#1 - Systems-Based Rehabilitation with Dr. Todd Riddle, Part 1

Today's episode is brought to you by chiroup.com. Be sure to check out the sponsor link in the show notes to unlock a special discount for all of our Factor podcast listeners. FAKTR, spelled F-A-K-T-R, stands for Functional and Kinetic Treatment with Rehabilitation. Over the past decade, this unique approach to treating pain and dysfunction has been utilized by healthcare providers on 6 continents, serving as a framework that guides clinical decision-making in patient visits around the globe on a daily basis. With this podcast, our goal is simple: to bring the best and brightest in clinical education to the forefront. And empower practitioners with cutting-edge, evidence-based content that improves patient outcomes and inspires healthcare providers to continually evolve their approach to treatment. In each episode, we will feature a training or interview with some of the top minds in healthcare in a short format that is easy to digest with actionable information that you can implement into practice right away. Let's get started. In today's episode, we will be discussing systems-based rehabilitation with Dr. Todd Riddle. Dr. Riddle is our director of global education for Southeast Sports Seminars and Factor, and has been continually updating and evolving our Factor Rehab course curriculum for over 5 years now. An avid reader of research, former professor at 2 chiropractic colleges, and a master of smoking meats, Dr. Riddle has over 2 decades of experience in rehab and human performance. He has served as the team chiropractor for several sports teams, elite and professional athletes, and has literally spanned the globe teaching FACTOR on 5 continents. His travels have even taken him to the 2018 Winter Olympics, where he served as team chiropractor for athletes representing Nigeria and Jamaica. In this 2-part training, Dr. Riddle will discuss how learning to utilize systems in your rehab can lead to improved patient outcomes. By streamlining assessments, improving diagnostic accuracy, and providing a more precise application of therapy. Let's get started.

Hello, good afternoon, everyone. What I feel like this is going to be a very important conversation about systematizing the things that we do with our patients. If you're keeping up with the literature, it's very system-oriented, very classification-oriented these days. So we're going to cover some. Topics in regards to how to systematize things, some conversations we should be having within our own office to make sure that patients are getting as consistent care as possible. Lots of topics to get through. I do want to say though that we only have roughly an hour or so to get through a massive conversation. So what I'm hoping to do here is just stimulate some thoughts, to stimulate some conversation between other practitioners really, so that we can provide the best patient care possible. So I'm going to get through as much as I can here and make this as informative as possible. So just to kind of give you a brief introduction to myself, I am a practicing chiropractor, have been so for going on 12 years now. I have been a kinesiotherapist, which is similar to physiotherapy, for shoot now 21 years. Certified strength and conditioning coach. I was a former professor at 2 chiropractic schools. And what I'm very proud of is to be a FACTOR instructor. We're going to talk just a little bit about FACTOR here, and also a dynamic tape instructor. And I love the pictures that I have on here because it's a little silly conversation starter I was also the team chiropractor for the Nigerian Women's Bobsled and Skeleton Federation at the last Olympic Games. So I had a great time there. And hopefully we'll be able to pull in a little bit of the experiences that I've had there that actually led to some of the information that we're going to share here. So really what we're trying to do is get practitioners thinking more about how to automate or systematize their patients' experience. This was kind of important to me. I have a bunch of certifications behind my name because it's a way for me to kind of start a conversation about a personal experience that I've had with having to systematize out of necessity. Over the course of many years now, accumulated a lot of letters behind my name and a lot of education. But early on, I found that that education, while it served me, it wasn't serving my patients because I didn't know how to put it in a useful order. That would benefit the patients. It was actually became very overwhelming to have a background in strength and conditioning. It became overwhelming to have a background in rehabilitation because I knew a lot of things. I just had no orderly approach to how I wanted to implement that with patients. And again, I'll be talking about Factor here a little bit coming up. And that was a big part of my ability to start to systematize and order the way that I treated patients. But Really overall, what we're trying to do here is find ways that we can improve patient experience through the application of clearly defined steps. So whether it's how you're doing your patient intake, which we'll talk about, all the way through patient discharge, there needs to be some kind of consistent, orderly way that we treat patients, the way that we see patients. So again, that's gonna be clearly defined steps from start to finish. Obviously, because it is a system, we have to check the efficacy of that system by doing evaluation of outcomes. And basically, there needs to be a checks and balance. How do we know we're going the right direction if we're not going back and looking at how the patient is doing, which basically is how the system is doing? And then obviously the goal is to identify the most efficient way to generate consistent optimum results. Obviously, as practitioners, the most important thing to us is to deliver the highest quality patient care to ensure the highest quality outcomes. Because with good patient care also comes the financial reward of providing good quality care. So really what we're trying to get down to is where does this process start? Where does the system