August 5, 2025 • 34 mins
Get $100 off my brand new course, Rehabilitation of Athletic Low Back Pain, with Mike Reinold!
https://mikereinold.com/athletic-low-back-evaluation-treatment-online-course/
We tackle how to assess and treat different types of back pain, combining evidence-based approaches with movement-based classifications that actually work for athletes and active individuals.
• Creating a systematic approach to back pain starts with understanding whether it's chronic sensitization or repeated acute flare-ups
• Clinical Practice Guidelines (CPGs) often provide overwhelming lists of possible treatments without clear direction
• Differentiating between extension-intolerant, flexion-intolerant, and compression-intolerant patterns guides treatment
• Daily habits and postures often contribute more to pain than specific incidents
• Modifying activities throughout the day helps reset pain sensitivity - "like recalibrating an alarm system"
• Education about what patients do outside of PT is often more important than any specific exercise
• For athletes, progression must include sport-specific movements and correcting technical flaws
• Basic exercises like bird dogs and dead bugs are starting points, not complete solutions
• Return to sport requires gradual progression through strength, power, and sport-specific movements
• Proper bracing techniques and movement patterns are essential for long-term prevention
Check out our comprehensive back pain course at the link in the show notes - $100 off this week only!
We appreciate you listening!
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 2 (00:05):
every day.
You essentially pay your duesby doing the harder thing when
it's the right thing to do.
I have been very good abouttrying to not work after five
o'clock on fridays and have allthe way through sunday at like
five o'clock.
I'm trying to get a full 48hours of whatever I want.
I'm doing pretty good.
The last three weekends havebeen like friends, family went
out.
It's like a sweet jazz band intown that I went to.
So, yeah, I'm doing good this.
(00:26):
The last three weekends havebeen like friends, family went
out.
It's like a sweet jazz band intown that I went to.
So, yeah, I'm doing good.
This is the last thing I haveto do today, and then after that
I'm done, yeah, same.
Yep, um, back in action.
We needed a much needed uh, two, three break.
I don't know what it was, but,uh, aaliyah was busy and I was
also super busy with some stufftoo.
So so, yeah, it's just thenature of the podcast is it's
here for when we can recordstuff, we will, and if we don't
have anything cool to talk about, we won't.
(00:46):
But now we have some things totalk about.
So I think I forget what thelast episodes we left off of,
but we definitely want to coversome stuff on back pain, because
that was one that was submitted.
Somebody asked about hip andlabor repair, so we'll do that
next week.
And then the last one in thethird week is somebody who was
asking about um, season iscoming up quickly, which is
crazy to say, cause we'rerecording in summer, but you
(01:07):
know, in the blink of an eyeI'll be like people back to
school and stuff.
So, yeah, we'll start with backpain stuff today.
And, uh, it actually kind ofworked out because you were like
kind of around at champion whenwe were going through like
developing all these systems,and I think that like a lot of
this stuff carries through.
But, yeah, we'll start it withthis.
So Jess submitted via Instagram.
She said how do you assess whatkind of low back pain it is and
(01:28):
then how do you approach it?
So pretty broad question, butI'll share my thoughts from the
outline that I had and then someresearch that we have, and then
you know we can chat back andforth.
But I essentially came out ofschool in 2013 when the CPGs the
clinical prediction guidelineswere first getting very popular.
So I think 11 maybe was thefirst one and there was an
update in 16.
But essentially that was likelooking at things through the
(01:49):
lens of like what is theevidence that people have and
like what category they fallinto for treatment.
So there was like themanipulation side, there was the
stabilization side, there was Iforget the other ones off the
top of my head but essentiallylike category based things and I
think that was super helpful.
I think that was a good start,um, but also during that time
was very much like the largegrowth of pain science and a lot
(02:10):
of people putting like chroniclow back pain, non-specific low
back pain.
So there's a lot of work thatcame out from like Lorna Mosley,
adrian Lau, uh, pretty much onpeople who are like really not
responding well to traditionaltreatment and they're kind of
getting like truly sensitized.
They're really it's affectingtheir whole life.
Um, and then my kind of storyis that I learned all of that
and I was using it.
But then I started gettinginvolved in like sports uh, more
(02:32):
particularly like middle tohigh level sports, high school
and college and I found thatwhile that stuff was helpful, um
, it definitely did not kind ofcover the whole gamut,
particularly because sportsrequire like very high loads,
very high workloads.
So I kind of found the work oflike Stu McGill more like the
strength and conditioning side,and I think that's more
classified like the mechanicalbucket.
So that was kind of how I wentthrough my traditional, maybe
(02:54):
the first six to seven years ofschool, and between like pain
science, the evidence-basedclassifications and then more of
the movement-based or kind ofmechanical-based approach, I
find myself just mushing themall together and using kind of
what I needed in front of me.
So yeah, that was my kind ofjourney.
What was yours?
Did you guys get taught theCPGs and then pain science stuff
or like, how did you come to?
Speaker 1 (03:14):
Yeah, I feel like it's kind of similar, like we
learned like buckets of backpain, but then, like that didn't
really apply very well in thesports world, particularly, I
think, in the adult world itfeels like it applies a little
bit more easily, I feel likewhen their pain is more
identifiable.
So they're like oh, it hurtswhen I'm sitting, yeah, exactly.
(03:35):
I feel like we learned verystrict buckets for back pain and
then we also learned thatthere's going to be just
generalized chronic back pain inits own bucket.
But then obviously I workedwith you like while I was still
in school, so I got the benefitof learning kind of your
structure and I know I thinkthis is probably I don't know
how early on you made this, butyou would always go up on the
(03:56):
whiteboard and like draw thatchart.
Speaker 2 (03:58):
Yes.
Speaker 1 (03:58):
Of like the different things you would look for.
Speaker 2 (04:01):
I will, I'll actually buy some time in a minute and
I'll pull that chart up forpeople.
But, um, yeah, I would agreewith that.
I think you were probably justI mean, I don't remember how far
I was at a school when you camebut like, I was kind of like in
the throes of trying to sortout like a system and how to
approach stuff.
Because what I found and youknow, mike was a big instrument
in this is that there's a verybig difference between chronic
back pain and like acutere-injury of the same thing over
(04:23):
and over again.
So chronic back pain is someonewho has one bout of pain or a
couple of butts of pain and thatnever quite resolves and they
become centrally sensitized, solike they truly have nervous
system level changes.
Um, you know, uh, there's awhole laundry list of stuff that
changes, but it's really likesomeone who has a couple of
events and then for many otherissues biopsychosocial, their
job, whatever they don't getover that one bout of back pain
(04:46):
and it kind of continues tomaintain a lot of like changes
in sensitivity.
And there's definitely a lot ofpeople 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.
But that's really not what Isee.
You know, those, in my opinionfrom the you know, I'd like two
or three years of a lot ofchronic back pain before sports
and that tended to be somebodywho was like really under active
(05:08):
, you know, they tended to notreally work out consistently,
they had a day job or they werereally busy and they, you know
there were a lot of other thingsrelated to like their sleep,
their nutrition, theirpsychological status, their work
status, their marriage, theirspouse, whatever that were
clearly influencing their youknow worries and their fears and
they kind of fit thetraditional mold of
biopsychosocial model.
But again, that was like oneperson who had out of back pain
(05:28):
and continued to kind of not getimprovements.
I found that I did see thatquite a bit and you would use
strategies from Adrian Lowne,stuff to teach them and stuff.
But chronic re-injury of thesame thing is more what I see
now, which is like there is aroot provoking factor, whether
it's workload, strength,conditioning, you know, mobility
or strength or kind of thatstuff and they have one bout of
pain it gets almost all the waybetter, and then another bout of
(05:52):
pain on top of that which thenthey don't really resolve fully.
So it's not like they're likeone thing is chronic.
It's that they constantly havespikes of like a little bit of a
set thing, a little bit of aset thing, and they get a little
bit of a set thing and they geta little bit of a stress
reaction thing, then a littlebit of a spondy thing, and it
kind of keeps coming and going.
But once you get to the rootlevel oftentimes a combination
of educating them about theirdaily life and then also
mechanical symptoms, which we'lltalk about next that is when
(06:13):
they see resolution, when youfinally play with the chessboard
of like maybe some of the rootlevel type stuff like that.
So, yeah, I find that all thethings I had learned were very,
very helpful.
Um, and I can share a couplearticles that we have.
So this is kind of a um, oh,not that one.
This one is a recent systematicreview that kind of looks at
like everything right.
It's looking at just likegeneral guidelines for low back
(06:34):
pain management and you know, Iread through it and it was
helpful.
I don't think it was earthshattering for like things that
it was new.
I don't think we've learned aton more but this.
There was a section of thiswhich I think completely sums up
like the frustration many gradshave with low back pain.
If I can find it, it was kindof saying, like all the things,
here we go, so Denmark, allthese studies, and then
essentially they're saying thattargeted recommendations
(06:56):
regarding acute, subacute andchronic low back pain right
across all these things andduration of symptoms, the things
that are helpful, is, I'm goingto find it.
Pardon my pause here.
Let me find this actually I'mtrying to read to my secondary
screen it's not working, butit's essentially it's going to
outline that, like everythingfrom medicine to every type of
(07:18):
exercise, is very helpful forthese people and it starts to be
oh, here we go.
So acute low back pain, right,so this is what they so.
Acute low back pain, right.
