Latest / Pelvic PT Rising / Preventing Patient Flares

Transcript

Preventing Patient Flares · Pelvic PT Rising

• 0:02
  Speaker 1: In the last 10 years, our field has gone from an unknown specialty to a household name.
• 0:09
  Speaker 1: This brings unprecedented opportunities, but we need to rise up to meet them and give our patients the care that they deserve.
• 0:17
  Speaker 1: In order to help others get better, we need to be better.
• 0:23
  Speaker 1: This podcast will help you to become more confident with your patients, more successful in your practice or business and a leader in pelvic health, and we're going to have some fun along the way.
• 0:36
  Speaker 1: Join us as we rise together.
• 0:39
  Speaker 1: We're Jesse and Nicole Cozine, founders of Pelvic Sanity Physical Therapy and the creators of the Pelvic PT Huddle, and this is Pelvic PT Rising.
• 0:53
  Speaker 2: Hey guys, welcome back to another episode of the Pelvic PT Rising podcast with Jesse and Nicole Cozine.
• 0:58
  Speaker 2: Hey, nicole, hello, talking today about how to prevent flares, and I cannot believe, nicole.
• 1:04
  Speaker 2: We've gotten 350 plus episodes into this podcast and we haven't talked about this yet.
• 1:09
  Speaker 1: Yeah, I feel like we haven't talked about flares, but we haven't talked about fully preventing them, and I think and I know what many of you guys are saying right now it's like, oh, we can't prevent them or I'm not good at preventing them, and we're going to talk about why that might be and how to prevent them.
• 1:27
  Speaker 2: So, before we dive in, just one announcement.
• 1:30
  Speaker 2: If you guys were not at PelvicCon and did not have that experience, make sure that tomorrow, the 19th of September, is the last day to get the PelvicCon recordings.
• 1:40
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• 1:43
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• 1:46
  Speaker 2: You will get access to 600 plus slides from all of those incredible speakers.
• 1:51
  Speaker 2: You will get access and be eligible for 14.25 CEUs.
• 1:56
  Speaker 2: So make sure you're doing that.
• 1:59
  Speaker 2: Tomorrow is the day that goes away forever.
• 2:01
  Speaker 2: So head to PelvicConcom, check that out.
• 2:04
  Speaker 2: Make sure you have ordered that, if that is something that is on your radar and it should be because it will be a absolute game changer for your practice.
• 2:12
  Speaker 2: So, nicole, let's dive in.
• 2:14
  Speaker 2: Preventing flares First of all.
• 2:17
  Speaker 2: As we define a flare, the traditional definition is just a sudden increase in symptoms, whether that's pain or other symptoms.
• 2:25
  Speaker 2: Is there anything that we should add to that?
• 2:28
  Speaker 1: I think, ultimately, it's inevitable that your patients may have a flare, but what really is also part of this definition is when it's exacerbated by a known cause or trigger, and so I think that you know, a lot of times we are afraid of a flare, our patients are afraid of a flare, but, simply put, it's just an increase in symptoms that happens in a relatively short period of time, and there are ways to prevent this from happening and prevent it from causing anguish and angst and your patients from freaking out.
• 3:05
  Speaker 1: There's ways to prevent that from happening.
• 3:07
  Speaker 2: Yeah, I think that that knowing why it happens and there's a ton of pain science research to support this that if you think that the reason for something is either totally unknown or is something potentially scary and your mind goes that way, of course it ramps up everything and the pain or the symptoms you're experiencing are worse because you're thinking the worst and it just is a if that's self-fulfilling feedback loop.
• 3:33
  Speaker 2: The opposite is true.
• 3:35
  Speaker 2: If you have an idea of why something happened and you know that it's transitory and you know that it's something that is not sending you back to square one, often the symptoms aren't either as bad or they're certainly not provoking the same kind of emotional intensity.
• 3:51
  Speaker 2: I mean just an example.
