Latest / Pelvic PT Rising / Navigating Highs, Lows, and Setbacks

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Navigating Highs, Lows, and Setbacks · 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, we have gotten some great feedback from you guys on our episode last week on needing more time, and it caused us to kind of think about this and dive in, and one of our employees actually had a situation like this.
• 1:11
  Speaker 2: But we wanted to talk about how to not get too high when your patient is having a really good experience good outcomes, symptoms are getting better and how to just maybe stay a little bit more regulated with that.
• 1:25
  Speaker 2: So before we dive into this episode, wanted to remind you guys that you've been listening to our PelvicCon speakers incredible interviews.
• 1:34
  Speaker 2: Make sure, if you are not attending in person, that you have the PelvicCon recording.
• 1:38
  Speaker 2: You can get an early bird discount on that.
• 1:40
  Speaker 2: Head to PelvicConcom for that.
• 1:42
  Speaker 2: If you are coming, make sure you've got your add-ons your clinicians lunch, your business owners lunch, the closeout dinner all the things that are going to make it really, really special.
• 1:52
  Speaker 2: You can find that as well at PelvicConcom.
• 1:54
  Speaker 2: So, Nicole, talk to me about this.
• 1:57
  Speaker 2: Why is the temptation there to get too high when your patient comes in and is having a great day?
• 2:03
  Speaker 1: You know, I think that there's a couple of things that happen.
• 2:06
  Speaker 1: Number one if you're not super seasoned and you haven't seen very many people go through an entire plan of care and you haven't seen their ups and downs and the things that will sort of get them off course a little bit, then you almost get tricked by that analogy of initial decrease in symptoms and they're so excited.
• 2:29
  Speaker 1: And then you're excited that they're excited, and I think that that's one of the areas that happens.
• 2:36
  Speaker 2: I think that's an interesting point too, because it feeds into that.
• 2:40
  Speaker 2: That's a cognitive bias.
• 2:41
  Speaker 2: If things are going well, I'm amazing, I'm great Look at how great I got this person and only a couple of visits, of course, if things go poorly, what else is wrong with the patient?
• 2:51
  Speaker 1: What did you do?
• 2:52
  Speaker 1: You must have done something between this last session and this session.
• 2:55
  Speaker 1: Did you go to Disneyland?
• 2:57
  Speaker 1: Did you walk a lot?
• 2:58
  Speaker 1: Did you do what?
• 2:58
  Speaker 1: You know what I mean?
• 2:59
  Speaker 1: It's like that's actually a really funny cognitive trick.
• 3:04
  Speaker 2: But it is interesting that of course, that kind of plays into your ego and they come in, they're really happy with you, they're happy in general, they're happy with you, they feel really great.
• 3:13
  Speaker 2: And I think you're saying, nicole, there is potential problems with feeding into that, with letting that kind of build.
• 3:21
  Speaker 2: They say something excited, you're excited, it's building, it's building.
• 3:24
  Speaker 2: Then really that kind of flows into what we were talking about last week on needing more time.
• 3:29
  Speaker 2: That can flow into an early discharge.
• 3:32
  Speaker 2: Wow, they're doing so good.
• 3:34
  Speaker 2: Oh, that's great.
• 3:36
  Speaker 2: They're certainly on the right track.
• 3:38
  Speaker 2: Why don't we reduce your number of visits?
• 3:39
  Speaker 2: Why don't we go ahead and have you go home and just see how that goes for the next four or five weeks?
• 3:44
  Speaker 2: Call us if you need us, or it leads to a major letdown.
• 3:48
  Speaker 2: Really, those are the only two options.
• 3:49
  Speaker 2: That either leads to an early discharge or a major letdown, because the assumption is the progress isn't linear, that next week is not necessarily going to be the best week they've felt in their whole life, especially with chronic pain people.
• 4:02
  Speaker 2: So you can't really expect that to continue.
• 4:05
  Speaker 1: Yeah.
• 4:05
  Speaker 1: So I think that there's a big disconnect here with the same information patient symptoms get better and what we need to remember and what the patient is experiencing.
• 4:17
  Speaker 1: So the patient remember doesn't have the context of knowing about all of how all the systems are integrated, how the nervous system is integrated, their movement patterns that might be influencing whether or not their symptoms got better, all of the different stacking on, of increasing load, and what strength gains, how long strengthening is really take.
