How to Run a Telehealth Visit That Actually Changes Pain

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You're listening to the Restoring Human Movement podcast, where movement experts discuss the latest evidence-based practices to help you and your clients move with mastery. And now, your host, Dr. Sebastian Gonzales. Hey everyone, it's Sebastian, your host with the Restoring Human Movement podcast. Thanks for joining the Movement Movement. If this is your first time on the show, welcome. You've missed a lot. We are about 45-minute to an hour-long format where we mainly try to improve our clinical skills. We try to improve our ability to help people, as well as we try to improve our patient's ability to understand what's expected of them. As I always kind of say, I don't think people are necessarily, they don't need to understand all the small details of why we're doing what we're doing, but they certainly have to understand enough to trust that the process is going to help them.

So, with that being said, this is going to be one mainly for clinicians today, but in the archives, there are ones that are more patient-friendly. But as always, we try to keep the terminology really general. That way, in case there's someone just wanting to learn more about what's going on on the clinical side, you can understand what's going on. Okay? So, sometimes I'll interview some people. Sometimes I'll interview people. Sometimes I won't. This one won't be. This will be a solo podcast today. The topic for this one today is how to wow your Zoom clients or your Zoom patients. And I did do a very short little webinar with this with just a handful of people recently. And I thought, why don't I just share some of the stuff on the actual podcast? And so, that's what I'm going to do today. I wrote down a little laundry list of things that I think that would be helpful for you guys to not only impress your Zoom clients, but also feel more comfortable doing Zooms. And at least, I can only speak from what I understand in California, but you can do Zooms with people in California. And you can give them a diagnosis and everything via Zoom, from what I understand from the Sam Collins workshop. By the way, the disclaimer is I legally don't know all the exact details, but I'm regurgitating from what I recall.

I would suggest if you want to know some of the legal aspects of telehealth in your state, contact Sam Collins, H.J. Ross. He's been on the show before and he did a little webinar that I purchased to learn about telehealth. And I think it was very helpful in regards to coding as well as some of the specifics of things and so on, or contact your state board as well. I don't think our state, we actually, we harassed the state to get a solid answer and it was very enlightening. So, I suggest you talk to your state. Now, so within California lines, at least it makes it less muddy about things you can and can't do. However, the things that I understood, at least from the H.J. Ross workshop, was that you can't really tell this, tell these patients that it's a substitute and equal to an in-person examination. And I do mean examination with this because obviously, I think the major concern that a lot of us do have is that we are concerned that we won't catch some of the big, bad, scaries for people. And I feel the same way. And as I go through some of this stuff today, they obviously know that we've turned away telehealth patients. By the way, I didn't realize until, you know, when earlier this year that we can't, chiropractors can't say telemedicine, you say telehealth. And I think there's probably, PTs will probably be the same. Interesting how the semantics of it. Anyways, we want to catch the big, bad, scaries. And what I started doing, what we started doing is we started trying to be very blatant with the patient before we even booked the session with them. And we try to ask them a lot more questions as well as updating our history form. And so what I mean by this is we try to pre-screen some of the ones that are people that we are kind of scared that we can't do a full exam on. And we want to do a full neuro workup, full ortho workup, and beyond reasonable doubt, figure out if this person should be in our office or not.

And obviously, the main way we can tell that is by doing a good physical exam too. History obviously helps. But what I think we need to be considered of is, do we feel comfortable helping this person? Do we feel comfortable guiding this person? Or if there's a certain time where you're working with someone who feels, you feel like you can help and all of a sudden something comes up where you can't help. Maybe some pertinent information comes up where they might have, you know, dizziness, fogginess, and you know, they were passing out or all these different things that maybe you don't feel comfortable with, whatever that might be. That might be a time where you tell the person to come in for full workup or you would refer them on and discontinue care with them. And so I think as long as we, you know, kind of stay along those guidelines with things, I think most of us should probably be okay because generally people have, I've talked about this through the workshop or through the webinar many times, and most people have very simple things and we assume or sometimes they assume that they're unicorns. They think they're the exception to the horse, uh, the hoof beat rule. And so if you hear hoofs beating and coming towards you, at least in California, we think probably cows, but if you're somewhere else, you think horses.

