The Hidden Signs: Detecting Red Flags & Visceral Referrals
In this week’s episode of the Unreal Results podcast, I talk about recognizing and responding to red flags in patient care. First and foremost, this topic is important to me because this is what happened with my mom’s cancer diagnosis, which I talked all about in episode 1 of this podcast. I talk about how it’s important to recognize when a patient’s condition isn’t progressing as expected and the need to consider possible underlying visceral issues or red flags such as cancer or infection. You’ll also hear me talk about the importance of referring your patient to a specialist and how to do that appropriately to ensure comprehensive care for the patient. This is a must listen episode for my physical therapists, athletic trainers, and other essential sports healthcare providers.
Resources Mentioned In This Episode
Episode 1: My Mom's Cancer Diagnosis Changed My Whole Approach to Sports Healthcare
Episode 36: Listening To The Body
Episode 42: The Fundamental Attribution Error and Why You May Be The Problem, Not The Client
Episode 46: Using The LTAP™ With Post-Surgical Rehab
Episode 47: Always Check The Distal Pulses
Get on the Online LTAP™ Level 1 Waitlist HERE
Check Out Veronika's Website HERE
Check Out Veronika's Instagram HERE
Upcoming In-Person LTAP™ Courses
LTAP Level 1 in Boston, October 2024
Considering the viscera as a source of musculoskeletal pain and dysfunction is a great way to ensure a more true whole body approach to care, however it can be a bit overwhelming on where to start, which is exactly why I created the Visceral Referral Cheat Sheet. This FREE download will help you to learn the most common visceral referral patterns affecting the musculoskeletal system. Download it at www.unrealresultspod.com
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Anna Hartman: Hey there, and welcome. I'm Anna Hartman, and this is Unreal Results, a podcast where I help you get better outcomes and gain the confidence that you can help anyone, even the most complex cases. Join me as I teach about the influence of the visceral organs and the nervous system on movement, pain, and injuries, all while shifting the paradigm of what whole body assessment and treatment really looks like.
I'm glad you're here. Let's dive in.
Hello, hello, and welcome to another episode of the Unreal Results podcast. We're back. And, uh, where we're at? Where are we? I'm still in San Diego. It is officially the last day of my summer break. Uh, that's just because tomorrow I am taking my first football season trip to go see one of my athletes. So, um, I'm sure there'll still be a lot of summer for me here though in San Diego.
Um, and then too, just like amping things, getting ready for the next launch. I think I shared a little bit about this on the last call. But, um, Coming into the fall means, um, a new cohort of the online LTAP Level 1 course. And the way I kick off the launch for that course is, well, one, to the waitlist. If you're on the waitlist, you always get priority.
And a discount, um, into the course. So if you're even semi interested, be sure to get on the waitlist. I'll make sure Joe links to the current waitlist for you because I actually am going to start the sale to the waitlist next week. So, um, I don't know. Is that Labor Day? No. Is this weekend Labor Day weekend?
Let's look in the calendar. Yeah, I guess it is. Right after Labor Day, starting the sale to the waitlist. We'll probably start on September 4th. Um, and it's usually a four day sale to the waitlist. Um, it's a pre sale. So then, after the waitlist pre sale, I open up the doors to the free course, which traditionally has been the results cheat code.
Uh, I might be changing the name this year to I did last round too, I said the result cheat code, the missing link. It might be the missing link again, I don't know. I'm playing around with the wording of it. But, it's gonna be the same content. Um, which is a little taster to the LTAP. And, um, like I said, that's free.
The door's open to that on September 8th. So, lots of fun things coming up. Um, text Mrs. Tweet. Which means, turn on my do not disturb. Um, so anyways, yeah, so, and then we've got, um, the October, we've got the, um, Boston in person LTAP. There's six spots left, so those are the last in person spots in courses. In 2024, the six week course starts right after that on October 7th, and then the last in person course, which is completely oversold is in San Diego the first weekend of November got some other, um, educational things coming down through the pipes for you.
