Good morning. Happy Monday. I have neuro coffee in hand and it is perfect as usual. Okay. Very solid Monday. Sun is out. It's going to get warm. Business is looking good. Things are coming back slowly. So that's exciting too. So let's dig into a Q and A. So we're going to talk about breathing, which is a shocker and a surprise, right? Which I don't know, breathing's become kind of popular for some reason. But I think a lot of the information is getting misinterpreted. And so let's try to clarify a few things by playing off of a question that I got from Adam. And Adam wants to know if his abdominal muscle should be contracted or completely relaxed at rest. So this gives us an opportunity to kind of talk a little bit about what's really happening during resting breathing and then how we're going to apply this in certain types of exercises when we're trying to restore movement capabilities or when we're trying to reinforced performance. So under resting circumstances you probably shouldn't have to think about your breathing very much. At least I would hope that you wouldn't. In most cases of resting breathing the inhalation has some measure of effort associated with it. It's primarily the diaphragm that's creating the negative pressure inside the body that allows you to breathe in. And then it's an elastic recoil of the thorax, the lung tissue actually recoils. You have the eccentric orientation of the diaphragm creating a positive pressure and then you exhale. So there's a slight little tweak of abdominal activity at the end of an exhalation that's almost non-existent. In fact, for a long time they said that there wasn't any, and then there's a little bit of research that says that there is. But point being is that most of our resting breathing should be relaxed and comfortable and not require any thought. Now, when I started talking about the two archetypes, I'm going to start talking about wide ISA's and narrow ISA's and classifying them in regards to their tendencies, we started to talk about using different ways of breathing to reinforce a change just to get someone to the opposite end of this. It appears to be this dichotomy of inhalation/exhalation. They're actually occurring at the same time, so it's not really a true dichotomy. But because the diaphragm does not descend uniformly in the two archetypes, it requires that there's two different types of breathing when we're trying to restore movement capability. So with the narrow ISA's, because of the way that they trap air in the thorax, if we use a high pressure strategy, all we do is reinforce the compensatory strategy. We continue to trap air and we don't make the changes that we've been attempting to change.

And so we would use a more relaxed mouth sort of, we always describe it as like fogging up a window, fogging up a mirror type of breathing, because if we can slow down the exhalation, we actually provide time to clear the air that would normally get trapped during the compensatory strategy that a narrow ISA would use. With a wide ISA, we tend to use a little bit more forceful exhalation because what we have to do is we have to close the wide ISA. And the way we do that is using superficial musculature like external oblique, which would then narrow that angle. So that actually does require a little bit more of an effortful exhalation. But here's the problem that people are running into, especially with the wide ISA archetypes. They're using high levels of muscle activity during the breathing activities and they're using a more forceful exhalation. The problem that you're going into with that is I've already got somebody that's utilizing a very, very strong exhalation concentric orientation type of strategy and then all you're doing is reinforcing that during the activities that you're attempting to use to restore movement capabilities. So what you end up doing is you just reinforce the strategy because by driving the exhalation too aggressively, they recruit their superficial strategy just like they're doing under most circumstances and then you don't get the changes that you want. And so we have to take the superficial strategies into consideration whenever we're trying to coach somebody through some form of breathing activity, especially when we're trying to restore movement. So, under those circumstances, we actually use a very relaxed, casual type of breathing with very slow, methodical movements. Very, very low tension, very, very low effort. Because again, if we have this really, really strong, wide ISA, superficial, concentric orientation, you're never gonna get your way out of that by trying to use more effort. Because again, you just reinforce the strategy. So again, I would caution you against thinking that there's only a way or there's only two ways. What we have to do is we have to consider what this person that we're working with is bringing to us. And then we have to reason our way through the strategies to alleviate whatever we're trying to change or reinforce what we're trying to reinforce. So from a performance standpoint, if I do have somebody that has to drive a lot of high force, then I do want to use a concentric strategy. I do want to use this aggressive exhalation. So always taking the individual into consideration is where we go. It's always N equals one. It's always in a gray. Everybody wants a black and white answer when it comes to all of these concerns. But the reality is that we have to adapt our treatment strategy or training strategy to the individual.

