It is December 8th. I've got my neuro copy. I hope you've got yours. Let's dive into this week's Q&A. So I posted a bunch of stuff up on YouTube this week, so if you haven't checked out last week's Q&A, that's up there. Podcast number five with Mike Robinson and I, the iFast podcast talking about how we train the pros was kind of interesting. I threw up a simple self-test for your breathing, some lower cervical mechanics video as well. And then as of today, I threw up a video on power output and how you generate that from the inside out, as well as some terminology concepts that we'll touch on today in today's Q&A. If you haven't been on Instagram, please check out the Instagram, Bill Hartman P.T. on Instagram. We've got a lot of topics that went up there, some short topics, couple of Instagram TV videos, and of course your 16% videos as usual. So please check those out as well. Now let's dive into the Q&A.

And so oftentimes what we find is that the typical orientation of the pelvis to manage internal forces is the exact opposite of what we need for speed skating. So thank you, Levi. That's a really good question. So our next question comes from Artem and Artem asks, when addressing elbow orientation by a training, what's the deciding factor when choosing between an elbow flexion or extension driven activity? A specific case would be someone that has an ER humerus in a pronated form. Well, clearly the orientation at the elbow would be wanting to relatively internally rotate the humerus and supinate the form. But then the deciding factor is, am I going to do a push or a pull essentially? And so this is going to be determined by some other measures that you need to attend to that will identify what is going on in the dorsal rostral space and whether we have an upper or a down pump handle. So specifically if we look at dorsal rostral expansion, that would be clarified by our ability to reach overhead in a normal short of flexion. So if I have normal short of flexion, then I have expansion in the dorsal rostral area. And so for me to reorient the elbow, I would want to use a propulsive activity, which would be more of an elbow extension driven activity. So we would say like a triceps muscle activity with the appropriate orientation of the elbow. Now if I wasn't able to achieve a full overhead reach or horizontal abduction then I would know that the dorsal rostral space is actually closed and I would need to expand that. So in that case I would use more of an elbow flexion driven activity so we would typically associate that with a biceps curl and that would promote expansion of the dorsal rostral space and then promote reorientation proximally and then progressively distally. So we would get the dorsal rostral space in the appropriate position, the scapular or shoulder girdle in the appropriate position, and then the elbow in the appropriate position. So we have the appropriate sequence to restore normal variability at the elbow.

That's my proxy measure for the entire system. And so that's what I monitor or try to influence. The hope is that whatever element or whatever subsystem within the system is the limiting factor is also addressed by the interventions that apply with the understanding that every sensory input is always an influence. Every movement is always an influence. Breathing is always an influence. And so we have to consider all of those elements to some degree. But I'm limited by my scope of practice. And so again, I have to use my proxy measure as a measurement of all systems that are taking place. Like I said, you hope that with your intervention that you're addressing that subsystem or element of the system that is either too rigid to allow adaptation or you're able to promote another adaptation that can overcome that limitation and then restore whatever it is that we're trying to restore, whether it be a movement or a subjective perception that is why the patient comes to you. Typically it's going to be pain under my circumstance. And so that's kind of how I look at things. And that's why I always say that I don't really know why they get better because number one, I probably can't really identify as to why they had the problem in the first place. But my hope is that it's represented in the movement system because that's the system that I actually have the most influence on based on my scope of practice.

And so over time, if I compress the anterior thorax, so if I pull the pump handle down, I pull the manubrium down, and I compress the dorsal rostral space, I'm going to create a compensatory strategy in my neck that keeps my airway open. But because I've compressed the dorsal rostral space, I'm also going to have to create some form of compensatory inhalation strategy in the thorax and what people typically do is they pull their sternum downward with rectus abdominis and they will flex forward at approximately the T7-T8 area because the T7 area is actually where the inferior angle of the scapula rests and so that's where the lower barrier of that compression is so below that there is space that can be accessed by flexing the spine forward. So from about T10 to T12, we do have some space in the lower posterior rib cage that we can use for inhalation. So that's typically what they do. But in doing so, and flexing forward, they have to bring their head back up into what appears to be a traditional forward head posture. So the fix, if you will, if there is such a thing, is to create dorsal rostral expansion, restore normal pump handle motion, and then what happens is we get a normal expansion anterior-posterior of the thorax, and the person actually gets taller and then the head moves backward over the shoulders into its normal resting posture. So that's why dorsal rostral expansion becomes so important. I would also offer that when you're making decisions about how you're trying to influence positions, let the internal mechanical drive your decision making in regard to how you're perceiving what is compressed and what is expanded rather than using a visual representation, especially in these types of cases, because if you try to drive it through a visual representation, you end up making a lot of incorrect assumptions, and then your exercise selection and intervention comes into question as to whether you're going to be successful or not. And that's basically what happened with this client, where he was following a pre-programmed set of exercises that weren't designed for him, and he ended up driving himself harder into his compensatory strategies, resulting in the forward head in the first place.

So when we talk about orientation, orientation simply refers to position. We could talk about the pelvis as a unit becoming anteriorly oriented, which would be a forwardly tipped pelvis, and it would just be relative to any other position of the pelvis. The way we would identify anterior orientation would be its relative position to any number of measures. It could be relative to the femur, it could be relative to the thorax. Again, we're not talking about any specific point of reference; we can use any point of reference to describe things. For instance, in normal respiration, I would say that the ilium is ER'd and the sacrum would be counter-nutated relative to the ilium. Again, we can talk about orientations relative to any point or any framework reference as long as we understand what we are describing. And so again, orientation is just simply a measure of position.

