Referred pain, muscle injury types and rehab by video call

When you say virtual, people actually didn't know what virtual meant. They're like, what do you mean? We're just going to talk about it? No, no, no. We're going to do something. Some people thought it was video. Just only, they're like, I remember one lady was like, so the video, she's like, the video is going to have you in it? I said, no, no, no. It's me in a video talking to you. It's really me there. 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. Welcome to the Restoring Human Movement podcast. This is your host, Sebastian Gonzales, and we're going to have a co-host on today. This is Mikey. Hello, hello, hello. Mikey, the intern. This is the third version of Mikey Ask. If this is your first time in the podcast, everybody, welcome. This podcast's whole intention is to improve our patient outcome, really. And so, if you're interested in improving what your patient's outcome is, then you're in the right place. We try to keep this good, easy communication, too. That way, there's not big technical terms in case you want to share it with your patients and you can.

This is like, we're probably in a 200 or something right now. So, we're doing every other week at this point. We were releasing weekly. But because I know some people still need to catch up, I'm going to give you the chance. And I want you guys to go backwards and listen to every single damn one because it's been helpful for me, at least for improving my clinical skills. So, I'm hoping you guys get the same experience in it. Plus, it's going to give me a little bit of a break. Yeah. Do you have anything to add in the beginning? You're the co-host. No, I hope everybody enjoys and I know this is a learned experience for myself being on a podcast, but I'm definitely enjoying it.

So, thank you for the opportunity. Yeah, I think this is, so, you're going to lead the conversation today and just whatever we talk about, there's, but yeah, we can ebb and flow wherever you want. Mike's always got good questions. And as an intern in the office, I feel like it would be a good way to record the answers and answer them at least with full attention because it's hard to answer during patient care time. Yeah, absolutely. So, you just come in a little closer to the mic. Eat that mic. I'm eating it. Good. So, as we all have been going through this pandemic, I know we're recently, you know, finally got the green light to be back in the clinic.

I just want to really, you know, know what kind of experience you had as a, you know, business owner and how did, you know, from a business perspective, you know, with this pandemic, how did you handle it? So, we had, I'll just tell you, listen, this is in California. So, I think there was a two-week period of time where chiropractors were supposed to close, I think, or at least we got the green light, you know, to become essential after, you know, two weeks after closing California. And so, you know, people, some people stayed in office. I opted to stay out of office for about, I think, about just over, just over 30 days or so.

And so, but I know the people that were open throughout, you know, most of that time. And, but it's, it's been different, it's been interesting as a business owner just because people, some people are still to this day, and this is now that California is in, I mean, they're basically, everything's open. Still to this day, people are still afraid to come in. Like, they're, they're, like, we have people filling out intake forms at, I mean, one lady, she's like, I want to book a time where nobody else is there. And that's okay, you know, but like, you consider like what restaurants are doing. Like, how are they going to survive if all they can do is seat every other table?

So, I almost kind of wonder, like, I kind of think at some point there'll be a division here of your people who are okay being around other people, which totally fine, whatever spectrum you're on, but they're okay being around other people. And it's, you'll be able to charge less to these people because you can do more volume. But if you're, say, you're only open eight hours a day and someone wants exclusive time to you, nobody else, no staff, things like that, you gotta, you kind of gotta charge top dollar, right? So, I don't know if the public quite understands that from, not everyone's a business owner, but I think it comes down to, to, to dollars and cents of it.

You can't have, you can't have both. So, we just gotta, I gotta figure out kind of where we're at in this, but we were able to do some telehealth and things like that. So, the park's always nice to do some rehab and everything too. And luckily we weren't, we're not really a, like a passive care treatment office. Like, we don't have a bunch of stem and ultrasound and massage and things like that. So, we're able to keep a good distance anyway. So, it didn't really matter too much for the application of care. Okay. Yeah. So, it was, so you really didn't have an immediate action plan. It was like you were kind of rolling with the punches as they were coming?

Well, because you don't know what you, it's hard to solve a problem if you don't know what you're dealing with. Okay. And so, people would like, there's still patients that we've had that they just completely ghosted on you. It's like, hey, are you, and you try to set the conversation with them, it's like, hey, would you like to do telehealth? You know, do you want to be seen in person? Do you want me to keep six feet distant? Do you want to be outside? You know, and not everybody has good communication. You know, I know I can always improve mine, but people just would rather not call back or email because it's something, I mean, and they're all dealing with their own different things.

There are different stressors going on. You know, they're losing their jobs. They're going on unemployment. You know, they might have a business of their own. I know there was a gym locally here that we kind of talked to that we, like, we want to do some more workshops and we'd have done some workshops and they were really, like, they replied back, they were being real nice. They're like, look, we're just trying to open, you know, people got their own stuff going on. So, it's hard to, my point is, it's hard to form a plan of attack if you don't know what you're dealing with and people were just a little scattered is all.

So, I just went with whatever I saw the trend being and I thought telehealth was the probably way to go on that. Yeah. And how would you say your telehealth experience was overall? I didn't mind it, you know. I didn't like the ergonomics that I had because I was doing it at home. Like, we found our internet, like, it's like everybody decided to go home and watch Netflix. You know, and all of a sudden your internet for, like, Zoom was crap. It was glitchy. We had to up ours and so that made it much better. We got a new modem. But even then, it's like, so my girlfriend was working virtually too.

Now, you got to find different spots where you can be on the ground with people. And it's not like you'd be in the same room. So, now you're going to be in split areas. Plus, if someone comes in, someone comes home, then what, you know? Not even talking about HIPAA privacy issues, but it's like, you know, they'll, like, they're trying to be quiet around you. So, it's, it wasn't bad for outcome of patient outcome. It was not bad at all. There was just other little kind of things you had to consider, just different problems to solve along the way. What were some of those, can you give me some examples?

