me well? Okay, perfect. Thank you for that introduction. That was great. It was the best one I've ever had. That's right. Exactly. How many people here have ever heard me speak before? Okay, so we've got some locals. Good to see y'all. I've spoken a lot at the MA conferences in South Carolina. We've been involved kind of heavily for a number of years now, but as the introduction said, I started 2006 Elite Integrated Therapy Centers, and we've had pretty substantial growth. We now have 30 standalone clinics in three states, but as the introductor said, we believe in clinical excellence, clinical education, and compassionate care. Those are our three pillars. That's what we kind of started to lead on, and it's served us well thus far, so I think we'll continue. As she said, I still am involved in clinical care. I do more administrative stuff now, and I guess my role is more of an operations person for 30 clinics and 200 employees, but I still actually this past week I was in one of our Bluffton clinics, which is in South Carolina on the coast, and actually saw patients this week while one of our therapists was on vacation, so I'm still involved. I still love what I do. I still love the profession. A little bit about this topic, and this is a topic that I think is a hot topic that maybe you've probably had some experience with. I want to get a show of hands of kind of what specialties y'all are involved in. How many people here work in primary care, family practice, internal medicine, stuff like that? Perfect. How many people work in maybe an orthopedic office? Okay. How about a neurological office? Okay. Anybody work in an ENT, ear, nose, and throat? Perfect. I'm going to get with you later. How many people work in a dentist office? Okay. I don't know. Do MAs work in dentist offices? Probably not. Okay. All right. Learned something. Yes? Surgery. Okay. Okay. Any other specialties out there? Rheumatology. Optometry. What was that? Vascular. Integrated medicine. Podiatry. That's right. Tell me about integrated medicine. Okay. Okay. All right. Interesting. Osteopathic. Yep. Okay. You have therapy in there as well? Perfect. Okay. So y'all are familiar with some of this. Yes, ma'am? All right. And I saw a hand over here. Cardiology. Yep. Oncology. Okay. Transplant. Wow. Okay. What was that? Nephrology. Okay. How many, this is oncologists, oncology people out there, do you send patients to physical therapy? Excellent. Yeah. Yep. Lymphedema, stuff like that. I will tell you, and I don't know where you work, but in the state of South Carolina, it has been hard for us to get in and show the oncology departments in South Carolina that we can help. Right. Yeah. Okay. So initial course of action as a physical therapist. So this is something you've probably run across. How many times have you tried to maybe in your office, the doctor has tried to prescribe a medication or prescribe a special test, an MRI or something, and they are told you can't do it yet until they've had physical therapy? A lot. Okay. And how mad does the doctor get? Very mad. Right. I agree. I agree. Why do you think the insurance companies are doing that? Okay. Okay. And so that's what this topic is going to be about. Why? And there are lots of reasons why. Some financial, some medical. Okay. And if we're looking at healthcare as a nation in a way that we need to start solving our problems better economically, okay, we need to start looking hard at this and making some decisions. So this is something that I know it's not very popular from a doctor's standpoint and I sit and talk to doctors about this topic a lot in South Carolina when I go around. And we'll talk more about through this presentation. But that's what this presentation is a little bit about. So questions, raise your hand. I like involvement in my presentations. If you ask a good question and have, I've got some t-shirts out here. I'm really big on rewarding people for good questions. So let's be involved and let's have a good hour and a half or so and then we can answer questions at the end. So anyway, does everybody know what physical therapy is? Okay. Everybody has a general idea. Historically the American Physical Therapy Association has done a very poor job of communicating to the general public what it is we do, okay. Everybody thinks they know what a physical therapist does, but they probably know about that much, okay. Because physical therapy is involved in a lot of different things, okay. Inpatient, outpatient, acute care, they're now putting physical therapists in ERs. Things like that that nobody ever knew that we had a foot in, we do, okay. So I think that is important. I try and be simple in how I describe physical therapy because it is so broad, okay. Very general, brief, what I tell people is that I am a neuromusculoskeletal specialist, okay. That's what I am, okay. Another one, PT is the art of returning, maintaining, and enhancing an individual's physical function. Broad, right. That can happen in the hospital, that can happen in an outpatient clinic, that can happen in somebody's home, that can happen in the ER, it can happen in a gym, it can happen in a field. Doesn't have to be any particular place that that happens in and that's what we do. As physical therapists, I've treated patients in their home, I've treated patients in my clinic, I've treated patients in the hospital, I've treated a woman during COVID in her front yard, I've treated another woman during COVID in her garage. I mean it doesn't matter, we would go to them, they would come to us, we would treat them, okay. And we would help them either improve their function, maintain their function, or enhance their function, okay. And everybody always asks, does my insurance pay for it? Absolutely it does. We are part of the medical model, we are inside the medical model, we are not outside of the medical model like maybe chiropractic or some of these other, you know, acupuncture and things like that, and some of the insurance are actually paying for some of those things now. But we have been within the medical model for years, okay. And so everybody says, well my insurance doesn't pay for it. Well, you may have a high deductible, okay, which with a high deductible, guess what? Your insurance doesn't pay for anything until you meet that deductible. That's why it's a deductible, okay. So, oh my insurance doesn't pay for it. Well no, you've got a high deductible. If you admit your deductible, yes, it pays for physical therapy, okay. So understand that. Most common diagnoses we treat, okay. This is a loaded question, and I hate this, I hate this slide, because back pain, headaches, migraines, knee injuries, balance gait, shoulders and weakness, right. That's what we treat. No, that's not all we treat, okay. We just pigeonhole ourselves with what we can treat. I like the broad spectrum problem. I'm a neuromusculoskeletal specialist. You have a neurological problem, guess what? I treat it, okay. You have a musculoskeletal problem, guess what? I treat it. I tell everybody I treat anything from TMJ to hammer toe and everything in between, okay. How many people know I get referrals from dentists to treat jaw pain every day, okay. I get referrals from dentists, okay. We treat that. Nobody knows we treat that, but dentists do, okay. How many people know that we treat vertigo? ENT. I get referrals from ENTs every day. We treat vertigo. We treat benign proxismal positional vertigo. We treat labyrinthitis. We treat vestibular neuritis. We treat all these balance disorders, inner ear issues, stuff like that. Nobody knows we do that, okay. There's a lot of stuff out there that I don't think people understand what PTs do to help. One of the things that we kind of coined at Elite was a couple of phrases that we use kind of on social media and it's kind of become a joke. We go, yeah, we treat that. Yeah, I can help that. Like just something with some random diagnosis out there and Elite goes, Elite Integrated Therapy Centers. Yeah, we treat that. People don't know. So common diagnoses, we treat anything and everything. It is really boundless. I will tell you, I get referrals from doctors that send the patient to me and go, Paul, I really don't know what's going on with this guy. Will you take a look at him and see what you think and call me back? What diagnosis is that? I don't know. Will you look at him and see if there's anything you can do to help him? I will tell you I probably get two of those a week. Yeah, don't we? We need an ICD-10 code for that. That's what she said. Yeah. I don't know. You figure it out. But, and look, I work hand in hand. I talk to ENTs probably on a monthly basis. I talk to dentists on a monthly basis. I talk to neurologists probably on a weekly basis. I talk to orthopedists probably on a weekly basis. Okay. What are you seeing? Here's what I'm seeing. Here's what we're doing. What are you doing? Great. We're working together to try and help our population or our community is the way we look at it. Okay. Let's get back to the reasons why physical therapists should be first in line. Okay. We're going to go through kind of five reasons. But again, we're getting back to that point of why insurance companies are saying not yet. Let's not order the MRI just yet. Let's send them to have an evaluation, a little bit of treatment, and let's see what happens. Okay. And you're exactly right. The insurance company's trying to save money. Okay. But the research is out there. There's a reason why they're doing it. You just can't say, well, it's all about the money. They have to have some medical backing that says percentage wise this has got a better percentage chance of helping than what? Does an MRI help anything? Does it help? No, it's a diagnostic tool. Okay. And we're going to talk a little bit about MRIs a little bit later and how sometimes they can be misleading. Right. More detail later. But so in this scenario, let's get them to a physical therapist. Let's evaluate them, treat them, and see if they start to show some improvement and get better. If they do, great. I've just saved $2,000. $2,000 MRI, which does nothing to treat the patient, okay, is the equivalent of 20 plus physical therapy visits. Anybody ever had a bout of physical therapy? Wow. Okay. How many visits did you typically go to see a physical therapist to get help? Six times. I heard a couple times a week for a couple of weeks. Stuff like that. So here's the typical national average. How many visits of physical therapy on average does somebody get per bout? Twelve. Twelve. Okay. So roughly, what's that? Does it depend on