A Physical Therapist Who Revolutionized How Doctors Diagnose Pain Through Movement

Vance Crowe [00:00:06] What is up guys? I don't know if you've ever been to a conference or some sort of dinner party and you find out that the person sitting next to you is a dietician, and suddenly you look down at your plate and you're wondering, should I have eaten all that? Are they judging me? Well, that same experience can happen if you're interviewing a physical therapist and not just any physical therapist. Today I'm interviewing Dr. Shirley Sarin. She's a world renowned expert and has actually moved the field forward by changing the way they thought about how should physical therapy work. We talked to about all of her experiences, how she came to the field and what she wants to see done. But some of the most interesting bits of this entire interview are when she says things like, I want people to earn feeling better, rather than just helping them to feel better. She has a way of thinking about pain and about movement, and about how the human body is designed to work that I think you'll find interesting and certainly can apply to your life, if not just to make you have better posture, but perhaps to help you understand what a physical therapist can do for you. If for some reason you find yourself hurt. I really enjoyed this interview, and I hope you do too. So I'm with Shirley Sarin, a world renowned researcher, PhD in neurobiology.

Shirley Sahrmann [00:01:24] Yes. Right.

Vance Crowe [00:01:25] And I'm quite fortunate that you're here because you were supposed to be in Japan. That's true. But I think some unfortunate Yes. Circumstances made it so you couldn't.

Shirley Sahrmann [00:01:34] Yes.

Vance Crowe [00:01:35] But before we get to that, I thought that I would tell you that you are singularly, I think, responsible for me living in St. Louis, Missouri.

Shirley Sahrmann [00:01:44] Oh.

Vance Crowe [00:01:44] And so my wife and I, I thought

Shirley Sahrmann [00:01:47] That's good.

Vance Crowe [00:01:47] It's a, it's a good story. Yes. So my wife and I were living in Washington DC and she was an aerospace engineer Yes.

Shirley Sahrmann [00:01:55] That

Vance Crowe [00:01:55] Had, we had just recently gotten married and we were talking about dreams and what do we want out of life? And my wife ends up telling me, I don't want to be an aerospace engineer. Oh goodness. I wanna be a physical therapist. And I think I'd always kind of known that, but I didn't really know that that how serious she was. Right. Because to me, the concept of being an aerospace engineer, that's a rocket scientist. Yeah,

Shirley Sahrmann [00:02:17] Absolutely.

Vance Crowe [00:02:18] And so, of course, Annie being who she was, she looked and searched and met with all kinds of different physical therapists. And the name Wash U kept coming up that the best students around that came to visit and, and shadow a PT or do a, a clinical always came from Wash U. And so she went to search that out as to why. And it turns out that Wash U is doing a program in physical therapy that it revolves around the movement system. And it is a very different philosophy, as you could even call it a school of thought. And, and that was originated by you or a per, you were a, you were definitely a key figure in all of this. That

Shirley Sahrmann [00:02:59] That's probably fair. Yes.

Vance Crowe [00:03:00] And so because of you and all the work that you did there, she wanted to go to the best PT school that she could possibly find. So that brings, brought her here on to get her doctorate. And now I'm sitting and talking with one of the world's leading experts in physical therapy.

Shirley Sahrmann [00:03:16] Absolute, yeah. Yeah. Kind of a fish in a little bitty pond.

Vance Crowe [00:03:20] And so I did a little bit of research on, well,

Shirley Sahrmann [00:03:23] Let me just ask you though. So was she happy with her choice?

Vance Crowe [00:03:26] Oh my gosh. So this was such a radical change that the entire time she had the question, am I making the right decision? Because if you go to tell somebody, Hey, I'm working on weapons systems, you know, for to to be sold all over the world, they look at you with these big eyes and then you tell them, I'm going into physical therapy. They don't understand. And frankly, I didn't understand. Right.

Shirley Sahrmann [00:03:47] Which

Vance Crowe [00:03:48] Is actually probably a very good place for us to start. Okay.

Shirley Sahrmann [00:03:51] Which

Vance Crowe [00:03:52] Is, I watched her go through the curriculum of physical therapy. It is extremely difficult, the things that your students are learning in movement systems, physical therapy. Why is it that physical therapists don't get the, why don't they have the respect that other people that, that an aerospace engineer does?

Shirley Sahrmann [00:04:12] Well, because it, because there's a history of what physical therapy was and what it's supposed to be. And it's very hard to change concepts that are already in place. And I think one of the big problems is even being labeled therapist, because it, it really kind of means somebody else figured out the problem and you just deliver up the therapy. And so that, that's probably one of the, one of the big reasons. And having been in the profession for so long, I went in with a very different kind of idea. And watching really changes in life, not just changes in the profession, has led to this difference in what I think physical therapy should be considered. This whole idea that we're not recognized for what we can do at all. And unfortunately, there aren't that many programs in physical therapy that understand what we can be and what we should be and are still kind of lost in some older concepts of what the, what the profession's about.

Vance Crowe [00:05:15] So my impression of a physical therapist would be, Hey, I broke my arm, or something happened to my shoulder. I went to the doctor, they told me, Hey, in order for you to get that better, you're gonna need to do some exercises. Go see this really bright, shining, athletic looking person that's super nice, and they're gonna tell you do this with your arm seven times a day. And then two weeks later, I'm gonna come back having only done the exercises for a day or two.

Shirley Sahrmann [00:05:39] Oh, you are so honest. It's so accurate. And

Vance Crowe [00:05:42] So, so that's my conception of physical therapy. Right. What, what should be my conception of it?

Shirley Sahrmann [00:05:46] Well, I see that that's, that's what the, this long journey has been for me. It, it, what it, what it should be, and this is part of what I'm trying to promote, is that why we talk about the movement system is that we, movement is such an intrinsic part of our life that we sort of take it for granted. It's, it's just there and we do it, and it's part of everything. But when you really stop to think about it, it's, it's such an intrinsic thing at every, every level. For example, even how insulin goes through membranes, how you release a transmitter to make your muscles contract, those are all movements at, at a micro level. There's nothing that isn't, doesn't involve, I mean, seriously, to, to listen is how the hair cells move in your, in your ear so that you can transmit sound. Everything, everything involves some aspect of movement. So, so you, it's so intrinsic that you don't think about that. You really need to define it. But then, then when you realize in, in the macro world of, of people moving, what became really kind of clear over time is that there's really a precise way and an imprecise way. That's why sort of being an engineer in some ways is so good, because you have an appreciation for what it takes to move precisely. And, and, and so we, we kind of take movement for granted that as long as we're doing it and it doesn't hurt, it has to be all right. But that's not the case. You can either do it optimally or you can do it in a way that has long-term consequences. And, and one of my best analogies is, is sort of like in, in some ways, to me, nutrition, before we took it for granted, as, as long as you had something to eat, it really didn't matter.

Shirley Sahrmann [00:07:24] And now we have to be, so we're so particular about what we eat and how it's made, whether it's organic, not organic, the right substances, you know, now we're all going against all the things that make food last forever. And I'm so thankful it does because I can't eat it that fast. So I think new insights into movement. And I think the other thing that, that has changed so much over the years is, for me, when I was growing up, no one thought your lifestyle had anything to do with your health. I mean, you just got the diabetes, you just got the hypertension, and you went to the doctor and you hope they could give you some medicine for it. Well, now we know that it's all about lifestyle and what are the big things that, what's the thing that's so healthy about lifestyle, activity, exercise. I mean, and so something we take for granted, it was part of life. 'cause you had to move around a lot before they had cars and TV and all the other ways of doing things. So the two things that led me to really appreciate that movement is so important is that here it is an intrinsic part of our life and it's what keeps us healthy. And yet we're doing less and less of it for, you know, lots of reasons, good and bad. And that it's, it's part of what we have to do precisely are we pay for it in the, in the long term, like almost every other health condition.

Vance Crowe [00:08:47] You know, it's interesting that you mentioned about nutrition. So today, I, I actually just retweeted a, a journalist that I know that has been writing about food in the Washington Post for, I don't know, 10 years or something like that. And she says, I've, I have come up with my list of dietary guidelines that the government should put in. And that is that we know nothing at all about nutrition. It's just too complicated,

Shirley Sahrmann [00:09:10] Discouraging

Vance Crowe [00:09:12] So, so discouraging. But then it also makes me think like, well, you know, food, at least you have some parameters, proteins, carbs and fats. When you're talking about movement, you're talking about, you know, range of motion going forward and backward and up and down and, and different people and different ligaments and different strength and age groups. And how in the world can this be something that you guys can fundamentally understand?

