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Providing Hope: Functional Neurological Disorder Physical Therapy with Zachary Grin

Karen Tanso, CEO of Inchstones PT

Today's interview features one of my coaching clients and dear friend, Zachary Grin. Zach is the owner and operator or Rethink Physical Therapy providing physical therapy services to patients with functional neurological disorders (FND) in New York and New Jersey. Zach shares his journey that led him to where he is today, providing PT services to a population he witnessed receive poor quality care during his time in the hospital clinical setting. Discover how Zach overcame challenges, embraced a "learner's mindset," and is operating a thriving practice providing high quality care to a population he is passionate about helping.

What we're covering:

Tell us a little bit about what you do, your story, background, how you got here.

Zach: Yeah, I've graduated from PT school. I went to Clarkson University in Upstate New York. Graduated in 2021. So I'm still fresh out of school, and, you know, prior to that, I majored in Psychology Neuroscience. I worked in community mental health for a year prior to starting PT school. Have always really been interested in neuro, and by really interested, I mean completely obsessed and can't imagine myself doing anything else. So, so I knew I was going to go into a neuro setting. Didn't quite know what exactly that was going to look like. I ended up getting my first job at a hospital system, doing outpatients, acute care, ICU, CCU, a little bit of everything. I would say it was pretty much the first day I started where I had the first thought of, 'I don't think I ever want to work for somebody ever again, and I think this will be my last job as an employee.' And so it didn't take long for that to actually become a reality. It was, what, like eight months, I think, before I began my private practice. I did that kind of on the side for a few months until it started picking up more, and essentially, I was working almost like what felt like two full-time jobs. So, I quit my hospital job last August and have been full-time in my private practice ever since, and it just keeps growing, and I am completely full, and it's, it's been a success. Yeah, it's been great.

Tell us the positives and pros you’ve seen since going full time for yourself.

Zach: I guess the biggest one is seeing the patients that I want to see. I didn't really have any sort of autonomy at the hospital. PTs typically don't. So, the autonomy and being able to do whatever I want whenever I want is really great. But, you know, I started this practice really because I saw a specific group of patients in the hospital setting that were being treated really poorly. I was shocked, actually, not being told the diagnosis, being told that they were faking it, that they weren't deserving of getting discharged to inpatient rehab because they didn't have a real condition. Meanwhile, this patient can't walk, can't talk. I was shocked. So, I started reading up more on it, and I was so surprised that nobody in New York City specializes in this or even just advertises it on their website. The more I started looking into it and the past history, I found it very stigmatizing, not well understood, but it is becoming a lot more understood, and there is actually effective treatment. Us as PTs play a huge role in that. So, I was kind of hooked from the beginning. Most people know it as conversion disorder, but the proper term now for it is functional neurological disorder. So, I started my practice specializing in that. I learned a whole bunch. I was treating some people in the hospital, and that's what I exclusively focus on now. To my knowledge, I'm the only physical therapist in definitely New York City, but probably close to the state. I know a couple in sahq who were awesome, but yeah, in this region, I'm the only person doing this, and it's a very common condition too. It's high up there on the list, similar to Parkinson's and MS. So, imagining yourself as being the only provider in a city of eight plus million people, only treating people with that, it's a lot of people. And so, being able to have that freedom and autonomy to do the things that I want to do is really essential for dealing with that kind of demand.

Morgan: I think that, you know, for a lot of us who have started our own practices or are thinking about it, I feel like the biggest kind of goals that come up are like financial freedom, time freedom, but clinical freedom is a big one. And like I know that was really important to me as well in just wanting to work with people, you know, that I'm interested in, being athletes, and like, you know, part of it is the enjoyment but also like finding just like some kind of clinical specialty where you feel really confident about your ability to help people. You know, like that obviously makes a huge impact on the community and your patients, but also it's very fulfilling, I think professionally, to be able to do that and create an opportunity for yourself to do that.

Can you tell us a little bit more about FND and the symptoms you see in people, like the typical things you work on with your patients?

Zach: Yeah, so the old thinking of this used to be that it was just psychological. Not that the symptoms were fake, although that's very common for healthcare providers to think, but that there was some emotional trauma or some type of suppressed emotion in the subconscious that was converting into these physical symptoms. Very Freudian, literally was developed by Freud, and totally is unsubstantiated with evidence. It's just not a testable hypothesis; it doesn't really make sense, and there's a lot of problems with it. So, in the last 20 years, there's been a huge resurgence and an interest in research and clinical practice for functional neurological disorders, and we have found out a lot since 20 years ago.

The symptoms can vary quite a bit, but the technical definition of it is any type of altered voluntary movement or sensory impairment that is not congruent with neurological disease. So, we look for, and it used to be a diagnosis of exclusion, it's now a diagnosis of inclusion. So, it has to be ruled in, and we do that by looking at what we call positive features or positive signs — clinical signs, symptoms that we only really see in people with FND and has high specificity for the condition.