the state? I think that's national average. I don't think it, yeah, I don't, I don't, I don't know. I think that's national average. But so twelve visits, $1,200. That's less than MRI. I just saved whoever $800. Multiply that by everybody in this room. Now we're talking real money, right? So understand that. Okay. Number one, expedited recovery time. Okay. Another thing that we want to try and push and this is insurance companies and I think the general medical research says if you can treat something quicker, it usually takes less time to get better, right? You have an infection and you don't go see your doctor. You have a UTI and you don't go. What happens? It gets worse, right? All of a sudden UTI turns into a kidney infection and whatever and it just starts backing up and more along your septum. Longer you got it, the worse it's going to get. But if you can get treated early for the UTI, you're good, right? Okay. They're finding the same thing with low back pain. Bow to low back pain. Every year leaves fall. I go out and rake leaves and ooh, I'm not as young as I used to be. Okay. And I go into work and I go, hey, come over here. Work on this a little bit and I'm better. Okay. But if I didn't have that way of getting in and seeing somebody, I may be like this for a while. What happens when I'm like this for a while? I start having other stuff going wrong, right? I mean, so voila, the quicker we can get in and get treatment, the less it takes for me to get them better. Okay. I have a patient who all of a sudden injures their back raking leaves and I get them in in the same week that they injured their back. That same day I get a patient referred to me who has had chronic low back pain for over a year. Who's going to get better quicker? The acute guy, right? It makes total sense. Okay. And then we go back to chronic issues or acute issues. Well, obviously if you and you all see patients all the time, which patients are harder to manage? The acute ones or the chronic ones? Okay. So you see where we're headed. All right. Nerve changes, muscle atrophy, all this stuff, basic science. You put somebody in bed, what happens? 24 hours they're going to lose a certain percentage of muscle mass right off the top. They're already atrophied. We know that research. That research has been around for ages, right? That's probably the first thing you learn. That's true. How come we don't tell people bed rest anymore when they throw their back out? Because of that. That's it. In one fell swoop we realize we're doing more damage than good when we tell them just to lay around and you need to just lay. You just need to have bed rest for a couple of days. Any doctors still doing bed rest? No. They shouldn't be. If they are, they're really old. Okay. They are really old. All right. So there's reason number one. Expedited recovery time. Okay. Again, we go back to oh I think that patient needs an MRI. Okay. So I threw my back out, raking leaves. How long did it take for me to get in to see the doctor? Okay. Two weeks? Three weeks? I get in to see the doctor. The doctor goes, you need an MRI. How long does it take me for to get an MRI? Okay. So now we've been however number of weeks, months, whatever. We've got no treatment and we're waiting on a test that is not going to help us. Okay. We're waiting on a test. We're wasting time. Right? So understand that. We'll get more in to it. Improved results. If a patient is seen within 14 days of onset, this is PT research, their recovery success rate is 93%. Man, if I could get everybody who ever has anything neuromusculoskeletal in my office within 14 days of onset, I'm pretty good. 93%. Okay. How do we streamline that process? You know how we streamline that process? It's called direct access. You ever heard of direct access for a physical therapist? It means we don't need a script or a referral from a doctor to see that patient. If I can educate the general public to say, hey, you threw your back out raking leaves, don't call your primary care doctor, call me. I will get you into the office within 24 to 48 hours and we will start evaluation and treatment. You're in with under 14 days and I'm 93% successful. Yeah. What's that? I do not. No. Not in the state of South Carolina. Not in the state of Louisiana. Not in the state of Pennsylvania. New York does, okay? So there's direct access legislation circling around. A lot of states have gone this route, okay? But some states are still holding out, okay? I get it. But in South Carolina, this is the law, I can evaluate anybody in this room, treat them for 30 days without a doctor's referral and your insurance will cover it. Now, if I wanna go beyond 30 days, I need a referral, I need a prescription. And so what I do is, you come into my office, Paul, I hurt my back raking leaves. Great, who's your primary care doctor? Dr. Smith, perfect. I'm gonna send him my report because I wanna work with your primary care doctor. I don't wanna do this alone. I work with doctors all the time. I want them to know, hey, he came to me, low back problem. I did this, I did this, I did this. If he comes in soon enough, 12 visits, it's probably not gonna take 12 visits. It's probably gonna take four or five because you're acute, I can get you in, you're better. Paul, I'm good, I'm going back to work. Great, call me if it ever happens again. Send that off to the doctor, whatever. Doctor then knows, wow, you helped him with four visits. He basically spent $400. No MRI, no X-ray, no injections, no opioids, okay? Voila, that's what we're trying to do, save time. Here's the question, yes. Oh no, we verify all their insurance before, tell them exactly what their deductible is, what their out-of-pocket cost is, what their co-pay is, what their co-insurance is before we even see them. Yeah. Everybody's leaving Michigan, right? Right, okay. Yep, you're exactly right. What size T-shirt do you wear? That's a great question. What size? Medium, you're not a medium, don't give me that. I'm gonna give you a small. I think these run a little big. Let's try, let's see, hang on. Is that you? That'll work. Small, it's a good T-shirt. She read my slide, this is exactly, she read my slide. Physical therapists are trained to screen for serious medical problems, okay? This is the great question. The question is, well, great, you have that guy come in, he's got low back pain, he has no mechanism of injury. Yes, ma'am. How do you know he has cancer? Okay, all right, and he has no mechanism of injury. How do you know he doesn't have cancer? How do you know he's not having something major medical go wrong? Like a tumor, yeah, okay. Does the MRI still find that? It will, yes, absolutely. What she said, what'd you say again? MRI can find that, yes. Sure, absolutely. So she's basically saying, you know, the MRI's gonna show what that is and that's why the doctor wants an MRI. But here's the way we look at it, and this is, again, this is statistics and this is research and this is what it shows. Number one, I'm trained in screening patients for do they need an MRI, okay? I cannot. But if you came in my office and said, hey, I have low back pain, and I go, okay, how'd you do it? I don't know. I woke up, you know, the other night and I just had low back pain, okay? How old are you? I'm 55. How old are you? 60, okay? He looks 55. He looks 50, but I gave it to him. Great. Do you have any past history of cancer? You do? You don't, okay? So no past history of cancer. Have you lost a lot of weight in the last three months? More than, right? And so you're going through your red flags, right? No, no, your history. Yeah. So everybody know what red flags are, okay? So you're screening them, right? Well, so what are you looking for with red flags? You're looking for something to raise the hair on the back of your neck, right? I mean, that's what you're looking. And you're not looking for just one, okay? What do they call it? You're looking for a cluster. You're looking for a cluster of red flags that kind of like make you go, hmm, this doesn't sound just like low back. And then guess what I do? I pick up the phone and I call your family practice doctor and I say, hey, I've got Jim in the office and I was just talking to him and going through the history and I found a cluster of red flags and he's got some low back pain and he's got this and he's got that and he's whatever, okay? I think he would probably benefit from an MRI. What do you think? And the doctors, usually the doctors that I know will say, yeah, that doesn't sound good. Tell him to call me, tell him to get into my office and let me evaluate him. Perfect, done, right? That's what it looks like. Now, let's take cancer off the board, okay? You come in, Paul, I did something to my back. Yeah, I was raking leaves, okay? Any history of this? No, any history of that? No, this, that, no red flags, no yellow flags, okay? I get into the evaluation and we find neurological changes. We find diminished reflexes. We find radicular symptoms. We find muscle weakness to the lower extremity. We find drop foot, stuff like that. Guess what that means, MRI, okay? Voila, hey, Dr. So-and-so, I've got Jim in my office and he's got, true story, I had a nurse practitioner that I know called me up, said, Paul, I've done something to my neck. Can you look at it? Yes, come on in. Got her in, looked at the neck. Everything that I found told me she had a cervical disc herniation. She had reflex changes. She had radicular symptoms down the arm. She had tricep weakness. She had dermatomal changes. She had a positive Hoffman's, which is a positive upper motor neuron test when the disc is compressing on the cord. I said, who's your primary care doctor? I need to call them. And she said, no, no, no, no, no, no, no. Don't do that. Just put me on traction. I think it can get better. No, no, I'm gonna call you. She basically would not let me make the phone call. I finally called her primary care doctor with her in the room and I said, I've got so-and-so here. You know her. She needs an MRI. Here's why. Here's what I found. He said, hand the phone to her. I handed the phone to her. He said, you are not to come here. You are to leave and go directly to the radiology department and get an MRI. They'll be waiting for you. Hung up the phone. She went there. The next day, she had emergency cervical surgery to remove the disc that was compressing on the cord. So that's how this works. That's how it should work, okay, and that's how it usually works. But this saves both you and the patient time. We, as physical therapists, are able to get patients in quicker than a