Eric Miller (24:09):

Okay. The tax codes, 3 million words, and, you know, no one's going to know every single passage of it. That being said, there are definitely some strategies out there that you can utilize. One that is that I've been talked about a lot is that you can actually rent your house out for 14 days out of the year and you can collect that money completely tax free. And you're probably thinking like, well, how, how would that benefit me? So where this came about was that in a, I don't know what year it was, but if you've ever heard of the masters golf tournament, there's a lot of, there's a lot of guys that have big houses there and on the golf course and they rent their houses out for thousands and thousands of dollars. Okay, well, legally they can collect all of that money, completely tax free.

Eric Miller (25:08):

Okay. Because the IRS code says, you can rent your house out 14 days out of the year and get that money complete tax free. And you probably thinking, how do I take advantage of that? Well, if you own a business, your business can rent your house out for 14 days out of the year. And as long as you have a legitimate meeting at your house, maybe you have with a key executive or even with yourself, right. You have an executive meeting at your house and you document that, then you can rent, you can have the business pay for that. Okay. It's a business expense. And then you get that personally. And as long as you do it correctly, you can get that money completely tax free. All right. That would be certainly one strategy you can use. It's called the, it's called the Augusta rule. You can look it up online and, and certainly there's. Yeah, yeah. That's where it came from. That's one and, you know, right there, 14 days, let's say that it's a thousand dollars, that'd be $14,000 that you could expense out in your business. And then you can get that personally. Oh, you have to do it right. You have to have a legitimate meeting. You have to like

Karen Litzy (26:14):

Say it's $10,000 a night.

Eric Miller (26:17):

I don't know. In New York, you may be able to write.

Karen Litzy (26:20):

I don't know. That might be a stretch too.

Eric Miller (26:22):

If you needed to rent out like a hotel or a restaurant, that's what you would need to do. You need to go get like an estimate like of where you would normally hold that meeting just for documentation purposes, but like anything else it can be done. You just have to follow through and have documentation, you know? And I just have the accountant guide you on how to do that. That's certainly that's one that would be, you know, 14, 15,000. So if people have kids, they can put their kids on payroll and they can, you know, show them that would be another deduction that you can use. You know, there's certainly a lot more, I could probably go on all night. But you know, I think another thing that people can do is just look at how they take their income.

Eric Miller (27:06):

Like you own a business, right? And most physical therapists are escorts. And you know, a lot of accounts will tell them to take bigger salaries than what they actually need to be taking. Right? So you can actually adjust your salary downs as long as it's a reasonable compensation and then take more an owner draws. That's going to help minimize the Medicare tax as well. So it really just boils down to, you know, finding the right information, finding a right advisor that can help you and, you know, provide tax deductions that your accountant can work with to minimize it. It can happen like you should, it's your responsibility. And I say this a lot. It's like, I've never read anywhere where it's my responsibility to maximum fund the IRS. Right? Like I know I have to pay taxes. I get that. But there's no one that said that I have to like pay, you know an ungodly amount of tax. But that's the way the IRS works. They just assume that your money is their money and you have to be proactive to show them otherwise.

Karen Litzy (28:11):

Yeah. I know this year when I paid my taxes, when I did my taxes for 2019, I was so excited. Cause I only owed like $309 after doing my estimated quarterly taxes, which I thought, well, this is great because I'm not giving them more throughout the year. And in fact I was almost like, spot on. That's pretty good. Yeah. That was pretty good. Because like, you don't want to, like, I understand when people get refunds, but if you got a refund, that means that you gave them more than was necessary throughout the year. Correct. Right. Yeah.

Eric Miller (28:53):

So it is something that you have to stay on top of because as your business grows, you know, your tax liability personally is going to be higher. So you really have to make sure you stay in good communication with your accounts. Like you should be talking to them every quarter, especially now recently where I think a lot of people have gotten the PPP loan. And if you, you know, if that gets forgiven well, you know, physical therapists didn't really shut down. I mean, some of them did, but you were still collecting money. So you know, you may have, you really have to make sure that you're not going to have a tax problem for 2020, it could happen. So just, you know, just getting in communication with your accountant. I think that that will help.

Karen Litzy (29:32):

Yeah. During the PPP loan phase and covert, I was thinking, I was talking to my accountant like literally every other day. Yeah. I'm like, does this make sense? Should I do this? Should we do this? Should I do this? Can I do this? Does this, is this the right form? Do I feel, and I did get a PPP loan because in New York, you know, we were done, like when I say shut down, like shut down, nothing, you know? And eventually I started doing more telehealth visits, but in the beginning it was quite scary. And so I said, you know, I better apply for a loan and, and I did get it. And now they haven't even asked, we haven't even filled out the forgiveness paperwork yet, but now I'm in contact with him like weekly, like, is this the right form? Did I fill this out? Right? Is this the right documentation I need? And he's like, yes, yes, yes. You're all good. So now when the time comes, I'll be able to get that in really quick.

Eric Miller (30:27):

Yeah. And it won't be a problem and you know, you'll have your attention on other things that'll help expand and that's good. And then that's just, that's not my experience. Most practice owners, they kind of don't confront it, they ignore it. And then it becomes a bigger problem down the line. And that's really needless. Right.

Karen Litzy (30:44):

I think that's how I used to be, but I have now been rehabilitated financially. So yeah, this was great. Now, what are in your opinion, what are the key messages that you would like the listeners to kind of take away from this conversation?

Eric Miller (31:02):

Well, I mean, you know, for me look, I mean, you can, regardless of what your financial condition is, like, you can do something about it. Right. And I think that's always been a pretty key, you know, philosophical viewpoint that I have. Like, I don't think that there's such thing as an unwinnable game and I know that even things get a little murky and they get a little dark and you know, sometimes you don't really see, you know, the future as bright as it could be, but if you just kind of like, just do one thing right. And complete that cycle of action and then go onto the next, then I think that starts to create more freedom for yourself. Like people get overwhelmed so fast. Right. And there's like, there's so many different things to do, especially financially. Right. That they just, they don't just do what's in front of them while they're doing it. Like just complete one thing at a time. And then you can go on to the next one. Right. Like do the next thing and then go on to the next one. And then to me, that's the key to success, right? There is, is getting interested in something that you don't want to do. Right. And completing it. And I think once you do that, you'll start to see a much brighter future, better things happening to you.

Karen Litzy (32:14):

Yeah. Great, great advice. Thank you so much. And before we get going, I'm going to ask you the same 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 your younger self?

Eric Miller (32:29):

I would simply tell myself that there are destructive and constructive actions that you can do in life, right. And that those destructive actions, while they may appear fun at the time will certainly prevent you from getting to your potential and leading the life that you want to lead. Right. I know we're all young. We all kind of make stupid mistakes and that's just part of the learning curve. But I would certainly tell myself, you know, your personal ethics is really part of your survival, right? And to the degree that you kind of keep yourself in good shape morally, and you do the right thing better things are gonna happen to you in your life. It's going to create more abundance for you. And I would tell myself that is just make sure you pay attention and do the right thing more often than you do the wrong thing.

Karen Litzy (33:22):

Excellent. And now, where can people find you on social media website?

Eric Miller (33:27):

Yeah. So if you want to go for a wealthforpts.com wealthforpts.com, you can download a free ebook that we have. You can certainly go to our website www.econologicsfinancialadvisors.com And then we have a YouTube channel, www.econologicsfinancialadvisors.com. And those would be three places that you can go to connect with us.

Karen Litzy (33:48):

Perfect. And all of that will be at the show notes at podcast.healthywealthysmart.com under this episode. So one click will take you to everything. So Eric, thank you so much. This was great. I was taking copious notes and you know, every time I have these conversations, I'm always thinking to myself, Hey, what do I need to do? What do I need to act on? And you know, a lot of the conversations that I've had with folks like yourself, accountants, even on this program and in my own personal life have just really been so valuable. So I thank you so much for taking the time out today. Thank you 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 Apple Podcasts!

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Stephanie Weyrauch on the show to discuss budgeting.  An active member of the national physical therapy community, Stephanie has served on multiple national task forces for the American Physical Therapy Association (APTA) and actively lobbies for healthcare policy issues at the local, state, and national levels of government. Stephanie is a nationally sought after speaker and consultant for topics on social media use, generational issues, and organizational membership.

In this episode, we discuss:

-Stephanie’s experience paying off student loans and still enjoying her lifestyle

-The budgeting tools you need to manage your expenses

-Why an accountability partner can help keep your budgetary goals on track

-How to incorporate pro bono work into your practice

-And so much more!

