-Physical therapy during Covid19.
-Managing arthritis and tendinitis during this time.
-How to get back into exercise and sports as things eventually open up again.
– Okay welcome, everyone! This is Siddharth Tambar from Chicago Arthritis and Regenerative Medicine. Welcome to our weekly live-live broadcast. It is July 29th, 2020. Before I get started, let me just make sure the audio is correct. For anyone that’s listening, please let me know if the audio that you’re hearing is okay. I’m hearing a tiny bit of sort of reverberation back here. But if it’s okay, I’ll go ahead and get started.
– Sounds good on my end.
– Okay, great! Keith, can you hear me still?
– I can hear you great.
– All right, awesome. Right so, this is our weekly live-live broadcast where I discuss topics relevant to what we’re doing here at work. As a reminder, Mondays I do a weekly live broadcast where I’m talking to my own team at work, answering questions that they have, answering questions that patients have as well, basically discussing kind of big principles and questions that people have. The Wednesday live discussion is more about sort of bigger principles and other topics, and all the things that are relevant to what do here at Chicago Arthritis and relevant medicine, and Regenerative Medicine, where we focus on arthritis, tendonitis, injuries and back pain. Keith, I think I can hear an echo coming from you.
– Yeah, can you hear it now? I turned my volume on my computer off.
– That sounds better, I think. I can still hear myself a little bit.
– I could switch and do audio from my computer, and let me try that. All right, so I took my phone all the way down, and I’ve turned it all on the computer, that might be better.
– I think so, let’s see. Yes, I think it is! Right, so on today’s episode, or today’s broadcast, I am speaking with Mr. Keith Travers, who is a clinic director, and owner of Fyzical Movement and Balance, previously known as Sovereign Rehab. I’ve known Keith for a while I think, probably like over a decade maybe, Keith? Or maybe a decade?
– Yeah, we’re gettin’ right around a decade, I don’t know the date.
– And I knew Keith back when he had a lumberjack beard, and so to see him clean shaven now is a little bit disturbing. But I have a huge amount of value and appreciation for Keith and all the folks at Fyzical Movement and Balance for what they do for my own patients in terms of physical therapy, and there are so many interesting topics to discuss at this moment during COVID, pre-COVID, post-COVID, all that kind of stuff when it comes to musculoskeletal issues. So thank you, Keith, for joining.
– Well, thanks for having me. I really appreciate being able to talk with you, it’s always a pleasure, and we always get on some really good topics, and I’m excited to see where we go over today.
– Awesome. So, how have things been? I mean we’re talking, and it’s July 29th, 2020. We are still really smack in the middle of COVID, let’s face it.
– And you know, physical therapy is such a hands-on, personal, direct, one-on-one sort of relationship with people. How have things been going?
– You know, so things have been going smooth. Obviously in the beginning we had a lot of work to do, everyday something was changing, so we were changing our plans on how we would reopen. I’ve did two weekly Zoom meetings with my staff, and we would go over, “Okay, what’s happened now, what are we going to change, what are we going to implement?” And eventually we came up with a plan that we feel is keeping everybody as safe as we possibly can. Certainly there’s no way to eliminate risk, but with us mask wearing, cleaning everything, separating tables, separating time frames when people come into the clinic, and then providing telehealth for whoever feels comfortable with that versus being hands-on, we feel like we’ve made it more comfortable for patients to come in and see us, and it’s showing in the fact that our volume is increasing. We’re getting more people coming in, and calling us, and doing evaluations because there’s a need out there for sure.
– Excellent. That’s outstanding.
– Echo, echo.
– Sorry about that, give me one moment to correct that.
– [Siddharth’s Phone] One moment to correct that.
