Exercise form focuses on just about everywhere EXCEPT the neck.
Yet neck position has a profound influence on the rest of the body position.
So where should your neck be while you lift? Like on a deadlift, squat, or press?
I'm answering that for you today.
If you want to protect ya neck as the Wutang said, then you definitely have to check this out.
We go over: 1. How neck position influences the rest of the spine 2. The biomechanics reason for the neck position I advocate 3. The top coaching pieces to think about with neck position 4. And more!
⏰ TIMESTAMPS ⏰
00:00 - Introduction 00:52 - Biomechanics behind neck position - it's really the whole spine 03:24 - What position should I have my neck 09:09 - How to coach neck position 15:44 - Sum up
Aug 07, 2022
Home Exercise (HEP) Compliance - PROVEN Way to Increase It
😱 Exercises don't work if your clients don't buy in or execute them well 😱
Exercise selection IS NOT the biggest barrier to client success.
What is? The client ACTUALLY carrying out the home exercise program and performing the exercises to your standard.
Sadly, there isn't a magical breathing technique that can help increase client compliance.
But there is something that does–an effective communication system.
What I'm going to show you in this post and video is the PROVEN system that I use that both enhances client/patient compliance and ensures that there exercise program is carried out savagely well.
If you care about client outcomes, then check out the post and video below to learn more
Here's what you'll learn in this video
1. How you can increase compliance and improve client learning within the session 2. The importance of debriefing the client once a session is complete 3. A BULLETPROOF follow-up sequence that keeps your clients on track 4. and more
⏰ TIMESTAMPS ⏰
00:00 - Introduction 02:09 - It starts before the session ends 07:22 - How do we make sure client actually does their exercises correctly? 08:57 - The power of the debrief 17:14 - Follow-ups that INCREASE compliance and exercise performance 20:03 - Sum Up
😱 How doing less can actually help you move more 😱
Have you ever tried to rehab someone in pain, but their progress continues to stall because they keep doing activities that cause problems? You know, the person who continues to get in their own way?
Although maintaining a physically active lifestyle is important for one’s health and wellbeing, some activities can be counterproductive during the rehab process. The cure can become the poison.
What are we to do? Stop moving and breathe on the ground FOREVER?
No. God…no.
Instead, we want to couple a stellar rehab program with activity modification, choosing activities that complement or enhance the rehab goal as opposed to getting in the way.
In today’s post, I’m going to show you the following:
Why activity modification is ESSENTIAL for a successful rehab, How NOT modifying activities can create a failure in patient outcomes the 3 ways I modify activities to SPEEDILY help some achieve pain-freedom How to help patients and clients buy-in to temporarily stopping the tasks they may love, but get in the way.
Sound useful? Check out the video to learn more.
Here's what we discuss
1. What activity modification actually is 2. Why eliminating certain activities, even if they don't cause pain, can be essential for restoring motion 3. The importance of reloading and how doing it well can improve fitness and minimize flare-ups 4. How to modify training so it helps improve motion AND fitness 5. An AWESOME way to improve client buy-in 6. and more!
⏰ TIMESTAMPS ⏰
00:00 - Introduction 01:14 - What the hell is activity modification anyway? 04:43 - Most extreme activity elimination challenge 14:31 - Slowing the reload (#slowcooker) 23:23 - Nate Dogg and Warren G had to accomodate (Activity accomodation) 27:12 - Do u even buy in, bruh? 30:17 - Sum up
😱 If you do these actions, you're screwing your breathwork up 😱
Breathing exercises can be useful at enhancing mobility throughout the body...IF they are done well.
Sadly, that rarely occurs.
Until now.
In today's post, I outline the major keys you need with each piece of common breathing exercise to ensure that you get the most out of these moves, maximize your range of motion, and move better than ever before.
Check it out!
In this video you'll learn:
1. How to determine what action should occur at the pelvic 2. How to properly inhale 3. How to exhale like a BOSS 4. How you need to reach
⏰ TIMESTAMPS ⏰
00:00 - Intro 02:55 - How to know which pelvic component you need to do 05:02 - Pelvic component coaching keys 09:17 - The #MAJORKEYS to breathing like whoa! 12:09 - You reach, I teach: Proper reaching during breathing exercises 14:00 - Sum up and outro
😱 The hardest thing you can do if you are in chronic pain 😱
Chronic pain can be one of the hardest conditions to overcome, though I think there is 1 variable that separates those who are stuck and those who breakthrough.
But this obstacle is one of the hardest things to overcome on the journey toward pain freedom.
Don't worry, I'll outline what this issue is, and provide some ideas on how you can overcome it, and hit your pain freedom goals.
🧑💻 Full show notes, blog post, and more can be found here: https://zaccupples.com/knee-pain-case 👨🎓 Learn more at https://zaccupples.com/ 🏃♂️ Check out the exercise clips channel here - https://www.youtube.com/channel/UC0OVPHLm6SYT6xYZFmKtoIQ 🙌 WORK WITH AND LEARN FROM ZAC! 🙌 👨🏫 Want to work with me? Sign up for a slot here: https://calendly.com/zaccupples 🏋️ In Las Vegas and want to work with me in person? Check me out at https://elevatesph.com 💨. Sign up for Human Matrix, my movement seminar, here: https://zaccupples.com/seminars 🎥 Camera set up - https://www.amazon.com/shop/zaccupples 💪 The best squat wedges EVER! - https://squatwedges.com?sca_ref=1466888.7tyWzxDgZI 👨🏫 My mentor, Bill Hartman - billhartmanpt.com 😱 If you notice your hips don't stay level during stairs, then check this out! 😱 Does your hip ever drop down and rotate funky when you are doing exercises like step-ups and downs? Do you ever wonder why? Well, we cover the why and some fixes in today's post, where I go through a case study that dealt with this exact issue. And the fix only took 3 exercises. Check it out! In this video, you'll learn: 1. What a flat turn compensatory strategy is (perfect for pelvic asymmetries) 2. How a lateral pelvic tilt compensation occurs and presents 3. 3 moves to correct a right lateral pelvic tilt 4. and more Let's get to it! ⏰ TIMESTAMPS ⏰ 00:00 - Intro 01:21 - Case overview, first session 10:15 - Second session overview 12:03 - The first exercise - starting the turn 17:19 - Second exercise - Hip approximation 21:14 - Cleaning up the step up 22:27 - Case debrief and The 4 steps for FIXING flat turns 26:10 - Sum up and Outro 📸 PHOTO CREDITS 📸 Photo by Kindel Media: https://www.pexels.com/photo/a-woman-having-a-knee-pain-7298659/
💰 The stark difference between cash pay and insurance-based PT
Cash pay and insurance-based physical therapy are quite different, but how? I’m going to answer that through my experience today.
\I’ve spent the last 2 years in cash pay physical therapy practice, having worked in insurance-based physical therapy for the first 8 years (aside from my stint in the NBA). All of these endeavors were as an employee.
And today, my fam, you’re going to learn the differences I’ve noticed between each of these disciplines. Check out the podcast to learn more!
With this video, you'll learn the following:
1. My experience in both insurance and cash pay physical therapy
2. The tradeoffs between these two practice styles
3. Are the visits really all that different?
4. How clients differ in these practices
5. The discharge, does it really happen?
6. And more!
Let's get to it!
⏰ TIMESTAMPS ⏰
00:00 - Intro
01:15 - The tradeoffs between cash pay and insurance
08:15 - Are the number of visits really that different?
12:39 - The caseloads, there are different patients yo!
😱 HAVING ROUNDED SHOULDERS DOESN'T OCCUR FOR THE REASON YOU THINK IT DOES 😱
Rounded shoulders are an often common complaint of folks who perceivably have poor posture.
Conventional rehab makes us think that the simple solution to this problem entails stretching the pecs, strengthening the upper back, attaining a good head position, and sitting up straight.
But what if conventional treatment for bad posture was all wrong?
The problem with typical treatments is that we rarely look at the foundational influence—ribcage dynamics—that likely governs where your shoulders go..
That changes today. In this video, we will outline postural factors that contribute to having rounded shoulders. The one’s your standard PTs gloss over.
Check out the video and post below, let’s dive in!
With this video, you'll learn the following:
1. The REAL reason why rounded shoulders occur 2. The thorax biomechanics that can create rounded shoulders 3. The top exercises to improve rounded shoulders 4. And more!
Let's get to it!
⏰ TIMESTAMPS ⏰
00:00 - Intro 01:43 - How the ribcage influences rounded shoulders 04:03 - The biomechanics of rounded shoulders 12:19 - How to improve an anterior thorax tilt 20:17 - How to improve ribcage pumphandle dynamics 26:05 - Sum up
The kettlebell armbar is a vastly underrated move for improving your range of motion, strength, and stability in your upper body. The reason why it’s underrated and underutilized is because it’s quite unclear when to program this activity and how to execute it most effectively.
We will change that with today’s video! With this video, you'll learn the following:
1. Why the kettlebell armbar is a useful exercise
2. What mobility improvements you can expect when performing a kettlebell armbar savagely well
3. The keys to perfecting the kettlebell armbar, as well as the common movement faults
4. The best kettlebell armbar variations out there 5. And more! Let's get to it!
⏰ TIMESTAMPS ⏰
00:00 - Intro to the kettlebell armbar
00:58 - Reasons to program the kettlebell armbar
03:03 - Coaching the Hooklying kettlebell armbar
06:54 - The kettlebell armbar with screwdriver
09:36 - The kettlebell armbar with head turn
11:14 - The screwdriver head turn combo
11:53 - The sidelying armbar
16:45 - Sum up
🎙 SONG CREDITS 🎙 Still Awake by Ghostrifter Official | https://soundcloud.com/ghostrifter-official Music promoted by https://www.chosic.com/free-music/all/ Creative Commons CC BY-SA 3.0 https://creativecommons.org/licenses/by-sa/3.0/ On My Way by Ghostrifter Official | https://soundcloud.com/ghostrifter-official Music promoted by https://www.chosic.com/free-music/all/ Creative Commons CC BY-SA 3.0 https://creativecommons.org/licenses/by-sa/3.0/ Equinox by Purrple Cat | https://purrplecat.com/ Music promoted on https://www.chosic.com/free-music/all/ Creative Commons Attribution-ShareAlike 3.0 Unported (CC BY-SA 3.0) https://creativecommons.org/licenses/by-sa/3.0/ Music: https://www.chosic.com/free-music/all/
Dec 13, 2021
Slouched vs Arched Posture - What's the Difference?
⚡️ IS YOUR POSTURE LIMITING YOUR TORSO MOVEMENT? HERE'S WHAT TO DO ABOUT IT!⚡️
If you have a tendency to be slouched, arched, or anything between, you might be wondering how you can improve the movements that are often lost with these presentations.
The hard part is that the motions limited with these postures, as well as the "fixes" to improve these restrictions, are far from intuitive.
Until today.
It'll all be cleaned up in Movement Debrie Episode 165.
With this video, you'll learn the following:
1. The biomechanics behind slouching, arching, and someone who is still everywhere 2. What range of motion deficits often accompany these presentations 3. Some easy fixes that'll improve range of motion in these cases faster than ever before 4. And more!
Let's get to it!
⏰ TIMESTAMPS ⏰
00:00 - Intro 00:56 - The Question 02:41 - Ribcage biomechanics during quiet breathing 06:16 - Why compensatory breathing mechanics happen 07:48 - The pros and cons of using models to illustrate biomechanics 11:09 - What is a posterior thorax tilt? (Arch) 16:33 - How to improve a posterior thorax tilt 23:37 - Posterior thorax tilt recap 24:03 - What is an anterior thorax tilt? (Slouch) 26:24 - How to improve an anterior thorax tilt 29:42 - Anterior thorax tilt recap 31:11 - What is anteroposterior compression? 34:28 - How to improve anteroposterior compression 38:30- Anteroposterior compression recap 39:30 - Sum up & Outro
⚡️IF YOU HAVE CARPAL SYNDROME, YOU MAY HAVE TO LOOK BEYOND YOUR WRIST! ⚡️
With an increase in computer and remote work, we may see the incidence of carpal tunnel syndrome increase.
The problem, however, is that most people only look at the wrist and the neural components in the arm.
This approach may be missing some critical pieces that can influence the health of the median nerve, the nerve which is affected by carpal tunnel syndrome.
What are those pieces? Don’t worry, fam, I’ll tell you in Movement Debrief 164!
With this video, you'll learn the following:
1. What carpal tunnel syndrome is 2. Important assessments to give you the most comprehensive treatment for carpal tunnel syndrome 3. Why nerve glides might not be the first thing you should do 4. The BEST order to improve impairments related to carpal tunnel syndrome 5. And more!
Let's get to it!
⏰ TIMESTAMPS ⏰
00:00 - Intro 00:59 - The question 02:00 - What is carpal tunnel syndrome? 09:07 - Red flags and evaluation 14:06 - Neurodynamic findings and the shortcomings of nerve mobilizations 17:58 - The first treatment strategies to do with carpal tunnel syndrome 29:34 - Improving neurodynamics 35:56 - Sum up & Outro
😱 QUESTIONS TO ASK PT SCHOOL THAT WILL ACTUALLY IMPACT YOUR CAREER! 😱
When applying for anything, especially PT school, it's common and expected to ask the school important questions. This shows that you are vested in the process.
The problem is that most of the questions people on the internet tell you to ask are IRRELEVANT to moving forward in your career. Like how to pass the licensure, what separates you from other schools, etc.
Although the PT school application process is nerve-wracking, never forget that YOU are also interviewing THEM.
You have to make sure this school is the best fit for you and will set you up for success for the rest of your career.
How will you know that? Ask the three questions in today's video.
With this video, you'll learn the following:
1. Three important questions to ask PT schools during the interview process 2. How these questions will impact your personal, professional, and clinical success 3. How not asking these questions will negatively impact your career and life 4. And more!
Let's get to it!
⏰ TIMESTAMPS ⏰
00:00 - Intro 03:15 - Question 1 (finances) 10:50 - Question 2 (clinical) 16:58 - Question 3 (didactic) 20:36 - Sum up & Outro
It’s common for people to have significant pelvis postures that may impact movement capabilities, but how do we know when these postures are problematic? What can we do about maximizing the movement of someone who has an anterior pelvic tilt or swayback?
Or heck, maybe you can’t even tell the difference between an anterior tilt and swayback posture. Where should you start?
Well fam, you should start by peeping Movement Debrief 163!
With this video, you'll learn the following:
1. The difference between anterior pelvic tilt and swayback 2. How these postures can influence available range of motion 3. How to improve movement capabilities for each of these presentations 4. Different compensations that cna present with a swayback 5. and more!
Let's get to it!
⏰ TIMESTAMPS ⏰
00:00 - Intro 01:18 - The difference between swayback and anterior pelvic tilt 04:51 - What is an anterior pelvic tilt?l 12:11 - What is a swayback posture? 16:57 - How to improve anterior pelvic tilt 19:31 - How to improve swayback posture 23:02 - Sum up 24:16 - Rectus abdominis activity in the swayback 25:53 - A swayback posture that can palm the floor 27:44 - How to introduce stacking with a swayback posture 29:11 - Knee hyperextension with swayback posture 30:18 - Outro
😖 RARELY DO WE DISCUSS OUR MISTAKES. I'LL BE THE FIRST 😖
We learn some of our best lessons from the mistakes that not only we’ve made, but those before us.
Yet rarely does one discuss the times that they’ve failed. Instead, it’s all puppies and rainbows on your social network of choice. Everyone has their best life and best practice all up in there.
But without that transparency, without sharing how we fail, we miss out on an incredible learning opportunity. We may fall victim to similar mistakes that can happen throughout both patient care and working with your supreme gym clientele.
That ends today.
I’m going to share with you 5 mistakes that I’ve made in my physical therapy career, what I’ve learned from those problems, and what I’m doing differently. Let ya boi screw up, so you don’t have to.
With this video, you'll learn the following:
1. How not having the right mentor killed my learning 2. The way ego can screw you up! 3. How to get better buy-in from your patients and clients 4. The art of being honest with your patients 5. Should you rely only on one thought process?
Let's get to it!
⏰ TIMESTAMPS ⏰
00:00 - Intro 01:18 - Mistake 1 06:30 - Mistake 2 09:27 - Mistake 3 12:35 - How to balance patient wants and needs 14:24- Mistake 4 21:07 - Mistake 5 24:39 - Sum up & Outro
🤸♀️ IF YOU CAN'T TOUCH YOUR TOES, YOU NEED TO CHECK THIS OUT 🤸♀️
The straight leg raise = a big deal for any hinge-type movement, yet it can also be one of the hardest measures to improve.
Or is it?
Understanding the order of attack when you see a limited straight leg raise can make this often difficult to change test WAY more simple.
Don’t worry, Movement Debrief 161 has you covered.
With this video, you'll learn the following:
1. Why the straight leg raise is important and what it tells you. 2. Three zones of the straight leg raise 3. What rotation occurs in each zone 4. Various movement strategies to improve these specific tests
Let's get to it!
⏰ TIMESTAMPS ⏰
00:00 - Intro 00:58 - The question 6:14 - Phase 1 - 0-45 degrees 11:49 - Phase 2 - 45-60 degrees 14:13 - Phase 3 - 60-90 degrees 15:21 - CRAZY Straight Leg Raises 18:08 - Sum up & Outro
🤸♀️ WHY HIP FLEXION IS SO MUCH MORE THAN A SAGITTAL PLANE MOVEMENT 🤸♀️
You may think hip flexion is as easy as bringing your knee to your chest, but there is SO much more going on.
In fact, the act of hip flexion has various rotational elements about it, and better understanding these elements can greatly enhance our exercise selection, helping our clients move and perform better.garageband
Don’t worry fam, we get into the weeds and come out with an easy understanding of hip flexion in Movement Debrief Episode 160!
With this video, you'll learn the following:
1. Three zones of hip flexion 2. How infrasternal angle presentations can be related to the rotations that occur in hip flexion 3. What exercises can be used to increase your hip flexion capabilities 4. How hip movements differ with breathing vs movement 5. Whether to prioritize external or internal rotation 6. When is hip flexion considered compensatory
Let's get to it!
⏰ TIMESTAMPS ⏰
00:00 - Intro 1:07 - The 3 Phases of Hip Flexion 25:07 - Combined femoral mechanics? 32:33 - A narrow infrasternal angle who has lost both ER and IR 37:46 - Testing 39:08 - Outro
The squat is an excellent exercise for both enhancing lower body range of motion and strength, but it’s not so great if you have a bunch of wild compensations doing it.
What are some of the common compensatory activities that we see in the squat, which ones are “bad,” and most importantly, what shall we do about it?
You are going to find all of that out with today's video. Here are the questions we answer:
1. What is knee valgus in the squat and is it a bad thing? 2. What is a butt wink, is it bad, and what should you do about it? 3. What is the sticking point in the squat, why does it happen, and what can you do about it? 4. How to fix upper back hinging during the front squat 5. Is there a squat variation that can make you move better and build muscle mass? 6. How can I make my overhead squat better?
⛹️♂️ TIMESTAMPS ⛹️♀️
00:00 - Intro 00:53 - Knee valgus in the squat 15:53 - Butt wink in a squat 31:57 - The sticking point in the squat descent AND ascent 38:44 - Upper back hinging during a front squat 40:55 - The best squat for better movement and hypertrophy 43:12 - Getting better mobility for an overhead squat
🏀 THE KEY TESTS TO HELP BASKETBALL PLAYERS MOVE BETTER 🏀
When you work with super tall athletes like basketball players, their movement demands and compensatory strategies are going to appear a bit differently than those of us closer to earth.
In order to determine what tests will give us the most information about basketball players, we have to look at what movement challenges they possess, the injuries they are most likely to sustain, and the movement qualities needed to mitigate injury risk.
But what tests matter the most? What will give us the information needed to make sound training decisions for these athletes?
Be prepared to dive into these areas and take your basketball movement testing to a different level with Movement Debrief Episode 158.
With this video, you'll learn the following:
1. How being tall impacts movement 2. What movement qualities are needed to mitigate the challenges from being tall 3. The most common and devastating injuries basketball players sustain 4. Four assessments that help look at passive and active movement capabilities relevant to basketball 5. A fifth bonus test that might surprise you ;)
Let's get to it!
⛹️♂️ TIMESTAMPS ⛹️♀️
00:00 - Intro 1:54 - What makes basketball players different 6:58 - Movement needs analysis for basketball players 8:34 - Common injuries for basketball players 14:22 - The Four Assessments 27:22 - A surprising assessment you may not have considered 29:52 - Sum Up
Sep 13, 2021
Maxillary Expansion Before and After 1 Year in the Crozat Appliance
HOW SLEEP IS IMPACTED AFTER ONE YEAR OF PALATE EXPANSION
I was tired of waking up tired. So I decided to do something about it.
It’s now been one year since I’ve begun working with Dr. Brian Hockel on expanding my palate with the Crozat appliance. And the results so far have been pretty solid.
Let’s dive into all the changes that have happened within the last year!
To improve my sleep, I've done a bunch of different treatments, which I will outline in this video, including:
You'll find out what did (and did not) happen after one year of treatment!
TIMESTAMPS
00:00 - Introduction 03:52 - Maxillary expansion treatments 06:39 - Key Performance Indicators (KPIs) 07:20 - Maxillary Structural Changes after one year 17:42 - Functional changes in tongue posture, nasal breathing, and more 26:56 - Sleep study before and afters 43:48 - Recap
Breathing is super important you know, but the base of breathing is the pelvic floor. Well fam, what if you don’t have the biomechanics on point down there? Check it out!
Take your golf, fitness, and rehab knowledge to the next level
It can be easy to get lost in the noise with all of the potential treatments, exercises, models, and more, when it comes to anything in the rehab and performance field.
Is there a way to put everything together? To use a wide variety of methods and be targeted with execution.
That, folks, is what few people do to the level of Dr. Mike Kay, and I'm juiced up to have done a podcast with him.
In this podcast, you’ll learn:
How Mike went from accumulating rehab tools to developing rehab principles t
How and why vibration plates, tiger tails, and needling can create CRAZY movement changes
How to make better decisions clinically and when to look at sensory systems
Why static postural assessment isn't so bad after all
How infrasternal angle archetypes can impact the golf swing
The best ways to train for better golf and baseball performance WITH MINIMAL COACHING
What the big keys are for basketball performance
How to get the most out of home exercise programs
Building a cash pay physical therapy practice
How to balance entrepreneurship with family
Look below to watch the interview, listen to the podcast, get the show notes, and read the modified transcripts.
https://youtu.be/oZ-mPPFt4CI
Learn more about Mike
Movement, in general, has always fascinated Dr. Mike Kay. Following this passion, Mike received his Doctorate in Physical Therapy from Chapman University in Orange, Ca. After graduation, Mike has worked in pediatrics to high levels of sports performance. Mike also has experience working in a cash pay environment and has spent time developing performance models for a private equity company.
Today Mike works in Scottsdale, AZ running his own company, Kay Performance Physio. He continues to work on implementing specific exercises and manual therapy to help alter complex dynamic movements. He also consults with many high-performance teams to get the best outcomes for their clientele.
Or check out this little teaser for Human Matrix home study. Best part is if you attend the live course you’ll get this bad boy for free! (Release date not known yet
Here is a signup for my newsletter to get nearly 5 hours and 50 pages of content, access to my free breathing and body mechanics course, a free acute:chronic workload calculator, basketball conditioning program, podcasts, and weekend learning goodies:
Question: Can you do some videos on how to correct a lateral pelvic tilt with breathing techniques?
Answer: A lateral pelvic tilt is where one side of the pelvis appears higher than the other. Sometimes this can be structural because of differences side-to-side in pelvic morphology, other times it can manifest because of reductions of movement.
Since we can’t change how you look inside, and we can’t accurately measure it, we are going to look at the movement side of the equation.
First things first, the ability to tilt the pelvis laterally is normal. As in fam, this is a normal movement that we have the capability of performing. If you have ever seen that Reno 911 drunk driving skit, you’ll know what I’m talking about.
In order for this lateral tilt to occur, we need the following actions to be able to happen in the lower body:
Sacrum nutates with a slight turn towards the tilted side
Pelvic outlet abducts
Femur adducts and internally rotates
All of the aforementioned actions create an internal rotation action through the lower extremity, and it’s commonly seen in the midstance of gait.
If you can’t do these actions for whatever reason, your body may have to utilize some type of compensatory strategy to make that happen.
Think of it this way, the body is going to try and change it’s orientation to where there is available space to move and demonstrate this action. There are many ways this can be done.
The most common way to “make up” for an internal rotation deficit is by tilting the pelvis anteriorly, as this will change the pelvic orientation so more internal rotation can be acquired.
If you notice a lateral pelvic tilt on either side, then you are likely dealing with varying degree of anterior pelvic tilt on one side of the other.
Let’s first start with the left side, since it’s the WAY COOLER side (trust me, I’m left-handed).
The left is also easier to see and think about, as it “fits” the rightward turn that our spine has. In order for this tilt to appear the pelvis on the left will move forward and obliquely to the right (this is called a right oblique pelvic orientation according to Daddy-O Pops Bill Hartman). The pelvis orients in this fashion on this side to not push an internal rotation range that can be achieved. You’ll know if you have this orientation if your straight leg raise on the left is greater than the right.
When the right pelvis is tilted higher than the left, the pelvic turn is actually still to the right, only it is flatter and not on an oblique axis.
In this case, both sides of the pelvis will be moving forward at a more equal rate, but the flatter turn allows the right side of the body to have more of an internal-rotation bias in comparison to the left both in the pelvis and the thorax. The combination of the right pelvic outlet abducting and the thorax right side bending gives the appearance of a right lateral pelvic tilt. Your telltale sign will be the right straight leg raise being greater than the left.
Cool fam, so we know what the heck is going on, what is a fam to do about it?
I’m…glad….you….asked.
Regardless of either case, stacking the thorax atop the pelvis is a rock-solid starting point. Since both presentations have an anterior tilt about them, you gotta pull that bad boy back to allow for any rotation to occur.
I would practice all of the moves from my stacking starter pack to get the ball rolling here.
Once you’ve done that, let’s now look at how to improve movement in each of these cases.
Treating a left lateral pelvic tilt
Remember, a left lateral tilt occurs because of the pelvis rotating obliquely to the right, so we have to reverse engineer this position.
Our first step is to get the pelvis to turn to the left. We can use the right side of our body to push back to the left. Given that the left posterior lower pelvis is eccentric (that cray cray straight leg raise, remember), and also given that you generally want to restore external rotation measures before internal, you’ll want to perform an action on the right side to get yourself some external rotation back.
A great move here is a sidelying stride:
Once you’ve nailed that, you then want to teach your supreme clientele to posteriorly tilt the left side and turn the sacrum to the left. At higher degrees of hip flexion, this will help “close” the lower posterior outlet. A posterior hip stretch on the left would do wonders here:
Treating a right lateral pelvic tilt
Don’t forget big fam, a right lateral tilt is more of a flat pelvic turn. There is more space available on the right posterior side, so treatment here is essentially going to be closing the right posterior and opening up the left anterior.
You can achieve this with something where it’s more of a shift in the 90 degree range. A sidelying hip shift on the left can be great here:
Gym-wise, you could similarly drive this position with either a shifted RDL:
And eventually progress to a split squat with contralateral hold:
Lateral shift
Question: Can you make a video about lateral shift?
Before proceeding with any treatment on this, you have to make sure you get checked out by a medical professional to rule out any serious pathology. If you are getting any pain, weakness, sensation loss, etc down the leg, well fam check that out first! Sometimes doing something quick to reduce inflammation medically can make a world of difference.
But let’s say you got checked, aggressive treatments are not indicated, what the heck do you do for this lateral shift.
We have to look at when I shift laterally, what range of motion is often lost in this case.
It’s not uncommon for a straight leg raise to be limited in this population. Moreover, sidebending maneuvers, at least based on what these occur in gait, are associated with more of an internal rotation-based strategy in my opinion.
Therefore, if I sidebend in one direction, I will pick up internal rotation towards the sidebend, and reduce it away from the sidebend. If I have less internal rotation, there will be less compression over the given area.
What I’ve found useful in these cases is to choose activities where you are doing your darndest to create some type of internal rotation restoration.
The two big keys would be to perform some type of shift towards the affected side, like a sidelying hip shift:
Then doing something to create lateral expansion of the ribcage. Something like this swiss ball stretch can be useful:
Trendelenberg gait
Question: How would you tackle trendelenberg gait?
Answer: Trendelenberg gait is where there is some issue with the hip abductors that causes a drooping of the hip towards the stance side. This issue commonly happens when there is neurological weakness from back issues or after hip surgeries that didn’t go so well.
Can’t get the relative motion, so let’s just orient it there big dog!! (photo credit: S. Bhimji)
Assuming you’ve ruled out structural issues, we have to look at what phase of gait this issues happens, and generally that’s midstance.
During midstance, the pelvic outlet needs to abduct, which helps create more ipsilateral adduction and internal rotation of the femur.
If the above action can’t happen, the pelvis orients in a way that drives a CRAZY amount of adduction and internal rotation. That, my dear fam, is your trendelenberg sign.
So, what we are to do is to get the outlet to open when we need to big fam. Anything that teaches this action to occur is useful. Your classic hip hike exercises actually work pretty slick here:
Sum up
Lateral pelvic tilts and shifts occur to orient the body so internal rotation can be expressed
Actions to increase internal rotation, which include stacking, frontal plane shifting, and rotational shifts, can be useful to increase these positions.
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The stack is one of the foundational components needed for A TON of movements and for restoring movement, but what if you are struggle bus with this concept?
What if you can't get a full exhale or get the expansion you need? Or maybe you don't even know where in the ribcage we should even see movement!
Don't worry fam, ya boy big Z has you covered.
If you want to beef up your stack, and your conversation with Zac, then check out Movement Debrief Episode 153 below!
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Question: With normal breathing appears should get expansion of all ribs, but yet With the stack it appears as though you should not allow ribs to flare out. So in a sense no expansion of ribs?
https://youtu.be/H4JS3IK0JnM
Answer: Oh fam, don't you worry. I want them ribs to get #expandedAF.
The key point here is we want to differentiate where the expansion is coming from.
Ideally, during the stack, we should see multidirectional expansion in the ribcage when we take a breath of air. In fact, the following areas should expand:
Buckethandle - Ribs will move outward and upward (predominantly lower ribcage)
Pumphandle - Front ribs should move forward and upward
Posterior expansion - Back ribs should move backward and upward
Slight elevation - The ribcage will lift upward slightly as a unit, as the scalenes are a primary muscle of inspiration
Slight depression - The ribcage will stretch downward slightly as a unit because of the pull from the abs.
As you can see, the ribs move just about everywhere!
This movement, however, is different from the ribs moving forward (aka the rib flare).
Ribs flared AF :)
With the movements listed above, you get relative motions occurring among the ribs. So the ribs will separate to make room for the increased air in the lungs.
With a rib flare, we don't see this as much. Instead, the ribcage migrates forward and upward as a unit. Imagine the thorax translating forward. That is the rib flare, and it is often accompanied with increased tension in the accessory muscles.
Compensations during the exhale
Question: As a narrow infrasternal angle, I am going to be taking a long relaxed exaggerated sigh. However, I get to a point where nothing is happening or I actually feel like my sternum is collapsing inward causing almost an out of breath sensation. Any idea what this might be? We want to be seeing the lower ribs dropping down correct? What if upon an exhale they don’t move?
https://youtu.be/O9bYviWlk4Y
Answer: You think you have a full exhale, but you have no idea.
This is the diary of someone who needs help getting a full exhale. (gah I'm old)
But don't worry, fam, it's totally common. Ideally, the deeper abdominal muscles compress the lower ribcage in all directions, assisting the diaphragm in full ascension. There are two big tells that let you know you have this position:
The ab wall will get smaller, especially the lower abdomen region.
The lower ribcage will drop downward and inward.
If you don't have these two points, then a full exhale is not attained.
The sternal collapse is a compensatory strategy to attempt to get this full exhale. Here, the rectus (damn near killed us) abdominis contracts, pulling the sternum downward. This can help create a pseudo domed position of the diaphragm, but you do not get changes in the lateral ab wall. You also can't get the complete air evacuation out that you normally would, as this altered shape change pushes air posteriorly and inferiorly, limiting posterior diaphragm ascension.
To mitigate these compensatory strategies, we need to emphasize the ab wall getting smaller and the ribcage dropping.
To get the ab wall smaller, the best way I've found this is to just utilize a self-manual cue. Put your hands right below your belly button, and do your darndest to get the abs to get smaller.
The second point is the get the lower ribcage to drop. If you get the abs moving but the ribs don't, then you need some help.
The Beatles got a little help from their friends, but you, my fine fam, are going to get a LOT of help from your arms. That is, you are reaching.
Reaching is like icing on the stack cake, as it can promote the ribcage shape change desired by affecting the upper components of the ribcage.
Depending on your infrasternal angle archetype, you have one of two options to start with.
For narrow ISAs, you'll want to reach forward, as this action will bend the ribs by generating anterior and posterior compression. I like doing these unilaterally, with a move like a hooklying tilt with a one arm reach:
https://youtu.be/-GwHrk0zmc8
For wide ISAs, an upward reach (around 100-120° shoulder flexion) can be quite useful. A move like this supine hip extension move can be a great choice:
https://youtu.be/NIt5Ass84VQ
Reaching during the stack
Question: What if the medial borders of the scaps were NOT flush with the ribcage, could then a reach at 90º be useful for posterior expansion, ribcage retraction, and getting those medials borders to find their nice cozy home along the ribs?
https://youtu.be/jJAZp-NeZoY
Answer: The big thing to watch on this lack of flushness on the ribcage is that it often accompanies the thorax migrating forward. If the thorax goes too far forward and you have lost the stack (and subsequently, the inability to talk to me), then you will not get posterior expansion.
However, I've been known to manually pull the medial border off of the ribcage to encourage posterior thorax expansion, and it can be quite useful. Yet, it's really fricken hard to perform this action actively.
UNLESS....
you create a relative motion between the scapula and humerus, aka scapular internal rotation.
How do you do this? I'M GLAD YOU ASKED!
If you can externally rotate the humerus without moving the scapula, this creates a relative internal rotation at the scapula. If you have internal rotation at the scapula, the scapular external rotators (which cover the dorsal rostral area) will be eccentrically oriented, which can allow for posterior expansion.
A great way to achieve this action is by performing armbars with screwdrivers:
https://youtu.be/EbgUI2jjN-4
Making prone and supine more comfortable during the stack
Question: I find it uncomfortable in the prone and supine position for the stack. Any tips?
Answer: If these positions are hurting, then there is an inability to express movement options, hence the increased pressure in respective areas.
In the prone position, gravity is pushing downward, which can drive more anterior orientation. If your backside is concentric AF, then it may be that this position pushes you even more forward. Problems ensue.
The prone solution? Take yourself out of the anterior orientation.
This action can be done by either putting a few airex pads underneath your stomach, or even lying over a swiss ball.
An airex pad underneath the stomach is s quick way to restore the anterior orientation.
The same issue can cause problems in supine. If you can't reverse the posterior concentric bias, then there may be increased pressure in the sacroiliac joint and upper back.
The solution could be the same. Placing a pad or wedge underneath the pelvis can help encourage the posterior orientation that you OH SO DESIRE!
Side planks for the deconditioned?
Question: When working with wide ISAs who are deconditioned and older, will you give them side planks right away? I worry about the shoulder.
Answer: Side planks can be great for creating the lateral compression needed to make wide infrasternal angle presentations dynamic.
The issue, however, is that you need to be able to produce enough force to get yourself into position. Otherwise, you are going to overload the shoulder.
That said, you can still get the benefits of "side planks," you just need to regress them.
Simply not lifting the body up in the air, instead pushing through the arm, can create a lot of benefits without as much load.
https://youtu.be/b-m54cWG95s
If that's too much, then you can bear weight through your hand like so:
https://youtu.be/fHkQJ_IdwH8
If even that is too much, you can simply lie over a swiss ball to create some lateral compression:
https://youtu.be/1j_9eJZRkDA
Neutral pelvis or posterior tilt?
Question: Neutral pelvis vs posterior tilt stack. Which/when?
https://youtu.be/5PxboQFisRg
Answer: While we cannot say what true "position" the pelvis is in, there are some indicators that can let us know if we have a good orientation during stack coaching.
The key is to orient the pelvis in a manner that allows the viscera to bob up and down as we breathe; restoring sacral dynamics.
Your key indicator that you are in a good spot is perception of the glutes and hamstrings contracting WHILE keep the pelvis and thorax stacked atop one another. If you have that, you are in a great spot :)
Too much rectus abdominis during exhales
Question: What kind of cues would use for someone who keeps kicking in rectus abdominis?
Answer: The rectus (damn-near killed us) abdonimis kicks in when we can't get a full exhale. You'll see that when the following stuff happens:
the sternum depresses
the belly gets bigger
the pelvis translates forward
If you see these things, you can bet your bottom dollar that your stack is whack!
Here are the keys to focus on to derectusify (technical term) the stack:
Keep the exhale slow and drawn out
Feel the lower belly get smaller
Drive upper cervical extension
Choose good positions that minimize rectus activity (e.g. sidelying for wide ISAs)
Stacking during rotation
Question: How do you ensure that you have a stack during rotation?
Answer: The most important piece is to ensure that you aren't bending as a unit when you reach.
Winging during front planks
Question: If I try a front plank and the scaps are winging, what is going on there?
Answer: If the scapulae are winging, the thorax is falling WAY too forward, which creates space between the thorax and the scapula.
To create space, you need to push the ribcage backward while achieving a full exhale. Less air in the front, more air in the back.
Too much lower back during the exhale
Question: I have a client who uses erectors to complete the exhale. Any tips?
Answer: You need to put the back muscles into an eccentric orientation so they don't create the exhale. Choosing some of the positions mentioned during the prone and supine portion of this debrief can be useful.
Cueing out of overtucking
Question: Any tips on client who overtuck during the stack?
Answer: I usually start with this person arching their back excessively, then slowly unarching out of that position. This helps them isolate the movement to the pelvis.
Sum up
The ribcage should expand in all directions during the stack, not migrate forward as a unit.
A full exhale should entail the ab wall getting smaller and the lower ribcage dropping downward. A reach can help facilitate a fuller exhale.
Scapular internal rotation can promote posterior expansion.
Prone and supine can be more comfortable by positioning passively into a posteriorly expanded position.
To reduce rectus abdominis overactivity, keep exhales slow, ab wall small, and chin away from neck.
The split squat is incredibly versatile, but how can I most effectively use it to drive the range of motions I need. Or why in the heck is my person compensating in that way when they do the split squat?
We will answer that with this post, as the split squat can vary its rotational qualities depending on factors such as depth, arm positioning, and more!
If you are ready to absolutely crush all things split squat, thencheck out Movement Debrief Episode 152 below to find out!
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Answer:It depends on what we are talking about respective to the point in the split squat. So, fam, let’s dive into the various aspects of the split squat.
For all positions, let’s assume we are talking about a split squat with the left leg in front.
[caption id="attachment_14459" align="aligncenter" width="810"] No asses outta me or you fam![/caption]
Split squat start position
At the start, the sacrum is right facing, but beginning to turn to the left.
Based on the relative rotation that occurs throughout the movement of flexion, the front leg will have a relative external rotation bias. This bias is due to the top leg being at around 20-30 degrees of hip flexion.
[caption id="attachment_14460" align="aligncenter" width="515"] Sacrum turns left, front leg ER'd, back leg IR'd.[/caption]
The back leg will have a relative internal rotation bias due to being at around 0 degrees of hip extension.
Split squat descent
As I descend through the squat, the sacrum will progressively turn more and more left, kinda like that one song by Joe but less seductive.
In order for this turn to occur, there will be progressive counternutation on the left side of the sacrum and nutation on the right.
As we move downward, we start to see a shift in the rotational influences of the femurs.
On the front, once the femur passes around 60 degrees of hip flexion, there is a progressive move towards internal rotation.
The back femur, staying at roughly 0 degrees of hip flexion, maintains slight internal rotation bias throughout the course of the movement.
Bottom of the split squat
Once we are at the bottom of the split squat, we’ve officially reached internal rotation city. Congratulations, you are the mayor.
The influence of 90 degrees of hip flexion on the front leg and maintenance of 0 degrees of hip flexion on the right both lends towards internal rotation occurring at the femurs.
Although the sacrum is continually turning to the left, this rotational influence causes the sacrum to perform the act of nutation. That doesn’t mean that the sacrum is nutated, but this is the direction it is moving.
Split Squat ascent
As I push out of the bottom of the split squat, the sacrum rotates back to the “start” position via external rotation of the front leg and maintenance of back leg internal rotation.
[caption id="attachment_14462" align="alignnone" width="810"] The rotational difference on the way up creates the turn back to the start[/caption]
How do offset loads influence mechanics?
All of the above points assume that there is no change with load distribution, but what if I hold a weight in one hand. How does that change things?
I’M GLAD YOU ASKED!!!!!!
Think of whatever arm I hold the weight in as creating a reach. Whatever arm I reach with will aid in driving rotation in the opposite direction:
Ipsilateral load:rotateawayfrom the front leg
Contralateral load:rotatetowardsthe front leg
[caption id="attachment_14463" align="alignnone" width="810"] Think of the weight distribution as reaching[/caption]
Therefore, an ipsilateral load will limit the sacral rotation towards the front leg, and a contralateral load will increase the sacral rotation towards the front leg.
Femoral, tibial, and foot split squat mechanics
Question: I watched the video of the Front Foot Elevate Split Squat Shift for driving supination/calcaneal inversion. Does this happen as a result of femoral internal rotation --> tibial external rotation -->supination--> calcaneal inversion. Would this line of thinking be correct?
If so, I am having a tough time wrapping my head around the fact that femoral IR (an exhalation measure) would bias supination (an inhalation measure) further down the chain, would it be possible to clarify?
Answer: Your line of thinking is tots mcgoats correct.
The reason why we have alternating actions occurring with the femur, tibia, and foot has to do with the relative motion occurring between the bones as I bend the knee.
There is this concept at the knee joint called the screwhome mechanism. As the knee extends fully, the tibia externally rotates to glide along the condylar grooves. This creates a relative femoral internal rotation.
As the knee unlocks from extension, we see the reverse of this mechanism. The tibia internally rotates, and the femur externally rotates. These actions roughly "cancel" each other out to create what appears to us as a purely sagittal movement at the knee (but it's not, folks).
According to these two studies (here and here), we actually see these rotational differences throughout the range of knee flexion:
90 to full knee flexion: tibial internal rotation & femoral external rotation
Taking into consideration what is happening as I drop into the bottom of the split squat, we hit roughly
Taking into consideration what is happening as I drop into the bottom of the split squat, we hit roughly 90 degrees of hip flexion and knee flexion. Therefore, we can see that we will be moving toward a tibial external rotation and femoral internal rotation orientation.
Given that tibial external rotation is paired with calcaneal inversion and subsequent supination, we now have a way to link a pairing of inhalation and exhalation orientations.
What doesn't necessarily change in this orientation is what is going on at the pelvis. There will still be the turn towards the front leg occurring.
One thing we have to be clear on is that although we have biases of specific movements, there are likely inhalation and exhalation actions happening simultaneously everywhere. So too with internal and external rotation. The combination of these movements working together is what provides us several movement options to put our bodies where we need to.
Deep hip flexion in a split squat
Question: Would mechanics change if I can dip below 90 degrees of hip flexion in a split squat?
Answer: As we pass 100 degrees of hip flexion, the femur begins to externally rotate again, and the sacral will turn even further towards the front leg, which will alter the mechanics at the bottom of the split squat to reflect in this fashion. Peep this article to learn more!
Hip shifting in the split squat
Question: Do you consider hip shifting in the lead leg of the split squat more external or internal rotation?
Answer: The split squat requires relative motions to occur at the various joints of the pelvis to create the motion.
If you can't create these motions, body regions will begin to move as one unit, and definitely not the cool G-Unit.
A common one you might say is the back hip flexed forward as opposed to going straight down.
When this happens, the pelvis and lumbar spine posteriorly orient as a unit, which flexes both hips forward. This allows me to attain depth while minimizing the sacral turn towards the front leg.
You could also see shifting backwards of the hip, which is essentially the sacrum turning away from the front leg.
What's more, you could also see a long stance that anteriorly orients the pelvis to create intenral rotation and depth.
In each of these instances, the major key is to keep the stance length shorter, stack, push the front knee forward and the back knee down. One can use a foam roller as a target can help with this latter cue.
Front foot elevated split squats can be good starting points for this:
Answer: Since powerlifting involves restricting motion and increasing tension to some degree, the rotational nature of splits squats can be useful to restore any lost range of motion to reduce the risk of tissue overload.
The difference between front heel elevated and front foot elevated split squats
Question: What are the differences in mechanics between front heel and front foot elevation in a split squat?
Answer: A lateral split squat induces more pelvic lateral tilt, whereas a regular split squat provides more pelvic rotation.
A lateral tilt will drive even greater internal rotation bias than your traditional split squats.
Dorsiflexion loss in a split squat
Question: Would a heels elevated split squat be better than squatting for a dorsiflexion loss?
Answer: Anytime you can use rotation and do it savagely well, you. can drive both anterior and posterior expansion. This will generate WAY more motion than bilateral stuff, whcih is why it's easier for peeps to generate more motion.
Back leg position in a rear-foot elevated split squat
Question: What position do I like for the back foot in a rear foot elevated split squat?
Answer: As I lower into the squat, the back knee is going to be in a relative tibial external rotation and femoral internal rotation position, which will bias calcaneal inversion. Inversion is associated with plantarflexion, which is a good reason to keep the back foot plantarflexed when. you are using this modality.
Sum up
The split squat starts with an external rotation bias, but progresses towards an internal rotation as we hit the bottom; the sacrum progressively turns towards the front leg
Ipsilateral loads decrease rotation towards the front leg. Contralateral load increases rotation towards the front leg
With progressive knee flexion, femoral and tibial movements rotate in opposing directions.
The deeper the hip flexion in a split squat, the more the sacrum turns towards the front leg.
Hip shifting magnifies the sacral turning depending on the depth at which it occurs.
The knee should be centered over the second toe in a split squat.
Loss of "ideal" motion in the split squat often results in the lumbopelvic complex moving as one unit.
Front foot elevation shifts bodyweight posteriorly; heel elevation increases leg external rotation
The back foot in a rear-foot elevated split squat should be plantarflexed, as this promotes the foot, tibial, and hip position needed throughout the range of motion.
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Bill Hartman - Daddy-O Pops. My mentor. Thought leader on propulsion arc concept and more!
Using Chops to Increase Range of Motion
Question:How can you use chops to bias expansion and compression to restore shoulder range of motion?
Answer: I'll do you one better. Let's dive into how chops and lifts can be used to improve BOTH hip AND shoulder range of motion!
Generally, chops and lifts are driving rotation about the ventral cavity. So if I chop to the right, the effects of expansion within the ventral cavity will be shown left anterior and right posterior:
[caption id="attachment_14181" align="aligncenter" width="600"] Blue areas are where expansion occurs to create the turn.[/caption]
But now how does this change when we go into each respective area?
Lower body component of chops and lifts
Generally, there are two ways to use these movements:
Increase rotation into a given area (chops)
Maintain position into a given area (lifts)
Let's take a half-kneeling cable chop for an example.
[caption id="attachment_14367" align="alignnone" width="600"] Just call me a worldwide chopper![/caption]
Both legs are in a relatively internally rotated bias, with slight sacral rotation towards the left
[caption id="attachment_14368" align="alignnone" width="600"] There is an IR bias at each respective femur[/caption]
If I chop towards the down leg, I'm going to rotate the sacrum towards down leg, from a leftward facing position. This will increase external rotation occurring on the left side, and further internal rotation on the right.
Conversely, if I chop towards the up leg, I will drive further sacral rotation towards the front leg, increasing front leg internal rotation and reducing the amount on the right.
[caption id="attachment_14370" align="alignnone" width="600"] More IR on the left, less IR on the right[/caption]
This is generally how I incorporate chops.
Chops help increase rotation towards a given area.
The way I utilize lifts is slightly different. Because I am reaching more overhead, there is more extension occurring throughout the axial skeleton, which limits rotation. Therefore, a lift can be useful to focus on maintaining lower extremity position.
Lifts help maintain position in a given area
If I perform a half-kneeling lift towards the front leg, I would be challenging my ability to maintain the position. There won't be as much rotational increase.
[caption id="attachment_14371" align="alignnone" width="600"] I keep the rough amount of IR I started with in the beginning.[/caption]
Upper body components of chops and lifts
You can bias airflow even further depending on what type of diagonal movement you perform.
Let's again, assume I am performing a rotational action to the right. In this case, I will be driving left anterior expansion and right posterior expansion.
[caption id="attachment_14181" align="alignnone" width="810"] Blue areas are where expansion occurs to create the turn.[/caption]
From there, you can manipulate airflow with various reaching directions. We can utilize the flexion arc model made popular by Daddy-O Pops Bill Hartman to illustrate this concept:
Chop (60°): Posterior expansion (T6-8 level)
Horizontal chop (90°): Anterior expansion
Lift (120°): Anterior expansion
Again, you have to look at the above ventral cavity orientation to appreciate that this is the starting point that we go from. We then superimpose the reach performed to alter airflow gradients.
Since rotation is still occurring, you will have the above differential in airflow, but you'll notice different airflow biases occurring in each.
With a chop, there will be more posterior expansion occurring on the left, but it'll be less so than on the right. I still need that gradient to drive the rotation.
[caption id="attachment_14184" align="aligncenter" width="425"] Dotted lines indicate less relative airflow compared to straight lines. so you can see, there will still be rightward rotation, even with the posterior expansion bias.[/caption]
Conversely, a lift is going to drive a BOATLOAD of anterior expansion, with more occurring on the left to drive the rotation.
[caption id="attachment_14183" align="aligncenter" width="390"] Dotted lines indicate less relative airflow compared to straight lines. so you can see, there will still be rightward rotation even with the anterior expansion bias.[/caption]
Horizontal chops simply magnify the original rotation.
Head motion during chops and lifts
Question: With chops/lifts in particular, what is the ideal motion of the head? Are there circumstances where you might coach it differently? For example, instead of turning the head with the rest of the axial skeleton towards the direction of the chop/lift, is there a circumstance you might coach it where the shoulders are moving around a non-moving head? Would this be incorrect? If not, how would you explain the difference between the two in terms of axial skeleton mechanics and expansion/compression? And what would be the implications for when to coach it one way or the other?
Answer: The ideal head position depends on what you are trying to drive.
If the eyes follow the rope, you will be orienting the entire spine in the direction you are rotating. Again, if we use right rotation as an example, turning the head can magnify the rotation.
But what if you are an ABSOLUTE REBEL and want to keep the head fixed forward as you chop or lift...
I'm
Glad
You
Asked!
Remember from our cervical rotation debrief, turning the head will create movement all the way down to T5-6. So if you keep your head pointing forward, you would bias expansion in the uppermost segments of the thorax.
Let's take our classic half-kneeling cable chop to the right. Only this time, let's fix the head forward.
As we recall, the thorax will be rotating right, creating left anterior and right posterior expansion.
[caption id="attachment_14186" align="alignnone" width="768"] Dotted lines indicate relative rotation from a given starting position. In this case, the upper thoracic segments would be rotating left from a rightward orientation[/caption]
If we look forward, the spine will rotate in the opposite direction from T5 on up. Crazy right?!?!?
[caption id="attachment_14185" align="alignnone" width="810"] I might make this an NFT[/caption]
To be clear, that doesn't mean you are getting this crazy torque of the spine going from one extreme range to another. T2-5 would be turning left from a relative rightward state. The spine could still have a rightward orientation in this example, but you'd have better uppermost expansion in the places you desired.
In the above example, someone with shoulder restrictions such as decreased left horizontal abduction and flexion and right horizontal adduction and extension, this chop variation could be money in the bank!
Sum up
Chops are useful to bias posterior expansion and increase lower body rotation.
Lifts are useful to bias anterior expansion and hold lower body positioning.
Fixing the head forward will help drive contralateral rotation in the opposing direction.
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Does a rib flare mean my core is weak?
Question:I have anterior pelvic tilt as well, and one thing that I often hear about treating anterior pelvic tilt and rib flare is to strengthen your core. I guess I'm wondering how to go about core exercises with my narrow ISA. Often times when I exercise my core, my upper obliques want to do all the work, which squeezes my ribs together and makes my ISA narrower. Do you think that as of right now, I should just stop doing all core exercises to prevent this, or should I continue to do the more standard types of core exercises like planks and dead-bugs?
Answer:Before we go through what to do for my main man Bob, we need to clear the air on a few different pieces:
Anterior pelvic tilt is normal to see when you are standing upright. According to this study, the sacrum is nutated during standing.
The key is to restore any loss of movement that may be occurring versus static posture.
Anterior pelvic tilt and rib flare does not occur because of a lack of core strength.
We don't have any evidence to point to a specific or series of causes for the body assuming the aforementioned positions.
If I had to hedge my bets, my thought would be these orientations occur because of one's genetic structure and attempting to manage internal anatomy to maintain being upright against gravity.
This position doesn't weaken the abdominal muscles but eccentrically orients the abdominal wall, more so the lower portions. This orientation would reduce force production at the abs to alter the position.
