Episode 54: The Return of Fear and Uncertainty in the Rehab Process

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• Joe Gambino
• Joe LaVacca

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Summary
In this episode of the Beyond Pain podcast, hosts Joe Gambino and Joe LaVacca discuss the complexities of managing pain flare-ups in clients, the importance of setting expectations, and the emotional responses that accompany these experiences. 

They share personal anecdotes and insights on how to navigate client fears and the significance of building hope in the rehabilitation process. In this conversation, Joe LaVacca and Joe Gambino explore the complexities of patient care in physical therapy, emphasizing the importance of understanding individual barriers to healing, managing patient expectations, and the critical role of communication in guiding treatment. 

They discuss the challenges of uncertainty in healing processes and the need for professionals to provide personalized guidance rather than quick fixes. 

The conversation highlights the necessity of building trust and understanding between therapists and patients to foster effective rehabilitation.

Takeaways

• The importance of setting clear expectations with clients.
• Building hope is crucial for client motivation.
• Understanding the emotional responses to pain flare-ups is key.
• Clients need to be prepared for potential flare-ups.
• Navigating fears is essential for effective rehabilitation.
• Communication is vital in addressing client concerns.
• Encouraging clients to engage in their recovery process is important.
• Recognizing the difference between new and old fears can guide treatment.
• Clients often feel shame or anger when flare-ups occur despite following a plan.
• Handling expectations can prevent clients from reverting to passive coping strategies. Understanding primary barriers is crucial for effective healing.
• Education helps patients change their perception of pain.
• Accepting uncertainty is a key theme in patient care.
• Patients often seek quick fixes instead of comprehensive solutions.
• Communication is essential for guiding patient expectations.
• Therapists should provide personalized guidance based on individual needs.
• The complexity of individual experiences must be acknowledged.
• Building trust with patients enhances treatment outcomes.
• Therapists should not let patients dictate their care entirely.
• A flexible approach in treatment can lead to better patient satisfaction.

Chapters

• 0:00 Introduction and Welcome
• 3:01 Sports and Personal Priorities
• 5:59 Understanding Client Flare-Ups
• 8:54 Navigating Fear and Expectations
• 11:46 Emotional Responses to Pain Flare-Ups
• 15:04 Understanding Barriers to Healing
• 24:08 Navigating Patient Expectations
• 38:33 The Importance of Communication in Care

Transcript

Joe Gambino (00:00)
Welcome back into the Beyond Pain podcast. I am one of your hosts Joe Gambino and I'm here with your other hosts Joe LaVacca You can find us on Instagram at Joe Gambino DPT for myself at strength and motion underscore PT for Lavaca over there Podcast is on Instagram as well Beyond Pain podcast and on YouTube cups of Joe underscore PT to make it really complicated for you to find us we have all different Ways to go about it

Joe LaVacca (00:25)
different titles and different

tags. ⁓ I think at this point, if you've been with us for a year, you've figured it out.

Joe Gambino (00:31)
That's right. But

Yeah, they figured out and the easiest way is there is

an application form down the show notes. So if you have questions, comments, concerns, you can just go over there, fill it out. And one of us will be more than happy to chat with you. Well, welcome back, Joey boy. You should be very excited today.

Joe LaVacca (00:52)
I'm very excited and I'm already good.

Joe Gambino (00:54)
And

do you know why I'm saying so?

Joe LaVacca (00:59)
⁓ I always just now reference everything to the Knicks and going into... Yep. That's what I figured.

Joe Gambino (01:02)
Yes, that's exactly it. Exactly. Last time you were talking about, hopefully we can

just put up a little fight against the Celtics and we're up to.

Joe LaVacca (01:08)
I know

what a difference a week makes. Cause now I'm sort of saying, welcome to the finals. Right. I mean, and now with the Cavaliers also being down two, ⁓ the pacer thing last year, when we lost to the Pacers, I just think it was due to injury. Like everybody got hurt at an OG tore his hamstring. Brunson has ankle again, or it broke his hand or something like that. so I am very confident.

Joe Gambino (01:17)
Yeah, let's go.

I think it was like both last year for Brunson.

Joe LaVacca (01:38)
that it

yeah it was was everything well i mean brunson like we talked about last week i mean he has a career ending injury every game walks it off in the locker room and then he comes out and scores 40 so i'm okay with the with the formula now it just makes me laugh but i'm okay with it and yeah things are looking good things are looking good

Joe Gambino (01:56)
Yeah, I'm hoping for

a continued run. I haven't gotten a chance to watch too much, but I'm gonna make an extra point to watch tomorrow. We got family in town, we got a lot of things going on. I got a graduation, my sister graduated from college over here, so we have that tomorrow. Yeah, so we got lot going on, but this is starting to take higher priority in my life now that the Knicks are making a run.