actually start? And frankly, I'm a very firm believer that the patient's road to recovery begins the moment that they step into your office. It's not when you put your hands on them for treatment. It's not when you start doing exercise with them. It literally starts the moment they walk into your office. It's how you intake them, how you start the process with them to get them speaking about themselves. So we're really gonna start from that place and start to develop systems that take care of a patient the moment they come into your office. So these are some of the components of the system that I think are really important, and we're gonna break each one of these down and hopefully give a little bit of clarification about why each and every one of these is important. And frankly, in and of themselves is a system. So that when you put them all together, they work cohesively like a gear would to make the engine that is your practice move forward. So we're gonna look at history and intake, and I think we'll see here in a little while. I think arguably that's one of the most important parts of the system. And if that's not working well, then you're gonna have a very hard time getting to know who your patient is. We'll take a look at examination and assessment, diagnosis. We'll talk a little bit about goal setting, obviously program design. Evaluation of that approach, which means how are you looking at if your system or systems are working? And then at the end, we circle back around and see how the patient is progressing. So what would the next steps for them be? Many of you are already maybe thinking in this way, but it's been my experience that even though we're thinking this way, we have sometimes a hard time implementing these systems or these ideas. Maybe you were thinking about how to implement something, or maybe you had it and you kind of got away from it. Again, what we're trying to do here is figure out how we can systematize this whole process. So we'll start to break these down. And as I said a minute ago, I truly think that the history and the intake of a patient is probably the most important part of your system. And that's why I said a minute ago, it's also, it's where their road to recovery starts is when they receive the email from you. If you're doing any kind of EHR where they receive the email from you to start filling out your forms, Truthfully, it could be when they decide to actually make the phone call to come into your office. So there's gotta be a starting point. And I think the history and intake is one of, if not the most important parts here. There's an old cliché that I like to use when I'm talking to clinicians, especially when it comes to history and intake, is we have 2 ears and 1 mouth for a reason that we should be listening twice as much as we are talking, which means we should ask good pointed questions. And then be quiet and listen to what the patient has to say. Because I believe that when we stop to listen to patients, they will almost always, 100% of the time, tell us what's wrong. We may have to filter through some of that information, but by stopping and listening, we will get a good idea about what's going on with the patients. So I believe that this process starts with outcomes assessment. So in my practice, my EHR is automated that when a patient signs up online for an appointment, And they click to register for that appointment, they automatically get an email welcoming them to the practice, obviously. But then they're also going to get the outcomes assessments that I use as a baseline to get an idea about who the patient is. Because quite frankly, if you're going to have them fill out a history form online, sometimes they're not entirely truthful. Sometimes they leave things off because they don't know that it's germane to the problem that they're experiencing. So for a variety of reasons, while the intake forms are useful, I feel that outcomes assessments are very, very important because they give you a better idea about how the patient's thinking, how they're feeling, how they're performing. So what I'm saying here is it should be an automatic— if you're using an EHR, it should be an automatic send prior to the first visit, really for early detection purposes. And the reason I think this is important is if you're keen to or understand the BPS or the biopsychosocial model of pain, These outcomes can be an important tool for identifying, is this truly a biological problem? Is there a pathoanatomical reason someone's in pain, or is there a psychological— which the more that we read, the more that we're starting to find out patients' pain is oftentimes very much driven by their perception of themselves, the environment around them. And then obviously socially, there are a lot of things that could be driving their pain as well. So I think this is a really nice way to collect information. To give you a better idea about what their subjective complaint is. So again, identify functional factors through these outcomes assessments. And there are dozens. I've listed a couple here that are very popular. Obviously, the Oswestry, the Neck Disability Index, the Lower Extremity Function Survey, your DASH. So there are so many different functional outcomes that we can give to a patient based upon their apparent presentation. But then again, I think this is one that I've been focusing on quite a bit more just because I want to understand more of the psychology of the patient, the Yellow Flags Questionnaire, that's been a great one. I was in a seminar a couple of weeks back and Annie O'Connor was really talking very highly about this Yellow Flags Questionnaire and about the importance of it for not just catching potential psychosocial issues, but also becoming a fairly good predictor of outcomes when it comes to using that as a good outcomes assessment. We've got the Orebro Musculoskeletal Pain Questionnaire. There's a catastrophizing questionnaire. So if you haven't been looking at the psychosocial side of a patient's pain presentation, I think now is a good time to implement that as part of your system. And there are some really great evidence-informed outcomes assessments for that.