A similar situation to the abs would be trying to do a bicep curl from an extended elbow as opposed to 90 degrees of elbow flexion. We can all agree that it's much harder to perform the bicep curl when the arm is fully straight compared to when the elbow is bent 90 degrees.
[caption id="attachment_13955" align="alignnone" width="785"] Trust me, I've done extensive research on bicep curls, how else would these gains exist???).[/caption]
However, we don't say that it's harder because the bicep is weak. The curl is more difficult because of the starting position.
So too with the abs when you see a rib flare and anterior pelvic tilt. In this orientation, the diaphragm is descended far (concentric), which places the lower abs in an eccentric orientation, as these muscles act in opposing fashion during respiration.
This position is especially the case with a narrow infrasternal angle, as the diaphragm is descended further in comparison to a wide infrasternal angle. This narrower angle will give the upper abs a bit more leverage than the lower, hence why when Bob does his core exercises it's all upper obliques all...day...every...day.
The "fix" isn't to stop all core training, but to perform activities that act in opposition to this current movement behavior.
What the stack aims to do is the exact opposite movement strategy that our caller refers to:
Posteriorly tilt the pelvis instead of anteriorly tilt
Restore relative sacral motion by breathing
Fully exhale to reduce rib flare and make infrasternal angle dynamic
You might start with a move that helps drive each of these positions without compensatory strategies. The hooklying tilt with a one-arm reach might be a great starting point.
From here, it's just a matter of being able to demonstrate a wide variety of movements without falling into these compensatory strategies. That would include lower body work like squats, split squats, hinges; and upper body stuff like pushes and pulls. This training could even extend to higher-speed activities or other terminal tasks.
All traditional "core training" serves for in my opinion is a lower level drill to teach your body to move while expressing desirable movement options.
Instead of thinking this move is great for them oblique gains. Think that I am teaching my body to rotate in a split stance position. I can use these activities to aid in shifting into the downside hip, which is important to loading a cut if we related this to a terminal task.
If you think of core exercises as a build-up to a greater purpose or task, then NO ONE will mess with you :)
Why do we drive a posterior tilt?
Question: I am very confused about core training. Why do we maintain posterior tilt throughout the range, when in real life the sacrum would nutate with hip extension?
Answer:The reason is that most of us wonderful fam have a bias towards anterior pelvic tilt that we struggle to overcome. We would know that this orientation would be struggle bus because of the range of motion loss in the hip joint.
What the posterior tilt does is it helps teach the individual to be able to move the pelvis in the opposite direction of their current bias. The hope would be that this helps restore some movement loss in the lower extremities.
Now, Mohamed is correct. The sacrum ought to relatively nutate when in hip extension, and counternutate with the hip flexed. However, there is an important nuance to know that we are leaving out of the equation:
The tuck does NOT counternutate the sacrum
There is only about 2 degrees of available motion in the sacroiliac joint. So to think that we can isolate nutation and counternutation by a posterior tilt is highly unlikely. We aren't that precise of movers.
Yet restoring these motions is important when creating a dynamic pelvis.
So how in the heck do we nutate and counternutate like bosses?
What drives these sacroiliac movements?
The answer: breathing.
Nutation and counternutation occur by tension changes in the pelvic floor. The relative tension and shape of the pelvic floor os determined by the natural visceral movement that occurs with breathing.
That's why you cannot tuck alone and hope for the best. Ensuring you have the breathing portion down pat, the top part of the stack, is key to driving this motion.
That said, I don't expect peeps to make sure that the pelvis is just so and the ribcage must be in the perfect position before doing any movement or else they'll die! That's unrealistic, unnecessary, and counterproductive when it comes to dynamic and explosive movements.
[caption id="attachment_13956" align="alignnone" width="810"] Just ain't gonna cut it! (Image by Alexandra Voicu from Pixabay)[/caption]
What's important is the body is moving in the directions necessary to maximize force production for a given task.
If you are trying to jump as high as possible with little ground contact, you want vertical pelvis displacement, not bending over at the waist and knocking the knees together.
If you are cutting and changing direction, your body needs to change levels and lower in position, again, not drastically anteriorly tilt the pelvis and staying too high into the cut.
If you are explosively rotating as in a golf swing, dumping the pelvis forward restricts range at the hips and will limit your ability to rotate fully.
All of these examples can be improved with technical coaching and appropriate drill selection that produces the desired outcome. This could be using resistance to assist to slow down people in specific directions. limiting motion with boxes, and many other things.
Slow speed exercises, however, are the prime time to focus on stacking and breathing, as technique can be better emphasized. The hope would be that this strategy increases movement options and helps build context to be used in terminal tasks.
Personally, I've found by emphasizing stacking and such in slow speed and with appropriate fast speed drill selection, you can marry both worlds effectively.
Ab contractions during gait
Question: Thoughts on abdominal activity during gait.
Answer: The abs should be active during the gait cycle, as your obliques are your big trunk rotators.
HOWEVER!
Gait should be a fairly automatic activity, so you shouldn't have to actively tense them during gait. This may impact your movement capabilities.
The most that I'll do is encourage someone to swing their arms or develop awareness of heel contact when they step.
Breathing exercises with hypertension?
Question: Are the breathing exercises I do safe for people with high blood pressure?
The breathing activity that we have to be most careful of is the valsalva maneuver, where you take a big breath of air in and exhale against a closed glottis.
Essentially, this strategy creates a high pressure environment in the body, which is useful when lifting heavy ass weights.
The problem, however, is that this action increases blood pressure considerably. So for those with hypertension and heart disease, it is often avoided.
The easy breathing exercises that I encourage, whether gentle nasal breathing (which can reduce blood pressure), or even exhaling with a controlled pause, are safe. And the reason why they are safe is because you are not creating a high pressure environment within the body during these activities, and blood pressure doesn't raise up (#joshgroban).
Are crunches and situps useful?
Question: Do crunches even have a purpose? Is it better to do planks, glute-focused core training, and dead bugs?
Answer: First off, spinal flexion is totally safe. The in vivo evidence seems to suggest very much so.
Though safety is there, are crunches, situps, and the like useful?
In certain instances, yes.
What a crunch or a situp can do is encourage segmental flexion within the spine; aka posterior expansion.
This maneuver, however, can be quite difficult for someone who has TONS of anterior expansion. They may not be able to push their stuff posteriorly, which can limit situp efficacy. In a similar vein, they may end up just bending at the sternum to complete the action. No bueno.
I start first with things that would drive posterior expansion a bit more easily. Moves like reverse crunches are a good starting point.
Propulsion arc and core training?
Question: Is using the propulsion arc a great way to choose core exercises?
Answer: Absolutely. You can select exercises to drive particular movements depending on how you place the body within these arcs.
If you have someone who needs external rotation to improve, you may choose exercises that involve:
And if you are feeling REAL frisky and need frontside and backside expansion, then any rotational activity can be useful. To get rotation through the sacrum and thorax, the high split chop is a wonderful choice.
Sum up
Though we don't know why compensations occur, we want to select activities that place one in the exact opposite orientation; restoring the full spectrum of movement options
Tucking doesn't driver counternutation, but places the pelvis in an orientation to drive sacral dynamics
We don't assume the stack in explosive activities. Coach position during slow-speed work, then choose drills with constraints that force desired positions.
Breathwork is safe for those with hypertension as long as the valsava maneuver is minimized
Situps, where there is some posterior expansion available, can be useful for further driving this adaptation.
They say when the foot hits the ground, everything changes, but what if your feet hit the ground in all types of wonky ways?
There seems like a bazillion different foot presentations:
Flat feet
High arches
Bunions
Plantarflexed first rays
Oh my!
We haven’t even talked about how the rest of the body can influence these strategies. YIKES.
Is there a way to make the feet ridiculously simple?
I think so!
Really, all you have to do is restore the two “normal” strategies of the feet, and that can lead to profound effects on any weird foot stuff you may see.
What are they?
Check out Movement Debrief Episode 149 below to find out!
Montreal, Canada(POSTPONED DUE TO COVID-19)[6 CEUs approved for Athletic Therapists by CATA!]
Or check out this little teaser for Human Matrix home study. Best part is if you attend the live course you'll get this bad boy for free! (Release date not known yet :(
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Bill Hartman - Daddy-O Pops, my mentor and one of the top people I go to for all things biomechanics
Answer:Well before we talk about foot compensations, why don't we first talk about foot...normalsations? Ooh, I like that. Could be the word of 2021!
There are three different foot orientations that correspond with the three different phases of gait:
Initial contact
Midstance
Propulsion
Here are the characteristics of each foot position in each phase:
Joint
Initial Contact
Midstance
Propulsion
Talocrural
Plantarflexing
Dorsiflexing
Dorsiflexed
Subtalar
Inversion
Eversion
Inversion
Midtarsal
Supinated
Pronated
Supinated
First Ray
Slight plantarflexed
Dorsiflexed
Plantarflexed
Big Toe
Dorsiflexed
Plantarflexed
Dorsiflexed
What we want to ensure is that our fellow fam can express all of these available movement options both passively and with their desired terminal task. On the low end, this could be walking. On the high end, this could be a cut.
How would you know what to look for?...Wait for it....
I'M GLAD YOU ASKED!!!!
We'd simply first test to see what range of motions are available.
You'll want to peep the following areas:
Ankle range of motion
Big toe range of motion
Midfoot flexibility
standing posture
Dynamic activities (gait and relevant activities)
Although I'm typically not the biggest fan of using static postures as an assessment piece, feet are the one exception to the rule. Seeing how the foot can organize on the ground can be quite telling as to what compensatory strategies one may be biased to.
However, they cannot tell the whole story, and that's why range of motion testing is so useful.
For example, it's not uncommon for the calcaneus toappearas though it's everted in the standing position.
However, there have been many times that I've tested these fine fam on the table, only to find out their eversion range of motion is LOL status. In fact, I would argue that this compensatory strategy is one of the most commonly seen (and missed). More on that later ;)
If you only looked at standing foot posture, you wouldn't be able to appreciate the subtle difference, and your fam would trick the snot outta you. Those pesky supreme clientele :)
Common foot compensations
Most foot compensations basically involve a person having a bias towards one extreme of a given range, and a subsequent inability to hit the opposing range.
Although there are many foot compensations that we can see, I'll go into the three most common variations that I run into:
The supinated foot
[caption id="attachment_13903" align="alignnone" width="810"] Notice the high arch, the space between the toes, and how "centered" the heel is.[/caption]
This is a situation where the foot is in that initial contact position/propulsion phase, so you'll see the following things:
Inverted calcaneus (with a loss of passive eversion)
Supinated midtarsal joint (high arch)
plantarflexed first ray (there is often a space between the first and second toe)
In terms of differences between initial contact and propulsive feet positions, Daddy-O Pops Bill Hartman does a great job explaining the differencehere.
the pronated foot
[caption id="attachment_13904" align="alignnone" width="810"] Look at the everted calcaneus, flatness of the arch, and how close together the toes are.[/caption]
This is essentially a foot in midstance orientation, with the following findings:
Everted calcaneus
Pronated midtarsal joint (low arch/flat feet)
Dorsiflexed first ray (first and second to are often bunched together)
Secondary foot compensations
In the previous two compensatory strategies, you basically have the same general movement happening throughout the foot complex: either pronation or supination.
Any other compensatory strategy typically involves a counterrotation in the opposing direction. So if the calcaneus is inverted, you may see pronation-based compensations in the remaining parts of the foot: mid-tarsal joint, first ray, big toe, etc. Vice versa with the everted calcaneus: supinatory-based movements. These actions could occur at one joint or multiple.
The most common compensation that I see/worry about:
The inverted calcaneus with a pronated mid-tarsal joint
[caption id="attachment_13905" align="alignnone" width="810"] You can see how the calcaneus looks everted, and the toes are a bit closer together compared to our supinated foot model.[/caption]
This one will trick the F out of you, fam. Because it will appear that the calcaneus is everted, but it's not.
What's happening instead is the midfoot pronates, which drags the calcaneustowardseversion, but it never really gets there.
How do I know this?
This foot type has a loss of passive calcaneal eversion.
If I can't evert the calcaneus, then the calcaneus cannot be everted. Instead, it gets dragged towards eversion, creating a twist between the subtalar joint and midtarsal joint; problems potentially ensue.
Here are the common findings with this presentation:
Externally rotated tibia
Internally rotated femur at the knee joint
Decreased calcaneal eversion
Loss of big toe extension
The most important component of restoring foot dynamics
So there can be several different compensatory strategies that happen at the feet that can make assessment be TOTALLY HARD.
But you know me, fam, I want to make the foot RIDICULULOSULY SIMPLE for you.
What is the most important foot movement to address when it comes to restoring movement options?
Priority #1: Restore calcaneus dynamics
Yes folks. Getting the calcaneus to invert and evert can restore most of the foot/ankle movement options you see limited.
If you see an inverted calcaneus, drive calcaneal eversion.You do this by cueinginside heel contact.The supine cross-connect is a great starting point for this movement if you are working with a narrow infrasternal angle.
If you see an everted calcaneus, drive calcaneal inversion. You do this by cueingoutside heel contact. One of my go-to moves is to either perform high-depth squats to drive this position.
Question:I would like to know what drives more supination, pronation, dorsiflexion, and plantarflexion of the ankles? because I have high arches but externally rotated feet, and more exhalation seems to increase even more the height of the arches so that the bones and veins protrude at the top side.
Answer:Alright alright. Your foot and ankle dynamics are whack, how do I make that better, Zac?
Well fam, we need to dive into what corresponding lower extremity movement occur with each of the respective foot and ankle actions discussed.
Because if you move your foot into various positions, and you keep going...and going...and going...a relative motion will occur at the femur, pelvis, etc. Conversely, you can drive particular motions up the chain to place the foot where you need it.
Let’s make life easy for you. Here is a super simple table that illustrates what movements are associated with various foot actions (like the store, but better prices ;)
Foot/ankle movement
Corresponding relative hip motion
Dorsiflexion
Flexion
Plantarflexion
Extension
Inversion/supination
adduction
Eversion/pronation
abduction
**This table assumes primary compensations, no secondary compensations. More on that later
Now that you’ve seen my table, let’s apply the F out of it and look at some moves that apply this concept:
Dorsiflexion
Squats are my de facto move to increase ankle dorsiflexion.
Plantarflexion
Although plantarflexion restrictions are a bit rare, getting hip extension is the major key to increasing this. You want to try and get towards end-range hip extension while keeping the stack if you can. The supine cross-connect mentioned above is actually a great choice for this, but if you aren’t there yet, start with the wall stride.
Question:So midstance favors internal rotation, pronation, hamstrings, and anterior gluteus medius. However, it's common that the left foot is already pronated, so why do we often focus on driving internal rotation on the left side?
Answer:The reason for this is because we are a bunch of twisted sisters (80’s hair included).
AND WE AREN’T GONNA TAKE IT!
What I mean by that is it’s quite common to have a “twist” occurring between the femur and the tibia. That means that the femur will be rotating in one direction, and the tibial will rotate in the opposite direction. This situation causes a mismatch in the common rotational action that this fam is referring to.
The most common compensatory pattern in this sense is:
Left femoral external rotation with tibial internal rotation and foot pronation
Right femoral internal rotation with tibial external rotation and foot supination
This presentation will usually see a loss of left internal rotation measures and right external rotation measures.
It’s this specific presentation where you work on “untwisting” the lower extremities. Basically, you reverse the aforementioned positions:
Left:Drive slight foot supination and femoral internal rotation
Right: Drive slight foot pronation and femoral external rotation
Question: Should the big toe dig into the ground with any exercise?
Answer: Big toe flexion occurs during first ray dorsiflexion, which is a part of midstance. Thus, if you need pronation, you might need a spot of big toe flexion.
Foot and ankle movement tests
Question: What movement tests do you use to test feet for compensations?
Answer: Basically, you want to look at all the physiological motions of the foot-ankle complex, which include:
Ankle dorsiflexion
Ankle plantarflexion
Ankle inversion
Ankle eversion
Big toe extension
Big toe extension in dorsiflexion
Midtarsal pronation and supination
Static foot posture
Dynamic foot posture
Sum up
Loss of foot and ankle dynamics occurs when an individual cannot place the body into a “phase of gait” position.
Restoring calcaneal dynamics is the most important factor in restoring foot and ankle movement options.
Relative motions at the hips can be used to drive ankle position
If there are twists present in the legs, you must drive counterrotation to restore lower extremity dynamics
Apr 05, 2021
The Darkside of the Movement Profession | Tim Richardt
Improving movement options is legit, but at what cost?
We know that this breathing stuff works, but are there drawbacks to this approach? Can we really make the changes “stick?”
These are a few of the many problems that Dr. Tim Richardt and I sift through, in a podcast where the script is flipped and Tim interviews me.
In this podcast, you’ll learn:
How I structure my own training
What's better, time management or energy management?
Forget following your passion, focus on this instead
What my biggest failure was and what it taught me?
The dichotomy of the type A personality
Movement behaviors: How do we get them to "stick"
The dark side of internal cueing
The best way to communicate effectively to clients
and more!
Is there a darkside to all this movement stuff? Is there a better way?
Look here to watch the interview, listen to the podcast, get the show notes, and read the modified transcripts.
Learn more about Tim
Tim Richardt is a Doctor of Physical Therapy, Strength and Conditioning Coach, and Owner of Richardt Performance and Rehabilitation located in Denver, CO. He specializes in the treatment and preparation of humans that like to run, lift, or play in the mountains. He currently offers personal training, physical therapy, and professional mentorship services.
Tim: So, my man, I thought we could start with your own training. And I'm wondering if you could describe the last workout that you personally did?
Zac: Well, that would have been yesterday. I train mostly at night after work. Yesterday, it was chin-up day.
I start with vision exercises because I did some vision therapy, so I'm just trying to maintain the visual skills that I currently struggle with, which is the ability to diverge.
So, divergence is the eyes moving apart. You basically stretch them out, which is kind of like external rotation of the eyes, if you can think about that way, which is expansion. And guess who doesn't have that? Ya boy, same thing with everyone else. So, I do some moves to work on divergence, but then focusing within the divergence, which is accommodation. I spent a few minutes doing that.
And then my warmup, I kind of do the same thing. I just roll around on the ground for a while, do just a few moves to - yes, I just literally - they were finishing class at Elevate and Francis is like, "Don't worry about the Ninja who works here in the background." Which was funny. So, just warm-up and then...
Tim: Just some spinning flying kicks?
Zac: Yes. Something like that.
Tim: Yes. Like three sets of five...?
Zac: Nunchucks.
Tim: Sure.
Zac: Yes.
Tim: Yes, of course. I saw those in your office.
Zac: Yes.
Tim: I was going to ask about that.
Zac: Once I do that, then I do my main move for the day, which yesterday involved post-activation potentiation combo. So, I'll do med ball throws up against the wall, rotational-style, and then chin-ups with some weight. I did these in the 3-6 rep range until I can't do that anymore. And then I ended up doing a trap bar squat and overhead press.
https://youtu.be/CJgcqP_X8jM
And then I usually do like a circuit of some - like something single leg. I did like a single-leg squat off a box. I do pushups. I do one-arm dumbbell row. And then, like the body saw. I did a circuit of that with just, you know, whatever reps I need.
https://youtu.be/uBRYEyebmAY
And then sometimes I'll follow with conditioning. But I did my favorite conditioning yesterday, which is kicking my man Francis ass and spike ball. Boom! You heard it internet. We usually play spike ball once a week and we have some good competition. We both have gotten pretty good.
We did this thing where we were just playing Spikeball one on one for months because we both sucked.
Tim: Sure?
Zac: We didn't tell anyone.
Tim: One on one spike ball?
Zac: Yes. It's weird, but it's fun. And so, Francis was killing me and I can't have that happen because I hate losing in all things. So, I'm like consuming YouTube videos and figuring out how to serve. And so, now I can serve with both hands...
Tim: Walking around with the spike balk all the time and go for it?
Zac: Yes. And so, now we have some great games and we're just like hitting it way good. And we finally played two on two, not together, but it was way more competitive than we ever did. So, that was the skill that I learned. And that was my training session.
Tim: How do you think kind of in the macro about structuring your own training? Like, do you have short, medium long-term training goals, and you kind of period eyes to accomplish those? Or are you more like a fly by the seat of your pants kind of guy?
Zac: I have my main moves that I alternate between. So, what stays the same, and I got this, it's the mass effect program from Daddy-o Pops himself, Bill Hartman, just with some slight modifications. It looks like this:
Lift one: 4-6 reps
Lift 2: 6-8 reps
Lift3: 10-12
You do each of these until you fatigue out of those rep ranges. And then I just do, you know, two to three rounds of whatever else I feel like I need, which can be like eight to 12 reps. And if there's a day I need to condition, I'll do that.
If I want to do some extra arm farm, I do that. So, the three mains are there. I keep trying to get better at them. But the other stuff just varies depending on what I'm feeling. Because my main goal training-wise is just to look good naked.
Tim: Okay.
Zac: And maintain decent body comp.
Tim: No, more fat Zac?
Zac: Yes. Fat Zac is done.
Tim: Fat Zac's not coming back?
Zac: He's done.
Tim: That guy was fun though.
Zac: He was fun. Yes. He had the beard. He is like a young Santa.
Tim: Couldn't touch his toes.
Zac: Yes. Definitely couldn't squat. I still can't touch my toes, but I can squat now. So yes. And then like, you mentioned like periodization, I need to train enough that someone can take me seriously from a movement standpoint. It's kind of like looking the part when you're being a PT because I do think that that matters to some extent.
https://youtu.be/UEZZEWyBN78
Tim: Yes.
Zac: But right now, the highest priority is work, teaching, all that stuff, learning the craft. And so, that's always going to be the A1 for right now.
Tim: The A1 of life. Yes. A2 is fitness.
Time management vs energy management
Tim: You gifted me a Scott Adams book about five or six months ago. In it, he talks a lot about this myth of time management and argues that time isn't necessarily the resource that we should be seeking to manage, but it's instead energy. And that in managing your own energy and taking on projects that seem to give you energy rather than drain them or tackling endeavors that seem to increase energy, you can get a lot more done versus just trying to very efficiently kind of micromanage your own time.
So, you're one of the most kind of efficient, effective, prolific people that I personally know within our field. What do you think about this energy management concept? Is that something that kind of lets you do the amount of work that you do?
Zac: It's very easy to waste time on frivolous things and I try to do my best to minimize that now. But I think because I have a little bit more freedom to do that now. I can, I think, for example, a couple of years ago I had the shackles of student loans, so it's like, I'll take on anything I can do to try to manage that. But I do think about that when I'm thinking about things that don't bring joy into my life, like social media, for example.
Tim: Sure.
Zac: I try to stay off that as much as humanly possible. Because it does take energy, even answering texts. Like I'm horrendous about getting back to people via text message or phone calls because I eliminated notifications on that. Because even that takes energy out.
Tim: Yes.
Zac: Even being around certain people who suck the life out of you...
Tim: Exactly the black hole type of thing?
Zac: Yes.
But at the same time, I do think time management to some extent is important as well because, sometimes you might have to do things that are energy-draining, but they help move the needle forward. Does he talk about following your passion as well and how that's BS?
Tim: Yes.
Zac: Okay.
Tim: And I've probably had that conversation with like 10 people over the past week that like passion is fleeting. It's, you know, rocket fuel, but it's not actually going to sustain you over the longer. It opposes a lot of advice that you conventionally hear.
Zac: Yes. Well, what you have to do and there's another good guy you should read it. I might have an extra book. I'll give it to you. MJ DeMarco. He wrote "The Millionaire Fast Lane" and "Unscripted." He talks about that as well in the sense that you don't want to do things that you're passionate about.
You want to do things that are going to have a positive impact on the world and change things forever. And then if you do that and you make enough money from that, you eventually will become passionate about it becauseyou're making an impact.
Tim: Yes.
Zac: I love video games, but I'm not going to be making money, playing video games unless I started...
Tim: I was thinking about Twitch and Onlyfans. And I'm like, is there a way to combine those concepts and maybe have people pay you to watch you play video games in a reduced amount of clothing?
Zac: Haha right? But even with that, sure, you can make money, but Twitch is not going to change the world.
Tim: Sure.
Zac: And I want to try to make the little world that I'm in, that we're in, a better place in that sense. And that's really the crux of what I do. That's why I try to take complex things and simplify them so most people can carry it out.
I have a lot of good friends who are really smart, but they might not be able to devote the time and energy to diving deep into topics because maybe they got kids to worry about and all this stuff and well, they still patients to take care of.
Tim: Yes.
Zac: And so, if I can help that person get better a little bit faster, then I think we all win.
Tim: I mean, and is doing that something that you find gives you more energy than it drains or drains kind of a minimal amount of energy?
Zac: Yes, absolutely. I could teach, talk all the time. I love that. Even doing these podcasts. It's so much fun and then it's just time flies by. Because then it's also, you're just interacting with people and...
Tim: Also real-life people.
Zac: I know. Right?
The failure that changed everything
Tim: That's useful. I think along the same lines of that book, it's in the title that he's amassed a massive amount of failures and yet still is an extraordinary success. Thinking about kind of your own life professionally in the past five or 10 years, what are some of your favorite failures?
Zac: Professional basketball.
The thing that I had going into that was getting to pro basketball kind of a big deal. And I probably let that get to my head a little bit. I think I had a little bit of a Dunning-Kruger effect kicking in. Even though like I still would say back then, I was a pretty good practitioner. I'm much better now. But I think I let that get the best of me that I was in that setting.
I can't say that that's why I was fired, but after that happened, it completely flipped everything.
I did a lot of soulsearching during that time period. And there were four books that I read that just like changed everything.
I read those four and that's when I realized my behaviors, my issues were the problem. And I was able to do things to flip that and just be more humble, reacquire the beginner's mindset, interact better with peers and people who I'm working with.
And it really made a big difference. And I'm grateful for that. I'm grateful that I was out of that situation. It pushed me towards more of what I really like, which is this. And the fact that now I have a bit more freedom flexibility than I did in the league, was huge. That's probably the biggest failure that has flipped things for me.
[caption id="attachment_13675" align="aligncenter" width="375"] the failure that led to this[/caption]
Tim: Going back to something that we discussed, like removing things in your life that are not really serving you. The hard truth is those are people and probably people that you've known a really long time.
And you know, If you can't kind of reflect back on your own life and make a decision about which people you're spending time with, you're liable to get trapped in a lot of, and trap is probably a strong word, but waste the resource of energy on relationships that aren't getting you to where you want to go.
Zac: Is that something that you ever struggled with? When you knew you had to move on from a situation or a person?
Tim: Yes. The job I took right out of school being a director of rehab in rural Colorado.
That was so nice because it was lucrative. It was flexible. I think I could still do a lot of the things that I wanted to, because it was a three-day work week.
In a lot of ways, it was the perfect situation, but it didn't have any upward trajectory to it. I started at the ceiling. I'm immensely grateful that I had that opportunity. And I think it changed me for the better, in many ways. But after my three years and change out there, I knew it was time to do something else. Something that had a little bit more of an avenue for growth.
Zac: Yes. It's hard when you get comfortable like that because the chance of getting stagnant is significantly higher. And so, you always got to put yourself in slightly uncomfortable positions, I think, to really grow.
Tim: Yes. It's a really interesting juxtaposition. I mean, that's something I think about all the time that type A people, kind of people like you and I, a lot of what drives us is we're not happy with the way things are. But if you let that mindset pervade everything, then you never really enjoy what you have.
So, it's a really interesting tight rope to balance kind of, as physical therapists, as athletes, as human beings, how do we hold these two seemingly opposing ideas in our head simultaneously and not kind of fall apart?
Zac: Yes. That's hard.
Tim: Yes.
Zac: I definitely let that bleed into areas that it shouldn't bleed into.
Tim: Yes. Some things in life are just fine and they're okay the way they are. They don't need to be optimized.
Zac: Yes. There are some things too that you got to just keep pushing.
Tim: Absolutely. I mean, that's how people do great things. You're not going to just get this great opportunity kind of plopped in your lab.
Zac: How do you find the balance? You probably are better than me.
Tim: I don't know. I don't think I have a really good answer. I was talking to a mutual friend that we have, Aline Thompson.
She was mentioning this friend that she has an incredibly high-powered tech broker of some type, makes boatloads of money.
But he's a really, really good chef. And he says that the second he no longer has time to cook each day, that's the line in the sand that he draws between. That means he's striving too much. That means he's packing so much into his day that he can't just enjoy what he already has, which is quality time doing something good for himself, for his family, for his children.
That really hit home. I love to cook as well. I also like to play Frisbee with my dog, Molly. If I can't take 10 or 15 minutes to do that like that's another - like I just want that to be built into my day-to-day. And then if I can maintain these things and then continue to strive and see certain life, key performance indicators trending in the right direction, I am doing an okay job.
Zac: That's something I probably struggle with because I'm thinking about like, as you were saying that I'm like, "That's brilliant. Like everyone needs to find their cooking." And I don't know what mine is.
Tim: I think for a lot of people it's working out.
Zac: Yes.
Tim: Probably not in our industry, because I think we are the people that will probably sacrifice in order to train and train at very inconvenient times. But I think for 99% of the American population, that's one of the early things to go.
Zac: Yes. That's very reasonable. See, I can't fathom not having that. It's so automatic at this point that - there was one time where maybe I didn't work out and I'm like, I'll notice that one day, if I had a plan to workout, I can't do it. But I've never gotten to the point where I've worked so much that I've had to cut that out.
Tim: And you do, and it's like a super power.
But you go about the rest of your day supercharged, you know that you've done something that's probably more difficult than 90% of the people that you're going to interact with have completed that day. Especially for people like I'm a big morning trainer.
Zac: Really?
Tim: Yes. I'd love to train at like 6:00 AM or 7:00 AM. And that's recent. That's as I've gotten older, but in terms of the Scott Adams concept of adding energy to your life, it's like, that is something that so acutely drains you of energy and yet so quickly fills you right back up.
Zac: Yes. It is interesting how that works. Isn't it?
Can we get postural changes to stick?
Tim: You and I, both physical therapists, we commonly see people that present with particular movement behaviors or positions. And I think one of the most pervasive ideas in our industry is that there's a bad posture or a bad position. Right? Like extension, anterior, pelvic tilt, rotation. What have you?
Zac: Oh sure.
Tim: There's this idea that there are these bad postures and people have bad postures and well just swap it out for a good posture and they're going to be good to go. Something you and I have talked about before is these postures positions, movement behaviors emerge in order to solve a particular problem? To manage gravity, to breathe, to better prepare you for a training stressor that you've experienced before.
So, I guess how do you think about replacing a less than ideal movement behavior or pattern with a better one, because that's kind of what we do with these resets, with these drills to regain mobility? And how do you think about making that intervention like quote-unquote, "sticky" enough so that a person doesn't revert back as quickly as possible?
Zac: I don't think it's replacing one for another. I think the key is giving more options. So, for example, if we go with like the forward head, I'm sitting at the chair for an extended period of time, you do that long enough, something might get cranky just because of tissue ischemia or whatever. At the same time, if you sit perched upright and have a good posture, and you hold that long enough, you could probably run into similar issues.
But if you can get into each of those and a bazillion more, well, then you're never really overloading any specific areas. And I think it makes you more adept to surviving in several different environments. And I think really that's the key and that's like, what movement variability is all about is you need as many different ways to perform the task as possible even if you're getting the same consistent output.
So, like if I did 10 squats and even though they looked exactly the same to the naked eye, if I have to remove that variability, there should be subtle differences with each one of those squats, but it's when I don't have those options available that problem ensue
Tim: In both coordinative and endpoint variability.
Zac: Exactly. I think that's really where the money is. Now, how do we get that to stick? It's basically, getting people into positions that they can't normally get into or struggle maintaining into and then being able to demonstrate that at progressive intensities and complexities.
So, for example, you know, if we look at you and you know because we worked together for a minute. In the beginning, we started with some simple drills, some single leg positions, more supportive, really emphasized breathing. And look at where you're ay when we worked together the other day. Now we're giving you loaded-based strategies...
Tim: Kicking ass, taking in?
Zac: Yes, yes. Getting you a ridiculous pump. But the thought process is still there because you have the same needs, but can you maintain the positions that we had you get into that we'll get you those needs under higher intensities? Yesterday he did.
Tim: And I like that. It's just it's incredibly intriguing to me, this notion that human beings lose movement options, either via physical structure or secondary training adaptations, lifestyle factors. And then it kind of, and I say this as a physical therapist who makes these changes on a daily basis, it shocks me that anything that we do has the power to override whatever stimulus came before to lead to that decrease in variability.
Zac: Yes.
Tim: You know what I mean?
Zac: Yes. Because you're looking at reps time, all that stuff.
Tim: Right. I mean, it's almost to think anything in the gym could actually have that prolonged, have an effect. I mean, it also brings up the issue of in a perfect world. Nobody would need activities to regain movement options. That would be the goal, right?
You just walk into the gym and you train and your body adapts to the training with no deleterious secondary consequences. That's obviously not the world that we live in, but it does seem like some people need a far lesser volume of these reset low-level types of activities. And they can kind of progress away from that over time. Whereas some people, for whatever reason, you know, need that consistent manual therapy, stimulus or consistent low-level stimulus in order to make these changes stick.
Zac: Yes. Well, I think the key is the body has to deem it meaningful and novel and salient. And I'll give you an example. If let's say, you witnessed something terrible happened, anything. Something of 9/11 proportions and it happened right before your eyes. You would remember that for the rest of your life. And it might be just one moment, one instance.
And that could shape and shift everything that you thought before that. And I remember when I listened to Lorimer Moseley, he was talking about - I think my buddy Eric was talking about how taking NSAIDs could impair learning. And Lorimer gave the analogy if someone shot a gun right by you, you would remember that that happened, even if you were dosed up on NSAIDS.
Tim: Sure.
Zac: Of it's meaningful and novel enough, I think it could still lead to long-lasting changes.
Tim: Right.
Zac: Right? Now, does that mean the equivalent of you doing quadraped breathing is something like witnessing a horrific event? No. But your body might deem it novel and meaningful enough that it does remember that. And it does stick for some people.
Tim: Yes.
Zac: So, my point by bringing that up is we just don't know what's going to cause things to stick. Whereas some people might need continual reinforcement over and over and over again to get meaningful change.
Tim: Something that, like David Gray and Gary Ward talk about all the time is, essentially that same thing, putting people in positions. But then if the nervous system likes that position, it'll remember that position and there's no need to revisit it as long as that's what it reaches for the next time it tries to solve a particular environmental or movement task.
And that kind of makes some sense to me because if we think again about the Genesis of these like maladaptive, postures and positions, they are trying to solve a problem, get air in, maintain your ability to view your monitor while you're sitting in a chair, they don't emerge for no reason. This is a Seth Oberst quote, but everybody's body is doing exactly what it needs to do.
The dark side of sensorimotor cueing
Tim: What you and I do with people involves a high degree of sensorimotor cueuing, right? Having people maintain particular positions. Do you think that there's a potential dark side to sensorimotor cueuing and that it might put people sort of two in their own bodies if kind of left unchecked?
If most of their program is find your heels, tuck your hips, breathe this particular way, shift left. Do you find yourself needing to pull that out at certain times for certain people when you design programs?
Zac: Yes. I definitely think there's definitely a certain portion of people who can fall victim to that.
Tim: Yes. What are those people typically like? I think I know what you're going to say, but I'm interested.
Zac: Yes. They're almost hyper-aware of everything in a negative sense. And then that becomes their identity essentially. I feel twisted. I feel twerked. It's the person who gives me the laundry list of anatomical terminology that they shouldn't know, but they know. That can definitely be a problem because it's almost like when they get so intune to their bodies, but focusing only on the negatives.
So, with those people, yes, a lot of it is education "It's no, you do not have to tuck your hips with every step you take every move you make."
Tim: Because Zac's going to be watching you.
Zac: Yes. In the creepiest way possible.
Tim: From a deep squat with a really long beard.
[caption id="attachment_13677" align="aligncenter" width="500"] Like a boss![/caption]
Zac: Yes. And then just like, no, you don't have to feel your heels all the time when you walk and stuff like that. And it's educating them that, "Look, we're just using this as a strategy to increase your movement repertoire."
And yes, I think if you can do that and frame the right mindset that can potentially mitigate some of that. Or I think that could also be where, especially when you get to loaded activities, a focus more towards external queuing might be useful. You know?
Tim: I like that. I think something that Michelle Boland, Coach Bo, and I talk about frequently. Shout out to coach Bo. Is the need to have things in a programmer or in your life that just make you feel like you're a strong, capable human that doesn't need to think him or herself into positions to be able to execute a task.
All of my practices have always been in CrossFit gyms. And I think that this is something that CrossFit gyms do incredibly well. And no CrossFit gym is perfect. And I have my issues with the moves that are commonly prescribed the over-reliance on barbells, but they do a really good job of getting people that haven't been doing anything intense and getting them to not fear doing a hang snatch, doing a deadlift from the ground.
And I think that's really impactful in a completely different way. Because I think people like you and I take into one extreme sort of becoming those clinicians, those practitioners that are really potentially propagating a lot of this like fear of movement.
Zac: It's something I definitely think about as well. Because I do get people who come to me and it's like, they've learned similar things to me, but they think about it in such a negative way. Like "I have to fix this anterior tilt." Well, if you're standing against gravity, you're always going to have that because that's the norm.
There's a good podcast that Doug Kechijian did with Boo Schexnayder. He mentions that you should always be exposing them to intensity. And in order to produce intensity or move fast, you can't think, and relaxation is paramount. And I think if there's one thing it's probably shifted this year, is really appreciating that.
But and here's where I still think respecting biomechanics comes in. You have to make sure that you choose activities that are appropriate for that individual, that they can execute without having the risk for potentially performing it in a negative manner.
So, that could be doing a seated box jump, which it's almost like the constraints of the activity, get them into positions that they need to. Or, I've been using a lot of fake throws lately.
https://youtu.be/riB-dGofs98
Tim: To load a cut?
Zac: To load a cut or just to get them rotating pain-free or anything like that. Because you have to relax enough and move fast, but then you also have to stop fast. So, it kind of hits everything or just med ball throws. Like even though I talk a lot about biomechanics and stuff like that, if you look at how I actually program for someone, it has all of those other elements.
And I keep the concepts the same and the progressions appropriate with within movement options that they have available. But they're not always having to think. They might think about the setup, but then when they're executing the movement, I don't have to think about anything. Because when you are thinking you can't move fast, that's when you get beat.
Tim: Yes. That's what I like. I mean, one of my favorite lifts of all time is a single-arm dumbbell floor press, for that reason. Because like there's still enough range of motion to load and you can let 98% of people that would ever walk into your training facility can do that drill.
https://youtu.be/oGKufR-a4Mg
And the single-arm just forces some innate sense of not having the weight, rotate you off your back. T
he goblet squats is another one. It's like, it's these things that people in our industry have been doing for a really long time, because they're just so simple and people can try hard, like you said, relax not think.
Zac: Yes. Or like sleds, med ball throws, and carries. Those are all - if you have someone who is not exposed to much loading, that's a great way to produce intensity and not have to think "Oh, you know, man, I love machines." Love them.
Tim: I know. We know you do.
Zac: love them. In fact, one of my training is I'll load up the BFR cuffs and I'll go into my complex and just go ham on a leg press and all that. That's great. I look good for one day of the week. And that's my day for about 20 minutes.
Tim: Got a sick leg pump.
Zac: Yes. Just the veins out...
Tim: Bursting out of your khakis?
Zac: Exactly.
How to maximize patient communication
Tim: Speak to your journey in regards to your communication. How have you arrived at your current strategy for how to best communicate with probably both your clients and colleagues? How has that changed over the past five years?
Zac: A lot. I was for a while, obsessed with learning about how to best interact with people. I think I was a pretty shy kid growing up. Quiet, uncertain of myself. But I found that whenever you got someone else talking, people would end up really liking you.
Zac: Honestly. Exactly. Yes. I forget the phrases that he says in his book? There's another one...
Tim: Is it be interested, not interesting?
Zac: Yes. Another quote I heard somewhere or this woman had met like these two higher-ups in English government and she talked to them about the first one. And she was like, "When I talked with this person, I thought he was the most interesting person in all of the UK." And then she said, "But when I talked to the other person, I thought I was the most interesting person in all of the UK."
And that really hit home for me. And I try to, when I'm interacting with people, get that vibe. But at the same time too, the issue that I've run with when I've spent all of this time, learning with my interactions is in the beginning, I was just asking a lot of questions, almost interviewing people. And sometimes that can be off-putting if done in that way.
So, to mitigate that, instead of asking a bunch of questions, there's a technique called elicitation that I've been experimenting with. And how people are going to be like," How is he eliciting me?" But basically, it's like getting information out of someone without coming off as a threatening thing.
So, like if I come to Tim and I say, "Did you do this?" And say you did something wrong, whatever. Your inclination might be to go on the defense. And so, you might lie or you might say, "Well, yes I did. But it was because of this, this, this, this, and this." And that's not good. But if I wanted you to admit to that, I might say something or like a presumptive statement.
It's like, "So what was it like when you did that?" Or "So you did X." And almost making assumptions to try to understand the other person or inferences based on what they said. I think helps build a greater connection because it shows that you not only are listening to them, but you're also understanding where they're coming from. And I think that's really important when it comes to human interaction and what I really focus on.
Zac: The inference, that's still, doesn't lead to a negative interaction because people are so willing to correct any mistake that you make, but you'll still get the interaction. Like in the book, he talks about, if you're talking politics with someone, you might actually say someone has, I don't know, they say something and they're a Republican and you make the inference like, "Oh, well it sounds like something you might've gotten from FDR."
And they might get so adamantly taking it back to like, "Like no, that's because Ronald Reagan did this, this and this." And so, then now you actually know their political bias and you didn't even have to ask...
Tim: That direct question.
Zac: Yes. And so, I think not having direct questioning can provide a lot more useful information because when you question can come off as interrogation. That's like some of the logistical things. But I think even more important than that is having good body language with someone.
We were talking about Bill Clinton. One of my clients knows Bill pretty well; has met him multiple times. Everything you read about Bill in a positive light, obviously he's done some questionable things. But from an interaction standpoint, is a hundred percent true.
And he has five different things that he thinks about when he's interacting with someone to build a rapport:
Eye contact
Close proximity
The person's name
Direction facing
Tocuh
Tim: Okay.
Zac: So, like now if you do all of that at once, that can be a bit much. But if you're alternating among all of those variables, you can build an intimate connection with someone and have good rapport.
And so, when I'm interacting with someone, I do think about those things. Not so overtly that it's like, "Okay, let's hit point number five." But those are things I think about incorporating whenever I'm interacting with someone, you know? And there's a reason why I try to sit on people's left most of the time, aside from it makes my neck more comfortable. And that's because the right hemisphere of your brain is where your emotional centers are. So, in theory, if I'm sending more information to that side, I could potentially build a greater emotional bond with you.
Tim: Yes.
Zac: You might be hearing this and it's like, "Oh gosh, this just sounds like every interaction is Zac making is this calculated thing." But it's not that. It's not if it's genuine. I think the reason why I dove into that so much is that I just wanted to connect with people, you know?
Tim: Yes.
Zac: I think back in my younger days, I was not in the best place mentally. I'm shy. And I didn't want that because human connection is something that we crave. So, if you can do anything that maximizes that, so it's beneficial for both parties or all parties involved. I don't think there's anything malicious about that. And that's something we should practice as a skill just like anything else.
Tim: And it's intentional until it becomes automatic.
Zac: Yes.
Tim: And then it becomes automatic because frankly, a lot of those things are probably some of the best ways to connect with people. And I'm right there with you. Like you know, I think 90% of the reason why I do what we do is the ability to connect with people. I used to think it was the biomechanics and it's not, that evolves, that changes, but that connection...
Zac: Absolutely.
Tim: You know, we're in kind of rarefied air in terms of healthcare practitioners.
Zac: Yes. And that's why I always wax and wane with manual therapy, but I always come back to it to some extent. Because touch is a form of connection.
Tim: Yes. And its proximity without threat. Right. It's not this interview type of vibe.
Zac: Yes, absolutely.
Tim: Although we have a good 90-degree angle situation going on right now,
[caption id="attachment_13679" align="alignnone" width="810"] Bruh on the left has it figured out (Image by uh_yeah_20101995 from Pixabay) [/caption]
Zac: And there's a reason for that. So, and especially too, this is an interesting, a little difference between the sexes. If women, when they're interacting with each other, they generally face each other. And that's probably because they're generally more social creatures than us. They have more agreeableness and things of that nature.
So, if you think back to like Hunter-gatherer times, that would be a useful thing. And so, that helps build more intimacy, but men who are close generally do not face each other. And the reason why is because when you're facing a man directly, it almost comes off as aggressive. Like you're going to challenge someone.
So, that's why like, you know, bros, when they're hanging out, they're always like sitting. Right. And I think that there's a reason for that.
And so, you can also based on whether it's someone's male or female, that can also influence the interaction depending on what direction you're trying to go. So, it's important. It's an important thing to recognize if you're working with people.
Sum up
Choose activities and people in your life that bring more energy, whioch will allow you to be a more productive member of society.
Failure allows you to learn from your mistakes and create the life you want to live.
You must push to great, but reconcile that some things are good as is.
Movement beheavior change requires novelty, which is different for everyone.
Sensorimotor cueing can have negative impacts on certain people; mitigate this through education and appropriate exercise selection.
Pleasant interactions are acheived by being interested, elicitative language, and effective nonverbal communication.
If you mouth breathe, struggle sleeping, snore, or have eustachian tube issues, then check this out!
Mouth breathing is linked to sleep disorders, tooth decay, eustachian tube issues, and so much more, what do you do about it?
Could the answer be myofunctional therapy? That’s what I sift through with Myofunctional therapist Melissa Mugno.
In this podcast, you’ll learn:
Why Steph Curry chews on his mouthguard the way he does
Why do we clench and grind our teeth?
The importance of breastfeeding on orofacial development
What myofunctional therapy is and where it belongs in the healthcare system
The two causes of the mouth breathing epidemic and how to tackle this problem
How behavior change plays a crucial role in a successful outcome
The intersection of physical and myofunctional therapy
Why belly breathing is totally overrated
The myofunctional therapy intervention process
The link between swallowing and eustachian tube dysfunction
and TONS more
If you are ready to make your upper airway healthy as can be, then definitely check this podcast out.
Look here to watch the interview, listen to the podcast, get the show notes, and read the modified transcripts.
Learn more about Melissa
Since becoming an Orofacial Myofunctional Therapist in 2014, Melissa has improved the lives of hundreds of patients and lectured around the country. Melissa treats patients of all ages suffering from a wide range of conditions stemming from adverse myofunctional habits. Her background as a Dental Hygienist and experience in the fields of Orthodontics and Pedodontics contributes to her success. Melissa works in Las Vegas, NV, and is a Breathe Associate at The Breathe Institute in Los Angles, CA.
Zac Cupples: So, Steph Curry walks into your office, and he asks you, hey, Melissa, why is it that I like to chew on my mouth guard so much?
Melissa Mugno: So, the chewing is because of his airway.
Zac: Mm-hmm. Do tell. Tell me more.
Melissa: So, in sleep dentistry or airway, we've really come full circle to understand that like chewing and clenching, has a lot more to do with a deficiency in the airway than it does anything else.
So, there are habits that are created, that actually kind of stimulate the jaw to come forward, and there's a feeling that feels good. It gives us more air, more serotonin overall, and it actually will give you a lot more clarity.
Get some good oxygen, you feel better. So that's actually what's happening. So, the chewing couple times you do it, you're like, it feels good, right? Most humans continue to do things that feel good, stop doing things that feel bad. So, please stop doing that.
But the thing was, Steph Curry that's quite interesting is he doesn't just chew on it. He doesn't even - more interesting, he flips it out of his mouth and holds it. And what I was saying to you before was, again, I have not worked on Steph Curry so I do not know. This is just me looking at it, I was intrigued by it.
My husband brought it up and said, ‘’Hey, this guy's really known for doing this’’ and I was interested. I've always thought there was a big sports connection. I started looking at how thick his mouth guard was and I'm like, "oh, it's at least two millimeters, two and a half."
One of the things we do, the dentist will do or to help patients that have sleep issues, is they'll actually open up their bite, open up the jaw, so they can't close all the way, which naturally will allow their jaw to come forward, and that does is it opens up the airway and allows for the air to flow easier. So, he's holding it, and he's protruding his own bite and you can see it's literally bringing his jaw forward.
I started looking and then I watched some YouTube video and I saw that Forbes I think it was? It might be off one of the bigger publications that did an actual survey or did some type of research of how many free throws that he made when the mouthguard was out versus when it wasn't. He shot significantly better with it in!
It was a no-brainer to me. he's breathing better.
Oxygen will absolutely get you focused and therefore he is more comfortable. So why wouldn't you keep doing it? Yeah, so now it's become this whole thing. Now, I guess like, tons of athletes do it and I was like, yeah, of course, yes, it protects your teeth, but there's a lot more to it.
Zac: But when you're clenching as well, how does that open up the airway then? Because I would think...
Melissa: Clenching and grinding are not opening up the airway. It's a side effect of having a reduced airway.
I love my analogies. So, I call it the body's fire alarm. And so, it triggers something and what's happening is the body knows it's getting a reduced amount of air, so it acts to check that. It's going to create some type of function, some type of habit to make sure everything's good down there. So, this, the grinding, and I have this little theory that we grind when we're kids because we're carefree and we clench when we're older because we're trying to control it.
[caption id="attachment_13634" align="alignnone" width="810"] Grinding, but not like the Clipse :( (Photo credit: Free Dental Photos)[/caption]
Zac: Gotcha.
Melissa: It seems that way more adults clench than kids and I realized some of my, I mean, it's not absolutely proven, but my adults that grind are usually my cool cats. They just grind it out, let that jaw flow. The adults are like they're trying to control, they don't want that feeling. It's they're trying to control that bite. They don't know why their jaw wants to move. So, I believe the clenching has a lot to do with trying to contro
Zac: Prevent it.
Melissa: Exactly. It's also connected to the mind--anxiety and all like so much more mental health and stuff like that. I think it's a natural thing that happens as we become adults that we just want to control.
Zac: Yeah.
Melissa: That control leads to me building some type of subconscious behavior, to take it out on, and activating the buccinators and we're straining out all in here. No nasal breathing.
Breastfeeding
Melissa: That's one reason why breastfeeding is so important.
Yes, it has a lot of cool nutrition value, but one of the coolest things is that happens is it actually teaches you how to breathe and eat at the same time.
The tongues pushes the nipple up, and then be able to help extract the milk, and then the baby's actually letting the mom's body know, hey, you got to keep producing.
When moms don't produce milk, they automatically assume it's their fault because they have mom guilt. So, then it's like, I just got to make my baby free to be able to eat and stuff. And they think that the formula is doing the trick but what's not happening is that then the bottle goes in, and now the tongue goes down.
Zac: Then you can't control the rate at which the liquid is coming in when it’s a bottle versus when you're breastfeeding.
Melissa: Then nipple companies make it go quicker, the older you get, make it easier, it just flow it in there, no work needed.
Then we don't learn how to breathe nasally really young, then problems ensue.
Teeth clenching and grinding
Zac: From my standpoint, when we see someone clenching or grinding on the PT side of things, usually that's done to restrict available movement. So, you almost make the system more rigid. And to your point when you're talking about who is this it's those type-A people and a lot of times, I forget what book it was where they talked about the chairs in the waiting room of a cardiologist.
Melissa: Oh, yes in the armrests. Yeah, because like they're gripping way hard; fight or flight.
Zac: Yeah, and maybe it's just to change the pressurization that's going on in the airway.
The importance of breathing
Melissa: I laugh a little bit, when people will be like, airway dentistry, PT, speech, what has that have to do with it? "I'm like, Oh, yeah. Who needs air?" Oh, we don't have enough research and I just want to be silly and be like, so we don't have enough research on how important oxygen is? Or seeing the interconnectivity of the body? We all heard that elbow bone is connected to the wrist bone song as a kid, right?
Zac: Yeah.
Melissa: I just paid you to tell me to breathe? I am breathing! Well, I mean, that's left to be decided, right?
[caption id="attachment_12187" align="aligncenter" width="250"] Then you end up looking like this guy #gross[/caption]
Myofunctional therapy
Zac: Well, and I think most people don't even know that your specialty exists; myofunctional therapy.
Melissa: I don't know if I'm the best representation of myofunctional therapists.
Zac: You're just my favorite.
Melissa: Because it's been more about connecting the dots for me and I think myofunctional therapy happened to be a vehicle that I could I drive that allowed me to go to all these places and I don't think that would maybe be the same for most. I think most love the skill and the passion of myofunctional therapy and what it is day in and day on and how to make the exercises better and that one on one with the patient.
I love my patients, don't get me wrong but it's more of this bigger thing for me. I like looking at the teeth, tongue, and more. It opens the door to another place. It's probably my ADHD.
The beginning of my journey was untraditional. I was an orthodontic assistant for a long time, hygiene, whatever but I ended up not really even practicing all. My real calling was running a business, selling dental stuff, and making sure the patient and being that liaison to connect everything but at the end of the day, what does that mean? It means making sure the numbers and production and collection were good and I was good at that.
We had this really amazing pediatric dental program, but we had this hole in our practice. We would get these referrals for kids who we couldn't start because they didn't have all their molars in yet.
How do I make that work?