A common one is what we call Hoover sign, which was taught, at least when in my PT program it was taught. However, it was taught to catch people for malingering, which is not, if you're going to take home anything from tonight, that's just not it. Hoover test does not show malingering; it's a clinical sign for a functional neurological disorder. What it tells us is that when a person voluntarily tries to move their leg or limb, either it's weak or paralyzed. The harder they try, the worse it gets, the more paralyzed it gets, the weaker it gets. When their attention is redirected away from it, though, they have full strength, or at least a lot more strength comes back, and it's very clear and obvious. So, that tells us a lot about what's going on with these conditions.

For the symptoms, it's weakness, full-body paralysis, to just paralysis of the legs, sensory disturbances. Usually, it's like a hemisensory syndrome where it's completely split down the midline with a very sharp edge. It's right here; you feel it right over the midline. We only really see that in FND. All types of movement disorders — tremors, myoclonus, Parkinsonism, even things that look like MS, stroke, Parkinson's. I would say probably almost like 90% of patients I've seen have been misdiagnosed prior to actually receiving their diagnosis. That's led to really intense treatments — IV steroids, IVIG, plasmapheresis, and replacements and also surgeries, cervical fusions, tons of invasive procedures that were totally unnecessary and had way more risk than benefit.

Yeah, so I treat all these conditions. The other common one is what we call functional seizures or non-epileptic seizures. That's another big one too that does have more psychological factors that play a role, and psychologists usually lead that treatment plan. There's no real good evidence that PTs have a role; it's just not in the literature. But from my experience, we definitely do, and it can be really helpful. But basically, we treat these people based on these principles of what's going on in the pathology. So, symptoms are typically worse with attention; they're better with distraction or redirected attention that actually improves the symptoms.

Expectations are also a big one too. For example, I'll have somebody who is not able to walk backward at all, and as I tell them, 'Guys, show me how to walk backward,' they can't. I tell them to fix their computer screen, and then I see them, and they take normal steps backward. So, it's this voluntary movement that they can't do, and learning how really requires being creative and figuring out how can I get this person to move without thinking how to move. And then reinforcing that over and over again across different tasks.

The work, you know, by them mostly happens outside of our sessions too. It requires a lot of practice and time, and it's a full-time job for those people to recover from this, but it's definitely possible. People make huge improvements when they get the right diagnosis and the right treatment.

Morgan: This is so interesting, and like, I think it's really amazing that you were able to find this niche, you know, that you're super interested in, but it clearly has a need. There is a need for it with patients. And, you know, like you were saying, they've kind of gone through the ringer with a bunch of other stuff and haven't really found anything to help. So, the fact that you're there, you know, and offering support and help, I think is a really, really cool thing. So, the more information you're able to put out there, hopefully, we can help as many people as possible. So, that definitely helps to clarify in my mind what it is that you're treating, what you do. And I just, like, neuro stuff is so cool because I mean, the whole body is like a puzzle, but I feel like, especially with neuro stuff, it's so cool. I always feel like the world's greatest detective when I pick the clues together and unlock exactly what's going on. So, yeah, I think you and I and everybody else out there clinically, we could just talk about things forever and how cool the human body can be.

With these patients that you are working with in your practice are you a mobile provider, do you have a space? You said you do Telehealth.

Zach: I initially started with telehealth and mobile. For anybody in New York City, you know how transportation can be here. It was taking a big toll on me pretty quickly. So, back in June, I got my first office in Manhattan. Right now, I'm just seeing people in the office and telehealth. Probably, I would say about a third of people I see telehealth. People with this condition, telehealth works out really great because it's a lot of hands-off. You're not going to do manual therapy unless they also have an orthopedic issue because people can have more than one thing going on with them. Yeah, and that's usually important to address in these people too. But typically, yeah, no hands-on stuff really, and it works out really well.

I'm licensed in New Jersey too, so I do see a lot of my patients through telehealth here in New Jersey or Upstate New York. I take, and to go on more, I take Medicare and cash as well for payment options. That's a whole conversation too. Medicare is a lot, yeah, definitely some pros, of course, but cons as well. I mean, just like any kind of payment method or different insurance you might work with.

Morgan: I can imagine. I know when I was doing mobile therapy and home health, I could really only do so much before it was just like way too much of a commute and everything. So there's definitely like limits to that. But being able to offer telehealth is amazing. You know, it works out, I think, really well for a lot of patients, more so maybe than people thought prior to COVID and everything. So I'm happy to hear that even with neurological conditions, it is also still super helpful.

A common question I get from others is, how do you figure out when to leave your job? What about it made it difficult do you think?