Joe LaVacca (02:09)
⁓ congrats!

Yeah, well, I look, I think that's the whole definition of priority. We've talked about that in an earlier episode. You can only have one. And yes, I know other things in life are important, but then the Knicks are only going to play for two and a half hours. That's it. That's all we need. It's not even a whole day. It's not a whole day. It's just two and a half hours. It's 10 % of the day that I'm just sort of asking to just be watching the game in peace. 90 % I'll do whatever else you want. I told Courtney, I'll wash your car. I'll clean the garage.

Joe Gambino (02:23)
Exactly.

Sorry family. Yeah, that's it. Nope.

Let's.

Joe LaVacca (02:48)
I'll do whatever you want for Mother's Day, which by the way, even though this is after Mother's Day, we wish everyone a happy Mother's Day. Thank you to all the amazing women who are out there and we've had a few amazing women in our lives, Joe. So that are probably responsible for us ⁓ being where we are right now. So thanks moms. And yeah, just give us a couple hours though. That's all we need. You've given us so much already. What's another two hours this weekend?

Joe Gambino (02:54)
Yes.

Correct.

That's it. That's it.

Yeah, and we don't

have to worry about the next playing on Mother's Day, right? So I think we'll be we'll be OK. Timing worked out wonderfully.

Joe LaVacca (03:17)
Right, that's the other great thing about it. exactly. Now you get 100 % of my time on Sunday and you get 90

% of it on Saturday. You're still at a 95 % of my total time and attention. I think that's fair.

Joe Gambino (03:31)
Yeah, it's pretty solid. Pretty solid. All right, man. Well, we got a question of the day and it's maybe a little less of a question, but a case or kind of a situation that helped up with the buddy of mine and one of his clients. And I think this is something that I see quite often with how clients and patients kind of respond to flare ups. So I'm curious to see where your brain goes.

Joe LaVacca (03:33)
Yes, ⁓

Love it.

Joe Gambino (04:00)
Um, and how you kind of educate this person. Um, so my buddy's working with somebody, uh, it has been for awhile, I think like over a year, um, up to this point, uh, his client went out to play 36 holes of golf, flared up. And then there's, know, I went to go see Dan again. And then the whole conversation was about.

⁓ you know, what was going on? Why did this happen? There seems to be fear and apprehension. Like he doesn't even really want to get back. He's like, I don't want squat anymore or deadlift anymore. Like, so starting to try to almost like, Hey, you know, this is how I kind of want to go about training now. ⁓ so the question really comes when someone has a flare, ⁓ you know, working with you, something happens. How do you have that initial conversation to educate them about what happened?

How do you figure out if there are new fears or old fears that pop up? How do you start going about navigating those things? And then how do you get them back onto a plan that you know will 100 % move them towards their goals? That's deep.

Joe LaVacca (05:02)
Yeah, think I

could probably answer everything except the last part, because I don't know if I have anything that would 100 % move them to it. But I think what, no, I know, I know, I know. I just didn't want to anybody's hopes up. Like, oh, Joe's got the answer. And I always say, like, if I had the answer, if I had the answers, it'd be on the yacht. I'd be on the yacht right now, not in Courtney's office. I think first and foremost, what I have been doing way ahead of time now,

Joe Gambino (05:09)
Yeah, sure. know it, Bo. You know what I mean. In your mind, like, this is the plan. Yeah.

You got all the answers, baby. I know it.

Joe LaVacca (05:32)
is preparing people for this to happen. And it is almost expected. So when we get going, they start to talk to me or you or anyone about their plan. They agree to it. And then we have a couple of sample sizes. I have a guy right now who's been in long standing back pain, multiple fusions throughout his spine, slightly older now. And

Joe Gambino (05:35)
Mm-hmm.