And then of course, Black Friday, I always do another flash sale. So if you didn't take advantage of the birthday flash sale, you'll want to take advantage of that. Um, so yeah, so exciting. The fall is always a really exciting time because yeah, everything is sort of happening again after a couple months of like, you know, slower season, especially this year, since I didn't run my mentorship.
Usually the mentorship is filling my time during the summertime. So, um, yeah, this, this, this year I've had an actual downtime, which 10 of 10 recommend, uh, anyways, um, so, The other update I promised I would continue to update about my health. I know a lot of people were like, oh I hope you're doing good.
Let me know. Um, I had a I got my blood work done I had a visit with my doctor. My thyroid is like down gone down a tiny bit But overall really hasn't changed much since I went off of it. So confirmed. I don't really need thyroid medicine. However, I do need some like support to my thyroid through different vitamins and minerals and things like that.
And, um, like overall, the cool thing is my blood work looks. Good, it's like looks better than it's looked in a while. Granted, we only did like a CBC and a thyroid so it's not like we had like a full picture, but we had a pretty decent picture and from that picture, which is like the standard one that I do like the check ins with, um, overall looking good, overall looking like two for the first time and Like decades like serious and this is not an exaggeration like first time in like decades that my cortisol has actually come down um, and my Solicitation of white blood cells as a stress response hasn't a stress response has improved and so it's like overall trending really well and um, I did talk to the doctor I was like, you know, part of me wonders if like i'm tired because My cortisol is finally coming down and like now I'm actually like feeling that.
I'm used to like, I always like kind of joke like I'm so amped up on such high levels of cortisol that it's like they come down probably is going to feel like this. And I'm okay with that. Um, if this means like more rest and more naps and more things, like In the journey to like heal my nervous system and I'm all for it.
Um, the other part, my red blood cells were a little smaller than we would like. And so, um, I already, before I saw the doctor started like taking a little bit more like vitamin support, which vitamin Bs and things, so I'm just going to add a little bit more of that and some iron. And, um, also I was realizing that as I've taken more potassium and Actually noticeably been sweating better like actually losing more sweat um, I think maybe my sodium was on the low end.
And so what was already on, I already know my sodium is on the low end, but I think maybe in the summer time it was sort of like exacerbated it from all the sweating. Um, and so I also added some more salt back into my diet via LMNT's like new sparkling drink. Cause I, I love a little bubbly drink. Um, but between that and the vitamin B's and things like I feel better now.
I feel much better than I did when I was like, okay, time to redo my blood work. So, and also not only energy and tiredness much better, but my body's not as achy. So there's my update. Turns out I'm fine, which is great. Um, I will say to my feet overall feel better. And I haven't been wearing the Birkenstocks.
now for like a whole week and it breaks my heart because perhaps the Birkenstocks are part of that picture. Though I still think it's a little bit of an inflammatory thing too. So anyways, that's my update. It's been
nice to get into a routine of working out, taking care of myself, and doing these things. And, um, I We'll say too that it's like a little bit of what I talked about on the last podcast is just like this is the importance of what I teach is to like be curious and to test and to Realize when you're doing the right things and not getting the right response This is when we need more data and this is when we need more help from other team members perhaps so Um, yeah, we're still in it.
Um, I don't think I have any other updates. Not really, no other updates. My, my oldest niece. Well, my niece turns 14 this week. She already started high school a couple weeks ago. Like, I, I'm not sure what time is, but I need it to like, slow down a little bit. Because I still feel like, relatively in my 20s.
So the fact that she's like, so close to her 20s, it, it's not, I am not well. This is not okay. So, um, but that's it. Going up to visit them this week. And, uh, should be good. Oh. That actually reminds me, I also, so when the LTAP course, online course launches, um, in a couple weeks, well in a month, to the wait list, and then to the public in a month, um, I will have the dates and locations of all the in person courses for 2025, and it's looking like I might have six classes.
So, super excited about that. Gonna put some new locations, uh, in the works. So, for those of you in the parts of the country where you feel like I'm neglected. Keep a lookout because I'm trying, trying to help you there. So super excited about locking in those dates I'm just working with the people who are hosting on like figuring out the dates and you know It's sort of like I have to wait for one person to choose before I offer dates another person because it's like your patience I'm sure you get like this like you're like, oh, yeah, I have a lot of openings.