So long story short, I'm from New Jersey, we don't have a very long summer there. And the doctor comes in and he’s like hand me this thing and he's like, we're going to go to this course, I'm like, in August in New Jersey, no, thank you, and ended up being a Myobrace course.
There was this patient with a class III bite (where maxilla is behind the mandible). These presentations can occur either genetically or because the tongue sits low, pushing the jaw forward instead of the maxilla. The only real way to fix it is to do surgery (or so I thought).
Zac: Yeah, a lot of times they'll break the jaw and pull it back.
Melissa: Yes. That's a whole other thing.
Zac: I had a friend who did that and I didn't know him at the time. He was a coworker and I told him ahead of time, my buddy was like, don't do this. If anything, you got to bring the jaw forward.
Melissa: Did you know that? This was before you started doing?
Zac: Yeah.
Melissa: so, you were already?
Zac: Yeah. I knew like a little bit of airway stuff and like some of my earlier things, it was more about using splints to change occlusion. I started with a gelb splint.
[caption id="attachment_13637" align="aligncenter" width="375"] Ah, the classic[/caption]
Melissa: Really?
Zac: Yeah, because my wisdom teeth were still in and I had no truce of movements in the jaw and so we use the gelb to try to get me a little bit extra just for moving perspective but then the fix was to get the wisdom teeth taken out. So, then we went that route. I wasn't really having sleep issues, then but as I got older, it was -
Melissa: Well, you did your sleep study show sleep apnea?
Zac: No, I got upper airway resistance syndrome.
Melissa: I wonder because of your athleticism and all those things that because you – elongation in the sense you did, it would look like you might be more of a sleep apnea patient, but really, you’re UARS? Apparently, you and I are in the same club.
Zac: I know right?
Melissa: So we had this mom who all three of her boys had an underbite. She challenged us and asked if there was really nothing I can do besides surgery?
We ended up implementing myobrace and started to notice some decent changes, but the execution was rough; we didn't know what to look for and how to progress.
So, the journey then, long story short, kind of went in that I really started to crave the need of like, okay, who created these exercises? Where did they come from and that actually kind of brought me full circle to Sandra Colson and realizing she was a huge part of working with them. Her husband was an orthodontist, she was a speech therapist, and they were getting amazing results. Learning from her made sense to the cases we had that relapsed.
And it was important. I didn't hear tonsils and adenoids so much like we weren't bringing like was sort of doctors doing an orthodontist is doing his you know console, he's usually rattling off stuff, that type of by you know, class one class two, upper post for your class or whatever, convex all the different profiles have any they might say, you know, within normal limits, but I noticed we started seeing WAY more enlarged tonsils.
[caption id="attachment_12197" align="aligncenter" width="500"] Tonsils are the bottom read and white spot thingy. Looks like a solid "3" there, Bob. (Photo credit: Spider.Dog)[/caption]
My real aha moment was working with this amazing orthodontist who produced incredible smiles. It was my first job assisting, so I didn't know any different, but he used removable appliances, nothing cemented.
Zac: Really?
Melissa: And we always were doing early expansion, twin blocks maras, we would use anything, everything was removable, prop that bite up, pull it forward, and expand the heck out of it.
Zac: Wow.
Melissa: Now he - how do I say this a nice way? He had, I guess back then I probably would have called an arrogance. He commanded the room. Right? Like you didn't question. He just carried himself in a way. There was no option but the one he gave. Like if Bobby didn't wear it. Like that's your problem, then you shouldn't make him wear like, so that level of expectation. So why that's important to understand.
So, I go through and I remember one day we're in the office and I know nothing, right? Like, I'm just figuring out how to do this. He walks by, and the patients are humble, we do and he's like God, somebody should cut that kid's tongue out of his mouth. It's messing up my teeth.
It sounds dramatic but now I totally understand but I didn’t. I was like, wow, what a jerk. Right? Like, he doesn't care. So, come all the way full circle, I'm now inMyobrace class, I'm doing it, and it was like this light went off, I was like, oh my gosh, this is what he was talking about. The kid was tongue-thrusting. No matter what he did to that bite, he couldn't close it.
Zac: Because the tongue kept pushing on the teeth.
Melissa: Yes, that's what he meant. He's like God, that tongue is going to destroy everything. So, he knew it. But the crazy thing is if you go back into his story, he was originally an engineer. He was a mechanical engineer prior. Then after had gotten married, went back in dentistry and became an orthodontist.
Essentially, orthodontics is engineering. It's all about force and movement and I think that's what makes most orthodontists very specialized is because they can see things in a different way.
With Myobrace, we could take it to another level.
Years go by and I go back to school and all those things. And I noticed, almost every orthodontist just cements everything in and they just, I didn't even know you cemented it. It allowed me to basically see all aspects of dentistry, and I needed this whole journey to see it. That myofunctional was the most powerful thing. Oh, that's why the teeth keep relapsing because we didn't address the tongue thrust or we didn't retrain the tongue, we would maybe tell the kid hey, Bobby, try to put your tongue up or we put a habit in there or something.
Well, anyone that's ever had a real habit, thought was very easy to overcome, right? Especially if you don't even know why you're doing it. And mouth breathing and tongue posture, I mean, if you're drinking all the time, you kind of know what you're doing is wrong, right? Well, you know what the culprit might be, like this is what's causing this? But if you don't even know that it's wrong to mouth breathe and have a low tongue posture, now I tell you, oh, you have a breathing issue. It's because of your tongue. What? Like how do you do that? How do you fix that?
Zac: Especially considering how common mouth breathing is.
Melissa: Well look at how it's changed. So, you look in Disney movies, so if you go back to like Snow White, the older ones, all of the characters are lips closed.
Zac: Really?
Melissa: And now you go to Frozen, she's drooling with her mouth open.
Zac: Wow. I never even noticed that but that totally make sense. Like sleeping beauty, was she snoring?
Melissa: No, no, lips closed, breathing through.
Zac: If you have this epidemic of mouth breathing, and maybe this is where you are realizing the limitations of myofunctional therapy. Just like I have limitations as a PT that's why I talk to you and work with a ton of other people who have skills that I don't.
Where myofunctional therapy starts
Melissa: In a perfect world, you'd start with breastfeeding. Every baby that's born would address whether or not the baby has a tongue-tie, and has a tongue tie to the new protocols and standards. Unfortunately, the system makes that hard. So now we go out longer and longer. Now, time starts dwindling. So that's in the perfect world, that becomes the standard and protocol.
Zac: Interesting.
Melissa: Just like, when you have a baby, they come and they check hearing and they've checked all the other stuff, like, we'd want to have the tongue checked as well.
I also think we could put protocols in and say what we should all do but I think maybe just the real simple of somebody when they come in and they talk, the lactations will come and I know when I had my first daughter, and they talk about why it was important to breastfeed, they definitely talked about how important it was for connection and they talked about the nutrition value but they didn't tell me that hey, by the way, she might have some breathing issues, she might not be able to latch, she might not be able to really eat, could change the way her diet is, it could change her airway positioning.
There is some research out there now that shows that unchecked could send somebody down the road of having sleep issues. Possibly, we know that there's a correlation in connection to ADHD with kids that snore.
I wish I would've gotten that information because I did not breastfeed my first daughter. I mean, I have lots of my own reasons, but I don't know I had made my decision but I didn't feel like I was given all the information, right. So, don't we have the right to know everything? So, if we don't educate the parents, how can they make an educated decision?
I don't know so I think education is probably the first thing that would make the biggest difference.
[caption id="attachment_13638" align="aligncenter" width="600"] Get your knowledge up, yo! (Image by Sasin Tipchai from Pixabay)[/caption]
It's all about building these programs, implementations, having standards and I mean, listen, when I first started and it’s been like 11 years, 12 years now, and where we are today is leaps and bounds.
But as you grow new issues happening, like places like the breathe Institute, Dr. Zaghi, I mean, the whole industry change from Dr. Zaghi chose sleep, airway, tongue positioning to become his passion and his drive for research. It opened the door for so much. So, I mean, you have all these pioneers that are pushing limits and doing things all the time.
Myofunctional therapy is what you guys do, in a way, but in the mouth. So, it's like physical therapy in the mouth. That's really all it is.
And I feel like maybe we should also use maybe some of your standards, more to standardize what we do. So maybe I have a question for you and your fam is this. I was just like, I don't know, anyone that ever has had a rotator cuff surgery and then they go, yeah, maybe do PT, maybe not, like I don't know, like, it's not an option, right?
Zac: Well, they're doing that for total hips now but sometimes you get a total hip replacement, and they will not recommend physical therapy.
Melissa: And can I just be honest, like, is that because they have insurances? Like, where does it come from?
Zac: I'm not sure. Yeah, I don't know.
Melissa: I am sure if we went down that rabbit hole, we could find out.
Zac: I have my suspicions. I think part of it is, you know, and in some cases, they're not showing physical therapy as having good outcomes.
Melissa: Because it's not quick. You got to put work into it.
Zac: Definitely.
Melissa: We have to train the tongue just like we do any muscle. You must address the structure, function, and behavior. So, fixing the structure, and not addressing how the structure got there, to me is kind of stupid. like, I don't get it. You have to put in the work.
Zac: Yeah, and that's the hard thing because really, any type of major lasting change has to do with a change in behavior of some kind.
Melissa: Oh, absolutely.
Zac: That is what makes our jobs that much harder as we really have to find ways to induce behavioral changes in the people, when, as humans, we inherently, if we can be lazy, we will and I don't think that's a fault, like a character flaw. It just, it takes work and work takes energy –
Melissa: and let's give everybody a break. Be honest, is like what is expected of humans and for us to survive and add some kids in the mix and the house and a spouse and a dog and, you know, podcast and two jobs and or whatever it may be, to level up or do what you needed to get your hustle on or whatever, maybe there's just not a lot of extra time.
And then you also are then to do to overcome these lifestyle changes, these behavioral changes that are going to have a Long Lasting structural and functional behavior change require self-assessment, looking in the mirror and taking time to evaluate and understand, oh, wow, I did not realize that was affecting this and connecting those dots. And when that doesn't, so you barely have time to do these basic little exercises that we're doing, and yet, you think you're going to have a behavior change?
You worked with my mom. I'm going to use it as an example and my mom's good with this because she doesn't know what she doesn't know. So, she came out and she pretty much just wanted to have surgery. Yeah, that was her goal. I mean, she was excited.
Now here's me, and I'm like, you even know why you're going to have the surgery? So, tell me exactly what's going to change after the surgery? And I was like, No, no, you're going to go see my buddy. And my mom is - she knows what I do for a living. She’s seen me lecture. My mother's gotten some decent gifts of any little success I have. So, you would think she's like, of course, I'll go see your friend and she found out you’re out of network.
And she's like, Oh, he's not covered by my insurance and I was like, and that's exactly why you are going to see him. I was going to pay for it but think about that mentality, and I'm like, Oh, my God, it’s touching nothing and then so now she comes back. She's like, wow, how amazing. I saw her really, you know, try and working and she started to feel better. She's like, it's so weird. I feel better. What do you mean, it's so weird?
I get like, so here's somebody and I'm using this as an example. Like, it is my mother. How is she not getting and yet when something successful happens, it's like, I wonder without, what do you mean I wonder without? She knew but it was like, she almost had to be reminded. It's because, in her mind, the only thing that was going to fix her is if you did the surgery, or whatever it may be, right. So, if you can play on that, like not to go into her stuff, but I feel like isn't that across the board some of the stuff we're dealing with?
Zac: Absolutely. Well, it's because it requires you to have some autonomy and you to have some ownership and almost intrinsic motivation to better yourself. It's within your control.
Melissa: And most people don't want to believe anything they're doing or what they could do could better it because then it’s on them.
Zac: Or something that they're doing is causing it.
[caption id="attachment_13639" align="alignnone" width="810"] But I'm not the problem. (Image by S. Hermann & F. Richter from Pixabay)[/caption]
Melissa: I could easily change destructive habits, but it made me struggle having empathy for people that couldn't do that.
Where does myofunctional therapy belong?
Melissa: I think it belongs in lots of different areas: in speech therapy, dental offices, and physical therapy. I mean, it's everywhere. I mean, it should be bodyworkers, there are so many people because it affects - it's part of the whole thing if your mouth is weak, and your tongue is out, your mouth opened, you're going to be mouth breathing with the oxygen is going to change, you're not breathing through your nose, it's going to cause sinus issues, you're going to be more likely to have sinus stuff. It's going to affect your face; it's going to affect your cranial facial development, and then that can affect not that I don't know, but neck, the shoulders, your posture.
Mom's will be like, if so if your teeth are off like this, I was like, so how's this constipation? And the dad's like, well, now you fix constipation. I was like, Oh, well, I mean, if you can't chew your swallowing whole, so hard for you know, go potty. And the mom was like "oh my god, he goes to the bathroom three times a week when that happens." It's really hard. I'm like, Oh, yeah, you can't? Yes. Yes. No contact back there. He's trying to so texture food is going to change the way he swallows the food. How quick he eats, how slow. I mean, it's like cutting scissors that don't line up. And he doesn't even know to tell you. Hey, Mom, I don't have any occlusion. I can't chew that meat.
And we're like, eat your food, Johnny better eat your food, close your mouth. And literally, he's like, I can't breathe, I can't chew but I got to do it all so I'm just going to swallow it and real quick, get that down. It's going to make it a lot harder for us to digest food and then digesting now sleep, right? Now that's going to affect other things, I mean, long term and I can't imagine that. Me talking about this, that we can't go connect us that people that end up in your position with you are suffering from my stuff. And the people I see that are suffering from this need to be seeing you. Right? So, it's important to keep the connection going.
Zac: Yeah, well, with that, the tongue is one component of the airway and, we've kind of talked about this a little bit where, you know, with you, you kind of specialize in the airway that's more upper whereas a lot of the PT stuff that I do is more airway lower. So, you really have to, I think, blend all of that in order to elicit or to maximize respiratory capabilities, which has wide-ranging effects. You know, we talked about vagus nerve, and you look at all the influences that I have across our physiology and -
Melissa: anything when you say like your family or people I mean, that's, that's your place. You guys are all cool with that. So, the fact of like, your people and my people, while we haven't all sat down had dinner, like, you know, I mean until today. That's important because I think there's so much, I should learn from you and you should learn from me. And I hope one day that there is a course, that helps us all connect the dots and my stuffs included in your education and your stuffs vice versa, right? Like, the idea is to up the ante and build the specialties, and really help teach the students how to connect the dots. It shouldn't be something you have to learn once you get out of school.
Zac: Yeah. 100%.
Melissa: That should be taught in the beginning.
Zac: Yeah, it's almost like you need a different profession that combines it all or you need a team and this is kind of where I think you are. You are realizing that you are one piece of a greater -
Melissa: Oh, yeah, I mean, I've known that. That's always been but sometimes you got to do all the work to prove that you need help.
Zac: Absolutely.
Melissa: You got to show where you're falling weak and collaboration is everything. But with collaboration, also will bring some other hurdles. Patients, like we were saying before, don't like hard work. Well, they also don't like being told they have to go see nine people.
Zac: Yeah, no, I and that's an issue that I've ran into with some people and I think I struggle with me, referring people into this space is, when I have that conversation of well, you might need a few different things, that’s hard.
I even just look at like myself, I've seen, I've been to Lincoln, Nebraska, and then that took me to getting wisdom teeth pulled in Phoenix, Arizona, and then that took me to getting the roto rooter done in Memphis, Tennessee. And then now I'm in San Francisco getting this and then working with you and it's just and then Zaghi cutting my tongue.
Melissa: How do you build the ultimate practice? So, the question is, does that practice look like an airway-focused dentist? and you know, this airway focus dental thing has become like, who is this person?
I mean, I hope that one day, it's just all dentists, because it's not about maybe others you know, they'll be Specialists of who does what technique, but the idea of, that's how you treatment plan. So, they actually, when you go get your six-month cleaning, it's discussed of what your airway looks like, or, hey, if you’re mouth breathing, you can cause more decay, tell me how many of most people know that? When people are like, if you mouth breathe, your mouth is dry. If your mouth is dry, you have no saliva, you have no saliva, no antibodies, you have no antibodies, you have nothing to protect your teeth, you're going to get more decay.
[caption id="attachment_13640" align="aligncenter" width="354"] But can you nasal breathe tho? (Image by Klaus Hausmann from Pixabay)[/caption]
You can brush your teeth all day long. Yeah, like, where somebody else who has tons of saliva, and, you know, it goes like, so these are things like, we should always treatment plan to, hey, your tongue is not sitting where it's supposed to, have you noticed this? And not wait till it's to the point where now it's like, right now you mouth breathe, you snore, you this, you have to go and drop, you know, I've seen my money insurance doesn't cover. I mean, that's a shock to the system. So hopefully that will come to a point of that. But for now, seeing groups come together and it might have a PT, it has a myofunctional therapist, it has a dentist, a body worker, but now it's also a lactation consultant. We could go across the board.
I hope that we'll be there and hopefully, we'll have these great little medical many places that can offer all of that, but you got to get your group, you got to get your crew. And I feel like also as a collaborative group, you got to talk finances with each other. What are your patients looking at? What's it going to cost for one patient to see everybody? Already, how many people know that? Like, if you refer, what's the end of the day out of pocket? I don't know. I've always been curious. I always think of that, like, so if I'm going to send the nine people. I think it'd be like, thank you for the $50,000 journey. I don't know.
Zac: Yeah, that’s quite conservative.
Melissa: Yes, and I've just seen because those are uncomfortable areas, right? You don't want to talk to your fellow colleague and be like, what you charge them. But what do you think about us working together? These are awkward conversations and I don't know if they're realistic. I don't know but I feel like no one ever says it, no one ever wants to talk about it.
Zac: Yeah, but it can be a big barrier to, like, if you know so and so's going to charge 10k for an appliance and that's not in the cards for someone because they're on Medicaid or something.
Melissa: It's just not in the cards.
Zac: Yeah, you have to find a different avenue for that person to get better.
Melissa: And I mean, like, again, going back to the things like what is wrong with you? What do you do? Well, you know, money.
Zac: It’s an unfortunate thing with our system.
Melissa: Yeah, but let's be honest, I think even in other systems, do you think they're really addressing this?
Zac: Probably not.
Melissa: I have to say, I don't think there's any system that's looking at truly getting into what's really going on, which I'll tell you, in all systems do. I think I could sit here and tell you that if we were more aware of some of these breathing issues, we would see a decrease in multiple things like heart issues, Alzheimer's, I mean, we could go down the line.
It's about more than fascia
Zac: I think all of the tissues adapt and accommodate to ensure our survival and I think if you isolate it to one specific thing, then you're probably missing the boat. And not only that, it's like, say you do a fascia treatment, so you mean to tell me that nothing else changed you and you were able to isolate fascia, you were able to bypass the skin? Not create a ton of changes within the muscle.
Melissa: Well, you literally had to go this whole journey to get there but nothing else was affected?
Zac: Yeah, you can't isolate the tongue, because you're probably going to also have influences on the teeth, the nasal airway, it all works together.
Melissa: And I think from your community and your family to ours, most people, and let's just get medical professionals out of here, let's just talk about our patients, the glaze people, right? You know, if you tell somebody like there's something that's connected to their toe all the way up to their tongue, they're like, no, and I'm like, No, really? Because we sometimes also forget, most people have no concept of what the body actually does, or how it actually is affected. Like, really, I find that to be - they have no understanding how if I walk one way with one shoe funny for a long period of time already, that's going to affect something.
That helps us try to explain a little bit easier to patients, how come the tongue position can affect other things? Yeah. So, learning where other systems would only make it better for us to talk about it.
Coaching breathing mechanics
Melissa: Let's talk about breathing. We're always hands-on, like, when you breathe, you need diaphragmatic breathing, right, like you want to breathe in. And so the beginning, we kind of tried to keep it simple for kids, it was just like a very basic of, you know, put your hands on your stomach and chest, sit up straight and don't let your chest move. Because it's really hard to do if you slouch.
So, it just became like, sit up straight, shoulders back, head up, because it felt like, at least opened it. But you would actually kind of had said, you know, it's not always about sitting like that. So, what would be that something to kind of show them that we can help each other? What would be a way that you would fix that?
Zac: From my standpoint, when I look at that, you have to look at the actions that should happen at the rib cage. So, the rib cage should move as you breathe in and breathe out because if you think about it, when I take a breath of air in the tissues are filling our lungs, so the rib cage has to make room for the lungs and so it has to stand in all directions so we have these actions at the rib cage called the bucket handle, which would be lateral expansion, pump handle, which is anterior and superior expansion. And then you have posterior expansion.
But I think what you were trying to do with the belly breath is trying to mitigate an accessory muscle breathing strategy, where I'm lifting the rib cage up as a unit with muscle such as the scalene, the sternocleidomastoid. We don't want that. I want the rib cage to stretch out.
Melissa: Yes, but you would normally want to be more about explaining how it's rounded out and how you want to see it go like here and there. But we're keeping and trying to be simple because oftentimes, I most of all, say like take a deep breath and it looks awful.
Zac: Well, when you demonstrated that you emphasize a lot of inhalation. Most people can't get an effective exhale.
Melissa: Okay, yeah.
Zac: So, you have to get as much air out as humanly possible and then guess what? So, if I am just doing a belly breath, I'm not getting any expansion of the rib cage. Well, you can think of it as like my mentor, Bill Hartman, he has a toothpaste analogy. So, if I take a toothpaste tube, and I squish the top of the toothpaste tube, I get all of the toothpaste going into the bottom. Well, the same thing happens with belly breathing, when I take a breath of air in and I do not allow expansion of the rib cage, I have greater downward pressure into the abdominal contents.
So, the diaphragm will actually descend to the point where it's flat, which creates a negative pressure environment in the thorax, which causes compression, too much outflow into the abdominal contents, which is the same thing you see in sleep apnea. But now - because what is that? I have a negative pressure environment that I can't maintain the integrity of the upper airway, it collapses. When you're coaching belly breathing, you're creating the same environment, but now you're doing it in the lower part of the airway.
Melissa: Wow.
Zac: So then now I have a mismatch of intra-thoracic and intra-abdominal pressure.
Melissa: So that is 100% correct. So, where we struggle with this is, most people I've noticed, I say breathe and they really do not know what the feeling is, like they really do not understand what it means to truly get a diaphragm out or like to really get that because that, like you see it in their eyes like to calm them down. So, they can't feel that difference. So sometimes, the way we kind of were like not saying, it's being picked from different kind of systems, and that we've been trained on, we got to get them to at least feel it before you can critique it.
And that the more the deeper that professionals getting, is, how do we evolve it, to also get them to feel it, but do it properly to promote positive and like, also children versus adults is going to be very different. How we do that, how we teach it, how long that habits been into play. And I am hands down. If you can't get the breathing, right. I think miles doesn't have a chance to stand.
So, to me, breathing has always been the biggest, has been a huge part and I have a lot of theories of like people, there are two ways that you end up with mouth breathing and one is like, there was something wrong with a structural situation with the nose early on and then that created low tongue posture because you had to breathe through your mouth. Or Yes, you had a tongue tie, right? And that tongue tie was tethered.
You could have been breastfed, but it was further back. Tongue keeps pulling down and then eventually just slowly opens and then you start to mouth breathe anyway and then you stop breathing through the nose and then that changes the way the air comes in, and now the nose becomes a face ornament, and it's just hanging out and therefore, it's very hard for people. They think they're breathing through their nose, and they're not. And you know, the ones that are like [whoo] like, though, like, you put like one of the boom, boom sticks. You're trying to incentivize some type of nasal breathing.
When you're stuffy, you should be doing nasal sinus rinses, 24/7 trying to force yourself to clean out your own sinus, but we go, Oh, no, I'm stuffy. Okay, you know, that's -
Zac: It’s not normal.
Melissa: It's not normal. You need to breathe more. I'm sick. I'm taping my lips up even more, forcing myself to breathe and it's hard, don't get me wrong, but you got to push through it and you will absolutely always overcome something sinus-wise; a cold or something quicker if you force more nasal breathing.
Treating adults with myofunctional therapy
Zac: Yeah. So then with your treatment process, why don't you talk us through the - And I know it's going to be case-specific and I hate protocols. Like that was one of my - it was a little bit of a beef with I think when you're first learning some of this stuff is, they say, first, you do this, then you do this. You do this, do this and I think there are some case-by-case variants. Yeah. I mean, we're doing weird stuff with me. But say someone comes to you, and we'll say it's an adult, because most of the family - hopefully now that you know, we're talking about some of the stuff that.
Melissa: you'll see with kids too
Zac: if an adult comes to you, and let's say they have these issues, they can’t attain a palatal tongue posture, they have difficulty breathing through their nose, they have the gamut but it's not a surgical case and maybe it's someone that could just - they just need you.
Melissa: They just need myofunctional therapy.
Zac: They just need you. Where do you start? And maybe we could talk into your assessment and
Melissa: So, I always have to be like, well, I do myofunctional therapy very different right off the bat than most. I only do it in conjunction with dentists. I mean, almost 5% of I mean, there's a couple of patients, I'm close with that end up knowing they're going to go into an appliance because they're going to somebody, but I very rarely not do that.
If I could get tongue space, probably tattooed on me. I would. For me, that's my objective. If you don't have enough space, I mean, anyway, if you have a lion and the little cat cage, yeah, doesn't really matter what we do. Right. And so, I get really frustrated sometimes. I don't know, I guess also, I don't love to do things myself.
I mean, you'll get changes and there's always benefit, like even myself, if I didn't do myofunctional therapy, I probably would have a way worse situation than I have. The therapies done quite well.
I should use myself as an example and I struggle with space, but because at least I have tongue strength, I am able to hold at least what I have so I don't collapse so much and it's funny a CBCT scan, if you look, my tongue is like flat up, because I have like a little cocktail straw. I have like three, four millimeters in my airway. It's really tight. And so, I don't have an option. My tongue can't go back. I mean, game over, right?
Zac: Yeah, low resting tongue posture.
Melissa: Yeah. And so that's why I can nasal breathe because I had no choice. Right? It was like, this is what it was going to be because it felt so much in my throat. So, you can do myofunctional therapy, just to be able to abstain from what you have if you don't want to fix it, right and so, what would be the base? If someone is really good at nasal breathing, they can breathe, that's fine and keep their lips closed and you can do an easy test like, someone just puts a popsicle stick or they hold and just breathe through their nose for two, three minutes and they're able to do that, then yeah, I would definitely do some therapy and starting off with just doing tongue, just getting to understand where the tongue supposed to be sitting and then from there, you kind of go into being able to move the tongue and then compensation comes into play of can we separate the jaw from the tongue?
Because that's when we really start to work the tongue muscles themselves because a lot of people think they can do things with their tongue but really, their jaws were doing it for them. And I mean, I'm no way in speech, but I always like, I asked parents all the time. I'm like, does he mumble and they're like - we'll say, well, do they have any speech issues? Or even adults? Oh, no, I go. Someone ever told you, you, you mumble Oh yeah, all the time. It's kind of a speech issue. Because the mumbling is if you do not have a lot of range, you'll notice someone will say like 123 their upper lip, like the inadequate movement of the upper lip because the lower jaw just kind of - well the tongue is down so you have to bring it up, right?
So, they reduce tone. So, they'll talk quicker to get it out or they'll change the words because they're modifying. Humans are amazing. We're going to figure it out. So those are areas that we might work in just to help you build awareness and then body scanning right? What does that feel like? Does that affect your neck? Do you feel that down in your back? Does it feel weird? Like, where do you notice it? Because if I don't build awareness so that you feel the difference of where the tongue is? What's going to keep you in the long run?
But I got frustrated with some cases that I wasn't getting better. In 2017 I was pregnant and watching everything Dr. Zaghi is putting out and what's this guy up to, whatever and I was like, oh, okay, I'm going to get this guy, I asked this guy, what about these patients? So, I actually started paying for consults for all my patients, just so I could get on this. So, I could introduce the patient, present it and ask him why they can't go any further. I know the joke is that eventually what I was like, sorry, on staff, like, Hi, like, I was just being me and I'm presenting patient and that and now I felt like oh, my God, someone was finally able to say like, oh, the tongue, he's tied, etc.
And now I had somewhere to send them. And I was like, ah, and now listen, the tongue tie got released and we were able to overcome it but the ones we couldn't, which, unfortunately, were more I shouldn't say my patients were, I was lucky enough, I already had the tool in my arsenal. There was expansion going on, right? Like I was working with doctors so if it was a BWS, which I know -
Zac: What’s a BWS?
Melissa: So BWS is a Bent Wire System, which comes from the company Myobrace and they use BWS, and then they have you wear the brace over it to kind of help do with [unsure word 1:06:10] The theory was to kind of do with the crows that did right, so. So whatever may be Crow's out all of these different things. I was lucky enough that I had somebody that we knew we needed to make t space like that's how we were showing that we were getting results. Or then if I would have somebody that would get good expansion, then they would relapse. That's how long I was keeping them so that they were relapsing with me.
Because I was on this journey, I needed to know where is going. So then now, I was able to show Dr. Zaghi like, okay, we've done this, we've expanded, we've done, and now this has happened. And like everything happens for a reason. That's how I was able to really so grateful for that situation. So now I was able to see, then you had that tongue-tie release in there, huh?
Zac: Because it really takes a team.
Melissa: It does. Yeah, and I know I have a hard time being like I could do the therapy, but we don't have enough space so I don't know. But that's me, right? There are a lot of therapists do it. And then they only need tongue ties in there to expand and that's fine. This is just my vehicle and that's what I saw.
And I really do think we now finally are like getting into a community. I mean, people are talking about tongue space more and we're more aware of the structure and that you need to be able to withhold all this, be able to have a place for the tongue, the tongue is able to be somewhere so that it can be in the right position. So, it is more and that's what's uneasy about it.
And then you know, they're finally in a good place, they've had the release, they go home and now they have anxiety, they’re depressed, I don't know, they get divorced, whatever their life comes into play. And we didn't really get into the fact of what the behaviors are, and then they come creeping back, or they get a little new doggie that they're highly allergic to, and they don't realize it and they’re mouth breathing again.
So, the body or they're doing you know, they have neck issues, or I don't know all these different things, I feel like you also have to bring that aspect into it, and you have to be able to address all of it. So, the treatment planning is complex so most of the time, when a patient comes, I feel confident, I'm able to quickly say to them, okay, this is what you present with, I know your low tongue posture, you have this, this is where I would go, I would start with probably looking to get some type of an appliance. Let's open up that bite work on that structure. While we're doing that, let's work on nasal breathing but while you're getting your structure fixed, let's work on nasal breathing. Let's see how you feel comfortable getting your lips closed.
Seeing how that becomes comfortable and then once that structure is done the right thing, then kind of come in, let's bring that tongue up, start noticing where the tongue spot is, and then kind of prepare for the tongue release. Because if I'm setting a patient up, I don't want them to go get the tongue release done until they have tongue space. So then now, I'm going to focus on that, I'm going to keep it pretty structured, there was that tongue ties done. Now we go in and we do some swallowing techniques and we really kind of bring it all around, and hopefully now they're able to keep it and now they don't have their teeth moving and they're not functioning as much. And if they do move a little bit, they know why they have the tools in their toolbox to go back and do the therapy again and do things on those lines,
Zac: Which again, gives them a locus of control. So then is it fair to say nasal breathing, space. Step one has to have that, range of motion, I'm assuming would be second and a little bit of awareness of the palatal tongue posture, because I would think if you don't have the range of motion available, it's going to be really tough to attain that position.
Melissa: Well, so right if I go back, so I don't know for me range of motion. Okay, so it depends on so, like, we have four grades of tongue-tie, right? Then a two-step release might be the first thing to do.
Zac: Interesting.
Melissa: Yeah, just get up there. We got now we got to just do that. Then once we do that therapy, work on nasal breathing, work on the structure, then we go back and prepared for the functional frenuloplasty.
Zac: Gotcha. Because I have a client who I'm working with right now, he's potentially a candidate for a second step. But so, they do anterior first, and then the posterior tongue tie second.
Melissa: So, the concept of why the therapy is so crucial for a tongue tie release, specifically functional for any of us, is because they need to be able to do certain exercises, certain motions and movements, and hold it during the procedure. So, they're numb during the procedure so, they better have really good muscle memory, and know how to do these things, to hold it when you're numb, right. So, you better be able to do a cave suction really well and also, that's going to help build muscles. So now when the doctor goes in, and does that release, you're going to see the separation between fascia, you know, fascia fibers muscles, it makes it a lot easier for the surgeon to get in there and see that difference.
Zac: Absolutely.
Melissa: Now anyone that's ever worked for a doctor, anything we can do to make their jobs easier is always a win. A win for the patient, win for the doctors, win for everybody. So that's what's crucial for that beginning step. So, if you're so tied, right, anteriorly, which is a lot of people that are out there that will say, Oh, I had a -you know somebody that had a tongue tie release 20 or 30 years ago, I promise you, they still need another one. Because that was a snip. They saw that it was so tongue-tied, they couldn't move it. So, they were just doing what we do with the first step to prepare for the second one.
I mean, that's how I look at it. Yeah, yeah. So, you know, look, I was like, Yeah, we got to give you enough rope so we can at least get you to move in, so we can get you to hit this, hit the tongue spot, and be able to then hold that cave, workup, get a little muscle tone, be able to, work there. So, we can get some identifying and be able then to get you ready for healing. And also, it's a lot easier to do therapy exercises for healing, when you already know them and you've gotten muscle memory when you're sore and in pain than it is to learn them when you're in pain. So, I'm like, Well, why would you not do it before the procedure?
Because who wants to be learning something when they're also sore? and it's crucial afterward. Once the sutures off, you're doing therapy, I mean, every four hours, six hours. You know you've regimented; you don't want that stuff to reattach. You want to keep that moving. I mean, you want to use this amazing moment, and ability to - now your range of motion being so much wider, you want to continue and that's not going to happen. You can see it become worse, tethered up if they don't have a really great regimen and they didn't have good muscle tone to begin with.
Zac: Yeah, and that's something that even in PT, like, if we have someone who's going into surgery, we try to see them - in a perfect world, you would see them pre-op for the exact same reason.
Melissa: Yeah
Zac: It makes it so much easier on the backend.
Melissa: Of course.
Zac: They have those concepts in place.
Melissa: It's not new. And most of it all, it goes back to the implementation and trying to make sure people understand it. I think that's going to be a battle but I think more conversations like this, more people using their mind and opening up and finding unique places to educate patients. We talk about something earlier, but not to go into I but I believe people are a little bit - I'd like to give them more credit than we do.
I think people are able to make decisions. I think we make a choice, unfortunately, to choose what information pertains to them and what they need. Because we don't think that they have the ability to always maybe make the right decision for themselves. I don't know. I feel like all people, this just should be spoken out. They should know, every option. Hey, if you choose not to do it once you've been given all the information. Okay, cool. It’s your choice. I have an issue when you weren't presented with the side effects if you don't do it like I'm sure if I was going and having that hip. If no one came in and told me Hey, listen, okay, you don't you know, you couldn't do therapy.
You could do PT prior, you know, pre and post. This is the benefits, whatever. If you don't, you know this can happen, this can happen, this can be a little bit more challenging, not everybody, but it does happen, and you truly set the expectations and limitations of both, let the patient choose. Once they're educated, they know, hey, do whatever you want. I have an issue that it's not. We don't do that.
Educating patients on airway without inducing maladaptive beliefs
Zac: Yeah, which makes sense, because then you're not making them an informed consumer. The thing that I struggle with, and I see this a lot, and I especially see this online is sometimes when you give someone a story, and you give them the doom and gloom of what could happen, a lot of times the maladaptive beliefs that they develop from that, become an issue.
So, there was this article, this guy was named Darlow, and I forgot the name of the title is I'll link it in the show notes. And he had this thing that this patient says basically interviewed all these patients based on what doctors had told them. Okay. And I don't know what the doctor specifically said but the patient's interpretation of what he said was, he was so afraid of back pain. He was so afraid of the disalignment of his back that he thought that his spinal cord was going to sever and that led to tons of anger, fear, anxiety, lack of movement, and things like that. And I especially think in this domain, because it is a huge rabbit hole and there are some scary procedures that some people may have to go down like, sure.
We're talking about appliances and myofunctional therapy and things of that nature but what if you got someone who needs the MMA surgery? How do you balance not instilling fear and maladaptive beliefs that this is, like, if I don't do this, my life is screwed versus informing them?
Melissa: This is what I know, I'll just live with it. And I mean, I truly understand that. So, I said to you like I have a formula for an airway. I do this for a living. I'm aware of what I should do, right. Like, do I know that I should have surgery? It's scary and I know, from the best. So now the other side, right? It's human. Like, I'm going to try this first one, it's a scary thought. And let's be honest also I go into like, do I have it in me to do, you know, my own insecurity of will I follow through? Will, I get it done? Will it truly make a difference? And I think it's just like, I'm always high energy. I'm always like, appear, right? My fight or flight? That's become part of my identity. It’s who I am. Is there something inside of me that also scares me from it? Because I'm scared of who I'd be without it. I mean, I'm going a little dark here and a little deeper, but it's, I mean, it's my truth.
Zac: Oh, or sure.
Melissa: And I play in my own head all the time. I'm like, I can't do it this because my kids like, you know, and I can make every excuse not to do it because at the end of the day, it's huge and it's a leap of faith. I think I respect that and I hope that nobody thinks that anyone's saying it's easy, and it's one shot and, and do it but the question is - then the other comes back to is, maybe I just don't think it's affecting my life that bad. Yeah. Yeah. Even though I statistically notice.
Zac: You know what you don't know.
Melissa: But the other thing is, you know, maybe I’m comfortable like this, I'm not ready to, I haven't hit my place of like, I can't do this anymore. This is no law. I can't live like this. Right. So, I'm willing to go do that. Where I think like, in some ways, like, those are extreme cases, right? But, you know, kind of just go away. Like, let's go to rotator cuff surgery, right, like, so that's not something, my arms like I can't move it, I don't want to have a choice. That's bottom. I got to fix it. Well, I'm almost saying like, what are we doing? Why are doctors not - Of course, PT or - Like, why would that not be automatic? I mean, that's part of it. I feel like to say that if that's not the standard, that's scary. And I think things like you've had braces three times.
Do you want to try something different. So, you've had braces three times and you also have sleep apnea and so there's a lot of things that have now are coming in your way that you'll pay for this, this, and this. Hey, do you want to also address these other issues? Then maybe we get through there? Just those kinds of conversations.
Zac: Yeah. You have to give people options. It's funny you when you're mentioning the identity stuff because I totally run into some patients who will forever be a patient because that is who they are. That is their identity and that's who they become. Yeah, you do have to wonder like if I take that away from them, so your high energy. Well, if you – you get the chill pill and I think it was in Mark Manson’s book, not the subtle art of not giving a Fuck but everything is, he talks about - I just read it the other day. Oh. In order to change who, we are, we have to mourn who we were. Yeah. It's such a profound quote and it's true. It's like some people just might not be ready to go through that grieving process of changing those things, those dark things that are about you.
Melissa: Well, if you're anxious, you're living in the future. If you're depressed, you're living in the past and if you're content you're in the now. It's hard. Mental health is a big deal.
Zac: In terms of like it being the X factor, or maybe the thing we're not addressing.
Melissa: Actually, it’s personal. So, that's like my connection to certain things. So, I had a patient, an office I was at and I walk into the room, they had the scan up. I mean, the kid has no airway. I mean, never mind, forget the cranial facial stuff and forget the teeth, who cares about the teeth? I like turned around and I was like, hey buddy, he was nervous. He's all these things anyway. So, I was like, great. I got the assistants taken out of the room and I said so any behavioral issues like the mom starts crying. I mean, anger issues, can't calm down, bathroom issues, can’t eat and I'm like, I want to like, just cry, right? Because I'm like, this is a kid in my mind, this young man and the mom is like, she thinks it's just who he is, right.
Like, you know, we have one bad seed because I'm telling you, I'm telling her things and she's like, so that has to do with that and like with a little bit of disbelief, right? Like, yeah. Right lady. No joke, the father was in there, he had a mask on, new design and I brought up one thing, I said, so is he really good in like science? And then all of a sudden, like he's reading and comprehension seems to be lower and the mom's like, yeah, he gets stronger grades. Then I asked if he keeps rereading the same page and the dad like takes on his thing, he goes, why he gets that from me.
Dad pulls down and he has this crazy deep bite. And I go, I know he gets it from you. I agree. You just have the same habits. And he's like, what? I go, yeah. I go, you both, like you live in fight or flight. Like you just, I just start reading out loud. It will change the game. His dad was like, no way. So the mom's like, I go watch it. So the kid came back and we gave him one little snippet of thing. We told him to read it to himself. I gave him three questions. and read it aloud. He was able to get it!
Zac: Essentially recruited another sensory system.
Melissa: Absolutely.
Zac: Well, and then that goes into, and I don't know if you've ever checked this with those folks. Like if they have any visual issues along with that. Because a lot of times -
Melissa: I got to fix it, I'm fixing bathroom issues. Now I got to fix my eyes.
Zac: Absolutely. Yeah. Which Dr. Kareen, if you're tuning, I got you!
Melissa: Okay. I'm sending it right. I mean, and I'm so sorry, not that I don't know how important the visual aspect is.
Zac: Well, to me, I think this all relates to airway because if I have to assume a particular head posture, well, that's going to change where my eyes are looking in space. And so, you could potentially see some changes in the shape of the eyes potentially, or the focusing type stuff or eye teaming.
Melissa: Well, we look at it when they, when they - Well, actually I always look like I can. They always like my little last, super what do you call it? Like my tarot card thing is I'll walk and I'll be like, Oh, so you only true on the left side of your face, where I looked in their mouth. And they're like, what? I'm like, well, one side of your face is stronger than the other. I can tell you only work those muscles, but also like the moment you bring somebody up and expand them out their eyes, all of a sudden open up. because they were squinting like this.
And so, I guess, yeah, I knew the eyes were part. Everything's affected.
Eustachian tube dysfunction
So, let's just wrap on the one last thing. I mean, now we've done ears, we’ve done eyes and mouth. So, kids that have had tubes in theirs. Okay. Kids that have tubes in theirs can't swallow, that's why they can't clear their eustachian tubes. So they have a swallowing issue. That's why it keeps building up fluid.
Zac: Yeah, so wait, you're going to have to unpack that a little bit because this is - so if someone has you stationed to dysfunction, how does that relate to the swallow? So are you saying that -
Melissa: So, normally what happens? Right. So, swallowing and I am not a hundred percent, but like if the idea of the concept of the swallowing is what helps clear it. Like it helps the fluid run through.
So, the concept of like, if you can't swallow, so if your tongue's low, so swallowing for anyone who doesn't know, right. So, the tongue should be up, you should be able to swallow with minimal facial movement. The tongue should just go up, down, up very easily.
Zac: So, it kind of scoops it back. Is that how you're approaching a swallow, it's almost like a whip.
Melissa: but the idea is like, I drink, it's actually suction kind of back, right. It should have like a natural sliding back to you know, kind of in a way, something along those lines, but minimal movement of the face. So, the idea is like swallowing should not be exciting to see because you shouldn't see it, you know, something silly like that. And the truth is when that doesn't happen and you had to work multiple swallows, like this is where chewing and right. Bulbous preparation people that have multiple swallows always have a drink while they're eating because they need assistance when they have to swallow their food. When all that comes into play. Well, when they're little, if there was a true issue with the way they were swallowing, it doesn't clear everything.
So, they're more prone to getting infections, now the tubes are in, and then the tubes came out and we had to re-put them in, and I'm sure ENTs will come back and say, well, there's so much more to it. And absolutely, I am not giving it near all the justice it deserves.
I'm just saying, so when I'm going through and I'm looking at somebody who's had tubes twice, they've had multiple ear infections. They have tonsils that are pretty enlarged, they have an elongated face, their teeth are crowded. I mean like how many things are, there's enough there to show like there's something bigger going on here and those are my things. My other thing is like if you had your - if your tonsils and adenoids were taken out when you were really young, I'm always like why, what created the tonsil and adenoid to be so large?
I just want to know why. I got something right. So is that maybe because they were breathing with their mouth a little bit more and the tonsils and adenoids are a secondary filtration system. It's a backup because they didn't nasal breathe as much as they were supposed to, so it kept the tonsils, adenoids constantly enlarge and created a lot of pressure in the back of the throat. So of course, we took them out and everything got better, but then we didn't address the fact that they really never learned how to breathe with their nose. We just took it away and now they just continue to mouth breathe. Now they don't even have any filter. I assume that they’re saying you have no filter in your mouth.
Zac: Interesting.
Melissa: But here I had tonsillitis like nine times.
Zac: Really?
Melissa: And I was like why? I asked my mom, why didn't you take them out? I don't think she wanted to tell me, but they probably did. I guess lucky for me, my mom didn’t make it to that appointment. I don't know but I, [inaudible] I remember one summer I was in bed for like six weeks. I remember like listening to all the kids play outside and I mean, I would get, and till this day, if I'm like traveling a lot and doing things, definitely the first thing that goes, my voice will dry and I'll get a sore throat.
I was always that kid. So, I did have those issues and I was grinding my teeth like there was no tomorrow, but I never had braces.
Zac: Wow.
Melissa: Because why? Because my tongue was plastered up there. I had to have a decent shape. Like it was right there, but I didn't grow forward because I was keeping everything like this, so it should be out. Right. But I'm usually like what my face looked like with am I going to be able to add here was the rest of my face back, I mean [inaudible] is what you think of, right? I'm like if I'm going to have that done, I was going to have like cheek implants, I’m going to have my eyes brought out, I don't know.
Sum up
Clenching, grinding, and biting can be an indicator of airway problems
Breastfeeding helps stimulate facial growth
Mouth breathing is either caused by tongue tie or nasal restrictions
Myofunctional therapy is physical therapy of the mouth
Addressing upper airway restrictions requires a team-based approach
Swallowing or lack thereof can negatively effect the eustachian tube.
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Bill Hartman - Daddy-O Pops himself. Originator of the hyoid position test.
Question: I've been enjoying the cervical extension test to help determine hyoid position. However, I had an issue last week where it didn't work.
This client had a military posture. We did this assessment, but as they opened the mouth, they got no additional cervical extension at all.
Usually, additional cervical extension is expected with military neck posture.
The result threw me off, however, the person did have zero IR of the shoulder and I'm wondering if that had any influence on the cervical extension test.
Thanks, Homie!
Answer: The hyoid position test was created by Daddy-O Pops himself, Bill Hartman, as a way to assess hyoid position, which is essentially the infrasternal angle equivalent in the cervical spine.
In noncompensatory mechanics, the hyoid should be able to depress and elevate without restriction. Functionally, the hyoid normally elevates with swallowing, which you do like a BAZILLION times a day. Loss of dynamics in this area could impact swallowing, neck motion, and a whole lot more.
The hyoid position test is a way to assess the concentric bias of either supra or infrahyoid musculature.
If you notice a restriction within cervical extension, opening your mouth can oftentimes lead to an increase in motion by eccentrically orienting these frontside muscles, which has to happen as I tip the head back.
So then what should happen in the case of a military head posture?
[caption id="attachment_13580" align="aligncenter" width="376"] Aka chin on chin on chin[/caption]
In this particular posture, the hyoid is elevated, which means that suprahyoid musculature is concentrically biased. You will also see lower cervical extension and upper cervical flexion.
Subsequentially, the infrahyoid musculature should be eccentrically biased.
In theory, when the mouth opens during this particular test, the upper cervical spine should tip further backward, enabling more range of motion.
But what happens when hyoid testing goes wrong?!?!
In the case that David mentions, we don't see this happen. Why is that?
I'M GLAD YOU ASKED!
If the infrahyoid musculature is eccentrically oriented, the sternum should theoretically be in an "up" orientation. Anterior thorax expansion ought to be available, thus shoulder extension, adduction, and internal rotation should be free.
However, David's tricky client doesn't present in this fashion. If there is a shoulder internal rotation loss, then the infrahyoid musculature will be concentrically oriented.
[caption id="attachment_13582" align="aligncenter" width="376"] Aka not a lot of motion going on[/caption]
So what my boi David has is a double concentric. With this situation, there is no position that the hyoid can eccentrically move into, thus, no change in motion. You'll likely either see restricted extension OR the thorax tilting posteriorly as the client extends, giving pseudo full extension.
What are you to do in this case?
The solution would be to create an eccentric orientation somewhere so you can induce some movement in the hyoid.
Following the filling the cup with water approach to airway dynamic restoration, you ought to start with getting the infrahyoid muscles to chill. This can be achieved by putting air into the front of that chest.
For a narrow infrasternal angle presentation, you may choose a quadruped activity, like the lazy bear.
https://youtu.be/WZtO_Gty2rU
For a wide infrasternal angle, you may reach about 110 degrees of shoulder flexion.
https://youtu.be/IEWg_sC8G2E
You then may have to drive manubrial expansion, which can be achieved with shoulder extension-based activities. Tricep extension exercises can work wonders here:
https://youtu.be/Xi3dfPp53OM
Okay, let's suppose that your anterior thorax is now dynamic AF, how in the heck do you get the suprahyoid musculature to chill?
This process is twofold.
At the cervical spine, we have to drive OA extension without inducing a forward head posture. The cranium moves, not the neck
[caption id="attachment_13584" align="alignnone" width="810"] We want the position on the right[/caption]
Simply cueing "undouble chin" during many moves can be helpful. You can kill two birds with one stone by choosing an activity where you are both driving air into the front of the chest and OA extension. A front plank can be a great choice:
https://youtu.be/xLN_bueVBv0
Now I've played with the hyoid position test and altering dynamics in that area, but I think measuring what the tongue is doing might provide more information.
I want you to consider this. When we are measuring things like the infrasternal angle, proxy measures for the infrapubic angle, and the hyoid, what are we really looking at?
The answer, folks, is how well we can manage the internal anatomy:
Viscera
The airway
This issue with proxy measures is that we are looking at a proxy. An estimate. The further removed we are from the actual thing we are measuring, the more prone we are to inaccuracy with testing.
In my experience, the hyoid orientation is often prone to this, as many can achieve full cervical extension in a variety of compensatory ways. You may get some false negatives.
What if we could directly measure the internal anatomy that the hyoid test is looking at? It turns out, folks, we can. How can we do that you might ask?
The answer: The tongue
Tongue range of motion, posture, and dynamics are the rate-limiting step when it comes to hyoid orientation. Simply put, the hyoid cannot be dynamic if you cannot manage tongue placement.
Here are the factors that go into tongue management:
Range of motion: Can you have roughly the same range of motion with a tongue tip open and a cave?
Here is what a "normal" amount of these measures looks like (I had a tongue tie release, so I cheated a bit):
[caption id="attachment_12201" align="aligncenter" width="500"] Great for catching flies[/caption]
Compare that with the limitations noted in this client:
[caption id="attachment_12202" align="aligncenter" width="500"] You can see here how with each position the available opening becomes less and less. There is likely a posterior tongue restriction with this person.[/caption]
2. Posture: Can the tongue be fully placed on the roof of the mouth, lips closed, face relaxed, and breathe through the nose?
If the tongue sits low, it will encroach on the back of the throat, decreasing the space in the pharyngeal wall. This position will restrict the airway dimensions.
And get this shit, fam. OA flexion will cause the mandible to protrude more, which aids in opening the airway. Consequently, movement options will be reduced. Here, we see a compensatory strategy to keep the airway open.
3. Dynamics: Do you possess all the movement options the tongue should be able to perform?
There are TONS of different positions the tongue can assume, all requisites to practicing swallowing without compensatory strategies.
If you want to learn all the positions you need to practice, you can peep that here.
Sum up
Military head posture involves lower cervical extension, upper cervical flexion, and concentric orientation of the suprahyoid musculature.
If shoulder internal rotation is lost, the infrahyoid musculature will also be concentrically oriented.
To restore movement options in this position, you must drive anterior thorax expansion, OA extension, and tongue position.
Montreal, Canada (POSTPONED DUE TO COVID-19) [6 CEUs approved for Athletic Therapists by CATA!]
Or check out this little teaser for Human Matrix home study. Best part is if you attend the live course you'll get this bad boy for free! (Release date not known yet :(
Here'sa signup for my newsletter to get nearly 5 hours and 50 pages of content, access to my free breathing and body mechanics course, a free acute:chronic workload calculator, basketball conditioning program, podcasts, and weekend learning goodies.
Bill Hartman - Daddy-O Pops himself. One of the biggest influences to my treatment model
Bill's model has simultaneously simplified and expanded the way I look at movement and most importantly provided principles that have helped me figure out areas within the model that were less clear for me.
Simply put, Bill helped me be less protocol-driven and more principle-driven.
For example, the elbow, wrist, and hand are still areas that the mechanics are a bit fuzzy and incomplete, yet thinking and studying this topic with his framework in mind have helped me develop a better understanding of what is biomechanically going on. To him, I'm grateful.
Myofunctional therapy has provided much of the biomechanical cleanup that I think was missing within my movement model.
We had all these great ways to improve movement capabilities below the neck, but once we got above C5...YIKES!
I think the missing piece here was appreciating just how influential tongue position can be.
Most of the movement stuff we discuss here focuses on managing viscera and airflow dynamics within the ventral cavity.
The tongue is the visceral equivalent in the upper airway.
Tongue = guts
Being able to place the tongue fully up onto the roof of the mouth can influence neck orientation, upper airways dynamics, and your ability to nasal breathe.