The internet was one. The internet was a big one because we, we never thought we had bad internet. But I guess I, I have a friend that he kind of explained that internet's not as just as simple as, as you just pay more. It's, has to do with people in your vicinity too. And so, that was one problem to solve. The other one was, was when you say virtual, people actually didn't know what virtual meant. They're like, what do you mean? We're just going to talk about it? No, no, no. We're going to do something. Some people thought it was video, just only, they're like, I remember one lady was like, so the video, it's like, I, I, the video is going to have you in it?

I said, no, no, no. It's, it's me in a video talking to you. It's, it's really me there. And so we, then we started, we started, I forget what we started calling them, but it was, virtual didn't make sense to everybody, you know? And some people were not tech savvy. I remember there was a couple people and they had, they had, for a period of time, there was like a looseness of what was considered HIPAA, okay, from what I understand. And some people, they could log on to Zoom. One person wanted to do Skype. Someone else said, hey, can you do FaceTime? You know, there was all these things that you just had to be aware of.

Like, I mean, we had this one couple that they, like, they wanted to, they just did not want to use an app. It's like, what do you do then? So there's just other little barriers. That was probably two was, you know, figuring out just tech issues. But yeah, the, the, the virtual conversation was interesting. And I think one, one barrier with that was they didn't quite understand that, like, we started sending out emails on this. We said, look, everything there for your care for this, like, so that one person, they say you that has a low back and it's just an acute disc. What I'm going to suggest to you, the cool thing is during, during this whole stay at home thing, what I would suggest to you, it would not change.

The results won't change. The only thing it will change is I can't do a complete exam. And here's the reasons why. And you're supposed to give them the verbal disclaimer and ask them if that's okay. And you weren't even supposed to, you can't tell them they can't come in either. It's not supposed to substitute. They could come in, but most people opted not to for a period of time. And you were considered a doctor in telehealth? Yeah, yeah. Or you are a trainer? So, in this goes, now this comes into state lines issues. And we call around on these things. And so, everybody's state's going to be different on this.

It's, and I'm not going to pretend to know all the answers on this because we still didn't get straight answers on a lot of them. And I'm going to try to recall them off the top of my head is that basically in California, if you, like if you, we called the, we called the state board literally for weeks just to get this one answer. Can we do telehealth? And finally, the, the interpretation they gave us was, yeah, you know, and there, it was, it was never, they, their emails were kind of like, we, we screenshot this email just because we wanted to make sure we had documentation. It was, it was, their, their answers were never precise.

It was like, yes or no, you know, and they just couldn't give you an answer. I remember we called Florida and cause there was someone interested in help in Florida cause they couldn't go anywhere in Florida. And Florida is a state where they would allow you to have a chiropractic license there. If you had filled out an application as like, uh, not a temp or they, it was basically like kind of like a guest, they would allow it, but then you had to apply. And so we asked that person, we said, how, how serious are you? You know, cause I'm not going to go and apply, apply if we don't, you know, if you're not going to, cause then it's funny after we said that they jumped ship and they didn't want, so we didn't proceed with that.

But we came to the conclusion that most states, um, did not really want a different state provider to do that, to do a diagnosis over the phone. So, uh, I, I know Sydney or Australia was the same way that, or I think they, uh, they were a no basically. I think Canada was a no. There's a bunch of places that were no's. Um, so we decided to say in California, it was just the easiest thing. And even one of the webinars we went on to on Cal Cairo, one of their telehealth things, their, their server systems are like, they're like, Hey, use this instead of zoom. It, it geo located where the patient was.

So you can prove they were in California state lines. And so it just kind of made me think, Oh, California is like, luckily we have a big state. So did you, did you have established patients come into you or what? Did you have any new patients? We had, we had both. We had both. Um, yeah, the examination was a little bit more tricky to be creative. Um, but we just, you told them, you know, you're supposed to give them the disclaimer. You can't do certain examinations. And, you know, and I said, look, if, if I just said, if, if things don't improve according to like, you should just come in, I need to do a full exam workup with you, you know, so it doesn't substitute.

It's just because of the situation. Um, but yeah, I had people that, you know, they emailed and they said, Hey, am I got an elbow issue? And, uh, what do you think about that? And I said, yeah, let's do a, let's do a thing, you know? Uh, well that brings me to my next question is like, say for instance, you have a new patient. Can you give me an example of like the workup that you, like, how did you go about it? How was your flow? Yeah. You can pick a specific case, like maybe the most interesting case that you had over this pandemic and then kind of give us the flow. Yeah. There was, um, there was, it was a, the core ones was a fun one.

Um, and so based upon, you, you did the webinar that I already put together. So, um, the, the rough percentages are that what was wrist, like 40%, 30% or hand, hand wrist was, okay, make sure you eat that mic. Cause, uh, they're not going to be able to hear your question. Got it, got it. Um, I want to say it was like 40% is, is spinal referred based upon that Rosdale, uh, 2019. And so with each person, I would just kind of screen cervical, at least with that person, I'd screen cervical, sustained postures, flexion, extension, rotation, so on. You know, um, uh, it was interesting to have them do, to try to do a foraminal, uh, foraminal compression test or, um, uh, I guess not max foraminal compression, but you have them look up to the side, you know?

Uh, so that was, that was, uh, useful. Um, a lot of the, a lot of the MDT kind of like end range loading stuff was helpful to see if it was, um, going to be there. You had to ask a lot of questions about like sensations of the wrist or of the skin and so on to check out at least beyond reasonable doubt if you have any issues up there. Um, and, and the red flags were useful. If there's anyone had like a red flag, I just told them I don't want to like, there was very specific, you know, circumstances where we would take these people. Um, so in that case in particular, I screened the cervical spine, you know, range of motion, as many orthopedics as I can verbally get them to do.

