I have a constraint. I am here to solve someone's problem that they came to see me for. Good morning. Happy Monday. I have no coffee in hand and it is perfect. All right, coming off a very solid weekend. Looking forward to the new week here. Quick housekeeping. IFAST University members, we have a Zoom call at 2 p.m. Eastern Standard Time. Please join us for that. If you're not on IFASTU, go to ifastuniversity.com. Get yourself signed up so you can join us on those calls. Okay. Now, let's dig into today's Q&A. This is with Victor. We've talked with Victor before. Very interesting question though. So there are situations that we run into where we have relatively unchangeable constraints. So in this case, we had, we were talking about a patient that had a very large abdomen. So internal adipose gets in the way, it takes up space. It prevents things from moving as we would like it to move. So for instance, you can't descend diaphragm when you've got adipose tissue in the way. Move an infrastructural angle the way you might want to move under those circumstances. So what do you do? And so we talked a little bit about that so this is actually probably very useful video for a lot of clinicians. Especially for dealing with folks that are in pain because sometimes we have to do some things that are a little counterintuitive and bias a window of opportunity or bias some time to where we can actually work towards normal relative motions. So again, I think this will be a really good one for you all. If you would like to participate in a 15 minute consultation, please go to askbillhardman at gmail.com. Put 50-minute consultation in the subject line so we don't delete it. We'll arrange that at our mutual convenience. I'll see you guys at 2 p.m. IFSU people and have a great Monday. All right. Clock has started. Video is rolling. Victor, what is your question?

All right, so I've run into this archetype, if you will, a couple of times in clinic. It's an older male with more adipose tissue than abdominal cavity that is probably needed, or a pendulous belly, if you will. Diastasis recti, I'm sure that's how you pronounce it. Diastasis. Low back pain. And obviously looking at your model and talking about reorientation and things like that, in my head of course I want to try to reorient ribcage and pelvis and things like that. I'm finding that that's not required to get people out of pain. But my question is I don't want to miss the forest for the trees either. Of course, it might be better for them to lose some weight as well for overall health, but if I were to try to go about reorientation and kind of things that you talk about with gaining relative motions with somebody like that, what are some considerations to take into account and in general how would you go about that?

Diastasis.

Diastasis. Low back pain. And obviously looking at your model and talking about reorientation and things like that in my head, of course, I want to try to reorient ribcage and pelvis and things like that. I'm finding that that's not required to get people out of pain. But my question is I don't want to miss the forest for the trees either. Of course, it might be better for them to lose some weight as well for overall health, but if I were to try to go about reorientation and kind of things that you talk about with gaining relative motions with somebody like that, what are some considerations to take into account and like how in general would you go about that?

Okay, so first and foremost, you have a relatively unchangeable constraint. Because the chances of them, if you tell somebody, 'Your internal body fat is so big that it's now interference, right? To make the changes that you want.' So to alleviate pain, you just need adaptability. If you got somebody that is internally rotated in the spine, so internal rotation would be like the anterior orientation of the pelvis, spine goes forward, people would describe that as an increased lordosis. That's IR. If you can actually take them farther into that IR and you create literally a window of adaptability—right direction or wrong direction—you actually may alleviate pain. Because all I need is change. Is it ideal? No. But you created a window of adaptability. So this happens a lot when people are trying to make a change. So let me give you a for instance. So somebody walks in, whatever presentation they might have on the table test or whatever. Somebody does an intervention and they gain internal rotations, but no external rotation. So that means you created more orientation somewhere. If I capture more internal rotation in a shoulder, but I don't capture the extra rotation that goes with it, all I did was teach the spine to turn a little bit farther than it did before. So internal rotation of the shoulders is spinal rotation away. So if I use your ability to turn your spine away, guess what? I gave you a bigger window of adaptability that actually may alleviate the symptom. Did I restore normal adaptability to where I can trust that you will have greater access to all relative motions? No. But I did make you feel better. Now we have an interesting game. You literally have a constraint that is interference. So now it's like, 'Okay, where can I create motion that will not make this scenario worse?' Give them a window of adaptability so they are at least comfortable. And then maybe with enough time, we can start to restore some of this relative motion that they truly need, right? Because that's what people do. So you ever have a patient with a herniated disc? A herniated disc is a connective tissue delay strategy to slow that side down. I created an expansion in the connective tissues, which is a yielding action just happened to be the disc because nothing else could yield to create the delay. So I had to use my spinal disc to do it. So that slows them down, right? That's a yielding action, just like I would want in a relative motion situation. It just happens to be an isolated one, and then it alters the structure, which can be risky. But that's how you get it. So people with an asymptomatic herniated disc, like the stuff just shows up on MRIs all the time.

