#106 - Game-Changing Research Every Clinician Should Know with Dr. Tim Bertelsman and Dr. Brandon Steele, Part 2

Welcome to The Factor Podcast, where we talk about the stuff they didn't teach you in school. How to grow your practice, refine your clinical skills, and get better results for your patients. We're here to help you navigate the real-world challenges of being a healthcare provider, from delivering top-notch patient care to running a business that doesn't run you into the ground. Whether you're fresh out of school or scaling your practice, we're diving into effective cutting-edge treatments to get patients better faster. We'll also talk about business strategies and tactics to help you work smarter and not harder, and the mindset shifts required to thrive as a top performer in your field so you can build a career you love without burning out. If you're ready to learn what works and what doesn't from leading experts, industry innovators, and respected clinicians across a wide range of specialties, you're in the right place, my friend. Let's dive in. It's time for another episode of The Factor Podcast. I'm your host, Jessica Riddle. Welcome and thanks for tuning in. Today, we're going to pick up where we left off with Dr. Tim Bertelsmann and Dr. Brandon Steele, co-founders of ChiroUp.com. We're covering part 2 of our deep dive into the latest clinical research shaping conservative care. In this segment, we explore even more conditions and concepts that can improve patient outcomes, from thoracic outlet syndrome and proximal hamstring tendinopathy to the science of placebo. And we'll learn how it actually influences your results. Plus, we'll break down the power of communication in clinical care, why sleep is an often overlooked component of recovery, and how movement is still medicine. If you're ready for another round of high-impact, evidence-based insights that you can take straight into practice, you're in the right place, my friend. Let's dive in.

So now we're going to dive into the shoulder. Here's all those slides. Also, with any kind of nerve mobilization or any kind of exercise, it's always good to have videos associated with this. So even if you have printouts of your exercises, still have a video backup because these exercises do take a little bit of nuance where you want your patients to understand. Now, when we talk about rotator cuff, we— the rotator cuff disorders, as far as our aging population, Very, very prevalent. So even though the rotator cuff may be the underlying tissue that's causing the problems, we still want to make sure we're assessing the nerves associated with the diagnosis. With any joint that we have in our body, there's always a continuum. Sorry for that being a little bit black there. But in the shoulder, we often find patients with scapular dyskinesis, which Charles Near said that 100% of the people with impingement syndrome started off with scapular dyskinesis. And 95% of people with rotator cuff syndrome started off with impingement syndrome. The other 5% were traumatic. So you can imagine that when we move down this continuum, people are starting with the first one and it's just unfortunately not being dealt with. And what we notice is that when people have something called scapular dyskinesis, this bone unfortunately starts to ride up into this bone because you're not— you don't have very good stability of your glenohumeral joint. And now when you start to move this arm, you have to force extra range of motion out of your glenohumeral joint. You have a bone on top, you have a bone on bottom, and you have squishy stuff in the middle. And unfortunately, with scapular dyskinesis or in some cases a postural syndrome called upper cross syndrome, these big movers start to become a little more hyperactive. Your big movers are your deltoids. Your big movers are your latissimus, your upper trapezius. And those are your patients that when they're moving their arm, it just looks like everything's kind of fused together. And unfortunately, your body can tolerate that for a little bit, but if you don't move with good range of motion and good quality, Something will pay the price. And if you are forcing too much range of motion out of that glenohumeral joint, the muscles that stabilize that glenohumeral joint, being the rotator cuff, need to start to work a little bit harder. So now you're starting to demand more out of your supraspinatus, your subscapularis, your infraspinatus, your teres minor, coupled with the fact that this glenohumeral joint now has to actually move more. And let's just say bad things happen to the rotator cuff. So if you have bad motion starting at the scapula, bad things are going to happen down the chain. That's what Ben Kilgore told us about not having proximal stability will unfortunately result in distal hypermobility, and it's going to put something at a disadvantage. In this case, with poor scapular kinesis, when you have tension and tightness in the pecs and the biceps, you have— you start to develop this weakness in your lower trapezius because when those muscles are really tight, It rolls your shoulder forward just like you see on all of your high school and college athletes start to have that, the pecs being a little bit overdeveloped and not working on those back muscles as much. And your thorax is a barrel. So when you start to pull that shoulder blade forward, the muscles in the back, they really try to hold that shoulder blade back, but they can't. And that's what develops that stretch inhibition of the serratus and also the middle and lower trapezius. You can do that for a while. You can accommodate any kind of compensation for a while. But unfortunately, what we know, is if you try to do that for too long or your activity increases too fast, you start to essentially squish this tissue so many times, that supraspinatus, that it starts to become inflamed. And now what you do is you go into this next category called shoulder impingement syndrome. Well, shoulder impingement syndrome is when you create a repetitive stress to that area through constant repetitive, usually overhead activities, or you can also get it from postural stress. And that would be as simple as just using a mouse without supporting your elbow or often Probably more common, it'd be postural stress like sleeping on it with your arm above your head. Well, if you do that all day long and you pinch that supraspinatus, eventually it's going to start to inflame and then it's going to start to cause pain. And what we know is there's certain tests when you look at the sensitivity and specificity. Now, the odds ratio is looking at sensitivity and the inverse sensitivity divided by the specificity divided and then the inverse specificity. And it's really looking at Does this person really have this diagnosis? Now, what you'll notice is Yergason's test has the highest odds ratio. So when you do Yergason's test, you're testing everything, including the biceps tendon. So when we're seeing this issue with Yergason, Neer's, Hawkins-Kennedy, please don't just do one test. What we know from the research is if you're going to do one test, just do 2 or 3 tests. Here are the top 2 or 3 tests you should be doing for impingement syndrome. With that being said, though, Don't do 7. If you do 7 tests, you can actually make it a little bit worse. So Yergason's test is essentially telling your patient to slap themselves in the face, but they're going to have their palm up and they're going to try to bring their palm up to their face as you resist that range of motion. And if you can do that and it reproduces their pain, then it's going to cause pain in that area.

