WEBVTT

00:00:02.418 --> 00:00:03.979
Okay, recording starting.

00:00:03.999 --> 00:00:07.421
All right.

00:00:07.461 --> 00:00:08.701
Well, hello, everybody.

00:00:08.842 --> 00:00:10.262
My name is Dr. Trenton Raymond,

00:00:10.301 --> 00:00:13.323
and I'll be hosting today's episode of the

00:00:13.364 --> 00:00:15.324
Hands-On, Hands-Off podcast.

00:00:16.405 --> 00:00:18.907
Today's guest is a pioneer in the space

00:00:18.946 --> 00:00:21.128
of plantar heel pain, or PHP,

00:00:21.167 --> 00:00:22.888
which we'll reference it.

00:00:23.690 --> 00:00:25.289
And he has been published multiple times

00:00:25.309 --> 00:00:25.850
on this topic.

00:00:26.780 --> 00:00:28.442
Not only has he been a large advocate

00:00:28.461 --> 00:00:29.983
for the use of manual therapy in the

00:00:30.042 --> 00:00:31.222
treatment of PHP,

00:00:31.864 --> 00:00:33.643
but he has also tackled the large task

00:00:33.683 --> 00:00:35.905
of evaluating the cost-effectiveness of

00:00:35.945 --> 00:00:39.087
physical therapy compared to other more

00:00:39.127 --> 00:00:40.387
common management approaches.

00:00:41.207 --> 00:00:42.469
Today we have the pleasure of speaking

00:00:42.488 --> 00:00:43.768
with Dr. Shane McClinton.

00:00:44.649 --> 00:00:44.909
Dr.

00:00:44.929 --> 00:00:46.970
Shane McClinton is a fellowship-trained

00:00:46.990 --> 00:00:50.612
physical therapist and is a professor in

00:00:50.633 --> 00:00:52.313
the Department of Physical Therapy at Des

00:00:52.393 --> 00:00:53.654
Moines University.

00:00:54.515 --> 00:00:55.335
Thank you for joining us.

00:00:56.084 --> 00:00:57.725
Thanks for having me.

00:00:57.945 --> 00:00:58.686
Glad to be here.

00:00:58.707 --> 00:00:58.927
Awesome.

00:00:59.567 --> 00:00:59.789
Well,

00:01:00.308 --> 00:01:01.811
can you just start by giving us a

00:01:01.831 --> 00:01:04.394
little bit more about your background so

00:01:04.414 --> 00:01:05.835
that the audience kind of knows who we're

00:01:05.855 --> 00:01:09.540
talking with and maybe touch on just

00:01:09.581 --> 00:01:11.843
briefly your career path and an overview

00:01:12.043 --> 00:01:14.287
of what led you to this topic in

00:01:14.326 --> 00:01:14.847
this research?

00:01:16.001 --> 00:01:16.180
Great.

00:01:16.400 --> 00:01:16.921
Yeah, thank you.

00:01:17.662 --> 00:01:19.962
And I'm humbled to hear you say pioneer

00:01:20.003 --> 00:01:20.664
in this area.

00:01:20.823 --> 00:01:22.805
I'd probably refer to myself more as a

00:01:22.864 --> 00:01:24.865
private if this were in the military and

00:01:24.906 --> 00:01:27.867
just making some small contributions to an

00:01:27.908 --> 00:01:31.609
area that there's lots of outstanding

00:01:32.370 --> 00:01:34.070
individuals contributing to this area.

00:01:34.370 --> 00:01:35.792
But anyway, thank you for that.

00:01:37.513 --> 00:01:40.134
I obtained my initial physical therapy

00:01:40.153 --> 00:01:42.055
degree from Des Moines University, which,

00:01:42.275 --> 00:01:43.135
yes, I'm still there.

00:01:43.596 --> 00:01:45.076
I did work elsewhere for a few years,

00:01:45.296 --> 00:01:48.498
but I went on to get my DPT,

00:01:48.518 --> 00:01:50.058
it's transitional degree again through Des

00:01:50.078 --> 00:01:50.759
Moines University.

00:01:51.358 --> 00:01:51.959
After that,

00:01:52.500 --> 00:01:54.359
went through fellowship training at Regis

00:01:54.420 --> 00:01:55.721
University in Colorado.

00:01:56.421 --> 00:01:57.161
Then after that,

00:01:57.180 --> 00:01:58.921
I got my PhD through Rocky Mountain

00:01:58.941 --> 00:02:00.843
University in Provo, Utah.

00:02:01.462 --> 00:02:05.784
and actually this um this study is was

00:02:05.844 --> 00:02:07.986
part of my initial dissertation research

00:02:08.687 --> 00:02:10.407
and kind of an extension thereof so it's

00:02:10.448 --> 00:02:11.709
been something that i've been working on

00:02:11.748 --> 00:02:13.590
for some time it's an area that i've

00:02:13.610 --> 00:02:16.850
been interested in for quite some time and

00:02:16.890 --> 00:02:18.592
actually just happy to get out the last

00:02:18.651 --> 00:02:19.893
part of it which is the economic

00:02:19.932 --> 00:02:23.794
evaluation following a follow-up that we

00:02:23.835 --> 00:02:27.076
extended out to three years afterwards so

00:02:28.682 --> 00:02:30.526
So I think your question along with that

00:02:30.545 --> 00:02:32.991
was also what kind of prompted this study.

00:02:36.411 --> 00:02:37.871
Being in clinical practice,

00:02:38.211 --> 00:02:40.171
I work at a multi-specialty clinic.

00:02:40.211 --> 00:02:42.032
So we work with family care physicians

00:02:42.052 --> 00:02:42.872
that refer to us.

00:02:43.353 --> 00:02:44.834
We work with podiatrists as well.

00:02:44.854 --> 00:02:48.115
We also have osteopathic manual physicians

00:02:48.134 --> 00:02:49.655
who are in our clinical practice.

00:02:50.514 --> 00:02:53.135
And one of the observations I made when

00:02:53.195 --> 00:02:54.877
working with plantar heel pain patients is

00:02:54.917 --> 00:02:56.176
I would see the patients that would come

00:02:56.217 --> 00:02:57.397
and be referred to me directly,

00:02:58.057 --> 00:02:59.518
but I wouldn't see many patients that were

00:02:59.538 --> 00:03:01.179
being referred from other providers,

00:03:01.299 --> 00:03:01.799
even though

00:03:02.508 --> 00:03:04.409
It was a condition that in my experience

00:03:04.430 --> 00:03:05.872
and also the literature at the time,

00:03:06.132 --> 00:03:07.932
and even since then has really supported

00:03:07.953 --> 00:03:09.774
the fact that it's a very multidimensional

00:03:09.813 --> 00:03:10.254
problem.

00:03:10.974 --> 00:03:13.197
There's issues that extend proximally.

00:03:13.477 --> 00:03:15.959
So we see a lot of neurogenic factors

00:03:15.979 --> 00:03:17.379
that are contributing to their heel pain.

00:03:17.860 --> 00:03:19.322
They have proximal impairments in the

00:03:19.361 --> 00:03:21.143
lumbar spine and the hip and the knee.

00:03:22.111 --> 00:03:23.653
They benefit from manual intervention.

00:03:23.834 --> 00:03:25.335
It seemed like these patients were just

00:03:25.455 --> 00:03:26.996
right down in our wheelhouse,

00:03:27.516 --> 00:03:29.497
but the referral rate in our clinic and

00:03:29.518 --> 00:03:31.400
across the board was very, very low.

00:03:31.539 --> 00:03:32.681
So for example,

00:03:32.781 --> 00:03:35.182
seven percent upwards of twenty percent

00:03:35.622 --> 00:03:38.745
from other providers are referring those

00:03:38.786 --> 00:03:40.727
patients to physical therapists.

00:03:40.947 --> 00:03:42.829
So it just seemed to me like, well,

00:03:42.868 --> 00:03:44.610
this is a population that we really should

00:03:44.650 --> 00:03:45.931
have our hands on and we can really

00:03:46.031 --> 00:03:46.330
help.

00:03:47.211 --> 00:03:48.612
But we're not getting a lot of them

00:03:48.652 --> 00:03:49.174
in our door.

00:03:50.234 --> 00:03:51.455
And there's a lot of factors that we

00:03:51.474 --> 00:03:53.536
can explore and discuss about why that is,

00:03:53.575 --> 00:03:54.276
but regardless,

00:03:54.316 --> 00:03:56.516
that was the facts of the healthcare

00:03:56.537 --> 00:03:57.116
situation.

00:03:58.637 --> 00:04:01.198
And so we embarked upon this study to

00:04:01.998 --> 00:04:04.460
see if we could provide some evidence that

00:04:04.620 --> 00:04:07.140
we can add value to these other providers.

00:04:07.181 --> 00:04:08.561
We're not trying to take away from what

00:04:08.580 --> 00:04:08.961
they do,

00:04:09.481 --> 00:04:10.542
but we want to just show that we

00:04:10.562 --> 00:04:12.002
can add some value to the things they're

00:04:12.022 --> 00:04:12.643
currently doing.

00:04:13.415 --> 00:04:15.296
And in our clinic situation,

00:04:15.537 --> 00:04:16.817
eighty-some percent,

00:04:16.877 --> 00:04:18.918
almost ninety percent of the patients,

00:04:18.978 --> 00:04:20.858
when they were coming on their own,

00:04:20.899 --> 00:04:22.620
they were going to see the podiatrist.

00:04:22.779 --> 00:04:24.521
So by far, the majority of them,

00:04:24.560 --> 00:04:25.322
and it makes sense.

00:04:25.422 --> 00:04:27.002
If you have a foot problem,

00:04:27.041 --> 00:04:28.322
you would want to go see the foot

00:04:28.362 --> 00:04:28.762
doctor.

00:04:28.802 --> 00:04:30.384
That makes a lot of sense.

00:04:30.423 --> 00:04:32.084
And that's what most of them were doing.

00:04:33.603 --> 00:04:34.464
So we felt like it was a,

00:04:35.384 --> 00:04:36.245
you know,

00:04:36.264 --> 00:04:37.865
the best approach was to start working

00:04:37.906 --> 00:04:39.846
with them since that's where the majority

00:04:39.867 --> 00:04:40.906
of the patients were coming.

00:04:41.747 --> 00:04:43.468
So that's really was the premise behind

00:04:43.507 --> 00:04:43.987
the study.

00:04:44.567 --> 00:04:46.548
And we kind of knew that when you

00:04:46.629 --> 00:04:47.689
added physical therapy,

00:04:47.709 --> 00:04:49.269
it was probably going to add some costs.

00:04:49.509 --> 00:04:51.550
And that's also the barrier to it because

00:04:51.591 --> 00:04:51.990
patients,

00:04:52.271 --> 00:04:53.451
it's going to take them a little more

00:04:53.512 --> 00:04:53.911
time.

00:04:53.951 --> 00:04:55.591
They have to participate.

00:04:55.672 --> 00:04:56.992
They have to be more engaged.

00:04:57.973 --> 00:04:59.694
So there are some upfront costs.

00:04:59.714 --> 00:05:01.115
So that's why we wanted to study this

00:05:01.154 --> 00:05:02.896
at least a year and why we even

00:05:02.937 --> 00:05:04.237
extended out to two and three years,

00:05:04.276 --> 00:05:05.478
because we wanted to see if there were

00:05:05.517 --> 00:05:07.678
downstream savings that we could then

00:05:07.699 --> 00:05:08.860
provide evidence to say, yes,

00:05:08.879 --> 00:05:10.180
there might be a little more upfront,

00:05:11.101 --> 00:05:11.762
but in the long run,

00:05:11.781 --> 00:05:12.521
it's gonna be worth it.

00:05:12.682 --> 00:05:13.923
You're gonna have better outcomes,

00:05:14.403 --> 00:05:16.324
hopefully less likely to have these

00:05:16.345 --> 00:05:17.024
problems again.

00:05:17.565 --> 00:05:19.026
And by the way, in the long run,

00:05:19.067 --> 00:05:20.927
we're gonna have a lot of cost savings.

00:05:22.576 --> 00:05:24.019
from managing other conditions,

00:05:24.038 --> 00:05:25.180
from managing that condition,

00:05:25.682 --> 00:05:26.583
from missing work,

00:05:26.923 --> 00:05:28.406
a lot of the other factors that are

00:05:28.446 --> 00:05:30.629
the economic burden of suffering from

00:05:30.668 --> 00:05:31.230
plantar heel pain.

00:05:32.488 --> 00:05:33.290
I mean, that's awesome.

00:05:33.610 --> 00:05:35.190
Thank you for sharing that background.

00:05:35.230 --> 00:05:35.872
And I mean,

00:05:35.911 --> 00:05:37.132
the thing that jumps out to me is

00:05:37.173 --> 00:05:40.154
that seven to twenty percent just seems so

00:05:40.254 --> 00:05:43.036
low for an area that, you know,

00:05:43.398 --> 00:05:44.978
I think most of us feel very comfortable

00:05:45.459 --> 00:05:46.620
evaluating trading.

00:05:46.699 --> 00:05:47.680
And like you said,

00:05:47.701 --> 00:05:49.682
there's some research to support what we

00:05:49.701 --> 00:05:50.142
do works.

00:05:50.202 --> 00:05:51.884
But this is awesome to see this like

00:05:52.124 --> 00:05:53.685
this lens and this side of it.

00:05:56.372 --> 00:05:59.514
For the viewers and listeners who haven't

00:05:59.615 --> 00:06:00.797
read your work yet,

00:06:01.076 --> 00:06:02.999
could you just orient us a little bit

00:06:03.038 --> 00:06:07.403
to the idea of your primary study and

00:06:07.423 --> 00:06:08.704
the subsequent studies?

00:06:10.404 --> 00:06:12.747
Then when you get to the cost evaluation,

00:06:12.766 --> 00:06:15.069
maybe just discuss the design so that we

00:06:15.350 --> 00:06:17.190
know what that looked like.

00:06:17.211 --> 00:06:18.833
Yeah, absolutely.

