[00:00:01] Chad: We’re waving a wand for eight minutes. I don't know why I did that for so long. It was just crazy. So that’s how I screwed up and I did that for years. And, it wasn't until, Nick, came along where I actually woke up and was like, why am I doing this?
[00:00:30] PODCAST INTRO: Welcome to “In The RACK” podcast, where we provide you with the practical framework for breaking PRs in all facets of health and wellness. We are just a couple of bros giving you the simple house in a world of complex wants. No filters, no scripts, no rules, just straight talk, talk tune. Now, let's get into the rack with your hosts, Dr. Chad and Dr. Nick.
[00:00:55] Chad: Alright, everyone. Welcome to another episode of “In The RACK” podcast. I am your host, Chad. And with me is my co-host and fellow physical therapist, Nick. You guys know what time it is. It is not only “Episode 20”, which is kind of a big deal. But it's another time for getting reckless “In The RACK”. And I think we've tried to plan this so that we get these reckless episodes every five episodes or so. So everybody keeps on giving us good feedback about the episodes, so we're just gonna keep on rolling them out. But this reckless “In The RACK” has a little twist to it. And instead of talking shit about everybody else, we're gonna talk shit about ourselves. We mentioned in the last episode, we want to take a step back and kind of talk about maybe things that we messed up on, whether it's recently or early in our careers, things that we were like, why are we doing this? Isn't that right? Whether it's something that changed in the research, or whether it's just something we saw somebody else doing and we're like, “Why am I doing this?” This doesn't make any sense. So we wanted to make this kind of like a another series of episodes kind of part of the reckless “In The RACK” series where we talk a little bit how we messed up. So we're going to talk about a couple of instances in early in my career and what I screwed up in. And Nick's got a couple instances what he wants to talk about as well. But if you are new to the “In The RACK”, or the “Reckless In The RACK” series, basically how it goes is this is where, Nick, and I share stories from our patients. But in this case, we're going to share stories about ourselves. We like to share these stories, not only because they're reckless, but because some of these stories may sound familiar. Now, in this case, it may sound familiar as you as a therapist. But as the patient, if you're like, “Wow, why would my therapist doing that they just talked about that, that doesn't make any sense”. So it's still good for everybody to listen to. In fact, that's the exact purpose of the series, just to create a little bit more awareness of everything that's going on. So for all of you that are joining us in this episode, we're going to talk about a few quick stories, and then give our two cents on the story. So in this case, we're gonna talk about how we messed up and how we made that better, or we learned from our mistakes. So today, let's talk about you, Nick. Well, how'd you screw up?
[00:03:16] Nick: So this one is actually pretty recent. So we're talking the last couple of weeks. And you guys know that we use the alias names for these episodes. So this one is a specific to know. We'll use one name on it. I only have one we're talking about. I know, but how I messed up with this person. So I have to talk about the person. So the patient will be vivo, because I messed up with the feet in the footwear. So everyone knows if you've listened to this that I'm big on the footwear and I incorporate footwear education and recommendations as part of my treatment for pretty much any everybody. Definitely lower body stuff, low back stuff, but maybe not so much with the upper body issues. But this individual came in vivo post host operation on the right knee. So she came in struggling. And we were we were working on a lot of the knee specific rehab. Afterwards, she developed a blood clot on the right side, all that so we had to get that under control with our doctors and all that kind of stuff. So once we were underway with that she was in better shape. Early on I had recommended, let's try to get you into some zero drop shoes because I think a lot of this extra stress and strain could be caused by the footwear to some extent. Not all of it, but to some extent. So we had done that all the while she was being treated for the blood clot. A couple weeks go by and she starts complaining of left hip pain. So it's just compensation, that kind of stuff. She's like, “I've had a history of left hip issues” and we're treating that as well. And obviously, we're doing some of the specific acute post op stuff, but also given some attention to the left hip and hip specific stuff. We've talked before that it's a whole body thing anyway. But now we're putting a little bit more attention diverting some focus there. And I'm treating it and still, it's just not progressing very well. So weeks go by, and I'm doing my normal stuff. This isn't going the way I thought it would. And now she's doing well, knees doing great, blood clots cleared up, she had the follow up ultrasound for that. So we're a couple months into this by now and her