Good morning. Happy Thursday. I have neuro coffee in hand, and it is perfect. Zach Fender, great shirt. Thank you. You're not required to wear that on these calls. You know that, right?

No, it's just laying on the ground, actually.

Oh, fine. I feel so much better. It was laying on the ground.

Well, it was folded. I didn't get to pull it away.

I found it in the trash, and I thought I'd wear it to do it.

No, it was folded and clean. It just did not make it back into the drawer. All right, so I have a question. Like just trying to refine the process that got me to an outcome a little bit. So I went to this patient once with their economy for low back pain, pretty much like anything where she had to assume like a flex posture. So toe touch was the main KPI that we were using. It was painful.

It was painful or just.

Painful. Yeah, like five out of 10 pain, kind of like both sides.

Pain scales are one of my pet peeves.

It's all right. I don't know those are pet peeveers. It is. It is.

Pain scales are one of my pet peeves. Because it's usually a yes or no, right?

Yeah. All right. A good amount of pain bending over. Or just like anything where it was like a flex posture, like sitting. She's a swimmer, so swimming's actually fine, but if she has to do her flip turn, she'll feel it.

Okay. That makes sense.

As far as a chessboard, like maximizing external rotation (ER) orientation with no internal rotations (IRs). So like zero degrees of IR in both hips, but 50 or 60 degrees of ER. My initial thought where I went first, which was unsuccessful, was just doing some manual work—basically putting her in a sidelying position and applying pressure to her pelvis and rib cage to try to reduce the ER orientation, which didn't do much. So then I decided to go after the anterior orientation instead. With a little bit of manual work and then I gave her a hook-lying position with a ball between her knees, trying to get a little more posterior pelvic tilt. That pretty much got most of her pain away. Just hook-lying with the ball between the knees and static breathing. That pretty much made the pain completely disappear at that point—she was almost touching the floor. I was initially confused why that worked, because I felt I would need to improve her IR for the toe touch. But then I realized I needed the ER first. Now I'm trying to refine my thought process: Was it just the fact that she was so far forward that I needed to break her back first before she had room for IR, or if I see someone else with a similar pain and motion but who hasn't lost as much IR and isn't as far forward, then maybe that's a case where I don't need to get the ER first. That question makes sense.

Okay. So where was, before you did the intervention, or you did the hook line. Where was her ER? Her ER was through the lumbar spine. I'm sorry, space, ER space. Up to the side.

Where was her ER? Her ER was through the lumbar spine. I'm sorry, ER space. Up to the side.

So it's way far away from midline, right? Because clearly, clearly she was pushed forward, right? Limited straight leg raise. Yeah. But was she touching her toes? Initially? Even though it was painful, was she still touching her toes?

No, she probably reached from fingertips to just past the kneecaps. Very limited.

So when you did the hook lying activity, you had her feet like really, really far apart on the table.

Nothing crazy, but definitely like further from midline.

Okay. But I mean, see where my hands, they disappeared from the screen. They were way out there where her space was. So you put her feet that far apart. Not a beach ball. You put a beach ball between your knees and you put her feet way out here.

Yeah.

So you put her feet that far apart. Not a beach ball. You put a beach ball between your knees and you put her feet way out here.

Not that extreme, but further than not—they were not shoulder width.

Okay. But the point being is, you actually brought her into some place where she could lay down some internal rotation, right? Okay. So what representation did you achieve relative to the starting conditions?

More internally rotated, which would be what?

So you superimposed internal rotation on extra rotation. So where did you bring her from?

And then you brought her to early to middle. You brought it early. Kind of makes sense.

The goal was simply to down regulate some of the motor output that she was cranking up, because she's all internally rotated, which makes sense given that she's a swimmer. You essentially reverse engineered the process. She was in an internally rotated representation, which was good because it's very easy to move somebody from a late representation to an early representation—the difference is just motor output. Then you get the connective tissue behaviors associated with the early representation, transitioning from overcoming connective tissues to yielding.

Which would be the goal. Yes.