• 3:52
  Speaker 2: I mean I'm such an idiot here that I go through periods of time where I work out and then periods of time where I don't, and then I'll start up again as if I've never stopped, as if it hasn't been a year and a half since I lifted weights, and I go do the same thing, right, I wake up the next morning.
• 4:08
  Speaker 2: What do I feel?
• 4:09
  Speaker 2: I can't even touch my face.
• 4:10
  Speaker 2: I'm so sore and I laugh about it because I know that I was an idiot and even though it's objectively painful, I'm not concerned about it.
• 4:20
  Speaker 2: I'm not calling a physician, I'm not trying to get into the ER.
• 4:22
  Speaker 2: If I had that literally that exact same sensation when I woke up in the morning and I hadn't done something stupid the day before, I for sure would be checking myself into the ER, like my arms are falling off.
• 4:32
  Speaker 2: What is happening?
• 4:33
  Speaker 1: Yeah, totally.
• 4:34
  Speaker 1: Or, you know, if you get a headache or something, it's like it's the same thing.
• 4:37
  Speaker 1: It's like, well, you were dummy, dummy and tried to lift 50-pound dumbbells when you haven't done that in a while, or it's not that.
• 4:45
  Speaker 1: Oh my gosh, if you wake up with a splitting headache, you're going to be like, wow, I have a brain tumor.
• 4:49
  Speaker 1: That is exactly the it, right?
• 4:51
  Speaker 1: So a known cause or trigger is a big piece of a flare.
• 4:56
  Speaker 1: And here's the problem.
• 4:57
  Speaker 1: And here's where it gets a little bit challenging.
• 4:59
  Speaker 1: Sometimes our patients think that they know what caused their flare, but maybe that's not the case, or that they think that the increase in symptoms just in and of themselves means that something is degenerative, or they have a framework of thinking about that that also up regulates their nervous system and goes into the catastrophic thinking that happens so often with our public pain folks, especially so before we get into how to actually prevent flares.
• 5:33
  Speaker 2: I thought it was something interesting you just said, Nicole.
• 5:35
  Speaker 2: You said that flares are inevitable.
• 5:38
  Speaker 2: Is that true for every patient?
• 5:40
  Speaker 2: For what you guys are saying.
• 5:42
  Speaker 1: So I'll say this.
• 5:44
  Speaker 1: I'll say in short the answer is yes, it is inevitable.
• 5:48
  Speaker 1: If you work in pelvic health rehab long enough, you will flare patients.
• 5:53
  Speaker 1: The longer answer is is really the why behind that?
• 5:56
  Speaker 1: Is that number one patients are just unpredictable and we're not getting all of the information that would help us to prevent a flare.
• 6:05
  Speaker 1: We're not getting all that information at the time where we need it all the time.
• 6:10
  Speaker 1: And then, secondly, like, we just can't know everything all the time.
• 6:14
  Speaker 1: So we would love to have this amazing hypothesis and be able to really nail it.
• 6:20
  Speaker 1: And then you know, your, our bodies are so complex it's almost impossible just to know everything all the time and know how everything's interconnected and how everything interacts.
• 6:30
  Speaker 1: And then you put a just complex human being, complex personalities, complex pain, brain changes, all of that on top of it, like it is inevitable that you will flare patients.
• 6:42
  Speaker 1: So I will say too, though, as one thing to piggyback on that comment is that I will say that the more experience that you have, the more experience that you have, the less you tend to flare people, because you have more n.
• 6:59
  Speaker 1: N equals 100,000, 10,000, whatever your number of patients that you see, the number of patient visits, that you see the number of people that you've come back where you've done x and they've come back and said why that is, is you just have so much more in your group that you can glean from, so typically more experience you are, the less this will happen and one real quick follow up, and this is probably a whole another podcast.
• 7:28
  Speaker 2: So if it is, then tell me.
• 7:29
  Speaker 2: But could you err on the side of being too cautious and being too afraid of flaring people so that you're not really doing all that you could be for them?
