Treating Athletic Low Back Pain

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every day.
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You essentially pay your dues by doing the harder thing when it's the right thing to do.
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I have been very good about trying to not work after five o'clock on fridays and have all the way through sunday at like five o'clock.
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I'm trying to get a full 48 hours of whatever I want.
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I'm doing pretty good.
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The last three weekends have been like friends, family went out.
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It's like a sweet jazz band in town that I went to.
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So, yeah, I'm doing good this.
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The last three weekends have been like friends, family went out.
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It's like a sweet jazz band in town that I went to.
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So, yeah, I'm doing good.
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This is the last thing I have to do today, and then after that I'm done, yeah, same.
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Yep, um, back in action.
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We needed a much needed uh, two, three break.
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I don't know what it was, but, uh, aaliyah was busy and I was also super busy with some stuff too.
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So so, yeah, it's just the nature of the podcast is it's here for when we can record stuff, we will, and if we don't have anything cool to talk about, we won't.
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But now we have some things to talk about.
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So I think I forget what the last episodes we left off of, but we definitely want to cover some stuff on back pain, because that was one that was submitted.
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Somebody asked about hip and labor repair, so we'll do that next week.
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And then the last one in the third week is somebody who was asking about um, season is coming up quickly, which is crazy to say, cause we're recording in summer, but you know, in the blink of an eye I'll be like people back to school and stuff.
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So, yeah, we'll start with back pain stuff today.
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And, uh, it actually kind of worked out because you were like kind of around at champion when we were going through like developing all these systems, and I think that like a lot of this stuff carries through.
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But, yeah, we'll start it with this.
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So Jess submitted via Instagram.
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She said how do you assess what kind of low back pain it is and then how do you approach it?
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So pretty broad question, but I'll share my thoughts from the outline that I had and then some research that we have, and then you know we can chat back and forth.
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But I essentially came out of school in 2013 when the CPGs the clinical prediction guidelines were first getting very popular.
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So I think 11 maybe was the first one and there was an update in 16.
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But essentially that was like looking at things through the lens of like what is the evidence that people have and like what category they fall into for treatment.
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So there was like the manipulation side, there was the stabilization side, there was I forget the other ones off the top of my head but essentially like category based things and I think that was super helpful.
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I think that was a good start, um, but also during that time was very much like the large growth of pain science and a lot of people putting like chronic low back pain, non-specific low back pain.
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So there's a lot of work that came out from like Lorna Mosley, adrian Lau, uh, pretty much on people who are like really not responding well to traditional treatment and they're kind of getting like truly sensitized.
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They're really it's affecting their whole life.
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Um, and then my kind of story is that I learned all of that and I was using it.
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But then I started getting involved in like sports uh, more particularly like middle to high level sports, high school and college and I found that while that stuff was helpful, um, it definitely did not kind of cover the whole gamut, particularly because sports require like very high loads, very high workloads.
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So I kind of found the work of like Stu McGill more like the strength and conditioning side, and I think that's more classified like the mechanical bucket.
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So that was kind of how I went through my traditional, maybe the first six to seven years of school, and between like pain science, the evidence-based classifications and then more of the movement-based or kind of mechanical-based approach, I find myself just mushing them all together and using kind of what I needed in front of me.
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So yeah, that was my kind of journey.
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What was yours?
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Did you guys get taught the CPGs and then pain science stuff or like, how did you come to?
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Yeah, I feel like it's kind of similar, like we learned like buckets of back pain, but then, like that didn't really apply very well in the sports world, particularly, I think, in the adult world it feels like it applies a little bit more easily, I feel like when their pain is more identifiable.
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So they're like oh, it hurts when I'm sitting, yeah, exactly.
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I feel like we learned very strict buckets for back pain and then we also learned that there's going to be just generalized chronic back pain in its own bucket.
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But then obviously I worked with you like while I was still in school, so I got the benefit of learning kind of your structure and I know I think this is probably I don't know how early on you made this, but you would always go up on the whiteboard and like draw that chart.
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Yes.
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Of like the different things you would look for.
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I will, I'll actually buy some time in a minute and I'll pull that chart up for people.
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But, um, yeah, I would agree with that.
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I think you were probably just I mean, I don't remember how far I was at a school when you came but like, I was kind of like in the throes of trying to sort out like a system and how to approach stuff.
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Because what I found and you know, mike was a big instrument in this is that there's a very big difference between chronic back pain and like acute re-injury of the same thing over and over again.
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So chronic back pain is someone who has one bout of pain or a couple of butts of pain and that never quite resolves and they become centrally sensitized, so like they truly have nervous system level changes.
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Um, you know, uh, there's a whole laundry list of stuff that changes, but it's really like someone who has a couple of events and then for many other issues biopsychosocial, their job, whatever they don't get over that one bout of back pain and it kind of continues to maintain a lot of like changes in sensitivity.
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And there's definitely a lot of people who treat that, you know, who fall into that category, and I would say there are definitely some, like you know, athletes or active people who kind of get that.
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But that's really not what I see.
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You know, those, in my opinion from the you know, I'd like two or three years of a lot of chronic back pain before sports and that tended to be somebody who was like really under active, you know, they tended to not really work out consistently, they had a day job or they were really busy and they, you know there were a lot of other things related to like their sleep, their nutrition, their psychological status, their work status, their marriage, their spouse, whatever that were clearly influencing their you know worries and their fears and they kind of fit the traditional mold of biopsychosocial model.