Joe LaVacca (05:59)
He was very scared and skeptical about starting some movement programming. Now he is working with another therapist, someone who does a little bit more hands-on. So I encouraged him to keep doing that while we sort of took care of some of the exercise description or movement. He has started now for this week and he messaged me that, hey, he hasn't been on pain medication this week. ⁓ He's been feeling good. He's been feeling more confident. He's been walking a little bit more. And I just said, this is terrific. You have step one.

is building hope. So that's what I want to instill in every plan. And not to rain on his parade, I also said, we will now be more prepared for when your pain returns and knowing maybe the path out of it. Because we're seeing how movement can help you, we just have to get the dosage right. And when you prepare people for the flare, it's not that it makes the experience better,

I think it just makes the suffering better. Hey, Joe, you said that this would happen. It did. You were right. Now, as a client, I expect you know how to help me navigate it versus me not addressing it. I wouldn't say not addressing it is not like this wishful thinking of, oh, you know, I thought this plan was 100 % dead on from the beginning. But just by not bringing up the fact that this could happen,

Joe Gambino (06:59)
Mm-hmm, ⁓

Joe LaVacca (07:28)
Right now you're sort of like a little bit worried and we can liken it to almost everything. I mean, and with the kids, we always come back to the kids, right? Uh, cause I just think that's very relatable. Whether you have nieces or nephews and brothers and sisters or kids of your own. But you know, if we let Avery and Olivia run wild on cookies or whatever they want all day, we can be like, Hey, look, you're going to get a stomach ache. Right? You're gonna, you're gonna feel sick when you eat these cookies. Now.

They could choose to listen or not. But then when they get sick, it's like, shit, like that was right. I didn't feel good after doing this. Now, here's where it always becomes a fun conversation for me with flares. Was it worth it? If playing 36 holes is worth it and you you go out with your mom and your family this weekend and that's how you guys bond and connect and you're OK with a couple of days of pain, then you keep going and play. I'm not going to stop you. That's your decision.

Joe Gambino (08:02)
Mm-hmm.

Mm-hmm.

you

Mm-hmm.

Joe LaVacca (08:27)
If 36 holes put this fear into you and this idea of like, well, now I don't want to deadlift anymore. Now I never want to swing a club. Well, now we need to understand that there has to be a different set of plans here. So I think we've kind of traded ideas on flares a little bit. Are you trying to get ahead of them yourself or are you kind of playing a kind of a wait and see game with clients right now?

Joe Gambino (08:43)
you

⁓ yeah. So, I mean, in this case, they kind of like what my, ⁓ you know, we just actually just hopped off the call right, right before we recorded this podcast. ⁓ and mainly what I was telling him is like, you know, if someone wants an answer, you're going to give them the best answer that you can. You know, I say like, you know, listen, like, this is kind of clear, you know, if the pain happened right around, you know, within a day or so after this 36 hole event happened, you can likely tie it.

to the event, right? It's an increase in volume. He hasn't done 36 holes and maybe never, but he says, you know, usually plays 18 every other week, right? So 36 holes in one weekend is a jump in volume and intensity. So you can tie it. And then he was like, yeah, well, you know, he's also getting older and there's these other things. I was like, sure, you know, pain is very complicated, but we don't need to give people perfect answers, right? We need to be able to give them something that's going to help them digest everything, right? And feel safe and like that, you know, like

You know, want to get the buying in a sense, right? So we're not trying to lie to them. We're going to give them their best educated guess that we can say that that's driving some of their symptoms. And then from there, like once you can give them something, you have to take them to the present and to the future. So you need to rehash their goals with them. So this person, you know, and then also, you know, as we were talking that he brought up the fear after I was like, well, if this person has fear and you didn't ask him why he feels like he shouldn't be getting squatting again or deleting again.

You need to find out why the underlying or what the underlying fear is so that you can then address it and then bring them to the present rehash their goals and then say, look, this is where we are today. This is where your assessment is. This is where you want to go. We're going to need to be able to do X, Y, and Z. Like if you want to swing a club faster, we have to lift a little heavy, right? We need to challenge your body. We need to jump. need to create speed. We need to create power. need to create strength because all these things are going to carry over to playing.

more golf to be able to sustain 36 holes for you to be able to swing faster, all these things that you really want to accomplish. Once you can do that. Sure. I understand your fear. We're not going to just jump there today. We're going to, you know, change your program. You know, we can take squatting out and deleting out. And if you're really fearful of it, but we're going to try our best to work our way back through. We're going to listen to your body and I'm going to be here every step of the way kind of guiding you there. And I think when we can reframe this and bring them, okay, here's, you know, why this happens to the best that we can.

These are your goals. This is where we are today. This is the plan. All of sudden, now they can kind of see what's going on and that like fear of the unknown. And again, you mentioned expectation management. Yeah, man. Flare up might happen again. That's okay. Right. Like, like that's just part of the cards. mean, I can tell you from having 10 plus years of back pain that flare ups will happen. Right. but, you can be frustrated and upset and fearful of it. Right. But we have to figure out how can we get you.

Joe LaVacca (11:38)
Yeah. Yeah.