Resources:

Stephanie Weyrauch Instagram

Stephanie Weyrauch Twitter

Stephanie Weyrauch Facebook

Email: sweyrauchpt@gmail.com

Dave Ramsey’s Complete Guide to Money - Hardcover Book

The Total Money Makeover

Dave Ramsey Podcast

Every Dollar App

A big thank you to Net Health for sponsoring this episode!  Learn more about the Redoc Patient Portal here.  

For more information on Stephanie:

Dr. Stephanie Weyrauch is employed as a physical therapist at Physical Therapy and Sports Medicine Centers in Orange, Connecticut. She received her Doctorate in Physical Therapy and Master of Science in Clinical Investigation from Washington University in St. Louis. Dr. Weyrauch has served as a consultant for a multi-billion dollar company to develop a workplace injury prevention program, which resulted in improved health outcomes, OSHA recordables, and decreased healthcare costs for the company’s workforce. She has served on multiple national task forces for the American Physical Therapy Association (APTA) and actively lobbies for healthcare policy issues at the local, state, and national levels of government. Currently, she serves as Vice President of the American Physical Therapy Association Connecticut Chapter and is a member of the American Congress for Rehabilitation Medicine. Dr. Weyrauch is also the co-host for The Healthcare Education Transformation Podcast, which focuses on innovations in healthcare education and delivery. Dr. Weyrauch has performed scientific research through grants from the National Institutes of Health and National Science Foundation at world-renowned institutions including Stanford University and Washington University in St. Louis. Her research examining movement patterns and outcomes in people with and without low back pain has led to numerous local, regional, and national presentations and a peer-reviewed publication in Archives of Physical Medicine and Rehabilitation, a top journal in rehabilitation.

Read the full transcript below:

Karen Litzy (00:00):

We are the facebook group so we'll be checking the comments regularly, but just know that we will be checking and we'll probably be a couple seconds behind you guys. So if you are on and you are watching throughout any point in our talk today about setting a budget definitely write your comments down like questions. Whether for me mostly directed to Stephanie and we will get to those questions as well throughout the talk or throughout this very informative talk. I was saying before we went on the air that I'm really excited to listen to this because I have always been impressed with the way that Stephanie and her husband Deland have been able to create their life and their budget, and it's still full and they get to do the things they want to do and go where they want to go all while maintaining a budget and all while they both have student loans.

Karen Litzy (01:07):

So what I'll do first is it's for people in the group who aren't familiar with you, Stephanie just talk a little bit more about yourself and then we'll talk about how you set your budget and what kind of framework you follow.

Stephanie Weyrauch:

Well, thanks Karen, for having me on, I'm really excited to talk about this because I'm running a budget as something that was really hard for me to do for a long time. I wasn't really raised to think about money growing up. So it's not, when I went through PT school, I just got my student loans and spent my money as I saw fit. And didn't really think about my money. So I'm Stephanie, Weyrauch, I'm a physical therapist here in Orange, Connecticut. I work at a private practice called physical therapy and sports medicine centers.

Stephanie Weyrauch (01:55):

And I do a little bit of consulting work privately through four different companies to try to help with occupational medicine and try to prevent any type of work injuries that happened in the workplace. So that's kinda my background a little bit, but when I went to, when I graduated from PT school and went to my first job, and at the time I was working in Minnesota, my student loans were becoming due and my husband is a physician. So he has a lot of student loans as well. So at the time total, we had pretty close to $300,000 in student loans. So quite a bit. And when my student loans were coming due and my boss hands me this little application for my 401k and like all these other very adult things, I just, I panicked. And I was like, I don't even know what a 401k is.

Stephanie Weyrauch (02:44):

I don't know how to pay my student loans. My husband was in medical school at the time. So I was the only one working. And my boss was just like, hold on. He's like, it's okay. I can help you. And so he handed me this book called the total money makeover by Dave Ramsey. And I read it and it changed my life. It changed the way that I thought about money. It changed the way that I handled money and it really empowered me to pay off my student loans and to not be afraid of debt to basically conquer it. So that's kind of the background behind it in the book. And also on his podcast, the Dave Ramsey show, he talks about how to manage a budget and how to set up a budget and how to stick to a budget. So the app that I use is called every dollar it's free.

Stephanie Weyrauch (03:30):

You can download it on, you can download it on Apple or Android, it kind of looks like this. So you can kind of set up, you can put in how much money you make and also what your expenses are for the month. Basically, it's very easy to use. You can use it on your phone or your computer. And so I started using that at the time, we were a one income household. I did pick up an extra job in a skilled nursing facility because my goal was, I didn't want to accumulate any more debt. So my goal was to try to make enough money and save enough money that we could pay for my husband's last year of medical school, which he went to an instate school. So his tuition was $25,000, which is very cheap, I think, by medical school standards.

Stephanie Weyrauch (04:19):

And we were able to cashflow that entire year of medical school, just off of the extra job that I was working at the skilled nursing facility. So every month, basically what I do is I go into the app before the month starts, I put in how much money I'm expected to make. Now, one of the things that happens when you're in private practice, especially if you're starting out is you may not know exactly how much you're going to make. And so it's hard to put in your budget like, Oh, I'm going to make, let's say, as Karen was talking about in the last course, you know, paying yourself by, let's say by biweekly or by month bi-monthly I'm gonna make $2,000 this next two weeks. Like you can't necessarily do that in Dave Ramsey's book. He has a sheet that you can use that lays out how you can do a budget based off of an income that fluctuates.

Stephanie Weyrauch (05:11):

I've never had a fluctuating income, so I've never used it, but he talks all about that in his book. And it's very easy to follow because he also talks about that if you are in debt and you're trying to pay off your debt, there's a certain amount, certain things you need to pay first. So food, shelter, lights, those are like the main things that you need to make sure that you focus on first. And then also the next thing would be like clothing. If let's say you're, you need to buy clothing. For some reason, I have really don't buy a lot of clothes. So I don't necessarily have to worry about that. And then after that is, comes your debt and any other miscellaneous things. So in this budget, you set up your income. If you were planning on giving any of your money away and like doing some charitable giving, that's something that he puts in there.

Stephanie Weyrauch (06:02):

If you're saving any money, there's a section for that. So then you can set aside how much money you want to save. And then for housing in my budget, I have my rent electricity. I put my cell phone cause that's my phone bill in there, my internet, and then my laundry. So those are like the five budget items that I have in there. And then in that month I set how much money I'm going to spend. And he thinks of a budget, not necessarily as a restriction, but permission for you to spend your money. So like throughout the month, if let's say your needs change, you can kind of rearrange how much money you're putting aside. So let's say for transportation, I need, let's say I'm taking my car. Cause I'm going to drive to a couple of patients’ houses. But this month, most of my patients are within a two mile radius of me.

Stephanie Weyrauch (06:53):

They're not far away, so I don't have to drive as much. So at the beginning of the month, I thought maybe I have to drive more. So let's say I set a hundred dollars for my gas and auto budget, and now I'm realizing I don't need that much. So what I could do with that is let's say I only need $50. So that extra 50, that I'm saving, I could potentially move to, let's say my savings, or if I have debt that I need to pay, I can move it down towards my debt. So you're giving yourself permission to spend that much money per month. The next item line item is food. So I've had groceries. And then I have, we have a section for restaurants. So if we want to eat out now with the pandemic, one of the things that was kind of nice about the pandemic is we weren't eating out nearly as much, but our grocery bill went like way up.

Stephanie Weyrauch (07:38):

So I noticed that we've been spending a ton more money on groceries. And I think it's mostly because food has gone up. So I had to adjust our budget based on that. Now this month we're, you know, things are starting to open up a little bit more here in Connecticut and Deland and I really haven't been able to go out and eat very much. And so now we're trying to put a little bit more money towards our restaurant budget because we want to enjoy that experience since we haven't had it for so long. So typically I set aside maybe $150 a month for restaurants, but this month we doubled that just because we haven't hardly eaten out at all in so long. So again, it's permission to use your money in the way that you think is going to be good for that month.

Stephanie Weyrauch (08:27):

And then there's a section for lifestyle. So I put like my subscriptions in there. So my Peloton subscription and my Netflix subscription, and then I have a vacation with my mom, hopefully coming up. And so I've been, you know, find some hotels and stuff for that. So I've been putting that under that, and then this one's going to be big if you're in private practice insurance and taxes. So there's another section for that. So if you have your, let's say it's the month where you have to pay your quarterly taxes, or let's say, instead of saving all this money and doing it in one month, you divide it up into three months. Well then you can kind of equally divide that four month, and then that way you're not forgetting to pay it. And then of course the last line item is debt. And so how much money you're going to be spending towards your debt that month.

