#36 - Reframing Acute Neurological Deficits with Dr. Harrison Vawter, Part 2

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 consume. to digest with actionable information that you can implement into practice right away.

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Hi guys, welcome to a new episode of The Factor Podcast. I'm your host, Jessica Riddle. If this is your first time tuning in, welcome, and thanks for listening. Today we wrap up part 2 of our training titled Reframing Acute Neurological Deficits with Dr. Harrison Vauter. We've all seen the headline stories about patients who have allegedly suffered stroke after receiving spinal manipulations. The media attempt to place blame on the chiropractor. But what does the research say? In today's episode, we discuss the signs and presentations of anterior and posterior circulation ischemia, and learn how to put these into context with current chiropractic research to help better structure and interpret your patient assessment. Dr. Vauder is a graduate of Cleveland University undergraduate and graduate programs. He now serves as an adjunct faculty at Cleveland teaching a course specifically dedicated to assessment and management of emergencies in the private practice setting. Over the last 10 years, Dr. Vauter has been a paramedic in the Kansas City area, working in both the field and in the Emergency Medical Sciences program at Johnson County Community College. He teaches EMR, EMT, cardiology, and paramedic content, both in didactic settings and also in clinical settings, working with students in a variety of hospital roles throughout the city. Dr. Vauter is also in private practice as a chiropractor, where he owns and operates Industrial Athletics, Which is an athletic development and monitoring strategy specifically for police, fire, EMS, and healthcare workers. This is definitely a topic I encourage you not to sleep on. During this 2-part podcast series with Dr. Vauder, you might learn something that helps save a life. Now, let's cue the intro music and get started.

Awesome. Thank you so much. So, we've received a few questions here, and guys, please go ahead and chat those questions in as well. A lot of what you talked about was some of these confounder relationships. I know you teach a lot of chiropractic students, you teach a lot of paramedic students. What are some big red flag type confounder relationships that you find in practice that are really relevant for chiropractors to keep an eyeball on? Obviously, there's these acute neurological deficits, but I know there's a lot of other red flag type conditions they might be dealing with that may look like something that's more of a typical pain presentation.

So I have a great analogy for this because I said this earlier, the stars have aligned in my favor like a lot of different ways. But my wife works in an interdisciplinary practice, and so she's a chiropractor as well. She works with a pelvic floor physical therapist. And so one of the interesting things that they get to run into a lot is who did what and what's causing what, because they refer to each other a lot, if that makes sense. So like somebody came in to my wife with pelvic floor pain, pelvic floor pain that radiated into her low back, which is like a fairly common thing. So my wife Treats her for low back pain. And then after not a lot of sessions or therapies, my wife is kind of like, hold on one second, this isn't doing what I am thinking it's gonna do. This isn't tracking, you're not progressing, there's some hiccup. And so my wife got referred to a pelvic floor physical therapist who then did what they do. And they got to have this really cool conversation afterwards where it was like, all right, You didn't cause this pain. You didn't cause low back pain by doing joint manipulation or by doing factor whatever onto their lumbar paraspinals. You didn't cause that. That's what they— but they didn't exactly come into you with that because it's pelvic floor pain. So who caused what and what's actually going on with the patient? So It's cool because she actually gets feedback is where like a lot of times if let's take that pelvic floor PT out of it, she would have rendered care, not gotten a lot better, or maybe been— I find this sometimes like maybe a little dishonest with the care provider, like, oh, it's kind of getting better, whatever. And really it's not getting that much measurable change. And then they discontinue care and that chiropractor's mind, they're like, oh, hey, I nailed that. It was only 5 visits. But the reality is, is— Not so much. So with those confounder relationships, it's helpful when there's feedback. And unfortunately, with the acute neurologic deficit picture, the feedback is like, hey, your patient's permanently disabled, or your patient's dead, or there's some like big problem that gives those chiropractors feedback. And so that's the unfortunate side of that dynamic, but the— We see, we get into these confounder relationships all of the time. It's a really common cognitive mistake that we make. And it's as— what's another good example? And that's like relative to the medical field. It's easy to pick ones out that are obviously wrong, like saying, hey, ambulances don't cause heart attacks. They call us to help with heart attacks. And sometimes we make them better. And sometimes your patients die. And there's like— That's just how heart attacks work. Let's do a soccer player. When that soccer player has asthma and that soccer player goes to play soccer, did the soccer exacerbate the asthma or was the asthma already an underlying condition? Does that make sense? The soccer, like, didn't have any bearing. He was going to have an asthma attack regardless of whether he played soccer or not. Soccer doesn't cause asthma.