Everybody is—

So she's going to try to bring her palm up to her face as I'm resisting. I like to have her Force that quickly. So it's a passive test, but she's really trying to really activate or eccentrically load that biceps tendon quickly. So Yergin's test is a test that really highlights a lot of shoulder problems, but really the more traditional tests are the Neer's and Hawkins-Kennedy. So I want to show those also. Neer's test is just below Yergin's test, and this is a 100% passive test. If you can go and show this. Now for this test, she's going to roll her thumb into internal rotation and I'm going to passively bring her arm up into full flexion. When I do this, I'm actually going to hold her— oh, that's an old— look at that old video, man. What you're going to do is hold that clavicle down. Now when I'm holding that down, I'm forcing impingement here because if I truly have impingement, I'm going to have an inflamed supraspinatus and she's going to tell me Ow, that hurts. And where does it hurt? Right on the lateral, lateral anterior aspect of the shoulder. And we're always looking for reproduction of pain. Can you move to Hawkins-Kennedy video please, Jessica? When I have a positive Neer's test and I have a positive Hawkins-Kennedy test, which is the test I'm going to show next, we have pretty darn close to a 98% positive this is impingement syndrome. So Hawkins-Kennedy test, what you're going to see— and once again, I would normally be in front of the patient doing this. I'm just showing this for demonstration purposes only. She's 100% passive. I'm going to bring her arm into 90 degrees flexion, elbow 90 degrees, a little bit of adduction, and I'm going to push the arm in. I prefer to support the elbow when I do this, and the reason I do that is because when a patient has pain, they often don't want to bring it up into flexion. But you can do it either way. It just depends on the author you read. Can you move back to the presentation, Jessica? So those are the orthopedic tests that are the most common. Often a patient's going to come in and they're going to tell you they have impingement syndrome without telling you they have impingement syndrome. And what they're going to do is they're going to tell you they have something called a painful arc, meaning I'm pretty good with my arms down here, but as soon as I get my arm up at 60 to 120 degrees, that's when I feel the test. You can of course do this and make this a An orthopedic test, but this is often something they're going to tell you. The last video I'm going to show you when it comes to this evaluation is going to be this video, an empty can test. And this one is a differentiating test. So if I take her arm— if you could show this one, Jessica— and I roll her into a full internal rotation with her thumb down towards the ground, and then what I'm going to do is bring her in 45 degrees of abduction and 90 degrees of shoulder flexion. And what this is going to do is kind of isolate that supraspinatus. And when I can isolate that muscle— and now I'm going to push down as she pushes up. And what we're looking for is, does that reproduce her pain? If the answer is yes, I still can have impingement syndrome and I can still move along that train and that pattern of impingement syndrome. However, if you have weakness, meaning she doesn't have strength in that, that's when I'm thinking— and you can move back to the presentation. If she has weakness, I'm thinking, hmm, this is probably more of a rotator cuff syndrome where I have a lack of capacity within that tissue. If I have a lack of capacity in that tissue, that means I probably just don't have inflammation. I might have tissue insult. Creating weakness in that tissue. And now I need to address that with not only things to calm down pain, but also some strategies to help increase strength and range of motion in that shoulder, which is more of rotator cuff pathology. Rotator cuff pathology is a little different than I learned in school. I always thought this was the case. Now, I went to the Harvard of chiropractic schools, which was Logan. However, even with that being said, I think I learned a model that was a touch antiquated, which was if you have any tissue— it could be soft tissue, could be hard tissue like bone— If you have any Any kind of force you put into it, like an insult, it could either tear, or in the case of bone, break, or it just goes through inflammation and healing. Regardless of the process, you end up with perfectly good tissue again. And what we know now is that's not really the case. In fact, yes, you can have insults that you heal completely from, but the vast majority of us and our patients keep on doing whatever that activity was that caused the problem in the first place. And they're probably going to keep on doing it again. It's kind of like a youth baseball pitcher that they can injure their elbow playing baseball and it's probably going to heal. Unfortunately, Johnny's probably the best pitcher on the team and he's going to play Monday through Friday and go to practices and he's going to play 6 games over the weekend and then he's going to go right back into pitching lessons again on Monday. So unfortunately, that tissue never gets a chance to heal. When it comes to the shoulder, you