#2 - Systems-Based Rehabilitation with Dr. Todd Riddle, Part 2

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 episode 1, we kicked off our training on systems-based rehab with Dr. Todd Riddle, our Director of Global Education. If you happen to miss that episode, I highly recommend you go back and give it a listen before diving into today's training. In episode 1, Dr. Riddle made the case for utilizing a systems-based approach to rehab. In today's episode, we will hear more about Dr. Riddle's catch and release approach to patient care. We'll discuss the importance of reassessments and quantifying quality of movement. And how to help your patients build resilience. At the end of today's episode, you'll also hear Dr. Riddle answer questions that were submitted by the attendees of our live webinar broadcast. But if you have a burning question that wasn't answered, you always have the option of submitting your questions in the Q&A link in our show notes, and we'll have Dr. Riddle discuss those on one of our upcoming Q&A episodes. Without further ado, Let's get started.

But I think a big thing here, and this is where I kind of want to pull FACTOR in a little bit, is Dr. Tom Hyde and Dr. Greg Dorr really devised a very neat program, a very career-changing program as far as I'm concerned, using FACTOR as a systematic approach to progressing a patient. So there are 5 Concepts really that we go through in the FACTOR classes and really break them down. We have our static, we have our motion, we have resistance, we have function, and then proprioception. So we will walk a patient systematically through an entire program using those concepts. Now, within each one of those concepts, there are further systems and ideas to break down. So I'm really pleased to be a part of that because I feel like we have established there an evidence-based and a very effective way to progress. Or sometimes when we to regress a patient in order to improve their outcomes. So if you're not familiar with a Factor class, I would love to talk to you more about that. If you are familiar with a Factor class and haven't been back to one, hopefully you'd be proud to know that we're consistently and constantly changing the programming with new research that's out, with new techniques that we find to be useful in patient care. So again, the whole impetus for this conversation was to talk about system-based rehabilitation. And FACTOR, certainly from my perspective, is one way to do that. There are a lot of other programs out there. Again, I've mentioned McKenzie before. I know the Mulligan folks, they have tons of systematic assessments and treatments as well. So the big take-home point there is you have to find a systematic way to progress a patient from where they're currently at to making them resilient and improved capacity. So at the end of all that, really what we're trying to do is build a patient's self-efficacy through consistency. And reassurance. And that's one of the things I talk about in my classes all the time. My programs that I develop for patients are entirely designed to build a patient's self-efficacy. I put the onus back on the patient to be doing their exercises at home by delivering low-tech, so using elastic bands, TheraBands, balls, things like that that don't cost a lot of money, that are easy to keep around the house so that they can take the responsibility on themselves to rehabilitate from home. My goal really is to try to get rid of a patient's pain and get them back up to the point where they feel like they can function on their own so that we can actually start cutting down visits. I probably feel much like many of you do. I don't want to see patients a lot in my office because that means I'm not doing my job well. So some of us perhaps use that term catch and release. I want to make sure that that patient is giving everything they need, but also giving everything that's required of them so that they frankly don't need my services after a period of time. So that's what I talk a lot about in class is trying to build up a patient's self-efficacy. And then finally, this is where we have to kind of test ourselves. We readminister those outcomes assessments. We readminister those functional assessments so that we can see what has changed. Obviously, I advocate using things that are objective in nature, not just, oh, you look like you're moving better, but ways that you can actually measure movement. So again, going back to using video analysis where you can measure joint rotation, where you can measure angles, using outcomes assessments that actually have numbers associated with them where you can add something up and show percentages of improvements. How often you do this is going to be entirely up to you, up to your insurance policy requirements. And then perhaps up to clinic policy. It was always been my policy that I, at the very least, will readminister them every 2 weeks or so. But in some cases, maybe even up to a month, again, based upon presentation and who I was having to report my outcomes to. But it's really important to readminister these on a regular basis so that one, you can demonstrate efficacy to your patients, but then also if you're trying to use this to get paid, that you're demonstrating progression. There as well. And then finally, really what this kind of comes down to is you get your patient better, which is great, but where do they go from there? Have you made them resilient enough to go back out into life and not reinjure themselves? I think we all know that the greatest predictor of a future injury is a past history of injury. So have you taken away as much of the possibility of that patient injuring themselves again by making sure that you've made them resilient? So I'm a very, very big fan of asking patients to transition into some sort of fitness programming. Again, underneath the Southeast Sports, The Factor banner, we have Rehab to Fitness, which is a great way for practitioners to learn about how to transition a patient from a rehab program, progress them through a rehab program into a fitness-based program. And even if you don't have a personal training background or a fitness background, the class is exceptionally well-written. It's very well constructed. And very informative, even for those that don't have that fitness programming background. So you can't just release them and say, hey, good luck, come back if you need me. You got to have some recommendations about how they can maintain their resiliency and how they can continue to improve. Okay, so there's a couple of takeaways that I kind of want to end up here, and then we can take some questions if we do have those. We should be listening to patients and we should be learning about them. Again, we have 2 ears and 1 mouth for a reason, and we should be doing as much detective work as we can in the front. So that we can learn as much about patients as we can. Pain does not equal damage. And that's a huge take-home for patients, not just us. It's just because they're in a lot of pain doesn't mean that something is necessarily broken. That doesn't equate to biological tissue damage necessarily. It's a brain output. So if we've got a lot of folks that are in pain, but we just can't seem to pinpoint where it's coming from, then that may be a great time to take a look at what's going on between their ears. Again, we got to be careful about scaring our patients with our words. Reinforce to the patient that they're fundamentally strong, that they can lift, that they can move, obviously under protected circumstances. But if there's any better person to do it with, it's going to be you. So making sure that you calm them down and load them back up. And again, it's important to find what they like to do. Get often asked, what's the best exercise for this, for low back pain? And quite frankly, it's the ones that they'll do. I may say that the McGill curl-up is great for one person, but they don't like getting down on the ground, but it may be great for somebody else. Walking is a great thing too. So it's whatever they'll do. And then finally reassure them that they're going to get better. Be realistic about what you reassure them. I've very rarely ever taken someone back to 100% satisfactory with their pain resolution, meaning I— there have been many times I've not gotten somebody out of 100% of pain. But if they go into the process knowing that that's a possibility, at least they're able to deal with that with you and as you go along. So all that being said, I hope you've gotten some great information on systems-based assessments. I have also included, and I think we're working on getting that up, I've included some articles that actually recently just popped back up into my line of sight. One was some new clinical evidence-based guidelines for the treatment of low back pain that I think all of you would probably find very interesting. And then actually Dr. Hyde sent an email to me just this morning talking about checklists for diagnostic quality of low back pain. So that's another one.