primary care or especially a specialist. I mean, I don't know what the wait time at a neurologist's office is. Now it used to be six months in Greenville. What is it now? Yeah. Right. What do you mean? For direct access? So direct access has been around as long as I've been in private practice, so since before 2006 in the state of South Carolina. So it's a matter of choice as to whether I accept the referral? She asked if it's a matter of choice of whether I accept the referral. So yes, I mean, we do both. I don't limit anybody to come into my office. If a doctor feels like they need us, great. If the patient feels like they need us, great. I will see you direct access for 30 days. I will see you with a script from a doctor. The way we train our therapists is you're almost an independent practitioner. Whether you have a script or not, you are evaluating that patient and you are treating them as you see fit. Now, if I have a prescription, I have to keep the doctor in the loop. I wanna keep the doctor in the loop, even if it's direct access, because I'm trying to build a communication with that doctor and obviously, we're on the same team, so I wanna make sure that that communication is there. What did I do with my? T-shirt got in the way. How valuable is your time? So this goes back to the question about serious pathology, and this is statistics, and statistics sometimes helps you, sometimes it hurts you, but only about 1% of the population will have a serious pathology requiring imaging, while a large amount are within the scope of physical therapy care. So out of 100 patients who come to me with direct access, by direct access, and I evaluate them, statistics tell me only one of them is gonna have a serious pathology that I have to refer out to an MRI. So that's, you know, and have I seen some of those? Yeah, I've probably seen thousands of patients, yeah. I've caught some of those and had to send them out. I've evaluated patients and called their doctor, and they called me a few weeks later and said, yeah, I got diagnosed with cancer. I've sent patients out, like that nurse practitioner who had a disc herniation. I've had patients that I evaluated and I sent to a neurosurgeon in Greenville, and they had low back surgery soon thereafter. It just depends. But statistics show not a lot of them need it, okay? So there are other examples of that, and I don't, the only other example I know in physical therapy, and y'all probably have some examples of that in your specialties where you are. Has anybody ever heard of the piriformis muscle, okay? The piriformis muscle in the buttocks, okay? Anybody ever heard? PT for it. You had PT for it, okay. Well, here's, right, so. Well, I gotta take a nap. Ha, ha, ha, ha, ha, ha, ha, ha, ha, ha, ha, ha. Yep, yeah, yeah. So have anybody ever heard of piriformis syndrome and all that stuff, okay? Well, here's a little bit of PT knowledge and a little bit of research and statistics on that. The piriformis gets a lot more credit for being the problem than it should, okay? It is rarely the problem, okay? So I hate to be the bearer of bad news, but some doctors get, oh, it's the piriformis. You got pain right here in the butt, right? Yeah, that is piriformis, and ooh, I take the, ooh, yeah, that hurts, and that's tight, and yeah, whatever. That's the piriformis. No, that's sciatica. That's a low back problem, until proven otherwise, you're treating the wrong thing, okay? It is very rare to have true piriformis syndrome, okay? But that's what we see. And so, as a young therapist, we're taught, oh, it's the piriformis, yes, I know that muscle. It's right there, and it's right there. So it's gotta be the piriformis. No, that's ridiculous pain going into the buttocks, and if it gets worse, it goes down your leg. It's sciatica. It's kind of the beginnings of sciatica, okay? So understand, that's an example of maybe statistics helping us out with diagnosing a problem, okay? I keep losing this. And the last one is saving money, okay? Less expensive than medical imaging, less expensive than pain management, reduced chance of further, more expensive treatment if handled immediately, okay? So those are, yes? So it's money that you save throughout the process. Yeah. Is that, I could save myself a lot of money at one time, not have to be given two prescriptions, and just be a physical therapist, and have it on my way to be later, when it grinds out pretty much, and then we're talking about $2,000, $200 later. Yeah, that's, and that's, we'll go more into it, but that's what the research shows, okay? And I think it's a change. And look, the problem, part of the problem, I think, with changing healthcare, if you will, how many of you work for doctors who are over the age of 60? Okay, how many work for doctors who are under the age of 60, but above 50? Okay, how many work for doctors who are under the age of 50 and above 40? Okay, how many of you work for doctors who are under the age of 40 and over the age of 30? Okay, do you notice a difference in how they practice? Okay. So they're teaching this in medical school, but the guy who's 60, I didn't teach this in medical school, and he probably hasn't heard it, and if he has heard it, he don't like it. So he's gonna resist it, and I get it. I don't have a problem with that. I had a very interesting conversation about this with one of my family practice doctors in Anderson, South Carolina. He called me up, irate. Paul, I've got this patient in my office. I wanna get an MRI on them, and the insurance told me that they cannot approve me to have an MRI until physical therapy has failed. And he's, couple other choice words, and this is BS, and voila, and then, and I said, you know what? You're exactly right. I said, but let me tell you, send that patient over, I will evaluate them. And I told him, I said, here's what I'm looking for. I went through my spiel, red flags. Any neurological changes, any dermatomal changes, reflex changes, muscle weakness, all this stuff. If I find any of that in my evaluation, I will go to battle with you against the insurance company, and we will get the MRI. Patient was in my office in 30 minutes. I evaluated him. He and I got on a conference call with the insurance company, and the lady says, well, physical therapy hasn't failed yet. I said, it sure has. It just failed. I just evaluated her, it has failed. She needs an MRI, approve it. We got it approved, and everybody was happy. Now, what if it, what if I didn't find neurological problems? I would've treated her, and I would've had to go back to the doctor and say, give me a couple of visits. Listen, I didn't find anything sinister, okay? Nothing's raising the hair on the back of my neck. I didn't find any clusters. I didn't find anything wrong. Give me five visits. If I can't make a change in five visits, I'll declare I can't, you know, it's failed. I don't have a problem with that. But if at five visits, she comes to me and says I'm 40% better, we're gonna keep going, because I'm helping her. So as long as we're on the same page, and I have to have that, I have that conversation multiple times with the family practice doctor or an internist who's over the age of 55, because they don't know the research. They don't understand, they don't like it. They don't like being told no. I don't like being told no. I get it, okay? But that's what we've gotta understand, okay? Seeing a physical therapist within 14 days of onset of pain can minimize healthcare costs by 50%, okay? It's huge. Using PT as the first treatment strategy rather than an advanced imaging referral results in 72 percent fewer costs for the patient within the first year. That's huge. Okay. And that's and look and that's why and don't get me wrong I don't want to I don't want to say that I agree with everything the insurance companies do because I don't. But the research is there. I'm sorry. Maybe better. I don't agree with all the stuff that the insurance companies are doing. So I'm not in their corner. But for this particular instance I do believe that it does coincide with the research and what is out there and that it is helping people faster and quicker and for less money. In this country we have a problem where we automatically go to the most expensive specialty or whatever when we have a problem. I've got got piriformis syndrome we're going to pain in my butt and I'm going to go see a neurosurgeon and the neurosurgeon is going to go. Why are you here. So we start here and then we start working our way down. We should start here and work our way up. Right. I mean I just think that makes more sense but we're stuck in. Oh well I got to go see a neurosurgeon. I need surgery. Wait a minute. You got pain in the butt. We need to. Yes ma'am. I think and this is. Physical therapy is more than just exercise. And I think that's the main thing and that's kind of and again this goes back to what is physical therapy. So what is physical therapy to me may be different to another physical therapist standing right here. Right. You may find and this is where I think everybody needs to find a physical therapist in their area that they like and they trust. OK. And that may be different for you. It may be different for you. But I try and tell my doctors like my therapist are trained through residency. They're board certified and they're fellowship trained. They're the highest trained therapist in the state of South Carolina. We have more fellows working at elite integrated therapy centers than fellows in the rest of the state. OK. So we have the brightest. OK. We believe that therapy is a lot different depending on the problem. And I was having this conversation with the therapist the other day and I've done a presentation here at the M.A. conference on dry needling. Have you ever heard of dry needling. OK. OK. Well I will tell you it is not everything. OK. It is a tool in my toolbox that I pull out probably 5 to 10 percent of the time to treat a specific problem of my patient. Now I know therapists in my zip code that if you go see them you're getting needled. They're needling 100 percent of the population. I don't agree with that. This is a whole other. Yeah. It's a dry needling. It's not injections. You're basically inserting like an acupuncture needle into the muscle to treat dysfunction. Yeah. Yeah. Yes. Exactly. Yeah. No dry needling alone is not the answer. Dry needling in conjunction with some hands on treatment and the right exercises and the right plan is great. OK. Yes ma'am. I love I have no problem with that. I actually work with an acupuncturist who was trained in China. Her name was Hong Zong