It goes up.

Don't say wide to narrow or narrow to wide, because you're not going to change that. What I would say is, can you get one to move? Okay. Because you're not trying to change somebody. You're not trying to change a wide to a narrow or a narrow to a wide. Okay. So I just want to interrupt you. So, change your thought process a little bit. Okay. Go ahead.

I would want them to be able to get as low as possible without the posterior orientation. So here's what we don't want to see. We don't want the pelvis and the lumbar spine to move as a single segment in a posterior orientation.

Right, so you're playing with center of gravity. So it stands to reason that there's going to be a sweet spot where you're going to, wherever your capabilities will be at that point in time, depending on what you're trying to maximize, there's going to be a sweet spot. So we have all the variations of platforms and stuff. And, you know, we can go from I think what is the lowest 10, 10, highest is 30. If you get on the 30, you can kind of tell if you were walking downhill and didn't want to fall face first down the hill, you have to lean backwards depending on the inclination of the hill. So the steeper I put you on a platform, it is likely that at some point in time, I'm going to actually get the opposing response of what I might be chasing if posterior expansion is my goal. Because again, it's just pure center of gravity issues, and you are absolutely correct. And so more is not better, better is better.

Yes. Oh, did you want me to expand on that?

You're doing like abduction or anything like table tasks. Yeah. Like you're measuring something on the table. Yeah, if their presentation is something you've seen before, but the interventions seem like they're potentially pushing it away from where you want it to go.

But, um and I guess it is context specific, but like what have you found to be like your go-to?

In cases where this represents the top of the thorax, if we have an anti-air post to your compression in the top of the thorax, you get a toothpaste tube that looks like that, so all the stuff gets squished down to the bottom. And what we'll see then is we'll see limitations in shoulder range of motion if we're looking at this from the thoracic perspective. In that case, what we need to do is increase the volume, the expansion in the upper part of the thorax. It makes it very difficult because gravity works, and gravity pushes air volume down, so air is affected by gravity just like everything else is. If we flip somebody upside down to a degree, what we can do is invert the airflow that goes into the lungs. If I take this person and turn them upside down, this now becomes the bottom of the lung, and it makes it easier for that air volume to get pushed towards the top of the lung, which is now the bottom of the lung if I'm upside down. You have to be careful because certain types of inversion are good for certain situations and are in conflict with what you're trying to achieve in other circumstances. More inversion is not necessarily better. Because of the way the diaphragm is shaped and the way it descends, in many cases, for instance, if I take a wide ISA and put them in some sort of prone inversion, I can actually magnify the problem under certain circumstances. If I have somebody with extensive compression on the posterior aspect of the thorax, especially below the level of the scapula, a lot of these inversion techniques that require support on the elbow are actually bad choices because you're driving them into a compensatory strategy as you're trying to achieve the expansion, especially posteriorly. You won't capture it because there's too much posterior compressive strategy on the backside of the thorax to allow the expansion. Those are just bad choices. You will probably see greater success with prone inversions with your narrow ISAs under most circumstances because, again, of the way the diaphragm is shaped as it descends, it's just a more favorable strategy for those people. With wide ISAs, starting them in supine is probably where you want to start inverting people, especially if you go to the video where I did the three strategies I use on myself, because I am one, you'll see that I started in supine. I would caution you against greater and greater inversion. What we're trying to do is just create a bias or a relationship where it makes it easier for that upper portion of the thorax to fill up with air versus saying, oh, more is better, because all you're going to do is magnify the current strategy they're using if you're too steep. Take that into consideration. You've got prone inversions and supine inversions. Remember that we're all toothpaste tubes. If we're squeezing down from the top and pushing those forces down, we just have to flip it upside down and squeeze from the bottom up, and then we have a nice full thorax, and then you get your shoulder range of motion back. Always test, intervene, and retest to make sure you're on track.

And so this is where you get the really lean guys with the six pack, but they got kind of like the round belly, right? Because they're compressed. But the guts have to go somewhere. Easiest place, I can't go back through the spine. It's really hard to do that, right? And so they end up going, again, they're gonna follow the path of least resistance. And so you get this, like literally it's like the guys are jacked and they got this kind of roundness to the abdomen because the guts have to move somewhere, right?