Yeah.

Well, and I think too, especially within the chiropractic and the physical medicine field, you all will see a patient who may already be in pain. And part of the process for them getting better may cause more pain sometimes, or you have to work through it. And it's not as simple as a quick fix where there's an end in the beginning that's very simple and easy. How do you combat that with your patients when preparing them for the fact that, okay, this problem didn't happen overnight? And even though sometimes with injuries and things it does, but it's going to take a little while. It may feel worse for a day or two before it gets better. How do you prevent your patients from going into that confounder relationship mindset of, oh, well, my pain was at a 6, but after I went to him, now it's at an 8 today. So therefore he must be making it worse.

I'm a McKenzie person. I really like using McKenzie on patients. When you do McKenzie, that— well, if it's— I'm going to generalize here, so if anyone's a McKenzie person, don't kill me. But like, it's generally your person has a disc injury and you're going to put them into lumbar extension, repetitive lumbar extension. Don't kill me, it's more complex than that, I know. But like, you put them in lumbar extension and that helps reduce that disc injury.

Okay.

It's super painful. I mean, it is super painful when you do that to people because you have an injury. How I explain it is pain is not injury, and injuries aren't always painful. They're 2 independent things. Sometimes we get hurt and we don't realize we're hurt until something else hurts. And then flip-flop, something else can hurt and you're not really injured. It's just hurting for Whatever reason. There doesn't have to be a reason for pain, every single pain we have. There's not always a musculoskeletal cause for pain, right? Sometimes it's psychological. Sometimes it's like gastrointestinal. Sometimes it's something that's like, we're not really that worried about it exacerbating a musculoskeletal complaint. So how I frame that for folks is like, if you break your arm, where everyone's on the same page, that's going to hurt pretty bad. So when you break your arm and you go to the doctor, the process of setting is gonna be painful. But everyone here would agree that setting an arm is the right thing to do. You need to get those bones roughly back together so that they can heal. Yeah, it's painful though. We just don't— in modern healthcare, we don't think of that setting piece as painful because we're going to give those people a bunch of drugs that they don't really remember it. So it's the same. I use that analogy because modern medicine has taken the pain out of recovery, which is great. That's not a bad thing, but it makes explaining why, hey, look, recovery is just painful. It's just how it is. It makes explaining that a little bit more challenging because people are not used to being uncomfortable and also recovering.

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Absolutely. And I think that's key in that patient education piece. So It's interesting, I actually have had the experience lately of serving as a standard patient at Texas Chiropractic College. And in one of the recent patient visits, I was a patient who had Bell's palsy, which as you know, presents with kind of a droop on half of the face. And the students were tasked with doing the necessary exam to determine, is this a stroke? incident or is this Bell's palsy? Obviously, without being given those 2 options. And one of the things that was fascinating for me as an observer was just looking at how the students talked to the patient about what could be a life-threatening situation. What would you suggest, obviously, having had experience with this for many, many years, how do you approach these situations where a patient comes in thinking They have a headache, thinking they have a sore neck. You as the practitioner know, okay, there are some red flags. How do you explain that to them in a way that keeps them calm and helps get them the care that they need?