– Yeah, it was, you know at the beginning, it was certainly a challenge. We think we’ve smoothed most of our processes out. We feel like we’ve got a safe environment, being able to provide the one-on-one care with patients because I can tell you, that’s all hands-on, you are going to need some manual hands-on work. And we’re going to be close to patients, so all of our patients are wearing masks, all of our staff are wearing masks, which sort of significantly reduces the chance of infection if somebody is asymptomatic. Taking temperatures too, so if somebody comes in and they have a temperature, they’re sent home, we honestly haven’t had a single person have a positive, anything over 100, 101, so we’ve been safe on that. And so no cases here so far.
– Excellent. What’s been the response from patients when it’s come to their sort of acceptance with that sort of new way of working? Or do you feel like it’s pretty much just sort of business as usual? Or besides the cleaning aspect, how do you think some of this stuff like tele med, telehealth, has affected things or worked out for your patients?
– Yeah, we know we’ve had some people, we’ve had an interesting, in fact some of your patients, which we never would have reached, would come from Flossmoor or Hyde Park and things like that, people that would never be able to reach us, and maybe would go to a different clinic or not have services at all, we’ve been able to do some telehealth, and they’ve almost all done very well. I was certainly a little worried initially, but our response of most, if not all of our patients is that they’ve been excellent with the telehealth, and not having anything that doesn’t work. So, I think in the clinic we have some patients who are like, “I really need to get in.” And we’ve had that, and we’ve seen that start to increase over probably the past six weeks, where it’s like, I just need your help, and I need you to watch me closely, and or I need some soft-tissue or deep-tissue work, and or joint mobilization. So, people have been open to it. If they’re uncomfortable we always offer telehealth, and we know that that’s going to be a viable good option for them too, because we’ve had people get better with it, so. It’s kinda, unfortunate that all of this happened, but it does open the door for us to be able to see more patients in a better way than we could before.
– Yeah, I mean the reality is that people still have their joint, tendon, back issues, right?
– Like, COVID or no COVID, it hasn’t gone away. Reality is I think for a lot of people who are sitting on Zoom calls for half the day, I think there’s a lot of people who have back and neck issues, shoulder issues that they probably didn’t before that they’re starting to deal with as well, and so I think the need for good quality practitioners when it comes to musculoskeletal health is still definitely there. And I think the question is even during times when we’re kind of fluctuating in and out of work, there’s still ways to kind of offer value to people. And so I know we had done a sort of brief video, you and I, where you kinda went through some things you can do for a shoulder. And I know for me that was a pretty good proof of concept that hey, this still works, right? I mean it takes a motivated patient, but that always does, but I think a good dedicated responsive physical therapist can still offer humongous value. And in a lot of ways, I think there’s oddly an opportunity to kinda continue to offer value after people go back to their regular lives, meaning when they’re outside that normal physical therapy window when you guys see people traditionally, that how do you continue to stay connected with them, because their issues don’t fully go away, they need to be managed and optimized. And I’m sure you hear this all the time, I mean I’ve done this myself, that I was really good with all my exercises when you were actively drawing them out for me and teaching me, but after a while, you start to lose some of the, not motivation, but you lose some of the connection with that. And I think a really great way for PTs to stay connected with folks is with the telehealth approach, to kind of people on target with what they need to do, in a way that I don’t think most people traditionally do, or most of medicine misses out. And I think PTs are uniquely positioned where you can still kinda get people to do some of these kind of things that keep them online.
– Yeah, you know it’s interesting. So, when we first, when everything was first going down, I asked the staff, “Okay, we’ve got time on our hands, let’s do some journal reviews, and let’s see what we can find that out’s there just in general.” And Kathleen, one of our awesome therapists, she found an article on telehealth versus in-clinic treatment on total knee patients, and what the study showed, now, the telehealth patients were getting sessions on a daily basis, six days out of the week, about a half-hour, 45 minute session with a PT via telehealth guiding them through the program. Had no hands-on treatment at all, for a total knee, which normally needs some stretching in order to get where they need to be. And they compared that to a model of in-clinic treatment, hands-on work, et cetera, et cetera, and the people in the telehealth group actually did better functionally, with less pain and a higher outcome level than your hands-on patients did.