a lover to death. It's a different philosophy. It's totally different. Like I don't see the I don't see the the problem sharing patients. Hong looks at a patient holistically. She is a doctor in China. OK. She came to the state she utilizes and treats patients through her mode of treatment which is acupuncture. And but she treats that patient holistically with needles and and whatever zones that they do. Totally different than my approach. My approach is more direct. You have pain in the piriformis muscle. Great. Then I'm going to put a needle in that piriformis muscle and we're going to try and activate that piriformis muscle and calm it down. OK. Totally different philosophy than acupuncture. She's treating systemic problems with acupuncture. I'm not treating systemic problems. I'm treating muscular problems. OK. So I don't I love it. I've been to her like I go to her for stuff. Yes. Similar. OK. So actually and this goes into the history of dry needle which is my presentation. But so the first trigger point injection back in the 40s and 50s was dry needle. They didn't do injections. OK. Robert Kennedy had historically a bad back and he went to a doctor. I can't remember the name but it's in my presentation. He went to a doctor in Manhattan who did dry needling on his back way back when and it helped him with his back problems. The same doctor went on and insurances finally said we're not going to pay for dry. Michael pay for it. You're not really injecting anything. We're just not going to pay for it. So the doctor said all right. No. And I'll inject saline. Trigger point. Then the insurance company says we're not going to pay for saline. Why would I pay for saline. I'm not doing anything. OK. Well then we'll add some marking. Trigger point injection. So that evolved into a trigger point injection. But the same doctor in Manhattan said I got better results with just a dry needle. That was his. I don't know. He's long dead I think. But in his research and in his stuff in his documents he said I actually had better results with a dry needle than I did with saline and the side effects of a steroid or side effects of an injection. So years later P.T.'s looked at that research and we said well this we feel like this is in our scope of practice because we're neuromusculoskeletal specialists. And so we started dry needling and insurances didn't pay for it. They still don't pay for it. We charge cash. You come in you we we needle two muscles. You pay so much more than two you pay a little bit more whatever but we utilize it within our practice. But again it's a tool. It's a tool. It's not the answer for everything but it does help a lot of people. OK. Yes. My hands. I'm a hands on therapist. I use massage and manipulation and mobilization and whatever to help that patient that joint or whatever move better or muscle fire better. So I'm I'm a hands on therapist. We call it a manual therapist hands on manual therapist to a lay person they go Oh you've got a manual. No I use these right. So I've gotten away from calling myself a manual therapist. I'm a hands on therapist. Here are some more interesting statistics and this is kind of dealing with MRIs. OK. And this is actually research. This is stuff I pulled. There's a there's actually a pretty large following of how MRIs can be misleading. OK. And this is something I did. So I go and present there's a there's a and med hospital has about thirty five forty family practice residents that are doing their residency through and med. So and med allows me about 10 minutes to come in and present to the residents every year one time a year. And I've always gone in there and tried to present something. I didn't feel like I was just getting any traction with them. So I decided that I was going to do something a little bit different. And so this one year I went in and I presented two MRIs. OK. And I said here's two MRIs for you two MRIs for you and there was MRI reports and one MRI report was you know basically read neurologist read it and basically said unremarkable MRI slight degenerative changes to the lumbar spine. And then the other MRI showed disc bulges a compression fracture spondylolisthesis all this just just gnarly stuff of the low back. And I said I have one question for you. OK. Which one of these patients has low back. And they were like oh this is easy. This is totally easy. I got guys got a fracture he's got disc bulges he's got all this stuff. So OK. I said you're wrong. I said the MRI on the right is my MRI. I have a disc herniation I have a compression fracture I have a spondylolisthesis that I had from when I was a freshman in college and played college football. I had all these injuries and just on a whim I went got an MRI the year before just to see what was left what was going on and that was my MRI. Now I work out I run I swim I jog I'm very active I have no problems. The other MRI which is unremarkable in disc degeneration is a patient in my clinic. So what does that tell you. You can't just look at the MRI. And there's actually research out there that talks about that and we've talked I mean I talk about that they they brought in 100 MRIs and this is the film put them up on the wall. They had doctors come in and look at every single MRI. So they're over there studying the MRI. The question is who has low back pain who doesn't. They went in and looked at all 100 MRIs. The doctors were like this you know this person that person yes this person knows it went through. None of them had back pain. It was all just a farce. They just took people off the street did an MRI. You have back pain. No great. We're going to do an MRI. They put it up on the wall. Doctors were like oh yeah they got back pain. No. None of them had back pain. Okay. What they should have done. How many of these are surgical. How many of these need injections. How many of these need MRIs. Right. None of them. They don't even have pain. There's nothing wrong with them. Okay. Painful shoulder. Okay. I got pain in my shoulder and I go get a MRI. 92.7 percent with a painful shoulder have a rotator cuff tendinopathy. You know what tendinopathy is. Tendinitis. Right. The chronic tendinitis. Okay. Non-painful shoulder. 88.6 have rotator cuff tendinopathy. Is that even measurable difference. Not really. Okay. If I did an MRI of your shoulder do you know that tendinopathy is going to show up. Anybody over a certain age. It's going to show up. Yes. Okay. So labral pathology. Everybody know what the shoulder labral is. Labrum. 91.9 had a labral. 89.4 had a labral pathology. No pain. So is that the problem. Is that the problem. If it's that close are we making a mountain out of a molehill for a labral pathology. Okay. AC joint pathology. AC joint. Right here. Chromioclavicular joint. 43 percent 41 percent. It's not that different. Okay. If you did an x-ray of my shoulder you're going to find degenerative changes to my AC joint. Yeah I'm 50 years old. I played college football. Tell me any joint in my body that doesn't have arthritis in it. I had a neck issue a couple of years about 15 years ago. I woke up one morning and had nerve pain going down my arm and I called my family practice doctor. I said I've got neurological changes. I've got reflex changes. I've got muscle weakness. I need an MRI. Got me in the next day for an MRI. Oh no. He called me in the office. He says have you ever injured your neck. And I said can you be a little bit more specific. He said have you been in a car accident or hit your head. And I said yes. Every day for four years when I played college football. Why. And he was like okay we're getting a neck MRI. So we got a neck MRI. MRI was fine. Showed nothing in my neck but I still had this nerve pain. Okay. Then we thought because then you're thinking this is not good. This doesn't make sense. And there's a rare case of a pathology or a tumor in the underarm that sometime can touch a nerve and cause called a Pankos tumor. And so we got an MRI of my shoulder. It came back fine. Okay. So now I've had two MRIs. That's four grand. I haven't even been treated yet. Well I'm getting treated by my therapist. But we never found out what the problem was. Okay. To this day I tell everybody I had spontaneous nerve death because I literally lost my arm atrophy down to the bone. But now it's back and it's fine. And just came back. It was just spontaneous. Dead. I don't know why. It just happens. And it does happen in a certain percentage of the population. You'll just have a nerve will just die. Done. Just demyelinate. Come back. And I think that's what happened to me. But again two MRIs we found nothing. Okay. Multiple guidelines agree that imaging should be avoided within 30 days of diagnosis or without exhaustive conservative options like physical therapy first. Exactly what we're talking about. A 2019 study of 2.5 million patients with new back pain among non-surgical treated patients. 98.8% of total patients. So 13.6% received physical therapy first. Cost of care was $509. 32.3% had imaging within 30 days of diagnosis. Cost of care $1,245. 35% had imaging without or before PT. Again increased cost. Okay. And probably slowed down the process of getting that patient in. Okay. Which then affects probably the cost of care on the PT side as well. Asymptomatic individuals. Okay. 37% of 20 year olds have disc degeneration. Okay. I was 18 years old. I was in college. I was playing college football. And I started having some low back pain. They sent me in and they said oh my God. You've got disc degeneration. Okay. I'm 18. I don't have any medical background or anything but maybe them strapping 400 pounds on my back and making me do squats probably might have had something to do with it. Right. 