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But again, that was like one person who had out of back pain and continued to kind of not get improvements.
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I found that I did see that quite a bit and you would use strategies from Adrian Lowne, stuff to teach them and stuff.
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But chronic re-injury of the same thing is more what I see now, which is like there is a root provoking factor, whether it's workload, strength, conditioning, you know, mobility or strength or kind of that stuff and they have one bout of pain it gets almost all the way better, and then another bout of pain on top of that which then they don't really resolve fully.
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So it's not like they're like one thing is chronic.
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It's that they constantly have spikes of like a little bit of a set thing, a little bit of a set thing, and they get a little bit of a set thing and they get a little bit of a stress reaction thing, then a little bit of a spondy thing, and it kind of keeps coming and going.
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But once you get to the root level oftentimes a combination of educating them about their daily life and then also mechanical symptoms, which we'll talk about next that is when they see resolution, when you finally play with the chessboard of like maybe some of the root level type stuff like that.
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So, yeah, I find that all the things I had learned were very, very helpful.
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Um, and I can share a couple articles that we have.
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So this is kind of a um, oh, not that one.
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This one is a recent systematic review that kind of looks at like everything right.
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It's looking at just like general guidelines for low back pain management and you know, I read through it and it was helpful.
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I don't think it was earth shattering for like things that it was new.
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I don't think we've learned a ton more but this.
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There was a section of this which I think completely sums up like the frustration many grads have with low back pain.
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If I can find it, it was kind of saying, like all the things, here we go, so Denmark, all these studies, and then essentially they're saying that targeted recommendations regarding acute, subacute and chronic low back pain right across all these things and duration of symptoms, the things that are helpful, is, I'm going to find it.
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Pardon my pause here.
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Let me find this actually I'm trying to read to my secondary screen it's not working, but it's essentially it's going to outline that, like everything from medicine to every type of exercise, is very helpful for these people and it starts to be oh, here we go.
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So acute low back pain, right, so this is what they so.
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Acute low back pain, right.
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So this is what they recommend for acute low back pain NSAIDs, therapeutic exercise, spinal manipulation, opioids, heat massage, acupuncture, muscle relaxation, spinal mobilization, self management, paracetamol, returning to work, progressive muscle relaxation, reassurance, avoidance, belief training, cognitive behavioral therapy, postural therapy, laser therapy, diathermy, laser therapy, short-term diaphragm, cold therapy, antidepressants those are all things that are useful for acute back pain.
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And then another CPG recommended mindfulness-based stress reduction, tens, lumbar supports, back school interferential current therapy, electromuscular stimulation, anti-epileptic drugs, herbal medicines, shockwave therapy, back school multidisciplinary treatment.
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What the hell do you do with somebody when you look at a CPG in a 13 CPGs say that for acute back pain, someone walks and says I hurt my back over the weekend.
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You have that laundry list of shit to try to do with them, right, and each of those is so insanely generic, right.
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Massage, multidisciplinary treatment like that is so insanely large of a treatment thing.
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So that's the problem that comes up with some of these large cpgs and this is systematic view of cpgs.
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It's great right.
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Subacute back pain exact same thing.
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Chronic low back pain like a giant paragraph of arguably 20 to 25 things that have some evidence, mixed uh populations, mixed chronicity, mixed uh goals, mixed diagnostics.
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It makes it extremely hard for a new grad who comes out and read this and says, oh yeah, look, I found this great.
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You know, systematic review of CPGs.
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What do you do with these people?
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Like how the hell do you organize?
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Just chronologically, go one by one and hope that something works?
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Like that was.
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My personal frustration is that I was reading all this evidence and I did not find as though it was very helpful, which again leads to like something that's more specific.
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Like this is more of a mechanical article that's talking about the use of McGill exercises for someone who has, you know, some functional disability, chronical back pain again, how they specify that versus this is more of like a pain science education type thing, which is more about saying that teaching someone about their back pain and understanding their life is probably helpful too as well.
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So I personally found that I needed to do more of like a movement-based category, which is what we'll talk about next, but I don't know if you share the same frustration with when you were trying to read evidence as a student or a new grad.
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It's like how the hell do you interpret a paper like that?
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And not to mention there's probably 50 more articles out there on, you know, recommendations for back pain yeah, no, definitely.
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I felt exactly the same way because I I feel like everything was like everybody has back pain.
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Uh, you can treat it all these different ways.
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None of them are great.
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They're all okay and good luck.
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And then it was like the recurrence of back pain too, like the research on that is also like really high recurrence levels.
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If you don't treat, like, if you can't figure out, I think, the lifestyle factors of the pain science contributors, I think the recurrence rate's really high.
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Um, and I I feel like I liked the mechanical models too, but then sometimes when I'm treating mechanical model and I think it's more acute, the recurrence like I'll have kids that'll keep coming back to me Like am I not touching on something that's a little bit more like chronic?
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Like are we?
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Are we treating all of these like pain science factors or like something in their daily?
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life, I think um I think one thing that's really hard is as a new grad, I think you often lean on social media, which can be very, very good, but oftentimes I don't know, I don't know how to phrase it like what you, what you want to find, you find on social media, right.
