Performance tech is everywhere. But here's the uncomfortable truth. Most clinics don't have a tech problem. They have a decision making problem. Welcome to the FAKTR Podcast where we talk about the stuff they didn't teach you in school. How to grow your practice, refine your clinical skills, and get better results for your patients. We're here to help you navigate the real world challenges of being a healthcare provider. From delivering top notch patient care to running a business that doesn't run you into the ground.
Whether you're fresh out of school or scaling your practice, we're diving into effective cutting edge treatments to get patients better faster. We'll also talk about business strategies and tactics to help you work smarter and not harder, and the mindset shifts required to thrive as a top performer in your field so you can build a career you love without burning out. If you're ready to learn what works and what doesn't from leading experts, industry innovators, and respected clinicians across a wide range of specialties, you're in the right place, my friend.
Let's dive in. Welcome back to the FAKTR Podcast where we talk about the stuff they didn't teach you in school. How to grow your practice, refine your clinical skills and get better results for your patients. I'm your host Jessica Riddle and today we're jumping into part two of our series with Dr.
Michael Giamarco. From Metrics to Movement if you caught part one, you already know the trap. Collecting more data doesn't automatically create clarity, it can actually do the opposite. Confuse the plan, slow your visits down, and turn objective testing into a fancy report that never actually changes what you do next. In today's episode, we move from theory to execution. Dr. Giamarco will break down how to integrate performance metrics into real clinical flow without bogging everything down.
He'll also talk through how to communicate results so patients actually buy in and how to think about the ROI so your tools don't become a bunch of expensive decorations.
Let's jump back in to part two of From Metrics to Movement.
Dr. Michael Giammarco
Roi. I want to make sure I touch on this one just because it is a significant issue when it comes to it's an investment. When I first started using this stuff, I was a solo practitioner. I was in an office by myself, no staff, and the cost of implementing this stuff into my practice was almost the same as what my rent was. But I saw the value and where I could go with this and within two years I was able to almost double double the profitability of my practice and the Only thing that changed was I added this.
So. So I'm also an incredible advocate for this on a business side in terms of what types of things this can really help with. So in terms of where we can see this, number one is it changes your systems from more of the traditional time based approaches to more criteria based care.
3:32
Benchmark-Driven Rehab for Progress
So rather than us saying, hey, we're going to give this four to six weeks now, it's no, we're looking at your strength and we're saying, hey, you need to hit this specific benchmar before we can move you on to the next phase of your rehab. And while on one end, yes, that could potentially elongate different types of care plans, it also makes sure that we're not rushing the patient to the next thing.
We're reducing when they have those big setbacks. Because how many times have we clinicians said, okay, hey, we've gotten to a point where now we're going to increase the difficulty, increase the load because your pain is down. And then we have a setback and then we go back to where we were or we go back something like that. By incorporating this data now we have our specific benchmarks where, hey, like right now you're here, I need you to get to this specific metric or this specific asymmetry before we move on to the next step.
It justifies longer plans of care, it justifies more thorough plans of care. And your patients are going to trust you significantly more because they know that you're doing the right thing for them.
You're not just rushing into the next thing. And that's a huge part of why this has made an incredible difference. One other thing I have on here as well is the normative data. So once again, speaking from Vault, and I'll see this, I'll demonstrate this when I get into my case studies. Vault has an extensive amount of data points when it comes to how they implement these different tests and how you can then look at where different types of people compare to those within their same age group.
And so I can look at a patient and say, hey, you might be perfectly symmetrical, but you're in the bottom 10% in strength in your age group. We need to get that up. Because even though, like you're even, you're not strong and your risk of injury is going to be significantly higher just because of that weakness.
Right. And how do we then build patients up in that way? Accessibility and competition, I think especially this is one that I hear a lot from people where it's like, I'll wait on this for later. Ten years ago, this type of technology took up an entire room and it was incredibly expensive and difficult for people to get their hands on. In the last few years, this has never become more accessible or affordable than ever.
It is something that does not take up nearly as much space as it used to. The ease of access and the user friendliness of the software that they have is so significantly better and eventually is going to become a gold standard of objective measures. If you are someone who is in network or out of network, there might be a risk that you might be getting reimbursed based on where these objective measures are and showing proof of your work.