Yeah.

one that you guys should take a look at. But if you hang out on social media, I would love to catch up with you if we're not connected there. I'm on Instagram, Facebook, Dr. Todd Riddle. I post a ton of research there. I'm trying to do my very best to spread information around as much as possible.

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I think we are now looking for questions. If anybody has them, I'm happy to take those. We can give that a second or two.

Okay. And it looks like one question that came through was speaking here about the pain response and how to not catastrophize that. What are some examples you can give of ways to help a patient that has like a chronic low back pain condition? What are some terms that you would use or some ways that you could explain to them that they have pain and it may be there for a little while, but it's going to take time to get better essentially?

This is a great question. And I think it's probably a difficulty for many people. And I by no means have it entirely nailed down. But there are some strategies that I have found to work very well. We have to get a patient to understand where their pain is actually being driven from so that once we can get them to understand that this isn't necessarily a tissue problem, then we can really start to talk about their perception of their problem in the first place. So again, going back to the beginning, do they feel like they're going to get better? How do they feel about their problem? Because a lot of times, There's anxiety associated with it. Is there a family member at home that may be driving the problem? So one of the recommendations that seems pretty consistent is to keep a pain journal so that they can start to understand when their pain ramps up, where were they when it happened, who was around them, what was going on, so that maybe you can start to correlate an increase in pain with the environment or their thought processes about their environments. But what I really try to drive home especially if I feel like there's a psychological component to it, is that they are not broken, that they are still strong. And right now that they may be experiencing pain is a culmination of a sensitive nervous system that we just need to calm down. So while I don't mind using pain, I definitely try not to use words again like dysfunctional. I try to use words that are more calming, like sensitive or turned up. Things that they're already used to using in their everyday lives that don't have the negative connotations of disability.