I guess it's a blessing and a curse. We don't have really any tools. So like, the reality is, is I cannot definitively tell any patient that has Bell's palsy, hey, you have Bell's palsy and you don't have a stroke. I could get pretty close. But there's a margin of error and the risk that you're taking saying, hey, that's Bell's palsy and not a stroke without any other further diagnostic equipment other than your hands and your brain, that could be a big risk. How I describe it to patients is the I don't know. What it would sound like is I'm doing all of these exams to confirm something. And there's confirming something. There's definitively saying it's not that. And then there's this middle ground that's, I don't know anymore. And that's where you're falling. I can definitively tell you something ain't right, but I don't know what it is. I don't have an MRI or a CT scan. I'm in a gym with like turf and people doing deadlifts and stuff. I don't know anymore. And that means you're not a good fit for me today. Will you be a good fit for me tomorrow when you go see your primary care physician? And they're like, oh yeah, it's just Bell's palsy. Yeah, for sure. Of course. But the reality is, is I don't know anymore. And because I don't know, I can't take that risk with that patient. Because think about it, how horrible would it be to say like, oh no, it's just Bell's palsy. And then 5 or 10 minutes later, they're like slurring their speech and they can't walk. And now that person has some major permanent deficits. It'd be horrible, especially And our target demographic, which is young, healthy people, usually when they have some kind of cerebral vascular event, it's like a big deal. It's not like young people don't get like these transient ischemic attacks very often. That's like not near as common as a bigger deficit-causing stroke. And that's what the rest of healthcare does is they do a lot of, hey, I'd rather be safe than sorrys. And they catch a lot of weird stuff and they catch a lot of patients that would fall through the cracks otherwise. I mean, you can look at emergency medicine. Here's a great example. I took care of a guy who I was 100% confident was having a stroke. He was at a long-term care facility. He had an altered level of consciousness, which was baseline for him. I think he drowned or something like that. He had some brain injury where I couldn't really get a lot of rock-solid assessments with him, but I was 110% confident that he was having a stroke. He had like facial droop.

Mm-hmm.

Arm drift. He had everything. So standard practice for most paramedics when they're concerned that their patient is having a stroke is to also check a blood sugar. And because I was so confident that I was like, oh yeah, dude, this guy's having— definitely having a stroke. I checked the blood sugar like last after I had called the stroke team down to meet me in the ER. Well, his blood sugar was like 5 and gave him some glucose and he perked right up and all of his deficits went away. And It was a pretty ruthless walk of shame into that emergency room with those attending physicians because I had to be like, hey man, I didn't err on the side of caution. I didn't do my due diligence, even as something as simple as like checking a blood sugar, which is such a simple skill that there's no reason not to. And we do it all the time. We just— erring on the side of caution is what the rest of healthcare does with all of their patients. So you don't get people slipping through the cracks. Like, I let that patient slip through the cracks. Fortunately, he slipped through the cracks in like a positive direction where I was like, oh, it's just a blood sugar, it's not like a major stroke. But it's that kind of casting a broad net with your patients and, and saying let's check everything that can get you really, really far and help you with a ton of patients.

Absolutely. So we do have some students that are tuning in, and I know many more will be watching this via the replay. Speaking of which, if you are watching this on a replay, you can still chat in questions and those emails will go directly to Dr. Vauders so he can follow up with you guys with answers. Again, if anyone has any questions that's watching live now, please feel free to chat those in through the chat feature. This is a great one that came in from a student. They were asking, going into private practice, and you mentioned that you're in a gym setting, so you don't have a ton of quote-unquote medical equipment at your disposal. What are some key pieces of equipment, tools, diagnostic instruments that you absolutely think every chiropractor, physical therapist, manual therapist should have at their disposal in their practice for these type of scenarios or situations?

The first thing is, if you get someone who has an acute neurologic deficit The Cincinnati Prehospital Stroke Scale is the most specific and sensitive tool that orthopedic, if you will, exam that we have. It just is. It's like if they fail all 3 of the exams, which is slurred speech, facial droop, and arm drift, that they fail all 3 of those, it's like 80% in, 80% out. And then I think if they fail like one of them, it's 70%. 70 in, 50 out, or something like that. As far as orthopedic goes, it's a really good exam to do with your patients. The other one that I tell people to do, and it's interesting because not a lot of private practice doctors consider this, take a blood pressure. I mean, if they're having a stroke or if they're having like an acute neurologic scenario, maybe you gotta take a blood pressure. That's like a Really, really, really baseline important thing to do with your patients that are having these incidences. Blood pressure, pulse. If you have a pulse ox, because that's the kind of practitioner you are like me, take a pulse ox, take a set of vitals. The last thing, a cranial nerve exam. Get good at a cranial nerve exam. If we think about it and we're like, man, How do I get good at a cranial nerve exam? It's not that hard. It sounds intimidating. It's intimidating in school, but let's take like 8, 9, 10, 11, 12. Just facial interaction and just looking at my face and listening to me talk and watching me move my shoulders, you can figure out a lot of those. If I can hear you and you can hear me, I'm not complaining about tinnitus or like Any of that stuff, and we're having a normal interaction, I probably have 8, 9, 10, 11, and 12. Now, 1 through 7, if they're maintaining eye contact, they're not having any visual disturbances, and your eye exam is pretty normal, your cranial nerve exam is looking pretty good. In school, I remember, because that was not that long ago for me, I remember it being like cranial nerve exam was like this cumbersome, choppy, thing when that's not how those muscles are designed to work. Your tongue and your airway is not designed to be this choppy, weird examined muscle group. They're designed to work synergistically so that we can like talk and swallow and like do all that stuff. So if you nail a Cincinnati Prehospital Stroke Scale and you nail a cranial nerve exam and their blood pressure, their vital signs are relatively normal, I should say, they are within normal limits, you're in a pretty good spot. If you can do those things, you should feel pretty confident in your stroke assessment. Now, I'm not including like all declines and like all those other VAT tests. I'm not including all that stuff because the truth is the specificity and sensitivity of those is just not very good. There's still tons of value in them. You just need to know how to apply it and explaining all that stuff. In the last 5 minutes of webinars, harder than just saying start with a stroke scale. That's a really, really good tool. And I don't remember learning about Cincinnati Prehospital Stroke Scale in school, but I learned about it on an ambulance because that was like anybody that came in with any kind of headache or any kind of neurologic anything, the first thing we do is a stroke scale and a blood sugar, typically. So wonderful.