Are you actually helping people better? If we're in the cash base, hey, we want our patients not only to tell us that they're feeling better, we want to show them how much better they're doing and we can now give them this kind of data.
And the other thing is, the question is not when, it's if, right? The when is in the next five years there's going to be a significantly higher number of practices that have this type of technology. And the question then is going to be, when you adopt me, it's going to be, hey, how quickly can I get this in here and how can I differentiate myself from the next person?
By being early adopters into this technology. Yes, there's a learning curve and being able to learn how to use this, but by being an early adopter, you can now also have better collaboration amongst other peers within the space and communicate with other practitioners. Based on the poll, this is all Kairos and one student and especially us Cairos. If we're dealing with larger hospital type systems or physical therapists or strength coaches, being able to speak their language and some of this stuff is incredibly important.
And being able to show our expertise in movement quality and expression of movement, expression of athleticism. With some of the patients that we work with, the sooner you get this, the better it's. You're going to be able to explain this stuff later on.
There's a huge push now for Total Health Wellness. We're talking about not just on the nutritional side, but we're talking about the physical side where people want to be more athletic. And by having a deeper understanding of these things and having these, this different technology and integrated your practice, it's going to be more appealing to those patients that want to come and see you. They're going to begin to compare other people to whether or not they have this technology or not.
The low tech clinic is going to become something that's going to be probably not as, I don't want to say desirable. That's the wrong word. It's something that's going to become not as attractive, I guess, to the layperson where they've seen the shiny tools, where they know what they do or not the optics might be there. And that's just something we have to keep in mind.
8:04
Expertise's Role in Future Outcomes
The last thing I want to make, kind of make a point out here is the expertise. As I mentioned, I've only been using this stuff for a couple of years and I feel like I know it pretty well. When I then talk to people have been using it for several years, I feel like I know nothing. As this stuff becomes more and more commoditized and more and more common over the next decade, eventually the question is not going to be who has this stuff?
The question is going to be how do they use this stuff? Who are going to be the clinicians that are going to make sure that they know exactly what's going wrong, what's going on with me and how are they going to be able to use this data that they've gotten on me and get me the best outcomes that I want and be able to discern what's what on these
sheets. That's where eventually this is going. And so the earlier that you as a clinician begin to adopt some of these things and begin to learn some of it, when that time comes, the farther ahead of the curve you're going to be. So now we're going to get into some of my case studies. So with this one, I'm going to talk about two patients that have made.
One, they both made significant impacts on me as a clinician. Two, they made very big impacts on me as a person. I'll get into the second one then. Exactly why. But what I want to make sure I address on this one is some things that might kind of go unspoken. So one is going back to our context continuum that we talked about. I'm going to show these different patients, I'm going to talk about what their goals were and we're talking about why I chose certain metrics for their testing and why that was what that context was for that person.
The other thing too is the patient buy in by using this technology and showing them this data that we were able to get specifically with the first one, it was something that they are someone that is going to see me consistently now for the rest of their lifespan.
I firmly believe that. And they told, they told me so. But it's something where in those moments where you see patients where they feel like they're regressing, you can now begin to show them, hey, even though you may not feel the improvement, I'm going to show you where you are improving. Because even if you don't see the change yet, here's where the change is coming. And that also goes into our progress monitoring.
So how do we then track a patient's lifespan? How do we track where they are improving? How are they changing throughout? All right, so case one, Alan. Alan is a 79 year old man, retired physician. When he came in to see me, his initial goals were just to continue moving and he was significantly struggling at that time.
He was someone who used to hunt, someone who used to do a ton of ice fishing. Afraid of falling on the ice, was afraid of, like, if for some reason he had to drag something off of the lake, he wouldn't be able to do it. And the first day he was in the office, I asked him to pick up a 20 pound kettlebell and he significantly struggled with it.
So when we eventually got to Alan, obviously for me, when I was looking at it, we're talking about someone who's in the older age, we are looking at things like lean muscle mass, we are looking at things that are going to help us with independence. So things like getting up and down out of a chair, we're looking significantly at balance.
So the first test that I started him with was what we call the quiet stand test. This is just your very basic balance test. So I had Alan stand on the plates and I was able to measure a couple things.