• 7:38
  Speaker 1: yes, I definitely feel that way so a lot of times, because we welcome to hire new grads at public sanity we're very much welcome that, and I always tell them I'm like if you're not flaring a patient in like six months, then you're essentially playing scared and you're not pushing people to right up to where the threshold is, and so it just takes time to learn where that is.
• 8:08
  Speaker 1: So you're not.
• 8:09
  Speaker 1: It's the same thing like working out like you've got to load the tissue just to the point of strain, but not to the point of failure, and so in some ways, working with somebody that has chronic pelvic pain is that you've got to challenge their system, you got to challenge their nervous system, you got to challenge their public floor, you got to challenge things just to the point where they can tolerate it to create change, but not to the point where it is going to backlash at you and revolt against you.
• 8:40
  Speaker 1: Essentially, and if you're playing the game right and if you're doing your job right, you're going to screw up and so you're going to just go just a little too far for the wrong person at the wrong time and it's going to blow up in your face and that's okay.
• 8:55
  Speaker 1: It's just that we can't have that beat all the time.
• 8:57
  Speaker 1: So if you're having person that flares all the time, like oh, how weird, all my patients are flaring, that's weird.
• 9:04
  Speaker 1: If you are having a bunch of people flaring and then not sometimes they are not coming back, you might not even know, but so it is something that it's difficult to have the trust and patience to come back to you and say like hey, this happened.
• 9:18
  Speaker 1: Some people just fly away and are like I'm not going back to that chick again.
• 9:21
  Speaker 2: So sometimes it's hard to evaluate whether or not you're flaring people as well okay, so let's dive into the really practical aspect of this, and I know you talk about, nicole, always assessing first.
• 9:33
  Speaker 2: What do you need to assess in order to determine whether you think there's a possibility of flaring this person?
• 9:40
  Speaker 1: so I think you need to assess a couple of things almost simultaneously but in different ways.
• 9:45
  Speaker 1: So number one I think you need to assess the actual irritability of the tissue itself, and this takes time to be able to have the touch and the kinesthetic awareness of what is an irritable tissue.
• 9:56
  Speaker 1: But just to give you one example of this if you go onto a muscle and you're like, wow, that's tense, that's overactive, that's hypertonic, if you will, if you hang out there for a little bit and the muscle itself starts to tense more, or the patient is saying that's burning more or that tissue is irritable, there's no reason, inherent reason why you holding pressure on a muscle should increase over time, increase with symptoms over time.
• 10:30
  Speaker 1: And so what that usually means is that there is like a nervous system response or a nerve or even a peripheral nerve response to that local tissue where it's hot, it's like it's really irritable, it's very volatile, like we're not sure what's going to happen with that muscle at that time.
• 10:48
  Speaker 1: So you've got to assess the irritability of the tissue.
• 10:50
  Speaker 1: Secondly, you need to assess essentially the irritability of your patient and how well they're going to tolerate an increase in symptoms.
• 10:59
  Speaker 1: So a little bit of that is their personality.
• 11:03
  Speaker 1: Some of that is their nervous system upregulation, some of that is the reason why they're in their office, some of that is their trauma history.
• 11:09
  Speaker 1: Some of that is a lot of other things that I'm not going to list here.
• 11:13
  Speaker 1: But essentially each patient is very individual and you've got to assess how would they respond to an increase in symptoms if it was presented to them, and so I hope that answers that question.
• 11:29
  Speaker 2: Yeah, I think it does.
• 11:30
  Speaker 2: And then so what do you?
• 11:30
  Speaker 2: So if you're assessing either the tissue or the person and you find them to be overly irritable, let's just say as a you know, like a catch all term for that.
• 11:42
  Speaker 2: So you guys know that we mean more than whatever that is.
• 11:46
  Speaker 2: But if you assess that either the tissue itself or the person or both are in that irritable category, what's the plan?
• 11:54
  Speaker 1: So the plan is then, to look at yourself.