can still have this model if you want, but really what we see is due to repetitive or postural stresses, we get failed healing responses in the rotator cuff, which of course leads to weakness because the tissue, its capacity is decreased because of that nice healthy tendon turning into beef jerky. And if we have weakness in the shoulder, especially the rotator cuff, which is responsible for holding this bone in and down, this is going to start to ride up. And we can actually see that from structural images on an X-ray. Now, I don't want to get too much into the biomechanics. Let's go ahead and exploit the biomechanics and show you the orthopedic That's going to identify this. Now, this is good research right here. This external rotation lag sign at 90 degrees is with your arm up at 90 degrees and going into external rotation. I'm going to show you a little bit of a different variation of that test, which is the next slide. And then actually, Jessica, if you could play this slide. This is the external rotation lag sign. This is perhaps my favorite video that I ever show in classes because we actually identified a weakness within this testing. So Dr. Burroughs and I were testing this on this unsuspecting model here, and when we did this test, you could actually see her facial expression. What you do with the external rotation lag sign is you can have it at 0 degrees, at 20 degrees, or 90. Oh, this is it. Oh, this is it. So what you're going to see is as you bring her arm up and then you slowly bring it into full external rotation, I'm going to have her hold that position. So I'm going to let go of her elbow, and I'm going to let go, and when I do that, We're going to look for reproduction of chief complaint. And in this case, it's at the teres minor, infraspinatus, the external rotators. You can actually get pain at the supraspinatus because that can influence this position. What this last paper said is the odds ratio is you had this arm actually at 90 degrees, which would incorporate more of that posterior supraspinatus in that situation. Also, if you take into consideration, if your arm is at 90 degrees in external rotation, that's the open pack position for the glenohumeral joint. You're putting the entire rotator cuff at a disadvantage and really forcing it to all move a little better. Can you go back to the presentation, please? Perfect. So external rotation lag sign, that's a great way to identify it. You can also isolate the specific rotator cuff muscles. The internal rotation lag sign, if you can go and play that video, Jessica. This is when I'm going to actually bring her arm behind her body. Everyone's familiar with the lift-off sign and the bear hug test, which are great tests. But what you'll notice here is I'm bringing her arm fully behind her back on the right side. I'm going to let go of my left hand. Hand, which is holding her wrist, and keep our right hand there. And you can see how there's a gap still between her hand and her back. What you'll notice on people with rotator cuff tears in the subscapularis is that the capacity of tissue isn't very good, and her hand's going to almost go back and hit the back part of her spine. If you go to the next video, please. So that is a great test for analyzing the subscapularis. Keep in mind the subscapularis is 3 times bigger than the other rotator cuff muscles combined. It takes a lot to get that muscle to become weak. It's kind of the Titanic when it comes to the rotator cuff. So very rarely are we going to experience any kind of issues in that muscle. And if you are experiencing issues in that muscle, then we're going to— and then this is the dime test. This is going to show any kind of weakness in the supraspinatus, which of course is the most common muscle that we're going to have issues with in the rotator cuff. I'm going to have her actively bring it all the way down in abduction, and then I'm going to have her resist as I push her down. And then I can even bring her up in the scapular plane. She does it actively in the scapular plane. And then I push down and looking for any kind of pain or weakness, which you're seeing here. I would, of course, do this on both sides, looking at the healthy and on the unhealthy side. Can you go back to the presentation, please? The dime test, when you really look at it, that has really the same sensitivity and specificity as an MRI. I believe the sensitivity is around 92%, which is really, really good. So if you're looking at making the diagnosis of a rotator cuff problem, those are your best tests. Notice I didn't talk about the drop arm test. If you do the drop arm test, you're mean. So that's just not nice to do to patients. So we can stay away from that if we'd like to. But this is really what we're looking at. How can we really accurately assess a patient quickly and get to the right diagnosis? I'll say that the DIME test for me is the fastest test to come to that diagnosis. With anything you see here, you're going to see resources on each one of these slides. So you can of course go into those. Also, if you have any other questions when it comes to any of the clinical information you have, you can send it to tim@chiro.com if you want an okay answer, and you send it to brandon@chiro.com if you want the right answer.