So you can see here that there was two different tests here. One of them was with his eyes open, one was with his eyes closed. And you're able to tell that obviously with his eyes closed, there was a significant difference in all of our metrics here. But what I wanted to get with this baseline was when he was on his two feet, how stable was he able to be? If he got bumped in a crowd or if there was some time where he just reached for something, he wasn't able to grab onto it, how stable was he going to be?
So we see these different metrics here. We're able to get these different asymmetries, but then I look within the normative range and this is comparing him to every other person in his age group. He's also in the bottom of that range. So that tells me, hey, this is a metric that we really need to look at. So when I talk about it, my training with him, this is Something I really need to address.
I also got into a single leg stand. Now with the single leg stand, going back to his single leg stand. There's a reason why the only measurement here was for his left leg. And that was because that was the only foot he was able to stand on for any period of time long enough for me to get a measurement on. And even when I did, you can tell that he had very poor stability in that single leg stance.
So we all know we're talking about risk of falls in terms of walking, going up and down stairs. That single leg balance is crucial for patients. We look at things like a squat assessment, concentric peak power, third percentile.
His eccentric deceleration, this is his brakes as he was going down, 4th percentile. Peak power on the way down. So strength to speed all the way down. He was very, very, very, very, very weak. Lastly was his sit to stand. Big key metric I want to show you guys on this one is his peak standing RFD. So rate of force development, 25th percentile. So this was his starting point.
13:09
Building Strength and Stability
We then went into his treatment and over the next several months I worked with Alan on basically he just came in for strength and conditioning sessions two times a week. We would work out for an hour. And especially due to his low training age, he never strength trained before, ever. And because of his elderly state, I wanted to make sure that we really pushed him in terms of building up movement competency first, making sure that he knew how to properly do a squat before we even loaded him.
What was his motor control like? Really getting into that balance phase early on, then just using traditional, more strength conditioning principles, just gradually building up load and tolerance for him and where, where he could go. The last part then is over the last few months we've really transitioned into not only the strength side, but also more demanding in terms of changing environments, balance, reactiveness in uncontrolled scenarios to help even further reduce his risk of falls.
So now we Fast forward to 10 months later and you do the quiet stand test. And we can see that some of these things may or may not be better.
But I don't know if you guys remember from the first one, the top one here, that was with his eyes closed. And if we compare that to his initial test, it's significantly higher. I know his mean velocity still isn't great, but when we get into some of these other ones, we'll see. Here we go into a sit to stand test and we have gone now from that peak standing RFD. We are now in the 67th percentile. So we have almost tripled what his peak standing rate of force development was.
And we've seen a significant improvement, his peak standing force, also significant improvement from the first time we tested him. Squad assessment, we are no longer in those 20s now we are in the 50s, 70s and 60s with all of these.
14:54
Patient Progress and Key Insights
Now, these down numbers you see here, these are just comparing to the last time we tested them. And he was also, if I remember right from this date, he was also not feeling 100 that day. So that might be part of the reason why we saw some of these metrics. But the fact that he is now in this upper region compared to where he was before says a significant amount. And I'm going to go into this too when it comes to my next patient.
But as great as all these metrics are, we as clinicians also know that when we talk to patients, it's a lot of things that you can't measure that are the most important things. With Alan, one of the coolest things that they told me was he came in one day and he told me I was able to hike into the woods almost a mile and hike back and not be afraid of falling or tripping over something.
I was actually able to go and scout out a hunting spot.
Even though I wasn't gonna go hunt, I was able to do that. He told me that he usually when he would go downstairs to put salt in his water softener, that he would have to roll it down the stairs on a gurney or something like that. And then he came in one day, says, I actually carried two bags of salt down the stairs today and I was able to hold them in both my hands.
And those are the things where you can look at these metrics, you can talk about how the data informs you, but those are the things that make the biggest impact to patients. And when I get into this next case, that's going to be. I'll let it speak for itself. So now we're going to get to Hannah. Hannah is a 41 year old female experiencing small fiber neuropathy in both of her hands and feet.
And part of that has been she's had significant weight loss over the past year. So I think well over £100. But this neuropathy is something that she has dealt with off and on since she was young. And it is something that has been progressing over the last several months. And she is also in a point where there's a lot of psychological things going on as well. She's worried about maintaining her overall function, not even just being A mom being active, she just wants to make sure that she's able to just do anything.
And when we then go and do our baseline testing for her, we look at our squat assessment once again, peak power, we're in that 29th percentile. We're peak force.