And you know, if you're in Africa or some other place that has zebras, you think they have the zebras, but most of the places we don't figure that they're unicorns. So thinking that they're a unicorn, um, obviously that is a concern and we need to do a full history and examination to figure that out. But I think a lot of us can do a lot of help for these people who are not able to come in, uh, either because of distance or just because of other circumstances, they can't come in and they're just suffering. And I think there's a lot of people out there like that right now. Um, I know that one person that I was able to see in person, she was a, she was a past patient, uh, and I'd helped her with a couple of other things. She had not, she had not, um, left her house in really, it's like, she was surprised the gas prices changed that much. She hadn't left her house in I think three, four months. And like, I'm not judging that, but I'm saying she suffered with this problem. She suffered with shoulder blade pain for months because she didn't know quite what to do and didn't know that, you know, telehealth was available and that you can help them via that.

I saw her in person because she opted to come in, but obviously if the person in this circumstance, if the person wanted to come in, I wouldn't deter them from coming in. But if they were, if coming in was not an option, then telehealth is, is certainly a valid secondary thing. Now, when we talk to people about telehealth on the phone, uh, we let them know that except for the exam, for the most part, we can get the same type of outcome. And I think it's important to tell the client that because they will almost always, unless they've been somehow conditioned and had a good experience with, um, some other type of care is they'll think that you need to be there in person to show them what to do or to do something to them. And if you use some of the things that at least we use, uh, telehealth is actually, it's very powerful and we've been able to help people without even having to touch them, physically touch them, uh, dramatically when all the other things that they tried have not helped and they've been suffering for weeks to months. Now, how to wow your clients is obviously, um, why we're here at this podcast today, but I want to make sure to go down the route of what I do too, because I want you guys to get an idea of what maybe what you could do, what works for you personally with your clients and in your state. And so treatment wise, uh, therapy wise, also a part of an exam wise, the things that I like to use is some of the McKenzie methods.

Uh, by the way, I'm not certified in McKenzie. I should note that. Um, but I have read the books, uh, and there are actually some McKenzie courses online that I recently saw that I'm considering taking one of those. And because a lot of the web, a lot of workshops aren't available right now. So I might take advantage of that because sometimes travel is a little bit hard to actually learn from the sources. So we typically use three things. We use a McKenzie style. We use a Michael Shacklock neurodynamics style, and we use a dermal traction style from Phillips Snell and Justin Dean. Uh, if I were you guys, if you're not familiar with at least two of these, you need to get familiar with them. Um, dermal traction is one that you can go to dermal traction, I think.com and, um, get access there. It's super cheap. If it even costs anything anymore. Um, I know for, uh, I think for a while, they had a nice promo code on there. Uh, if it's under, it's probably under 500 bucks. Okay. Go on there.