– So we took that and we said, “Okay, well we got to utilize that at some point in our practice, maybe our total knee patients become a hybrid.” And the thought process on it was you’re intervening with that patient on a daily basis, and nothing is more important than the whole program. So, if we can get them doing the program everyday for six weeks straight, and we see them every single day, obviously it makes a difference at least for that small of a group.
– Right. You know, there’s this concept in technology, and people are talking about it in medicine now about augmented reality, can you take, use technology, and so can you give practitioners a little bit more detailed, or information, than what they would normally have. And I was thinking about this this morning, that for physicians, like we use things like x-ray, dynamic ultrasound, MRI, that’s augmented reality to look at joints and tendons. If we’re doing treatments like injections, you’re using an ultrasound and x-ray guidance, that’s augmented reality. And there’s certain traditional things, hands-on things you can’t really replace, but if something as simple as a cell phone with 5G access, is that basically augmented reality for PTs?
– Meaning it’s not, it can’t replace the hands-on diagnostics that you can do, right?
– It can’t replace manual therapy, but it does augment what you’re normally doing in a way that extends that care further and with more distance. Which is really helpful when people are kind of living normal lives.
– Whether that’s related to work, whether that’s related to family activities, whether that’s related to anything else. Like, how do you keep people on target? Well, this is a nice augmented way to sort of keep people on target, something as simple as a cellphone.
– Yeah, I know we are brainstorming how do we use this down the road, if and when, you know, telehealth has to go away for whatever reason. Well, our thought process is there are so many people who are like, “Well, I can’t make it that time, I can’t make it that time.” Well, I’m going to come to you and then you have no excuse.
– Right. What I think is interesting is that the telehealth connection, like I think as a society we’ve gotten used to communicating like this, but from a like a professional standpoint, there is a little extra work involved. It’s a little bit different, right?
– Right, right.
– Like, it does require communication skills that are a little bit different than what you do in person. And so I think the technology is the easy part here, it’s the communication and the skill level that the practitioner needs, that it’s taking the same skills, but now expressing it in just a slightly different way, and I think some people will be naturally good at it, some people will get, they’ll learn it fast, but it’s not going to work for everyone. But from a patient standpoint, like that value is humongous, humongous. I mean, this is kind of an extreme version of this, but when I had my own shoulder injury and you helped me out, like a big deal was actually being able to work, like having you video tape me, going to midtown tennis, video taping me, talking to the tennis coach, so literally you’re talking to the tennis coach, and I realized that was above and beyond what most people are going to get. But the point was it was much more dynamic than what the traditional approach would be. And that little bit extra goes a humongous way because it’s doable now, and it takes a problem that is linear in terms of your treatment approach, and now you make it dynamic and much deeper in terms of what you can actually effect. And so it doesn’t have to be complicated, right? It’s literally something as simple as, okay, we’re doing good work here. Now you want to get back to golfing, tennis, swimming, whatever it is. Well okay, what happens when you’re out there? And that knowledge, like, you see that. I think that’s a huge thing for you guys.
– Yeah, you know the studies show too, you know, we can have them in the clinic doing things, looking perfectly right in line, mechanics are perfect, and even in the clinic when we throw like, a ball at a soccer player, and we go, “Okay, land appropriately.” Biomechanics fall apart. So, there’s a huge amount of training in the clinic, but then you got to get out to the field and see what really happens when they’re, because all the work we did, I don’t want ever to be for naught. You know, if I put in, and you put in six, eight weeks of treatment, and I know you’re going to go do those activities, I got to make sure you’re going to do those activities right.
– Right, yeah. And the reality is that, like that might apply to an athlete, but for all of us, like for human beings, your regular human being who’s commuting to work, walking up stairs, trying to navigate normal life, like, there’s a dynamic nature to how we’re stressing our bodies.
– And while it may not be to the full extent that someone who’s, let’s say a high level competitive athlete, for your average person, they’re still pushing their limits as far as they can. That’s just the nature of being a human, you’re constantly pushing your physical and mental limits. And so even for that dude who’s literally just commuting to work off the subway, like, even just getting a visualization of that, like man, you need to handle those stairs differently. Like, we need to change this up, because that’s not going to work for you longterm. There’s even value to something that small.