Zach: Yeah, that was hard. That was really hard. I got to the point, and I don't recommend this. This is not the right answer. I don't know if there's a right answer. It was not a good decision on my part, I think. I waited way too long and kind of got to the point where I was severely stressed 24/7 and felt like I had to, like, completely lost control over my entire life, to be honest. I mean, it was, I was working all day and getting home, jumping on the computer to do telehealth with a patient or two, spending my both my weekends seeing patients in my practice, and it was a lot. So when I got that feeling of like, I literally don't have a choice; otherwise, I'm going to have to quit everything, like, I'm going to need a break for a while. So once I hit that point, you know, I tried working with them to see maybe, like, part-time, which wasn't an option. So, I just put in my two weeks when they said no to the part-time, and I'm really glad they did because there was no reason for me to try to go part-time. I think it was, I didn't want to jump completely over the edge into the deep end, trying to take the ladder down, yeah. Instead, so they'll have maybe one floon, but yeah. But I'm glad it was like ripping the Band-Aid off, so just getting thrown in. So, yeah, I even tried applying for part-time jobs directly after that and I got offered a couple, and I turned it all down. I kind of felt bad, and yeah, I was really struggling with this being completely on my own. It was really hard for me to grasp that concept.

Morgan: What about it made it difficult do you think?

Zach: You always just work for somebody, and I've had multiple jobs in the past and stuff. You always just work for someone. It's like, how do you even find out about Medicare? How do you get patients? How do you, like, when do you get a brick and mortar location? What is all the software I need? What are the policies like? There's a lot, and like, I have no idea. Yeah, and I've just learned on my own and really through the help of like Facebook groups for the most part, and you obviously, yeah. Yeah, it is a lot, and I feel like for those of us who struggle with kind of figuring out structure and time management and everything, you go from the traditional structure of working for somebody where you know exactly what time to be somewhere, what time you leave, kind of what's expected and everything, to now you're designing all of that. It's hard to conceptualize.

Morgan: I think, like you were saying, and then just figuring out all the fine details to make sure that you're actually running a business, you know, it can be weird, sometimes scary. But, as you found, like a lot of it is doing the research and trying different things and figuring out what's going to work best for you. And I know lots of people are always worried about the legal aspect of things. I feel like when you're first getting started, most of what you can do is look into the laws and regulations and operate to the best of your knowledge, based on your best interpretation and everything, and just kind of go from there and adjust as you need to.

Do you think it would be better to get a second job working for someone else for a few hours weekly for a couple months before starting my own? What do you think Zach?

Zach: It's hard because it also, you know, it depends on like I don't have a family, you know, I don't have kids, I don't have, like, it's just I have to pay for myself. So, the financial stability, how much you have saved, like those are all things to consider when making these decisions, I think. But if you can do it, just do it. Yeah, I think like it is scary, it's hard, and they tell people, tell you how hard it is, and you know how hard it is, and then it's like 10 times harder than that. In a good way, though. It's not a bad thing, and it's 1,000% worth it. But yeah, I think, you know, working for somebody else for a couple of hours is a good option for people though. Really depends on your personal situation.

Since you started, what have been some of the biggest barriers or mistakes that you’ve run into with your practice?

Zach: There's a few, letting myself get behind on documentation, I'm just going to say I regret it. You know, that is a regret. We all hate documentation, we all have to do it, and that's been really kind of stressful, figuring that all out. I've always kind of been the person to over-document, I guess, or be very thorough and kind of take pride in that. And then I've realized how dumb that is and totally unnecessary. So, I've been trying to bare minimum it, really trying to cut down on that, and it depends on the software too that you decide to use. That's a whole other thing, figuring out which EMR to use and all of that, that's a whole learning experience. And I did make that, was probably one of my biggest regrets, trying to switch EMR systems when I was behind on documentation, behind on submitting claims, had a whole bunch of new people coming in, and thought I could try to switch EMRs because that would make everything better. It made everything so much worse, and I ended up not switching.

That was a very challenging experience. Yeah, and documentation, figuring out the kind of software and setup, and then getting help too because it quickly became too much for just me to handle. I had a full schedule of patients all day, submitting Medicare claims, and keeping up with everything. It was too much. So, I do have a virtual assistant, which just, I think adding any new person to a practice can be challenging, especially when you haven't really managed somebody else or worked with an independent contractor. So, just learning the ins and outs of that has been challenging. But that's why you have an awesome business coach to help you.

Check out my blog post here where I dive into the top 5 EMR systems for the cash based practice in 2024.

What have you found to be the benefits of working with a coach and do you think it would have made a difference at the beginning?

