In this episode, CEO of Fyzio4U Rehab Staffing Group, Dr. Monique J. Caruth, talks about how she, as a businesswoman, reacted to Covid-19.
Dr. Monique J. Caruth, DPT, is the CEO of Fyzio4U Rehab Staffing Group providing home health services in Maryland. She currently serves as the Southern District Chair of Maryland APTA and is the Secretary-elect of the Home Health Section of the APTA. She holds a Masters and PhD in Physical Therapy from Howard University, and she is a proud immigrant from Trinidad & Tobago.
Today, we hear what it’s like treating potentially Covid-positive patients, Monique tells us about the screening tool she developed, and we hear about the impact of the pandemic on mental health. Monique elaborates on the importance of Ellie Somers’s list of notable PTs, and she talks about her experiences of losing patients. How did she pivot her business to keep it afloat? How has her perspective as both a clinician and a business owner helped her pivot her business?
Monique tells us about obtaining PPE, offering Telehealth visits, and she gives some advice to Home Health PTs, all on today’s episode of The Healthy, Wealthy & Smart Podcast.
Step 2: Ask questions about symptoms, traveling, and possible contact with Covid-positive people.
Step 3: Ensure PPE is worn.
More About Dr. Caruth
Dr. Monique J. Caruth, DPT, is the CEO of Fyzio4U Rehab Staffing Group providing home health services in Maryland. She currently serves as the Southern District Chair of Maryland APTA and is the Secretary-elect of the Home Health Section of the APTA. She holds a Masters and PhD in Physical Therapy from Howard University, and she is a proud immigrant from Trinidad & Tobago.
Therapy, Rehabilitation, Covid-19, Health, Healthcare, Wellness, Recovery, APTA, PPE, Change,
To learn more, follow Monique at:
LinkedIn: Dr Monique J Caruth
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Apple Podcasts: https://podcasts.apple.com/us/podcast/healthy-wealthy-smart/id532717264
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Read the Full Transcript Here
Speaker 1 (00:01):
Hey, Monique. Welcome to the podcast. I'm so happy to have you on.
Speaker 2 (00:06):
Oh, thank you for inviting me. It's a pleasure to be on once again.
Speaker 1 (00:10):
Yes. Yes. I am very excited. And just so the listeners know, Monique is the newly minted secretary of the home health section of the APA. So congratulations. That's quite the honor. So congrats.
Speaker 2 (00:26):
Thank you very much. And
Speaker 1 (00:28):
We were just talking about, you know, what, what it was like being an elected position. I was on nominating committee for the private practice section. I just came off this year. Not nearly as much work as a board member. But my best advice was you'll you'll make great friendships and great relationships. And that's what you'll take forward aside from the fact that it's, you know, a little bit more work on top of the work you're already doing
Speaker 2 (00:57):
Well, I better get my bearings, right. So I will be on task from the one. Yeah.
Speaker 1 (01:04):
Yeah. I'm sure you will. And now, today, we're going to talk about how you as a business woman pivoted reacted to COVID. So we're, Monique's in Maryland, I'm in New York city. So for us East coasters, it really well, we know it hit New York city very hard in March in Maryland. When did that wave sort of hit you guys? Was it around the same time?
Speaker 2 (01:33):
I would say mid March, April because I had returned back to the rest of the first week of March. And then things just started going crazy. They were saying, Oh we have to be aware of COVID. But I was still seeing my clients that I had. Then we started getting calls saying that family members are worried that we'll be bringing COVID into the home. So they wanted to cancel visits. So we were getting a lot of constellations and then electric surgeries was shut down and that meant a huge drop in clients as well. Then we started seeing a spike in clients in mid April when the hospitals didn't want to discharge patients to the nursing homes, they were discharging them directly to home. So the majority of our clientele was COVID positive patients.
Speaker 1 (02:36):
And now as the therapist going in to see these patients, obviously you need proper protection. You need that PPE. So as we know, as all the headlines said, during the beginning of the pandemic, couldn't get PPE. So what do you do?
Speaker 2 (02:54):
Well, we were fortunate in Maryland that governor Hogan had PPE equipment ready at state health departments for agencies to collect. So they did ration them out. Also one of the agencies that I contract with MedStar hospital provided PPS to all the contractors and employees that were visiting COVID patients in the home. So we had the goggles face shield gowns mask, everything. There would be a specialized bag with vital sign equipment for that patient specifically that would be kept in that house and then taken back and disinfected at the end of the treatment. So we, we were shored through weekly conferences on what to do do South screenings and screening prior to each visit. So for my contractors, I developed a screening tool to ask questions if clients were having symptoms or if any family members in the home are having symptoms. And if they had exposure to anyone where COVID symptoms in the past 14 days, so we'll know what you will, that person as a person on, on the investigation or somebody who's COVID positive. So we had done the correct equipment when we go into the homes.
Speaker 1 (04:18):
And what does that, what does that look like? And what does that feel like for you as a therapist, knowing that you're going into a home with a patient who's COVID positive? I mean, I feel like that would make me very nervous and very anxious. So what was that like?
Speaker 2 (04:36):
To be quite honest, I was scared at first I try to avoid it as much as possible. But I got to a point where I needed to start seeing people or, you know, the business would go under. So you're nervous because nobody really knows how the disease will progress, what would happen. So it's a risk that you're taking. I, I probably developed compulsive disorder, making sure everything was like wiped down and clean. Even getting into the car, you know, this is affecting the stairway, the door handles double checking, making sure that they know the phone was wiped down. You know, as soon as you get in the house, after you strip washing from head to toe, making sure that, you know, you don't have anything that could possibly be brought onto the home.
Speaker 1 (05:35):
Right. And so when you say going back to that screening tool that you say you developed, what was, what was, what was, what did that entail for you for your contractors? Because I think this is something that a learning moment for other people, they can maybe copy your screening tool or get an idea of what they can do for their own businesses. Well, it's
Speaker 2 (05:58):
One that they we use to make sure that we don't have any symptoms. So checking the temperature every morning before you actually go to see a patient and asking the question, like certain questions, when, when you're scheduling a visit if they're filing in a coughing or sneezing when was the last time they got exposed or if they've been exposed to someone who traveled in the past 14 days or who's had any symptoms in the past 14 days. And so that was basically if they answered, no, then you be like, okay, fine. All you just need to do is wear the mask and the gloves and make sure that the patient that you're seeing wears the mask as well.
Speaker 1 (06:41):
Yeah. That's the big thing is making sure everybody's wearing a mask. Have you had any problems with people not wanting to wear a mask in their home when you go into treat them?
Speaker 2 (06:51):
We've had some, but most have been very compliant with, you know, wearing the mask because they realize that they, they, they do need the service. So like some patients who have like CHF or COPT that will have problems breathing while doing the exercises, I would allow them to, you know, take it off briefly, but I will step back six feet away and make sure that, you know, they get their respiration rate on the control. Then they put it back on. We'll do the exercise.
Speaker 1 (07:22):
Yeah. That makes sense. And are you taking, obviously taking vitals, pull socks and everything else temperature when you're going into the home?
Speaker 2 (07:31):
Yes. Yeah. Yeah.
Speaker 1 (07:34):
Okay. And I love the compulsive cleaning and wiping down of things. I'm still wiping down. If I go food shopping, I wipe everything down before I bring it into my home. And I realize it's crazy. That's crazy making, but I started doing it back in March and it seems to be working. So I continue to do it. And I'm the only one in my apartment, but I still wipe down all the handles.
Speaker 2 (08:02):
I would say don't lose sight of it though.
Speaker 1 (08:07):
I am. And I love that. You're like wiping down the car. I rented two car. I rented a car twice since COVID started. And I like almost used a can of Lysol one time. Like I liked out the whole thing and then I let it air out. And this is like in a garage going to pick it up for a rental place. And then I have like, those Sani wipes, like the real hospital disinfectants. And then I wiped everything down with those. And then I got in the car.
Speaker 2 (08:36):
Well, I saw it's very difficult to find Lysol here right now. So when you do find it, it's like finding gold. I know,
Speaker 1 (08:44):
I, I found Lysol wipes. They had Lysol wipes at Walgreens and I was like I said, Lysol wipes. And she was, yes. I was like, Oh my gosh. And then last week I found Clorox wipes, but in New York you can only get one. You can't there's no,
Speaker 2 (09:04):
Yeah. Care's the same thing. Toilet paper, whites, Lysol owning one per customer. So yeah,
Speaker 1 (09:09):
One per customer. Yeah, yeah, yeah. Oh, that's yeah, I was a thank God. I, I found one can of Lysol, one can at the supermarket and it was like, there is a light shining down on it and it was like glowing, glowing in the middle of the market. I'm like, Oh but I love, I love that all the screening tools that you're using and I think this is a great example for other people who might be going to P into people's homes who may be COVID positive. And I also think it's refreshing for you to say, yeah, I was nervous.
Speaker 2 (09:47):
I'm not going, gonna lie. You know, you still get nervous because you never know, like someone could be positive. And you're going in there, but you always want to be cautious because you're like, Oh my God, I hope I didn't like allow this to be touched or you forgot to wipe this and stuff too. So
Speaker 1 (10:07):
How much time are you spending in the home? Because there is that sort of time factor to it as well, exposure time. Right.
Speaker 2 (10:16):
It depends on the severity of the condition. But anywhere from like 30 minutes to like 45 minutes.
Speaker 1 (10:25):
Yeah, yeah, yeah. I know gone, gone are the days of, you know, spending that extra time and doing all this extra, extra work there, because if they're COVID positive, then I would assume that the longer you're in an exposed area, even though you're fully covered in PPE, I guess it raises your
Speaker 2 (10:48):
Well. Yeah. And, and the, in the summer, I would say, you know, depending on the amount of work that you had to do, like if you had to do like bed mobility and transfers with the patient, you'd be sweating under that gong. So you really want to want to be in there like a full hour anyway. But they were advising to spend, you know, minimum 30 minutes and to reduce the risk of you contracting it as well, too.
Speaker 1 (11:17):
Makes sense. So, all right.
Speaker 2 (11:20):
Decondition so they really can't tolerate a full hour.
Speaker 1 (11:23):
Right? Of course, of course. Yeah. That makes, that makes good sense. So now we've talked about obtaining the proper PPE. What other, what other pivots, I guess, is the best way to talk about it? Did you feel you had to do as the business owner? What things maybe, are you doing differently now than before?
Speaker 2 (11:49):
Well, as I said, I had to start seeing most of the cases to make sure that people were still being seen and like using telehealth. We started doing that. So eventually, well sky came on board to offer telehealth visits. So we were able to document telehealth visits as well. And people are responsive to those which worked out pretty well. So with some cases we'll do a one visit in the home and then do the follow-up visit telehealth. So one visit being in a home one weekend, one telehealth, if it was a twice a week patient. So that would also reduce the risk of exposure.
Speaker 1 (12:40):
Yeah. Yeah. Excellent. Now let's talk about keeping the business afloat, right? So yes, we're seeing patients. Yes. We're helping people, but we were also running a business. We got people to pay, we got people on payroll, you gotta pay yourself, you got to keep the business afloat to help all of these patients. So what was the most challenging part of this as from the eye of the business owner? Not the clinician.
Speaker 2 (13:07):
Well, you, you get fearful that you may not have enough patients to see, to cover previous expenses. So that was one of the reasons I did apply for the PPP loan. And as I mentioned to you before I was successful in acquiring that probably like around July and that, you know, cover like eight weeks of payroll, if that but it was strictly dedicated to payroll, nothing else. So everything else I had to do was to cover the bills and stuff, because that was just for payroll. Some of the agencies that we contracted for were having difficulty maintaining reimbursing. So that became a challenge as well, too. So what does that mean? Exactly. so when we contract with agencies, they're supposed to be paying us for this, the rehab services that we provide. Some of them were late with their payments as well, but I still had to pay my contractors on time.
Speaker 1 (14:19):
Got it. Okay. Got it. Oh, that's a pickle.
Speaker 2 (14:22):
Yeah, that's the thing. So that meant like sometimes some, you know, weeks of payroll, I would have to probably go over the lesson and making sure that the contractors were paid.
Speaker 1 (14:37):
And how about having a therapist? Furloughs? Did you have any of that? Did you know, were there any people, like maybe therapists in your area who were furloughed from their jobs and coming to you, like, Hey, do you have anything for me? Can you help? What was that situation?