They show you everything you need to do. And if you have not played with skin pulling yet, you should. Um, we've had surprisingly, I've had some videos on YouTube that have been, uh, I mean, I, I didn't really have a strong call to action after like, Hey, if this works, here's what you should try next. Or here's we call us or, you know, sometime obvious, you know, marketing advertising helpful thing because these people just pull on their skin. They feel better and they go away. Uh, I want you guys, you should go into my, our YouTube channel. Um, search performance, play sports care and at, on the channel, uh, put in, uh, on the channel search and search function, put in a knee and you'll end up seeing, uh, knee, uh, like a reduction in knee pain in 60 seconds or something like that. And read all the comments. It is literally person after person. When they followed that video, they feel dramatically better and they think it's a magic trick. This is the power of doing something like dermal traction. Um, it works especially well within the hip, the low back area, um, within the knee, the ankle, the shoulder, the neck. Um, and, and actually so funny with the shoulder, uh, we've had a couple cases where I remember there's one guy in particular, he had, uh, multiple labral surgeries in his shoulder. And all we did was pull on the skin around the superior radial tunnel. This was in person and, um, he can move his arm with zero pain whatsoever and blew his mind. So if you want to get number one, if you want to wow them and get some buy-in dermal traction is probably the easiest way to go because it defies all odds of what they think will work. Pulling on the skin should have no effect on muscle, tendon, ligament, cartilage, joint, right? I mean, bone. So it just blows their mind a little bit. So that's something that is very helpful just to get them to understand how well you can help them via virtual and gets them to listen a little bit more. Now, when you choose to plug that thing in is, is your call. Um, I've been experimenting with, uh, plug it in and in part of the movement exam or later on, I'm not quite sure what I'll do in the future, but, uh, sometimes the buy-in that I'm looking for is, uh, I kind of want to early that way their attention is there, you know?

Now moving to Shacklock's work, uh, Shacklock, I don't, is Michael Shacklock. Actually, I've had him on the podcast multiple times, excellent clinician, uh, very nice guy, wealth of knowledge, and he has a lot of things that do work very well. And, um, it's kind of like, I guess the, it seems like the opposite of like a McKenzie approach and it might or might not be, I have no idea, you know, what we're truly doing in some of these cases, although we have some of the, um, you know, mechanical theories of why we might actually just be pumping a joint. We might just be going down that route where you're moving, you know, in, in dispersing fluid. I have no idea.

Um, but either way, one of these approaches tends to work really well. Um, before you get to the four, actually the fourth one would be like a, uh, like a DNS type of approach, like a stabilization one. But, uh, Shacklock's work, if you have not done so already, you really should buy at least his book. Uh, I don't think he has any virtual courses at the moment. Um, his courses are generally about four days long for upper and lower. Uh, it's a, I mean, it's, it's a long course, very worth it. Mind blowing stuff. Uh, and even the people who have listened to the podcast where I interviewed him, like they would send me emojis with like the mind blown emoji. So, uh, wealth of knowledge.

