WEBVTT 00:00:03.552 --> 00:00:05.875 Most PTs will treat TMJ pain. 00:00:06.315 --> 00:00:08.278 Almost none will ever treat or even learn 00:00:08.298 --> 00:00:11.301 about a full bilateral TMJ replacement 00:00:11.461 --> 00:00:12.942 paired with mandibular advancement and 00:00:13.003 --> 00:00:13.882 upper palate expansion. 00:00:13.903 --> 00:00:15.744 That's a lot of words. 00:00:16.126 --> 00:00:17.766 Today's guest stepped directly into that 00:00:17.786 --> 00:00:18.068 void. 00:00:18.547 --> 00:00:20.429 Our guest is a sports and ortho clinician, 00:00:20.710 --> 00:00:22.472 multi-university adjunct professor, 00:00:22.532 --> 00:00:24.794 and fellow in training at the Ohio State 00:00:24.853 --> 00:00:25.274 University. 00:00:25.695 --> 00:00:27.896 Her path to fellowship wasn't straight. 00:00:28.335 --> 00:00:30.015 It was a decade of clinical growth, 00:00:30.115 --> 00:00:31.155 unexpected mentorship, 00:00:31.655 --> 00:00:32.957 accidental specialization, 00:00:33.576 --> 00:00:36.578 and cross-country reset that opened a door 00:00:36.698 --> 00:00:38.158 into advanced OMPT training. 00:00:38.677 --> 00:00:39.777 But during her fellowship, 00:00:40.279 --> 00:00:41.899 her professional world collided with her 00:00:41.939 --> 00:00:43.558 personal life when a family member 00:00:43.658 --> 00:00:45.299 underwent this rare complex surgery. 00:00:45.560 --> 00:00:45.979 Suddenly... 00:00:46.720 --> 00:00:48.222 They weren't just the clinician, 00:00:48.682 --> 00:00:50.344 they were the support system, 00:00:50.423 --> 00:00:52.204 the researcher, the problem solver, 00:00:52.545 --> 00:00:55.188 and the one building a rehab plan no 00:00:55.268 --> 00:00:57.548 textbook could offer. 00:00:57.569 --> 00:00:57.909 Today, 00:00:58.149 --> 00:00:59.710 she's bringing that lived clinical 00:00:59.750 --> 00:01:01.392 reasoning and that human experience and 00:01:01.411 --> 00:01:05.114 that emerging research to you. 00:01:05.155 --> 00:01:06.676 Say hello to clinician, educator, 00:01:07.057 --> 00:01:09.978 and researcher in progress, Katie Berry. 00:01:10.379 --> 00:01:11.140 Katie, welcome to the show. 00:01:11.933 --> 00:01:13.474 Yeah, thanks for having me. 00:01:13.495 --> 00:01:13.694 How'd I do? 00:01:13.715 --> 00:01:14.594 Did I do all right on the intro? 00:01:14.614 --> 00:01:16.256 Yeah, pretty good. 00:01:16.275 --> 00:01:17.716 I'm always nervous because we do 00:01:17.757 --> 00:01:18.617 pre-interview, obviously, 00:01:18.656 --> 00:01:19.737 because we want to get to the meat. 00:01:21.438 --> 00:01:22.918 I'd never like to show the intro to 00:01:22.938 --> 00:01:24.439 the guests because I want them to feel 00:01:24.480 --> 00:01:27.100 it at the same time that we're recording 00:01:27.161 --> 00:01:27.941 it so it's real. 00:01:28.361 --> 00:01:29.581 But that's a lot going on. 00:01:29.602 --> 00:01:30.683 We're going to dive into that. 00:01:30.882 --> 00:01:32.884 But I want to start with what usually 00:01:32.903 --> 00:01:33.623 people do at the end, 00:01:33.664 --> 00:01:35.665 which is thanks for being bold enough to 00:01:35.765 --> 00:01:38.225 tell this because this is not only work, 00:01:38.245 --> 00:01:39.727 but this is a little bit of personal 00:01:39.766 --> 00:01:40.167 involvement. 00:01:41.040 --> 00:01:41.281 Yeah. 00:01:41.361 --> 00:01:42.001 And that actually, 00:01:42.120 --> 00:01:43.682 that ended up being a really wonderful 00:01:43.742 --> 00:01:44.462 piece of this. 00:01:44.841 --> 00:01:45.061 Um, 00:01:45.522 --> 00:01:47.683 when I was thinking about the poster and 00:01:47.802 --> 00:01:49.102 obviously going through this whole 00:01:49.323 --> 00:01:49.944 process, 00:01:50.483 --> 00:01:53.465 when I reached out to other researchers or 00:01:53.625 --> 00:01:55.906 other folks who were working with TMJ, 00:01:55.945 --> 00:01:58.766 because it was something no one knew by 00:01:58.805 --> 00:02:00.787 the time we got to completion, 00:02:00.826 --> 00:02:03.147 which was wonderfully a successful rehab, 00:02:03.668 --> 00:02:03.947 um, 00:02:03.987 --> 00:02:06.049 which I'll get into the dicey bits of 00:02:06.069 --> 00:02:07.149 that later, but, um, 00:02:08.348 --> 00:02:11.350 that I had the perspective of being there 00:02:11.610 --> 00:02:14.552 at all aspects of it made it unique. 00:02:14.573 --> 00:02:16.594 And I think is what sort of set 00:02:16.615 --> 00:02:19.997 it apart as not just thinking about a 00:02:20.177 --> 00:02:24.200 new way to think about joint replacements 00:02:24.260 --> 00:02:26.062 or using an old way to think about 00:02:26.122 --> 00:02:27.563 joint replacements that we obviously know 00:02:27.604 --> 00:02:30.325 to a joint that's less known about, 00:02:30.485 --> 00:02:33.368 but also being able to integrate 00:02:33.889 --> 00:02:34.088 you know, 00:02:34.109 --> 00:02:36.290 we talked to nutritionists and speech 00:02:36.311 --> 00:02:38.331 therapists and kind of got the whole thing 00:02:38.372 --> 00:02:41.114 on board because I was there every day. 00:02:41.133 --> 00:02:43.215 So that was a unique piece to it. 00:02:43.254 --> 00:02:44.276 So I've got questions. 00:02:44.816 --> 00:02:45.396 Yeah. 00:02:45.437 --> 00:02:46.296 My job really, 00:02:46.417 --> 00:02:48.258 and any good host is to tell, 00:02:48.337 --> 00:02:50.460 help you tell the story so the audience 00:02:50.520 --> 00:02:52.661 can understand it the best. 00:02:52.681 --> 00:02:53.141 Sure. 00:02:53.181 --> 00:02:55.543 So where does this story start? 00:02:55.603 --> 00:02:56.764 We could start clinically, 00:02:56.824 --> 00:02:57.443 we can start personally, 00:02:57.463 --> 00:02:59.044 but I want to start where you think 00:02:59.064 --> 00:02:59.746 the story should start. 00:02:59.786 --> 00:03:00.826 Where should this story start? 00:03:00.847 --> 00:03:02.867 Yeah, I think, um, 00:03:04.832 --> 00:03:07.734 My first real big exposure to TMJ was 00:03:07.774 --> 00:03:08.974 actually in residency. 00:03:09.335 --> 00:03:11.254 I did the orthopedic residency at Memorial 00:03:11.275 --> 00:03:11.594 Hermann. 00:03:12.776 --> 00:03:15.497 And one of my main mentors, Caitlin Lang, 00:03:16.076 --> 00:03:20.179 we ran across a grouping of TMJ patients. 00:03:20.739 --> 00:03:22.859 And to most clinicians, right, 00:03:22.899 --> 00:03:24.319 we hear TMJ and we're like, oh, 00:03:24.570 --> 00:03:26.171 that somebody else is going to treat that, 00:03:26.211 --> 00:03:26.472 right? 00:03:27.973 --> 00:03:29.913 And I even ran into a couple of 00:03:29.973 --> 00:03:31.914 clinicians at AMT when I was talking about 00:03:31.974 --> 00:03:32.254 this, 00:03:32.914 --> 00:03:34.675 and one who works in a TMJ clinic 00:03:34.915 --> 00:03:36.097 looked at this case and was like, oh, 00:03:36.116 --> 00:03:38.277 my boss would treat that patient, not me. 00:03:39.479 --> 00:03:41.239 And so I think that perspective of like, 00:03:41.258 --> 00:03:43.320 this is complex and it's different. 00:03:44.580 --> 00:03:46.222 Caitlin was the first person who basically 00:03:46.241 --> 00:03:47.723 said the TMJ is just a joint. 00:03:48.302 --> 00:03:49.625 It is joint like any other joint. 00:03:50.085 --> 00:03:51.347 It's a synovial joint. 00:03:51.848 --> 00:03:53.849 We are going to look at the mechanics, 00:03:54.131 --> 00:03:55.372 the biomechanics behind it, 00:03:55.512 --> 00:03:57.335 and we're just going to treat these people 00:03:57.495 --> 00:03:58.096 as they are. 00:03:59.236 --> 00:04:00.399 And there's been some really wonderful 00:04:00.459 --> 00:04:03.201 research over the last couple of years 00:04:03.241 --> 00:04:04.883 from a couple of different groups. 00:04:06.346 --> 00:04:08.326 that have started to put out papers that 00:04:08.366 --> 00:04:10.627 really are, let's classify this, you know, 00:04:10.687 --> 00:04:12.028 myogenic, arthrogenic, 00:04:12.408 --> 00:04:14.069 is there a disc issue? 00:04:14.110 --> 00:04:16.151 And so I think my story started there 00:04:16.170 --> 00:04:18.012 at residency of someone just saying, hey, 00:04:18.911 --> 00:04:19.752 this is okay, 00:04:20.093 --> 00:04:22.014 we're just going to treat this and think 00:04:22.053 --> 00:04:23.894 about it with that clinical decision 00:04:23.915 --> 00:04:24.194 making, 00:04:24.235 --> 00:04:26.456 we would something else in the same way. 00:04:26.596 --> 00:04:26.956 All right. 00:04:27.336 --> 00:04:28.617 So let's jump back to something I 00:04:28.637 --> 00:04:30.156 mentioned in your intro. 00:04:30.216 --> 00:04:32.017 Your journey to fellowship wasn't linear. 00:04:32.077 --> 00:04:33.117 You worked for years, 00:04:33.218 --> 00:04:34.598 taught residents and fellows, 00:04:34.639 --> 00:04:36.800 specialized in TMJ, as we mentioned, 00:04:36.879 --> 00:04:37.740 almost by accident. 00:04:38.079 --> 00:04:38.680 And we'll get to that. 00:04:38.980 --> 00:04:40.300 And then jumped back into advanced 00:04:40.480 --> 00:04:40.901 training. 00:04:41.000 --> 00:04:43.562 You went back to school after you 00:04:43.581 --> 00:04:45.122 graduated from school and also taught 00:04:45.163 --> 00:04:45.562 school. 00:04:45.642 --> 00:04:46.702 You were like, you know what I need? 00:04:47.324 --> 00:04:47.744 More school. 