• 11:55
  Speaker 1: Right, I'm always all about like we assess the patient, we assess to address, we do all of those things, but then we also have to look at where are we in our clinical journey, because how confident are you that you know exactly what's going on and exactly you've seen this patient, this patient pattern, this musculoskeletal pattern, this neuromuscular pattern, this nervous system pattern?
• 12:18
  Speaker 1: How often have you seen this play out in what type of patient?
• 12:24
  Speaker 1: So I want you to do a little bit of a quick self assessment.
• 12:28
  Speaker 1: It's like do I really know what's going on and have I seen this happen a bunch of times?
• 12:33
  Speaker 1: So those are the three things that you're assessing your assessment, the irritability of the tissue.
• 12:36
  Speaker 1: You're assessing your patient, both their nervous system and their personality, and how well they would essentially deal with increase in symptoms.
• 12:46
  Speaker 1: And then how confident are you that you know what the hell's happening?
• 12:48
  Speaker 1: And then you take all of that into account with how you present something to a patient, because at the end of the day, you're treating the patient and then you have essentially like a week for these symptoms to do what they're going to do, for the patient to do what they're going to do and then you're going to hear back from them hopefully not before a week, but you're going to see what happens and that's what we need to prepare people for.
• 13:16
  Speaker 1: That week or the time in between sessions is how, and how we pre frame that for them is how we prevent a flare.
• 13:23
  Speaker 2: You know, and that's interesting, as we kind of.
• 13:25
  Speaker 2: I know we started off by talking about the definition of a flare, but that brings me back to just a.
• 13:30
  Speaker 2: Really I don't know, maybe this is insightful, maybe it's not.
• 13:33
  Speaker 2: Tell me if this is dumb, but I feel like that means that a flare is truly in the mind of the beholder, because somebody could have the same increase in symptoms and say, oh my gosh, I'm in a flare.
• 13:45
  Speaker 2: This is terrible.
• 13:46
  Speaker 2: It's never going to get better.
• 13:47
  Speaker 2: The place I went made me worse.
• 13:49
  Speaker 2: What am I going to do?
• 13:50
  Speaker 2: Or somebody could have that same increase in symptoms and say, wow, Nicole really cranked on that area last time.
• 13:57
  Speaker 2: She told me she was going to like this is a part of my healing journey.
• 14:01
  Speaker 2: I'm kind of stoked that it's a little bit sore.
• 14:03
  Speaker 1: Well, to be clear, I don't crank on anybody's internal muscature.
• 14:09
  Speaker 1: Sometimes Jesse is like oh, I really remember that you're not a pelvic PT.
• 14:17
  Speaker 2: Did you ever forget?
• 14:18
  Speaker 2: Has anybody out there ever listened to my voice on here and been like, wow, that guy sounds like a pelvic floor.
• 14:24
  Speaker 1: Oh, gosh Okay.
• 14:25
  Speaker 1: So just to be again.
• 14:26
  Speaker 1: Just to be clear, I don't crank on anybody but however, there may be something that I am doing or choosing to do in the session to see what happens, right, so I might, in the case of the muscle that we're on that isn't totally releasing and I'm like that muscle is irritable, I may choose in that session to try something and if it doesn't work, I know that like oh yikes, that patient's gun flare I mean, I made shoes to do that.
• 14:58
  Speaker 1: Now, that's not cranking, that's just meeting the nervous system and being like all right, nervous system, how y'all gonna respond to me right now.
• 15:05
  Speaker 1: And then it's like, ooh, if I hear from the patient, dang it.
• 15:09
  Speaker 1: That was too much at that time for that person.
• 15:14
  Speaker 2: That sounds an awful lot like a big euphemism for cranking.
• 15:20
  Speaker 1: No, you all know what I'm talking about, though.
• 15:22
  Speaker 2: How do you address that?
• 15:23
  Speaker 2: So, especially when you don't necessarily and you know you're you've recently evaluated somebody.
• 15:28
  Speaker 2: I love how you said at the beginning right, you don't have perfect information about them.