All right. Just want to be sure. Hi, Dr. Mike. Come on, guys. You have your hold your cup up. Let me see. You got it? There he is, ladies and gentlemen. There's your neuro coffee guy. I would be nothing without this guy. By the way, Dr. Mike, my coffee is perfect. I did not expect any difference.

Oh, maybe a little guess. OK, why? Is it because of his dashing hairstyle? Yeah, exactly. So you see the neck, and you immediately go, wow, that neck goes on a really big, strong guy, right? OK. So literally, just by looking at someone, you made a judgment call, right? And you're probably right, right? Because again, the muscle mass kind of goes with the territory. But again, you just have to respect the fact that everybody's going to be a little bit different. And so they're going to process information a little bit differently, a little bit more slowly. In many cases, so if I have somebody that has what I perceive to be sort of one end of the movement spectrum capabilities, then I do everything slower. I might need to create a vocabulary for them because if they don't spend much time being aware of movement and I need to teach them how to do that, then that's where we get this difference between sort of like this internal, external queuing kind of a thing, right? because the internal cues are designed to provide a sensation that most people may not be able to acquire themselves. Why do you do manual therapy? Well, you do manual therapy to give them a sensation that they cannot acquire themselves, right? So again, we have lots of tools. So we have physical contact. We have verbal cues. We have movement-based activities. We have awareness. Drills and things like that that we would use and we use them all for everyone to varying degrees. Some people just need a much stronger influence in one of those than the other where you take a high level athlete And literally you just say, go over and do that. And they immediately know what to do. Like they just intuitively know what to do because their movement intelligence is so high. And then you take the guy that's been sitting behind a desk as an accountant for 25 years that can multiply three, four digit numbers in his head in 10 seconds. And we don't appreciate that, but we knock him for not being a great mover, right? Because that's what we do. And we have to approach that just a little bit differently. We have to respect what people are bringing to the table, so to speak, right? And again, it's just sometimes I got to go slow. Sometimes I can go fast. Sometimes I got to develop the movement in vocabulary so we can communicate because they don't know what we're talking about, right? And then don't ever And we all do this, but don't ever, don't ever belittle someone, even internally. Like when you're giving your best cues and everything, you think you just knocked into the park and they just go, what? Because they just don't have that understanding, right? So we just got to find a way to do that.

I asked her that and then I was saying, Hey, what does this toe touch look like to kind of make sure that like where if he's actually posteriorly tilted or if he's in the position that you were describing.

Yeah. There's a lot of cognitive dissonance in the beginning. And I kind of disagree, Bill. You have defined quite a few things, and you have a language for those principles. And because there is a language for it, you're doing exactly what people did 2,300 years ago. And that is, it's a good thing though, because I say it's a good thing because the cognitive dissonance, it really turns things upside down. And now you have a new model and it's not just a model, there's principles behind it. And those principles support your model. And the language used to support the principles is what really drives this and it's what makes things challenging.

Yeah.

Discuss arm positioning using the reflection arc in general. You kind of talk about reaching or how you physically utilize that to gain something that they're looking for in exercise. Okay, so what do you want to acquire or reacquire? Yeah, so let's say you're trying to get lower thoracic expansion. Where, like, how would you place your arm to drive something in an exercise and stuff like that? And would you reach, would you move, would you have an extra rotation aspect, interrotation aspect, like, kind of this overall way of thought process, besides just that sort of jazz.

The mechanism that probably created the injury tends to actually be the ER and then the prolonged supination during the throw.

pitching mechanics and arm speed.