00:04:48.504 --> 00:04:49.223 But let's ask this. 00:04:49.545 --> 00:04:51.865 What part of that winding path, which, 00:04:51.906 --> 00:04:52.245 by the way, 00:04:52.266 --> 00:04:53.607 is always the best path who needs a 00:04:53.646 --> 00:04:55.348 straight straight lines are boring, man. 00:04:55.788 --> 00:04:57.348 But what part of that winding path shaped 00:04:57.369 --> 00:04:59.329 you the most as a clinician? 00:04:59.350 --> 00:05:00.471 Maybe I'll ask a better question. 00:05:00.490 --> 00:05:02.471 Like what a part what what parts of 00:05:02.492 --> 00:05:04.872 that winding path do you look back on 00:05:04.913 --> 00:05:05.492 and say, yeah, 00:05:05.512 --> 00:05:08.334 that twist or that turn really shaped me? 00:05:09.497 --> 00:05:09.858 Yeah, 00:05:09.877 --> 00:05:12.281 I think I get this a lot in 00:05:12.322 --> 00:05:15.547 discussions when I'm speaking with folks 00:05:15.567 --> 00:05:17.369 who are trying to decide about residencies 00:05:17.410 --> 00:05:19.072 or fellowships or other things because my 00:05:19.112 --> 00:05:20.754 path is a little bit different. 00:05:21.855 --> 00:05:22.697 My entire 00:05:23.331 --> 00:05:25.512 residency cohort were just out of PT 00:05:25.531 --> 00:05:25.831 school. 00:05:25.951 --> 00:05:27.872 So they had all just graduated, 00:05:27.932 --> 00:05:29.593 whereas I had been out for five years 00:05:29.932 --> 00:05:32.694 treating as a clinician with the mindset 00:05:32.853 --> 00:05:36.495 of personally for me that I'm someone who 00:05:36.855 --> 00:05:39.254 needs to know a little bit more about 00:05:39.454 --> 00:05:40.896 how I'm interacting with something and 00:05:40.975 --> 00:05:44.237 what I know and where maybe I could 00:05:44.257 --> 00:05:46.858 grow more and then seeking out something 00:05:46.898 --> 00:05:48.158 that will help me fill that. 00:05:49.291 --> 00:05:52.413 And so I think it sort of made 00:05:52.432 --> 00:05:55.115 that turn initially with residency because 00:05:55.295 --> 00:05:57.295 I got to go into residency as a 00:05:57.355 --> 00:05:58.896 five year experienced clinician. 00:05:59.557 --> 00:06:00.677 And so we hear all the time, right? 00:06:00.716 --> 00:06:03.057 Residency is the equivalent of three years 00:06:03.098 --> 00:06:03.997 of clinical work. 00:06:04.079 --> 00:06:06.319 You graduate and you're this expert 00:06:06.358 --> 00:06:06.860 clinician. 00:06:07.379 --> 00:06:09.620 I got to go in as a five 00:06:09.641 --> 00:06:12.521 year resident and have conversations with 00:06:12.601 --> 00:06:14.862 my mentors in residency that were just 00:06:14.903 --> 00:06:16.663 like a little bit higher. 00:06:17.064 --> 00:06:18.245 I could apply my 00:06:19.084 --> 00:06:22.086 day to day as a clinician into that 00:06:22.166 --> 00:06:23.026 advanced learning. 00:06:23.947 --> 00:06:26.988 And so I think that's sort of where 00:06:27.048 --> 00:06:29.050 my sort of winding path changed a little 00:06:29.089 --> 00:06:32.451 bit into I can utilize mentorship. 00:06:32.572 --> 00:06:35.432 I can be a mentor, share my experience. 00:06:36.053 --> 00:06:38.694 But as I was interacting with more 00:06:38.774 --> 00:06:41.716 researchers and more fellows in my day to 00:06:41.757 --> 00:06:42.716 day seeing, OK, 00:06:42.737 --> 00:06:44.517 there's there's a little bit more 00:06:45.341 --> 00:06:47.903 And there is already this wonderful 00:06:47.983 --> 00:06:50.346 established fellowship set of programs 00:06:50.925 --> 00:06:54.048 where maybe I can go and it's the 00:06:54.168 --> 00:06:55.468 next best choice for me. 00:06:55.509 --> 00:06:57.891 If I want to get into teaching a 00:06:57.930 --> 00:06:58.430 little bit more, 00:06:58.490 --> 00:07:01.853 if I want to experience research at more 00:07:01.872 --> 00:07:02.853 of a one-on-one level, 00:07:02.934 --> 00:07:04.694 there's already a platform for that, 00:07:05.415 --> 00:07:05.596 which 00:07:06.269 --> 00:07:08.692 sort of is just the next best step, 00:07:08.812 --> 00:07:09.271 I guess. 00:07:10.353 --> 00:07:10.774 Yeah. 00:07:10.853 --> 00:07:11.735 I like that phrase. 00:07:12.254 --> 00:07:14.898 A wise person named Helena Esmond always 00:07:14.937 --> 00:07:16.439 said, when you're stuck, 00:07:17.000 --> 00:07:18.961 just make the next best step. 00:07:19.783 --> 00:07:21.845 And that simple reframe is really, 00:07:23.065 --> 00:07:25.149 it's simple, not always easy, 00:07:25.925 --> 00:07:30.026 but if you become myopic on purpose and 00:07:30.086 --> 00:07:30.386 say, 00:07:30.946 --> 00:07:32.226 my only decision right here is to make 00:07:32.247 --> 00:07:33.107 the next best step, 00:07:33.127 --> 00:07:34.887 because I know from experience myself, 00:07:35.007 --> 00:07:35.447 I will think, 00:07:35.747 --> 00:07:37.288 but what about thirteen steps from now? 00:07:37.408 --> 00:07:38.629 We're not at thirteen steps from now. 00:07:39.108 --> 00:07:40.228 But I still leave you reminded of this, 00:07:40.249 --> 00:07:41.369 which is why Helena is great. 00:07:41.870 --> 00:07:42.370 She'll just say, 00:07:42.389 --> 00:07:43.350 what's the next best thing? 00:07:43.649 --> 00:07:44.730 So I think that's great that you end 00:07:44.790 --> 00:07:45.091 on that. 00:07:45.850 --> 00:07:46.930 So let's go to this. 00:07:46.951 --> 00:07:48.471 There's a game that we used to play 00:07:48.531 --> 00:07:50.951 at kids' birthday parties called Musical 00:07:50.971 --> 00:07:51.291 Chairs. 00:07:51.312 --> 00:07:53.273 And we always know who the 00:07:54.146 --> 00:07:56.187 We always go want want when the kid 00:07:56.228 --> 00:07:57.567 or the adult is left out when they 00:07:57.588 --> 00:07:58.447 got no chair, right? 00:07:58.567 --> 00:07:58.949 Yeah. 00:07:58.968 --> 00:08:00.389 You sort of ran into that situation. 00:08:00.809 --> 00:08:04.310 You encountered bilateral TMJ replacement 00:08:04.329 --> 00:08:05.630 case during fellowship. 00:08:06.411 --> 00:08:06.930 Sorry, sorry, sorry. 00:08:06.951 --> 00:08:09.711 You became a TMJ specialist when your 00:08:09.771 --> 00:08:10.793 colleague retired. 00:08:10.812 --> 00:08:11.312 Is that right? 00:08:11.372 --> 00:08:12.973 And then suddenly you were left with no 00:08:13.012 --> 00:08:13.273 chair. 00:08:13.312 --> 00:08:14.853 You were the TMJ person. 00:08:15.971 --> 00:08:16.370 Yeah, 00:08:17.031 --> 00:08:18.733 I was working at Kaiser in Northern 00:08:18.752 --> 00:08:20.654 California and I had this wonderful 00:08:20.675 --> 00:08:21.435 coworker, Frank, 00:08:22.815 --> 00:08:24.898 and he was just a wizard with TMJ. 00:08:24.937 --> 00:08:26.718 And we were I was working out of 00:08:27.238 --> 00:08:29.980 an office and he basically wanted to take 00:08:30.000 --> 00:08:30.482 a step back. 00:08:30.521 --> 00:08:33.543 He was in his path to retirement of 00:08:33.583 --> 00:08:35.686 sort of letting go of some of those. 00:08:36.645 --> 00:08:38.586 that he was doing and allowing other 00:08:38.626 --> 00:08:39.427 people to fill in. 00:08:40.187 --> 00:08:41.927 And I will be completely honest, 00:08:41.988 --> 00:08:44.028 I still don't consider myself at all a 00:08:44.089 --> 00:08:45.509 specialist in TMJ, 00:08:46.168 --> 00:08:49.390 but what it led me to was to 00:08:49.410 --> 00:08:50.211 say, again, 00:08:50.230 --> 00:08:52.392 that was an opportunity as a just out 00:08:52.432 --> 00:08:55.413 of residency clinician to gain a little 00:08:55.472 --> 00:09:00.274 bit more of a stepping stone in that 00:09:01.134 --> 00:09:01.835 medical system. 00:09:02.134 --> 00:09:04.296 And so I took it on and went 00:09:04.355 --> 00:09:04.796 and did 00:09:05.895 --> 00:09:08.677 the year-long course series of TMJ through 00:09:08.738 --> 00:09:09.298 University of St. 00:09:09.418 --> 00:09:09.878 Augustine, 00:09:10.798 --> 00:09:12.418 which was my first experience in 00:09:14.559 --> 00:09:16.760 continuing education that dove so deep. 00:09:17.422 --> 00:09:21.322 It was three full weekends of a very 00:09:21.443 --> 00:09:23.124 niche, very small. 00:09:23.144 --> 00:09:25.065 Inch wide but ten miles deep. 00:09:25.384 --> 00:09:25.706 Yes. 00:09:28.626 --> 00:09:30.128 Completed those courses. 00:09:30.327 --> 00:09:32.109 The reason I also say not a specialist 00:09:32.188 --> 00:09:33.788 is I never actually took any of the 00:09:34.048 --> 00:09:34.909 final exams. 00:09:36.056 --> 00:09:37.197 I will own up to that one. 00:09:37.658 --> 00:09:38.938 I got the content and then... 00:09:39.419 --> 00:09:40.500 Everything but the test. 00:09:41.001 --> 00:09:42.462 Everything but the test, took it and left. 00:09:46.168 --> 00:09:46.748 Classic. 00:09:48.210 --> 00:09:51.453 And so got a chance then to help 00:09:51.975 --> 00:09:55.438 redesign and teach some of the TMJ classes 00:09:55.499 --> 00:09:55.678 that 00:09:56.118 --> 00:09:57.438 Kaiser Permanente was running, 00:09:58.000 --> 00:09:59.581 and then work with some of the other 00:09:59.922 --> 00:10:03.365 sort of TMJ specialists within Kaiser to 00:10:03.946 --> 00:10:07.188 just have some amount of a TMJ caseload. 00:10:07.229 --> 00:10:08.730 And for us, it still was pretty low. 00:10:09.311 --> 00:10:11.033 It was probably, you know, 00:10:11.533 --> 00:10:14.576 three to five patients a week tops that 00:10:14.615 --> 00:10:15.116 we were seeing, 00:10:15.157 --> 00:10:17.239 but it was much more than I'd seen 00:10:17.298 --> 00:10:18.159 before any of that. 00:10:20.299 --> 00:10:21.581 What about stepping in that role taught 00:10:21.600 --> 00:10:23.522 you confidence? 