After nine years of working as an employee for a physio clinic I was ready to start out on my own. While there was the stress of transitioning my caseload, I was also worried about the drain of dealing with patient administrative tasks.

Thankfully, I chose Jane to manage all my bookings and charting tasks and after three years, I can say that it’s made a world of difference.

I just finished being a part of an in-person event for Jane Ambassadors and it was exciting to connect with the team behind Jane. I’m excited to see how they will continue to empower physiotherapists and other health professionals in the future.

I write a lot about clinical flow and what we can do to work in that state as much as possible. But we can’t do that without eliminating items on our to-do-list that take up our time, energy, and attention.

For this newsletter, Jane App is a guest author and shares some of the features they’ve developed to help take the stress out of collecting patient payments.

Note: Before we dive into this newsletter, I wanted to give a heads-up that I’ll be writing the Clinical Flow newsletter a little less frequently over the summer months to allow for little rest and relaxation.

Read on to hear what the authors at Jane have to say. 👇

Jane is a complete practice management software that offers helpful features like online booking, scheduling, charting, and a fully integrated PCI-compliant payment solution called Jane Payments. 👋 

Jane Payments is designed for practices like yours to help streamline your payment collection, increase your revenue without increasing your working hours, and minimize the time you spend reconciling payments.

Jane Payments works hard to make your payments easy 💪

Here are a few reasons why our community loves Jane Payments:

• 💳 Securely store patient credit cards on file - Request that your patients save their credit card on file via the intake form or at the time of booking online for faster checkout.

• 💲Revenue-maximizing features - With auto-recurring membership payments, online gift cards, and Payment Request emails or SMS, you won’t need to up your working hours to increase your revenue.

• 🙌Reconcile reports without leaving Jane - Fully integrated with your Jane account, Jane Payments helps prevent billing errors, makes payment reconciliation easier, and keeps all of your essential reports for bookkeeping in one place.

Best of all, you’ll be backed by Jane’s unlimited and friendly customer support team to answer all your payment questions, and more. 💙

To learn more about Jane Payments, visit jane.app/payments. Ready to get started? Enter 3601MO at signup for a 1-month grace period on your new Jane account.

While payment processing and reconciliation might not be the first thing on your mind, it is one of those items that is a relief to have streamlined. Building a solid foundation for your practice is done one brick at a time, and every small action counts.

To better flow,

Andrew

Clinical work can be draining and we can easily find ourselves feeling exhausted and going through the motions.

One day bleeds into the next and little excites us in our day.

We can find ourselves waking up with anxiety about getting through our day and then find ourselves worn out at the end of the day only to start the process all over again the next day.

Emotional exhaustion sets in.

And before we know it, we’re questioning what we’re doing in this profession. We can become detached in our interactions with patients and feel like we have nothing left to give.

The way out can feel murky.

When you’re feeling this way, it can be hard to know how to get out of this rut. We quickly realize that a holiday only invigorates temporarily, but it doesn’t solve our dilemma.

We find ourselves questioning our choice of profession and start contemplating an exit.

I was burnt out four years after practicing as a physiotherapist.

I was discouraged, drained and frustrated with where I found myself. I had gone through a significant amount of personal turmoil making the career transition to become a physiotherapist.

I felt like I had made a major mistake.

I explored the idea of becoming a teacher, but a morning of job shadowing made me realize this was not the answer.

I didn’t want to start over again, but I didn’t know how to get myself into a healthier place where I enjoyed my work. I knew that I needed to find a better way. I began exploring ways to gain better career alignment and searched for ways to better manage myself and my energy so I could enjoy my work again.

A new path forward.

While there are many elements necessary to move out of a place of exhaustion, I believe there is one factor that stands head and shoulders above all others. It doesn’t require a change in work environment or patient population.

The antidote is fostering curiosity.

Merriam-Webster defines curiosity as a “desire to know” or an “interest leading to inquiry”.

Curiosity is a trait that permeates all of life and isn’t relegated to only one or two aspects of life. It’s friendly and non-intrusive. It’s bi-directional - meaning that curiosity is directed outwards to people and things, but also directed inward through introspection and reflection. And most importantly curiosity isn’t a passive experience. It moves us towards thought and action. (Schattner, 2015)

Each of us is gifted with curiosity which thrives during childhood. Unfortunately, curiosity can often decline as we get older. We engage in less play as we get older and we can get comfortable with what we know and do.

I believe that curiosity is often one of the first traits that is dampened on the road to emotional exhaustion. Increased work pressures and stress can often result in curiosity being displaced for efficiency. We become less flexible in our ability to adapt. Rigidity is considered the personality factor most closely associated with burnout (Epstein).

We begin to adopt beliefs about curiosity during the early burnout process such as:

• I don’t have time to dig deeper right now. I just need to get through this session.

• It’s too exhausting to be curious right now.

• I don’t care why this is causing this clinical presentation.

• What’s the point of digging deeper?

• What if I look stupid in front of the patient?

When we become emotionally exhausted in our work, we look to preserve our inner self (see psychological immune system), reduce cognitive load and minimize challenge so as to conserve energy.

How curiosity can reinvigorate your work 👇

When I find myself struggling with early signs of burnout, I have found that focusing on fostering curiosity has been an important way to begin the reset process to more energy and engagement in my work.

Being curious is intrinsically a place of openness - an openness to one’s experience, to another person and to one’s self. Fostering curiosity moves us away from rigidity.

When I’ve been emotionally exhausted I find myself detached and checked out. Curiosity moves us out of passivity towards action. It signals a shift in how we interact with the world and within ourselves.

A clinical setback doesn’t end up causing more emotional exhaustion, but instead is an opportunity to explore and inquire. We struggle less because we’re not trying to control the outcome. We begin to move away from rigidity to a place of flexible openness.

Additionally, being curious leads to improved meaning and satisfaction. In a study examining the role of curiosity on life satisfaction and meaning, the authors found that study participants who were more curious, engaged in more growth-oriented activities and experienced greater meaning and life satisfaction (Kashdan et al, 2007).

And the ability to imbue more meaning into one’s day tackles another of burnout’s key characteristics - the sense of decreased personal achievement. When we’re curious, we experience more meaning because we’ve changed the way we’re interacting with the world. That shift will change our sense of accomplishment and elevate our achievements.

The beauty of focusing on curiosity is that it doesn’t require a change in one’s work environment. It’s something that can be added immediately. Curiosity can be applied in our personal life or work life and the benefits will be felt across all aspects of life. And finally, curiosity can start small and build as one’s energy and outlook improve.

Wrap Up

Curiosity can be a powerful antidote to burnout. Curiosity is often seen as a byproduct of emotional exhaustion, but it can be so much more. It can offer a way out of burnout.

This week, in the Clinical Flow Membership, I will be releasing a mini-course on practical steps you can take to leverage curiosity for less exhaustion, more energy and deeper enjoyment in your work.

To better flow,

Andrew

I talk a lot about the ways in which clinicians can boost confidence, decrease stress, and be better in a better state of flow. And I do my best to frame them in such a way where they are action-oriented and solutions-based.

Sometimes, we need to scan the environment to see what solutions are out there to help us move the needle in our work and be able to perform at our best. Technology, education, community, it’s all part of it of what we need to be successful.