Stephanie Weyrauch (09:20):

And then what happens is it will take, it'll give you like a picture and a graph of how much you're spending. So let's see if I can bring that up. So, so basically this is my debt and how much I spend this, this past 12 months on different things. So you can see that most of what I've been spending has been on my debt is debt, the green light, this light green color, this big one, that's all how much money that I've spent on debt this year, so far this year. So, you know, Karen had mentioned the other day that deal and I paid a lot on debt and we have, since I've been on this budget, I have been dedicated to becoming debt free.

Stephanie Weyrauch (10:09):

And our goal has been to be debt free in a total of seven years. So right now we're in year four of that. And within those four years, we've paid off $150,000 in debt, which is a lot. And that includes the cashflowing of Deland’s medical school, plus our move that we had to cash flow from North Dakota to here in Connecticut. So I'm not saying it's easy, like I'm not saying I live a luxurious life at all, but I would say that I definitely, like Karen said, I'm able to like go, I'm able to go well before the pandemic, I'm able to go to New York city, like once a month and see Karen and like hang out with my friends. But I plan for that every month. And if something comes up where I'm not able to do that, then I just have to make sure that I don't do it.

Stephanie Weyrauch (11:00):

And so it takes discipline, which you're all in private practice and you've started your private practice. So you obviously are all disciplined individuals. I will say that when you're managing a budget too, it always helps to have a partner who will keep you accountable. I am a spender and Deland is a saver. And so if I had my choice, I would probably go over our budget every month. But Deland is very good at saying now, Stephanie, do you really need that. And I fortunately must admit many times no. So having an accountability partner is really important. If you're in a private practice, that accountability partner can be your spouse or your partner, or it can be your business partner, or it could be a trusted friend. So having maybe you guys are both managing budgets at the same time and you can kind of be each other's encourager.

Stephanie Weyrauch (11:53):

So that is something that's how I run our budget. It is definitely, I definitely don't live a very luxurious lifestyle, but I wouldn't say that I'm just sitting at home, eating ramen noodles all the time either. So I'm able to put most of the money that we spend every month goes towards debt. So probably half of our budget each month goes towards debt, but that's just because we are dedicated to making sure that we become debt free within the next four years. So, yeah. And, and there may be people on here who have no debt and don't awesome. Right? And so that part of the budget and the app, I mean, how wonderful, if you don't have student loan debt, maybe you have credit card debt, and you're putting something towards that each month. But I think if you don't have, if you're past the student loans or you didn't have to have, you didn't have to take out any student loans, then you can certainly take that money that would go to debt.

Stephanie Weyrauch (12:57):

It would be substantially smaller if we're just talking about credit cards and you could say, you know, I'm going to dedicate it to XYZ. Now what happens? Oh, quick question. So what was the Dave Ramsey book? I put two books. One was the total money makeover and the other's complete guide to money. I put them both in the comments section here, but where was the one that said he had like that's total money makeover. Okay. The total variable with the variable income. Yep. That's at the very back of it. And you can just copy and I mean, I'm sure that there's a copy of it too, on the internet. You could Google it and it's palatable.

Karen Litzy:

Okay, great. Yeah. I think that for me, I look at, you know, this I'm taking care of your budget. I think a big part of it is writing everything down, right? It's the same way when we say to our patients to keep a journal or an exercise log, or if you've ever done weight Watchers, you have to write everything that you eat using weight Watchers. This is kind of the same thing. It sounds like this app, and you're really having to write everything down each month is definitely keeps you accountable, but also gets you into the habit of doing it.

Stephanie Weyrauch (13:44):

Yes. I definitely agree with that. And you know, the other thing too, that Dave Ramsey talks about in his book is he has these specific baby steps that you work towards to building wealth. So obviously I think all of our goals, some days to be financially stable and successful, right? So even utilizing his principles towards your business, I think is really important, especially because look at what happened to us during this pandemic.

Stephanie Weyrauch (14:34):

I mean, 80% of Americans are living paycheck to paycheck, and a lot of us needed PPP loans. And like some people's businesses just weren't prepared for this. So in his book, he talks about like having a small saving, like emergency funds, you know, paying off debt so that you can become debt free would be the next step after that. And then saving three to six months of expenses. And, you know, after this pandemic, one of the things I think I've learned is having that six months expenses saved is like so important and notice that it's six months of expenses, not six months of your monthly budget, but expenses. So then when you have an emergency, like something that you just can't even control, like you feel more in control, you're able to maybe provide more for your employees, or if you, you know, or even your help your patients out a little bit more pay your bills.

Stephanie Weyrauch (15:31):

And then the last three steps, which if you're a business owner, I mean, it's pay for kids' college, which you don't have to worry about that as a business owner, but pay off your mortgage. So if you have a brick and mortar practice paying that off, and then the last one would be to give charitable giving. And if there's one thing I think this will therapist are really good at it's giving to charity, i.e. giving out our services for free sometimes. So, I mean, at that point, when you're in that point in the baby steps, like you hypothetically are set enough that potentially you could do some pro bono work with your business, which would then put your business on the map as being a very solid community practice as well. So, I mean, I think a lot of the day to day principles that he talks about in the total money maker, that's meant for day to day stuff could easily be applied to business.

Karen Litzy (16:21):

Yeah. And I'm glad that you brought up the pro bono because the question that Gina had was, how do you decide on that pro bono? How does that fit into the budget? What kind of a sliding scale do you use and how do you do that? If you are a private practice, what kind of sliding scale are you using and how do you decide what to charge? And, you know, I say like I have a real Frank discussion with the individual patient. And if they say, you know, listen, I really need the help. If they were referred to me from another therapist who they were seeing using their insurance. And they say, you know, so-and-so says, you're the best person. You're best equipped for this. This is what I can afford. Can you do it? And because my business is at that point now where I don't, I can, I'm able to offer that kind of service.

Karen Litzy (17:11):

Then I say, yes, I can do it for this price. You know? So that's kind of how, and it's also depends on like, if the person, if I have to travel an hour and a half to get there and an hour and a half back, then it might not be best. Which in which case, I'm happy to find them, someone that will work for them. So I think when you're looking at the pro bono costs, if you're traveling to patients, you have to look at your travel time. You have to look at how that's going to cut into your overall budgeting and your overall key performance indicators, which we'll have a whole other talk about KPIs. But I think the bottom line is you have to know how much does your business need per month to be able to do everything you just said, right Stephanie.

Karen Litzy (17:57):

To be able to keep the lights on, to have shelter. So how much does your business need each month just in expenses? Have you met that goal, then? How are you able to pay for your insurance and your taxes, which I would say go into just the sheer expense of running the business. Yes. I would agree with that too. So that's the sheer expense of running the business. Do you need another new fancy gym equipment or this, that, and the other thing? No. Right. So if you can forego that to maybe help someone else at a pro bono rate or at a reduced rate, then my inclination is to forgo the fancy new treadmill and to treat the person that needs it. So I think how you decide what that pro bono rate is, I think depends on the person in front of you.

Karen Litzy (18:51):

And you could say, you know, you can ask, ask around and just say, Hey, listen, this is what other physical therapy practices are doing. This is what I'm comfortable with. This is what the least amount I can charge so that I break even. And I think people understand that. So I think when you're thinking about what's the lowest charge you can give to someone that would be it, or you can go perfectly free. If you can say, you know, I can treat, I can do one session free per week, and I'm still, you know, in the green and I'm not in the red, then go for it, you know, but I think you have to know how much you can make to keep your company in the green, and then you can decide, well, this would be my lowest pro bono charge.

Karen Litzy (19:37):

And then if someone comes in, who's really, really of need, or you're volunteering through an organization or something like that, where you're treating someone for free, then, you know, I think in my opinion, I think that's the best way to go about it. I'm sure there's some legal aspects around that. But from what I can tell in speaking with lawyers, they say, it's your rate. You know, you just have to be clear about what it is. You, Stephanie, where are you where you are? Do you have a pro bono rate?

Stephanie Weyrauch:

Yeah, so typically our pro bono rate is like $40 per session is what we'll do, but we are flexible. I mean, again, our practice, luckily my boss, he's been an amazing leader throughout all of this. We didn't have to fully lay off any of our physical therapists and we have five physical therapists, but we were very strategic with how we worked and when we worked.

Stephanie Weyrauch (20:30):

And so we've had that freedom from kind of how we've been running our practice to allow for us to sometimes even treat patients where they pay like $10 for a session. So, I mean, it varies from situation to situation. Things that we consider is how dedicated is the patient? Is this a patient that's actually going to come to therapy? Or is this a patient that's going to flake out on us because we don't want to save them a spot and then they not show up consistently also we've had instances where we've had maybe some where we've thought the insurance was one thing and it came out somewhere else. And so we ended up using the visits that we were given and the insurance company won't give them any more visits, which is a mistake on our part. So we always want to do, we always want to do right with any mistakes that we make.

