Good morning. Happy Monday. I have neuro coffee in hand. And it is perfect. Monday, big week coming up. And the Q&A for today is going to be very philosophical, so I'll give you a warning that if you don't want to understand the philosophy behind the model, you're not concerned about that, then don't watch it. Go watch something else. Go watch somebody working out on video or something like that. This will probably get all of maybe five or six views on YouTube as well. But I think it's a really, really good question because it's from my buddy Ed in Germany. And Ed asks really good questions. And I think that if you are interested in how the model evolves, then it might be a little bit useful for your discussion later on with other folks that are having trouble absorbing it. So let's dive right into this question. So Ed says, the model of inhalation exhalation works, and it is to your credit to show simple solutions to put the human body into positions and facilitate the desired outcome and to restore normal breathing mechanics and movement options. But I think we have to acknowledge that it's not only a body or body part position that influences the mechanics of movement posture, but also neurological in and output. And then he goes on to sort of express a number of ways that we can manipulate senses and gain movement related changes and finishes with, shouldn't we incorporate neurology of sensing and the effect of autonomic states into your model? And so Ed, I would offer that the model actually does take all of those things into consideration. They're just not always expressed for various reasons. So let's get into that. The goal of the model, first and foremost, is to be coherent. And so rather than coming up with explanations that may be overly complex, what we want to do is we want to be coherent with the rules and laws of the physical world or we can even talk about the universe. So when we talk about movement in general, you have expressed that you think the model is about inhalation and exhalation and I would offer that this is a gradient based model. So when we talk about any movement in the universe, it requires a gradient to move. So whether we're talking about planets moving through space or rockets moving through the air or human movement or cellular processes, all of these things require a gradient. So if there's no gradient, there's no movement. So let me give you, for instance, so I have a pen here. This pen is affected by gravity. If I hold the pen here, it has a certain amount of energy. If I raise it up higher, I've increased the potential energy that this pen now has. So what gravity is, is an energy gradient.

So the higher I lift something, and then as I release it, I just moved it from a higher energy level to a lower energy level by dropping the pen, by releasing that potential energy as kinetic energy. And so for us to move through space, we have to do so through gradients. out of respect for the physical laws of the universe. And so now we have to respect the fact that we have to be able to orient in space, we have to perceive that space around us, and then we have to manipulate that space to achieve the desired outcome. And so what the sensory inputs provide us is information about that space, and then every physiological subsystem in the body will respond and contribute to a solution or an output that emerges. So let's pick on a sensory input that may be the most powerful or at least the best studied is that we talk about vision. And so vision uses compression and expansion just like we do when we think about the physical movement. So vision actually expands space. We use ambient vision where we spread our vision out or we bring it back into focal vision and compress that space. So it uses the same rules. Hearing does the same thing. So it compresses and expands space to help us actually determine what our environment actually is. Touch is very, very similar in that regard. And then again, physiology responds through the manipulation of gradients. would include all of those senses that respond to A-sense re-input. And then we have the autonomic nervous system that would respond as well, which behaves on a gradient. So the gradient of the autonomic nervous system is flight or fight to rest and digest, and will be somewhere along on that continuum as well. And so all of these subsystems interact and they produce an emergent output as a solution. So the model does consider all of these systems. You manipulate any one of these subsystems to a sufficient degree and you can change the emergent output. The goal then would be to determine which subsystem is most rigid or least adaptable and then favorably influence that system to produce the desired outcome. But in the environment that I work in and the limitation of my scope of practice limits what I can actually measure. So thankfully, movement capabilities is a useful proxy measure for the interaction of many, if not all of these subsystems. So I also get the benefit of movement feeding back into the system and affecting all of these other subsystems as well. So movement becomes this really, really powerful aspect that I can actually measure and then utilize as the intervention to influence any number of things that I can't measure. So whether we're talking about pain or a movement restriction, or we're talking about psychological disorders and chronic disease, movement becomes this really, really powerful solution.

So I don't express these concepts very much, mainly because I don't measure them. I can't tell you where you fall on the autonomic gradient. I can't measure your blood pH in real time to determine what your other physiological needs might be. So again, I just don't discuss these things. What I do measure is movement, and what I do try to influence is movement. So I spend my time basically talking about that. So if we move through compression and expansion, we move through creating a gradient of pressures and volumes, then that's where the discussion should lie for a movement professional like myself. It's like we can discuss all these other cool influences, and by all means, study them to your heart's content. Gain as much depth as you can. I spend time doing that as well, but in the end, I'm a movement guy, and my goal is to create a model that is coherent with the physical laws and to measure the things that I can and influence the things that I can. So Ed, I don't want you to think that I've ever ignored any of those things, but again, I just don't discuss them because it's not a way that I can determine a useful outcome and create the situations that I'm looking to create, in the purple room or wherever I might be, whether I'm maybe in the training hall as well. So hopefully, Ed, that gives you a little bit of an understanding of where I'm coming from. Great question. Glad you asked it. Glad I got to express a couple things. Apologize for rambling; it's usually rather.