I’ve partnered with Jane, as I believe the app has a great solution to improve the way we as clinicians manage our patient loads.

Part of sustaining clinical flow is having the ability and the space to focus on what matters to you. So finding solutions that can help manage your time and ultimately decrease your workload is important.

For this week’s newsletter, Jane App is a guest author and has written the following article on no-shows and cancellations, something we’ve all been frustrated by in the past.

Read on to hear what the author’s at Jane have to say.  

Jane is a complete practice management software that offers scheduling, online booking, charting, integrated payments, and unlimited support.

No-shows and late cancellations have been a hot topic in our Jane Community Group and it’s no surprise why: they pose a real challenge for a lot of businesses. The Jane Community Group is a space for health and wellness practitioners to ask questions, share support, and gain insights, like preventing no-shows with Jane. 😉

Jane offers a whole suite of features to not only help you significantly reduce no-shows and late cancellations, but also to avoid the loss in revenue when they do happen.

Here are our top features to help prevent and manage no-shows ⤵️

• Start by setting up an Online Booking Payment Policy where you can request a full or partial deposit at the time of booking. With Jane Payments, you can also choose to collect a credit card via the intake form.

• Next, create a clear Cancellation Policy that lets your patients know when they can cancel without penalty.

• Then enable unlimited SMS and Email Reminders so your patients can receive a gentle nudge about upcoming appointments.

• If you still have a patient who no-shows, Jane’s Waitlist Management Features are a great way to fill any unexpected gaps in your schedule without any extra admin work.

Want to learn more? Head to jane.app/physio to explore all that Jane has to offer. Ready to get started? Enter the code 3601MO at signup for a 1-month grace period on your new Jane account.

Hopefully you found that helpful, I will continue to look for solutions that can put us in a better state of clinical flow. I’m working hard on next weeks newsletter topic that will be all about how we can reduce burnout through sparking curiosity.

To better flow,

Andrew

Clinical work is demanding.

And often times it can feel that we’re on the edge, between feeling good and giving it our all, and feeling exhausted, overwhelmed and burnt out.

A number of years ago I was sailing on Lake Okanagan with a friend in a hobie cat sailboat.

One of the thrills of this boat is riding it on the edge where one pontoon is out of the water. And on that day, the wind was strong and white cap waves were ever-present. We got the boat on one pontoon and I was standing on the upper pontoon - attached with a harness. My sailing partner was steering the boat and was riding the fine line between achieving optimal speed and capsizing the boat.

Things were going well until the storm continued to grow and the winds became more erratic. And before I knew it, I was flying through the air into the water as the boat completely flipped over in the middle of Lake Okanagan. It was quite an adventure getting rescued, but that’s a tale for another time.

As I’ve been reflecting on the topic of burnout I’ve thought about this story and how we have the challenging work of navigating the constantly changing tensions as we operate at full capacity without overextending ourselves.

And just like that day of sailing, life’s demands can change quickly and we can find ourselves struggling to balance the many competing demands of work and life. A sudden change in our personal lives or work conditions can leave us feeling exhausted and struggling to have the energy to face another day.

“I feel so burnt out right now.”

The term burnout is thrown around quite readily and it can be helpful to look at the term in more detail. Foremost burnout researcher Christina Maslach created the Maslach Burnout Inventory which measures burnout across three elements:

• Emotional exhaustion

• Depersonalization (aka compassion fatigue)

• Reduced personal accomplishment.

Balogun et al (2002) describe how health professionals display burnout: “feeling drained, unable to give of themselves anymore, and cope by decreasing client contact and adopt a negative attitude toward their job and subsequently towards their clients.”

5 Strategies to Avoid Burnout

As Benjamin Franklin so aptly stated, “An ounce of prevention is worth a pound of cure.” And I think this applies especially in our work of avoiding burnout. As I work on fine-tuning my ability to operate at a consistently high clinical level, I find myself asking how to avoid burnout.

Here are five strategies that I have been incorporating into my life and fine-tuning to ensure consistent engagement and growth in my work:

#1 - Listen for the early warning signs

I’ve found that emotional exhaustion and compassion fatigue often whisper to us in the early stages before they start getting louder and louder if unattended. Identifying and acting on those early warning signs can help us course correct. While there are common signs of emotional exhaustion and compassion fatigue it can be helpful to identify the warning signs specific to you.

I know for myself early warning signs of emotional exhaustion include:

• Eating more junk food and sweets

• Disrupted sleep, especially early morning awakenings where I can’t fall back asleep

• Mindless activities such as binge-watching TV as a way to avoid tasks

What are your early warning signs?

For Clinical Flow Plus members, this week I’ll be uploading a worksheet to help you pinpoint your early warning signs.

#2 - Take stock of our life consistently

The transition of one year to the next is often a time of reflection and planning. While annual planning can be helpful, reflecting on how we’re doing on a more regular basis is important.

In the Catholic tradition, Saint Ignatius of Loyola, a Jesuit priest from the 1500’s, created a process of spiritual reflection called the Daily Examen. It was developed as an exercise to reflect and take stock of the day’s coming and goings. This process can also be done on a weekly or monthly basis.

Reflecting on one’s day or week is a great way to slow down and take stock of what went well, what was draining and things to learn and grow from.

For Clinical Flow Plus members, I walk through my weekly review and reflection process along with a printable PDF that you can use for yourself.

#3 - Monitor our energy states

Dr. Drummond, in his book Stop Physician Burnout, shares an important principle around burnout prevention which he calls his first law of burnout:

You can’t give what you ain’t got.

While we can manage for a little, giving when we’re on empty is a recipe for burnout. He outlines our three energy accounts (physical, emotional and spiritual) that we need to pay attention to so that we have something to give to our patients on a regular basis.

For Clinical Flow Plus members, I walk through these energy accounts in detail in my mini-course Burnout: 2 Strategies to Overcome It.

#4 - Create more white space

A number of years ago I came across an author who talked about the importance of creating white space in our lives. Just like a book, we need margin in our lives. I found this a helpful analogy in better understanding the tension between demands and capacity in my own life.

When pages of a book are jam-packed with text, reading becomes a chore. A book would feel unwelcoming and even chaotic - something like our lives if we’re living without margin.

Unexpected things happen at work and in our personal lives that require us to have the ability to respond and adapt. That becomes all the more difficult when we have no physical or emotional buffer in place.

#5 - Set better emotional boundaries

Saying no can be hard.

Whether that’s saying no to that extra shift, or covering for a co-worker. We often think about boundary setting when it comes to our time and physical space, but it can be so much more.

Boundary setting is also important from an emotional standpoint. We’re invested emotionally in our patient’s recovery, but sometimes it can be easy to take on too much when it comes to their progress and outcomes.

I believe that emotional exhaustion and compassion fatigue can occur when we become too invested in our patient’s recovery.

Compassion fatigue can occur when we see another’s suffering, but feel unable to resolve the distress that we experience with seeing someone suffering.

As Ronald Epstein shares in his book Attending, “If I feel that I can do something to relieve the patient’s distress quickly, my own distress also dissipates. But if it’s not possible - if I lack the skills or if it’s going to take a long time - there’s a natural human tendency to withdraw, to pull away in self-protection.”