Stephanie Weyrauch (21:21):

That is another thing that we'll consider, or sometimes if we have a Medicare patient that can't afford their copay, you know, we'll exchange services and other ways, you know, whether it be like they come in and maybe fix something in our clinic. And then we exchange that with our services, bartering, bartering. Yeah. So, we've been able to be flexible. But again, we built up our practice enough. We've been in business now for over eight years and we're a well established in the community that we are able to do that if you're starting out, you may not be able to do it right away, but you can work up towards that as you start to manage your money and start to make a profit.

Karen Litzy (22:12):

Yeah, yeah. Yeah. Thanks for that example. And I think that you'll find that in most physical therapy practices, they have a pro bono rate. They work with people they're flexible. Every practice I've ever been in the owners have been super flexible because in the end, we're all in the business of getting people better. And sometimes that business, maybe doesn't yield a profit of $200 per person. Maybe sometimes it's 10, but if our business is to get people better, then that's what we want to do. And I will also say this just because that person let's say your patient needs that pro bono care, they can't, it doesn't mean that they don't know people who they will scream to the rooftops of how wonderful you are and how great you were and how easy you were to work with too. A lot of their friends or to their communities. And then all of a sudden you're bringing in more business because you did a good thing.

Karen Litzy (23:05):

So don't discount that. And perhaps, you know, that person can be the stellar Google review you need, they can be that video testimonial on your website. They can be that written testimonial on Yelp or on your website. So these are all ways to like, incorporate your pro bono services by saying, Hey, listen, we're happy to do this. If you're pleased with your service, if you feel better, we would love for you to put up a thing on Google or put up a review on Google or Yelp or on our website, if you're comfortable doing that. Right. I totally agree with that. That's another great way. So that's right. It's the same thing as, like I said what would the other night talking about lead magnets, put something out there that people can use. They then give you their email. And all of a sudden you've made this really fruitful transaction for the both of you.

Karen Litzy (24:00):

And that's what that pro bono type of situation can do. So just always think there's always ways to leverage a visit that has nothing to do with money. That's right. So, all right. So Stephanie, let's talk about if you would like to sort of wrap it up on the big budget issues that people need to be aware of. And I also put just so people know, I also put every dollar, the app in the comments as well.

Stephanie Weyrauch:

Perfect. So I would say that the first thing that you need to know is you need to stick with the budget. I mean, there's no point having a budget and you don't stick with it. Accountability partner, I think is key. Having somebody there that will keep you accountable. I mean, you're in private practice. You're probably a very accountable person, but it's still good to have somebody there that asks that says, do you really need that this month?

Stephanie Weyrauch (25:02):

Or are you sure that this is what you want to spend on this specific line item? So having the accountability, I think is the key and sticking to your budget is the absolute key. I think that if you allow yourself to go over your budget and you're like, Oh, it's just one month that develops bad habits. You just gotta break all your bad habits right now. And that budget is like your gospel. You need to have a monthly budget meeting with your staff. If you have a staff, if you don't have a staff, it's just you with your accountability partner and say, this is what I'm going to spend. You know, I have a little bit of extra money that I can spend it on. What, what should I spend it on? Should I spend it on my charity work?

Stephanie Weyrauch (25:48):

Should I spend it on my debt? Should I spend it on getting new equipment and have that accountability partner help you with those decisions? If you want somebody to help you, but at least they can be there to basically ask you those questions of is this really necessary? I think if you can stick to your budget, you will feel so much better about your business. You will be less stressed. Like Karen said, you will feel like you've been like you, you have all this extra money because you know where all your money is. And the reason that the every dollar app is called every dollar is because you give every dollar a name. You don't have any extra money floating around in your budget. You put it where it goes for that month. The other thing is, is that to think of the budget as permission to spend money versus being super strict with it.

Stephanie Weyrauch (26:41):

So you still have the bulk amount of money that you're spending that you, that you have for the month. But, you know, if you notice again, like let's say you don't have to drive as much, you can take that extra money that you would typically spend driving and put it towards a different line item, but just make sure that your budget always adds up to all these total $0. You have nothing left. Everything is going to something in the budget and it has a name. Your budget is your baby. You would not name your baby nothing. Well, no, I'm just kidding.

Karen Litzy (27:26):

Yeah, no, I think that's a really great point. And even if that money is savings, right, it goes, it has a name. So nothing thing, I'm just going to leave it in the bank. It's going somewhere every month. I love that. All right. So we have stick with it. Don't break it, give it a name, anything else? And just accountability partners. Yeah. All right. Well, this was great, Stephanie, and I hope that people this gives everyone an idea of having a good starting point, downloading the app, maybe reading the book. Like I said again, to repeat the name of the book, the total money makeover by Dave Ramsey, and every dollar.com or every dollar app. And in there, it also has in the book, like Stephanie said, it also has information for people who don't have that steady every two week paycheck. But if you're an entrepreneur, it gives you ways in order to kind of work around that as well.

Stephanie Weyrauch (28:27):

And if you do end up, if you guys are podcast listeners, and if you download the Dave Ramsey show podcast, a lot of his podcasts focuses on entrepreneurship and on business ownership. And so he has a lot of really great advice on running a business and budgeting for business. The budget that I talked about is more, it can be both used as a personal budget or a business budget, but he does talk a lot about business ownership in his podcast as well. So I would definitely recommend checking that out. If you have extra time and want something to play in the background, it's a good podcast to listen to in the background. You don't have to sit there and like learn from it. It's just kind of there. And he's a pretty entertaining guy. Yeah. I took one of his it was like a longer course a couple of years ago. So I still have all of the materials and everything like that. So yeah, he's very entertaining and he knows what he's doing and it works.

Stephanie Weyrauch (29:15):

And I will say, you know, you can have a personal budget and a business budget. You don't have to have just one. You can have personal, you can have business and then you'll know exactly where literally every dollar in your business and every dollar in your personal life is going. And like I said, on our talk, you know, after reading profit first from Mike, I just found it amazing of like, yeah, I know now where every dollar is going to. So now that I know where every dollar is going to my big buckets, I can now use this to see where it goes to the very last dollar.

Karen Litzy:

Right. Yeah. And like I said, when you do a budget, it's amazing how much extra money you have. And you're like, wow, I didn't know. I had all this money. What was I spending on before?

Stephanie Weyrauch (30:03):

Right. What kind of nonsense was I doing before?

Karen Litzy:

Yeah. That's one thing that I have to tell you after instituting profit first, I was like, the hell was I doing like, seriously? What was I doing before? Because I have so much more money in savings. I don't have to worry about paying taxes. Everything's awesome. Like, what was I doing? I can't explain it, but now it's like, yeah, now I get it. Now I understand. And I feel like you know, like you said, Oh, this is a grownup thing. Oh yeah. So I was like adulting hardcore when I learned this. So I think that's great. And now Steph, before we jump off, where can people reach out to you or find you social media if they have questions?

Stephanie Weyrauch:

So I'm on Facebook. Stephanie Weyrauch. Or you can find me on Instagram or Twitter at theSteph21 and I'm available on any of those platforms.

Karen Litzy:

Perfect. Well, thank you so much. And everyone, thanks for indulging us, at least here in the Northeast on a very rainy, very rainy Saturday to talk about setting your budget, sticking to your budget and creating more wealth from the money you're already taking in. So Stephanie, thank you so much. And everyone, thanks so much for listening.

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 Apple Podcasts!

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Dr. Adam Culvenor on the show to discuss ACL injury. Dr. Adam Culvenor is a physiotherapist, leader of the Knee Injury and Osteoarthritis Research Group and Senior Research Fellow within the La Trobe Sport and Exercise Medicine Research Centre in Melbourne, Australia. Adam’s research focusses on the outcomes of anterior cruciate ligament (ACL) injuries, in particular the prevention and management of early knee osteoarthritis in young adults following ACL injury and reconstruction.

In this episode, we discuss:

-The short-term and long-term burdens following ACL injury

-Why patient rapport is integral to effective treatment post-ACL injury

-Optimal loading strategies for non-surgical and post-surgical cases

-The latest research on prevention for early-onset osteoarthritis

-And so much more!

Resources:

Adam Culvenor Twitter

La Trobe SEMRC Twitter

Email: A.Culvenor@latrobe.edu.au

La Trobe Adam Culvenor

La Trobe University Blog

For knee injuries, surgery may not be the best option  

A big thank you to Net Health for sponsoring this episode!  Learn more about Four Ways That Outpatient Therapy Providers Can Increase Patient Engagement in 2020!