– Yeah, yeah, I would agree. Yeah you know, especially we touched on it at the beginning, like with the pandemic and everybody sitting, and sitting, and sitting. It was bad before. It’s kinds of exploded the amount of deconditioning that’s out there.
– We have patients coming in who, you know, A, I tried to do this thing, or now I try to go to the grocery store, and oh my god, I’m exhausted, and you’re like, “Okay, we can help that. Let’s get in, dig in, see what the problems are, and let’s fix those things.”
– Yeah, that’s wonderful. As people progressively start to get back to some version of normal, and I don’t know when that’d be. Is that three months, six months, who knows realistically? But how are you guiding people, right? Like, even before you get to let’s say, exercise, or high level kind of sports, just regular activity. A person who’s going from sitting on their couch taking Zoom calls, to now trying to get back into some version of normal, how do you ease them back into that? Or how do you guide them before they get back to that?
– Right, so I think the biggest thing is if we can get them in here into the clinic, we can check the body head to toe, and get a good baseline of what’s happening. Like, do they have tight hamstrings? Do they have a tight calf? Things that may, depending on the goal, like are we going to try and run, are we going to try and go out and play some sport or tennis? Find out that activity level, find out where the baseline of the body is, get a good systems check. Start integrating in things to fix the systems that are poor and then always, always, always start them at a slow pace. So, say they want to run two miles, well they’re going to start walking for a half mile first. Do that several times, let’s see how your body responds. And it’s really educating them on the fact that if you go too quick too fast, any work that you’ve done is, again, for naught, you’ll kind of go backwards. And then we’ve got a lot of work to do to recover if you’ve injured yourself because you pushed too fast.
– Yeah, you know it’s I think one of the more interesting aspects from a clinical care standpoint. Probably from your standpoint, so from a physician’s standpoint is to see how people dynamically adjust and adapt with time. And so what’s really great is you can get a snapshot of where somebody is at one time, but that dynamic change, and sort of guiding people through that, that’s a huge part of this. There’s a lot of subtle changes, but it’s the reason why I think for a good physical therapist the value is not just that initial sort of evaluation, it’s guiding them through those stages.
– You know, progressive, but sort of aggressive enough fashion at the same time, where you’re not too hard, you’re not too soft, you’re just kind of slowly progressively pushing it. And that makes all the difference in the world. Because if you go too easy, you’re not going to get them to wear they need to go. If you go to hard, and it’s not really personalized and specific for them, it’s going to be a problem as well. And I think that’s definitely a big part of this. I mean, I almost feel like for in the next few months if people are trying to get back to work activities, I mean they almost need to be thinking about the same way you got NFL players right now who are trying to get back to training camp. Like, they don’t just start hitting people or playing, like they go through weeks! And now it’s going to be abbreviated, but they go through weeks where they try to get back to that level. And is it ridiculous to say that your average person needs to get back into normal life commuting kind of shape? But I don’t think that’s too ridiculous.
– I personally don’t either. So, we are seeing a few post-COVID patients, and in doing so we’re like, “Well, what about all the other people?” So, on our website we’ve created kind of a program to where it’s like a reconditioning for the general population, and it’s just a head to toe evaluation. “Okay, what’s tight, what’s weak? Is anything bothering you?” “No, but I want to get back to doing this.” “All right, well let’s check your cardiovascular level, let’s check your flexibility, your strength, let’s fix the things that look off. And here’s a plan to reintegrate you back into society.” I guess you’d say.
– That’s fantastic. How much of that can you do via telehealth in this kind of format versus how much of that has to be hands-on in person?
– I think it could go either way. I really think it could be a telehealth version. We could easily do that and manage that with just a few, you know, modifications to how they do things, you know, if they’ve got a step at home we can do a step test and kinda check their heart rate, that might be a little bit of a challenge, but most everybody’s got one of these watches now that’ll tell us their heart rate so we can see how quickly their body responds to some cardiovascular stimulus, and how quickly it recovers. That’s kinda what we’re looking for in a cardiovascular fitness test for them.