And I know you had mentioned too, like taking blood pressure. Would you recommend taking blood pressure on both sides, pulse on both sides? Does it matter if you do it bilaterally or one or the other?

That is awesome. Yeah, so I would definitely do it bilaterally, and let me explain. So the reason that bilateral blood pressure can be important is sometimes An intimal tear can start really, really low. Sometimes it can start like the root of the aorta, so much so that in some patients it can occlude a coronary artery and it can present like a heart attack. But if you have a tear in the arch of the aorta and it goes over one of the subclavian arteries, you can have asymmetrical blood pressures. And all that does for you, because you really need a CT scan to like determine that, but all that does for you is say, I don't know anymore, man. Something ain't right here and I don't know what it is. So we need to get you seen by somebody else. Because if you're having a headache and you have asymmetrical blood pressures right and left, that's— you should be getting very anxious about all the things you don't know. Because there's a lot of stuff that can be scary that can also cause the things that you're talking about.

Absolutely. And when you make that call, when you make that decision that this is urgent, this is not a follow-up with your primary care, this is a I'm gonna call the ambulance now. How do you tell the patient that in a way that keeps them calm so that they're not in the midst of an incident and then their stress level goes through the roof?

So how I frame it to my students at the chiropractic college, I frame it as a shifting of liability. That sounds unpleasant, I think, but Your patient, I can almost guarantee, is gonna refuse the ambulance, and that's fine. That is totally fine. That's their prerogative. But what you can't do is you can't say, gosh, I think you're having a stroke. Why don't you drive down to the ER? You cannot do that because if they have a stroke and they get behind the wheel of a car and they kill somebody, that's a really, really big deal. And so how I frame this to my students Is you're putting the onus back on the patient to make a decision, and you're giving them the absolute highest level of care. You're offering them a ride to an emergency room where they can get an immediate 100% answer to their complaint. Because if they're like, hey, I have an acute neurologic scenario that's happening, that person's not going to sit in the waiting room. They're going to go relatively quickly to make sure it's not a time-sensitive Stroke, if you will. Frame it like that. Say, hey patient, this seems dramatic, but I need to give you the best standard of care, and I need to make sure that this is a liability thing. I need to make sure you understand that. Do I think you're having an actual stroke? I don't know, not necessarily, but I don't really know anymore because you failed a bunch of my exams. But you also weren't presenting like a classic stroke that I'm thinking of as a stroke. So to err on the side of caution and to give you the highest level of care, I'm gonna call an ambulance. What you can do when they get here is you can go with them, obviously, and that's what I think you should do, but you can also refuse care if you choose to do that. That's your prerogative. So you can frame a lot of those conversations with your patients in a way that's not like, oh, it's an emergency, as— because that freaks people out, rightfully so. You can frame it as like, hey, this is just a liability thing. I just need to make sure that I'm giving you the highest level of care that I can give you, and I'm giving you the option. To decline or take that. And that sounds weird, but as someone on ambulance, that's like a huge ginormous chunk of our 911 calls is people, physicians at a nursing home or at a care facility or at a primary care office shifting liability. And that's not a bad thing. Because your patient is getting really, really high level of care. throughout their entire patient experience. So like, you go to a primary care doctor and you're like, man, I'm having chest pain. I didn't think— I didn't want to go to the ER, but I'm having chest pain. That primary care physician is not going to keep you at his office. He's going to call 911 and he's going to say, do I think you're having a heart attack? Nah, not really. Should you go get some labs drawn to see if you have cardiac enzymes and actually if you're having one? Yeah, absolutely. And then me as a patient, because my wife will agree, this is just who I am. I'd be like, no, no, no, no, no. I'm just gonna drive myself. It's fine. And so that's my prerogative. And I made the choice to do that. My physician called an ambulance. I declined. The onus is on me. If anything bad happens, it's on me as a person. That's how I frame it with those patients. So now that's how I teach students to frame that, cuz that's how the rest of healthcare does it. It's a liability thing.