I mean with a yeah I'm not sure if it was truly symptomatic yet but

Not my question. So what is a herniated disc? A herniated disc is a connective tissue delay strategy to slow that side down. I created an expansion in the connective tissues, which is a yielding action just happened to be the disc because nothing else could yield to create the delay. So I had to use my spinal disc to do it. So that slows them down, right? That's a yielding action, just like I would want in a relative motion situation. It just happens to be an isolated one, and then it alters the structure, which can be risky, right? But that's how you get it. So people with an asymptomatic, like the stuff just shows up on MRIs all the time.

Right.

Oh, you have herniated discs. It's like, yeah, but I have, they say it's on the left. It's a left lateral L5S1 disc herniation. They come in with the right hip pain. You know, it's kind of not related, right? But it tells you the strategy that they're using to create the delay. It's like, so what do you do? I just need to give them a more distributed delay strategy on that side. And a lot of times that right side stuff starts to clear up. So when you have a constraint like this, this is where you get to be the clinician here and really think this through and say, OK, here's what I know. It's highly unlikely that I'm going to capture normal relative motions because I have somebody with a very large protruding abdomen. I have a diaphragm that will not descend the way I want it to under any circumstance, okay? You have a diastasis, which means that I have lost a connective tissue constraint. So I don't have normal ISA behavior, which means I don't have normal diaphragm behavior. So, OK, you see what we're building here? So it's like, now it's like, where do I create? Where can I create an expansion to create adaptability? Where can I get him the greatest relative motions? If I can't get him the greatest relative motions, where can I get motion safely? And it's very, very difficult to do this. OK, but it's possible, but it's possible. And then like I said, you get them comfortable, and then maybe you'll have more time and more opportunity, more windows of opportunity to try to access the normal relative motions that we always seek, which tends to be more protective than trying to drive somebody farther into a strategy. Cause again, that's risky, but like I said, it happens accidentally all the time. It makes people feel better quite frequently because again, all I did was increase adaptability. I just might have not given them a better strategy. OK.

Yeah, I got you. The other thing with this body type or archetype is that they tend to be what I would picture as a narrow ISA archetype from the lumbar spine down, like very flat from a visual representation, flat lumbar spine, but kind of tucked underneath like a frog that just stood up almost.

So the post your lower compression end game, they look like they either got off their Harley Davidson motorcycle or they rode a horse into the clinic.

Yeah, usually the horse on the sky.

Yeah. Dude, my hometown has the only McDonald's in the United States with a place to tie off your horse. True story.

That's awesome.

So I understand. No, but you're looking at a situation where somebody's pushed so far forward, right? They're trying to put the brakes on. Right. So they're using whatever they can. They're on the outside edges of their feet. So they, they look like they're in a supinated representation. They have what would be referred to as a varus knee, which is just external rotation coming down through the system because they're so compressed anterior to posterior they have to orient so hard into external rotation, right? So they're oriented into external rotation. All right. And then again, it's like your job is to try to create the expansion or like I said, you move them into a position where they do have a window of adaptability to alleviate pain. These are tough, these are tough because you're battling a constraint. It's just like somebody that comes in with like an altered joint because of arthritis. It's like, okay, I have a limited number of strategies in that joint because I don't have normal synovial behavior. What do I do to alleviate the load on that? Okay, I can move you in this direction, alleviate the load and give you less symptoms, but I might be creating another situation that ultimately results in another loss of adaptability. These are tough because again, it's like people come to you. They don't come to you to say they say Victor, I need, I need full relative motions. They don't say that. He'd go, dang it, and my knee hurts.