So there's no great subjective or objective way to measure tissue quality. Now, having said that, I do think that with practice we can identify some vague representation of tension in the system. So if you were to concentrically orient your biceps muscle aggressively, you can tell that it gets more firm. And as you relax, you can tell that it becomes more flaccid. So those would be some extremes. So if we can tell the difference there, then through practice, we may be able to identify a little bit of difference in regards to how much tension there is in the system. But we wouldn't be able to tell whether something is necessarily concentrically or eccentrically oriented. What we might be able to tell is, is there a difference? Is that difference favorable? I think that is determined by the outcome, maybe based on subjective information from your client or patient, or maybe some identification of sensitivity of that area, perhaps. But as far as trying to rate it or make some form of comparison, There might be, like I said, with experience, some qualitative level of identification. I don't think it's very useful. I don't think most musculoskeletal diagnoses by name are very useful. So, Michelle, you've asked some really, really good questions here, but I think that a lot of it is just unfortunately not very useful in what we do for a living. And so I would hope that we can sort of throw that one out along with any number of words like the C word, the F word, and the N word. And so I'm talking about core, functional, and neutral. And so let's put tissue quality on that list as well. Why don't we go ahead and do that?

So if I am already a wide ISA, I can certainly make myself wider through some form of training that increases my compressive strategy. For instance, with powerlifting, where it's all about compression, it's all about exhalation strategies, I can use my superficial musculature to compress my pelvis and thorax even more and make me seem even wider. If I was a narrow and I undertook those same activities, I might be able to achieve some measure of compressive strategy that might make me look a little bit more wide because I am going to create some measure of compression, but chances are I'm never going to be as wide as somebody that is born with a wide ISA. So again, this tends to be structural. Any activity that requires a strong exhalation strategy or compressatory strategy is ultimately going to result in an anterior-posterior compression of the thorax.

I think that it's a matter of determining what your key performance indicator is, what element of performance that you're trying to chase, and then you superimpose the strategy on top of that. So that's a really good question, Alex. Thanks for asking.

What I have is an eccentric orientation, especially of the external oblique, which allows that ISA to open in the diaphragm to descend. And so if I have to overcome that compensatory stretch, teach people to exhale more effectively, then I need to recruit those muscles that would close that ISA, which is the external oblique, which are the most superficial. And therefore I need a bit more of an aggressive acceleration strategy. And so what I would do is say it's a little bit more per-slip. It's a little bit more higher force and a little bit more of a higher pressure strategy. So one of the things that I encourage people to do under those circumstances is make sure that I can hear them exhale as they're moving through their prescribed interventions if breathing is associated with that. On the other side of the coin where I have somebody that would be an inhaled axial skeleton with a compensatory exhalation strategy, which would be your narrows. They're already recruiting the superficial musculature to close that ISA. Now, I still need to teach this person how to exhale, but if I teach them the same strategy that I used with a wide, all I'm gonna do is keep that ISA closed. What I'm looking for is the ability to prevent the trapping of air in the lungs. So when we have a narrow ISA with limited breathing excursion, they exhale so aggressively, they actually trap a lot of air in the lung because the pressure ramps up so quickly during the exhalation, that they can't get the air out in time. So what we teach out of those circumstances is a little bit more relaxed, open mouth, sort of a sigh for an exhale. Typically what I would cue people to do is to exhale as if they were trying to fog up the world's biggest window with their breath. So when you were a kid, then you would fog up the window and make a little smiley face or whatever you do. We would use that as a frame of reference for that type of an exhalation strategy because again, I don't want to ramp up the pressure so quickly inside the thorax. And so it becomes more of a sigh type of an exhale for your narrows.

So the two sides of the thorax in this case are behaving differently because chances are they're creating a turning strategy to help manage some of the internal forces or external forces that they're dealing with. So the simple answer is I treat the wide side like a wide and I treat the narrow side like a narrow. So in many cases we just perform an asymmetrical activity that flip-flops that strategy. So we will compress where they're expanded and expand where they're compressed to get them to turn in the opposite direction. In doing so, we restore dynamics to both sides at the same time. So that's a really good question because a lot of people don't understand that.

So again, I don't think I've worried so much about whether we would brand somebody in this situation as a wide or a narrow. I would just probably measure, make my best estimate, intervene and see what happens. So that wraps up this week's Q&A. So enjoy the rest of your neuro coffee. I will enjoy mine. We got a bunch of questions that are left there from this week's Q&A, so I'll probably spread those out during the week. Also, of note, got a bunch of applications for the intensive. So we had a record number of applications within less than 48 hours, so I had to shut it down because I'm already overwhelmed with the number of applications. Normally it takes about a week to get even close to this many and we did it in 48 hours. I appreciate your interest in the intensive. For those of you that don't get selected from this round, keep trying. I can only take eight at a time to keep this thing as powerful as it is. So again, I appreciate your interest. Keep watching the videos, keep commenting and keep asking questions. Ask Bill Hartman at gmail.com and I'll answer as many of those as I can.