E21: Stop Over-Assessing: What Actually Matters in Rehab with Chris Hughen

Jimmy: Welcome to the Physio Insights podcast presented by Runeasi. I'll be your host, Doctor. Jimmy Picard. I'm a physical therapist, running coach, and team member here at Runeasi. On this show, we have real conversations with leading experts digging into how we recover from injuries, train smarter, and use data to better guide care.

Whether you're a clinician, coach, or an athlete, we're here to explore what really matters in rehab and performance. Let's dive in. Alright. Chris Hughen, welcome to the podcast. Really excited to have you here.

Chris: Thanks, Jimmy. I I was telling you before recording, I'm a I'm a fan of y'all's podcast. It's like podcast inception when you you write a podcast and then you host and then you listen and then you're on others. But I appreciate you wanting to have me on.

Jimmy: Really excited to have you here. Was joking with my wife this morning. She was asking like what I had on my schedule. I was like, oh, I'm recording a podcast. And she asked with who?

I said, oh, remember that guy I told you who gets all the guests that I want on a podcast and he gets them first? She was like, yeah, because you recently had Dan John on your podcast who I also had on.

Chris: That's right.

Jimmy: You've had Chris Johnson, you've had Nathan Carlson on your podcast. I feel like we've had a lot of the same guests. So yeah, it's awesome to have you and get now I can pick your brain about a lot of things. But before we get started, why don't you tell the listeners a

Chris: little bit about yourself and what you're doing at Ether? Thanks, Jimmy. I have a variety of roles and and capacities at the moment. So I'm a physical therapist and I work three days a week in a orthopedic sports medicine clinic. My girlfriend and I, I don't know when this episode is gonna come out, but we're currently based out of the Southwest.

But in a few weeks, we're moving back up to Seattle and hopefully that will be our long term spot. But I'll be in the clinic there in a part time capacity as well. And outside of that, I work for E3 Rehab in a variety of positions, and I've been really lucky to to grow with them over the past three years. For people who maybe aren't familiar with three, it's three main individuals. We have some other people helping out, myself, Mark Surtica and Tony Camilla.

Mark and Tony are the co founders and the co owners, and I've been lucky enough to be a part of the ride. I am the podcast host. So like you, Jimmy, I record conversations with other clinicians, coaches, researchers, and I'm fortunate that selfishly I can bring on people that I'm interested in and sounds like I get to them before you. So I'm sorry about that. It is this weird like, because there's now so many physio and strength conditioning podcasts.

You see these other podcasts have the guests that you want on and you're like, Ah, do I still reach out to them? But I think ultimately the more avenues that clinicians and coaches can listen to really great individuals, even if they're on different podcasts, I think it's for the best. But I host the podcast which comes out weekly. I'm their head or lead remote coach. So I manage around 30 remote clients and we're fortunate with E3 that the spread or the reach is pretty large specifically through E3's YouTube videos where, I mean, props to Mark and Tony, they've had some really big videos that dive into a variety of musculoskeletal conditions or injuries like plantar fasciitis, low back pain, patellar tendinopathy, ACL rehab, and a lot of individuals will find us through those YouTube videos and people.

And the goal of those videos is to allow people to feel like they can self manage or feel confident understanding some things about what they may be experiencing. And for people that maybe feel like they need more assistance, their option is to work one on one with a coach. And I'm the lead coach for Youth. I see a range of individuals all throughout the world, which has been a cool experience. We, for whatever reason, have a big funnel of, or big bolus of people that come from The Middle East and Saudi Arabia.

And I don't know why that is, but I would say more than half of my remote clients are international. And that's been a good, as a newer clinician, a good experience in and of itself of trying to develop a relationship and rapport through someone online, not in person, across the world, and where English isn't their first language. And try to communicate rather challenging topics in a more simplistic manner. So I work with those individuals either in a remote coaching capacity where I can help them through anything from managing persistent aches and pains to they just want consistency of an exercise plan, or they don't have anyone in their local area that they feel confident providing rehab services. I have ACLs on my caseload, I have Achilles tendon repairs, I have persistent low back pain.

And a lot of individuals I'll work with for multiple months or years. And for other people, I provide just one off consults where we chat for an hour. I give them some reassurance or I answer their questions. I provide a long summary email and then hopefully that gives them the path to move forward. So it's either kind of a medium to long relationship or a short term kind of question and answer consult format.

And that's been really nice. So, yeah, I run the podcast, the main coach. And then we have right now a pretty big project that I've been chipping away at building out an e three course. We don't have the name for it yet, but it's kind of this love hate where there's so much time and energy spent in it, but there's so many hurdles. I don't know if you've built out a course, Jimmy, but just realizing the things that come with it of how do we get CEUs approved for trainers and clinicians and how do we want to host this platform and what do we want the flow to be?

But it's turning into kind of a behemoth of a course, probably fifteen hours that will end up recording. But that's taken up a lot of my time and energy, and it'll be oriented towards younger clinicians and trainers and students. And I'm sure we'll dive into that in a little bit. So I'm working a lot on building out that course. And then there's just some kind of side quests that I'll help with these, build out these free resource guides on a monthly basis, which is on the website and it's more clinician oriented, but it can also be for the patient where we have a topic like acute low back pain or sciatica or plantar heel pain.

And we provide a three to five page document on what are the key pieces of information to know about this condition? What is some research worthwhile to look into? What are some podcast recommendations? And then I'll assist with some YouTube videos and articles with E3 as a whole. So I I feel lucky to be in those capacities, but I also feel like I'm juggling a lot of balls at once.

Jimmy: Yeah, that's what I was going to say. It sounds like, a lot on your plate, a lot of different hats to wear. Going back to E3 Rehab, it sounds like there's a combination of audiences that you guys have. So you have the clinician, the coach, and the actual patient. You have content kind of for all of these groups.