Speaker 2 (14:54):
Yes. So I started getting free pretty among the calls about having to pick up to do work because they were followed or laid off. We currently have one contractor was working for ATI full-time that got followed. Now she's doing the home health full-time right now as a contractor we have some that are still doing it PRN, even though they went back to like their full-time jobs. But yes, we had people looking for cases to see, just to supplement the the income. Then we had a reverse situation where some people more comfortable getting the unemployment check than seeing patients at all. So, so that you had different scenarios, but it wasn't that we were in need of therapists during that time because people were willing to work.
Speaker 1 (16:00):
Yeah. Excellent. Excellent. And from the, I guess from your perspective being owner and clinician, so you're seeing patients you're running a business where there any sort of positive surprises that came out of this time for you, something that, that maybe made you think, Hmm. Maybe I'm going to do things a little differently moving forward?
Speaker 2 (16:30):
Yes. incorporating more telehealth visits. Definitely one of them and using the screening to there it helps in a lot of situations. So it makes you aware of what you might possibly be going into when you're going into the home. And I am realizing that there is one of the biggest things for therapeutic outcome is having a good relationship with your patients. So since most people aren't locked down, a lot of the patients that we do see they live by themselves, or they may just have one or two people in the home and they may possibly be working. So when going into the home, you're probably the only person that they're getting to talk to most days. So you, I saw the need to improve on soft skills and being approachable with your patients. So that was definitely a, a big thing for me.
Speaker 1 (17:46):
And how is that manifesting itself now? So now, you know, you figure we're what April, may, June, July, August, September, October, November, December eight, nine months in, so kind of having that realization of like, boy, this is this, I may be the only person this person speaks to today, all week, perhaps. I mean, that's can be a little, that can be a big responsibility. So how do you, how do you deal with that now that you're, you know, 10 months into this pandemic and yeah. How do, how do you feel about that now?
Speaker 2 (18:29):
Well, I still feel like some sort of contact needs to be maintained. So even though some patients may have been discharged they would contact the physician via a telehealth visit and asked to, you know, can you see it again? But you still maintain contact, make sure that, you know, you dropped a line and say, Hey, just following up to see if you're okay. That sort of stuff. So they, they will remember and they'll keep coming.
Speaker 1 (18:58):
Yeah, yeah, yeah. Oh yeah. It is such a responsibility, especially for those older patients who are, who are alone most of the time. I mean, it is it's, you know, we hear more and more about the mental health effects that COVID has had on a lot of people. So and I don't think that we're immune to those effects either. I mean, how, how do you deal with the stress of, because there's gotta be an underlying stress with all of this, right. So what do you do, how do you deal with that stress?
Speaker 2 (19:38):
Well, one was warmer. I would try to at least take the weekends off to go do something or those and like being around people where you can, you know, laugh and, you know, watch movies, you know, goof up, you know, I have to think about work, those things help.
Speaker 1 (19:59):
Yeah. Just finding those outlets that you can turn it off a little bit. And I love taking the weekends off every once in a while. I have to do that. I have to remember to do that. And I'm so jealous that you're just, you just came off of a nice little vacay as well.
Speaker 2 (20:19):
Well it was needed. I probably won't be taking one on till probably sometime next year, so yeah. But it was, it was definitely needed.
Speaker 1 (20:32):
Yeah. I think I'm going to, I think I'm going to do that too. All right. So anything else, any other advice that you may have for those working in home health when it comes to going to see those during these COVID times, whether the patient has, has had, has, or has had COVID what advice would you give to our fellow home health? Pts?
Speaker 2 (21:00):
Well, I know I've been hearing quite a lot of PT saying that they didn't want to treat COVID patients and they should not be subjected to treating COVID patients, but as we get more awareness of what the diseases and we take the necessary precautions, I think we will be okay. Cause everyone deserves to get quality care. And I know some people will say this person probably got COVID because they were being reckless and stuff. I mean, you can slip up, be as cautious as possible and still step up and get COVID. That doesn't mean you should be denying someone to receive that treatment just to make sure that you're protected when you do go in. Because we're gonna see a huge wave of COVID cases coming in the next few months and with elective surgeries being stopped and everything like that, that's going to be our only client population and to prevent the fools and the layoffs from happening again, I would just advise them, you know, do the screenings, make sure you get your PP and we'll see the patients. It's it's not as bad as, you know, they make it seem.
Speaker 1 (22:16):
Yeah. Excellent advice. Excellent advice. And now we're going to really switch gears here. Okay. So this is going to be like like a, a three 60 turnaround, but before we went, before we went on the air, Monique and I were talking about just some things that, that you wanted to talk about and recent happenings in the PT world, and you brought up sort of a list of influential PTs that was compiled by our lovely friend Ellie summers. So go ahead and talk to me about why that list was meaningful to you and why you kind of wanted to talk about it.
Speaker 2 (23:03):
Well, you know, for the past few years I've been noticing like people send us stuff to vote for like top influencers and, and physical therapy and stuff. Do you tend to see the same names like yesteryear? But you've never seen one that just strictly focuses on a woman in physical therapy. And I see a lot of women doing great things in the physical therapy world, but because they do not have as many followers on like Twitter or Instagram, they don't get the recognition that they deserve. For example, Dr. Lisa van who's I think she's doing incredible, incredible work with the Ujima Institute. I actually consider her a mentor of mine. She, she calms me down when I try to get fired. What's it and stuff,
Speaker 1 (24:03):
Not you. I don't believe it.
Speaker 2 (24:06):
So I appreciate her for that. So for Ellie to actually construct this list and, you know, I've, I've been observing her, her tweets on her posts for a while, and I see that she questions. Why is it that, you know, women do not get the recognition in a profession that is supposed to be female dominated. So for her to do the side, you know, it was, it was really thoughtful and needed.
Speaker 1 (24:40):
Yeah. Yeah. And you know, her shirt talk that she gave at the women in PT summit couple of years ago, I think it was the second year we did, it was so powerful. Like everybody was crying like in tears, she's crying, everyone else is crying. And that was the year Sharon Dunn was our keynote speaker. She got everybody crying. It was like everybody was crying the whole time, but crying in like in, in not, not in a sad way, but crying in a way because the stories were so powerful and really hit home and we just wanted to lift her up and support her. But yeah, and you know, the thing that I love the most about Ellie's list is she put herself on it. Yes. How many times have you made a list and put yourself on it? I can answer me. Never, never, never in a million years, have I made a list of like influential people to put myself on it? Never know. So I saw that and I was like, good for you. Good for you.
Speaker 2 (25:44):
Because you know, sometimes you, you and, and doing and doing stuff, you, you have to be kind to yourself first, love yourself first. And, and her doing that, I, I believe she's demonstrating that that is something that's that needs to be done. A lot of us, we don't give ourselves enough praise for the stuff that we do.
Speaker 1 (26:05):
Absolutely. Absolutely. It's sort of, it's a nice lead by example moment from her. So I really appreciated that list and, and yes, Dr. Vanhoose is like a queen. She's amazing. And every time, every time I hear her speak or, or I get the chance to talk with her through the Ujima Institute to me, it's amazing how someone can have the calm that she has and the power she has at the same time. Right. I mean, I don't have that. I don't, I even know how to do that, but she just, like, she's just gets it, you know? I don't know if that's a gift. It's a gift. Yeah, totally, totally. Okay. So as we wrap things up here, I'm going to ask you the one question that I ask everyone, and that is knowing where you are now in your life and in your career. What advice would you give to your younger self you're? You're that wide-eyed fresh face PT, just out of PT school.
Speaker 2 (27:16):
You can't save everybody. You can't save everybody nice. When you, when you just graduate as a therapist, you think you can save everyone a change, a wall. It takes time.
Speaker 1 (27:33):
Yeah. Oh, excellent answer. I don't think I've heard that one yet, but I think, I think it's true that having, and it's not, that's not a defeatist. That's not a defeatist thinking at all. Yeah.
Speaker 2 (27:54):
I think this year have thing come to more deaths as a therapist with patients than I have probably in the 12 years that I've been practicing. I'm sorry. Yeah, because you know, you do patients that you get attached to, you know, you have this person passed away and stuff like that. So it's good while it lasts, but to protect yourself mentally and emotionally, you just realize that you can save everybody. Yeah. I think this fund DEMEC is teaching us that too.
Speaker 1 (28:35):
Yeah. A hundred percent. Thank you for that. And now money, where can people find you website? Social media handles
Speaker 2 (28:47):
Social media handles are the same on Twitter and Instagram at physio for U F Y, Z I O. Number for you Facebook slash physio for you as well. And www physio for you.org is the website
Speaker 1 (29:01):
Awesome. Very easy. And just so everyone knows, I'll have links to all of those in the show notes under this episode at podcast dot healthy, wealthy, smart.com. So if you want to learn more about Monique, about her business I suggest you follow her on Instagram and Twitter, cause there's always great conversations and posts going on there initiated by Monique on anything from home health to DEI, to words of wisdom. So definitely give her a follow. So Monique, thank you so much for coming on. Let's see. Last time was a really long time. I can't believe it, it seems like 10 years ago, but I think it was really like three, three years ago. I think it was DSM like three years ago though. It seems like forever ago. So thank you for coming on again. I really appreciate it.
Speaker 2 (29:56):
You're welcome. And thank you for having me. Okay. Absolutely. And everyone needs to be safe. Okay. Yeah.
Speaker 1 (30:01):
Yes, you too. And everyone else, thank you so much for listening. Have a great couple of days and stay healthy, wealthy and smart.
On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Dr. Shannon Leggett, PT, DPT to talk about how to infuse yoga principles into physical therapy practice. Dr. Legget is a manually-based orthopedic physical therapist with 21 years of experience. I understand the complex nature of pain and the necessity to use a comprehensive, individualized treatment approach.
In this episode, we discuss:
More About Dr. Leggett:
I am a manually-based orthopedic physical therapist with 21 years of experience. I understand the complex nature of pain and the necessity to use a comprehensive, individualized treatment approach. I perform a thorough evaluation looking at movement, strength, flexibility and balance, as well as lifestyle. I believe that how we live influences our ability to heal. I combine my extensive background of treating musculoskeletal injuries with my training in mind-body techniques to formulate a holistic plan of care
Subscribe to Healthy, Wealthy & Smart:
Apple Podcasts: https://podcasts.apple.com/us/podcast/healthy-wealthy-smart/id532717264
iHeart Radio: https://www.iheart.com/podcast/263-healthy-wealthy-smart-27628927
Read the full transcript here:
Speaker 1 (00:07):
Welcome to the healthy, wealthy, and smart podcast. Each week we interview the best and brightest in physical therapy, wellness, and entrepreneurship. We give you cutting edge information. You need to live your best life. Healthy, wealthy, and smart. The information in this podcast is for entertainment purposes only and should not be used as personalized medical advice. And now here's your host, Dr. Karen Litzy. Hey everybody. Welcome back to the podcast. I am your host parents in today's episode is brought to you by
Speaker 2 (00:41):
Net health. So net health now has net health therapy for private practice. This is a cloud-based all-in-one EMR solution for managing your practice. It handles scheduling documentation, billing, reporting needs. Plus lots more in one super easy to use package. And right now net health is offering a special deal for healthy, wealthy, and smart listeners. If you complete a demo with the net health team, you'll get a hundred dollars towards lunch for your staff. Visit net health.com/see to get started, and you'll also get access to free resources for PTs like eBooks on demand, webinars, and business tools. Once again, that's net health.com/l I T Z Y my last name now onto today's episode, we are going to be talking about how you can infuse yoga into your orthopedic physical therapy practice. And this is more than just infusing some yoga moves, but really infusing the background and philosophy of yoga into your physical therapy practice and to help us navigate that I'm really happy to have on the program, Dr.
Speaker 2 (01:53):
Shannon Leggett, she is an orthopedic, a manual physical therapy with 20 years of experience. She understands the complex nature of pain and the necessity to use a comprehensive individualized treatment approach. She performs thorough evaluations, looking at movements, strength, flexibility, and balance, as well as lifestyle. Shannon believes that how we live influences our ability to heal. So she has been able to successfully combine her extensive background of treating musculoskeletal injuries with their training and mind body techniques to formulate a holistic plan of care. And in this episode, we talk about just that, how to infuse yoga into your regular physical therapy treatments. And like I said, it goes beyond just some yoga poses and stretches, but really infusing the background and the philosophy of yoga in with your patient in with your patient treatments, but also with infusing your whole philosophy of physical therapy and how you work with your patients. So a big thanks to Shannon and everyone
Speaker 3 (03:00):
Enjoyed today's episode. Hey, Shannon, welcome to the podcast. I'm happy to have you on. Thanks, Ken. I'm really happy to be here. So today we're going to talk about how you have been able to infuse yoga and not just yoga the movements, but yoga, the principles into your physical therapy practice. And just for the listeners, I actually took one of Shannon's yoga classes online and it was wonderful. So thank you for having me joining. Yeah, it was great. So before we get into how you do this within your orthopedic physical therapy practice, I would love for you to let the listeners know how you yourself came into the practice of yoga. Well, it's actually kind of a funny story. I was probably in my mid thirties, which I'm not going to tell you how long ago that was. I'm not dating myself here, but I ended a relationship and I think as so many women do, it's like you either cut or dye your hair or you try something new. Okay.