Shirley Sahrmann [00:09:36] Well, I mean there, there is this whole science that's taken that's gone on for a long time. It's called kinesiology. And the nice thing is about there are rules, there are relationships. Now you're quite right that there's individual variations. And probably that's the biggest challenge is picking out structural differences or individual variations. Like you're being tall versus my being short, people have wide hips or narrow hips. All all of those are different factors in how you're gonna move, but there's still a way to do it right. And a way to do it wrong. Those predisposing factors though, are also ones that are gonna give you the guidelines as to how you're gonna run into trouble because of the way you're built.

Vance Crowe [00:10:15] So you were a person that came into physical therapy. You had a, you had a short education in it two years to begin with, is

Shirley Sahrmann [00:10:23] That right? Yeah, I was, I was so smart, it only took me two years. And then these poor dumb kids now to go for seven

Vance Crowe [00:10:28] And then worked for, for several years and ran into a conundrum, right. Between treating a polio patient and, and very good. And the other one was somebody that had a,

Shirley Sahrmann [00:10:39] Well, it's a, what we call central nervous system lesions. So yeah, I started off, I mean, the whole interest for me was polio. I mean, you're these little paralyzed kids, and I was very physically active. And so what could be better than to become a physical therapist that would help little paralyzed kids move again? So, but I entered physical therapy right at the introduction of the soc vaccine. So happily polio went away rather rapidly. I had a few acute cases, but some residual, but that kind of condition is what we call a, a peripheral lesion, meaning that it involves the nerves that go to the muscles that the nerve,

Vance Crowe [00:11:20] You know, to be, to, to be totally honest, you know, I know so little about polio, I just know that I see occasionally an adult that has leg braces that, that, and, and so polio did something to the legs. I have no concept for what it did.

Shirley Sahrmann [00:11:31] Yeah, it, so you have the spinal cord that has in it what we call motor neurons. And the motor neurons are the nerves that go to the muscles, and that's what makes them work. And all of the control features on, on how they're activated, et cetera, are higher up in the nervous system. But that would be called a lower motor neuron. So when you cut those nerves, your, the nerves die, the muscles go away, everything, everything deteriorates. And the other kind of lesion, because right. At the same time, mainly because we had done such a good job with the polio patient, they started letting us see people that had, had strokes. So a lesion in the brain. So now you're dealing with the big controller rather than just the effector.

Vance Crowe [00:12:18] Okay.

Shirley Sahrmann [00:12:18] And then instead of the system dying off, it kind of gets corrupted and it has a mind of its own. So you get a disordered motor control muscles are still working, but they're controlled by lower centers that give you just gross reflexes. So you can't activate them. Precisely.

Vance Crowe [00:12:36] So someone's had a stroke and now they used to have full control of moving their arms, and now, now they can't, can't walk or

Shirley Sahrmann [00:12:42] Yeah, they'll, they'll be paralyzed on one side. They may lose their speech, they may have half of their vision, and the manifestations of that paralysis varies a great deal. You know, whether their arms all pulled up in some kind of funny way, or it hangs limply whether they can orient themself correctly or they, they fall over to one side. So there are a lot of different ways in which that lesion is manifested. And then also they were saving the lives of, of the head injured and the spinal cord injured, which they weren't before. I always think particularly somebody like you, that when I first started working this way, the men six foot tall that were rear ended became quadriplegic because there was no headrest and there were no seat belts.

Vance Crowe [00:13:28] Oh, really?

Shirley Sahrmann [00:13:29] And so it was just, they got rear-ended and bingo, the head went wobble, wobble and they were quadriplegic. So I had a lot of big, tall guys as, as patients.

Vance Crowe [00:13:39] And headrest made a difference in that. I didn't even know, know, headrest were a safety feature of that.

Shirley Sahrmann [00:13:43] Oh, absolutely. Essential. Because otherwise your head's just like a bowling ball, just slings around. And at first we just had lap belts and they didn't do so well. So you, it wasn't until you had the, the sling with the headrest that was so important.

Vance Crowe [00:13:56] Okay. Wow. Yeah,

Shirley Sahrmann [00:13:57] Yeah. So, so anyway, the, but they, they, they saved those people, but it, it wasn't, it wasn't easy. And their, you know, wheelchairs weren't good and et cetera, they were forever in a wheelchair or on a bed. So, but their, their kind of paralysis was totally, totally different, as I'm saying, instead of just the muscles going away and then they were too weak or didn't have limbs to move. These moves were mo their limbs were moving in uncontrolled ways. And so that's what fascinated me was trying to understand what we call this disordered motor control when it's in the central nervous system itself. And I spent about nine years as a clinician taking care of those patients, and I finally had to admit that I was not gonna solve this problem. And that the only way to, to do it was to, to go to graduate school and get my PhD.

Vance Crowe [00:14:52] Was that a difficult decision at the time to go to graduate school?

Shirley Sahrmann [00:14:56] It it, yes and no. I, I, you know, I, I didn't think it out well enough to know that it might be a financial challenge. I just knew I had to do something because I couldn't go on treating people and not understanding what I was doing. I mean, that was, that was all there was to it.

Vance Crowe [00:15:12] And so then when you entered the field, then going into get a PhD, what was known, how, how far along was, was the field of, of physical therapy?

Shirley Sahrmann [00:15:21] Well, they, they had just, well, it wasn't physical therapy. Now I was gonna go into neurobiology and I was, one of the things that's always been so fortunate for me is I was always had the right time at the right place. And so I got breaks that I wouldn't ordinarily have if my, if the timing had been slightly different. And the, the one that I got the break on two ways with the going into a PhD program is number one, they had just started this PhD program in neurobiology. So they didn't know what they were doing. I mean, I'm not, I'm not exaggerating at all. I mean, they, they really didn't, they like anybody say, I wanna get PhD. Okay, go ahead. So that was number one. Number two is a fourth cousin, 16 years old, had a stroke. And he, I had to take, I took care of him and so did this neurologist who was known for being very con cantankerous. And we argued about how this young boy should be managed. Yeah. He, he was trying to tell me what to do, and at that point, I, I didn't wanna be told what to do because I, I thought I knew more than he did about that, that, see, that's another part of the story. But anyway, and he ended up loving it that, that I was so aggressive. And, and so, and he had just been to a big conference where physical therapists were trying to explain what they were doing, and he just got up and said, black magic witchcraft crap. Really? Oh yeah, he did in front of everybody. That's the way he was.

Shirley Sahrmann [00:16:52] And so, so when I went in and said, I think I wanna go to graduate school, he just said, somebody's gotta straighten you physical therapist out. So he, so he took me on and as

Vance Crowe [00:17:02] Your advisor?

Shirley Sahrmann [00:17:03] Yeah. Oh my gosh, that's that. They just said, when I said, I wanna go get a PhD, they said, well just go find somebody. So I went to him and he said, okay, I'll take you on.

Vance Crowe [00:17:11] Well, it's a certain kind of person that goes to find the most disagreeable person they can and heads towards him.

Shirley Sahrmann [00:17:17] There was no choice. And, and so anyway, and he just turned out, he, he was actually head of the ACL U. I mean, he was a really great guy. I mean, really great guy, cantankerous, but I mean, never gave me any trouble. He was always quite good. So anyway, so the, they at that time too, in the, in the field of neurobiology, they were just beginning to, to record from the motor cortex of monkeys that were trained to do task. Because what they were trying to, to find out is whether the cells in the cortex behave the same as the motor cells in the spinal cord. You know, where they did, they respond to the, how, how high the load was to the direction of the movement, to the rapidity of the movement. What were, what were these cells coding for? And none of that was really known. They, they knew which cells kind of went to what targets, but they didn't know anything about the underlying physiology of what they were trying to control.

Vance Crowe [00:18:15] Wow.

Shirley Sahrmann [00:18:15] Yeah.

Vance Crowe [00:18:16] So this is the beginning of the field.

Shirley Sahrmann [00:18:18] Yeah. There were some really bright people that had started down that line. So my PhD was kind of like a marginal pursuit, even though it took me seven years and I did away with a lot of cats. But then they ended up, he ended up hiring me. See, that was the other thing we talk about serendipitous is is the woman that was his major right hand person that did, ran the EMG lab, the electromyography lab. And that worked in his research lab with him, was a physical therapist that never practiced. So she saw me as, you know, kind of a, a, a daughter that went onto the same field that she never worked in. So everything was too good. I mean, I was just so lucky. And then the other thing, financially, I had a patient that was paraplegic and he just hired me to go every day and give him therapy. So that was my source of income to live on for seven years. And then I got a scholarship from the A PTA and that took care of my tuition.