Not too bad. Pretty symmetrical, relatively symmetrical. Here we get into Our quiet stand, 57th, pretty average on there. And then we get to the single leg stand. Now, this one I was actually really, really impressed by. I looked at this and like she's in the 100th percentile on this, like zero excursion for all of these. And I was like, wow, this is awesome. And then I found out why, and that was because we were actually balancing our right foot.
17:31
Balance Test Center of Pressure
So one of the cool things you can see on the four stacks when you're doing these kind of balance tests is you actually can see where the center of pressure is while you're doing these tests. So the reason that one registered as 100% for the left foot was because it read as the left foot the instant that it started. But here, this is the plot, this is the data for where her center of pressure was on her right foot during a 15 second balance test on her right leg.
So incredibly scattered through here. And mostly because she couldn't feel her feet, she had no idea where her foot was at any given time. And so the balancing, a huge part of that. Then I reassessed the single leg stand and was able to get better metrics on it for both the left and right. And we found that now when we talk about like that mean velocity, so how much control she has in the actual balance, she's in that first percentile, incredibly low.
So here is now again the center of pressure on the second test. So we can see a little bit better on the right side compared to the first time we tested. Now we can also see what the left side looked like in terms of where that spread is.
So based on where she started, we were starting with just in person sessions once a week, exclusively strength training. The primary goal for me was obviously balance, a lot of just proprioceptive work. So even though she could not feel her feet, I wanted her to be able to tell where her feet were in space. So we're doing a lot of things with vision, a lot of things based on just building up strength, reactiveness, and then trying to also collaborate with her neurologists because there was a very difficult time.
She had seen two different neurologists, both had just written it off as diabetic neuropathies, and Just told her, congratulations, you're going to live with this for the rest of your life.
Get used to it. And it was a struggle. So three months later, we have a reevaluation. And her and I have been working together for this period of time. We've seen a lot of gains in terms of her strength, in terms of certain things in her balance. However, her symptoms have been progressing significantly worse. The numbness had now moved up into both of her shins, just below the knee she'd had. Her hands had gone entirely numb, even some tingling in her tongue.
She had had a couple falls at the home, was losing fine motor control in both her hands. As I mentioned, the neurologists had both written off his diabetic neuropathy. There was no further imaging or treatment suggested by the neurologists. I eventually suggested MRI to rule out some more significant cases. But when we went then and reinvestigated, the biggest things I was then looking at is where were some of the improvements, trying to get those wins.
So at this point, we're three months in and she's telling me, like, I don't feel any better. I'm not getting any progress in terms of the numbness. And I had to reassure her.
Like, I understand that, but with the work that you and I are doing, this is where you're seeing a ton of improvement. And we're seeing these things where now she's in these high 40s, 70s, 60s, we're seeing all this green and percentage of improvement side to side, we're looking at her quiet stance down to 82nd percentile before she was in the 50s. We get into the single leg stand, right foot, we're seeing some improvement in the single leg stand.
Obviously not where we want to be, but it was still some progress. Even the center of pressure, if you're comparing them side to side, from the first time we tested. The next time, left leg obviously a little bit wider. Right leg was a little bit more precise. So I tried to give her some hope and I tried to tell her, hey, this is working.
We're doing something. I know the symptoms are getting worse, but we need to talk with your neurologist. We need to collaborate some things and figure out maybe change what we're doing as well.
So we changed what we were doing, and I decided from my perspective to go a little bit more into isometrics. And still doing the once a week. I talked with a primary physician. She began taking some vitamin B injections in September. So when we talk about how her case has changed, we Also have to make sure we.
21:35
Hamstring Training Breakthrough Insights
We add that context as well. But one of the really cool things we saw with Hannah was that when we were doing those end range isometrics, one of the first times we did it, I had her on the force frame, and the force frame has a training mode on it where you can calculate her maximum contraction rate, and then you can then train it isometrically for a hole at a certain percentage.
So I had her doing 70% of her max knee flexion. So we're training hamstring jumps off halfway through a rep, and just goes, I just felt my toe twitch. And I looked at her, I'm like, what? What do you mean? She goes, I just felt my toe twitch.
And I'm like, was it painful? She's like, no, I just felt it. And that was the start of some very interesting things. Over the next several months.