I love that. Well, and I think too, framing it in the— under the context of, I want to provide you with the highest care possible. And right now, what you're presenting with has exceeded the care that I myself can provide you in this office. So I'm going to get you what you need immediately. I think that's wonderful. Yeah, absolutely. And it's interesting. I know that some people would think if you take a step back culturally, Physical medicine providers, and those would be anyone that falls under that manual care spectrum, tend to have a different bond or a different relationship with their patients than maybe even primary care that doesn't touch their patient. Medical doctors who come in, it's a conversation, it's a prescription, maybe it's a physical exam, but there's not a lot of hands-on treatment and care. Do you feel like that factors into the fact that a patient would come to their chiropractor with— a headache or if something's weird before necessarily thinking I need to call my medical doctor who I may only see once a year versus the chiropractor that I see on a regular basis or who's helping me with something right now?

Oh, absolutely. Okay. So I just this morning, right before I did this, this podcast, I was talking to my students at Cleveland about abuse and neglect. That was what our lecture was on today, because some people are going to avoid the medical, if you will, establishment, which I resist, but like avoid that medical establishment for a variety of reasons. Sometimes it's bad, like abuse and neglect. And so they'll go see a chiropractor. And which is what the context of the lecture was on, is how we need to be hyper-aware that sometimes people are gonna come to us because they don't want to go to a doctor because They're hiding something. But also, sometimes it's good. Sometimes it's a good thing. Sometimes patients come to me because we have a really solid relationship and they care about me and I care about them, and it's a working relationship. And that's a great thing. That is not a bad thing to have. And that's why I like what I do. But you can't just Pretend that that doesn't affect your decision-making processes. And that's why it's so important to have some kind of patient assessment algorithm that you follow. So like, shameless plug for not only my class, if you're like more medical stuff, that's what I'm trying to do with this continuing education class is like, here's what a patient assessment looks like. No matter if it's a stranger or your mom, this is the kind of patient assessment thought process and structure you're going to get. Or shameless plug for my colleague, Dr. Teeter. If you're more sports performance-based, that's a structured patient assessment model for sports performance, progressions and regressions of exercise. And it also includes like therapies. This is where mine's basically just patient assessment. But using those algorithms and those trains of thought to limit bias and emotional decision-making is so important. It's so important. There's a book out there called How Doctors Think, and one of the things that they talk about is like when you develop a relationship with a patient, it twists how you treat them. And more often than not, it degrades your level of care. For any of us that are in private practices, chiropractors or manual therapists, you all probably have had the experience where you render care to like a family member And in retrospect, you might look back and be like, that was actually really poor quality of care. I saw my mom for a complaint and I saw her like once or twice and I gave her some exercises and I was like, hey, you're good, right? Cool. I'll see you home next week. All right, cool. Yeah, we'll follow up then. Well, that's like garbage care. That's really terrible patient care. But we do that to people that we care about because that relationship changes. How we interact with those people. So it's great and awesome that we develop these really meaningful relationships with patients, the— and, and we build their trust and all of that stuff. But what we can't do is we can't let that affect our patient assessment and how we approach that patient, because something like this can happen where someone comes in, you're like, oh, one of my favorite patients ever. John, whatever. John, how you doing? He's like, oh, I'm not doing very good today, man. I kind of have a headache, vertigo. I have these complaints. I'm like, man, that's weird. You don't normally have that. What's going on? Oh, I don't know. Well, let's do some deadlifts, see if it goes away. Well, hold on. If John's having a headache because his blood pressure is 300 over 200 and you didn't do any patient assessment, anything, because it's just John— I mean, you know John. That's a major problem to ask him to start doing deadlifts. You need to do some kind of structured patient assessment to make sure that every interaction, the therapies that you get are appropriate for that patient, especially ones that you have a really solid relationship with. So when you start talking about building relationships and this, that, the other, that's a wonderful thing. And It's also a double-edged sword because we, we need to be super sensitive to the biases that come along with having a more relaxed doctor-patient relationship than your standard new patient.

