Alan Fredendall // #LeadershipThursday // www.ptonice.com
In today's episode of the PT on ICE Daily Show, ICE COO Alan Fredendall discusses being wrong about dogmatic approaches to physical therapy, the harmful influence of technology on daily life, and long-term changes to the American healthcare system.
Take a listen to the podcast episode or read the full transcription below.
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00:00 ALAN FREDENDALL
Team, good morning. Welcome to the PT on ICE Daily Show. Happy Thursday morning. I hope your morning is off to a fantastic start. My name is Alan. I'm happy to be your host today. Currently have the pleasure of serving as the Chief Operating Officer here at the Institute of Clinical Excellence and a faculty member in our fitness athlete division. We're here on Leadership Thursday. We talk all things practice management, small business ownership. Leadership Thursday means it is Gut Check Thursday as well. This week's Gut Check Thursday is a little test, Cooper's test in fact. This was a test created way back in 1968 by an Air Force Lieutenant Colonel Kenneth Cooper. He was a doctor in the Air Force and he wanted to figure out how to start to objectively assess the aerobic fitness of our military personnel, the Army and the Air Force, way back in 1968. This test is great. It has been studied a lot. It has a lot of normative data behind it. Very kind of similar to the six minute walk test that we use in the clinic with a lot of our patients to assess aerobic capacity. This is a 12 minute max distance run. Basically how far can you run in 12 minutes? So set a timer. The idea behind this test is that you would run it on a track or you would otherwise just basically run 12 minutes in a straight line. You don't want to end up running maybe in the CrossFit parking lot or the neighborhood where you have to turn and stop a lot. You really want to be able to pick up speed and stay at speed as long as possible. So make sure you're on a track. Make sure you're doing maybe six minutes out, six minutes back, or maybe 12 minutes straight out and then come on back with a walk. And then if you're on a treadmill, make sure you have the grade at 1% to imitate kind of the uneven nature of outdoor pavement. And then that's it. Figure out how far you ran in either meters or miles. There's some equations in the Instagram post to calculate, predict your VO2 max based on how far you ran. And then we've posted some normative tables as well. So this is a great test for ourselves. This is a great test for our athletes or patients as well to see how we stack up. So figure out Cooper's test. Yes, you can row it. You can bike it. Just be mindful that those are unloaded assessments of aerobic fitness so they don't quite translate directly to running. But as long as you retest under the same parameters, have at it with a biker row as well. Courses coming your way related directly to Leadership Thursday. Brick by brick, our practice management startup course starts again September 12th. That course just has one seat left. That's taught by yours truly. We cover everything you'll need to know about starting your physical therapy practice literally from step one of all the legal paperwork you'll need to figure out and file to get started. And then we get a little bit more into what it actually looks like to open and begin your practice. So that starts September 12th, one seat left. And then live courses I want to focus today on total spine thrust manipulation taught by our instructors Justin Dunaway, Jesse Witherington and Britt Lotteman. We have a couple courses coming your way through the end of the year. September 9th and 10th you can join Jesse down in Clearwater, Florida. September 16th and 17th you can join Britt out in Chicago. September 23rd and 24th Jesse again will be on the road this time in St. Mary's, Georgia kind of down in the southeast corner of Georgia by Savannah. October 7th and 8th, two chances to catch total spine thrust either in Columbia, South Carolina with Jesse or in Hendersonville, Tennessee right outside of Nashville with Justin Dunaway. November 4th and 5th Jesse will be out on the west coast, Simi Valley, California. And then two chances again in November before the end of the year November 18th and 19th. Britt will be on the road in Santa Rosa, California this time Northern California and Jesse will be in Albuquerque, New Mexico. So total spine thrusts coming your way. Today let's talk about this topic. So I do have some research to share with you regarding this topic but I really want to talk about the top three things I think I've been wrong about so far in my career. So we're going to talk about what it looks like to treat a comprehensive plan of care with a patient. We're going to talk about technology and we're going to talk about long-term changes to the health care system.