hip is still just bugging her, like she can't get more than three quarters of a mile before it hits that spot on there. And I'm like, “Man, what am I missing?” So I dial back to her footwear. And we talked about her initial shoes that she came in with, and those are a 12 millimeter drop, and I dropped her into ultras which is zero. So that 12 millimeter drop was probably just way too aggressive. So we took her body that's used to being propped up 12 millimeters from the ground at the heel and we just went boom to zero. So all those different tensions up and down from foot all the way to hit back, everything was just so abruptly changed, that her left hip was just going haywire on me, and I didn't catch it at first that's my thing is the feet, the footwear, and I totally just went way too aggressive on her especially in a post op situation. I probably should have waited a little bit to address the footwear. But nonetheless, we dial back to the back and said, “Let's hold off on the zero drop for now, let's go into this shoe”. She actually had some hope is that she had in the closet already, which are like a five to six millimeter drop. So I was like, “That's going to be good in between. Let's try that for a few weeks and see what happens”. And it made a huge difference, like was able to walk more than a mile plus within days, until she started getting some pain. So we were able to then get back on track. And obviously, the end goal is to get her back into the zero drop. And get her there at some point, it may take few months, who knows, we'll see as we go. I just dove way too quickly into that, that gets a zero drop, it's going to make all the difference, it's going to help your knees so much. And it may have helped her knee, but it definitely posted problems on her.
[00:07:28] Chad: I think that’s so common though, especially when anybody takes or any practitioner takes a new thing or learns a new thing that they want to learn so much about it and master it that they just incorporate it with everything or overdo it with anything and you're like, “I'm just doing it way too much, and it can have a negative effect”, because that's not really how it is supposed to do.
[00:07:48] Nick: And it's so interesting too, because I normally talk pretty thoroughly about the transition with people. But Vivo came in and was super active swimmer runner background and everything. So I'm like, “She'll be able to handle this”. So I projected my own thought process on her and said, “She'll be good with this. I could bring her at zero drop”. So I just kind of threw out everything that was already in my head from the gradual transition process in the progressive overload process and just throw it all out there after surgery.
[00:08:24] Chad: So in a situation like that, Nick, how did you go about telling that patient? Did you take fault, or it was one of those things where maybe we just progressed this little too fast?
[00:08:37] Nick: I think I may have recommended, I said, “I still want you in zero drop at the end of the day may not today. But that's our end goal”. Like I said, I think I may have progressed you a little too quickly. For everything that was going on for you post up blood clot, all this stuff. The body was in this heightened state already, and I had it scarred up and then I throw this new thing at it. So I did admit fault there. I showed her that it not a huge deal. She has the history of the left hip issue. So we didn't just spark something new. The issue might have been just kind of icing on the cake or that final straw type of thing. So I said let's just dial it back. Let's go into some of the footwear. We may even have to go into the shoes back into the shoes for that you originally came in the 12 millimeter just for the time being till we're out of this flared up state. But I did admit fault. I didn't want to but you have to for sure.
[00:09:32] Chad: I think it just instills more trust in yourself because you're like, “You know what, I screwed up”. We did that too fast. So this is what we got to do now and make it right. So I think it's okay to admit fault. And some people still have a hard time doing that.
[00:09:47] Nick: For sure. I definitely had a hard time. Especially because it was my wheelhouse. If it were something that I'm not as comfortable with, I would have just been like, “I see this but not that much”.
[00:10:00] Chad: But sometimes you never know, you have a patient that comes in like, “They could definitely do it and then they surprise you.” How many patients do we see that are going in for surgery like, “You're gonna crush it” and they come out and they're like, “Wow”, I didn't see that come in, and then the other way around you're gonna have a really time for the surgeon, then they come out, you're like, “Whoa, you're killing it”.
[00:10:17] Nick: And you're so right about that, because we go through that pretty regularly. I would say that with shoes, you want to try anyway. So you kind of have to an extent, you could just play it safe all the time. But that person may not need to play it safe. So sometimes you don't want to be like, you gotta buy these new shoes, these shoes, that's going to be the progression. It's like when we could just buy one and progress right away.