00:10:23.761 --> 00:10:24.822 Or did it give you confidence? 00:10:24.842 --> 00:10:25.643 I don't want to assume. 00:10:26.104 --> 00:10:27.845 Skill development, embracing uncertainty. 00:10:29.546 --> 00:10:30.546 With what I get to do for a 00:10:30.586 --> 00:10:32.126 job, one minute I am confident, 00:10:32.267 --> 00:10:33.087 maybe overconfident, 00:10:33.107 --> 00:10:35.428 and then ten minutes later I am wildly, 00:10:35.929 --> 00:10:38.010 wildly nervous about what is about to 00:10:38.030 --> 00:10:38.571 happen next. 00:10:38.650 --> 00:10:40.552 I'm assuming, hopefully, 00:10:40.572 --> 00:10:42.033 that I'm not alone, right? 00:10:42.052 --> 00:10:43.114 That happens a lot, 00:10:43.153 --> 00:10:44.434 even with someone with a lot of training. 00:10:45.322 --> 00:10:48.625 Yeah, I think anything new, right? 00:10:48.845 --> 00:10:50.966 We've got this like huge world that's 00:10:51.005 --> 00:10:54.548 available and we know a little bit about 00:10:54.609 --> 00:10:56.210 something and decide, hey, 00:10:56.230 --> 00:10:57.191 I'll learn a little bit more. 00:10:57.211 --> 00:10:58.392 And I think what it does or what 00:10:58.412 --> 00:10:59.993 it did for me in this instance was 00:11:00.312 --> 00:11:02.355 it sort of brought up the floor, right? 00:11:02.394 --> 00:11:04.716 So TMJ is this wildly complex tool 00:11:06.136 --> 00:11:08.418 sort of umbrella diagnoses that has so 00:11:08.437 --> 00:11:10.638 many comorbidities and so many different 00:11:10.717 --> 00:11:12.178 mechanisms that are involved in it. 00:11:12.619 --> 00:11:15.820 And so it made the like very standard 00:11:15.860 --> 00:11:18.840 TMJ care easy. 00:11:18.940 --> 00:11:19.179 Okay, 00:11:19.880 --> 00:11:22.041 I can do all of the simple stuff 00:11:22.140 --> 00:11:24.481 well and correctly and get my patients on 00:11:24.501 --> 00:11:25.282 the right path. 00:11:25.822 --> 00:11:27.682 And so for a good chunk of TMJ 00:11:27.721 --> 00:11:28.043 patients, 00:11:28.062 --> 00:11:29.663 we know that sort of takes care of 00:11:29.702 --> 00:11:29.802 it. 00:11:29.923 --> 00:11:32.583 It's education and sort of some of the 00:11:32.624 --> 00:11:33.624 basics and it can, 00:11:34.264 --> 00:11:36.226 it can really create a better scenario for 00:11:36.246 --> 00:11:39.131 them and then what it did was help 00:11:39.152 --> 00:11:43.197 me identify okay where do i put my 00:11:43.778 --> 00:11:46.261 more complex cases how do i think about 00:11:46.743 --> 00:11:48.505 what might more be going on 00:11:49.056 --> 00:11:50.577 that isn't just those basics. 00:11:50.638 --> 00:11:51.158 And so it sort of, 00:11:51.198 --> 00:11:52.000 it gave me that, 00:11:52.922 --> 00:11:54.663 to use our PT catchphrases, 00:11:54.684 --> 00:11:57.227 it gave me the toolbox to identify better 00:11:57.469 --> 00:11:59.230 what was going on with those more complex 00:11:59.270 --> 00:11:59.692 cases. 00:11:59.932 --> 00:12:01.094 New business idea, by the way, 00:12:01.193 --> 00:12:03.597 I'm going to produce my own actual 00:12:03.658 --> 00:12:04.339 toolboxes 00:12:05.379 --> 00:12:06.860 And then what you'll do is you'll prompt 00:12:07.360 --> 00:12:09.542 people to buy new grads a toolbox as 00:12:09.562 --> 00:12:09.961 a gift. 00:12:10.022 --> 00:12:11.241 And that'll be my only business model. 00:12:11.282 --> 00:12:14.383 I will sell the actual literal toolbox. 00:12:14.764 --> 00:12:16.183 Let's talk about the case that we alluded 00:12:16.224 --> 00:12:18.004 to in the intro. 00:12:18.764 --> 00:12:19.284 Where's this? 00:12:19.424 --> 00:12:20.105 Where's the start? 00:12:20.125 --> 00:12:22.326 Is this who is like paint the picture 00:12:22.346 --> 00:12:22.725 for the audience? 00:12:22.745 --> 00:12:23.086 Who this? 00:12:23.326 --> 00:12:24.506 Let's do the W's. 00:12:24.647 --> 00:12:25.346 Who are they? 00:12:25.826 --> 00:12:26.687 What happened? 00:12:27.148 --> 00:12:28.307 How were you brought in? 00:12:28.989 --> 00:12:29.749 What'd you do next? 00:12:30.423 --> 00:12:30.864 Yeah, 00:12:30.903 --> 00:12:32.024 this was also a little bit of a 00:12:32.065 --> 00:12:32.806 winding path. 00:12:33.907 --> 00:12:36.227 And I will say part of what made 00:12:36.288 --> 00:12:36.989 this case 00:12:38.365 --> 00:12:39.346 easier to write up. 00:12:39.385 --> 00:12:44.568 And obviously that's easier is still not 00:12:44.609 --> 00:12:46.129 alluding to the fact that I'm less than 00:12:46.169 --> 00:12:47.130 halfway done writing it up. 00:12:47.150 --> 00:12:47.990 Simple, not easy. 00:12:48.351 --> 00:12:49.152 Simple, not easy. 00:12:49.231 --> 00:12:49.511 Yes. 00:12:50.513 --> 00:12:53.774 Was that it wasn't a typical TMJ case. 00:12:54.215 --> 00:12:55.535 Which is what makes it so amazing and 00:12:55.556 --> 00:12:56.216 why people want to learn. 00:12:56.256 --> 00:12:57.378 You want to learn about the edges, 00:12:57.697 --> 00:12:59.259 the normal stuff we've sort of have in 00:12:59.278 --> 00:12:59.658 the bag. 00:12:59.719 --> 00:13:00.620 It's in the toolbox already. 00:13:00.639 --> 00:13:02.360 Yeah, sort of. 00:13:02.520 --> 00:13:06.744 But most folks who encounter this TMJ 00:13:06.783 --> 00:13:07.203 replacement 00:13:07.770 --> 00:13:12.014 It's juvenile rheumatoid arthritis or sort 00:13:12.033 --> 00:13:14.154 of a joint preservation procedure. 00:13:14.936 --> 00:13:17.057 So they've already been through the gamut 00:13:17.437 --> 00:13:18.937 and things aren't going well. 00:13:19.178 --> 00:13:20.578 And so they're going to replace the joint. 00:13:20.860 --> 00:13:22.301 And I think that's very typical to most 00:13:22.341 --> 00:13:23.280 joints in our body, right? 00:13:23.301 --> 00:13:24.562 We're not going to replace them until 00:13:24.581 --> 00:13:26.582 we've sort of run out of our conservative 00:13:26.623 --> 00:13:26.884 care. 00:13:27.203 --> 00:13:29.044 And then I on purpose did no research 00:13:29.065 --> 00:13:29.585 about this. 00:13:30.950 --> 00:13:32.250 Well, not none, but a little bit, 00:13:32.291 --> 00:13:33.652 but I on purpose don't go too deep 00:13:33.672 --> 00:13:34.753 because I'm going to have an expert. 00:13:35.153 --> 00:13:36.595 So paint the picture of what this 00:13:36.634 --> 00:13:38.336 replacement, if a PT is like, Hey man, 00:13:38.397 --> 00:13:38.496 I'm, 00:13:38.736 --> 00:13:40.938 I'm doing more knees and hips and ankles. 00:13:41.379 --> 00:13:42.841 What's she talking about with the TMJ 00:13:42.860 --> 00:13:43.380 replacement? 00:13:44.182 --> 00:13:46.323 What's that look like in general? 00:13:46.344 --> 00:13:47.565 And what's that look like in this 00:13:47.625 --> 00:13:48.505 particular story? 00:13:48.525 --> 00:13:49.787 Yeah. 00:13:49.826 --> 00:13:51.769 So in general, it's the same, 00:13:52.168 --> 00:13:53.831 and this is where I'll sort of use 00:13:53.850 --> 00:13:53.931 the, 00:13:53.951 --> 00:13:57.313 the comparison to most joint replacements, 00:13:57.354 --> 00:13:57.494 right? 00:13:58.054 --> 00:14:00.476 So whenever we're thinking about a knee or 00:14:00.537 --> 00:14:02.119 a hip or any of those things, 00:14:02.399 --> 00:14:04.860 what we're thinking about is the articular 00:14:04.880 --> 00:14:06.062 surfaces have broken down. 00:14:06.903 --> 00:14:09.424 And so you have a proximal and a 00:14:09.504 --> 00:14:10.586 distal end of that joint, 00:14:10.885 --> 00:14:12.988 and you're gonna excise the proximal end 00:14:13.067 --> 00:14:14.349 and replace it with a component, 00:14:14.830 --> 00:14:16.291 and you're gonna excise the distal 00:14:16.331 --> 00:14:16.772 component, 00:14:17.292 --> 00:14:18.793 and you're gonna replace it with an 00:14:18.893 --> 00:14:19.754 artificial component, 00:14:20.073 --> 00:14:22.015 and then they will articulate together as 00:14:22.076 --> 00:14:23.317 the new joint, right? 00:14:23.376 --> 00:14:24.158 Well, yeah, when you say it, 00:14:24.177 --> 00:14:24.979 it sounds easy, but... 00:14:26.389 --> 00:14:28.049 But it's exactly the same thing. 00:14:28.509 --> 00:14:30.230 And so in that TMJ, right, 00:14:30.250 --> 00:14:31.511 you have an articular fossa, 00:14:31.731 --> 00:14:33.273 and you have the mandibular condyle, 00:14:33.653 --> 00:14:36.794 and they articulate together in the native 00:14:36.835 --> 00:14:37.235 joint. 00:14:38.336 --> 00:14:40.756 It's both a roll and a glide that 00:14:40.797 --> 00:14:42.038 happens within that joint. 00:14:42.817 --> 00:14:45.559 Once they install it, it's just a ramp. 00:14:45.940 --> 00:14:47.240 And so it simply has, 00:14:47.640 --> 00:14:49.442 they replace that condyle with a ramp, 00:14:49.461 --> 00:14:51.722 or the fossa with a ramp and the 00:14:51.763 --> 00:14:52.322 condyle, 00:14:53.856 --> 00:14:55.236 again with kind of a mini condyle, 00:14:55.256 --> 00:14:57.097 but it simply articulates in one 00:14:57.138 --> 00:14:57.498 direction. 00:14:57.538 --> 00:14:58.378 It just glides. 00:14:58.758 --> 00:15:00.678 So it loses a little bit of the 00:15:00.698 --> 00:15:03.879 joint mechanics and it becomes 00:15:03.980 --> 00:15:04.659 unidirectional. 