Correct. And then the course that you alluded to, that is for clinicians specifically. You sent over kind of like the outline of that course. It looks great. And no, I have not attempted to create a course.

It looks super intimidating. I think it was a year ago Chris Johnson released his course, his online course and he had mentioned how difficult it was putting all that content together, recording everything, getting CEUs approved, yeah. So I don't envy you but please keep working hard to get this out. Jim. Because yeah, looked great.

So as I was reviewing the outline you sent, there were two themes that kind of stood out to me that I would like to talk to you about. The first one being communicating with patients, which I think is like really hard. It sounds really easy on paper. It's like, oh, we just tell them what's going on and we tell them what to do, right? In practice, I'm twelve years in and I feel like I'm still struggling, like I'm learning something new every day about how to communicate with this specific person or I just had a patient actually yesterday who I thought I did an amazing job reviewing his gait assessment two months ago with and he commented that he was having trouble on his runs because he kept thinking about his form.

I was like, what do you what do you think about? I thought we said like your form is good and like, you're fine. He's like, oh, but you pointed out like that I was heel striking, my foot was my leg was straight. And that image is now like in my head and I feel like I need to fix this. Even though I think, like from my memory is that I told him, your form looks pretty good.

I see this, it's nothing we need to worry about. But as you're creating this course, especially for younger clinicians and thinking about the topic of communication, what do you think is important here?

Chris: The thing that I have picked up with either, you know, hosting the podcast and talking with great clinicians or coaches or being around before PT school, in PT school, and as a clinician, just being great clinicians and seeing how they go about the communication process has been helpful. But I think the biggest thing is acknowledging that there's not a cookie cutter way to go about any conversation with any patient. And even if someone's presenting with a similar diagnosis or injury, how you navigate what to say, how to say it, how much to say is all about reading the room. And I think really where I come from at this point is acknowledging that there's a lot of things that I may want to discuss, or talk about, or I have kind of bullet points in my head of what I think they should know. But ultimately, if this person's seeking services, I want to come into it with, why are they seeking services?

Why are they seeking rehab? Why are they coming in for coaching? Whatever that context is. And then get an understanding of really what is their driver for what's going on. What are they understanding about their condition?

What questions do they have? Who have they seen before? What do they think is going on? And really my communication starts with hoping that they feel comfortable opening up to me about kind of their story as a whole, and more specifically why they're wanting to interact with a provider. And then get a framework or heuristic in my head of what have they already been told?

What things do I feel like are worth navigating in the short term about maybe some misconceptions that they have, clarifying questions, uncertainties, and then what do I think I maybe want to take hold of and discuss later down the road, but but it's not worth bringing up in in real time. And that's a balancing act. And I think any clinician, even if they're the best communicator, and probably the best communicators would be the most agreeable to this, that humans are super messy. And even if we try our best to feel like we're on the same page, we're aligned on this kind of shared discussion or shared decision making on the next steps, there can just be so many moving pieces with interacting with patients or humans in general, that I think giving yourself some reassurance that you're not gonna quote unquote get it right all the time, but you're gonna And do your I think doing your best starts with giving the patient or the client the space in the room to voice their whatever they wanna voice. The questions that they have, their whole story.

And I frame a lot of the starting conversations with patients, whether it's through Zoom calls with with E3 clients or in the clinic. I'll say, I appreciate you coming in. I read through your intake form. I know a little bit about what brings you in, I want to hear from you what else is going on. And I just stop there.

And the vast majority of people will just start talking and some individuals, it may take thirty or forty minutes to discuss all of what they want to discuss. And then based on what I'm picking up and hearing, then that orients the rest of the questions and the conversation as a whole. So I think what I want to get across in the course and in general, when I talk to other clinicians is you have to have some level of a framework of an understanding of MSK or whatever setting you're in, different conditions. And you have to be going through in your head, what are the questions that I need to ask or that I should ask at some point to help orient my decision making process or the communication from there. But you also have to acknowledge that the person is probably going to tell you a lot of really valuable things.

And if you're talking over them, or if you're trying to describe things too much, you're over communicating, then that may one damage the initial relationship, it may not give you enough information that actually helps guide the interaction. And I think listening, at least in the initial context is much more valuable than just trying to talk at someone. So I think all that being said, I try to start a relationship with understanding why they're coming in, what their questions are, and then I'll ask multiple follow-up questions or more clarifying questions. And then from there, towards the end of the initial conversation, I'll say, you know, is there anything else that we haven't talked about that you feel like is worth discussing? Or is there anything else you feel like I should have asked you that I haven't?

And really clarifying that they feel comfortable that all of what they want to discuss was discussed. That is, I think, a really big piece of communication that I prioritize. And I acknowledge that a lot of clinicians are in very busy, high volume clinical settings and that's harder to do. But I think in those contexts, you have to just do an even better job of setting the expectations of, I would love to talk to you for over an hour today. I know there's a lot we could dive into.

Somewhat limited with our time today. Whatever we cover is awesome. I really want to hear what brings you in, what questions you have. If we don't get to some certain things that I want to ask you or that you want to discuss, when I see you next in a few days or next week, let's continue from there. And it's caveating that you're time constrained, you're limited, but you really want to respect that communication element and that conversation as the highest priority.

Jimmy: And I think even if you have ninety minutes, it's still like, you don't need to put that pressure on yourself to do it all in that one visit. And I think that was like a hard lesson for me to learn is like, you feel like you have all this, like you kind of said, like you're unpacking their story, you're picking up on things that maybe some misconceptions and things that maybe you want to address, but if you try to do all that in one assessment, they're going to be overwhelmed, you're not going to be able to do it. And then, yeah, it's gonna be a messy road, you know. What I heard you say is you're trying to just open the door for them to give you their story. You're giving them that space, you're creating space and really you're focusing, your communication is focusing on listening.