Speaker 3 (04:06):
So trying to rock the pixie cut back then, like, I couldn't do anything with my hair. So I, I walked into my first yoga class of the New York health and racquet club on first Avenue on the upper East side. I know it, and there I was. And now that I know yoga, it was an Iyengar class, which is very alignment based very slow, very methodical holding poses. And I remember waking up the next day and being so incredibly sore and like a muscles. I mean, basically I should know what the muscles are, but like, Oh my God, that's what those feel like when you use them for long periods of time and the physical practice that, that sensation, that feeling kind of kept me going back for more. And then as time went on, I started to recognize the mental aspects of the practice that whatever I was walking into the yoga studio with or holding onto was kind of magically disappeared at the end of the class.
Speaker 3 (05:13):
And I am an anxiety sufferer, which I only have come to understand and realize what that was. And till like in a, within the last 10 years and yoga then became a very strong coping strategy for me. I found being connected to my body and connected to my person and putting an hour of self-care aside for me was absolutely essential. So it's definitely become one of my go-to tools to kind of handle the day in and day out stress of living, working in, in New York city. So I would think, especially now, during the times, yeah, hands down now it is. And I, and I was home for a couple of months, like everybody else. And it was, I was on my mat every single day. And then decided while I was home, I was like, well, why not see who else wants to practice?
Speaker 3 (06:14):
But yeah, so I, it has always been in the last like 12, 15 years, very much part of my life on a personal standpoint, it has led me to travel. I've met great people, I've taken amazing classes and explored studios in different forms. But it wasn't until probably within the last five or six years that I started to connect some dots professionally, right? Like how, how could this fit into what I do professionally? I, in terms of like a stretching standpoint, a strength building standpoint, yoga is amazing, but what about the body, the mind body connection. And I started to notice trends with a lot of my female patients I've been treating in Midtown for most of my career. And women would be walking into the clinic with your like standard orthopedic injuries, shoulder impingement, low back pain, and their response to an injury that would not necessarily be anything like, okay, just the pain was off the charts and difficult to get under control and not necessarily responding to what you would consider standard practice and you start to talk to them and they have fertility.
Speaker 3 (07:38):
They've had fertility issues. They've had gastrointestinal issues. They're working full time. They are full time moms too, trying to be the best they can be in both realms and self-care is last. They don't sleep well, they don't eat well. And I realized that the stress component was driving their inability to heal or meaning their ability to, you know, kind of get back to what they enjoyed. And I just was said to myself, well, how can I as a clinician kind of break into that stress cycle, how can I maybe help them Crump, you know, calm down some of their chronic systemic inflammation, how can we help them with negative thought patterns and, and whatnot. And that's not something that we traditionally are taught in physical therapy school and it, and is it my scope of practice and kind of going back and forth.
Speaker 3 (08:38):
So I started taking some continuing ed classes in the yoga world, and I've done some work with a clinical psychologist in Boston who treats her anxiety and depression patients with, with yoga and bodywork techniques. And, and she's a ton of research as to how mindfulness begins in the body that studies have shown that, that kind of short circuits, that stress response in your brain. So that kind of led me in that direction. And then I walked into my restorative yoga training, which I had never really taken, but it intrigued me. And because I just kind of felt intuitively that it was going to be the, like the last, not the last piece, because there's never a last piece, but a piece of the puzzle that I was missing. And it basically is how we can go from our sympathetic or fight or flight part of our nervous system into our rest and digest our parasympathetic sympathetic nervous system and how much our nervous system can drive, how we feel.
Speaker 3 (09:41):
And so often we have patients with chronic neck pain, chronic low back pain, like the massage, they feel better for an hour. It comes back and just this idea of chronic tension versus chronic tightness. And what restorative training does is it brings you into yoga shapes, but they're basically supported with props and it's a guided meditation and breath work. And as you move through the shape or state in the shape, you can flip the switch that vagus nerve stimulator, vagus nerve, and move into that rest and digest part of the nervous system. And I mean, in theory, like, okay, great. But four days of training and I always have neck pain, always. And I just attributed to everything we do. And that role was that from holidays and, you know, that's stressful time, but the month of December, yeah. Within four days, my neck pain was gone.
Speaker 3 (10:52):
It was incredible to me, how much of that pain was actually chronic tension and not necessarily this orthopedic tightness. So it was a kind of an aha moment for me in terms of what patients might carry. And I have used the teaching, the methodology in my treatment sessions, patients don't necessarily understand clients don't necessarily understand that they hold habitual tension. And so much of us, like when we say like, Oh, we have to relax. Like we sit down on the couch and drink a glass of wine and, you know, watch eight hours of Netflix. We're like, we're totally just chilling. But yet, like are holding our belly. Like our shoulders are up here, like clenching our jaw. Like we don't even know because we're relaxing. And part of, part of the restorative yoga is understanding where those patterns are. You get to know your body. Like for me, I'm a draw puncher, I'm a shoulder up late year. And, and, and once you understand that you kinda like kinda, I do like some check-ins during the day, like where are my shoulders? Where's my jaw. And taking a deep breath and kind of like letting that go.
Speaker 4 (12:11):
Yeah. As, as you say, this I'm unclenching my jaw a little bit. I'm a jock ledger also. So as you say this, I'm like, relax, the jaw, drop the shoulders. I am the same way. Well, it's, it's pretty amazing because it sounds like for you, and this happens, I've heard this over and over again, that it's this sort of personal experience. You have that aha moment. And then you say to yourself, well, I'm a clinician I'm trying to help people. So what can I do to improve my understanding as a clinician to help my patients? So you go, you take restorative yoga training, and then you are able to infuse that into your therapy sessions. And we were joking a bit before we went on the air. And Shannon said, well, it's not like I'm having someone who just had a labral tear, do a shoulder stand. Like that's not what it means to do, like yoga and PT. So when people think of yoga and infusing yoga into PT, I bet a lot of people think, Oh, you must do a lot of downward dogs and a lot of shoulder stands, but can you explain for a little bit more about what, what that means in, in your PT practice?
Speaker 3 (13:26):
Absolutely. I, if somebody comes in at, like, I was thinking a case, a case study, let's do I have a frozen shoulder? And how much of that again, tension versus tightness, how much of that tightness is being driven by the nervous system? So I'm, I always ask about stress levels. What's going on at home at work. You know, things that people do to, to, to maybe calm down or relax. And I might say, Hey, we're going to have a little bit of an experiment today. Okay. I am gonna prop you. We, I pull off of the blankets and the pillows and I'll put them in a very gentle chest opener because oftentimes you're doing a ton of stretching with a frozen shoulder or a lot of soft tissue work. If there's a level or component to stress or anxiety to that, that cranking is just going to cause your, your nervous system just clamp down and, and, and they're going to, you're going to get the exact opposite of it.
Speaker 4 (14:32):
Yeah, absolutely. And even like, we know if you're cranking on an arm and the, those first three to six months. No good, no good, no good. Not, not good for the patient, not good for the shoulder,
Speaker 3 (14:46):
Not at all. So I might spend a couple of sessions with a patient props, kind of guiding their nervous system into letting go. Typically the, you know, shoulders are rounded, pecks are tight, upper traps. So if I can kind of guide them into relaxing, letting go, I typically find a little bit more space. They're a little more trusting of me to like, maybe move them. Maybe I can modulate their pain a little bit. So they will be a little bit more, or a little less fearful of movement themselves because it's a big deal I'm to us are in pain and they don't want to move. They don't want to go in any direction that that is going to maybe reproduce their symptoms.
Speaker 4 (15:35):
Of course. Yeah. And, and so much goes into that sort of bucket when you're talking about pain. So there's so much that can fill that up. You know, we look at things through a bio-psycho-social lens, you know, you're asking about sleep and stress and all that goes into this, this sort of bucket. And then it gets to the point where the nervous system senses danger. And it's like, okay, that's it. We're gonna it's time. You know, the brain makes that decision. It's dangerous enough pain, right? Yep.
Speaker 3 (16:06):
We're going to fight, we're going to flight or we're going to freeze and think about a frozen shoulder, how much of that could be nervous system driven. And you know, and also too, just bringing in some of the mindfulness component of yoga, you know, the yoga sutras, which are kind of like the blueprint of yoga, the philosophy of yoga, the first Sutra is yoga is now that is, I mean, that is mindfulness. That is in the moment. That is the definition right there. So I use that idea of mindfulness or the tool of mindfulness to bring in throughout the day. Like I mentioned earlier, like doing a little check-in with yourself, oftentimes with my patients, I'll say, you know what, in the midst of your day, when you're like, Oh my God, if one more person calls me or how am I going to get these emails done?
Speaker 3 (16:54):
Or like, I have to make the train to get home to the kids. No, one's competing now. I want you to tap in or tune into your body and come back and tell me where you hold your attention. I want to know, are your shoulders up? And your ears are your jaw clincher. So often, do you hold your belly in? You think about our patients with urinary stress incontinence with low back pain. You know, I mean, if you're clenching your belly all day, that's, that is going to be, maybe unclenching will be part of the solution. So that idea of being present of checking in that is a tool I use throughout the day with my patients. That's great. And you know, with so many we're so externally focused, everything is outside. We're always 10 steps ahead. We just become very disconnected with our physical being. And I love bringing patients back into their body to teach them something that they didn't even know. You know? And I, I love when people are like, Oh my, my quadriceps. And they're like holding their hamstrings. Like we have this tool that we've been given this machine that we've been given, but nobody really educates us on how to use it or what it's about or how it moves. And I love bringing that idea of mindfulness and mindful movement into the physical therapy practice. Yeah,
Speaker 4 (18:17):
I think it's great. And the other thing, as you were talking about putting people into these different restorative poses that can then be transferred over to a home exercise program,
Speaker 3 (18:27):
Easy. I mean, honestly, like laying down on the floor, throwing your feet over the couch, the restorative doesn't even have to have props. It's basically the idea. Now don't get me wrong. The props are delicious, but the restorative is learning how to let go of that tension. As you breathe, it's letting the ground hold you up. It's letting the couch hold you up. It's letting, it's starting to kind of give into something else. You know, how much of us, like we put a coat of armor on every day, like, especially now to get through the day. And so in order to survive, we, we put on armor. Yeah. It's just in a physical structure. Yeah, yeah, absolutely. On the floor, legs on the couch, close your eyes and just breathe. And honestly, that's yoga.
Speaker 4 (19:21):
It doesn't have to be too complicated,
Speaker 3 (19:23):
Not at all. And sometimes when I start to bring things up, people like, Oh my God. Cause they think Instagram, they think poses, they think exactly very like thin, cute people, like by a pool. And it's just, it's mindfulness. It's the breath it's awareness. It doesn't have to be, it doesn't have to be twisty and credit. And I think, I think my practice is in twisting.
Speaker 4 (19:48):
Yeah. I think that's good to know, because I think a lot of people will look at yoga and they look at the show of it. You know what I mean? The spectacle, the show of, wow. Look at this person being able to, you know, do a handstand or a headstand and look at this and look at the positions. They can go, Oh, I can never do that. So
Speaker 3 (20:06):
I'm just not going to do it exactly like that. It's not for me. Or people feel ashamed and mean, especially like the, the men, they will not walk into a class because they don't want their I'd be embarrassed. And like, no one is looking at you. No one. And that's the thing I love about a studio. Like I'm an orthopedic physical therapist. I have, I'm not athletic. I love athleticism. I am not athletic. So when I love about the studio is like, I can move. I can breathe. I can exercise. No one's watching. Yeah. It's true. It's like in their own little world and that's speaks to the introvert in me like nobody's business.
Speaker 4 (20:49):
Yeah. Although sometimes I will say, if I go to a class, I will be looking at other people that being said one of the best yoga classes I ever did, we were blindfolded. All of that's extraordinary because it was a, it was a charity class for a charity called Achilles and Achilles supplies. Pairs runners who are hard of sight. Yeah. To do all different kinds of races from a 5k up to a marathon. And because the people they serve are usually blind. We did the whole class folded and I was thinking, Oh my God, I'm going to fall over because you know, vision is a big part of balance, but it was the best yoga class I'd ever taken because I wasn't comparing myself to everyone else. The instructor was giving really clear instructions and my balance was better because I was actually paying attention to myself versus looking at what everybody else was doing.