So this is what they recommendfor acute low back pain NSAIDs,
therapeutic exercise, spinalmanipulation, opioids, heat
massage, acupuncture, musclerelaxation, spinal mobilization,
self management, paracetamol,returning to work, progressive
muscle relaxation, reassurance,avoidance, belief training,
(07:39):
cognitive behavioral therapy,postural therapy, laser therapy,
diathermy, laser therapy,short-term diaphragm, cold
therapy, antidepressants thoseare all things that are useful
for acute back pain.
And then another CPGrecommended mindfulness-based
stress reduction, tens, lumbarsupports, back school
interferential current therapy,electromuscular stimulation,
anti-epileptic drugs, herbalmedicines, shockwave therapy,
(08:00):
back school multidisciplinarytreatment.
What the hell do you do withsomebody when you look at a CPG
in a 13 CPGs say that for acuteback pain, someone walks and
says I hurt my back over theweekend.
You have that laundry list ofshit to try to do with them,
right, and each of those is soinsanely generic, right.
Massage, multidisciplinarytreatment like that is so
(08:22):
insanely large of a treatmentthing.
So that's the problem thatcomes up with some of these
large cpgs and this issystematic view of cpgs.
It's great right.
Subacute back pain exact samething.
Chronic low back pain like agiant paragraph of arguably 20
to 25 things that have someevidence, mixed uh populations,
mixed chronicity, mixed uh goals, mixed diagnostics.
(08:43):
It makes it extremely hard fora new grad who comes out and
read this and says, oh yeah,look, I found this great.
You know, systematic review ofCPGs.
What do you do with thesepeople?
Like how the hell do youorganize?
Just chronologically, go one byone and hope that something
works?
Like that was.
My personal frustration is thatI was reading all this evidence
and I did not find as though itwas very helpful, which again
leads to like something that'smore specific.
(09:03):
Like this is more of amechanical article that's
talking about the use of McGillexercises for someone who has,
you know, some functionaldisability, chronical back pain
again, how they specify thatversus this is more of like a
pain science education typething, which is more about
saying that teaching someoneabout their back pain and
understanding their life isprobably helpful too as well.
So I personally found that Ineeded to do more of like a
(09:23):
movement-based category, whichis what we'll talk about next,
but I don't know if you sharethe same frustration with when
you were trying to read evidenceas a student or a new grad.
It's like how the hell do youinterpret a paper like that?
And not to mention there'sprobably 50 more articles out
there on, you know,recommendations for back pain
yeah, no, definitely.
Speaker 1 (09:37):
I felt exactly the same way because I I feel like
everything was like everybodyhas back pain.
Uh, you can treat it all thesedifferent ways.
None of them are great.
They're all okay and good luck.
And then it was like therecurrence of back pain too,
like the research on that isalso like really high recurrence
levels.
If you don't treat, like, ifyou can't figure out, I think,
the lifestyle factors of thepain science contributors, I
(09:59):
think the recurrence rate'sreally high.
Um, and I I feel like I likedthe mechanical models too, but
then sometimes when I'm treatingmechanical model and I think
it's more acute, the recurrencelike I'll have kids that'll keep
coming back to me Like am I nottouching on something that's a
little bit more like chronic?
Like are we?
Are we treating all of theselike pain science factors or
(10:21):
like something in their daily?
Speaker 2 (10:24):
life, I think um I think one thing that's really
hard is as a new grad, I thinkyou 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 likewhat you, what you want to find
, you find on social media,right.
So, like I remember, there aretimes when it was like in in a
broad range of people, a bunchof exercises help for somebody
(10:45):
with back pain.
It's like there was that campwhich is like do everything, do
like manipulation, do exercises,do McGill, do PRI, do SFMA and
all this stuff.
And then, literally in theexact same vein, you had social
media accounts that were likewell, back pain, nothing works
for back pain.
You know back pain is a normal,it's like a very common thing.
Everyone gets back pain, nomatter what.
So like they don't need PT toget better with time.
(11:08):
You just leave them alone.
You know rest in time is nobetter than PT or injection or
whatever it's like okay.
So somebody comes to you withacute ripping sciatica and
you're going to tell themexercise, you're going to get
the pain.
Science, education, like how inthe world, with the resources
(11:29):
available, do you go through asystematic approach?
And then, on the other side.
Just don't be like, yeah, well,you know, strength deadlifts
are good for back pain.
So like, go deadlifts and likegood luck.
Like I can't tell you how manypeople get worse with just
advice like that.
And I find that I'd beextremely frustrated if I hadn't
had, like the availableresources to take courses and do
stuff and then have mentorshipfrom people who were like had
years in their belt.
If you were like in the middleof Ohio or Iowa there was no
(11:52):
great centers around that areathletic based and someone keeps
coming to you for back pain,like I think you just get
frustrated, throw your hands upand give them the best you can,
but then, like I don't know,good luck.
You know I feel really bad forthose tech screws.
Speaker 1 (12:02):
Yeah, no, I completely agree.
I was lucky to have you early onin undergrad.
I feel like I helped sort mybrain out a little bit more with
that kind of stuff.
But I think it really depends alot on where you work, because
I feel like if you're workinglike more in the sports world,
you get a much different likedemographic usually of what kind
of back injury they're dealingwith, versus like working in
like an outpatient ortho, whereyou're getting a lot of like
(12:23):
older people who may just belike sitting at a desk all day
and, yeah, maybe a lot oftreatments work because they're
sitting down all day and theyjust need to move or they just
need like a little bit of tlcfrom somebody because their life
is stressful.
So it's hard to sort it outbased on the person.
And I think from an exercisestandpoint, there's so much like
you're talking about onInstagram.
(12:44):
It's like I feel like everyother reel that I pull up is
like this exercise will fixeveryone's back pain and I'm
like sure Everybody will becured by this one exercise.
I'm sure.
Speaker 2 (12:54):
Yeah, I think you you kind of learn to put your
defenses up as you get a littlemore experience in your grad.
But anybody, I'm not going togo into it, but there was a
brochure dropped off at ourclinic that had some therapy for
something I'm not going to gointo, but it was like the
brochure had probably 50, 40 to50 diagnosis that it helps with,
from like muscle cramps tosciatica to like allergies, and
(13:14):
I was like what I'm like there'sany anything that says that it
resets your nervous system andit works.
For 40 diagnosis is like brorun for the Hills, like there's
no way.
But also too is I think it'sthe more that I got into the
weeds I found that like everysystem and I kind of took like a
lot of courses and likeMcKenzie, pri, like a lot of the
big kind of names I found thatonce you got down the rabbit
(13:36):
hole far enough, it started toget a little funky on like how
to really like.
They kind of seemed a littledogmatic of like you always use
this system, you always do theseexercises, you always do what
we say, and it was like, eh,maybe not.
So you find that one is thatthe 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.
But also, like man, I've read somuch pain science and so much
(13:58):
mechanical literature and stufflike that.
A lot of it's overlapping, likethe explanation for why it
works or what the theoreticallike underlying mechanism is is
is different in terms of how youexplain it.
But like, how do you know?
How do you know it is a facetjoint versus a capsule, versus a
ligament, versus a muscleversus a nerve root?
You don't really, you know,you're kind of like you know,
giving your best educated guess.
(14:19):
But also with like pain sciencestuff is, how do you know
whether it's truly like anociceptive thing or maybe it's
a, uh, you know, some sort ofbrain neurotag sensitization?
Like you really don't knowwhat's under the hood with many
people, which, personally, iswhy I moved and developed like
more of like a movement basedcategory which is like a lot of
like the best of Stuart McGillplus strength conditioning, and
then you layer like workloadsand pain science education and a
(14:39):
good like SFMA eval on top ofthat, and so I tend to find for
the, you know, the long windedanswer to this question is you
know, the best way that Iapproach things is I find myself
having much more of asubjective eval than ever before
.
I find myself 20 of the 60minutes, doing a very good
in-depth.
When did your back pain firststart?
What makes it worse?
What makes it better?
You know, when can you lastremember the really bad flare up
(14:59):
was in your daily life?
What makes it worse?
What makes it better?
Like, what have you tried?
Like, if you go a really goodjust conversation with somebody
and back to the bio,psychosocial is a lot of people
just need a moment to vent andexplain that no one's really
listened to them.
They just give them drugs andlike said move on.
If you give them like a reallygood chance to tell their story,
they oftentimes put themselvesin a few different categories,
like, hmm, this sounds like it'smaybe compression intolerant.
(15:20):
Maybe this sounds flexionintolerant.
Happened after a couple longdays of work, they took a flight
somewhere, they tried todeadlift or whatever.
And so in sports, who are likethat too, it's like oh, I had a
big outing, you know, I I didtwo back-to-back hitting lessons
and then I went out and I triedto play and my back hurt really
bad.
It's like that kind of sounds,extension, rotation, you know.
So you go from there and thenyou do like a good movement
based approach and you try toconfirm or deny which of those,
(15:46):
um, which of those categoriesmaybe, is most present between.
But, like in your mind, you'relike, okay, this sounds like
it's flexion or compressionintolerant, which means that
probably extension is going tomake that person feel better or
not make them feel worse, andthe movement of Val and a bunch
of special tests then becomeswhat tells you you're in the
right bucket or not.
And then you treat someone.
You treat somebody withexercises.
You're like you in a couple ofdays, or have them email you and
you just see if you're better,worse or the same.
(16:13):
You know, along with you haveto reduce the workloads of the
things that are probably makingyou sore, you know.
Speaker 1 (16:17):
Definitely yeah, and I like the way that that is
organized too, because you'realso organizing it by like their
deficits.