Like here's the four openings I have And then, like, five people, four or five people, three people ask for your availability and you tell them the things, and they literally all pick the same opening, that happens. So, um, that's what I'm just trying to iron out with the courses, but you will know soon enough.
The people on the waitlist will be the first to know, and then everybody else will know, um, Shortly thereafter. All right. So topic for today. Today's topic is a little bit of like, we've been talking about this and I wanted to talk about it a little bit more formally because this came up, uh, you know, when I asked people for podcast questions, this came up as a question.
And then also, as I've stated in the last couple of episodes, sort of with my own health journey, It's a question that comes up in the LTAP Level 1 quite a bit. Um, when I'm mentoring people, when I start to expose this lens of view to people of the Viscera and the Visceral Referred Paints and even all of you that have maybe downloaded the free Visceral Referral Cheat Sheet is it makes you start thinking about, well, When do I refer back?
Like, when is it a red flag? When is this a scenario like my mom, right? Like, for those of you who haven't listened to that episode or haven't heard me talk about it is basically is my mom went to physical therapy for shoulder pain for years on and off and it was on because she wouldn't get have progress and the therapist would basically Shame her into, um, you know, shame her in a way of like, you're not doing your home exercise program, which is not true.
Um, you're overweight, you're out of shape, you're not active enough. Like, all of these things of why her shoulder hurt, which was really their fault. Which really was they were just they weren't getting results, but why weren't they getting results? Not because of that is because her pain was referred from her lungs.
She had Um lung cancer we found out right in hindsight But then it made sense why she was never getting better Why her shoulder pain never got better her shoulder pain that kind of shifted between shoulder and upper back and neck And the wrist and finger pain, right? Like it was kind of like shifty.
It never really changed. It never really changed all the physical therapy, all the exercises, all the manual therapy, all the stretching, all the things she was doing. And nobody thought to like, Ask her about some red flags. Nobody thought that just the fact that she wasn't getting better, right? The prognosis for a rotator cuff strain or shoulder pain secondary to like, I don't know, like impingement or whatever she was diagnosed with.
No one thought, hmm, she's not fitting in the typical prognosis for this. And we should refer back. And this is my whole shtick on like, why is so important to guarantee, be able to guarantee results is because the fact that you feel confident and confident enough to guarantee results means that you feel confident enough to know that when you're not getting the results.
Something is up. Like, that should be a yellowish red flag in itself, right? So, the problem is, is because the industry sort of rests on mediocrity, right? Right? People think they get good results if they can help like 7 or 8 people. And honestly, when I say 10, some of the physical therapists out there tell me that I'm being very generous with what is average and considered good.
Um, but they consider 70 percent success rate. good results because they have these beliefs that innately working with humans you're not going to be able to help everyone and you are working with a body that maybe has an injury to the tissue or a movement dysfunction motor control issue that takes time to change which means it takes time to heal and change someone's pain.
So that's the problem is when we think good results is seven out of 10 patients getting better. What about those three out of 10 people who don't? What happens like we just like sorry or that small amount of people that I guess just can't help I think that's a bullshit answer and um In my own practice i've seen that that's not true.
Um, most of the time I can help 10 people and uh When I can't help somebody it's an immediate red flag of like i'm missing something I'm missing something that could be a big deal like cancer or i'm missing something that You is like a big deal to my athletes, maybe some sort of internal derangement that the doctor thought they fixed, but didn't in a surgery or maybe something that was injured without them really recognizing it was like a huge mechanism or something else going on.
And I talk about this a lot and I'll have Joe link the episode in terms of my athletes and like, I talked about this and how important the swelling protocol is and the assessments we do in the swelling protocol is to determine that and I talked about that in one of the episodes about the swelling, um, using swelling post surgery, post surgery basically.
So I'll have Joe link that episode too, but, um, do you see my point here is it's when we. settle for mediocrity, when we settle for mediocrity, we're less confident that we can help everyone, which means we're less confident to like say we can guarantee results. And when we don't believe that to be true, we're less likely to allow the fact that they don't get better, be a red flag or at least a yellow flag, right?