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So, like I remember, there are times when it was like in in a broad range of people, a bunch of exercises help for somebody with back pain.
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It's like there was that camp which is like do everything, do like manipulation, do exercises, do McGill, do PRI, do SFMA and all this stuff.
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And then, literally in the exact same vein, you had social media accounts that were like well, back pain, nothing works for back pain.
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You know back pain is a normal, it's like a very common thing.
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Everyone gets back pain, no matter what.
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So like they don't need PT to get better with time.
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You just leave them alone.
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You know rest in time is no better than PT or injection or whatever it's like okay.
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So somebody comes to you with acute ripping sciatica and you're going to tell them exercise, you're going to get the pain.
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Science, education, like how in the world, with the resources available, do you go through a systematic approach?
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And then, on the other side.
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Just don't be like, yeah, well, you know, strength deadlifts are good for back pain.
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So like, go deadlifts and like good luck.
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Like I can't tell you how many people get worse with just advice like that.
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And I find that I'd be extremely frustrated if I hadn't had, like the available resources to take courses and do stuff and then have mentorship from people who were like had years in their belt.
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If you were like in the middle of Ohio or Iowa there was no great centers around that are athletic based and someone keeps coming to you for back pain, like I think you just get frustrated, throw your hands up and give them the best you can, but then, like I don't know, good luck.
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You know I feel really bad for those tech screws.
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Yeah, no, I completely agree.
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I was lucky to have you early on in undergrad.
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I feel like I helped sort my brain out a little bit more with that kind of stuff.
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But I think it really depends a lot on where you work, because I feel like if you're working like more in the sports world, you get a much different like demographic usually of what kind of back injury they're dealing with, versus like working in like an outpatient ortho, where you're getting a lot of like older people who may just be like sitting at a desk all day and, yeah, maybe a lot of treatments work because they're sitting down all day and they just need to move or they just need like a little bit of tlc from somebody because their life is stressful.
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So it's hard to sort it out based on the person.
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And I think from an exercise standpoint, there's so much like you're talking about on Instagram.
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It's like I feel like every other reel that I pull up is like this exercise will fix everyone's back pain and I'm like sure Everybody will be cured by this one exercise.
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I'm sure.
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Yeah, I think you you kind of learn to put your defenses up as you get a little more experience in your grad.
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But anybody, I'm not going to go into it, but there was a brochure dropped off at our clinic that had some therapy for something I'm not going to go into, but it was like the brochure had probably 50, 40 to 50 diagnosis that it helps with, from like muscle cramps to sciatica to like allergies, and I was like what I'm like there's any anything that says that it resets your nervous system and it works.
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For 40 diagnosis is like bro run for the Hills, like there's no way.
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But also too is I think it's the more that I got into the weeds I found that like every system and I kind of took like a lot of courses and like McKenzie, pri, like a lot of the big kind of names I found that once you got down the rabbit hole far enough, it started to get a little funky on like how to really like.
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They kind of seemed a little dogmatic of like you always use this system, you always do these exercises, you always do what we say, and it was like, eh, maybe not.
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So you find that one is that the last, maybe 30% of a lot of systems are like kind of, ooh, maybe I'll use this if I need it and it's appropriate.
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But also, like man, I've read so much pain science and so much mechanical literature and stuff like that.
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A lot of it's overlapping, like the explanation for why it works or what the theoretical like underlying mechanism is is is different in terms of how you explain it.
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But like, how do you know?
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How do you know it is a facet joint versus a capsule, versus a ligament, versus a muscle versus a nerve root?
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You don't really, you know, you're kind of like you know, giving your best educated guess.
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But also with like pain science stuff is, how do you know whether it's truly like a nociceptive thing or maybe it's a, uh, you know, some sort of brain neurotag sensitization?
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Like you really don't know what's under the hood with many people, which, personally, is why I moved and developed like more of like a movement based category which is like a lot of like the best of Stuart McGill plus strength conditioning, and then you layer like workloads and pain science education and a good like SFMA eval on top of that, and so I tend to find for the, you know, the long winded answer to this question is you know, the best way that I approach things is I find myself having much more of a subjective eval than ever before.
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I find myself 20 of the 60 minutes, doing a very good in-depth.
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When did your back pain first start?
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What makes it worse?
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What makes it better?
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You know, when can you last remember the really bad flare up was in your daily life?
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What makes it worse?
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What makes it better?
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Like, what have you tried?
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Like, if you go a really good just conversation with somebody and back to the bio, psychosocial is a lot of people just need a moment to vent and explain that no one's really listened to them.
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They just give them drugs and like said move on.
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If you give them like a really good chance to tell their story, they oftentimes put themselves in a few different categories, like, hmm, this sounds like it's maybe compression intolerant.
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Maybe this sounds flexion intolerant.
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Happened after a couple long days of work, they took a flight somewhere, they tried to deadlift or whatever.
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And so in sports, who are like that too, it's like oh, I had a big outing, you know, I I did two back-to-back hitting lessons and then I went out and I tried to play and my back hurt really bad.
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It's like that kind of sounds, extension, rotation, you know.
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So you go from there and then you do like a good movement based approach and you try to confirm or deny which of those, um, which of those categories maybe, is most present between.