So it's not as black and white as everybody makes it seem to be. So please, please, please take that into consideration. So thank you, Adam, for your question. Everybody have a great Monday and I will see you tomorrow.

So the calcaneus and talus doesn't come back up as it does as the foot tries to reciprocate. So because it pushes you medially and forward, you end up with a foot that is in a laterally propulsive position from the get-go. So what this does is it lowers the arch, it accelerates the rate at which the tibia moves over the foot, and then you have an anterior orientation of the pelvis. Now, if you have a wide infrapubic angle and you have this conical shape to your thorax relative to the pelvis, then you're also going to be standing in an antiverted position of the hip, which will actually allow this to occur a little bit easier than if you were, say, a narrow. But the narrows will experience some valgus orientation as well. They tend to have it show up a little bit more towards the performance end of the spectrum versus just standing around. But the thing I want you to recognize is that under both circumstances, whether I'm landing a jump as a narrow and the knees come together or as I'm standing, if I'm a wide ISA or if I'm a larger body size and I'm standing in this valgus orientation, your center of mass is medial and forward. And what that does is it quickly maxes out how much dorsiflexion that you're actually going to have. So you'll have overactivity of the posterior compartment of lower leg, it's going to limit dorsiflexion and then the valgus is going to occur under those circumstances.

We're going to do a lot of sideline activities because chances are you've got an anteroposterior compression in the pelvis and in the thorax. If we lay on your side, we're going to get some of that AP expansion. And then we're going to move you into inverted positions. So if I'm a wide ISA, I'm going to be supine-inverted. If I'm a narrow ISA, I'm going to be prone-inverted. If I have a larger body size or formerly pregnant females, they will have a yielding strategy in the pelvis, especially the upper part of the pelvis. So under those circumstances, this is where SI belts come in really, really handy to help them learn how to manage and control that yielding strategy until they can have the muscle activity that will eventually assist them and control that. I'm going to work towards half kneeling, eventually towards split stance to gain the tibial control through some of the posterior musculature, like hamstrings. So hamstrings are like reins on a horse controlling the tibia. So when I can finally get you into those half kneeling or split stance positions, that's where we're going to gain a lot of control. As we move out into the gym and we start talking about training strategies, these are where you're going to use unweighting strategies. So remember, this is a gravitational problem, right? So they're getting pushed down, their internal physics are pushing them down. So we're going to use unweighting strategies like reverse band squats, jumps with the band to actually lighten them. Chopping activities will become more important than lifting activities. So when we're talking about like cable activity, so we're talking about cable chops, because the cable chop actually unweights them as they're performing the trunk and hip activities. So those become much more valuable. Later on, once they've learned how to control their center of mass more effectively, now we can move into lifting activities and then progressive loading. So again, start with unloading strategies in the gym. If we're talking about box squatting, because I love box squatting under these circumstances, your narrow ISAs, they're landing with the valgus orientations, you're going to start them with a high box position because they have to learn how to control their pelvic diaphragm because that's what's accelerating them towards the ground with your wide ISA people. Again, you're probably going to use some form of belting strategy. So even a weightlifting belt, SI belts etc to reduce the yielding strategy as they unload their weight onto the box because if they're a wide ISA we've got to get the eccentric orientation of that pelvic diaphragm back but we don't want the pelvis to yield so we have to create this external compressive force to help them manage that. Once again, we're going to try to move them towards half kneeling and split stance activities so they learn how to control the foot position and then knee position.

So we've got a lot of influences here when we're talking about knee valgus, but understand what it is. It's a gravitational problem that's associated with the idiosyncratic physics of the individual. So it's not about tight muscles. It's not necessarily about weakness. It's literally about controlling the center of mass and the position. Matt, I hope that gives you a little taste of what you're up against when you're talking about dealing with knee valgus. If you have any more questions or concerns, please let me know. Go to askbillhartmanngmail.com and we'll try to get your question on here and I'll see you guys.

