Deep Dive on Tim's Low-Back Issues, How to Unlearn Painful Patterns, Movement as Medicine, and More | Transcription

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Introduction

Intro (00:00)

Hello boys and girls, ladies and germs. This is Tim Ferris and welcome to another episode of The Tim Ferris Show, where it is my job to deconstruct world-class performers from all different disciplines. My guest today is Shirley A. Sarmen, P-T-P-H-D. But before we get to her bio, let me just explain.

Discussion On Back Pain Causes And Treatment

"Shirley A. Sharmens" (00:33)

Shirley is a legend in the physical therapy world. She has influenced some of the top performance coaches in the world. She's also 85 years old going on 86 and is not only razor sharp mentally, but in excellent shape physically. So she walks the walk. So let me get to the bio and I'll also give you a bit of 101 on some of the terms that we'll use in the conversation. Shirley A. Sarmen, P-T-P-H-D, is Professor Emerita of Physical Therapy at Washington University School of Medicine in St. Louis, Missouri. She received her bachelor's degree in Physical Therapy and her master's and doctorate degrees in neurobiology from Washington University, where she joined the Physical Therapy faculty and became the first director of their PhD program in Movement Science. Shirley, and she asked me to call her Shirley, became a Katherine Wurthingham Fellow of the American Physical Therapy Association in 1986 and in 1998 was selected to receive the Mary McMillan Award, the Association's highest honor. She has also received Washington University's Distinguished Faculty Award, the Distinguished Alumni Award, the School of Medicine's Inaugural Distinguished Clinician Award, and an honorary doctorate from the University of Indianapolis. She has received as well the Bowling Earhart Orthopedic Clinical Practice Award from the Orthopedic Academy of the APTA.

Were serving on the - Board (01:45)

She has served on the APTA Board of Directors and as President of the Missouri Chapter. Her books are iconic. They have been the initial domino that has toppled over, so to speak, the enthusiasm, the ignition for many people to get into the field of Movement Science and Physical Therapy and Performance Coaching. Her first book, Diagnosis and Treatment of Movement in Parraman Syndrome, you may have heard Eric Cressy mention this, it was a hugely influential book for him, has been translated into seven languages. Her second book, Movement System and Parraman Syndrome of the Servicorn, Therphic Spines and the Extremities, has been equally influential in promoting movement diagnoses. And in this episode, we do a deep dive on low back pain and that is something that for the first time really I have been struggling with for the last, let's just call it nine months or so, could be a bit longer. And we do get into the weeds with regard to anatomy, particularly as it relates to the back stuff that I mentioned. So I'd like to go over a few terms before we start the interview, so you don't have to wonder what they are and feel like you need to pause to look them up. You can get through the interview without listening to my definitions, but some of them might be helpful. Also, if you're a kinesiologist or professional, please excuse these very simplistic and possibly slightly off definitions, but they'll help a lot of people. So the first one is the Iliac Cressy. What is that? That's the uppermost border of your pelvic girdle. So you can think of the pelvic girdle as that large bony ball that you see in the middle of a skeleton hanging in a science classroom or something. You can feel your Iliac Cressy if you press your thumb into the top of your hip. That sort of bony ridge is your Iliac Cressy. The Tensor Fesalate, and I've heard many different pronunciations of this, and the fact of the matter is no one really speaks Latin correctly, because we don't know if it was veini, veidi, vichy, or winy, winy, wichi, for those who get that reference. I came, I saw, I conquered. So anyway, it is better known and abbreviated as the TFL for a lot of people. So the TFL is a muscle at the outside, very outside portion of the thigh at the very top. So you could think of it also. People think of it as a hip muscle sometimes. Use it to balance your pelvis when standing, walking, or running. If you ever give someone a piggyback ride and a muscle gets super sore on the side of your hip, that is probably at least including the TFL. You also use the TFL for abducting your hip or pulling it away from the midline of your body compared to adducting with 2D's, which would be pulling it toward the midline. One way that I remember that, abduction, it's like an alien abduction taking you away. So moving the leg away from body abducting, bringing the thigh in, adduction. So like an adductor machine at a gym, one of those Susan Summers thymaster type machines would be that. We also talk about muscles that assist in lateral rotation. Lateral rotation is rotating away from the center of the body. Mio rotation is rotating towards the center. So imagine if you turned your feet outwards to look like you were duck-footed, that would be lateral rotation out to the sides. And then if you turn them inward to be pigeon-toed, that would be medial rotation of both femurs. Alright, so as major, I also mentioned so as major, that's spelled P-S-O-A-S major. That is a large muscle that joins the upper and lower parts of the body. And it also contributes to a lot of lower back pain. It connects to the inside of the lower back. And if you were to take, say, your four fingers and move them four inches to either side of your navel and then press in, say, four inches, that would probably touch your S.O.A.S major, which is why massage therapy that addresses it can be so uncomfortable. For you chefs out there or hunters or people who might recognize this, this would be the equivalent of your tenderloin. If you're wondering what a tenderloin is, it is this muscle in many animals. There may be other ways to use that butchering term. But so as major, tenderloin, there you have it, used mostly for posture and so on. We also get into stenosis, as it relates to my spine. So stenosis is an abnormal narrowing. And I have some stenosis around L4, L5, which is in the lumbar spine or lower spine, which puts pressure on some nerves there and causes all sorts of pain. The thoracic spine is more of, say, the middle of the back. And you just think between the shoulder blades for simplicity. Okay, last, and I could say not least, but who knows? These are all kind of equivalent and useful. You have supine versus prone positions. Supine is lying on your back, prone is lying on your stomach. If you've ever wondered what a supinated grip is or a pronated grip, supinated is palm up. And you can remember that because if you want to pour soup into your hand, you have your palm up. Okay, so that is supine. And honestly, learning the basics of anatomy and the basics of some medical terminology is, I think one of the best, absolute best investments you can make in your health, because then you can talk the talk with professionals and they take you more seriously. They give you better advice. They give you the straight scoop. So this is all a very good investment of time.

Essential Anatomy App (07:18)

You can find a glossary of these terms and more in the show notes for this episode at Tim.blog. And I do want to mention one other thing. If you want an incredible rotating view of different muscles like the QL, we talk about the quadratus lumborum. That's sort of this squarish, rectangular muscle in the lower back area. That is sort of the grand central station of all sorts of things. If you want to see anything, the Suez major, check out the essential anatomy five app for iOS and Android. And you can see all of this. You can also see the circulatory system and all sorts of other things. It's a great app. Really enjoyed it. And there are short YouTube tutorials that I recommend taking a look at if you end up downloading it. And that was referred to me by professional drummer Dave Eilich, who helps people improve their mechanics, technique and much more. And there you have it. So if you want a video to go with this, I did record a video of this conversation and I get up and walk around and she does an assessment with me live. You can go to my YouTube channel, youtube.com/timferris to our stresses. And that will have some helpful graphics and so on overlaid into the video. Okay, that's quite a bit guys, but I think it is a helpful prelude.

Dr. Sarmaon discuss Birds & Shirley discusses (08:32)

And now without further ado, please enjoy this wide-ranging conversation with Dr. Shirley Sarmon. Dr. Sarmon, Shirley, welcome to the show. It's so nice to have you with me today and I can't wait to ask a whole host of different questions. So thank you for making the time. My pleasure. I'd like to begin perhaps with the connective tissue that led to you being on the show today, which is a friend of mine and a well-known, suppose the label performance coach could be applied. He also has background of physical therapy, Eric Cressy. He works with many major league baseball players, has a high degree of success with pitchers specifically. But he has written and he also mentioned to me that diagnosis and treatment of movement impairment syndromes is probably the book and I'm quoting him here is probably the book that has influenced me more than any other in my career. It's worth every penny. I'm curious why it is that this book seems to have been so revolutionary for him and many others. What would you say explains that or differentiates that book? I think the one big objective and I've actually been a physical therapist for over 60 years. And during all of that time, I've been through different eras of changes in physical therapy. And where I've sort of gotten to and is how movement basically induces pathology. And part of trying to explain that and how it works is also developing diagnostic categories that direct physical therapy treatment. So what this book was about was a first attempt to really put together diagnostic categories that are based on movement and movement as an inducer of musculoskeletal problems. And also kind of working on the background of what are the tissue adaptations that contribute to this. So it really was an organizational attempt to identify in the first book, we covered the back and the shoulder and the hip. And so I guess the shoulder is one of the things that he must have been particularly interested in if he's dealing with pitchers. And the shoulder is really quite complex because you've got that shoulder blade as well as the glenohumeral joint. And it's not as easy as muscles just turn on or turn off appropriately, they've got to really be well coordinated. So I think that putting together this kind of information in a way that could be understood by a whole variety of people. In fact, I was so slow in getting it out that I was grateful that there was the internet and Amazon selling things because if it would have only been sold in medical bookstores, no one like Eric would have ever found it. And so that was one of the advantages of being a slow rider. And of course, I learned more while all of that was happening too. So that's probably the background. How did that attempt or maybe not attempt, how did that organization approach? Yeah. And also the maybe reframing of movement in the way that you just described differ from what came before or what was predominant at the time. Well, to be perfectly honest with you, Tim, it's not like this insight has been taken over by even the large majority of the people in my profession. It's still a bit of a struggle to have people move in this direction for a whole variety of reasons. But typically, and even though I wasn't there when physical therapy was first started, I wasn't too far behind.