Fast forward, we are now six months later. This is now her squat metrics. That's a lot of green. We have continually seen gains in her peak performance in terms of power, in terms of force, in terms of eccentric squat depth breaking. Now we're in these 90th percentiles, 83rd percentiles.
We go to the quiet stand. We're getting higher. Now we're getting into this 74th percentile in the quiet stand.
But the coolest thing is when we get into the single leg stand, test the left foot. Now we are in that 68th percentile. All of a sudden, we're seeing these huge jumps. Look at that left foot spread pattern compared to what it was even three months prior.
It is a tight dot. And the only thing we really changed was starting to do some isometric work. But part of going back into the. The essential of this technology is I could have told her all day long, I could see that her balance was better.
She saw this spread and almost cried because she was able to see the difference in the work that she had done throughout this entire time. And whether it was the stuff that I was doing with her or whether it was what she was also doing with her neurologist. Who cares, right? You end up seeing these different changes and being able to then communicate to that patient how much of a difference this has made, it's insane.
So as of this week, when I recently saw her, she's regained significant sensation in both feet. Self reported somewhere between 65 to 70% sensation, including hot and cold, being able to differentiate between textures. She told me this week that she. She went to a podiatrist, and the podiatrist accidentally cut her foot. And she told the podiatrist that hurt.
And the podiatrist looked at her like, you can't feel that. And she goes, yeah, I felt it. I know exactly where it is. I can just point it to you right now. And she wasn't even looking at her feet. And the podiatrist was taken off guard. She's retaken knitting again. So those fine motor movements and the other thing too is now she's able to run.
24:27
Embracing Technology in Healthcare
And for me, like being able to make those kind of changes, that patient's life and using this technology to show them the progress that they've made is really, really fun. And I know I didn't get a chance to dive as much into how I use this in terms of the training with athletes, but this is definitely I wanted to show that this is a proof of the pudding type thing as from a personal note, as a clinician, incorporating this stuff has drastically changed my approach as a
clinician, is made me a better clinician. It has helped me get way, way better outcomes with the patients that I've worked with. And I think that us as a profession really need to make sure we continue raising our standards in and rather than us kind of being wait and see when it comes to implementing technology like this, we're in a really good space to be kind of those early adopters and those forerunners and how we use this stuff.
So a couple references of resources that I would happy to make available to you guys. As I mentioned, I have worked with Vault significantly over the last year and a half. Vauld has amazing resources for clinicians through their practitioner series as well as their Vault Academy. I actually did an article for Vauld last year where I talked a little bit more about my experience and how this can be integrated in a chiropractic practice.
I also want to shout out a couple textbooks that I've used to do this as well as in my practice. 1 is the NSCA's essential sports science and also shout out to Mark Jameson and Andrew Virgil for their recent publications they had here the Sports Science Handbook is an incredibly short and digestible book if you're interested in diving into sports science and I highly recommend it, as well as Mark Jameson's return to play protocols.
A lot of different types of frameworks and things you can build on. The last thing I want to talk about too is other clinical experts. I by no means feel like I am top in the field. I definitely feel like there are a ton of great clinicians out there that are already incorporating this stuff and doing it way better than I am. I take a lot of their leads and I try to learn as much as I can from them.
A couple from this list I want to give specific shout outs to specifically Travis and Taylor from ORCA Performance.
Travis is a physio and Taylor's a strength coach based out of Canada, Calgary and Edmonton. How they have incorporated this technology into their practice and their continuum of care for athletes is a standard that we all should aspire to throughout the entire lifespan of a patient and what they're able to do with it is amazing. I also want to give one other shout out to Brian Serrano. If you're on LinkedIn and you are not following Brian Serrano yet who who does a lot of work for the Chicago Bulls, you need to today.
Same with Corey Schlesinger from the Detroit Pistons in terms of his approach to training rehabilitation movement patterns and also Adam Virgil in terms of his approach to sports science and data capture and how you can report this stuff to patients. There's several other people on the list that I want to shout out. Last one I want to shout out is one I totally forgot to put on. This is Stephanie Mock Grubs who's the head performance coach for the Houston Astros, formerly with University of Pittsburgh and her work as well with force plates and applying it to high level athletes at that level.
