Successful Physical Therapy for Ultrarunners with John Chao DPT OCS | Koopcast Episode 100

trail and ultra runners what is going on what's happening welcome to the 100th episode of the KoopCast as always and as has been for the last 100 episodes i am your humble host coach Jason Koop and first off before i get into this intro thank you to all the listeners that have made this podcast so special to me i when i first began this podcast i had absolutely no idea how meaningful it would be to me professionally and a lot of that meaning comes from you guys all of you the listeners that i get to see out of the races and i get to hear feedback from on social media and how much the content that is contained within the podcast that i have produced how much that means to you and how much it helps you on your ultra marathon journey so i am going to keep bringing it and true to form i could have done anything with the 100th episode i could have put together a bunch of silly clips of you know the most salacious things that people have said and the craziest stuff that happened on the podcast this podcast really isn't all that crazy but instead i'm just going to keep with the theme of the show and bringing you the listeners high quality information that can help you in your trail and ultra running journey and this episode is no different the long time listeners will know that this is we are right in the middle right now of a series of podcasts that i'm doing

all about how to utilize physical therapy and this podcast is really special to me because it is with one of my oldest friends on this earth somebody that i've known since junior high school we played all different kinds of sports together and now we just happen to be in the same field of working with athletes it is with my good friend all the way from dallas texas john chow who's a doctor of physical therapy and he uh happened to start his own clinic called the matrix physical therapy and wellness center in in santa monica california but i'm not just bringing on john because he is an old pal of mine i have come to really appreciate john's perspective on the space of physical therapy and in addition to that he just happens to be one of the smartest people that i have known in my entire life i think you guys will appreciate his perspective not only as a business owner and a high quality physical therapist but somebody that understands athletes and always always always puts the patient's needs first and will do whatever he can in order to get good patient outcomes john thank you in advance for being a friend a confidant and a fantastic physical therapist i am going to get right out of the way here's my conversation with my good friend my childhood friend john chow i determined in advance since you and i have known each other for so long we have to make a pact

before we actually get into the meat of this and that pact is is we can't talk about anything that happened before 2002 before 2002 but i was going to talk about your accolades in like high school how you were the star linebacker and football nobody would know how badass football player used to be and all that stuff well one nobody gives a shit about that but the second the second thing is is there's a certain level of professional decorum that for sure we would drop underneath if we talked about some stuff that happened but you know i'll be good no way no way i think it's 50 50 shots another before 2002 unfortunately both of our professional careers were after that so we can keep in pretty much that's when i started school in 2002 so yeah yeah all right good good so you just took me through a virtual tour of your space out there in santa monica to set the table with this why don't you take through the listeners through what they're going to see if they come into your clinic so our clinic is unique in that we have a lot more time one-on-one with the physical therapist we have 45 minutes of one-on-one time with the pt and also every pt has their own assistant physical therapy aid and so not only do you get one-on-one time with the pt you also get one-on-one time up to 45 minutes with the aid itself a lot of clinics have one aid working with multiple patients and or the pt works with multiple patients at once but in our clinic you get one-on-one time with pt for 45 minutes and

then one-on-one time with the aid for 45 minutes so it's up to an hour and a half of personalized one-on-one treatments and you have an array of things that you can do within your clinic i mean you just took me around it was kind of like part strength training area and part physical therapy clinic so what are all the things that you have access to the reason we named our clinic matrix physical therapy and wellness so not only do we offer physical therapy services the wellness services we offer are personal training um massage therapy and pilates because we feel like those are great adjuncts to build upon using while in conjunction of physical therapy and or you can graduate and then continue those things to further your individual goals so it is multi-factorial and we but i also am a big fan believe it or not i am a fan of chiropractic treatments i am a fan of yoga i'm a big fan of acupuncture anything that helps essentially we don't offer those here but we i do recommend it if it helps you by all means i'm very open-minded for that but in this clinic specifically we do offer um pilates one-on-one pilates sessions one-on-one personal training sessions one-on-one massage sessions okay so and it but it didn't always start out like that right there was some sort of evolution to you decide you want to be a physical therapist and then you want to start a practice and then you're going to have a practice with all of these different elements and you and i have had a number of different conversations about how that evolution has ultimately taken place and kind of what services make the

cut and what services don't make the cut based on any a number of different factors what the patients need what clientele you're serving there's a business component to this as well that that we've talked about and i want to i want to start to portray that aspect to the listeners as well because ultimately what i want to have them come away with is how can they how can they look at the physical therapy landscape on their own and start to determine hey i want to go to this clinic or i want to go to that practitioner i want to go over to this one because it'd be easy for me to just recommend something right but not everybody's going to reach out to me and say hey do you know a physical therapist in xyz place i'm happy to triage that but a lot of people are going to want to try to like figure it out on their own or figure it out in that area and i think the window to that to helping athletes figure that out is look at successful practices like yourself and see what they can draw from why they're set up why how they're set up and why they're set up so take take me through that like what was the evolution of the things that you've added in and how they make the cut versus they don't make the cut well the first to go to start from the beginning what i think is really important and what patients and your athletes really need to look for as far as determining what kind of physical therapy clinic to go to is there's many aspects of physical therapy in itself the main aspects is therapeutic exercise in manual therapy a manual therapist by definition is somebody that actually uses their hands and goes