00:15:05.320 --> 00:15:08.140 So the other complex piece to our native 00:15:08.181 --> 00:15:10.341 joint is if we're looking at it head 00:15:10.442 --> 00:15:12.621 on, it also rotates so that we can, 00:15:13.643 --> 00:15:13.863 we can, 00:15:14.883 --> 00:15:17.024 you do lateral movement in our jaw so 00:15:17.043 --> 00:15:18.224 we can go left and right. 00:15:19.224 --> 00:15:21.225 And that happens at the joint as well. 00:15:22.023 --> 00:15:23.984 In the new replacement joint, 00:15:24.583 --> 00:15:25.625 it just glides. 00:15:25.904 --> 00:15:28.005 All you get is an inferior glide. 00:15:28.025 --> 00:15:29.907 You don't get any more of that lateral 00:15:29.927 --> 00:15:30.287 movement. 00:15:31.106 --> 00:15:34.948 And so it restricts the motion slightly. 00:15:35.428 --> 00:15:37.610 It takes away those degrees of freedom a 00:15:37.629 --> 00:15:38.070 little bit. 00:15:38.710 --> 00:15:40.530 But you replace a joint that's broken 00:15:40.571 --> 00:15:40.791 down. 00:15:41.331 --> 00:15:43.451 And so you have this brand new surface 00:15:45.373 --> 00:15:47.553 that is able to move without those 00:15:47.634 --> 00:15:49.134 inhibitions that the native joint had. 00:15:49.537 --> 00:15:49.716 All right. 00:15:49.736 --> 00:15:51.720 So now we understand sort of the AMP 00:15:51.799 --> 00:15:52.600 a little bit enough. 00:15:53.861 --> 00:15:54.042 Yeah. 00:15:54.062 --> 00:15:55.043 I'm not sure if I did a great 00:15:55.083 --> 00:15:56.144 job explaining that. 00:15:56.164 --> 00:15:57.306 You were doing roll and glide. 00:15:57.346 --> 00:15:58.047 Trust me. 00:15:58.086 --> 00:15:58.628 Five stars. 00:15:58.707 --> 00:15:59.249 No notes. 00:15:59.509 --> 00:16:00.789 If people are watching the video to this 00:16:00.831 --> 00:16:01.370 podcast, 00:16:01.510 --> 00:16:03.413 you can see some great articulation with 00:16:03.433 --> 00:16:04.534 that. 00:16:05.196 --> 00:16:07.437 But when you encountered this particular 00:16:07.477 --> 00:16:08.099 replacement. 00:16:08.119 --> 00:16:08.440 Yeah. 00:16:09.571 --> 00:16:11.052 You found, am I right? 00:16:11.072 --> 00:16:12.351 Like you kind of found almost nothing 00:16:12.392 --> 00:16:14.932 about what happens next. 00:16:15.452 --> 00:16:16.214 What do we, 00:16:16.254 --> 00:16:17.934 so we got to the replacement. 00:16:17.995 --> 00:16:19.075 We know how to do that. 00:16:19.115 --> 00:16:20.676 We just described in general, 00:16:20.696 --> 00:16:22.556 in big picture terms, what that replay, 00:16:22.596 --> 00:16:25.018 why we do it, what happens during it, 00:16:25.118 --> 00:16:25.977 what happens after it. 00:16:26.592 --> 00:16:26.932 Yeah. 00:16:27.092 --> 00:16:28.293 But then where's the playbook? 00:16:28.894 --> 00:16:29.594 I guess you found, 00:16:30.073 --> 00:16:31.595 what'd you find when you looked and how 00:16:31.615 --> 00:16:33.174 do we bring this person back to function? 00:16:33.514 --> 00:16:33.754 Also, 00:16:33.794 --> 00:16:35.255 what did like paint the picture for me 00:16:35.316 --> 00:16:35.696 briefly, 00:16:36.035 --> 00:16:38.356 what deficits look like when we're not 00:16:38.417 --> 00:16:40.076 rolling and gliding, we're just gliding. 00:16:40.356 --> 00:16:41.697 So paint the picture of what this person 00:16:41.717 --> 00:16:42.577 looks like afterwards. 00:16:43.018 --> 00:16:43.798 What'd you find? 00:16:44.058 --> 00:16:45.239 And when, if you didn't find anything, 00:16:45.278 --> 00:16:45.918 what'd you do about it? 00:16:46.658 --> 00:16:46.940 Yeah. 00:16:47.299 --> 00:16:48.519 So when I went, uh, 00:16:48.559 --> 00:16:49.679 obviously the first place to go, 00:16:49.759 --> 00:16:51.221 especially when you're a fellow in 00:16:51.260 --> 00:16:51.581 training, 00:16:51.640 --> 00:16:53.022 but also when you encounter something you 00:16:53.062 --> 00:16:54.201 don't know is, um, 00:16:55.100 --> 00:16:55.941 What have other people done? 00:16:57.523 --> 00:17:00.065 And so what I found was this kind 00:17:00.085 --> 00:17:02.388 of wealth of research on outcomes. 00:17:02.988 --> 00:17:03.749 So, you know, 00:17:03.788 --> 00:17:04.829 these joint replacements have been 00:17:04.869 --> 00:17:06.231 happening and they've been happening for 00:17:06.291 --> 00:17:09.154 years enough that, you know, Stryker, 00:17:09.174 --> 00:17:12.417 who's one of the companies that develops 00:17:12.498 --> 00:17:13.660 artificial joint replacements, 00:17:13.880 --> 00:17:16.462 they have a specific three D printed 00:17:16.542 --> 00:17:17.564 patient specific 00:17:18.339 --> 00:17:20.701 joint that they'll three d print for each 00:17:20.780 --> 00:17:22.422 patient right it's common enough that 00:17:22.442 --> 00:17:24.522 they've developed a system around it sure 00:17:24.843 --> 00:17:28.104 um and so i found research on outcomes 00:17:28.144 --> 00:17:30.404 which is great for the surgeons right 00:17:30.444 --> 00:17:32.266 because that is their the question they 00:17:32.286 --> 00:17:34.047 have to answer is that's their stat that's 00:17:34.086 --> 00:17:36.607 their kpi what are the outcomes right and 00:17:36.667 --> 00:17:38.749 basically all of the outcomes were six 00:17:38.808 --> 00:17:41.750 month and one year follow-ups and the 00:17:41.809 --> 00:17:44.111 outcomes are great improved quality of 00:17:44.151 --> 00:17:45.751 life decreased pain 00:17:46.311 --> 00:17:49.016 near normal range of motion and opening at 00:17:49.056 --> 00:17:49.497 a year, 00:17:50.298 --> 00:17:52.141 but nothing about how they got there. 00:17:52.517 --> 00:17:54.538 Ah, the missing piece, the path. 00:17:54.617 --> 00:17:54.958 Yeah. 00:17:55.077 --> 00:17:56.518 And even talking to the surgeon, 00:17:56.557 --> 00:17:58.199 which I was lucky enough because it was 00:17:58.219 --> 00:17:59.920 a family member to be at all of 00:17:59.960 --> 00:18:01.660 the pre-op and post-op appointments, 00:18:03.260 --> 00:18:05.701 he was first hesitant about PT in general 00:18:06.182 --> 00:18:07.803 because there's not a lot of PTs that 00:18:07.843 --> 00:18:10.423 see it and treat it and didn't really 00:18:10.502 --> 00:18:12.763 know what was being done in PT. 00:18:12.844 --> 00:18:16.506 And so his only guidelines were no force 00:18:16.546 --> 00:18:18.105 on the upper palate because it had been 00:18:18.365 --> 00:18:19.747 obviously broken and there was a surgical 00:18:19.787 --> 00:18:20.047 plate. 00:18:20.755 --> 00:18:23.298 and no lateral movement whatsoever, 00:18:23.337 --> 00:18:24.960 because obviously the joint doesn't allow 00:18:25.000 --> 00:18:25.221 that. 00:18:26.201 --> 00:18:29.065 And so I found one case study that 00:18:29.125 --> 00:18:30.125 basically was like, 00:18:30.226 --> 00:18:32.148 PT is going to be so important. 00:18:32.568 --> 00:18:33.951 There's this thing called the therabyte, 00:18:34.191 --> 00:18:34.451 use it. 00:18:34.471 --> 00:18:36.653 I was like, okay. 00:18:36.673 --> 00:18:37.714 So I looked up the therabyte. 00:18:37.734 --> 00:18:39.637 What is the therabyte? 00:18:39.758 --> 00:18:40.317 It's like a 00:18:42.782 --> 00:18:45.724 imagine like a car jack, 00:18:45.865 --> 00:18:46.826 but for your jaw. 00:18:47.467 --> 00:18:50.348 Like you crank it and it opens. 00:18:50.789 --> 00:18:52.771 And so the idea is that this patient 00:18:52.852 --> 00:18:53.291 is using, 00:18:53.412 --> 00:18:55.554 and it's used in TMJ treatment pretty 00:18:55.574 --> 00:18:56.734 frequently actually when there's an 00:18:56.815 --> 00:18:57.536 opening restriction, 00:18:58.596 --> 00:19:00.439 but that's the best sort of way I 00:19:00.459 --> 00:19:01.138 can describe it. 00:19:01.519 --> 00:19:03.060 And so it's got a lever and you 00:19:03.080 --> 00:19:04.261 put it in between your teeth and you 00:19:04.281 --> 00:19:05.742 crank it and it'll hold it open. 00:19:05.762 --> 00:19:07.585 And so you can get a passive stretch 00:19:07.704 --> 00:19:08.306 very easily. 00:19:09.304 --> 00:19:10.224 On a daily basis, 00:19:10.664 --> 00:19:12.185 frequency is important when we're working 00:19:12.226 --> 00:19:13.067 with joint motion. 00:19:13.126 --> 00:19:13.467 And so, 00:19:14.508 --> 00:19:16.288 but that was the only indication was use 00:19:16.308 --> 00:19:18.810 the therabyte, work on range of motion, 00:19:19.411 --> 00:19:21.113 period, end of sentence. 00:19:21.133 --> 00:19:21.553 That was it. 00:19:23.522 --> 00:19:24.643 And so what it led us to do 00:19:24.883 --> 00:19:27.023 was, again, I had this three sixty view, 00:19:27.044 --> 00:19:27.723 which was wonderful. 00:19:27.784 --> 00:19:29.983 And so we could talk to a nutritionist 00:19:30.064 --> 00:19:31.724 because until twelve weeks, 00:19:31.825 --> 00:19:33.164 the patient isn't allowed to have any 00:19:33.204 --> 00:19:34.204 solid foods, 00:19:34.265 --> 00:19:35.705 no pressure on the upper palate. 00:19:36.385 --> 00:19:37.865 And so we were working at a nutrition 00:19:37.885 --> 00:19:38.425 deficit. 00:19:39.586 --> 00:19:41.727 But then also to say, OK, 00:19:41.886 --> 00:19:45.448 if this was a knee total joint 00:19:45.468 --> 00:19:45.968 replacement, 00:19:46.678 --> 00:19:49.499 We have both healing timeframes that we go 00:19:49.538 --> 00:19:50.039 across. 00:19:50.819 --> 00:19:53.942 Are those remarkably different in the jaw 00:19:54.142 --> 00:19:56.623 than the knee or the hip or anything 00:19:56.682 --> 00:19:56.923 else? 00:19:57.042 --> 00:19:57.742 No, they're not, right? 