Chris: Yes. Yeah. And I think that can be challenging, especially for a newer clinician because there's a lot of things going on in your head of these are these questions that I feel like I need to ask, I need to really Yeah.

Jimmy: Got your checklist of like, oh, I gotta ask all these questions. Yeah. Got yeah.

Chris: So trying to listen can almost feel like you're you're just distracted because you're you're waiting for them to stop talking so that you can ask another question. And I I acknowledge that that can be really hard to feel like you're fully present and to guide the subsequent questions based on what they're telling you. But I had a really good mentor and clinical instructor in grad school, Mike Amato, who was in Boston at the time. I think he's in North Carolina now, but it stuck with me. He said that there's certain things that you probably want to pick up on in the initial exam to ensure that they're appropriate for outpatient rehab services.

But you also don't have to feel, you don't have to beat yourself up if there's certain things in the objective exam or things in the subjective that you forgot to do, you forgot to ask, because you're likely going to see them in a few days. So there doesn't have to be this overly neurotic, rushed sense of, I need to get through everything. Because to your point, a lot of things you just may not be able to get to. And I think that can be easier said than done. But having some sense of take a breather, get through what you can, try to make sure this person is not in a situation where they need to be referred out immediately.

And then whatever things that come to your mind that you you realize you didn't ask, you didn't have time to ask, discuss it when they come in next.

Jimmy: It's interesting how people aren't used to that. They're not used to you like giving them that space to to share their story. I recently did some free screens at like, the local bike shop in town and a woman seemed like she was forced to go like talk to me and she showed up, she just kind of like sat down all grumpy and kind of like rude at first, but as soon as she realized that I was like there to listen to her, she opened up like it was it ended up being like a really good interaction. But I believe it was because I just gave her that space to talk when she wasn't expecting that, she wasn't used to.

Chris: Yeah, totally. And I made posts about this in the past and it's, these are made up numbers, but I said like the initial exam, 90% of it is subjective, 10% is objective. And that can be very context dependent and, but the messaging I wanted to get across is that the majority of things that you'll pick up is probably from the conversation as opposed to these nitty gritty objective elements that a lot of those are valuable, but the time and effort in which that that takes place is is probably minuscule compared to the the things you'll gather from the subjective exam that will likely clue you in on what you think is going on.

Jimmy: Yeah. So I'm going to piggyback on that because you recently did a really great podcast roundtable on assessments, and there is kind of unspoken communication that goes on while we're doing all these assessments with the patients. Can you talk about that?

Chris: Yeah, so what you're referring to, a few months ago, I had a great conversation with some close friends and clinicians and coaches, Q Willey and Katie Dabrowski. And I think maybe Q was the one that jump started that idea of having the conversation just from things we've seen or heard on social media about this overly technical assessment or trying to pick up or clue in on these specific movement strategies or quote unquote technical faults or joint positions. And we wanted to give our perspective as clinicians on what we think is the most valuable when looking at someone or starting the rehab or the coaching process. And our big emphasis in that conversation, and I align on a lot of what the two of them were discussing is that there are things definitely that we want to see and perform and hear and do, but a lot of what's going to guide our decision making about introducing a rehab plan or coaching plan is going to come from the conversation of all the things that I just discussed previously, what brings them in? What is their concerns?

What do they think is going on? What have they been told? But also their current day to day or week to week. What does a typical day look like for you? What currently are you doing for exercise or training?

Or what have you had to modify? Or have you had to modify anything? What do you want to get back to? Or what do you need to get back to? Are you playing a sport?

What is the demands of your sport? And get an idea of someone's typical life and their stressors, their training stimulus. All of those again occur through the conversation. And that's really probably gonna be the biggest thing to orient where our framework is of what levers need to be pulled, what do we need to adjust and what they're doing really well. And what are some missing pieces or gaps that we may need to fill?

And then the assessment aspect, I think the three of us in that conversation really noted that the assessment oftentimes can occur in that initial eval, but you're ideally assessing things day to day and you're adjusting a plan and it's being very fluid based on what you're seeing and hearing on a week by week basis. So there are things probably that you want to clue in on on that initial examination. And again, it's injury or context dependent of, are you trying to rule out, you know, some type of progressive worsening, you know, radiculopathy where they have foot drop or there's significant motor weakness or these things where it may be more appropriate that, they they get referred immediately. But outside of that, what are you generally cluing in on? Their Maybe their range of motion, their positions that are symptomatic, positions that they're more fearful of, discrepancies in certain strategies, whatever it is.

We think, and I think our summary was, a lot of these things are iterative and the way in which you adjust a rehab plan or adjust training doesn't occur through this really hyper hyper specific detailed one off examination objectively. It occurs through seeing how someone interacts in their environment and and what you're providing them week over week. And that in and itself is evolving and gives you the most information as opposed to, again, feeling like you need to get all of this information all at once, or you have to be hyper specific about looking at someone's pelvic position or rib cage position or something that we may not deem as the most valuable or likely won't change our initial plan of care. And that over time, with trial and error and experimenting and realizing this was a little bit too much, this was a little bit too little, that allows us to evolve the plan and hopefully build the momentum as much as possible. And I caveat that to my in person patients and my remote clients where I try to take some weight off of my shoulders, and also to the individual that thinks the first week has to be perfect.

Give the caveat and say, based on our conversation today and what you've told me and what you've currently done or are currently doing, I have a pretty good idea of where I want us to start. However, a lot of these first few weeks and these first few sessions, there's a lot of trial and error. And I'm gonna give my best interpretation of of what makes the most sense to start. However, there's probably gonna be some things that we realize we overdid, or that was too little, and we'll adjust week over week. And and the feedback that you give me and our communication moving forward will help the most to orient the best plan moving forward.

So I think having the caveats as well of no plan is perfect to start. Yeah. And you need to acknowledge that to yourself. So you don't fixate on trying to build out this perfect rehab routine over a month or three month block or the expectation that the patient has to feel this perfect plan to begin. That's in most cases pretty unrealistic.