Cause it's not necessarily a red flag because it truly just might Sometimes it is true that it might take time. Sometimes it is true that you're missing something, but that missing something is not an emergency red flag, right? It just might be that you're missing something. Um, but the key is that you know that it's not going how it should be.
And so you're, you're looking for other answers specific to that patient. Okay. So I got this question. Let me actually read the question. Because it's always good to hear your language versus my language, because it's different. From my girl Ashley Heller, she is a PT here in like, um, South Orange County, uh, Northern San Diego County.
She's gone through some of my training. She said,
Not sure if you've done a podcast on how to determine if there's something underlying in the viscera, red flag stuff, and what you look for slash patterns, which when something just doesn't seem like it's going in the right direction. And so that's exactly what I want to talk about today. And the resource I'm going to use to sort of help guide us on this is actually from a class I took from one of my mentors, Veronika Campbell, shout out.
Um, she's in Arizona. She taught a course, um, maybe in 2019, I think, called Differential Diagnosis of the Abdomen. Screening for Viscerogenic Referral Patterns to the Spine, Shoulder, and Hips. And it was a great course, and it was designed exactly to answer Ashley's question. Um, it was actually her course that sort of gave me some of the ideas for the LTAP.
And so, those of you who've taken the LTAP, you've probably heard me talk about Veronica before. If you were in our Arizona course, This last year, you met her, she came to the course and um, helped me out, slash took it. Um, so, you know, in one of these days, probably should just have her on the podcast to talk.
But, um, it's good for us to realize, right, so I already told you, like, one of the yellow flags is gonna be, just like Ashley said, what happens when it's not going the way you expect it to. So the fact that you're even thinking about that is good. And how I speak to this in the LTAP level one to my students is you have to remember your skillset, especially when it comes to the viscera.
If you think there's something driving this person's pain or dysfunction that has to do with a visceral organ or a nerve or the nervous system, you need to first really assess that. organ, right? And so if you don't have the skill set to really assess the organ, specifically the mobility, the motility, that kind of thing, then this is where you might want to consider referring to someone trained in visceral manipulation or neural manipulation, because we have a certain skill set that allows us to go one level deeper and really assess the organ.
and assess things. It doesn't mean that you're not going to continue to treat the way you're treating, right? The biggest thing I see this is people are like, I don't know, I'm working on their shoulder and then we make gains. The body's directed us to the liver. I'm treating their liver, makes a big difference on their shoulder.
We get some shoulder exercises in. They're doing, like, stuffed movement, manual therapy, self manual therapy, or movement to support the liver on their own, and it's helping them, but we can't, like, every time they come in, it's still the liver. So, if every time they come in, it's still the liver, You want to, like, again, that's like red flag in itself.
It's not progressing how you thought, right? It's not better and however many things. So you want to ask yourself two questions. Do I think this is a liver problem or a tissue problem in the joint itself? And if it's a tissue problem in the joint itself, it's sort of like, have they gone to the doctor and gotten an MRI or an X ray, right?
Like, They can still have musculoskeletal things going on even though the, the body is directing us to the liver being influencing it, you can still have a torn rotator cuff or you can still have like a hooked acromion causing, you know, primary impingement. There can still be musculoskeletal things going on.
So the first step is like, what's going on with the actual musculoskeletal system? Don't forget. All of the wonderful training that you have as a physical therapist or as an athletic trainer that you know how to do special tests to figure out if there is a pathology going on in a joint or around a joint, that kind of thing.
And that might mean that you need some support from the doctors in your team, right? Like an x ray or an MRI or a diagnostic ultrasound or something like that. Because you have to consider too, a lot of the time, you know, like it back in the day, you couldn't really treat a patient until they saw a doctor.
But nowadays many states have direct access. So a patient doesn't have to go to a doctor in order to go see a physical therapist or go see an athletic trainer for shoulder pain. They just go straight to that practitioner. So sometimes you're operating. on the assessment and diagnosis that you've done, and sometimes you need to collaborate or corroborate it with diagnostics that only a physician can order.