So we look at the pelvis from the side. For us to access full excursion of the hip joint, I have to be able to inhale and exhale. That changes the orientation. The retroverted hip socket is going to help us capture external rotation. The anteverted hip socket is going to help us capture internal rotation. So for someone to have a laterally oriented acetabulum, what has to happen under those circumstances is I'm most likely going to experience some form of compressive strategy on the posterior aspect and some form of compressive strategy on the anterior aspect. So I'm squeezing the pelvis front to back, and then I'm going to get kind of stuck in the middle because if I can move volume in the pelvis forward, I'll have internal rotation. If I can move volume backward, I'll have external rotation. So again, to get stuck in the middle, I'll have to compress on both sides. And so that's typically what we're going to see under those circumstances, someone that would be more laterally oriented. The dead giveaway, of course, is that if I'm compressed on the front side, I lose internal rotation. If I'm compressed on the back side, I lose external rotation. So what you're going to see is you're going to see some form of orientation starting to take place where we're going to lose the physiological motion of the hip. So under most circumstances, if we say that external rotation is 60 degrees, internal rotation is 40 degrees, our numbers are going to be less than those standards of normal range of motion when we get this lateralization. For instance, I've measured power lifters, they're really strong guys that have given up a lot of hip range of motion for their craft. And they might have 20 degrees of external rotation and 10 degrees of internal rotation because they're very oriented laterally due to the amount of compression that they have to use to lift such heavy weights. Now if we go to the second half, and you asked, what would we see in a more rightward orientation? When we talk about orientations, we're going to talk about the pelvis moving as a single unit. So an orientation forward would be the entire pelvis, the sacrum and the ilium moving together, posteriorly or anteriorly. When we talk about an orientation to the right, we can have any number of tilts and turns because I have two hip sockets. I have a way that I can move any number of different orientations because of the shape of the sockets themselves. I could have a relative position change into exhalation. So I could have a nutated sacrum with an anteverted ilium and then have the orientation tipping on an oblique axis or straight ahead, typically going to be trying to manage internal forces. We'll get that right orientation. I could have a relative position change where I have a counter-nutation of the sacrum with an anteverted ilium and then see the orientations as well. And under those circumstances, my internal rotations and my external rotations are going to be different. And that's how you would know. So you could also use your ISA measure as a clue as to whether I'm starting from my inhaled position, where I have lots of external rotation and then orient, or I have my nutated position, which I'm exhaled, and then capture the orientation. So I would go from a position where I had more internal rotation, and I would eventually lose that internal rotation. So hopefully that gives you a little bit of an idea. Oh, let me back up. I could also have that where I have an inhaled position on one side, exhale position on the other, and then drive the orientations. So again, I think that understanding the normal excursion of the hip joint as it moves through the full excursion of breathing is essential. So you do understand how you capture those motions. And then it's just a matter of looking at ISA orientation will help you determine where their bias is. And then you look at whether I'm losing the physiological range of the hip range of motion to determine whether you have an orientation. So if you put all those pieces together, I think it will help you with your diagnostic capabilities as to positions.

So I could have a nutated sacrum with an irate ileum and then have the orientation tipping on an oblique axis or straight ahead, typically going to be trying to manage internal forces. We'll get that right orientation. I could have a relative position change where I have a counter-nutation of the sacrum with an irate ileum and then see the orientations as well. And under those circumstances, my internal rotations and my external rotations are going to be different. And that's how you would know. So you could also use your ISA measure as a clue as to whether I'm starting from my inhaled position, where I have lots of ER and then orient, or I have my nutated position, which I'm exhaled, and then I capture the orientation. So I would go from a position where I had more IR, and I would eventually lose that IR. So hopefully that gives you a little bit of an idea. Oh, let me back up. I could also have that where I have an inhaled position on one side, exhale position on the other, and then drive the orientations. So again, I think that understanding the normal excursion of the hip joint as it moves through the full excursion of breathing is essential. So you do understand how you capture those motions. And then it's just a matter of looking at ISA orientation will help you determine where their bias is. And then you look at whether I'm losing the physiological range of the hip range of motion to determine whether you have an orientation. So if you put all those pieces together, I think it will help you with your diagnostic capabilities as two positions. Rachel, great question. If you have any other questions, please let me know. Askbillhardmanedgmail.com, askbillhardmanedgmail.com, and I'll see you guys tomorrow. All right, it is Thursday, 6 a.m. I have no coffee in hand, and it is perfect.