Vance Crowe [00:19:20] So the A PTA, so that's the American

Shirley Sahrmann [00:19:22] American Physical Therapy Association. So, and, and believe it or not, I had an apartment in Richmond Heights for 87 50 a month.

Vance Crowe [00:19:33] Yeah, you couldn't live in a, a box over there. I know. Garage. Yeah.

Shirley Sahrmann [00:19:36] Anyway, so everything fell into place. And so then I ended up actually training monkeys to do a task with their foot and recorded from their motor cortex for 19 years.

Vance Crowe [00:19:49] How do you even do that? How do you train a monkey to

Shirley Sahrmann [00:19:51] Oh, you, well that was, that's a whole story too. We had to, we had to fix it up so they got juice rewards. So we, we had to learn all kinds of things, and that was how to set up little solenoids so that you'd, you'd click, they would click on these things and then when they'd click, it would release a, a valve of orange juice.

Vance Crowe [00:20:08] Oh, I would imagine that that would have a pretty big impact on, on somebody going into physical therapy. If you have to train each one of the movements that you want to see by inducing,

Shirley Sahrmann [00:20:18] Well, this was big things. We had, we had a little paradigm. There were four different tasks that we felt were particularly, IM impeded in people with these lesions, particularly people that had stroke. That was his particular interest, that physician's interest. And he was a neurologist. He actually became head of the department. And so these tasks were ones we thought would show us how the cells would behave, and that when we would do a lesion, then we would see how the cells would adapt after this lesion. So that was the idea.

Vance Crowe [00:20:48] So how do you go then from working with monkeys to teach them movements and you're watching their brain function into physical therapy with enough time to make all of the additions to the field that you've made? Well,

Shirley Sahrmann [00:21:01] I actually, I mean, everything that I was learning in, in my PhD program about how the nervous system worked and, and you know, kind of discarding, it was kind of a time of also cleaning you, cleaning out your mind. I had certain preset ideas about, about things from working with patients in the first place. And then it was kind of like you had to get rid of some of those ideas because they really weren't very substantial. And then when you go and you study a, a system in depth and then work on it by actually recording from how that system's behaving. And of course nothing turned out like it was supposed to turn out anyway. And then, and then I'd always had this fascination with how people move. I mean, you know, starting with such things as how do you recognize somebody at a distance by the way they move. When I learned what normal gait was, and if everybody used normal gait, it wouldn't be individual. I

Vance Crowe [00:21:57] Heard you say that in an interview once about, about how you can identify somebody by how they move before you can see their face. Well, I'm sure many people can, I think you're, you're a hundred percent right on

Shirley Sahrmann [00:22:06] That. Yeah, right, exactly.

Vance Crowe [00:22:07] You, I mean, and, and it starts from in high school when you can spot the gangly guy and then all of a sudden you right. You, you intuitively know it. But I couldn't tell you anything about why they move that way or what they could do to make it so they didn't move that way.

Shirley Sahrmann [00:22:21] Yeah, well see that, that's what intrigued me is why if there were these set parameters and there are that underlie normal gait, then what is it that accounts for the variation that people have? Is it not just how tall they are, how big their hips are, how narrow their shoulders are? What, what, what are the things, how much do they just mimic and how much is built into the system? I mean, those were all things that I, I was very curious about. And did you know more empirical observations to put it together than, than anything else?

Vance Crowe [00:22:52] You know, it's funny, when, when I'm going with my wife, who is extremely sweet, you know, it just constantly finds the best in other people. But she sees someone running and you can just tell when she has that click in of like, oh, they're doing that wrong. Oh, that's, that's bad. Where's my car? Yeah. Well, and she's, oh, that their hip drop is just terrible. And it's amazing to me because it doesn't take very long of her pointing that out for me to go, oh, I see. You're right. Every time they take a step, it goes. But the, the thing that I think is probably not well understood by people that are not in PT is how in the world can you specialize in transferring? I'm gonna watch you walk into, I know what's, what you're in, what, what your pain probably is.

Shirley Sahrmann [00:23:39] Well, I mean, but, but that's easy because when you see these little deviations, then you know that that's, that's, I mean, it's like the engineer picking out the bad part in the whole system because you know that that's going to create a trauma of some sort. It's gonna create stresses that are undesirable by that little abnormal movement that isn't precise. So that's, that's how you kind of know.

Vance Crowe [00:24:06] Do you, are you sitting in a restaurant and watching e everybody seeing how they, they sit and it's

Shirley Sahrmann [00:24:11] Very hard. It's very, it's particularly hard when I'm at the airport and I watch, I watch people walk up and down or even how they're sitting. And

Vance Crowe [00:24:18] What do you, what do you see when you're there?

Shirley Sahrmann [00:24:20] Oh, well, I, I I, I see that they, they need to get a visit with a physical therapist for the most part. But it's, you know, now there, there was an era gone by, I think it actually was associated with when people were in the military that people cared about posture, you know, standing up straight, all the rest of it. And, and that's long gone. I mean, you look at the way people sit now and they, they're trying to make pretzels out of themself and, you know, they don't know it, but they're gonna pay a price. You know, I I, I'm reminded just talking to you, there was one man that was at the airport waiting to board a plane, and, and there was one man that was standing, and we would call it a sway back posture. His shoulders were switched or sway way back. Oh,

Vance Crowe [00:25:03] I know. I, yeah, yeah.

Shirley Sahrmann [00:25:04] Okay. I mean, and oh, I mean, it was the most extreme whatsoever. And I got on the plane and the man sitting next to me, he said, did you by any chance, notice that man standing? I couldn't believe this guy. He, he had so picked up on what this guy was, how he was standing, because it was so extreme. Now, there is no doubt that that man will have a lot of problems. He'll develop really musculoskeletal problems, hips back, it, it, yeah.

Vance Crowe [00:25:30] So all those things about sit up straight in your chair and boring,

Shirley Sahrmann [00:25:34] But really good.

Vance Crowe [00:25:36] What do you think has changed that made it so, is it that parents are not drilling that into their children? Is it that we have different ab control? Why, why? I mean, I know that if I'm sitting at my desk, I will eventually keep scooting down and down and down and down until I'm almost, almost horizontal. Why is what's going on there?

Shirley Sahrmann [00:25:54] Well, and part of that, I mean, that, that's the whole thing, is that your body, the the body wants to be efficient, even if it's not. Right. So your back muscles are used to being stretched out. Now, I I didn't look at you carefully enough to know if your knees are higher than your hips when you sit. They

Vance Crowe [00:26:11] Are. See,

Shirley Sahrmann [00:26:12] That's the problem.

Vance Crowe [00:26:13] Yeah.

Shirley Sahrmann [00:26:13] So then that already puts you into what we would call a posterior tilt. So you, you can't sit on your bottom the way you should because your knees are too high. So, so from all these years of sitting with your, with your hips slid forward, your back muscles get stretched out. So they wanna go to that same position all the time. They, you build in a pattern and then you get stuck with it, and it's kind of efficient for your body, but it's not right. It, it'll cause problems over the long, long haul.

Vance Crowe [00:26:43] So that analysis that you just made about the way that I sit, is that common? All physical therapists see the problems that way? They understand them and they fix them in the same way?

Shirley Sahrmann [00:26:54] I'm probably just nosier than most people. I think if you said, look at how that guy's sitting, they, they could say, oh yes, that's probably not good. But I don't think they're so attuned to making those observations. I, I, I don't know why. I've just always been so keen at looking, I, I think you know, this whole thing about how people move, but you also get impressions about people, don't you? Sure. You kind of decide. I think I may like them, or, you know, they're, they're a difficult person. And there, there are many ways it reflects. And I always wonder too, how the personality part was tied into the movement patterns and how you'd take away impressions of people from also how they move. Oh,

Vance Crowe [00:27:35] That's, I think that's a hundred percent. I mean, you can tell if somebody's feeling confident, if they're feeling right, if

Shirley Sahrmann [00:27:41] They're not bright, or if they're super bright or if they're enthusiastic or,

Vance Crowe [00:27:45] Yeah, absolutely.

Shirley Sahrmann [00:27:46] Yeah. So, so all of those things are just really interesting to me. And I don't know that other people that they have other interests, so they don't keep making those observations. I'm just kind of stuck on, stuck at it.

Vance Crowe [00:28:00] So one of the interesting things about having your wife enter into a, a, a doctorate program is that when I was studying, even at the graduate level, I never really thought about different schools having literal schools of thought. And so we've talked about the movement system is a, it's essentially a school of thought about how physical therapy or how people can move better. H how would you describe that?

Shirley Sahrmann [00:28:27] Well, I, I don't want it to be a school of thought. I want it to be what physical therapy is. Okay.