Speaker 4 (21:46):
Absolutely. And you really had to talk about a journey inward. Yeah. Right. And having to be in touch with like what your own body was doing and how you're going to assimilate. Yeah. Yeah. It was really interesting. The only weird part was the woman next to me, kept trying to hold my hand and I had to keep like, I'm like, what are you doing? And then after it, she was like, Oh, I'm sorry. I thought you were my friend. I'm like, I kind of kept taking me out of the vibe a little bit, but that is a loving community. Community is a loving community. Yes. But I really, I really loved the way I felt after that. And it, it, you know, it really got me thinking like, wow, this is something that I should be doing with my patients when we're just working on general movement is kind of have them close their eyes and really feel the movement and get into it. But now let's you, so you talked about some of the the tenants of yoga. One is yoga is now being very mindful. What other aspects of yoga aside from, you know, positioning people, restorative, what other tenants of yoga are you using with your clients or with your patients?
Speaker 2 (22:59):
And on that note, we're going to take a quick break to hear from our sponsor. And we'll be right back with Shannon's answer net health therapy for private practice as a cloud-based all in one EMR solution for managing your practice. That's right. One piece of software that handles all of your scheduling documentation, billing and reporting needs. Plus lots more and one super easy to use package right now, net health is offering a special deal for healthy, wealthy, and smart listeners completed demo with the net health team and get a hundred dollars towards lunch for your staff. Visit net health.com/see, to get started and get access to free resources for PTs like eBooks on demand, webinars, and business tools. Once again, that's net health.com/l I T Z Y
Speaker 3 (23:49):
I definitely, yes, I use the restorative, but I also use a little bit more of the, the poses, the strength building poses, the even some small sequences. I, I look at maybe look at the system as a whole, right? The fascial system, everything is connected especially my patients that sit all day. So that front body, everything is tight. Tip lecturers, chest front neck. I will give them maybe sequences of some easy poses that they can do at home to open that whole space. My runners runners don't like to stretch. They just want to run. So I always say, okay, we need to do some flexibility. And some mobility work to keep you running healthy. There's nothing better than yoga as far as I'm concerned. Thank for the buck. Especially looking through like fascial systems, you give someone a downward facing dog.
Speaker 3 (24:54):
Well, they're opening their shoulders, calves, hamstrings, low back. They're working on their core. So I love, I love the physical poses to help my runners, my sequences, my restorative, my breath work. How could I forget my breath work pranayama? Right? What's one of the eight limb path of yoga is breath work. And I pretty much teach every single patient who walks into my space to breathe. It is one of the most powerful tools that we have to connect to ourselves to calm our nervous system. But again, our low back pain patients, our neck pain patients, how many neck pain patients do we see that are breathing they're with their accessory muscles. So using maybe even to dossena another pose mountain pose, which is basically standing straight it's posture. So everybody learns to Dawson. And then from 2000, and once we get into that, that rib cage of pelvis alignment, we work on our breath and diaphragmatic breath, finding the belly, maybe then connecting to pelvic floor, especially for my women.
Speaker 3 (26:15):
So I definitely use Tadasana as my, like one point as to finding, finding a good position, finding a good home base and breath and how they can use breath work to help them with their stress response. And part of what I love is sometimes I'll teach my core patients and I don't even tell them what the breathing like. I'll tell them, listen, you know, reading is important for core, and it might with your neck pain and low back pain. So we're just, that's what we're going to start. And what I love is when a couple of visits later, they're like, you know, we feel really calm. I feel calm after I do that. And I'm starting, and I'm starting to use that like during the day. And I secretly love that
Speaker 4 (27:02):
Really giving tools that they can use throughout the day and that they can also see the difference. And we know that once people see the difference in the tools, we give them, they'll use them.
Speaker 3 (27:13):
Yes. And that's how I listen. Some people I know right off the bat that I can like infuse and introduce yoga and they're going to be all for it. Other people I know that are going to be skeptical. So that's,
Speaker 4 (27:25):
That's a good point. You bring up because a lot of people like yoga. So how do you, and so do you use then use the breath work to kind of open the Gates a little bit
Speaker 3 (27:34):
Sometimes, or I'll say, Hey, you know, the yoga has some amazing, you know, stretches that might help you with what's going on. And because they stretch multiple fascial systems, they can be very effective or, you know, not effective, but efficient everybody in the city wants to be efficient. True. So if you give them a couple of things and then they become more curious or I'll work on some mindfulness, or I will educate them, maybe how stress response can be driving their pain how having a hobby or movement can like also be an effective part of their healing process. So I, I kind of sneak it in, in, in different ways. Got it, got it. No, that makes a lot of sense. And also too, for like my, my runners, I have run a bunch of half-marathons. I did in New York city marathon in 2018, yoga is a tremendous compliment to running and read, like, it got me to the finish line. I don't think I'll ever do it again, but you never know. I've never say never, never say, never say never. So that's where, you know, anytime you tell a runner that you could help them be better, faster, stronger of they're onboard. Yeah. Very, very true.
Speaker 4 (29:04):
Now, what advice would you have to other physical therapists or other clinicians
Speaker 3 (29:10):
Speaker 4 (29:11):
Are interested in yoga or interested in infusing yoga into their practice? What are some good starting points
Speaker 3 (29:20):
For them? I would say, start taking some classes, yourself, understand how it makes you feel, understand the language, the sequencing the poses, you know, I, I think experience is one of the teachers. I learned by doing things in my own body and that makes me a much more effective clinician sometimes. So I would say, start taking some classes, notice the benefit yourself, listen to maybe even how yoga teachers instruct. I learned some of the best cues and best instruction from some of the yoga teachers that I have gone and work with. And starting to maybe infuse it a little bit in your sessions, in your, in your PT sessions and see how the patients respond. And then from there, there are continuing ed classes out there for physical therapists who don't necessarily want to take the 200 hour training that can learn how to use yoga in healthcare.
Speaker 3 (30:30):
Yeah. I took a, a great one threes, physio, yoga they are amazing. They're, they're great to follow on Instagram, if you want to learn a little bit more. I have, but they have they just did a class that I took, do I want to, no, it was maybe last year again, it's the whole thing of how to infuse yoga and physical therapy. So there there's plenty of stuff out there. There's plenty of PTs out there that are, that are doing this, that have Instagram pages. So just starting to follow, take classes easy. That's what I would do. It is so easy. It's easy. Yeah. I mean, I didn't do my yoga training until, you know, 2016, but I was using the poses and using some tenets like long, long before I was just from my own experience.
Speaker 4 (31:22):
Yeah. No, I love the advice to kind of take it yourself, see how you see how it feels. Cause listen, you may think you want to infuse it into your treatment and then you may take it yourself and be like, Oh, I don't, I'm not feeling this. And that's okay. You can, you can.
Speaker 3 (31:37):
Okay. Absolutely. It doesn't resonate with everybody.
Speaker 4 (31:40):
That's right. That's right. That's right. And that's okay. Awesome. So now before we kind of wrap things up, I think we, we have your one biggest takeaway is to start taking yoga classes yourself. Anything else that you want the listeners to walk away from this conversation?
Speaker 3 (32:03):
There are many modalities out there to help the healing process. And there are many practitioners that have different ideas to help you get there. And I think that I encourage people to find what works for them. And that sometimes some of the less traditional practices can be extraordinarily helpful. I mean, I think I personally think yoga is an extraordinarily powerful tool from the mind body perspective, we understand how much chronic pain does become a central nervous system, you know, issue that it's not just all biomechanical. So we do have to treat the whole person. We have to treat mind as well as body. And I think that yoga can be a very powerful tool, the combination and to, to, to seek and to try and to find what resonates and find what helps you. And to just, you know, it's not ever linear, it's not ever a straight trajectory. Healing is totally a journey and to not give up and just because you've tried one thing, does it mean nothing? Nothing is going to work, update, curious, stay active stay moving, find something you love to do. It doesn't have to be yoga, but move and movement is meditative. It's mindful. You know, the body, the body responds to movement.
Speaker 4 (33:53):
Absolutely. And now before we wrap things up, this is a question I ask everyone knowing where you are now in your life and in your career, what advice would you give to your younger self who graduated right out of PT school, a newly minted PT.
Speaker 3 (34:11):
I wish I had forged my own path earlier. I wish that I had listened to, you know, nothing has ever really fit for me until I brought yoga into my profession. It speaks to me. It makes sense to me. I wish I had, you know, when we did the webinar with sturdy, like let your freak flag fly, you know, be like, don't be like everybody else. I wish I had listened to that earlier, like towards my own path to not try to not try to fit myself into someone else's business model. Yeah. It's okay to want something different. It's okay. To think outside the box. It's okay.
Speaker 4 (35:01):
Speaker 3 (35:02):
You know, what, what you think at first is going to work doesn't and then you find another tool. Totally have a huge toolbox. Yeah.
Speaker 4 (35:12):
Oh, I know. That was such good advice, you know? Cause I think so often, especially in physical therapy, as we discussed during that webinar, it's like physical therapists tend to be type a, we want to, you know, we want to be the best we wanted. We want to do good. We want to help others. And so we tend to kind of just stay in the lane totally. And are afraid to like, let the freak flag fly if you want is very hard to say, but it's true. It's true. And I thank you for reminding me and reminding the listeners of that now, where can people find you? Yes. Be true to yourself and where can people find you speaking? You can find me on LinkedIn and Instagram and what's your handle on Instagram? That's funny. That is, that is my nickname. My family, my nieces call me Shanny.
Speaker 4 (36:03):
S H a N N Y O G a P T and my C O very long. Very cute. I get it. I get it. Shen yoga, PTM, YC. Perfect. Perfect. Awesome. So people can find you there and we will have links to all of what Shannon spoke about today, resources and things like that. We'll put them all into the show notes at podcast on healthy, wealthy, smart.com. So one click will take you to everything we discussed today. So Shannon, thank you so much for coming on and talking about how to use yoga in your physical therapy practice. So thank you. Oh, thank you, Karen. It was a pleasure. I love, I love, I got to share the best of like my favorite part of the world. Awesome. Thank you so much. And everyone who's out there listening. Thanks so much for listening. Have a great couple of days and stay healthy, wealthy and smart.
Speaker 2 (37:01):
Big thank you to Shannon for sharing how she incorporates her passion, which is yoga into her physical therapy practice. And of course thank you to net health for sponsoring today's episode net health therapy for private practice is a cloud-based all-in-one EMR solution for managing your practice. One piece of software that handles all of your scheduling documentation, billing and reporting needs. Plus lots more in one super easy to use package net health is offering a special deal for healthy, wealthy, and smart listeners completed demo with the net health team and get a hundred dollars towards lunch for your staff. Visit net health.com/ let's see to get started and get access to free resources for PTs like eBooks on demand, webinars, and business tools. Once again, that's net health.com/l I T Z Y.
Speaker 1 (37:53):
Thank you for listening and please subscribe to the podcast at podcast dot healthy, wealthy, smart.com. And don't forget to follow us on social media.
On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Dr. Joe, Tatta, PT, DPT to talk about using acceptance and mindfulness-based interventions to build resilience and overcome chronic pain. Dr. Joe Tatta is a global leader in integrative pain care and an advocate for the safe and effective treatment of chronic pain. He is the Founder of the Integrative Pain Science Institute, a cutting-edge health company reinventing pain care through evidence-based treatment, research, and professional development.
In this episode, we discuss:
1. Psychological variables associated with chronic pain
2. What is Acceptance and Commitment Therapy (ACT)
3. How is ACT different from traditional cognitive behavioral approaches and pain education?
4. How is ACT different from mindfulness, like the kind we encounter in popular culture?
5. How does ACT help physical therapists’ function better and prevent professional burnout?
6. Dr. Tatta's latest book “Radical Relief: A Guide to Overcome Chronic Pain
ACT for Chronic Pain Professional Training Course:
Mindfulness-Based Pain Relief Practitioner Certification
RELIEF: and online mindfulness community for pain care.
A big thank you to Net Health for sponsoring this episode! Learn more about the Redoc Patient Portal here.
More about Dr. Joe Tatta:
Dr. Joe Tatta is a global leader in integrative pain care and an advocate for the safe and effective treatment of chronic pain. He is the Founder of the Integrative Pain Science Institute, a cutting-edge health company reinventing pain care through evidence-based treatment, research, and professional development. For 25 years he has supported people living with pain and helped practitioners deliver more effective pain management. His research and career achievements include scalable practice models centered on lifestyle medicine, health behavior change, and digital therapeutics. He is a Doctor of Physical Therapy, a Board-Certified Nutrition Specialist, and Acceptance and Commitment Therapy trainer. Dr. Tatta is the author of two bestselling books Radical Relief: A Guide to Overcome Chronic Pain and Heal Your Pain Now: The Revolutionary Program to Reset Your Brain and Body for a Pain-Free Life and host of weekly Healing Pain Podcast. Learn more by visiting www.integrativepainscienceinstitute.com.