Um, I even had, uh, them push their own head down axially in some of them too. And if the person wasn't, it, some of them, you can see like they were, they were laterally bending, so you had to, you had to improve your communication with them. Um, and then Finkelstein, super easy one. And so with her, uh, I deemed it was not, uh, at least according to that exam, I deemed it not neck, neck cervical related. Uh, so we did a local attractor state with that. And so local stabilization around the hand, cause the odds are that it's 60% roughly is going to be local hand. And so I had her grab a, uh, a chair from her dinner table and I had her a lobster claw grip it so long that her, that her palm like spasmed.

And I said, good, take 10 seconds, do it again, do it again, do it again. And so her outcome measure was she had a pan or she had a big pot, like a stock pot. And so she was, she's like, yeah, my wrist hurts when I do this. And then I did that maneuver with her and she's like, oh, it's gone. And then a week later we followed it up and still gone. It's still gone to the, to, to what I know. Like she's, she's been in good communication with me for other things and she hasn't mentioned it. So, um, that would be an example of maybe a cervical, I screened the cervical and then I went local there, but it was just gathering enough information to try something basically.

Oh, so it was a Palmer intero, like the Palmer deep muscles. Yeah. Or maybe an inhibited that you just had to activate them. And that was pretty much the issue. It took away out from the extenders and the thumb extenders. Yeah. I think we just, you just shift around load, you know? Um, and you had mentioned that too, earlier you mentioned the 2A, 2B. I think that was probably 2B. You know, 2B is, uh, you know, hypertonic is working. The phasic were kind of shut down locally there maybe. Um, but, uh, category, uh, 2A, according to the 2012, uh, soft tissue injury paper, um, would be spinal, spinal referred and it didn't seem spinal referred.

So, and I doubt there was any terror or else you wouldn't be able to even pick up the pot. Right. So, yeah. We're not looking at a scar tissue or model or adhesions. We're probably just looking at inhibition. Wow. That's awesome. So, I don't think they, I don't think it really changed the course of care for a lot of people, but they didn't all understand that. Especially new patients didn't understand what was going to happen. Because what could you possibly do as a chiropractor if you weren't able to touch them, right? Yeah, absolutely. There's not much I can do. So, what do you think our, as a profession, the chiropractic profession, do you feel like, uh, there should be, you know, clarification when it comes to telehealth?

Clarification. Clarification and meaning like it for us to be able to, not like a gray area because I feel like they were not giving you an assertive answer. I don't think, I mean, yeah, I mean, I'd say, I'd say yes. You know, like I'd say it'd be nice, you know, I'm pretty sure nurses, I think, you can call nursing hotlines and say, hey, my chest is kind of tight and my arm hurts and I'm sweating. And they're like, okay, so, um, you, sir, are, have a heart attack, come in. Or vice versa, they say, oh, you're okay, it's an ingestion. Other professions can do it, you know? I think our, I call, I actually called, I called like, I want to say six, seven years ago, multiple states about this.

And their response was something to the effect of, huh, we never thought about that. Let us get back to you when we meet next time. And they didn't, they didn't get back. They didn't, they didn't rule anything like shit. Like there was an IV in the infrastructure for telehealth. In most medicine, there was HIPAA compliant most for the most part until this happened. And so, you, you'll find that, um, they allowed FaceTime. They allowed, um, like, Zoom got, Zoom got hacked a bunch, you know, with people throwing images in there. I'm sure Skype wasn't super secure either. Um, EHRs, Jane now has, Jane App, the, uh, which by the way, Jane App is killer in case you don't have an EHR.

That's pretty awesome. Uh, they now have telehealth. You know, there was a lot of things that weren't around. There was no infrastructure for it. So I just don't think it was part of the plan. And so the governing bodies just didn't really care to talk about it as all. But, um, I still don't know if there's a hundred percent like, um, what I, from what I've seen, yes, we can do it. Um, and even insurance companies will pay for it. There's a code now. Really? What is it? Um, they're, I did, they'll, they'll pay for, um, according to H.J. Ross, it was, uh, they'll pay for exam codes for chiropractic.

They'll pay for exam codes like your 99213, 214, so on. And I think it was time-based, not, not necessarily bullet point. Um, and then you had to, I think a modifier was 95. And I think the location on your, it was like box 24B or something. It's no longer office. Now it's like virtual. And so they, they actually, we had claims that were paid on that, um, through some of the carriers. Medicare, I think doesn't allow it, but I think the VA does, you know, TriWest does. So, um, I'd say probably yes, but y'all got to talk to your attorneys in your states about this kind of stuff. So we did a lot, like if we didn't do our due diligence, I'd be very surprised.

We spent hours and hours and hours trying to get the information and it was very hard to find. Wow. Well, at least you got it done and you adapted and overcame. Um, in regards to your, your patients, where they, after the first visit, did you have some that ghosted you or did you have the same ones as keep coming and keep coming to eventually you opened up shop here? Yeah, we had some that came after. Um, there's a couple of ones we're managing right now that are, um, that they started off as telehealth and when they came in the first time and did a full workup on them. Um, and the, I know there was one that I got wrong on, uh, on telehealth.

And then I, I flipped the switch when I, when I was able to, to test a little bit more thoroughly, but for the most part, I don't feel like I, I missed anything big, you know? Um, but yeah, there was, there was one guy took like by the time the whole thing like passed, like he was, uh, uh, he started on like day one of like closure. Um, he was all done, actually two people all done, closed out, um, no need to come in within, uh, I think two months or so. Just you periodically check-ins on, on, on virtuals. So, um, those are great, perfect, easy, super easy cases. Um, and they were managed, they're, they're super appreciative, um, willing to write reviews.

And so it was a good experience for everybody. Wow. That's awesome. Well, that was great information. And those are all my questions. That's it. We only got 20, that's 20 minutes. Gotta make it short and sweet, man. I don't know. We got time to fill. This is gonna be a full episode. What else you got? You talked about, um, 2A, 2B out there. Do you have any questions? Um, so Mike took the, uh, I, I just did the five step webinar. Um, there was a webinar series. Um, it was, I, I liked that it was done because, uh, I can train interns that way now. And I know Mike's got a lot of good questions, but I don't, I'm sure you have more questions about it.