04:08 BEING WRONG ABOUT DOGMATIC APPROACHES TO PATIENT CARE
So I want to start with talking about the kind of back and forth dogmatic guru battles that we see all day long on social media of manual therapy sucks, it doesn't do anything, you shouldn't do any manual therapy, if you do manual therapy you're committing malpractice. And then the far other side of that same continuum of if that's exercise only then the belief that manual therapy is the only thing we do that matters that we can somehow cure or fix patients with our hands, with our dry needling, our cupping, our spinal manipulation, whatever stuff we do with our hands. So two different kind of camps fighting and barking at each other on social media and then talking about the research supporting one side or the other or both or neither. So what I've realized and keep in mind I'm coming from a point where I have sat in both of these camps at different points in my career of coming into school as a background as an exercise physiologist, of having no way and no knowledge of how to put my hands on people because I was an exercise physiologist so my intervention, the only intervention allowed to me was exercise. So coming into grad school with a belief that exercise is medicine as taught by the American College of Sports Medicine and that exercise is the way that creates the long-term fix and that manual therapy has no value. So I certainly sat in that camp in the beginning of my PT school career and then I've sat in the other side of the campus while getting into PT school learning more about manual therapy residencies and fellowships and diving really deep into the weeds especially behind spinal manipulation and dry needling and going to the other side of manual therapy is one of the most robust tools we can offer and a little bit of exercise maybe at the end for the patient to keep up their progress in between but being very heavily in the manual therapy camp and holding the the previous belief that maybe folks who are in the exercise only camp are there just because they're not that good at manual therapy so I certainly held that belief for a while. Now I would say I'm in in neither camp and maybe not even in the middle of coming to the belief of the unfortunate belief that we just can't talk or exercise patients into better lifestyle choices no matter how much we have the answer of some sort of combination of both maybe one more than the other is needed for our patients depending on who they are and where they're at in kind of their health and fitness journey and this can be maybe I think the most frustrating part of being a physical therapist and being a health care provider in general of knowing the answer right of knowing that exercise and a solid nutrition plan go a very long way into helping you become and stay a healthy fit individual but that from time to time some hands-on treatment is needed so knowing knowing the answer walking the path but really unfortunately not being able to just give that to another person especially maybe a patient that at the beginning of their plan of care has no formal relationship with us yet. I myself have an unshakable belief that I will continue to probably encounter some minor musculoskeletal injuries within lines of statistical norms due to the impossible ability to balance a lot of different things essentially balancing workload versus recovery of there's going to be days where I don't sleep enough there's going to be days where I don't eat enough there's going to be days where maybe my training volume is higher than I wanted to be my overall life volume is going to be higher than I wanted to and otherwise I put myself at a greater risk for an injury and sometimes we'll actually encounter an injury so I believe that is just part of the journey of health and fitness. I also have an equally unshakable belief that the current meat suit that my brain sits in has been evolving and adapting to stress for over two million years and that it's a naturally resilient structure that's capable of healing itself from most injuries maybe not a car accident or getting hit by a bus but certainly encountering some shoulder pain or knee pain in the gym or out on the run or something like that so that's what I believe but it is hard to transfer that to another person that my third unshakable belief is that it does not matter how much I trust my own body how much I believe that the body can heal itself I can't just take that belief from my brain and put it into somebody else's brain no matter how much I want that to happen no matter how much I talk to that patient in front of me we just can't talk people better we can't talk people into better lifestyle choices we kind of have to show them and that can come from a couple of different angles that can come from having them do some manual therapy techniques maybe even self-manual therapy techniques that helps alleviate your own symptoms to help connect that stress recovery adaptation cycle maybe some exercises or maybe both but otherwise we we do need to show people that this this thing that I've been wrong about is that seeing is believing and 99 percent of people can't be talked better the interesting thing is we have more and more research supporting this now we have some fantastic articles coming out of the pain neuroscience education space that support this that we cannot just talk people better we cannot talk people out of pain we cannot talk people into being healthier we have to show them both by our own example but also by them seeing the success as well and part of that comes from showing them some sort of change manual therapy exercise based doesn't matter whatever you think the patient needs so they begin to buy in to I'm not broken I'm resilient my body can fix itself I don't need surgery I don't need an MRI I don't need pills but that we can't just talk that person better really fantastic article if you have not read it yet by shala and colleagues 2021 the journal of manual and manipulative therapy saying that same thing literally the title of the paper is can we talk patients better and the conclusion is no we can't that we need to combine these things and that the most successful interventions for pain are multimodal they involve yes education discussion of sleep and diet but they do also involve manual therapy and