#PTonICE Daily Show – Tuesday, January 2nd, 2024 – Dealing with doubt

In today’s episode of the PT on ICE Daily Show, Spine Division leader Zac Morgan discusses dealing with doubts in the clinic, how adopting a fitness forward approach can help solve a lot of “What if?” problems that arise when trying to pick “the best” intervention, the concept that doubt is bilateral, and how a fitness forward practice style can help build confidence with both patients & providers.

Take a listen or check out our full show notes on our blog at www.ptonice.com/blog.

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Alright, good morning PT on Ice Daily Show. For those of you who don’t know me, I’m Dr. Zac Morgan. I lead in the Spine Division with both Cervical and Lumbar Spine Management. Great 2023 with all of you all on the road. Exciting 2024 ahead of us. So we’ve got a lot of changes coming with ice, so keep your eyes peeled. You’ve seen some of the certifications roll out. You’re seeing courses pop up there on the website regularly. We will have more to offer there as well. So we’re not fully booked with Spine, but we’re getting close. So eyeball some of those dates. We’ll cover those in a little bit. Let me start off by kind of debuting today’s episode.

So I kind of want to set the stage with a little bit of an overview of what I’m talking about when it comes to dealing with doubt. And why I think using a fitness-forward approach in the management of your patients with really any musculoskeletal issues or whatever issues they’re coming to you with, I think using that fitness-forward approach adds so much certainty in those doubts. So what is fitness-forward PT and how is it different is a good place to probably start. Thinking about the concepts of fitness-forward PT and how that might differ from other approaches, I think this for me is obvious when you see it. Fitness-forward PTs are trying to at any corner to bleed fitness into their plan of care. They’re trying to bleed health concepts into their plan of care. So rather than your first choice always being mobilization, or manipulation, or dry needling, or any of those things that we also love, you might see fitness-forward PTs just as equally choose something like isometric loading to reduce pain symptoms, use cardiovascular exercise to reduce pain symptoms. More on those types of things later, but I just think it’s important to understand that those things could be utilized for the management, for the modulation of symptoms just as much as manual therapy and in fitness forward care you will see that. So we love highlighting these things. Let me tell you a little bit personally about why this episode is important to me. Early in my career the biggest thing that plagued me, the biggest thing that got in my way of helping patients when I think back to those times It was my own personal doubt. So I had a lot of personal doubt in the approach of care that I was delivering to people. That approach, for me, when I first started in this profession, centered a lot more around manual therapy. That was basically where my head was at, was trying to figure out the right mobilization for that person, doing it in the right direction, the right level of vigor. These types of concepts were always running through my mind in the middle of that evaluation. I wonder if this person would respond to thrust manipulation. I wonder if I should try grade 3 moving immediately. All of these concepts were bouncing around and I’ll be honest with you all, what it led to for me was a lot of confusion and a lot of concern that I might be selecting the wrong technique for the person.

And what that ended up leading to clinically was doubt that was bilateral. So what I mean by that is that my client, they could start to tell that really what I was doing was somewhat bouncing around interventions trying to solve their problem. The problem was it wasn’t solving their problem. So as we switched from intervention to intervention, that client often started to develop some doubt in my point of care. Perhaps just as importantly, if not more, I started to develop doubt in my plan of care at this time in my career. So I wasn’t sure what was going on. I knew I was recognizing some patterns in front of me, but whenever I would see them, I wasn’t sure exactly what the best solution might be for that person. And so I had a lot of doubt. And I think that then allowed space for that patient to also create a lot of doubt.

So let’s talk a little bit about dealing with this and what I think this kind of manifests as for most of us clinically. And I think this happens the most at the front end of your career versus the back end, but it happens really regardless. It’s imposter syndrome. So if you’re not familiar with imposter syndrome, this is that feeling you have where you’re not quite sure you’re good enough. where you think you might not be the right person for that client in front of you. If they had gotten the therapist next door, they would have been way better off, might be a thought that’s going through your mind if you have a lot of imposter syndrome that you’re dealing with. And I know I dealt with this tremendously, and all of the newer graduates that I talked to on the road, the ones that we mentor here at the clinic, all of these things, they often lead to imposter syndrome, and we get to the point that we’re not quite sure what’s going on with the patient, And that leads us to the spot of, I’m not quite sure I can help, and they would probably be better off with someone else. Well, team, we have to pull through that because we all have so much value we can bring to clients. And as you get further in your career, you start to believe that more, and it becomes a little bit easier to somewhat sell that plan of care to the client in front of you, to build them the bike, to get them moving forward. This happens to all of us at some stage. And so I think it’s important to understand if you’re there, what are the moves that I can make to get out of imposter syndrome? And if you’re not dealing with imposter syndrome, it could always come back up. It’s something that even to this day, there will be times where I’ll have that moment where I’m like, man, I’m not quite sure. So it is something you will deal with clinically and it’s something you want to be well prepared for because it has some clinical impact. The clinical impact that I was talking about before of lack of confidence, both for you delivering things to the patient, but also for the patient receiving those things from you. there is no doubt that there’s clinical impact to imposter syndrome and we want to get rid of that. That way that clinical impact is all positive. The way I believe that we’re going to do this is by shifting the manner in which we manage our patients.