Joe Gambino (11:46)
back on track, right? not, because something like this, if you didn't have Dan, this is something that can really derail somebody from making any progress in the future, right? So having someone like Dan and having, or whoever, right? Like having somebody to say, hey, listen, this is the reality of it. Sure, it sucks, but this is where we wanna go. This is where we are today. This is why this is happening and this is the plan. I think, you know, as best as we can answer those questions can really do a lot for somebody.

Joe LaVacca (12:15)
Yeah, I totally agree. And you brought up a lot there, especially at the end. I think when people have a flair and they're on a plan and they've been doing everything and they've been really diligent. And I think that's what makes it harder to accept the flair. Like if your life got crazy, you know, I was working too much, my kids got sick, I got sick. I mean, I went out and I played golf and yeah, my back hurt.

it's flared up, I'm not surprised. No, because you didn't have a plan, right? So what were the results, right? You didn't enact anything we spoke about, which is not a fault of your own. I'm not going to judge you or attack you on that. However, when you have the plan in place, and you're like, Joe, I've been doing the mindfulness and I've been doing the deadlifting, I've been catcalling, I've been doing my hip mobilizations, and this still happened. I think that's where a lot of those changes in mood come in. That's where

maybe not even fear, but then anger comes in, right? Because it's not fair anymore. I've been doing what Joe told me to do and this happened anyway. There's a little bit of maybe shame that comes in with that. Like, did I do something wrong? ⁓ Did I not do these enough? Did I not do these the right way? So it's all of these mixed bag of feelings, which really is sort of the whole idea of feelings, right?

If you've Inside Out 2, emotions just get more complicated as we get older and they happen together, right? I think ⁓ what I've seen happen when I don't do a good enough job addressing these fears, like you said, or the primary emotion that someone is facing, they go back to this idea of using passive coping strategies, right? And whether it's...

acupuncture or magnets or, you know, light massage or hard massage or grass, right? Everything becomes now done to them. So staying in front of this and handling expectations, I think, as you said, is is the key as we were saying is the key. Because if we don't handle the expectations, and then it's sort of like they go back to another provider.

that other provider now has a little bit more ammo to be like, yeah, I told you so. Like you can't, you can't sweat a golf club, dude. Like you got to keep neutral. Hey, you know, you have all of this tissue adhesion. Like you can't swing golf. You can't go back to doing that. Like we have to break this up first. And when that happens, that'll keep them in that spin cycle because for as good as acupuncture or massage and, and you know, all the things we've talked about, heat, ice, you name it, will make you feel better.

It does not cause system or tissue adaptation. So it's just shifting the signal. But when you shift that signal and you tell someone that story, hey, well, wow, that makes sense. You broke up this adhesion. You relieve this block of energy. You did this, you did that. And that's my path to success as opposed to doing the things that we think are important. So, or maybe become more valid, I would say, in terms of getting people where they want to be. So I think understanding

is really important, right? And I think if we don't understand that primary barrier, yeah, then we're just back to chasing paint. And then we become like the same passive modality.

Joe Gambino (15:49)
Yeah, no, that's a, like that. And I think it's one of the, you know, things I've learned from kind of understanding sales a little bit more is like, you never want to have like this somebody, you never want to have uncertainty about something, right? Because you don't want to be assuming that somebody's dealing with something and then trying to push or say like, this is what's gonna, you know, be the best thing for you. Because once you start doing that, then all of a sudden you're to kind of, you know,

someone's going to be taken back, right? And it's the same thing when we're working with someone in the clinic. If you don't know why this person's fearful and you're just going to say, well, you know, like we need to squat, right? Because you have to, know, like, you I told him, like, you need to understand why, so you can guide this process and not just use your biases and try to educate that way. Right. ⁓ because we certainly will do that based on our experiences. ⁓ so how can we start to really understand what this person is going through and then how can we use that as, okay, well, Hey, you're fearful because you don't want this to happen again. But you know,

Guess what, even if we do all that stuff, this can still happen again, right? But to have the best chances of success for your goals, this is what needs to happen. And this is why. All of a sudden now, education, not just the education, but then changing his program to something that he feels comfortable with. And then slowly heading back in some of the things that he's fearful of and showing that he can have confidence in his body again. Like when you put all those things together, you can start to help someone change their perception of.

being super fearful and actually get them back to higher level performance. It just takes some time and you have to, but you really do need to kind of go back and understand what this person is kind of going through and why they're feeling that way. Otherwise it's going to be, it will be a hurdle for somebody.