00:19:57.762 --> 00:19:59.403 So we have our tissue healing timeframes. 00:20:00.365 --> 00:20:04.166 We have our sort of must need early 00:20:04.227 --> 00:20:04.946 movement, right? 00:20:04.987 --> 00:20:05.906 We replaced a joint. 00:20:05.967 --> 00:20:07.607 We need to get that joint moving as 00:20:07.667 --> 00:20:08.528 quickly as we can. 00:20:09.169 --> 00:20:11.470 Does that still coincide with this joint? 00:20:11.529 --> 00:20:12.111 Yes, it does. 00:20:12.191 --> 00:20:12.730 Let's do that. 00:20:13.576 --> 00:20:15.256 And then beyond that, 00:20:15.436 --> 00:20:17.257 what are we preparing for? 00:20:17.317 --> 00:20:19.377 What are the milestones that we're trying 00:20:19.397 --> 00:20:23.999 to look for in a total joint replacement? 00:20:24.278 --> 00:20:27.559 First, let's get the quad active. 00:20:27.619 --> 00:20:29.680 Let's get them off their assistive 00:20:29.720 --> 00:20:30.300 devices. 00:20:30.361 --> 00:20:32.020 Let's get them walking normally. 00:20:32.300 --> 00:20:34.642 Then let's sort of expand on that. 00:20:35.162 --> 00:20:37.462 And so taking that same viewpoint for this 00:20:37.502 --> 00:20:39.583 patient, we were able to say, okay, 00:20:39.643 --> 00:20:40.982 our first is we need to get that 00:20:41.044 --> 00:20:41.683 early motion. 00:20:41.743 --> 00:20:42.483 How do we do that? 00:20:43.611 --> 00:20:45.032 with internal and external. 00:20:45.113 --> 00:20:48.715 And we chose to go with tongue depressors 00:20:48.816 --> 00:20:50.637 rather than a therabyte because we had 00:20:50.698 --> 00:20:53.080 them readily accessible in the clinic and 00:20:53.101 --> 00:20:54.781 you stack one more on top and you 00:20:54.801 --> 00:20:55.363 can measure it. 00:20:55.423 --> 00:20:57.744 And yeah, you don't use what you need. 00:20:57.765 --> 00:20:58.566 You use what you have. 00:20:58.911 --> 00:21:00.333 It was easy and it was free. 00:21:00.472 --> 00:21:02.234 So we went with that. 00:21:03.635 --> 00:21:05.719 And then as we were progressing towards, 00:21:06.440 --> 00:21:06.720 okay, 00:21:06.759 --> 00:21:08.781 we need muscular endurance because at 00:21:08.842 --> 00:21:09.583 twelve weeks, 00:21:10.084 --> 00:21:11.444 the patient's going to need to be able 00:21:11.464 --> 00:21:12.987 to chew and tolerate that. 00:21:13.126 --> 00:21:15.289 So how do we load the joint in 00:21:15.349 --> 00:21:17.352 different directions to be able to start 00:21:17.392 --> 00:21:18.292 to simulate that? 00:21:19.779 --> 00:21:22.282 And then as our like really big umbrella, 00:21:22.884 --> 00:21:25.626 any patient that has TMJ complications, 00:21:25.666 --> 00:21:27.068 there's regional interdependence. 00:21:27.108 --> 00:21:30.794 And so we need to address posture and 00:21:31.775 --> 00:21:34.538 upper cervical spine and the neck and all 00:21:34.578 --> 00:21:36.300 of our postural muscles and how this 00:21:36.340 --> 00:21:36.821 patient is 00:21:37.521 --> 00:21:39.123 moving about their day and going about 00:21:39.163 --> 00:21:39.742 that. 00:21:40.143 --> 00:21:42.023 We were able to just apply all of 00:21:42.084 --> 00:21:46.806 those same major concepts to this surgery 00:21:48.405 --> 00:21:49.586 and have a pretty good outcome. 00:21:49.949 --> 00:21:51.048 It's the next best thing. 00:21:51.088 --> 00:21:52.410 I mean, everything that you just said, 00:21:52.430 --> 00:21:53.470 I don't know if you noticed it for 00:21:53.490 --> 00:21:54.190 the last like two, 00:21:54.210 --> 00:21:55.529 three minutes when you're describing that 00:21:55.569 --> 00:21:57.010 you were talking about load range of 00:21:57.050 --> 00:21:58.451 motion and muscular endurance, 00:21:58.790 --> 00:22:01.290 where I think myself included, um, 00:22:01.471 --> 00:22:02.751 when I heard TMJ, 00:22:02.951 --> 00:22:04.432 I would look around for who I was 00:22:04.451 --> 00:22:05.991 going to pass the hot potato to. 00:22:06.833 --> 00:22:06.992 Um, 00:22:07.153 --> 00:22:09.633 but you're talking in terms that PTs use 00:22:09.752 --> 00:22:11.213 every single day and how we think. 00:22:11.253 --> 00:22:12.673 And one of the first things you said 00:22:12.713 --> 00:22:14.634 was, I believe it was your mentor said, 00:22:14.913 --> 00:22:15.575 this is a joint. 00:22:15.875 --> 00:22:17.134 It acts like any other joint. 00:22:17.154 --> 00:22:17.515 Yeah. 00:22:18.035 --> 00:22:18.996 but for some reason, 00:22:19.016 --> 00:22:19.655 and I can see it, 00:22:19.695 --> 00:22:21.637 why we might approach this or be hesitant 00:22:21.778 --> 00:22:22.538 to approach this. 00:22:23.159 --> 00:22:26.340 Since there wasn't a clear definitive CPG, 00:22:26.361 --> 00:22:27.781 it wasn't a path, right? 00:22:27.842 --> 00:22:29.462 You sort of built it while you were 00:22:29.603 --> 00:22:30.222 walking in. 00:22:30.703 --> 00:22:34.906 Were there any frameworks that you maybe 00:22:35.007 --> 00:22:36.047 stole bits from? 00:22:36.307 --> 00:22:38.108 Picasso said, good artists borrow, 00:22:38.148 --> 00:22:38.969 great artists steal. 00:22:39.028 --> 00:22:40.769 So were there things that you were sort 00:22:40.789 --> 00:22:41.871 of grabbing the best of, 00:22:41.911 --> 00:22:42.731 almost like a MacGyver? 00:22:43.740 --> 00:22:44.220 Yeah. 00:22:44.259 --> 00:22:45.361 So in general, 00:22:45.701 --> 00:22:49.544 we took a couple of different and I'll 00:22:49.564 --> 00:22:51.826 say Jake Bleacher, who is at Ohio State, 00:22:51.925 --> 00:22:54.227 was my main primary mentor working with 00:22:54.247 --> 00:22:55.708 the patient because they were also a 00:22:55.748 --> 00:22:56.328 family member. 00:22:56.409 --> 00:22:58.430 He was our primary treating PT and I 00:22:58.470 --> 00:23:01.372 was present at sessions and doing the 00:23:01.412 --> 00:23:01.751 home. 00:23:01.912 --> 00:23:03.413 PT by proxy. 00:23:03.433 --> 00:23:04.334 PT by proxy. 00:23:04.433 --> 00:23:04.773 Yes. 00:23:05.855 --> 00:23:07.435 And doing the accessory sessions at home, 00:23:07.476 --> 00:23:09.397 which was nice to have. 00:23:09.458 --> 00:23:10.678 But it's good to have a PT in 00:23:10.698 --> 00:23:11.259 the family, you know. 00:23:13.807 --> 00:23:14.028 You know, 00:23:14.048 --> 00:23:15.429 that's the Thanksgiving dinner topic. 00:23:15.989 --> 00:23:16.509 Correct. 00:23:16.528 --> 00:23:17.430 Oh, my knee hurts. 00:23:17.450 --> 00:23:19.830 My neck is feeling a little wonky. 00:23:19.851 --> 00:23:20.711 You're like, that's great. 00:23:20.750 --> 00:23:25.433 Pass the gravy. 00:23:25.534 --> 00:23:27.835 We took a look at frameworks in general, 00:23:28.174 --> 00:23:28.355 right? 00:23:28.414 --> 00:23:29.695 Again, saying this is a joint. 00:23:29.935 --> 00:23:32.356 What is the CPG? 00:23:32.436 --> 00:23:34.758 I was at Ohio State at the time. 00:23:34.778 --> 00:23:37.638 So what are our Ohio State guidelines for 00:23:37.759 --> 00:23:38.759 total joint replacements? 00:23:40.204 --> 00:23:42.086 And looking at those components helped 00:23:42.226 --> 00:23:45.788 give us that initial framework of how do 00:23:45.807 --> 00:23:47.307 we want to approach this and what do 00:23:47.327 --> 00:23:47.949 we need? 00:23:48.409 --> 00:23:50.730 What are the guidelines that we'd normally 00:23:50.769 --> 00:23:52.230 be looking for and how can we apply 00:23:52.270 --> 00:23:52.971 that to this case? 00:23:54.332 --> 00:23:55.912 The secondary piece were the surgical 00:23:55.951 --> 00:23:56.492 restrictions. 00:23:56.992 --> 00:23:58.772 So we did have the restrictions of, 00:23:59.173 --> 00:24:00.554 you know, listen to your surgeon always, 00:24:00.794 --> 00:24:02.653 the surgeon's right with kind of what 00:24:02.693 --> 00:24:03.513 they're looking for. 00:24:05.035 --> 00:24:07.075 And so we had no pressure on the 00:24:07.134 --> 00:24:07.734 upper palate, 00:24:08.295 --> 00:24:10.455 which meant that all of our distraction 00:24:10.476 --> 00:24:13.037 had to be only with pressure on the 00:24:13.076 --> 00:24:13.477 lower jaw, 00:24:13.497 --> 00:24:15.297 which is typically how we treat TMJ 00:24:15.356 --> 00:24:15.737 anyway. 00:24:17.577 --> 00:24:19.258 The guidance of no lateral movement. 00:24:19.478 --> 00:24:21.179 And then we also had the restriction of 00:24:21.338 --> 00:24:22.459 no dry needling. 00:24:22.919 --> 00:24:23.680 until three months. 00:24:23.740 --> 00:24:25.541 The surgeon wanted to be really clear of 00:24:25.642 --> 00:24:26.282 any infection. 00:24:26.962 --> 00:24:28.464 And so using those two things were sort 00:24:28.505 --> 00:24:31.048 of our bigger picture framework. 00:24:32.209 --> 00:24:33.730 But then we also dove into, 00:24:33.950 --> 00:24:40.237 there's a two article series that was done 00:24:40.297 --> 00:24:44.280 by, let's see, I have names. 00:24:44.421 --> 00:24:44.500 Okay. 00:24:48.476 --> 00:24:49.416 Stephen Schaefer, 00:24:49.737 --> 00:24:51.557 John Michael Brismee and Carol Courtney in 00:24:51.576 --> 00:24:52.357 twenty fourteen. 00:24:52.397 --> 00:24:54.817 And that was one of the first papers 00:24:54.837 --> 00:24:55.638 that really was like, 00:24:55.699 --> 00:24:57.338 let's break this down for the PT. 00:24:57.838 --> 00:25:00.720 How how do we conservatively treat the 00:25:00.740 --> 00:25:01.300 TMJ? 00:25:02.300 --> 00:25:04.801 And then there's a million articles that 00:25:04.821 --> 00:25:06.821 go back with Roccobato and de las Peñas. 