00:06:20.677 --> 00:06:21.516
So we do have a couple of,

00:06:21.596 --> 00:06:21.956
as you mentioned,

00:06:21.976 --> 00:06:23.798
we have a couple of publications from the

00:06:23.858 --> 00:06:24.637
same study.

00:06:24.858 --> 00:06:27.439
So from the start of this study,

00:06:27.519 --> 00:06:31.420
we were planning to collect the pain

00:06:31.660 --> 00:06:33.680
function, quality of life,

00:06:34.201 --> 00:06:37.062
and all of the costs related outcomes.

00:06:37.182 --> 00:06:38.482
So I think that's an important factor is

00:06:38.521 --> 00:06:42.122
that the design did include not just the,

00:06:42.163 --> 00:06:42.322
you know,

00:06:42.723 --> 00:06:43.523
I guess what I'm getting at is the

00:06:43.603 --> 00:06:44.923
economic evaluation wasn't an

00:06:45.004 --> 00:06:45.524
afterthought.

00:06:46.723 --> 00:06:49.105
We were planning that from the inception

00:06:49.404 --> 00:06:51.125
and quite a bit of planning went into

00:06:51.545 --> 00:06:53.446
designing that aspect of it particularly.

00:06:55.286 --> 00:06:57.226
So the study was a two-arm study.

00:06:57.266 --> 00:06:59.226
We had a group and it was a

00:06:59.286 --> 00:07:02.148
randomized clinical trial and it was also

00:07:02.168 --> 00:07:03.548
a very pragmatic trial.

00:07:03.608 --> 00:07:04.968
So when we talked about intervention,

00:07:06.069 --> 00:07:06.548
it wasn't

00:07:08.052 --> 00:07:09.012
I mean, it was structured,

00:07:09.072 --> 00:07:10.072
but it wasn't scripted.

00:07:10.932 --> 00:07:12.293
So it's important to kind of understand

00:07:12.314 --> 00:07:14.574
that the individuals involved in the

00:07:14.615 --> 00:07:14.875
treatment,

00:07:14.915 --> 00:07:16.516
both the podiatrist and the physical

00:07:16.555 --> 00:07:16.995
therapist,

00:07:17.755 --> 00:07:18.877
were allowed to treat the patients,

00:07:18.896 --> 00:07:19.516
for the most part,

00:07:19.557 --> 00:07:20.476
how they normally would.

00:07:23.021 --> 00:07:25.043
So because the patients were coming to see

00:07:25.062 --> 00:07:25.923
the podiatrist first,

00:07:25.983 --> 00:07:27.564
that's where they entered the study.

00:07:27.644 --> 00:07:29.665
So when they were seen by the podiatrist

00:07:29.826 --> 00:07:30.706
at our clinic,

00:07:30.747 --> 00:07:31.827
at the Des Moines University Clinic,

00:07:32.548 --> 00:07:34.269
they were then asked to enroll in the

00:07:34.310 --> 00:07:34.689
study.

00:07:35.771 --> 00:07:37.891
And so every patient started with at least

00:07:38.072 --> 00:07:39.434
one visit from a podiatrist.

00:07:40.173 --> 00:07:40.675
Then from there,

00:07:40.694 --> 00:07:42.836
we randomized them into the two different

00:07:42.857 --> 00:07:43.276
groups.

00:07:43.617 --> 00:07:45.379
One group would just continue with the

00:07:45.399 --> 00:07:47.120
podiatrist based on their recommendations.

00:07:47.721 --> 00:07:49.463
For the most part, they did follow suit.

00:07:49.504 --> 00:07:52.487
Their referral rate didn't increase much.

00:07:52.507 --> 00:07:53.028
For the most part,

00:07:53.668 --> 00:07:55.370
they managed them the way that they

00:07:55.410 --> 00:07:56.031
normally did.

00:07:56.990 --> 00:07:57.651
In the other group,

00:07:57.692 --> 00:07:59.473
they started with a physical therapist

00:07:59.533 --> 00:08:00.012
right away.

00:08:02.274 --> 00:08:02.415
Again,

00:08:02.435 --> 00:08:03.535
the physical therapist still would

00:08:03.555 --> 00:08:04.716
collaborate with the podiatrist,

00:08:04.735 --> 00:08:05.495
but for the most part,

00:08:05.536 --> 00:08:07.016
the physical therapist provided the

00:08:07.036 --> 00:08:10.619
treatment that they felt was warranted for

00:08:10.658 --> 00:08:11.240
that patient.

00:08:12.459 --> 00:08:15.822
We collected our outcomes at six weeks to

00:08:15.862 --> 00:08:18.403
capture what was going on early on after

00:08:18.423 --> 00:08:20.824
that first visit, and then six months,

00:08:21.464 --> 00:08:23.266
and then every year thereafter up to three

00:08:23.307 --> 00:08:23.547
years.

00:08:24.661 --> 00:08:27.103
So that's the design.

00:08:27.124 --> 00:08:28.764
And so the outcomes were the numeric pain

00:08:28.805 --> 00:08:29.485
rating scale,

00:08:29.745 --> 00:08:31.007
but an ankle ability measure was our

00:08:31.067 --> 00:08:32.227
functional scale.

00:08:33.428 --> 00:08:34.029
And then the,

00:08:35.791 --> 00:08:37.772
we use the EQ five D to get

00:08:37.812 --> 00:08:39.053
their quality of life,

00:08:39.094 --> 00:08:40.914
which was used in the economic evaluation.

00:08:40.934 --> 00:08:43.937
And then we used our billing records to

00:08:43.976 --> 00:08:44.778
get costs.

00:08:44.998 --> 00:08:47.500
So we knew all the charges in all

00:08:47.539 --> 00:08:49.361
of the departments that they were seen in.

00:08:50.543 --> 00:08:52.163
And then anything, any,

00:08:52.850 --> 00:08:54.672
treatments that they had outside of our

00:08:54.711 --> 00:08:55.091
clinic,

00:08:55.631 --> 00:08:56.793
there was a questionnaire that we

00:08:56.812 --> 00:08:58.214
developed that was modeled off of other

00:08:58.234 --> 00:09:00.095
questionnaires that have been validated in

00:09:00.115 --> 00:09:02.115
order to capture all of the costs.

00:09:02.336 --> 00:09:04.035
So if they went to an acupuncturist,

00:09:04.517 --> 00:09:05.636
they were documenting that.

00:09:05.756 --> 00:09:06.837
If they had to travel to those

00:09:06.878 --> 00:09:08.357
appointments, they were documenting that.

00:09:08.739 --> 00:09:09.798
If they missed time from work,

00:09:09.879 --> 00:09:10.940
they were documenting that.

00:09:11.460 --> 00:09:13.561
So we captured as best we could all

00:09:13.640 --> 00:09:15.902
the costs that we related to treatment,

00:09:16.581 --> 00:09:18.102
either directly or indirectly.

00:09:21.453 --> 00:09:22.494
And yeah,

00:09:22.554 --> 00:09:24.134
I think that was the general design that,

00:09:24.154 --> 00:09:26.015
oh, uh, as far as the studies,

00:09:26.056 --> 00:09:29.216
then we had our initial publication was

00:09:29.336 --> 00:09:31.097
in, uh,

00:09:31.177 --> 00:09:33.178
and that was just the one year follow-up

00:09:33.259 --> 00:09:34.438
and just the outcomes.

00:09:34.619 --> 00:09:36.679
So our outcomes with regards to pain and

00:09:36.720 --> 00:09:38.640
function between the two groups.

00:09:38.681 --> 00:09:40.422
And of course we described the study

00:09:40.442 --> 00:09:41.282
methodology there.

00:09:42.076 --> 00:09:44.538
We followed up with that in the next

00:09:44.600 --> 00:09:46.081
year with a case series.

00:09:46.142 --> 00:09:47.062
And in that case series,

00:09:47.082 --> 00:09:47.903
what our intent was,

00:09:47.923 --> 00:09:49.787
was really to describe the details of the

00:09:49.807 --> 00:09:50.528
treatment provided,

00:09:50.587 --> 00:09:51.729
particularly in the

00:09:52.994 --> 00:09:55.235
podiatry plus physical therapy group.

00:09:55.556 --> 00:09:58.076
So we went through our decision-making,

00:09:58.517 --> 00:10:00.437
the process, the details,

00:10:00.498 --> 00:10:02.158
how we prioritized what treatments,

00:10:02.198 --> 00:10:03.539
how we decided what treatments.

00:10:04.200 --> 00:10:05.760
Again, even though it was pragmatic,

00:10:05.780 --> 00:10:09.682
there was an impairment-based logic behind

00:10:09.702 --> 00:10:11.504
it that we tried to outline as best

00:10:11.543 --> 00:10:12.543
we could in that article.

00:10:13.585 --> 00:10:15.485
We also have a nice appendix that

00:10:15.525 --> 00:10:17.706
describes the exercise interventions done,

00:10:17.726 --> 00:10:19.307
the manual interventions that are done.

00:10:19.966 --> 00:10:21.006
It gives you a little bit of a

00:10:21.386 --> 00:10:23.568
depiction of the frequency of some of

00:10:23.589 --> 00:10:24.808
those interventions as well.

00:10:25.690 --> 00:10:27.410
And that's also described in the initial

00:10:27.431 --> 00:10:28.072
paper too,

00:10:28.951 --> 00:10:30.573
the frequency of which interventions.

00:10:31.313 --> 00:10:32.995
So you kind of get a snapshot of

00:10:33.034 --> 00:10:33.596
what was done.

00:10:34.744 --> 00:10:35.543
And then lastly,

00:10:36.105 --> 00:10:37.725
and recently published was our economic

00:10:37.765 --> 00:10:40.826
evaluation because that included the three

00:10:40.866 --> 00:10:41.648
year outcomes.

00:10:42.427 --> 00:10:44.548
So in that study,

00:10:44.889 --> 00:10:47.530
the focus was obviously looking at the

00:10:47.610 --> 00:10:50.732
cost effectiveness between the two groups.

00:10:50.812 --> 00:10:55.274
So can we improve their health related

00:10:55.315 --> 00:10:59.456
quality of life at a lower cost across

00:10:59.537 --> 00:11:00.778
a three year time span?

00:11:00.798 --> 00:11:02.399
Uh, and,

00:11:02.898 --> 00:11:03.139
You know,

00:11:03.418 --> 00:11:04.421
I'll let the cat out of the bag.

00:11:04.461 --> 00:11:05.722
Hopefully everybody's read the article

00:11:05.764 --> 00:11:06.104
anyway.

00:11:07.145 --> 00:11:08.087
But the good news is,

00:11:08.107 --> 00:11:10.231
is we were able to demonstrate cost

00:11:10.272 --> 00:11:13.859
effectiveness in economic valuation

00:11:13.899 --> 00:11:14.379
language

00:11:15.384 --> 00:11:18.424
the usual podiatry plus physical therapy

00:11:18.465 --> 00:11:20.966
treatment dominated the usual podiatry

00:11:20.985 --> 00:11:24.407
treatment, meaning it was more effective.

00:11:24.626 --> 00:11:26.868
You got a better outcome and it was

00:11:27.288 --> 00:11:29.828
less costly, meaning it costs less.

00:11:29.869 --> 00:11:30.769
It's kind of a no brainer.

00:11:30.789 --> 00:11:31.750
When you go to the store and you

00:11:31.789 --> 00:11:33.409
find something that's a better value and

00:11:33.450 --> 00:11:34.471
it actually costs less,

00:11:35.270 --> 00:11:36.631
you're buying that every time.

00:11:37.753 --> 00:11:38.854
So that was the good news.

00:11:38.913 --> 00:11:39.494
And again,

00:11:40.054 --> 00:11:43.157
fairly robust across the different

00:11:43.677 --> 00:11:46.458
replicates that we we tried to utilize to

00:11:47.879 --> 00:11:49.160
to demonstrate some of the potential

00:11:49.181 --> 00:11:49.861
variability.

00:11:50.902 --> 00:11:51.822
And pretty consistently,

00:11:51.863 --> 00:11:53.783
things fell into that category of being

00:11:53.823 --> 00:11:54.544
cost effective.

00:11:56.004 --> 00:11:56.644
That's awesome.

00:11:56.923 --> 00:11:59.524
And thank you for lining that out because

00:11:59.544 --> 00:12:01.306
that'll be nice as we're going through our

00:12:01.346 --> 00:12:03.206
discussion to have that orientation to

00:12:03.245 --> 00:12:05.067
kind of like the three tiers of the

00:12:05.106 --> 00:12:07.506
publication and especially referencing

00:12:07.547 --> 00:12:09.587
that case series,

00:12:09.648 --> 00:12:11.427
which was illustrating the interventions

00:12:11.467 --> 00:12:13.269
for the different heel pain presentations.

00:12:14.048 --> 00:12:14.708
I find that one,

00:12:14.928 --> 00:12:15.990
I find all of it interesting.

00:12:16.529 --> 00:12:18.070
I just love diving into the actual

00:12:18.110 --> 00:12:19.490
interventions you chose and why.

00:12:19.510 --> 00:12:20.490
I thought that was awesome.

00:12:21.311 --> 00:12:22.912
So let's start.

00:12:24.912 --> 00:12:26.833
And you already prefaced some of this,

00:12:26.874 --> 00:12:28.535
but let's just start with talking a little

00:12:28.576 --> 00:12:30.898
bit about the cost effectiveness study.

00:12:32.779 --> 00:12:34.782
Can you just talk a little bit about

00:12:35.202 --> 00:12:39.606
the two branches that you chose and maybe

00:12:39.647 --> 00:12:41.749
just give another overview of kind of the

00:12:41.769 --> 00:12:44.011
results and the biggest kind of takeaway

00:12:44.032 --> 00:12:46.193
that you found from that one?

00:12:47.966 --> 00:12:48.187
Yeah,

00:12:48.226 --> 00:12:49.769
so the two branches of the study or

00:12:49.788 --> 00:12:51.129
the two arms of the study would have

00:12:51.149 --> 00:12:52.390
been usual podiatry care.

00:12:52.410 --> 00:12:52.850
So again,

00:12:53.251 --> 00:12:55.072
following the care that the podiatrist

00:12:55.394 --> 00:12:55.974
recommended,

00:12:57.195 --> 00:12:59.177
primarily it was a handout on certain

00:12:59.216 --> 00:13:03.139
exercises, you know, your calf stretching,

00:13:03.220 --> 00:13:05.743
some banded plantar flexion exercises.