[00:10:44] Chad: And like you said, it's trial and error sometimes. You don't know. So Mickey learned his lesson.
[00:10:50] Nick: I did. I learned my lesson, “Stick to the progressive overload principle for everything”.
[00:10:56] Chad: Well, unlike Nick, my story is about myself. So there's no aliases here. This is just, Chad. This is the story of Chad. He graduated in 2009. Don't forget this guy's. I'm not like just fresh out, but I've been out long enough where I did some dumb shit. And I think it was mainly because that was kind of like the way it was done. And that's just the excuse that I have. And it's a bad excuse to have. But I learned from that and I don't do any of that stuff anymore. And I think as a practitioner, and if you practitioners are out there and listening, you guys probably fell in this and if some of you are in this funk right now, this would be a good listen for you. And it'd be a good wake up call to get out of that funk. But I was very much into passive modalities when I first graduated college and, and that was only because that's what I was exposed to sounds like, this is kind of work. This guy does it. This guy's been practicing for 25 years, and he gets great results. But is it the passive modality or is it what that practitioners doing after the passive modality that really makes a difference? So I'm gonna be honest, I was doing ultrasound and [inaudible 00:11:58]. Hell, when I opened up this place five years ago, I bought a laser machine that was cool. I was like, cold laser, I don't know, whatever. It was cold laser. It was cool. And I think I had that machine for a year and a half. And I used it maybe four times. And I ended up having to get rid of it because I wasn't using it.
[00:12:21] Nick: I actually think I tried to use it once. And I did not know what I was doing. Because I've never used it before. And I was like, I think I'm doing it.
[00:12:28] Chad: Half the time we were using it, we weren't even using the shades like the goggles that they give you with them. And I was like, it was so bad. But it was funny because we'd have patients that will come in and be like, “Oh man, my elbow, last time therapist uses laser on me it felt so much better”. And I was like, “I really want to grab the laser right now”. But I really don't want to grab the laser. Anyways, I kind of fell into that funk. When I first graduated, I was embarrassed to say but I was doing ultrasound up until about five years ago, when I first hired Nick, I was still doing ultrasounds. And I think that was the turning point for me. Because when Nick came in, he was looking at what I was doing, I was like, “If you want to use the ultrasound, the old sounds over here and the gels over here and all that stuff”. He was like, “I think I'm good with that”. So he politely was basically, “Why the fuck are you doing that?” After a while, I started phasing it out and phasing it out and phasing it out. And I don't think we have used ultrasound and probably the last four years, maybe I think the ultrasound gels long gone expired, we still have the ultrasound machines, and they get calibrated every single year. So I know they work, but they're really just ornamental at this point but that was how I screwed up. And to be quite honest with you. It's crazy that ultrasound has been used for clinical applications since the 1950s and we're still using it. And every single bit of research out there is saying that it's just as effective as placebo for everything, which is horrible to say, and this is not diagnostic ultrasound we're talking about. We're talking about therapeutic ultrasound, so it's different. But in terms of like promoting soft tissue healing or reducing pain, there's been no evidence to show that it's effective and that's systematic reviews. So what's even more baffles me is that insurance companies still reimburse for it. They still pay for it.
[00:14:16] Nick: But you got to do it for eight minutes.
[00:14:18] Chad: You got to do it for eight minutes. So you're sitting there and waving a wand for eight minutes. I don't know why I did that for so long. It was just crazy. So that's how I screwed up and I did that for years. And it wasn't until, Nick, came along where I actually woke up and was like, “Why am I doing this?” So I don't think that I hurt anybody with that. But I think that I could have definitely helped more people by substituting with that eight minutes of time with probably more beneficial exercise. I could have got eight more minutes of exercise out of every single one of those patients. And that sucks, but that's all good because I learned from that I don't do that anymore. I think the only modality that I use nowadays is maybe stem here and there.