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But, like in your mind, you're like, okay, this sounds like it's flexion or compression intolerant, which means that probably extension is going to make that person feel better or not make them feel worse, and the movement of Val and a bunch of special tests then becomes what tells you you're in the right bucket or not.
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And then you treat someone.
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You treat somebody with exercises.
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You're like you in a couple of days, or have them email you and you just see if you're better, worse or the same.
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You know, along with you have to reduce the workloads of the things that are probably making you sore, you know.
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Definitely yeah, and I like the way that that is organized too, because you're also organizing it by like their deficits.
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So if something is painful, like you know okay, extension rotation is painful then you know you can work in the other like realms and stay neutral for the rest of it.
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Like I feel like it helps you treat based on what you find like it's very easy to just be like okay, I'm testing all these things, okay, you hurt with this, you don't hurt with this, we're going to start here and avoid this and then, like it's very it makes everything much more like simply defined based on the deficits that you're seeing, based on their pain reports.
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And I think, like I think the harder like layer on top of that that is helpful to keep in mind, especially for new grads, is it's hard sometimes when patients come in with, like, a very acute back injury or if they're like even if it's not necessarily cute, but it's kind of that acute on chronic kind of like time is a lot of times I feel like with backs, people just get so flared up that everything hurts.
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So like it may be more difficult at the beginning, like the first time you see them, to really justify like okay, they only hurt with like right rotation and extension but, it might be flared up and flexion hurts and extension hurts and turning right hurts, and just because they're irritated so letting them kind of calm down and I think you did a really good job teaching me at the beginning.
00:17:31.861 --> 00:17:49.285
If you have someone that's really flared up like that and it's hard to kind of delineate which like route they might be or like which bucket they're in, is to just start with everything in neutral spine, like really basic, like let them calm down before you kind of start to tease out maybe what category they would fit into from an injury standpoint.
00:17:49.925 --> 00:17:50.586
Yeah, absolutely.
00:17:50.586 --> 00:18:05.428
And I think in that context you know you have to remember that regardless of whether somebody has a like more of a pain, science explanation of there's no like true tissue damage but it's just really, really sensitive, like a nerve root irritation or some sort of hypersensitivity.
00:18:05.428 --> 00:18:12.008
Or if somebody has a pars fracture and it's true bone inflammation, it's chemical, right, there's some degree of either chemical hypersensitization or very high elevated neural sensitization.
00:18:12.008 --> 00:18:19.070
That, in the same way that if you jumped off a curb and broke your ankle, you know you can't really figure out, is it the ATFL, is the bone, is the capsule?
00:18:19.070 --> 00:18:25.582
You can't really determine what structure is the most cranky because someone is so acutely guarded and so chemically irritated.
00:18:25.582 --> 00:18:37.432
And so having a couple days or a couple of weeks where you just let somebody kind of try to just move as best as they can but like kind of stay in a in a relatively low level of activity, it kind of lets your body do its thing naturally.
00:18:37.432 --> 00:18:44.421
And then after a week or two, you know you have a much better chance of diagnosing somebody properly and putting them into one of those categories.
00:18:44.421 --> 00:18:45.863
And the same thing happens for a shoulder.
00:18:45.863 --> 00:18:49.388
Somebody comes in if they get railed into the boards and their AC joint is super flared up.
00:18:49.388 --> 00:18:50.471
It's like they can barely move.
00:18:50.471 --> 00:18:51.553
They can barely really do stuff.
00:18:51.553 --> 00:18:53.134
They can't do exercises, they don't want to arrange motion.
00:18:53.134 --> 00:18:54.202
All their motion hurts.
00:18:54.202 --> 00:18:55.748
There's no capsular pattern at all, hurts, right.
00:18:55.748 --> 00:18:58.546
There's no exercise that feels comfortable, it's all cranky.
00:18:58.546 --> 00:19:14.980
So you just treat that person more in like a palliative setting of like okay, what can I do to help this person just get out of the oof cycle, right.
00:19:15.000 --> 00:19:19.805
That very acute situation is sometimes where those roles come into play and you led the witness pretty well because that's like the third question someone submitted which we'll get to.
00:19:19.805 --> 00:19:26.244
The second question works out well with this table, which is that somebody asked do you see kissing spine or interspinous ligament pain at L5-S1?
00:19:26.244 --> 00:19:29.871
So for sure, that's like pretty textbook straight extension based pain.
00:19:29.871 --> 00:19:40.046
So a kissing spine or a spinous process impingement is when somebody bends backwards very extremely and their spinous processes bump into each other and get a bone bruise and cause interspinous ligament like irritation.
00:19:40.046 --> 00:19:47.587
So that would be somebody who is doing like gymnastics, dance, diving, circus, like really extreme arching motions, ballet.
00:19:47.587 --> 00:19:52.667
Aesthetically those types of things demand like a lot of spinal motion, like doing bridges or whatever.
00:19:52.667 --> 00:20:06.482
So it's not as common as some other ones, um, but if somebody has, you know, predisposition where they're very lax, so they get put in a sport like that at a young age or they have very like angulated, narrow spinous processes, naturally they're going to be more prone to bump those into each other.