I’ve come to realize how letting go of the outcome with my patients is an important way to maintain healthy emotional boundaries with my patients.

Wrap Up

Staying engaged and energized in one’s work is not a one-and-done type of experience. I believe that avoiding burnout requires regular self-monitoring and reflection to understand the early warning signs that can cause us to slip into exhaustion.

Become a Clinical Flow Plus Member for only $5 per month and get access to my portal of practical teaching, tools and resources to help you put into practice the concepts I write about in my newsletters. Every month I’m adding mini-courses, tools and resources to help you move into a place of deeper flow in our clinical practice.

To greater flow,

Andrew

Anxiety.

It can range from minor annoyance to crippling.

And there’s no lack of opportunities to feel anxiety when seeing patients. Whether it’s an assessment that is running behind, a more complex assessment than expected, or a patient who appears to be rapidly losing motivation for treatment.

I’m no stranger to anxiety and have found it to be an important emotion to navigate to help move into a place of consistent clinical flow.

In my last newsletter, I talked about Clinical Flow and the important role it plays in both work engagement, burnout prevention and clinical performance. Mihaly Csikszentmihalyi is the foremost expert on the flow state.

He created a zone of flow - a sweet spot between skill and challenge. When our skill level matches the challenge of the activity, we are in a better place to enter into a state of flow. When the challenge is high and skill is low, the outcome is anxiety and we are far removed from flow.

When looking through this lens, it makes sense that one way to support working in flow is to improve our skill level. And skill improvement is a valid and important aspect to support operating in a flow state. The reality however is that our skills are constantly challenged by ever-changing complex situations.

Another way to reduce anxiety would be to reduce the level of challenge. However, within physiotherapy practice, it’s not all that easy to dictate the patients that see us or the level of challenge that they present to us.

I believe that we can manage how we interact with the challenges we experience in clinical practice. By modulating our perception of the challenges we encounter we can respond in a way that doesn’t result in increased anxiety.

Here are 6 strategies that I use to help reduce my anxiety level:

#1 Treat what you see

This was recommended during one of my clinical placements and it’s something that has stuck with me. It’s a mantra that I remind myself of regularly when I find my anxiety levels rising. When we’re dealing with a challenging assessment, we can feel pressure to try to get to the root cause. But the reality is that sometimes there’s so much going on that it’s hard to know what’s causing a problem versus what is the result of the problem.

We can put undue pressure on ourselves to figure it all out, and all in one session no less! I’ve found this to be a very effective release valve as it takes away some of the internal pressure that increases anxiety.

#2 Focus on the basics

This has been another valuable reminder that I use when my anxiety levels start to elevate. But what do “the basics” mean?

It includes:

• Taking a detailed patient history

• Screening for red flags

• Completing a neuro exam

• Evaluating range of motion and strength

• Basic palpation of affected areas

As I’ve written about in other newsletters, stress decreases our perceptual awareness and ability to process effectively. When we focus on the basics, it helps us get out of our heads by taking concrete action.

I’ve often found that when I’m doing “the basics” I can still feel anxious because I don’t know the outcome of the assessment. In those situations, I remind myself to trust the process and be ok with not knowing for a few moments in time.

#3 Principle-based treatment

Another important strategy is focusing on principle-informed action to help to navigate the complexities we face every day with patients. When anxiety begins to build and things are getting muddied in my mind, I find it is helpful to step back and ask myself the relevant principles at play.

There are many different principles you can lean on, but here are a few examples:

• Tissue healing times

• Tendon loading principles

• Level of tissue irritability

• Active listening principles

#4 Challenge the self-talk

Anxiety is often exacerbated by our own perfectionist tendencies. We put pressure on ourselves which can make it difficult to navigate complex clinical situations. It can be helpful to listen to your self-talk and listen for key words that highlight unhealthy thinking such as:

• “I must”

• “I should”

• “I need”

I’ve found it helpful to reframe how I speak to myself. Rather than saying “I must figure this out in this assessment”, I could reframe it to “It would be great to figure this out in this assessment, but it’s ok if I don’t. I’ll be ok either way.”

#5 Be okay with changing your opinion

I’ve found in my own practice that a lot of anxiety can come from the pressure I put on myself to figure everything out right away. When I shifted to approaching my assessments with a hypothesis-driven approach, I found the pressure dissipated. It allowed me to have a diagnostic impression, that would be validated in subsequent sessions. If things changed, I was ok with it because new information often came to light including treatment response (or lack of response) from the patient.

#6 Look at the whole person

I’ve found that my anxiety can increase when I hit a roadblock with treatment. Maybe the patient isn’t progressing as expected or the treatment response I was expecting doesn’t materialize. In those situations, I find it helpful to zoom out and look at other factors that could be at play.

What other psychosocial areas have I potentially missed?

What could be hindering progress?

Looking at aspects such as sleep health, pain beliefs, social supports, etc. can all be valuable areas to explore.

Clinical Flow Membership Updates

As part of the previous newsletter, Clinical Plus Members received access to a 7-lesson video course that helped to provide more understanding and strategies to start experiencing clinical flow in your work.

To complement that video course, members this week will receive:

Mini-Course: My Tried & Tested Approach to Meditate Daily for Better Clinical Flow: Building habits can be a challenge, especially when it comes to meditation practice. With a lot of trial and error, I believe that I’ve finally developed a system that makes meditation a daily habit. Over the past 6 months, I’ve had 88% consistency with daily meditation (that includes Christmas and being sick!). For Clinical Flow Plus members, I’ll be walking through my system and the tools I’ve used and created to help achieve meditation consistency.

Clinical Reset Meditation: Part of achieving consistent clinical flow requires not getting bogged down with the emotional baggage that can come from seeing a caseload. That’s why I’ve developed a four-part 10 minute meditation that helps you quickly and easily reset at the end of a clinical day. Clinical Flow Plus members get my walkthrough of the four parts of the meditation as well as the audio file to listen to the meditation on their favourite device.

To better flow,

Andrew

Liked this content and think it could help a colleague? Forward them this newsletter!

Clinical flow. It’s a topic infused in everything I have written about.

But sometimes it can feel a little fuzzy as to what it means.

Today I dive into the concept of “clinical flow”.

I believe that every clinician should improve their capacity to operate in a flow state. In my view, the ability to operate in a place of clinical flow may be the most important aspect of developing as a clinician. In this newsletter, I explain why.

What does ‘flow’ actually mean?

Being in ‘flow’ is a concept first articulated by psychologist Mihaly Csikszentmihalyi. It is where a person is highly engaged and focused while doing an activity. While the flow state is often associated with athletic or artistic endeavours, it can also occur in work settings.

And I believe we can experience it in clinical work as well.

At first glance, the concept of flow seems unattainable in a clinical setting, or at the very least unsustainable. The constant demands of a clinical day, moving from patient to patient, can make the concept of flow seem almost laughable.

It feels nebulous and ethereal.

It can even feel hokey.

Since it feels unrealistic or unattainable we tell ourselves that flow doesn’t matter. We shift our focus to skill acquisition. We focus on hard skills that feel more tangible and measurable. And at nearly every turn in our career, the pursuit of hard skills can seem to be the only thing that matters to getting better clinical results and improving our professional journey.