These pieces are important for a wide variety of reasons, but improving sleep might be the most important. Especially considering that sleep has a causal role in regards to pain. Exploring this path has led me down a personal rabbit hole of getting a tongue tie release, messing with palatal expansion, and a whole lot more.
It's also showed me just how much farther I need to go to help my supreme clientele become healthy human beings. It's one reason why I recommend my peeps get sleep studies quite often, something I'd never thought I'd be into.
What does my current treatment strategy look like
Basically, the name of the gave is to demonstrate movement competency and options across a wide variety of tasks. This involves breaking down tasks all the way to the basic constituents.
If we take a movement such as a vertical jump, demonstrating movement competency across a spectrum for this task might look like:
rowing machine (a conditioning option that explores the same range of motion)
In each of these examples, I'm demonstrating the biomechanics needed to complete the terminal task, which is a jump.
In order to jump, I need vertical displacement of the pelvis, which involves femoral external rotation and sacral counternuation. You get each of these with every listed move. Doing each action well helps you demonstrate the movement with power (jump), force production (front squat), dynamically (drunken turtle), statically (lewitt tilt), and for long periods of time (rower).
The above concept forms the basis of my programming. If I evaluate a client, I look at how many different ways I can push their movement options and design an according program. if someone needs to drive counternutation, I may opt to squat the snot out of them and abandon hinging for the time being. Whatever it takes to expand their movement options across a variety of intensities, which ought to help performance.
All that said, the above points are moot if your client has a stack that is whack.
https://youtu.be/7SQQeEuTPo0
A bulk of my process involves teaching clients this concept, as it provides the basis for exploring all of the aforementioned areas. In cases of pain, hammering this first is essential. Though since I've begun to work at Elevate, my more fit and active population has forced me to get fancier by re-incorporating shifting and such into the program.
Following that, demonstrating movement competency with plyometrics and the like has really been tripping my trigger for my peeps. This podcast has inspired me to push quite far in this domain, and is a reason why I've been programming many drop catches and such to keep intensity in my client's lives.
https://youtu.be/7TAEVNwgZ6E
By keeping some form of intensity occurring at all times, I've noticed smoother transitions back to full force as my clients rehab from given injuries.
Where will my treatment strategy evolve to next
The next however long will continue to focus on refining the biomechanics and finding better and simpler treatment strategies. Although I feel the movement model I subscribe to is dope as all hell, it's not perfect. It's incomplete. Moreover, I fall victim to making exercises WAY TOO COMPLICATED at times. If I can make this model ridiculously simple to execute, you and my supreme clientele will win.
Aside from refining, the areas I wish to dive into more are sleep medicine and pushing breathing physiology.
[caption id="attachment_13550" align="alignnone" width="810"] Sleep. It's a big deal, fam (photo credit - Image by PublicDomainPictures from Pixabay)[/caption]
Sleep is uber important. I've caught so many people in the last year who've had obstructive sleep apnea, and I think leaving these sleep disorders unchecked is hingering many of my client's wellbeing. I want to do all that I can to help them.
Lastly, learning more about expanding breathing physiology intrigues me quite a bit. Of course, my focus has majorly been on breathing biomechanics, but once you have the biomecahnics improved, where do you go next?
Just like once someone moves well you ought to expand work capacity, so to with breathing. Once someone "breathes well," we need to expand work capacity. That's where I'd like to learn more surrounding controlled pauses, resonant frequency breathing, and whatever else is out there.
Sum up
The major changes in my model involve Bill Hartman's model and myofunctional therapy
Movement competency must be demonstrated in as many different scenarios as possible
Simplifying the movement model, learning more about plyometrics, breathing physiology, and sleep are the next frontier.
How rotational athletes can fool you and your measures
Sports such as golf, baseball, tennis, and more involve TONS of rotation, yet are certain athletes better predisposed to rotate well based on ribcage structure? Can tests be thrown off because of particular sport adaptations?
We dive into these questions today. Here, you’ll learn:
Which infrasternal angle presentation has easier rotational capabilities
If ribcage structure predisposes someone to be “GREAT” at their craft
What shoulder external rotationreallymeans in this population
Be prepared, folks, to better help your supreme rotational clientele.
Checkout Movement Debrief Episode 146 below to learn more!
Montreal, Canada (POSTPONED DUE TO COVID-19) [6 CEUs approved for Athletic Therapists by CATA!]
Or check out this little teaser for Human Matrix home study. Best part is if you attend the live course you'll get this bad boy for free! (Release date not known yet :(
Here'sa signup for my newsletter to get nearly 5 hours and 50 pages of content, access to my free breathing and body mechanics course, a free acute:chronic workload calculator, basketball conditioning program, podcasts, and weekend learning goodies.
Bill Hartman - Daddy-O Pops himself. He is THE GUY for all things biomechanics
Authentic Movements - One of the best Yoga Teacher Training systems out there, and the one I choose to teach through.
Steph Gongora - An excellent yoga instructor and biomechanical BOSS.
Question: I have noticed that roughly 75-80% of my baseball players are narrow infrasternal angles (ISA). Do you feel this is representative of a normal population? I'm wondering if this is a case of selection bias where narrow ISA's, being more eccentrically oriented, have an easier time rotating, and therefore would be more likely to advance in a rotational sport like baseball or golf. Whereas a more concentrically oriented wide ISA may have a more difficult time and as a result would more bias towards sports requiring less rotation.
Answer: Terry, you are spot on in the differences between narrow and wide infrasternal angles and the subsequent ability to rotate within the lower thorax.
Leverage in the lower thorax is the name of the game, and the obliques are the major players (folks, don't hate the playa tho).
Your obliques are some of the largest rotators within the lower thorax. The better these puppies have leverage, the more your rotational chops will be on point.
Now the next question should be which obliques have more leverage with each respective infrasternal angle (ISA).
AND YOU KNOW I'M GLAD YOU ASKED, FAM!
According to this study, drawing a lot from Shirley Sahrmann concepts:
the internal oblique has more leverage with wide infrasternal angles.
The external obliquehas more leverage with narrow infrasternal angles.
Now, you need both obliques to perform rotation, so rotational function alone doesn't tell the whole story.
What does tell a larger portion of the story is the compressive action on the abdomen.
If you compare the attachment points of the external and internal obliques, the external oblique lies more superficial to the ribcage in comparison to the internal oblique.
[caption id="attachment_13522" align="aligncenter" width="399"] The big dog, external oblique itself! (Photo credit: Gray's Anatomy)[/caption]
External oblique proximal attachment: Outer surface of ribs 5-12
[caption id="attachment_13521" align="aligncenter" width="403"] The good ole' internal oblique (photo credit: Gray's Anatomy)[/caption]
Internal oblique proximal attachment: Deep layer of thoracolumbar fascia, iliac crest, ASIS (peep this anatomy textbook to learn more)
These anatomical differences allow the external oblique to generate greater compressive forces in the lower ribcage, contributing to the narrowness of the infrasternal angle.
When this muscle contracts, it assists in pushing the viscera downward. If we assume, based on compensatory mechanics, that the infrapubic angle is also in a narrow orientation (and likely structural), the pelvic floor will be eccentrically oriented. This position will allow the viscera to migrate downward, allowing for rotation to occur!
The simple reason why narrow ISAs can better rotate: The guts can get out of the way.
Contrast this to the wide ISA folks. The internal obliques have worse leverage to compress the ribcage and push the guts downward. Moreover, the wider infrapubic angle begets a concentric pelvic floor, which pushes the viscera upward. There simply becomes too much visceral interference in the ability to rotate.
Wide ISAs can't get guts out of the way.
Does this difference mean that there will never be elite wide ISAs in rotational sports?
FALSE!
In fact, many of the top golfers that I work with at Elevate have a wide ISA presentations. How in the hell does that happen?
Structural bias alone doesn't determine success in sport.
One thing to consider is the when looking at infrasternal angles, we have only concerned ourselves with rotation at the lower thorax.
HOWEVER, rotation occurs throughout the whole body.
In sports such as baseball and golf, you have to be able to rotate in the upper thorax, pelvis, axial skeleton, basically everywhere.
Each ISA presentation can have restrictions in the ability to rotate in these other areas, contributing to success or lack thereof in the ability to rotate.
Moreover, we cannot ignore the skill component needed in these sports. Again, many of our top golfers are hella stiff wide ISAs. It blows my mind how well these guys do at their craft. Some people are so skilled that they find a way to work within their body structure to achieve the desired output.
Lastly, considering the heavy narrow ISA bias within the population that Terry helps, I wonder what position many of his athletes play. Someone who has to move a lot within the game, such as an outfielder or shortstop, may be more biased to be narrow. Heavy hitters, first basemen, and catchers? Not so much, as playstyle changes for them, as wider ribcage have greater force production capabilities due to concentric bias within the pelvis.
[caption id="attachment_13520" align="alignnone" width="810"] Yeah, definitely not narrow, flaxseed oil aside (photo credit: Kevin Rushforth)[/caption]
None of the greats in the steroid era of baseball were narrow ISAs.
Pelvis movement during rotational sports
Question: What are the Ilial and sacral movements during rotational movements like a golf or baseball swing?
Single-extremity moves are essentially a cheat code to drive anteroposterior expansion, as these movements rotate the axial skeleton. Plus, they are WAYYY easier to coach than most shifting-based work.
Let's look at left rotation as an example.
You can see how if I turn to the left, I can drive expansion into the left posterior and right anterior aspect of the thorax. These rules also apply to the pelvis regarding expansion.
The above action happens when you reach with your right arm OR have your right leg forward ASSUMING that you can maintain the stack. Stacking sets the foundation for rotational actions to occur.
If you can't stack and you attempt to rotate, problems and a subsequent compensatory rotation could occur.
In the thorax, you may see the following compensations:
Crunching, which downs the pump handle and limits rotation
Anterior thorax migration, which restricts the posterior thorax
At the pelvis, you'll see an anterior pelvic tilt/orientation, which limits rotational capabilities in the pelvis.
What skills do each infrasternal angle excel at?
Question: What are some skills narrow infrasternal angles would be better at than wides and vice versa?
Answer: The infrasternal angle changes the relative contractile bias of the ventral cavity. This has to do with how the pelvic floor orientation that each type possesses.
Narrow ISA: eccentric bias
Wide ISA: concentric bias
Because of this, narrows generally have greater eccentric/flexibility capabilities in comparison to wides.
Also, because narrower ribcages have a larger surface area in relationship to the volume of abdominal contents, they are generally better at heat dissipation, which can help with endurance activities.
Wides, on the other hand, have a greater concentric bias, which is useful in terms of force production.
To summarize, here is what each could potentially be biased towards doing well with, with obvious exceptions to the rule (as there are many other influences to movement competency):
Question: Will there be a relative motion between the femurs and the whole pelvis or do we lock the hip joint as a whole and only work relatively within the pelvis? What actions would be happening?
Answer: Given that there is more relative motion available within the hip joint in comparison to the pelvis, the hips are most certainly going to move.
The movement that the hips perform depending on what direction my legs need to move.
For example, let's say I want to keep my femurs pointing straight forward in a golf swing. If we use the sequencing above in pelvic rotation portion of the debrief, you'd have the following motions occurring.
Suppose we are swinging right to left:
Backswing: Right hip external rotation, left hip internal rotation
Impact: Right hip begins to internally rotate, left hip begins to externally rotate
Follow-through: Right hip internally rotates, left hip externally rotates
Excessive shoulder external rotation?
Question: I work with 99% baseball players. You've talked about using shoulder external rotation at 90 degrees as a proxy for determining a need for expansion in the posterior lower thorax.
The majority of my guys are hypermobile in that measurement. However, I still believe there could still be potential restrictions in the lower posterior thorax. Is there another way to assess this? Additionally, is an increase in external rotation for a baseball player still indicative of a posteriorly oriented thorax? Again, thank you for your time and the work you have done!
Answer: As I have mentioned previously, shoulder external rotation can act as a proxy measure for the ability to expand the ribcage along T6-8 level.
In some individuals, the thorax can tilt/orient posteriorly as a unit to compensate for a loss of posterior expansion.
[caption id="attachment_12963" align="aligncenter" width="500"] Like this joker[/caption]
When the thorax orients posteriorly, the scapula will also externally rotate, retroverting the glenoid and subsequently the humerus. Due to this orientation, someone may be able to pick up shoulder external rotation beyond physiological normal (aka 90°). This change would actually coincide with the humeral retrotorsion often seen in baseball players. (If you want to check out a blog that goes into shoulder motion in baseball players, this one is awesome!).
So okay Zac. We know that a baseball player should have a LOT more external rotation available. How do we know if this is a structural issue that we should let chill or if the we need more posterior thorax dynamics.
Tons of humeral external rotation as I progress through the flexion arc (Yay for baseball players)
The scapula progressively upwardly rotates (yeesh!)
If I have a posteriorly orientated thorax, concentric bias of the posterior musculature is going to give the scapula a helluva time realizing full upward rotation. Thus, shoulder flexion will be limited in a posteriorly oriented thorax.
Some folks may have enough eccentric bias in the anteroinferior shoulder capsule to give the appearance of full shoulder flexion. You could check lower cervical rotation as well to ensure you are actually getting posterior thorax expansion, as cervical rotation can cross-reference the T2-4 expansion that is also needed in maximal shoulder flexion.
If you are limited in shoulder flexion, starting with cross-connect variations can drive expansion in the lower regions of the thorax.
Progress this to armbar activities, and NO ONE should mess with you.
Sum up
Narrow ISAs have better rotational leverage than wide ISAs due to ability to move the viscera.
Lower ribcage structure is only one component of rotational success. One must consider the ability to rotate in other areas of the body and sports skill.
The pelvis rotates through the swing as it does in gait: counternutation, nutating, then counternutation.
Single-arm and leg exercises can drive rotation, which acts as a cheat code to increase anteroposterior expansion in a given area.
Narrow ISAs are better at eccentric strategies; wide ISAs are better at concentric strategies.
The femurs rotate during the swing.
Posterior thorax orientation can give the appearance of humeral external rotation beyond 90 degrees. Shoulder flexion and lower cervical rotation can be used as a test in these individuals, as they are often limited.
Are pursuing better movement and better physiology mutually exclusive?
There appears to be a divide between performance and health.
Many argue that you cannot get bigger, stronger, faster, while still moving like boss.
Others fear pushing heavy weight, relegating their program to mostly ground-based breathing resets.
But does it have to be this way?
That’s the question that Michelle Boland, Tim Richardt, Francis Hoare, and I wrestle with, proving several examples of how this dichotomy is more often than not FALSE!
In this podcast, you’ll learn:
How Francis was able to put on 11 pounds in one year and have better range of motion throughout his body
The false dichotomy between performance and health
How to increase movement in those who already have lots of muscle mass, but seek to move better and have less pain
How the general population can increase fitness, muscle growth, and movement all at once
Getting a training effect to those who are in pain
Key Performance Indicators (KPIs) for moving well
Are basic resets necessary to maintain movement options?
How to balance expansive vs compressive activities
Pairing respiration with training
How to balance client's wants and needs
The big rocks to maximizing movement options
How to decide what your body composition should be
Ready to move better, get stronger, and become an absolute savage?
Look below to watch the interview, listen to the podcast, get the show notes, and read the modified transcripts.
Michelle is the owner of Michelle Boland Training which provides many services including, in-person 1:1 training sessions, coaching people remotely, writing training programs, and educational content for fellow trainers and fitness professionals who want to take complex training concepts and turn them into real outcomes for clients.
Michelle has a bachelor’s degree in Nutrition, a master’s degree in Strength and Conditioning, and a doctorate in Exercise Physiology. Michelle was previously a strength and conditioning coach at a Division 1 institution and Director of Education at a private training facility.
Tim Richardt is a Doctor of Physical Therapy, Strength and Conditioning Coach, and Owner of Richardt Performance and Rehabilitation located in Denver, CO. He specializes in the treatment and preparation of humans that like to run, lift, or play in the mountains. He currently offers personal training, physical therapy, and professional mentorship services.
He has helped hundreds of people of all ages and abilities improve their health, lives,l and athletic performance.
Hitting the path to your goals efficiently requires being specific. Francis excels at creating programs tailored to your needs and goals. If you need someone to hold you accountable with high energy, Francis is one of the best in our industry. His motivational tactics ensure you both get challenged and succeed.
When Francis is not coaching, he spends his time with his wife and two daughters, in the mountains or devouring a pint of Ben & Jerry's.
Peep the video below to see how my getting fat took away my squat:
https://www.youtube.com/watch?v=UEZZEWyBN78
The drunken turtle is a great move to improve backside expansion:
https://www.youtube.com/watch?v=yjmjUihXtrs
Lucy Hendricks - An excellent coach who does a great job of pushing physiology while improving movement options.
Bill Hartman - Daddy-O Pops, the godfather of many of the movement concepts we discuss.
Georgie Fear - My nutrition coach, and a master of behavior change
Modified Transcripts
A hypertrophy and movement case study
Zac Cupples: How can I get huge as all hell while still moving well? How can I preserve these two qualities?
That’s why I wanted to bring my boy Francis here. He is a very effective case study of how we were able to do merge these two goals. Here’s his story:
Francis Hoare: The last six years, five or six years or so, been doing a lot of running, 35, 40 miles mostly, mostly trail running. I competed in Spartan races, couple 24-hour races in there as well just for fun. I would spend quite a bit of my vacation time, go into places like Yosemite or Glacier National Park and either getting a cabin and going into the parks and doing a lot of hiking and running or backpacking.
Because of my exercise choices, I had a fair bit of strength, but more biased toward rock climbing, American Ninja Warrior type stuff, a few lifting sessions per week, and about 8-10 hours of running each week.
The issue was this style of training led to my like calves constantly hurting, hips constantly hurting, stuff like that. I was getting burnt out from the running.
I decided to take a break, then quarantine it. It was the perfect time to put on some weight!
I just met Dr. Zac and instantly, the stuff that he was talking about just captivated me. This stuff was hard. It would torture you, yet at the same time I’d feel good afterwards. I had a pump and felt more mobile.
That’s where it started.
Zac: We spent the first couple blocks testing you and trying a few different interventions just to see what would work. And then-
Francis: There was a lot of learn by doing. Because we weren’t working with clients during the quarantine, I was able to wrap my head around all this stuff that Zac was talking about. It helped me troubleshoot what areas to improve movement-wise.
If there were times where Zac was giving me some high-level stuff, and it just wasn't connecting with me, so we could pull the ropes back and build from the ground up. It was super beneficial as a strength coach.
Once our gym, our facility was able to open up, I had a whole new set of tools to work with my members with.
Zac: After you built that foundation, you took the concepts and ran with it for yourself. With more of a hypertrophy-focus.
Francis: This all started in April. So, I did not rush this process at all, which, which helped me immensely. I knew I wanted to put on weight but didn’t have a specific number. I just wanted to feel better and move better.
My first girl was learning the basics movement-wise; starting with squatting, tucking, etc. I paired all that with eating more. I was keeping things in the 8-12 rep range, and that’s how the process started.
Zac: Yeah. And so, I'd say, correct me if I'm wrong, we probably spent a couple months building the movement foundation, and then you just kind of made it more hypertrophy volumes and and intensities for the last four or five months.
Francis: No, I think I'm about eight weeks in to, you know, what on paper would look more like a hypertrophy phase, I was able to put on some weight again, just by hitting reps of 8 to 12 and doing new stuff and not running.
Zac: Always good. Always good to know.
Francis: Late October we really buckled down. Holidays are coming out and I'm going to eat a lot. So, let me take that guilt away from eating a lot by going into an official hypertrophy phase and yeah, all we did was we picked up the movements that we liked, assess how progress was going, and kept it simple over a 4–5-week span.
I kept the load down and switched to what I call the 2020 workout—two seconds on the eccentric, two seconds on the concentric, no pausing in between, always staying under tension, never going all the way down or all the way up. You do that for 10 reps, obviously the time should work out to 40 seconds, doing four sets in a row with little rest. I’d do that for my big lift, then do 10 reps of three accessory moves with 30 second’s rest. Four more sets of that.
So, I'm doing only one movement at a time, knocking out all the sets, then I move on to the next movement. It takes about 30 minutes, which is perfect for my busy work and life schedule.
Zac: How much weight have you put on over the year?
Francis: 11 pounds so, from 152 to 163.
Zac: That’s a pretty good change in a year!
On my on my end, at least with the movement testing, we had some great changes movement-wise:
Hip flexion improved from (left/right) 110 bilaterally to 125/140.
Hip internal rotation improved from (left/right) 35/15 to 30/40. Which I’m cool with as it’s more symmetrical.
I think it was really cool to see because I think a lot of people see this false dichotomy between moving well and getting big. You can only gain muscle by using machines, back squatting, and deadlifting.
Yet Francis didn’t do a single back squat.
Francis: I haven’t squatted more than 100 pounds.
Zac: But you're doing things well. You're getting tension where you need to get tension. You were able to pack on size without losing movement.
In fact, across the board your table measures improved.
There may be a path where movement and performance diverge, but not for the overwhelming majority of us. Most of us aren’t the elite bodybuilder who is debating whether or not to start using gear.
Pursuing hypertrophy and better movement is absolutely doable for the general population.
How those with substantial muscle mass can improve movement options
Michelle Boland: Why I wanted to jump in this conversation is I want to talk about tearing down vs building up. How do you deal with less loading.
I struggle with this personally because of the deep held traditional beliefs and expectations of not only my role as a strength conditioning coach and the years I’ve spent training.
This started with a same as a Francis. Quarantine hit, and I had to think about what my training needed to look like. Evaluate the good and bad.
My body shape is closer to a female cross-country runner, I enjoy running, but I went big into the bilateral lifts. Consequently, I’ve probably kept 12-15 pounds of muscle mass on my frame, past the point of probably where my body wants to be. I shifted to running a bit more and working out from home during the quarantine.
Because I didn’t track too much, I dropped about 11-12 pounds pretty quickly, and probably all that was muscle mass. This led to feeling some fear of switching my training, but I recognized some mistakes that I've made.
My question involves those who have a lot of muscle mass and are currently dealing with aches and pains. If you look at the long game, this may lead to major issues like joint replacements in the future. It’s a difficult perspective, but many leaders in the field have been ex-powerlifters who’ve had a shift in perspective. What are some strategies these people can employ? I’m sure some muscle mass will be lost in the process, but can they maintain some and move better?
Zac: What does it take to grow muscles? The big hypertrophy keys are volume and mechanical tension. That’s really it. Kudos to Ben House and Ryan L’Ecuyer for teaching me that.
Not once did these two mention back squat or bench press being essential. Hell, even most elite bodybuilders are doing machine-based work.
Volume and tension are the key, the modalities are likely irrelevant otherwise.
Michelle: Yeah, 100%.
Much of what we focus on is isolation exercise to alter position and shape change.
One thing I definitely missed was something that Francis stated before, and that’s tempos. I think that is a huge factor, especially with pairing movements, simply phases of movements with phases of respiration, the tempo, kind of prescription of exercises is, I think, something that would have maintained kind of gains in something that I'm trying to do now.
Francis: And I think stacking helps target the muscles you want better.
Squats for example. If you can shift to sandbags and still torch your quads and glutes without back tension, that’s a win.
Tim Richardt: Another thing that Francis mentioned with what you guys outlined earlier, which I thought was really interesting was just the skew towards higher rep ranges.
People talk about getting big, getting strong. 5x5 doesn’t quite produce as much of the volume and mechanical tension as the higher rep ranges do.
Going after 10, 15, 20 rep maxes lets you maintain movement quality, maintain the stack, and get a lot more of a training stimulus with a lot less of those deleterious secondary consequences that we're trying to step around.
Zac: If you don’t consider body position, then your only option to create tension is heavy loads.
When I was in Costa Rica, I was teaching some bigger dudes the way I coach squatting. Admittedly, I wasn’t coaching the squat as well as I am now. I was overtucking and flexing, which led to some trepidation with them.
Regardless, with very little weight, their quads were absolutely destroyed. The only other way that sensation could be recreated is through heavy weight.
Conversely, we just don't have data to support it one way or another aside from anecdotes. Is the only reason that you got this tension is because it's a novel position that you're not normally in? Or is it we're actually targeting the quads more? That’s just something I don't know or have an answer to.
What I have seen is those who do a lot of hinge-based work (I consider a back squat along this line) lose movement options. I think to preserve health of the tissues and joints, probably worthwhile to throw in at least some type of stuff that contrasts that.
Francis: Depending on the person, I don't think you need to go all one way.
If buy-in is limited, then give them a couple breathing resets at the beginning, for their warm up, give them one or two movements to do throughout their set. And take it from there, especially if there's someone who refuses to give up something like deadlifting or back squatting. Try to offset that with their accessory work.
Michelle: I think the best thing you can do is every coach needs a coach.
My current coach is Eric Huddleston. He’s done a great job putting programs together that feed into what I want to be doing and will do.
I told him I'm not going to lie on the ground and do resets. Some clients will be that way. ]
But he does an amazing, amazing job at creating exercises that just build those concepts in; using tempos paired with phases of respiration; almost like an active reset. With this, I’ve noticed muscles gains and better movement quality. And he only programs about six exercises per session.
The false dichotomy between performance and health
Tim: I just want to circle back to something Zac mentioned a couple minutes ago, we have two somewhat incomplete truths.
On one hand, we have that being strong is absolutely badass and having some muscle and the ability to produce power is kind of the sign of a healthy human right? It's the strength training is good paradigm.
And then there's a lot of people that just say, you know, strength training tightens up joints and muscles, and it leads to an achy, stiff human. And neither of those two statements is completely true nor completely false.
It reminds of the interplay between bulking and cutting. For 99.99% of people, it’s probably not a thing. Most individuals tend to be so detrained that they don't need to worry about a specific bulking protocol or cutting protocol. You can do both with intelligent eating and intelligent training. And I think what you guys have outlined is sort of the intelligent eating, intelligent training approach to improving movement options and improving like muscle bulk strength power output concurrently, which is cool.
Zac: Even this conversation to some degree is more focused on how coaches can get themselves as jacked as possible. For most of our clients, we are lucky to get them in the gym three times per week!
Francis: You definitely have those less dedicated, but I also have people I've trained for years that I’m excited to implement some of this stuff.
After the quarantine ended and our gym opened up, we started focusing on stacking; spending a few phases getting good at that. We built our initial phases on that, then were able to focus on more specific qualities.
It's not necessarily the what? But the how? And why? And that's where you can get really deep in all this stuff.
Tim: And Zac, I might respectfully disagree with the point that you made a couple minutes ago.
I think that the people that come to see, you, Francis, Michelle, myself, they tend to be people that are either bad at exercise or just really beat up.
If we take those people that have a limited movement option repertoire, and a lot of things are going to hurt, if we can get them a training effect while furthering their movement options, then they don't feel like they're bad at exercise anymore.
As opposed to the typical gym where someone might be back squatting on the first day of their program, potentially experiencing pain associated with that. That’s not going to retain clients very effectively. So, I think this stuff really becomes paramount to ensuring a long-term positive client experience.
Zac: I would agree with you.
Back squats and similar moves have a much higher technical demand than say a goblet squat or a sandbag squat.
Francis: You can hand someone a 50-pound sandbag on a ramp, and torch them. It makes your coaching job that much easier.
Key performance indicators for better movement
Tim: I think one big problem in our industry is not defining terms especially well, this is something that Doug Kechijian talks about all the time where we say things like we want to move well, we don't want to lose motion, but we don't really have a clear idea of what that means.
Zac, Francis, what were some of the Key Performance Indicators (KPIs) that you tracked every few weeks as Francis was putting on muscle? And how would you recommend people approach that?
Zac: Francis is so lucky because I can table test him on a fairly regular basis.
The issue with Francis is many of the standing measures I normally recommend he was pretty good it. His toe touch and squat were full. But if you are limited in those moves, you can always pursue getting them better. They can also be a good gauge on if you are going in a good direction or not.
Personally, if I get too fat, I lose my ability to squat and I got a really good video of that happening to me.
In the video, I was 200 pounds. Fat as shit. It was a Herculean effort to squat below parallel, I just couldn't do it.
But now that I'm leaner, I can squat fairly easily.
The key KPI is you need to find stuff that you're limited in, and then just recheck that periodically to make sure that you still have that. That could be an Apley’s Scratch test where you check shoulder internal and external rotation.
If you get bigger and lose motion, that doesn’t mean you need to stop pursuing hypertrophy. You just need to change something to restore some of that motion. It could be getting on the ground and doing a reset. Maybe it’s re-evaluating your exercise selection.
It’s not a matter of maintaining certain movements at all times, but can you get into positions that you should be able to.
For Francis in particular, we looked at hip and shoulder range of motion predominately.
Francis: Trunk rotation was another thing we tracked. But I also didn’t have the toe touch down pat.
Zac: You didn't?
Francis: No, not at first. But an exercise like drunken turtle cleaned most things up fast. It’s easy as a coach to check range of motion, but don't be afraid to use your Coach's Eye too. It can be sometimes hard to describe or put KPIs to good movement, but you also kind of know when you see it. I think this better translates to stuff clients care about as well.
Zac: Another example, Lucy Hendricks, she went through a phase where her clients were deadlifting a lot, and subsequently lost their ability to perform a loaded squat well. You could use that as a KPI for your clients.
Basically, you have to find a movement that is on the cusp of your capabilities, and then you would just continue to recheck that.
Tim, in your case, I think a toe touch is a really good move, because you are right on the edge of being able to get that. if you started severely losing that those gains, we might look at making small tweaks to your program to get that better.
Pairing resets with heavy lifting
Tim: Is there still a time in place for load it up, and then we'll reset it before you leave?
Zac: For me, resets are basically regressed versions of positions that you are trying to get into.
For example, Michelle is a good mover and well versed in the knowledge realm. She may be able to attain the positions she needs with loaded exercises.
If you can stack and achieve a full squat position under load, I don't see a need to drill down to something less than that. Because you can attain the position that you need.
But with the people we work with, they don't have that movement capability. So, we have to choose an activity that has more constraints to it, or get them on their back more, because they don't know how to get their bodies in the positions they need to.
Francis: We do work with athletes too and sometimes they come to us on a much shorter timeline than we would want. We understand they have to perform. We can’t put our vision ahead of them for that if they are close to in-season. Sometimes the priority is pain freedom. If we can get them out of pain, that can increase buy-in and allow us to do what we need them to do.
For me, I didn’t deadlift for three months. If you had asked me a year ago, what was my best lift? It would have been deadlift. Me stopping deadlifting was trusting my coach.
We have to ask where does this person want to go? How quickly? What kind of trust can you build with them and take it from there. There's not necessarily a broad stroke answer there. It definitely needs to be individualized.
Zac: it doesn't mean that a deadlift, back squat, and bench press are bad exercises. In fact, they’re quite good if you are chasing force production.
I’m currently working with an optometrist and in their field, they look at convergence and divergence. Convergence is really focusing in on a specific point, and then divergence would be looking further out. And it was interesting because she was talking about that, I saw a parallel in the movement realm.
She noticed that people who are really good at converging have a tendency to sit with their knees together and be more perched and upright, which is, you know, extension, internal rotation, force production-based qualities.
People who are better at diverging, looking further out and seeing large amount of space, sit more chill. Divergence is more expansion and external rotation.
Vision drives many of our motor responses.
When she's prescribing exercises, you can totally work on convergence-based activities. But these moves can be overdone, creating a loss of divergence in the process.
I think the movement realm operates similarly. You can do back squat, and you can do deadlifts. And you can do these activities that drive more force production, more internal rotation, more compression, or whatever stuff you want to say.
But if that's all that you focus on, you can potentially lose the other side of that equation.
It doesn't seem to be the case where if you do a lot of stuff that is more expansion-based that you lose the ability to compress, because Francis can still deadlift a fair amount. We’re tweaking some of your techniques, though.
Programming improved movement options
Tim: Would it be fair to say that if the goal is maintaining or improving movement options, your initial bias and program is going to be towards more squatting and counternutated-types of activities?
Zac: Yeah.
The only time I won't do that is if a client is pursuing a sport or thoroughly enjoys a bias towards force production
For example, I have one guy right now who we're working through some shoulder pain with benching, but he wants to bench and back squat. Cool, you can keep doing that, I’ll just tweak everything around that.
Now if I have a situation where I have free rein with someone’s program, they don't deadlift for the first couple blocks. The reason being is that most people have movement restrictions. My frame of mind is to first improve movement options as much as possible so their movement menu is larger. It seems like starting with a focus on front-loaded squatting, unilateral work, and considering ribcage structure helps with that.
Tim: Branching off that topic. Something I’ve seen Michelle do a lot is pairing different phases of breathing with different phases of motion. Is that something that you've been utilizing with yourself and with clients recently?
Michelle: Yeah, absolutely. That's something I've definitely been doing with my clients and also doing on my own training. It’s made a dramatic impact in how I feel.
I think the key with implementing is marketing appropriate expectations and linking these activities towards the client’s goals and how it can benefit them.
Zac: Could you expand upon that, Michelle?
Michelle: It's not that we're doing it bad. We just have to indentify our ideal clientele, and make sure I provide a clear message on how I train and what people can expect from me. By doing that, the people who approach working with me have changed.
I think I just got better at talking to people about reaching their goals, while also including maybe some other factors with that.
Zac, I think you do probably one of the best jobs at that; talking to people who want performance gains but also addressing any nagging aches and pains. Being clear that training or lifting weights doesn't have to hurt. The mainstream fitness industry doesn’t seem to think that way.
Tim: I think, you know, I think it's really interesting because when I think when Zac and I first got into the field of physical therapy, what, six, seven years ago, there was still a pretty big bifurcation between strength coaches and therapists, there weren't a lot of therapists that were strength coaches or word trainers. I mean, one doesn't even come to mind.
It’s positive to see both of these fields merging together, and starting to view training and rehab as the same thing, just different points on the same exact continuum. We are less in silos. We don’t worry about waiting until table tests are perfect before training, yet we also don’t let people go back squat until their eyes bleed.
I think everybody has a much better appreciation of what loaded activities might do to a person's range of motion, as well as what ranges a person might need in order to do the activities they want.
Francis: We see a lot of people who had a coach or doctor say they can’t do an activity.
We rephrase that by saying we can help you get there. We may need to shelve it now and work on a few other things first, then go from there.
Seeing the look of relief of rewarding.
We are either here to help people enjoy their life better or perform better depending on what exactly they're after.
For us at elevate, it's all about physical freedom, and not telling people no, but telling them Yes.
Zac: if you can keep that end goal in mind and relate activities to that goal, then it's more likely that that person is going to be up to doing things that maybe aren't as sexy, like being on your back and doing breathing exercises, or not back squatting.
Francis: Or just training more. I f we get you out of pain, your likelihood of training more goes through the roof, and then your likelihood of success of success goes through the roof.
Zac: You can't hit volume and mechanical tension if you can't train.
Michelle: Yeah, that's, that's a difficult one. If people aren't coming to see me, you know, they're probably not training. So, getting in people in the gym for training sessions, multiple times a week can be a big challenge with a lot of general population clients.
I'll just talk about myself. if I go to a physical therapist, I have a certain expectation of what that session is going to be like, versus coming to see your strength conditioning coach, I personally get a lot of people who really hard workouts. There are different expectations in those realms.
Zac: Francis does a really good job with classes and custom training of marrying those two things where you can give someone a really good training effect, while still helping them favorably movement-wise.
Francis: Yeah, just if you communicate with them and check to make sure they're feeling the right things, you can make all this stuff incredibly taxing and difficult in the moment for sure.
They might scoff at you because they’re moving less weight than what they’re used to, but wait to see how they feel with it.
Conversely, if they come in and they're strong. Don't be so set in your ways that you don’t give them heavier weight. But that’s always our job’s challenge; getting people to do the right things but be happy with what they're doing.
You just have to be on top of it and have conversations with your clients. Explain the “why.”
Though it can be hard in classes or small group sessions. The harder it can be explaining what’s going on. If it's someone new, you might have to give him a call or text after the session.
Finishers and conditioning sets at the end are always a good way to get them. A couple minutes on the assault bike does wonders.
Michelle: I think that's a huge point. Clients remember what you sent them home with.
Francis: It helps them walk out of your session with them feeling like they achieved something.
Tim: It seems like the programming keys then include:
Squats
Unilateral activities
Alternating activities
Slower tempos
The stack
Are there any other major keys?
Zac: Ideally, with all of the tenants that Tim outlined so eloquently, you should be doing some type of breathing during specific components.
Generally, that’ll involve inhaling during the eccentric, and exhaling during the concentric. But you have to look at what you are specifically trying to make eccentric? What are you trying to make concentric?
Suppose I’m doing a lat pulldown. Generally, we would exhale on the pull and inhale on the way up. Well, what if my predominant limitation is actually expansion on the opposite side? Well, I could totally inhale as I pull down to open that up.
But for the overwhelming majority of people, that could be a little bit too into the weeds. I probably program that more with coaches than general population. For them, it’s stack, full breath excursions during iso holds, then inhale on the eccentric, exhale on the concentric.
But, Michelle, I'd be curious to hear how you're incorporating phases of respiration into some of the training stuff that that you're talking about?
Michelle: You hit it on the head. I'm just making sure that people are going through phases of respiration that mimic their phases of movement. So, it's the eccentric concept that you just mentioned, and then have been messing around with a lot of inhaling the top position, holding my breath down, exhaling up, just kind of getting more into that and getting my clients used to it. So, adding more and more as I go and progressing with that stuff over time.
Zac: How about yourself, Tim?
Tim: I think that's a really interesting idea, Michelle. I so I guess the notion there would be that you're trying to create a bunch of expansion before you go into the range of motion that you're trying to load?
Michelle: Yeah, I'll have to give my coach Eric credit for that. We do a lot of oscillating isometrics—dropping an object and going to the bottom catching it. And a lot of is inhaling on the top, holding my breath down, and then exhaling up and pausing at the bottom. So, I think it's finishing that yielding strategy. So, I'll definitely give him credit for introducing me to that.
Tim: With my own training, I focus on getting full respiratory excursion through a range of motion. It seems most folks are just bracing and then like getting a little bit of airflow in whatever area we tend to be more hyper mobile at.
So, slowing things down, which again, that tempo helps with and actually. Also focusing on global ribcage expansion with whatever you are doing.
Zac: I think another thing that's vastly underutilized if you need to get extra volume, is machines and blood flow restriction training. Both are awesome ways to incorporate volume, especially if you get someone who has a low movement menu to choose from. This is especially true if you have someone post-op or morbidly obese.
So, Tim, how are we going to get you huge?
Tim: I think personally the passion lies in moving very quickly up mountains. So probably we're looking to keep me tiny yet powerful so that I can charge you up some tall stuff and hopefully not perish.
Zac: That's reasonable. Well, that makes sense since you said that my 13,000-foot climb was nothing!
Tim: And not to talk shit on your 13,000-foot climb. I think it's so complex man.
Zac: Yeah, you totally talk shit. That's fine. Ask Francis, I’m probably one of the biggest shit talkers out there.
Tim: Selfishly, I'm just trying to get you out to Colorado.
Deciding on body composition goals
Zac: When do you decide that you need to get bigger and when do you decide that you need to get leaner?
I talked with my nutrition coach Georgie Fear. If you're not following her, you should, she's really intelligent.
We got myself to a point where I'm fairly lean. And it's like, where do I go from here? And she had a really good point of does your body do all the things that you want it to do?
Tim, in your case, if you're trying to climb mountains, do you need to put on more or less muscle mass to be able to do that and then just let the ascetics do what they need to do? I'd be curious to hear everyone's thoughts.
Francis: If I go back to running, I’ll wonder how I’ll feel about things body-wise.
Michelle: Aesthetics really isn't my goal. It's more of how I feel and how I perform. I think it's just kind of what you're used to. You get used to certain body image looking at yourself.
Since my frame is small, missing 11 pounds is a very noticeable difference. But I think that was because of my reduced fitness that happened over quarantine.
I needed to get back on a training regimen. Surprisingly, I was still capable of moving a lot of weight. I think I just needed to build consistency. My bodyweight is back down to undergrad size, but I’m still capable of moving weight. But now, I can recover a lot faster compared to when I prioritized the barbell.
Sum up
Performance and health can be pursued simultaneously if you use volume, tension, and good exercise selection
Intensity can help muscle-bound folks move better
Pursue many expansive-based exercises to offset compressive-based exercises
Emphasize stacking, single arms reaches, and more to preserve movement.
Montreal, Canada (POSTPONED DUE TO COVID-19) [6 CEUs approved for Athletic Therapists by CATA!]
Or check out this little teaser for Human Matrix home study. Best part is if you attend the live course you'll get this bad boy for free!
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Question: If shoulder extension and horizontal abduction are both limited, which do you chase first? We could probably also add internal rotation in there.
Answer: Picture this, you have someone with measure XYZ limited on the right side, then ABC is limited on the other, where to start, fam?
If you've been following this site for a hot minute, you probably have the belief that humeral measures are used to approximate movement restrictions within the thorax. Put another way, airflow is going to be reduced in a given area based on particular shoulder measures.
Therefore, increasing shoulder mobility depends on where you have to put air and in what order you need to perform this.
When you are looking to improve shoulder measures, there are a few different principles that I operate by to enhance decision-making.
The lungs fill bottom-up
If you have a glass and you fill it with water, how does the water fill the cup?
[caption id="attachment_13466" align="aligncenter" width="500"] Preferably Topo Chico or Sedona Mineral Water[/caption]
The bottom-most parts of the cup fill first, then eventually it fills to the brim. You can't fill the middle of the cup, then a little bit at the bottom, and a little bit at the top.
Your lungs are like that cup of water (that's some philosophical sounding shit right?). When you take a breath of air in (assuming you are upright), the bottom parts of the lungs fill first, working up to the apex.
And just like that cup of water, you can't expect to put a bit of air in the top, a smidge down low, etc.
You gotta fill those lungs bottom-up
Restriction in the thorax will generally lead to greater lung fill in the bottom portion of the lungs, with restricted ability to fill higher areas. Because the intercostals cannot expand the ribs, accessory breathing muscles will lift the ribcage as a unit, increasing bottom fill.
We want to restore the ribcage's ability to expand in all directions. In order to make that happen, we have to restore this bottom-up fill that the lungs perform.
In order to know how to "fill" the thorax bottom-up, we have to understand how different shoulder measures can let us know where airflow is restricted.
The first heuristic that we operate from is breaking down how specific measures are related to thorax restrictions:
Flexion, abduction, and external rotation restrictions indicate decreased posterior expansion
Extension, adduction, and internal rotation restrictions indicate decreased anterior expansion
The reason why these measures are related is because of how scapular position changes when the thorax cannot fill adequately.
For example, if the anterior thorax cannot fill adequately, the shoulder blades will round forward, which leads to the humerus externally rotating to bring the arm back to center, causing an internal rotation loss.
Flip this for posterior restrictions, you'll see a flatter upper back, which pulls the shoulders back, which leads the humeri to internally rotate back to center, causing an external rotation loss.
You can have a mix of in-between pending what thorax levels are restricted, hence the wide variety of postures people assume.
But how can you tell where the restrictions lie?
I'M GLAD YOU ASKED!
Each humeral measure corresponds to a different level of the thorax. It has to do with the fiber direction of tissue excursions you are testing and their location relative to spinal level. For example, the horizontal fibers of subscapularis run from around T2-4.
Let's look at each of these measures and where they relate to on this fancy table. Only the finest for the fam!
Entire posterior thorax with a slight bias towards T2-4
Shoulder External Rotation
Oblique fibers of subscapularis
Posterior thorax at T6-8
Shoulder Horizontal Abduction
Transverse fibers of subscapularis
Posterior thorax at T2-4
Shoulder Extension
All anterior thorax tissues
Entire anterior thorax with a slight bias towards manubrium
Shoulder Internal Rotation
Oblique fibers of posterior cuff
Anterior thorax at sternal body (T6-8)
Shoulder Horizontal Adduction
Transverse fibers of posterior cuff
Anterior thorax at manubrium (T2-4)
Or if you are more the graphic kind of person, peep this:
[caption id="attachment_12233" align="alignnone" width="810"] With flexion and extension being general proxies for posterior and anterior expansion, respectively.[/caption]
So for example, if someone has a loss of internal rotation and horizontal abduction, internal rotation would be the first priority because it's a lower level on the thorax. of course, assuming you can stack, as that's what fills up the thorax period.
Exercise options to improve thoracic expansion
Now that we know how to assess each level of the thorax, let's look at some general ways of improving these measures.
Before getting uber specific with each measure, the first priority is to coach the stack. The stack helps create the necessary piston effect between the thoracic and pelvic diaphragm to allow for the ribcage to expand in all directions.
[caption id="attachment_12618" align="aligncenter" width="195"] And it's necessary for talking to me[/caption]
If you lack the ability to stack (#bars), then there will be increased accessory muscle tone, the lower portions of the lung will receive the most fill, and you won't have a whole lotta movement in your arms.
Now let's suppose that you stacked (even though trust me, you probably didn't), let's look at some strategies for improving humeral measures:
Shoulder external rotation: Reaching between 0°-60° shoulder flexion
https://youtu.be/pWKeFumljTY
Shoulder internal rotation: Reaching between 60°-120° shoulder flexion
https://youtu.be/WZtO_Gty2rU
Shoulder horizontal abduction: Drive thorax rotation while keeping the head forward, or drive active humeral external rotation. Driving cervical rotation
Shoulder flexion: Progressively go overhead, but restore external rotation and horizontal abduction first. You can also utilize rotation to make this happen
https://youtu.be/rD1Ejw5KKMs
Shoulder extension: Reach forward, then drive humeral extension
https://youtu.be/-kVMyKi4aoc
If you are in doubt, you can always drive rotation, which is an excellent way to drive anteroposterior expansion. You can also use inversion to get uppermost thorax expansion, as the lungs will fill top down in this case.
Now that we have an idea of what each measure means and what to do about it, how do I prioritize these restrictions based on the bottoms-up approach?
Simple (though not easy), you address the lowest most restrictions first, then work your way up:
Montreal, Canada (POSTPONED DUE TO COVID-19) [6 CEUs approved for Athletic Therapists by CATA!]
Or check out this little teaser for Human Matrix home study. Best part is if you attend the live course you'll get this bad boy for free! (Release date not known yet :(
Here'sa signup for my newsletter to get nearly 5 hours and 50 pages of content, access to my free breathing and body mechanics course, a free acute:chronic workload calculator, basketball conditioning program, podcasts, and weekend learning goodies.
Hypermobility
Question: How do you go about assessing and treating someone that has joint laxity and hypermobility; particularly if they don’t seem to have any limitations.
Answer: Hypermobility can mean a wide variety of things to people, but let’s break this concept down to the nitty-gritty.
There are established physiological normative values for what ranges of motion our joints should be able to express (e.g. the shoulder should have 90 degrees of external rotation, the knee should have around 5 degrees of hyperextension, etc).
Range of motion beyond the established norms would be considered hypermobile.
Just as range below the established norms would be considered hypomobile.
Based on this definition, there can be a wide variety of individuals who possess hypermobility. Here are a few examples:
A baseball pitcher with 120 degrees of shoulder external rotation
[caption id="attachment_13433" align="alignnone" width="810"] Elbow hyperextension in a patient with Ehlers Danlos[/caption]
On one end, the baseball pitcher may have hypermobility in only one specific direction. On the other end, one with Ehlers Danlos has a systemic hypermobility disorder affecting multiple joints (though not necessarily all).
Although these individuals are on different ends of the spectrum, they both have similar biomechanics occurring that are creating this situation.
That is:
eccentric orientation on one or multiple parts of the joint
[caption id="attachment_13434" align="alignnone" width="810"] Increased space between the joint surface can place stretch on tissues, causes eccentric orientation and increased motion[/caption]
The key components of this orientation manifesting are:
Joint space in a given area increases
Fluid position presses up against the tissues
ALL relevant tissues (muscles, synovium, connective tissues, ligaments, etc) increase tissue viscosity and reduce stiffness, increasing eccentric orientation and subsequent available motion.
To some extent, this process is NORMAL. The tissues in your body contain viscoelastic properties that allow them to be either stiffer (elastic, think fast folks) or less stiff (more viscous, aka flexible). Tissues have to be able to express both sides of this equation in order for movement to occur.
Hypermobility occurs when there is a loss of this process. Where the tissues develop a larger bias towards viscosity or have difficulty producing stiffness.
Now, most peeps hear hypermobility and think this is a bad thing. Hell, some people even say this is pathological.
OMG I'M PATHO AF, I BETTER JUST CALL IT QUITS
FALSE!!!!!!!!!!!!!
The problem is that there isn't really any research stating that those who are hypermobile (except diagnosed hypermobility disorders, NOT you have a bit more hip external rotation than normal, please reread that again) are more inclined to experience pain or injury compared to those without. In fact, being able to lock out joints may have some benefits:
Locking out joints allows for energy conservation between reps of an activity
Locking out joints can enhance needed stability in certain phases of activity (think gait, those who lack full knee extension have worse balance compared to those with full extension)
That said, having excessive motion could potentially increase injury risk when looked at from a movement variability standpoint. People who have too many movement options cannot move joint fluids as efficiently, thus having more difficulty recovering from perturbations.
That doesn't mean hypermobile folks are in a worse situation than stiff folks, they just may be more predisposed to other injury mechanisms. The latter population may hurt themselves from overloading specific areas due to the inability to offload structures. Each extreme can be problematic.
The solution, regardless of presentation, is as follows:
Restore all viscoelastic capabilities and contractile options
Thus, we want to first assess for any deficits, restore those deficits, then teach these individuals to generate tension.
The hard part though, fam, is that hypermobile folks may look like they move super well passively on the table. In fact, a large portion of people will lower extremity injuries have increased movement variability.
AKA YOUR APPENDICULAR MEASURES CANNOT BE TRUSTED
However, there is one area that is not predisposed to having excessive movement variability: The axial skeleton.
Thus, when testing these folks, you'll want to do the following to ensure reliable testing:
Use axial skeleton measures (Infrasternal angle, spinal rotation, etc)
Use loaded/dynamic measures, as they may rely more on compensatory strategies when challenged
Watch for compensations by monitoring joint motion during testing
Appreciate end-feel, some may be actually missing the last bit of range of motion
Note any symptoms of pain, pinching, etc, and call those points the limitation
If you pay attention, you'll still find that these peeps present with movement limitations that need to be addressed first. many times, restoring axial movement options can positively change sensations of excessive motion.
I've had many clients in my day who have had what appeared to be "joint laxity" upon testing, ranging from excessive motion or even feeling aggressive/excessive joint glides as I moved them through range, that magically went away once they restored axial movement. If that's the case, was there really joint laxity to begin with? Or was it merely a position, viscoelastic, and nervous system-influenced problem?
Once you've restored those movement options that were limited, you then want to focus on tasks that increase tissue stiffness.
Surprisingly, these tactics are well researched, and can be improved via the following mechanisms:
Breathing while you sleep….it’s kind of a big deal.
So much so that things like a CPAP exist to save lives, open the airway, and get your body the oxygen it needs to survive.
But is this the best option? What happens if you have a septal deviation? Are there any measures we can take to improve airway patency while we sleep, and even train!?
To better understand what our options are, we have to look at what a CPAP actually does, and we need to have our bodies be able to do in its place if it’s something we want to cease using.
So too with nasal breathing. What are the components needed to breathe effectively through our noses?
You’ll get to find all this out today in this debrief.
Checkout Movement Debrief Episode 144 to learn more!
Montreal, Canada (POSTPONED DUE TO COVID-19) [6 CEUs approved for Athletic Therapists by CATA!]
Or check out this little teaser for Human Matrix home study. Best part is if you attend the live course you'll get this bad boy for free! (Release date not known yet :(
Here'sa signup for my newsletter to get nearly 5 hours and 50 pages of content, access to my free breathing and body mechanics course, a free acute:chronic workload calculator, basketball conditioning program, podcasts, and weekend learning goodies.
Question:My question for you has to do with the CPAP machine and why it could be bad? I know it's a steady flow of air that can affect the pressure in the ribcage, but can you explain this further?
Would an APAP machine that does not have a constant flow of air be better? Or are there still risks?
Answer: CPAP and APAP are devices that alter the pressure of the air you breathe in, which helps prevent the airway from collapsing while you sleep.
Normally, we breathe through negative pressure. This means that as we breathe in, the diaphragm pulls downward, which creates a force that makes the airway and surrounding structures want to collapse inward. Fortunately, air getting pulled in the lungs helps maintain the shape, and life is good.
But what happens if this negative pressure is so great that the airway collapses too far and you do not get adequate airflow? Well, now you aren't getting enough oxygen, which causes major problems. Like uh....death.
A way to "fix" this is through positive airway pressure, which essentially has the reverse effect of negative pressure—creating expansion.
Now I have a situation where I still create negative pressure from the diaphragm, but I change the pressurization of air coming into my body in a manner that allows the airway to fill. Life is good.
There are three categories of devices you could go with to utilize this mechanism:
Continuous (CPAP): Blows a constant stream of air in under a single set of pressure
Automatic (APAP): Samples your breathing and determines what pressure you need to be at
Bi-level (BiPAP): The pressure changes depending on the breath cycle.
These devices are essential and life-saving for someone who has sleep apnea. This is especially true for central sleep apnea, where the brain causes the apneic events to occur. These devices can also mitigate many of the symptoms felt from sleep deprivation. So if you are someone with apnea, you most likely want to get one of these devices ASAP.