00:20:06.502 --> 00:20:11.348
And I have treated a few cases of people who were just like flexion didn't hurt, rotation didn't hurt, even extension.
00:20:11.348 --> 00:20:12.609
Rotation storks were negative.
00:20:12.609 --> 00:20:17.715
But straight extension, like in a standing backbend or a press up than a PA shear, were extremely painful.
00:20:17.715 --> 00:20:22.461
So that person was treated with non-steroidal anti-inflammatories they were given.
00:20:22.461 --> 00:20:30.750
They took a break off from gymnastics for two weeks and then we dry needled like soft tissue around their spine and then tried to get them as much hip extension mobility as possible.
00:20:30.790 --> 00:20:38.711
The person that I'm thinking about was a gymnast who had like extremely stiff hip flexors, groin quads, because she had grown a lot and she was like more of a kind of a power-based athlete.
00:20:38.711 --> 00:20:42.931
So when she tried to do your Chankos her hips wouldn't move and her back would bend a ton.
00:20:42.931 --> 00:20:57.730
So positive Thomas, positive Faber, um, very, very stiff lower body but her back was just kind of bending at L5 S1 to make up for that and in her case it just happened to be that her spinous processes, essentially what were painful, not her facets or not her, like you know soft tissue, qoi.
00:20:57.730 --> 00:21:17.510
So it's pretty common, uh, you back off the things that are irritable and then, yeah, look at below hips, above their extension shoulders, and then a lot of that stuff is required, is is a lot of strengthening directly at their glutes to try to get their hips to open more, and you just slowly get them back into reverse med ball throws and hip extension exercises and then tumble, track and trampoline and kind of slowly build them back in through it.
00:21:17.510 --> 00:21:20.425
So that's for the second piece.
00:21:20.425 --> 00:21:36.924
And then, yeah, I think the acute painful side I think that and you know that's from kind of like the teaching side is is, I think, when someone's so painful and they can't do anything, what you do with them to educate them, on the other, like 23 hours of their day is way more important than, like, the magic exercise that you give them.
00:21:36.924 --> 00:21:47.284
So people don't oftentimes realize that their pain is probably getting not acutely flared up by things in their daily life, but if they accumulate lots of time throughout their daily life where they don't feel pain and they go to bed.
00:21:47.284 --> 00:21:48.425
They wake up and do the same thing.
00:21:48.425 --> 00:21:55.343
Um, they tend to wake up and feel a little worse each day until eventually they put like, go to bend down and take their shoes and they throw their back out.
00:21:55.343 --> 00:21:55.824
Quote unquote.
00:21:55.864 --> 00:22:05.501
And the example that I always use here is a chemist that I treated named Matt, and he was very frustrated with two years of like multiple PTs and kind of like doing his daily life.
00:22:05.501 --> 00:22:08.307
But he was a chemist and I was like just tell me what your daily life is like before.
00:22:08.307 --> 00:22:11.635
You had back pain originally and got hurt with a squat, really deep squatting.
00:22:11.635 --> 00:22:14.382
And then I was like well, tell me like what your day-to-day life is like.
00:22:14.382 --> 00:22:19.721
I wake up, I take care of my one-year-old, I help my wife, I have breakfast, I drive to the office 40 minutes away.
00:22:19.721 --> 00:22:25.028
I usually sit and do like lab experiments or have meetings, and then I take my lunch break.
00:22:25.028 --> 00:22:26.691
I try to walk, but I do the best I can.
00:22:26.691 --> 00:22:30.454
I drive 40 minutes home, I go to the gym, I warm up and then I work out.
00:22:30.454 --> 00:22:38.278
And when I work out, I do conventional narrow stance deadlifts and squats, because I did some CrossFit stuff and that's what I like to do.
00:22:38.224 --> 00:22:42.938
And I was like all right man, you realize that like nine hours of your day have some degree of rounding or flexion or like kind of like speed forward.
00:22:42.938 --> 00:22:44.521
He's like, oh yeah, I never thought about that life.
00:22:44.521 --> 00:22:55.482
Don't sit in a deep couch, let's try to sit on harder chairs.
00:22:55.482 --> 00:23:00.426
Let's try to go for walks every two hours at the lab, if you can, can you stand or sit or kneel for parts of your experiments?
00:23:00.426 --> 00:23:01.430
And he said you can make it work.
00:23:07.068 --> 00:23:18.142
I said in a meeting just stand in the corner that you don't sit on the couch and get eaten alive, like try to like lie on your stomach or lay on your side or sit in a hardback chair with your family and then every two hours try to do cat cows or press-ups to whatever you could tolerate.
00:23:18.142 --> 00:23:19.468
And it took some time.
00:23:19.468 --> 00:23:22.660
It took probably like a week or two for him to even like consistently do it.
00:23:22.660 --> 00:23:23.340
So he felt better.
00:23:23.340 --> 00:23:25.923
But he probably got 20 better just in that alone.
00:23:25.923 --> 00:23:28.047
No exercises, just that daily life.
00:23:28.047 --> 00:23:30.289
And then from there of course it was like midline core stuff.
00:23:30.289 --> 00:23:37.384
But like what he did on his own was way more important than what I was doing in the clinic for like soft tissue work or dry needling or whatever.
00:23:37.384 --> 00:23:41.488
It gives you a window of like two hours to modulate tone, maybe so you can go do exercises better.
