The Guide to Travel Physical Therapy & Psychology – A Randy Bowling Movement Conversation

I recently had the pleasure of talking about all things travel PT and psychology with my dear friend, Randy “The Dolph” Bowling.

Travelin’ fam

Randy has been a traveling physical therapist for almost 10 years now, and has a substantial knowledge base on the traveling process. He also is very much into psychology, and thought me a few things.

You can find Randy on facebook and Instagram.

Here were some of the topics discussed:

  • Why Randy chose to become a traveler
  • How to best interact with travel companies
  • How to network with other travelers
  • The need for negotiation
  • What do travel contracts look like
  • What does the interview process look like
  • What makes a good traveler
  • Randy’s thoughts on psychology
  • How important is focusing on pain?
  • Why Randy is a big fan of Louis Gifford

Here is the video, audio, and scroll down to read the modified transcript.

Enjoy!

 

Here were some of the links mentioned by The Dolph

Fordyce’s Behavioral Methods for Chronic Pain and Illness

Clinical Reasoning for Manual Therapists

Pain-Related Fear: Understanding and Treating the Complex Patient

Aches and Pains

The Seductive Allure of Neuroscience Explanations

Modified Transcripts

 

Zac: Hello you beautiful, sexy, outstanding people. This is Zac Cupples from zaccupples.com, and I’m bringing you another movement conversation with my good friend, the legend himself, quo board extraordinaire, straight out of Arkansas, “The Dolph,” Randy bowling.

Say hi to the people Randy,

Randy:  Hey my name is Randy.

Zac: The reason why I wanted to bring Randy on for this movement conversation is because Randy is incredibly experienced at being a travel PT, and he knows a lot of the ins and outs.
Continue reading “The Guide to Travel Physical Therapy & Psychology – A Randy Bowling Movement Conversation”

Kinesiotape, Managing Performance Teams, and More – Movement Debrief Episode 14

Movement Debrief Episode 14 happened yesterday, and it was a good ol’ fashioned reader Q&A.

Here’s what we talked about:

  • Evidence (or lack thereof) for taping in general
  • How I incorporate taping into my practice
  • What the keys are to having a successful performance team
  • The keys to being a successful leader

If you want to watch these live, add me on Facebook, Instagram, or sometimes Twitter. They air every Wednesday at 8:30pm CST.

Enjoy.

Here were some of the links I mentioned in this Debrief.

The 3 Biggest Basketball Conditioning Mistakes

Effects of Patellar Taping on Brain Activity During Knee Joint Proprioception Tests Using Functional Magnetic Resonance Imaging

Systematic Review of the Effect of Taping Techniques on Patellofemoral Pain Syndrome

Effect of kinesiology taping on pain in individuals with musculoskeletal injuries: systematic review and meta-analysis.

Dynamic Tape

Leukotape

 

Pain Language and other Jive Talk

To All My Clinicians in the Struggle

It was all a dream, I used to read ortho magazines.
It was all a dream, I used to read ortho magazines.

 I struggle with patients.

Those patients that I am having trouble with are who I study the most. It’s that whole learning from your failures thing.

In studying these folks, I have noticed an interesting trend.

It doesn’t involve movement.

It doesn’t involve medical history

It doesn’t involve stress (though it always involve stress)

Instead it involves language. I have noticed a few commonalities in how those patients who are either not improving or have been in chronic pain for some time talk. There is one shift, however, that I notice more often than not.

Disembodiment from Your Sports Team

 I don’t really watch a whole lot of sports; I’d rather play them.  Sports fans however, interest me. It’s fascinating how much ownership a sports fan takes in his or her team.

Fascinating creatures indeed
Fascinating creatures indeed

This ownership is especially noticeable when things are going well.  Think of the language one may use during the following instances:

  • Huge victory – “We finally beat the Packers.”
  • Draft Picks – “Our team got some huge prospects.”
  • Championship win – “We are the champions….my friends.”

Notice though, how oftentimes language may shift when a team is not doing so well.

  • Huge loss – “The Bears lost…Again.”
  • Draft flops – “I can’t believe they chose Steve Urkel first round!.”
  • Championship loss – “They blew our chance of winning.”

Robert Cialdini discusses this concept in his book “Influence: The Psychology of Persuasion.” When our team is winning, we manipulate our association to said team to improve our self-image. On the flip-side, when our team is losing, we will do things to distance ourselves (you can read an interesting study on this here). Perhaps it switches from  “we win” to “they lost.” Or perhaps we wear team jerseys after a victory and regular clothes after a loss.