Subscribe to Healthy, Wealthy & Smart:
Apple Podcasts: https://podcasts.apple.com/us/podcast/healthy-wealthy-smart/id532717264
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Read the full transcript here:
Speaker 1 (00:00:01):
Hey, Joe. Welcome back to the podcast. I'm happy to have you on again.
Speaker 2 (00:00:06):
Hi Karen. Thanks for inviting me. I'm excited to be here.
Speaker 1 (00:00:08):
Yes. And today we're going to be tough. Well, let's not let's, let's roll it back for a second. So it seems like each time you've come on, we've talked about some different aspects of pain, right? We're both in that chronic pain world, we love treating people with chronic pain and talking about chronic pain or persistent pain. And we've done that quite a bit. We've talked about the psychological variables associated with persistent pain and how psychologically informed physical therapy is so important. So let's talk about which variables we should be most concerned about with regard to effectively treating pain, big question right out of the gate.
Speaker 2 (00:00:52):
It is, and it's a, it's a great place to start. And that's a question that all of us are asking ourselves and researchers are asking this question more and more and we're trying to figure out, okay, what is like the key variable? Is there one key variable that we should be paying attention to? And it's interesting if you look at the evolution of chronic pain and I think both you and I have been practicing for about 25 years. So we've really have seen things transitioned from this biomedical biomechanical model, right? And the core of that was let me figure out, let's try and figure out or identify what's wrong with the physical body. Right. Pretty easy.
Speaker 1 (00:01:34):
And then the pain goes away.
Speaker 2 (00:01:36):
Exactly. And we were all there at one point, then this bio-psycho-social model comes in and we're like, okay, there was there a psychological variables that we should pay attention to. And what's interesting is when I talked to physical therapists about the psychological variables, they bring in a little bit of that older biomedical model in the sense of how can I identify what's wrong. And then if I know what's wrong, then I can fix it. And it makes sense. And that even shows up in some of our mental health colleagues as well when they approach people with pain. So when we look at, you know, there's kind of like five big ones pink catastrophizing, can you see your phobia, fear, avoidance, depression, anxiety, those five persistently show up in the literature as variables that are associated with poor outcomes with regards to chronic pain. So you see them all the time and we have ways we can test for it, right? Pain, catastrophizing scale Tampa kinesiophobia scale, et cetera, et cetera, evolve are well aware of these. And we all use them. What I want people to consider for a moment is these are all what we would call vulnerability processes. So this is what makes someone vulnerable to transitioning, let's say from acute pain to chronic pain and they may be important and they are important, but I would like people to consider for a minute. If you flip the coin over, what's the opposite side of vulnerability.
Speaker 2 (00:03:13):
And this is really important when we think about chronic pain, because our job as professionals is not necessarily to identify here's, what's wrong. You physically, here's, what's wrong with you psychologically or emotionally. And now I'm going to fix, modify or change those variables. We want to focus on as professionals. The other side of that coin is how can I help someone be more resilient? How do I develop, build or foster a sense of resiliency. So that other side of the coin, which is really what has interested me the most, I'd say in the past 10 years is looking at those positive, psychological factors that are associated with resiliency. There's three of them. We can kind of talk about them a little bit each but there are pain, self-efficacy pain, acceptance, and then values based living.
Speaker 1 (00:04:01):
Okay. So let's dive into each of those. So let's start with pain. Self-Efficacy what the heck does that mean?
Speaker 2 (00:04:09):
Yeah. And we hear the word self-efficacy used a lot, and I want to make sure that we tag on the word pain with that because just normal quote unquote self-efficacy you can measure self efficacy, but really as a pain professional, whether you're a physical therapist or another licensed health, professional, or certified actualize professional someone's confidence or their ability and their confidence in themselves to function and figure out what the cause of their pain isn't to overcome. It is basically what we identify as pain self-efficacy. Now you can actually have good self efficacy and have poor pain self-efficacy so it's important as professionals that we look at him as, okay, how can I help someone with pain self-efficacy with regard to their rehabilitation and overcoming pain.
Speaker 1 (00:05:04):
And so say that one more time for me, I'm going to edit some of this out, but I just want to get that into my own brain.
Speaker 2 (00:05:15):
No, no problem. So paint, self efficacy is one's confidence regarding their ability to function while they experience a while they have pain.
Speaker 1 (00:05:24):
Okay. Got it. Got it. All right. That makes sense. And that is coming from someone, the long history of chronic pain. That's not easy. Can I say that? Is it okay to say that that's not easy?
Speaker 2 (00:05:41):
Absolutely. And it does go back to what I mentioned a little bit earlier, where okay. If I have pain, it's this message this signal, if you will, that something's wrong. And it's perfectly normal that your mind goes to the place of, I want to stop. I want to eliminate, I want to resolve this pain with acute pain. That's fine. With chronic pain. It's something very different. And if someone gets kind of caught up in that Whirlpool, if you will, of constantly spinning and trying to figure out, okay, what is the cause of this? And they go down that biomedical route, that's where people wind up in trouble and where they don't find a solution for their pain and why pain persists. So pain self-advocacy is interesting because it's like, okay, do I have the knowledge? Do I have the tools? I have the ability in myself, right?
Speaker 2 (00:06:36):
Because if we're not looking at vulnerability for looking at resiliency, really what we're saying is somewhere within, inside you deep inside you actually, you have the ability to contact something that you haven't contacted yet, or maybe you've only contacted a piece of it. But if I can help you with that, if I can help you along that path, if I can help you along that journey, then we can improve your pain, self efficacy. And it's potentially the research is still kind of unclear, but it's potentially the number one factor, the number one resiliency factor with overcoming chronic pain.
Speaker 1 (00:07:13):
Oh gosh. As you're, you're saying that I, in my head, I'm going back, you know, 10, 15 years to when I was in pain all the time. And yes, I was searching for that fix. And what I found when my pain started to recede, I started to feel better was that I was always looking for that external fix. When in fact I had to look into myself to see how, what I can do to overcome this and, and to kind of move forward and make the best decisions I can at the time, the information that I have and be okay with it and then move forward. And that was the thing that really helped to kind of flip the switch for me.
Speaker 2 (00:08:00):
That's right. And there's, there's two really important things embedded in what you just said. The first is, as physical therapists were very aware of pain, avoidance painted warnings is almost when I look at pain avoidance now after studying acceptance and commitment therapy, I look at painted. William says, it's too simple. So it's like, if the, you know, if you put your hand over the flame, I pull my hand away. I avoid pain. If there's a rock in your shoe, you want to walk differently or take the rock out. What you're saying in your experience, Karen, which is common in many, people's almost every single person's experience you've had chronic pain. Is that the pain persisted for so long that not only did I avoid pain, but I started to move away from everything that was important in my life. And I moved toward only those potential areas on the, on, toward the potential causes that could alleviate my pain.
Speaker 2 (00:09:00):
Now in the act that's called experiential avoidance. And again, it's a little bit different than regular pain avoidance because experiential avoidance means the entire experience. The entire capsule of my life what's encased in there is only to seek out the elimination or the control of pain. And when that happens, that's when people go down sometimes sad and sometimes very scary routes of things like surgeries that don't work and one medication or multiple medications, or we see, you know, behaviors lead to passive treatments you know, leaving work and disconnected from personal relationships, all the things that we see that our patients struggle with. So it's what you say is really important. And to try to make those distinctions for therapists, I think are also important as well, because we can skim along the surface of pain, avoidance, so to speak. But I really believe if we want to be effective with pain, we need to go on this deeper level with people looking at that pain, self efficacy, looking at pain acceptance. And then the last one looking at values based living, which is what ha, which is actually the flip side of experiential avoidance.
Speaker 1 (00:10:15):
And something that you just said that sort of avoidance becomes all encompassing. And, and I will agree. That's exactly what would happen. Like I can remember doing things like going to an acupuncturist and having them put all these needles in my ear. And then I had to walk around the plinth counterclockwise three times. I mean, when you think about that, you're like, what? But I was so desperate. Like I was doing anything and everything for that fix. When I knew even as a physical therapist that walking counterclockwise around uplift three times doesn't really make a difference. But yet here I am doing it and doing that instead of, I don't know, meeting up with friends, right. Relaxing, going to the gym. Like I was avoiding all that other stuff because I was so laser focused on finding this cure, so to speak
Speaker 2 (00:11:21):
That's right. And as you're talking to me and I'm imagining what it's like for YouTube and in that experience, and you're talking about going to an acupuncturist with which, you know, I tell people, look, if you have one passive treatment that you engage in each week as a, as a means of, stress-relief totally fine by me. I have those as well. So we're not suggesting that people avoid anything that's passive, but as I listened to you, and at first you started, well, I went to the acupuncture was for my pain, but you continue to talk what you actually revealed was most important. The real pain was, yes, it was physical, but the real pain was what, it's, what it's stolen, what it Rob for my life. Right. I think you mentioned relationships. That's kind of like, all right, there's pain avoidance here, but what's the real pain underneath that.
Speaker 2 (00:12:16):
Cause that's what I'm curious to talk to people about. And that's what I'm curious to learn about patients when they come to me and they say they're suffering and they say, they're struggling. I want to know, okay. What about your life? Do you miss? Who do you miss in your life? What aspects of your life do you miss? Because the truth is Karen. If we look at the, the vast body of research that reaction now have with regards to chronic pain, most things, no matter what it is, if you apply just one, intervention works minimally and the outcomes are not spectacular. So they're minimal and they're not spectacular. But when you start to combine different things together, then you see more moderate improvements in clinical studies and you see a change in someone's quality of life. But ahead of all of that, some of the most important outcomes that we're looking for is to look at, okay, what's meaningful in your life. And how do I help you reconnect with that? And I really believe that the resiliency processes that are out there, they exist in all of our practices and an acceptance that can move therapy kind of has a bunch of different processes that really lend well to this. But if we can engage people with these positive psychological responses and move away from the negative sodas, because people are aware that they realize they're scared, hell of pain, there is trouble.
Speaker 1 (00:13:45):
Oh yeah, yeah. When I had pain, like I totally understood. Yeah, I have it. I don't want to I'll avoid anything to have it that yes, we totally, 100% get that.
Speaker 2 (00:14:00):
Right. They realized, they realized, they think about it a lot. They realize they're a little sad or depressed about it or anxious about it. They realized that it consumes their time, but they really want to know is how do I get my life back? There's a whole chunk of my life over here. Yes. When you sit down with somebody who has pain, the first thing they're going to talk about is physical pain and that's Norma. And we should, we should make an attempt to validate that for them. But later on, as you're working on their self-advocacy and as you're working on that third week relationship, which really needs to start like the first 10 minutes of the treatments, it really does. Doesn't it doesn't start like three weeks later. What's the first five minutes. These are the questions that we should be asking ourselves. And these are the questions that we should be asking our patients to help them navigate what's happened to them.
Speaker 1 (00:14:48):
Okay. So let's, let's talk about that. So you're
Speaker 3 (00:14:52):
The physical, I'm the physical therapist, right? How do I broach these topics or these questions with the patient without offending them without coming across, as you know, you may have patients say, Oh, that's too personal. Do you know what I mean? So how as physical therapist, and this is where, you know, you had mentioned acceptance and commitment therapy, right? So how has physical therapists, can we incorporate, act into our treatment practice? How can we do this without being offensive,
Speaker 2 (00:15:34):
The best place to, and I'd like, I like the word offensive because I do believe as even though I'm a big fan of psychologically informed physical therapy, and I've talked about this on podcasts and everything, I've done books, et cetera. We have to realize as physical therapists, there's a cognitive dissonance there, which means when someone comes to see us, they don't expect that we're going to be talking about psychological variables. They don't expect that. And nor should they, we have a long, long, long way to go. Not only in our own profession, but in the entire healthcare system, before we get there.
Speaker 2 (00:16:15):
When you're talking about interviewing someone or evaluating someone or assessing someone during the evaluation, which is really where you should start to talk about values based living, there are a couple of just simple questions that you can add into your evaluation. So again, this is psychological informed care, right? We're not becoming psychologists. We're just using principles of to inform our care so that our outcomes are better. So for example, one of the most important questions, which I always get positive responses from, and people never feel taken aback by this is if you didn't have pain right now, what would you be doing with your life?