Definitely somebody I would recommend following and seeing the work that she does. Lastly, ways to get in contact with me. Easiest ways to reach out to me is either through email. Dr. Geo Rehabl, Wisconsin I'm also relatively I'm on Instagram a decent amount because they don't tell you when you are a clinician in 2025 you also need to be a part time media influencer. So feel free to reach out to me on Instagram, email LinkedIn, Mike Jamarco, D.C.
and with that, thank you all so much for your time. I hope you took something from it and I look forward to the Q and A.
Jessica Riddle
I do have a few questions though. Thank you so much. And everyone, if you haven't had a chance to enter a question in the chat yet, please do so. I have a few here that I've jotted down throughout the presentation that have come in. So one person was asking specifically, when you're working with an athlete, which metrics do you feel like have been the most effective when it comes to how you communicate with their coaches or even other healthcare providers on their support team?
29:30
Assessing Athlete Strength vs. Speed
Dr. Michael Giammarco
That's an amazing question. So I think for that one the we have to answer that question. I have to ask follow up questions. Right? First thing we need to know is what sport is this athlete doing? Are they more a strength based athlete or is it more fast twitch? So the easiest way I'd probably start is what's called the dynamic strength index would probably be one of the metrics I would think is really, really key.
So how you get the DSI is you would perform a counter movement jump and then you perform typically it's an isometric mid thigh pull or a isometric squat test. And what you're able to derive from that is basically whether or not you have an athlete that is very strength dominant or very speed dominant. So in communicating that back to coaches, it's hey, I have Jimmy and Jimmy is a lineman and he is able to squat 500 pounds and his strength index is through the roof.
But then when we look at his speed, he's slow getting off the line.
And so we then talk about how we can then can take that and how do we then go from either a rehab perspective or from a training perspective and is it going to be more beneficial for us to continue to build and put more and more strength on there or should we then switch and go more speed to even answer the question even more broadly, it's it really depends on what the athlete is doing.
It depends on what their goals are. Back to what I was saying, we have to reverse engineer it. Jess, you might give me like a specific example maybe of an athlete and I can maybe reverse engineer it here.
Jessica Riddle
And, and talk how I earlier you were speaking about soccer.
Dr. Michael Giammarco
Yeah, absolutely. Okay, so that would be a really good one. So obviously when we're talking about like soccer athletes very rarely are they going to spend a ton of time on two legs. Right. We're talking about we're running, we're sprinting, we're cutting, we're kicking. So first thing for me is I want to do some type of a single leg test. Obviously, when we then talk about what are the types of injuries that soccer athletes will commonly deal with, we're talking about, we're talking about like knee injuries, hip, ACLs, Achilles ankle, everything like that.
Let's say, for example, if I'm dealing with an athlete that we're afraid of for a knee injury, I might have them do either a single leg jump or have them do a single leg squat.
And one of the metrics I might look at would be their eccentric braking. How well are they able to slow themselves down that descent to absorb the force and then put it back off when they step? Because a lot of times we talk about like non contact ACL injuries. We saw a lot of them this weekend in the NFL. It's that quick, brief moment before that next step. So if all of a sudden we see that, hey, there's this, this gap here, that might be something we incorporate in their training.
So let's say, for example, I might have them do a lot of like eccentric catches. So something where they're maybe doing like a split squat and they have to quickly drop into the squat to catch themselves and then come back up. It's a way we can train that behavior and that strength and then see how it affects that metric later on.
Jessica Riddle
Awesome. Someone else is asking a little bit about when you look at the full spectrum of the patient care cycle, right. So you have evaluation, treatment, and then obviously planning for discharge or return to play. Where do you feel like this technology has made the biggest impact in your practice out of those three? I know you kind of use it at each of those phases, but yeah.
32:46
Crucial Role of Assessment
Dr. Michael Giammarco
I think obviously the assessment is probably where I get the most impact because that also, it's also where me as a clinician, I spend probably the most time breaking down the data because that's where you're really going to get deep into the context and the important things that are going to set up the entire rest of that training program. Right. And obviously when that path is done, the question is, what's the next goal?
And so I think that assessment process is really, really crucial. And so where I was kind of into discussing this on how then you assess an athlete and say, okay, based on xyz, here are the tests I want to do, here are the metrics I want to track. Here's how that's going to translate to their sport or to their goals. Being able to do that on the early end and then communicate that to the patient throughout the entire process is the really, really important thing.