So if something is painful, likeyou know okay, extension
rotation is painful then youknow you can work in the other
like realms and stay neutral forthe rest of it.
Like I feel like it helps youtreat based on what you find
like it's very easy to just belike okay, I'm testing all these
things, okay, you hurt withthis, you don't hurt with this,
(16:38):
we're going to start here andavoid this and then, like it's
very it makes everything muchmore like simply defined based
on the deficits that you'reseeing, based on their pain
reports.
And I think, like I think theharder like layer on top of that
that is helpful to keep in mind, especially for new grads, is
it's hard sometimes whenpatients come in with, like, a
very acute back injury or ifthey're like even if it's not
(17:01):
necessarily cute, but it's kindof that acute on chronic kind of
like time is a lot of times Ifeel like with backs, people
just get so flared up thateverything hurts.
So like it may be more difficultat the beginning, like the
first time you see them, toreally justify like okay, they
only hurt with like rightrotation and extension but, it
(17:22):
might be flared up and flexionhurts and extension hurts and
turning right hurts, and justbecause they're irritated so
letting them kind of calm downand I think you did a really
good job teaching me at thebeginning.
If you have someone that'sreally flared up like that and
it's hard to kind of delineatewhich 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
(17:42):
calm down before you kind ofstart to tease out maybe what
category they would fit intofrom an injury standpoint.
Speaker 2 (17:49):
Yeah, absolutely.
And I think in that context youknow you have to remember that
regardless of whether somebodyhas a like more of a pain,
science explanation of there'sno like true tissue damage but
it's just really, reallysensitive, like a nerve root
irritation or some sort ofhypersensitivity.
Or if somebody has a parsfracture and it's true bone
inflammation, it's chemical,right, there's some degree of
either chemicalhypersensitization or very high
(18:10):
elevated neural sensitization.
That, in the same way that ifyou jumped off a curb and broke
your ankle, you know you can'treally figure out, is it the
ATFL, is the bone, is thecapsule?
You can't really determine whatstructure is the most cranky
because someone is so acutelyguarded and so chemically
irritated.
And so having a couple days ora couple of weeks where you just
let somebody kind of try tojust move as best as they can
(18:31):
but like kind of stay in a in arelatively low level of activity
, it kind of lets your body doits thing naturally.
And then after a week or two,you know you have a much better
chance of diagnosing somebodyproperly and putting them into
one of those categories.
And the same thing happens fora shoulder.
Somebody comes in if they getrailed into the boards and their
AC joint is super flared up.
It's like they can barely move.
They can barely really do stuff.
They can't do exercises, theydon't want to arrange motion.
(18:53):
All their motion hurts.
There's no capsular pattern atall, hurts, right.
There's no exercise that feelscomfortable, it's all cranky.
So you just treat that personmore in like a palliative
setting of like okay, what can Ido to help this person just get
out of the oof cycle, right.
(19:15):
That very acute situation issometimes where those roles come
into play and you led thewitness pretty well because
that's like the third questionsomeone submitted which we'll
get to.
The second question works outwell with this table, which is
that somebody asked do you seekissing spine or interspinous
ligament pain at L5-S1?
So for sure, that's like prettytextbook straight extension
based pain.
So a kissing spine or a spinousprocess impingement is when
somebody bends backwards veryextremely and their spinous
(19:36):
processes bump into each otherand get a bone bruise and cause
interspinous ligament likeirritation.
So that would be somebody whois doing like gymnastics, dance,
diving, circus, like reallyextreme arching motions, ballet.
Aesthetically those types ofthings demand like a lot of
spinal motion, like doingbridges or whatever.
So it's not as common as someother ones, um, but if somebody
(19:56):
has, you know, predispositionwhere they're very lax, so they
get put in a sport like that ata young age or they have very
like angulated, narrow spinousprocesses, naturally they're
going to be more prone to bumpthose into each other.
And I have treated a few casesof people who were just like
flexion didn't hurt, rotationdidn't hurt, even extension.
Rotation storks were negative.
But straight extension, like ina standing backbend or a press
up than a PA shear, wereextremely painful.
(20:17):
So that person was treated withnon-steroidal
anti-inflammatories they weregiven.
They took a break off fromgymnastics for two weeks and
then we dry needled like softtissue around their spine and
then tried to get them as muchhip extension mobility as
possible.
The person that I'm thinkingabout was a gymnast who had like
extremely stiff hip flexors,groin quads, because she had
grown a lot and she was likemore of a kind of a power-based
(20:38):
athlete.
So when she tried to do yourChankos her hips wouldn't move
and her back would bend a ton.
So positive Thomas, positiveFaber, um, very, very stiff
lower body but her back was justkind of bending at L5 S1 to
make up for that and in her caseit just happened to be that her
spinous processes, essentiallywhat were painful, not her
facets or not her, like you knowsoft tissue, qoi.
So it's pretty common, uh, youback off the things that are
(21:00):
irritable and then, yeah, lookat below hips, above their
extension shoulders, and then alot of that stuff is required,
is is a lot of strengtheningdirectly at their glutes to try
to get their hips to open more,and you just slowly get them
back into reverse med ballthrows and hip extension
exercises and then tumble, trackand trampoline and kind of
slowly build them back inthrough it.
So that's for the second piece.
And then, yeah, I think theacute painful side I think that
(21:24):
and you know that's from kind oflike the teaching side is is, I
think, when someone's sopainful and they can't do
anything, what you do with themto educate them, on the other,
like 23 hours of their day isway more important than, like,
the magic exercise that you givethem.
So people don't oftentimesrealize that their pain is
probably getting not acutelyflared up by things in their
daily life, but if theyaccumulate lots of time
(21:45):
throughout their daily lifewhere they don't feel pain and
they go to bed.
They wake up and do the samething.
Um, they tend to wake up andfeel a little worse each day
until eventually they put like,go to bend down and take their
shoes and they throw their backout.
Quote unquote.
And the example that I alwaysuse here is a chemist that I
treated named Matt, and he wasvery frustrated with two years
of like multiple PTs and kind oflike doing his daily life.
(22:05):
But he was a chemist and I waslike just tell me what your
daily life is like before.
You had back pain originallyand got hurt with a squat,
really deep squatting.
And then I was like well, tellme like what your day-to-day
life is like.
I wake up, I take care of myone-year-old, I help my wife, I
have breakfast, I drive to theoffice 40 minutes away.
I usually sit and do like labexperiments or have meetings,
and then I take my lunch break.
I try to walk, but I do thebest I can.
(22:26):
I drive 40 minutes home, I goto the gym, I warm up and then I
work out.
And when I work out, I doconventional narrow stance
deadlifts and squats, because Idid some CrossFit stuff and
that's what I like to do.
And I was like all right man,you realize that like nine hours
of your day have some degree ofrounding or flexion or like
kind of like speed forward.
He's like, oh yeah, I neverthought about that life.
Don't sit in a deep couch,let's try to sit on harder
(22:55):
chairs.
Let's try to go for walks everytwo hours at the lab, if you
can, can you stand or sit orkneel for parts of your
experiments?
And he said you can make itwork.
I said in a meeting just standin the corner that you don't sit
on the couch and get eatenalive, like try to like lie on
your stomach or lay on your sideor sit in a hardback chair with
your family and then every twohours try to do cat cows or
(23:16):
press-ups to whatever you couldtolerate.
And it took some time.
It took probably like a week ortwo for him to even like
consistently do it.
So he felt better.
But he probably got 20 betterjust in that alone.
No exercises, just that dailylife.
And then from there of courseit was like midline core stuff.
But like what he did on his ownwas way more important than
what I was doing in the clinicfor like soft tissue work or dry
needling or whatever.
(23:37):
It gives you a window of liketwo hours to modulate tone,
maybe so you can go do exercisesbetter.
That's all manual therapy is Iagree.
Speaker 1 (23:46):
Yeah I think the education is more important than
a lot of the things that we dofor a lot of injuries.
So if we're only seeing themonce or twice a week for an hour
, I mean we're helping, butthey're going to help us out a
lot more if they're doing thesethings every day consistently.
Speaker 2 (24:01):
I think it's just hard sometimes because, like it
sets the perception that you'retaking the wind out of a PT
sales.
You're like might have a lot ofreally cool things to try and
to do and I don't.
I don't think that there's nota role for manipulation, dry
needling, cupping tool work wedo all that kind of stuff, man
Like.
I don't manipulate as much justbecause it's not my skillset and
I work with really looseygoosey people.
Um, but like all of the thingsthat you put in, like the acute
(24:22):
intervention bucket, fromexercise to manual therapy to
whatever all you're doing istrying to modulate someone's
pain levels, right, You're justtrying to find a way to get them
to be a little bit more.
And out of the pain sciencebucket there's a phenomenal
analogy about, like an alarmsystem on a house which I use
all the time, is that normallyif an alarm has a threshold
that's like right in the middle,when the mailman comes up to
drop the mail off, the alarm isnot triggered.
(24:44):
But if somebody tries to robyour house and break through a
window, that's when the alarmgoes off.
And the analogy you tell peopleis that when you're worried
about somebody you know damagingyour house or whatever, if you
have an acute sensitizationevent, your body lowers the
threshold of what is deemedthreatening or dangerous, right,
so it will give you painprotectively to try to make sure
that you're on top of it.