Jimmy: I use the term like, this beginning part is going to be trial and error. This is my educated guess based on everything we've done today. This is your starting point. I may overshoot, I might undershoot, but I need your feedback because you're as much part of this as me to kind of guide where we go. The other thing from that podcast, that episode that I really liked was thinking about when we over assess or especially as a new grad when I literally I can remember creating all these little templates where here's my hip pain patient eval objective exam, this is what I'm going go through, you're checking all these boxes.

And when you start pointing out all these deficits to the patient, what that communicates like unintentionally to the patient, Because I thought it was really interesting. I think Katie, was it Katie that was on there talking about how she does a lot of virtual assessments as well and she said her virtual assessment doesn't really look any different than her in person assessment. And I think, I remember when I first started doing some virtual assessments, that was a big thing. Was like, can I can you do this like without that? And I was surprised for most things, I try to screen people before I do them, but for most things that goes really really well.

What's been your experience with that?

Chris: I agree. I think there are some things in the clinic that I may take advantage of, or I may lean into. I think there is maybe this unspoken maybe set of rituals that can occur in person that someone coming into, you know, in network insurance based physical therapy is expecting. And leaning into some of those rituals of a very thorough exam, I think can also help with the trust and the therapeutic alliance. So yeah, if someone's presenting with, you know, right sided anterior hip pain, I may do more of a hands on assessment in the sense that they may be supine and I'm checking their their passive hip range of motion and I'm doing some, you know, manual muscle tests to see if there's any gross motor deficiencies side to side.

And and it's maybe a little bit more in-depth. Again, I'm not checking their their pelvic orientation or seeing if there's an upslip or downslip. I don't I don't have the belief that I can be that nitpicky. And I know that those assessments are quite unreliable and it likely won't change my decision making or plan of care. But there are some things I would say in person in that context where I'm doing maybe a little bit more.

But if I'm seeing someone remotely, really the majority of the decision making is based on the conversation. And then there are things definitely people can do on their own that I'm checking for, you know, active lumbar spine range motion, hip range motion, weight bearing tolerance, double leg pogo, single leg pogos, and then depending where they are during that consult scene, you know, how are some resistance training movements for the hip. And then over the first week or two, as I build out their plan, I'm asking them to send a video or upload set of an activity. And that also gives me more perspective. But I haven't felt in the vast majority of contexts working with someone remotely and having that initial conversation and exam, I haven't felt if only I was in person, this would really change whether or not I think something is going on or I need to have this on hands or physical assessment to really guide my decision making that hasn't occurred really in years of doing this.

And I think that's reassuring for myself to not feel like I'm doing a disservice or I'm providing worse care by not seeing someone in person. But I do think that in person, there are some things that I can take advantage of, which is physical touch or the things that can come from interacting with a human face to face that that is a little bit harder to do online. As a whole, I think my my plan of care, my decision making, my thought process is identical in person or remote.

Jimmy: Nice. I do feel like there's patients like seem to like when you can put your hands on the hurt spot and just like assess it, they feel like he understands exactly where it is. Put his thumb on that spot and I know he knows where it is. I do feel like there's some value there, but again, I think you can build that trust and alliance without that, it seems, for most patients. I'd like to take a moment to thank our Runeasi.

Runeasi is a running and jumping analysis tool that helps provide objective data on things like impact loading, dynamic stability and symmetry. I've been using it in the clinic for the past three years and I love how easy it is to add to my evaluations. Not only that, but it backs up my clinical reasoning and helps me with my decision making process when I'm doing exercise prescription. So if you're a physical therapist or running coach, head on over to runeasy.ai, book a demo. If you're lucky, it will be with me.

While we stay on this topic of communicating, I wanted to ask you about dealing with uncertainty in the clinic from the clinician's perspective first. And maybe you recently had this MSK terminology update, which kind of alludes to this fact of dealing with uncertainty where we're going away from kind of labeling specific structures and then just being really kind of generic, for lack of a better word, like not plantar fasciitis, it's plantar heel pain or whatever, right? So how have you learned to deal with uncertainty in the clinic and then how do you, through this, your course, how do you plan to like help educate the younger PTs about dealing with uncertainty?

Chris: I think the biggest thing that helped me in school and as a younger clinician was seeing other clinicians be comfortable with uncertainty and mirroring that. So I was really lucky before I started PT school, I spent a year in California as a trainer and I would shadow during my off hours, Derek Miles, and at the time he was at Stanford Children's Health. And he was really the first clinician that I saw be very comfortable sitting with the unknowns and discussing that with, he was at Stanford Children's, so it's mainly a pediatric population, but either with these youth athletes, and or their parents being okay with like, I'm not exactly sure. I don't have a specific timeline on this or the humble kind of shoulder shrug of, I don't know why this occurred. But then giving the caveats of this is what we do know, this is what I feel confident with us moving forward.

And seeing that from him was the first entry point to realizing that someone who's really, really smart and really, really well read, doesn't know it all, and probably is able to acknowledge the unknowns a lot easier because he knows that the research doesn't have all the answers and there's a lot of uncertainty. That initially going into PT school was just a great foundation.

Jimmy: Let me interrupt you real quick. I say, that seems like a unique experience for you. That is not the norm for at least for me, Mike, and I'm a bit older than you, but upon So I was a nerd in PT school and shadowed all the PTs in the area that were supposed to be like the gurus. My first job was with one of the gurus in town. And the stress, even my first two jobs I can remember was like, you got to like label this thing, you got to assess for the facet joint dysfunction, it has to be super specific, it has, you know, and then it puts this huge pressure and burden or did on me.

Eventually, feel like it did cause some some burnout. Ended up trying to move across the country to like see if it was different, if like the PT world was different in Utah than it was in Virginia, only to arrive there and see that it's the same. At least back then, this was ten ten years ago. And it does seem like it's it's gotten better, but yep, keep going with your story. Sorry to interrupt.