in and does soft tissue mobilization joint mobilization myofascial release manual stretching manual um proprioceptive neuromuscular facilitation things using their hands a lot of and but in my opinion a good physical therapist does some some of each they it but it all also depends on what the athlete needs and one thing i've noticed is some clinics only do modalities which is hot pack ultrasound electrical stimulation you actually find very little of that here because unfortunately the research is not that strong in the effectiveness of that and if you're actually looking to evaluate a clinic and if you if that's all they do i just had a patient this morning she's been to many clinics and i asked them what do they do and she said all they do is ultrasound simulation and hot ice pack and like that's not addressing the cause of your problem so the most important aspect of a physical therapy clinic is finding therapists that find the root cause of your problem essentially and because all these other aspects that were just mentioned as far as pilates therapy exercise or personal trainer and massage therapy is these are all adjuncts to treat the cause but the most important aspect is to find the cause of the problem not just the treatment so you have to find a clinic that that's where they're going to go to that's what they're

good the priority is to actually address the root cause of the issue and that's a that's a really hard thing to do right it's easy to say oh yeah go ahead and find the root cause of the injury but going through that process and i've been through this with any number of physical therapists both personally and then also with the athletes that i work with trying to figure out that root cause it's not as easy as you know a litmus test that turns red or turns green or turns purple or whatever it takes a really qualified practitioner to try to try to work through those things and i think a lot of the i'm going to kind of speak for you a little bit because you and i've talked about this a lot a lot of the frustration that you see with other practitioners in the space is they're just throwing shit at the problem right they can't figure out the root cause so they just throw they throw five modalities at it and then maybe one of them will actually stick yes yes so you then you have to you know it's a lot of we get a lot of referrals because the doctors know that we spend a lot of time and it goes back to the time aspect you have to have enough time to try different things you have to have the experienced clinicians to actually do that and so and then and then being able to utilize all these other things to to treat the the patient itself but um it we get a lot of referrals through word of mouth essentially when we first started the practice we spent a lot of money on marketing techniques on advertisements and going to every individual doctor and saying hey we have this

clinic we offer these things and everything you know how many referrals i got to from all those doctors that we actually physically went and saw zero wow the doctors don't care about what i say they care about what patients say so our biggest source of referrals are from other patients who've come to see us and then they fail treatments of other places they come to see us and like wow we work different we actually address the cause and then they tell they go back and tell the doctor this clinic does this they actually find the cause of the problem and they treat it and then it doesn't come back because we address the cause we don't just treat symptoms and then the doctors wow they actually do that then the doctor starts sending to us and then the patients send their friends family and all that so being successful with the patient is how we keep we've been able to grow we started with just my partner and i five years ago and since we are at 11 pts now so just in and that happened three years ago two years ago literally so in three years we were able to expand our practice in that big because of the way we are philosophy and how we treat patients and so when if it is is it really a time problem like if in terms of is in terms of trying to suss out the root cause of an injury it's actually a thought process problem okay the way i say that is so when i went to pt school back in the early 2000s i

when i graduated i knew i wasn't good enough to figure out the cause and that's the process called differential diagnosis and so i did an additional year of training called the residency orthopedic residency and that was highly intensive because i saw my professors who were very experienced they were able to see a patient know like listen to their history know what tests to do how to diagnose them so fast i'm like there's no way i could do that even when i graduated from a three-year doctorate of physical therapy program number one ranked in the country i when i graduated i knew i was not good enough to be able to do that so i voluntarily applied and got into this residency program and during that time is where they really hammer in the thought process with you and it's the whole differential diagnosis process and it's what that means is when somebody comes to me with a problem i am able to look at their demographics their subjective exam and come up with a list of 10 things that i think it probably could be and i'm able to rule in rule out by specific questions on um what the potential cause is and then the our objective exam is where i further rule in rule out the problem and i'm able to um hone in on the root cause of that so it's a whole process that goes on in my head that i have to go through and that takes a specific amount of training i can tell you from interviewing