For more information on Adam:

Dr. Adam Culvenor is a physiotherapist, leader of the Knee Injury and Osteoarthritis Research Group and Senior Research Fellow within the La Trobe Sport and Exercise Medicine Research Centre in Melbourne, Australia. Adam’s research focusses on the outcomes of anterior cruciate ligament (ACL) injuries, in particular the prevention and management of early knee osteoarthritis in young adults following ACL injury and reconstruction. His work has identified important clinical and biomechanical risk factors for post-traumatic osteoarthritis, and he is currently testing novel osteoarthritis prevention strategies in young adults following injury in a world-first clinical trial. He has published over 60 peer-reviewed articles in international journals.

Adam has worked in teaching and research at universities in Australia, Norway and Austria and is a graduate of Harvard Medical School’s Global Clinical Research Program. His research has been awarded American Journal of Sports Medicine most outstanding paper 2016, Australian Physiotherapy Association Best New Investigator 2013 & 2017 in musculoskeletal and sports research, and Sports Medicine Australia best Clinical Sports Medicine paper 2019.

Read the full transcript below:

Karen Litzy (00:01):

Hey, Adam, welcome to the podcast. I'm so happy you're here. And I'm excited to talk about ACL injuries with you. So welcome.

Adam Culvenor (00:08):

Thanks very much for having me, Karen. It's great to be here and chat.

Karen Litzy (00:11):

So now the bulk of your research is in ACL injuries and not the mechanism of injuries for ACLs, but what happens after that injury? So before we get into, and we'll talk about the burden of ACL and optimal treatment and osteoarthritis and why that happens. But what I would love to know is why are you interested in this subject matter? Sort of, why did you make this kind of the centerpiece of your research?

Adam Culvenor (00:43):

It's a good, good question. So about 10 years ago, also, now I had done a couple of years of clinical practice as a physiotherapist in Melbourne where I'm based and was interested in pursuing a bit more of the research line into ACLs because we had a patient come to myself and one of my colleagues who was a young guy, about 35 years old, who had a very active, healthy life up to that point, he'd suffered an ACL injury about when he was 20 years old, he was about 35. Now it had a number of issues. He'd got back to sport without any problems, but then now about, you know, 10 to 15 years later, started having some pain, unable to do the things he normally would love to do. Couldn't go back and play anymore.

Adam Culvenor (01:33):

Sport couldn't start, couldn't really play with his kids. He'd seen an orthopedic surgeon, he'd had an Arthroscope, had a bit of a cleanup now going back to the surgeon and he was really in want of a knee replacement because he could no longer do the things that he wanted. And the surgeon basically said to him, you're too young to have a knee replacement go and see, Adam and Tom, our colleague. And so what we can do, and that really opened our eyes from a clinical perspective about these types of patients and this particular young guy had on x-ray most of his changes were actually in his patellofemoral joint. So in the patella and the trochlea, and that really set my mind up to go and look into the literature in this space and see what's out there in terms of not only osteoarthritis in these young people. And clearly it was very burdensome to this young guy, but also why are we seeing this in the patella femoral joint in particular and why is it causing so many problems? And so that really set us off for my PhD, about 10 years ago, looking into these medium to longterm outcomes, ultimately trying to help these people get back to do the things they wanted to do without the pain and the symptoms that come with osteoarthritis a lot of the time.

Karen Litzy (02:48):

Yeah. Oh, great story, that's a shame 35 years old. Gosh, that's so young. I can understand why that would really peak your interest because you don't want to see these patients coming into you or when you do see them, you want to be able to help them with the best evidence and best things that you can. So you had mentioned in your explanation there as to why this subject interests you, is that there is this sort of burden after having this ACL injury. So could you talk a little bit more about the burden of an ACL injury and subsequent surgery?

Adam Culvenor (03:27):

Sure. So I'm sure it goes through a lot of people's minds, as soon as they hear that pop or click, that if they know they've had an ACL injury, that's the initial burden is, you know, that worry of, I can no longer play sport. And often if you do go and have a reconstruction surgery, it's often the nine, 10, 12 months of extensive rehabilitation, as we know, and not going back to sport that often people find a lot of personal satisfaction and get a lot of mental health benefit from playing sport and from their peer involvement and social interaction. So it's that initial burden of the extended period out of sport. Some people do really well with great rehab. They can get back to their sport. They want to play at back to the same level of performance, but there's a certain percentage at about 50% of people we know in the evidence will develop longer term, not only persistent symptoms from a patient reported outcome perspective, but also ongoing functional limitations.

Adam Culvenor (04:26):

And ultimately the development of osteoarthritis be that on radiographs, on x-rays. And some of our work is which we can go into a little bit more detail in a moment is looking at the earlier changes on some more sensitive imaging like MRI to try and detect these types of people who might be more at risk of developing longer term changes. So as I said, some people do really well following an ACL injury, but rehab only, or surgery. And we can chat about the differences in the treatment options later as well, but about 50% of people at the moment. And the evidence suggests that they will have osteoarthritis within about 10 years of their ACL injury. So if we think of the typical patient is, you know, the adolescent or the young 20 year old patient playing sport, they rupture their knee only 10 years, 15 years down the track.

Adam Culvenor (05:16):

They're still only 30, 35. That young gentleman I spoke to earlier. And they've got a knee of essentially that looks like on imaging of a knee of a typical 70 or 80 year old. And we know that imaging findings on x-ray don't necessarily match up particularly well with what we see clinically. So that's not necessarily, you know, a sign that they're definitely going to have functional limitations on symptoms, but it certainly increases the risk of that happening. And that burden at a time when people often have really important family commitments and young family commitments work commitments, and they often still want to be active in participating in sport. And so when you bring all of those in to a knee that might not be has have recovered as well, following an ACL injury, you might still have some muscle weakness if that wasn't addressed initially and create the picture of more of a persistent pain problem, then you start getting into being quite a burdensome condition that we say these types of patients clinically come back in often five, 10 years following their injury.

Karen Litzy (06:20):

Yeah. And I can imagine along with that, persistent pain comes decreased activity, decreased movement, and we all know all of the sort of cascade of events that can happen when you're not getting an exercise. You're not getting in movement. You know, then you have risk of obesity, risk of diabetes mental health issues. So all of that stuff can kind of stem from, you know, this burden of an ACL, which, you know, for a lot of people, I don't think that even would flash in their mind when you're looking at a 20 something year old who just tore their ACL, because we know that population who does tear are usually pretty athletic.

Adam Culvenor (07:03):

Exactly. And that's the thing prior to their injury. They're often very healthy and, you know, never seen a doctor or never been to hospital before and having the ACL injury can often be that initial. Unfortunately, you know, the cascade where you become less physically active in, might not be able to get back to the sport. You really want to start putting on weight. And that increases the risk of all of these other conditions, as you've just said. And I think there was a recent article a research paper actually showing that having an ACL injury increased your risk of a cardiovascular disease by about 50% longer term. So for me, that was a real wake up. This knee is not just a knee, it's actually affecting the whole person. Exact reasons you just mentioned that it can spiral into, you know, less physically activity, the pain putting on and then being the increased risk of all of the comorbid conditions as well.

Karen Litzy (07:55):

Exactly. And now, so you mentioned a couple of minutes ago about treatment. So you could have surgery, you can not have surgery. So can you talk a little bit as to what the optimal treatment is after an ACL and how one comes to that decision, whether you're the clinician or you're the patient, how does that work?

Adam Culvenor (08:18):

And that's the $64 question. And so I can have extreme of the spectrum. You can have one end, you can have everyone has surgery. The other end is no one has surgery and the truth probably lies somewhere in the middle. So if we look to what the evidence suggests in the literature, there's very little high quality evidence comparing the two treatment options. There's really only one, what we call randomized control trial. That's compared about 120 people. Who've had an acute ACL injury and they were either allocated to having early surgery. So a couple of months of having the injury and then an extensive rehabilitation period I've nine months or so, and then the other group. So exactly the same rehabilitation. The only thing is they didn't have the surgery. And so the only difference between these two groups of patients was the surgery or not.

Adam Culvenor (09:15):

Now the group who didn't have the surgery initially could have the option of having surgery later on if they had ongoing problems or symptoms, or desired to have the surgery later on, and they could cross over to the surgery arm. And what this study showed is initially this was published back in 2010 now. So we've not done this for over a decade, is that there's very little differences both at two years after surgery five years. And I think that the authors are about to publish their 10 year outcomes, but certainly the two and five year Mark, there's very little differences, whether you have surgery or not, in terms of pain symptoms, strength returned to sport the need to have more surgery, quality of life, and indeed radiographic knee osteoarthritis. So I was fortunate enough during my time in Europe, conducting a research fellowship recently to work with this group of researchers based in Sweden.