In terms of which device you choose, the BiPAP will most likely make a full respiratory cycle occur more easily, but it's also more expensive. Your best bet is to coordinate with your sleep doc.
Now before you read onward, let me be clear:
PSA - Do not perform the following recommendations without consulting a physician first. This is not medical advice and is for entertainment purposes only.
There are a few issues with using these devices as a treatment:
Compliance is SUPER low. 50% of users after 1 year will stop.
Several side effects can happen such as dry throat, difficulty falling asleep, etc.
The device may not be fixing the problem if sleep apnea is obstructive and not central.
What I mean by point number 3 is that the problem of sleep apnea has to do with the airway collapsing at some location. The machine does not fix the structural collapse but creates an artificial breathing environment; acting like a stent for your airway.
You could still have many of the following issues:
Restricted nasal airway
Low resting tongue posture, whcih collapses the pharyngeal wall during sleep
Low soft palate posture
restricted airway size
Limited cervical dynamics
Limited thorax dynamics
All of these factors could limit your ability to breathe effectively during sleep and life. I think they need to be addressed to really "fix" the problem.
[caption id="attachment_13405" align="aligncenter" width="386"] Make that airway dynamic AF, fam![/caption]
Consider if you cannot adequately breathe through your nose for whatever reason. You will not get nitric oxide production needed to dilate blood vessels, which has several cardioprotective effects by reducing blood pressure and such.
The key is to restore this mechanism.
How would you do that?
That I cannot answer, as each individual's needs will be unique. You need data, imaging, and a physical examination to make decisions.
Pursuing upper airway restoration involves working under a skilled physician (Dentist, sleep doctor, ENT).
Treatments could include the following:
Surgeries to impact airway at any level (maxillomandibular advancement, septoplasty or other nasal surgeries, surgical palate expansion, tongue-tie release, etc)
Oral appliance and airway orthodontics
Myofunctional therapy and physical therapy
Maximizing sleep environment
Eating foods that support a healthy sleep environment
Whatever you need, please consult a physician skilled in this domain, but I do think going this route is essential for improving upper airway dynamics, and subsequently sleep.
If you want to check out some of the stuff I've tried, you can see them below:
Question:When dealing with a client with a deviated septum, that is a constant mouth breather. What is the best route to take with them in order for them to improve their breathing during training? Would the tongue drill help? Are there other drills?
Answer: The best route to "fix" a deviated septum would be consulting a practitioner who specializes in the upper airway.
What will likely need to happen is some changes in mouth structure and position to improve the floor of the nose (aka roof of the mouth) and potentially a surgical procedure to correct the deviation pending the degree.
There are likely no conservative measures that can alter a septal deviation, this is a structural issue.
That said, many folks can still nasal breathe well despite this structural issue. In fact, I know someone right now who has an 80% blockage in one nostril who nasal breathes like a boss!
Just like you can have osteoarthritis without pain and a high level of function, so too can you have a structural problem in your nose but still breathe well.
The key is to have all the pieces in places needed to ensure a nasal breathing environment:
Palatal tongue posture
Ability to breathe through your nose
Carbon dioxide tolerance
Let's dive into each!
Palatal tongue posture
A palatal tongue posture is the ability to place your entire tongue on the roof of your mouth and keep it there.
Notice how the tongue is right up against the roof of the mouth (photo credit: Sémhur)The ability to get into this position requires adequate mobility and knowing how to get into position.
If you want some good exercises to enhance tongue mobility, check out this post and my Youtube playlist here.
If you want to better improve tongue placement, utilizing orthodontic elastics on your mouth can be a big help. Basically, you can put the elastics where you can't get your tongue up to as an external cue. Focus on pressing the elastic into the roof of the mouth.
[caption id="attachment_13409" align="aligncenter" width="376"] Elastic on the tongue tip. A good starting point[/caption]
Ability to breathe through your nose
This is as it sounds. Can you breathe through your nose while keeping a palatal tongue posture? Think breathe quietly and slowly through your nose in this position.
You can also use a saline rinse through your nose to keep it open and clean.
[caption id="attachment_13411" align="aligncenter" width="376"] Keep ya nose clean, fam![/caption]
Carbon dioxide tolerance
Mouth breathing is useful for keeping blood pH in a tight window during exercise. pH is governed by carbon dioxide, so the better you can tolerate carbon dioxide, the longer you can nasal breathe.
This quality can be improved by working on a controlled pause. Here are the steps to this action:
Attain palatal tongue posture
Exhale a normal amount through your nose
Pause and do not breathe. Hold to the point of first experiencing air hunger (where you feel the need to breathe in)
Breathe in lightly through your nose, and exhale again; repeating step 3.
Over time, your ability to tolerate air hunger should improve, and NO ONE will mess with you.
Sum up
CPAPs help keep the airway open and oxygen in your body, but improving airway dynamics and structure are key to "fixing" sleep apnea
Nasal breathing requires a palatal tongue posture, regular nasal breathing, and carbon dioxide tolerance
Lucy Hendricks is a gym owner, coach, educator, and speaker who not only takes a holistic approach to personal training but is known for her ability to take complicated topics and making them digestible for fitness and rehab professionals. She helps coaches who have clients that have been hindered by movement limitations get back to what they love.
Show notes
Here are links to things mentioned in the interview:
Seth Oberst - He's an awesome PT who specializes in trauma work. You can check out a course review I did on him here.
90/90 Hip Lift - An exercise commonly used in movement prep.
Crozat Appliance - This is the appliance I have in my mouth for palatal expansion.
Modified Transcripts
Zac: When I say "Personal Trainer," what does that mean to you?
Lucy: Just a joke of a career.
Zac: Really? Why do you think it's a joke of a career?
Lucy: Because I feel like it's based on a really faulty foundation of all this from the start of how we get people in the industry, how we train them, what expectations we give them, how we train them to do their job and the expectation of what they're able to accomplish with people's health.
Zac: You know, when you reflect back on your career and how you got started in this industry, did you ever get hit with that like, I'm working with some people and it's like, "Whoa, this person needs a whole lot more than what I learned in my beginning phases of my career."?
Lucy: I wouldn't say there was one time where it hit me. It was more of reflecting back on the first five years of my career. Always feeling like a fraud. Because right from the very beginning I started getting invited to podcasts, seminars and people always ask the question, "What do you do to get your clients results?" Which I always hated because I was really good at getting people to lift without pain.
But when people say "Results," they insinuate that you got them, their fat loss results, sleep results, just got them healthy. And for the first five years, I always avoided that question or didn't really answer it, beat around the bush, and went to the strength training without pain. And then I realized that the expectation that personal trainers are able to get people to the end result, which is completely healthy, is really unrealistic because no one has the skillsets for that.
Building a gym that appreciates holistic fitness
Zac: What kind of things did you first shift to that were outside of strength training without pain?
Lucy: I would say the functional medicine world and those concepts of working on your sleep, eating real food, at the time gluten-free, sugar-free, trying to go back to what your ancestors ate, and stress management, which I didn't really understand either other than promoting people need to chill out.
Zac: Of course, take a chill pill.
[caption id="attachment_13364" align="aligncenter" width="500"] Although I personally prefer red pill (Image by digipictures from Pixabay)[/caption]
Lucy: It should be less stressed. And telling people that meditation is important, but never actually getting them to do it. Maybe a handful of people tried it or tried other stress-relieving activities, but there was never a process. It was more trying to create the culture where we believed in all these other lifestyle factors that needed to be addressed, but never actually had a system for it.
Zac: And I know you like to have a systematic and consistent approach you might say. So, once you ironed out the kinks, so to speak with somebody approaches, as opposed to just say, "Try and relax" when it comes to stress management or meditation's important, sleep's important, but not having those processes in place.
What was your process like of making that more systematic in your community that you train?
Lucy: I wouldn't take this as advice, but we first started out with workshops. So, I remember we did the first sleep workshop probably three years ago and no one had signed up. So I gave away eight semi-private or something crazy without thinking, just wanting them to come so bad to the sleep seminar, believing if they worked on their sleep, they'll get better results. And then they'll stay longer, which the money won't be an issue. And clients knew that that was a horrible business choice, so they ended up coming, but never picked up the sessions.
People did buy blue-blocking glasses, the sunlight lamp, and started walking in the morning and started turning off their overhead lights at night. So, it did change a little bit and some people got results.
What really went well was the following year. We did a sleep challenge and we didn't want to attach the winning to results just because everybody's so different. And that's one thing that makes it so hard is you can't really control the outcome in a group setting unless you had one on one coaching, but that takes so much attention and skill sets that most trainers don't have to control a bunch of other aspects that influence someone's ability to get results.
So, what we ended up doing was we attached the outcome to participation. So, everybody had a checklist of, I think, 12 things that correlate to sleep hygiene or influence sleep hygiene.
And you had the check, I forget so many each day posted on Facebook. And each time you posted a picture, you got your name and a chance to win an Oura ring, which is like a $300 ring. And that worked really well. A lot of people got amazing results better than I thought they would. People who struggled to get up in the morning were able to get up in the morning with no problem. People started drinking less coffee. People started going to sleep faster. We had another client who started pushing herself harder with running. So, she felt that she was working out too hard, but really, she wasn't recovering enough. So, when she started sleeping better, she found herself being able to push harder in the gym. So that was really cool.
Zac: I think it's cool that instead of focusing on the outcome, you focus on the process. Because with something like meditation, I know you did a meditation challenge as well. How do you define a successful meditation?
Whereas you were able to get people to focus more so on just habits people need to do to be healthy. What constitutes healthy sleep? And it's these keys. And I mean, that's fascinating that you're able to get the buy-in on that. You had good retention rates with that as well? The whole challenge?
Lucy: With the challenge? Yes.
Zac: It seems like once you take the outcome, so to speak out of the process, it's like people still feel successful. And I think that's absolutely brilliant.
Lucy: And people are competitive. So, the minimum was you have to do X amount, but then sure enough, the first person that filled out the entire sheet went on there and got a bunch of praise from us on Facebook. And then other people started going through the entire sheet as well.
A lot of people kept up with some of the routines. But anything that pushes the needle in the right direction when it comes to health. And that's what we try to teach people is you can do just about anything and you will get results.
So, what we try to do is at least establish the basics of all these other life factors. So that way, we can start pushing the needle in the direction of better health and more sustainable results.
The pillars of health a beginner client should achieve
Zac: What are some of the key habits you want a new client to exhibit within the first year?
Lucy: If I were to pick three, I would say getting a movement routine, which can also mean exercise routine, where they're consistent and they enjoy it. Where it's no longer a struggle to attend the gym. So now you don't have to sit there and "Do I really want to go, or should I just skip this week?" So once going to the gym once or twice a week becomes an easy choice, that would be something that I would want in the first year.
The next two would be finding a meditation practice and getting them to teach themselves to be present and train their body to pay attention to what's going on inside and with their thoughts.
And the third thing I would say would probably be walking and spending time outside. So, if I were to pick three of those would be the three.
Zac: Why in your eyes are those three the most important? I think the movement practice makes sense because that's where people are coming to you for.
But as a trainer, that is our bread and butter. So, what about the other two? Why do you think walking is important and why do you think meditation is important and the first things that you put?
Lucy: Movement and exercise part is our bread and butter. If that wasn't a priority, then we probably wouldn't have clients.
We are really good at getting people to enjoy exercise. I think a reason why people can't stay consistent on a schedule is because they don't enjoy it. We focus on making training feel good.
The second one is building a meditation practice, training themselves to pay attention because a lot of people have either maladaptive beliefs, catastrophic thinking, unhealthy behaviors that really are impacting their ability to get healthy. And if you can't sit there and the present moment and pay attention to your thoughts, or even recognize that you have the behaviors that you're doing or practicing in or the self-awareness.
[caption id="attachment_13365" align="aligncenter" width="500"] And if you meditate just right, you too will become psychedelic! (Image by 3333873 from Pixabay)[/caption]
Self-awareness is the first step to changing any type of behavior, thought, or lifestyle that you're wanting to work on. If people don't have that, it's so hard to even change anything.
Our goal is sustainable results. Meditation helps build the foundation required to change all of these thoughts and behaviors that people are having.
Walking is to get people moving throughout the day. And that helps with our number one goal, which is getting people consistent in the gym.
What we find is if people can walk and move outside of the gym, they're able to recover faster from their workouts. That makes their workouts feel better, they progress a lot faster, which gets them excited.
If they're not moving outside of the gym and they're only exercising and only moving at the gym, then these people will progress a little slower. So, it motivates them less.
Zac: With the meditation in particular, because inevitably, especially when someone's starting out, you are going to fall off the wagon in some way, shape, or form. And having the self-awareness component and the ability to bring it back to whatever it is you are focusing on, probably helps them get back on track sooner than not.
Lucy: Oh, 100%. And then that's what you need. You need the awareness to see the patterns of "When I stopped sleeping and I don't pay attention to X, Y, and Z. When I don't do my movement routine, or when I don't do my morning routine of reading, getting my coffee, doing my meditating, I now notice that I go to the gym less, I start bingeing at night."
So, having this awareness of where you dropped off and what are the things that you need to do to get back is everything. Because if you don't have that, you don't know why you failed. So, it was just, "I failed. I suck." And then that's it. So, you don't even have the keys to even get back to where you were,
Mindful movement
Lucy: So, the idea of the mindful movement service that I created started out when I attended Seth Oberst's class.
[caption id="attachment_13366" align="aligncenter" width="500"] Ahh the gold ole days[/caption]
Zac: Yes.
Lucy: Where he first introduced the idea of how the body and stress and trauma interact together. And how trauma and stress influences what you see in the body. And how you can use a movement practice, meditation practice, and even things like yoga to impact someone's stress or trauma. And how both of them are really connected. So that was when I first got introduced to that idea. And I worked with him online where he did some of his work with me, and then I took a yoga class.
I am an ex-gymnast and super flexible, strong, and I take cues well. And yoga was very therapeutic for me. It was a time for 45 minutes for me to only pay attention to what was going on in my body. The muscles that I felt stretching, the muscles that I felt working, the cues that they were telling me to do, I was paying attention to that. And I got immense benefit with it when it comes to the struggles that I was having with my mental illness.
But then I noticed that the people that really benefit from it are people like me who are really flexible, take cues well, are strong and have a background probably in gymnastics, ballet, dance, or ice skating.
Zac: You got to express to yourself what you already knew how to do in just a unique way.
Lucy: Yes.
At the same time, I was starting to see the stuff that I was doing with our clients from a different perspective, because I train a lot of people in pain and who have an auto-immune disease. When they would try to cancel on me because they had a flare up, whether their back flared up for the fifth time in a few months or their Hashimoto's flared up. So, they were really fatigued.
I would try to get them in the gym anyway. And instead of their full-on workout, I would let them do breathing exercises for about 45 minutes.
So, with the information that I had and the outcomes that I was noticing, I thought for the longest time that because they did all the breathing exercises from a biomechanic standpoint, they were feeling really good because we just increased all these movement options. Which there's some truth to that, for sure.
But I think I was giving biomechanics way more credit with the information that I had.
Although I never did those breathing sessions myself, my client reactions were very positive, so I kept doing it. Sometimes they would even ask for those sessions because they enjoyed them that much. And they would take me aside and like shake my hand or like hug me. Like, "Thank you so much for letting me come in and do that."
So, when I learned about stress and trauma and all of that stuff, and I took the yoga class, I realized maybe it's not all biomechanics. Maybe they felt so great because they just meditated for a whole entire hour.
Zac: Yes.
Lucy: And when they stopped paying attention to their body, there I was reminding them, "Keep tucking, keep reaching, don't lose it, keep exhaling." Because I'm very detailed with my coaching. And that's when I started thinking that I could create something or a service that gave me what yoga gave me with the detailed coaching and the way I see the body, which is really good at meeting people where they're at, who don't move well.
People who don't take cues well, people who are deconditioned, people who are uncoordinated with their body, people who can't handle multiple instructions at once, which is about everybody. Which is most people. And that's when I kind of blended both of those worlds and created a service called mindful movement.
Zac: You've essentially made yoga so much easier to execute for a lot of different people, which allows those less flexible people to get similar benefits. because you get a wide variety of clients.
Have you noticed if mindful movement carries over into the gym?
Lucy: Their ability to take cues.
Zac: So, it's made your job even easier, even though you already make it easy with your coaching?
Lucy: It's crazy. I can just sit down and not do anything. And I've been talking to them about it all week. Last week. "Will someone mess something up because this is way too easy?" So, we started the service last year, during the meditation challenge. It has since evolved from then; from the one-on-one sessions, and then into actual classes once the pandemic hit.
Zac: What's a typical session like? So, you got, say, it's the first time someone is attending your mindful movement. What does that entail?
Lucy: Oh, I would say it's very similar to like a strength training session with two or three try sets. We pick three different exercises, go through them. I don't do reps. I do more for time just because everybody moves at a different pace.
It's a lot of the same cues that I use on the training floor, which, if you're watching this, it's focusing on the stack position, focusing on all of the skills or being able to coordinate your body in a way where you're achieving certain positions and certain moves.
[caption id="attachment_13193" align="alignnone" width="810"] The only way to talk to Zac[/caption]
I'm introducing one cue at a time and that's all they're paying attention to. And that's why, what I said before, it's making my job easier because that's all they have to focus on is that one cue.
So, an example of that would be one that I like to start with is in the supine position with their feet in a 90/90 position. Usually, when you introduce this exercise, people try to put everything together all at once: "Okay, tuck here and I'll fully exhale and I'll keep the ab tension and reach and don't shrug and don't lose a tuck." It's usually a complete failure. Or it's not a failure because you're really good at coaching, but the client is not competent in that move.
You might've gotten them there, but they don't even know how they got there.
Zac: Yes. They need you to complete the tasks..
Lucy: I did that in the past so much, and it was probably an ego boost of like, I just got this person in this position.
But then when I asked them "How was that?" They're like, "I don't know what just happened." Or they you them, "Where did you feel that?" And they say, "Oh, I don't know. Let me do that again."
Zac: Yes.
Lucy: So, with mindful movement, what I ended up doing was retracting all of those cues and introducing one cue at a time. And it's the example, the 90/90 position legs don't do anything. All they're focusing on is that full exhale. So, it's in through the nose, full exhale, and I'm telling them the count, try to get the 10 seconds and then just breathe in however. And then back over and over again. Breathe in through your nose, full breath out. And the goal is, each exhale you're going further and further and you're trying to count to like 10 to 12 seconds. And that's all they're focusing on.
The way I see it is like taking a dance class. It's, you're focusing on like taking a step forward and taking a step back and taking a step forward. And you're just really getting used to like what that feels like. And then I build up on top of that. And so that's the first set.
The second set, I tell them to do the same thing, "Full exhale, at the end of the exhale, you should feel some abs. So, hold that air out and even say in your head, holding onto the tension and then letting it go." And then that's what they're focusing on for, I think probably two minutes that I let them go.
Zac: So, you don't even mention Ab tension at all with the first round. It's just like the component of exhaling getting air out. And then you're building on top of that?
Lucy: Yes. Or I might check in like, towards the end, like "Everybody feeling abs at the end?" Because they're holding their air out. And I just get that confirmation of they are feeling abs. And if someone is like waving their hand saying, "No," I'll try to address it there. Like "Try to exhale a little harder. So, if you're not feeling abs exhale harder."
So, I'm getting the steps that are required to get me to the end goal, which is a full exhale with the ab tension and then breathing underneath that tension. So, they do that for the first set. Second set, they're doing the same thing holding for five seconds. And I also give them the right expectation. Like "This is going to be uncomfortable. If you feel uncomfortable, you're doing it right." Which I think coaches fail with that as well.
So, in their head, they're literally differentiating. And I tell them, that's their focus of holding onto the tension and then letting it go. Holding onto the tension and letting it go. So same thing. Like "Step forward, step back." Because when people can hold onto the tension and breathe in, usually the reaction is like, "Did I do it right?" Because they have no idea.
So, the third round, same thing: "Holding onto the tension, but this time keep the tension." They should know what that tension feels like, because they just let it go for like two minutes. So, breathe underneath the tension and then back to the full exhale. So, I'm building up to that end goal.
Usually in that triset, I'm also doing pelvic tuck where they're only focusing on "Rolling up the hips, feeling hamstrings and letting go. Rolling up the hamstrings or the hips feeling hamstrings and letting go." And sometimes I'll put those together. It's whatever I'm feeling, I usually do it on the fly, depending on who's in class.
Zac: Kind of your style.
Lucy: Yes.
Zac: Say you got a bunch of newbies, which I would assume you're triset with them be one move to focus on the tuck, one to exhale, then reaching for the third.
Once you have all that built up, then what does the second try set look like? Like if someone gets it with those, do you try to combine or do you focus on other things?
Lucy: I will usually move on to things like all fours. So, we'll either do some inverted quadrupeds or quadrupeds tucking, and where I tell them "The three main things that you're doing in the entire class, which is training your body to pay attention and being coordinated with your body." Which is also a huge thing.
Instead of telling them "You're learning how to do things right." They're focusing on a cue that I'm giving them. "So, I want you to do something a certain way. I want you to roll your hips instead of picking up your hips. So, you have to pay attention to that." I'm giving them a visual to pay attention to. Deflating their body, inflating, peeling, melting, and then I'm also giving them a feeling. So, if they're doing it the way I'm asking them to do it, I should be calling out the right muscles.
https://youtu.be/7SQQeEuTPo0
"You should be feeling your abs at the end of the exhale, or you should be feeling your glutes and hamstrings at the top of the tuck." I'm telling them what to pay attention to.
After we do the things like supine, reaching, exhaling, I usually move on to quadrupeds where I'm telling them to pay attention to their back pockets. So that's one of my favorite Quadruped tucking where they're inhaling, pulling the back pockets down, exhaling, pulling the back pockets back up.
And I do, which is also taboo for people who are into breathing extension. So yes, don't freak out. I do let people arch their back, but this is what I say.
I tell them to "Work with what you have." Because I do want people to be able to arch their back and be okay, even if it's a little bit uncomfortable. So like, this is what the class is for, is being able to move your body and be fine. We're not loading it.
What I say is "Work with what you have. Move as much as possible. As long as it feels good." So, for me, it's going to be very extreme. I can arch my back all the way and then tuck all the way.
But someone who's a little stiff. I don't want them to look like me and I don't want them to think that they need to look like me. They're working with what they have and I'm telling them, "You are differentiating between tucking and untucking. Your back pockets are either down or they're up. So, if you get distracted, where are the back pockets? Either up or they're down."
And then I'll move into some supine, like putting it together, like supine reaching like an ISO dead bug and working with that. And then a lot of squatting.
Zac: Squatty squats. I'm sure.
[caption id="attachment_13367" align="alignnone" width="810"] The only way to squat![/caption]
Lucy: Yes. Squat holds. Where they're focusing on the same thing, the same move that they've been practicing, the same exhaling, the same feed. So, I'm just telling them all the things to just pay attention to. And we progressed from there.
Zac: This is nice. You give an external cue, back pockets. You give an internal cue, tuck your hips. And then you almost get like an inter receptive cue. Like, "What am I feeling within me?" And that's good because if someone doesn't hit one and two, they might hit three and then they'll know that they're doing it correctly. So, I think that's really good to build in that redundancy because it makes your job easier.
Lucy: Yes. And what I learned actually recently, I've always done the three things. But now I see it or I can see why it works. Apparently, people need three things to see a pattern. So, if you can describe something three different ways, then they can almost see the big picture of - if I just say "You're reaching your chest away from your hands." Like that might not mean anything. But if I give it three different ways, like "Picture the space between your hands and your rib cage, getting away from each other. Think of your upper back getting wide. Think of everything being pushed back."
And then you're kind of painting the picture so they can see the cue. Because they don't know anatomy, they don't know anything.
Zac: No. They don't.
Lucy: And they're not aware of their own body. So, you're trying to just bring the awareness to them.
Zac: Well, I imagine it probably reduces the frustration. I've ran into coaching someone and asking if they feel a specific area. They'll say, "Well, no." And then they think they're doing it wrong.
But if they're feeling the sense that they're doing this movement, or they're envisioning this thing happening, it was within their bodies and you can almost point them towards, "Well, those are activating when you do that. If you can sense that your body's doing that, then you're winning!
Side note. How pissed were you when you found out that the rule of threes was a thing and not something you came up with?
Lucy: Really pissed.
Zac: There's nothing original, happens to me all the time!
Lucy: Yes. I had books on it.
Zac: Really? I've heard of rule of thirds in the video. Or when you're doing PowerPoints where you need to have like two or like three things filled on the PowerPoint and they leave one spot blank.
A consistent approach to coaching
Zac: Why is a consistent approach to movement and training so damn important?
Lucy: It develops a training model that produces clients that are so independent, making your job really easy. You create a training experience where people can socialize and you can catch up with clients because they don't need to be babysat.
I noticed all of these benefits when I went to the extreme thinking that neutral spine was the only way people need to be lifting because that's the safe way to lift. Even though I was wrong in that aspect of seeing the body that way and not fixating too much on biomechanics, I couldn't ignore all the benefits from that approach.
So, I had to figure out how to continue to have this approach and not have all these negative aspects? Because one of the benefits is the client independence, which is crazy. The other benefit is people can get strong, but not be so consistent in the gym, because everything looks very similar, even though an offset step up is different than a goblet hold step up or a higher step up with a zercher hold. It's still very similar.
Even though we're loading different tissues, we're loading similar moves and similar tissues. So, people can get strong and also experienced novelty. I can have a step up increase in weight, but then have different variations in step-ups.
Same thing with squatting. If I build a consistent squat that looks the same pretty much every time, I am going to be able to progress that person by doing different types of squats. That's how we're able to have people who've been strength training with us for nine years and they're still being challenged. And we are still able to find things that they struggle with.
And then two, it's not just about weight. You have all this sense of accomplishment throughout your training program every six weeks, that's not just attached to how much weight you're doing.
If we have an exercise that needs to be done a certain way, you now have a goal. Well, half kneeling cable pull down, needs to be done with me keeping my half kneeling position, me pulling down without shrugging without arching my back. So, I have to keep all of these things and do it this way for the next six weeks and feel that gets stronger, feel more coordinated or more efficient.
https://youtu.be/1x_Qc-41wEs
Even though technically you could totally do more weight if it was just a seated cable pulled down, but our clients don't see strength training that way. They see all these different exercises like a skill that they get to learn. And I kind of paint that picture like, "Ooh, half kneeling cable pull down. That's what you get to learn and get stronger in for the next six weeks." Even though it's not going to be as challenging technically as a seated cable pull-down where you can totally get more volume and more weight.
Zac: This challenge coincides with what you're trying to build with your mindful movement. It's mindful movement under intensity, staying attunded with your body while lifting heavy weights.
With you having consistency with your coaching, that it allows for people to not just want to work with you, but with other trainers who think similarly.
Lucy: Yes. It allows you to share clients. And you can still be your unique coach and have your own personality and people will have favorites. But the problem that a lot of people run into is you cancel when your favorite coach goes out of town and that's what you don't want to happen.
That used to happen to us. If I would go out of town, people wouldn't want to coach with Dave, or he went out of town, his people didn't want to be coached by me. So being able to have this consistency of how you provide a training experience and how you coach things needs to be pretty consistent.
The importance of working with people in pain or autoimmune diseases
Lucy: It just feels really rewarding to provide a training experience that people who otherwise wouldn't like to lift at all or had never stepped in the gym or never thought of themselves as lovers of exercise, get them to enjoy a training experience. Or get them to say things like, "I can't believe I like coming here or I can't believe it rained and I didn't cancel." I get them to that point.
I get these people who have never stepped in the gym or have had horrible experiences and they literally say they hate exercise. And I know that in a month or two or three, however long it takes, they're going to be a different person. I don't tell them that just because no one's going to believe it. But I know.
Zac: You can see the vision down the line and they're focus right now.
Lucy: Yes. And the joke that I tell some of my clients, because the people that we do attract are very similar. It's so cool that we have people who would much rather be at home with their spouse, drinking wine or smoking a bowl and watching TV and eating pizza.
But instead, they're here training twice a week, every week, pretty consistently. Sometimes they fall off because work of deadlines and shit happens. But we created an experience where those types of people are here. Not the gym rats, the meatheads, the people who enjoy fitness, the people who are advertised to join the industry. It's everyone else, regular people.
The future of healthcare
Lucy: I would want to redefine what it means to be a personal trainer or what it means to be in this industry. And redefine what it takes to be healthy. Because I think come to more of an agreement where perfection is not the goal and being healthy doesn't mean that your diet is perfect, you're always sleeping well, that you never do any drugs, that you never drink, that you never have times where you come in, hung over, that you have times where you spend too much time with your friends on the weekends.
Zac: Play video games too long.
[caption id="attachment_13368" align="aligncenter" width="500"] We all have our vices (Image by Rafael Javier from Pixabay)[/caption]
Lucy: Yes. You eat too much pizza. You travel too much and you don't take care of yourself or you went on too many vacations. So, we're like, what do we mean to be healthy? And redefining that. And then creating a environment, like a gym environment where that's what we push for, where we understand that people are social creatures, we understand that people cope in certain ways. And just because we think it's unhealthy, it doesn't mean that people should be shamed for it.
Like what's the difference between you drinking too much caffeine, which most trainers do, and then a client smoking weed? Or drinking a glass of wine at dinner? Like what's the difference there?
Zac: Or drugs.
Lucy: And also understanding that there's so many factors in someone's life that personal trainers have zero control over. So, all we can do is support them. Because I think the idea now is if you see something that's out of your scope or a roadblock that's preventing your client from getting results, like sleep apnea or severe mental illness, the idea that you can just easily refer out and things are taken care of is like from a fantasy world, because that doesn't happen.
One, people might not be able to afford it. Two, they may not even do it.
I've asked someone to get a sleep study five times and with three different people and they won't do it. But I still have to train them. Or someone might have severe mental illness and they're already seeing a therapist, but they're still struggling. Or people are still in back pain, even though they've gone to the Mayo clinic, Cleveland clinic, seen multiple physical therapists, pain management doctors, they're still in pain, and I still have to train them.
So, looking at all these other factors and realizing that we don't have control over that. So what we have to do is learn about them, understand how it works or how it's impacting our clients and just figure out how to support them best and create a service that meets them where they're at.
Sum up
Exercise, meditation, and walking are the first three areas a brand new client should focus on.
Mindful movement involves breaking down specific movement components to eventually progress through the weight room.
A consistent approach to coaching similar movements qualities allows for smart progression, variety, and better transfer between trainers.
The future of healthcare involves meeting clients where they are at and supporting them in any way they can.
Jan 16, 2021
Foundations of Athleticism and Health with James Cerbie
What does it take to be a well-rounded athlete? Find out below!
Perhaps you are into training or know it’s important, but what if you don’t have a particular goal? What if you just want to move better and look good naked in the process?
How can I know what to focus my training on if I don’t have a goal?
That’s where this interview with James Cerbie will blow your mind. He has carefully designed a training plan that builds all the essential performance qualities one needs to be a healthy human being.
In this podcast, you’ll learn:
What life proofing is, why it's important for your health and performance, and how to build it.
The 5 fitness attributes you need to become athletic as can be
Which metrics are useful to measure fitness qualities, and how to adjust your programming based on testing
Has your progress stalled? How can you pivot your training to keep the gains going
There are 4 categories of athletes, how does training differ for each?
How can you build athleticism with minimal gym equipment?
Is the performance vs health dichotomy really a thing?
If you are ready to push the envelope with your training, become more athletic than ever, then you definitely need to give this a listen.
Convinced that this training program is for you? Sign up for the Apex Athlete Team Training, which is open from January 11th-15th, 2021.
James Cerbie is the founder and head coach at Rebel Performance. He can be found lifting, drinking coffee, roaming in the mountains, reading research, or watching superhero movies.
Show notes
Here are links to things mentioned in the interview:
James: I've been an athlete my entire life, that's very much how I think of myself, my self-image.
I can remember there being this moment of crisis when college ended, and I was fortunate to play baseball in college. So, I was always on a team, I was always training, I was always competing, it was always underneath this umbrella of being a well-rounded stack across the board athlete. When college ends maybe for some people with high school or some people that are lucky enough as professional.
It's the Thanos finger snap moment where this thing you've known your entire life disappears.
Fortunately, I had fallen in love with the weight room along my journey of planning sports. And so, I looked at the landscape said, you know, I'll be fine. I'll go compete in something like powerlifting, maybe I'll try bodybuilding. CrossFit was a thing at that point. Strongman existed. I'm gonna go try these things. I'm sure one of them is going to definitely do it for me, that's gonna be my thing.
So, I started dabbling and trying all these things, just to come to the realization that none of them were for me. Just really frustrated in that journey in that process. Because I love training, I love throwing down but I couldn't find the right avenue or outlet for what I wanted. I wanted a blend of what these things gave me. Like, I don't want to just be a powerlifter.
I'm not attacking any of those sports, they are all each incredible on their own, right? They just weren't the right thing for me. I'd get to about eight weeks into a powerlifting program and I would feel like a refrigerator. It’s like I can't sprint, I can't jump, I don't move. Like, I just hated the tradeoffs that I was having to make.
And so, I said, all right, there has to be a better way of approaching this so that I can get the outcome I want, and then I've got to figure out how to make that competitive. So, I can still have a competitive outlet, I need to have a team component to this thing as well. And so that's where I started playing around with this concept of being Life Proof, or this concept of being Apex. It’s kind of saying, okay, I want to be well-rounded as an athlete. And I think if you're a human, you should want those things as well, right?
Because, in my mind, if you're a human, you're an athlete. And what that means in my definition is I want to give you kind of five attribute bars:
Strength
hypertrophy
Power
Endurance
Movement IQ
If I can give you all five of those, if you have all five of those, then I think you are pretty Life Proof. You're gonna be able to handle whatever life throws at you. Exactly how high you want these attribute bars to go will differ from person to person.
[caption id="attachment_13325" align="aligncenter" width="500"] Personally, I'm a level 35 physical therapist with Elven magic. (Image by Parker_West from Pixabay)[/caption]
How much time do you have to train, how much you want to make your life revolve around being in the weight room and lifting? But I don't care if you're a 55-year-old CEO, I want you to have all five of these things so that you just do well in life. If you want to ramp that up to a much higher level, then we can do that as well.
Are you the 23, 24, 25-year-old kid who wants to spend two hours training, you want to make your life will revolve around eating, training, sleeping, etc. We can bump those attribute bars up significantly higher for you. But regardless, I want all five and that's the point is I want to give you all five of those things. If you have all five then I think that you're probably pretty Life Proof. You should be able to handle just about anything that you're going to tackle in life. If you need to lift something heavy you can, look like a superhero, go rock in the mountains, do Matt Condon medleys, jump, sprint, throw. you have all your bases covered.
Zac: Do you think powerlifters get triggered and offended with your disclaimer?
[caption id="attachment_13326" align="alignnone" width="600"] the bigger the beard the more easily triggered, they say (Image by revolutionprinters from Pixabay)[/caption]
James: Nothing against the sports I think they're all incredibly they do shit that I could never do. It's just not for me. And I have found that there are a lot of people out there who have dabbled and tried these other sports and feel the same way I do so.
Zac: You sacrifice things
James: A lot.
Zac: I remember when we went to Costa Rica, there are these big dudes at the retreat that we went to, and they absolutely destroyed the weightlifting competitions we had. But then you go hiking and it's a struggle. Or we play a sport, frisbee on the beach. You're not gonna get picked first by any means.
James: And that was the tradeoff that I wasn't comfortable with. I still need to be able to go sprint, jump, cut, do athletic things. for me, that's where power lives.
Olympic lifting is cool. It's great. If you want to use it, awesome. Just not my interest. I would rather sprint, jump, throw, and cut.
Zac: Yeah. And I think as social animals, unless you're going to be spending all day every day in those, you know, doing Olympic lifting, which is fine. I've watched people do that. But sometimes you might meet up with friends and go play something Spike ball as we've been doing a lot at Elevate. You're limited in your capability of doing that and enjoying that. So, I think this concept is very useful.
I also think that having a baseline you need at least this amount of a given attribute, and then you can expand upon whatever you want to depend on your task is very effective.
I think a lot of people think that they have to push X number of weight in order to have success in whatever it is that we have in our movement realm. But that's most certainly not the case.
When you came up with these five qualities, do you feel as though it filled that void of not having baseball in your case? I went through a similar crisis with running. Now obviously, I could have kept running because that was my sport. But I hated it. I only did it because I was decently fast at it. But did you feel as though it gave you similar satisfaction in pursuing that compared to baseball?
James: Yes. So, the key there was in actually finding the other people, finding your tribe, finding your people who felt similar, who wanted to train in a similar way. And so, then you actually were able to get the team-based component back. So, it did successfully fill that void.
And the first experiment that I essentially ran with that was The Silverback Training Project. It was a very big success for the people that we got on board. We saw improvement across the board. We have people hitting 50 to 100-pound PRs in the big three! I'm not talking about going from 100 to 150 pounds either. We're talking people squatting 500 for the first time, people deadlifting 600 for the first time, people who were in pain who are no longer in pain and feel good. 30% improvements on 10-minute assault bike challenges. And all these other met cons we we're testing. They're putting on muscle, they feel good. We're hitting three, four-inch PRs in verticals, broad jumps, we're doing better on 10-yard and 15-yard sprint tests.
To go back to the attribute bar analogy, we're essentially taking all the attribute bars, and they're all getting moved up. And so that was a nice reassurance to see. One, conceptually, my thoughts on a whiteboard, when actually given to humans worked. Because there's always that thought that I'm gonna sit down and write a program and it's just not gonna work. But it does. Contrary to what a lot of people think, you can actually get a lot of progress across the board if you're smart in how you implement these things.
But the biggest one was just seeing how the people came together. You filled that void for them, they got to compete again, they got to have a team. And so, it was a lot of fun to watch that transpire. We did it for a couple of cohorts, just to make sure it wasn't an anomaly the first time. And you see a similar thing happen every single time. So yeah, that was the first big win into that realm. Now we just need to spread the word and find more humans that believe in this concept.
[caption id="attachment_13327" align="aligncenter" width="500"] Team work making the dream work and shit (Image by truthseeker08 from Pixabay)[/caption]
Zac: It's kind of what CrossFit was trying to do. And there are some CrossFit boxes that probably implement this successfully is you want to be well rounded in all of these qualities. But then the issue is that because you're varying the workout so much, you don't get that progressive improvement in specific qualities. Whereas you're advocating that you can get improvement in all these qualities, but you have to apply the concepts of progressive overload in order to make that happen. And it sounds like you also measure each of these qualities to let you know, where we have to tweak the program to improve even further.
The best tests to measure athleticism
James: Strength is pretty straightforward. We don't use one rep max very often just because it's so skill and technique based. So, I use more three, five, and ten rep maxes. I want to see strength improve across a range.
Hypertrophy is a much more difficult one to measure, I don't have a great performance-based metric for that. I think your performance on higher rep stuff or timed sets would probably be a little bit of an indicator, but we're probably going to use more just vanity metrics. Take a before and after picture. Do you look more jacked? Are you happy with this outcome? You could also test body composition.
Looking like a superhero just comes with the territory when you do what you're supposed to do training-wise and in the kitchen.
Endurance is easy, we use a 10-minute assault bike challenge. You go as hard as you can for 10 minutes, and let's see where you're at. Four miles seems to be a pretty good threshold. I've had a couple people push five, which is outrageous. These dudes are freaks. They just have engines for days. We will also look at the resting heart rate and see if there are any drops.
Zac: I can't push volume on a bike for whatever reason. And it's not because of the lack of the ticker. It's because of the local muscle fatigue for me.
It's the same for lifting. Although I've gotten significantly better at tolerating more volume with a single move, which I need for a training effect, I have to vary the. exercises to train enough. I might do an Arnold press and only get four sets of whatever rep range. And then I just I cannot output anymore. But then if I change to an incline, then I'm right back in action. we're back.
The cardiac adaptations are there, it's just the supporting structures aren't there to carry it out. So that's where a lot of my training has been going because that's what I know is the rate-limiting step.
James: It’s those capillaries and mitochondria, bro.
On the power attribute bar, I'm looking at jumps, sprints, and throws. Vertical, broad, lateral. I want to see multiple repeat jumps as well. 10-yard sprint, 15-yard sprint, maybe out to a 40 or 60.
I don't have Olympic lifts in my model. It's not because they don't work, I just choose not to use them. I think that jumps, sprints, and throws are more effective and less technical.
Movement is obviously really hard, so our measures are subjective; things feel easier, pain reductions, getting muscle fatigue instead of joint pain, etc.
Oo the endurance side of the coin, are resting heart rates dropping?
If I can get actual numbers, I want to get actual numbers. This allows us to see where we need to focus our efforts. Say all qualities but endurance are improving. We may potentially change volume or something else in their template.
Zac: Then would you do things to maintain the other quality, so perhaps, you'd increase volume to potentially improve endurance components, but then you're just adjusting maybe it's less volume, less volume on the power components or, you know, you're doing less volume of the strength work?
James: Yeah, I'm a big block periodization fan, physiologically. That just makes a lot of sense to me. And it works.
So, I talk about all five of these attribute bars, but we need to appreciate that I'm not hitting the Go button on all five of these all the time because that can't work. It's more of how you stack the blocks together in a sequential fashion, that allows you to get this good development across the board. And so that's the biggest thing. It's making sure that we have you in the weekly training template for whatever type of athlete you are. And we can talk more about that.
And then from there, it's just making sure we sequentially have a block of training that makes sense. What am I focusing on for these four to six weeks, and then what am I going to focus on for the next four to six weeks while I maintain these other things?
So, when I have maintenance with progress, you are slowly bumping these things up over time. If you only zoom in acutely, you may only see one or two attribute bars going up. But when you zoom out and look at what happened over 12 to 16 weeks, we've got all qualities to improve. And that's what we're chasing.
Zac: To be everywhere, to be nowhere.
That extends to not just fitness qualities, but all things. You can't be an expert in all things mitochondria and real estate at the same time. Your outputs in each domain wouldn't be as high as if it were a focused effort. So too with training.
But where I also think you are doing a far superior job compared to other people is you don't build one-trick ponies. You allow for adaptability. Mastering only one quality can help if pursuing a specific sport, but it puts you at risk for bad things to potentially happen when you have to call upon those other qualities.
James: Yeah, and if you have a highly specific goal, and you want to be the best in the world of that highly specific thing, then you have to be a one-trick pony. And that would be good for you. If you want to be an elite level powerlifter, if you want to step on stage for bodybuilding, if you want to compete in Olympic lifting, I think all those avenues are incredible. And if that's your thing, and that's what lights your fire, go do it. That's awesome.
But if those things don't light your fire, then maybe we think about training in a different way.
Athlete archetypes
Zac: Once you've established a life proof baseline, where do you go next?
James: This is where it depends on what avenue are you in? Are you in a one on one training experience where you're getting a dedicated coach with individualized coaching? Because those conversations happen pretty often, and we get pretty detailed nitty-gritty into the weeds.
Or you're doing more the team-based approach, where you're getting into a pre-written training template that you're funneled into based on your goals. So those go through more pre-determined cycles. We essentially will go through waves of hypertrophy, work capacity, focus block of training, and then we're going to go into a more strength, power, etc., focus block of training.
If we decide on improving a specific quality like strength, we may lower the rep ranges and have that be the main focus. Then, we're blending power and throughout that with jumps, sprints, throws, etc. Endurance is getting thrown in there as well, whether or not we're doing a short to long, longer, shorter approach, etc. It kind of depends.
But again, I think what we do first is we try to funnel the athlete into determining what is your specific archetype? Because the concept of life is very broad, so we need to narrow that down.
We've found that people generally fall into one of four categories:
Base athlete
Stacked athlete
Strong Athlete
Tactical athlete
Base athlete
A base athlete cares most about movement. They want to move really well and feel good while sprinkling other pillars on top.
These athletes will use more of a sensorimotor-based approach. Your big squat might be a heel-elevated Zercher squat because movement is the highest priority.
https://www.youtube.com/watch?v=gmDnYnGWA-I
Stacked athlete
Stacked athletes want the five attributes to be as level across the board as possible. They want to be the middle linebacker of humans.
For them, we're more aggressive at how we're chasing performance outcomes. They get put on a three training split: three lift days, two low conditioning days, one high conditioning day.
Strong athlete
The strong athlete cares most about strength and hypertrophy. Fantastic. You can put on a four-two training split into four lift days and two easy conditioning days.
You’re not going to get the hard conditioning day, because there's nowhere to fit it into your scheme. Plus, you don't care that much about that outcome. But we still want the two low conditioning days because we need that at least low-level aerobic ability and capacity to feed into everything else that you're doing.
Tactical athlete
The tactical athlete cares most about endurance. They have more met-cons and medleys, rucking in the mountains.
These athletes also are put on a four-two split as well. So, they have four "lift days" and two easy conditioning days.
Their lift days are a bit different. They'll first have two big lifts (e.g. squat and press, hinge and pull, etc) and instead of accessory work, they'll do met-cons or medleys. These exercise choices fall somewhere in the hypertrophy and endurance realm, so it helps them out.
How people should train who have general fitness goals
James: I would say the vast majority of people we get in this team-based programming training approach have very generalized outcome goals. They just want to see the attribute bars move up.
For these people, we bleed in competition throughout the program, allowing them to train for something. Whenever we can get away with it in 2021, we are going to do some events in-person.
Zac: In Salt Lake?
James: Yeah! There's a really cool facility up outside of Salt Lake. It's an old airplane hangar. And it's gutted out, and a gym. It opens up onto an outdoor rig, which then goes on to about a 40-yard field, and there's a sand volleyball court. So, it'd be the perfect place to do it. And you got the mountains as the backdrop.
We will likely split this meeting into a competitive and general division. The reason why is because we have people of various performance capabilities that believe in the concept. Some can squat 500 pounds, some just want to feel good, but we're all on the same journey.
Just show up with the mentality, attitude, and desire to get better. That's all we want. We are very fortunate to have a community of people where we don't have egos. We just want improvement. We just want you to get better.
Improving athleticism with minimal gym equipment
Zac: How do you adapt the thought process in the life proofing concept to someone who has minimal equipment? Especially during these home-gym COVID times?
James: We have three tiers of options for people that want training. So, the top tier is you come in, you get a one-on-one coach that's totally personally dedicated to you. And it's totally customized.
Then we have the Apex team, which is one that we've been talking about, which is a team-based programming approach. We put way more of an emphasis on the community, the competition bit, and you're plugging into just really, really well thought out, science-backed and tested programming that is going to work phenomenally well, for the vast majority of people.
For both of these tiers, you need to have access to equipment. So, I tell people that I write the programming assuming you have access to the same garage gym I do. So, my garage gym has a rack, a single cable machine, an assault bike, a rower, a ski erg...
Zac: A ski erg in your garage gym? That is badass.
James: Yeah, so I don't use a skier very often just because that's a weird one. Most people will have a bike or rower. And then assuming that you have access to most of the dumbbells and kettlebells. Assuming you have access to most of those things, we can make adjustments within the team training.
For the people that don't have any equipment, if you're the I have a dumbbell, maybe I have a kettlebell, I have a few bands or just my bodyweight, then we have pre-written programs in our program shop that are built for just at-home training.
To respond to gym closures, we added several different training programs that you can do at home. You don't need anything more than your body weight, maybe a dumbbell, kettlebell, or some bands.
However, training without equipment is not a long term strategy. We hope we can maintain during what is hopefully a short term problem.
Zac: Progressive overload in most things is really tough unless you have some degree of equipment.
James: Yeah.
Zac: However, there are people who exist who can get pretty big, doing just bodyweight things. Do you ever go on those YouTube benches of what was a guy called Kali Muscle?
https://www.youtube.com/watch?v=vUHRCipX_Sc
James: Oh, yeah.
Zac: He was just massive; doing just a bunch of stuff at playgrounds.
James: I'm always curious about what exogenous aids exist in those situations. Yeah, that's the first place my mind goes, just because I know there's gonna be some limit on what we can accomplish with just bodyweight and maybe a pull-up bar.
I have a program in there called Apex athlete at home, it assumes you have access to nothing. We rely on a lot of tempos and metabolic stress-type training such as timed sets. This works in place of mechanical tension and load.
Fortunately, you can still do jumps, you can still maybe do sprints, we can get outside. So, the power component we can still have, the conditioning stuff, we can probably still get in there.
Zac: Basically, your goals have to somewhat shift during this time period.
James: Yeah, we actually it was funny, I was talking to my buddy, Kevin Horton the other day who coaches with us at Rebel, and he was talking about some of his clients how it actually ended up working out in their favor.
He's working with a 40-year-old New York lawyer who's very type A. Gym closings were actually the best thing that could have ever happened. Because he didn't have access to a barbell, he had to focus on other qualities.
Armed with only a kettlebell, some adjustable dumbbell, and bands, he focused on movements he wouldn't normally tackle over a three month period. Lot's of sensorimotor work. He felt so much better once he got back to the bigger, sexier lifts; hitting tons of PRs in the process. He thought it was totally weird because he wasn't focusing on these qualities.
He finally addressed the foundation that he never spent time on. And so, once he actually put that in place, magical things happen. It's like a pyramid; the larger the foundation, the higher the peak can be.
Zac: I've seen that a lot of times with many of the big lifts. With most of the people who I work with, the first few blocks, especially if there's someone who's a little bit more beat up or they need a bigger movement foundation, we stay away from hinging. It doesn't extend movement options well enough for most people. Instead, we emphasize more squatting and other activities that increase movement capabilities.
Without fail, I see most people when they do go back to deadlifting, even if they haven't touched that for an extended period of time, numbers shoot up, it feels better, and/or they pull faster.
I think it really carries back to the concept that you're talking about James of you have to build up all of these bars to some degree, because there's just so intermingling between developing all of those qualities.
James: 100%.
Zac: Even the person who says they want to powerlift. I really liked that you're still emphasizing aerobic components for them because they still have to recover. They still need to be able to attain enough movement so they don't hurt themselves from the very heavy loads.
James: It's interesting because I think we have people who will go do powerlifting comps, and strongman meets and all this other stuff, yet they don't view themselves as those types of athletes. They simply spend time building their attribute bars, then eventually tweak their program to emphasize the quality they need for the given competition.
It's wild because they go win powerlifting meets and they win strongman contests. But that's not really who they are. They don't train that way all the time. We're just building all these attribute bars, and then we peak for a meet, and then they come back in right where we were. You might not be the best in the world, but you can still be pretty damn good.
Zac: It sounds like the key is to have the capability of doing pretty good in anything by starting with a robust foundation.
James: You can go and show really well both of those.
Zac: Yeah.
James: Which is awesome. , I think that's so cool.
Zac:Tim Ferriss would always talk about how it doesn't take much to get up to the 80th percentile in anything if you just spend a little bit of a dedicated amount of time to a specific thing. I think in the movement realm, or the performance realm, it's the same thing as long as you have that foundation to build on.
James: Mm-hmm.
James: We have another guy who's in the Apex team who had competed in the CrossFit Games. He eventually ran into the problem that I've seen from a lot of former crossfitters, which is things start to break down. It wasn't a sustainable training style for him.
We had to do a lot of work on the front end of cleaning up a lot of movement deficits; focusing on baseline foundational work. He totally bought in! He messaged me the other day saying that he was better than ever, even compared to when he was a CrossFit athlete.
Granted, if we throw Olympic lifts or gymnastic stuff at him he may not do as well because we don't train those movements. he's gonna get towards it because we don't do either of those. But he was mashing on squats, dead, and bench; hitting huge PRs in the process. His work capacity and engine is through the roof, his body composition is as good as it's ever been, and he feels really good. God forbid, you can actually perform well and feel good at the same time.
[caption id="attachment_13335" align="aligncenter" width="500"] You and me both, yikes! (Image by Kate Trysh from Pixabay) [/caption]
That was an interesting message for me to get because he's the one who's kind of getting ready for the competition roll around. He's totally bought in and plans to train this way for the rest of his life!
Performance vs health
Zac: It seems as though the concept of the performance versus health divide is something we don't talk about as much as we used it. It's such BS.
James: I think the only place it rears its head is at the very, very, very far end of the bell curve.
Zac: Exactly.
James: And I think that the bell curve is far larger than people want to give it credit. Because it used to be that you can't have both, but you really have to push to the far ends of performance to make that a thing.
If you want to be a world-class triathlete, a world-class marathon runner, if you want to be Thor and go be the strongest Strongman in the world, those pursuits likely aren't healthy. The sacrifices you have to make to accomplish what those people do results in some tradeoffs. But that is so far to the extreme end of the curve. People get lost in that conversation for some reason.
Zac: The reason why it is so far right on the curve is that you are literally are pushing your body to its physical limits.
But most people cannot output to that degree, whether it's the inability to coordinate their bodies the way they need to, not built for the task, etc.
Some cars can't go 100 miles an hour. And you're more prone to have a violent accident if you can go 100 miles an hour as opposed to 30.
And I think the same thing applies to us humans. I don't know if I'm going to ever pull 600. That ship likely sailed when I pursued endurance running. For the overwhelming majority of the population, you can pursue a lot of the performance qualities that we've been talking about this whole time with few ramifications.
James: If it's done well, it can work. If it's implemented poorly, it won't work.
Zac: Yeah. And I think most people just don't have an idea of how to do it well. Because there is an inherent risk when you're chasing these qualities. If you don't have technical mastery, if you don't have intelligent planning, you may be at risk for an injury.