Sounds like I wish I had that experience.

Chris: I was super lucky and Derek did a great job balancing that aspect of the unknown, but also very clearly having a plan and having principles that he prioritized to guide and help with coping with that uncertainty. And then in PT school, similarly, just had great mentors during clinical rotations. I alluded to earlier, Mike Amato, John Hodges. I had a great acute care PT rotation. All of those individuals did very similar things that Derek did.

Of one, very much stabilizing their practice with being really well read on the research and understanding how that guides their understanding. Very much basing their relationships with patients, their interactions with patients, leaning heavily onto the communication and really good kind of quote unquote soft skills aspect, but then being comfortable in their own skin and as a physical therapist leaning into the uncertainties. And so that was just kind of mimicked for me, clinician over clinician. And then as I became my own new grad, I was surrounded by a ton of great therapists at the first clinic I was at. And again, I think we all did a really good job balancing that unknown or unknowns when certain questions were asked by patients or by their family members that I didn't feel like I needed to have an answer when clearly I didn't have one, whether it was because I didn't know and probably the answer was there, but I was just, you know, this was my first patient in this condition.

I'm brand new out of school and I don't know and I'm okay acknowledging that. But then coming to them down the road with more clear answers, or we know that the research or the whole kind of clinical world doesn't have a great answer and I can sit comfortably with that. But at the same time, it is this balancing act of acknowledging, okay, you're asking when I can, you know, return to sport for this injury. You can still have some heuristics in your head or some ideas to help guide some framework of stability for that person. So it's it's not just leaving someone they have a question or series of questions.

You're not leaving them on an island, but you're kind of cluing in on the surrounding context of the conversation or what really they're asking and trying to stabilize to things that you do have a little bit more confidence over or that you can have more malleability on or that's more modifiable or controllable. And I think that's helped me balance the, you know, so many of these questions day to day or week to week where you just, you don't have a good answer of like, why did this happen to me? Why did it happen now? You know, I've been training like this way for a long time. Why did I just now rupture my Achilles?

And some of those where they're retroactively trying to tangibly find an answer to something that I really struggle with giving them a lot of, you know, comfort, but just acknowledging to them, you know, injuries a lot of times are so messy. There's a lot of moving pieces. Maybe, you know, we could play a guessing game, we could think of a few potential variables. However, that this is the current context you're in. I know it really sucks, but this is what we can do moving forward.

And so there's, I think, different levels of uncertainty or people wanting to grasp for confidence of why something is occurring or which specific tissue structure is involved. And this can present itself in so many different clinical conversations. And how I go about those conversations is dependent on what they're trying to come to terms with. And some of those conversations are easier than others. But I think I have just been very lucky over the years, seeing the uncertainty expressed consistently, and yet still feeling like I can do a really good job with clinical care amongst the uncertainty.

And to your point of how is this going to be kind of portrayed in the course or to younger students or clinicians? I think having an idea again of what is the research acknowledged on the topic. So in this first, as of right now, parts to this course, but the first part is trying to give kind of a primer or a summary on the most, or most of the most common musculoskeletal condition. So you're a young trainer or a young physical therapist or you're a student and someone's presenting to you with acute low back pain, what are the things you should generally know about this condition that will help you orient yourself to moving forward in the conversation and into the interaction? What is the likelihood of this being a pretty benign condition?

What is the probability of this resolving on its own or recurring down the road? Or what is the general timelines in which people have these symptoms? What are the red flags or the things you want to clue in that on that would make you more concerned? What does the research suggest around management options? Is that better than doing nothing?

Is one exercise better than the other? So these different musculoskeletal conditions that most physios and most trainers are probably going to interact with, whether they want to or not, can you grasp kind of what we do know or the lay of the land on these topics in a variety of big contexts? And I think the things for me is like, what is the natural history of this condition? If you weren't to do anything, would this kind of naturally resolve on its own? Does it need a specific intervention?

Are there things that we would do actually harmful for this condition? And those big points, I think are really stabilizing for clinicians or trainers or young coaches to have an idea of. And then maybe kind of touching on some of the common things that are the misunderstandings. So for example, like acute low back pain, we have been told or believed that it's because of the specific movement faults or this specific weakness or imbalance between their abdominal muscles, or their pelvic position, or their glute strength, or whatever it is. And so I go into some of just maybe the common myths that are worth bringing up.

And I think if people have an awareness of those things, that gives them some just general priorities to feel comfortable with. And then from there, they can kind of guide their decision making a little bit more smoothly, hopefully. And then the second portion of the course is someone's presenting to you with acute low back pain, you're a young physical therapist that maybe doesn't feel the most comfortable navigating an exercise based prescription plan, but this person wants to get back to lifting, but they're uncertain about it, they're fearful of certain movements. How do you think through in your head, things that are worth knowing and probably prioritizing of what are these big movements that you should feel somewhat comfortable integrating into a plan of care? Like what are different squatting movements look like?

And what could a starting point be for someone, you know, as simple as a wall sit or, you know, a sit to stand or a squat to a box? And how would you scale that up? And how would you scale it down? And then, you know, let's say they're already training consistently, and they have acute low back pain with a specific movement, you know, like a barbell back squat. You as the trainer, how do you think through in your head when and if it's appropriate to adjust their training, given the context of their acute low back pain?

And what are those variables you could adjust? Is it you're adjusting their repetitions in reserve? You're adjusting their intensity? You're adjusting their range of motion? You're adjusting their volume, their frequency, and giving clinicians and trainers kind of these big kind of levers that they can move and adjust in the training and rehab context.

And discuss why those are priorities versus going too much into the weeds and saying, okay, well, I need to like adjust their first toe range of motion or mobility, but they're having, you know, acute low back pain. What are the things I should probably prioritize? To me, that just gives more confidence, to the to the younger clinician or practitioner that I can lean into these things. They probably are gonna have a bigger bang for my buck. And I know when and if I need to adjust them, how to do so based on the the specific MSK condition.