Um, but you had a question about, or we were talking earlier, uh, about muscular injury categories. Um, did you want to talk about any of that stuff or, uh, I guess I can have like a, I guess I, I definitely, you, you definitely taught me over the, over the zoom call that you, you had for us for this lecture. But I mean, if you can just re-explain everything again, that'd be great, especially like, for your, for your, uh, the referral one, the referral one, everything. I mean, if we can just kind of give it a quick little breakdown, give them a little teaser of, you know, the paper itself. So, so there was, um, that was in, that was in lecture five of six.

And, um, that lecture was, it started, it was labeled upper extremity referral. Then I realized I should change it to, um, or sorry, it was ridiculous. And then I changed it to referral. Um, I honestly didn't know how to exactly teach it, but I think there was a godsend moment where R2P symposium decided to have Brett Winchester on who pulled the research from, uh, was it Rosedale 2019, which basically said that like the impressive numbers of 72% of thighs are not going to be muscle problems. And 71% of hips are not muscle problems. There are, or so basically they're referred. Um, and I think the criteria for that was, um, and I, I might misspeak here, but, um, they involved like 320 people.

The patient and the referring doctor said there's no spinal component. We're sure of it basically in so many words. And then they had MDT dumped to them and they found that there was 72% of thighs, 71% of hips, I think 48% of shoulders. Um, forearms were like 85 or something, you know? And so kind of like I tried to take that information and when presenting it to you guys about what do we do, like based upon the probabilities, like why would we pick what we're going to pick for treatment? And so say if we're looking at a thigh, like a rectus femoris strain, why would we do tissue work on it at the first go?

If we're 72% sure it's spinal related. You see what I mean? Yeah. And if we, and if it is a muscular injury, what type is it? So we know what type of care to do. Hence that 2012 consensus statement of soft tissue injuries. And so there was category one, a one B, which is basically like your DOMS and fatigue based muscle injuries that nobody ever comes in for. No one comes in for DOMS. And so let's just scrap those off the table. There was two a two B, which is spinal related. And then reciprocal inhibition was two, two B. And then there was three a three B, which is basically partial tears and like positive MRI stuff.

Right. Which we'll see those two. Um, but within there, they basically said 70% of what we see in clinic is going to be under, or it's going to have a negative MRI. And so that includes one a one B two a two B we already said that no one comes in for DOMS. So I doubt anybody's going to come in with one a one B. They're going to come in with two a two B. Yeah. Okay. Now with two a is spinal referred, which it would classify, I think in that McKen, uh, the McKenzie study, which is again, 72% of thigh, or let's just say we're talking about that wrist. Uh, probably the wrist is a better example. Um, so based upon the percentages there, that wrist is, and I might misquote this is 35% of wrist and hand problems are going to be, um, uh, spinal referred.

Okay. So when I did the exam on that lady, I just checked because you got to check anyway. So I checked the neck. I didn't see anything. I actually did a reduction, uh, to see if it affected her, her pot carrying ability. Um, and that didn't work. And so I'm not married to the idea of being spinal, but based upon the percentages, um, uh, or sorry, I like to start central first and move outward. So I just ruled the spine out and then we went into, okay, so this is, uh, since it's, it's probably going to be 70% roughly wrist hand local, we'll treat it like that. All right. And that's why that you did the attractor state, you know, deep finger, whatever you want to call them, intrinsic hand.

And that's why we went that way. But, um, if we're talking about this from a 2A, 2B perspective, if this was a, uh, let's just say if it was a spinal referred to the hand, say like your decuervins, which is like a radicular decuervins, like your radial nerve decuervins, then we would treat this from the spine. No big deal. It gets better. It's easy. 2B. You treat it as a spine thing. You're very good at treating your spine thing. It doesn't get better as a spine thing. And it doesn't differentiate in testing as a spine thing. It's probably a 2B, which is then reciprocal inhibition of the hand, deep, uh, intrinsic hand muscles took it away.

She was better and that's good. But this is where we get into the imaging then. Why would we treat it like a 3A, 3B if there's no proof? And there's a 70% probability it's going to be not going to be positive, right? Let's go off our probabilities. And that was the whole point of that presentation is, is don't start chasing these, these pseudo syndromes, um, especially pseudo IT band, you know, pseudo puriformis, all this, all this stuff. It's probably pseudo syndromes. They're not real. They're just, um, I'm sure there's real ones out there, but we're, we're chasing unicorns is kind of the point I made in the referrals, just plain devil's advocate.

Granted, there could be local stuff. There can be scar tissue. There can be, there can be all that stuff. But if we know in the thigh, someone comes in with an IT band, let's say hamstring is the easiest probably. I remember I had this lady who came in. She had a bilateral IT band tightness from driving her car for an hour. She was, she was, she was not in good shape. Is there any mechanism for that? Okay. 72% says she's going to be spinal anyways. She's deconditioned. She has no MOI for it. Why are we doing tissue work on this hamstring again? It probably has a negative imaging too. It's probably a, it's probably a 2A, 2B.

Screen out the 2A first. 72% is there. And then go to your 2B if it really is a local thing. But the don't go against your odds was the whole point of that presentation. No, that was a great presentation. And I feel like it kind of piggybacks on the whole Dr. Snell's course on fix your own back when he talks about the neurocentric approach. So it definitely reaffirms all that. Yeah. He, he does a good job. I remember talking to him and Justin Dean in a, a line at lunch one time. And I said, I said, basically sum it up, sum it up in a, in a, in a sentence. They said, start central, go peripheral, then go cutaneous.