Absolutely. And I think that's important too for those relationships as they grow over time. Like you said, that you don't just get too comfortable, or I hate to even say it, like lazy when it comes to your Assessments. Do you do a regular, like, reassessment with patients as they come in? Not only when you're treating them for one complaint. I know oftentimes, and I know with Factor, we really preach the importance of reassessment over time, but do you have a solid reassessment that you use with patients while you're treating them for one complaint, but then also new assessments that you do the next time they come in for something new?

2 things. You mentioned in your comment, you're like, oh, I hate to say lazy. Okay. This goes back to that Thinking Fast and Slow book about cognitive mistakes, but our brain is default lazy. It's— and that's okay. It's okay to say that my brain wants to do as little work as possible all the time. And one of the good things that I can do is use some kind of structure or checklist for my brain to go through every single interaction that I have so that I'm not letting stuff fall through the cracks because my brain's default Lazy. I use the medical model of patient assessment, which if you've ever taken like a CPR class or you've ever taken an EMT class or any of that stuff, you're probably familiar with like the airway, breathing, circulation. That's what I use to do my just daily patient assessment stuff. If you're talking about like full-on reassessment, where are we at stuff, I do that Every patient interaction that I have in my mind, I'm framing as a reassessment. And I should also add that I'm using that rehab to fitness or that Dr. Peters approach of the sports performance side because that's what my private practice is. I like this side of it because I have a lot of experience with these acute neurologic things and the medical model because that's what I teach at the EMT college. But in my private practice, that's what I use is that rehab to fitness model of for sports performance stuff. But every interaction is a reassessment. assessment, because I see patients sometimes twice a week, sometimes once a week, maybe every other week because they're phasing out of care. But twice a week would be like the most that I see patients typically, because like let's say Monday, Thursday, that's pretty normal for me. Well, man, a lot can happen between then. There's like a ton of change that can go on between those 2 appointments. So yeah, I would absolutely say I do my best to frame every single appointment as a complete reassessment, start from scratch, compare how far I got in the assessment model to the previous visit. And I use— my EHR system is called Jane. And so I use that Jane platform because you can customize all of your stuff. And so all my stuff's customized to look like a check sheet, and I just check sheet as far down as I can go, and then I compare it to the check sheet the last visit and go from there. Yeah, I'm very on the reassessment and thorough physical exam every single time. And that might sound like, oh well, yeah, of course, but that's not necessarily common practice amongst chiropractors.

Do you feel like the doing a thorough physical exam every time, does that really increase the time that you spend in each visit, or have you developed a system to where Pretty much know, like, I'm gonna be doing this regardless, but I have it systematized to where I can go through it fairly quickly.

The deal with the physical exam, a lot of it's happening in your brain. And same thing with the medical model of patient assessment, where you're looking at airway, breathing, circulation, and then secondary exams, history, vitals, and physical exam. Like, same with all that. On the surface, you're like, oh my gosh, that's really cumbersome. There's a ton of bullet points. There's a ton of stuff to do. But the reality is, is a lot of it's in practice internal. You're doing it in your brain. So on the surface, as long as you have the algorithm down and you know what you're doing and you're like using some mental horsepower, it should not take that long. It's not that cumbersome at all. My favorite example, the SFMA. If you ever take the SFMA from the FMS, on the surface you're like, that is cumbersome. I don't know if I can use that. There's too much, but with practice, it's extremely not only helpful, but it can be very, very, very streamlined because a lot of the stuff you're doing in your head. And so in that same vein with the SFMA, if any of you guys ever take that stuff, in my opinion, it has been the best marketing tool that I've found. Because when people go to the doctor, what they want is a really good physical exam because they want their doctor to pay attention to their complaint. They want their doctor to touch them. They want to interact with their doctor. They want to do all that stuff with their doctor. That's exactly what you're doing with the SFMA is you're touching, you're interacting, you're explaining. There's a lot of— if someone has a hip complaint, you're like, oh my gosh, let's look at all of your joints. And they're like, yes, this is what I want. I want someone to pay attention to me. I want someone to hear me and validate my feelings and explain stuff to me. And The SFMA takes patients that are sometimes complex and makes them really simple, and also it sells them on your care. And that's been my experiences. Almost everybody that I do a really good SFMA exam on, I explain what I'm doing and I'm like, this is what you can expect if you come see me or you come under care or whatever. They're usually sold on it because that's the kind of care that I think a lot of people have wanted from their primary care physician for a long time that they just have not gotten.