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So once I've gotten those sent to a patient, clearly the collection of their subjective information becomes very important. So again, my electronic record system sends out an intake form. Where I can get some general background on their OPQRST, their onset, palliative, provocative. You guys should know those OPQRSTs. Asking about family history, medications, trauma, doing a very significant review of systems to see if there's anything that you can catch from that information. And again, I think that asking targeted subjective questions about how they feel about their condition, because oftentimes, and especially if you've been injured yourself, you've probably experienced Some frustration or some sadness or depression or anxiety that revolves around that condition. And for a practitioner to pick up on that early on offers an opportunity for you to address that early on and expedite outcomes. So targeted questions like, do they feel they're going to get better? Do they feel that their condition is hampering their ability to live a full life? So Getting an idea about how they feel about their condition can really give you some insight into their psychology. So again, not to really beat a dead horse here, but I think the history and the intake is an extremely important part of this. And quite frankly, it's probably going to be where most of your diagnostic value comes from because this is what will drive your assessment, quite frankly. So moving on to assessment, I have this little acronym that again, many of you probably know it's VIPPI-RONELL. Basically, it's vitals, inspection, palpation, percussion, instrumentation, range of motion, orthos, neuros, and then x-rays, labs, stuff like that. What I like to do though is split that in half and then institute some sort of movement assessment if it's appropriate. Many of you are probably familiar with the SFMA, Y-Balance. I know there's a lot of McKenzie MDT practitioners, TPI, that are just a multitude of really good assessments out there to help drive information. It's important to note that most of the time these aren't necessarily meant to be diagnostic. Some of them probably, but they're basically just supposed to help collect information and give you a culmination of evidence to drive you towards a differential and then finally a working diagnosis. But again, what we have to remember here is what do all of these have in common is that they're a system. They're a systematic approach to assessing the way that someone moves. And I know that it's a little bit controversial for some people how much clinical value is in knowing this information. And I'll always be a very firm believer that there's a ton of clinical value in knowing how someone moves and quite frankly, how they feel about the way they move. And then a nice segue to how people move is, are you trained enough in watching the way someone moves to be able to pick out the little nuances in those movements? So that's why I'm a very big fan of using video analysis as part of my assessment. There's plenty of research to suggest that our eyes just are not fast enough to pick up the dynamic nature of the way that someone moves their body. So I'm a big fan of Spark Motion, have used that. Dartfish is another one, Coach's Eye. There are plenty of good video analysis programs out there. I'm not using any one of these as a particular example of the one you should go with, but these are ones that I'm familiar with and have enjoyed using in the past. And again, they can be very valuable from a patient education standpoint that when you use these videos and show a patient how they're moving or ask them if they realize that they were even moving in this way, that it becomes educational in a way that you can, again, improve outcomes. And then there's also your special subjective or objective rather testing, things like dynamometry, force platforms, mats. There's a lot of really neat technology out there that we can have a patient stand on or walk on or jump on. to get a better idea of how they produce force, how they distribute force, where they like to put force. And again, that can give us a great idea about perhaps why that patient is experiencing problems in the first place. So again, what do all of these have in common? They're all a systematic approach to assessing the way that a patient moves. Now, I clearly have not even touched upon the evidence-informed ways that we can hands-on assess a patient. There are plenty of orthopedic clusters out there, clinical prediction rules that we can use to assess a patient. There are plenty of neuro examinations we can do. So that's why up the top I have that VIPPI-RONELL so that we can remember there's a systematic approach that we can use to assessing a patient. And I think this is really valuable for practitioners that are new, that they're still trying to get their feet underneath them from an assessment standpoint. And I like to remind them that this is out there. So that they can go through this step-by-step process and have a reproducible way of assessing patients all the way through. So again, I'll split that Vippi-Ronell right down the middle and right in that range of motion ortho area, I will implement some kind of appropriate movement