Perfect. We're going to entertain another topic and then a couple of questions, but wanted to give you access to these slides as well. So if you'd like the notes, if you'd like to see any of the videos, you can scan this QR code. And as a Factor affiliate, if you use that code of FACTOR125, you'll be able to have access to all these for 30 days at no cost. If you like what you see, to be able to access these videos and hundreds and hundreds more on current best practices, you can keep it, 15% off your monthly subscription for 12 months. There's never any contract or commitment. Most importantly, you'll be able to deliver this information to patients. In 4 clicks, you can create an impressive condition report that's tailored to how you treat your patients. Scan the QR code and get started.

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Before we wrap up though, we are interested if there are any questions. We'd be happy to entertain those. If you have any questions that you think of afterwards, or if you're catching this not live, again, feel free to email either of us, tim@chiroup.com or brandon@chiroup.com. We'll be sure to reply to those. Jessica, did you have any questions?

Yes, thank you guys so much. And again, if you are watching this on the recorded replay, you can still use this comment section to ask questions of our presenters. So if you comment in with any questions, that will go directly to Dr. Bertelsmann and Dr. Steele so that they can reply and answer those for you. I do have a few that came in during the presentation. Someone was asking, with anterior shoulder impingement, is the supraspinatus the only structure being pinched, or is, is there multiple structures there that are being impinged or pinched in some way?

Yeah, I think that we don't technically know. Just like every other musculoskeletal diagnosis, we can only go based off of what we, we think is possible. Can you get an irritation of the bursa? Absolutely. Can it be inflammation in there? The DAC bars that I've talked to rarely see inflamed bursas, whether it's a shoulder, whether it's the hip. So, and we also take consideration, when does that person feel the pain? If you have something like a bursa that's inflamed, that's a chemical inflammation, you're going to feel All the time. In the case of a muscle, you're going to feel it when you use that muscle. So often what I'll find in impingement syndrome is that, yes, the most common muscle that's injured that's showing structural damage is the supraspinatus. So that would lead us to believe that's the tissue causing pain. However, it's when does it actually hurt? And that's why we have to go exploit that tissue with pushing on it, pulling on it, compressing it, which is what we call orthopedic testing, like Hawkins-Kennedy-Niers test. And when we compress that specific tissue is when we feel pain. So I think that's the most logical. However, could it be something else? Absolutely, 100%. I think you even see issues with labral lesions, SLAP tears, they still have a positive Hawkins-Kennedy-Neers test. So I would treat Hawkins-Kennedy-Neers, and in this case Yergason's test, as my screening evaluations. Meaning, yeah, they have that. Now what else could it possibly be? Could it be a little bit worse, being a full thickness tear that we identify in a dime test? Or can I need— or do I need to drop into more specific tests for labral Like a biceps load test or a crank test.