00:25:06.981 --> 00:25:07.142 Right. 00:25:07.221 --> 00:25:08.323 And sort of these more. 00:25:09.780 --> 00:25:12.843 contemporary TMJ physical therapy, 00:25:12.883 --> 00:25:14.383 really specialists and specialist 00:25:14.423 --> 00:25:15.023 researchers. 00:25:15.503 --> 00:25:16.003 And to say, 00:25:16.525 --> 00:25:18.905 if it was a conservative issue, 00:25:19.405 --> 00:25:21.067 how would we treat the muscles? 00:25:21.446 --> 00:25:23.268 How would we treat the joint restriction? 00:25:23.647 --> 00:25:25.729 And how would we treat the spine and 00:25:25.749 --> 00:25:26.909 the accessory to that? 00:25:27.450 --> 00:25:29.431 And so basically just combining it is a 00:25:29.471 --> 00:25:29.990 post-op. 00:25:30.590 --> 00:25:32.051 How would we take those conservative 00:25:32.092 --> 00:25:34.772 measures and those post-op milestones and 00:25:34.813 --> 00:25:37.473 guidelines and meld them so that we can 00:25:37.755 --> 00:25:38.615 make sure that 00:25:38.999 --> 00:25:42.460 we are engaging everything that we need to 00:25:42.700 --> 00:25:44.580 to give the best potential outcome. 00:25:45.141 --> 00:25:46.122 All right. 00:25:46.182 --> 00:25:47.821 So if we're making a movie out of 00:25:47.842 --> 00:25:48.142 this, 00:25:49.242 --> 00:25:50.923 we understand the problem where this 00:25:51.042 --> 00:25:51.403 started. 00:25:52.104 --> 00:25:52.983 And what was the initial injury? 00:25:53.023 --> 00:25:53.463 Did we skip that? 00:25:53.723 --> 00:25:55.265 What was the initial... We did skip it. 00:25:55.444 --> 00:25:57.204 So again, 00:25:57.826 --> 00:25:59.945 this was a little bit avant-garde in sort 00:25:59.986 --> 00:26:00.767 of how we got here. 00:26:01.227 --> 00:26:04.048 Instead of an actual TMJ injury, 00:26:04.407 --> 00:26:06.148 this was actually an airway preservation 00:26:06.209 --> 00:26:06.689 procedure. 00:26:06.929 --> 00:26:07.088 So... 00:26:08.201 --> 00:26:10.223 The family's got a history of sleep apnea 00:26:10.523 --> 00:26:13.526 and cardiovascular disease that comes with 00:26:13.546 --> 00:26:13.766 that. 00:26:14.605 --> 00:26:16.227 And so this family member was able to 00:26:16.247 --> 00:26:16.626 say, 00:26:16.948 --> 00:26:20.589 based on kind of sleep apnea testing and 00:26:20.690 --> 00:26:23.030 joint facial proportions, 00:26:23.211 --> 00:26:25.212 that they were already in a sleep apnea 00:26:25.232 --> 00:26:27.394 phase at a young age and that that 00:26:27.534 --> 00:26:30.415 would lead to- How old? 00:26:30.435 --> 00:26:31.195 Thirty-three. 00:26:31.455 --> 00:26:31.717 Okay. 00:26:31.757 --> 00:26:31.957 Yeah. 00:26:31.977 --> 00:26:33.577 So younger than I assumed when you were 00:26:33.617 --> 00:26:34.178 painting this picture. 00:26:34.238 --> 00:26:35.898 So that's a bad podcast host. 00:26:35.939 --> 00:26:37.319 I should have brought that up earlier. 00:26:37.796 --> 00:26:38.195 That's right. 00:26:38.236 --> 00:26:38.355 Yeah. 00:26:38.435 --> 00:26:40.116 And so this is sort of where we 00:26:40.297 --> 00:26:41.797 we ended up with a patient who had 00:26:41.936 --> 00:26:43.837 no TMJ complications to begin with, 00:26:44.738 --> 00:26:47.357 which led to, in my opinion, 00:26:47.377 --> 00:26:49.179 a much more clear cut recovery. 00:26:50.019 --> 00:26:53.539 Because there weren't that there wasn't 00:26:53.559 --> 00:26:56.361 that list of I've already gone through all 00:26:56.401 --> 00:26:56.800 of this. 00:26:57.300 --> 00:26:57.621 Instead, 00:26:57.661 --> 00:27:01.182 what we got was from an airway that 00:27:01.261 --> 00:27:01.701 was 00:27:02.657 --> 00:27:05.358 nine cubic centimeters of volume to twenty 00:27:05.398 --> 00:27:06.739 cubic centimeters of volume. 00:27:07.118 --> 00:27:10.019 That was the intent for surgery. 00:27:10.339 --> 00:27:13.260 But the same surgery is done for those 00:27:13.381 --> 00:27:14.641 joint preservation procedures. 00:27:15.340 --> 00:27:17.541 And so the other benefit for this is 00:27:17.602 --> 00:27:19.281 we had kind of a clear cut case 00:27:20.102 --> 00:27:21.623 quotes there, certainly. 00:27:21.663 --> 00:27:21.923 Right. 00:27:23.343 --> 00:27:26.344 And so in talking with other research or 00:27:26.364 --> 00:27:27.884 with other clinicians right now who have 00:27:27.943 --> 00:27:29.064 more complex cases, 00:27:29.505 --> 00:27:30.884 we have a little bit of groundwork. 00:27:32.398 --> 00:27:34.381 that we were able to develop on something 00:27:34.401 --> 00:27:35.642 that wasn't complicated. 00:27:36.403 --> 00:27:38.884 And so that path now is what are 00:27:38.904 --> 00:27:41.227 those complications with the more complex 00:27:41.247 --> 00:27:43.569 cases and how do we make this a 00:27:43.750 --> 00:27:44.349 deeper, 00:27:44.730 --> 00:27:48.673 more extensive journey towards a CPG or 00:27:48.713 --> 00:27:50.596 something like that with those patients 00:27:50.615 --> 00:27:53.699 that have a more typical sort of 00:27:53.739 --> 00:27:54.299 presentation. 00:27:55.219 --> 00:27:56.440 We need the moment then, Katie, 00:27:57.361 --> 00:27:58.582 if this is a movie and that's what 00:27:58.602 --> 00:28:00.002 a case report should be. 00:28:00.022 --> 00:28:00.983 It should be a snapshot. 00:28:01.003 --> 00:28:02.164 Everybody's on bated breath. 00:28:03.026 --> 00:28:04.807 How'd this turn out? 00:28:04.886 --> 00:28:05.186 Great. 00:28:05.847 --> 00:28:08.890 So we were able to, from, again, 00:28:09.270 --> 00:28:12.252 the main improvement was that airway 00:28:12.513 --> 00:28:13.034 preservation, 00:28:13.114 --> 00:28:13.453 so a 00:28:15.066 --> 00:28:17.507 to and change fold increase in airway, 00:28:17.606 --> 00:28:19.988 but opening over forty millimeters, 00:28:20.067 --> 00:28:22.489 no restriction in food, no pain, 00:28:22.729 --> 00:28:23.930 a return to full activity. 00:28:23.970 --> 00:28:26.230 So weightlifting, lots of aerobics. 00:28:26.691 --> 00:28:28.351 The patient can sleep on their back now, 00:28:29.051 --> 00:28:30.432 which is impossible before, 00:28:30.491 --> 00:28:32.373 impossible before because they stop 00:28:32.413 --> 00:28:35.614 breathing and just full return. 00:28:35.933 --> 00:28:36.855 The biggest hurdle. 00:28:36.914 --> 00:28:37.255 So we're 00:28:38.134 --> 00:28:39.375 it was August of last year. 00:28:39.394 --> 00:28:41.997 So we're a year and a half out 00:28:42.237 --> 00:28:44.798 a little over, um, has been salad. 00:28:44.818 --> 00:28:44.898 Okay. 00:28:44.919 --> 00:28:47.761 I don't understand. 00:28:47.801 --> 00:28:50.163 So you lose some of that lateral movement 00:28:50.324 --> 00:28:50.864 with the joint. 00:28:51.964 --> 00:28:54.326 And so chomping salad straight up and down 00:28:54.406 --> 00:28:55.768 has been a little bit more of a 00:28:55.867 --> 00:28:59.030 difficult, um, eating experience. 00:28:59.932 --> 00:28:59.971 Um, 00:29:01.699 --> 00:29:02.359 Who do you go to? 00:29:02.400 --> 00:29:04.279 You go to your speech pathologist and say, 00:29:04.319 --> 00:29:05.861 hey, how do we fix this? 00:29:06.922 --> 00:29:08.362 This is great interprofessional 00:29:08.382 --> 00:29:09.061 collaboration. 00:29:09.343 --> 00:29:09.682 Yeah. 00:29:09.722 --> 00:29:11.522 So we had an incredible set of 00:29:11.603 --> 00:29:13.903 myofunctional exercises for tongue 00:29:13.923 --> 00:29:14.805 dexterity, 00:29:14.884 --> 00:29:17.046 for stretching the muscles as they were 00:29:17.086 --> 00:29:17.885 recovering. 00:29:17.905 --> 00:29:20.067 I know some of these as a professional 00:29:20.126 --> 00:29:20.787 podcast host. 00:29:20.846 --> 00:29:22.488 I do need to increase my tongue dexterity. 00:29:22.849 --> 00:29:27.553 Honestly, we think as PTs, 00:29:27.573 --> 00:29:28.792 we have fun toys. 00:29:29.433 --> 00:29:30.894 I want to spend a little bit more 00:29:30.933 --> 00:29:32.796 time with SLPs, 00:29:32.816 --> 00:29:35.596 like very fun toys that we can- I 00:29:35.916 --> 00:29:36.758 call them cousins. 00:29:37.458 --> 00:29:40.819 PT, OT, speech, athletic trainers, 00:29:40.900 --> 00:29:42.240 chiropractors, right? 00:29:42.681 --> 00:29:44.261 We're all sort of in the same mess. 00:29:44.961 --> 00:29:46.022 I had a chance to work as a 00:29:46.063 --> 00:29:47.824 pediatric physical therapist in a clinic 00:29:48.023 --> 00:29:50.424 that was more OTs than PTs. 00:29:50.545 --> 00:29:51.605 And I sat back- 00:29:52.046 --> 00:29:56.691 And they were behavior magicians like it. 00:29:56.871 --> 00:29:57.270 I was like, 00:29:57.511 --> 00:29:58.913 I have no idea what you just did. 00:29:58.972 --> 00:30:00.114 I watched it in plain sight. 00:30:00.454 --> 00:30:01.214 I saw the trick. 00:30:01.536 --> 00:30:03.498 I'm still baffled how you did it. 00:30:03.538 --> 00:30:05.078 So this is a great example of bringing 00:30:05.098 --> 00:30:07.281 in our SLP friends that could make some 00:30:07.301 --> 00:30:08.442 amazing results together. 00:30:08.935 --> 00:30:09.355 Yeah. 00:30:09.415 --> 00:30:09.756 Yeah. 00:30:09.776 --> 00:30:10.376 It was really neat. 00:30:10.396 --> 00:30:11.196 There was a lot of, 00:30:11.577 --> 00:30:13.439 we had our one complication that we had 00:30:13.459 --> 00:30:14.578 was sort of a middle ground. 00:30:15.039 --> 00:30:17.340 We were getting really great range 00:30:17.381 --> 00:30:17.861 improvement. 