00:13:06.263 --> 00:13:08.904
They would almost always prescribe a foot

00:13:09.446 --> 00:13:11.748
orthosis in most cases,

00:13:11.908 --> 00:13:12.908
typically over the counter.

00:13:13.458 --> 00:13:14.379
typically are getting some

00:13:14.440 --> 00:13:16.140
anti-inflammatory medications with that.

00:13:17.321 --> 00:13:18.341
On lesser occasions,

00:13:18.361 --> 00:13:20.342
they might have injections into the heel

00:13:20.383 --> 00:13:21.023
that are performed.

00:13:21.644 --> 00:13:23.745
And in even fewer circumstances,

00:13:23.784 --> 00:13:27.027
there were a few cases that did end

00:13:27.047 --> 00:13:29.227
up having a surgery on the plantar fascia.

00:13:31.054 --> 00:13:33.856
compared to the group that had that

00:13:33.897 --> 00:13:35.738
initial visit with the podiatrist and then

00:13:35.758 --> 00:13:36.977
they saw a physical therapist.

00:13:38.058 --> 00:13:40.259
We were typically assessing for

00:13:40.279 --> 00:13:42.721
impairments anywhere from the lumbar spine

00:13:43.121 --> 00:13:44.081
down to the ankle and foot,

00:13:44.643 --> 00:13:46.264
generally prioritizing a little bit of the

00:13:46.344 --> 00:13:47.004
ankle and foot.

00:13:47.104 --> 00:13:48.684
So limited dorsiflexion is a common

00:13:48.705 --> 00:13:49.184
impairment.

00:13:49.284 --> 00:13:50.586
We were using joint mobilization

00:13:50.625 --> 00:13:51.125
techniques,

00:13:51.166 --> 00:13:52.586
manual techniques to the calf and the

00:13:52.606 --> 00:13:53.307
plantar fascia.

00:13:53.908 --> 00:13:55.471
to address those impairments,

00:13:56.693 --> 00:13:59.379
both medial and lateral gliding of the

00:13:59.418 --> 00:14:00.221
calcaneus,

00:14:00.301 --> 00:14:02.765
addressing issues in the forefoot as well.

00:14:03.186 --> 00:14:03.586
So again,

00:14:03.748 --> 00:14:05.951
any impairment that we commonly find

00:14:06.673 --> 00:14:08.916
we were managing that using manual

00:14:08.936 --> 00:14:10.357
intervention and then typically

00:14:10.398 --> 00:14:13.039
complementing it with or augmenting it

00:14:13.100 --> 00:14:14.981
with an exercise that would kind of match

00:14:15.001 --> 00:14:15.643
that impairment.

00:14:15.822 --> 00:14:18.585
So I would suggest a very impairment-based

00:14:19.125 --> 00:14:19.966
approach that was taken,

00:14:20.006 --> 00:14:22.308
but also very pragmatic in the sense that

00:14:22.908 --> 00:14:24.791
some patients might have almost exclusive

00:14:24.870 --> 00:14:25.851
ankle and foot intervention.

00:14:25.971 --> 00:14:26.673
Other patients,

00:14:27.253 --> 00:14:28.653
the priority might have been more in the

00:14:28.695 --> 00:14:30.176
lumbopelvic area where they had

00:14:30.682 --> 00:14:32.365
more impairments up there that we felt

00:14:32.384 --> 00:14:33.966
were contributing to their symptoms,

00:14:34.547 --> 00:14:36.087
of which we typically tried to confirm

00:14:36.107 --> 00:14:37.950
with a pre-post-test kind of assessment.

00:14:37.990 --> 00:14:39.331
So we might do some manual intervention to

00:14:39.351 --> 00:14:40.211
the lumbar spine.

00:14:40.913 --> 00:14:43.615
And if we measured their asterisk or

00:14:43.635 --> 00:14:45.216
comparable sign and they got better,

00:14:45.697 --> 00:14:46.818
then we would say, hey,

00:14:46.839 --> 00:14:48.179
that's probably something we need to

00:14:48.220 --> 00:14:49.400
prioritize in their treatment,

00:14:49.822 --> 00:14:51.222
in addition to whatever else we might be

00:14:51.263 --> 00:14:51.562
doing.

00:14:53.904 --> 00:14:55.245
I'm probably missing some things that we

00:14:55.285 --> 00:14:56.807
did treatment-wise,

00:14:56.866 --> 00:14:58.488
but off the top of my head,

00:14:58.967 --> 00:15:01.288
those were the primary things that we were

00:15:01.308 --> 00:15:02.389
working on with those patients.

00:15:02.409 --> 00:15:03.591
So they definitely got a heavy dose of

00:15:03.610 --> 00:15:05.831
manual therapy, heavy dose of exercise.

00:15:05.851 --> 00:15:07.113
They were doing a home program.

00:15:07.873 --> 00:15:10.414
And we were following up typically a

00:15:10.455 --> 00:15:11.635
couple of times a week at first,

00:15:11.676 --> 00:15:12.936
but then we would decrease to once a

00:15:12.975 --> 00:15:13.216
week.

00:15:14.336 --> 00:15:15.398
And I think on average,

00:15:16.418 --> 00:15:18.799
somewhere around six visits or so per

00:15:18.860 --> 00:15:20.961
patient in that group.

00:15:23.418 --> 00:15:26.081
So, um, those, those were the two arms,

00:15:26.441 --> 00:15:27.802
um, of the study there.

00:15:27.822 --> 00:15:29.123
Um,

00:15:29.182 --> 00:15:30.903
and then what was the next follow-up you

00:15:30.945 --> 00:15:31.144
wanted?

00:15:31.764 --> 00:15:31.884
Well,

00:15:31.965 --> 00:15:33.025
I just had a quick question on the

00:15:33.145 --> 00:15:33.306
arms.

00:15:33.446 --> 00:15:37.048
Was there any discussion of a PT like

00:15:37.269 --> 00:15:39.230
only arm, you know,

00:15:39.250 --> 00:15:42.092
just to see how that would compare with

00:15:42.852 --> 00:15:43.173
the other two?

00:15:43.874 --> 00:15:43.974
Yeah.

00:15:43.994 --> 00:15:45.475
And it would have been nice to, yeah,

00:15:45.495 --> 00:15:46.596
it would have been really nice to have

00:15:46.635 --> 00:15:46.836
that.

00:15:46.855 --> 00:15:47.937
And, and, um,

00:15:49.090 --> 00:15:50.169
So a couple of issues with that,

00:15:50.230 --> 00:15:51.730
obviously it increased our sample size

00:15:51.750 --> 00:15:52.811
significantly if we're adding another

00:15:52.831 --> 00:15:54.692
group in there, you know,

00:15:55.371 --> 00:15:58.212
that makes it kind of difficult to get

00:15:58.232 --> 00:15:58.832
the enrollment.

00:15:59.932 --> 00:16:01.354
The second thing was, is again,

00:16:01.394 --> 00:16:02.653
the problem at the time that we were

00:16:02.673 --> 00:16:04.254
trying to address is the fact that we

00:16:04.294 --> 00:16:05.695
weren't really getting patients referred

00:16:05.715 --> 00:16:07.155
to us from these other providers.

00:16:08.375 --> 00:16:12.157
So I do feel like we can treat

00:16:12.177 --> 00:16:13.898
these patients off the street or in direct

00:16:13.977 --> 00:16:15.097
access quite well,

00:16:16.298 --> 00:16:16.538
but

00:16:18.698 --> 00:16:19.458
But at this point in time,

00:16:19.479 --> 00:16:21.000
we really wanted to provide some evidence

00:16:21.019 --> 00:16:22.820
to other providers that if they're seeing

00:16:22.860 --> 00:16:23.100
them,

00:16:23.159 --> 00:16:25.421
then we can provide an added benefit.

00:16:25.500 --> 00:16:26.341
So I would say that would be the

00:16:26.380 --> 00:16:28.600
main reason why we didn't go that route.

00:16:28.640 --> 00:16:29.400
But you're right,

00:16:29.421 --> 00:16:31.282
it makes a lot of sense.

00:16:32.022 --> 00:16:34.062
I think that's a great answer, though,

00:16:34.082 --> 00:16:37.342
because as we'll talk about later,

00:16:37.423 --> 00:16:39.244
some of the takeaways from this is working

00:16:39.283 --> 00:16:42.624
with clinicians and working in teams is

00:16:42.783 --> 00:16:44.644
usually a multidisciplinary approach.

00:16:45.525 --> 00:16:47.126
So I actually kind of like that idea

00:16:47.167 --> 00:16:48.106
of having the two arms,

00:16:48.167 --> 00:16:51.708
both including the referral source.

00:16:51.729 --> 00:16:56.250
So then when we go into looking at

00:16:56.289 --> 00:16:59.052
that case series of those eight

00:16:59.091 --> 00:17:01.373
treatments, can you talk a little bit,

00:17:01.513 --> 00:17:02.993
well, I guess this is for both studies,

00:17:03.033 --> 00:17:04.433
but can you talk a little bit about

00:17:04.473 --> 00:17:07.454
the inclusion criteria that was referenced

00:17:07.494 --> 00:17:08.015
in the article,

00:17:08.055 --> 00:17:10.435
just so we kind of understand the

00:17:10.476 --> 00:17:11.777
population that was being treated?

00:17:13.734 --> 00:17:13.994
Yeah,

00:17:14.035 --> 00:17:20.258
so the patients had to have symptoms for

00:17:20.317 --> 00:17:22.137
long enough, not for too long,

00:17:22.178 --> 00:17:25.119
but long enough that it wasn't just an

00:17:25.140 --> 00:17:27.180
acute kind of situation.

00:17:27.881 --> 00:17:35.644
So I'm actually gonna go.

00:17:35.683 --> 00:17:35.864
The...

00:17:37.691 --> 00:17:39.813
The diagnosis was made clinically as it

00:17:39.853 --> 00:17:40.433
normally is.

00:17:40.493 --> 00:17:42.355
So they need to have palpatory pain at

00:17:42.375 --> 00:17:45.818
the medial aspect of the calcaneus near

00:17:45.838 --> 00:17:47.601
the proximal attachment of the plantar

00:17:47.641 --> 00:17:48.102
fascia.

00:17:49.943 --> 00:17:53.208
And it needs to be worse with the

00:17:53.228 --> 00:17:53.847
initial steps,

00:17:53.887 --> 00:17:54.949
typically first thing in the morning,

00:17:54.969 --> 00:17:56.250
but it could be after they've been sitting

00:17:56.290 --> 00:17:57.031
for a long time.

00:17:58.217 --> 00:17:58.798
typical patterns,

00:17:58.857 --> 00:18:00.499
it dissipates and actually move a little

00:18:00.519 --> 00:18:00.659
bit,

00:18:00.679 --> 00:18:01.920
but then gets worse the more that they're

00:18:01.960 --> 00:18:02.520
on their feet.

00:18:03.221 --> 00:18:04.742
So if they're meeting kind of that

00:18:04.782 --> 00:18:05.463
criteria,

00:18:06.825 --> 00:18:09.007
they did need to have enough of a

00:18:09.106 --> 00:18:11.628
disability on the FAM in order for us

00:18:11.669 --> 00:18:12.931
to make a meaningful change.

00:18:13.310 --> 00:18:14.332
So, you know,

00:18:14.511 --> 00:18:16.153
that was another part of the criteria.

00:18:16.354 --> 00:18:18.415
It is the FAM had to be low

00:18:18.455 --> 00:18:20.317
enough that we could make enough

00:18:20.837 --> 00:18:22.038
improvement in their case.

00:18:22.078 --> 00:18:22.940
So they couldn't just have

00:18:23.460 --> 00:18:25.964
a little bit of plantar fasciitis symptoms

00:18:26.025 --> 00:18:28.229
affecting and barely affecting their

00:18:28.249 --> 00:18:28.788
disability.

00:18:29.329 --> 00:18:29.691
Similarly,

00:18:29.711 --> 00:18:32.214
we had to have enough sufficient pain to

00:18:32.255 --> 00:18:32.836
be included.

00:18:33.922 --> 00:18:36.163
We did try to exclude other factors that

00:18:36.542 --> 00:18:41.705
wouldn't be considered plantar fasciitis.

00:18:41.766 --> 00:18:47.008
So radiculopathy is one of the exclusion

00:18:47.848 --> 00:18:48.509
criteria,

00:18:49.470 --> 00:18:50.930
and that would be hard signs of

00:18:50.970 --> 00:18:51.671
radiculopathy.

00:18:51.770 --> 00:18:53.991
So definitely seeing motor loss,

00:18:54.172 --> 00:18:54.991
sensory loss,

00:18:55.031 --> 00:18:57.133
that is something that we can measure with

00:18:57.153 --> 00:18:57.993
our clinical tests.

00:18:59.093 --> 00:19:00.933
And I say that because a lot of

00:19:00.953 --> 00:19:03.315
these patients seem to have something

00:19:03.375 --> 00:19:05.415
neurogenically going on when you test

00:19:05.435 --> 00:19:06.717
their neurodynamics, and again,

00:19:06.737 --> 00:19:07.916
when we treat the lumbar spine.

00:19:07.957 --> 00:19:09.877
So obviously there is something going on

00:19:09.917 --> 00:19:11.798
there that's the relationship between the

00:19:11.818 --> 00:19:13.539
lumbar spine, not just the nerves,

00:19:14.099 --> 00:19:15.921
but the structures of the lumbar spine are

00:19:16.020 --> 00:19:17.561
influencing their pain experience and

00:19:17.582 --> 00:19:18.061
their heal,

00:19:18.863 --> 00:19:20.482
which again is why I feel like physical

00:19:20.502 --> 00:19:21.723
therapists should be included in this

00:19:21.763 --> 00:19:22.243
population,

00:19:22.263 --> 00:19:23.444
at least just a screen for that.