Difference Between Palliative Treatment & Curative Treatment for Movement Problems (& Tips) (12:34)

Typically, the role of the physical therapist was the doctor figured out what the problem was, made the diagnosis and the physical therapist really provided treatment for what I think could fairly be called the symptoms or the consequences of that problem. In fact, I am old enough that I actually saw polio patients. The vaccine had just come out about when I was entering physical therapy school. So we had a role in providing the therapy for the doctor's identified condition. And that's very different than what I'm proposing or have proposed with this book. And I think what's beginning to be recognized, I think the other thing that's so important about all this, and I'm sure you are a reflection of this is in the old days, no one thought lifestyle had anything to do with your health. Yeah. I always, I took point out this story, my family was so much crisco, I don't know how my blood flows. And if the green beans were too healthy, we had bacon grease to put on them. But I was very fortunate. I worked with a physician for a while who was really leading the way and showing about the role of exercise and nutrition.

Translational Research (13:57)

And he did what this really called translational research, showing the cellular changes in animals and then also running studies in older people. And it was like an amazing insight for me to realize that your lifestyle had something to do with it. So I think that's behind what's slowly emerging as seeing movement play a different role. It's, I think what I'm like to get across to people, it's not inevitable what's going to happen to you, that you can do things via lifestyle to improve what your outcome is going to be. I would love to come back to, I believe, and I don't want to misquote you, but something you said, which is the treatment of symptoms. So many offices are treating symptoms, perhaps not root causes. And I have, I have read, and you can't believe everything you read on the internet. So please correct me if you get this wrong, but that you've, is that a new saying? That you've described low back pain as not a diagnosis, but a symptom. And could you just speak to that?

Pain isnt a Diagnosis, Its a Symptom (15:08)

Because I, as someone who currently, for the last maybe six to nine months, has had a very perplexing constellation of symptoms that I describe as low back pain. This, I think, will resonate with many people who are listening. So would you mind elaborating on low back pain as a symptom and not a diagnosis? Well, I mean, just what you're saying, you're saying, slow back pain, you're just telling me that you've got pain and you're telling me where you've got pain. That is clearly a symptom. Yeah, right. I am from Long Island. Sometimes I ask silliest of questions, but got to start with the basics. Well, the nice part is you can actually get reimbursed for making that big clever diagnosis. So even without an MD degree. So where I would be looking at that problem and I have an idea of what your problem is. Wow. Okay. Already. Well, just because we can talk about that. Okay. Yeah, we will. I mean, I don't want to sound too glib about it, but so what I would be doing is naming your low back pain by the movement that most consistently causes your symptoms and by changing that movement reduces or eliminates your symptoms. And so then I'm talking to you about a real cause of the problem. Now, it's not going down to the tissue level and saying, well, you know, it's a disc or a facet joint or any of the rest of it, but here again, in some ways, when you have a problem like that, you can't say in the back that one tissues at fault because a lot of tissues have to change if you're having pain coming from your back region. So the expertise of a physical therapist needs to be. What is the movement that's either causing or exacerbating that problem? So I'm curious. Well, maybe we can dive into you, said, that you thought you might know what my my issue is. That's because I know you're a big exerciser. Yes, indeed. I mean, do you want me to just give you a ballpark idea? I do, absolutely. Okay. Well, because would you believe that abdominals can get to be too much overdeveloped? You know, it makes some intuitive sense, but it's not something you hear many people talk about.

Exercise & Strengthening The Core (17:39)

I know, even within the community of physical therapists, people are really exercising big time. I mean, high intensity exercise is super popular. I'm all far because I'll increase our patient load. One of the things that happens when your abdominals are overdeveloped because what happens when muscles hypertrophy, they become stiffer and muscles are like springs. So they have a, I mean, I'm using the mechanical word of stiffness. And so when the abdominals get to be too much, they increase the compression on your spine.

Assessing the Variable Causes of Back Pain. (18:12)

And so the way you can check me out on this is if you look to see if you take a deep breath, if you go from maximum exhalation to maximum inhalation, you should be able to change the circumference of your rib cage about two and a half to three inches. And if you can't really do that, then it means that the stiffness of your abdominal muscles is so much, it's adding to the compression. And then if you have any kind of asymmetry, for example, if you put your hands on your iliac crest and one iliac crest is slightly higher than the other, then you're basically your spine is in a side bend. And if it's in a side bend and you're squeezing on your vertebrae, they're not happy because they aren't lined up as optimally as possible. Do you see what I mean? I do, absolutely. That's the ballpark I do. And that also reflects how we're looking at these problems. What is it about the way you move, what is it about the way you've exercised or done things that caused the symptoms? And I would love to spend more time on this selfishly, of course, because the reason I am sitting and not standing for this interview is because of this lower back pain, which is actually worse when you're standing than when you're sitting. It is worse when I am standing. Now, I do have, I guess what we can jump right into the weeds. I have a transitional segment if I'm using the right terminology in my lumbar. So I do have quite a bit of excessive lower back sway or atypical lower back sway just for people. When you say sway, do you mean an increased curve? Increased curve, yeah, like Lordosis and kind of guts hanging out. And with that anterior pelvic tilt, right, standing and slow walking, say, walking through a museum tend to aggravate it the most. My brother has the same thing. Although in the last six months or so, when I sit on a very hard surface, like a hard bench or something like that, it also causes this pain. I have had imaging, but maybe we could talk about imaging how you see some people who look like they've gone through a mulcher on their back MRI, but they're asymptomatic. And then you write that's the whole point. Yeah, then you have the opposite. So I do have some stenosis around like L4, L5, but the pain feels to me localized around the SI joint. The relief, if this is helpful, I know we're getting a little technical for some folks, but the relief that I've had in the last week was actually from seeing a chiropractor, there's a high degree of variability with chiropractors, but he works with a lot of athletes. And he put me on a machine that provided some traction, exactly. And he said, I think it's actually that you may have a disc pressing on a nerve that runs past the SI joint. So you're misattributing the cause to the SI. And I've had quite a bit of relief, but to answer your question, standing, slow walking combined with standing, like going through a museum or a cocktail party, sitting on hard surfaces, those are the three things that hurt. Brisk walking does not hurt. And actually that type of, and this is a primitive interpretation, but sort of repeated stretching of the hip flexors, if I'm getting enough terminal hip extension, feels really good to the back. So those are a few of the things. You put your hands on your pelvis to see when you're walking, if it rotates. I have not. I would love to know how to do that properly. Well, I mean, it's not rocket science. You know where your pelvis is, you know where your hands are. Just because very often when your hip flexors are not even just not sure to stiff, stiffer than your back, as you walk, it rotates your pelvis. And that's where you're going to be getting your symptoms from. And evidently, when you go fast enough, you're not staying static and you're causing enough equal movement, but that would be the big thing. When you stand up and you're in this anterior tilt, can you contract your abdominals enough to get out of the tilt? I can. Yeah. And then does that decrease your symptoms? It does decrease my symptoms. So if my back is bothering me, I'll very often do a basically a forward fold or a full squat and then round my back and get into that flexed position. I have the flexed position and even mild extension does not bother the back. If I do a compression test, like a heel drop test, or I pull myself into a chair, it's standing straight up and with compression that shows that type of intolerance, and I get that pain kind of directly on the lower spine. The other thing to try, Tim, is when you stand up, put your feet apart, separate them out and see if that changes your symptoms. And what is that doing? Number one is this little thing I referred to before, if one iliac crest is higher than another, it's a test for what we call relative stiffness. So if you're one of the big hip flexors that's problematic is called the tensor fascia lata, iliotilbial band, and it's an abductor. So if you put your feet apart, so your hips are abducted, it takes the stretch off of that band. And any kind of asymmetry that you would have, particularly with the transition vertebrae, would be playing into the symptoms. Do you see what I mean? I do. And then if you put them together and your symptoms increase, then you would know that that's what's playing a role in doing this. So I'll add a few more things just because this is a rare opportunity to talk with you about this.

Mechanisms and causality (23:59)