00:30:18.221 --> 00:30:20.403 It was kind of just before in that 00:30:20.442 --> 00:30:21.782 sort of eight to twelve weeks. 00:30:22.263 --> 00:30:24.664 But one of the typical complications, 00:30:24.684 --> 00:30:26.185 which was written up in all of the 00:30:26.226 --> 00:30:27.366 results papers as well, 00:30:27.767 --> 00:30:31.068 that seems to resolve is a facial palsy. 00:30:31.608 --> 00:30:33.269 Because when you go to replace the joint, 00:30:33.390 --> 00:30:34.891 you're going right next to the facial 00:30:34.931 --> 00:30:37.412 nerve that's right in front of that 00:30:37.451 --> 00:30:38.393 temporomandibular joint. 00:30:39.306 --> 00:30:41.267 And so there was some facial droop, 00:30:41.326 --> 00:30:43.968 which meant if you can only have liquid 00:30:43.988 --> 00:30:46.089 foods or soft foods and you're slurping 00:30:46.569 --> 00:30:48.671 and it's coming out of that side of 00:30:48.711 --> 00:30:49.570 your mouth, right, 00:30:49.590 --> 00:30:50.771 you're losing your nutrition. 00:30:50.791 --> 00:30:50.832 Um, 00:30:52.313 --> 00:30:54.253 and so that was really uncomfortable and 00:30:54.294 --> 00:30:58.256 it's annoying and all the real drooling 00:30:58.615 --> 00:30:59.056 rule. 00:30:59.076 --> 00:31:01.336 Um, and so, yeah, 00:31:01.356 --> 00:31:03.137 a really wonderful set of exercises to 00:31:03.178 --> 00:31:06.119 help, um, sort of regain that facial. 00:31:07.413 --> 00:31:09.913 tone to be able to control those muscles 00:31:09.993 --> 00:31:11.775 in a way that was really incredible. 00:31:11.815 --> 00:31:12.835 All right. 00:31:12.855 --> 00:31:14.796 Well, now we need a question for you. 00:31:15.856 --> 00:31:18.917 You were both clinician and family member. 00:31:19.057 --> 00:31:19.357 Of course, 00:31:19.377 --> 00:31:21.499 you kept your professional objectivity, 00:31:21.519 --> 00:31:22.479 but you're still invested. 00:31:23.039 --> 00:31:25.121 How'd that dual role change the way you 00:31:25.780 --> 00:31:28.102 thought about pain, healing, 00:31:28.142 --> 00:31:29.662 communication, drooling, 00:31:30.143 --> 00:31:32.443 the emotional side of this? 00:31:32.604 --> 00:31:32.743 Yeah. 00:31:34.108 --> 00:31:34.528 Tell you what, 00:31:34.588 --> 00:31:37.109 living with someone who is having trouble 00:31:37.170 --> 00:31:38.470 getting enough nutrition, 00:31:39.150 --> 00:31:40.891 like hangry to a new level. 00:31:41.131 --> 00:31:42.730 And I say that with great love in 00:31:42.750 --> 00:31:43.151 my heart. 00:31:43.651 --> 00:31:46.751 But that was a component. 00:31:47.071 --> 00:31:47.311 You know, 00:31:47.692 --> 00:31:49.593 I've I've thought about that nutritional 00:31:49.633 --> 00:31:50.972 component before when we're talking. 00:31:50.992 --> 00:31:53.753 I don't think I would have. 00:31:53.773 --> 00:31:55.913 But it like it really was. 00:31:55.993 --> 00:31:56.814 It made a difference. 00:31:56.913 --> 00:31:57.154 Right. 00:31:57.494 --> 00:31:59.015 Pain was was worse. 00:31:59.757 --> 00:32:01.999 compliance with exercises was worse. 00:32:02.878 --> 00:32:03.098 You know, 00:32:03.219 --> 00:32:07.982 all of this sort of wove around this 00:32:08.262 --> 00:32:11.585 continual, just like hunger, right? 00:32:11.625 --> 00:32:13.566 Like always hungry. 00:32:14.586 --> 00:32:15.807 And I don't think that I would have 00:32:15.887 --> 00:32:17.068 put those things together. 00:32:17.709 --> 00:32:19.130 I think I, you know, 00:32:19.150 --> 00:32:20.971 we did the pain neuroscience education, 00:32:21.030 --> 00:32:22.672 which is important with any of this. 00:32:23.192 --> 00:32:24.093 We did the, 00:32:25.346 --> 00:32:26.907 frequency education, 00:32:26.968 --> 00:32:29.028 we did all of the normal kind of 00:32:29.087 --> 00:32:30.429 PT line of things, 00:32:30.469 --> 00:32:32.309 but seeing it from that other side and 00:32:32.369 --> 00:32:34.250 recognizing it was coming from a different 00:32:34.289 --> 00:32:36.611 place was also, 00:32:37.211 --> 00:32:38.352 I don't think I would have asked those 00:32:38.392 --> 00:32:39.612 questions in the same way. 00:32:41.492 --> 00:32:41.712 Yeah. 00:32:41.833 --> 00:32:44.913 Asking those extra layer of questions of 00:32:44.933 --> 00:32:47.836 like, how, how is it going for you? 00:32:47.895 --> 00:32:49.375 And we, we sometimes ask that, 00:32:49.476 --> 00:32:50.916 but maybe not as open-ended. 00:32:51.676 --> 00:32:53.238 And so with something like that, right? 00:32:53.278 --> 00:32:53.498 Like, 00:32:54.537 --> 00:32:55.897 How are you actually feeling? 00:32:55.938 --> 00:32:57.098 Like, yes, you've got a little pain. 00:32:57.199 --> 00:32:58.299 Great, let's talk about that. 00:32:58.859 --> 00:33:01.162 Yes, things are coming along, 00:33:01.221 --> 00:33:04.023 but what are your biggest struggles right 00:33:04.064 --> 00:33:04.263 now? 00:33:04.324 --> 00:33:06.165 And for this patient, it was, I'm hungry. 00:33:06.826 --> 00:33:08.988 And that's making everything miserable. 00:33:10.027 --> 00:33:10.426 I am. 00:33:10.667 --> 00:33:11.667 And this is going to sound like a 00:33:11.748 --> 00:33:12.648 crazy aside, 00:33:12.868 --> 00:33:14.009 but maybe for some of the audience who 00:33:14.029 --> 00:33:16.092 knows I was a radio broadcaster and I 00:33:16.132 --> 00:33:17.573 was actually interviewing someone, 00:33:17.792 --> 00:33:20.094 a rock star who had some substance abuse 00:33:20.134 --> 00:33:20.494 issues. 00:33:21.255 --> 00:33:23.257 And it wasn't the first question I asked. 00:33:23.497 --> 00:33:25.117 It was probably six or seven in. 00:33:25.478 --> 00:33:26.078 But I asked. 00:33:27.256 --> 00:33:27.955 How are you doing? 00:33:28.115 --> 00:33:29.517 And I left it super open-ended. 00:33:30.257 --> 00:33:30.876 This was public. 00:33:30.916 --> 00:33:32.196 This was very, very public knowledge. 00:33:32.778 --> 00:33:35.218 And the entire tone of the conversation 00:33:35.258 --> 00:33:35.739 changed. 00:33:36.278 --> 00:33:38.778 And we got to something that I opened 00:33:38.818 --> 00:33:42.019 the door for, for the musician who wanted, 00:33:42.099 --> 00:33:42.941 he didn't have to walk through. 00:33:42.961 --> 00:33:43.820 He could have said, I'm doing great. 00:33:44.320 --> 00:33:45.881 We went down that road. 00:33:45.942 --> 00:33:47.342 I think I warmed him up enough. 00:33:48.156 --> 00:33:48.758 to do that, 00:33:48.798 --> 00:33:52.121 but that's not in your EMR. 00:33:52.921 --> 00:33:54.222 That's not a thing to ask. 00:33:54.482 --> 00:33:56.003 But I think the reason I'm telling both, 00:33:56.064 --> 00:33:57.204 you were telling both these stories is 00:33:57.486 --> 00:33:58.286 it's a thing to ask. 00:33:58.306 --> 00:34:00.909 And you're getting great information. 00:34:01.689 --> 00:34:02.951 That was one that was, 00:34:03.230 --> 00:34:05.093 we had already sort of consulted the 00:34:05.133 --> 00:34:05.792 nutritionist, 00:34:05.913 --> 00:34:07.394 but it took a whole different tone. 00:34:07.454 --> 00:34:08.356 Totally different tone. 00:34:08.755 --> 00:34:09.396 How can we 00:34:10.581 --> 00:34:13.123 you're having to drink all day, 00:34:13.304 --> 00:34:14.585 basically nutrition, 00:34:14.666 --> 00:34:15.746 how can we supplement that? 00:34:15.786 --> 00:34:17.128 And some of it was protein powder, 00:34:17.168 --> 00:34:18.789 but some of it was, 00:34:19.489 --> 00:34:22.592 there are really nutrient rich foods that 00:34:22.612 --> 00:34:23.994 you can blend pretty easily. 00:34:24.054 --> 00:34:24.773 And the patient- 00:34:25.775 --> 00:34:26.795 Yeah, it was like, you know, 00:34:26.856 --> 00:34:28.217 we weren't going to blend pizza or 00:34:28.237 --> 00:34:28.938 anything like that. 00:34:29.018 --> 00:34:31.579 But Indian food ended up being one of 00:34:31.619 --> 00:34:33.822 the main things because lots of chickpeas, 00:34:33.862 --> 00:34:36.483 lots of paneer, lots of tofu, 00:34:36.943 --> 00:34:38.105 Thai food as well. 00:34:39.106 --> 00:34:41.186 And those were things that the patient 00:34:41.206 --> 00:34:42.288 felt comfortable blending up, 00:34:42.307 --> 00:34:44.090 but all of a sudden had a wealth 00:34:44.130 --> 00:34:47.351 more nutrition than a fruit smoothie with 00:34:47.472 --> 00:34:48.273 protein powder in it. 00:34:48.791 --> 00:34:51.672 I did not have Thai food on my 00:34:51.793 --> 00:34:53.773 bingo card of things we would talk about 00:34:53.793 --> 00:34:54.472 in this episode, 00:34:54.512 --> 00:34:57.474 but it makes logical sense. 00:34:57.753 --> 00:35:00.753 So two more questions for Katie. 00:35:00.954 --> 00:35:04.494 What's one mindset shift clinicians need 00:35:04.534 --> 00:35:07.235 when facing a condition like TMJ 00:35:07.275 --> 00:35:08.795 replacement or just something where the 00:35:08.835 --> 00:35:11.436 research really is thin and the playbook 00:35:11.516 --> 00:35:12.717 doesn't exist yet? 00:35:12.856 --> 00:35:13.757 What would you say to them? 00:35:17.351 --> 00:35:20.054 I think where I went and the advice 00:35:20.074 --> 00:35:21.534 that I got and the advice that I've 00:35:21.554 --> 00:35:23.956 gotten from many mentors in the past is 00:35:25.217 --> 00:35:28.518 identify sort of your primary issue. 00:35:29.199 --> 00:35:30.400 What is it that you're treating? 