00:19:24.746 --> 00:19:26.587
If we can't find any impairments in lumbar

00:19:26.607 --> 00:19:29.510
spine or with our neurodynamic testing,

00:19:30.612 --> 00:19:33.095
then very well some of the excellent

00:19:33.115 --> 00:19:34.355
treatment that our podiatrists and other

00:19:34.375 --> 00:19:35.897
providers provide might be all that they

00:19:35.938 --> 00:19:36.238
need.

00:19:38.559 --> 00:19:40.241
But in some cases that could be,

00:19:40.422 --> 00:19:42.443
I would suggest it could be the reason

00:19:42.463 --> 00:19:43.705
why many of these patients go on to

00:19:43.746 --> 00:19:45.428
have persisting symptoms and continued

00:19:45.468 --> 00:19:45.688
pain.

00:19:48.865 --> 00:19:50.506
So we also want to exclude anybody with,

00:19:51.385 --> 00:19:52.945
you know, tumor or fracture,

00:19:53.105 --> 00:19:54.606
rheumatic inflammatory disease,

00:19:54.646 --> 00:19:56.846
so rheumatoid or reactive or psoriatic

00:19:56.886 --> 00:19:58.967
arthritis, inflammatory bowel disease,

00:19:59.688 --> 00:20:01.867
some of these conditions that might mimic

00:20:02.347 --> 00:20:03.188
plantar heel pain.

00:20:03.709 --> 00:20:06.028
We wanted to also make sure they were

00:20:06.108 --> 00:20:07.689
clean from any treatment in the past six

00:20:07.709 --> 00:20:08.009
weeks.

00:20:08.210 --> 00:20:09.549
So if they'd seen other providers,

00:20:09.569 --> 00:20:10.750
we wanted to have kind of a washout

00:20:10.789 --> 00:20:13.671
period and would exclude those that have

00:20:13.691 --> 00:20:14.790
had more recent treatment.

00:20:17.829 --> 00:20:18.770
Yeah, that's great.

00:20:18.790 --> 00:20:20.892
Thank you for that background.

00:20:20.932 --> 00:20:23.233
And I thought it was a thorough and

00:20:23.294 --> 00:20:26.396
thoughtful inclusion criteria based on

00:20:26.596 --> 00:20:27.738
what you were just discussing.

00:20:27.798 --> 00:20:30.039
And I thought it was interesting to talk

00:20:30.059 --> 00:20:31.421
about timeline,

00:20:31.861 --> 00:20:34.923
patients with greater than a year of heel

00:20:34.963 --> 00:20:35.324
pain,

00:20:36.244 --> 00:20:39.988
given that this is often a diagnosis that

00:20:40.008 --> 00:20:41.469
goes untreated for a long time.

00:20:42.569 --> 00:20:44.371
And it can be recalcitrant and

00:20:45.178 --> 00:20:45.778
and lingering.

00:20:45.898 --> 00:20:49.321
And so I think that speaks a little

00:20:49.342 --> 00:20:52.104
bit to where we can add some value,

00:20:52.124 --> 00:20:53.944
but also that idea of confounding

00:20:53.984 --> 00:20:55.686
variables that make diagnosis and

00:20:55.707 --> 00:20:56.867
treatment challenging.

00:20:56.928 --> 00:20:57.028
Yeah.

00:20:57.602 --> 00:20:58.382
Yeah, I mean, that's a good point.

00:20:58.402 --> 00:20:59.362
So, you know,

00:20:59.442 --> 00:21:00.462
I don't know if I clarified that,

00:21:00.482 --> 00:21:02.343
but we did exclude those who had symptoms

00:21:02.423 --> 00:21:03.083
more than a year.

00:21:04.263 --> 00:21:06.443
So not to say we can't provide benefit

00:21:06.463 --> 00:21:07.203
to those patients,

00:21:07.263 --> 00:21:11.765
but we also wanted to kind of mimic

00:21:11.845 --> 00:21:13.385
other studies that were kind of using very

00:21:13.445 --> 00:21:14.705
similar criteria as well.

00:21:14.766 --> 00:21:17.186
So we could compare our results to some

00:21:17.207 --> 00:21:18.146
of the other literature as well.

00:21:19.098 --> 00:21:20.019
Yeah, that's awesome.

00:21:20.579 --> 00:21:24.663
So diving into that article a little bit,

00:21:25.202 --> 00:21:27.924
the case series with the eight treatments,

00:21:27.944 --> 00:21:29.346
can you talk a little bit to the

00:21:29.425 --> 00:21:32.268
audience like how you chose those eight

00:21:32.307 --> 00:21:33.608
different cases and why,

00:21:34.049 --> 00:21:35.911
and why that would be important for

00:21:35.951 --> 00:21:38.153
somebody who's maybe dealing with this in

00:21:38.192 --> 00:21:40.773
the clinic of using that as a reference

00:21:40.794 --> 00:21:42.796
for different almost categories of heel

00:21:42.816 --> 00:21:42.955
pain?

00:21:42.976 --> 00:21:44.936
Yeah, I mean,

00:21:44.957 --> 00:21:45.678
that is kind of the point.

00:21:45.718 --> 00:21:47.719
So as I reflected on some of the

00:21:47.759 --> 00:21:48.259
cases,

00:21:49.211 --> 00:21:49.672
You know,

00:21:49.772 --> 00:21:52.234
it did seem like there were definitely

00:21:52.295 --> 00:21:52.775
different.

00:21:53.715 --> 00:21:53.935
And again,

00:21:53.977 --> 00:21:55.178
every patient I would say probably

00:21:55.218 --> 00:21:56.679
received a little bit different treatment

00:21:56.759 --> 00:21:58.340
because, again, it was pretty pragmatic.

00:21:58.381 --> 00:22:01.063
But there were some staples across the

00:22:01.083 --> 00:22:01.804
board in the treatment.

00:22:01.864 --> 00:22:02.785
So in that study,

00:22:02.825 --> 00:22:05.126
if you do look at the again,

00:22:05.146 --> 00:22:06.567
this will be posted, I'm sure.

00:22:06.647 --> 00:22:07.990
This is the case report published in

00:22:08.029 --> 00:22:09.471
Physiotherapy Theory and Practice.

00:22:09.510 --> 00:22:11.053
But we have some tables towards the end.

00:22:12.353 --> 00:22:14.134
which can be useful to give you a

00:22:14.473 --> 00:22:15.595
synopsis of what was done.

00:22:15.674 --> 00:22:18.236
So since this is the AONT podcast,

00:22:18.256 --> 00:22:19.915
we'll talk about the manual therapy first.

00:22:19.976 --> 00:22:21.237
If you look across the board there,

00:22:21.997 --> 00:22:24.738
almost everybody had myofascial treatments

00:22:24.778 --> 00:22:25.378
to the calf.

00:22:26.439 --> 00:22:27.759
So I would say this is something

00:22:27.960 --> 00:22:31.201
clinically we find quite effective to help

00:22:31.320 --> 00:22:32.141
manage our symptoms.

00:22:32.201 --> 00:22:33.862
So we would treat their calf and the

00:22:33.902 --> 00:22:34.541
foot as well.

00:22:35.123 --> 00:22:37.202
But I think calf is definitely a nice

00:22:37.262 --> 00:22:38.864
area because it's not right.

00:22:38.923 --> 00:22:40.105
If their symptoms are really hot,

00:22:40.285 --> 00:22:40.625
you're not...

00:22:41.484 --> 00:22:43.445
directly intervening right where their

00:22:43.465 --> 00:22:44.665
pain is the highest at.

00:22:45.146 --> 00:22:46.826
You're dealing with an area that typically

00:22:46.866 --> 00:22:49.167
tends to refer and can help calm that

00:22:49.228 --> 00:22:50.669
down a little bit and open up the

00:22:50.729 --> 00:22:51.849
door to more treatments.

00:22:52.930 --> 00:22:54.530
We're very commonly doing dorsiflexion

00:22:54.550 --> 00:22:55.111
mobilization,

00:22:55.131 --> 00:22:56.491
so working on the talocrural joint,

00:22:56.551 --> 00:22:58.172
working on the rear foot, which again,

00:22:59.053 --> 00:23:00.232
from an anatomic standpoint,

00:23:00.272 --> 00:23:01.354
makes a lot of sense.

00:23:02.559 --> 00:23:03.359
And then from there,

00:23:03.660 --> 00:23:05.881
you started to see some scattering of

00:23:05.921 --> 00:23:07.521
things to where there were some patients

00:23:07.541 --> 00:23:10.202
that tended to benefit a little bit more

00:23:10.282 --> 00:23:13.263
from midfoot and forefoot mobilizations to

00:23:13.903 --> 00:23:15.444
knee impairments,

00:23:15.464 --> 00:23:16.365
treating knee impairments.

00:23:16.384 --> 00:23:18.306
A lot of times if they lack a

00:23:18.346 --> 00:23:19.685
knee extension, for example,

00:23:19.705 --> 00:23:21.906
they're gonna load the heel a little bit

00:23:21.967 --> 00:23:22.467
differently.

00:23:22.707 --> 00:23:24.728
And there's some biomechanical rationale

00:23:24.748 --> 00:23:26.628
behind why that might be an issue.

00:23:27.429 --> 00:23:27.888
Similarly,

00:23:27.989 --> 00:23:31.030
lumbar impairments were considerations,

00:23:31.310 --> 00:23:32.250
again, not in everyone,

00:23:32.310 --> 00:23:33.451
but in many of the cases.

00:23:33.912 --> 00:23:35.992
And then neurodynamic impairments were

00:23:36.032 --> 00:23:37.012
things that were addressed.

00:23:37.933 --> 00:23:39.594
So those were some of the common things

00:23:39.634 --> 00:23:41.315
from a manual therapy perspective that

00:23:41.335 --> 00:23:41.976
were kind of done.

00:23:42.056 --> 00:23:42.415
And again,

00:23:42.915 --> 00:23:44.115
each of the eight different cases

00:23:44.196 --> 00:23:45.356
illustrates kind of a different

00:23:45.396 --> 00:23:47.817
combination of treatment,

00:23:47.837 --> 00:23:48.999
including that manual therapy,

00:23:49.019 --> 00:23:50.880
but then also the therapeutic exercise.

00:23:51.640 --> 00:23:54.181
And then the exercise, the most common

00:23:55.563 --> 00:23:56.762
I would say evidence-based treatment

00:23:56.803 --> 00:23:59.624
includes stretching or some type of

00:23:59.765 --> 00:24:02.046
mobilization of the calf and the foot in

00:24:02.066 --> 00:24:03.506
the plantar fascia as well.

00:24:03.625 --> 00:24:05.807
So we did use that most frequently in

00:24:05.866 --> 00:24:06.847
almost every case,

00:24:08.209 --> 00:24:09.709
following up if they endorse flexion

00:24:09.749 --> 00:24:11.490
limitations with some type of mobility

00:24:11.549 --> 00:24:12.371
exercise.

00:24:12.911 --> 00:24:14.310
It could be kind of a mobilization with

00:24:14.391 --> 00:24:15.392
movement type treatment.

00:24:16.288 --> 00:24:17.648
So it would mimic a lot of the

00:24:17.689 --> 00:24:18.469
manual intervention.

00:24:18.509 --> 00:24:20.130
So almost every manual intervention that I

00:24:20.150 --> 00:24:23.172
just described, in these cases,

00:24:23.211 --> 00:24:25.133
there would be a corresponding exercise

00:24:25.153 --> 00:24:26.993
intervention addressing that mobility

00:24:27.034 --> 00:24:27.493
impairment.

00:24:28.374 --> 00:24:29.954
Another thing I want to kind of highlight

00:24:30.474 --> 00:24:31.135
that we did,

00:24:31.855 --> 00:24:33.777
and I feel like there's a lot more

00:24:33.836 --> 00:24:36.939
evidence in this area that's been great to

00:24:36.979 --> 00:24:37.179
see,

00:24:37.239 --> 00:24:39.220
and that's the strengthening component.

00:24:39.949 --> 00:24:41.589
You know, our counterparts,

00:24:41.630 --> 00:24:43.849
the podiatrists typically tend to put foot

00:24:43.910 --> 00:24:45.730
inserts, which tend to support the arch.

00:24:46.250 --> 00:24:48.791
And that does affect the activity of the

00:24:48.811 --> 00:24:51.472
muscles, including the long-term strength.

00:24:52.153 --> 00:24:54.034
And so I think it's also a nice

00:24:54.054 --> 00:24:55.534
little pairing for us to work with those

00:24:55.574 --> 00:24:57.075
individuals because we can actually show

00:24:57.095 --> 00:24:58.375
them how to strengthen their foot,

00:24:58.394 --> 00:24:59.496
how to strengthen their calf,

00:25:00.316 --> 00:25:01.256
how to strengthen their hip,

00:25:01.936 --> 00:25:03.396
or wherever the impairment is,

00:25:03.457 --> 00:25:05.458
it might be related to muscle performance.

00:25:06.077 --> 00:25:07.559
we can address those muscle performance

00:25:08.000 --> 00:25:10.743
deficits and complement the more passive

00:25:10.784 --> 00:25:12.665
modalities such as a foot orthosis that

00:25:12.746 --> 00:25:16.570
could be in the long run detrimental to

00:25:16.892 --> 00:25:17.571
foot strength.

00:25:18.353 --> 00:25:19.734
And we did a prior study where we

00:25:19.775 --> 00:25:20.997
actually looked at the correlation.

00:25:21.436 --> 00:25:22.618
And again, it's a correlation,

00:25:22.679 --> 00:25:23.880
not necessarily causation,

00:25:23.900 --> 00:25:24.981
but a correlation between

00:25:25.321 --> 00:25:27.462
how long someone has worn foot orthoses

00:25:27.923 --> 00:25:29.324
and their foot strength with certain

00:25:29.344 --> 00:25:30.105
measures that we did.

00:25:30.164 --> 00:25:33.185
So toe intrinsic kind of flexor strength,

00:25:33.605 --> 00:25:34.747
calf raises as well.

00:25:35.166 --> 00:25:36.248
And we tend to find that those who

00:25:36.387 --> 00:25:38.689
use foot orthoses for longer tend to have

00:25:38.749 --> 00:25:39.328
more weakness.