Joe LaVacca (17:26)
Yeah. I think too, ⁓ I was listening to this other podcast this week and it was ⁓ Jared Powell's podcast and he had ⁓ Gordon Giedon who I don't personally, I don't think I had ever heard of, but is one of the founding fathers of evidence-based medicine. You know, did work with David Sackett and all these people that we've kind of grown accustomed to thinking about, you know, the evidence-based framework.

And it was really interesting hearing him talk because as he works with clients or patients, he's like, look, this is the best thing we have. You you can try this, it might help, or you can not try it and it still might help. Or it might not go away and it might come back and forth. Like we actually don't really know. But I think the thing that I valued from him being that upfront or truthful in what you just highlighted is

our professions resistance and I understand why to accepting uncertainty and then guiding people to realize that, everybody is so individually complex. And even if we had the recipe on what worked for someone, it's not going to work for you the same way. And I would be interested to talk to the client who did 36 holes because it's really easy to just think about it from a volume standpoint.

Right? Well, if he was also out there a little bit longer, was it hotter? Was he properly nutrition? Was he properly hydrated? If he was out there longer? Again, I know environmentally, perfect example, when I come out here to Colorado, I love going out with court outside having a beer. Right? I love like coming home from work, making, you know, a Negroni and just sitting with, with court and cooking dinner. But those are things that I don't do normally.

when I'm just by myself. So now if you're out on the golf course and you're with your friends, you go around to 18, are you having a beer or two at the clubhouse before you do another 18? Are you having another martini or two after you play the next 18? So it's really easy to look back and be like, oh, golf was the thing. But it could have been alcohol. It could have been

a confrontation you had with one of your friends. It could have been the heat. It could have been dehydration, right? So there's so many different elements that when you open up the eyes of people to that, then they're like, oh yeah, I guess, you know, I did have four or five beers. I didn't think about that. I didn't drink any water that day. I did sleep sort of like shit then because I drank alcohol and I was dehydrated and

Those are one of the master destroyers of your sleep cycle. And then I woke up the next day and there you go, I have pain and I'm blaming it on the golf. So they could be prepared for golf and maybe them getting through 36 holes is actually the sign that they were able to do it. You have all the capabilities, you have the muscle strength, you have the mobility, you have the skill. So it's hard, I think, to then also just blame it on that. But is that something that either

⁓ I think you said your friend's name was Dan. Did Dan tell you that they cry in a little bit deeper? Because I always think that those conversations are kind of interesting too.

Joe Gambino (20:55)
Yeah, he didn't give me too much as far as like the exact, you know, this is what the person was dealing with. So, but those are great questions. know, I mean, now you're looking at the recovery side of things and all that other stuff. they hydrated? they, are they eat enough? You know, you know, when I played the last time I played golf in Mexico was, I was at a bachelor party. I was very drunk playing golf. ⁓ you know, my back didn't hurt afterwards, but I'm sure, right. That can change things completely, especially if it.

Joe LaVacca (21:16)
Yeah. Yeah.

Joe Gambino (21:24)
Yeah, something like that can also mask pain, right? Like this guy could have had pain on the golf course, but you know, you have a couple of extra drinks and that's not going to happen. It's almost like taking, you know, like Puyo Pop and Advil before they play. And then when they're done with their round, they're backscaling them. Um, so yeah, there's, there's a lot of factors and that's why, you know, sure, we can't give this person an exact answer, but you want to be able to give them something that's going to make sense to them and help kind of steer the direction. You want to get back to the present in the future. You want to get away from the past, right? So sure. I them the answers that they.

Joe LaVacca (21:27)
Totally. Right.

Joe Gambino (21:52)
that they need, you're going to make the best inferences. You do want to ask all those questions to get the best answer, because if you do feel like, you know, like this is something abnormal, you know, maybe this can contribute to it and we should keep tabs on this in the future to see if stuff like this ever happens again. Because without trends, it's really hard to say anything. Right. But I agree with you.

Joe LaVacca (22:11)
Yeah. And,

⁓ even with trends, what you just made me remind me of, cause you were saying about Mexico and you know, like, Hey, I got through that. But let's even say like five days later, you woke up with pain and you didn't do anything the day before. Here's the thing that's really crazy about our nervous system. It could have been the input from golf on Saturday that made your back hurt Thursday. we're, we're just, we're so used to thinking that our nervous system is like this, like fiber optic highway of like,

instant information and instant reaction and we have to pair everything we're feeling with what happened or what preceded it directly in the moment or directly in the day before. And that's not how pain works. So it could have been the deadlift you did in the gym last week that made your back hurt after golf on Monday. I don't know. So that's where I always tell people, look, what's changed other than your sensitivity.