And basically, and I would take that interpretation. If there's nothing there, if there's no problem there, then go to your, your tissues that are like pawns in a chess game, you know, the things that are a little bit more of the obscurities. But I think we, I, I think, I think our profession does a lot of, of stuff that is against the percentages. And I know I do it often too. I do it because patients ask me to. And, and, and I, I, I do it because sometimes I'm not quite sure what to, to try from the spinal perspective or the, or the attractor state perspective. Um, but I think if we have the other tools in our arsenal, telehealth will get really easy.

Yeah. I'm not too sure if you explained what the attractor state is, but can you just, the list to, for the listeners, can you clarify that? Uh, I'll give you a basic rundown, but for the most part, um, I've interviewed Guido van Reisingen twice on this podcast. Again, this is the whole point of, of doing it every once or two weeks. Now, go back and listen to Guido van Reisingen. He explains, it's his whole, his whole thing. It's his bread and butter. Um, he explains it probably better than I will. I'll tell you, I'll tell you from a tonic phasic perspective. Okay. Does anyone ever come in? Uh, sorry.

I bet every muscle that everybody ever comes in blaming as being the tightest thing that they've ever seen in their life is always a tonic muscle. Okay. There's tonic phasic yanda. And I know people say, oh, yanda was like, there's no research behind yanda. Yeah, but it's general observation. You know, there's no research behind, you know, aliens, but people probably believe it too. Um, but, uh, upper trap, tonic, right? Lower back, uh, paraspinals, tonic. Um, so there's, these tonic ones are the ones that, um, will have an affinity to, uh, kind of, um, they'll, they'll create like a, uh, a protective type of position when, when something's under threat.

Um, I know when, uh, when I was, I think I was talking to you about it. Yeah, I did. If I punch in the stomach, what are you going to do? Brace or lean in. Your brace. Yeah. Well, after the impact, you're going to lean in a little bit, right? You're going to double over. No one ever just sits up and says, oh, yeah, it's great, right? Um, so you have an affinity to do that thing. When people dislocate their arm, they don't go away, a wave and stuff. They hug by their belly. Um, when someone has abdominal pain or appendicitis, they don't walk around, like they just curl up in a fetal position. There's general things throughout, I think, research that we found that generally happen.

Um, knee pain, let's look at the VMO, right? Let's look at the hip, um, and things like that, right? When you look at the back, let's look at the core. Um, and those are all going to be like your, your phasic group for the most part. Um, so it, with that being said, just go off of what has been found a bunch, you know, strengthen the phasic, beat down the tonic. Not necessarily the, the muscle that's technically overused, but the one that's underutilized. Yeah. The underutilization principle. And I don't, uh, I know I'm just feel like I'm bashing soft tissue work. I do, I've done soft, I did soft tissue work on, um, half the people I saw today, you know, but the, the purpose is, is, you know, people like to be touched.

It makes them feel better. And if I'm going to pick some muscles to do some tissue work on, it's going to be the tonic group. And then I'm going to take them out to the weight room immediately after, pick some very specific corrective exercises and then load them to get the phasic going. Um, you know, so that would be, I guess that'd be your basic, I'm sure Guido, I'm sorry, I probably I butchered your attractor's sake, but most people I haven't heard of Guido. Uh, he's always the Guido guy. He's awesome. Everybody should go look up Guido, Van, Rice and Gim. Um, good presenter, really good presenter.

What else do you want to talk about? Um, I guess, um, what is your plan now that we're back in clinic? Like how are we going to get, you know, people back in here? That's, that's a good question. It's a good question. Um, yeah, that's a little tougher. Uh, it's, it's, it's surprising after talking to Ali, some of her clients are still, still have not left the house in, it's been four, four months, three months now, you know, and uh, it's, uh, I kind of wonder with, uh, cause we're doing YouTube paid ads right now. Um, and by the way, YouTube, uh, you can do YouTube paid ads for as low as like a cent a click.

It's such, it's so good, especially if you're any good on camera. So I've, I've loved using YouTube ads over the years. Um, and so I started promoting those. We actually started to get a lot of, uh, YouTube calls, a lot of YouTube inquiries, people emailing us. They're, they're from different areas, which is a little bit of a problem, but, uh, we started surrounding the office in some, uh, areas that we think can afford our services. I don't want to necessarily like, like, I'm not going to say they can't watch our videos in other areas, but you know, I want to make sure my marketing dollars spent well.

And so we'll surround the, those areas and we'll promote the videos to them. And so, and I'm just set, I was setting this up last, this part less up last night, but you want to create a, a flow of how people are engaged with you. And so if nobody's seen or heard of you yet, your YouTube videos, or even know your exist, you have video one, which is like, you know, kind of like friendly, educational, show them how to do something, hit mobility, whatever, you know? And so if they're dealing, maybe that's someone who's dealing with low back pain, they're looking for hit mobility. And then maybe the next video, after they watch that video, then they're prompted, you remark it to them.

Uh, and you can do this through YouTube. You do it through Google ads and stuff like that too. Um, but you remark it to them, the next video in the series that you want them to experience you with, you know, it wouldn't make any sense for them to see a wrist video. They want to see a hip one again. Right. And so you keep going on that thread. Um, but I kind of wonder, cause we had a good spurt of like new, we had like, I think like six, six ish new patients. Like the first week we were really truly back, um, just from YouTube. And, um, I kind of, it slowed down a little bit. I kind of wonder how successful that campaign would be if we weren't in the situation that we're in either, you know, because we can't assume say those patients that haven't, the people who haven't left their house in three months, like just they're doing Instacart and stuff like that.

Like they're not, their pain point is not bad enough for them to risk going outside. Um, so it, it kind of muddies things up a little bit. Uh, another, another thing, which is a little bit challenging too, is that the sanitary procedure people generally, I, I guess I'm assuming they want to like, they want space. Like I mentioned that lady earlier. Um, I, I've gone to longer hours, um, and like the interns couldn't come, right? So that flow kind of screwed itself up cause you guys are working people on the floor. Um, so it's just, it's just different a little bit. And I think it's just going to take a little bit time to, to start narrowing that up.