We can put more effort into the lift itself and stay in a groove because if we create a situation that physically limits our range of motion, then all that energy that we would normally have to use to control the position, we don't have to worry about. Now there are secondary consequences which we'll talk about, but for now let's talk performance. So what we want to do, regardless of your physical structure, so we talk about narrows and wides, what we want to do is create as much anterior-posterior compression as possible because the stronger the exhalation strategy, the greater the force output into the extremities and then the more weight that I can lift. Now there's a subtle difference between wides and narrows. So with the wides you're going to want to emphasize the latissimus dorsi element of this posterior compression. So we're talking about below the level of T8. So we're talking about bilateral symmetrical lifts like barbell rows and lat pulldowns being staples for the wide ISAs because what we want to do is we want to create as much compression on that posterior aspect of that rib cage because the advantage that the wide ISAs have is the angles at which the musculature associated with their skeleton like their rib cage and their pelvis is generally more horizontal. Tremendous advantage for force output in things like a bench press or a squat or a deadlift. So if we can compress that lower posterior part of the rib cage, you immediately increase your arch. You immediately increase your compressive strategy. You immediately increase the amount of weight that you can lift. With a narrow, they tend to have greater expansion in the upper back compared to the wides. And so what we want to do is we want to emphasize more of the upper back type of compressive strategies that you would see associated with bilateral symmetrical face pulls, I's, T's and Y's. Okay, so there's the subtle difference now. They'll still do lat pulldowns and they'll still do their rowing in a bilateral symmetrical manner, but we're talking about emphasis as far as the subtleties between structures. The wides are also probably going to benefit a lot more from doing the back extension type of things or reverse hypers because what they have to do to actually maximize their arching capabilities in the bench press, but also to carry over to the other lifts, is they have to close the lower posterior aspect of the pelvis as well just like the lower posterior rib cage. On the narrow side of things they are going to want to do things that are more associated with like a glute bridge or the barbell hip thrusting thing because what that does is it compresses the back side of the pelvis. So we get a pelvis that instead of being nice and round like this, we want to flatten it out as much as possible.

So your glute bridges and hip thrusts with your knees apart will actually help compress that strategy right there. And now you've got compression where you typically would have expansion in a narrow. And so again, the goal here is to maximize the performance regardless of health, increase the arching capabilities in a bench press. Let's stay at the obvious don't forget to bench press because you have to practice the position because it's very very specific. And so all you have to do is get on YouTube watch a bunch of videos about it you'll see a bunch of high-level powerlifters getting into the position practice practice practice. The better you get at that more compressive strategy that you're gonna get. The bench press itself is a compressive exercise. So let's not ignore the specificity in regards to some of your other training the sumo pulls, cross bench pullovers, a good old classic. So drop your hips below the level of the bench, arch backwards over the bench, and perform your pullovers. Another great compressive exercise. Now, secondary consequences. Here's the bad stuff. You're gonna lose range of motion. Now on a certain level, that's performance enhancing. Like I said, it's going to keep you in your groove, it's going to improve your efficiency in the big lifts, but the secondary consequences of losing that range of motion is you're going to create a bunch of compressive strategies. You're more likely to see a bunch of soft tissue injuries because the concentric orientation associated with the compressive strategies will reduce blood flow to key areas like connective tissues and bone and things like that. And so that's why you're going to see a lot of the soft tissue injuries that you see in power lifters. That's why you're going to see the progressive arthritic conditions in power lifters. So the thing that I want you to understand is yes I'm talking by performance, yes I'm intentionally compressing you and yes you're going to increase your powerlifting performance, but there is going to be consequences that are going to compromise your health in the long term. So please keep those in mind. You get to be an adult, you get to make all of your own decisions here, but the reality is is that the harder you drive yourself into these positions, the more likely you are to experience the negative secondary consequences associated with high levels of concentric orientation over prolonged periods of time and exhalation strategies which can compromise who knows how many different levels of health.

Dr. Mike, it is perfect today. And it is so good today. Exercise protocols for reducing blood pressure.

This has just been something of interest lately. Exercise protocols for reducing blood pressure.