96% of 80 year olds have disc degeneration. So what do we get out of that? It's normal. It's normal aging. Okay. Discs are made of water. What happens when we age? Everything dehydrates. It starts to squeeze. It starts to squish. It starts to dry out. Welcome to normal aging. Okay. Is that the problem? How many patients? I probably get 10 patients a week with a diagnosis of disc degeneration. I don't know that that's a problem. Okay. I probably don't even tell the patient what that is. I'll probably tell them it's normal because their doctor might have said oh you've got disc degeneration. Sounds terrible. Right. I have to talk them off the ledge and say that's normal. That's not and I go in and I evaluate them and I say no this is moving wrong and this is moving wrong and we're going to fix this and we're going to correct that and we're going to do this and you're going to start to feel better. It has nothing to do with disc degeneration. I'm not going to automatically create space between your discs. That ain't going to happen. Anybody who tells you they can, they're lying. Okay. All right. Avoid surgery and opioids and this is a whole other topic. Right. Okay. How many people have seen back surgeries not turn out the way they expected? Okay. How many people have seen opioid addiction up close and personal, okay? Neither one of those are pretty if you've ever experienced it, and I don't wish that on anybody. I mean, I've seen my fair share. I don't care to ever see that again, and I'm afraid I see it every day. And so anything I can do to prevent them from going down those paths I think is a positive, okay? How many have ever seen an infection from a surgery or an injection or whatever, okay? And I used to get on my soapbox and talk about infection and stuff, and here I am doing dry needle. Okay, well, there's a chance of infection with dry needling. That can happen, okay? I haven't seen any. Will I? I don't know. I hope not. But we know that we're effective at avoiding opioids, avoiding surgery. We had a great surgeon in Greenville, and he doesn't do surgery anymore, but he's very well respected. And what made him so special as a neurosurgeon is that he actually believed in what we did. And he's, you know, again, top rung of the ladder, right? Patients would go to him first, I've got low back pain, and he would say, nope, you need to go to this therapist. They need to work with you for a certain period of time, and you're going to get better. A high percentage of them will get better. But if you don't, they will send you back to me, and we will discuss surgical options. That made him the best surgeon in the upstate of South Carolina, okay? I had a patient, he sent to us, and you talk about somebody, this guy had back pain, neurological symptoms, dropped foot, you name it. He was a surgical candidate. MRI was performed, huge disc herniation, touching the nerve. I mean, I sent it to this doctor. And the doctor said, nope, we're going to go with physical therapy, and we're going to try it. And I worked with this guy for, I don't know, six to eight weeks, and we did everything. And everything we tried, because we both knew that he didn't want to have surgery. We don't want to go down that path, okay? And I didn't want him to have to go down that path either, so we did anything and everything. I was dry needling, I was manipulating, I was doing anything and everything I could do. Anyway, he wasn't getting much better. And so I called up the doctor, and I said, you know, I'm just not seeing much change. I said, I'm afraid we're going to have to go and do something. He went in, scheduled surgery, went in to have surgery, went in, anesthesia, he's in pre-op, neurosurgeon walks in and says, wiggle your toes for me. And the guy wiggled his toe. And the guy said, we're not doing surgery today, you're getting better. Called off surgery. We've never had a neurosurgeon who calls off surgery after they've been given anesthesia. Nobody. Okay? Guy came back, we continued to work for him, got better. Crazy. Crazy talk, right? Yes, ma'am? Did I ask you a question? So, I have one more question. I'm sorry. Go on. You said, when you get born, you're there, when you get over, I heard you crack. Uh-huh. During the day. Yep. And my doctor knows all my problems. I'm sorry to hear that. And so I don't need your narcotic problems. I'm sorry to hear that. I'm sorry to hear that. I'm sorry to hear that. I'm sorry to hear that. I'm sorry to hear that. I'm sorry to hear that. I'm sorry to hear that. I'm sorry to hear that. I'm sorry to hear that. I'm sorry to hear that. I'm sorry to hear that. I'm sorry to hear that. I'm sorry to hear that. I'm sorry to hear that. I've done it many times where people have cracked. Okay. And, um, that's usually... So, you had a compression fracture. Well, I've done it. People have cracked. Gotcha. Okay. I've done it as well. And, um, you know, I have lots of those problems. Right. But, it's a very simple problem for me. Well, I've never touched a narcotic. Right. Good. Yeah, yeah. I think we need to avoid those at all costs if we can. Obviously, they're there. I mean, my nephew was playing football last night and broke a tib-fib fracture and he's in the ER and he's screaming bloody murder and I was like, okay, we need to get him something. Like, there's a time and place. Yeah. But, I just think, you know, for chronic stuff, like, you gotta avoid it. You gotta do the best you can. Yes, ma'am. I think it's fine. If it works, it works. If it doesn't, then it doesn't. But, it's not gonna hurt you. I mean, you can't get addicted to dye from tins, can you? I mean, I don't know. Unless you got a pacemaker on, you know, it's not gonna hurt you. I don't know that there's any bad side effects. Yes. Yeah. No. Yeah. Yeah, yeah. So, rule of thumb for rotator cuffs, and this is kind of the way I was taught, and it's kind of Cyriac's philosophy. And, it depends on the size of the tear. It depends on the place of the tear, things like that. But, if it's a 50% tear, I was always taught that's rehabbable until proven otherwise. So, you know, stuff like that. But, I evaluate those all the time, and a lot of times with the proper mechanics, you know, if you got somebody who's just forward shoulder, forward head, and they got a small rotator cuff tear, yeah, they're gonna have a lot of pain every time they raise their arm. But, if you correct their posture, and all of a sudden they're, oh gosh, that feels better. We didn't really do anything to the rotator cuff. All we did was change their posture. And, that takes stress off of the rotator cuff. Yes, ma'am. Yes and no. Soft wave therapy. Soft wave therapy. Uh-huh. Mm-hmm. Okay. Okay. Okay. I don't know much about it. It's something, if it is out there, I would say the research is preliminary, because I haven't seen much of it. You know, I go all the national conferences. I'm leaving to go to the private practice section here in a week in Denver. And, they roll out all these new laser treatments, and all this stuff. And, we review the data, and we review the research. And, a lot of that stuff is just not proven yet. Now, if it helps, great. But, as far as, you know, is insurance paying for it? No, because it's not proven. You're probably paying cash. And, so, you know, I tell patients. Patients will come to me and say, hey, you know, so-and-so's got this new laser. And, I'll go, well, if you got the money, and you want to go down there and drop a grand, and let him laser, and it might work, it might not, then have at it. But, you know, or if you want something that Medicare's going to pay for, and has been tried and true over the years, maybe we should stick with that. Yes, ma'am. Okay. So, you're talking about statistics, physical therapy, and you spoke first. Why are there not more physical therapists with the treatment in clinics? Yep. There are only 50,000 payments. And, I don't understand if they know, and the statistics show, that physical therapy, in conjunction with, or, you know, maybe it would be a short term, and if they actually were able to do it. Sure. Do you work for pain management? Pain? Okay. Sure. Yeah. So, I, yeah. So, I have great relationships with the pain doctors in the upstate of South Carolina. And, I have great relationships with the pain doctors in the upstate of South Carolina. And, I have great relationships with the pain doctors in the upstate of South Carolina. And, I have great relationships with the pain doctors in the upstate of South Carolina. And, what I tell them, and you said exactly what they tell me, patients so and so came back in and said, you hurt them. And, I say, okay. I said, well, she did not express to me that I hurt her. And, I will tell him. Like, I don't hurt patients. If I did something to hurt a patient, they need to tell me. And, I will not do it. Okay. I don't hurt patients. And, so typically, and these pain guys know me well enough to call BS. And, you know, but it took years of having that relationship to say, like, look, really? Like, you know, okay. Well, the same lady came and told me that you hurt her. I know you well enough that you're not hurting people. Like, come on, you know. And, so, and I said, you know, hey, let me guess. She said, I hurt you and you need to write her another prescript for lower tab, right? He's like, yeah, how'd you know? I don't know. I don't know. It's amazing. Yes, ma'am. What about people that are chronically, you know, chronically in pain? Yep. Like, when I have a patient who's programming constant, you know, a routine program. Yep. If I don't teach it to people, can you shut off the pain receptors? Because they're going this way, but not that way. Yep. So, there's. So, this is a whole other two-hour presentation. And that is, that is, that is new research. You're exactly, she's, she's talking about stuff that is brand new to the industry. Visual imagery, things like that as far as chronic pain. It's, it's still new. It's out there, but it's new and it's, it's, it's, it's changing pain and what we understand of pain. It's turning it on its ear. And it's, it's great research. It's changing. It's ever-changing. Okay. So, Cleveland is kind of at the forefront. Now, the problem is, at least my vision of the problem is, what the Cleveland Clinic is doing is, is, is huge. But it's a lot and it's not getting reimbursed. It's, it's, it's a lot of, it's a lot of psych stuff. It's a lot of visual imagery. It's a lot of time. It's a lot of effort to try and change. I agree, I agree. But at some point, we got to make some, somebody's got to make some money. We got to make it profitable. We got to make it sustainable. And having a, me bringing a patient in and working with them for three hours on visual imagery and, you know, different things mentally rather than physically takes time, a lot of time, a lot of treatments, months and months and months of care. It's just, to me, I think we're going to have to streamline the process in a way that we can make it affordable. Well, that's what they're... So, not to go into too much detail, but what they're basically, their premise is that pain is no longer a mechanical issue, okay? And this is, this is hard. I don't know everybody's pain background or how you understand or how you think of pain, but if my ankle is sitting sideways, I'm probably going to have pain, okay? But there's new research that says pain is here. It is not here, okay? There are people, you go to a third world country and there's a guy walking