If you're like, I've checked all that stuff and there seems to still be something, I still think this is a big visceral referred pain, then you want to be like, okay. Maybe I should refer to a visceral manipulation specialist. Maybe there's a functional thing going on. Maybe I need to refer back to like a functional nutritionist or a naturopathic doctor, or a functional medicine doctor or an MD that can really look at the function of.
Organ, the function of the organ when it comes to the liver around detoxification, nutrition, like digestion, all the rules that the liver does, right? Like we're gonna measure the li liver enzymes and the things around that. What's, what's, what's someone's cholesterol like, what's their blood pressure? Like, what's going on there?
Because maybe there's a functional piece that when we're doing manual therapy. So, um, there can be that. The other thing is, within this, is realizing like, is this visceral pain or is the liver causing a biomechanical situation that's leading to the shoulder pain. or a combination of the two. And then two, have I asked the patient specific questions to rule out this being a red flag.
And so that's what I want to talk about what red flags are. And then we go even further is like, okay, You think they have some of these red flags. You're still considered like, is this an emergency or not? Is this an urgent thing I need to do? Then you can actually do some actual physical exam of the viscera, right?
So the athletic trainers, you'll be familiar with this because These are the physical exam tests that we've learned when it comes to evaluating abdominal injuries and illnesses. Physical therapists, I'm not sure if you cover that in school, so I can't speak to that. I'm assuming you probably do, but also, I don't know.
I'm not a physical therapist, so that's where my, I just have to rely on my assumption. So, um, let's talk first about red flags.
Personal or family history of cancer. Specific cancers would be helpful to know in this case, right? So if you keep getting pulled to the lungs and they have shoulder or upper back pain and they have a history of lung cancer, I might be a little bit more concerned than if it's that scenario and they have a history of, I don't know, cervical cancer.
Um, a recent infection, trauma or trauma, like mechanical trauma. Such as a motor vehicle accident or a fall or some sort of like impact energetically like that. A history of immunosuppression or recurrent colds or flu with a cyclic pattern, cyclical pattern. So again using my mom as an example, she had this, right?
She had cyclic bronchitis. She was sick all the time. She was like, getting upper respiratory infections. Like, they were like, candy, right? Getting hung, hand, just handed out. Um, unknown etiology or insidious onset. unable to change, provoke, or alleviate signs and symptoms with assessment or treatment. So this is a big one because this comes back to like, what are you doing in your assessments?
So part of my assessment and part of even the LTAP, I use the inhibition test from the LTAP often, finally, once I've figured out what, where the body is directing me to an organ, if it is, once I've figured that out. Whatever pain provocation test I've used, I'm going to test with inhibition test and if I can't change their pain, Provoke it or alleviate it.
That is like a Okay, interesting. It doesn't mean on its own. It's not a red flag But it's just like one of those things and i'm like, okay I can't change it or just with any sort of pain provocation If I like pain provocation, I think it's positional and I change the position of things and it's still there like that's I'm not great, right?
Like, most things we should be able to sort of at least somewhat alleviate or make worse the pain. So if we, if nothing we do tends to change it, that's a little bit of a red flag. Another one big with the visceral organs is eating or bowel movements change your signs and symptoms. So it's like, I have back pain.
Until I go to the bathroom, and then I have some relief, but then the back pain comes right back. That would be a red flag. Um, pain is not relieved by rest positions or just changing positions. A greater than or equal to 10 percent change in body weight within the last 10 21 days. A growing mass or Virchow's node.
Virchow's node is a swollen lymph node above the left clavicle. This is a really important one for cancers. bilateral neurological symptoms, or any constitutional symptoms. So now let's go over constitutional symptoms. Constitutional symptoms are fever, diaphoresis, which is unexplained perspiration, sweats occurring any time of day or night, like without like working out, basically, or changing temperature, nausea, vomiting, diarrhea, palor, right, palest in the skin, dizziness, syncope, or fainting.
fatigue, like profound fatigue or malaise, like the fatigue more associated with like, most of us have gotten COVID at this time, like maybe that level of fatigue, you know, not just like, I'm tired because I've had a long day fatigue, but like deep fatigue. And again, unexplained weight loss is a constitutional sense symptom.