00:25:39.348 --> 00:25:40.970
So it seems to make sense that, hey,

00:25:41.009 --> 00:25:42.191
maybe we can intervene in these

00:25:42.211 --> 00:25:44.832
populations and help them with some

00:25:44.872 --> 00:25:46.313
interventions and direct them how to

00:25:46.373 --> 00:25:48.973
strengthen their foot and their lower leg

00:25:49.494 --> 00:25:50.855
to not have these long standing

00:25:50.894 --> 00:25:52.856
impairments that are likely only going to

00:25:52.876 --> 00:25:53.717
get worse over time.

00:25:54.590 --> 00:25:55.852
And then of course we would address their

00:25:55.892 --> 00:25:56.731
movement proficiency.

00:25:56.771 --> 00:25:59.113
So gait training and a lot of our

00:25:59.133 --> 00:26:00.814
strengthening would work up the chain too.

00:26:00.933 --> 00:26:01.753
So again,

00:26:01.794 --> 00:26:03.555
if they had lumbopelvic or hip

00:26:03.595 --> 00:26:04.795
impairments, we'd address those,

00:26:04.815 --> 00:26:06.115
we'd try to integrate it into their

00:26:06.135 --> 00:26:06.536
function.

00:26:07.036 --> 00:26:07.997
So if they were a runner,

00:26:08.017 --> 00:26:08.537
we'd try to,

00:26:08.896 --> 00:26:10.198
if they had to back down from it,

00:26:10.258 --> 00:26:11.877
we'd try to get them back into running

00:26:11.938 --> 00:26:12.218
again.

00:26:13.818 --> 00:26:15.759
So that in a nutshell is kind of

00:26:15.799 --> 00:26:19.080
the intervention and some of which is

00:26:19.161 --> 00:26:20.422
illustrated in that case series.

00:26:21.655 --> 00:26:23.477
Yeah, and I think that's great.

00:26:23.576 --> 00:26:26.159
I love the logical flow of, you know,

00:26:26.199 --> 00:26:29.099
you find that impairment that was either a

00:26:29.240 --> 00:26:33.522
direct area of nociceptive pain or a

00:26:33.563 --> 00:26:36.005
contributing factor, you know,

00:26:36.025 --> 00:26:37.384
that was driving the process of their

00:26:37.424 --> 00:26:38.226
persistent pain.

00:26:39.286 --> 00:26:40.626
And taking that approach of the passive

00:26:41.307 --> 00:26:43.348
intervention paired with an active

00:26:43.368 --> 00:26:44.789
intervention that fit the exact same,

00:26:45.170 --> 00:26:47.050
whether it was arthrokinematics or just

00:26:47.070 --> 00:26:49.112
functional goal.

00:26:49.251 --> 00:26:50.153
So I thought that was awesome.

00:26:50.884 --> 00:26:51.204
The,

00:26:51.285 --> 00:26:54.105
the part that I would draw attention to

00:26:54.165 --> 00:26:57.046
is I really loved appendix D where it

00:26:57.086 --> 00:26:58.586
showed, um,

00:26:58.766 --> 00:27:00.666
kind of like each case as a number

00:27:00.747 --> 00:27:02.067
and then like, um,

00:27:02.106 --> 00:27:04.686
which modality or which intervention was

00:27:04.807 --> 00:27:05.567
used with each one.

00:27:06.508 --> 00:27:08.708
And I loved obviously as an AM to

00:27:08.768 --> 00:27:10.367
podcast that all of them got manual

00:27:10.387 --> 00:27:13.729
therapy and, uh, in all,

00:27:13.769 --> 00:27:14.749
but one of the cases,

00:27:14.788 --> 00:27:16.469
they all got joint mobilization,

00:27:16.689 --> 00:27:18.410
which I think is something that goes

00:27:18.569 --> 00:27:20.130
underappreciated in the foot and ankle.

00:27:21.161 --> 00:27:23.903
and not that that was the entire purpose

00:27:23.982 --> 00:27:26.265
of this you know article but just from

00:27:26.325 --> 00:27:28.026
my lens it was really cool to see

00:27:28.046 --> 00:27:31.348
the use of things like uh manipulation of

00:27:31.409 --> 00:27:34.171
the of the subtalar joint or the calcaneal

00:27:34.191 --> 00:27:37.252
mobilizations which is um i mean maybe

00:27:37.653 --> 00:27:39.515
anecdotally underutilized in the clinic i

00:27:39.555 --> 00:27:41.635
think so very cool to see and i

00:27:41.655 --> 00:27:43.678
would draw the reader's attention to that

00:27:43.738 --> 00:27:45.078
appendix i thought it was really helpful

00:27:47.234 --> 00:27:51.718
You mentioned evidence-based references to

00:27:52.117 --> 00:27:54.640
driving decisions on what interventions to

00:27:54.740 --> 00:27:54.880
use.

00:27:55.840 --> 00:27:56.402
In the article,

00:27:56.422 --> 00:27:57.982
it talks about the clinical practice

00:27:58.002 --> 00:27:58.403
guideline.

00:27:59.084 --> 00:28:01.865
And can you just maybe speak to how

00:28:01.945 --> 00:28:04.167
much or how little that informed some of

00:28:04.208 --> 00:28:07.390
these decisions and maybe how that guided

00:28:08.371 --> 00:28:09.692
the more thorough explanations?

00:28:09.711 --> 00:28:11.292
Yeah.

00:28:11.353 --> 00:28:12.493
Well,

00:28:12.534 --> 00:28:14.715
so at the time that this was designed,

00:28:15.571 --> 00:28:19.775
I believe it was after the first

00:28:19.815 --> 00:28:20.194
guideline.

00:28:20.315 --> 00:28:21.435
The second guideline,

00:28:21.576 --> 00:28:23.137
I don't think had been published quite

00:28:23.178 --> 00:28:23.397
yet.

00:28:24.558 --> 00:28:25.398
So they're actually,

00:28:25.739 --> 00:28:26.920
when we designed this study,

00:28:26.960 --> 00:28:28.040
we felt like there was a lot of

00:28:28.080 --> 00:28:30.041
missing gaps and particularly in the

00:28:30.083 --> 00:28:31.282
manual intervention area.

00:28:31.383 --> 00:28:33.244
I think at that time there was only

00:28:33.285 --> 00:28:34.506
like expert level evidence,

00:28:34.546 --> 00:28:36.606
but I knew of a lot of articles

00:28:36.646 --> 00:28:37.468
that were coming out

00:28:38.228 --> 00:28:39.808
of which we've referenced that kind of

00:28:39.848 --> 00:28:41.449
supported the fact that, hey,

00:28:41.469 --> 00:28:42.670
this seems to be beneficial.

00:28:43.109 --> 00:28:43.450
And again,

00:28:43.470 --> 00:28:45.490
our clinical experience seemed to

00:28:45.750 --> 00:28:48.131
corroborate that and to indicate that,

00:28:48.171 --> 00:28:48.371
man,

00:28:48.391 --> 00:28:50.172
these patients really do better when we

00:28:50.231 --> 00:28:51.071
use manual therapy,

00:28:51.672 --> 00:28:53.893
plus just the support of how the manual

00:28:53.932 --> 00:28:56.354
therapy can inform our decision-making by

00:28:56.413 --> 00:28:57.874
getting within sessions treatment,

00:28:58.034 --> 00:28:58.453
or sorry,

00:28:58.473 --> 00:29:02.276
within session changes that can then

00:29:02.316 --> 00:29:02.596
direct.

00:29:02.615 --> 00:29:04.915
So if they do respond to an accessory

00:29:04.955 --> 00:29:06.436
mobilization of the talocrural joint,

00:29:07.877 --> 00:29:09.798
it helps us to understand that, boy,

00:29:09.838 --> 00:29:12.559
improving their dorsiflexion is going to

00:29:12.599 --> 00:29:13.641
really help this patient.

00:29:13.701 --> 00:29:15.301
And I'm going to really enforce that in

00:29:15.342 --> 00:29:16.942
their home program.

00:29:18.023 --> 00:29:20.765
So we certainly tried to revolve things

00:29:20.785 --> 00:29:22.486
around the guidelines as much as possible.

00:29:22.526 --> 00:29:24.126
But again, at the time, and remember,

00:29:24.166 --> 00:29:25.647
this is now we're talking the design of

00:29:25.667 --> 00:29:29.309
the study was kind of a while ago.

00:29:29.329 --> 00:29:30.711
I still feel like what we did is

00:29:30.790 --> 00:29:32.672
pretty relevant.

00:29:34.472 --> 00:29:34.813
Of course,

00:29:34.853 --> 00:29:36.554
there's always new little tricks and

00:29:36.594 --> 00:29:38.153
techniques that kind of come out and

00:29:38.193 --> 00:29:38.993
modifications.

00:29:40.213 --> 00:29:41.535
One of the things that comes to mind

00:29:41.654 --> 00:29:42.634
is in my practice,

00:29:42.694 --> 00:29:43.934
I used a lot of trigger point dry

00:29:43.974 --> 00:29:45.875
needling at the time I was trained,

00:29:46.336 --> 00:29:47.855
but very recently trained.

00:29:47.875 --> 00:29:50.436
And so we decided it was still fairly

00:29:50.517 --> 00:29:51.376
new in the area.

00:29:51.396 --> 00:29:53.596
I was one of the first three physical

00:29:53.616 --> 00:29:55.817
therapists doing that in our state.

00:29:56.337 --> 00:29:57.419
So we said, well,

00:29:57.439 --> 00:29:58.941
maybe we shouldn't be doing this in the

00:29:58.961 --> 00:30:00.863
study because not very many people will

00:30:00.883 --> 00:30:01.522
know how to do it.

00:30:01.542 --> 00:30:02.884
But nowadays, you know,

00:30:02.944 --> 00:30:03.986
I think everybody does.

00:30:04.046 --> 00:30:05.247
So I think you can kind of look

00:30:05.267 --> 00:30:06.788
at the trigger point interventions we did.

00:30:07.548 --> 00:30:09.730
And the study doesn't support that

00:30:09.770 --> 00:30:10.432
necessarily.

00:30:10.471 --> 00:30:11.231
But, you know,

00:30:11.251 --> 00:30:12.614
I think you could infer that that would

00:30:12.634 --> 00:30:14.275
be an intervention that could be included

00:30:14.295 --> 00:30:18.199
and to use as an update to what

00:30:18.239 --> 00:30:19.819
we didn't necessarily include in this

00:30:19.839 --> 00:30:20.080
study.

00:30:20.836 --> 00:30:21.836
Yeah, that's awesome.

00:30:22.356 --> 00:30:24.218
I thought because the guidelines are great

00:30:24.238 --> 00:30:26.759
and I use them frequently and I think

00:30:26.799 --> 00:30:27.901
most people are encouraged to.

00:30:29.221 --> 00:30:31.282
But they're a guideline.

00:30:31.502 --> 00:30:34.565
They don't give the detail of like that

00:30:34.605 --> 00:30:36.365
you illustrated in your articles,

00:30:36.385 --> 00:30:38.327
which I find a really good reference for

00:30:38.667 --> 00:30:39.969
different presentations.

00:30:40.845 --> 00:30:42.946
So thank you for that.

00:30:43.007 --> 00:30:43.748
I will say, though,

00:30:43.788 --> 00:30:46.770
that the core of our treatment was very

00:30:46.810 --> 00:30:47.771
much so the guidelines.

00:30:47.791 --> 00:30:49.993
And I think that still is kind of

00:30:50.034 --> 00:30:50.354
the case.

00:30:50.374 --> 00:30:51.335
That still is the core.

00:30:51.355 --> 00:30:53.517
And then in certain cases,

00:30:53.557 --> 00:30:57.361
there's evidence that supports why maybe

00:30:57.641 --> 00:31:00.063
that core is included plus a little bit

00:31:01.704 --> 00:31:02.484
of a different direction.

00:31:02.505 --> 00:31:02.846
Yeah.

00:31:03.165 --> 00:31:04.688
Yeah, that's great.

00:31:04.708 --> 00:31:06.910
Can you talk a little bit about,

00:31:06.930 --> 00:31:09.673
because like just in my clinical

00:31:09.712 --> 00:31:11.454
experience treating foot and ankle,

00:31:11.695 --> 00:31:13.478
given the persistence of that pain,

00:31:13.597 --> 00:31:16.641
there can be some chronicity to that

00:31:16.681 --> 00:31:19.825
experience like sensitization to the

00:31:19.865 --> 00:31:20.746
tissues locally,

00:31:21.446 --> 00:31:23.348
more central sensitization processes.

00:31:24.484 --> 00:31:27.228
Can you talk a little bit about how

00:31:27.268 --> 00:31:29.690
that was considered in the patients that

00:31:29.710 --> 00:31:30.631
were presenting to you?

00:31:30.790 --> 00:31:34.273
And were any of these treatments maybe

00:31:34.334 --> 00:31:36.175
delivered differently or tailored towards

00:31:36.236 --> 00:31:38.657
that presentation versus a more acute

00:31:38.698 --> 00:31:39.999
nociceptive presentation?

00:31:42.181 --> 00:31:44.563
So we certainly,

00:31:44.823 --> 00:31:48.846
our intervention was informed by

00:31:48.967 --> 00:31:50.528
considering pain mechanisms.

00:31:51.326 --> 00:31:54.349
And we did include, so for example,

00:31:54.369 --> 00:31:55.691
we did include pain neuroscience

00:31:55.730 --> 00:31:56.311
education.

00:31:56.372 --> 00:31:57.814
So part of our treatment included

00:31:57.874 --> 00:31:58.394
education.

00:31:58.414 --> 00:32:02.880
That's always, I think in any trial,

00:32:03.300 --> 00:32:05.502
it's kind of hard to control and kind

00:32:05.522 --> 00:32:06.744
of hard to appreciate how much of an

00:32:06.785 --> 00:32:08.886
effect that kind of has on things.

00:32:09.964 --> 00:32:11.426
But certainly while we were doing our

00:32:11.467 --> 00:32:12.568
manual intervention or exercise

00:32:12.588 --> 00:32:13.068
intervention,

00:32:13.128 --> 00:32:16.433
we were discussing their presentation and

00:32:17.034 --> 00:32:18.476
factors that are contributing to their

00:32:18.516 --> 00:32:18.876
pain.