Speaker 2 (00:17:00):
And it's an open-ended question, right? What kind of weaving in like, you know, principles of motivational interviewing. It allows someone to think, wow, if I didn't have pain, what would I be doing? And you, and I may be able to, to kind of access that very easily or rapidly. However, someone who's had pain for a long time. It's like, there's been a smoke screen in front of their eyes. They're no longer able to see that. Okay. There's another aspect of life for me, somewhere that I can begin to kind of work on. Another really simple one kind of a nice metaphorical one is if I had a magic wand and I can wave the magic wand and make your pain go away, what would you do? What would you do tomorrow? Or who would you visit? Who would you go see and spend your time with? So a couple of just really simple open-ended questions that you include an initial valuation. And I recommend, you know, when people first start training with me, I give them lots of different handouts with regard to values, because you can spend a whole hour on this, but if you're new, just seeding this into your practice just a little bit, day by day or session by session. So to speak, it's a nice way for you to change because there's behavior change. That's involved for us as professionals as we start to use these new interventions.
Speaker 1 (00:18:20):
Yeah. And I think as the, the healthcare professional, the physical therapist, like you said, there is still that unconscious bias of I got to fix it. Right. So I think I would imagine you can correct me if I'm wrong, but the more patients that we see and the more that we ask these questions, the more that I think we'll be able to kind of delve into this other part of the person sitting in front of us. Because the one thing that comes to mind when you said if you didn't have the pain, what would you be doing? What if someone's like, I don't know. I can't even picture it. You just put, I don't know. I can't picture it and move on to the next question. What, what, what happens next?
Speaker 2 (00:19:11):
Well, there's a couple of different parts there. Karen. the first part I just want to mention, so physical therapist and other health professionals who work in rehab are excellent at goal setting. And in fact, I think physical therapists and probably OTs are the best at goal setting, probably in the profession, in the, in the healthcare professions. Historically, we've not been very good at talking about meaningful or value based activities. What if I told you as a professional, that it's more important to help clarify someone's cloudy values instead of setting really precise short-term and long-term goals like we've been trained. So what I'm really saying is we have to challenge ourselves and look at our own practice and say, okay, what am I doing? That's effective and what am I not doing? That's effective. Now, the reason why it's called acceptance and commitment therapy is because with regard to pain, acceptance, that's, one's willingness to acknowledge pain as part of their life experience.
Speaker 2 (00:20:15):
And with that acknowledgement, they avoid the, they avoid the attempts to control or eliminate it. Now pain acceptance is important for people living with pain, pain. Acceptance is also vitally important for practitioners who treat people with pain because of the research is clear that we don't have a really spectacular way right now to eliminate someone's pain. I'm not saying that we can't do that. I believe it does happen, but what I'm proposing. So people who are listening to this episode is that in many ways, we put the cart before the horse, and we've said, I'm going to make your pain go away first. So we have all these ways to make your pain go away. And then you'll return to life.
Speaker 2 (00:21:03):
When in essence, we have to say, let's talk about how we can start to clarify what was important to you in life. Take little steps toward that. And then with that, your pain will start to go away. They're very different messages and they're also very different ways to approach a patient. So if someone turns to you Karen and says, I have no idea. I've had pain for 10 years. It's affected me so badly. I lost my job. I've lost my personal relationships. Let that person talk about their loss because just like that vulnerability process, right? They're talking about how they're vulnerable. Well, on the opposite side of that, they're really saying, I want to, I want to maintain relationships. I want to get back to work. So allow people some room, actually many times when, when questions like that come up, this is going to sound strange to people.
Speaker 2 (00:21:56):
But I just sit there in silence. I maintain eye-contact. I maybe move a little bit closer to the person. And I just give them some space to process that and to process the, the idea that someone's asking them, someone's interested in their life beyond just pain relief. And that can be really difficult, especially for physical therapists, because we went to school. And even if you go to like DPT program websites right now, it says like, you will learn how to like resolve someone's pain. And then we get out into the world. We got out into, you know, the profession. I mean, we figure out, Hmm, maybe I'm not as good at this. As I thought,
Speaker 1 (00:22:36):
This is, this is really hard. Am I missing something? I must have, they didn't teach me this in school. Am I, what do I need to learn to do this?
Speaker 2 (00:22:46):
That's right. So the question is, you know, what, if the way to help someone contact her values is to just sit with them and allow them some space to start to think about that. Because chances are, if someone's wrapped up in experiential avoidance, they're not thinking about that on a daily basis. They're thinking about, I need to take my medication this morning. I need a hot bath. I need to take my magnesium. I need to take my nap. I need to do some distraction activities. So I don't think about pain. That's what their mind is preoccupied with.
Speaker 1 (00:23:26):
Yeah. Or yeah, a hundred percent. A hundred percent. Yeah. Everything you're saying, I'm like, yep. I can remember like, Hmm, okay. I have to figure out what pillow I'm going to use. I have to figure out how much I'm going to put my bag. So it's not that heavy. When I walk around, do I have a break during the day? Did I take Advil? Did I? Yeah. So on and so forth, but that is, that's all encompassing during your day. And, and I don't think I had, well, yeah, well, when I sat with David Butler, he's like, well, what, what would you be doing? Right. And I, my answer is, I don't know. I, I never thought about it. Right. You know, and, and, and being able to send, he did exactly what you just said. He's like, well, think about it.
Speaker 2 (00:24:17):
And I w I want to, you know, reinforce what you're saying is that for some people it's extremely difficult for them to think about it. Yeah.
Speaker 1 (00:24:24):
Yeah. It's and it's really uncomfortable and it's uncomfortable. So just think of it's in control for the patient. And you're the therapist on the other end, is it uncomfortable for you as the therapist to watch someone be uncomfortable and wiggle in their chair, so to speak?
Speaker 2 (00:24:41):
Yeah. I love that. And my response to that is empathy for the people we work with involves a little bit of us feeling uncomfortable and sharing that unpleasantness with the person that's in front of you. And in many ways we mirror people actually. So as they're struggling and suffering as a human, who cares about someone we're struggling and suffering too, because ultimately, ultimately every physical therapist I've ever met. And, you know, I've interviewed a lot of therapist. Karen, when I asked him, why did you want to become a physical therapist? And they would say, well, I want to, to help people. And if I always dig, dig in there more, there's always a story of, well, when I was in high school, my, you know, my grandfather had a stroke and he wound up living with us and I saw the PT come in the house, or I was an athlete and I had an ACL repair. And I saw all these people in this PT place and how I could help them. So, you know, there's a, there's an aspect of human resiliency built in with that. I lost my train of thought. Sorry. one thing you can try for people who are having a hard time connecting to their values, their personal values is to ask them, Hey, if I were to share some information with you about how we can alleviate pain, who would you share that with in your life?
Speaker 1 (00:26:13):
That's nice. So then
Speaker 2 (00:26:15):
It takes it off of, it takes a little bit of the pressure off the person or off the patient.
Speaker 1 (00:26:20):
Yeah. Yeah. It takes a little bit off them and puts it onto someone else. Right.
Speaker 2 (00:26:25):
Right. And in general, we all want to help other people. And especially people with pain, they really do care about other people. And they really have an interest in not seeing other people's struggle the way, the way they've been struggling. So it's a nice way to just kind of shift the conversation a little bit. And if you continue with that, what you'll eventually see kind of like in ourselves when we learn things right. And when we teach things, we actually wind up implementing it into our life in a way that's more effective.
Speaker 1 (00:26:52):
Yeah. Yeah. That reminds me of Sharon Salzberg, loving kindness, meditations. So when she does those meditations, she sort of starts with, you know, think of someone else and, you know, offer them like a life of ease, a life of love, a life of serenity or kindness. And you kind of repeat that mantra for awhile and then just say, offer it to the world and you offer it to the world. And she's like, okay, now offer it to yourself. So that you've practiced someone else you've practiced the world. And then you can turn it back onto yourself. And it's, I always felt like, Oh, this is nice. Now I don't feel bad. Wishing myself a life of ease or a life of ex you know, love or XYZ. Right. Cause I think sometimes when you, I think a lot of people feel this way. They have a hard time being kind to themselves and allowing themselves to not suffer.
Speaker 1 (00:27:50):
Even though with chronic pain, you are suffering and you don't want to be suffering yet. It's hard to recognize that in yourself. You'd rather put it onto someone else or wish that for someone else. But it's just so hard to wish it for ourselves because maybe if, if you've had chronic pain and I'm just, I don't know if this is true or not, but you can't, it's hard to see yourself out of it. Right? And so it's hard to even think of yourself, elevating yourself up to something that maybe you'll never get to. So then you'll, won't be disappointed.
Speaker 2 (00:28:25):
That's right. I, I talk about this in my book, in the, in the sense of self-compassion, which can be difficult, as you said, it's a little bit easier to be compassionate toward other people. And it can be more challenging to be compassionate toward ourselves. Where I see this show up with regard to chronic pain is people have been taught. You have to fight pain. Yes. You have to overcome pain and you see this online people even come in, I'm a pain warrior.
Speaker 1 (00:28:50):
Yeah. Right. You gotta be tough.
Speaker 2 (00:28:52):
Right. You have to be tough. You have to fight it out. You have to struggle with it. And my question really with regard to that is, okay, there's definitely some work that we have to do here. There's some effort that we have to put into this and there's some behavior change. We know that as professionals, but if you enter into a battle with pain, what kind of message is that sending your mind?
Speaker 1 (00:29:17):
You're always on guard. You're always on high alert. And that's kind of the opposite of really what we want when we're working with people with chronic pain. That's right.
Speaker 2 (00:29:25):
And even, even Karen, because I can see you on video right now, as you do that, you're stiffening your whole body up. Right. And we know that things like spasm, muscle spasm, tightness is an outcome of some of these psychological variables. We're talking about being a warrior. Imagine you see holding a gun or holding like a spear they're stiff and very contracted, right. Really what we do with act. And many of the mindfulness and acceptance based approaches is we start to soften to the idea that maybe I don't have to fight this. And that may be my fighting. This maybe the battle with this is the worst, worst, worst part of this. And if I can just let this go just a little bit and allow it to be that maybe not only will my physical body soften, but also my mind will start to release a little bit with regard to some of the things that I've been struggling with or some of the things that I've been grappling with with regards to pain.
Speaker 2 (00:30:21):
And we know that when that happens, people work toward more pain acceptance. Not only does the quality of their life improve, but as I mentioned before, or that kind of cart before the horse, that's also when pain relief happens, why does pain relief happen with that? And that's, I think it's an important point to talk about, well, we have a reward system in our brain, right? That produces its own opioids. When you engage in activities that are meaningful and important to you, it kind of, you know, twinges that reward system in your brain over meaning it makes you feel good. Right? So engaging in things that make you feel good or rewarding or engaging in things that are rewarding, make you feel good, they bring you pleasure. Right. They bring you joy. And with that, it alleviates pain. So yes, there are ways for us to help with pain control. And there are ways for us to help people be a little bit more willing to engage in their life, even with a little bit of pain and both work effectively and both work synchronistically together to help people.
Speaker 1 (00:31:35):
Yeah. I know. I always look back and think, you know, there were days where I couldn't turn my neck from side to side, like I would be crying during the week, but then on Saturdays I pitch a double header and I was a windmill pitcher. No pain felt great, really good because I loved pitching. I love being with my team win or lose. It was awesome. Even if I got like hit with a line drive or something, I just, like, I was hit with a line drive in the shoulder. Didn't bother my neck at all. Didn't even think about it, no problems doing that. Right. And people would always, that's why, when you have someone with, in my case, like chronic neck pain or chronic back pain, and you see them doing something like pitching a double header, a fast pitch softball game, well, there's no way they could have pain because they're doing this. Right. Right. And so it's, it's from what you just said for me, this was really valuable in my life was meaningful. It gave me joy. So I was able to do it with
Speaker 3 (00:32:40):
Very little, if any pain, but on the outside, people are thinking she's faking it. Right. So what, what, what do you do in that respect? Yeah.
Speaker 2 (00:32:51):
Well, I just want to what you're saying resonates well with me, it takes me back really to like the first year I was practicing, which is like 25 years ago before I studied anything about acceptance and mindfulness based approaches. And I had a, a young woman who was, she was the same age as me at the time she was 26 and she was walking down one of the beautiful tree line Brown street, brownstone streets of Brooklyn on it's on a Saturday evening and a drunk driver. Kim wants to the curb and pinned her between the car and the steps of the brownstone. And instantly she was an above knee amputee on one side and the below knee amputee on the other side. And she was a patient of mine pretty much the first, entire six months of my career, basically. And the beginning of her rehab was so smooth.