If your range of motion has lost, are you having muscle weakness? Are you having loss of function? Was there something neurological where you started having a footfall sleep or you had a nerve tingling, things like that? Then maybe we can directly relate it to what happened the day before or the moment before. But if you're just waking up with a flare of pain, I don't know what caused that. So we're back to the roulette wheel of like, well, let's put our bets down.

What do we think? And it seems really appealing to put money on golf because that wedge is just a little bit bigger. Right. So, yeah, I want to put my money there. But again, there's still 99 other spaces on the wheel where the ball can land. So I think that accepting uncertainty is probably the biggest theme I would say or share was getting ahead of flares and then helping people manage them going forward.

Joe Gambino (24:08)
Yeah, I definitely think expectation setting is huge and, you know, letting them know and some uncertainty is, I mean, that's life. mean, it doesn't pain does not escape and movement and rehab doesn't escape that. Right. So I do want to shift here because I think it goes in line and it's something that we talked about right before we hopped on is, is when you get somebody who wants to dictate care in a sense. So like in this case, right. Of this person.

Joe LaVacca (24:17)
Mm-hmm.

Joe Gambino (24:35)
he's kind of dictating based on how he's feeling. Like I don't want to do X, Y, and Z, right? Trying to like, not necessarily push his own agenda, right? But saying like, you know, he's putting his input into it as far as this is what I think is best for me going forward. And there's a lot of people who do that, you know, not necessarily it's the distrust of the person that they're working with. And I do believe people understand their bodies and you know, we should take what they have to say to some credit. But when you get somebody who's, who says, and you can, you can mention the email that you, that you got.

And we'll keep this around kind of like general public and how you would help educate them in a sense. ⁓ When someone is saying, hey, I wanna do X, Y, and Z, or I only need this ⁓ to get better, how are you kind of going about having those conversations and what would you say to that person?

Joe LaVacca (25:23)
Yeah, most recently this week, email popped up and someone had low back pain and you know, they mentioned they're busy. They work from home. ⁓ They don't strain train a lot. They probably only come in, you know, maybe once a month, once every other month. And then, you know, they just wanted a handful of things they could do at home. Yeah, here's the problem with that. You're currently not doing anything. So why would all of a sudden I expect you to just miraculously put in three, four or five exercises that we would, you know, best guess for you?

and expect you that they're just gonna insert them into your life without accountability, without follow-up, without check-in. So I don't think it's realistic when I get emails like that or messages on Instagram or wherever that people are actually looking for what I can provide. Because that connotation to me is I'm still looking for a quick fix. I'm still looking for an easy way to manage this. And I do think it diminishes us as professionals a little bit when I get a question.

because I'm spending time, you're spending time, you know, we're doing podcasts, we're reading, we're, you know, constantly treating people, we're trying to work to get better. And then to deduce it to, just need a couple exercises. And I think as you so perfectly put it, great. That's what YouTube's for. YouTube, how to solve low back pain. You will have endless exercises to choose from. If you wanted something a little bit more personable, if you wanted to actually work toward changing lifestyle,

If you wanted to actually learn a little bit more about your experience and how to manage it, I'm your person. If you just want exercises, I ain't got nothing special. I'll show you the same stuff on YouTube, but I'll give you a why behind it. Maybe I'll give you some structure. Maybe we tweak something specific for you. But I just always hark back to what other profession does this work for? You bring your car to the mechanic because something's wrong and the mechanic tells you, hey, this is what I think you need to fix.

And you're like, nah, no, I don't think so. I would just like you to change my oil and check the tire pressure. Well, how is that going to help your transmission? So we entrust everything in our lives to other professionals. When I go to a restaurant, I'm assuming the chef knows how to cook a meal. Maybe I need to make a special request. Hey, I'm allergic to gluten or I'm allergic to shrimp. But then I'm entrusting that the chef is going to make that accommodation or the kitchen will make that accommodation.