And it does cover a lot of the, um, gaps of what we kind of understand about some of the mechanics that are surrounding nerves. So, uh, we use a lot of his type of openers and sliders within our virtual treatments too. They're very easy to show. Um, the McKenzie stuff, uh, that is something, again, I would check out the books and check out the courses. Um, I'll just tell you my, um, background, at least with, uh, exploring some McKenzie's is, uh, I, the first time I realized I didn't actually need to do any tissue work on a low back to make it feel better. It just completely blew my mind. Having them do like 20, 30 of, of low back extensions in that case, uh, and all of their back pain reducing their bending forward improved. Um, and their ability to squat improved. They had no longer had pain with walking. And I know in this one case, the intelligence went away and obviously the people who are spent time doing McKenzie's, they're thinking, no kidding. Like we, this, we see this all the time, but for somebody who has not really seen that side of things, it's actually quite startling. And it really makes you wonder what, uh, why do I need to do tissue work on all these things? What else can I not beat my hands up with? Now I'm, I'm a fan of doing tissue work and I do tissue work in the office. However, um, when I see suspected suspected disc come in, uh, or something like an ankle sprain, uh, or even like a meniscus of the knee, I kind of really consider like, maybe this is where a McKenzie approach would be a little bit more appropriate. And when we're talking about zoom, McKenzie's shack locks work in dermal traction are really the go, uh, the ways to go because you don't have to coach too much. It blows the person's mind when it works. And it's dramatic improvement by usually like 30, 40, 50, sometimes 90%. Crazy, right? So if you're not familiar with those, please get familiar with them. I've easily toggled between all three in a single session before, uh, to get more and more change or to try to pick up where the other one didn't work. And there's many times where I try a shack lock approach. It doesn't work. I go to dermal traction. It does, or a McKenzie doesn't work. So I go to a shack locks and that doesn't work either. And then I go to dermal traction or vice versa. You shuffle around a little bit in here. And so it helps me understand also to mechanically what's going on. And so it's part of the examination process. And I do a similar thing while I'm in person with patients too. Now, uh, in regards to, uh, history taking, uh, I suggest you guys update your history taking form or your intake form rather your intake form should be all of the questions you wish you could ask or had the guts to ask and you didn't. And so it should be very thorough and it should encourage open ended types of questions, not just check boxes. And so get a lot of information out of the patient. Even in my intake form, it encourages them to, you know, what would you like to do that you can't do now dig deep? I want to know the deep down reason why you're coming here. And some people will ignore that. And then people say, you know, if I got to dig deep, well, you know, they, they go back to, you know, their, their father hated them or whatever. So they dig a little deeper. Um, and it's always nice when people are very, um, upfront about, you know, what their concerns are, because then it allows you to, to bond with them a little bit better via zoom and obviously be a via zoom or by the way, I guess I should mention, uh, I do mind via Jane. Uh, I I'm sure you guys have heard me, uh, interview, uh, Alison from Jane. Uh, Jane is, uh, they, they patched in like a, uh, uh, a telehealth type of thing that is so easy. Uh, and even helps with the billing too. You can set up a virtual, um, site, which changes the, uh, 20, 24 B section on your HICFA form. Uh, and it helps out with billing. So, um, consider Jane, if you haven't already every day, it's like, Holy shit, Jane gets better and better. Jane, uh, Jane app, uh, EHR. So, um, where's I going with this? Uh, anyways, so I, I have my intake form via Jane and it sends it directly to them. And so I can change that it will. Um, but where was I going with that? Uh, zoom, zoom, zoom, zoom. Oh, I was going to say, um, that, uh, video overall, like obviously if you're not in person, it's, it's rather in personal anyways, it's less personal. And I think, you know, obviously, you know, email or text or email, least personal phone call, more personal zoom call, more personal or Jane call. And then in person.

And so we're just scaling back a little bit. So it's always nice to get that touch point and get them to, um, understand that you care. Now, physical exam is something that you guys are going to have to practice a little bit, to be honest with you, obviously with the three types of methodologies that I use for treatment, you're going to have to use, um, you're going to have to practice as well. If you feel like you're lagging on them or that you're concerned that you won't be able to get the change with them, start working with them with real patients that you see in person that have become stagnant in your care. So the exam process, I would suggest that number one, you want to be confident, obviously like we all need to be, but also confident.

And so confidence will, will ooze out of you to where the patient wants to continue working with you via this, um, less personal media. And so, um, you need to be able to practice this and know it by heart today. Actually at our office, we're doing an in-service for a shoulder exam, um, because, uh, some of us struggle with shoulder exams and hip ones and knee ones. And, and so we'd like to do a little update. And so we're going to do an update one here where we can get a, we call them shoulder exam flows or low back exam flows. And so I know that with hip and low back and neck, I can easily go through it and just go through the exam. And if the patient stops me or I make a joke or whatever that we can, I can jump back in right where we were, and I'm clustering a lot of tests to really figure out what's what it is and what it's not.