00:23:41.488 --> 00:23:46.827
That's all manual therapy is I agree.
00:23:46.847 --> 00:23:50.902
Yeah I think the education is more important than a lot of the things that we do for a lot of injuries.
00:23:50.902 --> 00:24:00.951
So if we're only seeing them once or twice a week for an hour, I mean we're helping, but they're going to help us out a lot more if they're doing these things every day consistently.
00:24:01.580 --> 00:24:06.680
I think it's just hard sometimes because, like it sets the perception that you're taking the wind out of a PT sales.
00:24:06.680 --> 00:24:11.800
You're like might have a lot of really cool things to try and to do and I don't.
00:24:11.800 --> 00:24:16.001
I don't think that there's not a role for manipulation, dry needling, cupping tool work we do all that kind of stuff, man Like.
00:24:16.022 --> 00:24:19.305
I don't manipulate as much just because it's not my skillset and I work with really loosey goosey people.
00:24:19.305 --> 00:24:31.292
Um, but like all of the things that you put in, like the acute intervention bucket, from exercise to manual therapy to whatever all you're doing is trying to modulate someone's pain levels, right, You're just trying to find a way to get them to be a little bit more.
00:24:31.292 --> 00:24:44.144
And out of the pain science bucket there's a phenomenal analogy about, like an alarm system on a house which I use all the time, is that normally if an alarm has a threshold that's like right in the middle, when the mailman comes up to drop the mail off, the alarm is not triggered.
00:24:44.144 --> 00:24:47.567
But if somebody tries to rob your house and break through a window, that's when the alarm goes off.
00:24:47.567 --> 00:25:03.936
And the analogy you tell people is that when you're worried about somebody you know damaging your house or whatever, if you have an acute sensitization event, your body lowers the threshold of what is deemed threatening or dangerous, right, so it will give you pain protectively to try to make sure that you're on top of it.
00:25:03.936 --> 00:25:17.730
So if you irritate your back over a couple of weeks and then maybe you deadlift and it gets really sore, to that analogy Now, anytime a leaf blows by your house, your alarm system goes off, it gives you pain and you have to reset your baseline level with, you know, avoiding things that are cranky.
00:25:17.750 --> 00:25:18.575
Education, exercise, all that kind of stuff.
00:25:18.575 --> 00:25:20.807
Really, all we're doing is just like a graded exposure to stress.
00:25:20.807 --> 00:25:34.974
You know all exercise, all whatever we're doing to educate somebody is trying to find ways where, okay, well, maybe we can't run, but maybe that you know, like a split squats with body weight are tolerable if we use BFR, or maybe we can tolerate cat cows, or maybe we can tolerate, like bird, dogs and dead bugs, but nothing more.
00:25:34.974 --> 00:25:41.022
And you just do whatever that level is that you're at, until you can kind of raise the threshold higher so that things don't feel as uncomfortable.
00:25:41.022 --> 00:25:42.025
You know what I mean.
00:25:43.528 --> 00:25:43.588
And.
00:25:43.628 --> 00:25:50.269
I think the other thing that comes into mind too is, I think again, new grads, doing less is more, you know, sometimes like a lot of education on the backend for yourself.
00:25:50.269 --> 00:25:52.472
So you can deliver a very simple just like.
00:25:52.472 --> 00:26:04.103
We're going to start with these basic things consistently and then you know, in time we'll do it If you, if you have a good system in place for movement based to vow and kind of like your handful of exercises that you do with people, um, it's pretty easy to you know.
00:26:04.103 --> 00:26:05.285
I wouldn't say it's hard, it sucks.
00:26:05.285 --> 00:26:12.300
Nobody wants to be in pain, you know they.
00:26:12.300 --> 00:26:16.986
So a lot of empathy is required, but the approach sometimes is a little bit simpler than I think people make it out to be.
00:26:17.501 --> 00:26:18.680
Yeah, no, I agree completely.
00:26:18.680 --> 00:26:33.641
I think watching you do like some very simple exercises like simple for PTs at least was really like reassuring as a new grad, Cause it was like even if you had this like high level athlete, they can't do very much anyway.
00:26:33.641 --> 00:26:40.124
So you give them like the most basic exercises like a bird, dog and a dead bug, and you can make those hard enough for them.
00:26:40.124 --> 00:26:45.323
Like they'll still feel shockingly humbled when you give them a certain like form of dead bug.
00:26:45.323 --> 00:26:46.184
That's challenging for them.
00:26:46.595 --> 00:26:53.980
You can still do those things with a neutral spine and like there's lots of other things that you can do while they're not inflection or extension that will challenge them.
00:26:53.980 --> 00:27:07.198
And so getting a little creative with like those kinds of exercises I think is still like super meaningful, especially in the acute phase, to get them to continue like their movement and strength without being in like an aggravating position like flexion or extension.
00:27:07.700 --> 00:27:08.561
Yeah, and then to that.
00:27:08.561 --> 00:27:13.240
I think the on the other side of the coin is that problems come up when maybe it's a PT or an AT or whatever.
00:27:13.240 --> 00:27:24.126
That's all you do right, like that's good for the first like month, maybe if someone has an acute flare, but like you got to get your way away from bird dog dead bug side plank basics right, like you need an intermediate and a more advanced progression.