they do also involve exercise it's everything together it's and not or most physical therapy studies if you read the methodology if you read the inclusion and exclusion criteria and if you read and find out in these papers why they initially studied a thousand people but only 760 people completed the study what happened to those other people well yes people get busy yes people get injured or whatever else they drop out of the study but in a lot of these studies folks drop out because they're not getting better they are maybe even going to get care somewhere else outside of the research study which you can imagine creates a lot of confounding variables that makes us need to exclude that person's data from the study there's a lot of really cool research now looking at that of that if we do not offer hands-on care there seems to be a sub-population of people who will leave our care and go get it somewhere else that if you try to talk somebody better and you say i am not going to do anything hands-on because i'm going to make you addicted to manual therapy there are people who will leave your clinic and immediately go get a massage or go see a chiropractor or maybe go see another physical therapist they will go get the care they think they need somewhere else sometimes immediately after your appointment and we need to to be cognizant of that likewise there are people who believe that if there's nothing hands-on as far as doing exercise of them being hands-on that the therapy has less value and likewise they will leave your clinic and go get extra care somewhere else so we need to be cognizant of that as well i think often of i get my hair cut every three weeks on thursday afternoon i see the same stylist i've seen her for years now she has had what i believe to be a pretty gnarly case of achilles tendonopathy from overdoing it increasing run volume i see her i've seen her progression of having a soft brace on to having a walking boot to now having a full cast on of chasing down what she thinks is going to help her in the health care system even though she talks to me for about an hour every three weeks and i try to talk about anything i can to get her to try literally anything else except pills and casting and surgery and imaging and she still won't come down to my clinic to see me even though i've offered to treat her for free of i cannot take the beliefs in my mind and put them in somebody else's mind they have to come unfortunately to that conclusion on their own so being wrong about being able to talk people better about being able to exercise people better and more understanding and recognition as my career has gone on that i need to recognize that every single person who comes into the clinic is different they have different beliefs and i need to recognize what those are and address them accordingly some people may need to start with a bunch of front-loaded physical therapy some people may not like to be touched at all they don't want to do any manual therapy they only want to do exercise and maybe some sort of blend for folks in between.
04:08 THE DANGERS OF TOO MUCH TECHNOLOGY
The second thing I've been wrong about is technology if you know me you probably have the belief in your mind that i am the biggest nerd you've ever met and i'm okay with that i grew up playing world of warcraft you can find me in my limited spare time probably trying to sneak in a video game or two every now and again so i'm certainly a giant fan of technology but as my career has gone on as i've gotten older i now have the belief that i think technology creates more problems than it solves the previous point was a great example of we would probably not have these dogmatic arguments and be so fervent in these different camps if we did not have technology to use to yell at each other from across the planet that the computer the internet the mobile device the whatever you're using has revolutionized humanity maybe for the better but i think nowadays more bad than good that having access to all the combined knowledge of our species is amazing but also being a button push or click away from constant contact with friends family frenemies work whatever can be really bad for us especially our mental health of you maybe you're this person maybe you are the spouse of this person or a friend of this person of that person who says did you see what so and so just posted this person is is my wife in our relationship of getting really upset at what other people put on social media and kind of letting it ruin your day and i think that happens a lot in modern society i think back to a question that i was asked very very early on and again i used to have the belief that more technology was better that we could talk other practitioners into better practice habits if we just argued with them on social media if we yelled at them on twitter and about nine years ago jeff moore saw me in an argument on twitter and just sent me a simple message that said hey do you think this is the best use of your time to advance the profession of physical therapy and obviously probably most things in our our life if we ask ourselves that question is this the best use of my time the answer is probably no but definitely to that question the answer was no definitely not and so i often ask myself that question a lot and what i've found over the years is that question and that answer that question takes me further and further away from engaging a lot on social media if you follow my social media now you see pictures of my son in my workouts and that's pretty much it right if far by far and large disengaged from physical therapy social media as a whole i don't listen to any podcasts anymore i listen to the news in the car and music when i work out and that's pretty much it so i've pushed technology away as i've gone through my career as i've gone through my life and i think i'm the better for it and i think having access to all of the gadgets that come along with technology is really doing us a disservice as well of i used to be a big proponent of whoop if you've listened to us here before if you've come to our fitness athlete classes you've heard us talk about whoop and other devices like that and likewise i think those cause more harm and good that having a constant stream of data letting us know you're not moving enough