Why am I focusing on pursuing flow when it is hard skills that seem to be all that matter to improving our clinical results?

Because focusing our attention on flow, and the necessary ingredients needed for moving into a place of flow, sets us up as clinicians for a lifetime of highly engaged work that enables us to consistently experience meaning and joy in our work. And when we experience deep meaning and joy in our work, there is nothing that can stop us from fully realizing our unique potential as healers with the people we serve.

I believe that flow, and more specifically clinical flow is what we need to draw our attention to if we’re serious about professional growth and enjoyment.

It’s time to define Clinical Flow.

I believe that the concept of flow needs to be refined within a clinical setting as we need to acknowledge the inherent constraints, such as time, that exist within a clinical context.

I define Clinical Flow as a state of persistent psychological engagement - an energized focus that is embodied with the values of curiosity, collaboration, creativity and courage. It is where our attention can be leveraged to be fully present in our patient/client interactions in delivering high-quality care within the bounds of our knowledge, skills, and abilities.

I believe it is in this place that we experience meaning and joy in our work. It is a place where our ego-protective defences are held at bay so that we are fully engaged in the patient interaction. It is in this place where we operate best as healers.

And I don’t think that this experience is something that is fleeting or haphazard at best. I believe that clinical flow can be sustained by having the right work environment, an optimized state of self, and a flexible learning process that supports growth and development.

I believe that there are four pillars foundational to the clinical flow state. They are curiosity, courage, collaboration and creativity.

At the foundation is Courage. Courage may not seem to be something necessary for clinical flow. But as I’ve reflected on this topic, I’ve realized that courage is needed to advance in all other elements of clinical flow. We need courage within ourselves and we need courage with our patients.

The next element needed to support a flow state is Curiosity. After courage, curiosity is the bedrock for nurturing clinical flow. Why? Because curiosity fosters engaged openness. It helps us to move beyond our perceptual blinders.

Collaboration is at the core of the patient-therapist relationship. It is open-handed interaction that focuses on working together. I believe that collaboration has an understanding of humility. It is not a top-down power hierarchy, but instead one of joint decision-making and journey-making.

Finally, we have Creativity. When we deal with complex problems and situations, we need to be creative. As I’ve written before we need clinical agility. We need to be able to bring novel solutions to complex situations.

So how does this focus on clinical flow actually help me be a better clinician?

When we can consistently enter a place of clinical flow in our patient interactions, we are in the best position to maximize our skills, thinking, personality, and experience for that unique patient interaction. We create the opportunity to bring our best selves forward and deliver the best clinical experience.

Do you want to go deeper?

For this topic, Clinical Flow Plus members get access to my new mini-course on clinical flow!

This 7-lesson course goes into more depth on clinical flow and covers the following topics:

• Background & characteristics of flow

• More depth on clinical flow

• Why clinical flow matters to your performance, patients & career

• More detail about the four pillars of flow

• The Clinical Flow Ecosystem

• Clinical Flow enhancing techniques

• Clinical flow and its role in preventing burnout

This video-based course will help give you more understanding and strategies to start experiencing clinical flow in your work. Plus get access to the members-only section which is filled with exclusive clinical strategies on previously covered topics.

It’s only $5 to join and you get immediate access to this course and the membership content.

Also, thanks to everyone who responded to my survey. I really value everyone’s feedback! (If you still would like to share your feedback, you can still respond here.)

Congrats to Jill and Ramanpreet for being randomly selected as winners of a $20 gift card. I’ll make sure to reach out later this week with details.

To better flow,

Andrew

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Myotome testing is often seen as a necessary, but not always insightful element, of a shoulder assessment.

It’s easy to fall into the trap of seeing myotome testing as optional for the shoulder patient — especially if there doesn’t seem to be any suspected radicular or peripheral neuropathic indications from the patient history.

Do you find yourself checking any of these boxes?

• Feeling pressured to leave out myotome testing because of limited time.

• Avoiding myotome testing because of pain potentially confounding results.

• Not sure of the value of myotome testing beyond typical C5 involvement.

Then you’ll want to keep reading to learn how you can use myotome testing to gain fresh insights and gain more confidence treating painful shoulders.

To help improve my ability to connect the dots in my clinical assessments, I’ve come to more deeply integrate myotome testing with every shoulder patient. For me, myotome testing has moved beyond identifying frank neurological issues towards understanding the role that neurological function can have on muscles and tissues impacting shoulder movement, strength and function.

In this newsletter, I’ll be sharing why skipping out on myotome testing can be a big mistake for shoulder patients and why we need to look beyond the typical myotomes related to the shoulder to improve our clinical assessment outcomes. Plus, Clinical Flow Plus members will get access to my specific clinical approach and techniques that I use regularly with my shoulder patients.

The 4 Mistakes That We Make with Myotome Testing & Shoulder Pain

Mistake #1: Assuming neurological involvement isn’t there

I think it’s easy to dismiss neurological involvement with shoulder patients. They may have weak and painful shoulder external rotation and abduction which may confound our ability to identify possible neurological influences. But other nerve root levels can be involved that can impact shoulder movement.

Since being trained in GunnIMS over ten years ago, I’ve gained a deeper appreciation of the nervous system’s role in affecting muscle tone. Even mild spinal root irritation can influence muscle tone of those the muscles supplied by the affected nerve root distribution. Increased muscle tone can result in decreased muscle length which can influence shoulder biomechanics.

Mistake #2: Going too quickly through myotome testing

I have found that it’s easy to go too quickly through myotome testing. When time is limited, we try to be efficient. However, in that quest for efficiency, it’s easy to give a cursory look at a narrow set of myotomes. Incorporating a greater number of upper extremity myotome levels will help give you a broader perspective of contributing factors affecting the shoulder.

Mistake #3: Not adapting to more sensitive testing positions

As mentioned in Mistake #2, we can go through testing too quickly. We were taught in school to go through myotome testing in sitting. An efficient body positioning standpoint doesn’t necessarily allow us to pick up on subtle fatiguable weakness. Optimizing our body mechanics becomes even more important when looking to identify fatiguable weakness with patients bigger and stronger than ourselves.

Mistake #4: Seeing it as a basic skill and not refining application within assessments

Since myotome testing is something that is covered early in orthopaedic training, it’s easy to see it as a basic skill. I believe that there is real value in revisiting these ‘basic’ skills to understand how to refine the approach used, as well as its role in helping to connect the dots in our shoulder assessments.

Why are Myotomes Such a Powerful Tool for Shoulder Assessments

There are three reasons why elevating the use of myotome testing can improve your shoulder assessments.

First off, cervical myotome testing helps you identify the contribution of neurological impacts on muscles affecting the shoulder girdle. When you’re identifying movement restrictions with shoulder testing, you’ll be able to better sense if the movement restrictions are a result of cervically-mediated muscle tone changes.

Second, myotome testing is an excellent way to incorporate testing-retesting into your assessments. Patients can appreciate the visible fatiguable weakness of muscle testing during your assessment. As well, this testing is typically done on non-irritable muscles outside the shoulder girdle.

Finally, addressing the cause of the myotomal disturbance can be starting point with treatment and can give you a quick win with your patients. There are a variety of ways to influence neurological function. Patients can see an improvement with these measures which helps build trust and confidence in your skills.