Yeah, but it was only on one side. Okay. Right? But what you start to recognize is that, oh, okay, so what I have is this really big, and it's an orientation. So it's the whole, take the whole pelvis and tip it on an oblique axis. And that's how you get crazy measures like that. Okay. Whenever you're in doubt as to what you're looking at, take all your measures into consideration. Identify what you think you're looking at and then intervene and then do something right and then remeasure. Because a lot of times we don't figure these things out until after we do something where we can say, okay, this was the initial representation that I had, here's what I did with the intention of something right, and then what happened. And then you look back and go, oh, now I get it. She was tipped up like this and this was turned this way and this was turned this way. Or you say, oh, as I was measuring what was happening was that the pelvis was actually turning towards me, and then that's what skewed my measurements. Because again, and this is a really difficult thing to grasp because it's just another layer of complexity when we're looking at things and measuring things. We have to consider and it makes it very gray, right? Instead of like, oh, I know exactly where this person is. I have to say, maybe, right? Another thing that you can do is you can do something manually to induce some form of sensation, right? And then see what happens under those circumstances. So let's just say that you've got the crazy external rotation, no internal rotation. What would be a manual technique that you would use to recapture internal rotation? Do that and see what happens, right? Because the lady that I was working with, that's exactly what I did. It's like, I had this crazy, like a right hip external rotation of 80 degrees and then like minus 10 for her internal rotation, right? So I just mobilized her hip to recapture the internal rotation. And then lo and behold, wonderful things happened. That's acceptable because, again, these things are hard. We don't always know exactly what our representation is going to be. And there's nothing wrong with experimenting in this situation because it is in a complex domain. We only figure things out in hindsight.

Sometimes when it comes to rehab kids, I would say to Mike that there's a lot of literature now in almost every sport that looks at game analysis of physical outputs. Depending on the sport, you can see what normative data exists. While it might not apply exactly to your athlete, it can be a decent starting point. For example, when I was in soccer, GPS technology became prominent about a decade ago, allowing us to see what each league worldwide expects of each position during a 90-minute game. The same is happening now in basketball, and I know they have some data for lacrosse and football too. So even if it's not athlete-specific, it gives you a starting point for what you're trying to achieve, like Bill was saying about establishing the end goal. But if you need sport-specific terminal tasks, that's where my mind immediately goes: what sport is it, and what does the current literature say, because there's so much available now due to technological advances.

I was. I've been listening to your podcast with you online with three other people.

And that's what we do. Like the worst thing I think you could do under those circumstances is try to restrict his behaviors. We want to provide exposures to behaviors. Kids figure it out. There are concerns like, oh, is this normal? It's like, yeah, absolutely. It's normal. They've just found a strategy that worked and they're going to play with that for a while, and then they're going to do something else. So it's not like there's something wrong with them. It's just a matter of like, this is how he figured it out for right now. The thing you want to recognize is just expose him to a number of different environments. So if you take him outside and he's crawling around in the grass, he's going to be in a totally different position, and that's what we're shooting for. We just want lots of exposure. If you ever have an interest in that kind of developmental stuff, Esther Thelen looks at neonatal development from a dynamical systems perspective rather than milestone reflexes. Because the baby's head is about a third of his body weight, it's one of the reasons why babies squat well but can't hinge. Because their heads are too heavy—if they try to do an RDL, they face plant. So people get so excited about, oh, look at the baby. He's got a perfect squat. He didn't have a choice; he had to do it that way. I don't like giving credit to the young ones for being such great squatters. They're just figuring out, based on the system, what is available to them and how to do it in the most efficient way.

This is a condition that basically it's genetic that reduces the size and total numbers of hemoglobins in the blood that will cause anemia. So she's constantly very vigilant and well, this can be good or bad depending on circumstances. So we try to get it into a more rested state. So her resting heart rate is now around 75 to 85 in the morning. So I figure if we can lower her resting heart rate, that would be a good indication of improving her recovery. So we've been doing some low intensity aerobic protocols but didn't see very much improvement in the resting heart rate. So my question is if it is even possible to lower her resting heart rate or if the condition is a physiological constraint that is very difficult to overcome.