hey you need to move you need to exercise you're not eating enough you're not eating right you're not eating enough you're not sleeping enough you're drinking too much you're overeating this specific type of food i think those constant technological inputs into our life really set us up for a lot of unhappiness of folks who look at a whoop and think what if my resting heart rate is high because i had a beer last night what if it's low because i underate what if my respiratory rate is high because i'm sick what if i have coven 19 what if i have cove 23 what if i put strawberries up my butt would my fart smell better like we can what if this stuff to death and we i think we are doing that with our technology that i do think there is a sub-population of people who have to see that data that have to see whoop say hey every time you report drinking two or more beers you have an 18 reduction in your sleep quality i do think there is a group of people who need to be smacked in the face with that realization of again they can't be told that by somebody else a friend or a family member they have to be showing that objective empirical data but i also think there's an equal sub-population of people who will go completely insane festering about that stuff of worrying themselves to death about what does this data mean i shouldn't exercise today uh maybe i ate so wrong my resting heart rate my hrv is messed up i'm just gonna fast today or i'm not gonna work out for a week and they literally what if themselves to death about this stuff until probably the end result is that most of those people just ditch the gadgets i no longer wear a whoop i haven't wore one for many many years i have a pretty neat cassio g-shock this is a solar powered watch its only thing it does is tell time and then i have a fitbit which tracks my steps i try to hit 25 000 steps a day and that's it right i have no access to any sort of heart rate data or sleep data and i think i'm all the better for it so i think technology is really doing a disservice and i think the more we can intentionally disconnect from some of these data streams and communication streams we will find that we're a lot happier for doing so.
20:07 LONG-TERM CHANGES TO THE AMERICAN HEALTHCARE SYSTEM
My third belief is maybe a little bit pessimistic that i think unless something considerable changes with the american health care system i think the way that our health care system currently works is not going to alter significantly at least in our lifetimes that when we step back and zoom out and look at how a lot of stuff in our life is run they're run by for-profit companies the power company is a for-profit company the internet company is a for-profit company the health care clinic company is a for-profit company the insurance company is a for-profit company so we need to ask ourselves are we just victims of people trying to maximize profit and that's why we can't really seem to get ahead in a lot of big system changes and i think the answer that question is yes that's 70 percent of all americans still get their health insurance through their employer so they receive health insurance insurance from a for-profit employer that's run by a for-profit agency the insurance company that uses that insurance at a for-profit health care company so it's no wonder that we are trying to keep margins really narrow high profit low expense and at the end result the person that suffers is usually the health care provider and the patient while the overarching organizations post record profit after record profit year after year after year that both the input and output sides of the system have a vested interest in minimizing costs and maximizing profit and at some point we need to acknowledge and recognize that we also need to recognize acknowledge that with some exception health care providers are really uninvolved or minimally involved with the ownership and management usually of the business that they work for insurance companies are led by led by corporate executives and large health care systems are also led by corporate executives and if we look who sits in the leadership positions of a lot of these companies they're not health care providers they are investment bankers venture capitalists that sort of thing they're interested in profit it really starts to explain and i hope that this doesn't come off as a conspiracy theorist of why our outcomes are so poor despite how expensive our health care system is and that we really need to see big system changes if we're really going to make a dent in the issues that we have which is 90 of humans are sedentary 70 of of americans have chronic pain and we seem to be going backwards despite how hard we get up and go to work ourselves individually every day what do those changes need to look like i don't know i'm not i'm not a big picture person i'm kind of a logistics person but i think that's kind of the frustration that we all experience day to day of yes our individual patients are getting better but why are we still seeing people who got a knee replacement two days after going to see a provider about knee pain why have they not tried physical therapy first why have they not tried literally anything else first except getting booked right into surgery we feel those frustrations we wonder where those are coming from and it's no surprise i think it comes from our giant for-profit health care system as a whole so three things i've been wrong about been wrong about being on one side of the fence or the other the belief that we can talk or fix somebody with our hands or just help them with exercise only that we can take the beliefs in our mind about our bodies and the proper plan of care at least in our mind and put that into somebody else's brain been wrong about leveraging maybe too much technology especially both in personal and professional life and been wrong about the belief of really creating long-term systemic change in the health care system so i'd love to hear what you've been wrong about i'd love to hear questions comments discussion about this topic as well i hope you all have a fantastic thursday have fun with with cooper's tests if you're going to be at a live course this weekend enjoy yourself other than that have a great thursday bye everybody.
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