That's a huge point there. And I think that's a really, really important point you made to highlight is that patients are looking for someone to pay attention to them. Like, people inherently want to know more about themselves. And part of taking that first step to reach out to a provider is like, I got some things going on, I can't handle it myself. What can you help me learn about what's going on with me? But then also, what can you do to help that? And would you say that in the cases where you're spending that time with the patient, you're validating the fact that, okay, there are some things here that are not working the way they should be. Do you feel like that gives you better buy-in from them in terms of like, now I'm going to give you the exercises to do, now we're going to do these treatments? Do you feel like patients, after having you spend that time explaining what's going on, have a little bit of better compliance when it comes to your care plan?

Oh, absolutely. A great example that sneaks up on people is ankle dorsiflexion. Tons of people struggle with ankle dorsiflexion, and when you do the SFMA, or when you do like a really in-depth physical exam And you're like, hey, your hips are fine. There's not a single loss of range of motion in your hips. There's not a loss of range of motion in your lumbar spine. There's not a loss of range of motion in your knee flexion extension. I hear you when you're telling me your low back hurts when you squat, but look, this is the deal. This is literally the only thing that you and I collectively can find, because it's always a group effort. The only thing that we can find together is this ankle problem. And then when you explain why it's important for ankle dorsiflexion to be around when you're doing things like squatting, when you go to the therapy side and you're like, all right, so we're gonna do— this is what I personally subscribe to, which like when you start doing pails and rails of ankle dorsiflexion, you start working on some of that ankle joint dysfunction. They can connect in their brain, hey, I'm doing this to improve This. Him and I worked on it together. I get a lot of buy-in just by explaining stuff as I'm going through the SFMA. And remember to like zoom out. The SFMA is just a component of an entire physical exam model or concept. And the way Rehab and Fitness does it with Dr. Teeter versus the way I do it with using the medical model, they're all relatively similar. I would say That one fits more for sports performance and the other fits more towards like straightforward medical assessments. But when I teach this class or this topic at Cleveland, I touch on things like functional exams and all that stuff because it's— I teach a class about medical emergencies and like how to handle those in private practice. But usually my patients don't ever make it down there as far as that far down the algorithm because The class is about medical emergencies, and you shouldn't be doing the SFMA on someone who's having a heart attack or an asthma attack or something. You need to be able to recognize those kind of things before it happens. And so while I touch on it, it's not like a big part of what that class is structured to. It is a big part of how I practice in private practice.

Thank you so much, Dr. Vauter.

Great presentation today.

We really appreciate you joining us.

Thank you guys. Appreciate your time.

That's it for today's episode. Be sure to tune in for episode 37, where we kick off a new training titled Demystifying the Nutrition Conversation: Cut Through the Confusion to Help Your Patients Succeed. In these next 2 episodes, you'll learn how to have the dreaded conversation about food and nutrition with your patients. Learn common sense guidelines for proper nutrition that any patient can follow and help them cut through the confusion of the latest diet trends they read about online. In this 2-part training, Dr. Christopher Marvin will discuss how to meet your patients where they are, provide guidance without demonizing food or creating labels of good versus bad, and how to dispel common misunderstandings and misinformation. You won't want to miss it. Episode 37 drops in 2 weeks. In the near future, we're also planning a few special Q&A episodes With our past instructors. So please be sure to click on the Q&A link in our show notes and ask any burning questions you may have. You can subscribe to The Factor Podcast on Apple, Spotify, iHeartRadio, or the podcast app that works best for you. Please give us a 5-star rating to help us grow the show. Every little bit helps. And last but certainly not least, be sure to visit the show notes for a link to download the PDF of today's full presentation, as well as learn about any special offers that we featured in today's episode. 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-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 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.