I don't know if there's such a thing per se. But this brings up a really interesting point as to what high blood pressure really is. Okay, so if we think about the circulation having two sides, right, you have the output side and the input side, okay, to make it simple. All of the fluid shifting that goes on, that's associated with circulation is based on gradients. It's just like we talk about with range of motion and things like that, and we talk about gradients of pressure and volume. So on the front side, so as the blood leaves the heart, the gradients are such that the fluid shift is away from circulation. So it's moving stuff into the cells. On the backside, the byproducts of cellular metabolism are coming back into circulation. So any ions, hydrogen ions, chloride, et cetera, et cetera, increases the concentration of the blood flow coming back into the heart. And then that increases the fluid volume coming back into the heart. The larger the ion concentration, the more fluid that comes back towards the heart, right? So that means I have more fluid coming back into the heart. So what the heart does is it doesn't actually create the pressure that manages the flow of blood because blood flows all by itself, okay? What the heart does is make sure that the flow gets vortex. So the heart actually spins. It doesn't pump. It spins blood to make sure that it's a non-turbulant flow that enters and leaves the heart. So if you were deconditioned, as it were, as the people that tend to get high blood pressure are, they will produce more ions. They will have a larger volume of fluid returning to the heart that the heart has to manage. And so that's why you're going to see higher resting heart rates with people that are deconditioned. But you'll also see higher pressures because it's a back pressure coming from the backside. So the fluid that's going back to the heart after cellulose metabolism creates the resistance, if it were, Okay. And so that's my spiel. And so if you become more aerobically conditioned, you don't produce the strong ion concentration that's associated with cellular metabolism like people that are deconditioned. And therefore you have a greater likelihood of lower blood blood pressure. Now, having said all that, I'm sure there are things that I don't understand that I don't know that can actually increase blood pressure. But when we're talking about the conditioning effect, that's where my head would be.

Okay, let me hear what you have to say about it.

Okay, so if we think about the circulation having two sides, right, you have the output side and the input side, okay, to make it simple. All of the fluid shifting that goes on, that's associated with circulation is based on gradients. It's just like we talk about with range of motion and things like that, and we talk about gradients of pressure and volume. So on the front side, so as the blood leaves the heart, the gradients are such that the fluid shift is away from circulation. So it's moving stuff into the cells. On the backside, the byproducts of cellular metabolism are coming back into circulation. So any ions, hydrogen ions, chloride, et cetera, et cetera, increases the concentration of the blood flow coming back into the heart. And then that increases the fluid volume coming back into the heart. The larger the ion concentration, the more fluid that comes back, towards the heart, right? So that means I have more fluid coming back into the heart. So what the heart does is it doesn't actually create the pressure that manages the flow of blood because blood flows all by itself, okay? What the heart does is make sure that the flow gets vortex. So the heart actually spins. It doesn't pump. It spins blood to make sure that it's a non-turbulant flow that enters and leaves the heart. So if you were deconditioned, as it were, as the people that tend to get high blood pressure are, they will produce more ions. They will have a larger volume of fluid returning to the heart that the heart has to manage. And so that's why you're going to see higher resting heart rates with people that are deconditioned. But you'll also see higher pressures because it's a back pressure coming from the backside. So the fluid that's going back to the heart after cellulose metabolism creates the resistance, if it were, Okay. And so that's my spiel. And so if you become more aerobically conditioned, you don't produce the strong ion concentration that's associated with cellular metabolism like people that are deconditioned. And therefore you have a greater likelihood of lower blood blood pressure. Now, having said all that, I'm sure there are things that I don't understand that I don't know that can actually increase blood pressure. But when we're talking about the conditioning effect, that's where my head would be. Well, what's your aim? Because let's talk about it because it might be useful.