So if you irritate your backover a couple of weeks and then
(25:05):
maybe you deadlift and it getsreally sore, to that analogy Now
, anytime a leaf blows by yourhouse, your alarm system goes
off, it gives you pain and youhave to reset your baseline
level with, you know, avoidingthings that are cranky.
Education, exercise, all thatkind of stuff.
Really, all we're doing is justlike a graded exposure to
stress.
You know all exercise, allwhatever we're doing to educate
somebody is trying to find wayswhere, okay, well, maybe we
can't run, but maybe that youknow, like a split squats with
(25:28):
body weight are tolerable if weuse BFR, or maybe we can
tolerate cat cows, or maybe wecan tolerate, like bird, dogs
and dead bugs, but nothing more.
And you just do whatever thatlevel is that you're at, until
you can kind of raise thethreshold higher so that things
don't feel as uncomfortable.
You know what I mean.
Speaker 1 (25:43):
And.
Speaker 2 (25:43):
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 ofeducation on the backend for
yourself.
So you can deliver a verysimple just like.
We're going to start with thesebasic things consistently and
then you know, in time we'll doit If you, if you have a good
system in place for movementbased to vow and kind of like
your handful of exercises thatyou do with people, um, it's
pretty easy to you know.
(26:04):
I wouldn't say it's hard, itsucks.
Nobody wants to be in pain, youknow they.
So a lot of empathy is required, but the approach sometimes is
a little bit simpler than Ithink people make it out to be.
Speaker 1 (26:17):
Yeah, no, I agree completely.
I think watching you do likesome very simple exercises like
simple for PTs at least wasreally like reassuring as a new
grad, Cause it was like even ifyou had this like high level
athlete, they can't do very muchanyway.
So you give them like the mostbasic exercises like a bird, dog
and a dead bug, and you canmake those hard enough for them.
(26:40):
Like they'll still feelshockingly humbled when you give
them a certain like form ofdead bug.
That's challenging for them.
You can still do those thingswith a neutral spine and like
there's lots of other thingsthat you can do while they're
not inflection or extension thatwill challenge them.
And so getting a littlecreative with like those kinds
(27:02):
of exercises I think is stilllike super meaningful,
especially in the acute phase,to get them to continue like
their movement and strengthwithout being in like an
aggravating position likeflexion or extension.
Speaker 2 (27:07):
Yeah, and then to that.
I think the on the other sideof the coin is that problems
come up when maybe it's a PT oran AT or whatever.
That's all you do right, likethat's good for the first like
month, maybe if someone has anacute flare, but like you got to
get your way away from bird dogdead bug side plank basics
right, like you need anintermediate and a more advanced
progression.
And the other side of thisquestion somebody asks is like
how do you help somebody getback to sports if they're not in
(27:34):
pain and they kind of you knowstrength conditioning and
workloads and stuff, because theathlete is going to need way,
way more than the average person.
So Matt and his example justwanted to get back to like
lifting and strengthconditioning and he had a
newborn daughter that he wantedto take care of so he really
needed at the time it was Jonah,one of our strength coaches.
He needed Jonah more than me.
It was like modify your program.
Let's trap bar deadlift, let'sbox squat, let's do more of our
(27:55):
single leg and split squat aslike our big loading movements.
You had a brace properly.
Add some core stuff in, getthese hips moving.
A bit Like Jonah's strengthprogram probably helped him way
more than I did, because no onehad ever given him many other
options for programming besidesjust conventional narrow stance,
deadlift and squatting Right.
So for him he kind of stopped it, like I would say the advanced
strength phase, cause he justwanted to work out three days a
(28:15):
week, take care of his kids andgo to work, at which he got back
to, whereas someone who's youknow, uh, a high level softball
player who has a scholarship andis trying to go to a big
university in a year after afacet fracture or something like
that spondy fracture.
They need much more plyo, powerprogressions, you know med ball
stuff to prepare their workloadbefore hitting.
And then eventually, once theyget back to it, you just do a
(28:36):
needs analysis of what the sportrequires aggressive extension
or rotation, throwing andrunning Right and you just toast
them on frequency, intensityand repetitions like a baseball
program or a running program oran Olympic lifting program.
That's like knowledge of thesport, but that is how you get
somebody that fifth kind offinal stage.
Speaker 1 (28:52):
Yeah, I agree.
I think that I think with themost obvious sports where you're
doing a lot of like extension,inflection, people are like, oh
yeah, they need to be able tolike tolerate a lot of loads in
those forces.
I feel, like with other sports,like rotation gets missed, a lot
like being able to like one getinto enough rotation, like why
are they having back pain?
Are they missing the rest ofrotation?
(29:12):
And they're used tocompensating with their lower
back.
Instead, like trying to figureout, kind of like what you're
talking about at the beginning,finding the root of why they
might be.
Like having this injury,especially if it's not like a
one, like one-off injury, it'slike more of like a acute, like
micro um stress type of liketrying to figure out what the
root is and solving that rootand making sure they can
maintain it and then workingback up to those like those
(29:33):
workloads with your back,because your back is ultimately
the thing that is stabilizingeverything while you're doing
anything, so you have to haveeverything around it strong.
And then I think, the bracingpiece of it too, a lot of,
especially with kids like highschool athletes.
They don't know how to bracewell, like that's not a skill
that they're taught very often.
Speaker 2 (29:51):
Yeah, which leads to.
You know, the most humblingpiece of most of these rehabs
for someone who is either activeand just wants to be fit like
Matt, or someone who's anathlete, is ego checking about.
Why are you doing so muchweight?
Why are you doing so much load?
Why do you do this?
Can we just do a mediumintensity adult fitness program?
Don't need to snatch, don'tneed to clean and jerk super
(30:12):
heavy.
You could just do a basicstrength program.
It's like that piece, like youcould just do a basic strength
program is like that piece.
But honestly, technique is justlike a massive thing.
There's so many like we seethis all the time with young
kids throwing have like reallydon't have great mechanics.
You know, in gymnastics we seelike a lot of basics are missing
.
A lot of fundamental technique.
Things are basic are missingand every sport kind of has this
that if you just don't likereally work on your baseline
level of technique and you knowdiscipline to strengthening
(30:35):
those fundamentals, um, and youskip steps, that's where it
always comes back to haunt you.
So along the conversation ofusually like advanced to return
to sport is hopefully throughoutthe process you have kind of
helped correct some of thosebasic underlying mobility or
strength issues that then atsome point you guys say, listen,
man, I need to break your heart.
But like you don't have a great, you know baseball, you know
(30:55):
swing, you know you really arenot technically doing this well
with your hips and you'reletting your back take all the
load.
It might be a good idea for usto get you with a hitting coach
and kind of, when you're goingthrough your hitting program is,
have a coach watch you on yourbasic dry swings, watch you on
your basic soft toss programsand make sure that, before we
ramp you to a hundred percent,that you're fixing some of these
technical things.
You know elbow throwing, elbowrunning.
I think you know, uh, sprintingtechniques.
(31:16):
Another big one that getspeople is they don't really have
great sprinting technique andso they're just kind of like
hawking themselves around.
So yeah, I think that's hard,but that's an important part of
the conversation.
Speaker 1 (31:25):
Yeah, and I would encourage I think especially for
acute back injuries doing areally good reevaluation, like
after they've calmed down andyou're doing a basic strength
program, like that's the timewhen you need to really assess
what their range of motion lookslike.
Like they might be lackingsomething and you might have
just thought previously that itwas, oh, because it hurts.
So they're not moving thatrange, but doing once they're
completely like out of the painrange for normal basic movements
(31:48):
and range of motions.
I think it's really reallyimportant to go through
everything kind of again andmake sure you're taking those
measurements and seeing ifthey're missing anything big in
to go through everything kind ofagain and make sure you're
taking those measurements andseeing if they're missing
anything big.
You can work on that and theycan improve their technique,
because if they're missing therange of motion to improve a
certain type of technique thatthey need, then they're not
going to be able to just getthere or they're going to end up
back in the same place thatthey were previously Go back to
(32:09):
their sport.
Speaker 2 (32:10):
Yeah, absolutely.
I agree it does work out not tosales pitch this, but the week
this podcast comes out, myselfand Mike actually just finished
back pain course.
So Mike and I have been workingon this for like 10 years.
I feel like I finally got myish together and put this all
into one format.
But yeah, mike and I haveshared a lot of ideas over the
years and I've seen I think I'veseen 1000 people for back pain
Like I'm not even shitting you,I think that's how many people
(32:32):
I've seen over 10 years, which Iwish I didn't have to but
essentially all the stuff thatwe're talking about we put into
short little course.
You know, see your prove whereyou can kind of learn all this
stuff.
If you wanted to hang out withme in the clinic and see how I
treat athletes for back pain, oh, jen King, speaking of which
it'll give you, uh, the movementmisclassifications, the
literature reviews, like all ofour sport progressions, exercise
, manual therapy, needling, allthat kind.
(32:58):
So, yeah, mike and I finally hadtime after the mentorship was
close to sit down and do this.
So get all our lectures andthen I think it's a hundred
dollars off the week that it'scoming out.
So I'll put the link in theshow notes.
But I tried to make the coursethat I wish I had when I was a
new grad.
That's kind of what Iessentially did.
So if it helps people, that'dbe really great.
But yeah, I don't know, I feellike I wish I had this when I
was younger.
I mean, you kind of got me, butit'd be sick to have a six hour
course.
You know you're in this course,by the way, the videos, yeah.
Speaker 1 (33:19):
Hopefully it's not my jumping.