Adam Culvenor (10:07):

And we looked at the MRI outcomes in this population, as I said earlier, trying to identify people maybe earlier in the process initially after that ACL injury, to see if we can identify those more at risk of longer term problems, which might present opportunities to intervene a little bit earlier to stop that cascade of negativity and what we found really, interestingly, when we looked at the cartilage on MRI between the time of injury to two years and to five years, is it the group that had early surgery actually had more cartilage loss compared to the group that didn't have surgery and you sort of asked, well, why might that be? Because, and I think I haven't had an ACL reconstruction, I'm injuring myself, but I know from colleagues and working clinically that the ACL surgeries is almost a secondary trauma. Like you're going in there, you're drilling tunnels, you arthroscopically opening the joint.

Adam Culvenor (11:04):

You come out of surgery, having a very angry, hot red, swollen knee. And so I think that whole cascade of inflammation can soften the cartilage, can create a knee that's not particularly happy. And then when you go and potentially, you know, put that knee through load, maybe going back to sport and whatnot, then that might actually be related to the development of osteoarthritis more so than if you don't have the reconstruction. And so we've actually done a little bit more work on the return to sport type of thing. And, thankfully in a group with ACL reconstruction, it doesn't seem to increase the risk of osteoarthritis if you do go back to sport. So that doesn't seem to be the main things. That's a good thing for patients knowing that if you've had an injury or reconstruction, you can go back to sport knowing that you're not going to put your knee at more risk, but it's probably more the inflammatory markers, the secondary trauma of that that's reconstruction surgery that increases the risk even longer term as well.

Adam Culvenor (12:03):

So I think what I always tell my patients is that you should always trial a non-operative period. First, you can always go and have surgery later. And I think, I always say, you need to prove to me that your knee is unstable. So some people can do really well without having surgery because their neuromuscular and muscle systems can compensate for that ruptured ACL and the mechanical instability, the neuromuscular system, the humans are very clever. They can really compensate quite well, and they feel you don't need the ACL. If you're only going to perhaps not go back to that high level pivoting sport, where you put your knee at high stress, a lot of the time, then if you just want to run straight lines and play with the kids, then you're likely not needing to have the reconstruction. If for instance, you try a really intensive, progressive rehab strengthening program and you're starting to run, or you're starting to get back into a bit of sport and your knee starts to become unstable at that point at the level that you want to get back to, then that sort of probably instigates the conversation.

Adam Culvenor (13:12):

Well, maybe your knees actually not able to overcome the structural instability to the level of activity that you want to achieve. Maybe let's have the discussion of a reconstruction as a potential option, but always get them. You need to prove that your knee's unstable by going through this rehab and putting yourself through these activities. But it's not going to do well without surgery because we know that the outcomes that are quite similar for the majority of people if you have early surgery or even delayed surgery and doing a period of rehab, irrespective of whether you go and have surgery or not, will be beneficial, if you do go and have surgery. So that prehab, if you like. So that's, I think it's my take home is it's probably actually just educating the patient to empower them with the evidence because they're the ones ultimately that need to make the decision. And so presenting them with all the best available evidence and guiding them for the initial rehab stage often can change their mind that they need surgery once they realized they were actually doing quite well without it.

Karen Litzy (14:17):

And when you're saying to the patient, let's do a trial for a non-operative phase, so that you can prove to me that this knee is unstable. What kind of length of time are you talking about for that rehab process and knowing that it's going to vary person to person obviously.

Adam Culvenor (14:37):

Oh, of course, of course. So I think a period of two to three months is sufficient to provide an intensive strengthening program. Let the knees settle down initially and then actually start you know, within the first month and even two months getting them to start really loading their knee. That's the thing, if you actually don't have surgery and actually responds a lot quicker because you don't have any of the graft morbidity, you're not taking out some of the hamstring or the patellar tendon. There's no real reason why we need to be conservative about you know tearing a hamstring or whatever that might be cause of the graft or rupturing the graft because you haven't had the graft reconstructed. So it's different for everyone because different people will respond differently, but actually there's no real hard and fast rule with this because you need to rehab them to get them to a point where they're starting to do the activities that they want to get back to.

Adam Culvenor (15:37):

And at any point in that step ladder of increased physical activity demands that they might fail or start having, you know, severe giving way episodes. Then that's the point that you might have that conversation with someone, but if you're running and you start giving Y and these people want to go back and play elite football, then clearly maybe you're not getting, being able to run without a stable knee. You're probably not going to be able to play football with that with a stable knee. Then that might be the point where you revisit, you're running no problems and you tried playing football and it starts giving way, but really you actually just want to run, right? Playing football is just something you tried, but didn't really want to do. Then you probably don't need the structural stability. If you just want to run off another thing, I like to set a patient's, is it like a seatbelt?

Adam Culvenor (16:28):

Is it, we all wear a seat belt when we drive, but very rarely do we have a crack and we rely on that seatbelt to keep us safe. So if you're someone who walks around and might run, then the ACL is a bit like a seatbelt, is that you actually don't need that seatbelt on because you're not having a crack. You're not putting the need through that real pivoting type movement to rely on it. So unless you're going to go back to a high level sport and, you know, put your knee through those pivoting jarring mechanisms of movement, then you probably don't need that seat belt. You don't need that ACL to protect the knee. Does that make sense? Yeah,

Karen Litzy (17:06):

That's perfect. That's really great. And it sounds to me like when, if you're the clinician working with this patient during, let's say this non-operative trial period where they have to prove, again, the instability, every single person is different. So what you're going to be looking at is different meaning, right? So if I just want to be able to play with my kids, I wasn't a runner before I don't really need to run. I just want to ride a bike or, you know, you want to put people through the things that they want to be able to do. And that would kind of be the way you would test for that instability. But are you also using sort of standardized tests when it comes to seeing if people have the stability in the knee?

Adam Culvenor (17:54):

Exactly. so it's really a goal based discussion with the patient come. The desires of the return to activity comes is driven by the patient. And as clinicians, you know, it's good to have that discussion to then work out, you know, what level do we need to get at, but certainly there's a number of standardized clinical tests and really great patient reported outcomes that we can use with these patients. So the very common ones are the strength tests. So if you have the resources, you know, a dynamometer, an isokinetic dynamometer in the clinic to look at the three range of quads and hamstrings strengths and making, you know, the criteria we typically use in the literature is meeting 90% of the strength compared to your uninjured side. Now, there's obviously some pros and cons about doing that.

Adam Culvenor (18:44):

And the other tests are typically hop tests. So single leg hop, as far as you can, with a balanced landing site, decide hop tests. There's a number of different tests we can use to try and assess the stability, the functional stability and confidence of the knee. Having said that though, we've actually just done some work I've led by Brooke Patterson here as part of our team, looking at the limb symmetry index, which is the ACL rate constructively comparing to the, I mean, delayed and what we found sort of between one and five years after their reconstruction is that often the non-injured leg isn't that healthy gold standard cause that often deteriorates because it's a period of an activity, you be back playing the sport you’re back to. So that's sort of the crisis in capacity. So it's not that reference standard that we should necessarily be comparing our rate constructed.

Adam Culvenor (19:44):

And so there's been a couple of other bits and pieces that people have looked at alternatives to this type of measurement. And whether it's, if you have say someone initially after injury, it's a great opportunity to start doing these tests is actually the estimated pre-injury capacity. So to estimate that it's best to try and do it as soon after injury as possible, given that patients might have some fear and confidence, you know, respect that obviously, but actually trying to do a hop test quite early before that other leg has the chance to start decreasing in capacity because often the limb symmetry index overestimates, what the reconstructive legs capacity actually is. And so they're the functional type of measures that I think we should be using in this patient population, not only to assess outcomes, but also patients get in my experience really like seeing their improvements and getting feedback about having, going along their journey totally. And then an objective test of strength or a hop test they can see right in front of their eyes, how far they're hopping and if they are improving and if they're not, then why not have that conversation. And so that can be great for adherence motivation because this journey of a rehab, irrespective of whether you have a reconstruction or not, can be quite long and tedious, it can be boring. You're sitting there doing strength exercises, you know, any type of motivation to get people to continue is going to be beneficial.

Karen Litzy (21:14):

It's always, one of the biggest complaints is, gosh, these exercises, when do we get to the X, Y, Z, you know, that you see on, on Instagram or on YouTube. And I was like, you know, you're a month in buddy. This is it.

Adam Culvenor (21:28):

Exactly. And I think as physios and the evidence suggests that, we're very good at doing the early stage of the rehab because patients are probably more compliant at that point as well. But there's evidence actually coming out of Australia that less than 5% of people who have had an ACL reconstruction, so less than 5% actually go through a period of rehab beyond six months and include and return to sport type training. So I think whether it be a lack of understanding from a clinician standpoint, or also that, you know, financial and motivational points of view from the patient after six months of like, I've had enough, I'm out, I've good enough. I don't need that extra, you know, icing on the cake to get back to sport. They tend to drop off. And that's when not having that really high level agility capacity returned to school at top training, you increase the risk of re rupture. And that obviously is a devastating impact for these patients and increases the risk of longer term negative outcomes as well.