Yes. He's walking on his ischial tuberosities. And if you watch him walk, you will see that the pelvis and the thorax advance at the same time in the same direction in the same way. The iterations are what is going in the same direction. So the pelvis and the upper thorax are both turning the same direction at the same time. And you'll see that just about any activity. That is, they will turn together. So when we're talking about relative motions of the ankle. Right. Before you hit a constraint. You'll have opposing movements. So if I have, if I have a pronating, like a closed kinetic chain that defined pronating ankle and foot, and the talus is adducting and plantar flexing, the tibia is externally rotated until you hit the constraint and then it follows the talus. Okay. So which is it? Is it tibial internal rotation or is it tibial external rotation? Until you clarify your point of reference, you're not really certain how things are being described. And so, again, I think that creates a lot of confusion. Because when things start moving together, then you don't have the relative motions to describe the movement. So you have to be very, very clear as to where you are in all of this. And again, we have to appreciate that because that's how you end up turning anyway. If you just reduce the relative motions. And then things start to move in concert because they're at the constraint. And so then they bring stuff along. And that's how we actually turn. Because as long as you have relative motions, the external rotations and internal rotations cancel each other out. And that allows you to go in a straight line, which is why we can talk about there's no sagittal plane if you want to talk about that.

Let's call it that. Can we do that? Yes. He's walking on his ischial tuberosities. And if you watch him walk, you will see that the pelvis and the thorax advance at the same time in the same direction in the same way. The iterations are what is going in the same direction. So the pelvis and the upper thorax are both turning the same direction at the same time. And you'll see that just about any activity that they will turn together. So when we're talking about relative motions of the ankle. Right. Before you hit a constraint. You'll have opposing movements. So if I have a pronating, like a closed kinetic chain that defined pronating ankle and foot, and the talus is adducting and plantar flexing, the tibia is externally rotated until you hit the constraint and then it follows the talus. Okay. So which is it? Is it tibial internal rotation or is it tibial external rotation? Until you clarify your point of reference, you're not really certain how things are being described. And so, again, I think that creates a lot of confusion. Because when things start moving together, then you don't have the relative motions to describe the movement. So you have to be very, very clear as to where you are in all of this. And again, we have to appreciate that because that's how you end up turning anyway. If you just reduce the relative motions. And then things start to move in concert because they're at the constraint. And so then they bring stuff along. And that's how we actually turn. Because as long as you have relative motions, the external rotations and internal rotations cancel each other out. And that allows you to go in a straight line, which is why we can talk about there's no sagittal plane if you want to talk about that.

Yeah, go ahead. I'm up for that.

But there's no sagittal plane?

Yeah, go on.

There's no schedule plan.

Problem solved. Cool. Done.

That was awesome. So straight plane movements. And honestly, straight movement in any direction is a cancellation of rotations. Right, so if I want to, let's just say, let's use the ankle and the lower leg as an example, okay? Because it's a really good example. If I want to move my tibia straight over my foot in the classic closed kinetic chain dorsiflexion kind of movement, right? For that to happen, like there is, and if I just use calcaneus, talus, and tibia, for that to go straight over the foot, you have to cancel out three rotations to get that to happen. Because the calcaneus doesn't move in a straight line, the talus doesn't move in a straight line, and the tibia won't move in a straight line. Right. So I have an ER in calcaneus, I have an IR in talus, and I have an ER in tibia to go straight plane dorsiflexion, which is in the sagittal plane if that actually existed, right? Visually, it goes in that direction. But for that movement to occur, I'd have cancellations of rotations. Otherwise, it does not happen. So if the calcaneus and the talus move together, okay, I can't move the tibia straight over the foot. And it's like what we visually represent. So we can have that conversation. We say, oh yeah, you're moving in a straight plane. It's just space that in human movement, it doesn't exist. What humans do is turn; we have inversion and eversion, and the way we manage those turns allows us to move in different directions. You're teaching people to do that by moving them forward as you're teaching them how to access relative motions at the segments that are supposed to have relative motions. The people that come to us with problems don't have all of the relative motion available to them. That's part of the problem, right? If I don't have relative motions between segments that I'm supposed to have relative motions at. So let's just say that I have a femur and a tibia that are trying to turn in the same direction when I need them to move in opposite directions so they can go straight ahead. Then I have a knee that torques in a direction, right? Then it can't bend and straighten like it's supposed to because I have to do this to bend and straighten my knee in normal circumstances. If I have a knee that can only do that, right, then I've just taken away a movement capability that I need to produce movement in whatever direction I want to move in.