Speaker 2 (33:21):
No, actually it is.
It's your broad jumping withWyatt, it's all like the way
that they are.
The core progressions.
No, you were good, you'rekilling it.
I take the photos with Jen andthen I film the course with you,
and then Mike and I waited acouple of years to get other
stuff done before we finished it.
And there's Courtney speaking ofanother OG student.
Look at us.
Go, courtney, shout out Okay,anywho.
Yeah, if you want the courseyou know, check it out.
(33:43):
A hundred bucks off tonight,tonight this week.
It's in the show notes forlinks, but I think we cover the
rest of it.
Those are all the questionsthat we had.
So anything else on this?
We got it All right, friends.
We.
every day.
You essentially pay your duesby doing the harder thing when
it's the right thing to do.
I have been very good abouttrying to not work after five
o'clock on fridays and have allthe way through sunday at like
five o'clock.
I'm trying to get a full 48hours of whatever I want.
I'm doing pretty good.
The last three weekends havebeen like friends, family went
out.
It's like a sweet jazz band intown that I went to.
So, yeah, I'm doing good this.
(00:26):
The last three weekends havebeen like friends, family went
out.
It's like a sweet jazz band intown that I went to.
So, yeah, I'm doing good.
This is the last thing I haveto do today, and then after that
I'm done, yeah, same.
Yep, um, back in action.
We needed a much needed uh, two, three break.
I don't know what it was, but,uh, aaliyah was busy and I was
also super busy with some stufftoo.
So so, yeah, it's just thenature of the podcast is it's
here for when we can recordstuff, we will, and if we don't
have anything cool to talk about, we won't.
(00:46):
But now we have some things totalk about.
So I think I forget what thelast episodes we left off of,
but we definitely want to coversome stuff on back pain, because
that was one that was submitted.
Somebody asked about hip andlabor repair, so we'll do that
next week.
And then the last one in thethird week is somebody who was
asking about um, season iscoming up quickly, which is
crazy to say, cause we'rerecording in summer, but you
(01:07):
know, in the blink of an eyeI'll be like people back to
school and stuff.
So, yeah, we'll start with backpain stuff today.
And, uh, it actually kind ofworked out because you were like
kind of around at champion whenwe were going through like
developing all these systems,and I think that like a lot of
this stuff carries through.
But, yeah, we'll start it withthis.
So Jess submitted via Instagram.
She said how do you assess whatkind of low back pain it is and
(01:28):
then how do you approach it?
So pretty broad question, butI'll share my thoughts from the
outline that I had and then someresearch that we have, and then
you know we can chat back andforth.
But I essentially came out ofschool in 2013 when the CPGs the
clinical prediction guidelineswere first getting very popular.
So I think 11 maybe was thefirst one and there was an
update in 16.
But essentially that was likelooking at things through the
(01:49):
lens of like what is theevidence that people have and
like what category they fallinto for treatment.
So there was like themanipulation side, there was the
stabilization side, there was Iforget the other ones off the
top of my head but essentiallylike category based things and I
think that was super helpful.
I think that was a good start,um, but also during that time
was very much like the largegrowth of pain science and a lot
(02:10):
of people putting like chroniclow back pain, non-specific low
back pain.
So there's a lot of work thatcame out from like Lorna Mosley,
adrian Lau, uh, pretty much onpeople who are like really not
responding well to traditionaltreatment and they're kind of
getting like truly sensitized.
They're really it's affectingtheir whole life.
Um, and then my kind of storyis that I learned all of that
and I was using it.
But then I started gettinginvolved in like sports uh, more
(02:32):
particularly like middle tohigh level sports, high school
and college and I found thatwhile that stuff was helpful, um
, it definitely did not kind ofcover the whole gamut,
particularly because sportsrequire like very high loads,
very high workloads.
So I kind of found the work oflike Stu McGill more like the
strength and conditioning side,and I think that's more
classified like the mechanicalbucket.
So that was kind of how I wentthrough my traditional, maybe
(02:54):
the first six to seven years ofschool, and between like pain
science, the evidence-basedclassifications and then more of
the movement-based or kind ofmechanical-based approach, I
find myself just mushing themall together and using kind of
what I needed in front of me.
So yeah, that was my kind ofjourney.
What was yours?
Did you guys get taught theCPGs and then pain science stuff
or like, how did you come to?
Speaker 1 (03:14):
Yeah, I feel like it's kind of similar, like we
learned like buckets of backpain, but then, like that didn't
really apply very well in thesports world, particularly, I
think, in the adult world itfeels like it applies a little
bit more easily, I feel likewhen their pain is more
identifiable.
So they're like oh, it hurtswhen I'm sitting, yeah, exactly.
(03:35):
I feel like we learned verystrict buckets for back pain and
then we also learned thatthere's going to be just
generalized chronic back pain inits own bucket.
But then obviously I workedwith you like while I was still
in school, so I got the benefitof learning kind of your
structure and I know I thinkthis is probably I don't know
how early on you made this, butyou would always go up on the
(03:56):
whiteboard and like draw thatchart.
Speaker 2 (03:58):
Yes.
Speaker 1 (03:58):
Of like the different things you would look for.
Speaker 2 (04:01):
I will, I'll actually buy some time in a minute and
I'll pull that chart up forpeople.
But, um, yeah, I would agreewith that.
I think you were probably justI mean, I don't remember how far
I was at a school when you camebut like, I was kind of like in
the throes of trying to sortout like a system and how to
approach stuff.
Because what I found and youknow, mike was a big instrument
in this is that there's a verybig difference between chronic
back pain and like acutere-injury of the same thing over
(04:23):
and over again.
So chronic back pain is someonewho has one bout of pain or a
couple of butts of pain and thatnever quite resolves and they
become centrally sensitized, solike they truly have nervous
system level changes.
Um, you know, uh, there's awhole laundry list of stuff that
changes, but it's really likesomeone who has a couple of
events and then for many otherissues biopsychosocial, their
job, whatever they don't getover that one bout of back pain
(04:46):
and it kind of continues tomaintain a lot of like changes
in sensitivity.
And there's definitely a lot ofpeople 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.
But that's really not what Isee.
You know, those, in my opinionfrom the you know, I'd like two
or three years of a lot ofchronic back pain before sports
and that tended to be somebodywho was like really under active
(05:08):
, you know, they tended to notreally work out consistently,
they had a day job or they werereally busy and they, you know
there were a lot of other thingsrelated to like their sleep,
their nutrition, theirpsychological status, their work
status, their marriage, theirspouse, whatever that were
clearly influencing their youknow worries and their fears and
they kind of fit thetraditional mold of
biopsychosocial model.
But again, that was like oneperson who had out of back pain
(05:28):
and continued to kind of not getimprovements.
I found that I did see thatquite a bit and you would use
strategies from Adrian Lowne,stuff to teach them and stuff.
But chronic re-injury of thesame thing is more what I see
now, which is like there is aroot provoking factor, whether
it's workload, strength,conditioning, you know, mobility
or strength or kind of thatstuff and they have one bout of
pain it gets almost all the waybetter, and then another bout of
(05:52):
pain on top of that which thenthey don't really resolve fully.
So it's not like they're likeone thing is chronic.
It's that they constantly havespikes of like a little bit of a
set thing, a little bit of aset thing, and they get a little
bit of a set thing and they geta little bit of a stress
reaction thing, then a littlebit of a spondy thing, and it
kind of keeps coming and going.
But once you get to the rootlevel oftentimes a combination
of educating them about theirdaily life and then also
mechanical symptoms, which we'lltalk about next that is when
(06:13):
they see resolution, when youfinally play with the chessboard
of like maybe some of the rootlevel type stuff like that.
So, yeah, I find that all thethings I had learned were very,
very helpful.
Um, and I can share a couplearticles that we have.
So this is kind of a um, oh,not that one.
This one is a recent systematicreview that kind of looks at
like everything right.
It's looking at just likegeneral guidelines for low back
(06:34):
pain management and you know, Iread through it and it was
helpful.
I don't think it was earthshattering for like things that
it was new.
I don't think we've learned aton more but this.
There was a section of thiswhich I think completely sums up
like the frustration many gradshave with low back pain.
If I can find it, it was kindof saying, like all the things,
here we go, so Denmark, allthese studies, and then
essentially they're saying thattargeted recommendations
(06:56):
regarding acute, subacute andchronic low back pain right
across all these things andduration of symptoms, the things
that are helpful, is, I'm goingto find it.
Pardon my pause here.
Let me find this actually I'mtrying to read to my secondary
screen it's not working, butit's essentially it's going to
outline that, like everythingfrom medicine to every type of
(07:18):
exercise, is very helpful forthese people and it starts to be
oh, here we go.
So acute low back pain, right,so this is what they so.
Acute low back pain, right.
So this is what they recommendfor acute low back pain NSAIDs,
therapeutic exercise, spinalmanipulation, opioids, heat
massage, acupuncture, musclerelaxation, spinal mobilization,
self management, paracetamol,returning to work, progressive
muscle relaxation, reassurance,avoidance, belief training,
(07:39):
cognitive behavioral therapy,postural therapy, laser therapy,
diathermy, laser therapy,short-term diaphragm, cold
therapy, antidepressants thoseare all things that are useful
for acute back pain.
And then another CPGrecommended mindfulness-based
stress reduction, tens, lumbarsupports, back school
interferential current therapy,electromuscular stimulation,
anti-epileptic drugs, herbalmedicines, shockwave therapy,
(08:00):
back school multidisciplinarytreatment.