And for people, it's, I think it's all about trust. People have to trust that you're clean, you know, and if they don't trust that you're clean, they don't know you, they're going to ask that nobody else is there or that, Hey, can like maybe they want to see you clean the table. So everybody's just a little different. I don't know how we're going to get them all to come back in, but, uh, YouTube is high. It's, um, they don't even charge you unless someone watches your video for 30 seconds. It could be a one minute video. So they watch half the video. So it's a YouTube, I think is the way to go, but I need to get on that train.

I can't wait to see you make a video. I saw that one video you made. It was fun. It was nerve wracking. I mean, I just kind of said, you know what? Screw it. I'm just going to be myself in front of the camera and give it a run. And it was fun. Yeah. What was that? The heart, that was the hard plank you did. The hard plank that was influenced by you. But, uh, I'll be making, I'll be dropping one hopefully this upcoming week. I'll be hopefully using your facility here and hopefully you can help me out with proper cues. Cause I, I tend to, um, over explain and over, um, complicate, you know, just simple cues.

Yeah. I think you, I think you do a pretty good job, but it's, uh, uh, yeah. So like that girl you were working with earlier, right? So I don't know if you know if she's done that exercise like three times already, right? Yeah. And so I think the way you explained it, it was from like somebody who has never seen it before. Oh. And she, so maybe you could have asked her like, Hey, uh, I'm going to show you something real quick. Remember, do you remember this one? Have you done this one? Yeah, I have. Show it to me. And then you can clean up the little bits. You don't need to like start from ground zero.

I definitely assumed there. She was probably, I was looking at her. I was, I was like, yeah, I was thinking, I was thinking, man, she guys are, she was probably thinking, Oh, I've, yeah, I've done this before. I think that's great because now that before I just jump in and try to explain something that, and I assume that I've never done and then I'm just going to make my, I'm going to make myself look, you know, silly. So I think definitely I would, I'm going to ask them if, you know, they've done this before or even demonstrate and be like, does this seem, does this look familiar? And then just clean it up.

Like you said. Yeah. Yeah, you're doing pretty good so far. I think, uh, I mean, but the best thing you got is that people will like you. Hope so, man. I just gotta, yeah, you just gotta be nice to them, I guess, especially in tough times around this, around this time. So you just gotta love on people. Yeah. Um, let me, can I ask you a question? Of course. Okay. Cause I, uh, uh, I'm going to, I'm going to apologize, but I'm not going to apologize to everybody, but I'm going to be talking about the, the five step course for a little bit of time here because I put a lot of time and effort into it.

Um, I want to see what was your, what was your experience with it? Um, when, what were some takeaways, by the way, where I will, I will put a link. It's a six part series. Start with the hip. Um, I changed the flow a little bit as I went. Uh, did you have any, any constructive criticism? I don't know if I'll record it again, but I can patch things in. No, I honestly, it was, for the most part, it was great. Um, and I, I mentioned this in my first, um, podcast when you told me like, you know, what do you want to learn from, like from being here? And I told you, I want to create a structure, you know what I'm saying?

Cause I'm, I'm the type of person that I need structure to follow. If not, I'm going to be all over the place. So the fact that you have a five step and I know where things I'm familiar, where things like where to place different, um, you know, parts of the treatment, it's, it has allowed me to flow and, uh, allow my mind to be, um, more on a straight line rather than, you know, going off of the road, you know what I'm saying? And so I feel, um, it's helped me the fact that it's structured. Yeah. It's like my favorite part of it, to be honest. Okay. Yeah. I think, uh, did you, did you have, I know you weren't working in clinic.

Um, did you have a chance to try any of this stuff on people yet? No, only, only in the beginning. And I already told you about that experience. Um, I did, I believe I had a, uh, a shoulder, uh, come into the sports medicine clinic at SCU. And, um, again, I followed the five step protocol and you already had some like pre-written. So I kind of followed those steps. Oh, you took those ones that were in the Google drive, right? Absolutely. I used everything. And, uh, and he was, and you know, my patient responded well and I was able to get them out like in four to five weeks. So, I mean, yeah, those are money.

So if you're listening and, and you are like myself where you're trying to find structure in it with the rehab protocol, I highly recommend these webinars and said, put a lot of hard work into them and you will see how helpful, you know, they are. So, yeah. Well, thanks. I had, I had a good model too. Um, yeah. So I'll probably, I'll probably, um, I'm going to interview, um, somebody about like one of the guys in there, he, he was able to implement quite a lot of it. And so he had some, he kept emailing me with some really cool stories of, of things. Practicing doctor. No, he was a student, he was a student.

So I, I don't know what the thing was in their state about, you know, what they could and couldn't do time with, but, um, he has some, he has some really good, I'm like, as I read it, I was, uh, he was talking about a couple of hips and I was like, dude, like, like I'm proud to say like this hat, like this is like, that's good. That's really good. And I'm like, damn, like that, it seems so, I was kind of jealous cause I had a hip case at the same time. And I'm like, why is your hip so damn easy? Like he followed the process and it was easy for him. And I was like, dude, I got a hip that just sucks right now, you know?

So, um, but it was nice to see that things were working for people. Um, and, uh, but I want to, I want to see some more stories. I want to see what, um, comes out of it. Cause it's, uh, I was talking to, I'm sure Cody's has, will have already released. We're talking about, um, how people can like, what's, what's kind of missing in, in, in education. If there's any ways to bypass, you know, um, bypass some of the, some of the things and workshops and books you should read, or if you should just take them. And he's like, I think you just take them. I said, I think you're right. But, um, the thing that we could not come to terms on was that there's really almost no place to learn how to do, uh, use exercise as a, as a strategy, um, at least into the higher levels.