[00:15:04] Nick: I would say that we use the stem because we both use it from time to time. And my big thing for using it is to calm someone's central nervous system. So if they come in, and in the eval, I get a sense that they're just one of those sympathetically overdrive people mean that they're just fight or flight all the time, I will set them up on some stem at the beginning, say, “Look, this is just going to calm the tissues down, we're just gonna relax a little bit, I want you to just focus on your breathing. Don't think about anything else. Let go work stress, like all this other stress, and we're just gonna relax, let the tissues relaxed, and just get in a good state before we get going”.
[00:15:44] Chad: And I don't know if you consider BFR passive modality?
[00:15:48] Nick: Not at all.
[00:15:49] Chad: I don't think so either. The machine maybe, but you don't with exercise. So it's not really.
[00:15:52] Nick: I takes very much active. So it burns, it's very active.
[00:15:58] Chad: So if any of you guys are out there, or gals are out there, and you're still performing ultrasound, just stop and spend time doing some more exercise with them. You're better off having a conversation with them. Pain science is more is going to be more applicable than it is waving a wand on somebody's knee.
[00:16:14] Nick: And if you want to wave a wand while you talk to them, or whatever, it's fine. If you just want to be moving your hands to pretend you're doing something but be talking to them during while you're doing that, if you're going to wave the wand, at least talk to them. And they'll get benefit from the conversation and you just listening.
[00:16:33] Chad: Totally 1,000%.
[00:16:37] Nick: So my other one where I kind of screwed up was very similar to that. It was when I first became certified in dry needling. And like you said, before you learn this new thing, you want to do it on everybody. And we see a lot of runners in this area. So I was at the time seeing a lot of runners for hamstring issues. And I was in the course for the needling. I was the guinea pig for the hamstrings. So all into the hamstrings for whatever reason. So all these runners, I come back and I'm just hacking away at these hamstrings with the needles, and they're very, very thin needles. So it's not like you very rarely drop blood. So it's a very, very small needle going into the muscle, trying to create what's called a twitch response. Basically, the way it's described is like hitting a reset button. I would call it more so a refresh button. I wouldn't say full on “Reset”, to me implies that everything's restoring, you just wiped out everything. And we're just starting all over, I would say more like refresh. It's working a little slowly. Let's try to hit the refresh. So it comes a little quicker, kind of thing. So I was needling away at all these hamstrings. And it was just painful for everybody. And I'm like, “No, that's normal”. And then I listened to a podcast with a researcher by the name of Dr. Andy Galpin. He's big into EMG research, muscle biopsy, all that kind of stuff. And I heard him talking about all this research he was doing out in California, and he said, “I don't biopsy the hamstrings anymore”. And whoever was interviewing them was like, “What was that?” He said, “Because for whatever reason, people take so long to recover”. He was like, “I've biopsied people's patellar tendons on the day of marathons. And they're good run the marathon later that day. And I biopsied people's hamstrings, even my own hamstrings, and it takes weeks to recover fully from that biopsy”. So I was like, “Maybe we shouldn't be putting needles into people's hamstrings”. And I still don't really know why we shouldn't be, but I just really don't do it too much anymore. I might get like a little part of the hamstrings. But I stick to the other areas that really tend to work pretty well, the calf muscles, the quad muscles, those muscles tend responded really, really well. But for whatever reason, the hamstrings just weren't, but I was just going for it on all these runners and that hurts so much and that's normal. And I just kept going, and they'd come back and be like, “How do you feel it's in meals”. They'd be like, “I didn't really feel any different actually felt more”. So I'll be like, “Oh, that's that, it'll take me a couple of times. It'll take a couple of times”. So I don't really need all hamstrings anymore, dry needle. After hearing Dr. Dr. Galpin talk about that. And then the experience is actually taking a step back and seeing these runners were getting needles, and they were just more sore, like they didn't really feel the benefits from it. Maybe it's probably best to just get what I'm trying to get out of the manual therapy with other things. And really with these runners with the either long term hamstring issues or even acute, we're trying to get blood flowing. But also we're trying to retrain mode patterns, so we got to get them up and moving. So decreased sensitivity away with whatever grass to end, whatever you got to do to decrease that initial sensitivity and then let's just get them moving, returning those patterns getting the fire those hamstrings a little bit more so than just jabbing him with them.
