Thank you. And so, John, I want to go through one of your cases because I think the perspective we talk about between ourselves and with the group that's been through the intensive is quite different from what we would consider a traditional viewpoint. The way we try to influence the system is somewhat different as well. I know you've got a couple of interesting cases, so I'd like you to pick one and go through and describe what you were seeing, why you made some of the choices you did, and then some of the surprising outcomes, especially with these difficult cases. You and I are very similar in that we just don't get the easy people up the street like a lot of people do. We don't see the acute angles like everybody else does. We see the ones who have a really long history of this and this and this and this and this. They've seen six practitioners that do all these things, they've been told these many things, and now they're at a point of frustration, confusion, and really at an impasse as far as their progress goes. So go ahead and offer up one of your cases for me, if you would.

Yeah, so this case was really exciting to me. I had a patient come in because she's been dealing with symptoms of disc herniation since February. She was a yoga teacher. And she began initially what they thought was a joint pain. She attributed it to pushing her body into position she wasn't ready for, which I feel like we see a lot in some of these yoga practitioners, especially as they're going through teacher training. At that time she tried PT for three months at what we consider a traditional clinic and their plan focused on trunk and core stability as you would expect. She didn't really feel any better after three months and they discharged her saying there's nothing else they could really do, but she wasn't happy with that. She's very active, she's a kid, trying for another one, and this is something she didn't want to continue with as she continued to try to live her life. She has a young kid and wasn't able to pick him up off the floor, not able to get down on the floor with him without pain. And then in this time before she saw me, she's been trying myofascial release, cupping, and cine acupuncture what she described as 20 plus times. She said that would make her feel good for about a week, but if she doesn't stay on top of it, the pain comes back. There was a little bit of, to me, something missing in the equation because the pain wasn't resolving. She went back to the physician October, so a month ago, and she got a cortisone shot which didn't provide any relief. In an effort to kind of continue to stay active, she connected with one of my friends who's a personal trainer, a kettlebell focused personal trainer, to kind of stay active and be more guided and exercise so she could try to exercise without pain. The trainer then said, why don't you try my guy? He thinks a little bit differently. I've had great outcomes with him and then we can coordinate the care, right? As Lauren, her personal trainer is going to be a huge part of her process as Lauren came into the session and now we're able to coordinate and through the process and maybe this patient feel pretty good at the end. So basically came in with a diagnosed herniation and hasn't had any relief with much of anything. Two out of 10 pain at its best, so it's always there and 10 out of 10 at its worst. Again, it was really, she can't sit for extended periods, driving's a pain, can't bend over, touch her toes, pick up her kids or lift objects. Looking at her, she definitely had some soft tissue restriction through her right low back and into her right glute. That was where she was tender on palpation, which you can kind of see why some of the manual interventions with the acupuncture might have helped provide a little bit of relief. But in my opinion, it wasn't lasting because you're not making a change in the system to promote better position, better stability with that lumbopelvic complex.

Okay.

An effort to kind of continue to stay active. She connected with one of my friends who's a personal trainer, a kettlebell focused personal trainer, to kind of stay active and be more guided and exercise so she could try to exercise without pain. The trainer then said, well, why don't you try my guy? He thinks a little bit differently. I've had great outcomes with him and then we can coordinate the care, right? As Lauren, her personal trainer is going to be a huge part of her process as Lauren came into the session and now we're able to coordinate and through the process. And maybe this patient feel pretty good at the end. So basically came in with a diagnosed herniation and hasn't had any relief with much of anything. Two out of 10 pain at its best, so it's always there and 10 out of 10 at its worst. And again, it was really, she can't sit for extended periods, driving's a pain, can't bend over, touch her toes, pick up her kids or lift objects, right? So looking at her, she was definitely had some soft tissue restriction through like her right low back and into her right glute. That was where she was tender on palpation, which you can kind of see why some of the manual interventions with the acupuncture might have helped provide a little bit of relief. But in my opinion, it wasn't lasting because you're not making a change in the system to promote better position, better stability with that lumbopelvic complex.

Yeah. So what you're dealing with there is some muscle activity, most likely. So the acupuncture or cupping is impacting that to a degree. But if there's no follow-up, if you're not teaching the system how to manage position, pressures, et cetera, then obviously that's why they're hitting this impasse. So what measures were impactful for you, from the perspective that we discuss on a regular basis, what stood out to you?

So going through her evaluation, she's going through yoga teacher training, but her active straight leg raise was 65 degrees on both sides. So that's a big thing right there. Her hip internal rotation was 25 degrees on her right and 15 on her left. That was another one that really stood out. Then looking at shoulder flexion for her bilaterally, it was 130 degrees. So that was okay; we need to clean up hip internal rotation and shoulder flexion, and then with that, hopefully the straight leg raise improves.

Yeah. So what you literally have here is something that is stuck in a very compressive type of strategy. And you can see it right away that you've got inhalation and exhalation measures that are very limited. So this is a superficial strategy that we wish to talk about.

Yeah.

So this is a superficial strategy that we wish to talk about.