• 4:39
  Speaker 1: They don't know any of that.
• 4:41
  Speaker 1: The only thing that they're looking for is very singularly focused.
• 4:46
  Speaker 1: It is the symptoms that I came in for are either and they're usually determining whether they're better, worse or the same and if they come in and they're better, the patient assumes, without all of that context that I just mentioned, that oh, if it gets better one day, it's going to continue to get better, and a lot of them think that same amount and it's like, wow, if I'm 50% better today, then that means next week I'll be even better and the week after that man, this thing's, it's going to get knocked out in four visits.
• 5:15
  Speaker 1: This is amazing.
• 5:16
  Speaker 1: I love pelvic PT or pelvic OT and so I feel like there's a big, huge disconnect in the, in the facts around symptom reduction, where we get in trouble if we take the patient's emotion and run with it and forget about all of those other facts that put it into context a little bit better.
• 5:39
  Speaker 2: Yeah, I could also see that meaning that you start doubling down on stuff that you've already been doing.
• 5:43
  Speaker 2: Oh cool, I gave this patient one set of exercises.
• 5:46
  Speaker 2: Well, if they did so well with one, will happen if I give them 11,000,000.
• 5:51
  Speaker 1: 11,000,000.
• 5:53
  Speaker 1: Yeah, no, totally.
• 5:54
  Speaker 1: I mean.
• 5:54
  Speaker 1: I think that, and patients want that too.
• 5:56
  Speaker 1: They're coming in, they're being like, okay, what's next?
• 5:59
  Speaker 1: What's next?
• 5:59
  Speaker 1: And it's hard to say, okay, what that means is that we're on the right track, we hit something.
• 6:08
  Speaker 1: Well, so what we need to do is do exactly the same thing again.
• 6:12
  Speaker 1: I think that makes patients feel like, oh well, I'm not progressing, and it makes therapists feel like am I even doing anything if I'm not changing something up?
• 6:24
  Speaker 1: You don't have to change something every visit for each visit to be a success.
• 6:30
  Speaker 1: Sometimes the best thing you can do is the same freaking thing that you did last time to see and to test.
• 6:38
  Speaker 1: Was that something that was really a fluke?
• 6:41
  Speaker 1: Was it my thing that we had the patient do that was responsible for that decrease in symptoms, was it?
• 6:48
  Speaker 1: It's like well, so to me it's a little bit more of an attitude of like cool, let's see if we can do that again, versus cool, let's change everything up and make everything harder for you and assume that that decrease in symptom is going to be exactly linear.
• 7:06
  Speaker 2: So is this true for both chronic pain people as well as your incontinence, your prolapse, your painful intercourse type folks, or is this more?
• 7:18
  Speaker 2: Are you speaking more to the chronic pain population, or is this a trap that we can fall into with any type of patient?
• 7:24
  Speaker 1: I really think it's a trap that you can fall into with any type of patient.
• 7:27
  Speaker 1: I feel like it's easier to see in the chronic pain population.
• 7:31
  Speaker 1: But even for somebody that has symptoms of incontinence and they come back and they're like, oh my gosh, I didn't even leak that much and my response is the same.
• 7:42
  Speaker 1: It's like that is so awesome, I'm so happy.
• 7:46
  Speaker 1: Let's take a look at what we did last time and let's just stay the course and see if we can have another week of that.
• 7:52
  Speaker 1: Let's see.
• 7:53
  Speaker 1: So we're very much a oh cool, let's see.
• 7:56
  Speaker 1: But that can happen for things in the postpartum phase.
• 7:59
  Speaker 1: That can happen for incontinence, that can happen for any sort of issue that's not necessarily chronic pain related.
• 8:07
  Speaker 1: The feeling of prolapse is another big one.
• 8:10
  Speaker 1: So, especially because we know that prolapse grades are not analogous to the severity of symptoms, so someone could have severe symptoms, get better quote unquote in a short period of time, because maybe we released some tension around the pelvic floor that was actually creating some of those symptoms, but we haven't actually addressed the why of the pelvic floor tension that was causing that.
• 8:36
  Speaker 1: The patient comes back.
• 8:37
  Speaker 1: They say, oh my gosh, this is amazing.
• 8:39
  Speaker 1: My prolapse must have lifted right, or it must be higher up there now, even though what's really happened is just the symptoms around the pressure is changed, and so they can be feeling like, oh my gosh, this is so great, it's done like that, you fixed it, like that's it.