• 15:32
  Speaker 2: They filled out their forms, you spent 30 minutes talking to them and all of a sudden you're working with them.
• 15:38
  Speaker 2: How do you prevent a flare if you're not 100% sure about the irritability of the tissue?
• 15:44
  Speaker 2: You don't really know their personality or their amount of upper regulation yet, or you're kind of guessing at that.
• 15:50
  Speaker 2: What do you actually say?
• 15:52
  Speaker 1: The thing is is that I usually, if, when, in doubt, I give people three options.
• 15:59
  Speaker 1: And this is kind of the same when we're working with people, when we're like, when we're asking, we're trying to ask a non-leading question Are you better, Are you worse, or is it the same?
• 16:09
  Speaker 1: If I've touched this, is it better, worse or the same?
• 16:13
  Speaker 1: If I do this, we kind of inherently know how to talk to patients within the session about that.
• 16:19
  Speaker 1: So I'm asking you to extend those same choices or those same things to your patient, to pre-frame for them that, hey, there's essentially three things that can happen.
• 16:33
  Speaker 1: Number one what we did here is freaking awesome.
• 16:38
  Speaker 1: Your body is going to love it and it's going to be like thank you, holy crap, I cannot wait to come back here and get more of that amazing treatment to decrease my symptoms.
• 16:50
  Speaker 1: On the flip side, there is holy shit, what did you do to me?
• 16:55
  Speaker 1: I'm pissed, and you know what?
• 16:57
  Speaker 1: I know I came in here with urinary urgency frequency, but now I'm going to give you burning urethral pain because I don't want that thing that just happened to happen again.
• 17:08
  Speaker 1: Those are the two extremes, and the middle ground is that, yeah, you worked there.
• 17:14
  Speaker 1: I can feel it a little bit and then it went away or some variation of like no big deal.
• 17:20
  Speaker 1: So usually, if you're in doubt about what might happen, or you're in doubt on what to say or what, if you're not really confident in predicting what will happen which comes with time and experience in treating pelvic health patients then I would present those three options.
• 17:38
  Speaker 1: I would say here's what we did, and this is why we do this in the last 10 and be like this is what we did, this is what we worked on and this is why.
• 17:44
  Speaker 1: Now this is what may happen over the next few days.
• 17:50
  Speaker 1: Number one your body.
• 17:52
  Speaker 1: And I say exactly that.
• 17:53
  Speaker 1: Your body could be like oh my gosh, this is so amazing.
• 17:56
  Speaker 1: I love it.
• 17:56
  Speaker 1: Your symptoms could be so significantly down, because that is also something that I want to know and something that may not last and might be transient.
• 18:05
  Speaker 1: On the flip side, your body might be like what the hell just happened?
• 18:10
  Speaker 1: Someone was up in there and I don't like it.
• 18:13
  Speaker 1: And now I'm going to give you your symptoms times five, just so you're paying attention or you know you could feel something in between.
• 18:21
  Speaker 1: I just want you to pay attention to it and let me know what happens, how long it lasts for, and what you were potentially doing or not doing at the time to give me information and that's it.
• 18:34
  Speaker 2: I think that's so profound.
• 18:36
  Speaker 2: It's just pre-framing basically what the different options are.
• 18:39
  Speaker 2: I mean that takes the fear out of it.
• 18:42
  Speaker 2: There is an increase in symptoms.
• 18:44
  Speaker 2: Whether I'm still a little bit torn on whether, like, an expected increase in symptoms is in fact a flare or not, I don't know how we're truly defining it, but no matter what, if you're expecting that it is way less scary and it's way less of a problem, you're way less likely.
• 19:01
  Speaker 2: I mean this is an example of if you're getting a lot of people calling the clinic or emailing the clinic and being freaked out about this.
• 19:08
  Speaker 2: It means you're not doing a great job at this part.
• 19:11
  Speaker 1: It just means you're done doing a good job of communicating and that's the biggest thing here with if I can depart one piece of wisdom with this podcast about for this topic, how to prevent a flare it's to talk and communicate with your patients about the choices that we have that your body has to deal with.