What the hell do you do withsomebody when you look at a CPG
in a 13 CPGs say that for acuteback pain, someone walks and
says I hurt my back over theweekend.
You have that laundry list ofshit to try to do with them,
right, and each of those is soinsanely generic, right.
Massage, multidisciplinarytreatment like that is so
(08:22):
insanely large of a treatmentthing.
So that's the problem thatcomes up with some of these
large cpgs and this issystematic view of cpgs.
It's great right.
Subacute back pain exact samething.
Chronic low back pain like agiant paragraph of arguably 20
to 25 things that have someevidence, mixed uh populations,
mixed chronicity, mixed uh goals, mixed diagnostics.
(08:43):
It makes it extremely hard fora new grad who comes out and
read this and says, oh yeah,look, I found this great.
You know, systematic review ofCPGs.
What do you do with thesepeople?
Like how the hell do youorganize?
Just chronologically, go one byone and hope that something
works?
Like that was.
My personal frustration is thatI was reading all this evidence
and I did not find as though itwas very helpful, which again
leads to like something that'smore specific.
(09:03):
Like this is more of amechanical article that's
talking about the use of McGillexercises for someone who has,
you know, some functionaldisability, chronical back pain
again, how they specify thatversus this is more of like a
pain science education typething, which is more about
saying that teaching someoneabout their back pain and
understanding their life isprobably helpful too as well.
So I personally found that Ineeded to do more of like a
(09:23):
movement-based category, whichis what we'll talk about next,
but I don't know if you sharethe same frustration with when
you were trying to read evidenceas a student or a new grad.
It's like how the hell do youinterpret a paper like that?
And not to mention there'sprobably 50 more articles out
there on, you know,recommendations for back pain
yeah, no, definitely.
Speaker 1 (09:37):
I felt exactly the same way because I I feel like
everything was like everybodyhas back pain.
Uh, you can treat it all thesedifferent ways.
None of them are great.
They're all okay and good luck.
And then it was like therecurrence of back pain too,
like the research on that isalso like really high recurrence
levels.
If you don't treat, like, ifyou can't figure out, I think,
the lifestyle factors of thepain science contributors, I
(09:59):
think the recurrence rate'sreally high.
Um, and I I feel like I likedthe mechanical models too, but
then sometimes when I'm treatingmechanical model and I think
it's more acute, the recurrencelike I'll have kids that'll keep
coming back to me Like am I nottouching on something that's a
little bit more like chronic?
Like are we?
Are we treating all of theselike pain science factors or
(10:21):
like something in their daily?
Speaker 2 (10:24):
life, I think um I think one thing that's really
hard is as a new grad, I thinkyou 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 likewhat you, what you want to find
, you find on social media,right.
So, like I remember, there aretimes when it was like in in a
broad range of people, a bunchof exercises help for somebody
(10:45):
with back pain.
It's like there was that campwhich is like do everything, do
like manipulation, do exercises,do McGill, do PRI, do SFMA and
all this stuff.
And then, literally in theexact same vein, you had social
media accounts that were likewell, back pain, nothing works
for back pain.
You know back pain is a normal,it's like a very common thing.
Everyone gets back pain, nomatter what.
So like they don't need PT toget better with time.
(11:08):
You just leave them alone.
You know rest in time is nobetter than PT or injection or
whatever it's like okay.
So somebody comes to you withacute ripping sciatica and
you're going to tell themexercise, you're going to get
the pain.
Science, education, like how inthe world, with the resources
(11:29):
available, do you go through asystematic approach?
And then, on the other side.
Just don't be like, yeah, well,you know, strength deadlifts
are good for back pain.
So like, go deadlifts and likegood luck.
Like I can't tell you how manypeople get worse with just
advice like that.
And I find that I'd beextremely frustrated if I hadn't
had, like the availableresources to take courses and do
stuff and then have mentorshipfrom people who were like had
years in their belt.
If you were like in the middleof Ohio or Iowa there was no
(11:52):
great centers around that areathletic based and someone keeps
coming to you for back pain,like I think you just get
frustrated, throw your hands upand give them the best you can,
but then, like I don't know,good luck.
You know I feel really bad forthose tech screws.
Speaker 1 (12:02):
Yeah, no, I completely agree.
I was lucky to have you early onin undergrad.
I feel like I helped sort mybrain out a little bit more with
that kind of stuff.
But I think it really depends alot on where you work, because
I feel like if you're workinglike more in the sports world,
you get a much different likedemographic usually of what kind
of back injury they're dealingwith, versus like working in
like an outpatient ortho, whereyou're getting a lot of like
(12:23):
older people who may just belike sitting at a desk all day
and, yeah, maybe a lot oftreatments work because they're
sitting down all day and theyjust need to move or they just
need like a little bit of tlcfrom somebody because their life
is stressful.
So it's hard to sort it outbased on the person.
And I think from an exercisestandpoint, there's so much like
you're talking about onInstagram.
(12:44):
It's like I feel like everyother reel that I pull up is
like this exercise will fixeveryone's back pain and I'm
like sure Everybody will becured by this one exercise.
I'm sure.
Speaker 2 (12:54):
Yeah, I think you you kind of learn to put your
defenses up as you get a littlemore experience in your grad.
But anybody, I'm not going togo into it, but there was a
brochure dropped off at ourclinic that had some therapy for
something I'm not going to gointo, but it was like the
brochure had probably 50, 40 to50 diagnosis that it helps with,
from like muscle cramps tosciatica to like allergies, and
(13:14):
I was like what I'm like there'sany anything that says that it
resets your nervous system andit works.
For 40 diagnosis is like brorun for the Hills, like there's
no way.
But also too is I think it'sthe more that I got into the
weeds I found that like everysystem and I kind of took like a
lot of courses and likeMcKenzie, pri, like a lot of the
big kind of names I found thatonce you got down the rabbit
(13:36):
hole far enough, it started toget a little funky on like how
to really like.
They kind of seemed a littledogmatic of like you always use
this system, you always do theseexercises, you always do what
we say, and it was like, eh,maybe not.
So you find that one is thatthe 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.
But also, like man, I've read somuch pain science and so much
(13:58):
mechanical literature and stufflike that.
A lot of it's overlapping, likethe explanation for why it
works or what the theoreticallike underlying mechanism is is
is different in terms of how youexplain it.
But like, how do you know?
How do you know it is a facetjoint versus a capsule, versus a
ligament, versus a muscleversus a nerve root?
You don't really, you know,you're kind of like you know,
giving your best educated guess.
(14:19):
But also with like pain sciencestuff is, how do you know
whether it's truly like anociceptive thing or maybe it's
a, uh, you know, some sort ofbrain neurotag sensitization?
Like you really don't knowwhat's under the hood with many
people, which, personally, iswhy I moved and developed like
more of like a movement basedcategory which is like a lot of
like the best of Stuart McGillplus strength conditioning, and
then you layer like workloadsand pain science education and a
(14:39):
good like SFMA eval on top ofthat, and so I tend to find for
the, you know, the long windedanswer to this question is you
know, the best way that Iapproach things is I find myself
having much more of asubjective eval than ever before
.
I find myself 20 of the 60minutes, doing a very good
in-depth.
When did your back pain firststart?
What makes it worse?
What makes it better?
You know, when can you lastremember the really bad flare up
(14:59):
was in your daily life?
What makes it worse?
What makes it better?
Like, what have you tried?
Like, if you go a really goodjust conversation with somebody
and back to the bio,psychosocial is a lot of people
just need a moment to vent andexplain that no one's really
listened to them.
They just give them drugs andlike said move on.
If you give them like a reallygood chance to tell their story,
they oftentimes put themselvesin a few different categories,
like, hmm, this sounds like it'smaybe compression intolerant.
(15:20):
Maybe this sounds flexionintolerant.
Happened after a couple longdays of work, they took a flight
somewhere, they tried todeadlift or whatever.
And so in sports, who are likethat too, it's like oh, I had a
big outing, you know, I I didtwo back-to-back hitting lessons
and then I went out and I triedto play and my back hurt really
bad.
It's like that kind of sounds,extension, rotation, you know.
So you go from there and thenyou do like a good movement
based approach and you try toconfirm or deny which of those,
(15:46):
um, which of those categoriesmaybe, is most present between.
But, like in your mind, you'relike, okay, this sounds like
it's flexion or compressionintolerant, which means that
probably extension is going tomake that person feel better or
not make them feel worse, andthe movement of Val and a bunch
of special tests then becomeswhat tells you you're in the
right bucket or not.
And then you treat someone.
You treat somebody withexercises.
You're like you in a couple ofdays, or have them email you and
you just see if you're better,worse or the same.
(16:13):
You know, along with you haveto reduce the workloads of the
things that are probably makingyou sore, you know.
Speaker 1 (16:17):
Definitely yeah, and I like the way that that is
organized too, because you'realso organizing it by like their
deficits.
So if something is painful, likeyou know okay, extension
rotation is painful then youknow you can work in the other
like realms and stay neutral forthe rest of it.
Like I feel like it helps youtreat based on what you find
like it's very easy to just belike okay, I'm testing all these
things, okay, you hurt withthis, you don't hurt with this,
(16:38):
we're going to start here andavoid this and then, like it's
very it makes everything muchmore like simply defined based
on the deficits that you'reseeing, based on their pain
reports.