• 8:57
  Speaker 1: And the reality is is that maybe they just didn't have that high pressure of a day, Maybe they were just in a better mental place and have had a better outlook, so that those symptoms were feeling better, but there was actually no real physical change yet.
• 9:13
  Speaker 1: And so that's where yes, I believe it does apply to pretty much any type of patient.
• 9:20
  Speaker 2: I think prolapse is a good example.
• 9:22
  Speaker 2: It kind of goes back to that cognitive bias we were talking about earlier, but that's one where people's symptoms change throughout the day a lot of times.
• 9:29
  Speaker 2: So even just a morning person versus an afternoon appointment, you might be getting different results, different symptoms, and again it's not like when things go well, you're doing this the investigative journalism to go in and say, well, did you not go into work yesterday?
• 9:46
  Speaker 2: Where you off of your feet?
• 9:48
  Speaker 2: There must be some explanation, because my intervention couldn't have done all of this.
• 9:52
  Speaker 2: You're just like ah, I'm freaking great at my job.
• 9:55
  Speaker 2: Look, it's good man, this is awesome.
• 9:57
  Speaker 2: And so I think that that is an important point.
• 10:01
  Speaker 2: Can you give an example, nicole?
• 10:03
  Speaker 2: Like what language would a patient come in with this?
• 10:05
  Speaker 2: Maybe do a chronic pain person?
• 10:07
  Speaker 2: I know it's not exclusive to chronic pain, but what would this be like for someone who's had penenal neuralgia, for example?
• 10:15
  Speaker 1: So if someone came in with penenal neuralgia and there's actually a patient who comes to mind that I treated for a long time actually and I could remember the first time she came in and she was like she had had a pretty significant symptom decrease.
• 10:31
  Speaker 1: I mean, she was had her husband driver in.
• 10:33
  Speaker 1: It was like eight out of 10 in her mind.
• 10:36
  Speaker 1: She was on massive amounts of pain pills and then within the first week of me seeing her, I had her come in.
• 10:44
  Speaker 1: I think I had her coming in for like three times a week for that first month or so and I remember after a couple of visits towards the end of that first week she was like I didn't even feel it for half of the morning.
• 11:00
  Speaker 1: One day I was able to sit down and eat breakfast.
• 11:03
  Speaker 1: This is amazing.
• 11:05
  Speaker 1: This is the most improvement that I've had in the two years that I've had these symptoms and I was like that is so great.
• 11:15
  Speaker 2: Hold on.
• 11:15
  Speaker 2: So that's got to feel great.
• 11:16
  Speaker 2: Right, that's an ego boost.
• 11:16
  Speaker 2: That's, I feel like the temptation there is to just jump in with it and be like, yeah, that's why you came and this is I remember who you're talking about had been to like the Mayo Clinic.
• 11:25
  Speaker 2: Yeah, had done everything, quote, unquote.
• 11:28
  Speaker 2: And then within a couple of weeks with you, she's coming in and saying this is the best I've felt in years.
• 11:34
  Speaker 2: That must have been really tempting to just celebrate, take the win.
• 11:38
  Speaker 1: Yeah Well, and you know, I do take the win.
• 11:40
  Speaker 1: I mean, your ego is your ego, it's there and you should.
• 11:45
  Speaker 1: But I think that the key here is to take the win in a way that is like cool, I'm on the right track, we hit something and we need to ride this train until we need to get off.
• 11:58
  Speaker 1: Instead of being like cool, we're going to hop off here and then find another train to get on, it's just like.
• 12:05
  Speaker 1: We just need to be like great, we need to stay the course.
• 12:08
  Speaker 1: Then this is, we need to ride this out and see what happens and also help the patient to see that, yes, that's awesome.
• 12:16
  Speaker 1: Because if there wasn't a nugget of truth to that like we are on the right track, what?
• 12:22
  Speaker 1: Maybe?
• 12:22
  Speaker 1: What we're doing is working, really awesome.
• 12:26
  Speaker 1: But I think that there's a lot of other variables too, and just the nature of chronic pain itself and what it's doing to the brain and movement patterns and all of the things.
• 12:37
  Speaker 1: I think that that it's something that we have to make sure to talk to patients about in a way that's like great, this is awesome.