I just want to hear about some of the effects of the gradients within the knee and how quick maybe that synovium repairs when it comes to some of those weight-bearing activities.

So I just look at the synovium as I would a laceration of your skin, right. So they poke holes in a structure that is supposed to contain the fluid, right. And the way that I move that fluid through the joint determines how well that joint behaves, right. And if I poke holes in it, I've just altered my ability to manage the volume of fluid that's in the joint and how I manipulate the pressures inside the joint, right. And so one of the concerns that I have early on is that fluid that is either within the joint that I need for the normal behavior of the joint, and then the fluid that is around that joint that restricts my ability to move that joint, right. And I don't want to create irritation because the more swelling I have, the harder it is for me to get range of motion back. So in the initial post-surgical phase, it's like, well, we'll talk about these because that's kind of where it shows up the most, I think. But my concern is that I don't have an intact synovium when I do stand up on it, right. And that's going to alter my ability to manage the joint like I normally would, so it doesn't behave normally. So am I creating more irritation? Right. So do I have a stronger inflammatory response? Am I irritating structures that aren't supposed to be touched at rest? Am I allowing them to touch? It's like all of those things are my concerns with this early phase. So being on your back for 10 days after a knee surgery doesn't do anything negative other than help me manage the swelling. The grave concerns over getting strength back after a knee surgery are ridiculous. Strength is the easiest thing in the world to regain. Fitness is easy to reacquire. What's very, very difficult is to manage a joint that's not intact, right. And so again, I'm using the typical 10 to 14 days for tissue healing that would be associated with, like I said, you get a laceration of your skin, they sew it up, and they say we'll take those stitches out in like 10 to 14 days. So I figure if all the tissues are the same, they're probably going to heal very similarly. And so I just use that window to manage the swelling post-surgery. It doesn't mean you can't get up and go to the bathroom. It just means don't be spending a bunch of time on your feet thinking that it's going to be helping anything, right. Because the more swelling that anybody has after a surgery, the harder range of motion is going to be. So I think it's a little bit more important to be protective in that early phase.

Manage the swelling, get the range of motion back very, very quickly. Well, these people are coming back better and faster, right? And so now we have this acceleration. And now it's now, the doctor says, OK, now how fast can we do this? But we have to consider the consequences of that. Right. And in some circumstances there may be no problems at all. Right. Like somebody might be able to get up after surgery, walk around, do everything that everybody wants them to do. They might be very, very quick and they might still have a great outcome. But we have to respect the people that don't do that. Right. And so, it's always going to be an n equals one situation, right? That's why we got to be careful with the cookbook.

In PT school, we don't really learn how to quote unquote measure things like tibial internal and external rotation. You can look at it in isolation, right? So if you take somebody to 90 degrees of knee flexion, right? So that's where your constraints are lessened. So like you do your anterior drawers and all that kind of stuff in that position because because the constraints are lessened in that position. And that's looking at it in isolation. Michelle, what I would say is that the most important thing is that you have the full excursion of knee range motion. So you think about this. So as I flex the knee, the tibia internally rotates on the femur. And then as I extend the knee, it externally rotates. So if you have normal knee extension, you can make an assumption that you've got enough tibial external rotation. If you've got normal knee flexion without resistance, then you can make an assumption that you've got enough tibial internal rotation. It'll be like if you get down on like in tall kneeling and then sit down on your heels. Okay, you would want to me that could do that right and and and so that is that is a passive that like that's at the passive constraints. I have a user goniometer other than to prove to to students that they're horrible eyeballing measurements.

You can look at it in isolation, right? So if you take somebody to 90 degrees of knee flexion, right? So that's where your constraints are lessened. So like you do your anterior drawers and all that kind of stuff in that position because the constraints are lessened in that position. And that's looking at it in isolation. Michelle, what I would say is that the most important thing is that you have the full excursion of knee range of motion. So you think about this. So as I flex the knee, the tibia internally rotates on the femur. And then as I extend the knee, it externally rotates. So if you have normal knee extension, you can make an assumption that you've got enough tibial external rotation. If you've got normal knee flexion without resistance, then you can make an assumption that you've got enough tibial internal rotation. It'll be like if you get down on like in tall kneeling and then sit down on your heels. Okay, you would want to me that could do that right and that is that is a passive that like that's at the passive constraints.