Zach: I wish I found you a lot earlier, to be honest. Yeah, it's, I mean, there's tons of information, free information, you know, out there, and like you can sit there all day and just read and learn. But it's totally different to have somebody talking to you and telling you, like, has gone through the same stuff that you haven't, and the way, you know, they were able to navigate through that. Just hearing a different perspective of what you're thinking is like huge. Like, you get very stuck on viewing something a certain way, and so being able to hear it from an outside person was very helpful. And like our brains kind of work the same in terms of organization and planning and like that. So, you have a handle on it, and I did not. And so, it was very helpful, just like, yeah, time management-wise and organization, and you know, tips and tricks here and there too and stuff. And yeah, I mean, I think everyone should probably go with a business coach right from the beginning. I think it would have made things so much easier.

Morgan: Definitely, it helps so much to be able to talk through everything. I have a coach too, and I'll talk to him about all the ideas that I have, and he helps me kind of put into perspective, like, maybe these are the good ideas, and maybe these are the ideas for not right now. And just being able to ask questions to avoid mistakes or avoid things that are going to end up taking you a lot more time to work through on your own, that's also super helpful. So, yeah, like, I think I've done a few different programs, and I've worked with the same coach now for a couple of years, but it's really nice to just be able to talk to somebody and have them kind of help you plan things in order to move forward because definitely something that can be really overwhelming is the fact that when you own a business, nothing is ever done. For those of us who like checklists, we like when things are done. It can be very frustrating, but first, you just kind of have to make peace with that, like, nothing's ever complete and figuring out ways to find success for yourself, to get that feeling of like, okay, I'm done. Working with a coach can also help you with that kind of thing too.

Should you hire a business coach? Check out my blog post here where I go into detail about why hiring a business coach may not be right for you.

Tell me a little bit more about how since you’ve started, you’ve adopted a learner’s mindset?

Zach: I have kind of that perfectionist mindset originally, like everything has to be perfect before I can implement it, or everything has to be figured out and planned. That's just not the case with this. You're going to sit there forever and not actually get anything done. And really, I mean, fear of failing is a big one of that, and impostor syndrome and those things. Adopting this learner's mindset is probably the number one thing that has got me through all of this. It really changes your perspective on facing these challenges. It's hard to even call things failures because even when you do go through something like an experience that you would call a failure, you still learn a ton from that. Like, no matter what you do, good or bad, you're always going to learn something, and then you're going to be able to apply that for the next thing that you do. So, I think it creates this resilient mindset, this resilient mindset of, you know, you can do anything, really. And yeah, and it keeps you interested too. It doesn't feel like when you're going through these challenges that it's dragging you down, holding you back, holding you down. You feel empowered by it, keep moving forward.

Morgan: Yeah, and I think, like, something that reminds me of – and I mean, it's something that I have to work on pretty much on a weekly basis – but like the concept of failure. I think for me, my experience going through grad school was so intense. It was, I think, for a lot of us, you know, where it literally was like pass or fail, and if you failed too many classes, you get kicked out of school, and that was just like the absolute worst possible thing that could happen. But I don't know about you, but there were students in my class who unfortunately did have to leave the program, and they're doing just fine, all of them, you know? So, like, I think for me, it's been kind of like this trying to coach myself through it and reassociate, I guess, maybe what failure really means. It's just something that didn't work maybe the way that I wanted it to. But like you were saying, you learn something from that. And I think, especially with business stuff, it can apply to a lot of marketing stuff where you might have a great idea for something that you want to do with marketing, you try it, and you get crickets. It does not work at all. And you could look at it as a failure, or you could say, like, 'Wow, I learned for sure I do not want to do direct mailers to try to find patients,' you know? And you move on from there, and you learn something. So, I think that's a big part of the learner's mindset that you mentioned, realizing, like you said, there really is no failure because also, none of this is an emergency. I think that's also where a lot of the stress around quote-unquote failure comes from.

Check out my blog post here where we dive into tips for smashing imposter syndrome.

For anybody who is thinking about starting a practice or just getting started, what are your top two pieces of advice?

Zach: Definitely figure out your foundation beforehand, but also be flexible with it. Know that it will change when you get started, but have some type of idea, like a semi-structured plan. And then I think really, like, a learner's mindset. You have to go into it with a learner's mindset. I think if it's really hard for you to deal with failure, not to say that you can't learn, it's going to be very hard. If failure really sets you back, being able to kind of work through that might be something that you might need to work on prior to going on this adventure, I guess. Yeah, I think that's totally fair. And just have the mindset that you are a problem solver. If something doesn't go your way, be stubborn about it and figure out a way to make it work. You know, like, stick. You have that freedom to do whatever you want. Yeah, exactly. Like, as weird as that can feel, like we talked about earlier, to have complete control over what you're doing, it's also super cool. You know, because you can literally do whatever you want.

How to contact Zach:

*Find him on Instagram

Listen to this episode on my podcast!

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