assessment. Movement doesn't lie. Okay. You can lie about pain. Somebody can tell you that they're not in pain, but you make them get up and move that painful part or the part that's not painful. You'll see it straight away because we all adapt movements to avoid pain. So just some neat ways that we can take a look at examining or assessing a patient. And then diagnosis, I think if there was another really, really important part here, it's going to be getting the name of whatever you think the problem is correct. Now, recently I've been finding, at least within practitioner circles, that there's diagnosis is becoming a bit of a bad word, meaning we overuse it, we don't get it right. Oftentimes it creates anxiety and fear in patients, but quite frankly, I think it's some of the most important information you can give to a patient is what their diagnosis is. I think it's in the delivery of that information where we can really positively or negatively affect a patient. But classification is another systematic approach to figuring out what we're gonna call that patient's condition. If we don't get that right, the treatment that you choose is more or less going to be hit or miss. And frankly, I personally feel like with the majority of practitioners right now, I feel like we're just kind of feeling around in the dark because we haven't taken this systematic approach to figure out or classify what a patient's actual pain really is. Looking at the physiology, the acute versus the chronic nature of someone's injury, because there's going to be a very different way that we treat a patient with an acute problem versus somebody with a chronic problem. And there becomes another litany of other issues, some comorbidities or other things that would be involved in that chronic problem as well. So there's a lot to look at. It's not just calling something low back pain. It's really trying to get a better idea of really what's driving that low back pain. So other ways that we can sort through this diagnosis would be to look at their adaptive or their maladaptive behaviors. Adaptive behaviors during an acute injury are Normal, we would expect that. Are they walking on crutches because they're trying to take a little bit of a load off? Are they using a compression bandage because there's a little bit of swelling? Those are normal, natural behaviors to help the healing process along. It's really the maladaptive behaviors that we need to pay more attention to. Is their injury— are they 4 months into their injury and they're still using a cane, they're still using crutches, they're avoiding work, they're avoiding activity because of fear avoidance beliefs, because they feel like they're going to make themselves worse if they continue to do it, or they expect that it's going to hurt when they continue to do it. So again, all of these things will go into our diagnosis. Is the pain ischemic in nature? Is it inflammatory? Is this an affective problem? But all of these questions should have been answered through your examination, but then also through your intake forms with your OAT forms there. So Either way, I think classification of your patient's condition and pain is a very valuable tool to educate them on what's going on, because a lot of their fear behind their condition or their injury is they, one, may not understand it, and two, they just want to have a name for it. But down there at the bottom where I say that words matter, the words of the clinician are absolutely some of the most important things that you can deliver to a patient and you can make it go really well, or you can make it go very poorly. So when we use medical jargon, when we use terms that patients have come to understand as life-limiting or even derogatory, like arthritis and degeneration and dysfunction and weakness, we become the reason why that pain intensifies or that pain doesn't go away. So whatever classification that we decide to give to that patient's condition, the way that we deliver that diagnosis is going to be very, very, very important. And I think we'll see this here in a little while, that not catastrophizing, not trying to make a patient feel like their life is going to have significant or severe limitation, but using positive words around the way that we talk to a patient about their condition. Giving them reasonable expectations behind their recovery. I'm not trying to say that we should be trying to blow sunshine on everybody, but I am trying to suggest that patients catastrophize a lot more because of the words that we use and being careful about that can actually improve their outcomes as well. Okay. So, and obviously when it comes to goal setting, I'm certain everybody is familiar with the SMART goal setting. They should be specific, measurable, Achievable, realistic, and timed. And I think these are really important because if you can get the goal-setting part right after the diagnosis, then I feel like the patient really becomes engaged in the process because they now have affirmation that you've heard them, that you're interested in getting them better, and that you're now going to develop a plan based upon what they want to get them back up and moving. Now, sometimes their goals are unrealistic. You know, if you have a— Broken ankle and you want to run a marathon next month. I