Vance Crowe [00:28:31] And,

Shirley Sahrmann [00:28:31] And you know, we talked about before that this work that I did with the monkeys for 19 years, I was actually, so seven years of graduate school, 19 years with Mon in Monkey Business. I was part of the Department of Neurology and seeing what it was like to be a whole department that was an expert in a system, the nervous system was really also a big message to me. And that's why I pushed so hard on a movement system because it, it would mean that we had expertise about a, a, a physiological process. That physiological process being movement. And so for am mere 30 years, I've kind of taken every opportunity to promote that idea. So in, in 2013, the whole association adopted the movement system as our identity. So, so it shouldn't be a school of thought that's a subset of any kind of physical therapy. It's just taking a while to pull everybody along into the same mindset and recognize what the profession should be about. Do, do, do, do you understand?

Vance Crowe [00:29:43] I do. It's just, it's hard to, even for somebody that's on the outside to know what that even means. So the, the A PTA then said, we ag we all agree as a, as a field, that movement system is what we are doing is

Shirley Sahrmann [00:29:58] Our identity.

Vance Crowe [00:29:59] Is our identity, right? And so then they start aligning all of the curriculum to go in that direction.

Shirley Sahrmann [00:30:05] Well, that, that would, that would be what makes sense. But of course there's a lot of people that aren't convinced that that's what it is. And then you also have to,

Vance Crowe [00:30:12] Oh, so we've just found the, the controversy in the Oh,

Shirley Sahrmann [00:30:16] For sure. Yeah. Oh yeah. I mean, there was controversy before, and in fact it, it, it was such a Washoe thing. There was a, a lot of resistance just because it was a Washoe thing. And instead of, it's something for the profession and somebody had to get there first to, to, you know, that's the way it is. Somebody's gotta think of an idea and then other people realize that it's a reasonable idea and move along with it. So they, so they, rather than just, I was afraid that they would make this identity statement and then just leave it in a document somewhere, never to be seen again. But actually they appointed a work group, and happily I was on that work group and, and we were to charge with, come up with a definition and, and a plan for how would you implement this into the association. People had been saying leaders since 1975, that physical therapy didn't have an identity. And, and again, it's kind of like you said, you know, somebody breaks their arm or there were war injured and there were the polio patients. So people can't move and you give 'em an exercise and you practice with them so they can do it. Well, that was one aspect. So it didn't seem like it took that much. I still, I think it, it is a lot like the, the eating part that the nutrition part, people don't realize how complicated movement is until they really are forced to think about it and that there is a, a good way and a bad way. So even surgeons, et cetera, they just take for granted that it's that simple. You just have to encourage people to move and then all will go well.

Shirley Sahrmann [00:31:49] And maybe some people are better at encouraging them or figuring out certain muscle groups or something instead of really having a good appreciation for the precision that's starting to happen now. That's why this is also so timely. Some surgeons are actually saying things like, there's a condition called shoulder impingement. So you lift your arm up and you get a pain here because things are pinching. And so they would just shave down your collarbone, get it out of the way, you know, kind of sounds like you're 55 and your collarbone just got too big. It's craziness. But anyway, and now there's, they're saying, oh, it's probably not that. It just started pinching. It's probably the way you move. Well,

Vance Crowe [00:32:30] So would that be the equivalent of the, the lobotomy that that used? Used to, yeah,

Shirley Sahrmann [00:32:34] Don't do that anymore. You're putting a hole in the head. Right? It's not a good plant. Yeah. Oh, there's lots of things that surgery did that wasn't good. But, but anyway, so there is some recognition that things are, it's, it's a little bit, so the all all to my point that, that all of physical therapy should be moving along this way, but it's not easy because everybody has to change what they're teaching. And see, there's, if you wanna say there are two schools of thought, if you wanna put it that way. I, I don't think any, any physical therapist could possibly argue with the fact that movement is, is incumbent in everything we do. I mean, we even treat with movement.

Vance Crowe [00:33:13] So

Shirley Sahrmann [00:33:15] Movement's what we're treating, and we use movement to treat it. But some people are more focused on what we would call the patho anatomical problem. Meaning you've got a bad bone up here or the muscle's bad, something something's wrong with the tissue itself rather than something's wrong with the way you move. And that's what injured the tissue. See, see the surgeon, like I said, if you use the example of the shoulder will go in and try to cut away the bone that's bad or repair the ligament that's torn or something like that. I was always interested in why it got that way. And, and, and I always think it, you know, that athletes are the perfect example because who has more injuries than athletes? And it's not because people are running into 'em, they're running down a field and whoop, here's an injury, just tore my anterior cruciate ligament in my knee, or I've been shoveling now my shoulder hurts. Well, why?

Vance Crowe [00:34:08] And are those mistakes of the, of the movement? Yeah, I mean like, so okay, that's a very interest. Is that controversial? It seems not like in two, it seems like something I didn't know, right. That I would've just said, oh, well that guy has bad ACL or that, that, you know, that's not true. No,

Shirley Sahrmann [00:34:24] No, it's not true. It's, it's, it's, and see this is what's so I think it's just so fascinating is, for example, one of the ACL is, is one example, but also what we call a patella pain, you know, your kneecap, that becomes painful. You can't have trouble going up and down steps just four degrees. More of your hip rotating inward is enough to start you on that problem of getting pain in your patella, in your kneecap and a little more rotation in your knee and you can tear your a CLI mean, we're talking small, small degrees of movement over time, over time. And that's why, see, I mean that's the other irony of my life is that I was interested in the nervous system. I think it was because my family were all electricians. It's true. Anyway, that, and so I was particularly interested in this disordered motor control when you had a, a big lesion in your central nervous system. But it really turns out that training the nervous system is the really key to even musculoskeletal problems. The, that kind of example I was giving you, you Sid and your back muscles get stretched out. So you keep wanting to go there. Well, your head also tells you that's how you're comfortable. There's, there's a feedback system and all of it works together. So you establish this pattern and, and you have to know that to change it, but it's the body being efficient even though it's wrong. So, so it's really fun because that's, it's a lot of teaching and correcting. You

Vance Crowe [00:35:55] Know, it strikes me as I've had a chance to go speak with dieticians before, and I often talk about how they have one of the most difficult jobs in the world because you have to convince a person that they have control over this thing that they, they feel very far out of control and you can't do anything to make them make better food choices. You can only convince them, you know, wake them up to some other idea. But in physical therapy, that is much the same way, right? If you actually want to stop your pain, then in the moments when you are feeling relaxed, you have to trigger yourself to do something different because it's those relaxed things when you're not thinking about it. So are you, is that something you have to teach the students? Like how to Oh,

Shirley Sahrmann [00:36:39] Well, yes. Yeah. I mean your, your your course right on. And then one, one of the faculty, Linda Van Dilen, by by name, has done all this really good research. I, I call it, she, her work has separated fact from fiction. So I had a lot of theory and she went after sorting it all out in ways that I couldn't even imagine. I mean, she's so good. And what's really turned out to be 100% true is that it's the way you do your everyday activities, that it causes the problem. And guess what? You have to correct the way you do your everyday activities. That's the most effective treatment. She's shown that in, in several studies. Is that hard? Yes. And, and in some ways it, it turns out people don't like to do exercise. Now there are some people that do, but the majority of people don't. In, in fact, Linda's studies have shown that people stop doing the exercises, even if they're coming in once a week to, to be monitored on their exercises, they fall off rather quickly. But if you really get them to change the way they do their everyday activities, they do that much longer. And, and they can associate, that was always been the way I tried to approach patients. I I never wanted them to feel better unless they earned it.

Vance Crowe [00:37:50] Oh, that's very interesting.

Shirley Sahrmann [00:37:51] Yeah, no, I absolutely not. I I, and so the whole method was you show them how to move so it doesn't hurt.

Vance Crowe [00:37:59] So tell me that psychology, that you never want them to feel better unless they've earned it. So tell me more. That's very interesting.

Shirley Sahrmann [00:38:05] Well, I mean, so for example, people would have been to other physical therapists and they say, well, the other physical therapists put that nice heat on me and they did these other things. And I'm like, it obviously didn't work. You're cooked enough and you're here, you are still needing help. So you're not going to, I'm not gonna do anything to make you feel better unless you weren't it. Oh,

Vance Crowe [00:38:22] That is great. I love that.

Shirley Sahrmann [00:38:24] No, it's true.

Vance Crowe [00:38:24] And it actually leads me to a question that I was gonna say for later, but I think is is a good one to ask you now, which would be, what are your thoughts on chiropractors?