00:27:24.126 --> 00:27:40.616
And the other side of this question somebody asks is like how do you help somebody get back to sports if they're not in pain and they kind of you know strength conditioning and workloads and stuff, because the athlete is going to need way, way more than the average person.
00:27:41.019 --> 00:27:49.997
So Matt and his example just wanted to get back to like lifting and strength conditioning and he had a newborn daughter that he wanted to take care of so he really needed at the time it was Jonah, one of our strength coaches.
00:27:49.997 --> 00:27:51.057
He needed Jonah more than me.
00:27:51.057 --> 00:27:52.920
It was like modify your program.
00:27:52.920 --> 00:27:57.566
Let's trap bar deadlift, let's box squat, let's do more of our single leg and split squat as like our big loading movements.
00:27:57.566 --> 00:27:59.367
You had a brace properly.
00:27:59.367 --> 00:28:01.270
Add some core stuff in, get these hips moving.
00:28:01.310 --> 00:28:10.928
A bit Like Jonah's strength program probably helped him way more than I did, because no one had ever given him many other options for programming besides just conventional narrow stance, deadlift and squatting Right.
00:28:11.394 --> 00:28:27.265
So for him he kind of stopped it, like I would say the advanced strength phase, cause he just wanted to work out three days a week, take care of his kids and go to work, at which he got back to, whereas someone who's you know, uh, a high level softball player who has a scholarship and is trying to go to a big university in a year after a facet fracture or something like that spondy fracture.
00:28:27.265 --> 00:28:33.824
They need much more plyo, power progressions, you know med ball stuff to prepare their workload before hitting.
00:28:33.824 --> 00:28:47.365
And then eventually, once they get back to it, you just do a needs analysis of what the sport requires aggressive extension or rotation, throwing and running Right and you just toast them on frequency, intensity and repetitions like a baseball program or a running program or an Olympic lifting program.
00:28:47.365 --> 00:28:51.505
That's like knowledge of the sport, but that is how you get somebody that fifth kind of final stage.
00:28:52.115 --> 00:28:52.736
Yeah, I agree.
00:28:52.776 --> 00:29:01.244
I think that I think with the most obvious sports where you're doing a lot of like extension, inflection, people are like, oh yeah, they need to be able to like tolerate a lot of loads in those forces.
00:29:01.724 --> 00:29:11.856
I feel, like with other sports, like rotation gets missed, a lot like being able to like one get into enough rotation, like why are they having back pain?
00:29:11.856 --> 00:29:12.679
Are they missing the rest of rotation?
00:29:12.679 --> 00:29:14.362
And they're used to compensating with their lower back.
00:29:14.362 --> 00:29:18.590
Instead, like trying to figure out, kind of like what you're talking about at the beginning, finding the root of why they might be.
00:29:18.590 --> 00:29:41.576
Like having this injury, especially if it's not like a one, like one-off injury, it's like more of like a acute, like micro um stress type of like trying to figure out what the root is and solving that root and making sure they can maintain it and then working back up to those like those workloads with your back, because your back is ultimately the thing that is stabilizing everything while you're doing anything, so you have to have everything around it strong.
00:29:41.576 --> 00:29:46.799
And then I think, the bracing piece of it too, a lot of, especially with kids like high school athletes.
00:29:46.799 --> 00:29:51.455
They don't know how to brace well, like that's not a skill that they're taught very often.
00:29:51.875 --> 00:29:53.336
Yeah, which leads to.
00:29:53.336 --> 00:30:03.044
You know, the most humbling piece of most of these rehabs for someone who is either active and just wants to be fit like Matt, or someone who's an athlete, is ego checking about.
00:30:03.044 --> 00:30:04.424
Why are you doing so much weight?
00:30:04.424 --> 00:30:05.486
Why are you doing so much load?
00:30:05.486 --> 00:30:06.406
Why do you do this?
00:30:06.406 --> 00:30:09.848
Can we just do a medium intensity adult fitness program?
00:30:09.848 --> 00:30:12.451
Don't need to snatch, don't need to clean and jerk super heavy.
00:30:12.451 --> 00:30:14.271
You could just do a basic strength program.
00:30:14.271 --> 00:30:18.160
It's like that piece, like you could just do a basic strength program is like that piece.
00:30:18.106 --> 00:30:18.902
But honestly, technique is just like a massive thing.
00:30:18.902 --> 00:30:21.990
There's so many like we see this all the time with young kids throwing have like really don't have great mechanics.
00:30:21.990 --> 00:30:24.175
You know, in gymnastics we see like a lot of basics are missing.
00:30:24.175 --> 00:30:25.538
A lot of fundamental technique.
00:30:25.538 --> 00:30:38.877
Things are basic are missing and every sport kind of has this that if you just don't like really work on your baseline level of technique and you know discipline to strengthening those fundamentals, um, and you skip steps, that's where it always comes back to haunt you.
00:30:38.939 --> 00:30:52.115
So along the conversation of usually like advanced to return to sport is hopefully throughout the process you have kind of helped correct some of those basic underlying mobility or strength issues that then at some point you guys say, listen, man, I need to break your heart.
00:30:52.115 --> 00:30:59.910
But like you don't have a great, you know baseball, you know swing, you know you really are not technically doing this well with your hips and you're letting your back take all the load.