Dr. Riddle, you mentioned that you have a catch and release philosophy when it comes to your patients. What do you do for maintenance care in your office? That's the first part of the question. The second part is specifically for those patients that still want to continue to come in on a regular basis.

Yeah, so that's where I kind of open the conversation back up to the patient. About how they would like to proceed, because again, that's where I am the teacher. That's where I'm kind of the guide, so to speak. So we have a frank conversation about what they want to do. And it's very, very common for patients to want to come back in and kind of get the tune-up, so to speak. And I have no problem with that. But again, if we refer back to the research, maintenance care can be very, very valuable for some people. And not entirely valuable to others. I can track down that piece of research and repost that. I can't quote it right off the top of my head, but there are populations that do not respond well to maintenance care because of the conditions that they have. But as far as the catch and release, it's a simple conversation with patients. What would you like to do? Well, I want to join a gym. All right, well, let's talk about what gym. Let's talk about your goals. Let's talk about the people that are there to help you. What are you trying to achieve? So yeah, that's pretty much how I take that. And again, I want to refer back to a class that we've instituted here recently, the rehab to fitness, that if you're wanting to keep those patients, I think that a good model of maintenance care is actually fitness model in your office if you have the space for it. So that would be my last suggestion is learning how to prescribe fitness so that you can actually keep those folks in your office. And if you don't want to do the fitness recommendations, you can still have someone in your office that would be able to make those recommendations for you. So I think that's a very solid maintenance plan right there. If they can tolerate that.

You mentioned in your assessments you offer something called a Yellow Flag Questionnaire. Could you explain a little bit more about that, what that is?

So again, and I can conclude that in the link as well, it's an open-source document. It was actually the work of Craig Liebensohn, man, almost 20-plus years ago now. But it's basically an outcomes assessment where the patient is asked— I believe it's 15 questions right off the top of my head— that Asks questions pertinent to their feelings about their condition, and again, it's a great tool for getting to know how they feel about it. But as I was mentioning earlier, Annie O'Connor, the author of *A World of Hurt*, she was really talking very, very highly about the use of this both as a net to catch problems, but also it can actually be used pretty significantly as a predictor. So again, I can post that for you guys if you like. You can take a look at it. It's a very simple. Very elegant questionnaire that really gets down to the bottom of a potential psychological problem, psychosocial problem, really very quickly.

How do you simply explain patients a model such as fear avoidance behavior? How do you explain that to patients who are in chronic pain and who want to get the quick fix?

That quick fix part has always been something that's vexed me. That's where we come back to the goals setting. Is this something that's necessarily achievable? And is it something that's necessarily relevant? And if it is, then we have to have a frank conversation about how achievable it is and in what timeframe. So I always try to downplay the quick fix. And if they're looking for a quick fix, then I may not be able to deliver the results that they're looking for and certainly wouldn't want to shortcut corners and potentially even put them in harm's way by making them feel better, but not necessarily have given them the capacity to go out and start that fitness programming. So again, this comes back down to patient education where I say, look, I feel pretty confident that I'm going to be able to get you there. I just don't know that your timing is necessarily a good idea at this point. But I also don't just leave them hanging. I will try to give them activities to make them feel like they're developing progress. So if they're a runner and want to get back into running marathons, I've been using that example, but they're not ready for that. Then we'll find other activities. Maybe it's cycling, maybe it's rowing, maybe it's swimming, something else that we can do to make them feel like they're still making progress, feel like they're getting stronger without putting them further into harm's way and delaying their healing.

Do you send your questionnaires online or in paper format to the office? And what have you found are the benefits of the one you've chosen?