Speaker 2 (00:33:44):
It was wonderful. And you know, it was a physical therapist. We just feel good because we're helping someone walk again and we're fitting them for prosthetic limbs and we're making them stronger. And that went all really well until two things happen. Once you start to lose some weight because she was in the hospital and eating better and exercising. So the prosthetic didn't fit as well. So it was a constant struggle with the prosthetics every day. And then two, she developed a neuroma on her, on her. One of her legs, there was a period for about two weeks where she was so utterly depressed and unhappy. Cause she was in so much pain and suffering so badly. And all of us, the PT, the OT, the nurses, the psychologists, I mean, everyone went into her room and try to motivate her. You know, we use these like rah, rah, watch your tacky.
Speaker 2 (00:34:36):
Yeah. Cheer her up kind of thing. So one day I went into her room and I just sat next to her. And I said, I don't, it doesn't seem like you want to walk today because that was my job. Right. As a PTA, she said, no. And I said, okay, well, what do you, what do you want to do? Then? I said, you can't stay here. You can't stay in this bed forever. You know that, you know, eventually you they're going to send you home. And she said, there's only one thing I want to do. She said she was engaged at the time. Actually. She's like, I want someone she's like, I want to get married. And I want someone to wheel me out into the dance floor in my wheelchair. I want to stand up and I want to dance with my dad.
Speaker 2 (00:35:23):
And that's all she wanted to do. She didn't want to walk. She didn't want to walk 50 feet in a hallway with a Walker times two. Right? Nope. Didn't care about that. She didn't care about the prosthetic legs. Really. She didn't really actually that at that time she didn't even really care if she was in a wheelchair, the rest of her life. That's what she wanted that moment. So you know what we did together. Okay. Put your hands on my shoulders. Stand at the edge of the bed. I put some music on and all we did was weight shift. Now, could I have done something more therapeutic from like a physical therapy perspective? Of course I could. Was there something, was there anything that was more important to her in that moment? No. No.
Speaker 1 (00:36:10):
Yeah. And now, now given the knowledge that you now have and what we know about pain and what we know about this more value-based activities and mindfulness and act, looking back on that, what does that do for you? What does that make you think of now where you are now looking back on that as such a young therapist?
Speaker 2 (00:36:36):
Well, it makes me think two things. First I am eternally grateful for the skills and knowledge I have now that I try to share with people as much as I can. And then I also reflect on who didn't I help? Oh, that's a can of worms, right? Yeah. Who slipped through my fingers that I wasn't aware of. And that makes me reflect back on, okay, what are we not teaching licensed professionals, especially physical therapists in school, right? So the amount of time we spend on evaluating the structure, function, the structure and function of a joint is in my opinion, at this point in my career is kind of absurd.
Speaker 1 (00:37:23):
That's the word? That is. So that's the word that came into my mind too.
Speaker 2 (00:37:27):
The reason why it's absurd and not no offense against, you know, our colleagues in academia is that this is so much packed into a PT program now. Yeah. So we have to get better at, okay. What do we have to, obviously we have to, we have to understand how to measure strength and range of motion, function, et cetera. But it's perhaps most important that we learn how to motivate and change behavior.
Speaker 1 (00:37:56):
Yeah, absolutely. Because when you, when you think about pain and certainly chronic pain, but even acute pain, what does acute pain do to us as humans? And then as a result, chronic pain, it changes our behavior. It forces us to change our behavior. If we sprain our ankle, we've got a big puffy ankle. Are we going to walk and run for the next week or so? No, it's going to change our behavior. And in chronic pain, that behavior change becomes more than just a few weeks of a behavior change. It becomes an embedded behavior change into personality and into everything that we do.
Speaker 2 (00:38:39):
That's right. And the reason why acceptance I commend therapy is so important for physical therapists is because when we look at all the literature on cognitive behavioral therapy, traditional cognitive, behavioral therapy, and even pain science education, and both of those I'm I'm in favor of, and I support, but the outcomes actually may be a little better with act with an act approach specifically for the pain, the population of those living with chronic pain and as physical therapists, knowing that we function in practice settings, where we come face to face with people who are in acute pain. And if we can start to deliver some of this during the acute setting, right, then we can prevent the transition to chronic pain. And I think that's the most important. So if you're in acute orthopedics, if you are working in inpatient rehab, I mean home care, all the various places that we function, physical therapists are in the perfect position to take the brain and the body or the minds and the body put them together and help someone overcome their pain.
Speaker 1 (00:39:50):
Yeah. And, and it goes back to what you said in the beginning, it's sort of fostering that resiliency in people, and that can happen the day one, you injure yourself. You know, last summer I, I had a partial tear of my calf muscle. And the first thing that came into my mind was, well, the first thing was I felt down when it happened, I was like felt for my Achilles tendon. I'm like, okay, the Achilles tendon is there. I'm good. And isn't that amazing? Like I, anything else to me was like a nothing thing. Right. But the first thing I needed to do was I felt down, I was able to point and flex my foot. My Achilles tendon was intact. I got up, I lived up the field fine. I was like, okay, I'm good. But the next day I was like, Oh my gosh, what if this doesn't go away?
Speaker 1 (00:40:41):
What if this, because of my own history with chronic pain, it's what if this is chronic? What if it never goes away? But, and I, instead I went the next day, I went to see an orthopedist and he did kind of what you're saying. He was like, listen, this is what's going on. This is what's going happen. And he gave me out like a timeline of expectations and for me, and, and the way that I function, that was a great way to build up my resiliency to know, Hey, first of all, it's not my Achilles tendon. And second of all, this is what's going to happen over the next couple of weeks and over the next couple of weeks, what he said happened. And so I felt okay, I'm good. It's a little sore. It's a little painful. I'm okay. With the backdrop of that chronic pain history was really meaningful to me.
Speaker 2 (00:41:30):
Yeah. There are variations of informed consent, just informing someone, okay, what here's what's happening. And here's how this is potentially going to play out. Can be really, really important and powerful for someone. It can help ease someone's anxiety. It can help ease their worry and concerned about it. And as I mentioned before, these are the places where, you know, we thrive as PTs actually, especially with regard to pain. I mean, if you look at pain education in licensed health professional training, PTs have the most more than psychologists were than the other mental health professionals, more than OTs. So, you know, we're putting all these pieces together. And in fact, when you look at what are the most important factors to help someone with pain it's pain education, right? So we talked about that some type of cognitive behavioral therapy, acceptance and commitment therapy is a third wave generation, cognitive behavioral therapy. And then something related to lifestyle, probably the most important factor with regard to lifestyle is movement is exercise and physical activity. So when you put pain education together with act together with helping someone or promoting physical activity, that's probably the kind of trifecta. Those are the, that's the secret sauce, if you will, of helping someone with pain.
Speaker 1 (00:42:52):
Yeah. I, I agree a hundred percent and now let's dive in just quickly. If you can give the listeners kind of like, what's the difference? You, you sort of alluded to it now between acceptance and commitment therapy and cognitive behavioral therapy, and also the difference between act and mindfulness.
Speaker 2 (00:43:19):
Sure. All really important distinctions. Thanks for the question. So cognitive behavioral therapy is kind of the first therapy that was used with regard to people's thoughts, beliefs, and emotions around pain. Most of that work focuses on identifying or challenging problematic, problematic, or modifying thoughts. And with that, as someone modifies their thoughts, you hope that it modifies and changes their behavior. So restructuring thoughts, we've heard these words before restructuring thoughts, reframing thoughts even the reconceptualization of pain, which is a purely from like a pain education perspective. It's still a more traditional cognitive behavioral therapy model, helping someone identify their thoughts, and if their thoughts are maladaptive, how can we change those thoughts now they're important. And there's a place there for that. What I propose to people when they start to look the literature on changing thoughts, specifically with pain or the route with regard to pain, it can be quite difficult and quite sticky to do that.
Speaker 2 (00:44:29):
There's some pretty good research that shows that there's a small group that will reconceptualize their pain really early on. There's another smaller, equally small group that will never change. And then most people are kind of somewhere in the middle. So they understand what you're saying. They understand that, okay, the herniated disc in my back, isn't the only factor with regards to my chronic lower back pain. And they understand that, you know, thoughts about your thoughts about pain, negative thoughts about pain are not necessarily good, but they don't reconceptualize. They don't change those thoughts on a hundred percent. The difference with acceptance and commitment therapy and even mindfulness, they're both what they call third generation cognitive behavioral therapies, which instead of targeting these maladaptive thoughts and beliefs, we simply help people observe that they have thoughts about what's happening. And instead of changing that we help people understand or identify, recognize that they can have those thoughts and beliefs, but still continue on with the things that are important to them in their life. So it's a big distinction. It's especially challenging for physical therapist who spent a lot of time studying pain education. And there's a physiotherapist from Ireland that came into my act program and she studied pain education for a long time. And then she studied cognitive functional therapy, both two evidence-based wonderful ways to treat pain, but she found that there were some people, a lot of patients actually, that they understood didactically what you were saying to them, but it didn't change their behavior.
Speaker 2 (00:46:10):
So what's wonderful about act is that act is a behavior change model. It's really based in behavioral therapy. And there's also something nice about not having to struggle with someone to change their thoughts and beliefs all the time. It takes a little bit of pressure off the person who has pain and it takes a little bit of pressure off of the therapist,
Speaker 1 (00:46:30):
Right? Because sometimes when you try and change those thoughts and behaviors, and I don't know about you, but I've heard this when I first started you know, really studying more about pain science and, and understanding how, how pain affects people in so many different ways. And when I first would talk to people and I bet, you know what I'm going to say here? What, what would they say to you? So you're saying it's all in my head. That's right. Right.
Speaker 2 (00:47:00):
And the, you know, when that happens, people feel invalidated and it kind of takes us full circle to the beginning of our conversation is it focuses on their vulnerability. Oh, so you're saying there's something wrong with the way I'm thinking. And the truth is if someone thinks about their pain, a lot, that's 100% normal. Cause that's, that's a pain supposed to do. Pain is supposed to alert you to something that's potentially harmful or something that's dangerous. So just normalizing that everyone's mind my mind, Karen, your mind, someone who has pain, we all think all, most of our thoughts throughout the day, our thoughts about how do I avoid things that could potentially harm me, things that are potentially uncomfortable, helping people just observe that actually can be the step before even the reconceptualization of pain, because how can you, how can you expect someone? How can you help someone to target thoughts and beliefs about pain if they haven't even thought about, okay, what are my thoughts?
Speaker 2 (00:48:12):
What are my beliefs about pain? What am I thinking right now? The average person has somewhere between 6,000 and 12,000 thoughts per day. And the truth is most of them are negative because it's a survival instinct, right? We brought this through with survival instead. How can I observe these thoughts? How can I observe my emotions? How can I be getting to observe the physical sensations in my body, whether that be anxiety, whether that be physical pain and realize that I can have contact with that, but not let it impact my behavior. So that's really the biggest difference between an act or a mindful, acceptance based approach versus a more traditional cognitive behavioral approach.
Speaker 1 (00:48:57):
Yeah. Thank you for that. That is very helpful. Cause I'm sure you get that question quite a bit. So it's nice to be able to clear that up. So now let's shift gears slightly ever so slightly and talk about your new book, right? So your new book, radical relief, a guide to overcoming chronic pain. So let's talk about it. Why the title why'd you write it? Go ahead.
Speaker 2 (00:49:27):
Well, after my first book came out called heal your pain. Now in that book, I had a section called the brain and pain. And at that time, the author only gave me so much space to write about the mind, so to speak. So I had to, I had to include small sections about mindfulness and about act and in general about the mind and how the mind responds to pain. And it kind of forced me to take a very didactic approach to pain. And people would reach out to me all the time. I want to learn more about mindfulness for pain. I want to learn more about this thing. You mentioned act about pain. So both professionals and people were coming to me. So I couldn't put it in that book. And I really firmly believed that deserved its own resource because there are solid mental skills, training and exercises that are in this book, radical relief that wasn't in my, in my first book.
Speaker 2 (00:50:24):
Second is it's a little bit tongue cheek, so to speak, it's a radical idea to think that two physical therapists want to spend their Thursday evening talking about the mind and mental skills training with regard to pain. So as we said before, like there's a little bit of a cognitive dissonance in there, but we know that physical therapists have a very important part with regard to helping people cope both physically as well as psychologically and emotionally. You know, the third aspect is just in general to give people this notion that it's not a radical idea to use your mind, to use mental skills training, to use mindfulness, to overcome pain. And that can be a part of your treatment. And in fact, as you and I are sitting here counting, I can guarantee you there's someone right now, who's being treated for pain who are not being offered these types of skills and you know, you, and I think it's absurd actually, but this is still happening. So radical relief really is a short book. It's only about a hundred pages. It's a workbook that includes over 50 cognitive and mindfulness type exercises to help people overcome their chronic pain in essence. And it's also written for practitioners to use as a guide in the manual that they can use in clinical practice.