How do Myotomes Impact Your Shoulder Assessment & Treatment

When looking at the shoulder complex, the rotator cuff muscles are innervated by C4, C5, C6. The deltoid is innervated by C4, C5, C6, C7 and the latissimus dorsi is innervated by C6, C7, C8 (bold highlights indicating primary innervating segments) (Gunn).

Neuropathy and radiculopathy can result in nerve disturbances including super sensitive nerves and innervated structures which Chann Gunn outlines in his book The Gunn Approach to the Treatment of Chronic Pain. His radiculopathy model is based on Cannon & Rosenblueth’s Law of Denervation which states that the function of innervated structures is based on the free flow of nerve impulses (Dommerholt et al, 2006). It is hypothesized that these disturbances can result in increased muscle tone and altered muscle length within the affected distribution.

A Clinical Example

Let’s look at someone with some contribution of poor cervical posture (e.g. head forward posture). With this posture, there can be increased irritation at the lower cervical joints, specifically C7-T1.

With myotome testing you would pick up on some fatiguable weakness potentially at C7, C8 and perhaps even T1.

When looking at the muscles innervated at those levels, we must take note of the latissimus dorsi.

The latissimus dorsi is a muscle that is notoriously hypertonic and shortened, especially in individuals with poor cervical and thoracic alignment. Given the nerve root supply of the lats muscle (C6, C7, C8), the influence of the cervical spine on this muscle can create a feedback loop that perpetuates shoulder, scapular and cervical dysfunction.

Clinically, I found that the lats, when hypertonic due to neural irritation, corresponds consistently with positive myotome testing at the C7 level.

The lats can contribute to disruption of the scapulohumeral rhythm as well as increase shoulder girdle depression. It can also alter scapular elevation resulting in increased resistance when performing overhead movements of the shoulder (Sahrmann, 2002).

What to Go Deeper?

To help improve the experience for Clinical Flow Plus members, I’ve been working behind the scenes to improve how Plus content is shared and organized. Since we’re still doing some finishing touches, Part 2 of today’s topic is a little delayed and will be released on Monday.

On Monday, I’ll be releasing Part 2 of today’s topic, where you’ll learn:

• How I’ve adapted my myotome testing to improve uncovering potential neuro involvement

• How I test lats length to pinpoint the influence of the lats on shoulder ROM & function

• The clinical reasoning algorithm to assess the influence of myotomes on shoulder function

• Transformation worksheet to help you put this into clinical practice

To better flow,

Andrew

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Yesterday I shared about the common challenge of patients forgetting to do their exercises and the importance of using existing routines to build new exercise habits.

Today I dive deeper into this topic with clinically focused strategies that I use regularly with patients.

Clinical Flow Plus members are getting the following:

• A deeper dive into 360Clinician Exercise Adherence Framework

• A walk-through of the different types of triggers that I’ve found success with clinically and how to combine them for maximum success

• A patient collaboration tool called Daily Exercise Trigger Guide (with video walkthrough) that gives you 16 triggers to walk through with patients to pinpoint the best triggers for establishing consistent exercise habits

• A therapist script video that will give you the words to use to introduce trigger conversations with patients

• A transformation worksheet to help you start putting triggers into your exercise prescription conversations with patients

Here’s a quick scroll through everything you’ll get 👇

For less than $5/month get access to a growing amount of cutting-edge thinking and clinically tested strategies to help you get better results with less stress while loving your work more.

Upgrade to access this now!

Ok, let’s dive in!

Patients not doing their exercises is frustrating.

We spend time teaching them exercises and we feel confident that they know the parameters of the exercise for at home practice.

But when we ask them how their exercises went the past week, we can get a lukewarm response or hesitation from our patients. Pressing a little deeper we come to understand they either didn’t do their exercises or did them “occasionally”.

It can be frustrating when patients don’t follow through with their exercises.

But it’s not uncommon.

In studies regarding exercise adherence, it’s accepted that exercise adherence can be around or even below 50% (Eckard, et al, 2015).

Exercise adherence has been a real interest of mine for some time now. I see it as such a powerful lever to helping patients get better results. Better adherence helps guide treatment and helps give a stronger signal regarding treatment and exercise effects which helps increase one’s ability to stay in a place of flow.

In earlier writing, I shared what I call the Exercise Spiral of Despair. It’s a process that I’ve observed in my own clinical practice where poor adherence results in poor outcomes or shift to passive treatment.

Helping our patients with behaviour change extends beyond exercise and can include changes to stress management, sleep habits and more. That is why I think it’s such an important area for a physiotherapist.

A few years back, I developed a framework which I presented for my patient exercise adherence workshop that looks at what I believe are the essential ingredients necessary to see patients achieve success with building new exercise and movement habits. It answers the ‘What’, the ‘Who’, the ‘How’ and the ‘Why’.

A Missing Piece to the Exercise Puzzle

A while back I had a patient who experienced regular headaches, neck, and jaw pain. After a few sessions to address the neck and jaw, she shared how she felt a lot of her symptoms were triggered by her stress response. She was open to meditation but had found it difficult to develop a meditation habit in the past.

In this situation, we would think that all the ingredients were there - there was meaning with the activity, and there was a supportive therapeutic alliance, but we were missing an important ingredient - behaviour design.

So what could be the reason why a patient wouldn’t end up doing an exercise even when they’re motivated and are able to perform the exercise well?

While at times, a lack of consistency with exercise may be a result of a patient not being ready to engage in the activity (i.e. Transtheoretical Model of Change), I’ve found that more often than not, the patient lacks a system to integrate movement practices into their life.

I’ve come to realize that patients who quickly adopt an exercise program are those who are already skilled and experienced at developing exercise routines and habits. But there are many people who struggle or who have had little experience in developing movement or exercise routines.

We can fall into one of two traps

Unfortunately, it’s easy to fall into one of two traps when we encounter these situations:

1. We may encourage our patients to try harder in the upcoming week. We may acknowledge that doing exercises consistently can be challenging.

2. We ignore the lack of exercise consistency and end up giving more exercises.

Unfortunately, both of these responses don’t equip our patients with the tools and strategies to make progress toward better consistency.

An often insidious belief can creep into our thinking where we end up placing the responsibility solely on the shoulders of the patient for not being consistent with their exercises. We come to believe that it’s a patient problem.

But what I’ve come to realize is that it’s a design problem and not a people problem.

One of the common causes of patients forgetting to do their exercises is the lack of a trigger or prompt to help integrate a new exercise behaviour into their day.

I’ve heard so often patients telling me how they remembered their exercises as they were laying in bed at night. Unfortunately, I haven’t had many patients who told me that they would then do their exercises with that reminder!

We just need a better reminder.

With the constant barrage of distractions that exist today with the pervasive use of technology, it’s easy to forget about our exercises.

While I won’t be going through all the components of designing new exercise behaviour, I want to talk about an important area of helping our patients identify a successful way to remember to do their exercises.

There are many different triggers that prompt us to take an action.

BJ Fogg outlines in his book Tiny Habits that we can have internal triggers, and environmental triggers, and we can have existing action (or routine) triggers.

Let’s take the example of brushing one’s teeth. An internal trigger may be the taste in your mouth after eating or drinking something. An environmental trigger may be walking into the bathroom and seeing your toothbrush. An existing action trigger would be brushing your teeth after completing a meal.