00:32:19.557 --> 00:32:20.659
One of the things that we described a

00:32:20.699 --> 00:32:21.098
little bit,

00:32:21.539 --> 00:32:23.281
not that we were giving a lot of

00:32:23.342 --> 00:32:24.943
advice on weight management,

00:32:24.963 --> 00:32:26.226
but there was a lot of discussion around

00:32:26.266 --> 00:32:27.748
the time this study was designed.

00:32:28.387 --> 00:32:29.808
uh, around, you know,

00:32:29.970 --> 00:32:32.592
weight management and, and, and, and,

00:32:32.731 --> 00:32:33.893
and some of those factors.

00:32:34.614 --> 00:32:35.493
Um,

00:32:35.534 --> 00:32:37.596
so we certainly provided some education,

00:32:37.615 --> 00:32:39.597
uh, that revolved around,

00:32:40.096 --> 00:32:44.260
things that could more positively affect

00:32:44.441 --> 00:32:45.922
their pain experience and help them to

00:32:46.021 --> 00:32:47.363
understand their pain experience,

00:32:47.824 --> 00:32:50.726
as well as the prognosis, you know,

00:32:51.047 --> 00:32:52.688
making sure their expectations aren't that

00:32:52.708 --> 00:32:53.828
they're going to be better in two weeks

00:32:53.888 --> 00:32:56.211
after treatment or fully cured in two

00:32:56.230 --> 00:32:58.653
weeks when the literature supports that

00:32:58.693 --> 00:33:00.394
this could take up to a year, honestly.

00:33:00.535 --> 00:33:00.775
Now...

00:33:01.771 --> 00:33:03.212
I like to think with the approach that

00:33:03.313 --> 00:33:06.094
we took and which illustrates this and and

00:33:06.114 --> 00:33:07.075
things that we can do,

00:33:07.454 --> 00:33:08.615
we can improve that approach.

00:33:08.654 --> 00:33:10.355
And some of those estimates that say it

00:33:10.375 --> 00:33:12.596
can last a year are based on not

00:33:12.636 --> 00:33:13.478
getting this treatment.

00:33:13.617 --> 00:33:15.098
So I do think that we can reduce

00:33:15.118 --> 00:33:15.358
that.

00:33:15.459 --> 00:33:20.681
But I always like to kind of under

00:33:20.721 --> 00:33:22.382
promise and over deliver versus the

00:33:22.461 --> 00:33:22.942
opposite.

00:33:23.022 --> 00:33:26.364
So getting them on on the same page.

00:33:27.105 --> 00:33:28.845
So we definitely considered

00:33:30.798 --> 00:33:32.078
you know, some of the pain mechanisms.

00:33:32.098 --> 00:33:35.280
And that's also why we considered any

00:33:35.340 --> 00:33:38.481
potential patho-neurodynamic contributions

00:33:38.501 --> 00:33:39.221
to their symptoms.

00:33:39.261 --> 00:33:40.402
So, you know,

00:33:40.501 --> 00:33:42.843
if we were doing neurodynamic testing or

00:33:42.863 --> 00:33:45.564
if we found palpatory tenderness along the

00:33:45.604 --> 00:33:46.263
path of the nerve,

00:33:46.284 --> 00:33:47.565
we were certainly providing intervention

00:33:47.605 --> 00:33:50.526
at those areas to facilitate the nerve

00:33:50.566 --> 00:33:53.906
being as healthy as possible and hopefully

00:33:53.946 --> 00:33:55.607
reducing any potential for that to be

00:33:55.647 --> 00:33:56.867
contributing to their pain experience.

00:33:57.816 --> 00:33:58.675
Yeah, that's great.

00:33:59.156 --> 00:34:00.557
I think that's really helpful.

00:34:00.656 --> 00:34:02.317
And as I read through the article,

00:34:02.538 --> 00:34:04.238
it kind of came to light that

00:34:04.298 --> 00:34:05.759
decision-making I thought was great.

00:34:06.699 --> 00:34:09.860
Um, especially just given, uh, well,

00:34:09.920 --> 00:34:12.280
my fellowship training was very, um,

00:34:12.340 --> 00:34:13.902
very heavily, um,

00:34:14.001 --> 00:34:17.083
ingrained that process of like, uh,

00:34:17.123 --> 00:34:19.664
persistent pain and, um,

00:34:19.704 --> 00:34:21.204
just how that can affect different areas.

00:34:21.244 --> 00:34:21.724
So the,

00:34:21.744 --> 00:34:24.286
the heel is just a really good area

00:34:24.306 --> 00:34:25.485
that I think it illustrates it well.

00:34:26.929 --> 00:34:29.672
um with your you commented earlier so i

00:34:29.692 --> 00:34:31.213
don't mean to be too redundant but i'd

00:34:31.273 --> 00:34:34.496
love to hear your thought process on kind

00:34:34.516 --> 00:34:36.838
of using the check recheck asterisk sign

00:34:37.077 --> 00:34:39.739
and using that to differentiate between

00:34:41.041 --> 00:34:43.081
picking the foot and ankle as your primary

00:34:43.121 --> 00:34:46.625
source versus proximal sources as the area

00:34:46.644 --> 00:34:48.806
to target uh with your primary

00:34:48.827 --> 00:34:50.248
interventions like how did you choose

00:34:50.307 --> 00:34:51.528
proximal versus local

00:34:52.884 --> 00:34:54.585
So I would say just because our, again,

00:34:54.726 --> 00:34:55.887
this comes back to the guidelines.

00:34:55.907 --> 00:34:56.827
So I'm glad you kind of brought that

00:34:56.887 --> 00:34:57.007
up.

00:34:57.068 --> 00:34:58.949
So guidelines really support more of that

00:34:59.010 --> 00:34:59.909
local intervention,

00:35:00.251 --> 00:35:01.692
addressing impairments in the ankle and

00:35:01.731 --> 00:35:02.012
foot.

00:35:02.532 --> 00:35:04.193
And so I would say in almost all

00:35:04.233 --> 00:35:04.574
cases,

00:35:04.614 --> 00:35:06.175
we would definitely start there first and

00:35:06.215 --> 00:35:08.318
we would kind of see, you know, let's,

00:35:08.358 --> 00:35:10.119
let's find the impairments there first.

00:35:10.539 --> 00:35:11.561
Not that we didn't look elsewhere.

00:35:11.581 --> 00:35:13.302
We still screened our initial evaluation.

00:35:13.583 --> 00:35:14.844
We're trying to take a big picture

00:35:14.903 --> 00:35:17.626
overview first and then narrow down and

00:35:17.686 --> 00:35:18.407
identifying.

00:35:18.972 --> 00:35:21.655
you know, what impairments are A,

00:35:21.896 --> 00:35:23.938
most significant.

00:35:24.097 --> 00:35:25.980
So oftentimes as you kind of go through

00:35:26.000 --> 00:35:28.382
the process, you can kind of say, wow,

00:35:28.443 --> 00:35:30.083
the impairments in the ankle are kind of

00:35:30.164 --> 00:35:30.445
minor.

00:35:31.251 --> 00:35:32.992
but the impairments in the lumbar spine

00:35:33.393 --> 00:35:34.434
are major.

00:35:35.494 --> 00:35:38.016
So that might be something that would skew

00:35:38.036 --> 00:35:39.376
me to go up a little bit more,

00:35:39.416 --> 00:35:40.077
but I still,

00:35:40.137 --> 00:35:41.619
I wouldn't ignore that foot and ankle.

00:35:41.639 --> 00:35:43.219
I kind of want to do some intervention

00:35:43.239 --> 00:35:44.900
there to see what effect that they had,

00:35:45.181 --> 00:35:45.702
because again,

00:35:45.742 --> 00:35:47.063
that's the most guideline and

00:35:47.123 --> 00:35:48.923
evidence-based treatment is in that area.

00:35:50.054 --> 00:35:51.755
and then assessing their response.

00:35:51.795 --> 00:35:53.976
And then sometimes I would do that within

00:35:54.016 --> 00:35:54.416
a session,

00:35:54.436 --> 00:35:56.177
but it sometimes might be between

00:35:56.237 --> 00:35:56.677
sessions.

00:35:56.697 --> 00:35:58.538
So might just only treat the foot and

00:35:58.577 --> 00:36:01.039
ankle one session or treat kind of more

00:36:01.099 --> 00:36:01.579
locally.

00:36:02.139 --> 00:36:03.039
Next session they come back,

00:36:03.079 --> 00:36:03.800
I might start,

00:36:03.860 --> 00:36:05.061
if I had found some things in lumbar

00:36:05.101 --> 00:36:06.222
spine, I'm like, boy,

00:36:06.242 --> 00:36:07.902
your response to the foot and ankle was

00:36:07.943 --> 00:36:09.043
kind of mediocre,

00:36:10.003 --> 00:36:12.125
or maybe it didn't have any much of

00:36:12.144 --> 00:36:14.005
an effect when they come back or even

00:36:14.045 --> 00:36:14.726
within a session.

00:36:15.469 --> 00:36:16.550
So then I go up and I treat,

00:36:16.809 --> 00:36:17.030
you know,

00:36:17.050 --> 00:36:18.831
whatever the other most significant

00:36:18.851 --> 00:36:19.610
impairment was.

00:36:19.731 --> 00:36:21.431
And if we get a more substantial change,

00:36:21.931 --> 00:36:23.592
then to me that gives a little more

00:36:23.672 --> 00:36:26.393
credence that that's kind of one of the

00:36:26.414 --> 00:36:28.614
driving factors in their symptoms.

00:36:29.175 --> 00:36:30.896
And especially if we get that response on

00:36:30.956 --> 00:36:32.056
multiple occasions now.

00:36:33.746 --> 00:36:34.887
And I still feel like you can do

00:36:34.927 --> 00:36:37.128
that fairly well, even with, like I said,

00:36:37.168 --> 00:36:39.829
on average, I believe our visits were,

00:36:40.009 --> 00:36:42.329
say, around six visits per patient.

00:36:43.610 --> 00:36:43.909
Again,

00:36:44.170 --> 00:36:45.369
some patients had a little bit more.

00:36:45.949 --> 00:36:46.170
Actually,

00:36:46.190 --> 00:36:47.990
some patients had fewer than that.

00:36:48.471 --> 00:36:49.670
I still think you can do that reasonably

00:36:49.710 --> 00:36:51.291
well within that timeframe.

00:36:51.331 --> 00:36:52.692
And to me, that just adds

00:36:54.030 --> 00:36:56.090
more evidence to where the impairment is

00:36:56.130 --> 00:36:58.733
coming from and what they can dedicate

00:36:58.753 --> 00:36:59.532
their time working on.

00:36:59.572 --> 00:37:01.014
Because the other thing is we only have

00:37:01.034 --> 00:37:02.014
so much time in the clinic,

00:37:02.393 --> 00:37:03.855
but also our patients only have so much

00:37:03.894 --> 00:37:04.536
time out of there.

00:37:04.596 --> 00:37:05.775
So if I can just give them a

00:37:05.815 --> 00:37:07.137
handful of things to work on,

00:37:08.476 --> 00:37:09.777
I find that tends to work a lot

00:37:09.818 --> 00:37:10.958
better than, you know,

00:37:11.159 --> 00:37:13.239
we're throwing everything at them and

00:37:13.519 --> 00:37:15.561
they're doing a pretty bad job at all

00:37:15.601 --> 00:37:15.940
of them,

00:37:16.802 --> 00:37:18.362
doing a really good job at just a

00:37:18.402 --> 00:37:18.802
few of them.

00:37:18.822 --> 00:37:20.963
Yeah, I think that's awesome.

00:37:21.023 --> 00:37:21.403
Thank you.

00:37:22.398 --> 00:37:23.938
for kind of talking us through that

00:37:23.958 --> 00:37:26.541
because I think it's super helpful using

00:37:26.583 --> 00:37:28.023
that thought process.

00:37:28.043 --> 00:37:30.007
But then definitely when you have a

00:37:30.067 --> 00:37:32.268
complex case with so many impairments and

00:37:32.309 --> 00:37:32.789
factors,

00:37:32.829 --> 00:37:35.152
I think it's nice to take that approach

00:37:35.193 --> 00:37:36.574
of like take one primary,

00:37:36.675 --> 00:37:38.476
treat it and see if it changes so

00:37:38.496 --> 00:37:40.840
we don't cloud the whole scenario too

00:37:40.860 --> 00:37:41.019
much.

00:37:42.509 --> 00:37:45.371
So then kind of walking this back to

00:37:45.391 --> 00:37:46.331
that original article.

00:37:46.931 --> 00:37:48.853
So we just had a great discussion on

00:37:49.313 --> 00:37:52.934
how there was this original basically

00:37:52.954 --> 00:37:55.597
report about treating the foot and heel

00:37:55.637 --> 00:37:55.916
pain.

00:37:56.478 --> 00:37:58.259
And then there was a breakdown of the

00:37:58.338 --> 00:38:00.320
eight cases that presented differently and

00:38:00.340 --> 00:38:01.701
our manual interventions for those.

00:38:02.320 --> 00:38:05.242
And then that final kind of like piece

00:38:05.262 --> 00:38:06.963
to the original idea was the cost

00:38:07.423 --> 00:38:08.605
effectiveness study.

00:38:09.125 --> 00:38:09.405
Can we...

00:38:10.126 --> 00:38:11.027
Talk a little bit more.

00:38:11.067 --> 00:38:13.471
You gave a synopsis of like the how

00:38:13.510 --> 00:38:13.911
it turned out.

00:38:13.931 --> 00:38:15.373
But can you just talk to us again

00:38:15.413 --> 00:38:17.775
about the results and if it surprised you

00:38:17.795 --> 00:38:18.336
or not?

00:38:18.436 --> 00:38:21.842
And kind of how that goes together with

00:38:21.882 --> 00:38:23.083
how as a profession,

00:38:23.103 --> 00:38:25.045
we're trying to push ourselves as like a

00:38:25.106 --> 00:38:27.208
primary provider in that area.

00:38:27.248 --> 00:38:27.409
Yeah.