and having other pts who work for me not everybody does that not everybody teaches that in the pt profession so it's kind of but the harm the problem is how do you find somebody who actually is able to do that right no so that was going to be my question how do you do that like you hire pts you have a successful clinic you've had to go through that in your hiring process how do you do it correct because i we during our hiring process we specifically ask those questions because i know that's the most that's what makes the most successful therapist is someone who's able to have that thought process when they're treating because if something's not working you have to constantly be going through this thought process you can't just be very simple simple-minded and think oh the height andry has to be that you have to link all the different body parts all the different processes and it it is it actually goes further into that process and that's when somebody has tight hamstrings weak glutes tight calves those are what we call impairments and so you have to be able to link all different kind of impairments to a diagnosis in itself as well so um and not only that you have to be able to see the body as a whole picture so many people get tunnel vision narrow-minded and only look at that injury however they don't see the the link between all the segments above and all the segments below and how and what we call the connect chain and how that's all leaking and how that's all causing the problem hence addressing the cause which is not always the area that you're being

treated for and my clinic we actually are a clinical site for the usc's orthopedic residency and so we take residence which is the same program i went through and so these residents get mentored by us and people who did this and that's the biggest thing that we teach and that's the biggest problem i'm seeing from these new graduates is they're not able to link all of these different body parts together and all of these different impairments to find the ultimate root cause of the problem so it's a whole process not only differential diagnosis but also linking multiple impairments to find that diagnosis essentially you so you already hit on my like you know one of one of the things that i just get consistently irritated at whenever i send an athlete to a physical therapist and they come back with the diagnosis of weak glutes for whatever reason that just seems to be like the blanket the the blanket cause for everything within running it's it is definitely a big buzz i can point out to one one specific pt who kind of started that craze but i'm not i'll mention his name but uh some people really agree with him a lot and some people um don't agree with him a lot it's it's definitely present in a lot of people however it's rarely the only problem okay but let's get let's let's kind of get back to this evaluation piece because once again you've got this perspective where you hire physical therapists you also mentor physical therapist from is it still the top program in the country one of the top three programs in the

country number one still number one program in the country so you're like you've literally kind of got the cream of the crop there right and still when you see these you know knucklehead you know about to graduate vts in there just like you and i were knuckleheads in 2002 yes i definitely was when i graduated we were for sure we were for sure that that that that that place you took the extra step and you got yourself extra education but if you were if you were to look at that class that comes in and say okay i need to hire somebody from this class how is that person going to stand out for you what are they actually doing in the clinic what is their thought process because once again i want to use this as a window so that athletes can look at that and identify either identify that or not identify that with their like practitioner circles practitioner circle that they are trying to figure out i think one of the most important things we look at is the person's ability to look at the whole picture not just the problem and not just treat symptoms but treat um again trying to find the root cause that's the biggest thing and not and and being able to see it from a grand point of view because we actually test the pts like if this person has let's just say lateral condylitis of the elbow um how do you treat that do you and i it's literally everything so um an elementary very simplicity physical therapist will look at lateral condylitis and just naturally

assume they have weak wrist finger extensors tightness in the forearm but they don't look at the proximal shoulder joint they don't look at the rotator cuff strength they don't look at the biceps triceps they don't look at postural the shoulder position the mid scapula how all the proximal aspects and even distal where they may not look at workstation economics they have to look at everything that contributes that why is the forearm tight why is it getting overworked and many of these people lateral condylitis don't play tennis even though it's called tennis elbow so you have to look at all of these different factors and so we look at their thought process to see if they actually take into all these different accounts and so if you're looking for physical therapists those are questions you can ask say i have a knee problem i have to tell her tendonitis please explain to me your thought process and how you treat that and if they start off by saying we throw modalities at it like ice electrical stimulation ultrasound to treat that i would say then don't go to them because that is not the proper way you have to look at so many other factors and so many things from if somebody lacks dorsiflexion in the ankle if they have tight calves the hamstrings the core you have to look at the whole body you can't just look at the knee itself so trying to ask the therapist do you treat the whole thing you look at all the different training like how tell me how you would design a training program for me if all they do is give you straight leg raises and squats and you just focus on the quads that's not good you have to find the the multiple different factors that can contribute to

that so you can flat out and ask them how do you treat this you know how like give me a treatment plan and we are actually getting a lot more and more patients calling us asking that very question oh really i have this i have low back pain please can you please run me through your treatment plan how do you do this and so the way i explain it is you know ask a very thorough subjective evaluation i have this list of in my head what i think could be causing it and the all the things i look at as far as posture what you do during the day any changes in your activity level pre post covid and work demands and then looking at the body and whole everything we just talked about and then designing a treatment plan to address everything that could be contributing to that because they're they're they're the ones who've gone to all these other clinics and they just do a very simplistic thing and you know low back pain and everyone says okay just strengthen the core but it's rarely just a weakness issue with a little back well i think i think what you're kind of getting at is is like somebody comes in with you know they they have runner's knee right their knee hurts some physical therapists will say okay let's focus on managing that pain and see if we can get you back into the field of play just through that pain management what you're saying is is your clinic will take a more comprehensive approach and say why is that pain happening in the first place we're going to target 100 exactly why did you get it did you have a change too dramatic of a change in your training