So my TFL tends to be very tight and sensitive. That's what I... Yeah. The piriform is also very tight. A piece of this that may or may not be helpful, but what gives my back also some release is working on the... Very specifically the iliacus and then some of the adductors. So on the inside of the thigh... Tell me what that means. Well, having someone really dig into the abdomen to have me say extend the leg almost. It's not you working on it, somebody else. No, it's somebody else working on it. And then it's not very pleasant for people who are listening. And then some of my adductors, I don't know if it's Magnus, Longus, or whatever, but also very tight and seemingly potentially weak. But to come back to the height, maybe the asymmetry of the iliac crest, my right side seems to get hiked up a lot and doing wall sits to try to press them maybe back into some symmetry seems to alleviate some of the symptoms as well. I don't know if any of this makes any sense. See, you've just confirmed one of my thoughts is that if you're right iliac crest is higher than your left, but then I would also bet that your right TFL is stiffer than your left. So if that's playing a role, then when you put your feet apart, your iliac crest should level out. And that should help with your symptoms. So historically, when I've been recording podcasts, I basically end up in that really wide stance. I mean, that's useful for maybe temporarily relieving the symptoms of him recording a podcast in terms of corrective measures. Have you ever tried anything where you're in the quadrup head position? I have actually a long time ago, I did a lot of movement in quadrup head position, but I would be curious to hear what you have in mind. Well, because part of what happens when one iliac crest stays higher than another. And I'm not to be perfectly honest with you, I haven't quite figured it all out yet. But there's some adaptation of the other hip muscles. And I've just found that if you do this in quadrup head, you just rock back. Mm hmm. Often it will improve the asymmetry. So basically being on hands and knees. Hands and knees, right, and let your hips drop to about 90 degrees. You don't have to go back all the way. You just need to go back a little bit and go back by easily pushing with your hands. Because otherwise, if you activate your hip flexors, it could pull it contribute to your problems. Right. And then, and then can you tolerate prone? Yeah, I can tolerate prone. And then you need to just do like just flex your knee. And then you need to laterally rotate your hips. So you're letting your your knee flex to 90 degrees and then let your foot go in towards the other leg. That's lateral rotation. Yep. And that kind of motion will help to elongate the TFL, ITB. Interesting. And you're doing that leg by leg. Yeah, one leg at a time. One leg at a time. Okay. Yeah. And you do everything by bilaterally. Mm hmm. Yeah. Okay. Very interesting. So you can try those things. Let me know. I will. I will do both of those. So let's, if we zoom out, just for a moment, thank you for that, by the way. We may come back to it. How would you describe the movement systems syndromes approach, though the MSS approach? What would the sort of lay description of that be? In 2013, the American Physical Therapy Association adopted the movement system as its identity. And to me, what's really important about all of this is that it's a way of trying to say to the public that there is a body system called movement, the movement system. Mm hmm. And it's not like the traditional anatomically defined systems like the cardiovascular system or the muscular musculoskeletal system or the nervous system. It's a system of systems. But that's just like, in my mind, the immune system, which nothing is more important in medicine these days than the immune system. And it's a system of system. It uses many of the different organs in its function. Metabolic system is the same way. When you think of it, it's running from subcellular all the way up to how do you move in your environment. Movement is critical. Yeah. When movement stops, everything stops. And so I think we take it in some ways. To me, it's like a parallel to the nutrition system. Because we take for granted doing it. And yet there's right ways and there are wrong ways. And so the whole idea of this is to realize that their movement does involve a system. And just like we were talking about before, movement, if you have a lesion in a system like you have rheumatoid arthritis or something or you have a stroke, then you've got pathology in your movement. But as I indicated, movement can also induce pathology. In fact, we know if people don't move enough, they develop the metabolic system and syndrome and other kinds of things because for lack of movement. So how important it is to move, this is related to the lifestyle issue and doing it right. One of the things I always loved doing with patients was saying, so who taught you to walk? And they say, nobody and I say, that's the problem. Just because you're doing it doesn't mean you're doing it right. You're just doing it. Just like you, if you're walking and you're getting lumbopelvic rotation, that's playing into your problem. Right. And also if I don't have, which I don't think I do, this is a one pattern of diagnosis with me that I think is accurate that I don't have much terminal hip extensions when I walk, I'm using my lower back to fake extension. See, that's what I'm saying. And you really can't do that. I mean, there's no way you won't keep injuring your back if you keep walking like that. And how do you re-pattern or help people to adopt so that they can use it subconsciously new motor patterns or new movement patterns? Because I've been doing this for God knows how many decades. Well, not that many. You don't look that old. Thank you. Thank you. I appreciate that. My new best friend.

How to help patients change (30:29)

How do you help patients to get to that point where they've changed something as fundamental as how they walk? In my mind, it's twofold. In one, we know it takes a while, just like if you're learning a sport or you're learning to do anything, it takes time and it takes attention and it takes specificity. And so one is just like we're talking about with you. What are the most important kinds of exercises? What are the issues that are an impediment to doing it the way you should do it? What are specific exercises that can help you and minimize those? And then what's really important is showing you in your everyday activities, what you should do. For example, if you already know that your hip flexors you're calling it the iliacus is problematic, then even when you're sitting, making sure you're not pulling with your hip flexors to stay forward when you're sitting. I know I've been watching you. It's how you even roll over again out of bed. We go through every one of these things teaching you in your everyday activities so that it does become automatic. But it obviously takes participation on the patients or the subjects part as well to learn it. And then you know it's going to take time. I think it's important for people to realize they can't just do 10 repetitions or three sets of an exercise and then they're going to move differently. I think that's been part of what's been picked up in my book is that you have to bring people along, show them how to do that, and that exercise won't change the way you move. You have to change the way you move and that can improve how muscles function. You mentioned this to us. I'd actually like to come back to this to us. In my particular case, because I have been an aggressive athlete or was for several decades and accrued an impressive number of fractures and surgeries and so on, I get manual therapy once a week, some type of soft tissue treatment. And what I found for me personally is it seems like so has major and so on when someone does a manual release. For whatever reason, when they get sort of inside that pelvis a bit more to what I've been told is the iliacus. That's when I feel the most symptomatic relief for my back.

Two back pain culprits (32:56)

But the so as seems to hold some importance. I don't know if you could speak to that, but in terms of the role of so as overactivity as it relates to back pain, is that something that you still feel is something people pay too little attention to? I don't think it's always the cause, but it can certainly be an exacerbator because the so as attaches to the lumbar vertebrae. And it also attaches to the interfertebral disc. So it's a muscle that's constantly pulling on your back and pulling it in sort of a translation motion. iliacus is attached to your pelvis. So it's not directly acting on the vertebrae the same way the so as is. In fact, people that truly have a hardy-headed disc and they're in that acute phase, I try to have them do nothing with their iliacus. If they want to lift their leg up, use your hand to lift your leg up. To put your shoes on or to cross your legs or get into the car or something if you're sitting down already. So you minimize that use. And just like we were talking about in quadrup head, if you are in quadrup head and you want to rock back, you will probably use the so as to do it. And that's why I suggested to you to push with your hands so you go back and you don't use that muscle. Well, these are small samples of what I'm talking about as far as identifying what are the factors that are contributing and how do you change that in your everyday activities? What would be some other repeating culprits that you see? Let's just say someone has the symptom of low back pain. You take them through an assessment or identify that they have an overactive so as. What might be some other low hanging fruit with respect to helping them to identify common patterns or positions that contribute to that overactivity? I would be looking more specifically at which particular movements do it and then try to identify. For example, it would be hard for me to believe this. But if you're hip flexors and it makes a difference, like the tensor-facial-ada is a hip flexor. But it has a rotational component that's much stronger than the so as does. The so as has more anterior pull. The tensor-facial-ada is going to pull more on the pelvis. And I will tell you that in my judgment, and I don't think I'm way off on this. At least 70% of the people with back pain, it's because their hips not moving optimally. And you said it yourself. My hip is not moving and then it bothers my back. Well, that's exactly what goes on. And it doesn't take some big structural fault to have that, just a difference in the passive tension. So usually with younger people, if I'm going to generalize about back pain, it's related to their spine flexing. Because when you're younger, you're more flexible. And I think the other thing that's tied to that while we're talking about the hip is they're identifying more and more that hips, what they call thermal acetabular impingement, hips aren't flexing as much. There's structural changes going on. So if your hip only flexes 90 degrees, then you want to bend over, you're going to do it much more in your back, because your hips not doing it. So I want to know all the things that relate to flexion. In the older person, then it's more related to extension, just like the stenosis thing. Stenosis is that's when you really can't extend. That's why you see old people walking bent over, why they need a walker when they're bending over. And then the element of rotation. And because it's not just, is it one ileosois that's problematic or both of them, one tensor that's pulling more strongly than the other? And that's the passive tension, not just the active tension. And that's what you have to know. Now you were asking about my breathing and the deep breath. When I met with Eric, and I could be totally screwing up this terminology, so you may need to reign me in. But he had me take off my shirt and he's, I think it was, I had a very low, it might be high, but infrasternal angle. So I have a bit of a depression in the chest. I have a very minimal ability to expand my rib cage. I'm a belly breather. And I've had a number of people note that it's likely when I breathe, I kind of rotate my entire rib cage backwards, which also causes that excessive symptoms. Exactly. That excessive hinging at the at the lumbar. What do you do with somebody who's got this type of predicament or pattern? Well, usually, as I was saying before, if your rib cage doesn't expand, then it's often because your abdominals are too taught. I see. So one of the ways is to elongate them. So arms up over your head and taking a deep breath. And just trying to increase the, I mean, you probably know that with breathing, you've got two modes of movement. One they call pump handle and the other is a bucket handle. I'd love for you to elaborate on that. Okay. Well, pump handle means the front of your chest, your sternum is going up like a pump. And bucket handle is like the sides expand. And so with arms up overhead, you want to really think about lifting your chest as well as pushing your rib cage out. Laterally, you mean? Yeah, laterally, like it's all going up. Yeah. Can you do that? Can you take?