Shirley Sahrmann [00:38:36] Y you know, they aren't good. I mean, the, the, the big reason isn't, and there's a whole thing in physical therapy called manipulative therapy or, or sometimes it's also called manual therapy, though. That's it. Including many more things than manipulation as such. It just as chiropractics does too. What never made sense to me was that you could go in and somebody would push on something and then you would be, well, because it doesn't address, how did it get that way, and what are you gonna do to keep it from getting that way again? Those, those things just never made sense to me. And then, and then there were two schools of thought in chiropractics. I don't know whether you know, that they called them straits and mixers and, well, the straits were ones that believed that when, if your spine was out of alignment, you would push on the nerve that went to your pancreas, and that's how you got diabetes.

Vance Crowe [00:39:26] Oh, okay. I have heard of that. Yes. Okay. So, so

Shirley Sahrmann [00:39:28] It was a, a real that all of your disease problems were related to the, the spinal alignment and impeding nerves and nerve function,

Vance Crowe [00:39:38] And that doesn't fly with the neurobiologist. That,

Shirley Sahrmann [00:39:42] And then, and then the mixers were ones that saw it as more musculoskeletal related. They didn't mix in other kinds of diseases, but, but chiropractors, see that was the other problem, is chiropractors would use physical therapy because that was a generic definition of physical therapy as a physical modality. Well, and that's of course where we, where we were known for where the use of physical agents, you know, and again, if you go back far enough before pain pills and anti-inflammatories, et cetera, which you have to get another look. See now using physical modalities was what we did, you know, hot packs, cold packs. There was even a thing called diathermy I just saw before. Oh,

Vance Crowe [00:40:25] That's what you did in physical therapy in the beginning. When you,

Shirley Sahrmann [00:40:27] In the beginning, well, you know, when people had had pain problems in the musculoskeletal world, you would use some kind of physical agent, hot packs, cold packs, ultrasound, diathermy to try to relieve the pain. And in those days you kind of thought if the pain went away, then everything was healed. Well, it didn't take me a whole lot of years to sort of figure out, no, you still have the same problem. You're just taking away the symptoms, doesn't fix the problem. And that's why I've been trying to promote the idea we can address cause while physicians take care of consequence and symptoms.

Vance Crowe [00:40:59] Well, and that, that's what I heard you one time talk about because I am a very big proponent that the name of your field has to change.

Shirley Sahrmann [00:41:08] Yeah, you and I both,

Vance Crowe [00:41:09] Because until you change that, everyone is going to think, I hadn't thought of it until you had said it. Like they're gonna think the, the doctor gives you a diagnosis that you're in pain. So this person's gonna give you some exercises. And that's what a therapist is. That's

Shirley Sahrmann [00:41:22] Exactly right.

Vance Crowe [00:41:23] I think he's very insightful. And I was saying, well, why don't you become kinesio pathologist? So kinesio the movement and pathology. But you have an issue with that because I do, because it, it's saying we only treat it when things have gone wrong.

Shirley Sahrmann [00:41:37] Correct. And that, and our whole big thing should our claim to fame should be prevention.

Vance Crowe [00:41:42] So be more like a dentist than, than than like the, the therapist. Yeah. And

Shirley Sahrmann [00:41:47] It's a little more complicated than brushing and flossing.

Vance Crowe [00:41:49] Okay. So you want people to be coming in and checking in.

Shirley Sahrmann [00:41:54] I, I think we should be, I mean my, the two things are lifespan practitioners, that is like the dental business and also yearly exams. And, and, and if you're gonna change activities or you wanna take up a sport or you wanna do something, then you come in and see your physical therapist to make sure it's the right sport. Because there are these structural variations that say there are some things you shouldn't do because you're going to get problems with them.

Vance Crowe [00:42:20] Really. So there are some sports that, that people just shouldn't play. They're just, sorry, the genetic dice just didn't work, work out.

Shirley Sahrmann [00:42:25] Pick the wrong parents. Sorry about that. Too late To go back,

Vance Crowe [00:42:29] What would be an example of something? Well,

Shirley Sahrmann [00:42:31] A very real example is, and, and I've had this, there, there's a condition of the hip. It is of the, the long bone of the thigh, and it's called femoral inversion. So, and what it means is like you've got the long bone of the thigh, and then there's the head and neck that fit into the hip joint. Well, it's supposed to be about 15 degrees rotated forward when it's sitting correctly in the hip joint. But it turns out, and particularly in women, that that can be turned a whole lot more forward. So that means that when it's sitting correctly in the hip, you don't have, you can't turn out very far, you can't rotate your legs out. You cannot be a valet.

Vance Crowe [00:43:12] That was a valet. Yeah,

Shirley Sahrmann [00:43:14] You got it. You can't. Or even cheerleading, all those things that require extremes of turnout. Now when you're younger, you'll do it, but it's gonna injure your hip in the, in the long haul, you see. So somebody should be monitoring that sort of thing. I'm sure you've noticed people that have what we call knocked knees.

Vance Crowe [00:43:34] Yeah.

Shirley Sahrmann [00:43:34] Well, they shouldn't run marathons because that's going to cause more damage to their knees by being in that alignment. They can run limited amounts, but it'd be better if they cycled and had right adaptations in how they line up their bicycle pedals. So those are just little examples of things that,

Vance Crowe [00:43:54] So if a parent is sitting out in Manhattan, Kansas and they say, oh, my, my son's thinking about playing basketball, running cross country or, or doing football. They could go in and see their PT and say, what do you, what do you think? Or would they have to go see a certain kind of PT to be able to do that?

Shirley Sahrmann [00:44:13] Well, in, in the ideal world, they should be able to see any physical therapist that could give them that advice. Right Now, I don't know that they would get it first. They'd have to go to a doctor to get a referral in many states. Well, actually a lot of states you can go direct, but insurance won't pay. I think see that, that's my other big belief is that people, if they really understood how important this knowledge about movement, about structural variations, about how you play your, how you play the game, I mean your, your sport. Because children lack the fundamentals of body control. I mean, I, I just pick out pictures that are on the internet and they make me stay up at night because of the configurations that these kids have their bodies in. You can just see this is, this is really a disaster waiting to happen. So if people knew that they would be willing to pay out of pocket because it wouldn't be that much to just have an examine and some guidelines on, on what to do, it would be well worth it. I always say, you know, here, here the dentist, you know, we go twice a twice a year. We wear braces that cost thousands of dollars and our teeth, our teeth barely show. We only use 'em to speak and eat. And you need your body for everything. And we don't do anything to make sure it's operating optimally. It makes no sense.

Vance Crowe [00:45:28] And do you think the, so like you clearly believe that the field is changing. Is it changing fast enough?

Shirley Sahrmann [00:45:34] Well, I, I do think speed is an issue because all you have to do is listen to the radio and you hear how they're gonna try and take more and more money out of, out of healthcare. And I see us as quality of life people, not quantity of life people though, if you exercise, you do live longer, but so we're gonna be some of the people that are gonna get cut out, they're gonna reduce payments. It's not gonna be, it's, it's been going on anyway. There's a, a thing called bundling though. And bundling is, well first of all, they, they had to do for the hospital because when Medicare came in and they were paying for procedures that the cost of Medicare for people in the hospital got so out of control. They did what they called diagnostic related groups. What that meant is if you came in with a stroke, the hospital got, we'll say $10,000. I don't remember what it was. And the, the hospital knew that if they got you out in four days, they made money. If you stayed six, you, they lost money. So all of a sudden we had this great flx, people didn't stay in the hospital anymore because, and then physical therapy jobs went away too, because before physical therapy was a, a, an income source because they had to pay separately for all the things that the physical therapist did. So we were basically a cash cow. That's why physical therapy has grown in this country because we've been an income source. Well, that's changing. And so they're trying to do now this bundling thing, which means now if you get a new knee, there's gonna be a lump sum that's paid for the hospital, for the operating room, for the surgeon, for the MRIs, for everything.

Shirley Sahrmann [00:47:14] Everything comes out of that. Well, not too many. If, if we can cut out PT and just say, go on the internet or here's your exercise sheet, that's gonna be more money for somebody else. In fact, the surgeons are already found a way around it because now they're doing outpatient knee replacements.

Vance Crowe [00:47:31] You go home at the end of your

Shirley Sahrmann [00:47:33] Yep.

Vance Crowe [00:47:34] Wow. You

Shirley Sahrmann [00:47:34] Get your new knee and then you go home or you're there less than a day because that way they aren't, they don't have to do the bundling thing.

Vance Crowe [00:47:42] So, you know, one of the,

Shirley Sahrmann [00:47:43] See, it's all about money.