I'm not going back there being like, you know, I love chicken, but I like the ratio of salt to pepper to be 49 to 51. I like it to be slow cooked. I like it to be this, I like it be that. Well then go home and cook. Do it yourself. You know? So I mean, one other instance that just popped into my head, and I think again, it's just like knowing what you provide as a physical therapist and being comfortable with that too. Some guy came in looking for deep tissue massage.

and he came in from the gym. And I had met him before a couple times, we had some pleasant exchanges. And he was like, Hey, you know, you mind if I just get changed? You know, in the area where I, you know, typically see people so it's like, sure, no problem. So I put up like our little sliding walls, like we have those like little, like, privacy walls that I can kind of put up. And then I opened the wall again, and he's laying face down in his boxers. And I'm like, Hey,

what are you doing? I thought you were gonna, you know, get prepped for the session. And he was like, yeah, I am. I'm just here for massage. And I was like, Well, that's not what I do. I'm not a massage therapist. So I had to have him sit up. And I started doing I'm like, Do you want to get dressed? And he's like, No, no, no, what do you have to ask me? So I'm literally now doing an interview with this man in his boxers. And I'm trying to understand what's going on. And what's going on? What's this? What's that? And he's just like, and here's the funny thing, he wants deep tissue massage.

I start just laying my hand on his back and he's like, ⁓ yeah, yeah, yeah. Push, push harder.

touching you. What are you talking about deep tissue massage? So I actually just ended the session. I was like, look, we're clearly not going to be a good fit. I don't provide this service. Okay. And I can give you the name of some great massage therapist and he huffed and puffed and he got all pissed off that he wasted his time. You wasted my time. Right? So you know, I again, there's nothing on my door that says massage therapist, there's nothing that your trainer told you that this is going to be about. So I think having a little bit more respect.

for yourself as a professional helps navigate this. And then you realize that people are seeking your opinion, just like Dan Polk told us, right? Like I can't make a decision for you, but it's my job to give you the best guidance. And if you don't want to follow that plan, well then I'll help you find another plan. Have you had, I imagine you probably have people like this, especially virtually. So how do you manage them virtually?

Joe Gambino (30:16)
Yeah, I mean, you know, I mean, I, you know, my current landscape of things, and even if I was seeing people in person, you know, I have a lot of conversation. I have two conversations before I work with anybody. I have a 15 minute call that I go through just to kind of see if I can work with them. And then we do a deeper dive, 45 to an hour minute call that, you know, we kind of go through what's going on in a much deeper level and then an overview of my process to see if I can help. So by the time I'm working with somebody, I already know.

You know, can, you know, I'm 110 % confident I can help them that they're looking for my kind of service, things like that. And when things do pop up on those calls, say, or in the past when I was working with somebody, my questions are like, well, you know, if they're asking, you know, this person's asking you, I just need this program I can do at home. Well, sure, I can create a program for you, but you know, is this something, you know, what have you been doing in the past before? And if it's constantly the same things, like they're always doing this, but they're still struggling, well then.

Is this something that needs to change? Right? So I always wanted to go back right as far as I can to see, you know, if this is a trend, it's like, you know, where's their biggest struggle? What, can't they get over the hump? You know, is it just, they've never done anything before? Is it, they've tried the same things over and over again and just kind of piece together these routines and it's not really quite getting them there. and then, you know, when I'm going through it, you know, I don't sell my program.

to somebody. I'm not selling you a four week program or an eight week program or a four month program. I'm selling you my process. Right. It's the process of working with me from top down. Right. Our assessment process, our, you know, sure. Right. Custom programming over whatever time period, the accountability, the support, the guidance, how to understand pain better, all the education that comes with it. Right. It's not one thing that you're getting. You're getting all of my clinical experience, training experience, everything combined all into one.

⁓ And that's how I propose it to people right? It's not like hey, know, like hey, you know come get this four-month program and it's gonna solve all your all your issues, right? You can get a four-month Program you can get a year program Off of anything we talked with Britt about Chad GPT you can get anything off YouTube these days Instagram like go go through my Instagram account. You'll get countless mobility drills Countless. How do you change this exercise? If you have like squat if you have knee pain, you get all that information now these days, right? But how do you?

make sure that it fits within your life. How do you make sure that you're actually gonna do it? What happens when shit hits the fan and you do have these flare ups like this guy that Dan was working with, all these little things kind of come together and really kind of guide a process. How do you modify things? How do you make sure you're not pushing too hard? We talked about paying guidelines on here. That's a huge thing and what I provide people an educating guide on. You can get that on this podcast, right? But if you take that and you're still not having success, well, why is it, right? it something is missing?

in your understanding or your approach that's still missing the mark, so to speak, right? So I guess that's kind of how I'd answer that question. I don't know if that answers it well or not.