00:35:30.420 --> 00:35:31.860 How did you get here? 00:35:32.320 --> 00:35:33.963 Get your baseline of what it is. 00:35:34.663 --> 00:35:35.983 Look for what does exist. 00:35:37.083 --> 00:35:38.545 Researchers have come before us and 00:35:38.565 --> 00:35:40.106 they've done a wonderful job to outline 00:35:40.146 --> 00:35:40.666 those things. 00:35:42.057 --> 00:35:43.318 especially when it's sparse, 00:35:43.458 --> 00:35:46.822 a case report or not necessarily looking, 00:35:46.862 --> 00:35:48.862 it doesn't have to be a systematic review 00:35:48.983 --> 00:35:49.443 always. 00:35:50.824 --> 00:35:51.824 I got a chance to work with Todd 00:35:51.864 --> 00:35:56.108 Davenport writing up some case studies in 00:35:56.148 --> 00:35:58.148 the Kaiser residency and his perspective 00:35:58.168 --> 00:36:01.331 was every case can be a case study. 00:36:01.411 --> 00:36:01.552 It's 00:36:02.052 --> 00:36:04.835 the viewpoint of what you did and how 00:36:04.875 --> 00:36:07.237 you did it that's impactful and so when 00:36:07.277 --> 00:36:08.898 there's a sparsity of research sometimes 00:36:08.918 --> 00:36:11.659 those case studies can give you at least 00:36:11.701 --> 00:36:14.463 a leg up of how someone thought about 00:36:14.543 --> 00:36:18.306 an idea but beyond that using the things 00:36:18.326 --> 00:36:20.307 that we already know we are 00:36:20.387 --> 00:36:22.530 musculoskeletal experts right on 00:36:22.550 --> 00:36:25.092 graduation and only increasingly so as we 00:36:25.552 --> 00:36:28.695 have career and hopefully advanced 00:36:28.715 --> 00:36:29.255 mentorship 00:36:29.735 --> 00:36:30.556 A big plug for that. 00:36:31.797 --> 00:36:33.677 But using the things that we know and 00:36:33.757 --> 00:36:36.159 breaking things down to the simplest 00:36:36.179 --> 00:36:39.061 blocks and then making sure that we're 00:36:39.121 --> 00:36:41.001 engaging our patient in those things so 00:36:41.021 --> 00:36:42.782 that we have our sort of research centric, 00:36:43.282 --> 00:36:45.563 our clinical decision making hat and then 00:36:45.643 --> 00:36:46.905 our patient and putting those things 00:36:46.925 --> 00:36:48.885 together to have the best outcome for the 00:36:48.925 --> 00:36:49.306 patient. 00:36:49.567 --> 00:36:49.786 Right. 00:36:49.827 --> 00:36:51.947 Which may not always be our best outcome, 00:36:52.068 --> 00:36:54.048 but combining those things in that way. 00:36:54.599 --> 00:36:54.778 All right, 00:36:54.798 --> 00:36:55.798 so that was a sort of an open, 00:36:55.878 --> 00:36:56.858 wide open question. 00:36:57.059 --> 00:36:58.599 The last question we'll ask here, 00:36:58.639 --> 00:37:00.380 we'll make it very specific to this 00:37:00.440 --> 00:37:01.539 episode in this case. 00:37:02.099 --> 00:37:03.601 What's only one thing, 00:37:03.621 --> 00:37:05.740 what's one thing you hope every clinician 00:37:05.860 --> 00:37:09.702 does differently the next time a TMJ 00:37:09.742 --> 00:37:12.081 patient walks into their clinic? 00:37:12.222 --> 00:37:14.202 What's a thing that you hope every 00:37:14.222 --> 00:37:16.523 clinician hearing this does? 00:37:16.643 --> 00:37:19.583 Yeah, I guess a couple of fold. 00:37:19.623 --> 00:37:21.304 First, I hope they take that patient, 00:37:21.744 --> 00:37:21.923 right? 00:37:21.983 --> 00:37:22.704 Don't pass it off. 00:37:23.423 --> 00:37:24.063 Take the patient. 00:37:25.829 --> 00:37:29.893 and give a baseline at least in our 00:37:29.994 --> 00:37:31.795 own clinical experience of having treated 00:37:31.835 --> 00:37:35.880 that patient or being the point on that 00:37:35.920 --> 00:37:37.083 patient, right? 00:37:37.543 --> 00:37:38.985 The second would be involve other 00:37:39.144 --> 00:37:39.726 clinicians. 00:37:40.423 --> 00:37:42.505 The reason we love working in clinics with 00:37:42.565 --> 00:37:44.525 other people, right, or at least I do, 00:37:45.527 --> 00:37:48.068 is that there are other people there who 00:37:48.108 --> 00:37:50.048 have seen things and treated things 00:37:50.088 --> 00:37:51.909 differently or that approach problems in 00:37:51.929 --> 00:37:52.610 different ways. 00:37:53.130 --> 00:37:55.311 And so using the knowledge of others is 00:37:55.793 --> 00:37:57.432 absolutely one of the strengths of our 00:37:57.472 --> 00:37:58.954 professions. 00:37:59.695 --> 00:38:01.815 And then the third would be to say, 00:38:01.996 --> 00:38:02.195 you know, 00:38:02.215 --> 00:38:05.038 there are these great breakdowns. 00:38:05.197 --> 00:38:06.557 There's a couple of those articles from 00:38:09.898 --> 00:38:12.920 that go through and start the breakdown of 00:38:13.519 --> 00:38:17.021 here is what muscle, what joint, 00:38:17.141 --> 00:38:18.681 and what disc looks like in those 00:38:18.742 --> 00:38:19.202 patients. 00:38:19.503 --> 00:38:22.423 And here's how we can at least baseline 00:38:22.463 --> 00:38:22.963 treat them. 00:38:23.364 --> 00:38:24.425 Those things exist. 00:38:24.684 --> 00:38:26.306 I don't think we see them as often 00:38:26.346 --> 00:38:28.606 as we see ACL and the rest of 00:38:28.626 --> 00:38:29.507 that in the literature. 00:38:30.655 --> 00:38:32.896 they are there as at least your like 00:38:33.137 --> 00:38:34.918 initial blueprint printed out, 00:38:35.257 --> 00:38:36.960 read it right before you see that patient 00:38:37.940 --> 00:38:39.240 and then come in with a little bit 00:38:39.280 --> 00:38:40.722 of a toolbox and then an area to 00:38:40.762 --> 00:38:41.001 grow. 00:38:41.543 --> 00:38:42.503 Perfect. 00:38:43.563 --> 00:38:44.704 Katie, before we started recording, 00:38:44.744 --> 00:38:45.905 we said we hope we made this a 00:38:45.965 --> 00:38:46.585 conversation. 00:38:46.626 --> 00:38:47.527 We hope it was useful. 00:38:47.786 --> 00:38:49.608 The audience decides if it was useful. 00:38:50.048 --> 00:38:51.449 How did we do on conversation, though? 00:38:52.193 --> 00:38:53.134 I think pretty good. 00:38:54.195 --> 00:38:55.255 Yeah, 00:38:55.416 --> 00:38:57.717 I've definitely enjoyed sort of nerding 00:38:57.818 --> 00:38:59.099 out a little bit on this. 00:38:59.219 --> 00:39:00.659 Obviously, it's something I dove into. 00:39:00.719 --> 00:39:03.963 So I appreciate the open-ended and direct 00:39:04.023 --> 00:39:04.583 questions. 00:39:04.742 --> 00:39:04.983 Good. 00:39:05.103 --> 00:39:05.184 Well, 00:39:05.204 --> 00:39:07.686 that's the idea is PT is super narrow 00:39:07.706 --> 00:39:09.686 and then all these little nerddoms that 00:39:09.786 --> 00:39:10.648 exist in those. 00:39:10.688 --> 00:39:12.188 And I think now in twenty twenty five, 00:39:12.228 --> 00:39:12.989 twenty twenty six, 00:39:13.831 --> 00:39:15.532 I don't think nerd is the term. 00:39:15.552 --> 00:39:17.414 I don't think it has the sting of 00:39:17.434 --> 00:39:17.974 what it used to. 00:39:18.054 --> 00:39:19.876 Now it's like people embrace the nerddom. 00:39:20.996 --> 00:39:22.597 And I think especially in our profession, 00:39:23.536 --> 00:39:25.297 we all benefit from that. 00:39:25.697 --> 00:39:27.679 And when you can get these like minded 00:39:27.739 --> 00:39:29.878 or opposite minded people together and 00:39:29.938 --> 00:39:30.719 learn from each other, 00:39:31.099 --> 00:39:32.780 an episode like this might not make sense 00:39:32.800 --> 00:39:34.920 for someone who typically only sees knees 00:39:34.940 --> 00:39:35.440 and hips, 00:39:35.920 --> 00:39:39.822 except it does in case or the mindset 00:39:39.862 --> 00:39:41.443 shift of the things that Katie did or 00:39:41.463 --> 00:39:41.862 learned. 00:39:42.583 --> 00:39:44.143 You had a lot of different things that 00:39:44.244 --> 00:39:46.065 aren't necessarily standard in this 00:39:46.105 --> 00:39:47.025 particular situation. 00:39:47.065 --> 00:39:49.806 So on behalf of AMS, thanks for sharing. 00:39:50.512 --> 00:39:52.713 yeah thanks for having me i'm glad to 00:39:53.353 --> 00:39:55.494 again the hope with this really is just 00:39:55.534 --> 00:39:58.336 to start a conversation because these 00:39:58.376 --> 00:39:59.677 surgeries are out there people are 00:39:59.717 --> 00:40:01.938 treating them i'm working with a few 00:40:01.978 --> 00:40:03.860 clinicians right now and we're it's the 00:40:03.920 --> 00:40:06.481 first real wonderful discourse that i've 00:40:06.501 --> 00:40:07.842 been able to have in a way like 00:40:07.862 --> 00:40:09.862 this so hopefully it just builds so that 00:40:10.543 --> 00:40:13.364 when it does come across you or me 00:40:13.465 --> 00:40:16.126 again that there's there's something 00:40:16.925 --> 00:40:18.947 that conversation has been started and we 00:40:18.967 --> 00:40:19.567 can go from there. 00:40:19.907 --> 00:40:20.807 And if people feel stuck, 00:40:20.827 --> 00:40:21.708 what they'll do is they'll go, 00:40:21.728 --> 00:40:22.728 I heard this on a podcast. 00:40:22.789 --> 00:40:23.730 Let me find that episode. 00:40:23.769 --> 00:40:24.650 I'll send it to you. 00:40:24.909 --> 00:40:27.291 And now Katie's the resource. 00:40:27.371 --> 00:40:28.572 Yeah. 00:40:28.692 --> 00:40:29.472 Uh, Katie, thanks for your time. 00:40:29.492 --> 00:40:30.052 We appreciate it. 00:40:30.072 --> 00:40:31.733 Thanks for coming on this podcast. 00:40:32.173 --> 00:40:32.914 Yeah, I appreciate it. 00:40:32.954 --> 00:40:33.474 Thanks so much.