[00:20:16] Chad: I definitely did that a lot too, when I first got certified in dry needling and I screwed up too, because not only did I do multiple spots, but I was trying to get that level two. So to get that level two, you have to do more than three different regions. So I'd be like glue just so I could mark it off the list the same thing. And it would have to be on the same day.
[00:20:38] Nick: It was the weirdest thing. So you had to do it on the same person. But three different groups, sounds like your calves definitely played a role here. Let's needle that.
[00:20:47] Chad: Some of it was trial and error. And then somebody that was like, I just want to get those 200, and I got the 200. And I never took the second level. So I apologize for those people that I did that do.
[00:20:58] Nick: But if you are listening out there, and you're joining me for that helped me, the glutes is fantastic. It works wonders on the glutes. Like I said before the quads like it, it does wonders to these other areas. But for whatever reason, the hamstrings and it could be could it be a sciatic nerve thing like the hamstrings covering the sciatic nerve. So it's more sensitive than other areas potentially. Could it be the type of tissue I probably argue that it's more the fiber breakdown of that particular tissue? That’s why it's not responding well. Same reason, for example, I think it was Brad Schoenfeld. He reported that on average triceps are 70% fast twitch, and when you needle draining someone's bicep is twitch and that’s crazy. So maybe the fast twitch is more importance of that hamstring to you're hitting and that's what's creating that significant response. Who knows, but it's probably a combination of factors more or less.
[00:21:59] Chad: Cool. Any anything else that we'd like to add? I don't want to talk too much about all the stuff that we messed up on because I'll save other stuff that I screwed up on for next episode. But is there anything else with the needling or anything that we kind of want to touch upon for that?
[00:22:13] Nick: I think the biggest thing with it, something like the needling and even you said the ultrasound. It's easy to get carried away with either a new scale or something that you can do after you do it enough, it becomes second nature to the point where you can almost do without thinking, I know that sounds a little crazy, you can just put needles in something without thinking but you're thinking but you're doing it. And it's your nature at this point, it's like you would do anything else, brush the teeth, stuff like that. So we get into these and you can fall into this habit where you just do it to do it or just do it to kill time or something. But you gotta you gotta step back to the basics step away. Why am I doing this? Just constantly go back to what's my reason for doing this? Do I have a reason? If I don't, I probably shouldn't do it. If I have a good reason, let's do it, see what happens. And if they're not responding, I gotta be able to change course. That's probably the biggest thing there is to be able to be flexible.
[00:23:16] Chad: I agree. And make sure it's your reason and not somebody else's reason, because you need to understand that reason. So, Nick might treat a knee one way, I might treat it another way. But as long as the goal is reached, that doesn't really matter. So if, Nick, decides that he wants to do a certain type of exercise, and I want to do a different type of exercise, that's okay. As long as the goal is reached, that's fine. But take it from me. Don't fuck around with the pastor modalities too long, that's not gonna make anybody better. But just because somebody else does. It doesn't mean it's the right thing. And that's the trap that I got caught into. When I first graduated, I was thinking everybody else is doing this. It must be the thing to do, but you got to learn to think for yourself whether you become more of an advocate in terms of research, whether you reach out and talk to people like Nicaragua and be like, “Oh, I'm doing this what do you think whatever” you just need to kind of open up and in kind of learn more for yourself instead of just kind of copycat and everybody else for lack of better words.
[00:24:15] Nick: You got to try stuff as long as it's safe. Try it because you that's the best way to learn, we just talked about times. We messed up and we learned from it. That's one of the best ways to learn because once you mess up, you're not forgetting it.
[00:24:28] Chad: That’s true. That was a quickie. I like these ones. I think we're gonna have some fun with these ones in the future for sure. Moral of the story, “Don't be that PT. If you find that you are that PT, then please, for the sake of your patients and clients make that change today. Learn from our mistakes. Remember that life's greatest lessons are usually learned from the worst mistakes”.
[00:24:54] PODCAST OUTRO: Thank you for joining us “In The RACK” this week. Make sure to subscribe so you don't miss out on any future episodes. You can also find us online at proformptma.com, or on social media at ProForm PTMA. And remember;
“If you train inside the rack, you better be thinking outside the rack”.