Or perhaps he's wondering why he'd determine a structure at fault, before considering it's the brain....Yes, this just happened. Gratefully accepted by Bill Hartman, I did need it.
Or perhaps he’s wondering why he’d determine a structure at fault, before considering it’s the brain….Yes, this just happened. Gratefully accepted by Bill Hartman, I did need it.

This same concept seems to apply to pain states. Think about those folks in acute pain/injuries:

  • My neck hurts.”
  • “I tore my ACL.”

Compared to those who perhaps are in more chronic pain states, or at least those folks who I have noticed are not doing well.

  • “It hurts in the neck.”
  • “It must be that bulging disc.”
  • “I have the neuropathy.”

The former examples still have ownership with their problem, while the latter distances themselves. They become disembodied from the perceived affected area.

They lose the area’s image. They no longer love their team. That shoulder jersey they used to wear stays in the closet.

What the zaccupples.com team jersey is.
What the zaccupples.com team jersey would be if the skeleton was actually asymmetrical.

I’m going to quit using my arm.

I’m going the start calling my arm “the” arm.

I’m going to start saying the arm is killing me (to which I ask the patient if I should call the cops).

I’m going to persist in a chronic pain cycle.

 What to Do What to Do

 A patient’s descriptors and metaphors can play a critical role in how the pain experience is perceived. If thoughts and beliefs are what seem to impair one’s function, then it is those impairments that must be addressed.

Your goal is to get the patient to fall in love with the affected area again.

In order to play neurological cupid, shifting a patient’s language can have profound effects. It may be as simple as just making them aware of how they are describing the affected body region; relating these descriptors to brain smudging. You could also use the sports fan example above:

“Your perception of pain has led you to become a disgruntled fan of your shoulder. You need you [notice how I frame the needs to what they need to improve] to become a super fan of your shoulder again. It is your shoulder; take ownership in it. I’m going to show you some gentle exercises that will give you that winning streak you need to start cheering for your team again.”

This will happen in your educational conquest I can promise you that.
This will happen in your educational conquest I can promise you that.

Regardless of what direction you choose to go, you have to do all that is possible to change your patient’s perceptions, thoughts, beliefs, and fears regarding the pain experience.

It’s one of the hardest things we have to do.

What are some of your tips, tricks, phrases you notice?

New magazine I may start??
New magazine I may start??

Lessons from a Student: The Interaction

The Inspiration

Over the past few weeks I have felt called to write about an often uncovered yet extremely important component of the therapeutic process: Patient interaction.

We had an instance in which I came back into the clinic from my lunch break and my intern was supposed to have a patient evaluation. Instead, she opted to have me take this particular patient. This patient was a lovely 17 year old lady who was being seen for bilateral foot pain. This was her second bout of therapy, and her and her mother was very dissatisfied with their last physical therapy experience just a few months (and 17 visits) prior. She was not a happy camper and wanted a second opinion. After hearing stories from my coworkers, I expected the worst.

We progress through the evaluation, and my student observes nothing but smiles throughout from the patient and her mom. Jokes were cracked, movement was looked at, and edumacation happened. At this point, after a little explain pain and kinetic chain discussion, these women were sold.

Truf.
Truf.

We leave the treatment room and I said “that wasn’t so bad yes?” My student replies “that’s because they are in love with you.”

But really, that essentially is what you have to do with the patient interaction. You can have the greatest hands, the greatest exercise plan, and evidence up the wazoo; but if your patient hates your guts you will fail. I heard this from Patrick Ward that 80% of your success with patients depends on if they like you. A recent RCT supports this notion as well. You have to get your patient to fall in love with you and your approach, in a nonsexual manner of course.

While I am neither aware nor sure if possible there exists any evidence regarding the best way to interact with a patient, I am going to run through how I approach the patient experience. I don’t know if my way is the most successful or even the best way, but I generally get good patient satisfaction reviews so deal with it.

The Goal

Here is what an excellent patient interaction achieves:

1)      Reduced threat perception.

2)      Establishes a bond and rapport.

3)      Maximizes placebo effect.

4)      Makes rehab fun.