So all of those are still might feel kind of vague, and maybe on their own, aren't a big deal, but when you pair them to sometimes it's multiple of those, on top of you have have been able to help them. Their, their rehab with you has not gotten the way that you predicted it to be. Those are things that it's like, maybe we should have you go see a doctor.
Like, maybe we should rule this out. Rarely somebody is going to be mad at you for ruling out some sort of life threatening disease. And while you're on the path of ruling it out, because we know that a lot of times it takes time to get into a doctor, right? Not necessarily these things are going to be like, go to the emergency room.
Though sometimes that's the case, right? Depending on the situation and the level of the constitutional symptoms. Um, Might take some time. So you can, you know, you can still be working the plan while ruling these things out. So, um, with that said too, I want to talk a little bit about the visceral referred pain.
So the visceral referred pain, like the visceral referral cheat sheet, if I bring it up so I can see it. We've got like general visceral referrals, different viscera, and then the body part that they refer to. These visceral referrals are going to be referred pain, which is away from the site of the problem supplied by similar neural segments or some sort of nerve relationship.
The viscera almost always will refer to the body, but a body part, right? The body, um, But the, or I don't want to say body, viscera is part of our body. The viscera will always refer to the somatic body, like the musculoskeletal body. The musculoskeletal body will rarely refer to the viscera, right? Because we can also have visceral pain at the site of the viscera.
It's not always referred pain. We can have liver pain at the liver itself. Right, this is like an appendicitis. We can have pain in our appendix when our appendix is inflamed and ready to burst or has burst. That feels a certain way versus referred pain from maybe inflammation in that area or just like the mechanical pain or tension around the structures that hold that visceral organ into place, right?
So I want you to remember that that revisceral referral cheat sheet is sort of like to consider these areas influencing other areas. And in the presence of disease, they're going to be more likely to happen, but sometimes they don't, right? It also means that we've discussed on a lot of the podcasts, and this is why the LTAP still matters, right?
If the only chance of the organs causing issues was the ones listed on the visceral referral were just because of the neural segment relationships, or the sensory nerve relationships, then I wouldn't need to teach the LTAP. But the need for the locator test assessment protocol is one, to figure out where the body wants you to start, but then two, because we know that when the body organizes itself around a structure that has mechanical tension or inflammation or needs to be protected, that it changes the entire dynamic alignment.
And we know from our biomechanical lens of view of the body, which is not necessarily wrong, it's just not complete. And we know that sometimes biomechanics can lead to pain or injury of joints and muscles and tendons and ligaments. and cause problems, right? So we have two things going on here. This is also why in the, in the visceral referrals, I'm like, it's, it can be like, knees can be kidneys, but knees can be liver too, right?
Because sometimes if we're protecting the liver and we're kind of side bent to the right, and we're not rotating very well, if we're doing a sport that involves some sort of rotation, which is sort of like every sport. If we can't rotate in our thorax, oftentimes we make up for it in our knee by our knee caving in, and then that can create some knee pain, right?
So this means that the liver was part of the knee pain story, but it was not referring the pain to the area like the kidneys can. will Understanding that difference is important as well. And that's the whole reason why, like, I do all these podcast episodes and we do the LTAP is because it can literally come from anywhere.
But when we're talking about red flags and catching diseases and, and hopefully helping our patients like my mom, sending them back to a doctor when things don't go our way, and they have the presence of referred pain. from a visceral organ, potentially, then This is what we care about. So some other things when it comes to visceral, well, visceral pain in general, we can have mechanical pain or tension that occurs with stretching the wall or the capsule of the organs, the suspensory ligaments.
We can have inflammatory pain, right? We can have ischemic pain, meaning when the blood flow to the area is not very good, and then we have that referred pain that we already talked about. Um, oftentimes visceral pain. So this goes back to the visceral pain, not the visceral referred pain, right? Shoulder pain would be visceral referred pain.