00:30:59.910 --> 00:31:12.582
It might be a good idea for us to get you with a hitting coach and kind of, when you're going through your hitting program is, have a coach watch you on your basic dry swings, watch you on your basic soft toss programs and make sure that, before we ramp you to a hundred percent, that you're fixing some of these technical things.
00:31:12.582 --> 00:31:14.344
You know elbow throwing, elbow running.
00:31:14.344 --> 00:31:16.547
I think you know, uh, sprinting techniques.
00:31:16.547 --> 00:31:22.319
Another big one that gets people is they don't really have great sprinting technique and so they're just kind of like hawking themselves around.
00:31:22.319 --> 00:31:25.439
So yeah, I think that's hard, but that's an important part of the conversation.
00:31:25.940 --> 00:31:38.990
Yeah, and I would encourage I think especially for acute back injuries doing a really good reevaluation, like after they've calmed down and you're doing a basic strength program, like that's the time when you need to really assess what their range of motion looks like.
00:31:39.316 --> 00:31:43.527
Like they might be lacking something and you might have just thought previously that it was, oh, because it hurts.
00:31:43.527 --> 00:31:49.700
So they're not moving that range, but doing once they're completely like out of the pain range for normal basic movements and range of motions.
00:31:49.700 --> 00:31:58.648
I think it's really really important to go through everything kind of again and make sure you're taking those measurements and seeing if they're missing anything big in to go through everything kind of again and make sure you're taking those measurements and seeing if they're missing anything big.
00:31:58.648 --> 00:32:10.057
You can work on that and they can improve their technique, because if they're missing the range of motion to improve a certain type of technique that they need, then they're not going to be able to just get there or they're going to end up back in the same place that they were previously Go back to their sport.
00:32:10.957 --> 00:32:11.637
Yeah, absolutely.
00:32:11.637 --> 00:32:19.102
I agree it does work out not to sales pitch this, but the week this podcast comes out, myself and Mike actually just finished back pain course.
00:32:19.102 --> 00:32:21.503
So Mike and I have been working on this for like 10 years.
00:32:21.503 --> 00:32:25.685
I feel like I finally got my ish together and put this all into one format.
00:32:25.685 --> 00:32:38.193
But yeah, mike and I have shared a lot of ideas over the years and I've seen I think I've seen 1000 people for back pain Like I'm not even shitting you, I think that's how many people I've seen over 10 years, which I wish I didn't have to but essentially all the stuff that we're talking about we put into short little course.
00:32:38.193 --> 00:32:40.299
You know, see your prove where you can kind of learn all this stuff.
00:32:40.299 --> 00:32:58.188
If you wanted to hang out with me in the clinic and see how I treat athletes for back pain, oh, jen King, speaking of which it'll give you, uh, the movement misclassifications, the literature reviews, like all of our sport progressions, exercise, manual therapy, needling, all that kind.
00:32:58.117 --> 00:33:00.067
So, yeah, mike and I finally had time after the mentorship was close to sit down and do this.
00:33:00.067 --> 00:33:01.244
So get all our lectures and then I think it's a hundred dollars off the week that it's coming out.
00:33:01.244 --> 00:33:02.707
So I'll put the link in the show notes.
00:33:02.707 --> 00:33:05.875
But I tried to make the course that I wish I had when I was a new grad.
00:33:05.875 --> 00:33:07.478
That's kind of what I essentially did.
00:33:07.478 --> 00:33:09.640
So if it helps people, that'd be really great.
00:33:09.640 --> 00:33:12.343
But yeah, I don't know, I feel like I wish I had this when I was younger.
00:33:12.343 --> 00:33:15.366
I mean, you kind of got me, but it'd be sick to have a six hour course.
00:33:15.366 --> 00:33:18.770
You know you're in this course, by the way, the videos, yeah.
00:33:19.954 --> 00:33:21.058
Hopefully it's not my jumping.
00:33:21.580 --> 00:33:22.344
No, actually it is.
00:33:22.344 --> 00:33:26.520
It's your broad jumping with Wyatt, it's all like the way that they are.
00:33:26.520 --> 00:33:27.884
The core progressions.
00:33:27.884 --> 00:33:29.188
No, you were good, you're killing it.
00:33:29.188 --> 00:33:34.980
I take the photos with Jen and then I film the course with you, and then Mike and I waited a couple of years to get other stuff done before we finished it.
00:33:35.000 --> 00:33:37.623
And there's Courtney speaking of another OG student.
00:33:37.623 --> 00:33:37.942
Look at us.
00:33:37.942 --> 00:33:41.266
Go, courtney, shout out Okay, anywho.
00:33:41.266 --> 00:33:43.188
Yeah, if you want the course you know, check it out.
00:33:43.188 --> 00:33:44.829
A hundred bucks off tonight, tonight this week.
00:33:44.829 --> 00:33:47.352
It's in the show notes for links, but I think we cover the rest of it.
00:33:47.352 --> 00:33:48.315
Those are all the questions that we had.
00:33:48.315 --> 00:33:49.839
So anything else on this?
00:33:49.839 --> 00:33:52.416
We got it All right, friends.
00:33:52.416 --> 00:33:52.617
We.