regimen did you try to progress too fast too quickly did you change the the surface of that you're running did you try to change like add hills did you add biking to it you know we treat a lot of triathletes and then as soon as they start increasing um they they started biking more or they change a variable that that can contribute to that you have to consider that variable what aspect of that variable is causing the problem in running so you have to take the whole account you can't just again treat the symptoms you have to treat what it happened otherwise it's going to have it's going to come back and then their attitude is physical therapy didn't work so and then there's like i tried pg didn't work but the problem is they didn't address the cause and why it happened so then a lot of people would give up on it and then they'll continue to have pain and they're having to stop or they just have or they just have weak glutes for the rest of their lives correct but we pick on the weak glutes people i mean i remember this when i was working with i can't remember what the specific ailment was with you and and you asked me this battery of questions that i was exhausted afterwards like just one after the other after the other after the other like it was just so mentally taxing for me to recall all of these things how much time are you sitting how much time do you spend walking around what were you doing here what were you doing there but then after afterwards i appreciated that so much because i was like okay well now he has the whole context in the same way that i would look at an athlete's like previous training history and what they do for a living and what their day-to-day lives are and are they the

soccer coach and all these other kind of things like that intake is it was once again you're doing it for me because i'm a friend but i i feel that a lot of times in the physical therapy world relating to an earlier point that i was making they're kind of get pinched by time right because they've got to see so many patients all at once so how why why i think it's important for the listeners to understand why specifically is that a problem like why is this time crunch so pervasive in the industry unfortunately you're seeing this in every medical field and i hate i hate to bash insurance companies but the insurance reimbursements have gone down so much literally that they've been they've been cut in half so we are so i understand a lot of different clinics a lot of different people they have to see more patients in order to get paid enough to pay their bills it's a business component it's the it's the business component yeah it's strictly we are able to make up for strictly on volume because we have 11 physical therapists we have expanded the space and we have added these other adjuncts to supplement our income so and honestly like my partner and i we just don't make as much money because we are not motivated economically we're really literally motivated by getting the people better and what they need is more time in order to do the things to do a proper evaluation do a proper subjective do a proper objective evaluation to truly have that there of course there are some more simple patients who you don't need a lot of time they come in and you're like

okay it's this isn't this because they they know a lot about their body and they tell you all the information you need and they say i tried i changed this training aspect and this is what happened and this tightened up and like okay and we treat that it's very simple but there are a lot of people who just don't like you mentioned it is really the questions we ask are really hard because people are paying attention to that so i asked them like look then the beauty of what we do is we see people twice a week for however many weeks and i said well next time you come and just pay attention to that and tell me next time and this i didn't even realize i was doing that i didn't realize this change and what i did was he was doing that so a lot of people just aren't aware but when we're able to see them multiple times a week then we can we don't have to figure out that first visit and it doesn't always happen in that first visit so so is that luxury is it a reasonable screen i'm kind of putting you on the spot here with your profession so you can you can punt this question if you really want to but is it a reasonable screen for an athlete to say okay i'm going to call this physical therapy clinic and just ask them how long their initial intake is and if it's below luckily most clinics that i know of their initial intake is up to an hour they do have that amount of time but the follow-up isn't always there and like i just mentioned if you can't figure out that first time you need more time in those follow-ups to ask those questions and then do more evaluative techniques but if you only have 15 20 minutes of time and you you have to do treatment you it's hard to do treatment and evaluation at the same time if you only have that minimal amount of time so um one thing we do do and

i don't necessarily get paid for this is a lot of my patients they always email me in between their visits and say hey i have this this is how i reacted i went to the golf course and i hit this many balls and this is how i reacted what should i do here how should i do and so i'm spending time like literally guiding them in between their sessions in addition to their sessions also so it is a time commotion as well and so you want a physical therapist that cares about you and who will take that time where you can email and they'll get back to you just like anybody who has a surgeon or a doctor who they go to and the doctor drew receptive on on emails and they have questions postoperatively even they can email the doctor and doctor gets back to them you know so a lot of a lot of complaints they get from patients doctors don't do that and infections get missed or postoper complications get missed because there isn't good follow-up care so you do need good follow-up care with pt as you do with any other medical profession it's a tricky proposition from a business perspective though because you understand that like you just mentioned that your insurance reimbursement rates are crap and now you're spending more time in between the visits to answer questions and answer emails and things like that and i know i know you have this frustration eventually the time that you spend working versus how you are remunerated right you remunerate yourself as a business owner and things like that starts to become out of proportion you got kids and a wife and you want to live your life and things like that like it becomes tricky right well luckily i don't live extravagant so it's okay we manage right let's pivot a little bit nobody i don't i don't know if people how many people believe