If you read The Polyvagal Theory, Stephen Porges discusses neuroception, which is basically how your nervous system responds to situations after evaluating all given sensory input. If your autonomic nervous system perceives someone or something as threatening you will either fight, flight, or freeze. The goal then, is to make the patient feel safe when working with you. This shift allows for decreased sympathetic response and increased prosocial behavior, both necessary and influential when working with pain states.

The patient interaction is also a great way to get the placebo effect. I know the placebo effect often is thought of as deceitful and providing ineffective treatment, but that is far from the truth. All the placebo effect does is maximize the belief and perception that a treatment will work. In fact, the belief that something will work is part of a recent CPR developed for cervical spine manipulation in neck pain. In On Intelligence, perception and behavior are one and the same. So by optimizing one’s perception, we can optimize one’s motor behaviors.

Theatricality and deception are powerful agents to the uninitiated.

Moreover, I think it is important to have fun with what you do, and make the physical therapy experience a pleasant and rewarding time for all involved. Think of how we are perceived; “PT stands for pain and torture,” or “I hate physical therapy.” Adding humor and performing fun activities can make PT a more fruitful time.

Seeing how my student has been progressing is a good example of this. When she first started out, much of the focus was geared toward getting all the relevant information, making sure she was performing all the tests, manual therapy, and exercises well. One thing that was really lacking was the patient interaction.  After stepping in a few times when she struggled, you could see some of her patients just open up and smile during our short stint together. After explaining the above to her, my intern is now asking patients about their life stories, weekend plans, and empathizing with their problems. She is even stealing some of my jokes, which is okay because half of my material is not original.

Be like the rehab version of Carlos Mencia.

The Greeting

The first impression is very meaningful and sets the tone for the patient interaction. When I meet a patient for the first time, I will call them by name and have them walk to me. I get several pieces of information from this introduction:

1)      Their sitting posture.

2)      Their facial expression when you make eye contact.

3)      How they get out of the chair.

4)      Their gait pattern and speed.

These pieces help me understand how well and willing the patient moves, as well as their general demeanor. Depending on if I see someone hop right up with a huge smile on their face versus someone who is slouched in their seat and slowly trudges over towards me, my interaction with them often changes. With the former, I will be more upbeat, with the latter, I will be mellow. The more you can mirror the patient, the greater bond you can develop.

The Handshake

This small gesture reveals so much about your patient. The firmness and way they shake your hand can tell you a lot about their personality. There are several different handshakes you may experience:

Which you should use depends on how you wish to be perceived. If I see someone who seems to need more guidance, I may use a more dominant type of handshake. If I see someone who needs reassurance, I may use a more submissive handshake. Regardless of how you shake one’s hand, make sure you use firm pressure and warm eye contact.

The Subjective

The subjective examination is very important, but not for the reasons you think. I know my mentors in my residency will kill me, but I personally do not feel the subjective examination really steers me in a particular treatment direction. Rather, I see the following as the subjective exam’s goals:

1)      Find out how you may help them.

2)      Establish rapport.

3)      Understand the patient and their story.

4)      Make the patient feel understood.

5)      Rule out red flags.

You obviously want to find out what brings them to you, but for me the objective tells me where to go. The subjective examination is more for the patient than you, so let’s talk about how to maximize that interaction.

The Setup

How you face the patient can make or break your interaction. Remember the goal is to reduce threat perception and make them feel comfortable with you. To maximize this goal, you want to eliminate as many barriers as possible. So you probably do not want to face the patient like this…

qAdYbetfk_P-eN9NPa96aOJyTuUPKC8_DMvm6LpKYzc
No focus; barrier

Or This

_6zqczBAzFtjybMHOAULjXxqv6pOEtkbWEHoYsrJTZQ
Focus, but barrier of leg and clipboard.

Or this

BW90UgG_6zoz5LWhUnDebd7o8-IoVy_93uWlVRw8k0Q
Focus, but table is a barrier and too far away.

Or this

bEU-zFcKxhiWg-A13BDdcWtZ6NXH6kZkOhuyvF_3aGk
Not even in the same room…barrier.

And definitely not this

Too up in the business.
Too up in the business.

Rather, I like this orientation

More ideal...minus my slouching posture.
More ideal…minus my slouching posture.

Here you are staying close to the patient while simultaneously respecting their privacy because you are not directly facing them.

Now I know what you are saying, “But Zac, you are using a computer, clearly that is going to kill rapport and act as a barrier.” I would agree to some extent, there are two things here that you ought to notice:

1)      The computer is not directly in front of the patient, thus is not a barrier.