Techniques For Isolating And Managing Back Pain

What aggravates your back pain (38:56)

Yeah. Yeah. It's sad. Yeah, I don't have much. It doesn't do much. Yeah, I know. As it stands right now. Yeah. That's what you need to do. And then here's the other thing that if you stand with your back against the wall, and then you try to do a side bend, but, but, but you want to make sure the side bend, you're moving through that the axis of rotations through your chest, not in your lumbar spine. Yeah, that'll make my symptoms worse. And you want to be sure, Tim, that you don't just pull yourself over. You want to try to fall like you've got a heavy elbow. In other words, don't contract the muscles on the same side, but try to get these to elongate. Right on the opposite side. So, like falling over more passive elongation rather than an active contraction. Now, you're not going to go real far initially, unless you got a really heavy elbow. Yeah. So the axis of rotation should be through the middle of your chest. The fulcrum should be in the middle of the chest. Yeah, right. And don't, I always like to say, I don't care how far you go. I care how you get there. Yeah. Okay. So don't push it for big range, and just make sure you're not moving your lumbar spine, and that you're doing your thoracic spine. And are you breathing in those positions, or is this stretching your intercostals, or what is the objective of the side bend? The objective is to elongate those abdominals that are not letting you. Oh, I see. And you know, the other thing is, just even when you were doing this, you don't have any symptoms at all when you're sitting there right now. I have a little tightness in my low back. I am sitting in a chair with lumbar support. Why do you do that when you had too much lumbar curve anyway? Well, because I've noticed that for whatever reason, symptomatically, I get relief with a small amount of lumbar support. No, small amount. Okay. If it's a flat back chair, and I end up kind of falling forward and flattening my back, it ends up hurting me much more later. Yeah, because you're getting a translation motion. Yeah, I can. But okay, what if you put your arms up overhead and take a deep breath? Does that decrease your symptoms at all? I would say it doesn't noticeably, I don't have any severe symptoms right this instant. No, but it doesn't. It doesn't worsen it, for sure. But it doesn't make it any better either. It might lessen it slightly. Okay. The degree of pain right now, I would say, is pretty low, so it's hard for me to... That's good to monitor. And again, if you look at it from the standpoint, the more you move someplace else besides your back, the better off you're going to be. Yeah, definitely. So that's part of the whole strategy is make sure, because usually the problem is that motion that's problematic is occurring during all of your activities. The body follows the rules of physics. It takes the path of least resistance. So if it's easy to move there, it keeps moving there. Right. And that's what you're trying to change to make it easier to move at other places where you should be moving more. This seems to me to be very, very, very important. So would you mind just saying that again, just reiterating that the body follows the path of least resistance? So if you have a warm groove in its leading to pathology, you need to sort of grease a different groove. Could you just speak to that because it strikes me... You're doing a beautiful job yourself. I don't think you need me. Well, I'm great at pontificating. I just need to change my movements. Father's superior. No, I just... I talk a good game. I just have to fix my movement patterns in my breathing. But I like how you phrase it. I mean, the body is going to take the path of least resistance. Yeah, it's it, exactly. I'm going to follow these exercises. I will... I'll experiment with the elongation. I wanted to add one more data point, which is if I do, for instance, Pilates classes with someone is very technical. If I'm in that flexed position, which tends to be more comfortable for my back, if I'm experiencing a lot of... You know me, are you supine? I am supine, yes. Okay, you're supine. And then what are you going to do?

Rectification exercise to fight symptoms, challenge legs and reduce abdominal tension (43:15)

Basically, I'm trying to sort out for myself as if the overly contracted abdominal resting state can contribute to the symptoms of experiencing. What I have also experienced is if I do a workout that seems to be focused, or is focused on a lot of core musculature and pelvis work, and so on, that my low back doesn't bother me for a few hours after that workout. And I don't know how to interpret that. Maybe these things are not at odds. Maybe they can both be true for different reasons. I mean, it depends what your workout is. What would be bad in the long run is if you're doing a lot of holding your legs up and moving those around while you're supine. Because again, you're going to be using your ileo-sos and it's going to be pulling on your back. Yeah. The big thing is for you to be able to contract... I'm getting the picture from you that I didn't have before that here you are with an increased lumbar curve, and that your lower abdominals aren't as taught. In lower abdominals, I mean external obliques, not just the ones that are lower. And when you contract those muscles that they tend to flatten your back and decrease your symptoms. Yes. And so that would be, to me, what the advantage is when you're supine and starting to do the exercise. What would be not the long run good is if you're holding your legs up and trying to do something with your legs while you're holding that position. Right. Because you're building in too much activity from the ileo-sos. So if anything in that position, I would just have you slide your leg down and try to keep your pelvis from tilting. Put your hands on your... I'm sure you probably know what ASIS is our anterior superior iliox bine. I do on the front of the hip. Yeah. And just make sure they don't tilt. For people who are wondering, could you just describe what that is? It's a little bony prominence on the front of your pelvis. And some of your major hip flexors attached there. But it's also an indication of what your pelvis is doing as far as tilting forward or tilting backward. And in your case, what you want to do is not have it tilt forward. So the importance of that exercise would be that you can move your legs without your pelvis tilting anterior ili. Got it. But I wouldn't put a big load on them. I would only have them slide down. Like you're sliding your heel along the supporting surface. Got it. Get it all the way down on one leg with no tilt. See if you can do the same thing with the other. If you have difficulty from what we've talked about before, if you take them out in abduction, you should be able to get them down easier. Because your tensor is going to be pulling on your pelvis as well. Right. So for people listening, if I'm interpreting this correctly, if your legs are separated, so your legs end up more in a snow angel type of position as opposed to directly in front of your hips. Now is that predominantly a diagnostic or is it also a training move that sliding of the heel? All of the above. All of the above. Okay. I mean, that's the nice thing about going through an exam in which you're looking for this path of least resistance, the motion that is occurring too readily. Because it'll occur too readily with all of the activities.

Personal Story of Chronic Lower Back Pain (46:35)

Goes back to what we were saying before. Then you try to make sure that you're either not getting that motion or you're moving where you should be moving. And when you're taking people through the exam, and I think this is what's so valuable, is you're also showing them how to be in charge of their symptoms. Because nothing is more scary than here comes the pain. What did I do? How did I do it? How do I get out of it? And if you're showing people, if you go this way, it hurts. If you do it this other way, it doesn't hurt. And that helps also with people following the program that's recommended. Because their symptoms are there in charge of them, and they know what to do to decrease them. Yeah. This personal experience has been incredibly frustrating, kind of horrifying, because it's the first time in my life. If you tear a labrum in your shoulder or you break an arm or break a collarbone, it's oftentimes reasonably straightforward, or it seems that way. Whereas with this lower back pain, I would feel better for three days, and then I would wake up and I would just be in incredible eight out of 10, nine out of 10 pain. And I could not identify what the cause was. There have been times when my QL and my external obliques and so on are so locked up in the paraspinals that I can stand for a few minutes and I have to sit down, find something soft. And that's not the case right now, but the recurrence of symptoms has been so unpredictable on some level that it's a friend of mine who's in medical professions that know how long have you had that? And I said nine months. She said, well, we technically qualify for some of those chronic pain. And I was like, oh my God, is this the new normal? This cannot be the new normal, which is why I appreciate you taking so much time speaking about this. When someone comes in and they have not identified anything, they come to you for help. Or someone who's trained in your system. What does the exam look like? What does the session look like? First, it's looking at what they look like. I mean, for me, just like if I saw you standing, I would know a whole lot more than just looking at you sitting because all of these things that we've talked about indirectly, I would see immediately. So one is just looking at alignment and believe me, that's a roadmap to a whole lot of things. And I think it's also worth noting that it's why people stand the way they stand is to minimize energy expenditure. So you can see what the passive tensions are, which are reflective of how hypertrophy to muscle is. And then it's simple motions, Tim, have people forward bend. Does their back flex too much? Does it not reverse its curve with you? And how much do their hips flex? And typically in men, there's more of a problem of excessive lumbar flexion than there are in women just because the center of gravity is higher, the hips are stiffer, et cetera. So how do they forward bend? How do they rotate? Because many people will twist rather than really be able to rotate. And then side bending. Does it hurt? But where do I see the motion? Now by twist, you mean their pelvis follows them instead of that. See, that's the other thing that's interesting is because I'm sure with you, people have looked at what your range of motion is in your hips. But when you're standing, you don't have that same range of motion. Your pelvis won't rotate on your femurs the same amount. Yep. So one, does your hips not move and therefore you have to move in your back more because your pelvis isn't rotating? Or is it asymmetrical? And then the other thing is that actually, ironically, if your abdominals are really good, instead of sort of rotating off more of an axis, though it's not perfect, your trunk shifts over because if your trunk shifts over in a twisting motion, it's because your abdominals won't elongate easily. Fascinating. And then which one of these motions causes symptoms? When I see that it's bad, I will correct it. For example, if you had pain side bending, then I'd put my hand above your iliac crest, have you side bent again? And if I've blocked it and you don't have pain, then I know that that motion occurring there is causing your pain. The movement of the pelvis or the iliac crest? The movement in your back. Yeah. And the same thing, if you bend over and there's no pain, but you come back up and you lead with your back rather than your hips, then that causes pain. Then I know, again, that extending is causing your symptoms. And then if your symptoms, as you have reported, get better when you bend over. Again, I know that extension is causing your symptoms. And then I go through little tests in supine to see the length of the hip flexor muscles.

Assessment Technique for Isolating Pain (51:34)

I look to see what your symptoms are in supine. If you have symptoms, just like you sort of suggested, if we flex your hips and knees, you want to be more comfortable than when they're down straight. If I abduct your hips, I know that what's causing it that way. Do you see what I mean? So then I will passively move your hips to see what the range is. Make sure it's passive. Then I'll have you do it actively to see if that elicits symptoms, show you how to change it. So I'm going through an exam looking for that movement that shows up consistently. If I stop it or improve it, the symptoms go down. So I do in supine, side line, prone, quadrup head, sitting, watch people walk. Everything that gives them pain, they get in and out of their car, how to roll, how to go up downstairs, whatever activities would give them pain, I'll go through them. And is the assessment largely the same for athletes versus non-athletes? It's kind of... That's a really interesting point because in some ways people have a hard time because I'm looking for little baby things. Ironically, there's really good research that's been done by Linda Van Dillon. And these movements that cause the symptoms occur very early and they're only a few degrees. And so sometimes with athletes, I've had the issue that, well, these are just baby things and they don't really matter, but they do matter. You've got to stop that and then you can build on bigger ways. There's a therapist by the name of Robby O'Hashi who's put these into... It's like a movement spectrum. That's not the exact words I'm blanking on right now where you do isolated exercises, combined exercises, and then more putting them together for your sport, whether it's tennis or whatever, and then he's seen a lot of athletes. And that's the whole idea is that you would get somebody to correct the little bitty movements and then you build on the more complicated, the more demanding movements. Do you have an opinion of... I've not experienced this personally, but something called DNS. I think it's dynamic neuromuscular... Neuro-muscular stimuli. Yeah, I do. Because it seems like they build based on some sort of motor skill development chronology from childhood. So you'd start with supine or prone and then move to like one to crawling or something like that, quadruped and then kneeling and so on. Do you have any perspective on this? To be perfectly honest, I think you're already grown.