That brings up a really good question. It's like, well, okay, so if I'm biased towards external rotation because of my inhalation bias, then how do I lose the ER? That would be associated with the compressive strategies that we see in this upper posterior region on the pelvis. This musculature changes its direction of pull based on the orientation of the pelvis. So anything above the trochanter, as the hip orients forward, if I get a compressive strategy posterior here and I get a push from behind, that's going to increase the anterior orientation, and that's where you're gonna start to lose your external rotation because all the musculature above the trochanter re-orients its structural pull from external rotation to internal rotation. So the more anterior orientation that I have, the more ER that I'm going to lose. If we would go forward symmetrically in this situation, I would lose external rotation on both sides. If I have a lead with the left side, then I'm going to see a greater loss of ER on the left side. If I'm tilting on an oblique axis over to the right, then this side's going to lead a little bit, and so that's going to show a decrease in external rotation to a greater degree on the right side. A cool little thing that we can do is we can also confirm this from the ground up in some situations. So if I have this left side leading and I see this reduction in external rotation greater than it is on the right, typically what I'm going to see in this side, the foot on the same side foot, which would be the left side, is I will see a mid-propulsive kind of a foot, which would be typically described as a closed chain pronation of the foot, and so that kind of goes together. So that'll give you a little clue. In many situations, not in all situations, but in many situations, you're going to see those two things go together. When I get this tilt over to the other side, what you're going to see is you're going to see a late propulsive foot under those circumstances, and so I'm going to see what would be considered an open chain pronation where I'm actually pushing through that medial aspect of the right foot when the right hip is a little bit more forward based on the oblique tilt of the pelvis to the right.

Josh and I'm going to paraphrase Josh's question a little bit because some of it was directed towards a couple of things about his own Representation, but he brings up a really good point that I wanted to make. Josh mentions when in situations where you're doing a lot of side plank, suitcase carries, deadlifts, heels elevated squats, and lateral split squats for people with wide infrastructural angles. The question is, is adding load to these activities beneficial or is it counterproductive? And so here's the answer to that. It's a big fat maybe because it depends on what your intention is. But under most circumstances, when you're trying to capture a position, so we're trying to reacquire relative motion between segments, if I increase the load to a significant degree, what I end up doing is recruiting a great deal of superficial musculature, which increases my compressive strategy. It may drive me towards breath holding. And so those strategies constrain segments together. Now, that's not always a bad thing, because I can also create an emphasis in certain cases. So let's just pick on the Camperini deadlift for a second, where if I increase the load on the Camperini deadlift, I will actually increase the constraints at the ankle of the foot and the knee, but I may be able to access a little bit more hip motion under those circumstances. And if that's my goal, then adding load under those circumstances may actually help me to be successful. However, if I'm trying to recapture relative motions at the ankle, and the knee to a certain degree, then again, promoting the superficial musculature, promoting a breath hold, and creating a propulsive strategy may actually be detrimental for me to recapture that relative motion. So you can't say yes and you can't say no, but if we had to throw in a general recommendation, it's like increasing load when you're trying to recapture relative positions is usually not the best case scenario. So let me give you another example. So if we were doing say a cable chop versus a cable lift, so one of the distinguishing characteristics between the two is that a cable chop actually reduces the gravitational load on the human being because the resistance is pulling me upward. So as I pull down, even though I'm creating a compressive strategy to pull the weight down and cheerfully on the backside, I actually have the capacity to expand. Whereas if I was doing a cable lift and I'm lifting upward, that's more of a propulsive strategy, which is going to create a lot of superficial musculature. And again, it promotes the overcoming, breath holding type strategies that actually may reduce my relative motions. So again, Josh, I think this is a really, really great question that when in doubt, the answer is determine what your needs are through a test, you intervene, and then you retest to see if you're actually accomplishing what you intended to accomplish. But as a general rule, the greater the load, the greater the compressive strategy, the greater the breath hold, et cetera, you're going to actually reduce and constrain segments. And if that's your goal to reduce more force, then more power to you. If you're trying to recapture ranges of motion, then your ability to breathe through an activity will allow you to capture those relative motions that tend to restore ranges of motion, comfort, et cetera.

When in doubt, the answer is to determine what your needs are through a test, you intervene, and then you retest to see if you're actually accomplishing what you intended to accomplish. But as a general rule, the greater the load, the greater the compressive strategy, the greater the breath hold, et cetera, you're going to actually reduce and constrain segments. And if that's your goal to reduce more force, then more power to you. If you're trying to recapture ranges of motion, then your ability to breathe through an activity will allow you to capture those relative motions that tend to restore ranges of motion, comfort, et cetera.