me but honestly my biggest reward is when patients come back and say i could i went and did this bike ride in the 120 mile bike ride i went and did this huge hike i was able to run the marathon i was able to do that that gives me the greatest reward and satisfaction and they can tell that's genuine so i think when so when patients are choosing physical therapists they'll know they can tell the pt really cares the the effort the amount of questions they're asking how much they're really paying attention to what they're telling them how much they're paying attention to change little things here and there to really give them back to their athletic training goals so you i would try to find a pt who actually genuinely has empathy and cares as much to get you back to what you want even if something as simple as i slept through the night or i was able to pick my kid up i was able to throw them in the pool all these little goals functional goals or what we i truly live for that people that gives me chills every time they come back and they tell me i was able to do this i'm like that's exactly why i do what i do all right ciao so we're we're gonna get you more ideal patients right here right now right so anybody in santa monica area could can go to john chow but what can patients or athletes do when they come and see you to get into that category to get into the category where they sleep through the night they do their first marathon they complete a triathlon things like that to have that successful outcome what can they do with their physical therapist and what they do at home to kind of maximize that experience the biggest thing in my opinion is to be an active

participant in the physical therapy itself and what i mean by that is take notes and try to give their physical therapist as much information as you can as far as changes even even daily habits how long you sit for it's and things what we call aggravating alleviating factors give me specifics on what hurts you what makes you feel better and the more information i have on all those little things can clue me in on all the things that are affecting you and all the things that are contributing to the why and not only being active in that being super active in your and adhering to your home exercise program because patient compliance is probably the biggest problem that we have athletes it's actually much less because they are very motivated to get back to what they want but general population the adherence to their exercise program as far as the exercises itself the stretches the self-soft tissue mobilization i'll i tell patients all the time the more you do and the more frequent you do the faster your rehabilitation process will go and then the um more likely the positive outcome will be so taking and being very active actually doing what your pt says and then journaling taking notes and trying to be give them as much information as possible i i think so you're not aware of this john but i am because this podcast hasn't been released i just i recorded it literally yesterday with a very good friend of

mine very high level physical therapist jessica layman so the listeners can refer back a week ago to this podcast i asked her that similar question and she went on to the notes take notes take notes in your day-to-day life take notes during the meeting that's your biggest conduit so it's really interesting to hear both of you to say that and independently you know it's not like you guys like collaborated with each other in advance or anything like that but i think the listeners can like really take that peace to heart that you're an active participant in this process you're not just a passive piece of clay to be molded or anything like that and and unfortunately i think that's one not to um not to go off on topic but i think that's a big aspect of medicine today is people are too reliant on the health care system to help them instead of being more helping yourselves and my brother-in-law is an internist and he says everybody just goes to him and says fix me give me a pill give me this to get me better instead of uh what can i do to help myself and we're here to guide you and tell you that but you have to be an active participant and i i i tell my patients i'm only with you an hour and a half a week you know you're by yourself that entire rest of the week you have like you're responsible for all that other time i'm responsible for the time you're near but you have to help yourself during that all that other time so okay so just we just built your business up a bit now we're going to tear it down how do people stay out of your office like who are the people that you don't see what are they doing

right that you never are going to interact with them honestly if i see people on the street and i haven't seen them in a while i consider that a good thing because that means you're not in pain you don't need to come see me so the people who aren't in here are the ones doing the job they're doing the things that are supposed to be doing or not doing the things they're not supposed to be doing you know so there's many activities as you can't do that when it's lifting there's certain lifting techniques that they shouldn't be doing there's certain training things they shouldn't be doing that are that's hurting them so it's like you know that's probably an activity you shouldn't be doing but specifically with with running or you can kind of expand it into any endurance sports triathlon cycling and things like that like is there a common set of all these athletes are doing this right and so they very rarely get injured or when i do see them that it's very kind of minor versus the people and you you have i know you have these patients every physical therapist does that's in there every single month and it's always something different you know it's this this to that to that like is there any commonality that you can find amongst those two groups of of athletes that you've worked with interesting question the ones that i don't see who are doing who who kind of avoid injury i would say i think what something that's very overlooked and that that you're probably doing a lot the athletes who are relatively injury free is they are stressing the importance of recovery and when i say recovery i mean