Depth Narrow Motor Series & Back Pain (54:26)

Certainly. If my shiny, pay it with his any indication, then yes. You know, looking at your well-shaved head, I always reminded what my father used to say, who was also bald from an early age. He would always say, "grass can't grow on a busy street." That's hilarious. I'm definitely going to use that grass can not grow on a busy street. I don't think you need to stage it like that. That's why I go through the whole exam and look at the finished product that needs some fine tuning. The thing we talked about in the beginning in that movement causing pathology and the fact that it's really your everyday activities that cause it in the first place. So that's why you've got to change the way you're doing basic things. I do. And look at that because that's what caused the problem. That's what you need to change. What is, I believe, you call it, "collapso smasho"? Where did you get? I didn't even put that down. Well, there are two farms here. It relates to this fact that what we talked about already, that the abdominals can get, well, that the spine suffers from compression type things. And in the older individual, without muscles, it's "collapso smasho." In younger individuals like yourself or others who have done a whole lot of abdominal exercises, I call it "squeezo smasho" because the passive tension from those muscles is adding to the compression.

What are the two common posture abnormalities? How to find the sweet spot of hypermobility and hypomobility (55:59)

In the older people are people who are hypermobile, then it's kind of collapsing down without enough support. So it's not good if you don't have enough muscle and it's not good if you have too much muscle. It's what's in between that's most important. So how do you find the goldilocks amount of... No pain and they look great. All right, keep fine-tuning. The other thing is, you know, obviously we aren't all built the same. I think that's one of the other important things is looking for structural variations and building that into the assessment. That's the part that's tricky. People don't always pick the right parents and when they find out it's too late to go back, you know. All right, so let's talk about perhaps other common pathological patterns. I've read the you've said or written perhaps that most people wear their shoulders too low. Could you speak to that and perhaps also mention what corrective measures can be taken? What does it mean for people to wear their shoulders too low? It means that they should sit up at an angle that is about six degrees or so higher and often you see when you don't look so bad but when people have done a lot of weight training that's one end of this scheme. You'll see that their shoulders look really dropped. They look lower. So that the end of their shoulder isn't sitting up. They look like they're sloped down right? Yeah, if you know the cervical vertebrae between C6 and C7 you should have, that's about the level where your shoulders should be. And so if that's way down or you can look at your clavicle and you see that there's not this six degree angle but your shoulder is slower than your clavicle should from inside to outside have roughly a degree upward angle upward angle right? So it could be too low. And then the other way I like to talk about it is just the weight of the world, the husband, the children, the bra straps, all of that pulling down and women's shoulder girls are on a stiff. And what's important about this is it's not only a factor of what it does to your shoulders it also does a number on your neck because the muscles that help to hold your shoulder blades up attached to your cervical vertebrae. And the really big important thing on trying to address that is using I think the muscle that's called the serratus anterior. The serratus anterior attaches to your ribcage and it can act like a sling so it attaches to your ribcage and to your shoulder blades. So it's like a sling that can help to hold your shoulder blades up and take some of that load off of your cervical spine as well as put your shoulders in the right position. And having your shoulders sitting at the right position is important for the glenohumeral joint for all of the shoulder joint motions to work without subjecting them to too much injury. It seems like perhaps in weight training I don't know if this contributes to the the slope shoulders and maybe the flat or downward angle of the clavicle but the advice to depress and retract your shoulders is common right for any number of exercises and I recall meeting with Eric and what he has a lot of his athletes do and this is very individual dependent so I'm not making a blanket recommendation and I'm not speaking for Eric but for instance as as he has someone maybe retract on some type of standing pulling motion with say some type of cable machine he'll have them reach forward with the opposing side and it seems to me that there's less of that kind of fixed depress and retract retracted position in a lot of what he recommends is working on the seridus interior doing exercises for the seridus interior enough to correct that downward slope to angle in people who have that as a current state of affairs. Number one is you have to be sure when people have worked out now it depends upon again what their workout routine is if there's somebody that hangs and does chin-ups one of the things can be the latissimus dorsi is this big muscle and people do lap pull downs etc or they do climbing things or hanging things and that muscle will pull your shoulders down so you got to make sure that that muscle hasn't gotten too short and that you can get your arms up over your head in the first place.

Exercise And Stretching Programs

Stretching Cues (01:00:05)

Number two is what you really want to do is use the upper trapezius and the exercises where you're down here is using the rhomboids and the middle trapezius and just for people who are listening this is like a rowing motion. Yeah anything where your arms are below your shoulders or at the level of your shoulders you're using muscles they pull your shoulder blades together but particularly the rhomboids downwardly rotate so it's going to make it more difficult to get your scapula to upwardly rotate and to get the upper trapezius to work. So one of the things that is probably more effective is actually I like to start people off and I think that's the other thing that when I look at what recommendations there are on the internet they never show people where to start it's like do this exercise well not everybody's ready to do that exercise they've got to get ready to do it right the way that's recommended but if you can face the wall and slide your arms up the wall and then once your arms get to shoulder height particularly when they're lower then you shrug a little bit to get them up and then you try to lift them off while holding your shoulders up. How far are you standing from the wall? Oh you're right up you're right up your facing it. Okay got it right up there facing your elbows are flexed you're sliding the little finger side of your hands up there to get it and then if you just let your shoulders drop you've gained nothing but you've got to also hold them up as you lower your arms keeping your shoulders up as you do this exercise right keep them up get them up to where they should be worn not closer to your ears than your iliac crest. So you're looking to keep the shoulders in that in the position where the clapicle is angling up yeah slightly yeah. The other thing is it just makes such common sense you can't spend the rest of the day having them hanging down either. So you should have a chair that has arm rests on it so that they're up when you've got your arm rest up. If you have to stand a lot you can put them on your hips if one shoulder in particular is problematic you can support it with the other hand. I mean so again exercises will mean nothing if you don't follow through if you're doing even 20 minutes of exercise but you're spending 12 hours with your shoulders hanging down it ain't gonna work. What is your position on and I know there are many different types but stretching this can be a controversial sometimes polarizing topic but can you elaborate on how various forms of stretching should or shouldn't be used in healthy and rehabilitating populations? Number one is really understanding what you're meaning by by stretching. When I've talked about this as we've gone on through this but I keep using the term stiffness because I feel like I was sort of misled during my early days as a physical therapist when I didn't use my own sense of looking carefully because we were told that certain movements occurred because the muscle was too short and it needed to be stretched. I'll give you an example well the example we talked about already if you're on your back and you slide your legs down and your pelvis tilts forward your hip flexors are too short. Well actually what it is is the struggle between the tension from your abdominals and the tension from your hip flexors. So stretching your hip flexors is not going to fix the lack of tension in your abdominals and so what I find is that most often there aren't muscles that are short there's a relative stiffness problem. So improving the stiffness of your abdominals will elongate your hip flexors. Do you see what I mean? Yeah it's a relationship not just an isolated muscle that you need to stretch. Right and that it isn't the length of the hip flexors that's the problem it's the passive tension from those muscles because when you're sliding your leg down that muscle isn't that active anyway and if it's related to the length of the muscle it shouldn't occur until you get to the end of that muscle length. Right. And that's not when the tilting occurs so there's all these things that just don't make sense. So what I found through these numerous years of experience I've had is that there's many more problems with relative stiffness than there is with muscles really being short. Now if it's really short then you also need to find out what's making it short because it doesn't just like oh I think I'll go short today. Right. It's a matter of what is your activity for example when I'm teaching courses I have a great picture of a young man who has a big curve like you're talking about an increased lumbar curve clearly his hip flexors are short and he's a cyclist. Well you usually don't see that kind of alignment in a cyclist you usually see a flatter back but if I didn't let him use toe clips he couldn't move the pedals around. So he moved the pedals by flexing rather than pushing. So that's why his hip flexors were short. So it wouldn't matter how much you stretched him if every time he went out to ride the bicycle he's using his hip flexors all over again in a shortened position. Got it. So he's basically in that rear half of the rotation of the pedal he's pulling with his hip flexors.

Stretching in sword sell programs (01:06:51)

Right. Instead of more pushing than just the lifting. So what is it that people are doing that's causing that muscle to get short. You know other examples and again I find it so interesting about what intensive weight training is doing because if you're lifting I've actually examined young women who are lifting twice their body weight. Well you know how many muscles do you use if you're lifting twice your body weight in a deadlift like every little muscle you've got in your body. Well what happens is you end up training all of those muscles to come on and they don't just go off. So they walk stiff-legged because there's too much activation of these muscles. And so they can't stand and have muscles relaxed because everything comes on. It doesn't say I'll only come on when I'm weight training. You've trained them to come on. And now you've got much more output for a given muscle than you would otherwise. So it's too much so you've got to learn also how to not activate them as much as you're learning how to activate them. I'm not against any of this. It's just that you need to know what all the additional factors are that take place with this training. So it's a long answer to the question about stretching but my big point is you've got to figure out what's making it short. That if you need constant stretching you've got a problem with what's active what's making it short that has to be addressed. So I've been advised and it seems to help a bit but to do a fair amount of say hip bridging or glute activation alternated with say hip flexor stretches. And if I have in addition to that the stiffness in the abdominal muscles contributing to this low back presentation right these symptoms I'm experiencing. Could you just remind me of how I would then work on that abdominal stiffness?