When it comes to exercise adherence, a common internal prompt may be doing an exercise when you feel pain or discomfort. An environmental prompt may be seeing a yoga mat on the floor in the living room that triggers one to do their exercises.

Just put a reminder in your phone, right?

For some people, technology prompts can be helpful triggers to do exercises.

But I would say that given the number of notifications that we have on our phones on a daily basis, it’s something that can fail quite easily. For most of us, we’ve been conditioned to ignore technology prompts.

More often than not, we rely on internal prompts with exercise adherence. Patients will be reminded to do their exercises when they’re experiencing pain.

Fogg shares that habits need an anchor. He has found that existing actions or routines can often be the most reliable triggers to help with instilling desired behaviours.

So what happened to my patient struggling to meditate?

So getting back to my example of my patient struggling to implement meditation into her day… we brainstormed different types of habit triggers, as well as, desired time of day. We explored different triggers and landed on the trigger of doing a short meditation after she ate breakfast each morning.

The following week she had a big grin on her face as she shared how consistent she had been with her meditation practice and how she hadn’t had any headaches that week.

Want to go deeper?

Clinical Flow Plus members will be getting Part 2 of the newsletter tomorrow which is filled with valuable tools that can help you implement real change with your patients. Here’s what’s included:

• A deeper dive into 360Clinician Exercise Adherence Framework

• A walk-through of the different types of triggers that I’ve found success with clinically and how to combine them for maximum success

• A clinical worksheet called Daily Exercise Trigger Guide (with video walkthrough) that gives you 16 triggers to walk through with patients to pinpoint the best triggers for establishing consistent exercise habits

• A therapist script video that will give you the words to use to introduce trigger conversations with patients

• A transformation worksheet to help you start putting triggers into your exercise prescription conversations with patients

Join a group of ever-growing, engaged family of physiotherapists and movement professionals that strive to be in a place of persistent curiosity, collaboration, and creativity in their clinical work.

To better flow,

Andrew

Liked this article and think it could help a colleague? Forward them this article!

Today I’m be diving into some practical assessment and treatment strategies that I use regularly in my clinical practice to identify and address a lack of scapular upward rotation. It builds on my newsletter from yesterday.

Here’s what is included today for Clinical Flow Plus members:

• Video walkthrough of assessing active scapular movement

• Video walkthrough demonstrating how to passively test scapular upward rotation

• Video walkthrough of loaded testing of the scapula

• My two go-to exercises to engage the serratus in upward rotation

Plus get these extra goodies to help with clinical integration:

• Clinical Transformation Worksheet - this 1-page worksheet simplifies working through evaluating upward rotation with a shoulder patient.

• Clinical Decision Cheatsheet - this 1-page flow diagram gives you a great summary walkthrough of how to approach assessing and treating the scapula to improve upward rotation. Get a downloadable cheat sheet and a short video walkthrough. Here’s a screenshot 👇

Ok, let’s dive in!

Before diving into today’s clinical topic on shoulders, I wanted to let you know that I’m going to be alternating newsletter topics between clinical and self-improvement topics moving forward. Each newsletter will continue to focus on helping you move from frustration to flow in your practice.

Treating painful shoulders can be tricky.

When we’re dealing with a painful shoulder and we see a loss of overhead movement, it’s easy to focus our attention on the glenohumeral joint. We may jump to mobilizing the shoulder joint to improve joint biomechanics.

The scapula can often be put on the back burner of our attention.

But there’s a growing body of literature that shows the scapula plays an important role in shoulder pathology (Ludewig, 2009). Unfortunately, the scapula can often feel like a bit of a black box to assess and treat.

One of the big issues I see with patients experiencing painful overhead movement is the problem where the scapula has insufficient upward rotation.

My goal for this newsletter is to give you a fresh perspective to approach treating the scapulae so you’ll feel less frustrated treating shoulder pain and help you move into a deeper place of flow with your patients with shoulder pain.

Upward Scapular Rotation Demystified

Before we dive into today’s content, I thought it would be helpful to review the movements of the scapula.

In order for the shoulder to move through full range of motion, we need 60 degrees of upward rotation of the scapula (Sahrmann, Diagnosis & Treatment of Movement Impairment Syndromes)

Upward rotation of the scapula is when the scapula (in the frontal plane) rotates in an upward direction.

Ludewig, 2009

A simple way that I explain it to patients is that when there is a lack of upward rotation of the scapula, an increased amount of overhead movement needs to come from the shoulder joint. I share the movement systems principle that the body takes the path of least resistance and if there is increased resistance at the shoulder blade, more of the movement will occur at the shoulder joint.

This is a diagram I often will doodle for my patients:

Symptoms of decreased upward scapular rotation

Patients with limited upward rotation will often experience pain and limitation with overhead movements. You may also see early and excessive upper traps activity during overhead movements. Also, given the limited scapular movement, you may also see an increased extension of the thorax in attempts to increase shoulder movement.

What limits upward rotation of the scapula?

Often patients are not using their arms overhead often enough. Over time adaptive shortening can take place of muscles that limit the upward rotation of the scapula. Coupled with this, key upward rotator muscles of the scapula can become weak, further reinforcing limited scapular movement.

Understanding scapular rotation muscles

As mentioned earlier, certain muscles can become shortened over time, especially if overhead movements are limited.

These muscles (aka the downward rotators) include the levator scapulae, rhomboids, and latissimus dorsi.

Muscles that support upward rotation (aka the upward rotators) include the serratus anterior, and lower and upper fibres of trapezius.

How to Identify a Poor Upward Rotating Scapula

I find that it is important to assess upward rotation both actively and passively, as well as through loaded movement, to better understand the scapula’s role in a patient’s movement dysfunction.

Active Movement Observation:

In standing, I’ll have a patient go through active flexion & abduction movements. I observe the scapula and identify the amount of upward rotation present. Often it can be helpful to place your hand on the medial border of the scapula to better gauge scapular movement. To watch me walk through observing scapular movement, make sure to upgrade to Clinical Flow Plus.

Passive Movement Testing:

I’ll also test the scapula passively to gauge scapular movement. This can help to gauge the amount of passive resistance to upward rotation of the scapula. To learn how I test passive scapular movement, make sure to get Part 2 of this newsletter by upgrading to Clinical Flow Plus.

Loaded Testing Through Movement:

I’ve found it helpful to understand how well the scapula rotates in loaded positions. Loaded testing can give you a good sense of how well the scapula maintains contact with the thorax and how quickly the scapular muscles fatigue. To learn how I test the scapula in a loaded position, make sure to upgrade to Clinical Flow Plus.

How to Improve Scapular Upward Rotation

I like to keep things simple.

To address this scapular fault, I focus on decreasing muscle tone (and shortening if present) of the downward rotators and improving activation of the upward rotators.

To improve the tone of the downward rotators, I focus on addressing the levator scapulae primarily. This could include levator scapula stretches as well as needling the lev scap. Oftentimes, patients have found self-release with a used tennis ball (not as hard as a lacrosse ball) to be helpful for at-home treatment.