No, I think so. I think that's actually interesting. I've never thought of it that way. I think that is interesting. When I think about what's got me thinking about this lately is there was a new research paper from this study called the Mesa study, which is essentially just a modern day, large population health study. Like in America, the classic one was the Framingham heart study. This is like a newer version of that. What they showed was that, which is also an interesting commentary even from a fitness perspective, is that blood pressure levels have basically been set based on unhealthy people. So what we would consider healthy blood pressure is just where we took the population and said, here's where pathology begins. So let's be here, not necessarily that 120 over 80 is good. It's like from a BMI perspective right? It's not that BMI of 25 is good. It's just not overweight. Similarly, being not hypertensive is not necessarily good. It's just not hypertensive. There was an editorial that went along with this new paper and they were talking about that and really how we didn't start appreciating how early negative cardiovascular effects start taking effect until the Korean War, when unfortunately they had all these young people dying, but then they were able to look at their arteries. They found that all these young, healthy soldiers had all this atherosclerosis that had started. Long story short, the Mesa study, this new paper from the Mesa studies, is really suggesting that a hundred is more of the healthy level for systolic blood pressure. Beyond a hundred, you start getting stepwise increases in risk of cardiovascular disease.

Right.

And they were like all these young, healthy, soldiers had all this atherosclerosis that had started. And so long story short, The Mesa, this new paper from the Mesa studies really suggesting that a hundred is more of the healthy level for systolic blood pressure. And beyond a hundred, you start getting stepwise increases in risk of cardiovascular disease.

Okay.

Which is like, how many people do you know that have a blood pressure of a hundred? Like my mother. And she's always been told she's hypotensive and has been too. And so I don't, you know, I think that if you look at then all these, so for me, it was just a couple of interesting questions. Like my blood pressure is like, my systolic blood pressure is like 110, 114, which I would generally have to consider good. And now I'm like, I mean, it's not so good. And so then I'm thinking all the levers that you can pull to lower blood pressure. Exercise being one of them from an ability to the not Bill Hartman version, pump blood, more blood per stroke, right? So create more elastic vasculature would be kind of the other piece. And, you know, then they're kind of some nutrition, some different nutrition things. But, you know, I think that, unfortunately, exercise is like complicated to study because you start dealing with population, intensity, duration, mode, you know, all those different variables, then all of a sudden it's like how could you even figure something out to say, here's a good prescriptive approach?

Yeah.

Yes, and so I don't, you know, I think that if you look at then all these, so for me, it was just a couple of interesting questions. Like my blood pressure is like, my systolic blood pressure is like 110, 114, which I would generally have to consider good. And now I'm like, I mean, it's not so good. And so then I'm thinking all the levers that you can pull to lower blood pressure. Exercise being one of them from an ability to the not Bill Hartman version, pump blood, more blood per stroke, right? So create more elastic vasculature would be kind of the other piece. And, you know, then there're kind of some nutrition, some different nutrition things. But, you know, I think that, unfortunately, exercise is like complicated to study because you start dealing with population, intensity, duration, mode, you know, all those different variables, then all of a sudden it's like how could you even figure something out to say, here's a good prescriptive approach?

The sequence of events that resulted in that, okay, is not what the surgery addresses. It addresses the structure and nothing else. You know and then we have to rely on the rehabilitative process after the fact. You know, we're not just reconditioning people in these post-surgical scenarios, right? Right. We have to, you know, recapture their ability to manage themselves in space. If you don't do that, then whatever was causing the problem in the first place can still be there because we did a few tricks with her and her are turned into 10 degrees of tibial IR after we messed around with it. Yeah. Right. Exactly. And it's like, okay, so she's changeable. So what's the limiting factor? So we're going to see her next week and we're going to spend a couple hours with her actually next week. So I might have something really cool to report on the next call. At least I hope to do because I'm fascinated by this one.

Right.

You know, and then we have to rely on the rehabilitative process after the fact. We're not just reconditioning people in these post-surgical scenarios; we have to recapture their ability to manage themselves in space. If you don't do that, then whatever was causing the problem in the first place can still be there because we did a few tricks with her and her knee turned into 10 degrees of tibial internal rotation after we messed around with it. Right. Exactly. And it's like, okay, so she's changeable. So what's the limiting factor? So we're going to see her next week and we're going to spend a couple hours with her actually next week. So I might have something really cool to report on the next call. At least I hope to do because I'm fascinated by this one.

Yeah.

You know, these are the people that you really, really, really want to help a lot.

Right. Like she's been trying to get help for years and years and years.

Right. Yeah, so it'll be interesting to hear what you have to say about this, too, after you actually get to evaluate.

What interventions did you use to try to restore? You had a cough.

I had a cough.

You had an exhale?