And it it hopefully should feel more stabilizing for them to have not a complete pathway and not have a cookie cutter approach, but to sit with the uncertainty of these different MSK conditions with some strategies about adjusting the plan or progressing a plan accordingly.

Jimmy: It sounds like it all starts with you gave yourself permission from the beginning to say things like I don't know and to sit in that uncertainty. It's like you allowed yourself that. I think so often, especially at the beginning, we feel like, yeah, can't. Like if you do that, you're a bad therapist. You need to explain this, you need to have a diagnosis or whatever.

So it's like, you give yourself permission to say things like I don't know. But the big thing is you do that and you have to rule out these big bad scary things so that you know you have permission to start loading it. So you do it's not like you're working from a place of total uncertainty. You have, like you said, these areas where you're very certain, like, oh, we've rolled out, this is not a stress fracture, so I know we are safe to load. But at the same time, maybe you don't know the exact tissue or something and that's okay.

Chris: Yeah, exactly. I think giving those that sense of reassurance of this is what I'm quite confident that it's not. Based on what you're telling me, based on what I'm seeing today, that that stress fracture standpoint of these are the things that I'd be hearing or seeing or clueing in on that would make me maybe more suspicious of this thing that is what's called a stress fracture. And that we'd be need to be a lot more cautious of, and that would change our management. However, you're not describing, or I'm not seeing anything that would make me suspicious of this.

There may be a variety of tissues involved. This may be termed a variety of different things. However, because we've removed the concern around the more sinister or more scary things, our starting point is probably going to be quite similar. Don't think you need further imaging to guide our decision making. I'm not concerned about us needing to escalate to further medical management at this point in time.

And this is where I think we can start, even though it may be kind of uncertain as to which tissue or tissues are pissed off.

Jimmy: Love it. Yeah. Alright, so then switching gears, you brought this up a second ago indirectly, but this topic of load management and rehab and you had Dan John on the podcast fairly recently and he from one of his books I picked up on this, he's big on establishing point A, kind of doing your assessment, figuring out the loads that the athlete or the patient has been putting themselves under so that you know how to start moving towards where you want to go. In the coaching world, I feel like we do a really good job at like assessing patients prior training and going through what they've been up to. In the PT world, sometimes I feel like, especially sometimes I see like a runner who their past PT, like never asked them one question about their training or looked at what they had been doing at all.

When you're working with either like a patient or a young clinician, how do you help like, with this idea of like, when we're in the rehab context, we need to pay attention to load, we need to look through their training, we need to spend time doing that.

Chris: Yeah, I, again, I think because my background conditioning and being a in different SNC context or being a personal trainer, that is my natural bias or awareness that that is very valuable to bring up. And I'm also comfortable in having those conversations and kind of having the same terminology with someone who is training that maybe allows me to feel more okay entering those conversations and knowing that they're important because the comfortability I have of maybe the training landscape. So I acknowledge that maybe a younger physio that doesn't have some of those initial frameworks of what do I ask? How do I know what's important for exercise? I can acknowledge that that can be maybe more intimidating or more scary, or you don't, you're not aware of how important it is.

But I think once you get a baseline understanding of kind of general exercise parameters and prescription and programming, like you have some level of a framework, you can enter those conversations a little bit more comfortably. But as a whole, if you're working with either a general population client and they're not exercising at all, or they just integrated into exercise, knowing what their baseline level of fitness or lack thereof is and what they jumped into and seeing what that discrepancy is and or a, you know, a really active individual or specific athlete or a specific sport, really get an idea of what their baseline is and has that baseline fitness or training evolved much in a short period of time or over the course of time and getting that mental or kind of picture of what they're doing. And what if anything they've modified is hugely important. And acknowledge that my bias with a lot of rehab and adjusting someone's plan is based on what they're currently doing or what they're not doing. So inherently, I need to ask these questions about, you said you go to the gym twice a week.

What what specifically does that look like? Can you walk me through a typical training session? Are you programming for yourself? Are you using an app? Are you working with a coach?

And and getting into the specifics, even though it may feel, I don't know burdens burdensome, getting more clarity of, okay, I've been doing the same routine for ten years and this is exactly what it looks like. Or, you know, I kind of program hop and I don't really know what I'm doing, but I go to the gym and experience or experiment with a variety of things. That level of granularity, I think is hugely important to determine what is this person's, this patient or this client's awareness of their own training? Do they, are they comfortable manipulating certain variables or adjusting their training on their own? Or are they working with a coach?

Or are they using an app? Or they're really just winging it? That also allows me to enter the conversation with more or less, like similar vocabulary of someone's familiar with RPE or RAR or their overall kind of weekly mileage or their intensities, like I lean into those conversations or someone who's new to training, and they just go to the gym, mess around with a few machines, go on the treadmill and walk. I'm navigating those fat terminology and those discussions in a maybe a more simplistic manner. But as a whole, my prescription and my management a lot of times evolves around modifying activities or progressive loading or graded exposure of activities.

And if I'm not aware of what their current training or their day to day or their exercise parameters look like, then I'm just gonna be throwing stuff at the wall and seeing what sticks. And a lot of times I'm either doing way too much, or I'm doing too little, or it's conflicting with what they're already doing, or it's doubling up and it's redundant because they're already doing the same thing. So and I've noticed that a lot with my remote clients where maybe they have a little bit more means to seek remote services and they're actually working with another remote coach, and they're working with me and they're working with an in person physio and I need to ask explicitly, what exactly are you doing with this in person physio? What are you doing with this other coach? What are you expecting from me?