downtime not training as far as and then when they do train they properly stretch afterwards they i remember talking to you about this how much you stretch after you run no i love you you will stretch like 30 minutes you used to stretch you know so so many people always ask me what so they they they they do the things before but i i says you should you should do them before during and after especially the after is the most important part as far as icing as far as stretching as far as active rest as far as it's doing soft tissue the foam roll i was like your foam roll is your best friend you should be doing that all the time because this brings on the point of i always tell people don't wait until you have symptoms to treat things you should always because things there's a pain threshold and we are always flirting with that pain threshold if you can stay below it by doing the proper strengthening by doing the proper stretching by doing the proper soft tissue mobilization you will stay below that threshold so many the biggest problem i see people have is they don't do things until they have the pain so they're more reactionary instead of pro-actionary instead of being proactive and so i tell people and so people who don't come in here who are able to avoid injuries they're being really good at stretching soft tissue recovery icing all that to prevent the accumulation of inflammation the accumulation of tightness the accumulation of problems so they never hit that pain threshold so out of all those maintenance activities that you just

mentioned stretching foam roll icing which ones are the heavy hitters because they're going to be people out there they go okay i got to pick one or i got to pick two because it's only time right it depends and it depends is the most common answer for any physical therapist when we get asked questions so it depends on the nature and the cause of your problem if you have an inflammatory problem if you're just prone to having a tendon inflamed so icing afterwards even if you don't have pain so you want to keep inflammation down because inflammation is very cumulative each time you run it builds up it builds up it builds up that's why you see so many professional athletes sit in ice baths you after pitcher pitches he has an ice on his arm even though he doesn't have any pain that ice is bringing that inflammation down so it never gets to a point of hitting that pain threshold so you always want to keep inflammation down in ice if it's an inflammatory problem if you have a muscle cramping muscle tightness muscle strain issue you want to do more stretching foam rolling to keep that muscle loose because if you keep doing your athletic activity and then the tightness keeps building and building and building until it gets so tight and then you do a sprint the muscle is so tight and then it's going to tear because it's so tight you want to prevent it from getting so tight by constantly soft tissueing it constantly stretching it and keeping it loose so it doesn't get to the foot where it gets tight and you strain it so it depends on the nature of the issue if you have an older athlete may have some kind of arthritic change in the joints the most common symptom is stiffness and joints get stiff and so because of that you always want to stretch the joint out you want to teach them trouble some

self-mobilization of the knee joint maintaining full flexion full extension and make sure they are doing these mobility type exercises to keep it mobile because that stiffness can be accumulated and build up over time so you whatever issue they have you want to target those modalities to keep it down just don't throw shit at it i think is the thing that you're kind of getting specific for that patient correct why would you ice a muscle strain necessarily when it's not an inflammatory issue you know you can't and that's the problem when people who do treat with ice heat in all those things heat don't get me started on you know i'm not a big believer in superficial heat because it just doesn't penetrate deep enough so it doesn't really do anything to quote-unquote heat up the muscle the active warm-up is more important to actually warm up the muscle versus heat so um you can't just throw anything it has to be very specific to that to the patient this is something that i've always had an issue with within the recovery space that i think translates into what you do as well every you know six or nine months there's a new toy out there you know first it's a you know kinesiote we could go through all these we're not going to throw them all under the bus CBD oil right there's a new theragun there's normatec boots there's you know now now compression boots that will circulate cold water through them there's contrast therapy there's cryotherapy and you know they they keep going through cycles right you and i've been doing this a long time we've seen

all these things kind of come and go and we both get the same question does this work and i give the same answer that you do most of the time some of the times just no it's just we could just throw some things completely out but sometimes there is a it can work for this thing very specifically and i think that that's the that's what gets lost because product manufacturers they want to sell products to everybody not just the things that are going to work for them right correct so with that being said a new a hot thing and we actually use it here are the hypervolt stair guns everybody is using them every every athlete is using it and i get that question all all the time should i get one will this help me and so my answer and i've used it i i personally don't use it i like using my hands my elbows to actually feel in it because i can't feel through a machine however people they want to buy it and use it for themselves so um it it works for some people it doesn't work for some but again it depends on what it's specifically for it works on a vibrational technology base where it's vibrating it does it has shown to increase blood flow to there has shown to loosen up muscles and it can help with recovery and or prep for an athletic activity however if you have a knot and you need deep tissue release it really can't do that because it can't go deep enough and it's too it's too painful if you try to push deep so if you have that kind of a problem that's not going to be effective for that but if you're using it to try to warm up a muscle per se and or you have general tightness not like a deep knot

it can be effective for that or you can think that it really helps and for the placebo effect and you want to use it and you're like i'm not going to get injured because you use it and it helps and by all means and do that so i'm going to give you a great idea for an infographic not to throw more work on your plate because we just talked about how much time you don't have but let's do an infographic and take all of those and say every single one kinesio tape the theragun normatec boots heat hot cold every every single one use this for these not for this simple x y grid modalities right down the y axis yes no on the x axis and then the caveats as another point of the x axis what do you think give that to your students there you go dude i've just helped you out now give that to your students that you have come through i i would do that except i i'm not one of the i'm you can call me old-fashioned that i am more of um i don't like i don't necessarily i don't want to call buy-in but i i don't rely on those i again go more as far as i feel like most things can be handled by the traditional manual therapy therapeutic exercise you know habit changing postural changing i feel like most things can be handled by those things are those can they be helpful yes but are they necessary necessary no you can use a frozen bag a piece for the ice you don't need to go to cryotherapy