around on the side of his ankle and he's been walking on the side of his ankle his whole life and has no pain. How does that work? That doesn't fit the mold. That doesn't fit the model. And so they took that and started looking at pain here rather than pain here. And it's different, you know, you talk about the TENS unit. The TENS unit is supposed to block the pain coming from the ankle to the brain, okay? That's old school pain science. They're now saying, oh no, you've got to block it here, not necessarily here. So it kind of turns our TENS unit on its ear. Does the TENS unit work? Yes, it works. Okay, well then why are we, okay, so it may be both, right? I mean, you know, so they're doing this research and they're trying to figure it out, but they're doing lots of visual imagery, doing lots of different things, but it's just time-consuming, and I think they've got to kind of zero in on it. Yes, ma'am? Yeah. Okay. Yeah. Sure. Sure. Okay. Sure. Yep. Well, and there is good research out there as far as, like, opioids will change the pain threshold in an individual based on chronic opioid use. So if you've got somebody who's, okay, well, they're taking one Lortab a day, well, great. Their pain threshold just went from here to here. So now, you know, they stub their toe. It didn't really hurt that bad, but now that they're taking Lortab, they stub their toe and it's excruciating pain because their threshold's down here. Well, then two Lortabs and three, and then all of a sudden everything hurts. Well, then how do you get them back to here? You just don't stop Lortab, and it just automatically comes back up. They're stuck, okay? So there's research on that, too. Yes. Yeah. Yep. Mm-hmm. Yeah. I've worked with doctors and actually put patients into rehab to get off of stuff. Yeah. Okay. No, no. No, it depends. No, it depends. Saline, some lidocaine, other types of medication. Say that. Yep. Yeah. They want to get paid, so they're usually injecting something these days. And we do it. We just do it for cash. We just, you know. Cupping is not proven to do anything, really. It's a fad. It's, yeah. I will tell you, and this is my bias. This is my bias, and I think, who is the swimmer? Phelps. Yeah. Yeah, Michael Phelps had these patterns of cups across his back, and, of course, his back is, like, jacked. Everybody's like, oh, my God! Okay. I think manipulation's good. I manipulate joints every day. Every day. Yeah. Yeah, yeah. Yeah. Yeah. There is very good research, as far as low back and spine research, as far as mechanical spine pain, that manipulation or mobilization of a joint will help with dysfunction. He needs to review his research. Yes. Okay. Keep going. Okay. Right. Yeah. Everybody get that question? Okay. So, say it again. I'm sorry. Speak up. You're good. Here. Don't write it. Okay, so... Just say, for instance, somebody at the age of 30 got into a car accident. They went to their doctor. The doctor only recommended pain meds, just like ibuprofen, 1,000, et cetera, no opioids. They developed chronic back pain. But now they want to get the right care with you. Okay. Since you said 14 days is considered 93%, where would the puncture level be at for... It drops significantly. So, and this is... That's a great question. What size T-shirt do you wear? 3X. I got a 2X, and I think they're big. We'll do that. It's a great question. So, the 93% within 14 days. So, outside of 14 days, it drops to, like, 55%. Huge. Huge, right? So, five years. I mean, and this is somebody chronic. This is, yeah, no. Can we help them? Yes. How much? I don't know. Depends, depends on what they got going on. Depends on, but again, going back to our pain question, it's now a mindset. It's now ingrained. In 14 days, your mind has not wrapped its mind around the problem and the pain yet. I can get them out of that pain problem early. Later, somebody chronic, it's a long haul. It's hours and hours of mental therapy. It's hours and hours of trying to change their mindset and their perception of pain, okay? There's some interesting pain if you, ah, I didn't expect to go into pain today or I'd have been better prepared, but go to YouTube and YouTube some of these pain doctors that are talking about the new ways of looking at pain, and they have ways of communicating it that you're like, holy moly, why did I not think of it that way? Because it is very interesting. Yes, ma'am. Yeah. Oh, yeah. Yeah. She asked us if we have pre-surgical patients. Yeah, we have a program called Prehab, and so they'll come to us and we'll teach them. It's kind of more of an introductory, hey, I'm going to have a total knee next week. What do I need to know? Great, I'm gonna, we're gonna do this, and I'm gonna show you this, and when you come to see me after surgery, we're gonna do this and this, and you can be doing this at home before you come to see me, so it's just kind of priming the pipes of what's coming. Yes, ma'am. Back to physical therapy, how much total weight do you need to do physical therapy? Do you have to tell anyone before you do the acupuncture? No, I usually have the conversation. I think it, I don't want to tell them, you need to lose 50 pounds before we can do physical therapy, but I'd usually have to have the conversation, and it's more like, and look, I don't think I'm telling anybody something they don't already know. But do you have somebody that you can help with? I don't. If you do, will that help you? I wish I did. If I could find that person, I would hire them in a skinny minute, because I do think that is a problem. I do think that that... Do you recommend more of the weaning if you've been moving and you're active to help with the therapy? I address them, I address them nutritionally. You know, wait, but then, if you can have, kind of, stomach muscles back, or... Sure. Yeah, so, it's addressing it as a weight issue, just addressing it as a need to be active with you, and getting your muscles and your body back in. I mean, myself, I was in a car accident, way back years ago. I had three different circumstances in my life. I had a seatbelt operation, and... Yeesh. I was in a car, well, after I had the accident, I couldn't put any pressure down on my legs, but I had a lot of pressure. And then, I went to my orthopedist. He said, after he got, well, MRI, by the way, and he said to me, he came in the room, he goes, have you looked at getting a lawyer? I said, no, not yet, because I don't know what's going on. He said, you need a lawyer, I'm gonna give you mine. And then, whoa, yeah, it was a semi-truck. Okay. The guy saw through the wheel, and my car was like that. He was like, I don't know what he went out the window. It was real bad. But, and after surgery, I was like, I was okay for a while, and then I got so bad that I literally had to be, was sprained on the bed, was sprained on the bed, on the bed. And my dad had to go, and I had my dad pulling me by my legs to get me out of the bed in order to push me to the knee. I've had so many times on the team that there's so much, there's front issues, and when they do it, you can hear it when they clunk. Now, I couldn't do everything, but I pushed myself to get through it. I think from a physical therapy standpoint, look, I want all my patients to be as active as they can. Right? Does that mean going and running a marathon? No, not for everybody, but could it mean having a routine of some stretches to do every morning to get us limbered up for the day? If that's all we can do, that's where we're starting. Right? And that's the way I kind of address maybe some more of my, you know. And look, I'm not immune. I played college football. When I finished football, I weighed 275 pounds. And I knew it. I felt it. I felt it in my bones. I felt it in my body. I was 22 years old, and I was like, I gotta lose some weight. And I dropped down a lot of weight, and I felt like a new man. Okay? And so, I mean, can it cause problems? Absolutely it can. Is there a quick fix for it? No. It's lifestyle, it's intake, it's activity levels. The more I've gotten into this, and I've been doing this for 25 years, is that I'm realizing, and I think the research is backing this, is that nutrition is a huge component, much more than we ever thought in the medical world. Even so, and look, I'm a physical therapist. I push exercise. I will tell you nutrition is more important than exercise. Okay? You can ruin a good workout with one meal. Okay? And that's what I tell my patients. We need to get into a routine. We need to start making better decisions, and that's the way I kind of address it. Do I have a magic diet plan that works? No. Do I have a magic bullet, magic pill? No. But I do want them to be as active as they can, because activity and stuff builds muscle mass, and they'll be healthier overall. Okay? Yes, ma'am? I have a question for you. Growing up, you would eat at the end of the hour. Mm-hmm. Okay. And you studied it, and it was like hard towards the surface fitness. Okay. So, does it increase when there are people from who are physically active, or are these people not physically active and they're like, is it one or the other, or is it both, or is it multiple? I don't know. I don't know. Are they both? Yeah. I would say it can turn into one, and then it can go back to the other. Yeah. I don't know. I think it's easier if you want to get up and walk. How we doing on time? Ooh. We got 30 minutes left, 29, 28 minutes left. We getting out early? Is that what you're saying? No. Annual cost of chronic pain, 635 billion. I think I've done this presentation maybe four times over the last six years, and that number continues to increase. I think that's the latest number. That's more than the yearly cost for cancer, heart disease, and diabetes combined. Okay. So that's an epidemic, right? Patients who consult a physical therapist more than 14 days after the onset of neck pain, 5.34 times more likely to get an injection, 1.24 more likely to prescribe opioids, 4.6 times more likely to get an MRI, spend 1,630, and $1,063 more on healthcare. Okay. So again, proving my point, right? Okay. Something that I think we have to remember in physical therapy is that the patient actually takes an active role in their care. Okay, what do we know about passive care in healthcare? Right, we want the patient to help themselves. They have an integral part in this, okay? Well, they may not want to, but they should, right? And as healthcare professionals, we need to be able to communicate that. We need to kind of force them into that, right? I mean, it makes total sense. If we're talking about anything in life, you