Appendicitis is visceral pain. Visceral pain presentations that are of concern would be sudden, recent, insidious, or nonspecific cause. Often they're deep, aching, throbbing, stabbing, knife like, and not depending on a certain position or activity. They can be random pattern pain, they can be dull to severe in intensity, and can be unilateral or bilateral.
And often are cyclical, wave like patterns, or they might even be more prominent at nighttime than during the day. the hours that we're awake. So, um, visceral referred pain can be like that too. It can be a little bit like more wafty. We talked about because of how it's being referred on the nerves, it tends to have like a very like, this kind of description, this like wiping phenomenon when somebody is describing where the pain is or there'll be like, Oh, sometimes it hurts when I lift my arm up and not all the time.
Right. So these are sometimes more indicative of these referral things than not. But um, the big thing always goes back to how confident and getting results are you for your patients? How confident are you with your plan of care? Have you thoroughly done a musculoskeletal or orthopedic assessment on top of the LTAP on top of consider the viscera?
And, have you asked questions about red flags or constitutional symptoms? Do they have any, or mult, any of these? Multiple of these. How long has it been going on? Does it change with food? Eating food? Or going to the bathroom? Does it change with positions? And again, sometimes these yellow, these red flags seem a little bit more yellow than red, and so when they seem more yellow than red, like, just start the process of of gaining more information, referring them to a visceral manipulation specialist, referring them to a functional doctor, referring them to an orthopedic doctor, get more tests, rule things more, rule out.
And then also Communicate with these people. Don't just refer them to the doctor and that's it. Don't let the, and also don't let the patient be the one that's communicating. Pick up the phone, write an email, and be like, Hi, Dr. So and so, or hi, this person who's a visceral manipulation specialist. I've been seeing so and so for this many weeks about this problem, and I think that their liver is driving the symptoms a little bit, and I'm just concerned with some sort of underlying condition.
So I'm looking for your help to evaluate it further with functional tests, with general physical exam, with whatever you need it to be, right? Because you don't want to just waste a referral, meaning you just want, don't want to be like, well, you need to go see your doctor for the blood work. Well, That can mean a million different things.
And also when you ask your patient to tell their doctor, it's a game of telephone and the actual message to the doctor, maybe sometimes doesn't get through. You can still tell the patient what you're telling the doctor. I believe in like full transparency in that standpoint and having the patient be an advocate for their care.
But also your job as the medical professional is to pick up the phone and communicate with the other medical professional you're asking for help for. Whether they think you're full of shit or not, guess what? You have no control over that. That's not what you need to worry about. And I know that sometimes that's like the hard part is calling an orthopedic surgeon who doesn't believe in this bullshit visceral shit and being like, I need your help ruling out some things.
Chances are if you think it's really visceral, guess what? You're not referring to the orthopedist anyways. Maybe you're referring them to the general physician. Now we're in the same boat. General physicians is going to be like, okay, I don't, you know, it's not normal that they'd be like having shoulder pain, but also don't assume what the physician's going to say.
You don't know. Maybe they're very open to it. Maybe they're just trying to do the best they can for the patients and they think that the physical therapist or that a trainer is going to be asking these questions to and refer back when needed. This is how the system's supposed to work. But again, if the reaction from the doctor is not one that you like, it's not your job to care about that.
Your job is to, like, Be very secure in what you know and that you're doing right for your patient. And sometimes it's very clear that their doctors are not open to things, but then it's like, well, the patient's going to go back there anyways. So the doctor's either going to be great and run tests. and be proved wrong, or maybe the patient is encouraged to get a new doctor, and then that's when you can utilize a network of people that you know and trust and see the body in a similar way and refer to those people.
Um, my story with that is I have this patient who had, um, a paralyzed diaphragm and, um, nobody could figure it out. Nobody knew why. Insidious onset. It was very strange. After, I think it was on the third visit, I was like, Oh my gosh, I think you're having some sort of, um, thoracic outlet, like compression syndrome on your phrenic nerve.