With that biceps being one of the things that's certainly going to get pinched too, that the biceps is coming up from the front, the supraspinatus is coming across the top, and when that humerus rides up and abuts the acromion, well, the squishy stuff that Dr. Steele talked about is going to suffer. One of those is definitely the biceps tendon. And one thing we know about those tears or damage to the rotator cuff is that most of the time the rotator cuff starts to tear on the undersurface as opposed to the top surface. So let's imagine that we have this big Swiss ball and that's my rotator, my humeral head. And so the rotator cuff comes across and then drops down. So this is my right shoulder now. The top of those fibers are going to be of the greatest tension, just like my shirt, that if it's down, the top fibers are the greatest tension. It's going to wrinkle up on the underside. So that tension up top, it's not the tension that's the problem. Yes, 5% of tears happen as a result because they were tensioned too quickly and they tore. But almost all tears start on that undersurface where it's being compressed. So it's that compression which causes ischemia. When you push on something, it has a lack of blood supply and that's where the degenerative process starts and then perpetuates. But it's just that constant irritation to all that stuff getting compressed because the humeral head is riding up.

Wonderful. Thank you. Now, in preparation for today's webinar, I know it's kind of a tall order to ask Let us know about the most important research for the past year that, that docs should be looking at. What was it specifically about neurodynamics and the prevalence of these nerve entrapment syndromes that made you guys feel like this was so crucial? We have a lot of students and new doctors that tune into our webinars and to our podcast. How frequent are docs seeing these in practice? And do you feel like, as you mentioned earlier, the shift in Using books to using electronic means, text neck, things like that. Are you seeing more and more of it in practice nowadays as opposed to when you guys first got out of school? And do you feel like that's going to continue to be a trend?

Yeah, maybe we could split that up. Brandon could talk about, are we seeing it more in practice and what are the reasons? From the research standpoint, the reason that we thought that it was important is a couple of things. Number one, there's abundant data that's come out That a lot of the things that we shared today, they're systematic reviews, they're studies that have significant backing behind them. And there are a few topics that are really emerging in the literature. And that is the concept of tendinopathy, where what can we do? We realize it's not inflammation, it's degeneration. So what can we do? And it's exactly what Faktor does. It's eccentric loading, it's the neurodynamics, it's getting blood flow to the tissue, it's things like dry needling and shockwave and laser. That all of our treatments for those tendinopathies in the past were designed to suppress blood flow, whether it be ice or ultrasound or anti-inflammatories, and it didn't work. But what does work is to stimulate blood flow. So now all the types of things that you're teaching in your classes and those newer modalities like the shockwave, which is lithotripsy, it's designed to blow stuff up, that doesn't suppress blood flow, it generates blood flow and generates a controlled inflammatory reaction. And laser, which stimulates a mitochondrial reaction, and transrestriction, and IASTM with a factor instrument, and eccentric loading, not just any loading, but doing it eccentrically. That's an emerging topic that has tons of data, and certainly neurodynamics goes with that, realizing that if you irritate any part of the nerve, the whole thing starts to not, not have the right glide and stretch mechanism that it needs. So that's why we chose those topics, is the abundance of research and the impact of recognizing those 2. That if you learn how to stimulate a controlled inflammatory reaction through factor techniques and the affiliated types of things, and you learn how to floss a nerve, you're going to get much, much better outcomes. So I think it was not just the didactic aspect of, oh, here's something cool, but the practical aspect. And we are seeing tons of those patients now.