2)      I maintain quite a bit of eye contact while typing.

Now granted some people may still feel uneasy about me typing in front of them, so I will usually ask if I sense that this is problematic. But you can still develop some semblance of intimacy with the patient by playing with 5 different variables.

The 5 Intimacy Variables

In order to develop an intimate experience with the patient, we can add/subtract 5 different ways to create a bond with someone:

1)      Proximity

2)      Eye contact

3)      Touch

4)      Direction

5)      Saying the person’s name

The more of the above variables you utilize when you interact with someone, the more of an intimate encounter you may experience.  You want to use neither too many nor too few variables when interacting with someone. Too many will make you seem creepy (and potentially send the wrong message) and too few will make you seem distant. I generally shoot for 2-3 at a time.

So if we take the above setup example, I am keeping a close proximity toward the patient and maintaining eye contact, however I am not directly facing the patient. I may modulate the interaction throughout by saying the patient’s name or providing a light touch of the arm. So here I can utilize my 2-3 variables at a time.

The Objective

While the objective’s goal is to guide your treatment plan, it can also be a great time to further build rapport. Perhaps the best way to establish that you care is by providing a thorough examination.

How many people have been to a 5 minute physician visits compared to one who may spend up to 30 minutes taking a look at you? Which physician is better liked? The fact of the matter is, people want and expect a thorough examination, so give it to them.

This is where I feel like something such as the SFMA can come in handy.  People may have gone to other clinicians who just looked at the affected region, but this clinician is looking at everything, he/she must be different. So when I am performing an assessment, I generally perform something closer to the SFMA top tier and then do my own type of breakouts from that. What can I say, I’m a rebel.

A clinical Badass, one might say.

Throughout the examination, I will sprinkle compliments or ask about things like their plans for the rest of the day, anything I can do to further establish rapport.

The Education

So you finished the subjective and objective, and you likely have the information that you need to treat. The post-evaluation education is the spot in which you can really win or lose people. David Butler suggests that there four questions that the patient would like answered:

1)      What is wrong with me?

2)      How long will it take to get better?

3)      What can I do to make it better?

4)      What can you do to make it better?

I will usually educate the patients to some degree on pain physiology, followed by whatever objective impairments I find that can improve upon one’s complaints.  In order to maintain low threat perception, I will rarely break out models or use terms such as “motion x is crushing body part y” or “you have weak area z” or “your spine is unstable,” even if these components may be somewhat true.  Reason why comes back to reducing threat perception. Seeing models of bulging discs or using some semblance of the above language tends to just freak people out and moreover is often inaccurate. People just need to know that it is safe to move, when it is safe to move, and move well when they do.

I will finish my education by asking the patient an incredibly important question. Drum roll………………………………

Do you have any questions?

Especially the case with pain neurobiology, if the patient does not understand where you are coming from, they will not be able to fully buy in to your methodology and plan. So make sure any questions the patient has are answered to the best of your ability.

 

The Ending

I always finish my interaction with patients with the following phrases

1)      “Do you have any questions, comments, concerns, or complaints?”

2)      “Is there anything else I can do for you or that I did not cover?”

I ask these questions to again establish an open communication and rapport. I want to make sure that the patient is completely satisfied with the experience that I have provided them. Moreover, finishing the session with the same ending every time they come in provides the patient with some consistency and helps establish your brand; in my case, the Zac Cupples brand.

With extra placebo-enhancing effects...works best when not plugged in.
With extra placebo-enhancing effects…works best when not plugged in. For sale soon on www.zaccupples.com

Conclusion

So there you have it, the above methodology is how I approach a patient interaction. I have based many of these methods on what I have read regarding people interaction, so the below resources might be good to check out. If you can get your social capabilities to a high standard, the rest will take care of itself.

“The Definitive Book of Body Language” by Allen Pease

“How to Win Friends and Influence People” by Dale Carnegie

“Made to Stick” by The Heath brothers

“Influencer” by Joseph Grenny et al

“Social Intelligence” by Daniel Goleman

“Just Listen” by Mark Goulston & Keith Ferrazzi

“Never Eat Alone” by Keith Ferrazzi

“The Power of Self Confidence” by Brian Tracy

James Bond – Seriously, the way he interacts with people is gold, especially if you kill bad guys and woo women like I do in my spare time.

Cupples, Zac Cupples