Um, I know DNS is, is, is a good spot to go to for a lot of things, but also it's, uh, um, it kind of keeps it like people are still on the floor at that point, you know, so in scaling the exercise and, um, I asked him how he got his experience and he's like, I was just around the gym a lot. And I was like, I was too, like, I really don't know any other way to, other than just have someone show you. So, um, I'm hoping the webinar, uh, filled some of those voids for people was the point because it's hard to get people off the floor sometimes in rehab. Yeah. If you're not familiar with Dan John, I highly recommend because that was my foundation coming into this clinic and just knowing the, the functional movements, you know, the very basic movements.

And I feel like that allowed me to come in here and told me, okay, this guy's, uh, uh, you know, flexion intolerant, you know, do, you know, follow Dan John's protocol and give them their exercises. And that's exactly what I did. And it was just so simple to just pull things out and get creative with it. Did, did you do Boyle yet? Have you read Boyle's book? I have not read my book. Oh, I got Boyle's book here. I think Dawne Costantino has it right now. Oh, is it? Yeah. You can borrow that one. That one, that one's good and simple too. It's a really easy starting point. Yeah. Um, so yeah, Mike Boyle. You'll love a video.

Cause I, I, that, I didn't read the book. I read, I saw the video. Um, I am not aware of him. No, his is, I would just read his book. His book is actually pretty, it's pretty easy. You know, um, I'm sure if you go onto YouTube, there's, you know, simple things like I, I think some of the stuff that they are able to plug in with, you know, seeing people like lift weights, like just general safety precautions. And I remember seeing one video that he had that was on, I forget he made it for a, I want to say like bodybuilding or something like that. Like one of the magazines or something like that.

And, uh, it was basically, it was like a two minute video on deadlifting. He's like, like, find the way, get a comfortable stance, stand up, put it down. You know, it wasn't like, Oh, like it was just simple cues. I think as you see more of the coaches, there's more simple cues. And, um, one of the thing criteria he had in there is like, look, if your athlete can't touch your toe, don't teach them deadlift, you know? And it's like, great. Like, I think that's a good call. I can hear if someone comes in, they can't touch your toes. Uh, I'm going to scale their deadlift a bit. If I need to build that hip hinge, I'm not going to put them on the floor.

Um, so there's just easy stuff to learn from. I think I just bought Winkleman's book too. I didn't, I didn't read, read that yet, but that's going to be a good one too. There's a lot of books that I have that I have not even touched. So I'll definitely, but first crisp that needs to be done. Hopefully. Still going to crisp it? Yeah. I need to finish lower back crisp, cervical crisp. And then, uh, you said a McGill, right? McGill. Low back disorders. Um, what do you say locomotion first before McGill? Uh, I do locomotion later. It's, uh, mainly just because of how easy the other ones are to read.

Uh, Michaud is, he's a badass. That book is meaty. It is meaty. I think I learned more about human evolution from that book than it, like, it's like, it's, when you go through it, he actually, he drew all those pictures. They really? Yeah, that's, they're really good. Um, but yeah, it's just, it's just big and it's meaty. I want to say it has like over 2000 articles referenced, you know? So it's, um, uh, it's, it's, it's a, it's a good book though. So from the parts that I've gotten, um, just, I know we've already hit on this before. I probably, I probably have with other people, but, um, what's the, I've interviewed Don Murphy, uh, from crisp on this podcast before.

For some reason, I, I noticed that people don't give crisp a chance. What is the, have you noticed this or, um, I was, I first heard about the crisp protocols in clinical reasoning three from Dr. Lee, Felix Lee out in SU and, uh, but definitely listening to your podcast and actually listening to the podcast that you had Dr. Murphy in. I was like, I just, I just really believed on the way you treated patients. And I was like, I, that's exactly how I want to treat it. So I, I was like, you know, the only way to learn is, you know, follow what they're recommending. And those are the books. I started reading it and I was like that chapter five alone, just to kind of, that's the only chapter I've read.

I need to go, that's exactly the one they told me to just read chapter five. And I was just kind of, I like how they have the regressions and progressions when you're doing N-range loading and you're doing, um, examinations. It's pretty cool. Yeah. I think, uh, like he was a badass, like on that podcast, like I really enjoyed talking to him. Um, I kind of wonder what's in that, uh, that, um, that program he has, what is it called? The primary PSP, primary spine practitioner. Oh, it's a whole program, right? Yeah. It's out of, uh, is it, um, Pittsburgh, University of Pittsburgh. But, uh, I know I have one, I have one guy, I know that it's going through it, but I think it's, it's multiple weekends, kind of that kind of thing.

But, uh, what he talks about, like, is that, you know, as, as chiropractors, I'm sure PT is same thing, you know, it's like you have so much knowledge of musculoskeletal anatomy. Why are you not the primary care, the place that people go to when they have spinal problems, like, like back and neck pain? Like, why are you not the first stop and why are physicians, uh, not referring to this primary spine guy before they refer on to an ortho? Um, because we have all the tools in our tool belt. We just have to organize, but, um, it's funny. We said that, uh, he said that I said, how close is each, each graduate from becoming like a, basically a bad-ass in the spine?

And he's like, yeah, not even close. So, uh, I think that book's a good starting point for everybody. I feel like at school, they, they, they over, they throw us so much information. It's just, I think it really comes up to mentorship and really having somebody to really help you organize everything that we learn. What things to kind of, you know, okay, that was just for us to pass boards, you know, but in reality, this is what we use. I feel a mentorship is honestly key. And if you want to have some sort of success when you get out. Yeah, I agree. Um, as we start to close up here, uh, is there anything that you want to talk about or question?