Yeah, I don't think it's any more prevalent. To Tim's point, it's not really more prevalent, it's just what you're recognizing at the moment. I'm sure I'm not the only one that when I learn something new at an outside seminar, magically I start to see more of those patients in my office. I mean, it's not because those patients found their way magically to me. It's that I'm recognizing it more. And I can tell you from my own personal ignorance is that in my first 10 years of practice, I never made the diagnosis of thoracic outlet syndrome. And it wasn't because none of those patients came in my door. It's that I was classifying them incorrectly. So I think that if anyone has a patient that after you've been treating for a while, if they're not making the appropriate progress, We need to look for other things that could be helping them or maybe a different diagnosis. So in that respect, even if I have a patient with a rock-solid diagnosis, I'm still going to do nerve tensioning tests on them to see if not only are the musculoskeletal treatments appropriate and the rehab appropriate, is there a nerve that's also at play? And is there something else I can add to this treatment plan that's going to help me get them out of pain faster and help them? get out of pain faster, and then we all are excited and I get a nice Google review.

Awesome. Well, and I know we were very pleased to hear you talk about Maine syndrome too, because that's something that we highlight a lot in our courses, both online and in person. I feel like, and I've heard often, that that's something that a lot of docs come out of school really not understanding well, or sometimes maybe not even being aware of, that that can be some of the cause for their patients' low back pain. I did receive a question here, and I'm going to try to not butcher some of these terms, but how do you all feel the iliohypogastric and the ilioinguinal nerves fit into mains since they come from the same nerve roots as the superior cluneal roots?

We don't have a slide on that, so this is something that I have to be honest, I don't have a lot of familiarity with either of those 2 nerves and how they fit in, but I can do some research. And I'm happy to come back and include that in our next webinar. I'm not sure if Brandon has any information.

No, I don't. I will say that as soon as you start to get— I believe those are both sensory nerves. So I don't get too excited for attachments of nerves, kind of like saying that we need to treat the common peroneal nerve versus sciatic nerve, is that often when I get any kind of— and I believe you had a picture of this— of buttock achiness, discomfort. In this case, if you get groin or testicular pain, is something that often with going through the same assessment, you're going to get radiation along the entire distribution. So no, I don't have specifics on those 2 nerves, but I would say that treating the, the big nerves first and then moving to the branches is how I normally do things when it comes to, to really anything.

I think this, this is a great example of too that we're all in this together, that there's no one who has all the answers, that we don't have all the answers, Factor doesn't have all the answers, and certainly no one who's listening has, has all the answers either. And some have more than others, and some have a lot more than we do, but we're all in this together. So when we can have resources that share knowledge through classes, through online resources, that's how we get better, that we have to help each other. And there's never been a better time for fast knowledge transfer than what there is now, that it used to take a long time to learn about these things. Now it can happen quickly. And hopefully the person who asked that question can send us a message because it's obviously an area of interest for them. We'd love to dive deeper. We'll make a blog out of it and we'll let you know.

One last thing is that I do know that one of the big mimickers in this area is going to be ischiofemoral impingement. So making that differentiation is also important. We don't have time to cover that, but I would say that when it comes to MEING and ischiofemoral impingement, those two kind of play off each other. So something to keep your eye on also.

Absolutely. And what's interesting is, I think, and what I hope a lot of our listeners will get from this, is that these are opportunities to continue to advance your education. When it comes to everything that you all have covered today and what you've uncovered in this, this research about these specific impingement syndromes, what do you feel like are some of the misconceptions or things that are myths or misunderstandings that a lot of practitioners have when it comes to these different types of conditions or patient presentations that you're hoping we can dispel through looking at the research and really giving them some better resources?

I think a number of things. I think number one, if we go back to the stroke, that this misconception that spinal manipulation causes stroke, and that's prevalent in society, is prevalent in the PCP population. And they should be listening to articles like that, that we as providers, if we hear something that's done is very dangerous, we'd want our patients to know. Unfortunately, the case studies is what's perpetuating that myth. So I think that's the big myth that we overcome. I think the second myth for me is thinking that I have too many of the answers sometimes in practice, that we have something incredible, and that's spinal manipulation. And when we add things to that, unbelievable outcomes. So too many times a patient will come in and we know that if we adjust their lower back or if we stretch out their hamstrings, they're going to feel better. And the myth being that we have the answers as opposed to realizing there's always going to be a better way to do things and continually searching for those things to say, how do I treat that condition better? If you don't know about Maine syndrome or cluneal neuropathy, look deeper. And if you don't know about ischiofemoral impingement, look deeper there as well. So I think that would be the take-home lesson for me is that there's not a year that goes by that there's not many, many things to be learned. So never stop learning.