Yeah. Right. So they're using whatever they can. They're on the outside edges of their feet. So they look like they're in a supinated representation. They have what would be referred to as a valgus knee, which is just external rotation coming down through the system because they're so compressed anterior to posterior they have to orient so hard into external rotation. So they're oriented into external rotation. And then again, it's like your job is to try to create the expansion or like I said, you move them into a position where they do have a window of adaptability to alleviate pain.

Right. So they're using whatever they can. They're on the outside edges of their feet. So they, they look like they're in a supinated representation. They have what would be referred to as a, as a varus knee, which is just external rotation coming down through the system because they're so compressed A to P they have to orient so hard into ER, right? So they're oriented into ER. All right. And then again, it's like your job is to try to create the expansion or like I said, you move them into a position where they do have a window of adaptability to alleviate pain. These are tough, these are tough because you're battling a constraint. It's just like somebody that comes in with like an altered joint because of arthritis. It's like, okay, I have a limited number of strategies in that joint because I don't have normal synovial behavior. What do I do to alleviate the load on that? Okay, I can move you in this direction, alleviate the load and give you less symptoms, but I might be creating another situation that ultimately results in another loss of adaptability. These are tough because again, it's like people come to you. They don't come to you to say they say Victor I need I need full relative motions. They don't say that he'd go Dang it and knee hurts. Only if they listen to these videos, right? In all seriousness, it's like nobody comes to you. They just want the pain to go away. It's like there's certain things that we can do that will alleviate pain, but it's not always the best strategy because we might have to push them farther into something to catch that because of the constraints. Right. I want to make it very, very clear that I'm not saying that this is the ideal situation. This is actually just to alleviate the symptom. It doesn't, it's not the fix. It's like, okay, I have a constraint. I am, I am here to solve someone's problem that they came to see me for.

I would love that

Only if they listen to these videos, right? In all seriousness, it's like nobody comes to you. They just want the pain to go away. It's like there are certain things that we can do that will alleviate pain, but it's not always the best strategy because we might have to push them farther into something to catch that because of the constraints. Right? I want to make it very, very clear that I'm not saying that this is the ideal situation. This is actually just to alleviate the symptom. It doesn't, it's not the fix. It's like, okay, I have a constraint. I am here to solve someone's problem that they came to see me for.

Right.

Yeah. With enough time, you try to go in the other direction and recapture everything that they can for health purposes.

I gotcha. How would, yeah, that's gonna be a conundrum. So it's not worth pushing at this point. I can see how balancing like what they're coming in for—just pain alleviation—with what your preconceived, okay, gaining relative motions, like that internal battle would definitely be, I feel like that would be a struggle, especially early on, for someone like me who's learned from your model as much as I can online instead of imposing my ideas on that person, just giving them what they want, but also needing to understand the consequences of what I'm doing. You got a new point.

I think you just lost control of all their boss. Does that help you at all?

Yeah, that does. I appreciate it.

So under the circumstances, as far as a solution is concerned, we need to talk a little bit about that before we go. You still want to try to capture the relative motions. You're going to have to rely on some way to create some shape change. Wide ISAs respond really, really well to sideline activities, rolling and things like that to create the shape change that you want. So they can create a delay strategy laying on their side that they might not be able to create when they're upright or when they're supine. So think about all the rolling activities or stepping activities—that's just walking, laying on your side, right? You can start to create those and they tend to be fairly comfortable for most people. And again, it's like they don't have to worry about the protruding belly when they're laying on their side nearly as much as when they're upright or laying on their back, because they're going to spread out side to side when they lay on their back, which is where they already are in most circumstances. Lay them on their side, let gravity squeeze them and try to create some expansion that way. That's where you're going to probably buy your best relative motions. Okay.

I see. Okay. And that plays really heavily like the herniated disc yielding posterior strategy, like you were creating that delay as well. Okay. Yes.

All the herniated disc is a focal delay strategy. You want a distributed delay strategy. So no tissue is under its maximum load where it's not this focal stress. If it's distributed, that's how you do everything.

Right? Yeah. Okay.

Cool.

Awesome. Well, I appreciate it.