Vance Crowe [00:47:44] The the, and the interesting thing I think about physical therapists or the type of person that goes into physical therapy. Well, I, so I have a hypothesis and I wanna run it past you.

Shirley Sahrmann [00:47:53] Okay.

Vance Crowe [00:47:53] And that is that the type of person that goes into PT has to be caring in some way because you generally are seeing people in very, very serious pain.

Shirley Sahrmann [00:48:03] And,

Vance Crowe [00:48:04] And there's only certain kind of person that wants to do that. I don't wanna see people in pain every day. Right. And so I think that tends to put people, if, if you were to say on a scale of agreeability or disagree ability, right? We were talking before about your, your doctor friend that, that really loved just pushing back and saying, no, that's not right. I think you have some disagree ability in you because you're, you, you kind of like, but a lot of the people in the field that I meet when I go to, you know, luncheons or or weddings with Ann's friends, they are all very much like caring. I don't want to fight. I'd rather see people get along than I would be to see a problem that I have get resolved. How in the world will a field filled with people that are highly agreeable, that don't really want to get into the fight, going to win in this political melee? Which, which, because like you were, you know, one of the things that you've mentioned just briefly was in a lot of states you have to go see a doctor before you can get to a pt, despite the fact that a PT has a doctorate, that's just a legal hurdle. But it takes somebody willing to go fight that legal battle to change it, right?

Shirley Sahrmann [00:49:11] Yeah. And we're trying it in the state right now. They're trying to get direct access. It. I mean, the other thing, there's even states that have direct access, the insurance won't pay and Medicare won't pay unless there's a doctor's referral. So legally it's possible. Now there are some entrepreneur physical therapists who are having people is a cash based practice. And in many ways it's, it makes more sense. I mean, all, all the way around. So, but people don't know this is our whole problem that we have enough to offer to make it worthwhile. In fact, I I heard a, a big discussion at one of our big meetings about actually only 20, I think it was 22% of the people with a referral to physical therapy go, why? Number one, their copay is too high. Number two, they're deductible. They haven't met their deductible yet. And number three, they don't know that they're gonna get something that's worth the cost. So, so we've got this big thing to do. Like, are we worth the cost of going, what do we have to offer? Yes, yes. Do think that if people don't see us as necessary and they're not gonna pay the cost and the government keeps cutting back on what they will pay for, it's, it's not gonna be all the field that it should be. And, and you know, the, I think the thing that makes me so passionate about it is I know what we could do for people's health. I mean, it, it's not just I'm, I'm trying to, I have a vested interest in the profession and that's all I care about. No, I care about what we could do to save people musculoskeletal problems.

Shirley Sahrmann [00:50:42] Well,

Vance Crowe [00:50:43] I mean, I know that, you know, so the, the thing that I see is there's people that are about my age, they're in their late thirties. They've started to do really well in their career, but they've also hit a place where they're like, I'm not gonna become the CEO, so I need to pour this energy, this intellect, this into something. And a lot of times that becomes athletics running marathons or triathlons, right? Right, right. And so they go out and they do this and they find meaning and the meaning in this suffering of going out and enduring cold or hot or whatever. But then they run into pain,

Shirley Sahrmann [00:51:16] Right?

Vance Crowe [00:51:17] And, and if they can't find somebody to solve this pain and it keeps them from exercising, then suddenly the meaning that they were deriving in their life evaporates and really bad things start happening. And I've seen it happen multiple times. And that's one of those things that when I saw that happen firsthand in what a PT could do for that, I was really thinking, you know, physical therapists are actually repairers of meaning in people's lives, I think.

Shirley Sahrmann [00:51:47] Yeah. Yeah. I mean, absolutely. I mean the, you know, whether you're, some people are doing things that are too extreme and they need to be consulted into cutting back. Are the way they do them, are they doing the right thing for their, for their body? Do they have the right mix of activities? Yeah. Yeah. See, I, it doesn't cut out the personal trainer or, or, or whatever. It just means those people don't have the knowledge about movement precision. They don't have the knowledge about structural variations. And so the PT should be the one who provides this overall direction for the program, and then they can work with a personal trainer, but it should be a, a cooperative venture.

Vance Crowe [00:52:27] Yeah. I, and I really don't know how you solve the problem that you have right now. It's probably doing conversations like this one on podcasts, but the, the, the number of problems that physical therapists can at least contribute towards are really quite staggering. In fact, I sat at a wedding and was hearing a specialist that all she works with are women that have finished pregnancy

Shirley Sahrmann [00:52:52] And

Vance Crowe [00:52:53] Now they want to get back to exercise. And I was sitting there listening and almost becoming, you know, emotional about that because you think about the woman that thinks, I can't go tell anybody about this because I'm the only one this has ever happened to, and this woman saying, my schedule is filled from now into six months from now, because I have so many people with this challenge.

Shirley Sahrmann [00:53:14] That's

Vance Crowe [00:53:15] Really astounding.

Shirley Sahrmann [00:53:15] Yeah, yeah, yeah, it's great. I mean, it's great that, that we have this expertise that there's enough people that are learning it and will open more doors. I mean, you know, the, the good and bad of social media are somebody like that who has a good practice. The word will get out. I mean, even the practice I had, just word of mouth of one person to another kept my schedule very full. So if you get quality pt, I, I don't, I'm not too worried that it won't, it will take off. I think we're, we're in this really tricky spot between the way we made money before, and the employers wanting to continue to make money that way. And like everybody, even physicians, they're cutting down on the time spent with the patient while that that is the valuable time that gives you a really good program or a not so good program. So there won't be enough PTs that know what to do with adequate amount of time. So because our practice has to change, there's gotta be enough time available to establish that relationship. It's like we were talking about before, you have to establish this relationship that that patient knows that they've got to do what you're recommending to them.

Vance Crowe [00:54:25] Right? Because you're gonna ask them to endure pain and to do exercises. And they're gonna have to do,

Shirley Sahrmann [00:54:29] I'm gonna teach you how not to do it, how not to have pain, but they've gotta change their everyday activities.

Vance Crowe [00:54:33] I mean, they're gonna have to endure some level of suffering, right? They're gonna have to do some

Shirley Sahrmann [00:54:38] My way.

Vance Crowe [00:54:38] Okay. But maybe, maybe that's not the right word. I'm saying. It's much, you're gonna dedicate some amount of time to it.

Shirley Sahrmann [00:54:45] It is you, you, you, you've gotta take hold of, of, you know, how you're sitting, how you're moving, how you do your everyday activities, and everybody's like, in a hurry, let's just get it done. It's, it's hard to appreciate that because it's not like common knowledge anyway that this is so important. But that's got to happen for people on the outside as well as people within the profession to appreciate what we can really offer and for people to be willing to pay for it.

Vance Crowe [00:55:11] And I think that the, the other added challenge you have is in order to be good enough to be able to actually make changes, you have to go to school for a long time, and that ends up being pretty expensive relative to how much the, the, the, like your, the insurance pays. Yeah. What do you think of that?

Shirley Sahrmann [00:55:31] Well, I, I, I think I, I know the program's gonna try to cut back a bit on the, the length of the curriculum. I, I think there are also ways in which the education can be become more efficient by using prerecorded things. I think, you know, there, there, there's these things, they're called flip classrooms. Well, a flip classroom is you basically get all the lecture material at home and then you come in and do your homework, so to speak. You, and in other words, here's an example for physical therapy. Instead of us standing up lecturing about here's how you do these tests, that they're all video recorded. So people can look at them, learn them on their own, and then they come in and they just practice exams. So we won't watch people practice individual skills, they just practice the whole exam. And that way you find out what they're missing in the way of their exam, as well as you find out whether they missed the whole diagnosis thing. So instead of belaboring, here's how you do this test, here's how you do this test. You come in and make them do the whole thing. So that's kind of an idea about flip, flip classrooms. You learn on your own and then you come in and you do the, do the work or demonstrate what you've, what you've learned.

Vance Crowe [00:56:50] So I've, I know that you travel around the world and what is the state of physical therapy in other places, in other continents and countries?

Shirley Sahrmann [00:57:00] Well, it, it, it varies a great deal. Obvi, I guess I should say. Obviously the countries that are the farthest ahead are Australia and New Zealand.

Vance Crowe [00:57:09] Really?