– That’s cool. It would probably be worthwhile for those individuals to even be tracking that themselves. Right, so that they get a sense for what their baseline is. I think a lot of times, one of the most interesting aspects of physical therapy for a patient, and I’ve been one, is to actually track, to realize where you are at baseline.
– And to then track to see some of those gains. Like, the knowledge gained about where you are is very interesting, because it gives you insight to how you’ve been living, and how you can push and progress further. I think that’s, as much as it’s possible to sort of tie in the person to that own process, like where they have and understanding and ownership to that, I think there’s so much value to that as well. And I know that’s kind of a hallmark for most PTs in terms of how they try to work with clients.
– We’re always trying to set goals, and then show them the beginning, middle and end, and where they were so that they get the feeling for, “Hey, I’ve been putting in this time, and this time is actually leading to something valuable. I’m stronger than I was.” And guess what? It ties to, “Hey, I can lift my arm up over my head, and I couldn’t do that before.”
– Yeah, let me ask this. I mean, I think if we make the assumption that for the next three to four months at least we’re going to still be in this weird kind of pseudo-quarantine, pseudo-life kind of situation. What recommendations do you have for people to live healthier lives during this kind of period where they don’t have full access to their normal gym, their normal sports activities, what do you generally recommend to people?
– Well for the most part, obviously sitting is what most of them are doing, so I advise them, use their wearables, use their phone, use their watch, set a timer for an hour, at every hour you get up and walk. Make sure that you’re doing some form of exercise in the morning to get yourself going, and then throughout the day when this thing is telling you and buzzing at you, don’t just turn it off. Even just stand for 30 seconds and get some blood flowing through the body. I generally tell them to start a routine that is every hour, every two hours, that they get some input into their body to say, “Okay, I’ve got to move around a little bit.” That’s the first thing. And then also, don’t go too far too fast, and if you’re having any issues, please contact us, and let’s make sure your systems are right, and let’s fix ’em if they’re not.
– Yeah. So, you’re obviously back in clinic now, so obviously, you personally have access to all the equipment you need. What did you do when you guys were shutdown? How did a high-level, trained, intelligent physical therapist, how did you care for your own sort of physical health when you were locked down at home?
– Well you know, I worked out more than I used to, because I had a little more time. I started integrating a little bit of weights. You know, my routine is generally pretty early in the morning I get up and I warm up the body a little bit, do a good amount of stretching, and then I integrate in some weight training into it, so I’m getting a little bit of a bone stress with the weight training, building a little bit of strength. I always integrate in my stabilizing musculature, and don’t always integrate, sometimes I’m able to get the bigger muscles in, but I make sure that I always get the stuff that stabilizes so that I can do the bigger group, and train bench press, and train squats, and train bicep curls. So, I’m working my middle trapezius, I’m working all those little subtle muscles that help me a lot, that allow me to do all the other stuff down the road. And I had a little more time, so I was able to get a lot of that stuff in. I probably would do an hour of work in the morning, and then throughout the day I would set my timer, and every hour or so, I would at least stand and walk around and then come back to the computer, because I was at a computer way more than I was ever in my life.
– Right, it’s remarkable how much you can do on your own just with body weight sort of exercises.
– Oh, for sure.
– And I think that’s an interesting part of what’s, I think, some people who have been proactive, I think are realizing that they really can sort of still take care of themselves even when their normal sort of access to things is gone. And it’s different, but I think it’s empowering to think that you can actually do things on your own with just body weight. Without significant equipment, all by yourself. And that’s regardless of whether it’s COVID or no COVID, because you can’t control those macro issues, you can control the micro ones, which is your own body, your own health, your own environment. Which is a big part of it.