Completely. And then even working further down, shoulder internal rotation was commensurate with the flexion, where it was 30 degrees bilaterally. Then hip abduction bilaterally was 30 degrees. And the infersternal angle was 100, so not terrible, but it wasn't dynamic. She didn't get good rib motion when she would inhale and exhale.

Right. And again, that's indicative of somebody that literally is not expanding or compressing. They're sort of in this middle ground superficial strategy, not allowing the axial skeleton to behave normally.

Yep. Yeah. Listening to our exhale, it's like 90% of it came out in the first second.

Right. And so I'm really glad you bring stuff like this up because this is something that people need to pay attention to because there is actually a pitch. You can kind of hear the pitch go up and down. And so this is indicative of the shape of the airway. This is indicative of the shape of the thorax because in often, in many cases, these actually are sort of complementary relationship, right? So if I get this sort of like this forced expiratory volume type of an exhale, then you know that you're not getting this full excursion of respiration, right? And they're going to be biased towards this compressive, exhalation-based strategy.

Yeah.

Okay, so now let's talk about approach because under many cases, some of the things that she's already been through will be defaults for many therapists or practitioners. So what did you go with?

Yeah, so I did four different things and it was really cool again because our trainer came with her to the session where we did an inverted hip lift where we put her heels on a 12-inch box, had her tuck under, roll up, bridge up as high as she could. So her hips were above her shoulders, and had her reach at a 45-degree angle and reach further into the reach with every exhale for four breaths to kind of help her find and feel hamstrings, internal obliques, and then maybe push the air up into her pump handle. Because of the training she'd been through, she loved diaphragmatic breathing and that was where everything was. Um, so I wanted to try to get a full excursion of rib cage as the breath worked up into the pump handle and into her neck. I'll even cue like 'breathe into your neck' to over exaggerate it a little bit and get people to feel okay, I need to get air all the way up. Right.

Right. So the compressive strategy actually, as we say, it's like squeezing the toothpaste from the top down. You get this compressive strategy where you don't get the sternum pump handle like you normally would. And of course, that's going to impact everything from scapular position to neck position and then the resultant shoulder range of motion that you've already measured.

Yep, yeah. So we went through four sets after four breaths and then we carried it on to a TRX lat hang with a hip lift. So we had her on the ground grabbing a TRX strap, same thing with her heels on a 12 inch box, bridging up to get her hips as high as she could. Then making sure she's kind of rolling up for us to kind of get a good zone of opposition and help to get her ribs a little more dynamic and get the exhale to bring her ribs down into position. And then we cued letting her bra strap kind of fall between her shoulder blades to get scapular upward rotation. I like that sometimes just because gravity helps pull them into position if they're able to let go without using these high tension superficial strategies.

Right. And so this is another case where we do have the superficial strategy, which is very concentrically oriented. And so in many cases, the breath alone is insufficient to drive the eccentric orientation. So right now you immediately created sort of a loaded strategy that allows you to capture the eccentric orientation and then you reinforce it with the internal expansion via the breath and now you have a very powerful strategy.

Yeah. So same thing. Four for four breaths is generally what we can do. And we won't always go to that unless we think someone can handle like the grip component of that. Sometimes that's the limiting factor.

Right.

But then we followed that up with the reverse crunch where she's holding a kettlebell behind her head and she was rolling up into a crunch holding her hips above her shoulders for a breath and then slowly controlling it back down. And I think that might have been the most powerful thing that we did.

So let's talk about this for a second, because this is very counterintuitive, especially with somebody that walks in with a diagnosis of a disc herniation, because a lot of people would immediately go to some form of extension-based protocol with such a diagnosis. And so the reality is that in many cases, obviously, it's not the solution, right?

Yeah. I think this just goes back to trusting your numbers or trusting your measurements, right?

Exactly right. Exactly right. Yeah.

I was looking at this and thinking if I can restore shoulder internal rotation, shoulder flexion, hip abduction, get a more dynamic Zone of Apposition, then I'll be good and we'll be on the right path.

You're treating the person instead of the diagnosis and I think that that should be something that we have to consider across all clients. It's like just treat the person. See what they're presenting. They're telling you what their needs are if you can respect the measures and then just follow through on that.

Yeah, and I think when I did the reverse crunch and she saw that it was actually more of the workout exercise, the type of things she wanted to get back to and it was tough for her and she was making comments like, this is a workout, this is not supposed to be a workout, it's PT. When able to achieve that, I love it.

Yeah, exactly. It's like we don't have to pigeonhole these people into these protective atmospheres in every case, especially when she's demonstrating the fact that it's OK. It's safe for her to proceed. So I think this is brilliant.

And I like changing people's perspectives on what PT is. Yeah. That's the biggest thing. I love that. Excellent. So we did that. And we did eight reps of eight sets of one to have her really focus on the control and working through breath and not reverting to their high tension, breath holding strategies. And then we just finished it off with some supine rocking. I had her lie on her back, grab her thighs behind her knees and back and forth, making sure she kept like in zone of apposition. making sure she kept ribs down, hips tucked under, and then stood up. And keep in mind, Bill, we're retesting every single time we make a change.