From a muscle activation standpoint, my first go-to upward rotator muscle that I address is the serratus anterior. Ludewig et al (2009) highlight it’s the “only scapulothoracic muscle that can produce all of the desired 3-dimensional scapular rotations of upward rotation, AC joint posterior tilting and AC joint external rotation.”

More than just the punch-out exercise

The punchout exercise is often a go-to exercise for the serratus. Unfortunately, it’s not terribly functional exercise when it comes to improving the upward rotation of the scapula. I focus on engaging the serratus in a more functional fashion that works through the entire scapular range of motion.

There are two exercises that I’ve tested that work well in my clinical practice. In Clinical Flow Plus, I walk through an exercise completed on all fours as well as another one that is done in standing which is especially useful for the older adult who may not be able to get into a kneeling position. To learn more about the serratus exercises I use, make sure to sign-up for Clinical Flow Plus.

To help you gain more flow treating painful shoulders, I’ll be diving into other scapular issues in upcoming newsletters.

Want to Go Deeper?

Clinical Flow Plus members will be getting Part 2 of the newsletter which will include:

• Video walkthrough of assessing active scapular movement

• Video walkthrough demonstrating how to passively test scapular upward rotation

• Video walkthrough of loaded testing of the scapula

• My two go-to exercises to engage the serratus in upward rotation

• A clinical transformation worksheet giving you the simple action steps to begin addressing upward scapular rotation deficits in your patients

• A decision-making flow chart cheat sheet to help you navigate assessment and treatment (along with a video walkthrough)

Become a Clinical Flow Plus member for $7 a month ($4.95 USD) to get practical, clinically focused content with each newsletter (every two weeks) along with extras such as a clinical cheatsheet, private podcast episodes or clinical videos and more. Plus, if it’s not hitting the spot for you, you can unsubscribe at any time.

If you’d like to learn more about how to improve treating the scapula, then subscribe to Clinical Flow Plus with no obligation or commitment so you can get access to Part 2.

Stay tuned for Part 2 tomorrow!

To better flow,

Andrew

PS. Sign up to Clinical Flow Plus to get access to today’s newsletter upgrade coming out tomorrow as well as future newsletter upgrades.

Today I’m pulling back the curtain of how I use doodling regularly in my own clinical practice for less stress, better thinking, and improved clinical outcomes.

For under $7 CDN a month, you’ll get practical, clinically focused content with each newsletter (every two weeks) along with extras such as a clinical cheatsheet, private podcast episodes (or videos) and more. Plus, if it’s not hitting the spot for you, you can unsubscribe at any time.

Ok, let’s get started…👇

I find that sometimes I get stuck.

Not unlike when I was in my teens and my brother and I got our parent's 1987 Ford Taurus stuck on a forestry service road in the Cascade mountains. No matter how many times we tried to go forward and backwards we were stuck. (I'll share more of that in my upcoming podcast on this topic!).

Getting stuck is a regular part of our clinical experience. It's part of the job.

We’re problem-solving and troubleshooting with every patient we see. The problems we’re solving are complex and change regularly. Whether it’s establishing a diagnosis, or troubleshooting a patient that isn’t progressing, we need to figure out how to help get the best possible outcomes for patients.

It can be frustrating and tiring.

We need a way to gain clarity in our thinking.

Having a conversation with a colleague or peer can be a great way to gain clarity, but sometimes we don't have access to talk to someone.

When we're stuck in our thinking, it's easy to believe that we just don't have enough information to get us through. But I've found that more often it's our ability to gain fresh perspective that helps us get unstuck.

But gaining perspective can sometimes seem elusive. The good news is I've found a simple way to help gain perspective and clarity that anyone can use.

You know what it is?

Doodling.

For many of us, doodling is simply a way to pass the time. However, what many of us don’t realize is that doodling can actually help improve our clinical reasoning skills.

Doodling has been a powerful tool in my own clinical toolkit to sharpen my thinking, improve my clinical reasoning, and accelerate problem-solving.

It's more than a mindless activity. Doodling is a method that engages different areas of the brain to support concentration, memory and problem-solving (Andrade, 2009; Ainsworth et al, 2011).

What is Doodling?

It's interesting when you look at the current definitions of doodling. The existing definitions of doodling don't shine a positive light on this powerful technique. Merriam-Webster defines it as “an aimless or casual scribble, design, or sketch" while Wikipedia defines it as "a drawing made while a person's attention is otherwise occupied."

Sunni Brown, the author of the book Doodle Revolution, feels there is a lot missing with the definition of doodling and I agree. Her revised definition of doodling is that of "making spontaneous marks to help yourself think."

What I love about her definition is that it is accessible to non-artists - anyone can make marks on a piece of paper. And I love the purpose of doodling - to help yourself think. I think that is the key - regardless of how one doodles (or how good a doodle looks), the key is to help you think.

We're always thinking as clinicians, but there aren't many things that we are using to help us think better, especially something that is accessible at any moment in our day.

5 Ways that Doodling Helps Improve Clinical Performance

Here are 5 ways that I've found doodling has improved my own clinical thinking and performance:

#1- It gives your mind space to process

I like to think of doodling as a form of journaling that is more visual and less structured. It's a way to draw out thoughts and ideas in the moment.

It slows everything down.

It gives the mind space to pause, reflect, and process information without feeling pressure to come up with an answer right away.

Doodling is known to be an effective aid in problem-solving because it helps us to break away from traditional thinking ruts and opens us up to more creative solutions. Making marks on a piece of paper (or tablet), engages multiple centers of the brain allowing you to look at the problem from different angles and come up with innovative ideas that you might not have considered in the past.

#2- It helps you get out of your head

It’s easy to fall into the trap of mulling problems over in one’s head. Problems just keep running around in our brains without any progress or conclusion. It’s an inefficient and time-consuming process. There’s something transformative when we get our thinking out of our heads and onto a piece of paper. Fresh perspectives come much more quickly with doodling than going down the same thinking pathways.

#3- It helps you see things differently 

To solve problems effectively we need to see things differently. I’ve found that doodling helps me see clinical situations in new ways. Externalizing key data points about a patient case can help you see potential connections more easily and quickly. The process of doodling allows some parts of our brains to relax so we can tap into other, perhaps less often used, areas of our brains which ultimately may help us see a problem from a different vantage point. I would argue that doodling regularly, will actually make you smarter, retain information better, and problem-solve more effectively.

#4- It helps you to slow down

Doodling is believed to stabilize arousal at an optimal level thus assisting in concentration and thinking (Andrade, 2009). A little creative pen-to-paper has been shown to reduce stress as measured by cortisol levels (Kaimal et al, 2016). If stress hormones are high, our ability to think gets clouded. In tomorrow’s newsletter, I will show you how I doodle in my clinical work to improve our clinical reasoning and problem-solving.

#5- It can reveal unexpected connections

When my mind is stuck, it's easy to get fixated on one way of thinking, seeing or doing things. But when I'm doodling, I often find connections and ideas that I wouldn't have come up with before. These unexpected connections can help me to build on my existing thought process and create a bigger picture.

When you doodle, you're engaging in deep and important information processing. As Sunni Brown shares, it's "connecting neurological pathways with previously disconnected pathways" and you're "concentrating intently, sifting through information, conscious and otherwise, and...generating massive insights."