Upping the repetition taboo Starts with Two Piloti Scission inside V single arm kusz Q case (01:08:53)

I could do the overhead breathing and the side bends. No that's for that stiffness but again what you're telling me and again I haven't seen you standing but... I could stand. We're also on video. Okay. Would you like me to stand? Please please. And I can tilt the camera as needed. Okay. Yeah pull up the shirt so I can see. Now turn sideways for me. Oh. Oh boy. No no no I mean I don't know what you're talking about your tummy sticking out. Oh well yeah I mean like if I want to look kind of in my second trimester I can do the... Which one's the real you? This is probably the real. This is the real me. This is this is how I would stand. If I were standing at an event I would probably try to tuck my hips a bit to take pressure off the back. Yeah but you see you don't have an increased lumbar curve. You've got an increased thoracic curve. Like the kyphosis on the back toe. Yeah. Yeah right up there. And part of that kyphosis comes from your rectus abdominis pulling down on your thoracic spine.

Rectus abdomini dozen posiceniddle Folate (01:10:04)

Interesting right here. Yeah and see when you lean back like that then the rectus and the other abdominals become your anti-gravity muscles so they're constantly being used. Meaning that I lean back and then these are pulling me forward. Yeah you lean back to get away from those but you need to... The rectus needs to be a little bit longer. Okay this needs to be a bit longer. And the best way for you to do that is to do the quadrup head thing and then let your thoracic spine go down. So that would be almost like the cat of the cat cow I guess sort of as I'm on my hand to do this. All you need to do is think about letting your chest go towards the floor and like you feel the load on your shoulder blades. Okay now let me watch you just easily like you're going to contract your tummy to pull it in. Yeah let me see you do sway back. Okay stop. You did lean back. That's it. That's better. That's better. Now do you have any symptoms like that at all? No there's a little bit of tightness here but it actually it doesn't bother me right now. Yeah okay and it looks like your hips are fairly straight so go ahead and turn put your back to me for a minute and put your hands on your iliac crust. Now with your hands like that they don't look so bad to me. Okay. That's do what we talked about before. Put your feet apart and let's just see what happens if that changes your symptoms at all. Is it better? Yeah this would help if I was say recording a podcast. What would help even more is if I put my one leg up on something. If I stepped on something. Does it matter which leg? Right leg. Right leg. Yeah. Right. Where I feel most of the pain is a little wiser around this body process. Right right yeah so that is going to be the tensor on that side. Now let me do you one more thing just bend over and come back up. From the side like this? Yeah. Well yeah see now you need to work a bit on how you come back up from forward bending and don't worry about going over that far. Okay. You need to come up with your hips and let's back. As you finish off your back you sway back and do too much back extension. Oh what I get to the top. Yeah about the last 30-40 percent. So hinge more at the hip. Is that what you mean? Just think about going over and coming back up by making your hips extend. Hold it there. Now hips just come back up with hips hips hips hips yeah that was better. More like that. So yeah and try not to let your back sway back. You use the momentum of your upper back coming back to finish up. I see I get a little extension and that's not good. Over extension. Right. Right. Right. Anything else that I can yeah I mean I can do more certainly. This is helpful. If you can easily practice you've got those the lower abdominals or the external obliques they're the ones that tilt your pelvis and if you just easily practice tightening those but don't work hard at it so that you sway back. So this is the external obliques and then what was the other musculature you mentioned? I'm saying don't sway back just easily try to tighten them so you get a little bit of a pelvic. Yeah. Lenny. Now are you good that way? Yeah I'm good. Yeah. And this would be an astounding position when I would have just a little bit of tension in the external obliques. If you do that as much as you can because you see it limits your symptoms that's all you need to do and then work on that little increase the rasic kifosis. Or I'm I guess reducing this kifosis by lengthening. Yeah if you decrease that then you won't sway back so much. I got it. And if your rectus abdominis elongates better you won't have that tendency for thoracic kifosis. And to extend then elongate the rectus abdominis for people listening this is like six backs right the stuff running down the front of the abdominal. I'm having a hard time hearing you Tim. Oh sorry I forgot about the microphone over here that to elongate the rectus abdominis I could get in that quadrup head position and basically drop my chest to the floor as I'm pushing my hips backwards. Just in that position just let it go down. It's amazing how much you can improve your alignment and it looks like you could change pretty readily. Okay great. And the big thing so we started off because you were doing the bridging exercise. I wouldn't be tempted to do that.

Tightening glutes causes issues (01:14:59)

Okay. One you'll do a much better loading of your gluteal muscles by that bending over and coming back up with your hip extensors. Yep. And if you tighten it there there's also a tendency for the glutes to actually posteriorly tilt the pelvis but the spine doesn't go along for the ride. Hmm. Could you say more about that please? Well it's kind of like this is one of my guilt trips because many years ago I was working to get the point across. I'll tell you my little story. Yes please. I was working with this older woman. I thought old was my age now. And so she did have spinal stenosis and I was working on sit to stand so she didn't have any symptoms. And I had her try to tighten her abdominals and she was doing pretty good. And then I said okay now let's tighten your gluteal muscles as you get up. Well she did that and she got pain shooting down her legs. And the reason being that your gluteal muscles as you know attached to the pelvis so if they posteriorly tilt the pelvis but if the spine doesn't want to go along for the ride it stays there and you get a translation motion between where the pelvis is moving and the vertebrae are not moving. Right the gluteal muscles are basically pulling the pelvis out from under the spine in a sense. Exactly. Exactly. Not a good idea. Now if your spine moves easily then that's all right. And you can get the same effect. If you would put your hand where your spine is and tighten your glutes you'll see your spine doesn't move. Did you see what I mean? Right. If it wants to go along for the ride it'll go along for the ride but the problem is those people where it doesn't want to go along for the ride and you're going to be one of them. So in what ways do I need to be careful then? I mean I just don't think that's a good exercise for you. Got the bridging. The bridging. Yeah. Yeah I feel especially if I do bridging single leg but even double leg I remember it's been recommended to be by a number of PTs and I've told them all like guys this really bothers my back. Yeah and it's arching your back it's not a good plan. Yeah okay I'll skip those. I will skip those. When do you have time to do all this? I don't. I don't. That's honestly surely been one of the compounding factors that has been so frustrating. It's not only am I getting very often entirely different diagnoses but I also get 37 different programs and there's just no way that I can fit them in and many are probably conflicting also. Right. Yeah yeah yeah. And I found the movement focused approach to make a lot of at least intuitive sense to me.

Age & fitness routine (01:17:50)

If our entire conscious experience of reality is modeled on a brain that is evolved to move us through space it just seems to make sense that that is the variable to pay a lot of attention to because it's not just a variable but a system of systems as you put it much like the immune system so it makes a whole lot of sense. Now you you just mentioned older woman but she's now my age. Would you mind sharing your age but also your own self-care I suppose routine what do you do to keep as sharp and as in shape as you are? I would love to know more about that. Well next month I'll be 86 years old. It's incredible. It's just amazing. I would never guess in a million years. I'm so lucky. I'm so fortunate too because I don't mind saying both of my parents had dementia. I've now exceeded their ages both in life and in dementia. Right now I don't know that I have any. I would not think you have any. Very very short. So far so good. So far so good. As I told you that number one choosing to be a physical therapist and also I was very fortunate because growing up I refused to grow up and I played sports and in my day just when are you going to grow up and stop all that stuff and that was very good. We also didn't have air conditioning and we only had one car so instead of paying more for a bicycle than a car I had to ride a big old bicycle and ride it everywhere. So I happily laid down enough bone and enough muscle in my early years and then the physician that I encountered who was part of the Department of Madison at Washington University in St. Louis his name was John Hollissey. He started bringing in the lifestyle issues and as a physical therapist even though I got a PhD in neurobiology because I wanted to solve the motor control problems of the stroke patient I stayed very physically active. I started really running and doing things when I started my PhD studies and after encountering this physician and learned a bit about nutrition breaking all the family tendencies and then again learning about musculoskeletal problems even though I was really interested in working with neurological patients people with spinal cord injury head injury stroke. I had always had this tendency to look at how people moved and I totally tried to figure out why they were moving the way they were moving etc and got involved with musculoskeletal patients and they started getting better and so I had to figure that out and then I applied my own ideas to myself. In fact I don't know how folks who you want to get up but there are really some funny stories connected with that. Oh let's do it. Oh yeah no we love funny stories around here. And it really related to doing this quadrup head little exercise because so one sort of funny story was I was really poor going through getting my PhD because I didn't have any income and was living off of a minimum amount of money and so I didn't get to buy new clothes very often and I had a pair of slacks that I was wearing for a long time and a friend actually took me out to play golf and it was an older woman at that time and we're out playing golf and she says you know surely you've got your pants on backwards and I said you know I'm working on my PhD I think I ought to be able to know how to put my pants on and so we started looking at the darts and sure enough I had them on backwards. Well before before my alignment was such that they looked all right but now that I was doing this quadrup head exercise they didn't look all right they were they were looking funny because I had changed the curves in my back and my buttocks and so that's why she caught the idea that I wasn't wearing my pants right. Which quadrup head movements were these? It's just the idea of being in quadrup head and just letting your back go down and then rocking back. I tended to sit ride the bicycle I was a catcher for three different softball teams so I was really in a poster tilt with a really flat back. Got it. And I had never really gone the other way. And just for people who are listening if you don't know I just do it to imagine if you imagine that they sort of the pelvis as a bowl of soup post your tilt your kind of pouring soup out the back of your pelvis just holding it in the middle. Yeah yeah right yeah got it. So your back your whole back goes kind of flat then. And when you're pushing your hips back you're facilitating more of a natural curve in the lower back. Well I was you know getting my hips to bend and yeah letting my back go down so he's getting more of a curve. And I think also decreasing a bit of a Tennessee towards a thoracic hypheosis.