Okay, so if we think about the circulation having two sides, right, you have the output side and the input side, okay, to make it simple. All of the fluid shifting that goes on, that's associated with circulation is based on gradients. It's just like we talk about with range of motion and things like that, and we talk about gradients of pressure and volume. So on the front side, so as the blood leaves the heart, the gradients are such that the fluid shift is away from circulation. So it's moving stuff into the cells. On the backside, the byproducts of cellular metabolism are coming back into circulation. So any ions, hydrogen ions, chloride, et cetera, et cetera, increases the concentration of the blood flow coming back into the heart. And then that increases the fluid volume coming back into the heart. The larger the ion concentration, the more fluid that comes back, towards the heart, right? So that means I have more fluid coming back into the heart. So what the heart does is it doesn't actually create the pressure that manages the flow of blood because blood flows all by itself, okay? What the heart does is make sure that the flow gets vortex. So the heart actually spins. It doesn't pump. It spins blood to make sure that it's a non-turbulant flow that enters and leaves the heart. So if you were deconditioned, as it were, as the people that tend to get high blood pressure are, they will produce more ions. They will have a larger volume of fluid returning to the heart that the heart has to manage. And so that's why you're going to see higher resting heart rates with people that are deconditioned. But you'll also see higher pressures because it's a back pressure coming from the backside. So the fluid that's going back to the heart after cellulose metabolism creates the resistance, if it were, Okay. And so that's my spiel. And so if you become more aerobically conditioned, you don't produce the strong ion concentration that's associated with cellular metabolism like people that are deconditioned. And therefore you have a greater likelihood of lower blood blood pressure. Now, having said all that, I'm sure there are things that I don't understand that I don't know that can actually increase blood pressure. But when we're talking about the conditioning effect, that's where my head would be. Well, what's your aim? Because let's talk about it because it might be useful.

where I should have a maximum propulsive strategy in the pelvis. Now I have a problem because now I have too much relative motion occurring where I should not have relative motion. Then I can't produce forces the way I want to. And now I got to distribute it differently. And then that might cause a problem. So either I lack performance, I can't push hard enough, or it becomes a point of discomfort.

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.

Okay. The trampolines all set up and it's got the springs that attach it to the frame, right? And then you have the center part, which is what you bounce on. So what I want you to do is fix the size of the thing that you're bouncing on. So the surface that you actually bounce on on the trampoline is fixed. We're going to manipulate the tension on the springs. If I loosen the springs and get on the trampoline and it gives way, that's yielding. If I tension up those springs and make them really, really tight, now the surface is more taut, but it's exactly the same as it was when it was loose. Now when I get on the surface, there's not as much giveaway, and because the springs are stiffer, more of that tension actually goes into the frame and into the ground—that's overcoming. Now I want you to stand in the trampoline when it's yielding, so on the loose springs. The trampoline's not gonna change size, but I'm gonna tension the springs while you're standing on it. And so you're actually gonna go up, feel that? You understand? So you just went from a yielding action to an overcoming action. The way that this happens inside of us is based on the rate of loading associated with the activity. The slower the rate of loading, the more yielding you'll have. So the tissues that approximate the musculature that's doing the work will basically elongate, and that creates a dampening effect. Let me give you an example. Have you ever done a box jump? If you jump off of a box and come down and absorb the landing so you're really quiet but you feel that you lower your center of gravity and it takes time for you to come to a halt, that's yielding in a dynamic activity. If you land hard at the very end of the jump instead of absorbing it gradually, that's overcoming. There's always a yielding and overcoming that happen at the same time. It's just a bias. We're doing this to varying degrees. There's a gradient of activity here that we're talking about. And that is the representation of what yielding and overcoming is. So we're talking about cutting. As I'm dynamically moving, whether I'm doing a drill or playing sports, and I'm going to go cut off my right foot, I reach out with my right foot. It touches the ground, and then everything moves in that direction. Unless I want to hit a big hard jolt, I got to be yielding. Initially I'm yielding, but I'm also decelerating, changing joint angles. So I have muscles that are changing links and connective tissues that are absorbing force. The rate at which I absorb that force determines whether the tissues are really, really stiff overcoming or whether they're softer in yielding. So you see how there's a combination of things, but we tend to just represent the description by the bias. So where you're gonna see the biggest overcoming element is at the turnaround. I move into it. I'm yield, yield, yield. Less yield, more overcome. Less yield, more overcome. Boom, overcome going in the other direction. But this is happening all the time, just to varying degrees.

That's awesome.

Have you found that some of the base movements are a challenge for some of these kids, like skipping, jumping? Do you know what I mean?

Yeah. Have you ever drawn it out? Have you ever drawn out your model?

Bill, how are you doing physical therapy? Well, if you're in your office, so you can do it, you're not doing it virtually.