So I'll give a little plug here. I'm a big fan of Jane App. That's what I've been using. I like it because it's very malleable. It has its little hiccups here and there, but I think the benefits definitely outweigh the downsides to it. So I send everything out now electronically. I was prior to that having to do everything where it would go out through email and usually had to be printed and then brought back into the office, which you can imagine is a significant barrier to many populations. One, maybe they can't afford a computer to— or a printer rather— to do the printing. There's the paper cost. Frankly, it's just kind of a pain in the rear end. So I'm glad the technology has improved in such a way that we can do this stuff electronically now. So I set up my system that baseline an intake form and OATS questionnaires went out about what they were suffering from, whatever their condition was, so I could get a better idea. So long story short, everything goes out electronically.

You mentioned that you have a lot of different treatments that you may use with a patient and kind of how you decided on that. How do you manage the time that you have that person in front of you? How do you get them through all of these various treatments and still have it in a timeframe that's doable for the patient and for your schedule?

Sure. And that's going to be entirely patient and clinician oriented. I choose to develop a schedule that at this point allows me to spend a little bit more time with a patient. And that doesn't mean that I can't just waste time talking about the dog and the kids and how life is going. I have to be very task-oriented with getting my job done because the patients have a life to live as well. So I will set up usually half-hour appointments so that the patient has the expectation that they will be spending up to that amount of time with me. And in that time, I have to achieve whatever I'm going to get done that day. So whatever follow-up questions I'm going to ask, whatever new movements I'm going to ask them to do, whatever chiropractic-oriented treatments I may be delivering, such as manipulation. But I'll be perfectly honest with you, my goal is to get someone moving nearly as quick as they come in, but also as fast as possible within their program. It's really one of the things that I use most quickly. And again, kind of referring back to Factor, we've got a variety of different ways that we incorporate soft tissue techniques with movement in positions of provocation. So we're really focusing on the things that are bothering them from a biological standpoint to have them move and provide treatment at the same time. And it usually turns out to work pretty quickly within that half-hour timeframe. So I can very easily ask my follow-up questions, do whatever manipulation I may be doing, and then spend another 15, even sometimes 20 minutes working on moving with a patient. Because at the end of the day, that's to me what it comes down to is purposeful movement with a patient.

Typically, how often do you perform reassessment if there is no insurance involvement? Is that based on the period of time or number of visits?

That's a good question. So if there's no insurance, and you're not worried about a payer, necessarily a third-party payer, I think it does come down to the number of treatments over a period of time. Like, if you're only seeing a person one time a week, then I don't know that 2 treatment periods with them is going to be necessarily enough. I suppose it can be if it's a highly motivated patient. So I will say that it's definitely time dependent, but it's also visit dependent. And I don't have a specific number of visits. I generally personally like to reevaluate if we're going just based upon visits every 8 visits or so. So if you're seeing someone 2 times a week, that'll be in about 4 weeks. But if you're seeing someone 3 times a week, you're going to be reassessing them in roughly 2 weeks. So I think that the question, the way that it was asked, kind of really gets down to the heart of the matter, which is it's going to be definitely visit-oriented. It's going to be time-dependent, but quite honestly, I think you could probably also throw in condition-dependent, that if they're in a pretty rough way and you need to start demonstrating progress, you may end up having to do it even sooner. So I know that was kind of an obscure way to answer that, but there are definitely different variables that go into that. Thank you all.

Wonderful. Thank you guys. Have a great day. That's it for today's episode. If you have a burning question that wasn't asked by our live audience, please click on the Q&A link in our show notes to submit your questions to Dr. Riddle, and we'll be sure to cover those in one of our future Q&A episodes. Be sure to tune in for episode 3, where we'll be featuring a brand new training with Dr. Tom Teeter, developer of FACTORS Rehab to Fitness curriculum. This episode and the follow-up episode, which will be the part 2, are going to focus on how to integrate fitness into your clinical practice. This 2-episode training is full of tons of great insight into why you should be using fitness as an evidence-based approach to maintenance care. Topics Dr. Teeter will be covering include the difference between rehab and fitness, The reasons why rehab programs fail, and why injury just isn't about load and load management. 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 the show. Every little bit helps. And finally, remember to visit the show notes after each episode for a link to download the PDF of today's full presentation. 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. 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 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.