– Yeah, and you know I had the realization that I wasn’t, in the daily routine here, I’m using my body a bunch, now I’m burning calories, and I’m keeping myself active, and I knew I was going to be doing that, so I tried to extend the timeframe that I would work in the morning. No way I was going to mobilize a shoulder that day, or stretch a hip out, that kind of stuff.
– So, the next question is if you take someone, let’s say middle aged or slightly older, individuals trying to stay physically active, athletic. I mean, just as an example.
– Like some people on this call!
– Let’s just say for example. Somebody who is trying to get back into playing tennis who hasn’t done that for about four months now, who’s had a little bit of a shoulder or neck issue in the past and wants to get back at it. Just as an example.
– How would you guide that kind of middle aged individual?
– So, I would start with the basic fact that they need their flexibility back no matter what, so they need to spend probably two weeks stretching out the shoulder, both shoulders probably. And maybe a week into that they can start to integrate in, as I spoke of, those stabilizing muscles, like your rotator cuff muscles, your middle trapezius, all those muscles that are used pretty aggressively to stabilize your arm as it goes through that really quick motion. You probably need a good three weeks of working on that, and then you can start to integrate in some band work, doing a little bit quicker velocity for a couple weeks, and then you’re probably ready to start hitting a little bit.
– So, I didn’t hear you mention anything about I can just, not me, but that individual could pick up their tennis racket and just start wailing away at first serves on day one. When does that become part of the plan?
– So, ideally in this situation for somebody who would want to play tennis again, and they haven’t done it for four months, that’s a good four to six weeks of getting the body ready. During that time he could maybe start, you know, four weeks in, or five weeks in hitting a few balls, just to get the body ready for that. But you got to get the body ready to do it, you have to do the proper work or you’re going to jump in there, start hitting the ball, start having pain, and then ignore it, and then four months later we’re going to have a three month session of PT, which I would rather you avoided for your own health.
– Right, right, right, right. Awesome. Well, Keith, tell me more about sort of what is new and coming up with Fyzical movement and balance. I know there’s a lot of interesting and exciting stuff that you guys are looking forward to. But tell me sort of what the next six months to a year you guys are planning, because I know that’s something you’re excited about.
– Yeah, yeah, so we have some things that we’re rolling out as we speak, we have a therapist who’s been through some public health training, so she can treat patients who are having issues with urinary incontinence, male, female, and actually kids, so that’s a new aspect of our clinic that we just started over the past several months. And eventually she’s going to be able to treat pelvic pain, and there’s a pretty solid need, I’ve noticed as I’m going out to some of their primary care physicians recently, they’re like, “Do you treat public health?” And I’m like, “As a matter of fact, we do.” Which is a new thing for us. So, that’s one thing. And then our balance systems will be getting more intricate. We will in the next six months have our safety overhead rail system, which I’m not sure how much I’ve showed to you before, but it’s a rail system that puts a patient in a harness so that if they were to fall, the harness holds them up, there’s no chance that they could fall. So in doing that, we get to challenge the much more aggressively in their balance, and put ’em on super unstable surfaces they would never feel comfortable doing otherwise. And not just for fun, but we’re doing that because know the results of that treatment will be so much better than if we just had a hand on a belt, and we’re telling them to step over this or do that. So, that safety overhead rail system will be here in the next six months to a year if not before then. And that’s going to help us be able to advance our vestibular, balance, dizzy, vertigo patient, that we’re growing as a practice into.
– Excellent, good! Any last thoughts before we call it a week?
– No, let’s stay healthy, stay safe, and wear your mask!
– Yeah, for sure. Well, thank you everyone for your time. Keith, thank you very much for your time. Like I said at the beginning, I have so much value and trust in your skills as a physical therapist, you’ve helped me out personally as well. I know you guys at Physical Movement and Balance are always doing great work. Appreciate all your help for myself, family, as well as patients. And I appreciate all your thoughts and ideas today as well.
– Well, and I appreciate the time, and thanks for the opportunity.
– Great, thank you everyone for listening in, and until next week, have a good day and live well. Bye-bye!