And based on what you're telling me, I don't think it's appropriate for us to add anything else. You're already doing what I would recommend, if not more. And so that level of just awareness, I think drives the direction of the plan of care. And for me, plan of care is often loading an activity or modifying activities. So I need to be aware of their current landscape or else I think the decision making is going to be maybe a little bit more inaccurate.

Jimmy: Yeah, so it's not enough to just say, ask like, what does a normal week look like? And they say, I run three times a week, I go to the gym twice. You want to go a layer deeper probably and say, yeah, tell me what does the gym session look like? What do these runs look like? Why?

Chris: Yeah, that one allows me to understand their sense of comfortability discussing their own training. And I think that gives information in and of itself of, hey, this person's, you know, really on it with their understanding of of building out their own programming or they acknowledge, I actually I don't do mess around with this at all. I just follow this training app that I just got and I'll ask them, Hey, can you show me like what that training app looks like? And they're kind of unaware of what the plan looks like, they just kind of blindly follow it. Then I look through it And then I can just go deeper on, okay, when you go for that run for thirty minutes, is that, you know, are your symptoms coming on during that run right when you start?

Are they coming on later? Have you tried to manipulate how long your run is? Or the train in which you're running, or the speed, or the cadence? And that, again, allows me to decide what is my entry point for either adjusting things or acknowledging what they have adjusted. I get again, I think it just gives more clarity to the starting point of rehab and their own kind of, you know, schema of how they've tried, if at all to manage their plan and their own comfortability with training.

And there's a huge continuum of what that is and what that looks like. But just hearing, I go to the gym twice a week and I run twice a week. That's not enough information for me to then build out a plan. Because just going to the gym for you look like you train, you know, for two hours and you're just, you know, crushing a ton of volume or you go to the gym and you do two or three exercises, then you go to the pool and then you leave like that level of fitness and preparedness and training variability is gonna look so different that it then leads me to understand where they are and where I can kind of start to interject with some perspective and adjustments.

Jimmy: Yeah, so you're really, you're trying to get a really thorough understanding of what exactly they've been up to so that you can then take that and say, you're not tolerating something, you're here because you're in pain. And then looking back through that training and say, is there something or is there a training error that's occurring? Is there overload issue? Is it load management? Whatever it is.

But without knowing and unpacking all this other the details, it's going to take time unfortunately. But it's without it, like you said, you're kind of just guessing. And then I remember early in my career when I wouldn't do this, you get to like the exercise prescription part of the eval and you pick your like whatever, the three exercises and they're like, I'm already doing those. And you're

Chris: like, dang it. Yeah, for sure.

Jimmy: So that's kind of like an even more reason, like making sure you understand this person fully. So one other question like I often ask during this part of the exam is, what are the things that you've tried to help with this situation? Because if you've tried stuff and it didn't and it failed, maybe it was there's a reason why it did, or maybe that was just the wrong approach and we don't need to do that stuff.

Chris: I also, I think a lot of these MSK conditions, we should be aware that in a lot of contexts, one specific type of exercise or series of exercises probably isn't superior over others in a lot of these contexts. And there are some cases where you have to like, really, what is the Chris Johnson quote, like stress the tissue with the issue, and you need to be a little bit more specific. But I think in others, someone's presenting with, you know, chronic low back pain, or persistent shoulder pain, or rotator cuff related shoulder pain, or, you know, these other patellofemoral pain, these other diagnoses that are somewhat broad, we know that exercise and leaning into a little bit of symptoms is okay, we probably want to stress that general region, but we also don't need a hyper specific protocol. That gives flexibility and understanding someone's plan allows me to get an idea of, are you doing this routine because you really enjoy this type of exercise format or because you think you need to do it? And then we have a lot of options.

These are some things we can consider. Do you have a preference? Do you want to integrate back into, you know, you're having rotator cuff related shoulder pain. You said you like to go back to the gym. Do you prefer machines or free weights or dumbbells or a body weight?

And based on that, it can then tailor this relatively broad management plan, you can tailor it towards the person. And I think that specificity is also helpful knowing that these conditions exercise in a lot of context is helpful, but one is probably not superior over the other in a lot of situations. You can then really bring about, you know, specificity to the person based on their preferences, their resources, what they feel comfortable starting back with, as opposed to, I know I need to start with these isometrics on this specific activity because that's the only way or that's the best way. And again, there are some tissues or contexts and injuries where maybe you need a little bit more of that narrowing down of a starting point or an ending point. But a lot of times you can give yourself some relief and give the patient just options and more autonomy.

Hey, here are all the things we could experiment with. This is what you're telling me you used to do, or this is what you said you want to get back to. Let's tailor your plan towards that. And again, that's why asking the nitty gritty questions about training and what they're doing is also helpful because it just orients maybe their goals or their interests and you're not just giving them a cookie cutter plan or things that aren't salient to them or they just don't care about.

Jimmy: Yeah. And by getting into that nitty gritty, they understand that you understand, you've listened to them, you've heard them. It's not cookie cutter. Yeah, that's that's amazing. So tell me this course, you're working on it, you seem very passionate about it.

What inspired you guys to like sit down and like spend time doing this?

Chris: I I think it was a few things. I've had we also offer one on one kind of one off mentorship calls for trainers or clinicians. And I'll take those calls for thirty or sixty minutes and and ideally, people come in with some some pointed questions or concerns that they have. And I've had numerous trainers and clinicians that have brought up the idea of, hey, you should do a course bringing up some of these things that that will be in the course. And then Mark Sertica, one of the owners of E3, I think he has been a really big advocate for me and really pushed me to expand the idea of doing more things within the company and then having some course in some capacity, whether it's online or in person.

And he gave me a lot of flexibility of you can do whatever you want to talk about, but I think this would be really good. You, over the past few years have really improved your communication skills. You like certain topics that you can really probably easily expand on in our course, I think this would be good for you to do. So it's been kind of nudging from multiple individuals. And then me realizing, I still have this strong sense of imposter syndrome of I look up to all these amazing clinicians that have great courses.