get more out of it what you put into it, right? I mean, those hold true in many different areas, not just in PT or healthcare. If you have a, if you were able to put something into something, you're gonna get more out of it, okay? So. Home exercise program, I'm sorry. Great, I'm sorry. Physical therapists know what that is, I'm sorry. There's only one of me in here. Yes. Yep. Okay. Yeah, and. So, depending on what's going on, and so you're exactly right. If, like, my cousin broke his ankle last night, football game, he had surgical surgery this morning. No prehead, right? He's healthy, otherwise, he's in good shape. Most of your athletes, you tear an ACL, they're usually getting surgery soon, so they don't have time to atrophy. We had a girl, my daughter's played volleyball, and one of the girls on her team tore her ACL, and I'm good friends with her father, and I said, well, when's she getting surgery? And he goes, well, we're getting ready to go on vacation, so she's not gonna have surgery until after we get back from the new year. I was like, I had to tell him, I was like, that's not a good idea. Like, you need to do it now. And he stood me down and said, no, we're gonna wait until after Thanksgiving, after Christmas, and after New Year's, and we're gonna have it in January. So she was in a brace forever, and she has not done well. And I, like, look, I can't, I can't, I only do this for a living, right? I mean, I wouldn't question you if I had a question on whatever you did for a living. I'm just telling you what I do for a living, okay? Yes, ma'am. So, you're a doctor, and you're a pharmacist, and I'm watching you for the time I have. Okay. And I'm gonna go, and I'm gonna ask you a question, and I'm gonna ask you a question. Yep. I'm gonna ask you a question, and I'm gonna ask you a question. Right. I do not walk. Good, good. And I, every time I go home, I say, well, as far as you know, I don't walk. Right, right, right. And she didn't cut me out, so I'm walking. Yeah, yeah, yeah. But I think it depends on the individual as far as prehab. I mean, if you've got a 50-year-old, and maybe they're not very active, and they've got atrophy to the quad, and they're going in to do knee surgery, we need to wake the quad up. Because if it's asleep going into surgery, it makes it that much harder to fire after surgery. I want to look, hey, this is what I'm looking for. And you need to get used to doing this day one. So we're gonna practice this for a week up until surgery. As many as I can. I've had, you know, I don't, we do not have any hospital contracts, so we do not do a lot of that. But I've had patients literally check themselves out, and their significant other drove them right to our clinic, and we got started, yeah. But, you know, I'm not in the recovery room doing stuff or anything like that. Yes, ma'am. Yep. Okay. Yeah. Right. Right. Yep. Yep. Yeah. Yep. Yeah. Yeah. Right, yeah. Um. And this is just kind of the plug for, look, physical therapy is still a good first step, whether it's chronic, whether it's acute. Going back to kind of the chronic issue again, look, and I work, the only way I know to work with somebody with a chronic issue is kind of a team approach. Because I don't think, you know, physical therapy is not the only answer for a chronic patient. I work with many doctors who are, you know, they may get a round of injections. I'm working with that patient through their round of injections. I may work with a surgeon, and I may work with them before surgery and after surgery. I may work with a pain specialist who's prescribing them opioids, and we're trying to manage their pain and try and keep them active and kind of on the straight and narrow, but at the same time wean them off of the opioids. So I do believe that there needs to be a team approach, and I think that has helped many of our chronic pain patients to know that, okay, I have a pain management doctor, I have a physical therapist, I might have psych involved, I might have this team approach trying to help me get through this, okay, and somebody who's, you know, five years into it, right, they're gonna need a team approach. There's no good answer for that. Now, 30-year-old, acute car accident, they should be better. They're young. They will bounce back quicker, right? I mean, I wish I was 30 again, okay? I mean, we bounce back better at 30. That's one of the things I tell my patients. We're not 18 anymore, and I used to get hit by a truck when I was 18 and playing football and bounce right back up. You do that to me now? I'm humpty dumpty. They'll have to take days to put me back together again. That's not gonna work, all right? So, basically what we do and what we train our therapists, and we kind of alluded to this before, but I train all my therapists to be independent practitioners, and like I said, we've got lots of different tools in our toolbox. We utilize those tools specifically for that client and that patient and use the different tools that we have to help get them better in a team approach or individual or whatever, okay? Yes, ma'am. Yep. Oh, yeah. I have prevented people from having knee surgeries my entire career, okay? Whether they're bone-on-bone, I had a, and I've had a patient who literally, I wanna say for the last 15 years, the doctor said, oh, you're bone-on-bone, you need to have a knee replacement, and she was like, I don't wanna have a knee replacement, and he said, well, then, get out of my office, and she happened to call me. I actually was treating her husband. She called me and said, I've got knee, I've got bone-on-bone, can you help me? And I said, come in, let me evaluate you and let's see. Literally treated her the first time. 100% better. She went back to the Y, resumed her active lifestyle. I think she was in her late 60s at the time. I wanna say five years later, she had another bout of knee problems, came back to me, we worked on it again, got her back to the Y, again active, okay? 15 years later, she ended up having a knee replacement, okay? But she prolonged having that done for 15 years and stayed active in the process, and loved every minute of it. She just didn't wanna have surgery. I don't know, something about surgery, but over 15 years, finally came to her mind that, okay, I'm gonna have to have this eventually, but I'm gonna hold off as long as I can. And she did great for 15 years. Yes, ma'am. Yep. Yeah. Yeah. Yep. Okay. Yeah. I'll talk to them and see. I mean, I wanna have that conversation, depending on, because you got different schools of thought, right? I worked closely with two orthopedic surgeons early on in my career. This was before I got into PT school. Both trained by Jack Houston, the inventor of the ACL repair in Houston, not Houston, in Georgia, South Georgia. Anyway, he invented the ACL, patellar tendon ACL repair. These two orthopedists trained by Jack Houston came to Columbia, South Carolina. They started doing ACLs. Both of them, totally different protocols, okay? One was non-weight-bearing for eight weeks. One was weight-bearing as tolerated after surgery. And I'm like, you do the same surgery. You do the exact same thing. You were trained by the same person. And I went to them and I said, why do you have such different protocols? Their answer was, because that's what I want. Okay. So we had this guy's patients over here and this guy's patients over here. And these patients would look over there and go, wait a minute, I had surgery the same day you did. And you're walking around and I'm still on crutches. This is crazy. And I said, well, go talk to your doctor, right? Yes. Yep. What would you do if you had a patient who was on crutches for eight weeks and you had to take them off the wall? I would probably say, unless they're crazy, I'd probably look at them. And if I had some suggestions, I might talk to her and say, hey, you know, let's look at these or let's review these. Because in some instances, they may be off the wall. And it sounds like she's a younger surgeon. Where was she trained? Okay. So that's not, I mean, I would say, depending on where she was, I mean, they're kind of state of the art. So they may have changed some things up. But PTs need to either get on board or figure it out. But I don't, you know, I don't, if I go and talk to a doctor and he says, look, this is just what I want. Okay, then I'll follow your protocol. Yeah. Yeah. Yeah. Yeah, yeah. I would tell you it's probably a little bit of a dancing act because you don't want to piss off a referral source. Right? You want to do what they say. But at the same point, if I feel like I can do better for the patient, maybe following this other protocol and be able to show that to them, it may be a conversation worth having. Yes. Chief what? Okay, all right. There you go, there you go. Yes. Gotcha. Yeah. Yeah. Yeah. Yeah. Yeah. Yeah. Yeah. Yeah, I will tell you, and look, I don't have a problem. There's some great trainers out there that can do the exercise portion. They can't do the hands-on portion. They can't do the dry needling. They can't do other tools in the toolbox, which. Yeah. Yeah. There is, and this, that's a great question. What size T-shirt do you wear? Medium, medium. So I can't remember which state it is. I want to say it's Wisconsin. Has anybody from Wisconsin? Yeah. So Wisconsin, where'd she go? Oh, okay. So Wisconsin has just done legislation where they have done away with co-pays for physical therapy. Okay. Why did they do that? I'll tell you why they did it. Maybe it's not Wisconsin. Maybe I'm wrong on my state. There's a state in the union that has passed legislation that has done away with co-pays because of PT First. They're trying to incentivize patients to go to PT First because the outcomes are so much better. There is one company, and this is a, it's a large PT company, and they're big enough, and we're not big enough yet, but we're looking at it. We love this model. They are self-insured. Everybody knows what self-insured means? So they basically self-insure all of their employees and stuff, and so, and part of their way of doing it is they got to set up their own insurance the way they want it. And so they believe in this research, and they basically set up their insurance within the company, so thousands of employees, and they don't have co-pays for PT, OT, and speech because they believe that if you can get into those specialties sooner rather than later, you will avoid MRIs and X-rays and all the expensive stuff, and they've now got data that proves the fact that they are saving healthcare dollars because of this insurance, and now they're taking that