By the way, I think it's, um, I don't know if you guys use this line with your patients or not, but I say it's, it's equally important to figure out what it's not as what it is. Okay. Cause they want to know an exact diagnosis and that's not always going to be possible, but you can figure out certainly when it's not, and that's important to know what you should do. Uh, also another quote, which, uh, I guess I should, um, quote time, I guess. Uh, I have this, um, uh, pediatrician that comes in. She's, she's, uh, she said that although that the, uh, although the medicine is based upon the hard sciences, uh, it's actually an art form. And so I, I've said that to a couple of clients and they said, Oh, I totally get it. You know? And so, because they think there's like a magic pill or a magic exercise or a treatment that will help them. And the artistry comes in, you know, uh, ebbing and flowing with how their symptoms change as well as who they are and what they're able to do. So, um, it gives us a little bit more leeway rather than thinking that, you know, your treatment didn't work. So just like the three I mentioned above, it's an art form to figure out which one to try first and which one to go to next and how to tweak it. So, um, the exam, the basic exam that I kind of go through is, um, by the way, I should know, I really like seeing low backs, hips, um, and necks that are not ridiculous, uh, not ridiculous in the neck, mainly for, uh, telehealth. Uh, I don't really like seeing too much of, uh, hand numbness with telehealth. Uh, I mainly because numbness is, uh, it's so distal, you know, it's so far away. Um, I think with the foot and ankle, it's a little bit more understandable that it could be coming from the spine, but, uh, talking about hand numbness with people on telehealth sometimes doesn't go extreme. There's a lot of, uh, yeah, buts and distractors cause they've been told that it's carpal tunnel or it's cubital tunnel or whatever, you know? So there's a lot of other things that, um, kind of go into that conversation. They don't really love as much. It just steals away, but low back and hip and shoulder and neck. And, you know, those are a little bit better. Um, they're a lot better actually, even knee and ankle a little bit more, um, if they're actually knee and ankle and not referred, those ones are, those ones are okay too. And they're simple to exam for. And so usually active range of motion is my first go-to. And I do a lot of copy, like copy me. Um, and I'll do, I won't do all of them at once. I won't go, okay, I want you to bend forward and then backwards and then side to side and then turn and turn. Like, I'll just say, bend forward, turn to the side, go down, go up. How does that feel? Good. Now let's do this now. Let's do that. Um, cause I don't want them to sit there and look at me and, um, wait for me to finish talking about it. Cause I'm just going to say all that again. So bend forward, attempt to touch your toes. If you don't want to, you don't have to. Do you want to? No, I don't feel comfortable doing it. Okay, cool. Can you bend backwards? Um, and so the range of motion or the degrees is probably the, I know it's the most visual. I don't want to say it's probably the most, it's probably the least important. In my opinion, the quality of movement is important as well as the subjectivity. So how they move as well as how they feel. And so some people, when you ask them, bend forward, they will flatten their back and hinge from the hips and be definitely afraid of rounding the spine. In that case, that might be an important part of what's going on for people who've been backwards. They might notice that there's no hip range of motion moving. That's just the lumbar spine. It's like they've bent over a pole. And so quality as well as subjectivity are important, but the person will probably care more about range of motion and subjectivity. But just kind of note, because that'll be good information for you. Um, especially since we're going to be logging on other things with the physical exam. Visual inspection, I think is important to do because, um, you know, as they're talking, usually in person, you can kind of look at, you know, as they're sitting there, you can see how they're sitting and you can see, you know, um, any varicoses they might have. You might notice that, you know, they walk with a limp, but there's inspection things that you can do. Even, even things like, uh, you know, skin quality, nails, um, general, general posture. Um, does their face move, you know, cranial nerve assessment, things like that. Um, with tele, with telehealth, uh, you kind of get stuck in whatever panel they put you in. So whatever the camera showing, you're kind of stuck in. And so you might suggest, you know, can you, uh, back up from the camera a little bit for me, sit right there, turn to the side. Cool. Uh, and so as we're doing certain things like range of motion testing, you might actually look at some other parts too. Um, orthopedic testing is something that will, you got to get creative with now for a low back. I can, um, we can obviously do something like camps. We can do, um, a trend Allenberg, uh, we can do, what else can we do? Um, gosh, I guess we can't do any of the SI joint testing, can we? So there's obviously things that are lagging, right? Movement is probably going to be your best asset in these cases. Um, for cervical, you can have them do, um, flexion compression. If you can test them or if you can coach them into that, um, you can also have them do things like foraminal compression, uh, or, uh, foraminal compression, not maximum foraminal compression, unless you can coach them into that. You can have them do things like shoulder depression and things of that nature. So there's, there's things that you can do orthopedic wise, but you are going to lose some things. However, your range of motion testing and getting them to do movements that bother them as well as it make them feel good will probably help kind of fill that void a little bit. Um, I'd suggest that get with a friend and start practicing some of these things, especially your orthopedic and neuro testing and get creative. Uh, I know that with neuro testing, we had to get a little bit more creative for lower extremity. You can easily do things like, you know, how many heel raises can you do? Um, uh, Phillips Nelson is generally about 20, I think equal side to side subjective and objectively. Uh, we have the, uh, foot tap, which is roughly about five or so you can have them get on and off the table with one leg, which is I think about five or so 10 is pretty good in my opinion. And you want them equal side to side upper extremity. Now you got to think about how you're going to test for like C five, six, seven, eight, nine, uh, God, there's no nine. Sorry. Um, I just kept going, uh, C five, you might have them seated and kind of pull up on the table. Um, C seven, you might have them pushed down on the table with their fist with C six. You might have them pull up on the table again. Now in the position where they're stressing the brachial, uh, brachioradialis, um, fingertips possibly make bare claws, push them really firmly on the table, but stiffen up your claws. Now try to lean those claws on the table too, from the backside. Uh, what else can we do? Grip, you know, squeeze your grips really hard. Does one feel weak or not? Obviously this is their subjective. You can't use the, you can't use your subjectivity any really more cause you can't feel it. Um, and what are we missing there? Uh, um, yeah, it's gonna be hard to do T one. And so, Oh yeah, I guess you could do T one. You can have them squeeze in their fingers, their fingers into their fingers. And obviously you might have to show them these things. However, just know how creative you have to get with these things and you have to be able to talk to them about the outcome. And as I mentioned before, if there's something that makes you feel suspicious, uh, ask them to come in.