Personal Fitness Routines And Exercises

Tim What have you been Up To (01:23:08)

The other thing that was really interesting I used to bowl you know like with a bowling ball. And while I was in my PhD program which took me six years I didn't have any money to bowl. And so when I went and got my bowling ball out again I had to change the finger grips because I had stretched my finger flexors out. And so the finger grips no longer fit me because my fingers were longer. Can you do explain that? See your your grips had been molded to fingers that were well my fingers were always flexed from everything I did. Right. And I never really thought about stretching them out. And so when you're in quadruped you end up stretching those all out. Right okay I see right instead of so for people who are listening because we're making movements with their hands and gestures with the hands. Oh you can't see. We're going to make the video available as well but some people will only hear audio. So instead of being sort of that keyboard you know hawk tellin position when you're in quadruped right as if you were doing a push up but not that push up position.

Exercises When you Got Back (01:24:05)

If your hands are flat on the floor then you're going to be stretching those flexors. Stretching across the wrist and across the fingers yeah. Got it. So you had to change your bowling ball that's wild. Yeah. And then the other thing is I had always worn my shoes off so that they were going off to the side. And after I did this you know few years of this quadruped rocking I didn't walk in the same way and I didn't have my shoes worn off to the side from just walking. Oh interesting. So worn off to the side you mean the shoes on the inside were worn or on the. Yeah like the outside of the right and the inside of the left. So there were all these little changes that took place just from improving my alignment partly with that. So to go on to answer your full question so what do I do these days. Guess what I still do quadruped. I don't go all the way back and sit on my heels. And I also want to tell you about one thing people need to know about that exercise. And then I do a modified push ups modified push ups in prone and I think that if you could do this carefully it would be good is in prone I flex my knee so that my leg as much as possible is falling falling on my thigh. So is this similar to what you're describing? You're laying down on your chest. Yeah I'm laying down face down bend my knee and I tried to get my leg to fall back on my thigh because I don't want to hold it bent at 90. In other words if you flex if you bend your knee you can go to 90 degrees if you go more than 90 degrees your leg is falling on your thigh. I see right your lower leg is sort of falling under your hamstring. Yes that's your thigh. Yeah got it. Okay. In that position then I lift my thigh off of the floor. I do hip extension but not high. There's only 10 degrees of motion but it's a way to stretch. It's a way to use your gluteal muscle because if you use your hamstring you'll get a cramp. Yeah. You'll get a bad cramp in your hamstring. So just a little bit of hip extension to use my gluteal muscle. How many repetitions are you doing on each side or what is... I just do 10 repetitions on one side and then 10 repetitions on the other. And you're doing roughly 10 repetitions of the quadruped rocking as well. Yep. That's the regimen. 15 push-ups. 15 modified push-ups. Modified is your knees are bent. I don't go to my toes. Got it. Okay. And then still in the prone position knees flex to 90 degrees and then I do hip rotation. You know in both directions letting my lower leg come in and then go out. Come in and go out. Right. So just if I can translate and please correct me if I'm getting this wrong but you're bending one, you're laying on your chest. One leg bent to 90 degrees and basically windshield wiper with that lower leg on each side. Yeah. But I do both at the same time. Oh you do both at the same time. Okay. Yeah. So they're not quite you know ones maybe 80, the other maybe 70. Just because it doesn't take all that long. Yeah. Right. And then with my knees extended straight with my lower extremity straight, I alternate doing hip extension but I think about using my gluteal muscle. I think about activating my gluteus maximus. And again only about 10 degrees of hip extension. Okay. And then in that same position I do hip abduction. In other words, one leg out to the side 10 times because you use your gluteus medius and that better if you're working against gravity and extension than you do when you're supine. Okay. Supine, you tend to recruit the tensor too much. Oh I see. Mm-hmm. Got it. And is there anything that follows that abductor work?

Abductor & Supine and Active Hip & Knee (01:28:22)

Then I go supine, turn over. And I think this is really you know I'm pretty good about not having a kyphosis but I have to adduct in supine. I adduct pull my shoulder blades together and slide my arms up over my head so that my arms are all the way up over my head as much as I can. And I'm on a hard floor. And I'm starting with my hips and knees bent, arms up overhead and then slide one leg down, slide the other leg down. And believe me for an older person who's got a tendency towards collapse, so smash, oh, just getting yourself as stretched out as possible is so important. Mm-hmm. Yeah. I mean really. Sounds like for me with my kyphosis that would also be important. Yeah. The biggest worry is going to be with the older person that if you have a kyphosis, you're not going to be able to get your arms on the floor all the way up over your head. Mm-hmm. You know when any pain on top of your shoulder because that's not going to be a good plan. So they may need to have a pillow up there when they're first starting to, so their arms don't go all the way back because you want to avoid any kind of pain on top of your shoulder. Mm-hmm. But happily I know how to do it and I can do it. Mm-hmm. And then I do active, actively hip and knee flex, you know, bring one knee towards my chest, put it down, and the other one. And ten times with each leg. And then with one foot on the floor, I do a straight leg raise. But I don't like tighten all my leg, my thigh muscles, so that my knee is perfectly straight. And I turn it out a little bit so that I don't use the tensor. I'm going to, if I rotate it out, you'll use the sewers more. And I think about tightening my abdominals. Okay. Because I have had a significant problem. And I don't want to put too much stress on my lumbar spine from the ileo sewers. I want to use it, but I want to protect my back. That's why I have one foot on the floor. I see. That's why you're doing one leg at a time. Well, yeah, it's certainly one leg at a time. So could you just reiterate, given the last lumbar issue, why you would want to engage the sewers instead of the TFL in this case? As a good muscle to use, I need to be able to flex my hip. But the tensor, it has a real low threshold for activation. I mean, interestingly enough, that if you would scratch the bottom of your foot, the first muscle to go off will be your tensor fascia lotta. No kidding. Yeah. In fact, I think it's so interesting because I've tried to contact the World Health Organization because all over the world, the tensor is run amok. But they listen to me. They're not returning the calls. You know, I know. And it's this little bitty wimpy muscle and you say, "How can it cause so much trouble?" But it sure does. You know, it plays a role in what happens to the knee, plays a role in what happens to the back and the hip. I mean, it's an evil thing. But anyway, you know, an interesting thing, one of my colleagues was doing a study and we actually had a student that did not have a tensor fascia lotta. No kidding. Yeah, we didn't throw out a school or anything. But anyway, I couldn't wait to do all the tests that we do to look for the length of the tensor. And she was a, you know, a fair athlete. So it wasn't like it had been sitting not doing anything if it was there. And I did all the tests and they were negative, which was kind of supportive to me that indeed, the tensor does do things that aren't so kind to the rest of the body. So anyway, all that to say, that's why when I do the straight leg raise, I try to laterally rotate my hip, because I'd rather use the solace than I would the TFL. And it's not causing many problems. Clearly, if I thought I was injuring myself, I would not would not do that. And then I do one other thing with one leg straight and the other foot on the floor so that my knee is bent, my foot's on the floor, I let my leg go out to the side. And that's my way of trying to work on controlling rotation with the trunk. My leg goes out to the side. It wants to rotate your pelvis. But contracting your abdominals prevents that rotation. So that's another way I'm trying to work my abdominals. And then, and then I stand up and, you know, I'm so proud of myself because I can get up from the floor without any difficulty. And many people at my age are many years younger than that can't do that. And put my back to the wall and then do what I was telling you to do, arms up overhead and do the little side bend thing. And you do this every day? I do. And I walk three to four miles a day. Amazing. And sometimes ride a stationary bike.

Check the location of the velo Femoral joint (01:33:45)

Well, these are things I'm paying more and more attention to. I'm so impressed. But let me tell you one thing now, Tim, that the quadrup head is as much as I love it. And I think it's important whether you have a shoulder problem, a cervical problem, etc. Is that one of the things that's a problem though, and it can be for several reasons. But again, the tensor is one of them. If you rock back and your hip medially rotates, in other words, I found this in some patients that as you rock back, your hip should just flex. But if you are monitoring the femur, you can sometimes see that it immediately rotates. That is really bad. And the reason why it's really bad is because it's rotating in your knee joint too. And that's a good way to set yourself up for an ACL tear, anterior cruciate ligament. Yeah. Yeah. Yeah. And I think people should be monitoring that. Anybody that's doing that. One of the things that helps is if you slightly laterally rotate your hips, many people, particularly men, come with what we call femoral retroversion. Do you know what that is? I don't. Okay. Well, you probably have a femoral retroversion. It's a structural variation. And so the femur, as you know, has a head and neck on it, it's angled. Well, it's also rotated on the shaft. Right. And if it's in the ideal world, the average, not the normal, the average, is that that rotation is 15 degrees. So the head and neck of the femur are pointing 15 degrees forward. Now many men, it's not rotated. So what it means is that when you're doing your hip rotation, you go out a long ways, but you don't go in. That's true for me, for sure. Yeah. My internal rotation is terrible compared to my axial rotation. But that's because you came that way, and it should never change. No, I mean it. And so you and men need to know that. And so, in fact, that's a problem because if your tensor is really developed, you could be sitting and hip medial rotation when you shouldn't be. And if your glutes are really good, that'll also medially rotate your hip when you're sitting. That's a problem. Okay. Yeah. Okay. So one of the ways to, if you're trying to do the quadrup head thing is to turn your hip out a little bit when you're in the quadrup head position. So your feet would come together a little bit closer. Right. More of like a wrestling partier position. Yeah, I don't know. I never wrestled. Yeah. Yeah. I could, I can pick up the slack on explaining that then. So from now with a referee anyway. Okay. Anyway. Right. So from the feet to the knees, it would just be making a very, very, very slight V shape.