Joe LaVacca (33:16)
No, it does. And you actually made me consider a couple of things by just listening to you. And I love that idea of like, I'm giving you my process. And that's your clinical experience and judgment and working with people, coming together to make best decisions. And that's what chat GBT will do. Like it'll scour the internet and come up with a best fit. Just realize there's a lot of shit out there. So it's processing the shit also.

just like we talked about with the golf person, you know, it'll be like, yeah, you know, maybe your hip is limited. Maybe this is limited. You know, maybe you have to check your volume. You know, it'll give you some practical advice. And then you go do that. And then you slam five martinis again, you wake up in pain and you're like, ⁓ no, Chachi BT was wrong, I guess, you know, and then we're not just connecting it to anything else. So think that's the value of knowing the right questions to ask. And I think that's where you and I can provide the most value to someone.

And I did have a great call with the new client that's coming in next week. And very similar to the process you outlined, she booked an appointment and made a 15 minute phone call, which I love when people do, right? Get proactive. If you decide it's not for you, we can always take you off the schedule, but now at least you have the time booked. Works for you, works for me, obviously, because my schedule is open and we go from there. And all she wanted to just understand was, hey, are you flexible?

in your treatments. Like if I did need manual therapy, you can provide that. If it was exercise related, you can provide that and I'll be willing to do it because she had two very opposite pendular experiences in New York City, right? So she went to, you know, one place for PT and it was within the hospital she worked, very manual based, very busy, same three exercises all the time. Then being educated, I went to this.

Really famous big clinic in New York City and all they wanted to do is exercise. They didn't want to touch me they said that's not what I needed and I just want someone that's going to Be able to listen and ask me questions and potentially do both if that's what's warranted and she had found me on Actually listened to one of my lectures from Pessy that I had recorded and she bought like a continual education pain package And she was like, yeah, I just no one was really talking to me about pain the way that you were mentioning

in that course and that rang true to me. So that's where, hey, you can find information. It can be good or bad or indifferent, but we still have to make that information fit you as best as possible. So now she's more willing, like you said, you know, if it's an eight week program, great. You know, she seems willing to go and do that. If it's a 12 week program, great. But we also talked a lot about, this may or may not work for you. You know, then what?

Then we have to find a different sport maybe than running or you try the surgery or you play golf or I don't know, maybe even six months there's a new treatment out there for hip pain or something like that. Who knows? But I think that's really, really an important piece. So I think just listening to you, think that that word of just learning when to be flexible and learning where your boundaries are as a clinician are probably just as important as understanding the boundaries of our clients.

Joe Gambino (36:39)
Yeah, I would agree with that. it's, you know, I was, I mean, if someone came into my clinic and I was like, ah, you know, like, just let them dictate everything, right? A, they're not going to, they're not going to trust me, right? They're not going to respect me, right? And they're probably not going to work with me for very long. Right? So being like, you know, not necessarily like the, you know, an authority figure, so to speak, but like, you know, you need to give your opinions on what you think is happening and, know, kind of just

Joe LaVacca (36:53)
Right.

Joe Gambino (37:09)
not dictate, you know, this is, this is it, right? This is how I work. This is my plan. This is my process is I can help. This is the plan going forward, right? Like you lay it all out very, very nicely for them so that this way they can figure out a does it work for them, right? Do they fit, you know, do they believe it? Do they trust the process? Do they think you can actually help? ⁓ and you know, I think that will, that will do a lot. I think this person that you're talking about, if, those clinicians actually just ask more questions on the front end, so you probably would have had better experiences.

upfront and didn't need two or three PTs to kind of, you know, potentially, right. If, if, know, you're the person that ends up helping her, right. Like she doesn't have to keep looking for these things. I think that's where a questioning in the beginning and going deeper and understanding what is underlying there. And like, you know, Hey, you know, good, great. You know, you want a flexible person based on whatever you feel like you need. And now we can have that plan and you know, you can guide that process from here.

So the more information you can get about somebody's situation, why they feel certain ways, how it's impacting their life, what they're looking for. ⁓ then you can say, Hey, well, does my process fit this? And if it doesn't fit this, then I refer them to somebody else. And if you do fit within my process, then great. You know what? I should certainly can help you. I know it's going to resonate with you because you already told me all of these things and that what you're looking for is what I can provide. And then you go from there. Right? So I think that's pretty good. I don't know if I have anything else on this top. Is there anything else that you kind of want to add in here?

Joe LaVacca (38:33)
No, no, think ⁓ both sort of questions kind of streamlined nicely into one another. So hopefully that's some good value for our listeners. And then I think ⁓ we pick it up next week, brother.

Joe Gambino (38:45)
Sounds good, Well, take us home then.

Joe LaVacca (38:47)
All right, listeners, we love you. Joe, I love you. Thank you, as always, for joining us. And please continue to come by next week for another exciting episode of the Beyond Pain podcast.

Joe Gambino (39:01)
Bye!