There's nothing wrong with that. If they say no, um, warn them. And I have had a person where I told her, I don't, I don't feel comfortable working with you unless you come in to let me do a full workup. I did a full workup. We're, we were very safe. Uh, she was comfortable with it and we did a full workup and, uh, she felt it was all negative. And so moving forward, I know that now it's a baseline knowledge that I needed to know. Um, we obviously can't do pathological reflexes when, when they're, when they're not here, you can't do reflexes either. You can't do light touch. You, um, you can do some cranial nerve stuff and you can probably do, uh, some, uh, some CNS stuff. I mean, you can do Romberg. Hopefully they don't fall. Uh, you can have them do tandem gate. You can have them do rapid movements. There's a lot of things you can have them do to do a fairly competent screen. However, let me warn you again, this is a lot to go through. So make sure that you have a flow and that you feel confident and competent doing it. Because if you lose their trust and you don't get the results that you were able to, that you're able to do with those three things I mentioned earlier, they're not going to come back, you know, and they're just going to suffer through this more because, um, I mean, they haven't been anywhere yet, probably. And they're probably not going to come see you on a virtual and they think virtual is worthless. I might as well just come in person. I'm going to wait till, uh, I can come in person and I totally get it, but it's your responsibility to break that, um, thought process. So practice with friends, get good at your verbal and your copycat cues. Uh, and those are going to be helpful, um, figuring out what to, uh, how to coach these people, uh, and, and make really colorful words. I know this is going to sound like I'm just name dropping, um, of things to look at through this podcast, but, uh, I can't stress it enough.