you know i'm very simplistic people always ask me should i buy this should i buy that and i never push products i'm like no you can get the same effect by much simpler way so i so with my residents with students i never say oh yeah you should definitely recommend normatec for the compression therapy afterwards you should recommend this i never push those products however patients ask me should i do this should i do that i was like well do you feel like it works if you feel like it does by all means that's funny like a common thing that i've always had with really high quality physical therapists is they like to use their hands like they just feel that their hands are the best tools because they get the kinesthetic feedback of the quality of the tissue and how does it actually feel and things like that versus the tools that are really specifically where whether it's an a stem tool or grassed in or the theragun or whatever that has that has some sort of barrier between them and the them and the patient where they can actually feel it they just feel that they have a better they have just a better take on the situation i guess it's the best way to put it correct and that was my training is they really taught us how to feel with our hands and get that feedback with our hands and we can feel the problems and so i'm more old school i can tell you the newer school therapists are less manual therapy based and they're more therapeutic exercise based and while there is benefits of therapeutic exercise i do not believe that it's the nlb all i believe you have to have a combination of both in most cases some things don't get me wrong some cases it is a

weakness issue it is the tightness issue and they can get by with therapy exercises yes but the majority of patients my patients in my experience i think people need both you may not need a lot of manual than everybody could help initially because if somebody has a knot the muscle is not going to be able to function and perform to the higher stability because there is a late tension relationship as far as far as much as a muscle's ability to produce torque and or get stronger muscles are made of fibers myofibers and they have to be able to slide back and forth and if a muscle's knotted it can't so you can't it's going to be really limited on how strong it can get so you can throw all the therapeutic exercise or stretches that you want but it will have a ceiling for how strong you can get if you have knots so i'm a big component of finding those knots and getting rid of them if you want an athlete to reach its maximum their maximum potential as far as strengthening goes so that's i think where a lot of it's missed and so because there has been new research showing manual therapy is not as just as effective as therapeutic exercises and these new therapists they point to that research but you have to look at the nature of the research and whether or not it's level five evidence which is a double-blind randomized controlled trial study and those aren't those so the evidence is not necessarily strong with those but the but the the studies aren't necessarily looking at necessarily this certain outcomes as far as the the outcomes are more like um pain

either pain reduction or function they don't necessarily look at strength production and all that so that's why i've always i've always thought that it's important to look at clinics like yourself that have to balance the needs of the patient the business needs and come up with very kind of like practical like not only practical solutions but just like a practical way to set up the business versus with all due respect the olympic training center here where it's a different population of athletes and also they have a different like it's the athlete's job so in a lot of ways they can just kind of like throw stuff at whether it's a you know training intervention or recovery modality or they're trying to recovery from recover from an injury like they've just got more tools that they can use and if it's not gonna do any harm right they can they can they can afford the time the cost and the energy to do that with that specific population base i don't think that that's like useful to look out as a model as compared to what you guys do it is useful in that patients always ask me how do athletes get recovered faster and i said well they don't have anything else to do except dedicate themselves to their body and they can do it for four or five hours a day they have somebody working on them they can't dedicate that amount of time that goes back to the patient compliance issue the more you do the more you spend the more you dedicate on this the faster your recovery will be so you can use athletes as far as uh good examples on that and i tell patients that all let's be compliant and take notes right there you go exactly athletes are like i mentioned earlier

athletes are some of the most compliant one issue i have with athletes they do way too much to work because they are so complicated they they end up i say do this exercise and they end up doing it way too much and then i'm like whoa they come back and like it kind of flew out like how much did you do they said oh i thought just because you told me i did it the more the better i'm like no that's too much so do you have to do you have to tailor that i mean normally you're in a in a i say normal population so somebody just comes out of surgery right they're a normal person they're not a high level athlete or whatever do you have to tailor the how you deliver the advice to this first group versus that group you have to you have to get a read on the personality of the patient yeah and if you can tell if they're really gung-ho and they really want to do things they they say when can i take the brace off when can i walk when can i do this and i have to say the number one goal right now is to protect the integrity of the surgery you don't do that because that risks redamaging the surgery you can't do that so i have to calm them down and walk them off the ledge you know so and but some patients are really nervous like oh i don't want i'll give them actually oh i can't do that no i can't you know i'm like no you can't it's fine so you so every patient is different and and you have to kind of gauge their personality and how they feel on that but that's a good sign of a good pt is somebody who can who has the experience who has worked with all different kinds of people and who can read the kind of person they are and then you have to you have to like adjust how you talk to them and what you give to them as far and and how you and the advice you give to them and things you