00:38:29.583 --> 00:38:31.726
So I would say as far as surprising,

00:38:32.367 --> 00:38:36.534
obviously I had some expectations and that

00:38:36.655 --> 00:38:38.757
we would add value and that we could

00:38:38.777 --> 00:38:39.800
produce better outcomes.

00:38:40.632 --> 00:38:41.532
at a lower cost.

00:38:42.052 --> 00:38:43.333
I guess I was maybe hoping it would

00:38:43.373 --> 00:38:45.574
be more of a slam dunk per se,

00:38:46.094 --> 00:38:48.617
but I think part of it is we

00:38:48.637 --> 00:38:50.217
did get ninety five participants in the

00:38:50.257 --> 00:38:50.577
study,

00:38:50.737 --> 00:38:52.498
which is which was really hard to do,

00:38:52.579 --> 00:38:53.219
to be honest,

00:38:53.840 --> 00:38:55.380
over a long period of time and probably

00:38:55.420 --> 00:38:57.302
was a little bit more than I should

00:38:57.322 --> 00:39:01.103
have tried to bite in a PhD program.

00:39:01.643 --> 00:39:03.025
But it's

00:39:03.485 --> 00:39:06.527
It's added years of enjoyment in getting

00:39:06.568 --> 00:39:08.489
to follow this up and to see some

00:39:08.528 --> 00:39:10.251
of the stuff come to fruition.

00:39:10.311 --> 00:39:13.213
But yeah, if we had a larger sample,

00:39:13.273 --> 00:39:14.934
I think we would have a little more

00:39:14.994 --> 00:39:15.574
confidence.

00:39:16.436 --> 00:39:17.175
But regardless,

00:39:17.215 --> 00:39:19.699
we did some sensitivity analyses.

00:39:20.458 --> 00:39:22.300
So again, the primary results,

00:39:22.320 --> 00:39:24.063
when we look at the base case,

00:39:24.103 --> 00:39:26.925
so everyone that was allocated into both

00:39:26.965 --> 00:39:28.628
of the groups kept them in those groups.

00:39:28.668 --> 00:39:29.449
We didn't exclude,

00:39:29.789 --> 00:39:31.210
we didn't take anyone and remove them from

00:39:31.250 --> 00:39:31.831
the data set,

00:39:31.971 --> 00:39:34.152
analyzed all the data and analyzed all of

00:39:34.173 --> 00:39:34.753
the cost,

00:39:34.893 --> 00:39:36.155
all of the cost data that we had

00:39:36.195 --> 00:39:36.956
available to us.

00:39:37.876 --> 00:39:38.396
which again,

00:39:38.476 --> 00:39:40.898
that would include the direct costs of the

00:39:40.918 --> 00:39:41.318
treatments,

00:39:41.478 --> 00:39:43.420
so the podiatry and the physical therapy

00:39:43.440 --> 00:39:43.840
treatments,

00:39:44.260 --> 00:39:45.900
but also if they saw their primary care

00:39:45.940 --> 00:39:47.521
physician for back pain,

00:39:47.581 --> 00:39:50.543
if they had a surgery,

00:39:50.623 --> 00:39:51.603
a bariatric surgery,

00:39:51.623 --> 00:39:52.943
a couple of the patients had bariatric

00:39:52.963 --> 00:39:53.324
surgeries,

00:39:53.344 --> 00:39:54.764
which we know that patients with plantar

00:39:54.784 --> 00:39:56.585
heel pain struggle with weight because

00:39:56.606 --> 00:39:57.666
they can't exercise.

00:39:58.567 --> 00:40:00.648
there's some other little interesting cost

00:40:00.829 --> 00:40:03.389
kind of things there too for things that

00:40:03.590 --> 00:40:05.532
could be somewhat indirectly related to

00:40:05.552 --> 00:40:07.393
their heel pain but anyway all the costs

00:40:07.413 --> 00:40:10.034
were included in that base case and we

00:40:10.094 --> 00:40:12.896
saw that the plus physical therapist

00:40:12.916 --> 00:40:16.018
approach uh was we had better outcomes so

00:40:16.057 --> 00:40:18.840
their quality of life so again the eq-d

00:40:19.340 --> 00:40:22.463
measures a person's quality of life uh and

00:40:22.503 --> 00:40:22.583
it

00:40:23.143 --> 00:40:25.385
basically we will index it to a zero

00:40:25.405 --> 00:40:27.748
to one scale where one is a year

00:40:27.807 --> 00:40:30.710
of optimal health and so we follow this

00:40:30.791 --> 00:40:32.512
up over three years so we have three

00:40:32.532 --> 00:40:34.114
years to where you know they could get

00:40:34.153 --> 00:40:36.456
a score from zero to one uh and

00:40:36.496 --> 00:40:38.097
we saw that those in the plus pt

00:40:38.117 --> 00:40:40.780
group uh rated their their health

00:40:42.181 --> 00:40:44.422
is their quality of their health to be

00:40:44.463 --> 00:40:46.003
greater in the end.

00:40:46.063 --> 00:40:47.804
And that was even as early as one

00:40:47.824 --> 00:40:49.804
year, we saw that kind of coming out.

00:40:51.106 --> 00:40:52.746
The cost as well at about one year,

00:40:52.786 --> 00:40:53.686
we saw the costs,

00:40:54.568 --> 00:40:57.548
all those costs being less in the plus

00:40:57.588 --> 00:40:58.510
physical therapist group.

00:40:58.530 --> 00:40:59.130
And then of course,

00:40:59.150 --> 00:41:00.530
when you look at that cumulatively over

00:41:00.550 --> 00:41:00.990
three years,

00:41:01.971 --> 00:41:03.592
uh, it was, it was cost savings.

00:41:03.913 --> 00:41:05.012
So when you put those two together,

00:41:05.032 --> 00:41:07.434
an equation of cost effectiveness,

00:41:07.474 --> 00:41:10.297
the costs of the plus physical therapist

00:41:10.356 --> 00:41:13.579
minus the podiatry, uh, and then the,

00:41:13.838 --> 00:41:16.559
sorry, the outcomes over the costs, uh,

00:41:16.599 --> 00:41:19.581
we saw that plus physical therapist was

00:41:19.641 --> 00:41:20.302
lower costs,

00:41:20.922 --> 00:41:22.804
plus that we saw a better outcome.

00:41:22.824 --> 00:41:25.326
Uh, and, uh,

00:41:26.561 --> 00:41:28.882
So the takeaways are is that, you know,

00:41:28.902 --> 00:41:30.844
we can collaborate with our podiatry

00:41:32.204 --> 00:41:34.885
partners to provide better care for our

00:41:34.945 --> 00:41:36.626
patients and they can achieve better

00:41:36.706 --> 00:41:37.226
outcomes.

00:41:37.887 --> 00:41:40.528
And many patients are,

00:41:40.608 --> 00:41:41.889
and I'd say podiatrists as well,

00:41:42.028 --> 00:41:44.050
the podiatrists are hesitant to send them

00:41:44.090 --> 00:41:44.951
to physical therapy.

00:41:45.764 --> 00:41:46.724
Because they know it's going to be an

00:41:46.744 --> 00:41:48.226
extra burden to their patients and they

00:41:48.286 --> 00:41:51.086
don't want to impose that greater burden

00:41:51.106 --> 00:41:52.588
on their patients, that greater cost,

00:41:52.628 --> 00:41:54.208
having them to go through all these

00:41:54.528 --> 00:41:56.090
additional visits and these additional

00:41:56.130 --> 00:41:58.271
costs and transportation costs and missing

00:41:58.311 --> 00:42:00.291
work and all the things that go into

00:42:00.351 --> 00:42:00.492
it.

00:42:01.192 --> 00:42:03.273
But hopefully they can use this data then

00:42:03.313 --> 00:42:04.413
to say, hey, yes,

00:42:04.452 --> 00:42:06.014
it might cost a little more up front.

00:42:06.034 --> 00:42:07.235
It's going to be a little more work

00:42:07.315 --> 00:42:07.815
up front.

00:42:08.461 --> 00:42:09.862
But in the long run,

00:42:10.822 --> 00:42:12.724
what could happen is this could go on

00:42:12.784 --> 00:42:13.284
and on and on,

00:42:13.324 --> 00:42:14.706
and you're gonna end up missing more work

00:42:14.726 --> 00:42:14.965
days.

00:42:15.005 --> 00:42:16.146
You might have other problems.

00:42:16.166 --> 00:42:17.726
You might end up not being able to

00:42:17.766 --> 00:42:18.788
manage your weight as well.

00:42:19.047 --> 00:42:21.009
There's a lot of downstream consequences

00:42:21.068 --> 00:42:22.989
that perhaps if we nip it earlier,

00:42:23.510 --> 00:42:26.192
then we won't have those downstream

00:42:26.251 --> 00:42:26.592
issues.

00:42:26.672 --> 00:42:28.713
And this study provides support to that,

00:42:29.114 --> 00:42:31.135
that yes, it was cost-effective.

00:42:31.355 --> 00:42:32.114
In the long run,

00:42:32.215 --> 00:42:34.157
it costs less and you got a greater

00:42:34.217 --> 00:42:34.617
value.

00:42:35.911 --> 00:42:37.592
So the base case showed that we did

00:42:37.632 --> 00:42:39.371
some sensitivity analysis because some of

00:42:39.391 --> 00:42:42.193
the patients, I mean, spoiler alert here,

00:42:42.273 --> 00:42:45.494
they didn't participate in the program in

00:42:45.554 --> 00:42:47.516
the plus physical therapist program.

00:42:47.715 --> 00:42:49.436
You know, I don't know about you,

00:42:49.476 --> 00:42:52.838
but I have a few patients that tend

00:42:52.878 --> 00:42:54.579
not to be adherent to the things we

00:42:54.619 --> 00:42:55.199
might recommend.

00:42:56.039 --> 00:42:57.920
no matter how hard I try.

00:42:58.139 --> 00:42:59.360
And this was the case in the study

00:42:59.380 --> 00:42:59.599
too.

00:42:59.679 --> 00:43:01.260
So we found a way to kind of

00:43:01.280 --> 00:43:01.760
say, okay, well,

00:43:01.780 --> 00:43:04.260
what if we remove them from there?

00:43:04.280 --> 00:43:04.561
And again,

00:43:04.581 --> 00:43:05.961
we saw a little bit better results,

00:43:05.981 --> 00:43:07.101
but still for the most part,

00:43:07.521 --> 00:43:09.902
we had the same, we had cost,

00:43:10.023 --> 00:43:11.643
we demonstrated cost effectiveness in the

00:43:11.663 --> 00:43:12.182
base case.

00:43:12.663 --> 00:43:14.844
We also demonstrated it when we removed

00:43:14.884 --> 00:43:16.523
those who did not complete with treatment.

00:43:16.923 --> 00:43:19.324
And then we also just looked at plantar

00:43:19.364 --> 00:43:20.184
heel pain costs.

00:43:20.405 --> 00:43:21.226
So we tried to say, okay,

00:43:21.246 --> 00:43:22.786
let's cut out all the other stuff

00:43:23.226 --> 00:43:24.927
what was just related to managing their

00:43:24.947 --> 00:43:25.547
plantar heel pain.

00:43:25.967 --> 00:43:26.266
And again,

00:43:26.306 --> 00:43:31.489
we saw very similar cost-effectiveness of

00:43:31.510 --> 00:43:33.431
which the plus physical therapist approach

00:43:33.471 --> 00:43:36.911
was more cost-effective in all of those

00:43:37.771 --> 00:43:38.873
sensitivity analyses.

00:43:39.963 --> 00:43:40.523
That's great.

00:43:40.983 --> 00:43:42.784
I mean, in my mind, right,

00:43:42.885 --> 00:43:43.965
obviously I'm biased because I'm a

00:43:43.985 --> 00:43:44.786
physical therapist,

00:43:44.947 --> 00:43:49.170
but it makes sense that if you see

00:43:49.250 --> 00:43:52.291
more preventative care, conservative care,

00:43:52.351 --> 00:43:57.916
less aggressive care maybe that follows

00:43:58.016 --> 00:43:59.197
evidence-based guidelines,

00:43:59.237 --> 00:44:00.759
you'd think it would give you better

00:44:00.818 --> 00:44:01.199
outcomes,

00:44:01.239 --> 00:44:02.400
but it's nice to have a study that

00:44:02.440 --> 00:44:03.061
supports that.

00:44:03.681 --> 00:44:04.902
So do you see,

00:44:05.061 --> 00:44:06.063
now that this has been out,

00:44:06.103 --> 00:44:08.505
have you seen it making changes in...

00:44:09.755 --> 00:44:13.222
the behavior of patients or podiatry or

00:44:13.282 --> 00:44:15.346
even other physical therapists and their

00:44:15.827 --> 00:44:18.472
approach or like, you know, marketing or.

00:44:19.588 --> 00:44:20.989
Yeah, it's a great question.

00:44:21.228 --> 00:44:21.989
And, you know,

00:44:22.090 --> 00:44:23.610
I've reflected on this a little bit.

00:44:23.670 --> 00:44:24.952
My practice is a little unique.

00:44:24.992 --> 00:44:26.432
I would say, oh,

00:44:26.472 --> 00:44:27.454
maybe it's not all that unique,

00:44:27.474 --> 00:44:32.318
but the majority of my patients are direct

00:44:32.398 --> 00:44:32.838
access.

00:44:32.998 --> 00:44:34.639
So not that I don't have anyone that's

00:44:34.699 --> 00:44:35.019
referred,

00:44:35.039 --> 00:44:36.481
but most of my patients are direct access.

00:44:36.501 --> 00:44:38.041
So it really would be nice,

00:44:38.061 --> 00:44:39.704
and I haven't had time to really look

00:44:39.804 --> 00:44:40.123
into this,

00:44:40.164 --> 00:44:41.344
but it would be nice to do some

00:44:41.364 --> 00:44:42.945
follow-up just to see if anything is

00:44:43.266 --> 00:44:43.827
changing there.

00:44:44.286 --> 00:44:46.568
Now, granted, this study just came out.

00:44:46.788 --> 00:44:48.329
You know, the outcome studies were out.