• 19:28
  Speaker 1: Whatever just happened in the session, your body could love it, your body could hate it and it could be sort of neutral, but no matter what happens, it's going to give us information and I think that that is the other piece to this conversation.
• 19:43
  Speaker 1: And preventing a flare, or essentially preventing an increase in symptoms with the combination of an exacerbated phone call to your office, is I want you to pay attention because all information is good information.
• 19:56
  Speaker 1: So if you were in bed for two days because of whatever we did, like that's data and that still is very difficult to have someone navigate that and we hope that that doesn't happen and we try everything that we can to prevent somebody from being having some huge exacerbation that's debilitating after our session.
• 20:16
  Speaker 1: But if it does happen, it's still important information for us to gather, to know how long it lasted, to know if it led up, to know what you did in order to get that to go down.
• 20:28
  Speaker 1: Was it an opioid?
• 20:30
  Speaker 1: Was it, you know, muscle relax and suppository?
• 20:32
  Speaker 1: Was it the stretches that I told you to do?
• 20:34
  Speaker 1: Was it talking to your girlfriend, you know?
• 20:39
  Speaker 1: Like what was the thing that finally got that to go down?
• 20:42
  Speaker 1: That's also good information.
• 20:44
  Speaker 1: It's also good information to know what's happening around that.
• 20:47
  Speaker 1: So, inevitably, what can happen is that your body can feel great.
• 20:52
  Speaker 1: How you pre frame this, too, and why it's so important, is that if you tell someone your body might feel great or your body might hate you, whatever.
• 21:00
  Speaker 1: But here's the thing is, if your body feels great, that pre frames for them like, oh, if I'm feeling great, then I may be overdid it with going to Disneyland or whatever.
• 21:10
  Speaker 1: And so suddenly you help them to put into context why something happened.
• 21:15
  Speaker 1: So if they flare two days after your session three days after your session and the day before that they went to Disneyland because they felt so super awesome and walked 20,000 steps when they normally only get 500, then they can start to put the pieces together and instead of calling you frantically, being like, oh, my gosh, I am aching, my hip is my vagina is burning.
• 21:40
  Speaker 1: I don't never been this bad, instead what they might do, because you've pre framed them so much to be like it could be better, worse or the same.
• 21:47
  Speaker 1: Then you can have them be like it was feeling amazing.
• 21:53
  Speaker 1: You know if I'm really thinking about it.
• 21:55
  Speaker 1: Those first 24 hours were awesome.
• 21:57
  Speaker 1: That's why I scheduled to go to Disneyland.
• 22:00
  Speaker 1: Then I overdid it, then I had a problem.
• 22:03
  Speaker 1: You're helping them to create their own timeline and giving you information and helping to your their nervous system to make sense of what's happening.
• 22:11
  Speaker 2: So I feel like this is a super practical episode.
• 22:14
  Speaker 2: I'm really excited we got to talk to this.
• 22:16
  Speaker 2: Thank you guys who reached out and asked questions about this.
• 22:18
  Speaker 2: We're going to leave it there, I think, and if you guys have further questions, feel free to reach out.
• 22:23
  Speaker 2: We love hearing from you guys.
• 22:24
  Speaker 2: Just a reminder if you are interested in the Pelvicon recordings and you have not gotten those yet, tomorrow is the absolute final day, so make sure you head to pelviconcom, get those.
• 22:37
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• 22:38
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• 22:40
  Speaker 2: 15 plus speakers are 15 plus topics.
• 22:43
  Speaker 2: They are super practical takeaways from each one.
• 22:46
  Speaker 2: You will not want to miss those, so make sure to check that out at pelviconcom.
• 22:51
  Speaker 2: As always, we appreciate you guys for listening, for being around, for your reviews, for reaching out.
• 22:57
  Speaker 2: We want to keep this conversation going.
• 23:00
  Speaker 1: And let's continue to rise.