Up here, side of your neck. And, um, I was like, Here's exactly what I need you to tell the doctor. Because I couldn't access this doctor. It was like a vascular surgeon or a thoracic surgeon or something. He was going to talk to. And I said, here, right, right down this, Like, this is what I would tell him. Like, this is what I think.
I think the phrenic nerve is being compressed. At this location. It's acting like thoracic outlet. I love it. I found a couple articles in the research that it's called this thing in this one case study. Could you rule it out? And the doctor looked at the patient and was like, this chick's full of shit.
This doesn't exist. But also I don't know what's going on for you. And my tool is doing surgery. And so I'm happy to go in there and check things out and see if we can figure out the driver. And so sure enough, he did surgery. He went in and what did he see? The exact thing I told him that I thought it was, which is like pat myself on the back.
Great. But then what happened after surgery, the doctor fixed it. And then the doctor like afterwards was like, Oh my gosh, I'm the smartest doctor in the world. It's it was this problem and I can't wait to write a case report up on it And of course the patient was like, um You should probably include anna on that because that's exactly what she said She said it was and the doctor was like, whatever.
I don't remember. I don't recall that conversation and That's just how some people be It is what it is. Do I care? No. Because my ultimate thing was like, getting him healthy, not getting recognition for it, and then also like, I don't care. I'm never gonna do business with this doctor again probably. Who cares if he likes me?
I don't care. I got the outcome I wanted. He got the outcome he wanted and the patient got the outcome he wanted. Everybody was happy. So don't take things so personally when it comes to that kind of thing. And remember that you have a really good amount of knowledge, more than the doctors do sometimes in certain things.
And so don't like stand up for what you believe in. And that also too is like part of Ashley's thing that I wanted to also reiterate is, she said, when something just doesn't seem like it's going in the right direction. That's the little whisper of your body being the wise one, knowing that something's funny, something's funky, something's not going well.
Trust that. Trust that. And you know what? It's easier to trust that little voice when you are better at feeling things in your own body. When you're better at feeling things in your own body, you're starting to trust the wisdom of it. And the fact that we are feeling beings and our body is feeling things that maybe we are not cognitively appreciating.
Though paying attention to those sensations in our body, call that intuition if you want, are the trusting of like, yep, something not right. So, if her body is saying like, Mmm, it's not going in the right direction, time to, time to refer back. Does it mean sometimes you refer back to people that have nothing wrong with them but a musculoskeletal thing?
And, yeah, sometimes. Okay, continue as normal. This is truly going to be someone that takes time. Right? So, hopefully this was a helpful episode. Hopefully. I know it was longer than I anticipated, but it's also like This is important work. This is an important place for you as a clinician to realize that you are part of someone's medical team.
You are not just a movement practitioner. You are not just a hands on manual therapist. You are a medical professional trained to assess, and diagnose and like triage the person. Triaging the person might be keeping them with you and doing the rehab. Triaging the person might be pulling in someone trained more specialty in visceral manipulation.
Triaging the person might be calling a functional medicine doctor. Triaging the person might be literally sending them to the emergency room. It can be any of those things. Now, also, and I kind of said this at the beginning, there are physical exam special tests for multiple organs in the body. A simple one is just simply rebound tenderness in the different quadrants.
That's a red flag. But also the internet has lots of information. If you think that somebody's having an issue with the kidney, Be like, what are physical exam tests for the kidneys? Shoot, books from college you have might still have them in there too. So remember that there are things that you could do to add on to these constitutional red flags, these other like question red flags you ask.
You can do actual physical exam for visceral organs. Just like a doctor would in the emergency room. Just like a doctor would in the, in an exam. Hopefully they're touching you. Palpating lymph nodes, like simple stuff like that. Does this mean you have to get good with your palpation skills and know where the organs are, know where the lymph nodes are?
Yeah, but again, athletic trainers, I know you learned this in school. Physical therapists, I'm assuming you learned this in school. But if you didn't, these are the times where it's like, if you think someone might have something going on an organ, Get into the books. See how you can evaluate it furtherly or pull someone in on your team.
So that's it We'll see you next week. Have a great day