What I mean by that is if you’re not already, you have to move towards a fitness forward mindset. You have to kind of underline your care with fitness forward. The issue with the way I did it early in my clinical career of being more like manual therapy focused. is that you’re constantly using all of your brain power to try to figure out which mobilization the person would respond to. To try to figure out what direction, what level of vigor, how long should you do the mobilization. All of these factors are running through your mind clinically. And a lot of times, the answer doesn’t live with manual therapy. The answer lives with what that person does for the remainder of the hours of their life when they’re not on your table. That’s a huge portion of what’s driving people’s pain scenarios. And the beautiful thing about that is the things that work for all pain scenarios are lifestyle changes. They’re these fitness forward approaches. So you take something like cardiovascular training. So getting the heart rate up, whether it’s for a short time at a higher heart rate or a long time at a bit lower of a heart rate, that no doubt will reduce symptoms. So in those patients that I’m confused on, I’m not quite sure what’s going on, I feel a little doubtful, early in my career I would be trying 10 different mobilizations on them and by the end of that hour They would have got up probably sore, mostly maybe even just from laying in all those different positions while I was troubleshooting different techniques. But overall, they would often get up off the table, they’d be sore, and I’d be confused. They’d be like, ooh, it doesn’t seem like Zac knows what’s going on. In the back of my head, I’d be going, ooh, I really don’t know what’s going on. This person seems worse, not better. The way I would approach that person now is completely different, and that’s because I’ve shifted in the direction of fitness forward. Now, when I’m unclear as to what’s going on, if it’s early, think like really acute neck pain, really acute back pain, those people that move through the door and you can just tell by looking at them, this person’s not going to tolerate a whole lot of movement today. In the past, I would have badgered that person with a lot of manual therapy. Now, I’m going to get that person really comfortable and give them a cardiovascular stimulus. Maybe that’s standing on the bike where they can use arms and legs. Maybe it’s on the rower. Maybe it’s on the skier. Could be the arm bike. It could be really anything. Could be the new step. The beautiful thing about cardiovascular exercise, it doesn’t really matter how you leverage it. The pump gets going regardless. So as long as that heart rate gets up, you’re gonna see some pain drop. I might would choose some isometric loading for this person now. I might would choose some breath work, right? Just having them in a comfortable position, just simply sitting down, thinking about nothing other than their breath, doing some physiological size or box breathing or 478 something to stimulate that parasympathetic output. When you think about this, this is a lot more global on the human than that local joint and how it moves. Do we want to address that local region with even with manual therapy? Absolutely. Does it always have to happen on day one? Absolutely not. And I think that’s where it has shifted for me. So rather than being focused on kind of underlying my whole plan of care on did I select the right treatment plan, the right mobilization, the right progression of forces for this person who has a pattern of pain I recognize in front of me. Rather than doing that, now it’s how can I get this person fitter? What in the world can I do to get this person to adopt a more healthy lifestyle? And in the short term, I still want to recognize those patterns. I still want to provide those positive stimuli, but at the end of the day, I’m trying to get after the big rocks, the big levers in their lives.