00:44:48.409 --> 00:44:49.369
The case series was out,

00:44:50.429 --> 00:44:51.710
has been out for a little bit now.

00:44:52.391 --> 00:44:54.012
So I don't really think there's enough

00:44:54.052 --> 00:44:56.632
time there to be much impact other than

00:44:56.693 --> 00:44:58.034
I would just like to think that even

00:44:58.074 --> 00:44:59.175
before this study came out,

00:44:59.315 --> 00:45:02.315
hopefully others were realizing this.

00:45:02.356 --> 00:45:02.896
Like you said,

00:45:02.956 --> 00:45:04.737
it kind of it seems like it makes

00:45:04.757 --> 00:45:05.617
a little bit of sense.

00:45:07.139 --> 00:45:09.300
And so I'd like to think that this

00:45:09.320 --> 00:45:10.181
will make some changes,

00:45:10.221 --> 00:45:11.822
but I'm not sure that we're seeing

00:45:11.862 --> 00:45:12.663
anything yet.

00:45:14.184 --> 00:45:16.106
Although I would love to hear from others

00:45:16.146 --> 00:45:17.806
who might be seeing something different,

00:45:17.867 --> 00:45:20.349
but also I'm hoping that we can be

00:45:20.389 --> 00:45:23.972
change agents with this information now

00:45:24.391 --> 00:45:24.992
and help

00:45:27.014 --> 00:45:30.096
you know help our patients who may not

00:45:30.135 --> 00:45:32.496
be getting uh the plus physical therapist

00:45:32.516 --> 00:45:34.657
approach who might need and benefit this

00:45:35.217 --> 00:45:38.320
and and maybe spreading the word uh will

00:45:38.340 --> 00:45:40.021
then help to make that shift and we'll

00:45:40.041 --> 00:45:41.402
start to see that in the coming years

00:45:42.581 --> 00:45:44.603
yeah i mean that's great and i i

00:45:44.623 --> 00:45:46.704
guess it's you know it's new so that's

00:45:46.905 --> 00:45:48.806
not the fairest question but so my

00:45:48.846 --> 00:45:50.465
follow-up to that i work in private

00:45:50.505 --> 00:45:50.987
practice

00:45:52.054 --> 00:45:54.916
So cultivating referral sources is a big

00:45:54.956 --> 00:45:57.077
part of my role at our clinic.

00:45:58.398 --> 00:46:00.981
So maybe just ask you to speculate on

00:46:01.021 --> 00:46:02.461
this a little bit or give some advice.

00:46:02.922 --> 00:46:05.664
Do you view this as a marketing tool?

00:46:05.884 --> 00:46:06.985
And do you have advice of how to

00:46:07.125 --> 00:46:07.465
use it?

00:46:09.646 --> 00:46:11.188
I see it as a good selling point

00:46:11.409 --> 00:46:13.750
of how we can work together and how

00:46:14.070 --> 00:46:16.072
we should be involved in more cases than

00:46:16.112 --> 00:46:16.733
seven percent.

00:46:17.713 --> 00:46:19.795
I could also see it as potentially

00:46:20.675 --> 00:46:22.376
competitive, you know, because in that,

00:46:22.797 --> 00:46:23.516
in the article,

00:46:23.536 --> 00:46:24.878
it talks about how people who went to

00:46:24.898 --> 00:46:26.938
PT went to the podiatry less often,

00:46:27.418 --> 00:46:29.199
but ultimately it was better for the

00:46:29.260 --> 00:46:29.820
patients.

00:46:30.000 --> 00:46:31.760
So do you have thoughts on that and

00:46:31.780 --> 00:46:33.342
how it could be implemented in more of

00:46:33.402 --> 00:46:35.382
the, like the private practice setting?

00:46:37.014 --> 00:46:39.896
Yeah, so I will say this, though.

00:46:39.936 --> 00:46:41.476
I don't think they necessarily saw the

00:46:41.496 --> 00:46:43.577
podiatrist a lot less.

00:46:43.637 --> 00:46:45.800
I feel like their average was even like

00:46:45.840 --> 00:46:46.440
two visits,

00:46:46.980 --> 00:46:48.900
even if you were just in that group.

00:46:48.940 --> 00:46:50.001
It might have been a little bit more.

00:46:50.943 --> 00:46:52.063
Don't quote me off the top of my

00:46:52.123 --> 00:46:52.304
head.

00:46:54.684 --> 00:46:56.206
I think it was maybe on average two

00:46:56.246 --> 00:46:57.806
compared to six in the plus physical

00:46:57.827 --> 00:46:58.608
therapist approach.

00:46:58.648 --> 00:47:01.590
So I don't think we'd be stealing a

00:47:01.630 --> 00:47:02.710
lot of business from them.

00:47:04.170 --> 00:47:06.432
And I would also suggest that as you

00:47:06.452 --> 00:47:07.112
kind of alluded to,

00:47:07.132 --> 00:47:08.414
that's not really the point.

00:47:08.434 --> 00:47:09.195
The point is,

00:47:10.034 --> 00:47:10.675
We both,

00:47:10.735 --> 00:47:12.157
podiatrists and physical therapists,

00:47:12.177 --> 00:47:13.297
want our patients to get better.

00:47:13.719 --> 00:47:15.260
And so if this is a way,

00:47:16.501 --> 00:47:18.202
if it was something else besides plus

00:47:18.242 --> 00:47:19.083
physical therapist,

00:47:19.744 --> 00:47:21.585
I think the podiatrist would be on board.

00:47:22.226 --> 00:47:23.306
I don't see any reason why they wouldn't

00:47:23.327 --> 00:47:24.748
be on board with this if it's put

00:47:25.648 --> 00:47:26.610
in that context.

00:47:26.670 --> 00:47:28.072
There are patients that we should be

00:47:28.112 --> 00:47:29.612
referring to our podiatrist because

00:47:29.632 --> 00:47:30.853
there's things that they can do that we

00:47:30.893 --> 00:47:31.195
can't.

00:47:32.679 --> 00:47:34.981
So I think it's a two-way street,

00:47:35.021 --> 00:47:36.161
and I think if we approach it that

00:47:36.181 --> 00:47:37.963
way, and like I said,

00:47:38.003 --> 00:47:40.563
this study really is an example of shared

00:47:40.603 --> 00:47:42.726
decision-making between the podiatrist,

00:47:42.766 --> 00:47:45.047
the patient, and the physical therapist,

00:47:45.106 --> 00:47:46.827
although some of them were kind of

00:47:46.907 --> 00:47:50.048
strongly encouraged to add a plus physical

00:47:50.068 --> 00:47:52.030
therapist approach to their treatment.

00:47:53.972 --> 00:47:56.313
But yeah, in my opinion,

00:47:56.554 --> 00:47:58.293
maybe I'm overly optimistic.

00:47:58.713 --> 00:48:00.894
I see nothing but a win-win in this

00:48:00.934 --> 00:48:02.875
case because they're still going to go

00:48:02.954 --> 00:48:05.295
see, they are still the foot experts,

00:48:05.335 --> 00:48:05.576
right?

00:48:05.795 --> 00:48:08.376
A podiatrist is still known for their

00:48:08.436 --> 00:48:09.637
expertise in the foot.

00:48:09.956 --> 00:48:11.597
Patients are still going to go see them.

00:48:12.938 --> 00:48:14.637
And if they see us as well,

00:48:16.139 --> 00:48:17.418
more patients, unfortunately,

00:48:17.438 --> 00:48:19.119
this is a very common condition and I

00:48:19.139 --> 00:48:21.219
don't see it going away anytime soon.

00:48:22.338 --> 00:48:23.940
But we'd like to try to decrease the

00:48:23.980 --> 00:48:28.786
repeat offenders and the longer disability

00:48:28.806 --> 00:48:29.809
that's associated with it.

00:48:30.639 --> 00:48:31.280
It's a great point.

00:48:31.360 --> 00:48:33.240
And thank you for the clarification on

00:48:33.280 --> 00:48:33.581
that.

00:48:33.601 --> 00:48:36.623
That really does help understand like

00:48:36.983 --> 00:48:37.963
keeping it all in context.

00:48:37.983 --> 00:48:38.664
So thank you.

00:48:40.123 --> 00:48:40.324
Okay.

00:48:40.483 --> 00:48:44.065
So Shane, I think this has been great.

00:48:44.206 --> 00:48:45.766
One of the things we do here at

00:48:45.806 --> 00:48:47.807
the very end is just like a take-home

00:48:47.847 --> 00:48:50.608
message or like if there is one thing

00:48:50.708 --> 00:48:52.730
or one comment you had that you wanted

00:48:52.789 --> 00:48:54.210
all the listeners to take away,

00:48:54.990 --> 00:48:56.672
could you please just share us with that

00:48:56.711 --> 00:48:57.032
message?

00:48:58.697 --> 00:48:59.259
Yeah, thanks.

00:48:59.338 --> 00:49:00.423
And again, thanks for having me on.

00:49:00.443 --> 00:49:02.050
This has been a great conversation.

00:49:04.338 --> 00:49:07.458
I think we just discussed probably

00:49:07.518 --> 00:49:08.838
something that I think is good for

00:49:08.878 --> 00:49:10.798
everyone to kind of reflect on,

00:49:10.838 --> 00:49:12.480
and that's the collaboration with our

00:49:12.519 --> 00:49:13.420
healthcare partners.

00:49:13.619 --> 00:49:16.099
And it's really for the betterment of our

00:49:16.119 --> 00:49:16.521
patients.

00:49:16.561 --> 00:49:18.860
So if they need to see a dietician,

00:49:19.081 --> 00:49:20.621
if we don't have the expertise in that

00:49:20.661 --> 00:49:20.820
area,

00:49:20.840 --> 00:49:22.021
and that's gonna help them manage their

00:49:22.041 --> 00:49:23.422
weight, then we need to work with them.

00:49:23.501 --> 00:49:25.702
If we need to work with a podiatrist

00:49:25.742 --> 00:49:27.563
because they do shockwave therapy,

00:49:27.663 --> 00:49:29.922
or they perhaps might need an injection to

00:49:29.943 --> 00:49:31.664
give us a window of opportunity based on

00:49:31.684 --> 00:49:32.284
what's going on,

00:49:33.244 --> 00:49:34.925
or maybe they do need some specialized

00:49:34.965 --> 00:49:37.228
foot orthoses for a while that we can

00:49:37.248 --> 00:49:39.550
then use to complement our treatment with

00:49:39.590 --> 00:49:39.771
too.

00:49:39.811 --> 00:49:42.454
I think it's important that we make sure

00:49:42.474 --> 00:49:43.655
to continue to work together

00:49:43.715 --> 00:49:44.496
collaboratively.

00:49:44.657 --> 00:49:46.778
I'd like to think that this is to

00:49:46.818 --> 00:49:48.880
some extent an example of that and how

00:49:48.940 --> 00:49:50.063
we can be better together

00:49:50.583 --> 00:49:53.224
than necessarily in isolation and i know

00:49:53.244 --> 00:49:55.364
we don't know what the isolated plus uh

00:49:55.384 --> 00:49:58.224
sorry isolated physical therapy arm might

00:49:58.244 --> 00:50:00.105
have been and we can suppose what that

00:50:00.164 --> 00:50:02.385
is but but again i still feel like

00:50:02.405 --> 00:50:03.985
there's there's there's things we can do

00:50:04.005 --> 00:50:07.126
uh together and then the other part which

00:50:07.166 --> 00:50:09.447
is an interest of mine that i continue

00:50:09.487 --> 00:50:12.148
to explore and that is the strengthening

00:50:12.188 --> 00:50:14.527
part of it i feel like in in

00:50:14.568 --> 00:50:16.929
plantar heel pain uh strengthening has

00:50:16.969 --> 00:50:18.829
been underutilized and underdosed

00:50:19.728 --> 00:50:21.429
And I would suggest that we shouldn't be

00:50:21.469 --> 00:50:26.414
afraid to utilize those interventions in

00:50:26.494 --> 00:50:28.954
this population as well if you do find

00:50:28.974 --> 00:50:30.735
yourself not utilizing them commonly.

00:50:31.277 --> 00:50:32.858
Not to undervalue manual intervention.

00:50:32.898 --> 00:50:35.079
I know this is a podcast through the

00:50:35.179 --> 00:50:35.599
AOMT.

00:50:36.159 --> 00:50:38.201
It's definitely of high value here.

00:50:39.202 --> 00:50:41.523
I see plantar heel pain being very similar

00:50:41.623 --> 00:50:43.063
to low back.

00:50:43.224 --> 00:50:43.925
So I would say...

00:50:44.684 --> 00:50:45.166
Uh,

00:50:45.206 --> 00:50:46.867
plantar heel pain is the low back pain

00:50:47.027 --> 00:50:47.947
of the lower extremity.

00:50:48.108 --> 00:50:49.688
So a lot of the approaches that we

00:50:49.728 --> 00:50:51.630
take in the lumbar spine, uh,

00:50:51.670 --> 00:50:54.652
I think can be very similarly applied, uh,

00:50:54.693 --> 00:50:56.494
in, uh, persons with plantar heel pain.

00:50:57.635 --> 00:50:58.255
That's awesome.

00:50:58.976 --> 00:50:59.115
Um,

00:50:59.275 --> 00:51:01.277
thank you so much for taking your time

00:51:01.438 --> 00:51:03.798
and sharing your expertise and for doing

00:51:03.818 --> 00:51:05.880
all this work to support the profession.

00:51:05.900 --> 00:51:06.902
I mean, this stuff is,

00:51:07.362 --> 00:51:08.402
we can't do what we want to do

00:51:08.422 --> 00:51:08.822
without it.

00:51:08.842 --> 00:51:09.824
So thank you so much.

00:51:10.264 --> 00:51:10.945
Yeah.

00:51:10.985 --> 00:51:11.284
Thank you.

00:51:12.661 --> 00:51:13.123
All right.

00:51:13.704 --> 00:51:13.925
All right.

00:51:13.945 --> 00:51:14.626
Thank you, listeners.

00:51:14.646 --> 00:51:16.833
That's today's episode of Hands On,

00:51:16.873 --> 00:51:18.036
Hands Off podcast.