And I think, like I think theharder like layer on top of that
that is helpful to keep in mind, especially for new grads, is
it's hard sometimes whenpatients come in with, like, a
very acute back injury or ifthey're like even if it's not
(17:01):
necessarily cute, but it's kindof that acute on chronic kind of
like time is a lot of times Ifeel like with backs, people
just get so flared up thateverything hurts.
So like it may be more difficultat the beginning, like the
first time you see them, toreally justify like okay, they
only hurt with like rightrotation and extension but, it
(17:22):
might be flared up and flexionhurts and extension hurts and
turning right hurts, and justbecause they're irritated so
letting them kind of calm downand I think you did a really
good job teaching me at thebeginning.
If you have someone that'sreally flared up like that and
it's hard to kind of delineatewhich 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
(17:42):
calm down before you kind ofstart to tease out maybe what
category they would fit intofrom an injury standpoint.
Speaker 2 (17:49):
Yeah, absolutely.
And I think in that context youknow you have to remember that
regardless of whether somebodyhas a like more of a pain,
science explanation of there'sno like true tissue damage but
it's just really, reallysensitive, like a nerve root
irritation or some sort ofhypersensitivity.
Or if somebody has a parsfracture and it's true bone
inflammation, it's chemical,right, there's some degree of
either chemicalhypersensitization or very high
(18:10):
elevated neural sensitization.
That, in the same way that ifyou jumped off a curb and broke
your ankle, you know you can'treally figure out, is it the
ATFL, is the bone, is thecapsule?
You can't really determine whatstructure is the most cranky
because someone is so acutelyguarded and so chemically
irritated.
And so having a couple days ora couple of weeks where you just
let somebody kind of try tojust move as best as they can
(18:31):
but like kind of stay in a in arelatively low level of activity
, it kind of lets your body doits thing naturally.
And then after a week or two,you know you have a much better
chance of diagnosing somebodyproperly and putting them into
one of those categories.
And the same thing happens fora shoulder.
Somebody comes in if they getrailed into the boards and their
AC joint is super flared up.
It's like they can barely move.
They can barely really do stuff.
They can't do exercises, theydon't want to arrange motion.
(18:53):
All their motion hurts.
There's no capsular pattern atall, hurts, right.
There's no exercise that feelscomfortable, it's all cranky.
So you just treat that personmore in like a palliative
setting of like okay, what can Ido to help this person just get
out of the oof cycle, right.
(19:15):
That very acute situation issometimes where those roles come
into play and you led thewitness pretty well because
that's like the third questionsomeone submitted which we'll
get to.
The second question works outwell with this table, which is
that somebody asked do you seekissing spine or interspinous
ligament pain at L5-S1?
So for sure, that's like prettytextbook straight extension
based pain.
So a kissing spine or a spinousprocess impingement is when
somebody bends backwards veryextremely and their spinous
(19:36):
processes bump into each otherand get a bone bruise and cause
interspinous ligament likeirritation.
So that would be somebody whois doing like gymnastics, dance,
diving, circus, like reallyextreme arching motions, ballet.
Aesthetically those types ofthings demand like a lot of
spinal motion, like doingbridges or whatever.
So it's not as common as someother ones, um, but if somebody
(19:56):
has, you know, predispositionwhere they're very lax, so they
get put in a sport like that ata young age or they have very
like angulated, narrow spinousprocesses, naturally they're
going to be more prone to bumpthose into each other.
And I have treated a few casesof people who were just like
flexion didn't hurt, rotationdidn't hurt, even extension.
Rotation storks were negative.
But straight extension, like ina standing backbend or a press
up than a PA shear, wereextremely painful.
(20:17):
So that person was treated withnon-steroidal
anti-inflammatories they weregiven.
They took a break off fromgymnastics for two weeks and
then we dry needled like softtissue around their spine and
then tried to get them as muchhip extension mobility as
possible.
The person that I'm thinkingabout was a gymnast who had like
extremely stiff hip flexors,groin quads, because she had
grown a lot and she was likemore of a kind of a power-based
(20:38):
athlete.
So when she tried to do yourChankos her hips wouldn't move
and her back would bend a ton.
So positive Thomas, positiveFaber, um, very, very stiff
lower body but her back was justkind of bending at L5 S1 to
make up for that and in her caseit just happened to be that her
spinous processes, essentiallywhat were painful, not her
facets or not her, like you knowsoft tissue, qoi.
So it's pretty common, uh, youback off the things that are
(21:00):
irritable and then, yeah, lookat below hips, above their
extension shoulders, and then alot of that stuff is required,
is is a lot of strengtheningdirectly at their glutes to try
to get their hips to open more,and you just slowly get them
back into reverse med ballthrows and hip extension
exercises and then tumble, trackand trampoline and kind of
slowly build them back inthrough it.
So that's for the second piece.
And then, yeah, I think theacute painful side I think that
(21:24):
and you know that's from kind oflike the teaching side is is, I
think, when someone's sopainful and they can't do
anything, what you do with themto educate them, on the other,
like 23 hours of their day isway more important than, like,
the magic exercise that you givethem.
So people don't oftentimesrealize that their pain is
probably getting not acutelyflared up by things in their
daily life, but if theyaccumulate lots of time
(21:45):
throughout their daily lifewhere they don't feel pain and
they go to bed.
They wake up and do the samething.
Um, they tend to wake up andfeel a little worse each day
until eventually they put like,go to bend down and take their
shoes and they throw their backout.
Quote unquote.
And the example that I alwaysuse here is a chemist that I
treated named Matt, and he wasvery frustrated with two years
of like multiple PTs and kind oflike doing his daily life.
(22:05):
But he was a chemist and I waslike just tell me what your
daily life is like before.
You had back pain originallyand got hurt with a squat,
really deep squatting.
And then I was like well, tellme like what your day-to-day
life is like.
I wake up, I take care of myone-year-old, I help my wife, I
have breakfast, I drive to theoffice 40 minutes away.
I usually sit and do like labexperiments or have meetings,
and then I take my lunch break.
I try to walk, but I do thebest I can.
(22:26):
I drive 40 minutes home, I goto the gym, I warm up and then I
work out.
And when I work out, I doconventional narrow stance
deadlifts and squats, because Idid some CrossFit stuff and
that's what I like to do.
And I was like all right man,you realize that like nine hours
of your day have some degree ofrounding or flexion or like
kind of like speed forward.
He's like, oh yeah, I neverthought about that life.
Don't sit in a deep couch,let's try to sit on harder
(22:55):
chairs.
Let's try to go for walks everytwo hours at the lab, if you
can, can you stand or sit orkneel for parts of your
experiments?
And he said you can make itwork.
I said in a meeting just standin the corner that you don't sit
on the couch and get eatenalive, like try to like lie on
your stomach or lay on your sideor sit in a hardback chair with
your family and then every twohours try to do cat cows or
(23:16):
press-ups to whatever you couldtolerate.
And it took some time.
It took probably like a week ortwo for him to even like
consistently do it.
So he felt better.
But he probably got 20 betterjust in that alone.
No exercises, just that dailylife.
And then from there of courseit was like midline core stuff.
But like what he did on his ownwas way more important than
what I was doing in the clinicfor like soft tissue work or dry
needling or whatever.
(23:37):
It gives you a window of liketwo hours to modulate tone,
maybe so you can go do exercisesbetter.
That's all manual therapy is Iagree.
Speaker 1 (23:46):
Yeah I think the education is more important than
a lot of the things that we dofor a lot of injuries.
So if we're only seeing themonce or twice a week for an hour
, I mean we're helping, butthey're going to help us out a
lot more if they're doing thesethings every day consistently.
Speaker 2 (24:01):
I think it's just hard sometimes because, like it
sets the perception that you'retaking the wind out of a PT
sales.
You're like might have a lot ofreally cool things to try and
to do and I don't.
I don't think that there's nota role for manipulation, dry
needling, cupping tool work wedo all that kind of stuff, man
Like.
I don't manipulate as much justbecause it's not my skillset and
I work with really looseygoosey people.
Um, but like all of the thingsthat you put in, like the acute
(24:22):
intervention bucket, fromexercise to manual therapy to
whatever all you're doing istrying to modulate someone's
pain levels, right, You're justtrying to find a way to get them
to be a little bit more.
And out of the pain sciencebucket there's a phenomenal
analogy about, like an alarmsystem on a house which I use
all the time, is that normallyif an alarm has a threshold
that's like right in the middle,when the mailman comes up to
drop the mail off, the alarm isnot triggered.
(24:44):
But if somebody tries to robyour house and break through a
window, that's when the alarmgoes off.
And the analogy you tell peopleis that when you're worried
about somebody you know damagingyour house or whatever, if you
have an acute sensitizationevent, your body lowers the
threshold of what is deemedthreatening or dangerous, right,
so it will give you painprotectively to try to make sure
that you're on top of it.
So if you irritate your backover a couple of weeks and then
(25:05):
maybe you deadlift and it getsreally sore, to that analogy Now
, anytime a leaf blows by yourhouse, your alarm system goes
off, it gives you pain and youhave to reset your baseline
level with, you know, avoidingthings that are cranky.
Education, exercise, all thatkind of stuff.
Really, all we're doing is justlike a graded exposure to
stress.
You know all exercise, allwhatever we're doing to educate
somebody is trying to find wayswhere, okay, well, maybe we
can't run, but maybe that youknow, like a split squats with
(25:28):
body weight are tolerable if weuse BFR, or maybe we can
tolerate cat cows, or maybe wecan tolerate, like bird, dogs
and dead bugs, but nothing more.