• 12:46
  Speaker 1: And also we need to wait to see what happens over a period of time, because that's really where it is, and especially with someone in chronic pain, we can be like great, and now we're going to wait, for I don't necessarily say this right away, but we're basically waiting for the next flare up though, because we know that process and symptom reduction isn't linear.
• 13:10
  Speaker 1: So there will be another time when the pain shoots back up to that eight out of 10.
• 13:16
  Speaker 1: And then the key there is to make sure that they know that, we know that that's going to happen and be able to navigate that blip Like that's where that we make our money is in the coming back and navigating the flare up to back to the eight and not having the patient believe that it's not the end of their life, it's not the end of the road, it's not all the way back to the beginning, it just is a blip which they will think if you do get too high with them when that person comes in and let them believe that this is where everything is going.
• 13:51
  Speaker 2: Now, what do you actually say?
• 13:53
  Speaker 2: So that person comes in, says, man, I had a morning where I was without pain for the first time in two years.
• 13:58
  Speaker 2: What do you actually say?
• 14:00
  Speaker 2: Are you warning them that this isn't a linear process?
• 14:03
  Speaker 2: Right then, is that too much raining on the parade?
• 14:06
  Speaker 2: How do you navigate that?
• 14:07
  Speaker 2: And I know this is a tough one, with soft skills, and it depends on the person's personality and your relationship and all the things I know it does.
• 14:14
  Speaker 2: But.
• 14:15
  Speaker 2: But okay.
• 14:16
  Speaker 1: So framework wise, though.
• 14:17
  Speaker 1: So, if you think about what we're doing right, we're at a follow up visit and the follow up visit we're talking to them when they come in about, hey, how have you been since last visit?
• 14:26
  Speaker 1: So we're finding out that they had just like a really wonderful time right, or, and they're so excited, and so I ask a ton of questions around the positive experience so great, what else were you able to do?
• 14:42
  Speaker 1: Because I also want to pull out it's going to sound a little bit opposite to what I just said, but I do also want to pull out all of the things that were better, not just the ones that they told me to see how long did it last, what really was the impact?
• 14:56
  Speaker 1: And then I hold that information and then we sort of talk about what we're going to do this session, which is usually going to be pretty similar to last session.
• 15:08
  Speaker 1: So my education on hey, this is we're got to stay the course starts with my actions of what we do that day.
• 15:18
  Speaker 1: Cool, so if you recognize that there was such huge symptom decrease, then we're essentially gonna repeat again what we did.
• 15:28
  Speaker 1: Sometimes I even pretend to look back at my notes and be like, okay.
• 15:31
  Speaker 1: So we worked on your adductors and we worked on your abdomen and we did this exercise.
• 15:36
  Speaker 1: Great, if we do that same thing again, I think that we'll maybe make a small tweak to this part of whatever I'm saying, and then we'll sort of see how you do next until next time.
• 15:51
  Speaker 1: And so then we do the treatment.
• 15:53
  Speaker 1: Meanwhile, then we're talking about how the nervous system is responsive and how sometimes you have a little bit of rebound effect and I'm so happy.
• 16:04
  Speaker 1: What we need to remember is this day.
• 16:06
  Speaker 1: I want you to remember this feeling, and I want you to remember this day because if we can get it here and it happens to blip up again, we can get it back here.
• 16:15
  Speaker 1: I'm 100% sure of, and so you're already kind of foreshadowing the, just in case something happens.
• 16:21
  Speaker 1: And then towards the end or when you guys know I like to wrap up my sessions, in the last five we summarize.
• 16:27
  Speaker 1: We'd be like, okay, you came in today with some really amazing results, but what I really wanna make sure of is that we're not putting the cart before the horse, and what I really wanna make sure is that this is a true change and not just a nervous system trick right now.
• 16:46
  Speaker 1: And so we're gonna do very similar things.
• 16:50
  Speaker 1: I actually don't want you to change that much stuff from what you did before.
• 16:53
  Speaker 1: We tweaked a little bit of what we did here in the internal exam part.
• 16:57
  Speaker 1: I worked on a little bit different part of your pelvic floor and I wanna see how you do after that.
• 17:02
  Speaker 1: So same exercise, same stretch, same breathing.
• 17:06
  Speaker 1: Those are the three things that you're supposed to be working on, and I want you to come back and tell me did that last?
• 17:13
  Speaker 1: Do we have the same thing that happened?
• 17:15
  Speaker 1: Or pay attention.