It's not like learning a musical instrument where there's an inherent negative feedback loop when you don’t hit the notes well.
James: I'm very upfront in saying that, if you look at all five of those attribute bars, those five pillars, I can find you numerous coaches that are far better at me at any one of those attribute bars. If you just want to focus on strength, there are people way better at that than I am. If you just want to focus on power, people way better at that than I am. If you just want to focus on hypertrophy, just endurance, just movement. There are coaches that specialize in those pillars, and they are far better at that than I am.
I haven't met many people who are as good as we are at actually taking all five of those and blending them together into a comprehensive plan that makes sense, and that works. Because I found that that's where people really struggle is in putting it all together.
People have ideas or concepts, but they get stuck. They overthink things. They second guess stuff. They develop shiny object syndrome and jump from program to program. And it's simply because it's hard to put all that together in a way that works and makes sense. That's where I find that people really struggle.
Zac: And that's why I'm excited that you have put this together. Because I would agree with you 100%. It's really hard to coordinate a lot of concepts into one thing and it goes back to the conversation we were having about developing expertise in a given thing. But if you can get good enough at several things, that just leads you to be more enriched, adapted, and being able to do a wide variety of things.
Sum up
Life proofing involves increasing your power, strength, endurance, hypertrophy, and movement over the course of a block periodized training program.
One can better specialize when one builds a bigger foundation.
Though harder to build fitness, power, movement, and endurance can be improved with minimal gym equipment.
The divide between performance and health only exists at the extreme ends of the bell curve, and most people can pursue high levels of performance with few ramifications.
So the neck, thorax, shoulders, and more are all related, but is there a convenient way to illustrate the interconnectedness of these areas?
I think there isone testthat can provide TONS of insight here.
That test?
Lower cervical rotation
The ability to rotate the lower part of the neck can demonstrate how well you can move the uppermost parts of the thorax and can help differentiate if you need to drive interventions either below or above the neck.
Want to know all about the importance of this often-overlooked test?
Checkout Movement Debrief Episode 142 to learn more!
Montreal, Canada (POSTPONED DUE TO COVID-19) [6 CEUs approved for Athletic Therapists by CATA!]
Or check out this little teaser for Human Matrix home study. Best part is if you attend the live course you'll get this bad boy for free! (Release date not known yet :(
Here'sa signup for my newsletter to get nearly 5 hours and 50 pages of content, access to my free breathing and body mechanics course, a free acute:chronic workload calculator, basketball conditioning program, podcasts, and weekend learning goodies.
Risk of Vertebrobasilar Stroke and Chiropractic Care - Does joint manipulation pose a risk for vertebral artery breaking? Not as much as going to your primary care physician. Read this article and prepare to have your mind blown.
Cervical rotation assessment and treatment
Question:"Hey Zac, What do you look for when you assess neck rotation and needs for lower cervical rotation?"
Answer: Cervical rotation is an excellent measure that bridges that gap between craniocervical and thorax limitations.
We will be separating measuring this area into upper and lower cervical contributions.
The bulk of cervical rotation happens at C1-C2, which accounts for about 45 degrees of motion in each direction.
The remaining 45 or so degrees happens in the rest of the cervical spine. You'll also get some thoracic spine movement down to T5-ish with cervical rotation.
An easy way to measure upper cervical rotation is the classic flexion-rotation test. Here, you'll flex the neck until the chin is touching the chest, then rotate the head, shooting for 45 degrees each way.
But how in the heck do you measure the remaining cervical rotation contributions?
I'm glad you asked!!!
There is a test called lower cervical rotation, where you essentially grab the neck and rotate it as a unit.
The way you perform the test is by approximating your index fingers up against C7. Grasp the neck and rotate it as a unit, as you can see in the video here.
There isn't really a "normal" degree on this test. You have to go by feel. Usually, the test is restricted if you feel an abrupt halt or block as you into the rotation.
If you can't test someone manually, you can simply look at seated cervical rotation, then have the client actively perform the flexion-rotation test, and note the difference.
So we have two areas to target: lower cervical rotation vs upper cervical rotation
Lower cervical rotation
If there is a limitation in cervical rotation in one direction, that means you'll have reductions in:
ipsilateral posterior expansion
Contralateral anterior expansion
This limitation will occur all the way down to T5. Meaning that this test can be another test to determine if one needs upper thorax (T2-4) expansion. This test is especially useful if your supreme clientele has REALLY FLEXIBLE shoulders. Can't trust 'em!
If you see a restriction here and you've already stacked, then you want to drive activities that isolate rotation here. Movements such as cross-connects, where the thorax rotates one direction and the head rotates the opposite direction, can be a useful way of targeting this region.
You can also combine head rotation with humeral rotation, like with an armbar screwdriver.
Upper cervical rotation
If you have cleared up everything else, yet you notice there is still a restriction in upper cervical rotation, you'll likely need to either drive upper cervical mobility or target the cranial sensory systems.
Most people are either biased towards a forward head posture or a military posture. For the former, you'll need to drive slight OA flexion. You can accomplish this position easily with a drunken turtle.
If you need OA extension, simply cueing undouble chin during any move can be enough. Looking ahead in a chair and wall squat can do the trick.
You can also utilize manual therapy in this area to attain desired outcomes.
Let's suppose that you've tried this to no avail, you may have to consider affecting different sensory systems. This "fix" could either involves a dental (or myofunctional) to improve palatal tongue posture, working with a neuro-optometrist, or potentially impacting other sensory systems.
When should I refer to an optometrist?
Question: "How do you know if vision is a factor in limited cervical movement?"
Answer: There aren't really hard and fast rules when it comes to determining when you need to make the optometric referral. It's usually a cluster of exhausting conservative options and history indicating visual disturbance.
I cannot stress this enough: make the vision referral AFTER exhausting all conservative options. Meaning, you've stacked and taught other basic movement skills.
If I bold and italicize at the same time, you know I mean bidness!
The reason why I say this is because many times you can refer someone who doesn't necessarily need this discipline or doesn't have the fundamental movement skills needed to build upon visual training. Do the basics first.
Now if you've gone after conservative measures and things just aren't bopping, you might consider a referral to a neuro optometrist if you see some of the following medical history indicators:
High prescription (4.0+/- or more)
strabismus
Lazy eye
concussion history
cataracts
monovision
Abrupt changes in prescription
difficulty focusing, brain fog, have to consistently re-read, poor penmanship
LASIK/PRK surgery, especially if botched
blind in one eye
There are likely others that I'll be able to contribute as I work on this referral source and knowledge base more.
There isn't really a specific test that would point you towards seeing an optometrist, but one thing that I've seen is severely limited straight leg raise that doesn't improve with interventions.
If you need to make an optometry referral, again, try to find a neuro optometrist. Working on visual skills other than sight is critical for influencing movement options.
An overview and novel assessment of gait mechanics
Walking is one of the most fundamental movements we have as humans, yet how often do we see movement inefficiencies present in this common pattern?
You know who I’m talking about. The person who has no arm swing. The waddler, the toe walker. Clearly, something is going awry, but how do we determine what?
The best way to determine how to best improve gait abnormalities is by thoroughly understanding whatnormalgait mechanics look like.
If we know what the biomechanical ideal is for gait, we can then work backward from where our supreme clientele starts at.
Be ready to take your gait knowledge to the next level bychecking out Movement Debrief Episode 141 below!
Montreal, Canada (POSTPONED DUE TO COVID-19) [6 CEUs approved for Athletic Therapists by CATA!]
Or check out this little teaser for Human Matrix home study. Best part is if you attend the live course you'll get this bad boy for free! (Release date not known yet :(\
Here'sa signup for my newsletter to get nearly 5 hours and 50 pages of content, access to my free breathing and body mechanics course, a free acute:chronic workload calculator, basketball conditioning program, podcasts, and weekend learning goodies.
Human Locomotion - This book is the gold standard when it comes to gait mechanics.
Bill Hartman - Daddy-O Pops is one of the best PTs I know and is a big mentor to me.
Veronika Campbell - She's an incredibly smart clinician who you definitely should check out.
How to Stack - This post is the fundamental concept I teach all of my clients.
Here are some of my top articles outlining our inherent asymmetry in our bodies:
When I am beginning left stance, the sacrum is oriented to the right. As I progress through left stance, the sacrum will begin to rotate to the left; pivoting around the left leg.
During initial contact, the sacrum starts from a right orientation and begins rotating leftward towards a "centered" position. Here, the stance femur will be in flexion, abduction, and external rotation. The swing leg will be in extension, adduction, and internal rotation. The bias in the pelvis is more towards external rotation.
[caption id="attachment_13227" align="aligncenter" width="500"] Early stance - sacrum is rotating to the left, towards a "centered" position[/caption]
During midstance, the sacrum continues rotating left, and a frontal plane shift occurs within the pelvis. The left innominate will be higher than the right, placing the left femur into extension, adduction, and internal rotation. The bias in the pelvis is more towards internal rotation.
[caption id="attachment_13229" align="alignnone" width="810"] Midstance - Pelvis rotates towards the left, and there is a frontal plane shift with the ipsilateral innominate higher than the contralateral side.[/caption]
Lastly, with propulsion, the sacrum rotates fully to the left, with the right innominate being further forward than the left, completing the gait cycle. Though the left femur is still in extension adduction, and internal rotation. The bias in the pelvis is more towards external rotation
[caption id="attachment_13230" align="alignnone" width="810"] Late stance involves the sacrum rotating all the way towards the left.[/caption]
Once you've stood on your left leg like a boss, the exact opposite rotation occurs about the right leg.
Determining phase of gait restrictions
Question:How do you conclude which stance of gait is each pelvis stuck in?
Answer: Though we don't necessarily get "stuck" in various positions, understanding what happens femorally during the gait cycle can give us an idea as to what areas we need to focus on.
PUBLIC SERVICE ANNOUNCEMENT: Please, for the love of all the things I discuss on this site, make sure you can stack before doing all this rotational stuff I'm about to show you. If someone has fairly bilateral restrictions, they will benefit from bilateral work. You go too fast down this progression, and you won't get the results you'll desire. You aren't ready for the big move ;)
Once you've stacked, and you see sizeable asymmetries present in the lowers, going through the different gait phases can be the cleanup your peeps need to move ever so freely!
Let's dive into how. (left leg will be our reference)
Initial contact and propulsion activities
During left initial contact, the femurs are doing the following:
Left femur: Flexion, abduction, and external rotation
Right femur: Extension, adduction, and internal rotation
If I have femurs that are in these positions, and I've lost dynamics within the pelvis, the following motions will then be restricted:
Limited left hip extension, adduction, and internal rotation
Limited right flexion, abduction, and external rotation
If you see the above presentation, you are dealing with someone who needs to drive left sacral rotation and rotationalhip shifting. The reason for these needs is because these gait positions require pelvic external rotation, which is appreciated during initial contact and propulsion.
You'll want to start this shifty party up by rotating to the center position (initial contact activities). If driving left initial contact, you'll rotate the sacrum to the center with the left leg in front and the right leg back.
Once you've nailed this position and got some motion improvements, then get ready to propel like you're on a boat (cue early 2010's). Here, you'll rotate the sacrum left with the left leg back and the right leg in front. Posterior hip stretching is money, as are single-leg squats.
Midstance activities
During left midstance, the femurs are doing the following:
Left femur: Extension, adduction, and internal rotation
Right femur: Flexion, abduction, and external rotation
If I have an inability to reach midstance on the left, the common finding I see is:
Limited left hip flexion, adduction, and internal rotation
Limited right hip abduction, rotation can be either
It's not a crystal clear as the previous iterations. I think left extension clears more in this scenario because the left femur is extending to reach midstance, but what I see restricted is the frontal plane hip shift needed during midstance.
This hip shift is going to be the major focus of improving these restrictions. Any activity where a pelvic obliquity is created (left innominate higher than the right) is money for improving these issues. A table side stride is one of my classics in this regard:
Waddling gait
Question: What can I do about a client with a waddling gait pattern? This person has limited hip extension and internal rotation, along with very stiff feet?
Answer: You see that person who has that waddle waddle (probably not much shaky shaky), and you are thinking: "why in the hell does this person waddle?"
The answer, folks, is pretty simple:
Midstance deficiency
As you remember (hopefully), there needs to be a frontal plane shift occurring in midstance, with the stance-side innominate being higher ipsilaterally than the contralateral side.
At this gait phase, the ipsilateral femur will adduct and internally rotate.
But what happens if you lack the ability to attain this position?
I'M GLAD YOU ASKED!!!!!
If I can't adduct, the femur will aggressively abduct, causing the pelvis and trunk to sway ipsilaterally away from midline; hence the waddle:
[caption id="attachment_13232" align="alignnone" width="810"] Waddling = you can't get into midstance, fam![/caption]
Your solution to this problem is twofold: drive frontal plane shifting and pronation.
A great move to achieve this goal would be the table side stride or any type of lateral squat progression.
Sum up
Gait involves the sacrum rotating around the stance leg, with an ipsilateral frontal plane shift midway through.
Reduced external rotation-based measures respond well to activities mimicking initial contact and propulsionl internal rotation loss often improves with midstance activities.
Waddling gait patterns indicate a loss of midstance mechanics.
You’ve been all excited about teaching everyone to tuck their hips during exercise, then it happens:
“Coach, my back HURTS!!!! WTF?!?!”
That tucking must be a bunch of bs then, right?
FALSE!
Many peeps have a markedly difficult time differentiating pelvic motion (aka what is needed during the tuck) vs lumbar flexion (a common compensation seen when tucking).
When you “tuck” using the lumbar spine, there is no change in the pelvic floor orientation, reduced leg activity, and increased spinal load, which can be straining on some of your favorite lifts.
Want to know the difference and how to make your tuck feel great!?
Montreal, Canada (POSTPONED DUE TO COVID-19) [6 CEUs approved for Athletic Therapists by CATA!]
Or check out this little teaser for Human Matrix home study. Best part is if you attend the live course you'll get this bad boy for free! (Release date not known yet :(
Here'sa signup for my newsletter to get nearly 5 hours and 50 pages of content, access to my free breathing and body mechanics course, a free acute:chronic workload calculator, basketball conditioning program, podcasts, and weekend learning goodies.
Hip flexion debriefs - If you want to deep dive into hip flexion, then you'll need to check this out.
Improve your hip flexion like a boss with this move.
Spinal flexion can occur without changing pelvic floor orientation
With sacral counternutation, the posterior pelvic floor concentrically orients, and the anterior pelvic floor eccentrically orients. You will also have a concomitant reduction of lumbar lordosis (some spinal flexion) that is oftentimes uniform.
Visually, when this is performed, you will see a subtle reversal of lumbar lordosis, with minimal hinging at specific segments in the lumbar spine. Counternutation will visually look like superior and inferior pelvic motion.
[caption id="attachment_13193" align="alignnone" width="810"] You'll notice that there isn't really any indent in the ab wall as I do this. It's a good thing :)[/caption]
We typically do not see this with isolated spinal flexion. Usually, this action occurs as a compensatory strategy when someone cannot alter pelvic floor orientation.
[caption id="attachment_13189" align="aligncenter" width="403"] See how I can sweep the pelvis "underneath" me without changing the pelvic floor shape. And yes, your spine will turn green if you do this.[/caption]
Instead, the person will typically flex at a particular segment or two within the lumbar spine. You may see one part of the lumbar spine bulge out when someone does this action. Visually, the pelvic will move more in an anterior direction.
[caption id="attachment_13194" align="alignnone" width="810"] You'll see my pelvis dips forward, I crunch a bit, and have an overall stack is whack![/caption]
This strategy is undesirable because it can increase strain in particular segments in the lumbar spine. The lack of changing pelvic floor orientation will also reduce the contribution of glutes and hamstrings to the movement, as rectus abdominis becomes the predominant tucker. If you are someone who attempted to make your squat more squatty and your back hurt as a consequence, this compensation is a probable reason for it.
The solution is to drive more sacral counternutation with your tuck. There are a few different verbal cues that I like which helps attain this position:
Back pockets to heels
Pubic bone to nose
Buttflap to thigh
Tuck with abs relaxed
If someone is still strugglebus when it comes to this strategy, having them arch their back, then un-arch their back slowly usually will clear this cheat up.
Hip pinching at the bottom of a squat
Question:I'm struggling with deep hip flexion and it feels like I'm "blocked" or pinched in the front of my hips when I try to sit deep in a squat or at the setup position for a barbell snatch.
I noticed when I am good about prepping with your Wall Stride breathing that you gave me, I'm more comfortable in those positions, but it still feels somewhat blocked.
It seems that hip flexion issues are complicated, but I wanted to try and make a little sense of it if possible and see if you had any resources.
Answer: There are only about 120 degrees of hip flexion available. YET, peeps can squat well into 145 or even 150 degrees.
HOW IS THAT EVEN POSSIBLE?!?!!?
The answer, folks, is relative motion. As you progress through deeper hip flexion, there is a relative movement at the pelvis, sacral counternutation, that assists in hitting depths beyond what the femuroacetabular joint allows.
This concept of relative motion is the same reason you can go fully overhead with your arm, yet only 120 or so degrees of it comes from the glenohumeral joint proper. So-to with the pelvis.
Therefore, full thigh to abdomen hip flexion can only occur if the sacrum can counternutate.
If this relative motion is absent, pressure will buildup in the anterior portion of the femuroacetabular joint at the end of available hip flexion, often creating a sense of pinching of blocking.
The fix? Increase your counternutation skillzzz!
I sequence improving sacral counternutation in a 4-step process.
The first step is to increase sacral counternutation by working on squat progressions. Ramp squats work great for this.
If bilateral counternutation efforts don't do the trick, then you have to begin rotating the sacrum. When I perform hip flexion unilaterally, the sacrum will have to rotate towards the flexed leg. This will present with increased counternutation ipsilaterally relative to a bilateral action.
[caption id="attachment_13195" align="aligncenter" width="425"] And the sacrum will turn left![/caption]
Performing asymmetrical exercises like the wall stride are great ways of initiating this process.
But sometimes even this movement isn't enough. Now is the time to introduce hip shifting-based exercises to complete the action.
An early phase hip shift is more frontal plane in nature, mimicking pelvic position in midstance. The pelvis will appear at an oblique angle (one side higher than the other). The table side stride is a great choice for this.
If you want to push the envelope even further, you'll need to do a full-blown hip shift, actively rotating the sacrum towards the side in question. A posterior hip stretch is a prime example of this action.
If you go through this progression, there's a good chance that your hip flexion will improve, and ought to be less pinchy.
Sum up
Sacral counternutation involves pelvic floor motion, whereas spinal flexion can occur without this motion.
Flexion without sacral counternutation is an inefficient way to demonstrate intra-abdominal pressure.
Hip pinching can occur when there is no relative sacral counternutation in deep hip flexion. Drive counternutation and hip shifting to restore this motion.
Manual therapy is one of the more polarizing topics in the movement world, and no doubt you might wonder if this modality is efficacious for improving pain and/or movement.
The evidence on manual therapy in isolation is mixed, but perhaps the modality itself is not the problem.
Perhaps the problem is not having a model that can explain the utility of manual therapy, when to use it, and why.
With a decision-making model, manual therapy is something that can most definitely fit within the interventions you like.
Ready to see how manual therapy can be best applied for your supreme clientele?
Montreal, Canada (POSTPONED DUE TO COVID-19) [6 CEUs approved for Athletic Therapists by CATA!]
Or check out this little teaser for Human Matrix home study. Best part is if you attend the live course you'll get this bad boy for free! (Release date not known yet :(
Here'sa signup for my newsletter to get nearly 5 hours and 50 pages of content, access to my free breathing and body mechanics course, a free acute:chronic workload calculator, basketball conditioning program, podcasts, and weekend learning goodies.
Maitland - One of the classic places to learn joint mobilizations
Mulligan - His joint mobilizations are great, as movement is involved along with it.
Is manual therapy effective?
Question: I've been in a "structural integration" training program (aka rolfing), and can't help but notice that some prominent PTs seem to hate any method of manual "myofascial release" or which seems to have an effect on the myofascial matrixes and ease of movement in portions of the body.
Why is this? Clearly, people do improve from manual therapy, and while it is not the only answer, and can be better or worse, it seems to be wholly discredited as a pseudoscience, implying merely a placebo effect. But shouldn't there be credence to the case-studies, instead of picking-and-choosing studies with the intent to discredit contrasting strategies?
To be frank, it seems like unnecessary bullying, as each professional seems to have a tendency to smack-talk other modalities. In short, do you think manual therapy (increasing "fascial glide") is useless or inefficient, or that they may be a synergy between manual therapy and coached movement?
Answer: To say that manual therapy is useless is a bit hyperbole. Although the evidence isn't definitive (what is in our field), there are a few different areas where it has shown to be effective. In fact, in hip osteoarthritis, manual therapy has been shown to be more effective than exercise (GASP!!!).
To completely throw out manual therapy is potentially missing out on a worthwhile treatment that can help your supreme clientele. Chances are, it's likely more than a placebo. There are neurophysiological and viscoelastic changes that can occur because of manual interventions, and there are several other variables that we simply aren't measuring.
For me, manual therapy plays a role in my care, with the intent that it is used to change objective tests meaningful to both myself and the patient.
There are three specific instances in which I use manual techniques:
As a regression from active exercise
Symptom management
Patient preference
If a client cannot achieve the position they need to be successful (e.g. sacral rotation or a full exhale), you can use manual interventions to put them into the position needed, building context so the client can at some point actively get there.
[caption id="attachment_13124" align="aligncenter" width="500"] Took me FOREVER to draw this[/caption]
I also use manual techniques if someone needs increased symptom relief after exercise. Sometimes, a local input can help reduce symtpoms for a shorter period of time, allowing them to exercise more effectively.
Lastly, if a patient wants to be touched, I do not see the harm in getting them the hands on contact. We are social creatures, social grooming is in our DNA, give your surpreme clientele a bit of what they want, then you'll have the buy-in to give them what they need!
What manual therapy techniques do I recommend?
Question: What types of manual therapy techniques do you most recommend?
Answer: There isn't one specific technique that is going to lead to profound results versus others. You have to choose what you are comfortable with executing and which changes relevant objective measures.
That said, I discussed some of my most used techniques here. It's a bit of an older post, but much of the framework remains.
There are different methods that I gravitate toward now then in that post. Here is the list:
Ribcage and pelvic mobilizations: Some of these I've gotten from PRI, some from Greenman, and some I've just made up.
Joint Manipulations: Mostly spine and extremities, often for symptom relief and to gain particular ranges of motion.
Dry Needling: I don't use often, but I do have some of my population request it. It's quite effective and can be performed fairly quickly
Soft tissue mobilization: I've taken ART in the past and Dermoneuromodulation, which are both my top choices. The former for speed, the latter for those who are a bit more sensitive or acute in symptoms. Sometimes I'll just do some classic manual contact holds.
Joint mobilizations: I've grown to appreciate the utility of these techniques more. I'll usually start passively, then glide into a position while the patient peforms the movement with me, and then choose an active exercise to reinforce.
The Best Manual Therapy Techniques
Question: Do you use manual therapy for example to release posterior lower compression?
Answer: Yes. You can see many of the techniques I use in the video, but the major key is to use your hands to "block" the places you don't want air, which forces air to go in the places you oh so desire.
Sum Up
There is some research to support manual therapy and is particularly effective when applied in a cohesive model
There is no specific technique that is better than others
Utilize test-retest methods to determine treatment efficacy.
If you want to improve your movement capabilities, is there gym equipment that can help you?
If moving better is important to you, you’ve probably wondered what gym equipment would best help me reach that goal?
Gym equipment is endless and often gimmicky, so what would the essentials be to get me to where I want to go?
Fortunately, you can improve your movement capabilities without much equipment. Being able to position your body with many of the coaching tactics we discussed is the #majorkey
That said, there are some equipment pieces that make coaching WAY EASIER.
And I’ll tier this for you fine folks based on your budget :)
If you are just building a home gym or beefing up your current gym, then check out Movement Debrief Episode 138 below!
Watch the video here for your viewing pleasure, or listen to the podcast if you can't stand the sight of me :(
If you want to watch these live, add me on Instagram.
Montreal, Canada (POSTPONED DUE TO COVID-19) [6 CEUs approved for Athletic Therapists by CATA!]
Or check out this little teaser for Human Matrix home study. Best part is if you attend the live course you'll get this bad boy for free! (Release date not known yet :(
Here'a signup for my newsletter to get nearly 5 hours and 50 pages of content, access to my free breathing and body mechanics course, a free acute:chronic workload calculator, basketball conditioning program, podcasts, and weekend learning goodies.
The best exercise equipment to get
Question: Would love to see a video on the best equipment for building a performance/rehab gym in regards to the model you use. Even the brands/model ....safety bar, ramps, hex bar, etc.
Answer: To improve movement options, you don't really need a whole lot of equipment. You just have to ensure that you can challenge your body to get into positions it normally struggles with. The hope is then that you are crushing life once that happens.
That said, the right piece of equipment can help quite a bit at enhancing both your movement and fitness.
Here is a list of stuff I would look into, depending on what your budget is:
The home gym essentials
Heel Ramp - These are essential to improving your squat depth, which is a critical motion to improve your movement options throughout the body. A heel ramp makes it easier to vertically displace the pelvis. I like the one that my boy Levi Kirkpatrick makes get large. Olympic lifting shoes can also be an alternative, to which The Nike Romaleos are the best. If you want to save some buck, use books
PVC pipe - These are useful to do supported lower body activities and can incorporate rotation through the trunk. Dowel rods work great as well.
Kettlebells - These are quite versatile and offer way more loading options than dumbbells. They are much easier to hold for squats as well.
Power blocks - These are adjustable dumbbells that can save you space.
Superbands - these are great bands that provide versatility in loading for pulldowns and chops.
Cook bands - These bands are great for jumping, chops and lifts, unloading exercises. They rock!
Airex pads - These make any kneeling or inversion-based activities go WAY better.
Slideboard - A great piece of equipment for improving frontal plane mobility, pronation, and gives you tons of variety. You can do hamstring curls, body saws, the possibilities are endless.
Sled - Use for pushes, drags, pulls, all types of awesome stuff.
TRX - The amount of variety you can get to do with bodyweight stuff is endless with this piece of equipment.
Plyo boxes - You want something with a hard surface to land on and is adjustable. If you are doing any jumping, this is a must.
Mini hurdles - Once you've nailed box jumps, hurdle jumps are the next logical progression.
Glute ham raise - Great for nordic hamstrings and side hangs.
Specialty bars - I don't use often because you can accomplish most things with the regular stuff. If I had my choice, the spider bar, safety bar, and neutral press bar would be my top choices. The transformer bar also sounds appealing but I haven't played with it.
Raptor - Great for resisted sprints, backpedals, and more. The best part is your hands can stay free and move!
The best cardio machines that also improve your movement
assault bike - I love it because you can alternate pushing, pulling, and rotation!
Versaclimber - One of the best options to drive frontal plane conditioning. Your ribcage is going to be opened up like cray cray.
Jacobs ladder - Resisted crawling for conditioning? Drivinng all types of thorax rotation? I'm sold.
Treadmill - Although the free-running treadmills are dope, I like the classic ones to drive high incline walks and to run on when they are turned off.
If you got the money and space
Buy machines. Straight bodybuilder stuff. I love these for the following populations: geriatrics, obese, deconditioned, post-surgical, and variety with peeps who do a lot of free weight work. It's just fun.
What is the best home office set up for health and productivity?
No doubt your virtual work has increased since COVID began, but should you spend more time sitting, standing, or even on the treadmill as you work?
Unsure what equipment is going to keep you healthy, productive, and moving like a BOSS?
Surprisingly, there is a TON of debate around what type of desk or sitting recommendation is most effective for health and work output. The winner isn’t clear cut.
If you want to beef up your workspace, then
Check out Movement Debrief Episode 137 below to learn how.
Montreal, Canada (POSTPONED DUE TO COVID-19) [6 CEUs approved for Athletic Therapists by CATA!]
Or check out this little teaser for Human Matrix home study. Best part is if you attend the live course you'll get this bad boy for free! (Release date not known yet :(
Here'sa signup for my newsletter to get nearly 5 hours and 50 pages of content, access to my free breathing and body mechanics course, a free acute:chronic workload calculator, basketball conditioning program, podcasts, and weekend learning goodies.
Secret Lab - My colleagues swear by this chair. It's comfy as all hell.
How to set up your home office
Question: Hi Zac! Any chance you can squeeze in some recommendations on home office set up in your next live session? Curious if you have preferences for types of chairs, desks, standing vs sitting.
Answer: With this whole COVID thing going on, there is no doubt a lot more remote work to be had, which comes with increased sedentarism.
Anything that can be done to offset the lack of movement is going to be quite important. With the increased popularity of stand-up desks, are these worthwhile to invest in?
As of right now, the research is mixed. Let's first look at the difference in mobility in comparing three options: sitting, standing, and treadmill desks.
Though treadmill desks may have you moving more, there doesn't seem to be much difference between sitting and standing. The issue in both of these cases is a lack of movement. No one posture or position for long periods of time is desirable. This may contribute to increased tissue ischemia, and subsequent pain or discomfort.
The key is you need to move!
My other question was do these desks impact work performance at all?
According to the aforementioned systematic review, most typing and mousing activities were not reduced with a standing desk. In fact, one study showed greater task engagement when working at a standing desk for 30-minute bouts. In comparison, a treadmill desk seems to reduce performance in typing, mousing, and other fine motor tasks.
One thing that is missing in the literature is can meaningful work be pursued while you are standing or on a treadmill? No one is measuring if the next great American novel can be written well and without interruption on these devices. Or if Zoom calls can be performed while staying on task. We just have a lot of unknowns.
Given the current body of literature, and the cost/benefit analysis (standing desks are HELLA expensive), I'm going to sit this one out for right now (HA!).
[caption id="attachment_13061" align="aligncenter" width="810"] This is my current desk setup. The dual monitors KILL[/caption]
What I would recommend instead is taking periodic breaks as you work. Go out for a walk, do some pushups or kettlebell swings; anything to break up the monotony. The research varies on how long we can focus, so find your sweet spot between 30 and 90 minutes, and get up and move. I go for short walk breaks of 5-15 minutes periodically throughout the day. Stay off screens during this time. You need to rest.
If you are sitting, get a chair that's comfortable. I found an old chair that works well for me, but many of my colleagues swear by Secret Lab. When I'm due for a chair, I'll probably go this route.
One other thing I would strongly encourage you to get is a separate bigger monitor, especially if you work on a laptop. This has been the biggest game-changer for me productivity-wise. If you have a small screen that you have to focus on for extended periods of time, your eyes will strain WAY more, which can fatigue your eye muscles; especially if you split-screen on your laptop.
When you have a bigger monitor, your focus can be a bit more diffuse, which is a huge win. Doing this as well as air casting my movement consults on my TV has significantly reduced the eye strain I used to experience on calls, and I can keep better focus.
I would also strongly recommend getting evaluated by a behavioral optometrist. I like COVD-trained. I worked with one in the past when I did PRI Vision, and my reading comprehension was quite a bit better.
I also recently met with an optometrist in Vegas with who I will be doing vision therapy to better help my ability to focus on screens. She also updated my prescription to help reduce eye fatigue. Even if you see well, your eyes may not work well together or have other skill deficits. Vision therapy can improve upon these areas. You may also look into apps and glasses to reduce blue light at night.
Also positioning your desk near a window is big, as looking off into the distance periodically can help give your eyes a break from the constant convergence required for screen use.
The other thing I would strongly recommend investing in is a good pair of headphones. Preferably ones that have noise-canceling, that way the volume can stay low, and your ears can stay protected.
I have two pairs that I use. If I'm not moving around much, The Sony WH100XM3 (the 4 is currently out) is amazing. Best noise canceling in da game.
[caption id="attachment_13063" align="aligncenter" width="451"] Plus you look like a cool DJ on calls[/caption]
If I have to move around for a call, they suck to demo exercises in. That's where a lot and can't do the ear coverage, the Status BT Transfer are my go-to.
If you are someone who has to read a lot for your job, and you don't want to hold onto a big textbook, I strongly encourage that you get a bookstand. I like the BestBookStand brand.
Sum up
There is minimal activity or productivity differences between all desk types; movement is the key.
Using a big monitor and glasses can reduce eye strain
Use noise-canceling headphones to reduce ear strain
You might be head over heels for all things breathing,but what if your clients aren’t?
Maybe you are the person who struggles to get buy-in to breathing-based exercises? Or you are unsure where to put it into training. Or maybe you are looking for sneaky ways to incorporate the principles WITHOUT YOUR CLIENTS EVEN KNOWING.
The biggest error peeps make incorporating breathwork into training is making it something separate.
In fact, looking at movement in this fashion is an all-encompassing model. Following principles that go BEYOND BREATHING is a major key.
Don’t worry folks, we will go over those principles, and make it SUPER EASY to get your clients all the benefits with less pushback.
Check out Movement Debrief Episode 136 below to learn how.
Montreal, Canada (POSTPONED DUE TO COVID-19) [6 CEUs approved for Athletic Therapists by CATA!]
Or check out this little teaser for Human Matrix home study. Best part is if you attend the live course you'll get this bad boy for free! (Release date not known yet :(
Here'sa signup for my newsletter to get nearly 5 hours and 50 pages of content, access to my free breathing and body mechanics course, a free acute:chronic workload calculator, basketball conditioning program, podcasts, and weekend learning goodies.
How to Coach the Stack - This post outlines one of the most fundamental moves I teach clients
Question: I know we talk about when working with a person on breathing, to have them breathe out for 15 seconds or think about blowing out a bunch of candles.
But in pursuit of progression or keeping a client motivated and not bored. What do you find is a good standard to move them to the next progression (pullover to hanging breathing into a balloon)? Is it, you see them able to get abs immediately or are you looking for, say 3 sets of good position and breathing, everything? Is it table tests and you retest and find improved movement?
Getting someone to breathe right can be slow and monotonous, so how can a professional present the roadmap of progression for a client buy-in?
Answer: The biggest error most people make when attempting to build breathing buy-in is to make breathing something different than regular training.
It's not.
The positions coached during breathing exercises are fundamental components used during training. Think of them as regressions from skills you want clients to be able to perform.
For example, a chair and wall tilt looks a lot like the squat when you tilt it right side up.
[caption id="attachment_13032" align="alignnone" width="810"] Only with the highest levels of innovation and technology could a visual like this be created[/caption]
Well, consider if you can't get into the positions we need you to on your back. How well do you think the squat will go? You probably won't die (except that one time), but you won't get all that you could from the movement.
The low-level breathing positions help set the stage for the rest of the training program. They build context for what you need to do at higher intensities.
It's just like if you wanted to play Stairway to Heaven on the guitar, you have to learn to put chords together first. So-to with training. Breathing is the chords, and if you get good at it, you'll be Jimmy Page in no time!
And if you do them right, many times your clients will get smoked and have a HUGE training effect from them. I can't tell you the number of times when people get the stack on point how cooked their hamstrings, glutes, and abs will become; key areas that will likely resonate with your clients. If your gen pop client gets the association that these moves build my glutes and abs, then you've won.
Ideally, the concept taught in the breathing move would carry over elsewhere to training. So you should see a relative "stack" in most activities your clients perform. In terms of when you focus on different movement qualities, seeing test changes can guide your next focus area. In PT-land, these can change weekly to biweekly. If I'm training someone, it might be every block change.
Now that doesn't mean that if your client can't stack that they aren't allowed to get off the ground. You may just modify your exercise selection to things with a lower error risk. Most people can do iso holds, med ball throws, sled push/pulls, and upper body movements in the sitting position. Select activities with the lowest error risk.
Now I get it, you will have those clients who just won't be about getting on their back and breathing at all. We all have them. For those peeps, you may just consider working on tucking to "work the glutes and hamstrings" (tell them this because that will better resonate with them) and coaching loaded exercises as best as possible. Just like the above client who doesn't move well, choose moves that your client will be able to perform with fewer coaching requirements. The best part? Your clients will still be breathing while they train, so you can still get some good movement benefits.
Where should I put resets in the training program?
Question: Is there any value to inserting "movement restorative" exercises/positions in between reset breathing sets to facilitate or further drive the resetting process?
I ask, especially when in coaching breathing to start the session, sometimes the clients are geared up to get into a movement - either from being stimulated to get the work going or from a stressful meeting, etc., so I see the struggle to maintain a degree of focus in accomplishing the reset work.
Answer: Totally! A lot of my programming involves sneaking in these moves during the rest periods for clients. It'll save them time, keep them loose, work on the movement qualities they need, and potentially enhance recovery.
Aside from choosing the particular resets, they need to work on specific limitations, you can choose activities that will complement the areas being trained.
For example, if someone is doing some heavy upper body stuff, a bar hang could be effective at increasing motion in the upper body.
Or if you have someone squatting, the drunken turtle may enhance depth by reinforcing the positions needed on the squat.
Conditioning for different infrasternal angles?
Question: Would certain types of cardio benefit one postural archetype more than another? If I’m working with a compressed a-p person and a wide ISA person with the same goals, would your cardio choices differ?
Answer: In a perfect world with unlimited equipment, absolutely. Just like we can pick loaded exercises to reinforce particular movements, this doesn't change whatsoever for conditioning tools.
For example, certain cardio machines may be effective for driving particular movement adaptations:
Versaclimber: Increase ISA dynamics and frontal plane pelvis mechanics
Jacob's ladder: Improve spinal rotation
Elliptical: Improve spinal rotation
Airdyne (high seat): Improve spinal rotation with an external rotation bias
Airdyne (low seat): Improve spinal rotation with an internal rotation bias
Slideboard: Improve frontal plane hip and ankle motion
The options here are limitless, but if you lack the equipment, you might not be able to be that specific.
Don't worry, your client won't be doomed to movement failure, there are a myriad amount of other benefits you can get from cardiovascular work aside from movement skills.
Regarding specific energy system adaptation, it depends on what task we are trying to improve. If in the early stages of training, I may bias more cardiac output or extensive tempo intervals; both to build work capacity and because aerobic exercise may enhance learning.
From there, it depends on your client's goals. If hiking is the prime target, high-intensity continuous training may be a great choice. If they need to be faster for a sport, you may do speed work.
As with anything, look at the demands needed of the terminal task, your client's movement, and physiological capabilities, and give them what they don't have.
Sum up
Breathing is not a special part of training; the positions are taught as components needed for more challenging movements
Breathing exercises can be used to increase motion or to maintain motion potentially lost from challenging moves
Conditioning exercises can be chosen to improve motions needed for longer durations.
How a dentist can improve your sleep, breathing, and more
If you have perfect sleep, NEVER mouth breathe, and have excellent tongue posture, then you can skip this post.
But if you are like the rest of us, no doubt you or your clients struggle in one or many of these areas.
What if all of these issues were related to the structure of your mouth?
That’s why I interviewed Dr. Brian Hockel, a dentist who I work with personally, and a leading expert in the field of dentistry and airway orthodontics.
[caption id="attachment_12956" align="aligncenter" width="600"] The legend![/caption]
In this podcast, you’ll learn:
How facial structure can impact breathing and tongue position
Why a CPAP doesn’t really fix sleep apnea
How a well-trained dentist can improve mouth position to enhance your sleep and breathing
How occlusion, tooth contact, may not be the exact science that people make it out to be
What you need to look for to find a dentist who can best help your sleep and breathing
If the health of your airway is important to you and you want to get your sleep on fleek, then you need to check out this interview.
His practice is located in Walnut Creek, CA 64598.
Bio
As a graduate of the University of California, San Francisco, School of Dentistry in 1989, Dr. Hockel is a general dentist in private practice with a focus on orthodontics that aims to prevent or treat airway problems like sleep apnea.
He aims for more permanent solutions to Airway-Friendly Smiles, going beyond the dental oral appliance approach, often having to reverse previous orthodontic treatments.
He has lectured nationally and internationally on topics of facial growth guidance, orthotropic, and airway orthodontics, and is an orthodontic instructor for the Academy of Airway and Gnathologic Orthopedics (AAGO).
He is also co-founder of the Team Airway Study Club, a co-founder and board member of the North American Association of Facial Orthotropics, and a board member of the AAGO.
Show notes
Here are links to things mentioned in the interview:
Joe Cicinelli - He is our mutual physical therapy colleague, and a dear friend.
ALF - A lightwire appliance that is often used when there is cranial dysfunction present
DNA - An appliance that aims to expand the palate in multiple directions. It's akin to the Invisalign of palatal expansion
AGGA - An appliance that is used for sagittal palate expansion
The difference between conventional dentistry and airway dentistry
Dr. Hockel:I think a lot of it has to do with the understanding of how we get to where we are and what the underlying causes are of some of the problems that we're dealing with. And then the connections to what we're doing in the orthodontic world, the orthopedic world. By that I mean if you understand that our growth really affects our function, especially of the airway but certainly of the jaw joints and of the bite, how those relate to each other?
if someone says “we are the way we are because of our genes; we're just going to grow.” “This is a set shape to the skull, a set position for the jaws and it is what it is and make the teeth fit within that confine of the skeleton.” That's going to lead you to a very definite approach in orthodontics.
As opposed to the belief that the way we posture our mouths and the way we use the muscles of our mouth and head and neck, that's going to affect how our face grows at a young age.
Then as an adult, it's going to affect the function of the airway, again of the joints and that maybe if we look for the underlying causes and address them, we can have other successes beyond just getting the teeth to fit.
So it's looking beyond how the teeth fit together and looking at the overall structure; jaws, airway.
It turns out that the roof of the mouth is the floor of the nose. The nasal airways are our next-door neighbor that way going up and the oropharyngeal airway is right behind the tongue. We're always looking at the back of the throat but we don't recognize that that's where the air has to go to be able to breathe. So there are neighbors in the dental world and it turns out that the things we do affect them.
Zac:It's a lot more than making a pretty smile in terms of the impact that you can have on someone's health and well-being.
What kind of implications or negative things have you seen from people who don't respect that? We've spoken before having this conversation about some people who are just doing retractable orthodontics which maybe you can talk about. They're just pulling teeth so things can fit and the smile can look nice.
What are some of the implications of not taking into consideration the structure of the face?
Dr. Hockel:It might be an overstatement to say that most orthodontists are focused on just making the teeth pretty because obviously there's a lot of science that goes into how we try to make the teeth fit. Jaw joints and even airway are in the conversation, though the latter seems to be lip service.
The best way to answer your question would be to use a term that was coined byDr. Bill Hangin Southern California, he calls it ERRS (extraction retraction regret syndrome). He purposely called it errs because it's based on the answer to your question,what are the errors that we've been forced to live with?
The first is kind of an aesthetic one where people don't like the way they look and with a lot of traditional orthodontics. There's a feeling like maybe the teeth are further back in the face than they should be or the lips seem sunken in or thin. There might be a feeling like the face has lengthened after orthodontic treatment has been done.
Then there's the whole functional side and this includes, both the airway and the jaw joints and also includes the bite, of course, the way the teeth fit together can be affected by that. How we chew and how we breathe, they can go hand in hand.
If you bring teeth too far back in the face, the tongue doesn't have enough room, the chewing motions of the jaws can be affected and of course, the dimensions of the oropharyngeal airway can be affected. People who live with this for a long time and have been told this or that thing is all in your head and you just need to learn to deal with that.
[caption id="attachment_12855" align="alignnone" width="810"] How embarassing[/caption]
We who work in the orthodontic profession may be saying your bite is fine, everything fits together, it meets every possible standard that or criteria that I could have treated it to. So whatever you're not happy with, it's not what I did and maybe I did treat to the best standard of care that's out there.
But we're learning now that there are things beyond what we've been held to and by ourselves and others and what we try to achieve that have really profound and far-reaching effects that we weren't even aware of.
Zac:I mean you just think of this area of the body, you have most of your sensory systems there. There’s a lot of prime real estate that could potentially be influenced in one direction or the other.
It's intriguing that you're saying the wide-ranging effects that can happen on this. I remembera studyI read years ago about people who had PTSD. They put an appliance in the person's mouth as treatment in this randomized control trial and it had a profound impact on symptoms.
We can have large substantial changes on someone's health and well-being by affecting this area of the body in the way that you're talking about.
Now you weren't always into the airway side of things so in your career what led to you appreciating this side of dentistry more?
Dr. Hockel:I think it was contact with doctors like Bill Hang andJohn Mew.
John Mew is an orthodontist in the UK who for many years developed treatments that were based on what he called thetropic premise.That was the belief that the jaws are going to grow to the position that they most commonly adopt, so keep your jaws closed, pointed forward they're going to grow forward. Keep them apart, pointed away from each other they're going to grow away from each other.
It turns out that the treatments he was doing to get the face to grow to what was a better proportion, more aesthetically pleasing result; it was also making a difference with the airway.
Initially, he didn't really even realize this so he's one of these people that looked at the results of what he was doing and actually saw something really good. There were a lot of us that looked at the results of what we were doing with more traditional methods and saw that we weren't doing things that were good.
Bill Hang, who I already mentioned, is probably the biggest influence on how I’ve been able to connect the dots between the airway and what we do in the orthodontic and orthopedic world.
I thought I had every answer that I needed at one point and I suppose sometimes we get that state of pride in our careers. At first it can be unnerving to learn something new but then you can get to a point where you're kind of in a zone, you feel comfortable and I felt like I had a tool to treat pretty much every type of bite problem that I could come across.
It was right then that Bill Hang dropped into my life and taught me to look at things in a very different way that included growth direction, growth guidance, developing more space for the tongue, looking at the oral posture. Especially looking at what was happening with the airway and how things affected that.
Like most of the people who've heard Bill Hang, there was some of it that I readily accepted and other things I was skeptical about. I had to go home and think “I don't know if he's really right about what he says about theherbst appliance” for example. I’m going to go home and look at my cases a little more critically and I just shook my head as he was right.
There were things going on that I didn't want to have going on right under my nose because I wasn't paying attention to it. So now my attitude is“just don't cause any harm, don't do anything that's going to make anything worse.”“And if you're doing something that has made other people worse and you're not sure if it's going to make this person in front of you worse, just don't do it,” it's the safest thing to do.
Zac: Yeah and I imagine too if you're not taking into consideration things like oral posture airway and things like that just because of how important respiration is. You could have wide-ranging effects of doing harm that you didn't know you were doing.
Dr. Hockel:Right or at least miss the opportunity to do good, to me that's just as bad; if I had an opportunity to do something a lot better for someone and I missed the chance, I don't like that.
Zac:Was that hard for you to have that kind of paradigm shift?
Dr. Hockel:Yeah my wife would tell you, I was in a very difficult mental state during those years. It was a big paradigm shift and very emotional and around that time we had a lot of little kids around the house. It’s hard to realize your professional foundation isn’t as solid as you thought it was. I knew however, that I needed to keep growing and learning; not being foolish to where I thought I knew it all.
Zac:Yeah, that's when you know you need to retire or quit.
What types of patients would benefit from airway orthodontics
Dr. Hockel:I think the people that search me out know that there are important ramifications of the types of treatment we do in orthodontics and in growth guidance. And they don't want something bad to happen to their kids or they're an adult that has already seen something that happened to themselves.
We talked about extraction retraction regret syndrome and there's either an emotional component or an aesthetic component, more often I see the functional component. People will come wanting to know what they can do to improve their situation as an adult and some of them might come very bitter about what was done with them in orthodontics.
It's unfortunate because the person who treated them was only treating what the standard of care was at that time and they probably did a very good job.
[caption id="attachment_13014" align="alignnone" width="500"] Making kids unhappy in more ways than one since 1960 (Photo credit: Orthodontist101)[/caption]
I don't see too many people who were treated by an orthodontist who did a bad job; they were just doing it with a very different philosophy of how to treat and why to treat. So there are the moms with the kids that want them to grow right, that's a group of people who have young kids and they want to catch them as early as possible.
The earlier we get to kids the better.
I’d rather get kids at six days old and talk to the parents at that point. Make sure there's no tongue tie, make sure you're breastfeeding as long as you can, try to switch to solid food as early as you can, and the whole concept of baby-led weaning. Take away bottles, pacifiers, and sippy cups.
So it's not classic orthodontics to talk to a parent about their child when they're that young. And yet, if they follow what advice I’m giving them, it can help minimize what I might have to do later on.
I think the goal would be for us to really find as far upstream as we can go to find the causes that can be addressed so that we don't have to treat them at the stage where we are. Even at age four and five when I’m treating a child that young in a way, it'd be better if I could have got them earlier.
Tongue ties
Zac:It seems like even the concept of having your child have a tongue-tie release is very controversial. I read stuff on the internet all the time where it's like “oh, we don't need to do that” and it's unfortunate because it can definitely negatively impact things like breastfeeding and things of that nature.
Let's say I have a kid and I say “Dr. Hockel, do unto this child what we can do to minimize any negative effects,” where would you start?
Dr. Hockel: Well those things that I just tossed off a little bit of a list when they handed me that little scissors to cut the umbilical cord in the delivery room for my kids. I look back on it now and think I probably should have just looked around like lifted their tongue going “okay, I’ll just do that first!
Tongue ties can affect speech and growth. When they’re really bad and a lactation consultant picks it up and says you're not able to breastfeed because of the tongue tie, they deal with it. Or if a speech pathologist says your child can't make those sounds because he's tongue-tied, they deal with it. But there's a wide range of restricted mobility of the tongue that can come before you ever have any of those kinds of troubles and it does affect the tongue posture.
There's research that's being done now bySouresh Zaghi,but it’s going to take time to build the evidence body.
They showedat Stanford that when you have a tongue tie, there's a correlation with narrow palates, and it kind of makes sense, it’s common sense. The tongue is the scaffold of the palate so if it isn't able to posture up against the palate, how is it going to grow wide and up and forward? It's going to tend to be narrow and down and back.
While we cannot expect adults who get a tongue tie release to grow differently, we do know that the muscles of the head and neck can be in better balance with good oral posture. I’m not an expert in cranial osteopathy but I’m told that the cranial bone and the balance of how they fit together and move, you know cranial bones move right?
[caption id="attachment_12694" align="aligncenter" width="329"] Now I got the loosest tongue in the game...wait....[/caption]
Zac:Haha yes I do!
Dr. Hockel: Some adults will report some wide-ranging improvements of symptoms and you got to be careful about that. Because they'll tell their story on the internet and somebody else thinks “oh if I go get my tongue-tie release, all my troubles are going to go away.”
It is controversial probably because there's such a wide range of techniques in doing it. Back in the day, I got my laser in 1999 and I thought “oh, there's a tongue-tie, I’ll just release that tongue-tie with my laser” and it's like getting a lightsaber on Star Wars. There's no bleeding and all of a sudden the tongue can just elevate really easily.
Mainly, all I was treating was that flap of tissue on the outside not knowing that there were deeper fibers that of fascia or even the mylohyoid going deeper that needed to be dealt with. Then the scar tissue would come because I wasn't having them do exercises afterward and the scar tissue ends up restricting the tongue down even more than it was before.
Doing it the wrong way is oftentimes going to make things worse and not any better at all so the data points that people have to compare to are very limited.
The unfortunate thing is we currently lack a body of knowledge out there of training. It's changing slowly because people know improvement when they feel it. You can't put an idea in somebody's head that effectively after I do this all of a sudden you're just going to imagine that you have a tension release in your whole head and neck area. They're going to tell you stuff like that or you see a child who has a tongue tie and you get a certain growth direction improvement. Then don't treat the tongue tie and you see the growth direction tend to drop back, that's kind of the lost opportunity side of it.
You want to get everything going in your favor for optimal mouth posture.
Facial underdevelopment
Zac:Now if you have someone who was breastfed, had a tongue tie release, did myofunctional therapy, addressed nasal patency, do you see a reduced need for orthodontic services down the line? Or do you think that our altered cranial shapes are generational?
Dr. Hockel: If I had seen that happen here or there, that's such a small number of patients, it's really anecdotal and there's confirmation bias. I’m not sure how valuable that would be, I do know that I see patients who were breastfed very early on and their parents follow Westin Price. They feed them really well and try to avoid sugar and stuff, they avoid bottles and pacifiers, avoid milk, avoid wheat and they seem to be doing all the right things.
Yet there are still issues there so there's so much that we don't understand about it. I feel like we're just at the tip of an iceberg and we're doing our best, we know certain things do affect it and we're trying to change those but we don't know everything.
I can sympathize with the mother who says that “I’ve done all this, what else do I need to do?” Well, sell everything you own, give it to the poor and then maybe… I don't know.
Zac:It's hard, especially in health and wellness. You want people to do everything right. They eat healthily, they're sleeping and they're doing all of this, but sometimes there are genetic factors, epigenetic factors, and exposomal factors outside of your control that are the rate-limiting steps. It's unfortunate. But life's not fair either so I get that.
Airway orthodontics for children
Dr. Hockel:Orthotropicscan be used for kids in a particular age range. There’s a narrow window because orthotropics is growth guidance, and if you're trying to guide growth you need growth to be able to guide.
There are actually a couple of different windows where you can do it but for practical reasons, it tends to be a better fit somewhere in the 7-10 age range. In England, they'll say eight is too late, but in America, we tend to do it at nine or ten as well.
The older you get, the less growth there is and the less cooperation there is to be able to do what’s required for the treatment. So guiding growth and starting at that age; say seven or eight, you want to look at how the face is growing. You want to look at imaging to see how the airway might be restricted.
Although you can’t diagnose from imaging, it's a glimpse into what's going on in the nasal airway, the oropharyngeal airway, and tongue posture sometimes.