data to Blue Cross Blue Shield and Cigna and some of these other insurances to say, you might need to think about doing this. So there is, there's some rumblings happening there to say, well, if you believe in the research, you should make it easier for them to get into PT rather than harder. You should make it more affordable. Yes, ma'am. Yeah. Yep, yep. Right. What insurance company? Right, yeah, yeah. No, no, you're right. We can't see multiple disciplines in the same day as well. I've never heard, we do do pediatrics, and we have OT, PT, and speech, and we have a lot of people that are in the same day as well, so we can't see multiple disciplines in the same day as well. I've never heard, we do do pediatrics, and we have OT, PT, and speech, and we have a lot of people that are in the same day as well, so we can't see multiple disciplines and we have OT, PT, and speech that we do PEDs with. Yeah, Aetna, you know, Aetna's Aetna. I think, and I may be wrong about that, I wanna say Aetna just got slapped with a huge indictment of avoiding payment and stuff like that that I think is coming out as we speak. So it doesn't surprise me. You're gonna see kinda the pendulum swing back and forth with some of these insurance companies, and I think, I wanna say it's Aetna, but it was specifically for their Medicare replacement plans. Aetna was, I don't know, was doing something because the federal government pays them for these Medicare replacement plans, and they were lying about their outcomes and all this stuff to get more money from the federal government. So there's lots of stuff going on in the insurance industry. I will tell you, we have 30 clinics. We have 200 employees. We're not big, and we're a gnat. So nobody's listening to me, okay? I'm not big enough, but I still talk as loud as I can, and I try and teach, but I'm not big enough to make a difference. I can't walk in Blue Cross Blue Shield and tell them how they need to do things. They will not listen to me. So I don't know how you battle that. I really don't. I hope to get big enough someday where we can have that discussion and maybe change some of the ways they do things, but we'll see. Obviously, at Elite, we spend a lot of time on the medical history. We spend a lot of time reviewing stuff with the patient, provide guidance, anything and everything, specific treatments. Like I said, lots of tools in our toolbox. I am a hands-on therapist. I utilize lots of hands-on tools. We're not huge modality people. Do I believe that TENS works? Yes, but I still don't use a ton of eSTEM and things like that in my practice. If I feel like somebody would benefit from TENS, I'll say, go buy a TENS unit, and I'll show you how to use it. You can use it at home, and you don't need me for that. You need me for two things, and that is my right hand and my left hand, right? And that is typically what brings patients into my office, is they want me to work on a certain joint or work on something and make them feel better, and I'll utilize other types of things to make them feel better along the way. Yes, ma'am. Okay. Great question. Great question, because I get that question a lot. What's the difference between you and a chiropractor? Great, okay. I had this conversation with somebody yesterday. How can I be diplomatic about it? And nothing against them. Look. No, no, look, I don't, and what they do, I do lots of similar things, okay? I manipulate the spine just like a chiropractor would. Similar techniques, similar philosophies, okay? But I don't do it on everybody, okay? So if you're going to a chiropractor, what are you getting? You're getting an adjustment, right? You're getting an adjustment. Guess what? I got an inner ear issue, and I got vertigo. What you getting? You're getting an adjustment. I got ankle pain, and it's kind of hurting out here, doc, and guess what you're getting? An adjustment, okay? If all you have is a hammer, everything looks like a nail. You ever heard that before? Okay? So I'm gonna spend an hour evaluating a patient, and what am I gonna do with them? An adjustment. Well, what are we evaluating for? We know what we're getting, and there's nothing wrong with it. I go to a chiropractor, I get an adjustment. I got no problems, but I know what I'm getting. I know what I'm getting, okay? And I like, look, there's some points in my back that, you know, just get stuck, and I need to go in there and get them unstuck, and he can do it. He's ex-football guy, he weighs about 400 pounds, and he can get me moving, okay? Yes, ma'am. Okay. How old is too old? No, I don't. How old are you? No, no, I don't think that's too old. Yeah. You don't look 70, so I think age is a number. Okay, well, me neither. No. All right, there you go. I think, look, I think somebody said it. You're active, you're gonna be fine, and you're healthy. Now, if you were 70 and bedridden, total different question, total different scenario, right? I'm running out of time, sorry. Okay. Yeah. No. Yeah, not currently. Not currently in today's healthcare. Now, there may be a time where they start cutting it off and saying, well, you're not gonna get, at age 100, how much longer is she gonna live? Yeah, but I mean, they may, and I don't know how they look at it, but they probably got people there who look at it and go, well, she's not gonna live five more years, so it's really not worth it. I don't know. Well, I agree, I agree with you. Yes, sir. Yeah. It's a PT practice act, it's a legislation issue. Yep. I thought North Carolina had direct access. Well, I don't know. Yeah, I think it does. Right. Okay. Okay. Yeah. Yeah, because the PTs aren't allowed to do it in your state, in Wisconsin. So it's a PT practice act, and so from what I understand, the PTs cannot go in and change their practice out without the support of other medical practitioners. So maybe the MDs are ganging up against the physical therapists and won't let that practice act change, or the PTs are cowards and don't want to change their practice act to get in line. I don't know. But South Carolina's been a pretty rebellious state in its history, and we just like to do things, and I think. Yeah. Yeah, I mean, if Blue Cross Blue Shield told me that I could do, if I could perform heart surgery, my practice act will not let me do it, and then I'm in violation of my practice act, and I could go to jail. Yep, yep. I don't know why Wisconsin wouldn't enact it. I don't know, I've got friends in Wisconsin. I'll have to ask them. I did not know that. Yeah, I'll see them next week in Colorado, but I'll ask them. Obviously, we offer all these services. We're in South Carolina, Louisiana, and Pennsylvania. 13 clinics across the upstate and York County's in South Carolina. Multiple services across South Carolina. You can find us if you know us. Different entities, Precision Rehabilitation is in Louisiana, and Elite Therapy Solutions is in Pennsylvania, but they are part of us. I would love to. I've got good friends in Georgia. We're looking at Georgia. Oh, yeah. Come where? To Atlanta, okay. Atlanta's big. Atlanta's real big. North of Atlanta, okay, perfect. Yes, ma'am. Yes, ma'am. Yep. Yep. It's a great question. Yep. I think you encourage them. I think you tell them, if you get to know your therapist, like, I know my doctors. My doctors will tell them, hey, I want you to go see this guy. He's got a good reputation in town. He's helped a lot of people. You're kind of priming them for success, okay? And there's actually research on this. You all ever heard about the research where they brought in patients, and before they brought the patients in, they called them on the telephone to remind them of their doctor's appointment, okay, and said, hey, you got an appointment tomorrow with Dr. Smith. Be here at 11 o'clock to fill out paperwork. Your appointment's at 11.30. Great. Then they called another patient. Hey, you got an appointment with Dr. Smith. He is the best doctor in this facility. You're really gonna like him. You know, primed that doctor. Brought the patients in. Patients saw the same doctor, okay, and then when they left, they did a satisfaction survey, what they thought of the doctor. The patients who got primed, the patients who didn't get primed, okay. So just by priming that patient, trying to tell them, like, look, I know you're not excited to go do physical therapy, but high success rate. This is going to help. You're gonna like the experience. These guys are good, or whatever you can do, and I like, and again, I want you to know me. Like, I don't want you to lie. I want you to believe that I'm going to help your patient, and that makes the difference, but if you can have that conversation, and maybe, you know, you can't spout out statistics. Well, 98% of patients get better if they're in within 14 days. You're like, that doesn't help. It's more about what you feel, and you know, you're trying to prime them into an emotional connection with going to physical therapy. If you can do that, it makes my job a ton easier, and it makes your job easier. I say the same thing. If your front desk fumbles the ball before they get to you, guess what? It's hard, but if your front desk can cross all the I's and dot all the T's, and everything runs smoothly, and you walk in, it's a piece of cake. We can have, everything's better, so again, if we can prime the patients on the front end, it just goes smoother. There's usually a better chance of success. Do we help 100% of people? No, I don't have a problem telling patients, we're gonna do this, and we're gonna do this, and we're gonna see how it does, and you're gonna come back and see me and give me some feedback, and if it's doing well, great, we'll do a little bit more, and we'll keep moving. If it's not helping, we may change gears. We may do an about face and do something totally different, okay? And we'll get through it, and usually I tell them, after five to seven visits, we're gonna have an idea. Is this helping, or is it not? And if it's not, I have no problem sending you back to the doctor saying, we tried this, we tried this, we tried this, we tried this, we tried this, and nothing helps. Here's what I'm suggesting, okay? Great. I think we're out of time. Thank you. Thank you for everything. Very nice seeing everybody. Y'all have fun in Myrtle Beach. Don't get too crazy. Good job, mom. Do you remember her? I do.

founder

Elite Integrated Therapy Centers

physical therapy

early intervention

cost-saving

MRIs

recovery time

misconceptions

hands-on techniques

dry needling

surgery

disc herniation

active patient involvement

team approach

pain management