The things that I've learned over time have been, uh, monumental. And, um, Nick Winkleman has a book is, uh, what we say matters where he kind of goes over the, the whole thing of having colorful cues and, um, making it more external, but also colorful and vibrant. And, um, there has been, uh, I like to, I like to coach people when they are doing a foraminal compression testing, uh, rather than kind of moving them into the position, I like to just say, okay, I want you to, you should actually have pipes on my ceiling, which are perfect because they're in the corners of the room. And so I say, can you look up at that pipe and follow it all the way to the wall? Good. Now look curiously at it, like you're a curious dog. And so they can kind of visualize that if they've had a dog, if they can't, I need to move them a little bit. If you don't have pipes, you can put, uh, stickers in the corners of your room, the exact areas. Generally you guys probably have, um, you know, the same areas that you're doing exams in. So set those things up appropriately. Um, when I'm coaching exercise, uh, I have to be colorful with that as well. Excuse me, uh, burp there. Um, you have to be colorful with that as well. And so, um, I know that with Valsalva's test, you know, you can say, or let's just say, um, now let's skip that one. We'll skip that one. We won't go there. Um, let me, let me, let me digress a little bit here. Um, when we're talking, cause we're going to talk about cues. Um, by the way, if people don't respond well to McKenzie shacklock, general traction types of things, usually I'll push them into a little bit more DNS. And it takes me a little bit longer to get there because I've trialed all these three things first, because usually one of them is going to work, um, to cool things down. We, me and an intern have talked a little bit about this is, is that sometimes you can't predict how someone's going to respond to load. Uh, and they might not be very good at retaining cues. And so sometimes you give people an exercise a little bit too soon and it lights them up and then they don't trust you. And I totally get it. But if these three other things didn't work and I did my job well, and they did them well, and we can tell that there was no change whatsoever. Um, let's just say this was over the course of a week they were doing their homework and so on. Then, uh, I might want to progress them to more of a DNS type of model or like just a high tension exercise model. If we don't want to call it DNS, that's fine. You can use something like the McGill's bird dogs or the McGill big three just include some tension. Um, with DNS, uh, usually we like to include more tension. We can, we can use things that will kind of move into the, uh, attractor state model, which is the Guido van Rysigen type of model where we're trying to really improve the muscular tone momentarily to help break a movement pattern or a compensated movement that they've been doing for quite a long time. We're building some support. Um, but obviously there's a lot of ways to go with this. However, uh, my point was that is, is when you get into exercise, uh, I would show them the position, get in the position and then coach them colorfully when you can. Uh, I would probably first start with the position, show the basic movement, let them be sloppy with it. If it doesn't hurt, add tension, push your heel through the wall as if there's a wall attached to your foot.

Okay. I want you to squeeze a walnut as if you're trying to make walnut juice harder, harder, harder, right? Um, so be colorful. I know Dawne Costantino uses a very good one with a hard style plank where she says, look through the tunnel and then peel. She said like this, peel your belly button off the floor. I started to add peel your, then peel your zipper off the floor because we want to keep it a little bit more external. Uh, I guess we were to be true to cut, uh, true to form on that external cueing process. She should change her cue to peel your belly button ring off the floor, you know, but they might giggle and that might be good actually. So, uh, make sure you're colorful in your cueings.

Obviously we use an audit process where we say, okay, do a movement that's meaningful to you. That hurts squatting down, kneeling down, twisting, turning, go for a run, whatever it might be. And then we're going to do these three things, or in this case, the fourth thing, which might be the exercise. Um, we should have a 30 to 50% change roughly within about a couple minutes of doing this. As long as it's progress, it doesn't have to be perfect as you understand that. Yes, I do. What you do throughout the week is going to be helpful. Um, do what I have you do and just answer me honestly, if it works or not. Can I see in a week? Yes, you can. Perfect. Okay. Generally, we don't use stretches. The problem with stretches is people can always stretch further and let's have a reference point of how far the stretch has changed. Uh, it's, it seems you're just chasing like a, you're chasing multiple rabbits. It's really tough. So I like to pick something that has a bottom floor, like a squat.