Then you look at obviously orthodontic issues like how the teeth are fitting together, and how the jaws are fitting. If the jaws have not grown as far forward as they should and there's an oral posture issue, those are two things you can consider affecting at that age.
Younger than that age, it's harder to make a change with how the jaws are growing with appliances and postural changes, and after age 11 or 12 it's very difficult, so during those middle years is prime time for treatment.
I had two boys in my office yesterday morning. Both of their faces were tending to grow more downward and backward than they should, and I always say “welcome to our world.” That's all of us to one degree or another much more so than our ancestors a few hundred years ago.
I looked at their imaging, teeth, questionnaires, and my notes from their exam and I thought I think they could really benefit from just simply widening out the dental arches. This would give their tongue and teeth more room. Then releasing the tongue tie could really help oral posture.
Then I got their sleep studies. Both boys had overnight sleep studies and had sleep apnea at over 11 events an hour. For a child that's severe. For you and me it'd be 32, 35 or 40 times an hour (normal is less than 5 per hour). When I saw that, the scale was tipped WAY in favor of orthotropics. Meaning it'd be worth the cost, the time, and the hassle if the parents and the patients were candidates for it.
Cooperation both by the child and by the family is so much a part of orthotropics. It's not like any other treatments that we do. Lack of family support, discipline, or money are all factors to consider.
What I like to do is look at what are the problems; what are this family's capabilities and desires and then what's possible from a technical point of view. How can I put all that together in a way that's going to be a win-win and get a good result?
[caption id="attachment_13015" align="alignnone" width="810"] Yeah, let's discuss airway later honey. (Image by Dimitris Vetsikas from Pixabay)[/caption]
Had it been a family that came in where the kids were climbing up and down the chairs in the room, they weren't listening to me at all when I talked to them. The mom's on her phone trying to carry on a conversation at the same time talking to the dad who doesn't live with them and is trying to tell him “don't worry, I’ll bring them over;” you know just a lot of other challenges in life for a situation like that.
Even though I knew it would make a big difference for them, I wouldn't even mention the word orthotropics because it's going to be frustrating and in the end, not a fruitful endeavor.
Airway Orthodontics for adults
Dr. Hockel:Let’s assume there’s an airway problem, have sleep-disordered breathing, and don’t want to be on a CPAP for the rest of their life. What are the options?
Although everyone is different, there are a lot of commonalities. The three general approaches are:
Dr. Hockel:The first is to push harder on the air going into the airway.That's the CPAP option and usually, there's kind of an x through that option, but for a lot of people, it is a realistic option. If those boys from earlier had severe sleep apnea, I told them “you need to follow the doctor's recommendation.”
CPAP is a viable first aid option. Whenever we do growth guidance, changes in the skeletal structure aren’t going to have an effect overnight, so just get some good sleep and get healthy in the meantime.
Oral appliances
Dr. Hockel:Option two would be to open the airway temporarily at night time, and that's effectively what the dental appliances do.
When you see dentists or orthodontists talking about how they treat sleep apnea, generally it's because they make appliances like this. There are over 200 different FDA approved designs for the appliances so there are lots of ways to try something and not be happy and then try something else and not be happy.
Or you get a good fit, if somebody really knows what they're doing and making these appliances, they look at other things beyond just the appliance itself then they can be effective too.
They have their place; everything has advantages and disadvantages and the big advantage of an oral appliance is you don't have to be married to this machine on the bedside table. You're not dependent on electricity, you could bring it with you when you travel a lot easier, it's less bulk in the mouth, it's not as unromantic as having this thing strapped around your head.
It’s got downsides too and that is it's not really fixing the underlying problem, it's not addressing the structural underlying problem for most people.
The other downside is that it's anchoring a lot of force, pulling the lower jaw forward on the upper teeth. So there tends to be a reciprocal effect on the upper jaw of pulling it backward and over time that can allow for changes in the bite, how the teeth fit together or even on the jaws themselves.
It may not be the end-all be-all for many years for everyone although there are people who've gone many years and have not had bite changes, but you just don't know if you're going to be that one. It helps with cardiovascular effects with sleep apnea which cpap does not.
Zac:Why is that?
Dr. Hockel: They don't know.
Zac: It is so interesting.
Dr. Hockel: It is.
Zac:Because they say CPAP will save lives right, but if you're not getting the cardio protective effects...
Dr. Hockel: When my dad heard that he said “what should I just give up on my CPAP?” I said, “no dad breathing is important, you need to be able to breathe and without that, you might stop breathing in your sleep.” “You will stop breathing and that's not a good thing,” but it's kind of artificial breathing, forcing the air in and out. And the parts of the brain that control your breathing are like “all, right don't need us anymore” and may become less responsive over time, but I don't understand the physiology of it completely. I know that it’s better than not breathing and it does save lives when it works, but the compliance goes way down after six months or so and for a lot of different reasons.
Feeling claustrophobic, drying out the airway if it's not humidifying it, restriction of movement in bed just the hassle of wearing it, the feel of it on the face, a lot of reasons why people might not want to wear it. For them, the dental appliance might be a good alternative and it's got the added bonus that it turns out it does help with the cardiovascular effect.
Zac:Is it effective in severe sleep apnea?
Dr. Hockel: It can be. Medical doctors will often tell you if you're over 30 on your AHI, the score of how severe the sleep apnea is, you should be on a CPAP. But if you're under 30, you can try an appliance.
However, my friendPat McBridehas treated more people than I know using appliances like this, including a lot of people with very severe sleep apnea, and she's been very successful at it so I think a lot of it has to do with the skill of the person making the appliance and how they adjust it.
It has to do with what else they do in addition to it: do they work on vitamin D levels? Nutrition? Overall body markers? Breathing mode? Are they lip taping? Is the nasal airway clear?
There's a lot else that can go into it; the tongue-tie for some people can make a difference, so it can be a part of a good regimen for some people, but then there's that risk of the bite changing.
Change the airway structure
Dr. Hockel:Option three is to structurally open the airway; do something so that the airway is able to be more open by changing the structure around the airway.
Ear nose and throat doctors do the same thing with different types of nasoseptal surgery or reduction of turbinates or any number of things there.
But what we do in the dental world is either move teeth to a different position to allow more room for the tongue to come forward out of the way of the airway or work with an oral surgeon who's able to move the jaws themselves into a more optimal position.
So in both of those cases, you're trying to change the underlying structure. They have the potential of being a more definitive change to the airway but they're also more involved.
Going through orthodontics takes time and going through double jaw surgery, first of all, it has to be done right and a lot of times it isn't as effective as it should be, but even when it's done right it's still an expensive and invasive procedure. Everything has pros and cons.
In our world, we ask what can we do to change the shape of the jaws? Either by moving teeth or by moving the bones of the jaws.
Zac:I appreciate you listing out those options because I want people to know that if you do have some type of sleep issue. Like I had a guy reach out to me where he's like “I got my CPAP and my numbers are good according to my doctor, I don’t need to do anything else,” it's like it depends right? If we're just looking at pure symptom management you're probably okay but if you want to fix the underlying structural issues maybe we do need to go down a different pathway.
Using oral appliances and orthodontics to improve the airway
Zac:So there are some people who would argue that they're creating bone growth with some appliances versus you're saying moving teeth. What is the underlying physiological way that an appliance like I have (Crozat) works and what is likely not happening?
Dr. Hockel:It's a good question and it's a hard one that I don't have a fully comprehensive answer to, but I’ll tell you what my thinking is on it today. Bill Hang calls it the alphabet soup appliances; we've got the AGGA, DNA, ALF, and all these different types of appliances that are out there.
Zac:And they're all three or four letters, just like in our industry!
Dr. Hockel: Right, yeah pretty much yeah so but like you say claims are being made about the growth of the jaws and I’m skeptical of that in the way they make it sound. When you move teeth, you don't just move teeth, you move the teeth and you move the bone around the teeth.
Technically, that alveolar bone is part of the upper jaw and the lower jaw. So yes you're expanding the jaw by moving the teeth, but you're not really expanding the jaw when you think about the basal bone, the roof of the mouth, the hard palate.
In a child, you can much more dramatically change the shapes of the jaws. You can apply to pull forward force with something that touches the chin and the forehead and rubber bands come forward out of the mouth and attach to that reverse pull headgear. Not like the old headgear that pulled things backward but a reverse pull headgear at the right age can bring the whole upper jaw forward; that's moving the base of the jaw.
I think the bottom line is most of the time for adults; it's not a huge order of magnitude in terms of the growth changes.
Now you're going the right direction if you keep your tongue on your palate, you push it up there and help your oral posture. Maybe you're going to slow the worsening of it.
You're going the right direction if you expand both side to side and somewhat forward with any appliance; I mean to a certain degree if someone can get it done with an appliance that's different from the one I use then great.
I think as practitioners we get better with specific appliances by using them a lot. We learn the idiosyncrasies of them and it probably makes sense for practitioners to stick with tools that they are proficient with.
But on the other hand, I think there are some tools out there that don't accomplish the same thing even though a lot of times the people who use those appliances are talking about them accomplishing the same thing. For example, I’m asked a lot of the time what about the ALF appliance?
Derrick Nordstromdeveloped this appliance from the Crozat, which was a lightwire appliance, just not as light of a wire as the ALF.
He wanted to develop an appliance that was cranial compatible because he was looking at what was happening with the movement of the head bones. He found that with certain adjustments of the wires in the mouth, he could help the mouth posture and encourage the mouth posture to help develop the jaws themselves. It's a way of letting the body's healing potential come out on its own to help the body do the healing from within.
As a pure mechanical tooth moving device, it's probably not as efficient. I know it's not as efficient as other appliances would be, but it's not really fair to compare the two. Because the objectives that a good ALF practitioner is going to have are cranial stability and health; likely working together with an osteopath.
They're doing very different things than somebody like I am is doing. I’m trying to accomplish larger-scale changes in either lateral arch development or forward arch development by advancing front teeth.
As for something like the anterior growth guidance appliance (AGGA), the claim is that it's stimulating the growth center of the premaxilla, that with that pressure behind the upper front of the jaw there that now the maxilla is going to grow further forward. I have yet to see either case, research or x-rays, where that kind of growth could be anything more than dental alveolar changes. A dental alveolar, meaning the teeth and the bone around them moving, and I think they're going in the right direction.
I love to see the changes in advancing the front teeth with those kinds of appliances, but my question is what do you do after that? What about the side-to-side expansion? What about the lower jaw position? There's more to it than just bringing the upper front teeth forward. I think that's a good direction to go in. Do I think it's something that's happening with the epigenetic change now and activating the bone growth genes to grow? I don't know enough to say that it's not; I’ll just say that I haven't seen the cases that have shown me the kind of bone growth that is making that kind of a claim.
It's a very different order of magnitude of change compared to what you would do with orthognathic surgery, where you may be going forward 18 millimeters and able to change the whole plane of the occlusion at the same time. The ALF crowd would say, “but that's completely destroying the cranial mechanism,” now the bones are frozen and unable to move as they should. I'm not going to say that they're wrong about that. I don't know enough to say when they are and when they aren't, the osteopaths I know will say, “Yeah they shut down for a period of time, but they work their way back to normal.
There's this inherent healing potential the body has and that it's worth it to be able to get the kinds of changes in the structural airway that you would get.
However, picking the appliance you want to use for yourself is like telling your contractor he should use a Craftsman hammer. What do you know about the appliances? The consumer really is in a worse position than we are as professionals. We're going to lectures and hearing pro other experts talk about these things, it's confusing for us to try to piece together what's really going on.
So for the consumer to be able to do that same thing and say, “well based on what this person said I want their results, so I want you to use this particular Craftsman hammer.”
On the other hand, the consumer could say, “well to me the osteopathic angle is the highest priority and I want to work with an osteopath,” and so in the hands of that practitioner, the ALF appliance might be the best thing to achieve those goals.
Zac:It's just funny because we have the same issue in the movement industry. You have these people who are in these different camps and systems, all three or four letters.
But the tools themselves are irrelevant, it just depends on what you're objectively trying to achieve.
I actually really like how you broke it up into different camps because this was one thing that I wanted to talk to you about a little bit. You have Alf, which is more cranial osteoporosis driven, you have the Crozat which I have in right now, which is more airway focused?
Dr. Hockel:Well no, the Crozat started out as something that osteopaths like to do. In my dad’s book,Orthopedic Gnathology, is the best textbook out there on the Crozat.
The idea was that it was developing the potential that was there and the growth, both for the kids and for the adults and they knew there was an effect on the airway, not to the degree we know it now. There's a whole chapter in that book on cranial osteopathy and the pictures that are in that book are used in almost every cranial osteopathic lecture that I’ve gone to because they're well done.
So the thinking by the osteopaths with Crozats was that they were also very cranial compatible. I'm not one to say how to compare Crozats versus the ALFS, but I know Derek Nordstrom's position as the very light biomimetic forces seem to be more cranial compatible. The Crozats to me having a larger body wire on them are more effective at getting transverse arch development, especially in the back in a more defined time period.
An ALF practitioner will often go much longer periods of time than we would be comfortable in the orthodontic world wanting to have someone commit to. The objectives of the end of the treatment aren't what are focused on; it's more the journey along the way. Let's do the tweaking we need to do now, see if that's getting you going in the right direction and then nine years later maybe we're still doing the same tweaking and your bite is nowhere near fitting together.
We've been looking at the symptoms and the cranial situation, it can go in a direction like that and maybe it's helping people, I'm not going to say it's not; it's just not what I do. I can't comment on it, except to say that I want to have a more defined period of time to accomplish certain objectives and in my world, I can do that. The Crozat is a common tool that I’ll use, the sagittal designed by Bill Hang has been a very effective tool, as well as different kinds of other expansion screw appliances.
They're different approaches depending on what you want to do and it's really hard to say, “I want this appliance.”
The most important thing would be to say what it is you want as a result of your treatment? People say, “Well can you use the ALF appliance to do what you want to do with that particular appliance?” I’ll say, “yeah I could use my kids watercolor brush to paint that whole wall over there too,” it's not the most efficient way to do it, give me a roller and I’ll just go like that and there it's painted. I think certain things can be done in other people's hands if that's the way they choose to do it.
How to seek better dental care
Dr. Hockel:That's a really hard question because what job do they want to have done? What's their goal?
I think if I could rephrase your question it might be “how could I help people know whether they're seeing a practitioner?” Who's going to do things that are not going in the wrong direction for the airway and sometimes for the jaw joint? Better yet, that they're going to be focused on ways that they can help improve the airway and there are other people around the country and around the world that focus on this and we all have our different approaches, but that's okay!
I think asking questions like:
“If you have a child and the front teeth seem to be a little bit ahead of the upper than they are on the lower, what would be your favorite way to try to correct that kind of a bite problem?”
I can tell you that almost all the time the solution is going to be some type of mechanics that's going to end up pulling the uppers backward to a certain degree. We'll conceptualize in our mind that the appliance we're using is bringing the whole lower jaw forward, but that's a really hard thing to do.
So dentists end up using things to pull teeth back. Back in the old days, it was headgear, now it might be the Herbst, the twin block, or the Carrier appliance, it could be the Invisalign with attachments on the side that brings the lower jaw forward. It could be class two elastics rubber bands going from the top to the bottom. There are all kinds of things: twin force bite correctors, jasper jumper. They've invented all these different things because it's the most common malocclusion, the class 2 malocclusion.
I won't say it’s where the lower is too far back and I won't say where the upper is too far forward. I’ll say where both jaws are too far back, but the lower is further too far back than the upper. So to do something that's going to pull it back even more is going further in the wrong direction, and it's not following the best principle which is do no harm.
So if you found an orthodontist that had a way of leaving those upper front teeth where they were, not pulling them back and consciously trying to hold them where they are and do something to compensate for it with the lower, you have somebody who is really on the right track.
For an adult when there's a big discrepancy between the upper and lower like that there really aren't a lot of things that they can do.
I have a patient who went to a local department head of orthodontics in the local dental school because her dentist had told her before he did porcelain veneers that she really should just get her bite fixed, which was a class II malocclusion.
They recommended that she take out two teeth on the upper and just pull the upper front teeth back to match the lower teeth, a very common way of fixing it that's been done for many years for many people around the world. It's considered the standard of care in many ways, but she felt that everything went downhill for after that: diabetes, hair falling out, she got atrial fib and more.
She remembers having dreams while her front teeth were being pulled back of choking. So she thought that this is probably affecting my airway health, my sleep, and my breathing. This is all on her own, from her own research, and she told her doctor, “you need to do a sleep study for me,” it turned out she had sleep apnea.
Then she was recommended to have laser surgery from the back of her tongue to reduce the size of her tongue. They recommended double jaw surgery to bring the jaws forward; of course, there was CPAP, which she wasn't able to tolerate.
She attributes all of this to pulling the upper teeth backward. Reversing that for her opening up that space again and eliminated the sleep apnea!
Her hair didn't grow back, but she felt overall so much better and people report little things that they notice along the way when you reverse that kind of extraction orthodontics. Our experience of patients reporting what negative things they went through, the extraction retraction, regret syndrome stuff, in her case it was functional, but it became emotional and aesthetic too. She didn't like how her face looked with those teeth further back.
People generally look better when you bring the teeth forward. Their lips look fuller; they aren't sunken behind a line between their nose and their chin.
She's a good example of an overjet problem. When people have this they have an overjet problem, but they call it overbite.
Zac:Just so people have that definition and I know this is not correct. It's when the top part the top teeth appear to be further forward than the bottom teeth even though from a facial structure standpoint that's not the case, versus an underjet, commonly misnamed an underbite would be the reverse of that where the lower teeth appear further forward than the upper teeth even though both are back.
[caption id="attachment_13017" align="aligncenter" width="255"] Overjet is front to back, overbite is top down (chrome spinnin') (photo credit: Nielson2000)[/caption]
Dr. Hockel:Yeah exactly, even though both are back that's the key, you see people with these really big chins, they're probably too far back.
Zac:Like Jay Leno?
Dr. Hockel:Like Jay Leno, his chin is actually not too far forward, if you put an outline on his face and make a comparison to the ideal. You'd see that it's really mainly the upper jaw that needs to be more forward and his lower if anything is slightly back.
[caption id="attachment_13018" align="aligncenter" width="272"] HE HAS AN UNDERDEVELOPED JAW?!?!?!?! (photo credit: Wikimedia Commons)[/caption]
Zac:Gosh could you imagine if he worked with you, he would have the most prominent chin.
Dr. Hockel:No he'd have a balanced face because we get the whole midface further forward. He probably has sleep apnea as a result because his tongue must have nowhere to go. You see in his smile, it's a very narrow upper arch. Poor celebrities getting diagnosed by us dentists all the time on TV.
Another thing to ask a practitioner is:
Do they think that there are times when it's worth taking teeth out and pulling front teeth backward? Are there cases they think that can be helpful for?
If they say yes, I would probably just go somewhere else because if it's okay for an exception it's probably okay as a general rule. I'll tell you, the last time I took a tooth out and pulled things back it was when somebody had five lower incisors.
Zac:Normally there are four.
Dr. Hockel:There are four, so taking one out and pulling them together now we're just right back to where a normal set of teeth would be. Although there's a case to be made for leaving that tooth in there, allowing the lower arch to be that much bigger and then just making the upper fit bigger over the top of it. That would be a question to ask you:
How do they know if there's an airway problem?
If your medical doctor has told you have sleep apnea then I know you have an airway problem and you might want to ask:
Is sleep apnea the only kind of breathing disorder that you address? What are the ways that you address it?
If they say yes, that's the main kind of disorder we treat and we treat it using appliances that bring your lower jaw forward. Well on the diagnostic side, if sleep apnea is the main thing that's being treated they might be missing something that's even more prevalent than sleep apnea and that's upper airway resistance. It's a whole side to sleep breathing disorders that get missed for kids, for thin, fit adults; people like you or women especially. It isn't always apneas, although the sleep medical doctor I was talking to yesterday was telling me if you score the sleep study the right way you'll see the apnea is there.
It's just not things that would be traditionally called an apnea, so finding upper airway resistance as a potential confounding factor of these patients who have problems is important.
I think for the dental practitioner either working with a medical doctor who knows what they're doing with this or maybe helping the patient get the sleep study yourself.
Another important question to ask would be:
If they are finding the upper airway resistance, then what are the ways that you try to treat it? Are they doing expansion arch development, getting the tongue more room, and working with a myofunctional therapist, in either their office or somewhere else to try to optimize the oral posture?
If that's not a part of what they do to try to treat it then they're probably not as deep into this rabbit hole as they should be, because that's at the outer rim of the rabbit hole. That’s the basics: create more room for the tongue however you're going to do it, don't close spaces generalized.
You could ask them:
If my child has a lot of gaps between his teeth, how would you tend to treat that? And whether you do it with Invisalign or braces or whatever to take spacing between teeth and close all that spacing up?
You're talking about a friend who had a bunch of missing teeth, when people have missing teeth the jaws don't develop to the size they should. If you just close all the spacing where there were teeth missing the tongue is going to have much less room to fit into, it's going to go back toward the airway and there's going to be a risk for sleep apnea, so that's another combo.
Zac:The big things are you want are:
Moving teeth forward and outward
Prioritizes expansion
Appreciation of sleep disorders
Focus on attaining palatal tongue posture and adequate lip posture
Utilizes myofunctional therapy
Dr. Hockel:Yeah it's the tongue posture and the lip posture: lips together at rest all the time breathing through the nose and the teeth either together or in near contact. so lips together, teeth together, and tongue to the roof of the mouth; those are the three things posturally that a good myofunctional therapist is going to work towards.
Keeping Our Wisdom Teeth
Zac:Now I want to talk a little bit about getting teeth pulled, the ones that I'm going to bring up of course are the ones that are old remnants from caveman days, wisdom teeth. I was recommended by a practitioner to get mine pulled out, I didn't get them pulled out when I was 18, I actually pulled them out in my late 20s. The reason why I got mine pulled out was because I had no lateral jaw movement. Are there instances in which you should have wisdom teeth pulled out?
Dr. Hockel:In the ideal world we would not have to take wisdom teeth out. In the ideal world, our jaws would be further forward and we would all look way better than we look now. In the ideal world, our airways would be massively open, we’d be breathing through our nose, and our muscles would be much stronger to support that.
We're not in an ideal world, so taking wisdom teeth out now it’s not the best way to go, and our hope in developing more forward growth of the jaws is that there would be room for them, but sometimes there just isn't room for them. Sometimes they're at crazy angles and you really don't have much of a choice.
I don't tend to focus too much on the wisdom tooth issue. As much as I’d like everyone to have 32 teeth in position with the way they should, once the growth is done (age 12-14), there’s not as much that can be done to make a difference in how much room they have or whether they come in.
In my family, my dad tended to have us just keep them in our mouth and he didn't want to take the wisdom teeth out. So I still have all four of mine, I’ve got all 32 teeth and occlusion, but it's still somewhat tight on space back there.
I think it's the case that when you leave them in you tend to get more growth of the jaw. I can't prove this and I don't know if there's research to show this.
I’ve had a lot of kids where they'll come in and maybe the general dentist has said take the wisdom teeth out I'm looking at them thinking, “you know what there might be room. You're only 18, go another seven years let's see how you grow.”
I think that there's more and better jaw growth as a result of those wisdom teeth being there. We know that people like your friend with missing teeth get less jaw growth; why wouldn't having extra teeth back there help encourage more jaw growth?
At the same time, as an adult, if you're wisdom teeth are sideways pointing forward, now it's a liability for the bone integrity around the back of that molar in front of it better not to take that chance.
I know that there's a discussion of meridians attached to different teeth and I'm not an expert in that. People might tell you if you lose that tooth that's going to affect some other part of the body, that may be true, but I'm just not sure what the best compromise is. I’d rather not lose that second molar in front of it by having more bone loss there, and I’d rather just lose the wisdom tooth.
Zac:Yeah because I think in my case, mine were pointing straight forward at least on the lowers.
Dr. Hockel:There probably was nothing that could be done to try to straighten them yeah and even if you went and did heroic orthodontics to try to move them up then where are they going to go? There's no space back there.
Occlusion
Zac:When I was first getting exposed to this even being a thing because in PT school, we never talked about when you need to refer to sleep apnea or how teeth influence things or anything. My anatomy is still lackluster up here;what is occlusion?Is it from your perspective an important thing that we need to consider? I know that they make appliances to alter occlusion, if you could just give a little overview of that I think that would be amazing.
Dr. Hockel:Sure, that's kind of where I started, I was a senior in high school and my dad said “I bet you could earn more making teeth than you could slicing salami at the deli where you're working, why don't you give it a try?” I was like sure, I don't know what it really involves but that was my start in dentistry. I was working as a dental technician doing full mouth reconstruction. We call it wax up where you create and wax how the teeth should fit together, upper and lower, and it's a very precise scheme of how the teeth should fit.
Gnathology was where I came from and people who are in dentistry would know they're kind of different camps of different types of occlusions and gnathology is the one that really raised the bar for how teeth should fit together.
There were certain principles you always tried to follow with it, and as a dental technician and as an early years in practice as a dentist, I focused a lot on the occlusion of my patients and trying to get the bite right.
Gnathology means trying to get the bite right, but it turns out that some of the things we do to try to get the bite to fit right can work against the bigger picture. So I’m not against looking at how the occlusion fits and trying to be as precise with it as you can, but that's a tree. And if you don't see the forest, then you're way down a side path that's going to be very distracting.
We'd always try to get the canines to touch each other to guide the jaw as it moves side to side. It's called canine guidance, and the thinking is that there's enough leverage this far forward in the jaw to separate the back teeth as the muscles are chewing side to side.
It's got leverage against the muscles way back here if the molars right next to the muscles that are chewing are the ones that are mainly hitting when you go side to side, it's much stronger bite forces and it's a risk for wear or for the fracturing of the teeth.
The idea was the front teeth protect the back teeth and the back teeth protect the front teeth; when you close, the back teeth should touch stopping the closing motion of the jaw. When you move side to side, the front teeth should touch so that you can bite through things and so that you separate the back teeth in those other positions.
All this works great if you have jaws in a face that's in the right position so that now the joint is in a favorable condition and the airway is in a favorable condition.
If you have jaws that are somewhat too far back, take the case of my patient who had the bicuspids extracted and the front teeth pulled back. They did that partly because it looks better but mostly because we're just taught that's how teeth should fit together; the front teeth should fit with overbite and overjet. Also close contact or maybe slightly away so that they can slide against each other to separate the back teeth during the chewing movements.
The problem is her jaws were already too far back and by pulling front teeth backward to meet against the lowers for the sake of what we disclusion, the best functioning of the teeth against each other. It can be making things worse for the airway, it can also be making things worse for the jaw joint when front teeth are brought back so that you have that contact which in the gnathological occlusal philosophy you want to have. Then it can tend to cramp the style of the joint, the whole lower jaw can be held in a position that's too far back.
That was one of the things in the early years of learning about the airway is how do I mix this with my occlusion...I won't say beliefs, but it's almost like beliefs.There's no research to show that this kind of occlusion is better than that kind of occlusion.Even class one, ever since Edward Angle the father of modern orthodontics came up with his ways of putting a bite together and one of them is the molars need to fit like this what we call class one.
There's no research to show that that's any better functionally or any other way than any other kind of occlusion. So yeah I had to balance how do I mix gnathology with the airway, and I think that you always put the airway first.
Michael Gelbhas termed this ‘airway centric;’ instead of having a centric relation which is what his dad and my dad and I would all be worried about. How do you make the teeth fit together when the jaws are in their center position? That would be the best connection of the two. The tooth home is the same as the bone home and they just work in coordination with each other.
Well, maybe the bone home is pathologic, maybe there's something about that bone home that isn't right. Because maybe the lower jaw and maybe the upper jaw belongs further forward for the sake of the airway or for the sake of the function of the joint if the little disc gets displaced, then the lower jaw might need to be further forward.
If we do things with the bite, the occlusion, that works against that, the results are never going to be what they should be.
Another philosophy of occlusion might be to go to where the muscles in there are in their most relaxed or harmonious state and make the teeth fit there. Here again, in any philosophy of occlusion, if you're not looking at the airway function, you might be going down the wrong path.
Zac:It's funny you mentioned Michael Gelb because that was the first appliance that I was exposed to. I wore it because we were trying to improve my jaw motion, and I definitely got some interesting changes within my body.
Dr. Hockel:His dad Harold Gelb is the one who developed the appliance. It allows the bite to open and it allows you a lot of times to bring the lower jaw forward a little bit, which can decompress the joints. It can be good for a TMJ appliance and without knowing it, it was sometimes also helping the airway.
Zac:Yeah, but it's also doing so without necessarily affecting the airway dimensions or the health of the airway, whereas it may be affecting other areas like you said the TMJ.
Dr. Hockel:There are some people that when you put a thickness between the teeth, the lower jaw rotates as the lower jaw opens, it goes backward. There are some people that put a thickness between their teeth like that and it can make the airway worse, it'll make them grind their teeth even more so it isn't the same for everyone.
Zac:Interesting, because they definitely said it would be bringing my jaw down and forward.
An analogy in my domain is shoe orthotics. Sometimes, shoewear is something that we can use to influence someone's movement versus not. I’ve had people where we've put them in really supportive shoes and have a completely undesirable outcome from a movement perspective versus someone having those same shoes doing very well. It's just funny how you kind of have the same thing.
Dr. Hockel: We call them the same thing; you call it an orthotic, we call it an orthotic.
Dental pathology.
Zac:There are a lot of other pathological processes that some people may be dealing with. Like people who have gum recession or crowns or veneers; I don't know much about this. Sometimes I’m sure that my clients and people are getting exposed to these things, how does that influence and play a role in the airway health?
Tooth implants
Dr. Hockel:Well you didn't mention implants. If somebody's thinking about getting an implant, but they also think they may have bite or jaw position or airway problems, they've got to be analyzed and diagnosed really completely first from the big picture before putting in an implant. Because once an implant's in, it's not going to move ever; it's just going to stay right where it is.
I’ve had patients where I’ve had to do a lot of expansion of the arches and just leave the implant where it was. So in the end, the implants are like way over here toward the inside and sometimes you can work with it and just kind of warp a tooth out to where everything else is and leave it.
But I’ve had other people where the implant has to be taken out and then put back in or another crazy way I’ve done it before is to have an oral surgeon just create corticotomies. Cut around the bone where the implant is and then I’ll make an appliance so that after I’ve expanded everything else, he just cuts the bone around that section where the implant's sitting and then moves it out into the position where it belongs. Then we just let the bone heal there.
Don't do an implant until you know where it's going to need to end up. I saw someone yesterday that's going to need one for an upper front tooth and their front teeth may need to be in a different position. I’d rather catch them now and say just don't do anything until it's in the right place.
Gum recession
Recession is the gums moving down the root of the tooth exposing some of the roots, and it's generally a function of some bone loss around the tooth as well. It's not a good thing, but you don't look at any gravestone and see recession as a cause of death, it's usually not even a cause of death of an individual tooth even when there's a lot of recession. It's the bone between the teeth that tends to hold the teeth in really well so it's not a crazy bad thing if somebody does have some recession.
Having said that, you'd rather not have recession. So we look now at ways of expanding the upper jaw for example, that the base of the upper jaw will expand skeletally so that the teeth don't have to be moved in a way that might risk recession.
Of course, there are procedures the periodontists can do to help minimize it or add bone back to those areas, different kinds of bone grafting procedures. It's sometimes a necessary evil.
But it's often a sign that something's going wrong functionally with the tongue and the tongue space. You'll see people whose teeth don't even meet together in the front and they have recession. It's not from heavy bite forces or clenching or grinding on the teeth that caused it which is one cause of recession; it's like if you take a fence post and shakes it, the dirt kind of moves away and you're going to lose the support down where it's coming out of the ground.
If the bite is putting forces on the teeth up where it comes out of the ground at the gum line, the bone may be getting lost and the gums may be receding. That would be like shaking the fence post but in the analogy another thing that happens you get a cow that comes up to the fence post and just leans against it all day long. That can also make it come loose and lose the support down below.
That's the tongue on the inside without enough room putting constant force against teeth either forward toward the front teeth, sideways toward the back teeth and sometimes recession is the tongue's fault and the tongue just not having enough room.
We've been talking about the airway and when you don't have enough room for the tongue, you often want to make more room for the tongue so that the airway can be healthy. But making more room for the tongue might be important to try to prevent further recession when there's already been recession.
Zac:Have you ever seen a case where you improve tongue positioning and you give the tongue enough shape where you've had a positive change in gum recession? Because I think with Wolf's law you might be able to get some bony adaptation.
Dr. Hockel:No I can't. What I have seen is sometimes if there's a little recession in the front and you bring front teeth forward, it just from the way that it's moving through the tissue, the recession seems to look a little bit better. Other times the recession just follows it along; I don't know if there's really a pattern to when you're going to keep it or see it get worse.
For some people it will get a little worse, it's a risk of any orthodontics you could have some recession, but grafting is a possibility and trying to do things that avoid that. Moving slowly, lighter forces, and getting the tongue in balance too; get the tongue enough room so it's not going to be putting pressure on the teeth as well.
Crowns and veneers
Dr. Hockel:Those are the world of restorative dentistry and that was my world for most of the early years of my practice. I love doing crowns, I love doing veneers, I love changing the way people look with veneers and especially having been a dental technician.
I love the aspects of what makes a crown really good but it's a different world than what we're doing with the treatments in orthodontics, orthopedics, orthotropics, and airway growth, orthognathic surgery.
If those kinds of restorations for teeth are necessary from a functional standpoint, it's better to do those after you're done moving teeth around. If they're necessary for front teeth from an aesthetic standpoint, it's better to do it after you've dealt with the airway.
I had a case, his name was Jim. We'd pour some veneers for all his upper front teeth and it looked beautiful. Within the next few years, he must have broken every single one of them, just kind of grinding them off; either made them pop off or more likely just chip the corners of them.
I redid a few of them, but at the time I didn't know what was going on. I know now for sure that he had sleep apnea, there were other signs that were there. I know that it was my failure to recognize an underlying airway occlusion and functional problem.
Veneers are great but don't build them on teeth that are in the wrong place. Don't build them on occlusions that aren't functioning in the right way or there's going to be a lot of trouble later on.
Clenching and Grinding
Zac:Well I think they're actually like with… because you mentioned like clenching and grinding that's considered with some of the research I’ve looked at as sleep disorder. I’m assuming it's a symptom of something like sleep apnea or UARS.
Dr. Hockel:It's not a hundred percent but I feel like it's guilty until proven innocent; when somebody is coming in and they're grinding their teeth and they have ascalloped tonguewhich means indents on the side of the tongue. Meaning the tongue is a six-foot tiger in a three-foot cage trying to push out and get more room and let's say they told me they snore at night time. Now I could get rich if I could just bet the clenching and grinding the scalloped tongue and the snoring, I’m sure they've got sleep apnea. It's just a question of how severe?
But you get the people who don't snore at all and there's a woman on my practice, her name's Corey and she's got a lot of wear on her teeth, tons of wear but she doesn't snore. For the life of me I can't get her to get a sleep study because she doesn't think that there's a problem with the airway, but like I said probably guilty until proven innocent.
Most of the time that reaction of clenching and grinding of teeth is from the sympathetic reaction to the airway starting to close off a little bit, upper airway resistance, or closing off all the way because of the apnea. One of the things we can notice; scalloped tongue, a lot of wear on the teeth, recession, broken teeth, clenching, grinding; those are things that any dentist or dental hygienist can look for and see them as red flags.
Then ask the question: do you get to sleep well? Do you stay asleep well? Do you wake up feeling rested? If it's no to any of those, dig deeper and find out.
The second question is do you snore? Has anybody told you that you snore? And if the answer is yes to those two and you're seeing those other structural clinical signs, the odds are it's going to be worth doing a sleep study to find out what's really going on.
Sum up
Airway is the most important factor when it comes to dentistry done well
Focus should be on making room for the tongue by expanding the teeth and face, ideally at the youngest age possible
Cosmetic dentistry should be done after the airway has been maximized.
Montreal, Canada (POSTPONED DUE TO COVID-19) [6 CEUs approved for Athletic Therapists by CATA!]
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Is Spinal Flexion Bad? - This provides an evidence overview on whether or not spinal flexion is a safe position. It's a close to a diss track as we will get in rehab.
The Spinal Engine - This book takes a completely different look at the function of the spine as a mobile area, not a stiff supporting structure. The research presented in this is quite profound.
Which Limitations to Treat First? - The infrasternal angle dictates we should focus on certain limitations in some people, others in those who are built differently. This debrief provides the guide.
Heel Ramp - This ramp is the best in the biz to improve your ability to squat deep. I coach all my clients on this ramp.
Elevate Sports Performance and Healthcare - This is the spot that I work at in Las Vegas. We've built a cool model because we integrate several disciplines to help our clients reach their goals like whoa!
Question: Quick question about squatting. I know the stack is important but what are your thoughts on “butt wink” especially when loaded?
I'm not sure if I'm getting a good view here but it looks like some lower lumbar flexion at the bottom.
I know Stuart McGill is big time against this and has his research with loaded posterior pelvic tilts which caused a lot of pain. So I just wanted some clarification or some perspective if you have the time!
Answer: Ahh that dreaded butt wink. A wink that catches your eye in all the wrong ways.
But is it a bad thing?
For those who do not know, the butt wink is when you have what appears to be a dramatic posterior pelvic tilt at the bottom of the squat. It looks like this.
The buttwink is most commonly seen on the back squat, although can be seen on other squat variations as well.
While there isn't much research I could find that looked at exactly what is biomechanically happening with a buttwink. I hypothesize that it is likely increased lumbar flexion that occurs at the sticking point of the squat in order to attain depth and increase verticality. Sacral counternutation is subtle, lumbar flexion is dramatic.
The reason why the buttwink is most common in back squats has to do with bar placement. The bar position on the back pushes the thoracic spine forward, increasing extension. Since the thoracic spine and sacrum have matching curvatures, there is likely an increase in sacral nutation at the starting position. This position is likely why the back squat is a tad more hinge-y than other variations.
However, you still have to hit depth, fam. So if counternutation is HELLA tough because of the starting position, I can create vertical pelvic displacement by flexing the lumbar spine. In fact, we see this in the research. As soon as a barbell goes on the back, the lumbar spine becomes kyphotic. Totally out of your control, and these authors argue doing the converse may negatively impact squat performance. SORRY!!!!!
These thoughts lead me to believe that buttwink during a back squat is likely normal (GASP).
But wait, isn't spinal flexion bad?!?!?!?!?!?!
[caption id="attachment_12998" align="alignnone" width="810"] And they turn red too when they hurt right??!?!?! (photo credit: Wikimedia Commons)[/caption]
We really don't know. While there are some in vitro experiments demonstrating flexion being bad for the discs, in vivo research does not seem to demonstrate any issues with loaded flexon whatsoever (I deep dived into this topic here). However, there aren't really any in vivo studies looking at lifting heavy loads with lumbar flexion.
Does that mean McGill and flexion-phobia win???
NOT NECESSARILY
Reading The Spinal Engine (and the studies within this great book) has really made me realize just how controversial and unclear the in vitro studies on spinal health are.
According to research in this book, it appears as though compression (as we notice with axial loading) is not necessarily sufficient for disc or spinal injury. In fact, inducing some lumbar flexion with lifting may better allow us to recruit thoracolumbar fascia and posterior ligamentous structures to assist in lifting heavy ass weights!
Muscles alone, especially the erector spinae, cannot produce sufficient force to move the weights we are trying to lift when it comes to back squatting. Therefore, recruiting other tissues to assist in the lift is ESSENTIAL.
We may only be able to lift maximally with some degree of spinal flexion, which can be attained via a posterior pelvic tilt.
I would argue then tucking to some degree is not only safe but likely required to squat well. The buttwink is the body's best way to attain that position given the constraints the back squat provides.
Ideally, we ought to see less buttwink in anteriorly loaded squat variations, as these exercises allow for better verticality and place the sacrum in less nutation. For these moves, tuck with reckless abandon, with a caveat!
Ideally, you want the tuck to occur predominately in the sacrum to enhance squat verticality. If you overflex at the lumbar spine, the pelvis will translate forward and be anterior relative to the thorax. This translate into:
UHHH FAM, YOU CAN'T STACK
I've been emphasizing this subtle change over the last month, and anecdotally the clients that both my colleagues and I work with have noticed favorable changes.
Tucking with the lumbar spine was likely the issue I had made with a lot of the heavy lifting bros who ended up getting some back discomfort when they tried to "tuck" on their squats. The problem was they couldn't get the tuck through the pelvis, then they loaded their spine in a position that they weren't well adapted to, and problems ensued. (My fault, fam).
Making the movement more sacral (think tailbone pulled to the ground), would likely change the response these peeps had to the squat.
Squatting deep with restricted hips
Question: If someone is clearly a better hinger than a squatter, has only 5 degrees hip IR, and also limited hip ER, which would you attack first? I know you said if you go after primary compensation first interventions can be less successful, so I want to make sure I get this right from the start.
Answer: Building the squat is WAY important, as being able to hit it @$$ to Gra$$ is an expression of being able to eccentrically orient the posterior aspect of your body.
Secondary compensations are as follows for each ISA:
Narrow ISA: Decreased external rotation
Wide ISA: Decreased internal rotation
If you want to increase external rotation, you have to target posterior expansion. High or low depth hip flexion activities are money. A simple high depth squat could be a good starting point.
Internal rotation restrictions require anterior expansion to occur. For this, you are either looking at mid-range hip flexion exercises or driving hip extension.
If you want to target both internal AND external rotation limitations simultaneously, sidelying exercises are absolutely money. The reason being is because gravity will push the viscera downward, letting the goods do the pelvic expansion for you!
Hip shifting can also be quite effective at driving anteroposterior pelvic expansion. Hip shifting is merely pelvic rotation, which requires both anterior and posterior expansion. Just like in the thorax!
When you hip shift to the left, you will get left posterior expansion and right anterior expansion. This move is great for that.
Make sure you stack before you shift though fam, otherwise it'll fail miserably.
Lastly, once you've ironed out the movement restrictions, you should probably practice squatting.
Question: Would lots of exposure to HEAVY mixed grip deadlifts influence the infrasternal angle (ISA) over time?
I have a few clients with asymmetrical ISA (wide right, narrow left) who are strong (200kg+ deadlifts) and they all historically have opted for right hand supinated, left pronated especially for near-maxes.
I guess it could be a chicken-egg situation where they opt for that strategy based on structural constraints, or the structure is re-inforced by that strategy?
Answer: We don't have any studies to demonstrate if the infrasternal angle (ISA) can be changed with particular activities, or if a particular ISA biases someone towards certain activities.
We must also factor in that some asymmetry within the ISA is normal secondary to our asymmetrical organ anatomy.
Interestingly enough though, I think we can see some links between the asymmetrical ISA listed above and the preferential grip.
Asymmetry in ISA presentation is likely due to spinal sidebending. In the above case, the spine would have a leftward sidebend through the thorax.
Though not perfect and differ within a few factors (sagittal plane orientation, rotational center, etc), Fryette's laws would dictate that sidebending and contralateral rotation are paired mechanics in the thoracic spine (Type I mechanics). This position would be considered a normal finding in the human spine, as organ asymmetry creates a rightward spinal rotation in this region.
Guess what folks??? A supinated right arm and pronated right arm would also rotate the spine to the right. I would argue this grip is likely favoring the normal asymmetry that is present in us all.
To offset this asymmetrical presentation (especially if movement options are lost), activities that rotate the spine left can be quite helpful. Aside from switching your deadlift grip up from time to time, this squat variation below would be a prime example.
Sum up
Butt wink involves lumbar flexion to help attain a vertical position during squatting and in some variations (i.e. back squats) is normal.
Improve squat depth by addressing secondary compensations first, working on anteroposterior pelvic expansion, and squatting
Asymmetry in the infrasternal angle is normal, and may contribute to preferences in deadlift grip per Fryette's Laws of spinal mechanics.
Losing internal rotationmay notbe a shoulder problem
If you’ve been told you have GIRD, a forward head posture, or you slouch with reckless abandon, read on!
These issues are often linked to reduced shoulder internal rotation; a motion necessary for throwing, pressing overhead and reaching behind your back.
So the fix is to sleeper stretch and then the angels will sing right?!?!?!?
I was young. I needed the work!
Uhh….no fam!
Instead, your whack shoulder motion can be profoundly influenced by altering dynamics within the ribcage.
The ribcage forms the base for your shoulder girdle. If you can’t move the foundation the way you want to, then you won’t be moving your shoulders the way you want to.
Ready to figure out assessing AND improving this important motion you and your clients NEED?
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ISA overview - Learn all things infrasternal angle with this post
Airway Orthodontics with Dr. Hockel - Want to learn how a dentist can improve your sleep, forward head posture, and more? Then this post is a must-read.
Scapulohumeral rhythm - Learn how the scapula and humerus move during each phase of shoulder flexion.
Manubrial expansion - Here we discuss the best ways to improve mobility in the uppermost segments of the anterior chest wall.
Rounded shoulders and shoulder internal rotation
Question: How do I improve my shoulder internal rotation, and by that I mean dealing with shoulders that have rolled forward and not budging no matter what drill I try?
Answer: For visual reference, we are going to assume in this case the person in question has a depressed anterior chest, increased hinge in the thoracic spine leading to the appearance (not necessarily actual) of increased kyphosis, and a forward head position. See the picture below for reference:
[caption id="attachment_12963" align="alignnone" width="810"] Notice how the ear is head of the shoulders, the scapulae are rounded forward, and the humerus appears internally rotated (thumbs are pointing inward is the tell). Or were you just staring at my booty??? MY EYES ARE UP HERE![/caption]
While there are several variations to this position (which will influence testing) and "causes," the axial skeleton change that puts someone into this orientation is a concentric anterior thorax. This would be synonymous with a down pump handle or an inhaled axial orientation.
The sequence of the anterior thorax becoming concentrically oriented has an end result in decreased shoulder internal rotation. Here's how the sequence happens:
[caption id="attachment_12964" align="alignnone" width="810"] Anterior thorax concentric, scapular IR, humeral ER = Decreased shoulder internal rotation[/caption]
Before we go into what to do about it, it's SUPER TOUGH and likely unnecessary to sweat changing static posture for a few different reasons:
Postural presentations have structural influence. You can only change how you look insofar as your structure allows.
We aren't static creatures, we move. It is more important to be able to change into several different postures
Sustaining any singular position for too long is undesirable. Lack of motion leads to tissue ischemia and problems
With that in mind, let's first look at what we need to do to improve the dynamics of this presentation.
Thorax treatment for rounded shoulders
The first line of defense should be to improve thorax movement options and shape. If the pump handle is down, we need to raise it up like Josh Groban!
To improve movement in this region, the best choice is to do one of the following:
Reach between 60-120° of shoulder flexion
Drive shoulder extension and scapular retraction
Exercise choice will depend on which infrasternal angle presentation (ISA) you are dealing with, as this changes the "cause" of this position.
Narrow ISA: concentric anterior thorax is due to skeletal structure (primary compensation)
Wide ISA: concentric anterior thorax is a secondary compensation.
Therefore, what you go after changes with each presentation. For the narrow ISA, you need to restore structural dynamics to elicit a change. A narrow ISA has reduced lateral ribcage dimensions, so you need to do things to expand that. A forward reach can be useful in this regard.
If we did the above move to a wide ISA, who has increased lateral ribcage dimensions, this would not be the best choice to improve ribcage dynamics. If you reach between 110-120° of shoulder flexion, the serratus anterior will aid in lateral ribcage compression.
Now I would be remiss to say there aren't upper airway influences to this bias. Rounded shoulders are often associated with a forward head posture. A forward head posture can be a compensatory action for the inability to nasal breathe:
You can't breathe through your nose for whatever reason
Tongue posture sits low to open the oral airway
Forward head posture occurs to increase airway size
Depressed hyoid position occurs
Now, diving into ALL the possible treatments goes beyond this post, but myofunctional therapy can play a major role in improving dynamics in this region.
The two major keys you will need to focus on will be:
Attaining a palatal tongue posture
Elevating the hyoid
For palatal tongue posture, this involves placing the tongue on the roof of the mouth and holding it there. Simply working on clucks can improve this position.
If you want to get ya hyoid up, son, then you need to get your swallow on point! The smiling swallow is an excellent drill to focus on this limitation.
Exercises for shoulder internal rotation
Question: If someone is missing shoulder IR, how do you decide if you load an exercise either in the suitcase/low hold position or the goblet position
Answer: As we mentioned above, shoulder internal rotation restrictions are likely due to a concentric anterior thorax. The treatments (uh, hopefully, you know from above fam!) would be to place your arms in one of the following positions:
Reach between 60°-120° of shoulder flexion
Drive shoulder extension and scapular retraction
The goblet position is roughly between 70°-90° of shoulder flexion, so I think it's pretty easy to see how that can help improve internal rotation, but what about the suitcase position? How do those lovely suitcase carries influence thorax dynamics?
I'm glad you asked!
The reason why suitcase carries are useful activities has little to do with the weight side. The #majorkey is actually the swing arm.
When you swing your arm to and fro, you are driving trunk rotation. Since the weighted arm is minimally moving, it gives your trunk a fixed point to rotate about; making the suitcase carry money for anteroposterior expansion.
Where air will go depends on what arm swing position you are dealing with:
Left rotation: Expansion left posterior and right anterior thorax
Right rotation: Expansion right posterior and left anterior thorax
Since you'll rotate both directions with the suitcase carry, you'll get a bit of air EVERYWHERE. That's why I coach the suitcase carry as such.
If someone has difficulty keeping the stacked position on the suitcase carry, working drills that drive hip extension and humeral extension can prove useful, as these actions will challenge your ability to keep the stack in this move. Split squat variations come to mind.
Pec minor strain
Question:Can u do something on pec minor strain (right side). Seems to keep recurring every time I perform any chest exercises. Keep up the good work!
Answer: First, let's look at the pec minor anatomy.
[caption id="attachment_12965" align="alignnone" width="626"] Ain't no muscle finer than pectoralis minor (photo credit: Powellle)[/caption]
Proximal attachment: ribs 3-5
Distal attachment: coracoid process of the scapula
Actions: elevate ribs (pump handle), downwardly rotate and protract the scapula
Now if you doing HELLA chest work because you want them pecs like whoa, then that may contribute to the concentric bias of the anterior chest wall. This bias would make pec minor eccentric proximally. Couple that with pulling the shoulders back for bench press and such, and you get a stretched AF pec minor. This could be a contributing factor to the strain.
The solution is simple: get air into the chest to drive some concentric activity into the pec minor. Hell, even get some reaching forward to protract the scapula. Put the pec minor in the orientation it's not in. This will restore contractile options in the pec.
Question: You mentioned limitations in horizontal adduction. How do you assess this? Are you just holding the ribcage down and then adducting the arm until the ribcage starts coming up? Or are you holding the scapula down?
Answer: You want to isolate the movement to the humerus. The big issue that will happen when you run out of humeral room is the scapula will go along for the ride.
And I don't want the scap in my car ;)
So, you'll want to pin the scapula down with your thumb. Then pull the humerus across the body. You are looking to get the olecranon to get slightly past the nose, which is about 135°.
Horizontal adduction measures T2-4 anterior expansion, so you'll want to drive stuff that involves the following:
Horizontal adduction
Humeral extension
trunk rotation
One of my favorites that has been killing it because of the cervical rotation component has been the sidelying armbar. I'll even do this as an iso, it's been that good.
Abdominal overactivity during exhales
Question: What do you do about ab overactivity on exhales?
Answer: Generally, if you see too much abs during the breathing sequence, there are a few simple tricks you can do to get the abs to chill.
Make sure the tuck is ab-less.
A lot of times, peeps will kick in the abs to perform the tuck instead of the glutes and hamstrings. This will then lead to further concentric activity of the abdominals during the exhale.
WE DON'T WANT THAT!
So ensuring that they can get a tuck without kicking in the abs is WAY important. Working on a hooklying tilt progression can be a great way to teach this action.
2. Exhale slower
Most people exhale WAY too quickly, which will greater bias superficial abdominal musculature, limiting your desired thorax expansion.
I usually tell these people to either go 50% slower than what they did or make the exhale be 15 seconds long. No one will exhale for 15 seconds, but they'll get the idea.
3. Use prone or quadruped
When your stomach is facing the ground, gravity will push the viscera anteriorly into the ab wall, thus creating an eccentric abdominal orientation.
Sum up
Rounded shoulders are caused by a concentric anterior thorax, which reduces humeral internal rotation.
Reaching 60°-120°, humeral extension, trunk rotation, and horizontal adduction can all improve anterior thorax mobility.
Reduce pec minor strain by driving air into the anterior thorax and reaching.
Horizontal adduction is tested by pinning the scapula down and going across the body.
Reduce ab overactivity by tucking without abs, exhaling slower, and using prone/quadruped.
Improve your exercise selection by learning what limitations to prioritize
So you have all these limitations you’ve found. You may inevitably ask yourself:
Uhh...where do I start, fam!?!?
While you can get results withjustabout anything, prioritizing certain aspects over others can enhance your success rate.
If you hit the right dominos, you can knock down the entire stack (and talk to Zac).
But how do you know what is important and what is not? That’s what we will dive into in this debrief.
If you want to reduce the overwhelm of your assessment findings, and better categorize your supreme clientele, then you gotta check out Movement Debrief Episode 133.