I recently had a patient that looked at this and I did a test on them and they're like, well, okay, but how's this going to help my pain? And I had to communicate with them, well, you have a 25% asymmetry on this side compared to this side. So what that's telling me is that this side isn't doing the work it needs to and it's hurting.
Yeah. Okay. So as we work on this and hopefully as your pain gets less, hopefully we can also see it in the data that you're also trusting it more and you're using it more and having be able to have that conversation and translate that to the layperson, no matter at what point of the process you are, that's crucial. But even back to the assessment, it's how you get people in the door in the first place and it's how you build that trust with them on the get go.
That's probably where I'd say the number one priority is.
Jessica Riddle
Well, that's a great little segue into this other question that was submitted regarding those patient conversations and the interaction whether you're speaking with the patient themselves or if you're speaking with the parent. If it's a youth patient, how do you typically, first of all, introduce the technology and say, this is what we're going to be looking for and this is how it will kind of help me assess you. But then the second part of that question is, how often are you reassessing?
And then have you seen that be really effective in helping your patients either become more compliant to whatever your treatment plan is or help them stay engaged as they're seeing that progress over time?
Dr. Michael Giammarco
Yeah, absolutely. So the first part of the question is how you have that conversation. Right. For me, it's how I set myself apart from other clinicians. Right. Especially for us in the chiropractic space. There's stigmas around chiropractors that sometimes we have to try to break. Right.
Especially where if we're very more rehab based or performance based, a lot of people come in to say, hey, you just do adjustments. Right. And I have to kind of tell them, no, we do we do a lot else? So it's one way to also kind of break that stigma a little bit, saying, hey, this is something that is part of my evaluation process and I'm not going to do the same test that you have in the clinic at the pt.
And they just push on you and I tell you how strong it is here. It's, I get to take my bias out of it. So a lot of times it's, especially with people that may be a little more resistant to starting care, it's, well, you can just tell me whatever I want. And I go, no. The robot tells me what I'm saying here.
35:57
Assessing Gaps and Asymmetries
I take my bias entirely out of it. And it's saying, all right, so here's what the big gaps were seeing. So if we're going back to even like the metrics that I would even start off with, the crucial things I usually will point out to patients on the first couple sessions is the asymmetries and the normatives. So how much of a gap do you have side to side in certain movements? And where do you compare to other people in your age group?
Now that's just skimming the surface in terms of the total picture. But for a lot of people, that's an easy way to really explain some of the big key things that you want them to know. And that's where you can get a lot of buy in later down the line. Then going back to how frequently I test, it depends on the patient. There are some patients where I will schedule out regular re exams every three to four weeks, where I will retest those specific measurements that we have.
There's other ones where I will test them every single session. They come in in some capacity. And that test doesn't necessarily have to be strictly for the benchmark either. It can also just be like, hey, we're also going to just do this today and I want to see how your measurement is one of my favorite things to do with the force decks. My Allen, the patient I was talking about in the case study, when I first started working with him and he was doing his squats, he was really, really hesitant to put any weight on his left leg.
And part of his rehabilitation was I would get him on the force plates and I would have him do goblet squats to a box. And while he was on the force plates, you can see exactly how much pressure you're putting on the left foot compared to to the right foot. And I told them the entire time you're squatting, I want those lines Equal.
So you get some biofeedback as well. And so like some real time training where they have that reinforcement. Yeah, visual and you gamify it and it's. And even with the second case study, Hannah, the proprioceptive piece, she couldn't feel her feet. So there was another day where I did that single leg balance test and I had her standing on it and she could see the dot and I said, okay, I want you to make circles on the screen.
So she had to shift her weight around her feet to make a circle on the diagram. Do we save the data for it? No, not necessarily because it wasn't pertinent to what we were testing. But she was able to see that and visually get that.
And that was, that's a huge part of using this. If, say, for example, we're dealing with post op, we obviously want to consistently test honestly post op. I usually want to test weekly just to make sure that we're seeing the progressions we want. And if you, if we're able to hit those benchmarks that I mentioned in terms of strength, capacity, speed, and we're able to advance them into return to play faster, as long as they're also meeting those criteria.
Great. So we don't have to necessarily talk about those 9 to 12 month timelines anymore if they're able to meet that criteria. And obviously like there's variables as well, tissue healing and things like that, but just another aspect of it.