Applying Doodling to Clinical Reasoning

There’s no need to have skill in drawing

First off, there is no requirement to have any gift or skill with drawing. Doodling is not about creating realistic impressions of your patients or their body parts. It’s about helping you think. The doodles you create are for you and you alone.

The outcome isn’t about how pretty it looks

We all have an inner critic and, unfortunately, it is alive and well when it comes to any artistic or creative endeavour. If you find yourself being critical of your doodles, gently remind yourself “This is not art. This is to help my thinking.”

Keep things simple

When doodling to solve clinical problems, I’ve found it helpful to keep the shapes and doodles simple. Simple stick figures and body parts are quick and require zero artistic flair.

So if you're feeling stuck in your clinical work, give doodling a try. It's worth it - trust me!

Want to Know the Exact Steps I’ve Used to Doodle for Better Clinical Results?

Are you interested in knowing how to doodle to improve your clinical decision-making?

Tomorrow I’ll be pulling back the curtain of how I use doodling regularly in my own clinical practice for less stress, better thinking, and improved clinical outcomes.

But to get access to tomorrow’s content, you’ll need to upgrade to become a Clinical Flow Plus member.

For this newsletter Clinical Flow Plus members will be getting:

• Two different doodling approaches I use for clinical problem solving

• The exact steps to get started with doodling for better clinical problem solving

• A video of me doodling a clinical problem

• A clinical transformation worksheet giving you the simple action steps to begin doodling

For less than $5 USD a month, you’ll get practical, clinically focused content with each newsletter (every two weeks) along with extras such as a clinical cheatsheet, private podcast episodes (or videos) and more. Plus, if it’s not hitting the spot for you, you can unsubscribe at any time.

If you’d like to learn more about doodling, then subscribe to Clinical Flow Plus with no obligation or commitment (you can unsubscribe at any time).

Hope to see you tomorrow!

To better flow,

Andrew

PS If you don’t see this email before Sunday, no worries! You can still upgrade after today and get access to Part 2 of the newsletter and all of the Clinical Flow Plus benefits.

A Path Forward to Get Results

In yesterday’s newsletter, I went over some difficulties we face with certain patients and I took you through some common pitfalls. Once we understand these common pitfalls, we can begin to approach treatment with increased clarity and structure. Today, I will walk you through some solutions.

It’s easy to get flustered when one treatment approach doesn’t work and then we jump to another treatment approach. That can quickly result in feeling disoriented and unsure of how to approach treatment.

By organizing treatment into themes or buckets, you can organize your treatment approach and the emphasis based on the treatment bucket.

I have found that there are three treatment buckets that are necessary to get results with this patient archetype and one that doesn’t rely on poorly tolerated manual therapy.

Treatment Bucket #1: Downregulate the nervous system

When patients are sensitive to any kind of manual therapy, it's important to have different strategies to downregulate the nervous system.

Breathing Intervention

Breath is an important nervous system regulator. And it’s something that you can use on different levels. In pain science training I did with Neil Pearson, he highlighted experimenting with both breath awareness and breath regulation. From his experience patients respond differently to different breathing strategies.

Breath Awareness: Have the patient focus on being aware of their breath - both inhale and exhale. They are not trying to control their breath. They are just aware of it.

Breath Regulation: Have the patient control the length of inhale and exhale. For example, they breathe in for 3 counts and out for 4 counts. Find a comfortable rhythm and one they can sustain for 1-2 minutes.

In testing what’s most beneficial for the patient I’ll run an experiment where they engage in an assisted movement (e.g. shoulder flexion) while doing the breathing technique. Once one version of breathing with movement is completed, I then retest an aggravating movement. If there is no change, we then run the experiment with the other breathing technique.

During these experiments, I provide simple explanations of the power of breathing to influence the nervous system, improve oxygenation and how sensitive nerves are to oxygen levels.

Free the Diaphragm: Another way that I use breathing is that I focus on addressing breathing pattern dysfunction. Oftentimes, this patient archetype has a poorly functioning diaphragm. They may be apical breathing or may have limited diaphragm contraction ability. I’ve found it beneficial to perform manual therapy and breathing instruction to assist in improving diaphragm and rib mobility.

Harness Sleep: It is important to understand if this patient archetype has disrupted sleep. Sleep is an important modulator of the nervous system and helps to downregulate the nervous system. I’ve found that patients who are struggling with persistent pain can often experience breakthroughs by addressing sleep.

Treatment Bucket #2: Shift patient beliefs

With this patient archetype, they have some pretty entrenched views about their pain and body. They can believe that it's up to someone else to fix them, that there is a magic cure and that treatment is something that is done to them.

Trying to treat within this patient paradigm is near impossible and one that is likely destined for treatment failure.

It's important to begin to shift and challenge the patient’s beliefs toward their body. They need to understand that there is no magic cure and treatment requires both patient and therapist working together.

This sounds easy, but I’ve found that how you approach these conversations is paramount.

Beliefs are shaped by one’s perception of reality. It's important to challenge one's perception of reality in order to begin shifting beliefs. If this patient archetype believes they need hands-on therapy, but can't tolerate light touch, we have a problem. I've found it helpful to highlight the discrepancy to the patient.

I might say to the patient: “I know we agreed that we’d incorporate some hands-on therapy to help your neck, but I’m seeing that your body is quite sensitive whenever I start to work on your neck. Wouldn’t you agree? I think it’s important that we look at some other options that may be better tolerated by your body.”

Rather than putting the onus on yourself to come up with all the solutions (See Pitfall #1) it’s important to begin to shift to a collaborative approach. I provide some other options and come to a joint decision with the patient.

Treatment Bucket #3: Channel patient motivation

It's easy to fall into the trap of assuming you as a physiotherapist are responsible for motivation, especially when we want our patients to succeed and get better. But it's not up to us to create motivation for our patients.

Instead, we must step into our role as a health coach and help them find a source of sustainable motivation to support them moving forward.

For this patient archetype who has few if any movement habits, I focus initially on building a simple movement habit. I focus on consistent action that is easy for the patient to do and does not wind up the nervous system. For example, for this patient archetype with neck pain, I may have them start with some shoulder slides up the wall. They feel comfortable doing the exercise and they see the connection between the shoulders and neck (it’s meaningful).

Then I write down the micro action on an index card along with the frequency to be done each day (I cover a system that I’ve developed in my exercise adherence workshop). I then proceed to make an agreement with the patient. I ask about their confidence in doing this on a daily basis and then adjust the action parameters so that their confidence is high.

Something that helps overcome hesitancy on the part of the patient is to frame this micro action within the context of an experiment. We’re doing a time-limited experiment and then taking stock after X number of days to re-evaluate if it’s something that should continue.

Once a patient is consistently performing a micro-action, I then look to move to a more challenging and likely more specific exercise (or I may add to the existing action). Getting the patient to be successful in regularly completing a simple micro action is an empowering step in the patient’s recovery journey. You’ve shifted the relationship from one where the patient expects all the answers from you the therapist, to one where there is a collaborative partnership where the patient is building self-efficacy and autonomy.

Wrap Up

This patient archetype may be challenging to treat, but when you identify and troubleshoot the pitfalls, you can move forward by reframing treatment within one of the three buckets I walked through.

To better flow,

Andrew