The Tensor Fasciae Latae and its Association with the Male Genitalia (01:36:44)

It's not a V shape, but the lines would converge in other words. Your feet would be a little bit closer together. Exactly. Mm-hmm. You're funny. All right. So that makes a lot of sense to me.

Sitting vs. Standing (01:37:01)

And I'm certainly comfortable that what, what would it mean or how would you read the movement pattern that I have of sitting and having my legs sort of splay open? That's also something that alleviates my low back symptoms. If I'm sitting in a chair, oftentimes I'll take my shoes off and fold them up on top of the chair. Restaurants hate this, by the way. So I do get chastised occasionally, but, but it alleviates so my lower back issues. Yeah. You're getting it four and a half because you're probably in this, this is one of the syndromes I have of the hip that I've described to the hip because if your tensor is really developed, it's going to be holding your femur in medial rotation when you're standing because it's pull taught then. If your gluteals are really well developed, when your hips flexed to 90 degrees, they become medial rotators too. So they're trying to hold your hip in medial rotation and you're probably getting that twist on your back then. Do you see what I mean? Yeah. So when you laterally rotate your hips, then you're taking that pull off of them. Taking the pressure off of it. Yeah. Yeah. You're not getting that extra pull on your pelvis from those gluteal muscles being pulled so taught. And that's where you should be. That's your normal thing because you have femoral retroversion. See, and that's one of the things that's bad is because, you know, like when people go in and they're taught deadlifts and they say, "Well, make your feet point straight ahead." Well, many men in particular shouldn't have their feet pointing straight ahead because they have this femoral retroversion. And also when they do things that rotate like play golf, their feet should be turned out because if they're straight ahead, they're at the end of their medial rotation range. Yeah. Do you see what I mean? So then it'll be the knee or the back or the hips that are going to go. Makes a lot of sense. Yeah. It's also interesting. Yeah. Super fascinating. Yeah. It's like the backbone attached to the pelvic bone. You know, and I think to me, that's what's so valuable about being a physical therapist or looking at people because I can't, like an orthopedic surgeon, just look at the knee or I can't just look at the hip because it's the result of all of these interactions of the body.

Body Posture And Pain Management

Femoral Retroversion (01:39:01)

That's what's so important. And in a case like mine where if you look at family photos, right, especially on my mom's side, the feet point way out. I mean, a lot of the guys stand like ducks. Now, at the same time, I have been told and I agree with this that if one were to watch me walk, I have probably because I have at times the feet pointing out very little sort of glute hamstring assisted hip extension. So I tend to bend at that lower back, maybe a misdiagnosing things, but how would you sort of make sense of that? Would it be bad for me to try to point my feet a little more straight ahead so that I get better hip extension using the gluteal muscles and the hamstrings versus the lower back?

Shoulders vs. Low Back (01:40:01)

Or is that going to be setting me up for knee problems? Usually if you're not using your gluteal muscles and that is because you're swayed back. If you're swayed back, your line of gravities behind your hip joint. And if your line of gravity is behind your hip joint, you don't need your gluteals, those other muscles. So if you reduce that kyphosis and get rid of the, which isn't bad, it's just not helpful for what your condition is. And then you go forward. And then the other thing is if you also push off, in other words, when you're walking, and this could be another way in which you're reinforcing what your tensor is doing. If you tend to walk by pulling your leg through rather than pushing with your feet and letting it swing through, and if you push with your feet, you'll activate the extensors more. So the two things, the things that may be contributing to you, and I'm not saying this is for sure because I'm obviously not analyzing you. But let's say if we paint a scenario that you're swayed back with a kyphosis, your line of gravities behind your hip joint, I always call it then the gluteals do not have good definition. I call it missing for lack of action. And so then you pull your legs forward with your hip flexors, you're just reinforcing the overuse of the tensor. But if you decrease your kyphosis, so your line of gravity is a little more running through your hip rather than way behind it, and you roll over your feet and you push with your feet. Do you know what I'm saying? I do. So you roll over so that you're pushing with the ball of your foot and your leg swings out, you'll use your gluteals more. Yeah, makes perfect sense. Just pushing instead of pulling, you want to chase your center of gravity, not pull it. Yeah, this kyphosis has been with me since I was a little kid. And it's, it's, I've tried foam rolling manual release, strengthening the mid back end. But I have not worked on and elongating the rectus abdominis. You know, there's a condition called Sherman's disease, which isn't really a disease. But it, if you had it, particularly it happens in your teenage years, where you get a, do you've heard of it? No, I haven't heard of Sherman's disease. But ever since, I would say since I've been like 12, 13, I've had this kyphosis, lordosis combo. Well, then you probably got Sherman's disease. Oh, okay. I have to look it up. It's S-C-H-E-U-E-R-M-A-N.

S-CORE RATING +MORE (01:42:44)

Okay. And it's kind of a idiopathic compression fracture of the thoracic spine. It means you won't get rid of it. Oh man. Okay. Well. But I think if you, if you just don't sway back more, you know what I mean? Uh-huh. And just stay forward a little bit if you can make peace with that. Well, I can try to work on the elongating of the- Well, it's not going to change. The big thing is don't let it get worse. Right. If that's what you have. I'm not saying that's what you have, but I'm saying- Right. It's possible. Yeah, because it happens around the teenage years. So what would be the keys to not letting it get worse, would you say? Don't have an increase. I mean, you can still do the same things, Tim, but- Yeah. Just don't say, I will be absolutely perfect. I have to settle for kind of perfect instead of absolute perfect. Yeah. That's probably good. Emma, for most of my life, I would say. All right. Well, I'm most of us don't get that close. There we go. Oh, probably. For their way, then I would like to admit. So surely this has been such a great conversation. We've covered so much. I've taken copious, copious notes, and certainly people can find your books. The Diagnosis and Treatment of Movement and Pyramid Syndrome, which has been translated into seven languages, as well as your second book, Movement, System and Pyramid Syndrome of the Extremities. Surivocal and Thoracic Spines has been very influential in promoting movement diagnoses. Is there anything else you would like to mention, anything else we should talk about, anything you would like to draw attention to with my audience, anything at all that you think is worth saying or discussing before we begin to wind to a close? Well, it's probably just a little repeat of all the things we've been talking about. It's been really great and generous of you to allow me to discuss your issues. But you know, what's really nice is here you are somebody that's worked so hard to address all of these things with all the discipline that most people don't have. And it's still hard to get a straightforward story about what's going on and how best to suit you. And that's what worries me a lot is number one is I look on the internet for exercises and most of them people can't do, and they're not taking into account the variations in how people are. I mean, here you've been through all this exam and nobody said you have femoral retroversion, which you need to know because you came that way, you need to stay that way. So I would like to see that there's more respect for how difficult exercise is. It's not like here's the way everybody should go out and do this one thing and then they'll all will be well. I'd like to see this recognition of that movement is as complicated as anything else that the body does, that there is a movement system of physiological thing and that we should have diagnostic categories so that people when they're consulting a physical therapist get a diagnosis just like when they go to any doctor. I mean, that's to me why you go to a doctor is to get a diagnosis or find out what condition you're you're working on. And I think that would do a lot to help reducing all this variability in treatment. And I think helping people to understand how it's the way they do their everyday activities that causes the problem and that those can be changed with with good direction. You know, I can't help but say this too. I help a good friend who's actually on a dementia floor, I go to help feed her twice a day. And I look at all the other people, older people that are in assisted living and the majority of them are there because they have physical disabilities. I'm older than most of them. And I think if people had a chance to address these things early on and with a discipline like you show in good direction, we could cut down on and improve the quality of life. I know you've interviewed a doctorate and much of what he says, you know, medicine 3.0 or something.

Addressing Adult Issues With Disabilities

How to Address Adult Issues with Disabilities. Particularly Stemming from Childhood or Young Adulthood. (01:47:03)

And if we did that with more care on exercise and knowing how to do everyday activities and not just take them for granted, I think people could have longer, fuller lives and be as fortunate as I am. I agree to, I agree to, I agree to, I agree to. What a great conversation. I've learned so much and I've taken so many notes. I have a lot to dig into. It's also given me some renewed optimism in terms of exercises that I can work with, movements I should say that I can experiment with. I hope you'll get back to me if I can help further. I will. If you find out that these things are going along, I would be more than happy to. Thank you. Do this a little more formally. Yeah, absolutely. I really appreciate it. We can do it on Sue. I mean, we can do it on this. Yeah, I would very much like to do that. So thank you for the very kind offer and thank you for so kindly taking the time to have this conversation. I think it'll be really helpful to people. As my dear friend, Michael said, you are tremendous. I've really enjoyed talking to you and you do have a sense of enthusiasm and how to ask the right questions to make it fun for both of us. Thank you so much. And for everybody listening, we will link in the show notes to everything we discussed. As usual at Timn.blog/podcast and until next time, be just a bit kinder than is necessary, not only to others, also to yourself. And as always, thanks for tuning in.