The reason I think this is so advantageous when you compare it to that manual therapy based approach, or just maybe more focus in the manual therapy based approach that I kind of grew up in in this profession, is it builds confidence. It builds confidence for a few reasons. One, you know that you’ve provided this person with something that’s positive in their life. They may not get any exercise without you encouraging them to do this. you know what you’ve done for them is helpful and potentially life-changing. Like if you can convince that person to sleep a little better, you can convince them to do a little bit more on their day-to-day with exercise, that may dramatically alter the course of their life. The beautiful thing is, odds are pretty good it will also reduce their symptoms, which is why they walk through the door. Now if you did it the old way, you might be trying to select the right mobilization, the right direction, the right force. All of these factors would be at the foremost of your mind versus how do I get this person fitter. And while I’m okay with you thinking about these things, and I hope you’re not hearing down manual therapy, I just don’t think it’s where your brain should be. Because when you think about it, if that doesn’t work, and you get through the session the way I used to, at the end of that hour, the person’s often sore. They’re often a little achy, and they’ve lost a little bit of faith in what we’re doing here, and so have you. And so that prognosis at the end of the session doesn’t sound as strong. But when you know what you’re giving the person is something that will be beneficial and positive to them, you can feel really confident when you deliver that plan of care. And team, in watching a lot of young therapists and doing this for a while now myself, I think the delivery of the confident plan of care, reassuring that patient, we see folks like you a lot, what we’d like to do now is X, that moment for patients is more important than what mobilization you selected. It’s more important than what manipulation you did. It’s more important than the direction you went. We want to create that moment where the patient goes, oh wow, I think they’ve got me. I think you will feel more confident delivering that moment when you underline your plan of care with fitness forward care versus when you’re trying to select the perfect treatment. We have to absolve ourselves and understand no one knows what’s going on with our patients. We’re never going to have our exact finger on the pulse of precisely what’s wrong with that person from a tissue diagnosis standpoint and it wouldn’t matter if we did. What we do know is when we get people more towards a healthy lifestyle, when we give them some psychologically friendly understanding of what’s going on, when we give them some skilled manual therapy, and when we do that in a fitness forward package, we move that person forward. And that has just given me so much more confidence in my plan of care delivery, as well as just prognosis delivery with those patients. And I see it happen a ton with new grads and folks that I mentor all the time. So I think the last thing I want to say here is if you still feel a little bit of that imposter syndrome and you still feel like, oh man, I’m not quite sure if I’m the right person for this patient to see who’s dealing with acute back pain, I want you to think of where else they could go. So, yeah, not only could they not receive a fitness-forward approach, which is a bummer, but on top of that, if they didn’t go to you, who may not know what is going on and may be a little nervous about treating this patient, if they didn’t see you, they might go to Urgent Care. They might go to the emergency department. Those places are no place for you if you have acute back pain, if you have acute neck pain. You need to be in a conservative provider’s office. Now if that conservative provider decides that you need to be elevated into the healthcare system, so be it. But we need to be at the forefront of that. Because think about it. Not only do costs go up, think about the psychological sequela of going to the emergency department first. having that scan done, being told here’s what’s wrong. Think about the patients you interact with who have chosen this route that right now are probably the most frustrating ones on your schedule. We have to get them out of that muck and if we sit here thinking what we do isn’t effective, we’ll never be able to get patients out of that muck. We have to be completely confident that what we deliver is the most effective thing that they could get and And that is fitness forward care. And when we deliver that, we can be confident in it. And when we’re confident in it, we can pull people out of that muck of the healthcare system. This is the point of today’s episode. And so team, I think that’s why we, that’s the way in which we can deal with doubts and shift away from imposter syndrome. So just quick summary. All of us deal with imposter syndrome. We all deal with doubts. There are times where a patient is in front of you and you go, man, it could be one of these three patterns and I’m just not quite sure. Rather than trying to be perfect and select the perfect treatment every single time, why don’t we select the actual best treatment for that person, which is probably to move them more towards health. That may come in the form of fitness, it may come in the form of sleep improvements, perhaps changing some of their dietary factors, dealing with their stress differently. TINA could be any of these factors, but we have to be ready alongside of this person to move them dramatically in that direction quickly, so that when their symptoms start to drop, they associate that with those health behaviors. Once we get that association going in their brain, You just changed the person’s life. You didn’t just stop at back pain. Sounds dramatic, but it’s true, and that’s what we’re after. So team, the way we deal with doubt is to use fitness forward care. The beautiful thing about fitness forward care is even if you were wrong, you helped the person. You helped them dramatically. So even if you thought it was a derangement, it turned out to be a dysfunction, doesn’t matter. That person still left 1% fitter. That person’s moving forward, dramatically in their life, you’re going to figure that out session over session. So the next time you see the person, it may be a different pattern. That’s the point of the symptom behavior model. That’s why we gather data. That’s why we look at asterisks, so that we know we’re helping. So maybe the pattern wasn’t perfect on day one, but when you choose fitness forward, the treatment will be.

Team, that’s all I’ve got for you all this morning. I just want to kind of last wrap things up with a few quick point outs of where we’re going to be on the road this year. So starting in Q1, if you’re looking for a little bit more in the clinical reasoning realm, if these words like asterisks and rechecking asterisks and kind of forming that plan of care or things that you’re looking to improve on in the new year, I would definitely suggest jumping into cervical or lumbar. That’s where we really focus on those clinical reasoning measures. And in February, on February 3rd and 4th, we’ve got two courses for you. So there’s Hazlet, Texas and Wichita, Kansas. be aware Wichita, Kansas only has a couple seats left, so if you are near there and you want to jump into that course, do it soon, because that course is about to sell out. And then at the end of that month, February 24th and 25th, West Coast, Simi Valley, California, so right outside of LA, that one’s selling really well too, so there won’t be a whole lot of seats available by the end of that. So if you’re looking for any of those, jump in. If you’re looking for lumbar management, January 27th and 28th, Rome, Georgia, Cincinnati is close to sold out. That one is actually the March 9th and 10th, and then March 23rd and 24th, Milwaukee still has some seats left. So if you’re looking for either cervical or lumbar, those will be your Q1 dates to look for. That’s all I’ve got for you all this morning. If you want to continue the conversation here in the chat, I will be on it all day, but thank you for your attention this morning, and I will see you on the road in 2024.

SPEAKER_00: Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you’re interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you’re there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.


Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you’re interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you’re there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.