Karen Litzy (22:27):

Yeah. And I know here in the United States, not so much in other parts of the world, but insurance will oftentimes cut people off at three or four months.

Adam Culvenor (22:36):

Okay. So it's different everywhere. Yeah.

Karen Litzy (22:38):

So it's like, okay, so the person can walk and run and then, then what do they do? You know what I mean? So it kind of depends on your clinic model and things like that. But I mean, I've been lucky enough that I've been able to stay with my patients for 12, 13 months and upward. So it's been really great to be there the week they are out of the OR to getting them on the field and actually doing things that are going to, you know, mimic their soccer, their football place. So, but it's, yeah, there's so many obstacles. It seems.

Adam Culvenor (23:25):

Totally. And I think there's some really great evidence coming from Scandinavia that for every month that you delay the return to sport up to nine months, it actually reduces your injury risk by 50% that's mind blowing for me. So not only, you know, it was it from a rehab point of view, but actually from a range, point of view, having that nine months will actually you know, reduce your risk substantially of re rupturing when you do go back to sport. And I think that is why it's so heavily on people's minds when they're first going back to sport. That fear that's a huge impact psychologically for these types of patients. And I think often an ACL injury can happen. So innocuously, like you've done this movement a thousand times at training before, so why this time and that fear of, Oh, it wasn't a major blow when I first did it, like it wasn't someone running across and really hitting my knee. It was, I was on my own. And so what's stopping that from happening again. And that's that, I think that feeds into the fear of what could happen anytime again. Yeah. So I think I often try and say to patients while you injured your ACL, initially let's get your knee back to better than it was before you injured it, to prevent it from happening again. Because once we know once you have one injury, the biggest risk factor. So the biggest risk factor for a second injury is having a first.

Karen Litzy (24:51):

Exactly, exactly. And I've quoted that that study of that nine months reducing 50%, especially when you're working with kids who think I'm fine. Now I can walk. And I was like, listen, this, and you have to have that conversation with the child and with the parents. And once the parents hear that, they're like, okay, like we get it. Even though her physician was onboard, like you're not playing until you're one year out from surgery. I mean, wherever it is on the same page, but it's hard to keep. It's hard to keep everyone on the same page, but being able to use the literature and say, listen, I'll send you the study here it is.

Adam Culvenor (25:34):

When actually pulling it's actually for some people it's not in needing to encourage them, it's actually needing them to pull them back. That's where your education and clinical reasoning and discussions with patients will differ quite a bit is that some people are so gung ho in their rehab and they just want to get back to sport. You actually have to, as I said, pull them back, whereas the opposite might be true for some alpha people. So it's really interesting how different people respond differently to this type of quite devastating injury.

Karen Litzy (26:03):

Right. And how they respond, how you can use, like you mentioned the study of Scandinavia, how we can use that study with both of those extremes of people, right? So the people who are afraid and the people who are gung ho, so again, it's having this good rapport with your patient and their other stakeholders to kind of get them through safely through their rehab. But now we talked about it earlier on and that's osteoarthritis. So 50% of people will develop some sort of osteoarthritic changes in their knee. So what do we do about that? Are there prevention strategies? What can we do?

Adam Culvenor (26:54):

So this is something that we've been looking at for a few years now and obviously you know, we'd love to be able to have a treatment to stop this from happening, but we're not actually there yet. There's a lot of really nice longitudinal studies investigating risk factors for the increase prevalence of osteoarthritis in this population. And there's a number of risk factors that we can start informing how we might treat these people initially as well. So the number one risk factor is having a combined injury with a meniscus tear or a cartilage lesion. So if you have not only an ACL injury and very rarely, is it just an ACL injury, it can often be combined with a meniscus tear, cartilage lesion, bone marrow lesion, et cetera. So that more severe sort of type of injury will automatically put you at risk longer term of having osteoarthritis.

Adam Culvenor (27:46):

That's not that exciting because as clinicians, we can't do much about that. It's not really modifiable. So we're really trying to identify some factors that might be modifiable that we can address. So things like BMI being overweight, we know increases the risk of osteoarthritis longer term not only after injury, but in people of older age who have the traumatic type of osteoarthritis what's coming emerging from the literature more and more is the quadriceps weakness. So quadriceps in particular the muscle weakness in that muscle and also the functional impairments. So we talked about hop tests and in a balance in your muscle control a little bit earlier. So they're actually starting to become more and more prominent as risk factors for the medium and longterm outcomes for osteoarthritis. So we've just published a paper in the British journal of sports medicine, which looked at this exact question.

Adam Culvenor (28:44):

So do functional outcomes. So typical tests, we might use to clear someone to return to sports, a hop tests and strength tests. Do these actually have a relationship with future osteoarthritis? And what we found is, so this is a one year we tested them. And then at five years we measured their osteoarthritis on MRI. So quite sensitive measure of osteoarthritis, but also an X ray. And what we found is we combine a lot of these tests together into a test battery. So side to side hop test, single leg forward hop test. If you have a poor outcome at one year in these tests, then you're more likely to develop osteoarthritis at five years down the track. And so there's other studies that show quite similar findings in this space as well, which is really, I mean, it's upsetting because they're more at risk of osteoarthritis, but it's quite encouraging as clinicians.

Adam Culvenor (29:34):

This is our forte. We can actually do something about it in the initial stages of rehab. And again, this can be a great education motivational tool to say on this test, you're not achieving at a level that you need to achieve. This is not only going to put you at risk of reinjury. The research shows that this is actually going to increase your risk of developing arthritis. And we need to be a little bit careful about how we inform our patients about this. Cause as I said, some people can be really fearful and terrified about reinjuring and worried about what it is going to look like. And so presenting them with, Oh, you're going to be, you're going to have arthritis in 10 years as well. Might not be quite the right moves to allay that fear at that point in that patient.

Adam Culvenor (30:16):

Whereas other people having a knowing that information can be really motivating to try and get them feedback to the best possible condition that it can be. So again, it's very personalized how we educate our patients, but I think it's really important to educate them along the journey about that increased risk of OA and encouragingly. There's some, some really positive signs that we might start to be able to modify that risk with some really great rehab, getting back to the strengths, getting back to improving function in our clinical work as well. So I think that's really, really exciting moving forward.

Karen Litzy (30:50):

And that's great news for physical therapists because this is where we live, so wow. We can really make a difference in someone's life by good comprehensive rehab within that first year after ACL injury. And again, that's, regardless of whether they have surgery or not, is that correct?

Adam Culvenor (31:08):

Exactly. Yep, exactly. And as I said earlier about the return to sports, so we've also done some research which should be published shortly, hopefully looking at the fact that again, encouragingly, if you have an ACL injury or reconstruction and then decide to go back to these pivoting type sports, some people say, well, you shouldn't go back to that. You know, the high impact sport, because that's going to put your knee at undue stress and you're going to have more arthritis longer term, is that what we've found is actually that's not the case. So we can be confident that we can give these people you know, the advice to go back to sport. If that's what they really want to, for their quality of life and mental health, they do drive a lot of social pleasure from playing sport. The good thing is, is if you have a great functional and strong knee, then that's not going to put your knee at further risk by going back to sport. Sure. It's going to perhaps increase your risk of re injury compared to sitting on the couch at home. I heard that from a lot of mental health and also physical health being physically active and involved in sport has so many more benefits to our general health as well.

Karen Litzy (32:11):

Absolutely. And now can we, if you don't mind talk about the patient that I think a lot of physiotherapists are going to see, and it's like the patient that you saw 15, 20 years after their ACL. So we're not, we're not seeing them one to five years, but now we're seeing them 10 to 15 to 20 years later. That's when a lot of people are going to come to us with knee pain. So what can we do for these patients? Do we want to look at these hop tests in these patients? Does that make a difference? What happens then? Cause that's a big bulk of our population.

Adam Culvenor (32:54):

You're exactly right. And it varies about again what their goals are, but often if they're 10 to 20 years down the track and they've got osteoarthritis, we can look to the literature in the osteopath writers field. And in that space, it's very, very compelling evidence that exercise therapy and education provides the strongest effect for pain and symptoms and function in this population. And so that's almost reassuring that it's quite similar to what we're seeing in the early post-operative or post-injury stage is that whatever level on the spectrum you are post-injury and the development of osteoarthritis, essentially your treatment's going to be quite similar where you're developing the strength that underlies everything that we do in day to day activities. And indeed, if we want to get back to sport and also the functional capacity, so ask for the, what they want to do, what they can't do because of their pain and symptoms and make it a really goal oriented treatment.