Mine would be recipes. That so many times people are looking for that one thing that's going to solve someone's problem, but chances are there are many things that actually caused the problem. So I spend much more time now educating a person on how something started or what do I think caused the problem. And then setting a hierarchy as far as that goes, as far as, because if you don't stop what caused the problem, you're probably not going to get the symptoms to die down. So we can use multiple tools to get symptoms to die down. Like nerve loss and like manipulation, mobilization, what have you. But until we can master how something happened in the exact tissue that gave way, I think that sometimes we can get led down paths that aren't quite as efficient or effective.

No, that's, that's a great point. And I think they say commonly, and I've heard this not only in chiropractic but in physical therapy as well, that the best home exercise to prescribe your patient is the one they actually do, right? So actually getting them to do those exercises that home. Have you guys seen a great increase in patient compliance with their home exercise through using tools like ChiroUp so that they have a video, they have something that guides them through specifically how to do it? Because I know for some of these, you have to be pretty exact in terms of how you move your body, and otherwise it's not effective. So do you feel like that's been a useful tool from that standpoint when it comes to patient compliance?

I honestly don't know how people do rehab without videos. I don't even— I don't understand it. And not that I don't think I could teach someone on how to do all these exercises and get compliance out of patients, it's that as a chiropractor, I get paid to evaluate and manipulate. And if I'm spending all my time showing exercises and reviewing exercises and making sure they're doing everything appropriately, unfortunately, in today's world, it's not cost effective. So I'll say— and I don't want to be like that, but I mean, in all honesty, in the business world, We have to have tools that can do those things that doctors don't need to do. So yes, I need to be able to show the exercise the first time and deliver it, whether it's through an app for some patients, an email, or print. But also, you need to provide the resources on a platform that your patients can go back to and get their information. Because the worst-case scenario on a Monday is if I gave someone 4 exercises and on Monday I said, hey Bill, how are your exercises? He says, great. Bill didn't do any exercises. If Bill has questions on his exercises, that's a good thing. That means Bill probably did his exercises. But if Bill had questions on his exercise and they might have caused some discomfort, he's going to start to question himself on how he learned his exercises and he's not going to do them. So providing not only exercises, but ADL information and patient education on their condition just solidifies what you're telling them in their office and provides them the confidence to kind of move forward and keep on doing what you recommended in your practice.

Along those same lines, I feel like now of days, and we've seen this just in those of you that are in clinical practice, I know you'll probably shake your heads and agree with this. More and more patients are educated and informed about healthcare than I think ever. Sometimes that's a really good thing because they come in already having a working understanding of things they can do to make their, their life better, to really improve their healthcare. Sometimes that can be a double-edged sword though, because they go to WebMD and they look up all sorts of scary things and try to diagnose themselves. Do you feel like having this education to provide your patients about their conditions has really helped lessen the catastrophizing that happens when they start Googling things on their own and they get told they have lower cross or upper cross syndrome, and then all of a sudden they're in a panic? Do you feel like even just communicating about their diagnosis and their care plan has been made much more effective by just giving them some resources from a trusted source such as their doctor to really understand what's going on with them and how to make it better.

Yeah, I, I think that's definitely the case, that I'm, I'm in favor of patients Googling and, and consulting with Dr. Google along the way to find out what's going on. I think getting a little background about a condition or potential condition is good, but then that— and because it was in writing, the patient tended to believe it. If their neighbor just told them something, they might not have believed as much, but if they found it on the web or on Instagram Or YouTube, all of a sudden it has a little more credibility because it was in writing. And so we can leverage those things that when the patient comes in, they have questions, they've probably seen conflicting information, and then now they have a provider who can answer those questions. So number one, I know that my answers are much more confident for my patients than they were a decade ago because I've seen the literature. We keep up on the literature, and I know that the team of 4 doctors who harvest that information is feeding me good information. So, when we have confidence in delivering that to the patient, the patient perceives that and that outweighs it. And then, when we can support that with a written resource to back it up, now the patient says, okay, I think I have the answer. So, yes, I think that we've been able to combat that with the right information. But without those sort of resources, yes, it would be tougher because you're just another voice in the patient's head.