have to look for and say look if you're sore then make sure you back this down because i'm anticipating they're going to do too much and getting so and get sore and then trying to foresee and anticipate potential problems with that patient you know because otherwise they'll be like you didn't tell me about this you didn't tell me about that you know but if i anticipated that i tell them and like you're like no i told you not i told you not oh yeah okay so they're more likely to listen there are a lot of triathletes in santa monica and we always throw triathletes under the bus they're the most notorious group for doing doing way too much like that um yes all right man so you started this thing you're now how how long has the clinic been in business seven years now five years five years okay let's look 10 years down the road what do you want it to look like then as compared to well we're kind of i would love to actually add other services such as acupuncture i do i do feel acupuncture has its strengths i would like to add occupational therapy i would like to add potentially a chiropractor they're like i mentioned chiropractors have there are a lot of good chiropractors and it is just another modality agile treatment that could be very helpful so we would if we did expand here i wanted to add other services however we want to be able to add different locations to hit more of los angeles go more east into beverly hills west hollywood that area and then eventually go to the valley so i want to add more locations and be able to reach more people with our model here interesting man you're taking a risk with the chiropractors man they get such a bad rap

people ask me all the time what do you think of chiropractors i say it depends on what they're claiming they do if they claim they can realign the spine by cracking your back i'm like that's not possible physiologically it's not possible but if they claim you know joint manipulations the studies have shown they can cause muscles to actually relax they can cause temporary you know analgesic releases and so you can treat pain and or you can there are certain conditions where chiropractors are highly effective such as the set syndrome such as rib subluxations they can pop a rib back place i can't do that i was taught that but i do not trust myself so if i had a patient i felt the rib was out i'd say go to a chiropractor they're so much better at the end so there are absolutely conditions and some chiropractors do the more holistic chiropractors they do look at the whole body in the same way we do they do um work on muscular imbalances they can treat in that way i wouldn't hire a chiropractor that only manipulated just to get the crack and say that fixed everything you know you have to follow up that with strengthening and whatnot you know it's just like anything it's just like anything else whenever you're pitching something as a panacea those people are the quacks and for whatever reason that field gets a gets like a lot of that compared to the whole unfortunately they they do and but and you also actually look at their research the research is mostly done by chiropractors so naturally they can be biased so but there are plenty of chiropractors that i know that aren't like that and they are they're very good and they they do treat the whole body

and they so and i've had a lot of patients who tell me about them and again this goes back to the patient referrals so those are the ones that i like to send to i'm gonna uh you just gave me a good idea for my next podcast i'm gonna bring a chiropractor on just so they can talk about that field because it does get you get asked it a lot i get asked it a lot and yes it's a tricky it's a trick it's a trickier one to navigate than the physical therapy field for sure it is and you know that you see chiropractors everywhere i mean they they do do it i patients who go to chiropractors and see me at the same time and they they all all my patients who see me they say oh no he's not the chiropractors he just cracks my head he actually does this and that i'm like okay fine so keep seeing him as long as it's like he helps by all means you know all again a good physical therapist all we care about is getting the patient better all we care about is getting them back to that activity all we care about no matter what whatever it takes you know a bad physical therapist like don't go there do what i say listen to me i know everything that's not the case i am the first one to say i don't know everything if that helps you by all means is that i don't care what helps you as long as you get better that's a brilliant place to leave it my friend that's my number one priority is to get you better i don't care i love it man thanks for carving out the time i know you got a full clinic behind you man we're gonna let you go i'm gonna include uh links in the show notes to where where the clinic is and things like that but is there anything else you want to say about how people can get in touch with you and all the physical therapists and things like that that you

have at the clinic you want to give out your cell phone number people can just text you randomly no i don't know if i i gotta be careful who i give my cell phone number too but you know you can in our our website metrics 50 and wellness.com and you know our phone our clinic number is probably better sorry go find john's clinic number thanks man i appreciate it again my pleasure always good to talk to you yeah man all right folks there you have it there you go much thanks to john for coming on the podcast today thank you for being a great friend of mine over the course of the last 30 some odd years that we've known each other thank you for being a professional confidant of mine and helping me navigate this uh crazy world of physical therapy and thank you most particularly for keeping the athletes that i've sent over to you on the right side of the injury line this conversation was extremely enlightening this is the 100th episode of the KoopCast i still kind of can't believe it as i'm recording this outro so a very special thanks to all of the listeners out there that has made that have made this podcast so special i appreciate the heck out of each and every one of you let me know what your feedback is let me know what you want to see coming up for the next 100 episodes of the KoopCast as always folks we will see you out on the trails you you