Shirley Sahrmann [00:57:10] Yep. And, and it is the reason because they're like new countries. The the older the country, like England, et cetera, the farther behind they are in some ways, well, it's because of tradition. See, physical therapy was a, on the job training thing, they were called plaster sisters in England. And so it, it wasn't, you couldn't even go to school. Now, and Australians also are, are they, they have characteristics. I mean, they're really assertive, aggressive, go for it. And the men took hold of the profession in Australia. And so they, and they, they really kind of, most of 'em went and learned from one, one physician in England and they did this manipulative kind of therapy. So in Australia and New Zealand, when many people get a musculoskeletal pain, they just go see their vis, their physio. And also it was never the, the cash cow that it was in the United States making money for other people so that they have fairly low reimbursement, but the treatment didn't take all that long, but they go see physios. So they had direct access in 1979. We're still fighting to get it here, meaning

Vance Crowe [00:58:20] That you can just go straight to it, go straight, I'm feeling pain. I wanna go straight to physical,

Shirley Sahrmann [00:58:24] Straight to physio. Yep. Yeah,

Vance Crowe [00:58:25] It seems so crazy to me that there is a law that says if I wanna get medical treatment, I have to get permission. It seems so bizarre to me.

Shirley Sahrmann [00:58:33] Well, and particularly when you could go to somebody who doesn't know what they're doing, but you can't,

Vance Crowe [00:58:37] Right. As soon as you become a licensed pt, now all of a sudden you have a big block. But if I was just like, Hey, I'm helping people. Right?

Shirley Sahrmann [00:58:43] That's, that's exactly right. That's what personal trainers do in masseuse and yoga teachers, people are going to them with paint, but, and they know nothing. But we can't, we can't do it because we know something.

Vance Crowe [00:58:55] And so in Australia, you said it's, it's more of a, like a masculine field or more, more men are in the field.

Shirley Sahrmann [00:59:00] I'm say that the, the men learned these manipulative skills. It was, it wasn't quite chiropractics. It was, they were, it actually came from a physician in England, may Syriac by name. And then they, they started their own private practices and start seeing people as you, well, if you don't know these days, it was always easier for men to, to be the knowledgeable person, you know, to, to know more women were the nurse mates, you know, the doctors told them what

Vance Crowe [00:59:32] To do. No, no position of prestige. Yeah.

Shirley Sahrmann [00:59:34] The doctors knew everything. And, you know, doctors were men. They weren't, they weren't women. So in, in the field of physical therapy, then you had predominantly women, particularly in this country, it's still about 70% women compared to 30% men. But, and there were certainly women physios in Australia and all that, but, but it was, the men took charge in established this relationship. I don't know how they pulled it off so well, but they did well, just like they got the vote for women in Australia long before we got it either, huh? Yeah,

Vance Crowe [01:00:06] I guess I didn't know that.

Shirley Sahrmann [01:00:06] Oh yeah, that's true too. Oh, yeah.

Vance Crowe [01:00:09] And, and knew, but,

Shirley Sahrmann [01:00:11] And then, so, so then if you went now, well, there was a hangup though, in England because their whole school system was different, meaning that they were in a, in a technical or vocational school. So only in their aggressive, assertive ways, they, a few people managed to turn it around so that they could move on to a, a sort of a bachelor's degree and then go on to graduate education. Now in Italy, there's like two PhD physical thera physiotherapists because it's still a technical field. So they do not qualify for graduate school when they finish physical therapy school. So it's, it's still a field that doesn't other, the Scandinavian countries, Denmark, they do well, I mean they, they have high educational levels and they do research, but other places,

Vance Crowe [01:01:00] Japan and Asia. Yeah,

Shirley Sahrmann [01:01:02] In Japan, you still have to have a man, a doctor around, particularly when a woman is treating a patient physical. Oh, really? Oh, yeah, yeah. Because you know how we attack men when they're unprotected. But yeah, so it, it varies a lot according to the, to the country and the male female relationship.

Vance Crowe [01:01:24] And so it sounds like in

Shirley Sahrmann [01:01:26] Russia, in Russia in, I mean, even doctors aren't looked on that because they're more women doctors than men, and they aren't looked on with much respect. Engineers have a whole lot more respect.

Vance Crowe [01:01:35] This is very what, so what country would you say is leading the charge? Is it Australia then? It's,

Shirley Sahrmann [01:01:40] Yeah, they, I think they, they've done more in the way of research. They're also out and about lecturing. Yeah. I, I, I would say that they really did a lot to sort of the, the importance of what this manual therapy or manipulative therapy did was do more about physical therapists trying to figure out the problem a little bit along the chiropractic lines. In other words, here, this joint is not working. Right. That's the problem. Before, we were never expected to figure out the problem. It it, we did muscle testing to say these muscles were affected by polio, but the information was turned over to the doctor to make the big decision about things. So we were in, we were like day, kind of like laboratory tests are in the doctor. They look at

Vance Crowe [01:02:26] The MR mri. Oh wow. Oh,

Shirley Sahrmann [01:02:27] So we, we gathered data,

Vance Crowe [01:02:29] Go tell us what's going on here and we'll then make the decision.

Shirley Sahrmann [01:02:32] Exactly. Right. And so that's, and, and in fact, even when you look at it this way, the, the referral, they, they weren't referral slips. They were prescription slips. And the doctor was to check off whether it was an active exercise, passive exercise, hot packs, cold packs, and they were to check off the things we were to do. So I mean, that, this is why it's so hard to turn around because you had this whole history of we were just people that carried out the orders. It's kind of like going to the pharmacy and the pharmacist gave you the pills. Well, we gave you the hot packs or the cold packs, and we weren't supposed to figure much out.

Vance Crowe [01:03:07] So I, I have seen firsthand that you have a large number of people that are, you know, cheering you on and want, want to see you be successful. But I've also heard you say, Hey, I want you guys to get in the game. What is it that you, if you know, as young people are graduating or maybe they've been in the field for five years or 10 years, what do you think they should be doing that they're not right now that would move the field forward? If you could just get people to wake up to these activities, things would change.

Shirley Sahrmann [01:03:39] You know, the Vance, the, the big issue is, is meeting the productivity requirements. I mean, people are working for somebody in, in fact, we've had different stages. In some ways the profession was gaining respect at a time when there were more private practices. Because to go to a certain private practice, you had to have a reputation. And then because they were making good money, large corporations bought 'em out. Well, then the large corporations made an arrangement like with McDonald Douglas or somebody else. So all of their people went, all the people that needed physical therapy went to this corporation owned thing. Well, guess what, it wasn't built on reputation then. And so the, the whole practice

Vance Crowe [01:04:25] Oh, went down

Shirley Sahrmann [01:04:26] Because

Vance Crowe [01:04:26] That's So it became a commodity because

Shirley Sahrmann [01:04:28] It came a commodity. Exactly. Right. And then it was just making money, or not having the cost go up. Yeah. So, so then we, then, then things went down. So we, we still have this problem now of everybody needing to make money. It's in, it's, I mean, it's with the doctors too. I, I don't wanna go on and aside, but I'll, I'll just do one aside because

Vance Crowe [01:04:50] No, you've got all the time in the world. Go

Shirley Sahrmann [01:04:52] Ahead. Well, it's this really interesting thing because I'm taking care of somebody that's on, on, no, I think it was my own, my own bill. Let, let's say it was like a bill for a, a mammogram or something. And by the time everything went through, the cost was $5 and 33 cents. Now how much do you think it cost to send out a bill for $5 and 33 cents? Yeah,

Vance Crowe [01:05:20] Probably about that much.

Shirley Sahrmann [01:05:22] It more than that by the time they did all the paperwork.

Vance Crowe [01:05:25] Oh, that's true. Yeah. Yeah, you're right. We worked it all down.

Shirley Sahrmann [01:05:27] And then, and then I'm gonna write a check for $5 and 53 cents. And how much is it gonna cost the bank to process this? Oh

Vance Crowe [01:05:33] Yeah.

Shirley Sahrmann [01:05:33] I mean, we are at the stage of ridiculous.

Vance Crowe [01:05:38] I, I read an article the other day that said people in the medical field click their mouse something like 4,000 times a day in order to be able to get through all of the various dropdowns that you have to do your medical record keeping.

Shirley Sahrmann [01:05:52] I know. So, so anyway, I'm just saying that my big example is because cost drives everything. So I could say to physical therapist, you need to take, you need to have at least 45 minutes to do an exam on a patient. Their employer is not gonna let them have 45 minutes to do that exam. You're gonna have to hurry up and get this done in a hurry because we need three other people to come in. And then one of the problems with Medicare is the exam is not time coded, which means that you're gonna get, I don't know what it is now, let's say $120, whether you spend two minutes or two hours, guess what your employer wants you to spend.

Vance Crowe [01:06:29] Wow.

Shirley Sahrmann [01:06:29] But if you do therapeutic exercise, that's time coded. So at 13 and a half minutes, it's another charge if you get up to 14 minutes. But you have to be one-on-one, and you have to keep track of how much time you spent doing that. So you're not gonna make as much money you doing that as you would if you did more exams and then just send them out to somebody else. That's a lower level to do the therapeutic exercise.