38:46
Key Metrics for Patient Care
Jessica Riddle
Well, and I love kind of incorporating like you said, the, the visual reinforcement, like especially when you struggle with propriet, when you struggle with hesitancy because of injury or whatnot, being able to lock your brain in in a different way to make your body move obviously pays dividends in the long run. I had one that I thought might be kind of interesting if you had to create or could create your own data dashboard for each patient.
And obviously we know patients are not cookie cutter. Everybody's not the same and everyone's individual. But if money was no object, you had all the technology and the assessment capabilities that are out there, what would be those three main metrics that you would think of as non negotiables? Like every single patient, I need this specific information in order to best serve them and best help them with whatever it is they have going on.
Dr. Michael Giammarco
Okay, so we're talking about like which piece of technology or like which, which actual number do I want every time I test them?
Jessica Riddle
Well, let's talk about the metrics and then if there's any specific technology that is kind of on your dream list of equipment and technology that can help you get all of those data points.
Dr. Michael Giammarco
So I'm one. I'm very, very lucky that with rehab lab and with my own practice previously, I have had access to this tech for a while and still do, and I get to use it every day. And it's really, really fun. It's also really fun for me as a clinician to use this stuff. I would say in terms of metrics, number one is always going to be peak force. I think for me, that is the one metric I always want to make sure I know with a patient is where their strength is at that given time.
Because at the end of the day, that is going to be how they express themselves in the real world is what that strength measurement looks like. That would probably be my number one.
My number two would probably be. It's like picking your favorite children. It's hard to do.
Jessica Riddle
It's hard when you narrow it down to three.
40:45
Balance and Eccentric Deceleration Insights
Dr. Michael Giammarco
Yeah, I would probably do something along center of pressure, so something along with balance because that's something throughout our entire lifespan we want to make sure that we're able to do. And then lastly, lastly, because I. This is a metric that I never really thought I would use a lot, but I've. I've really been seeing myself look at it more frequently because of the patient I've been working with has been that eccentric deceleration impulse.
So that ability for someone to break either in a squat or in the counter movement jump and quickly build up that force into that last moment. I think that's one of the things where we talk a lot about injury. When it comes to things like change of direction or like that rapid loading, it's a lot of times. One thing I talk to patients a lot about when it comes to injury is it's not necessarily about the movement that creates the injury.
It's the moment that creates the injury. And that impulse is a really good way to get an insight on that moment when those injuries might occur. So that's. It's a stat that I always, as a metric, I always like to look at just because I'm always curious at how that person's able to express that in that moment. When it comes to, like the pieces of technology, for me, if we're talking my favorites that I've used, the force plates are probably the most diverse and accessible tools you can use.
They're the kettlebells of the performance testing pieces of equipment. They're incredibly versatile with the tests they can do. You can test Upper extremity, you can test.
Lower extremity, you can test isometrics, you can test so many things. I joke with patients, they tell me everything about you but your blood type. And then in terms of this ease of use, a handheld dynamometer is, is really great. And you and especially like talking about like easy point of entry, just being able to grab a patient and say, okay, hey, I'm going to just have you do a grip squeeze test and we're going to see how much stronger one hand is compared to the other.
That's a great way to get that conversation going on why asymmetries are important or in certain athletes, not important. My intern, Lauren, that was in those pictures that I had in the presentation. D1 softball player, if you measured her, her internal rotation on her shoulders, it's 30% side to side. I'm not going to fix that because she's a D1 softball player.
So once again, like talking about context and how we can look at these different things and we can measure that with the handheld dynamometers.
Jessica Riddle
Very cool. Very cool. Well, thank you so much. That wraps up part two of our conversation with Dr. Michael Giamarco on turning performance metrics into real clinical decision making. Here are a few final takeaways from today's discussion. Data doesn't create clarity frameworks. Do metrics only matter when they actually change your plan? If your testing doesn't influence dosage, exercise selection or progression, it's not really an assessment, it's entertainment.
43:41
Better Decisions, Stronger Outcomes
And finally, the win isn't more numbers. The win is better decisions, stronger patient buy in and more defensible outcomes. If you enjoyed today's episode, be sure to like follow and leave us a review on your favorite podcast player. It helps more clinicians find our show and as always, you can find all of our upcoming courses and free trainings at faktr-store.com that's F A K T R hyphen or-store.com and be sure to subscribe so you never miss a new episode.
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