Speaker 1 (00:51:45):
Yeah. And the one thing that I liked about the book aside from, as we were talking before we went on air, it's very, very pretty all of the illustrations are quite beautiful. But I like the fact that within each chapter there's like exercises and you have to literally write things down, pen, take pen to paper, and you can do it right in the book. Or you can grab the extra sheet of paper or what have you. But I like the fact that you have to write things down because there is something to that, you know, there is something to writing to the physical act of writing something down on paper versus typing it out or just thinking about it. And so that's something that I really appreciated throughout the book.
Speaker 2 (00:52:30):
Yeah. And I learned that from my first book as my first book was a very education based approach. As we mentioned, pain education is important, but it, it doesn't do a great job of changing behavior when you get involved with act, act as a very experiential therapy. So you're not sitting across from someone like talking to them, you're actually engaging with them in a lot of different ways. So what I really found was, and people can, you know, note this down for themselves. The average person doesn't want to flip through 300 pages of a book to learn about pain. They want something that's relatively short. They want something that's clear. They want something that's useful that they can really pick up, you know, now and start to use. And I think it's the same with practitioners, right? There's only so much theory and philosophy we can think about before we say, okay, what do I do with my patient today? What am I do with patient? I have at nine o'clock tomorrow, who's been suffering with fibromyalgia for 10 years. So that's why I tried to approach this book very differently from, from the first book.
Speaker 1 (00:53:35):
Yeah. And, and before we went on air, you, you asked me if I had a post-it note to which I said, I have a large sheet of white paper and you said, no, it needs to be a post-it note. And I said, well, I have a mini post-it note, will that do the trick? So please, please tell me why I needed a post-it note and not a large white sheet of paper. And perhaps the listeners, if they have a post-it note, they can go and grab one as well.
Speaker 2 (00:54:05):
Yeah. So if everyone has a post-it note and a pen or a pencil, please hit pause and grab that and come back. But as you mentioned, Karen, it's a workbook. And you said putting pen to paper changes things, right? Because in some ways it's it's experiential. So I was, as, as I was mentioning before, we don't have a good way to change thoughts and beliefs. So with that, we have to help people relate or respond differently to thoughts and beliefs. Right? All of us have things in life, thoughts and beliefs about ourselves that are somewhat unpleasant and painful, right? Some of them are really, really horrible things about ourselves. And some are, some of them are things like, you know, not so horrible. So if you'll kind of engage in this with me, I'd like you to just reflect on yourself and your own life experience and think about one negative, thought about yourself, not the worst thought possible, but one thought that, you know, maybe on a scale of one to 10 with like one the least impactful and like 10, the worst, maybe you're somewhere like a four or five. And then I want you to write that down on the post-it note.
Speaker 3 (00:55:19):
Speaker 2 (00:55:20):
So we can't change this thought, right? The thought is there and just rip it off a little post-it pads,
Speaker 3 (00:55:31):
Still writing. Okay.
Speaker 1 (00:55:42):
My pen's running out of ink, but I remember what it was. It's, it's half written. It's written. I just, my pen ran out of ink, but okay. We can, we can go on. It is written.
Speaker 2 (00:55:52):
I'm going to do this with you actually. So it's written there and what I want you to do is pull it off the, pull off the post-it pad. Okay. And I want you to hold it up. I don't know, maybe about a foot or so away from your knees. I want you to look at it. And in your, in your mind, I just want you to repeat the word nice and slowly, and really kind of get lost in that word just for a moment. And then as you get lost in that word, just notice if you feel anything different in your body.
Speaker 1 (00:56:37):
Yeah. Looking at the yes.
Speaker 2 (00:56:39):
Right? Okay. So you see how thoughts have an impact on how we feel now, what I want you to do is I want you to take your arm and stretch it out as far as you can go. And I want you to look at that word. And what I want you to do is I want you to flip it upside down. Now, just turn it 180 degrees and now look at it and now see if it has any less of an impact on how you feel.
Speaker 1 (00:57:07):
I mean, maybe a little,
Speaker 2 (00:57:09):
A little bit right now. What I want you to do is I want you to maybe prop it up on the computer screen in front of you, and I want you to push back. So maybe you're 10 feet or so.
Speaker 1 (00:57:22):
Okay. Go. As far as my mic, as my ear, phones will take me
Speaker 2 (00:57:28):
And then maybe just stand up as you're there and now look at the word and then notice if there's any difference in how you feel or how you relate to that word.
Speaker 1 (00:57:43):
Yeah. Maybe a little bit, now that I'm standing and people can't see me, but I think I automatically stood up in the power pose.
Speaker 2 (00:57:49):
I noticed I still noticed put your hands on your hips. Right. So would you say there's less of an impact as you move away from the words so to speak? Yeah. Great. Okay. Come back forward. So what I just did is what they call cognitive distancing. So it was a way to distance yourself, literally as well as figuratively. So now what I want you to do cameras, I want you to take that same post in them. I want you to fold it up into a little square And I want you to put it in your back pocket.
Speaker 1 (00:58:24):
Okay. I don't have one. So I'll pretend I do.
Speaker 2 (00:58:28):
Yeah. Just stick it up your sleeve there. Okay. So now you have this unpleasant unwanted thought about yourself. It's not going away cause it's in your back pocket or it's in your front pocket or wherever it is, wherever you placed it. And my question for you is would you be willing to be with that thought and to be with those uncomfortable sensations you feel on your body, if it meant you could be a more effective physical therapist or be a more loving daughter sure. Or a more supportive wife or a girlfriend, or a more effective member of your community or a leader of your profession.
Speaker 1 (00:59:14):
Yeah. I can do that. Right.
Speaker 2 (00:59:16):
So it just shows you that we can change how people relate to thoughts. We didn't change the actual thought. Still there. We can change how people relate to them, to it. And we can also show people how, okay, this thought can be present with us and I can still experience it and not feel good about it, but I can still go about my life. And what I do with patients is I have them take these thoughts. Like I have a big herniated disc at L five S one. Okay. Write that on a piece of paper, put it in your back pocket in your briefcase and carry it around with you today and notice how at times that thought wasn't even present and didn't talk to you at all. And other times maybe it was present a little bit, you thought about it, but it didn't stop you. And other times it was like a big barrier. Right. And within those three, they're really important teaching moments that we can help patients with.
Speaker 1 (01:00:09):
Yeah. Oh, that's great. Great, great. Is that in the book? So
Speaker 2 (01:00:14):
The book is full of
Speaker 1 (01:00:17):
Nice. Nice. Yeah, no, I think that's great. And, and for, you know, physical therapists or other healthcare professionals that might be listening, that my hope is that this podcast will plant a seed in them to say, you know, maybe, maybe I'm I need to do a little bit more, you know, and what can I do to do more
Speaker 2 (01:00:43):
The biggest ask the biggest, one of the great gifts that I have come across in teaching physical therapists about act is yes, it helps your patients, but physical therapists notice a change in themselves from it. Because look, we struggle with not being able to help people. We get burnt out because of it. Absolutely. We have our own personal challenges that cause us pain and suffering. So to speak that we struggle with outside of our clinical work, that this type of work becomes really important to you. And the truth is, as you know, Karen pain will show up in life. Yes, it will show up when you least expect it. And these are effective skills that I really believe all of us need to learn and adopt not only for our patients, but for us to be effective clinicians and effective professionals for us to embody them in ourselves, then we can help people with these types of aspects and these, this type of care.
Speaker 1 (01:01:44):
Yeah. I don't disagree with that. I think that's great. And you know, I was just going to ask you to sort of put a bow on this conversation, if you will, and what would you like people to take away from it? I think you gave a little bit of it just now, but is there anything you'd want to add on to that?
Speaker 2 (01:02:06):
What I want people to take away from a mindfulness and acceptance based approach to care is that there's hope in it. And that hope really resides in helping helping, giving you the skills that help someone reconnect with their life. And that resilience that we spoke about in the beginning, the hope is really what people are looking for because they feel helpless. They feel hopeless. And this work is really about, okay, maybe there's some things in your physical body we have to work on. Maybe there are some thoughts and feelings and emotions that are difficult for you. Let's yeah. Let's kind of work on those, but know that you're whole, as you are, as a human being and everything that's required to overcome this already exists in you, I'm just going, gonna help you contact that in a way that's more efficient that moves you along this path in a way that's faster. So the whole part is really important and that's really what people are coming to us for.
Speaker 1 (01:03:07):
Yeah. Yeah. That's great. And then last question or no, well, last question before we get to, how do we contact you and all that other fun stuff, but, and you know what this question is, I think I've already asked it to you like three times, however many times you've been on the podcast, but let's say knowing where you are now as a therapist and as a person and in your life and your career, what advice would you give to your younger self? Maybe not right out of college, but let's say 10 years ago, before you really started delving into working with information surrounding chronic pain,
Speaker 2 (01:03:48):
I would say, give yourself space to fail and just allow that stuff, exploration of exploring different things and realizing, Hey, I didn't do that so well, or I wasn't so great today and allow yourself, there's a lot of pressure on us as professionals to be this, you know, master healer, so to speak. And I really think it's damaging to us as professionals.
Speaker 1 (01:04:20):
And I think that can lead to burnout, all that pressure on you to be the person, the one person in someone else's life. That's going to take away all their pain or take or add this, or take away that boy, that's a lot of pressure.
Speaker 2 (01:04:37):
That's right. I, I actually, I asked therapists now, who are you to take away someone's pain. Cause really think about what that really means.
Speaker 1 (01:04:46):
Like the wizard of Oz,
Speaker 2 (01:04:48):
Right? Like, is there some like magic fairy dust that you have that the rest of us don't have? And again, it doesn't mean that we can't help people with their pain. I mean, we can alleviate some of that pain, but that's not what, that's not what we're there for. We're there to be a witness to someone on their journey to overcome whatever it is that they're struggling with. And the kind of take that into a mindfulness realm, allow yourself to be your own witness as you move through the profession and you navigate and negotiate. Okay. Here's what I'm really good at and why I want to kind of cultivate and things that I don't have to necessarily engage with that.
Speaker 1 (01:05:29):
Yeah. Well said now, where can people find you? Where can they find the book, social media websites? What do you got for us?
Speaker 2 (01:05:39):
Easy. People can go to my website. The website is integrative pain, science institute.com or one very long word, integrated pain science institute.com. The book is called radical relief, a guide to overcome chronic pain, which you can find on Amazon in most countries. If you go to either one of those two places, you'll find the book and all the information about me. I also want to plug another book Karen, in which you're involved in.
Speaker 1 (01:06:03):
Oh yeah, yeah, yeah. That's right. It's a couple of months out still. Yeah,
Speaker 2 (01:06:08):
I'm working. I'm the chief editor on a book that involves about 45 different physical therapists, some from academia, some from private practice and it's with regard to how physical therapists can use lifestyle interventions and practice that book will come out probably in the fall of 2021. And I want to plug it because it's an awesome book with, you know, as I mentioned,
Speaker 1 (01:06:32):
Amazed some amazing people involved,
Speaker 2 (01:06:34):
Amazing people. And Karen is one of those amazing people. Who's doing the chapter where she's offering the chapter on private practice, physical therapy and how to integrate lifestyle interventions into private practice PT. So yes. Check out my book, radical relief now, but look out for that book.
Speaker 1 (01:06:50):
Yeah. And you, and, and our lovely ginger garner. Yeah.
Speaker 2 (01:06:54):
Ginger Gara and I are the chief co-editors. Yeah. And then we're fortunate enough to have about 42 other amazing PTs from all over the globe actually.
Speaker 1 (01:07:03):
Yeah. Yeah. On different topics. Yeah. It's going to be cool. I'm looking, I can't wait to read everybody else's chapters. It's going to be awesome. And then social media, I think your social media is pretty easy. I think it's at Dr. Joe Tata across the board. Am I right?
Speaker 2 (01:07:19):
I've spent so much time just getting that. Yes. It's at Dr. Joe Tatta across the board. You can find me on Instagram, LinkedIn, Facebook, Twitter, all the main ones.
Speaker 1 (01:07:28):
Yeah. Awesome. Well, Joe, thank you again so much. It's always, always have a great conversation. When you come on the podcast and you make me think of a lot of things past and present, so thanks so much for coming on. I appreciate it. Thank you so much. And everyone else. Thanks for tuning in. Have a great couple of days and stay healthy, wealthy and smart.