Vance Crowe [01:06:55] Wow.

Shirley Sahrmann [01:06:58] I mean, I, I could go on with examples for physicians too. It's, it, it's a business. And so, but you know, physicians have respect and even though they're under the gun, I think now the average is eight minutes a patient with a physician,

Vance Crowe [01:07:13] Which is a big difference with the chiropractor, for example, they spend on average something like 20 to 25 minutes or something like that with the, I dunno what they're doing, but it, I mean, and it's because they don't have all the record keeping requirements and they don't have all that billing and it, I mean, they have billing, but it's just done very differently. So yeah.

Shirley Sahrmann [01:07:30] So, you know, we're, we're a victim of our own success. So number one is the, you're answering to your question is the practicality of number one, people don't know what, most physical therapists don't know what to do in the first place because they've been taught on a different, a different model. They're, they're still trying to relieve symptoms and do some, they don't understand about precision in motion. They don't know motion is a cause.

Vance Crowe [01:07:51] Okay.

Shirley Sahrmann [01:07:51] Okay. So that, that's a big problem. And number two, they have pressure of productivity. And so what, what I would like people to do is to be able to take the time to get the right job so that they get some mentoring, I mean, and so that they get adequate time to establish a relationship with a patient. Those places that have really sort of followed the model are doing well because people, it's that word of mouth thing we talked about earlier. I mean, almost every patient I saw had been to physical therapy before and they say, well, nobody ever did an exam like this. Nobody ever showed me how to do all this stuff. They just did the little walkthrough thing. Well, one, they've gotta know it. Number two, they've gotta have the time. But

Vance Crowe [01:08:32] Then if you fix somebody, then if you

Shirley Sahrmann [01:08:34] Build up a big, a big, a big practice, I think,

Vance Crowe [01:08:36] And if you fix somebody that brings back meaning to their life, they, they won't shut up about it. They'll go tell everybody. That's what I'm, it's like the best book they ever read, or the best sermon they ever heard. It's, it's, it's

Shirley Sahrmann [01:08:46] Kind of like the good doctor. I mean, you had to wait a month to get an appointment with me. So, you know, that's some ways too long. So we're always adding hours because you wanted to get them in because a month is much too long to wait. But yes, I think you could have a, i I, in fact, I wanted them to set it up so that you would have somebody that you work with, like a doctor has a, a, a partner that they work with, so that we would have the physical therapist and I would have say somebody like Anne and somebody else like Nancy, and they would, we would be our particular team so that if I was full or Nancy was full, that those patients would know. They would be getting someone in this, this little group, you know, you know, to answer those problems.

Vance Crowe [01:09:26] So maybe kind of wrapping up, but I think that this has been a very, very interesting conversation, but you have talked in many of your other interviews about the, the length of your career. You, you spent 60 years in physical therapy. Yep. When you look back on it now, what is a sacrifice or a thing that you wish you would've realized was worth making earlier? If you, if you say maybe towards, you know, I wish I would've focused on the field more, or what is something that you wish you would've, you look back and you say, I wish I would've known this earlier. I'm glad I know it now, but I wish I would've known it earlier.

Shirley Sahrmann [01:10:10] Well, in, in, in some, I think, I think the only thing I didn't do well, I wasn't a good researcher. I, I, I didn't have enough OCD and also at the time, I mean, there's a little bit of excuse an animal research seemed to be the only thing you could really do. I mean, it, it wasn't too acceptable in this program that I was in to do human research. That was, that was a little bit of a drawback. At the same time, I, I don't regret it because I think that it would've been easy to go down a line without continuing to make the empirical observations that helped me to understand things. So I kind of ended up rationalizing or reasoning, whatever is the accurate term, that I was good at developing theory based on a lot of empirical observations that I would've never gotten to do if, if I had just kind of focused narrowly on, on a line of research.

Vance Crowe [01:11:18] And you had made the point earlier that by stepping away, you got to clean out your mind of a bunch of, i

Shirley Sahrmann [01:11:24] I did

Vance Crowe [01:11:25] Ways of thinking.

Shirley Sahrmann [01:11:26] And, and then, and and, and that process continued, continued to, to go on, you know, it was kind of like see the forest and then the trees and we're back to the forest. I mean, it was a lot of, oh, I think I need to do all this. No, I only need to do this. And then understanding more and more, and even even up to the current time, getting a, a bigger and bigger respect for how much the nervous system decides things about what we're supposed to do on Thursday. I'm supposed to lecture to the students about back muscles, but I will be so busy telling them about how muscles don't take kinesiology. All these things you're learning that they're supposed to do, they really won't do in the real world because there's so many different ways of, of pulling something off. Let me tell you what I mean. For example, and this has to do with this whole alignment thing. So the back muscles, if you lean forward, they should hold you up. But then it turns out that if, if you really exercise your abdominal muscles, they end up getting sort of short. And then you get this increased curve in your upper back, and then you sway back. And when you sway back, your abdominal muscles become the muscles that hold you up and not your back muscles. And then if you wanna bend forward, you lean forward by pulling yourself forward with your abdominals, and you just use your, your back muscles barely get to do anything. If anything, they become a source of resistance. So this theoretical paradigm of here's the back muscles, letting you go over is good theory, but it doesn't always work out very well.

Vance Crowe [01:12:52] I mean, it sounds like what you're describing is that physical therapists are in many ways much more mental than, than than many other thing. Yeah.

Shirley Sahrmann [01:13:01] They, they they should be. Yeah. I mean that, that's the whole thing. It's, it's not just standing around counting to 10 without getting bored. I think that's, In fact, one, one of the, one of the fun things I do is I give a, a lecture to the first year medical students in their muscle physiology course, and I do my best to scare them to death about their exercise program. By the time I finish the lecture, everybody's sitting up straight and then, and then, and then I do, I do, I've been doing some exams with the medical volunteers outta the audience. And, and that's such fun to be, because then they just see, wow, I never thought all of that could, could really take place. Or they'll, they'll have a pain problem and then it's gone by the time I finish my exam. Well, and, and they understand why they got it. And, and that's my big message to them is it's, you know, if you take something to relieve the symptoms, you aren't figuring out what caused the problem. And it can be a simple, a simple little things in how you move.

Vance Crowe [01:13:53] That seems like the, the take home message, right. If you have pain, it's because something is not moving correctly. That's

Shirley Sahrmann [01:13:59] Exactly right.

Vance Crowe [01:14:00] And that, and anybody that's in pain, like you have a, you have a very clear path towards you should probably go see a, a physical therapist. Yeah.

Shirley Sahrmann [01:14:09] You gotta see the right one because,

Vance Crowe [01:14:10] Or the ologist. Yeah.

Shirley Sahrmann [01:14:12] Well, you know, in fact, now you bring that up, there's somebody, actually, there are two physical therapists that have already set up a, a website with ologist, which is kind of distressing me. Because if, if, if they're doing that, then it's gonna be hard for the association to adopt that, adopt that name. But I, I admire them for, for jumping on the idea, because you and I couldn't agree more that we've gotta get rid of the therapy thing. We, we, it's, you've got to say that you understand a system, that you're an expert in something that

Vance Crowe [01:14:43] I, I mean the system, you understand the system. And that, that is so, so deeply important. It's the patterns within the patterns within the patterns,

Shirley Sahrmann [01:14:52] Right. And I know something that nobody else knows. And it's the expertise in that system. And it's the one you need to get through your life every day. You're moving something.

Vance Crowe [01:15:02] Well, it, it, it is created a level of fulfillment in my wife's life that I think neither of us had any idea was even possible. She

Shirley Sahrmann [01:15:12] Delighted she

Vance Crowe [01:15:12] Loved it so much. Yeah. So delight. And for me personally, to be married to a physical therapist, there

Shirley Sahrmann [01:15:16] You

Vance Crowe [01:15:17] Go. Although I'm always having to do exercises and getting lots of criticism how I walk, I don't have pain chair.

Shirley Sahrmann [01:15:22] Yeah,

Vance Crowe [01:15:22] That's right. And the amount of pain that I've been able to avoid in my life is truly profound. So with that, I guess I owe you a, a great debt of gratitude. And, and well,

Shirley Sahrmann [01:15:35] You just picked the right woman.

Vance Crowe [01:15:36] I did. So thank you very much for coming over and having a conversation. It was great to, my pleasure

Shirley Sahrmann [01:15:40] To chat. Thank you. Thank you. Thank you. Okay. Alright. So that was all right.

Vance Crowe [01:15:44] I think so.