mean, obviously that's not a realistic goal, but perhaps maybe after that broken ankle, their goal is going to be to run a marathon in a year. I don't know, but we need to have goals that match up to and are reasonable to what the patient is trying to achieve. So I actually use SMART as the goal setting criteria when I'm making notes. I try to make the goal specific to the patients. Try to give it a timeframe or some other objective measure so that I can demonstrate to the patient progress. I try to make it something that is worthwhile to them and achievable. Again, if they have an injury that basically is going to preclude them from a specific activity, then that becomes another point of patient education. Realistic, should we be doing that? And again, time. So again, I feel like everybody's probably pretty familiar with those. Again, should be included in the notes that we're doing. So finally, this is kind of what I really wanted to get down to. This is the bread and butter Of trying to clear up the problems that we have unearthed with our patients up to this point. So it is exceptionally important that we use our history, we use the assessments, and we use the goals of the patient, so their feedback, to design our program. So we use the history and the assessments and their feedback to deliver a solid program for their rehabilitation. Now, when I'm saying program design, this is going to include basically Everything that you have in your capabilities, whether it's myofascial release, whether it's manipulation, whether it's acupuncture. I mean, there's just a litany of things that we can add to that list. But I think the question you have to answer first, because this is what's important for the patient, is are you the right person for them from start to finish, or should you get someone else involved in their care because That other person will deliver something that perhaps you're not qualified to deliver, or you just think that them going to see somebody else for that particular thing— case in point, that if you have someone that through your assessments and through your outcome forms, you have found that there is significant biological component to their pain, but there's also significant psychological component to their pain, that perhaps you manage the biological part of that, but then you also get a mental health specialist involved. in the psychological component of their care. So again, are you the right person? That doesn't mean that you shouldn't be seeing them, but it may mean that you need to co-manage them. It could mean that you don't need to be seeing them because it is entirely a problem outside of your scope of practice. But this one floats around quite a bit. I always like to use the terms calm it down, which is to support that adaptive phase of an acute injury or an exacerbation. And then build them back up. So we get the patient's pain to calm down, perhaps we get some of their anxiety to calm down, and then we take the steps to rebuild them. We build them back up both psychologically but also physically. And again, this comes back down to what's in your clinical toolbox. I have a background in strength and conditioning, so I have absolutely zero problems with designing a progressive strength and loading program to help someone Readapt, to build their resiliency. If you are not comfortable with doing strength and conditioning, but you are comfortable with doing minor rehabilitation, then you should be getting someone involved that can do the heavy lifting, no pun intended there, from a loading standpoint. So again, what's in your toolbox?

So that's it for today's episode. Join us for episode 2 and part 2 of our systems-based rehab training. In part 2, we'll be looking at best practices for leveraging systems to improve patient outcomes and Dr. Riddle's catch-and-release approach to patient care, along with some tips and guidelines for developing resiliency in your patients. You won't want to miss it. You can subscribe to The Factor Podcast on Apple, Spotify, iHeartRadio, Or the podcast app that works best for you. Be sure to give us a 5-star rating to help us grow. Every little bit helps. And remember, visit the show notes for a link to download the PDF of today's full presentation, and be sure to click on the Q&A link if you have any questions you'd like Dr. Riddle to discuss in one of our Q&A episodes coming up in the near future. The Factor Podcast is edited and produced by the incredibly talented Marissa McCool. A special thanks goes out to her for making all of this possible. See you next time. Hey guys, if you like what you heard today, I encourage you to visit our website at factor-store.com. That's spelled F-A-K-T-R-store.com to find out more information about all that we have to offer. We have a variety of online offerings as well as our hands-on Factor Rehab System course scheduled in cities around the globe. Be sure to also check out our event calendar and bookmark any of these upcoming live webinar dates coming up in the near future so you can join us live. And of course, the biggest compliment we can receive is for you to help us spread the word to your friends, colleagues, and classmates. You'll find all the important links as well as info about our sponsors in the show notes, so be sure to check those out.