And you just do whatever thatlevel is that you're at, until
you can kind of raise thethreshold higher so that things
don't feel as uncomfortable.
You know what I mean.
Speaker 1 (25:43):
And.
Speaker 2 (25:43):
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 ofeducation on the backend for
yourself.
So you can deliver a verysimple just like.
We're going to start with thesebasic things consistently and
then you know, in time we'll doit If you, if you have a good
system in place for movementbased to vow and kind of like
your handful of exercises thatyou do with people, um, it's
pretty easy to you know.
(26:04):
I wouldn't say it's hard, itsucks.
Nobody wants to be in pain, youknow they.
So a lot of empathy is required, but the approach sometimes is
a little bit simpler than Ithink people make it out to be.
Speaker 1 (26:17):
Yeah, no, I agree completely.
I think watching you do likesome very simple exercises like
simple for PTs at least wasreally like reassuring as a new
grad, Cause it was like even ifyou had this like high level
athlete, they can't do very muchanyway.
So you give them like the mostbasic exercises like a bird, dog
and a dead bug, and you canmake those hard enough for them.
(26:40):
Like they'll still feelshockingly humbled when you give
them a certain like form ofdead bug.
That's challenging for them.
You can still do those thingswith a neutral spine and like
there's lots of other thingsthat you can do while they're
not inflection or extension thatwill challenge them.
And so getting a littlecreative with like those kinds
(27:02):
of exercises I think is stilllike super meaningful,
especially in the acute phase,to get them to continue like
their movement and strengthwithout being in like an
aggravating position likeflexion or extension.
Speaker 2 (27:07):
Yeah, and then to that.
I think the on the other sideof the coin is that problems
come up when maybe it's a PT oran AT or whatever.
That's all you do right, likethat's good for the first like
month, maybe if someone has anacute flare, but like you got to
get your way away from bird dogdead bug side plank basics
right, like you need anintermediate and a more advanced
progression.
And the other side of thisquestion somebody asks is like
how do you help somebody getback to sports if they're not in
(27:34):
pain and they kind of you knowstrength conditioning and
workloads and stuff, because theathlete is going to need way,
way more than the average person.
So Matt and his example justwanted to get back to like
lifting and strengthconditioning and he had a
newborn daughter that he wantedto take care of so he really
needed at the time it was Jonah,one of our strength coaches.
He needed Jonah more than me.
It was like modify your program.
Let's trap bar deadlift, let'sbox squat, let's do more of our
(27:55):
single leg and split squat aslike our big loading movements.
You had a brace properly.
Add some core stuff in, getthese hips moving.
A bit Like Jonah's strengthprogram probably helped him way
more than I did, because no onehad ever given him many other
options for programming besidesjust conventional narrow stance,
deadlift and squatting Right.
So for him he kind of stopped it, like I would say the advanced
strength phase, cause he justwanted to work out three days a
(28:15):
week, take care of his kids andgo to work, at which he got back
to, whereas someone who's youknow, uh, a high level softball
player who has a scholarship andis trying to go to a big
university in a year after afacet fracture or something like
that spondy fracture.
They need much more plyo, powerprogressions, you know med ball
stuff to prepare their workloadbefore hitting.
And then eventually, once theyget back to it, you just do a
(28:36):
needs analysis of what the sportrequires aggressive extension
or rotation, throwing andrunning Right and you just toast
them on frequency, intensityand repetitions like a baseball
program or a running program oran Olympic lifting program.
That's like knowledge of thesport, but that is how you get
somebody that fifth kind offinal stage.
Speaker 1 (28:52):
Yeah, I agree.
I think that I think with themost obvious sports where you're
doing a lot of like extension,inflection, people are like, oh
yeah, they need to be able tolike tolerate a lot of loads in
those forces.
I feel, like with other sports,like rotation gets missed, a lot
like being able to like one getinto enough rotation, like why
are they having back pain?
Are they missing the rest ofrotation?
(29:12):
And they're used tocompensating with their lower
back.
Instead, like trying to figureout, kind of like what you're
talking about at the beginning,finding the root of why they
might be.
Like having this injury,especially if it's not like a
one, like one-off injury, it'slike more of like a acute, like
micro um stress type of liketrying to figure out what the
root is and solving that rootand making sure they can
maintain it and then workingback up to those like those
(29:33):
workloads with your back,because your back is ultimately
the thing that is stabilizingeverything while you're doing
anything, so you have to haveeverything around it strong.
And then I think, the bracingpiece of it too, a lot of,
especially with kids like highschool athletes.
They don't know how to bracewell, like that's not a skill
that they're taught very often.
Speaker 2 (29:51):
Yeah, which leads to.
You know, the most humblingpiece of most of these rehabs
for someone who is either activeand just wants to be fit like
Matt, or someone who's anathlete, is ego checking about.
Why are you doing so muchweight?
Why are you doing so much load?
Why do you do this?
Can we just do a mediumintensity adult fitness program?
Don't need to snatch, don'tneed to clean and jerk super
(30:12):
heavy.
You could just do a basicstrength program.
It's like that piece, like youcould just do a basic strength
program is like that piece.
But honestly, technique is justlike a massive thing.
There's so many like we seethis all the time with young
kids throwing have like reallydon't have great mechanics.
You know, in gymnastics we seelike a lot of basics are missing
.
A lot of fundamental technique.
Things are basic are missingand every sport kind of has this
that if you just don't likereally work on your baseline
level of technique and you knowdiscipline to strengthening
(30:35):
those fundamentals, um, and youskip steps, that's where it
always comes back to haunt you.
So along the conversation ofusually like advanced to return
to sport is hopefully throughoutthe process you have kind of
helped correct some of thosebasic underlying mobility or
strength issues that then atsome point you guys say, listen,
man, I need to break your heart.
But like you don't have a great, you know baseball, you know
(30:55):
swing, you know you really arenot technically doing this well
with your hips and you'reletting your back take all the
load.
It might be a good idea for usto get you with a hitting coach
and kind of, when you're goingthrough your hitting program is,
have a coach watch you on yourbasic dry swings, watch you on
your basic soft toss programsand make sure that, before we
ramp you to a hundred percent,that you're fixing some of these
technical things.
You know elbow throwing, elbowrunning.
I think you know, uh, sprintingtechniques.
(31:16):
Another big one that getspeople is they don't really have
great sprinting technique andso they're just kind of like
hawking themselves around.
So yeah, I think that's hard,but that's an important part of
the conversation.
Speaker 1 (31:25):
Yeah, and I would encourage I think especially for
acute back injuries doing areally good reevaluation, like
after they've calmed down andyou're doing a basic strength
program, like that's the timewhen you need to really assess
what their range of motion lookslike.
Like they might be lackingsomething and you might have
just thought previously that itwas, oh, because it hurts.
So they're not moving thatrange, but doing once they're
completely like out of the painrange for normal basic movements
(31:48):
and range of motions.
I think it's really reallyimportant to go through
everything kind of again andmake sure you're taking those
measurements and seeing ifthey're missing anything big in
to go through everything kind ofagain and make sure you're
taking those measurements andseeing if they're missing
anything big.
You can work on that and theycan improve their technique,
because if they're missing therange of motion to improve a
certain type of technique thatthey need, then they're not
going to be able to just getthere or they're going to end up
back in the same place thatthey were previously Go back to
(32:09):
their sport.
Speaker 2 (32:10):
Yeah, absolutely.
I agree it does work out not tosales pitch this, but the week
this podcast comes out, myselfand Mike actually just finished
back pain course.
So Mike and I have been workingon this for like 10 years.
I feel like I finally got myish together and put this all
into one format.
But yeah, mike and I haveshared a lot of ideas over the
years and I've seen I think I'veseen 1000 people for back pain
Like I'm not even shitting you,I think that's how many people
(32:32):
I've seen over 10 years, which Iwish I didn't have to but
essentially all the stuff thatwe're talking about we put into
short little course.
You know, see your prove whereyou can kind of learn all this
stuff.
If you wanted to hang out withme in the clinic and see how I
treat athletes for back pain, oh, jen King, speaking of which
it'll give you, uh, the movementmisclassifications, the
literature reviews, like all ofour sport progressions, exercise
, manual therapy, needling, allthat kind.
(32:58):
So, yeah, mike and I finally hadtime after the mentorship was
close to sit down and do this.
So get all our lectures andthen I think it's a hundred
dollars off the week that it'scoming out.
So I'll put the link in theshow notes.
But I tried to make the coursethat I wish I had when I was a
new grad.
That's kind of what Iessentially did.
So if it helps people, that'dbe really great.
But yeah, I don't know, I feellike I wish I had this when I
was younger.
I mean, you kind of got me, butit'd be sick to have a six hour
course.
You know you're in this course,by the way, the videos, yeah.
Speaker 1 (33:19):
Hopefully it's not my jumping.
Speaker 2 (33:21):
No, actually it is.
It's your broad jumping withWyatt, it's all like the way
that they are.
The core progressions.
No, you were good, you'rekilling it.
I take the photos with Jen andthen I film the course with you,
and then Mike and I waited acouple of years to get other
stuff done before we finished it.
And there's Courtney speaking ofanother OG student.
Look at us.
Go, courtney, shout out Okay,anywho.
Yeah, if you want the courseyou know, check it out.
(33:43):
A hundred bucks off tonight,tonight this week.
It's in the show notes forlinks, but I think we cover the
rest of it.
Those are all the questionsthat we had.
So anything else on this?
We got it All right, friends.
We.
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