And I've learned a ton from those. But I can also do something that is really valuable. And even though I still feel like a young clinician, what are the things that I think would be super useful for someone that is just starting their career, or that is just starting being a trainer or a coach or a student physio or a new grad physio. And if I didn't have all those great relationships and mentors and learning opportunities early on, and I was going into it, you know, somewhat blind, what would I have really wanted as a great foundation? And that's really the goal for the course is to build out just a general primer understanding of a lot of these conditions that clinicians or coaches are going to face.

Here are some really big rocks and buckets of need that you should probably consider. Here are some things that you've probably heard that probably don't matter as much as you think or are flat out wrong. And then here are a lot of training variables that are worth considering when you're working with someone experiencing pain. And how do you navigate pulling which variable or which lever at one point? And how do you think through this process?

As opposed to I'm just going to give you the plan, here are the things that you should be familiar with and you should consider. And then it's, you know, choose your own adventure. Now you have the, hopefully the knowledge and skills and the understanding of the freedoms and moving through those plans a little bit more comfortably. And then at the end, I give four kind of big case studies walking through different contexts, trying to pull together the earlier parts of the course. And then at the end, we have like a big, I think 50 plus Q and A that we would expect.

Okay, these are some of the common things from the course that people will probably have questions about. How can I elaborate on those? And really, I've gone to so many great courses that are hyper specific on, you mentioned Chris Johnson and Nate Carlson, like running related injuries or stress fractures, or an Eric made a course on ACL rehab, or, you know, these more niche courses. How do I bring a really well rounded, somewhat general course to the younger clinician and coach that just needs like really solid foundations on a lot of different topics, that then as they evolve or as they grow, they can go to kind of more niche courses. But this hopefully gives them a really great building place to move from and to grow from.

Jimmy: Love it. I'll agree with the owner of the E3 Yes, Rehab Mark saying your communication skills are great. Like, I love listening to the podcast, you articulate yourself really well during this conversation as well. So for the course isn't out yet, hopefully we'll let everyone know once it's live. But in the meantime, are there resources that you can think of, whether it's some of your podcast episodes, books, or whatever,

Chris: to help clinicians improve their communication skills? I'm down to shout out the E3 course or the E3 pod at any time. I think some of those conversations are are more oriented towards communication than others. But you and I, you know, off air discussed both of our interests with Louis Gifford, and I can't recommend it. His his books enough that the trilogy, Great Exposure, The Neuro Root, and what is the other one?

Just aches and pains. I think that's the first one. Seeing what he was talking about decades ago at this point is really cool to see some of those through lines now in 2026. Yeah, I think it depends where someone's at in their career. I had a conversation with Jared Powell on the podcast a few years ago about what he wish he had known or messages for newer clinicians.

So if someone looks up Jared Powell on the E3 podcast, there's an episode with him talking about messages for new grads. And that was a company in a paper that he had put out with Chad Cook and a few other authors. Having some book recommendations, having some articles to read. But I do think a lot of the communication just comes down to reflecting on your practice and your day to day and just thinking through how did that conversation go with that patient? Or what do I feel like I said really well?

What do I feel like I stumbled over or I could have done better articulating? And again, not putting so much pressure on yourself that you have to get it right every time, or that you have to be perfect as this new clinician. In a few years, hopefully you're just evolving your ability to articulate complex topics, to simplify information, to understand what to say and what not to say. I had an individual, a younger clinician reach out to me from Rehab to Perform. I think he's taken over their podcast as the host, and he asked me any words of wisdom.

And I gave him a few recommendations, but one of the ones was, even if it may feel uncomfortable, listen back to the podcast that you record and clue in on the things that you say maybe too often or filler words or things that you realized you could have said better. And I think that's valuable. Maybe you can't record your patient conversations, but just having an awareness of, here are the things that I think I'm doing really well with my communication or on certain topics when I discuss things with patients, but here are the things that I realize, Oh, I just went on a ramble for five minutes, I probably don't have a coherent thought that I need to, I could probably improve upon. Or I have a mentor that they're okay sitting in on some of my initial evaluations and they're going to give me feedback. So I think there's almost endless ways to improve your communication, whether it's through means of reading books or research or listening to conversations.

But I think a lot of it is just having the conversations over and over and reflecting on how those go and then hopefully improving that over time and giving yourself some breathing room that you can be the best communicator and there can still be things you wish you had said or done differently. And that's the nature of of being a human and interacting with humans as well.

Jimmy: Love it. I think that's a great place to kind of wrap this up here. So for the listeners, where can they go to learn more about you?

Chris: Chris Hughen is my Instagram, you can follow me there and reach out. We have, you know, if you're a younger clinician or student and you want to have one on one conversation, we have those mentorship calls on E3 Rehab. I didn't mention Mark and I currently over the past six to eight months have a pretty affordable premium platform where we have students, clinicians, coaches ask a variety of questions. You can go to the website and there's a premium membership. It's $4.99 a month where we record weekly podcasts that is just for those premium listeners.

And we have research review episodes, we have Q and A's for the members. And then we have case studies where a clinician or a student is struggling with a case, they run through it and then Mark and I discussed in real time. So if you feel like you want just a little bit more, you know, clinical mentorship, but at a, you know, pretty affordable price, you could go there as well and have some discussions with us on that platform.

Jimmy: Awesome. Yeah, would encourage everyone go check out the podcast. I think there's like over two sixty. I don't know, there's a lot of episodes in there. So yeah, check them out, listen to them.

And yeah, go follow Chris on Instagram. Chris, I really appreciate your time. Yeah, appreciate you coming on and love what you're doing over there. So keep up the good work.

Chris: Thank you.

Jimmy: That's it for today on the Physio Insights podcast presented by Runeasi. Would you like to share an interesting case, insight, or have a thought about the podcast? Comment below, and don't forget to follow us for more episodes.