Cause when we walk out of here and you ask me a question, I'm gonna say, how come you didn't ask that in the podcast? One more question. Like, cause I feel like, I hope I'm not, maybe I'm the only one, but I, I overthink things and I over tend to, uh, over cue and complicate, uh, the cues. Um, why do you think that, you know, coming out of school, is it because, you know, you want to show them how smart you are or to overcomplicate it, not overcomplicate, like just over explaining things. Oh, I don't know. I don't know. I, I, I, I do it too. I think I, I think I talk a little much for when, when we're doing that mainly because I'm trying to do fun analogies, but, um, I don't know too.

Are you doing like the whole, like, okay, you want to do this to get your glute on and get that and so on? Like I catch myself doing it, but I definitely want to deviate from it, but, and make it just simple, fun and understanding. That's exactly, essentially what the goal. Well, why, why do you think that you make it longer than it needs to be? Like what's the, maybe I'm trying to like say word for word what I read in a textbook. Yeah. You know, it's, it's funny. Uh, I have a friend, he, he helps me with some of the online like aspects of the business and, uh, he, he called me the other day and so there was a picture of a bird dog and so I'd, I'd like put in with like a photo editor, I'd put coffee cups on the person's back and there's like little steam coming off him and so on.

And, uh, so he's like, there were, there's written instructions too, which, um, obviously I think people only the first time, but he, uh, he's like, so then he's not, he's not in, he's not a physician. He just does something else. And so he's like, what's with the coffee cups? And I said, well, so if you read the bottom, it says, uh, it says don't drop the coffee cups. There's hot coffee in the cups. And he's like, but the, in the picture, it's a little, they're a little crooked and I'm not quite sure what I mean. I know what you mean by don't drop the coffee cups. And I said, look, if you're on the ground and there's coffee on your back, don't drop it.

Simple as that. Don't drop it. And he's like, do you mean not drop it off the back and the side? I said, don't drop the cup. Okay. And so I'm like, do you want me to overcomplicate this? Cause I can. Um, and, and I, I just told him he's a, he's a little bit intricate with like, um, he was even telling me like the low, he's like your logo and your shirt and Dawne Costantino's shirt don't always match. And I think you need to, I'm like, look, no one's looking at our shirt, man. Just chill. And, um, he's a little perfectionist about it, but he, uh, he, he wants more detail about how to do that exercise. And I know that's a certain type of person, but for most, I told him, I was like, look, I'll tell you what, I've done this cue.

I don't know how many times in office I just pat their back and say, look, there's a coffee cup on your back. Do not drop it. It's full of hot coffee. It's going to hurt. And it works out fine. I don't have to overcomplicate this. Don't overcomplicate this. Just don't drop your damn cup. So, um, I don't know. They could be super simple as I guess the point, just, uh, make the cue real, you know, as probably the easiest. Um, you ever, did you see a lady earlier this morning where I put the stick out and I said, touch the stick and she didn't touch the stick. She went towards the stick. Yeah, she wasn't.

She was reaching towards it, but now she didn't. Yeah. But I said, touch the stick. And, uh, she was doing what I needed her to do. She was feeling what she needed to feel. So I didn't fuss about it, but some people all say, I said, touch the stick, you know, like in a nicer way, but touch the stick, you miss the stick again, touch this, touch the stick. I mean it like touch the stick, like it, like your life depends on it. It's like, touch the stick. So I don't, I don't know if everybody, like if you make the cue real enough, movement will emerge. Like it will happen. But if you, um, if you don't emphasize enough, I think, I think sometimes they think that you're saying things not for a reason, you're saying them for a reason, but the more that you say, the more you water that down, I think anyways, but just find some cues that work for you.

Different cues work for you and different cues work for different patients too. You have to have a little arsenal on you. I guess that's going to come with experience, right? Yeah. Um, yeah. And through you, you'll get it. Um, but I think the, I forget the thing you can, you can do environmental cues, restrictions. Um, you know, you can, uh, there's, there's other, there's other ways to cue people. Um, the stick, the reaching one's a super easy one. Um, you know, if they, but, but again, they have to understand that you mean it. I said, I said, touch the stick. I didn't put it there for fun. I said, touch, touch the stick, you know?

So that'll get you where you, that'll get what you need. What am I supposed to feel? Just touch the stick and then tell them what you feel. Well, I feel that, I feel the hip working in the thigh. Perfect. Just touch the stick, you know? So I don't know. I don't know why it's over. I think, I think people just need reps. It's exactly what it is. Do you, do you get enough reps in school with, uh, well, since this pandemic, I was only maybe a, maybe a one term, one solid term of clinic. And after this, I, hopefully I get this half term. And then the, my last term at SU, I'm, I'm pretty solid once I'm, I'm done, but we'll see.

Yeah. Are you, are you noticing the cues I'm giving, giving you? Yeah. So at least, so I'm giving the mic, I'm giving Mike the cue to, I'm waving my hand because he's drifting away from the mic. Um, but remember in the beginning, I explained what this cue meant. If I go like this, it means get close to the mic, eat the mic. So I don't have to go over explaining it every time because you're already, and I can talk to you at the same time just to keep you, you know? So I think you need, sometimes you need to explain your cues. Yeah. But I'm sure, I'm sure you'll get there. I'm, I still got to get better, I think.

Um, I think that's all I have to say. We're about 50 minutes into this. Um, this, I hope, I hope it was helpful for everyone. Yeah. Thank you. I'm just listening to you. Are you going to close it out for us? Yeah. I look forward to, uh, getting better at, you know, being in front of the, the mic. No pun intended. Um, well, yeah, thank you so much for your time and hope you guys enjoy the rest of your day. Yeah. Thanks everyone for coming and listening and, uh, share this with a fellow clinician. If you think they will benefit from the information. Again, I apologize if I sound like I was down on tissue work.

I'm not. I just think the pendulum has swung a little far. Um, but yeah, uh, thanks for joining the movement. Thanks for being part of the movement and look forward to seeing you in a couple of weeks.