Montreal, Canada (POSTPONED DUE TO COVID-19) [6 CEUs approved for Athletic Therapists by CATA!]
Or check out this little teaser for Human Matrix home study. Best part is if you attend the live course you'll get this bad boy for free! (Release date not known yet :(
Here'sa signup for my newsletter to get nearly 5 hours and 50 pages of content, access to my free breathing and body mechanics course, a free acute:chronic workload calculator, basketball conditioning program, podcasts, and weekend learning goodies.
Answer: Inhalation and exhalation strategies are a reference to normal respiratory mechanics as the reference guide. You have to know these first to really be effective with this nomenclature.
Because you NEVER EVER EVER see people exhibit normal respiratory mechanics, I've moved away from talking this way.
But don't worry, fam. I'll iron this out for you :)
When discussing compensatory mechanics, we are using axial skeleton position as our initial reference point. So you have to know what the inhaled and exhaled spinal positions are.
To keep it ridiculously simple:
Inhaled spine = Spinal curves are pushed backward
Exhaled spine = spinal curves are pushed forward
Here are the directions the spine moves in these cases
If someone has reduced movement options, they may not be able to move the spine so well in the opposite direction. One can have an inhale-biased spine and may hella suck at exhaling the spine. The reason for this bias is likely due to anthropometrics and genetics.
The problem: you still have to complete the respiratory cycle!
An easy way to compensate is at the lower ribcage. These ribs are more flexible due to lacking a sternal attachment. This is where we get all hot and bothered by infrasternal angles (ISA)!
Someone with an inhaled spine will have an exhaled lower ribcage (narrow ISA), and one with an exhaled spine will have an inhaled lower ribcage (wide ISA).
You wouldn't have matching inhaled and exhaled positions at the spine and ribcage unless we are exhibiting full respiratory movement options, which NO ONE does. Why? Your guess is as good as mine!
Can cranial issues limit movement?
Question: Can you help a person having jaw and visual issues causing movement limitations?
Answer: Though cervicocranial influences—occlusion, upper airway, vision, etc—can most certainly impact movement restrictions, the frequency at which someone needs to go down these paths to get changes is overstated.
The overwhelming majority of people lack mastery of movement basics: aka the stack.
If you cannot get the stack, squat, shift, reach, all of these things anyone ought to be able to do, then don't even consider working with a dentist or optometrist to improve you movement. Especially considering the current lack of research supporting efficacy in these treatments (not to say that they don't work, but there are hit or miss results).
The human body is INCREDIBLY adaptable, and many can get decent changes despite visual and dental influences.
Caveat: if you have upper airway or visual pathology, then I recommend pursuing these routes, but not to improve your movement.
For example, if you have sleep apnea or bruxism, you should find a good dentist to improve health in those areas. If you have a lazy eye or botched LASIK surgery, vision therapy could be quite impactful.
Prioritize the interventions best suited for the problem, the low hanging fruits. If you did that well (and trust me, you didn't), then go into addressing other possible influences.
Should I address the right or left side first?
Question: We usually focus on helping clients shift into their right side since they are buried into their right side. I've heard that sometimes, but you need to integrate right side before left. What does that mean?
Answer: First off, be careful with what language you use to discuss what is going on with someone. If you tell them they are buried, that may encourage maladaptive beliefs about their bodies. No fun, and WAY more likely to have poor outcomes.
But on the real, prioritizing left vs right side misses one things that's extremely important:
The stack.
There are several reasons why I prioritize the stack first before trying all types of wild and crazy single arm, single leg, shift this, twist that, go right then left then right exercises:
Bilateral movements are easier to teach and learn compared to unilateral moves
Although there is a unilateral restricted pattern, most people have restrictions bilaterally and have unique limitations that require unique solutions
Unilateral movements require greater movement excursion and make one more prone to compensation because of difficulty
Think less formulaic of right first then left, and utilize testing, critical thinking, and expert coaching to get the outcome that your supreme clientele deserve.
Primary and secondary compensations
Question: I frequently see you referring to primary and secondary compensations. I must have missed the day at university where they defined these.
Any chance you could define them in one of your videos? I'm not having luck finding definitions elsewhere.
Answer: Let's provide the definition better than that Blackstar song (which is a tall order):
Primary compensation: A restriction that counteracts structural bias to stay upright
Secondary compensation: A restriction that counteracts the primary compensation to stay upright
Let's look at a wide ISA for example. If you remember from our exhaled spine discussion from above (you read that, right?!?!), a wide ISA's structural bias would tend to the spine falling forward. Think the sacrum nutating "causing" a forward fall.
You don't want to fall forward. You'll totally have a bad time. To counteract these forces, a wide may concentrically bias posterior musculature to maintain an upright posture. This would be the primary compensation.
A wide ISA with a primary compensations. I do tattoos as well if you are interested.
How would you know if you were dealing with a primary compensation? Remember the following heuristic:
Concentric backside: Decreased flexion, abduction, and external rotation
Concentric frontside: Decrease extension, adduction, and internal rotation
So in the case of a wide ISA with a primary compensation, you'd have the following findings:
Decreased flexion, abduction, and external rotation measures
Normal extension, adduction, and internal rotation measures
Now suppose that the primary compensation for this wide overcorrects, and this person starts to fall backward. SNAP! Now what do we do?
This problem is where secondary compensations are useful. This bias counteracts the forces the primary compensation induces on the body. In the case of the wide ISA, the secondary compensation would involve concentrically biasing the frontside of their body.
That font tho
For this person, you'd likely have restrictions (and in some cases, hypermobility) in all planes.
Flip flop all of the above for a narrow ISA, and then you'll have an idea of the differences between primary and secondary compensations.
Infrasternal angles and compensation order
Question: So treatment for wide ISA with only primary compensations and narrow with 2º compensations are very similar. And treatment for narrow ISA with only primary compensations and wide with 2º compensations are also very similar.
So to determine treatment options, is it almost more important to just see if that person is more concentric on the front side or backside since the ISA is not that relevant when the person has 2º compensations?
Answer: Although peeps can develop restrictions in similar areas, that doesn't mean that you need to ignore their body structure and the compensatory order. These areas still matter when it comes to intervention selection.
The big reason is because of what "causes" the restriction.
Let's take the case of someone who has a concentric bias of the anterior thorax (aka a down pump handle).
Both a narrow and wide can present with this, but each has a different way of achieving this restriction:
Narrow ISA: anterior concentric thorax is a primary compensation
Wide ISA: anterior concentric thorax is a secondary compensation
So the reason the narrow has this limitation has to do with the ventral cavity structure, wheras the wide has this limitation to mitigate a posterior concentric bias.
Though both archetypes need air in the front, we have to respect the structural differences between the two.
To improve this restriction in the narrow ISA, I need to make that person's ventral cavity structure dynamic AF. Meaning, I need to expand the ventral cavity laterally. Choosing a move which "squishes" the body front to back can be useful in that regard. A great example of this would be a lazy bear exercise.
Whereas with the wide, the anterior restriction occurs to counteract the posterior restriction. I do not want to choose an activity that squishes the body front to back. That would potentially reinforce the limitations caused by structural bias.
If I choose the lazy bear for my wide, the scapular external rotation occurring from the 90-degree reach would further concentrically bias the backside of the body, which the wide already has. This is why a lot of times your clients who have a flat upper back struggle feeling ANY posterior expansion. You are robbing Peter to pay Paul, and I hear they're both jerks anyways!
You can see how ignoring the structure may not get you your desired outcome.
What would be a better choice would be something that involves a 120-degree reach. You get less posterior compression reaching in this direction, and the upward rotation will give serratus anterior leverage to compress the lateral ribcage. You'll still drive air forward AND you are helping make the wide structure more dynamic. This move is great for that.
Does that mean if you give a narrow ISA an overhead reach you'll kill them?!? No (except that one time). But you may not give your client the activity with the best odds of success.
Put some respek on the structure, and prioritize well.
Addressing multiple limitations at once
Question: If a narrow ISA has external and internal rotation limitations you say to address the external rotation limitation first. What happens if you address both at the same time?
Answer: Killing multiple movement restriction birds with one stone is totally effective and encouraged (especially because birds scare me, I'll tell you the story one day).
The easiest way to make this happen is by encouraging some type of rotation in your peeps. When I rotate, I drive relative external rotation on one side, and internal rotation on the other. It's great for those who have anteroposterior restrictions.
Answer: The goal with exhalation for wides is to close the infrasternal angle. Make it smaller. So the #majorkey is to use pursed lips AND breathe slowly. This action increases resistance enough to recruit external obliques to close the lower ribcage.
Some of my favorite cues to give are:
Flicker birthday candles
Do an impression of a windy day
You are the big bad wolf, blow the house down
Sum up
Inhaled and exhalation nomenclature use the spine as a reference point. The lower ribcage compensates when there is a loss of spinal respiratory dynamics.
Cervicocranial influences can affect movement, but conservative measures should be pursued first barring pathology.
Use testing to determine interventions, while emphasizing bilateral before unilateral exercises.
Primary compensations occur to counteract structural bias, whereas secondary compensations occur to counteract primary compensations.
One must consider both structure and compensatory order when selecting interventions.
Both anterior and posterior restrictions can be simultaneously addressed with rotation.
Wide infrasternal angle presentations benefit from slow, purse-lipped exhales.
If you can raise your arm fully overhead WITHOUT compensating, don’t read any further!
But if you are like most of us, reaching overhead probably draws its fair share of LOLZZZ.
Exhibit A
Yet raising your arm overhead isHELLAimportant for things like lifting weights, moving your neck freely, and even rotation through the ribcage.
So if ya ain’t got it, you might want to work on it!
That’s why I put out this debrief for you that dives into mechanics, what directions to reach and clarifies any confusion that may surround arm elevation biomechanics.
Let’s channel our inner Josh Groban and raise you up (your arm that is).
Montreal, Canada (POSTPONED DUE TO COVID-19) [6 CEUs approved for Athletic Therapists by CATA!]
Or check out this little teaser for Human Matrix home study. Best part is if you attend the live course you'll get this bad boy for free! (Release date not known yet :(
Here'sa signup for my newsletter to get nearly 5 hours and 50 pages of content, access to my free breathing and body mechanics course, a free acute:chronic workload calculator, basketball conditioning program, podcasts, and weekend learning goodies.
All About the Scapula - This debrief goes into scapular movements during respiration, compensations, and more.
Joe Cicinelli - He is a PT colleague of mine who is my go-to guy for all things upper airway.
Scapulohumeral rhythm
Question: Been reviewing your scapula debrief and the motions getting me a little hung up. I've always thought that shoulder flexion, upward rotation, ER, and posterior tilt were together? But you're saying the scaps upwardly rotate, internally rotate, and anteriorly tilt? What's the reasoning behind this or something I'm missing in research?
People always drove into my brain upward rotation and posterior tilt helps clear space for shoulder flexion. Any relationship or misunderstandings there?
Answer: When discussing the motion of the scapula and the humerus during shoulder flexion, it's all about timing and location.
We typically break down shoulder flexion into 3 different phases:
0-60°
60°-120°
120°-180°
During these distinct phases, you have different actions happening at both the scapula and the humerus that will drive expansion into various areas.
First, we need to know what the starting position is for the scapula. “Scapman Begins” you might say...Or not...Whatever!
Most of this stuff is drawn from this article here, so please check this awesome study out if you haven’t.
The resting position of the scapula is:
41° internal rotation
5° upward rotation
16° anterior tip
Humerus starts in slight external rotation
There’s going to be some slight variations among peeps of course, but this is a solid starting point.
Now, let’s look at how the humerus and scapula move throughout the three phases.
Phase I: 0°-60°
There is pretty much no movement of the scapula in this phase. It’s all humerus. No joke. (Damn I’m on fire today!)
Most of the humeral action is biased towards external rotation. If the humerus externally rotates, then the scapula will relatively internally rotate.
How do I know that? I’M GLAD YOU ASKED!!!!
It has to do with the posterior cuff muscle’s proximal line of pull.
The arrow denotes how the scapula would move. Looks like internal rotation to me big dog (Photo credit: Henry Gray)
If I contract the proximal end of these muscles to the distal attachment, you’ll notice how the medial border would lift away from the ribcage. This action, my fine fellow fam, is scapular internal rotation. Glorious, right?!
If the medial border is away from the ribcage, the scapular external rotators (rhomboids, traps, subscapularis) will be eccentrically oriented. Since the big dogs are posterior, you’ll get more posterior thorax expansion in this phase. In particular, T6-8 because of relative scapular downward rotation compared to later phases.
In this phase, the scapula has to pick up some slack to clear room for the humeral head to do its thing. So it’s gotta move!
The big scapular movements that happen during this phase are:
Upward rotation
External rotation
Posterior tipping
These combined actions suction the scapula up against the ribcage, enhancing stability and reducing stress load on the cuff muscles. When you see peeps winging and whatnot, that’s typically an inability of this phase to properly occur.
Just like in phase I, scapular external rotation is associated with a relative humeral internal rotation. Peep the line of pull of your big internal rotator, the subscapularis:
This pull would put the medial border up against the ribcage #scapularER (photo credit: Powellle)
Same song and dance. Proximal pull would compress the scapula up to the ribcage, and life is good.
Due to scapular external rotation, the posterior thorax is more restricted from airflow. Thus, airflow in this flexion phase predominately occurs anteriorly. The bias is at T6-8 level in the early range, and likely T2-4 in the later range.
The grand finale, and the most confusing part of scapulohumeral rhythm.
Scapular upward rotation, external rotation, and posterior tipping continue to happen with reckless abandon.
BUT.
There are a few major keys that happen which allow for posterior thorax expansion during this phase:
The humerus maximally externally rotates (creating a slight internal rotation bias
The scapula orients into the scapular plane (45 degrees anterior of the frontal plane), which positions the scapular back near the resting position (which was internal-rotation.
the more lateral position of the scapula away from the spine increases eccentric orientation.
The upward rotation will eccentrically bias the downward rotators (rhomboids), which have a location posteriorly
For these reasons, you will get some posterior expansion at T2-4 as you reach overhead.
120°-180°= Humeral external rotation = relative scapular internal rotation (though the scapula is still actively externally rotating) = posterior expansion (T2-4 level).
Anteroinferior glide during shoulder flexion
Question: Could you explain what to do if someone overstretched the ligaments in their shoulder. Like after doing the shoulder flexion test and their humeral head pops into your thumb when it's in their armpit, what can I do to restore normal flexion and how can I continue to keep that person resilient?
Answer: Sometimes, when testing shoulder flexion, you can feel the humerus glide anteriorly and inferiority if you place your thumb in the client’s armpit. It’s all types of fun.
If shoulder flexion is more external rotation-bias, what I think is likely going on is a combined internal rotation and abduction action that causes this excessive gliding, hence the pop forward.
Is this actual tissue laxity? Ehhh. It’s hard to say. I’ve seen this glide change quickly with interventions, and my skills are DEFINITELY NOT that good. I think it’s unlikely a true tissue laxity, which would likely need surgical repair.
An alternative story is there is an eccentric bias of anteroinferior tissues to compensate for a lack of scapular upward rotation needed for full shoulder flexion.
You can guess the fix right? Get air in the back with a low reach, and you ought to be rocking and rolling!
Then progress to a single arm reach to drive rotation and more isolated posterior expansion.
Improving shoulder flexion
Question: You and others have mentioned that when someone who is compressed in the dorsal rostral thorax and it is proven with your shoulder flexion assessment between the ranges of 60°-120° among other measures, that you would intervene with low reaching exercises below 60° flexion in various positions depending on the presentation of the ISA.
Is it possible that in this instance we could intervene with a position that includes reaching in that 60°-120° degree compressive range if we IR at the humerus?
Answer: If you peeped the scapulohumeral rhythm component above (uhh, why haven’t you read that yet fam?!), you probably garnered one thing:
Shoulder flexion is hella complicated.
In fact, the entire arc of flexion involves both anterior and posterior thorax expansion to be completed.
Although I love shoulder flexion as a test, it is more a gross measure of thorax expansion with a bias towards posterior. Whereas shoulder extension is similarly a gross expansion measure with a bias towards anterior.
In order to know where you need to drive air, you have to look at segmental expansion within the thorax. Get your tight green wrestling pants on and lather up in baby oil, because we’re about to break it down Degeneration X-style.
Filling the thorax with air is similar to filling a cup of water. The cup fills bottom-up completely.
So to do the lungs during progressive shoulder flexion. The fill occurs in a sequential manner that corresponds to scapulohumeral rhythm.
Remember this general expansion trend with scapulohumeral rhythm:
0°-60°: lower posterior expansion (T6-8)
60°-120°: T6-8 anterior expansion in early phases, progressing to T2-4 expansion in later phases
120°-180°: T2-4 posterior expansion, with likely some anterior T2-4 expansion as well.
With that in mind, you have to look at other individual tests to determine where you have to drive specific airflow to get changes in shoulder flexion:
T6-8 posterior expansion - shoulder external rotation at 90°
T6-8 anterior expansion - shoulder internal rotation at 90°
T2-4 anterior AND posterior expansion - Lower cervical rotation
Oh, just checking your ribcage expansion, NBD.
Before you get all wild and crazy with your specific expansion efforts, make sure you have the stack.
If you don’t have the stack, you have no base to drive this segmental expansion, and you won’t be able to talk to me, and I’ll stay forever lonely. I NEED YOU FAM!
Once you have the stack, then you can pinpoint where the mobility restrictions are, then fill up your cup!
If you have decreased shoulder external rotation (less than 90°), I’d go with a reach in the 0°-60° range.
You can combine expansion in both these areas by driving single-arm reaches. If I reach with my right arm, that will drive anterior expansion on the right and posterior expansion on the left.
If you have decreased shoulder horizontal abduction (less than 45°), I’d go with something that drives rotation with a more horizontal plane-bias. The sidelying armbar roll is a go-to for me.
If you have decreased shoulder horizontal adduction (less than 135°), you can use similar rules above and drive horizontal adduction. Short lever side planks are money here.
Lastly, if you want to drive anterior and posterior expansion with the upper segments, you can combine unilateral reaches with cervical rotation. The armbar screwdriver with head turns is an absolute beast-mode for this.
Manubrial Expansion
Question: How would you differentiate an overhead reaching exercise for purpose of upper anterior ribcage expansion (manubrium) VS upper posterior ribcage expansion (T2-T4)?
Answer: The thing with expansion anywhere is that it’s not on/off switches with exercises. You can get expansion with a variety of moves and positions.
If we want to bias expansion into the manubrium (anterior T2-4), we have a few different options:
High reaches (say 100°-180°) - because of circumferential expansion when going overhead
Humeral extension - Due to scapular anterior tilt. And downward rotation biasing pec minor
Cervical/Trunk Rotation - Due to general anteroposterior expansion that accompanies rotation
Inversion - Due to gravity assisting the lungs in filling top-down
Some of my favorite activities to make this happen have been listed above.
Scapulohumeral rhythm involves combined posterior and anterior expansion, with the overall tendency occurring toward scapular AND humeral external rotation.
An anteroinferior humeral glide during flexion (barring injury) occurs due to eccentric bias of the inferior humeral tissues.
Specific limitations in thoracic expansion can be addressed by corresponding shoulder flexion loss with other measures.
Manubrial expansion (T2-T4) occurs by using high reaches, humeral extension, cervical/trunk rotation, and inversion.
Montreal, Canada (POSTPONED DUE TO COVID-19) [6 CEUs approved for Athletic Therapists by CATA!]
Or check out this little teaser for Human Matrix home study. Best part is if you attend the live course you'll get this bad boy for free! (Release date not known yet :(
Here'sa signup for my newsletter to get nearly 5 hours and 50 pages of content, access to my free breathing and body mechanics course, a free acute:chronic workload calculator, basketball conditioning program, podcasts, and weekend learning goodies:
Bill Hartman has a great video dispelling misconceptions around anterior pelvic tilt. It's. a must-watch.
Compensatory Movement Patterns - If you have no clue about the difference between primary and secondary movement compensations, this debrief should help. You'll better learn when to apply certain exercises in a specific order to maximize movement improvements.
How to Coach the Stack - This position is fundamental for improving movement options. If you are just getting into coaching exercises in this fashion, this is the post.
Bill Hartman - If you want to learn the theory and practical components of many of the concepts I discuss, this man is pushing the field more than anyone else.
Course Notes: Explaining Pain Lorimer Moseley-Style - If you work with people in persistent pain, you MUST read this. It goes into the physiology surrounding how this happens and may help you learn how to better serve these clients.
Pat Davidson - One of the smartest trainers in the field. Excellent with physiology and pushing the training envoelope.
NOI Group - A great group to learn neurodynamics and pain science from.
Michael Shacklock - Mike is THE GUY for learning the biomechanical aspect of neurodynamics. I also did reviews on his book which you can check out here.
The Slump slider is a great neurodynamic move to apply with any posterior neural restrictions.
If you haven't seen the Jefferson curl, here is a good example.
Is Spinal Flexion bad? - If you are afraid of flexing your spine, you NEED to check this out.
Hyperlordosis and rib flares
Question: What are your thoughts on someone who has a combination of hyperkyphosis and hyperlordosis with ribs flare? Could these be due to mouth breathing as compensation for improper breathing patterns? And how would you try to improve it?
Answer: First things first, we need to dispel some preconceived notions regarding posture. Some might call this a diss track (and by some I mean me):
Static posture in and of itself doesn't mean much.
There is no singular cause for exhibiting a certain posture.
There are likely structural, genetic, and behavioral influences that predispose someone to look a certain way, posture included.
We are mobile creatures, what is more important is expressing as many different movements as possible.
So really, fam, don't sweat the posture you possess. What is more important is being able to move.
What could be an issue is an inability to move out of this posture. Examples may be an inability to reduce the lumbar lordosis or rib flare. This deficit may indicate restricted movement.
The most important piece to improving your movement is the stack. The easiest way to teach this concept is in the sidelying position. The reason being is because its gravity eliminated and minimizes rotational effects on the body. Check it out here.
From here, the pinnacle of lumbar spine curve reversal is achieving a full-depth vertical squat. Teaching the stack in this maneuver is the first line of defense, and the sink squat is a great way to do that.
From here, the best loaded version that makes stay vertical "easy" is the Zercher squat.
Flexed Lumbar Spine
Question: What is the lumbar spine looks relatively flexed and the arch starts at the thoracolumbar junction?
Answer: Although we cannot rely on static assessments, there may be some tests that indicate there is a loss of lumbar "extension" that may lead to drive an appropriate amount of this motion.
Here would be typical test findings:
Decreased hip extension, adduction, and internal rotation measures
Full hip flexion, abduction, and external rotation measures
If you have someone with this finding, choosing hip extension-based exercises are primo, as this will help restore normal sacral nutation, and subsequent lumbar lordosis.
One of my go-to's is a glute bridge variation like this one.
Lateral shift
Question: Hey Zac, can you talk about a chronic lateral shift? Your take, management, and prognosis Toughest group for me.
Answer: A lateral shift is likely a compensatory action the lower back takes to offload an irritated nerve root and/or disc. It typically involves lateral flexion away from the affected area with a side glide. You'll the top half of the body gliding away, and the lower half gliding towards.
And they always have back hair. ALWAYS!
In acute instances, this shift is useful at protecting the injured areas, but less desirable once the tissues have healed.
If looking at this shift from our perspective, you'd see two components that we'd need to address:
thorax translated away from the lesion
An oblique pelvis where the ipsilateral innominate "sits" lower than the contralateral.
With this presentation, the first line of defense is OF COURSE....
The Stack
With the translation of the lower thorax, the lower ribcage will need to be dropped down to promote expansion of the involved side. The sidelying tilt progression per above is a great starting point.
Once you've gotten adequate ribcage positioning, squat progressions shown above are useful for opening up the neural foramen.
If your squat is on point, doing shiftwork that emphasizes oblique pelvic movement can assist in maximizing both expansion AND compression of the involved area. I start most peeps with a sidelying stride to introduce this concept.
With my terminal exercise being a lateral squat or lunge. Add some rotation in the mix to REALLY get nuts!
If you've tried these activities and movement/symptom issues persist, neurodynamics could be a great next place to go. A simple way to incorporate these concepts is by slouching the spine during an offending movement and performing the movement. I dive into this concept a bit more here.
Radicular symptoms during exercises
Question: I was wondering what kind of modifications you may make when teaching the stack and trying to restore movement options when a patient experiences radicular symptoms during resets?
I’m having good success with other treatment approaches for controlling their symptom profile, but am struggling to address their true underlying compensations/patterns without eliciting the radicular symptoms.
Answer: These symptoms are often associated with flexion intolerance, so do we do prone press-ups, and the angels will sing?
Ehhhhhhhhh.....
While I don't F with McKenzie a whole lot, we can apply similar principles by emphasizing anterior expansion. Moves that bias sacral nutation and air into the chest.
The sink squat we have shown previously is also another money move. I also like to emphasize hip extension and adduction to drive sacral nutation. This move is pretty bomb.com for this.
My hypothesis as to why this approach works is because, in order for us to create movement, we need to have a contractile gradient. Certain things need to be concentric, and certain things need to be eccentric.
If we cannot establish a gradient (e.g. someone who has multidirectional limitations), this will likely lead to altered loading patterns when we perform an action. Perhaps in the case of radiculopathy, we may not have adequate segmental mobility going into certain positions, and increase strain occurs over the affected area.
Chasing anterior expansion helps create this gradient while choosing a direction that does not evoke symptoms. This may allow for more even loading distribution when you inevitably flex on fools.
And we always gotta flex on fools ;)
When to hip shift
Question: What test results would indicate when someone needs to get their shift together (aka a hip shift)?
Answer: Typically, I use hip shifting to clean up the last bit of motion that I wouldn't normally get with stacking. If someone needs those last 10 degrees of rotation in any direction, a shift would be indicated.
However, milk the stack until that cow is DRY fam. Generally, if someone can attain a good looking squat to parallel, they can probably shift without too many issues.
Then, you may help them get their shift together!
Is the Jefferson Curl useful?
Question: I'm interested in some version of the gymnastics drill the "Jefferson curl" (extension from full forward-fold flexion but with hands-on legs) for those with narrow ISAs.
Some say that loaded /unloaded flexion drills are is just accumulating tissue damage, but I have doubts, assuming a person doesn't jump up to loading too quickly.
Answer: I'll preface that the Jefferson curl isn't something I've really messed with a whole lot, so take what I have to say with a grain of salt.
First things first, I agree with you, caller, on doubting the flexion avoiders. I went ether on this topic here, and basically there is no evidence to support that flexion is dangerous under load. Most in vivo experiments say otherwise.
But does that make The Jefferson Curl useful?
The assumption we have here is that people can segmentally flex at all, which most peeps who are tight like a tiger cannot. So is the curl doing what we think it's doing? Maybe not.
However, if you have someone who does has some segmental flexibility, I could see it being a useful progression. The person who comes to mind is the narrow infrasternal angle type who needs to progress nutation while maintaining an inhaled spine. In that case, it could be effective. You'll also get some tissue tolerance into flexion, which is never a bad thing.
Sum Up
For someone who has hyperlordosis and cannot reverse the curve, focus on the stack and progressing the squat to improve movement options.
Truly flexed lumbar spines require driving sacral nutation through hip extension.
Lateral shifts can be improved by stacking and working on oblique shifts in the pelvis.
If one gets radicular symptoms with resets, chase anterior expansion before driving posterior expansion.
Hip shifts are effective at cleaning up mobility deficits. Use this activity when you can squat to parallel
The Jefferson Curl is likely safe to use IF you have some degree of segmental motion at the spine and need to progress sacral nutation under load.
Have you ever wondered how muscle contractions impact movement? Or why in the hell we are using fancy terms like compression, expansion, all that mess? Or how does tissue tension create movement limitations?
I get it, the terminology and stuff can be confusing AF, but passing that learning curve will allow you to:
Figure out why movement limitations happen
Better make decisions based on the infrasternal angle
Determine how loading changes contractile orientations
Are you ready to take your programming and exercise selection to the next level?
Montreal, Canada (POSTPONED DUE TO COVID-19) [6 CEUs approved for Athletic Therapists by CATA!]
Or check out this little teaser for Human Matrix home study. Best part is if you attend the live course you'll get this bad boy for free! (Release date not known yet :(
Here'sa signup for my newsletter to get nearly 5 hours and 50 pages of content, access to my free breathing and body mechanics course, a free acute:chronic workload calculator, basketball conditioning program, podcasts, and weekend learning goodies.
Bill Hartman - Bill is a great resource and thought leader on compression, expansion, joint mechanics, and so much more.
In Vivo Observation of Articular Surface Contact in Knee Joints - This was an amazing study that looked at knee joint surfaces under load and extreme end-ranges. THE BONES NEVER TOUCHED!!!!!!! Mad props to the guy who underwent the scope to demonstrate this. Yikes!
Complete Anatomy - This app is my go-to for looking at anatomy in 3d. It's basically the destroyer of all anatomy textbooks.
Question:How can I tell if something is being held in place and can't change position vs something not being able to move any farther because it's already there (e.g. a door that can't close because it's already closed)?
Answer: To learn how a movement becomes limited, we have to look at joint mechanics. Let's look at a muscle contraction.
If I contract my biceps and my elbow flexes, anterior tissues become concentric. This pushes synovial fluid posteriorly, making posterior tissues eccentric. It looks like this, and my biceps wow and impress everyone:
All we need are some POWS and BAMS and we got ourself a new anatomy comic
If my resting bias was this state, I would have decreased elbow extension.
The above graphic is how movement limitationshappen.
The limitation occurs because the elbow extensors cannot create enough tension to shift the synovial fluid in the opposite direction, changing the concentric tension of the elbow flexors.
Therefore, the concept of a door that is already closed creating a movement limitations cannot happen.
If the door were "closed" (aka a maximal concentric bias), my elbow would be flexed to the nth degree and I would have absolutely zero extension capabilities.
Although I appreciate da biceps pump as much as the next bloke, we really do not see this much if at all in reality. the only times I can think of would be a contracture or severe structural compromise, which is rare.
But Big Z, what about when I feel that pinch in the front of my hip when I flex, certainly the door must be closed worse than that Teddy Pendergrass song with Cialis, right?!?!?!?
False.
What would happen here is you would have a concentric bias of the hip extensors limiting hip flexion first. The then likely issue you have is a lack of relative motion occurring at the pelvis (aka you can't counternutate the sacrum, which would be due to concentric bias of nutaters), causing you to hit your perceived end range a lot sooner. In some people, this can lead to a pinch (and not the cool kind that makes you grow an inch).
You can call me Robert Plant because the song remains the same: concentric bias limits fluid shift capabilities, creating a restriction in the opposing direction.
Pursuing extreme flexibility
Question: With pursuing extreme flexibility, 1) how much of this capacity is genetically and/or structurally determined (I've pursued this with little progress), 2) how pursuing this level of mobility would fit in or clash with your model, and 3) how and if this can be achieved without long term consequences?
Genetics and structure play a HUGE role in how well someone does with any activity. There's a reason elites at almost all sports have similar builds. Runners are tiny and long-framed, NFL linemen are built like fridges.
For people who are very flexible, you need a structure that has a greater eccentric bias. Eccentric tissue action is needed to contort into wild position.
The narrow infrasternal angle with a narrow pelvis has a structure built for eccentric bias.
Thus, the narrow ISA has the best body type for flexible pursuits. That's likely why prepubescent females absolutely demolish gymnastics. They have narrow ribcages, and the pelvis hasn't widened yet. Also, because females are inherently more flexible than males, they are prototypical for this sport.
See how narrow the ribcage is and how big the ribcage goes front to back? She's built to exhibit this type of mobility. Whereas ya boi strained every muscle in his body just contemplating this move. (Image by Anastasia Gepp from Pixabay)
Just because a narrow body type has the ideal structure for pursuing flexibility, that doesn't mean that people who lack this body can't pursue the task at a high level, they may just have a lower ceiling than someone who has equivalent features with a different axial structure.
Another thing to consider is when someone began training for their given sport. If you started practicing something at a younger age, it is easier to develop structural adaptations needed for the sport. It's why kids have an easier time learning languages and musical instruments (the jerks). They have the plasticity to acquire skills easier compared to adults.
It becomes much harder to alter your structure the older you are. Doesn't mean it cannot happen, but the ceiling is likely lower.
Flexibility training and the model
Pursuing extremes in any task can potentially compromise health, so one must do all they can to support the person as they chase the adaptations they need.
If you are trying to be flexible AF, you will be trying to making your body more eccentrically-biased. It would be wise to do activities that help you generate concentric actions to not push you so far in one direction.
Also, just because you are as eccentric as can be, it doesn't mean that you have FULL movement options.
Many times, hypermobile peeps have a loss of axial skeleton measures. Hip extension restrictions are also common. If you train these types of people, I would look at axial measures (e.g. infrasternal angle, lower cervical rotation, etc) and movement quality under load to keep an eye on one's movement capabilities.
Pursuing flexibility while minimizing injury risk
The most important thing with chasing any physical quality is load management.
If you are new to ANY activity, you have to progress slowly. Find a good program or coach that intelligently progresses you towards the task you want to do, and keep track of your workload as you do it. A 10% increase in anything—volume, intensity, new activities—on a weekly-ish basis is a prudent progression. You can also mess with measuring acute:chronic workload with my calculator.
Also, make sure you are keeping the areas you tend to get restricted flexible as can be, keep strong, and ya ought to be in bidness!
Muscle compression and expansion
Question:I've heard you mention the role of muscles in compressing or expanding (e.g. the serratus anterior's role in compressing the rib cage laterally).
I was wondering how I would go about learning more regarding the roles of different muscles in compression and expansion, and how this information could be applied to exercise selection and progressing/regressing movements?
Answer: I wish there was a good anatomy resource, but sadly I haven't seen a whole lot of anything consider proximal muscle actions, especially when it comes to the axial skeleton (like the serratus).
Like this picture, you can't get a good picture of the curved shape of the serratus, so people think this muscle pulls the ribcage backward. WRONG. Check the superior view of an anatomy app and you'll have your mind blown. (Photo credit: Thieme)
Most of looking at anatomy this way comes from looking at tissue attachments and visualizing how the body was to move if it contracts. That's why an app like Complete Anatomy is so useful because you can view the body in ways that anatomy textbooks are limited. These thought experiments and checking yourself with biomechanical research could prove useful.
But instead of sweating individual muscles, I'd prefer looking at how the body has to change its shape and positioning to complete movement tasks. Visualizing movement in this way makes you worry less about muscles and more about movement. Muscles do not act in isolation, so it may not be as realistic to think in isolated actions.
Lastly, compression and expansion are terms commonly used in physics. Compression means molecules get closer together, whereas expansion is molecules spreading apart.
Gases are the matter state which corresponds the most to these terms, whereas liquids and solids are significantly more challenging to change molecular distancing.
Although we are composed of gases throughout our body, I question the accuracy of these terms when it comes to movement. I need to learn more.
Moreover, compression is a scary term to use with clients. Think compression fractures. I don't want to risk them taking what I say in a maladaptive context.
Because it's familiar, I gravitate more to concentric (compression) and eccentric (expansion) to describe movement.
How loading influences movement
Question:I just saw your debrief about reaching mechanics and talking with a colleague we have one doubt.
He says that If you reach overhead, you will compress the upper thorax naturally, due to the upward rotation of the scapulae.
Plus, when you add load (which is compression) you will further induce compression.
But in your debrief you said that reaching overhead facilitate T2-T4 expansion
Answer: Upward rotation is often paired with external rotation when we are talking about arm elevation. Scapular external rotation will definitely make the posterior thorax as concentric as can be.
BUT........
There are a few things we have to consider when going overhead that allow posterior thorax expansion to happen:
The scapula rests around 41 degrees of internal rotation and moves minimally in the first 60 degrees of humeral elevation (posterior expansion allowed)
Humeral external rotation creates a relative scapular internal rotation, which happens predominately at the lower and higher ranges of humeral elevation (again, allowing for posterior expansion)
Although the scapula progressively externally rotates throughout range, the scapula aligns in the scapular plane (45 degrees forward from abduction) at the uppermost limits (giving me posterior expansion) (peep this article to learn more)
When the scapula upwardly rotates, there will be some eccentric orienting of the downward rotators. The rhomboid perform this action, and run from C7-T5 (giving me some posterior expansion in the upper segments)
Therefore, posterior expansion is TOTALLY possible as you elevate the arm.....until loading happens.
Then all hell breaks loose, yuck.[/caption]
When I start moving the big weights, muscles need to generate hella more tension to complete the task. Meaning you will get more concentric activity, and subsequent compression, of the posterior thorax.
Therefore, heavy loading isn't all that helpful at getting your upper back mobility on fleek. You'd be better served before lower load activities, unilateral exercises, or rotational stuff to improve your motion back there.
Sum Up
Movement limitations likely occur when there is an inability to push synovial fluid into a restricted joint area, not because you are already in a particular range.
Extreme flexibility has structural influences (narrower ribcages have better builds), genetic and epigenetic influences (how early did you acquire adaptations), and must be intelligently progressed through load management and maintaining appropriate movement options.
To look at proximal muscle actions, performing thought experiments, and looking at three-dimensional anatomy representations are the best way to learn anatomy in this fashion.
Heavy loading increases concentric demands of muscle to complete the task, reducing movement options.
Montreal, Canada (POSTPONED DUE TO COVID-19) [6 CEUs approved for Athletic Therapists by CATA!]
Or check out this little teaser for Human Matrix home study. Best part is if you attend the live course you'll get this bad boy for free! (Release date not known yet :(
Here'sa signup for my newsletter to get nearly 5 hours and 50 pages of content, access to my free breathing and body mechanics course, a free acute:chronic workload calculator, basketball conditioning program, podcasts, and weekend learning goodies.
The seated box jump to a box is a great starting point for introducing both force production and absorption. The box basically allows you a tucked start, then minimizes the eccentric demands to allow for an effect jump.
The Guide to Physical Therapy School - If you are interested in attending physical therapy school, want to pick the best place, and get the most out of it, this is the post for you.
Sawbones - This is the website where I get all my bones in the Movement Debrief.
If you want to learn how to stack, you'll want to check out this post.
How to Improve Agility and Cutting Mechanics with Lunge Variations - This was an awesome video by Daddy-O Pops himself Bill Hartman where he outlines how to manipulate trunk rotation to improve your cutting skills. If you feel "stuck" in a hip, these are great variations.
If you want to improve shifting into a hip to help with loading, then you could try this low-intensity move to acquire the skill.
For a higher intensity variation, try this move, which can also bias some trunk rotation.
Lee Taft - Lee is THE GUY for all things agility training. You definitely want to check him out. If you want to peep a course review I did on Lee WAY back in the day, you can read that here.
Derek Hansen - He is my go-to resource on all things sprint training. I reviewed a private course he did here.
Agility - This is my compendium of several resources that are agility-related.
Acceleration - This is my compendium of several resources that are acceleration-related.
Brian Chandler - The owner of Elevate, and one of the top 50 coaches in Golf Digest. Has a vast experience working with elite golfers
Brad Thompson - Our Strength and Conditioning director at Elevate. He's a beast at all things golf.
Force Absorption and Production of Infrasternal Angles
Question: From the point of view of sports training, which ISA would be more efficient in generating force and which in absorbing it (Acceleration Vs Deceleration)? Why?
Answer: The #majorkey is understanding what type of contractile action is needed to both generate and absorb force.
Force absorption = eccentric
Force production = concentric
Absorbing force requires accepting the forces imparted on a body, and an eccentric contraction is needed for that acceptance. Whereas producing force requires going against the forces imparted on the body, thus a concentric contraction.
Assuming no secondary compensations, there are certain infrasternal angles (ISA) that have greater eccentric ventral cavity bias, and some that have a concentric bias:
Narrow ISA = eccentric bias = Force acceptor
Wide ISA = Concentric bias = Force producer
Now there is a HUGE (HYOOGE? SP) caveat to this: Assuming no secondary compensations.
This is a poor assumption because it seems like all the fam nowadays have compensations left and right. You can have narrows that develop concentric biases that make force absorption whack, and you can have wides that develop weird eccentric biases that make their force production weaksauce.
Moral of the story? Don't assume...fam.
Alright, so we can't assume certain presentations will be good at anything, but are their useful heuristics to follow for improving absorption and production?
I'M GLAD YOU ASKED!
There are some useful strategies that can get your force utilizing on point. Here's what I recommend:
Improve force absorption by:
Squatting
High depth shifting
Slow eccentrics
Drop catches
Reaching
Improve force production by:
Hinging
Shifting OUT of shifts
Move heavy shit
Move shit fast
plyometrics
Pulling
May the force be with you!
Balancing PT school and outside learning
Question: How does someone who is interested in practicing PT similar to how I do stay relevant while in PT school?
Answer: My biggest PT school regret (besides taking out too much in loans) is not mastering the basic sciences. Same with undergrad. Acquiring a black belt at the basics is going to make you a better consumer of research and concepts, and allow you to make better clinical decisions.
I was having this great conversation with Bill the other day about this very topic. The issue with the way school teaches the sciences is there is no application, so you memorize a bunch of stuff, then fuggedaboutit.
You need application.
This is where learning stuff outside of school can be helpful, especially if you aren't seeing patients on the regular. Jokers like myself can help provide context to what you are learning in school. Why is that kinesiological concept important? We can show you why.
Reduced hip explosiveness
Question:When working with an athlete in a transverse plane move, they feel "slower" on one side of the hip (left) compared to the other (right) side. Or if I have someone who feels "stuck" in a hip during sprinting or agility work, what do I prioritize and what drills do I like?
Answer: You are dealing with one of two problems when you have someone struggle with getting into/out of hips:
They cannot shift far enough into a hip to take advantage of the stretch-shortening cycle (SSC).
They cannot produce enough force to quickly get out of the loaded position
Before performing either of these actions, YOU MUST have the ability to stack. If you can't stack (don't talk to Zac), then you cannot adequately get the hips into a position to load OR explode.
Translation: You slow AF, fam.
So you basically have two qualities you need to work on:
Work on shifting into the hip
Work on shiting out of the hip
If you need to shift into the hip, you'll want the sacrum to rotate towards the desired hip. Here is a great move to work on that.
If you need to shift out of the hip, you'll want to sacrum to rotate away from the desired hip. Here is a great move to work on that.
From here, it's simply a matter of progressing intensity.
Stacking = posterior tilt?
Question: Is stacking promoting posterior pelvic tilt?
Answer: To some degree, yes. The goal of the stack is to "align" the thoracic and pelvic diaphragm. Or in laymen's terms, make sure your top half is atop your bottom half.
Most people compensate through an anterior pelvic tilt, so you need to posteriorly tilt your way to a stacked position.
Realize that I'm not advocating for you statically walking around keeping a tuck 'til death do you part. The maneuver is used to improve your movement options big dog.
Trunk rotation for the rotational athlete
Question: I would love to hear about how you handle trunk rotation with the look for rotational sport athletes ie. golf, tennis.
Answer: Not a whole lot changes from any other person. Sorry, you are not that special :(
I'm just starting to get into working with more golfers, and colleagues and I have been applying the concepts discussed throughout this site. And boy oh boy, it's incredible how giving the same poop that we do to everyone else REALLY HELPS this population.
Most people lack the stack, and this population it's especially so. I'm blown away daily by how many great golfers do so amazing with such little ability to legitimately rotate.
As always, start with the stack.
Once you have the stack down pat, you can start introducing some rotational-based activities. My early phase rotation can start within the first block. How do you do this? Two key moves:
Single-arm pushes
Single-arm pulls
Carries
All of these activities will allow for some degree of trunk rotation to occur, especially if you allow a big ole' arm swing on your carries.
You can make any push or pull exercise more rotational in nature by alternating as well, such as this move.
Once they've mastered the above moves, AND they can squat parallel, I would incorporate the shifting work discussed above.
Then, they will be royalty of the rotation nation!
Sum Up
Those with an eccentric bias (narrow) will be better at force absorption, those with a concentric bias (wide) will be better at force production. Most people, however, stink at both.
Master the basic sciences while in PT school, use outside learning to apply your knowledge gained.
To better explode in/out of hips during sport, stack, then focus on shifting in and out of hips.
Stacking uses a posterior pelvic tilt to attain the position, though a static posterior tilt isn't necessarily the goal.
Improving trunk rotation involves first stacking, then driving rotation through pushes, pulls, and carries, followed by shifting.
Or check out this little teaser for Human Matrix home study. The best part is if you attend the live course you'll get this bad boy for free! (Release date not known yet :(
Here'sa signup for my newsletter to get nearly 5 hours and 50 pages of content, access to my free breathing and body mechanics course, a free acute:chronic workload calculator, basketball conditioning program, podcasts, and weekend learning goodies.
Hip Rotation Explained - If you want to learn how the pelvis influences hip rotation, why someone could have a hip rotation restriction, or a CRAZY amount of mobility, check this debrief out!
If you need a move that drives counternutation and spinal flexion in general, the drunken turtle is one of my go-to activities.
If you need a hip shift that drives more pelvic external rotation, you'll need to try this move
If you are going after more pelvic internal rotation, then the classic sidelying hip shift is a good choice.
Pelvic orientation versus compensation
Question:In Human Matrix, a lack of humeral internal rotation suggests concentric activity of the external rotators (a secondary compensation, if I'm not mistaken). This activity is brought about by your arms returning to an orientation that makes them more useful (for hugs, yuck).
In your hip rotation debrief, however, it seems that the mechanism is a bit different. What I came away with is that limitations in internal or external rotation are brought about by orientation (via inhaled or exhaled spines).
It seems that rotation in the first scenario is limited by compensation, and the second by orientation. Am I getting that right?
Answer: First, let's get some definitions out of the way when discussing joint position:
Orientation: The relative position of a body area. Generally, this is a positional bias one has (e.g. anterior pelvic orientation)
Compensation: How a body region may respond secondary to a given orientation (e.g. the femur may drive compensatory external rotation in response to an anterior pelvic orientation)
Though it's likely orientation and compensation occur simultaneously as a grand compensatory strategy, it's useful to think of these actions as a sequential process.
If you know the compensatory biases each infrasternal angle presentation ought to have, this makes the process WAY simpler.
Here's the short version:
Narrow Infrasternal Angle: Counternutated sacrum with decreased extension, adduction, and internal rotation (femur is oriented into external rotation)
Wide Infrasternal Angle: Nutated sacrum with decreased flexion, abduction, and external rotation (femur is oriented into internal rotation)
Any deviation from the above patterns is considered compensation. To determine if the compensation is occurring at the femur vs further concentric bias at the ventral cavity, you could look at more distal measures to confirm your suspicions:
So then aside from compensation being more common in the thorax, why do I not teach scapulohumeral rules as I do with the femurs. Two reasons:
Reason 1: No time
In a two day seminar, you can only accomplish so much. I'd rather give what is most commonly seen than tell the whole story. If you want the whole story, substitute all of the above information with scapula and humerus!
Reason 2: Scapular and pelvic ER/IR ARE NOT the same
When you drive rotation at each of these bones, you get a different movement along a different axis. Peep this video to see what I am talking about.
Femoracetabular Impingement
Question:I was wondering if you could talk a bit more about femoroacetabular impingement (FAI). What would increase it's potential? How it would be seen in measuring? What kind of interventio
Can’t get the relative motion, so let’s just orient it there big dog!! (photo credit: S. Bhimji) 
Ribs flared AF :)
Rectus damn near killed us. The worst! (Photo credit: 
An airex pad underneath the stomach is s quick way to restore the anterior orientation.
No asses outta me or you fam![/caption]
Sacrum turns left, front leg ER'd, back leg IR'd.[/caption]
The rotational difference on the way up creates the turn back to the start[/caption]
Think of the weight distribution as reaching[/caption]
Blue areas are where expansion occurs to create the turn.[/caption]
Just call me a worldwide chopper![/caption]
There is an IR bias at each respective femur[/caption]
More IR on the left, less IR on the right[/caption]
I keep the rough amount of IR I started with in the beginning.[/caption]
Dotted lines indicate less relative airflow compared to straight lines. so you can see, there will still be rightward rotation, even with the posterior expansion bias.[/caption]
Dotted lines indicate less relative airflow compared to straight lines. so you can see, there will still be rightward rotation even with the anterior expansion bias.[/caption]
Dotted lines indicate relative rotation from a given starting position. In this case, the upper thoracic segments would be rotating left from a rightward orientation[/caption]
I might make this an NFT[/caption]
Trust me, I've done extensive research on bicep curls, how else would these gains exist???).[/caption]
Just ain't gonna cut it! (Image by 
Notice the high arch, the space between the toes, and how "centered" the heel is.[/caption]
Look at the everted calcaneus, flatness of the arch, and how close together the toes are.[/caption]
You can see how the calcaneus looks everted, and the toes are a bit closer together compared to our supinated foot model.[/caption]
the failure that led to this[/caption]
Cranky AF[/caption]
Like a boss![/caption]
Bruh on the left has it figured out (Image by 
Grinding, but not like the Clipse :( (Photo credit: 
Then you end up looking like this guy #gross[/caption]
Ah, the classic[/caption]
Tonsils are the bottom read and white spot thingy. Looks like a solid "3" there, Bob. (Photo credit: 
Get your knowledge up, yo! (Image by 
But I'm not the problem. (Image by 
But can you nasal breathe tho? (Image by 
t
Aka chin on chin on chin[/caption]
Aka not a lot of motion going on[/caption]
We want the position on the right[/caption]
Great for catching flies[/caption]
You can see here how with each position the available opening becomes less and less. There is likely a posterior tongue restriction with this person.[/caption]
Sleep. It's a big deal, fam (photo credit - Image by 
The big dog, external oblique itself! (Photo credit: 
The good ole' internal oblique (photo credit: 
Yeah, definitely not narrow, flaxseed oil aside (photo credit: 
Like this joker[/caption]
More gains AND better movement? Sold![/caption]
Preferably Topo Chico or Sedona Mineral Water[/caption]
With flexion and extension being general proxies for posterior and anterior expansion, respectively.[/caption]
And it's necessary for talking to me[/caption]
Elbow hyperextension in a patient with Ehlers Danlos[/caption]
Increased space between the joint surface can place stretch on tissues, causes eccentric orientation and increased motion[/caption]
Axial measures don't lie, fam! (credit: 
Make that airway dynamic AF, fam![/caption]
Elastic on the tongue tip. A good starting point[/caption]
Keep ya nose clean, fam![/caption]
Although I personally prefer red pill (Image by 
And if you meditate just right, you too will become psychedelic! (Image by 
Ahh the gold ole days[/caption]
The only way to talk to Zac[/caption]
The only way to squat![/caption]
We all have our vices (Image by 
Personally, I'm a level 35 physical therapist with Elven magic. (Image by 
the bigger the beard the more easily triggered, they say (Image by 
Team work making the dream work and shit (Image by 
You and me both, yikes! (Image by 
Terminal stance = propulsion (Source: 
Early stance - sacrum is rotating to the left, towards a "centered" position[/caption]
Midstance - Pelvis rotates towards the left, and there is a frontal plane shift with the ipsilateral innominate higher than the contralateral side.[/caption]
Late stance involves the sacrum rotating all the way towards the left.[/caption]
Waddling = you can't get into midstance, fam![/caption]
Counternutation + lumbar flexion = YASSSS[/caption]
See how I can sweep the pelvis "underneath" me without changing the pelvic floor shape. And yes, your spine will turn green if you do this.[/caption]
You'll see my pelvis dips forward, I crunch a bit, and have an overall stack is whack![/caption]
And the sacrum will turn left![/caption]
Took me FOREVER to draw this[/caption]
This is my current desk setup. The dual monitors KILL[/caption]
Plus you look like a cool DJ on calls[/caption]
Only with the highest levels of innovation and technology could a visual like this be created[/caption]
The legend![/caption]
How embarassing[/caption]
Making kids unhappy in more ways than one since 1960 (Photo credit: 
Now I got the loosest tongue in the game...wait....[/caption]
Yeah, let's discuss airway later honey. (Image by 
It saves lives, fam! (photo credit: 
#overrated (Photo credit: 
Overjet is front to back, overbite is top down (chrome spinnin') (photo credit: 
HE HAS AN UNDERDEVELOPED JAW?!?!?!?! (photo credit: 
And they turn red too when they hurt right??!?!?! (photo credit: 
I was young. I needed the work!
Anterior thorax concentric, scapular IR, humeral ER = Decreased shoulder internal rotation[/caption]
Ain't no muscle finer than pectoralis minor (photo credit: 
Here are the directions the spine moves in these cases 
A wide ISA with a primary compensations. I do tattoos as well if you are interested. 
That font tho 
Exhibit A
The arrow denotes how the scapula would move. Looks like internal rotation to me big dog (Photo credit: 
This pull would put the medial border up against the ribcage #scapularER (photo credit: 
Or coffee. Yeah. Let's go with coffee (Image by 
Oh, just checking your ribcage expansion, NBD. 
And they always have back hair. ALWAYS!
All we need are some POWS and BAMS and we got ourself a new anatomy comic
See how narrow the ribcage is and how big the ribcage goes front to back? She's built to exhibit this type of mobility. Whereas ya boi strained every muscle in his body just contemplating this move. (Image by 
Like this picture, you can't get a good picture of the curved shape of the serratus, so people think this muscle pulls the ribcage backward. WRONG. Check the superior view of an anatomy app and you'll have your mind blown. (Photo credit: 
Then all hell breaks loose, yuck.[/caption] 
DJ ZACLED! (photo credit: 