And I think that it's always good to address their concern if they have something else that they think is going on. However, so many DCs are nervous about the informed consent. And I love delivering the informed consent for every diagnosis because during that process, I can tell them what I think and I can bring up what they— I've also heard from other providers. But then I can say, listen, Sally, I think you have this thing. Here's what I'm going to do for you. You can also go see PT, or you can also go see that doctor, or you can go get that massage or get dry needling or whatever it may be. But here's what I think is going on, and here's what I would do for you. And here's how long I think it'll take. Which option would you like to choose? I can send you to one of those doctors or we can start treatment here. And instantly I get that buy-in, like, okay, yeah, I think he knows what he's doing. I've never had a patient say, I heard you, I heard your diagnosis, but I'm going to go with Google and I'm going to go see a massage therapist. They came in our office for a reason. And all they really want to hear is the confidence and the plan coming from a provider that cares.

And that's the key. And that's everything that I know you all stand for and that we stand for with Factor is that patient-centered care and making sure that the patient is first and foremost in your mind when it comes to clinical decision-making, but then also being able that you communicate effectively to them. So any final questions, guys, please be sure to put those in through the chat. I do have one last one that came through regarding some of the orthopedic tests that you covered. They were asking about how You feel about sequencing your tests. I know you mentioned earlier there may be some that you do initially as kind of screenings, and then you dig a little bit deeper. So for example, this person was asking, how do you feel about doing the Hawkins-Kennedy first, then the shoulder flexion, then the scaption, and essentially abduction to test different structures? Do you kind of utilize these orthopedic tests in any type of clusters or any type of sequence so that you really can kind of drill down and look at really trying to decide which specific structures are being affected there?

Yeah, certainly clusters. That, that study that we'd shown you, which was a systematic review, the opening statement to it was there is no single orthopedic test that can diagnose any of these things. So for me, I like to identify what tissue is it first of all. So I'd look for the rotator cuff tear test first. And then once we've identified what tissue it is, then I'd want to know why did that happen? Because the tendon didn't just start degenerating on its own. In this case, it's usually pretty simple. It, 95% of the time, it did that because it was getting impinged repeatedly. So then I'd go to the scapular dyskinesis test to determine is this patient's problem because their shoulder is too mobile or it's too, too stable, too inflexible? Do they have a stability problem or a mobility problem? So saying when they raise their arm and I help move that scapula along with them with a scapular assistance test, does that make it better? Or when they raise their arm and it hurts, if I stabilize their scapula, does that make it better? And once I know what tissue it is first with a cluster of tests and then determine through the functional tests why did that happen in the first place. So that's generally my assessment is as far as identifying the tissue that's irritated. And then once I know what tissue it is, identifying what were those factors with functional testing.

Yeah, I wouldn't change much of that. I would just say the one thing that I always try to do when I first see a patient is first, based on their first name, I try to guess their age. It's just fun. Like when I see them come in as a new patient, like Gladys is probably 72. No, but the second thing I try to do is just understand the negative tests because in the case of the shoulder, what I'll do first is rule out the cervical spine. I'll rule out a space-occupying lesion. I'll rule out an infection. So I try to rule out everything else before I dive into those tests. But I would agree 100% with what Dr. Burden said in the shoulder exam.

Wonderful. Thank you. As always, you guys have provided some incredible information for our listeners. Again, both of you guys, thank you so much for all of your great information today. And we very much look forward to continuing this with some future trainings in the future from ChiroUp and learning more about the research. Thank you so much.

Thanks for inviting us. We're always proud to be part of your tribe and welcome any input that you have.

That's it for today's episode. If you loved today's conversation and are interested in learning more from ChiroUp.com, or would like to learn more about all of the different offerings that we have through our Factor Network, please be sure to check out the show notes where you can explore our full library of online courses, hands-on training events, and free clinical resources. Wanna bring a Factor hands-on training course to a city near you? We host private clinical trainings for groups and organizations around the globe. Just visit our website to learn how to partner with us. And bring the Factor Rehab System to your team. And if today's episode sparked some new ideas for your practice, be sure to share it with a friend or colleague and leave us a quick review. We'll 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 hyphen store dot 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.