It's like, they're only going to get so far with their squat, getting on off the chair has a floor to it. Uh, reaching overhead has a, has a limit, um, or picking up a weight, walking those all limitations. So those ones are the best to do. Uh, other considerations too, which, uh, I know that I'm, it seems like I'm going to be rushing through. This is going to be a shorter podcast today, but I'm hoping this is all good information for you is that there's three other parts that might make it so just a general, better customer service is in play. Uh, number one is you need to have good lighting. The lighting should be in front of you, not behind you. And so, uh, make sure lighting is in play and we're considering actually getting more lighting at our office because when you do zooms at night, uh, we're in it's, it's a little bit tougher and I don't, I don't like moving lights around. Um, but we have had to jump around rooms here and there to, to make, uh, make room for in-person clients. And so, um, but yeah, consider lighting. Uh, you might want to look up some YouTube videos on lighting for zooms and just see what you, what it shows you. Nexus audio. Um, earbuds work. Okay.

Um, I've started to go more towards the beginning. If I'm talking with a person, I'll go, um, if my earbuds have died, uh, then I will put in just, uh, like a, like a headset and I'll talk to them like that. And I'll say, I want to take the headset off. Uh, and I'll back up. If you can't hear me, let me know, but we're going to start, uh, I need to, I need to take these headsets off. Okay. Does that sound good? And they're good with it. Most of the time they can hear you unless you have a lot of background noise. Every time I want to say something meaningful, I walk up to the camera and just kind of put my mouth next to it almost, you know, um, they need to have good internet.

You do as well. So make sure that is set up. Um, if by chance you run into trouble, you can always change your phone to a hotspot. So make sure that you know how to do that. If by chance you're having a router issue, like a wifi router issue, you can actually take that window. We've done this at the office. We take the ethernet cable out of the router and plug it into the main Mac and we make the Mac a hotspot. So you can do that too. Desktops won't work with that because they won't have ethernet cables. Uh, lastly is smile. It's very easy to become very impersonal when you're doing zooms because you're just staring at a screen. Um, uh, smile. They'll like it for it. Like you for when, if you do a lot of zooms, consider a blue light, uh, glasses. I've gotten a pair of those recently because it gets pretty old staring at the screen all day. I know us as chiropractors, we have not really been in that type of situation. So, uh, now you're going to know how the other half lives. Uh, and the last thing before I leave, which I already mentioned before, make sure your disclaimers are in there. Um, you have to, um, go through the Sam Collins workshop, but I'm pretty sure you have to tell people that this does not substitute for an in-person exam. You know, uh, the person is aware that you can't perform certain tests and they're okay with that, blah, blah, blah.

Right. Um, uh, we have something we write into all of our notes when we do telehealth. Uh, last thing is if the case or the, even the history taking makes your butt pucker a little bit, makes you a little uncomfortable and unsure if you should see this person, just refer them on, uh, or tell them to come in person. It's not fair to you or them to have a half-assed exam and then suggest care that might not work or you miss something like a, like a sinister pathology. So make sure you feel good about it and be honest with them about it. They're there. Um, they'll, they'll thank you for it. So, um, thank you guys. Uh, and by the way, if you have not already, I know that, um, there has been a couple of suggestions of things you can do, um, uh, within these podcasts recently. I do think that there's things that, that I can offer you guys that will be very helpful through free clinical practice. I have the five-step patient care system, which is on the website. It's p2sportscare.com slash products. Um, go one through six. I've had a couple of people buy them already. They've been very happy about it. Um, and it is, it's, it's how I train my interns. It's like 15, 18 hours of, of training in this style. Um, that I'm kind of talking about things that work for it very well for us. And, um, you can plug in a lot of things you already know in there, but also hopefully it's exposing the things that you need to be a little better at. Uh, there's also the Cody DMAC workshops, which is upper and lower extremity, uh, coaching for low back disc, uh, as well as upper extremity cases like neck and shoulder. Like they're phenomenal. Like his coaching style is great. It's epic. So you guys will not lose out by doing this and go onto the website, take advantage of them.

Um, yeah, you will not be disappointed. And remember there is that podcast, uh, exclusive version. So become a member. Um, I share some really good stuff within there. And so that's it. Thanks for being part of the movement, share this with a friend and please give a five-star review on your podcast player. It only takes a minute, but it means a lot. Thanks guys. Talk to you soon.