• 17:17
  Speaker 1: You might notice that there's a little bit more.
• 17:20
  Speaker 1: We might go from a two to a four out of 10, like I don't know what's gonna happen.
• 17:24
  Speaker 1: But I want you to pay attention and every piece of information that you can give me is super valuable in the next steps.
• 17:31
  Speaker 2: Ooh, that's good.
• 17:32
  Speaker 2: So that sends them away with a sense that this isn't linear, that it could pop back up, that this is not their new normal.
• 17:41
  Speaker 2: But it is possible.
• 17:43
  Speaker 2: You're cementing that hope but also leavening it with the dose of realism.
• 17:48
  Speaker 1: Yes, exactly, and that I mean that's the name of the game, I feel like and because we have so much more information than they do, then we have to slowly drip out the information at an appropriate time so that we can help them when, inevitably, this person and this is exactly what happened is that she went back, and inevitably because she's feeling better, she's doing more stuff.
• 18:15
  Speaker 1: So she came back and her pain was back up to a six.
• 18:18
  Speaker 1: She felt like that was a huge failure and I felt that that was a huge win.
• 18:24
  Speaker 1: And so now we have another conversation about you were at an eight, you came down to a two, went up to a four and then a six.
• 18:34
  Speaker 1: We're still have a delta of two points less on this scale, and I don't love the 10 point scale for pain, but in this case, this patient really was in it and had been marking her symptoms like that for years, and so we were using that.
• 18:50
  Speaker 1: So, but then we can.
• 18:52
  Speaker 1: Now we are in the conversation of oh, it can change, it can move.
• 18:57
  Speaker 1: What are we gonna do to take it down off that six?
• 19:01
  Speaker 2: And she wasn't shocked by the fact that happened, because you had told her that was a possibility.
• 19:05
  Speaker 2: So she was disappointed.
• 19:07
  Speaker 2: She might've been a little bit frustrated and scared, but she was not truly surprised.
• 19:12
  Speaker 1: No, she wasn't surprised Very much.
• 19:14
  Speaker 2: warned her that that would be where it is.
• 19:16
  Speaker 2: And she wasn't mad either Right, and that would've been really damaging for your relationship If you had just celebrated that two.
• 19:23
  Speaker 2: This is incredible.
• 19:25
  Speaker 2: I can't believe it.
• 19:26
  Speaker 2: We got to something, we're really on the right track, and then that thing flares back up and you don't pre-frame that that's a possibility.
• 19:33
  Speaker 2: You're losing credibility, you're losing trust.
• 19:36
  Speaker 2: You might lose your patient.
• 19:37
  Speaker 1: You might lose your patient and you're gonna get an at the very least, you're gonna get a frantic phone call and that person never once had to call the clinic in a huge flare, because we had always talked about what if that happens, and we have a podcast on what if your patient flares and how to navigate that.
• 19:54
  Speaker 1: But part of it is this, part of it is not giving them false hope by getting wrapped up in the emotion, the positive emotion of like oh my gosh, you're so much better, and then not preparing them for like okay, that is wonderful.
• 20:09
  Speaker 1: And also, if something else happens that makes you feel like you're backsliding, like all I want you to do is notice, write it down and bring it back to me, because all information is good information and all change is good change.
• 20:23
  Speaker 1: We just have to figure out what clues that helps me with in terms of how we're gonna move your next sessions forward.
• 20:31
  Speaker 2: Perfect.
• 20:32
  Speaker 2: So we're getting practical today.
• 20:33
  Speaker 2: Guys, I hope that is really helpful for you as you navigate this and as you keep that even keel with your patients.
• 20:40
  Speaker 2: If you have questions about this, if you have challenges with this, if you have an example of a recent patient where this was an issue or you're not sure you handled it the right way, please reach out, let us know.
• 20:50
  Speaker 2: We love hearing from you.
• 20:52
  Speaker 2: Shoot Nicole at DM, that's at Nicole Cozine, dppt.
• 20:55
  Speaker 2: Shoot her an email.
• 20:56
  Speaker 2: Nicole Cozine at Pelvic Sanity, nicole at Pelvic Sanity, and we'd love to hear from you.
• 21:02
  Speaker 2: So, as always, let's keep this conversation going.
• 21:04
  Speaker 1: And let's continue to rise.
• 21:06
  Speaker 1: Ujeiday overlapped landing hoyday.