Adam Culvenor (33:54):

And I think it's really important to also ask them what physical therapy have they actually done. A lot of those people come to us and they've seen five different surgeons and they've got different opinions. And when you actually question them and interrogate them, they've actually never had a gym program or they've never done any strength training. And it's like, well, of course you're having a few problems. So let's start you from the very basics. And not, you know, not flare them up by going too hard, too fast, but actually educate them around the importance of strength and functional control that the knee will benefit a lot from that. As well as from a function symptomatic point of view and start building on their strength, capacity and functional capacity to be able to meet whatever goal that they want to get back to. So I don't see it as being a totally separate patient from the post-injury one to the osteoarthritic, it's on a spectrum. And a lot of the treatments going to be very similar in principle depending on what their goals and their goals might change over time. So the treatment can as well.

Karen Litzy (34:58):

Yeah. Yeah. Well, thank you for that. That's great. Now, can we talk about the study that you are currently undertaking at La Trobe University. So can you tell us a little bit more about that? What is it and what are your goals for it?

Adam Culvenor (35:18):

We're super excited. Pardon the pun. So this is a project that's really stemmed from over the last 10 years of our work. Looking at identifying those risk factors, as I've talked about earlier to then be able to get some funding. So we've got some funding from the Australian government health and medical research council to perform this really world first randomized control trial, to see if we can actually prevent early osteoarthritis and improve symptoms and function through an exercise therapy intervention. So in essence, we're going to get a whole lot of people, about 200 people who are one or two years following there ACL reconstruction. So they've had that initial period of rehab to get better. Cause some people do really well. We need to remember that, that some people do great following the injury and surgery and don't need more intervention longer term.

Adam Culvenor (36:14):

So we want to try and capture the ones that have some ongoing symptoms and functional impairments. Haven't got back to doing what they want to do at one year post op to two postop at a point where they should be able to do those things and because they are going in out by some of the research, that's just, those people are more at risk of developing longer term problems. So we want to capture those at high risk and we're going to separate them into two different groups. In our clinical trial. One group will get a really intensive physio therapist, led exercise therapy program. So a lot of strengthening, agility, neuromuscular control, education, around physical activity you know, loading of the knee return to sport. And then that's over a period of four months initially. And then the other group gets what we're trying to say is usual care.

Adam Culvenor (37:06):

So very little intervention, they get a little bit of education and some booklets with the types of exercises I could do if they want to essentially, which is what they'd probably get it from their GP or their surgeon. Similarly, am I going to then assess their needs and their general health and symptoms and function from baseline and that changes over four months. And then also look at the changes up to 18 months as well because the MRI is one of our main outcomes looking at early collagen changes, which is our osteoarthritis marker. And some of these can take a little while to show up. So if you have an MRI on one day and then go and have an MRI the next week, chances are, you're probably not going to see much difference. So we need that period of, you know, 12 to 18 months to be able to see an effect of our exercise therapy intervention.

Adam Culvenor (37:56):

Whereas the symptoms of function we're expecting to be able to improve quite a bit within the first four months, which is going to be the most intensive period. And so yeah, our hypothesis is yeah, is that there's really strong, intensive, progressive rehab program strengthening, getting nice knees back to better than what they were before is going to be beneficial for their symptoms, function, general health quality of life, but also hopefully be able to show that that's actually preventing the early changes that we see on MRI or indeed maybe slowing the changes. So we know that cartilage thickness decreases. So we have a loss of cartilage, bone marrow lesions can start developing also for small osteophytes and bony spurs can start developing over a course of one or two years. And so we want to see if there's a difference in the development of those features in the two different groups. So we are ready to hit, hit, go on this study and a little bit delighted with COVID effecting us at the moment as well. So we're really excited to get going on this study and hopefully be a really impactful research project, moving the field forward and empowering clinicians to say, we actually can make a difference in this space for these patients.

Karen Litzy (39:07):

Yeah. I love it. Well, I look forward to when you guys can actually get started and maybe 12 to 18 months from then. So it sounds like a great study. And like you said, it's something that can be so empowering for physical therapists or physiotherapists to then pass on to their patients and kind of transfer that power from the physio to the patient to give them a greater sense of wellbeing, which is exactly that's what we do, right. That's why we became PTs or physios. So before we sign off, I have a couple other things. Number one. What are your biggest sort of takeaway messages for the listeners?

Adam Culvenor (39:55):

So I think the biggest thing is probably when you first see the patient, whose had an acute ACL injury in front of you and they're devastated. They often might come into your rooms and have heard particularly here in Australia. Our media is very centric on if you've had an injury, you need reconstruction because the elite athletes tend to have the reconstruction and I want the best treatment. And therefore I need a reconstruction is actually having a conversation with them and saying, presenting them with the evidence as I spoke about earlier. And there's no problem trialing a period of non-operative management for a couple of months, because that's going to be a great help if you do go down and have surgery afterwards. And it's, I think the reality is that a lot of people given the opportunity to do is to not pretty, very happy, actually can change their mind over the course.

Adam Culvenor (40:45):

And I realized actually, my knees gone really well. I actually don't need to have surgery where I was. I thought I would. So that's instead of just going gung ho into surgery, I think the evidence is very clear that a period of non-operative management is beneficial. Most patients almost all. And then the second key take home for me is, is during a postoperative or post-injury rehabilitation is actually working these patients intensively and progressively, I think we tend to shy on the side of being a little bit cautious, particularly after they've had a reconstruction, we worry about the graft rupturing. And of course we have to respect the surgeons requests of what we need to do with the patient from a restriction standpoint. But I think there's evidence growing now that we can be a lot more intensive early on and progressive with our exercises and looking to the strengths and conditioning research like these guys are trained specifically to develop strength and conditioning programs.

Adam Culvenor (41:46):

And I think as physios where we're pretty good at it, some better than others. And I think meeting the American college of sports medicine, you know, criteria for strength gains is actually, you need to work really hard. You need to get sweaty, you need to actually be working at an intense level. And so unless we put our patients through that, those sort of levels of intensity, we're not going to see the best outcomes that these patients can then can achieve. So there my two take homes is I think try non-operative period of rehab initially and revisit that along the course of the program. And then don't be afraid to actually build a lot of strength in those people because that's going to be beneficial. So they short term prevent re injury and the longterm of preventing arthritis, likely down the track as well.

Karen Litzy (42:31):

Awesome. And then number two, next question is, and it's something I ask everyone knowing where you are now in your life and in your career, what advice would you give to yourself right out of a physiotherapy school?

Adam Culvenor (42:51):

Ooh, good question. I'd say don't worry so much about things. Things will work out. I think in the research I'll probably have my research hat on a little bit, is often clinicians who want to start in research or even researchers who want to continue in research is that the funding can be really you know, tricky and really competitive and can often make and break careers. But I think some general, you know, I'd tell myself is don't worry too much about that. Just link up with good people and strong mentors. So, and I think finding, I'm sure you've had other guests say this as well, but finding good people who can mentor you really well and put your interests or your goals in your career sort of forward to their collaborators. So you can meet new people and open doors.

Adam Culvenor (43:46):

I think I was always worried that it wasn't gonna be enough doors opening, but I've been really lucky in my career that I've been surrounded by a great team throughout and doors have inevitably even though I don't expect them to keep opening. And so having the being in the right place at the right time is important, but you can, you can help to create more instances of being in the right place and more instances of being in the right time by putting yourself out there and meeting new people and surrounding yourself with really good mentors.

Karen Litzy (44:20):

Great advice. And number three, last question. Where can people find you?

Adam Culvenor (44:25):

Peak pool can find me in my lantern at the moment I'm up? No. So I'm have a Twitter account @agculvenor. My profile's on the Latrobe sport and exercise medicine research center page at Latrobe university. So we have a blog at our research center with a lot of really nice impactful easy to digest, short blogs, short videos, infographics designed for clinicians designed for patients. So you can take them off the blog and give them to your patients so I can not recommend that resource highly enough. And then my email, feel free to email me. You can find that email address on the La Trobe website page as well.

Karen Litzy (45:13):

And, we'll have all the links to that at the show notes for this podcast over at podcast.healthywealthysmart.com. So we'll have a link to your Twitter and to your page at Latrobe and also to the blog. So people want to get those resources, they can, and we'll also put in links to the papers that we spoke about today so that people can go and kind of read those papers as well. So we can link up to all of that. So, Adam, thank you so much was a great conversation. I appreciate your time.

Adam Culvenor (45:44):

That's been fantastic. Thanks Karen.

Karen Litzy (45:46):

You're welcome. And everyone, thanks so much for listening. Have a great couple of days and stay healthy, wealthy and smart.

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