Why Exercise Alone Isn’t Enough | Nathan Sherwood PT, DPT, OCS, CSCS

Automatic captions from YouTube, shown unedited apart from name spellings; they may contain errors, especially in medical terms.

Ideally, what you're looking for a positive change in your symptoms, but a negative change in your symptoms still tells us a lot of information. How your body responds tells me a lot about what I should be expecting and what's needed here.

Yeah.

And it it's usually helpful for understanding the cascade of symptoms. I'm sure you see this all the time. We see it a lot where what the patient comes in with is not the primary issue.

Hi, I'm Dr. Jason Seafferman and welcome to Care Beyond the Pain. In each episode, I will sit down with a provider, a person with pain, or a supporter to explore their experience and share their perspective on the pain journey. Together, we will navigate care beyond the pain.

Hi, I'm Nathan Sherwood, physical therapist.

Nathan, thank you for joining us today.

Thank you for having me.

Tell me a little bit, how did you become a physical therapist?

I took a very winding road to get there. Uh I'll spare the uh the extra details. I came to this profession a little later in life. Um I was a little I was always been fascinated by the human body but I I took a very roundabout way of getting there. I used to be in performance uh I was a former actor uh artist and when I realized that that was not the business for me, I started to like look for something else that would really capture my attention.

a good friend of mine is an actor and he uh he took to that with such gusto and such a verve that I was very interested in like what what is that for me what do I care deeply about and so I

went on a bit of path of self-discovery got into exercise science and sport science for a little while I worked as a trainer and was aspiring to be a strength coach

and my clientele that I had often were in problematic positions of orthopedics and pain issues that often limited they were able to do. And after a number of years of learning how to try and address that as best as I could with the tools I had at the time, I decided at one point it would just be it behooved me to go into physical therapy and just do it more directly because they were often having less than stellar experiences in the rehabilitation process.

Uh so I there was a e egotistical part of me that I think said fine, I'll go do it. There's something to be said for wanting to do something as well as it can be done.

Absolutely. Absolutely. And I think that was my sort of my mission statement when I got into this, especially coming into it a little later in life. I didn't want my inexperience to get in the way of like some of the years that most people would develop kind of like right out of of college when they're like 20 and something like that. And they have a lot of time to like kind of build on their their process. I had already had a little bit of process ahead of me in my experience as a trainer for 10 years and I felt like I needed to accelerate the process.

So I delved deeply into continuing education even when I was in school and really tried to train deeply in a paradigm of treatment that had a holistic approach um that covered as many bases as possible.

Tell us a little bit more about that. Like what in physical therapy drew you?

Um that's that's an excellent question. I think it was the possibility to greatly affect the human system, the person, the person in front of me in a way that had a lot of one-on-one potential time. So, I had a lot of time. Now granted, not every setting gives that opportunity, but more so sometimes than the the medical doctors and more so than some of the other like ancillary like components of like health care, physical therapists have tremendous one-on-one potential time with patients to really dive into some nuances and some of the deeper aspects.

Can you tell us a little bit more about how that drove you to craft your current practice?

Oh, absolutely. Um, so that idea of wanting to be specific to the person, specific to their needs, and really cultivate a a a through line. Um, I think the idea there was essentially one that I wanted to offer as much possible benefit and change with a person, collaborating with a person over a set of time using a skill set that really hopefully cut to the chase in terms of like could make quick progress with somebody but also then like really layer on some nuance over time if as necessary.

And that's kind of driven me to be in a situation where I am fortunate enough to work one-on-one with people. I have hour treatment sessions and that really gives like a a real depth and breadth of like treatment opportunities to help them recover from injury and get out of pain and hopefully reach their more efficient state of being.

That's fantastic. Uh when we speak of the pain journey, we think of the discovery phase which involves diagnosis and thorough understanding. the treatment phase and then maintenance. So once they've sort of accomplished the healing for the most part, how do they keep themselves safe and functioning and preventing re-entry?

If we jump into the treatment phase, the way you describe it, just to repeat some of what you said, the continuity of care is really important because it's during that linear care where you really uncover the next layer. And having that intense time with the person allows you to really

visualize to really see what's going on mechanically, mentally, uh how one piece of the body affects another piece of the body. It allows you to put those pieces together and seeing them sequentially over several weeks allows you to really build upon that.

Absolutely. I may have just taken words out of your mouth, but no. Can can we explain it a bit more granularly? How that iterative uh ongoing process is part of the treatment process? It's not a magic wand that just comes and waves itself. There are layers that must be worked through.

Well, especially with somebody who's dealing with more a more complex injury history or more complex chronic pain presentation,

there is that kind of peeling back of the layers. Hopefully with a good subjective intake we can like be as clear as possible of like what a maybe a primary driver or primary drivers of the issue are. But sometimes it is very nebulous like especially if somebody has like a very chronic presentation where their their symptoms have become diffuse and we have to like peel those layers back and it has to be through a process of success. We have to find what is the main thing that seems to be in the way or the main thing that's important to them that needs to be cleared out of the way.

And as we address some of those things, we might find, and this is often the case, as we help resolve some elements of pain, there's like new pain that gets discovered, stuff that was maybe buried beneath the amplitude of that previous pain. And so there may be other issues, other body regions that may need to be addressed to then continue to like calm the system down and calm it down and calm it down. It it it is not often a linear process, but it is a stripping back of the various components.

And hopefully through the process of successfully taking it one step at a time, we can really peel back the layers and get to maybe a an underlying hidden driver or just the accumulation of the secular of like all the various things that have come together and form the current picture that that person is living with. What's it like from the patients perspective to recognize that there are these layers and that they are more work to do

that and that is a very as I'm sure you know like a very very challenging things thing potentially because like one in order to take the person on that journey you have to earn their trust they they have to invest in the process you have to show them that there's reason to invest in the process but also to take the responsibility which can be a challenging thing for many of us to like take some ownership of this is the situation and this is the process by which I have to go.

It's it's a very challenging thing I think to comprehend sometimes the complexity especially with more complex cases. Uh I think having the person take ownership in part by like really helping in the analytical process really like helping the practitioner the provider to sort of uncover the layers and provide feedback and really have it be a collaborative effort where there's a back and forth and essentially a teamwork which really can very much help in that building of trust and building in in the understanding of the process.

It really sounds like how psychologists work.

Oh, very much. I think so. like I I will not claim any such like abilities in terms of the psychological aspect but there's there is so much of that that pervades into like I think healthcare in general but also like in the kind of like one-on-one physical functional aspects like a lot of this is taking accountability responsibility understanding the nuances that are in front of them but also [sighs and gasps] being aware that this is a a journey that is not often going to just be like have a nice sunny clear as day outcome.

It's it is a peeling back and in some cases it's just a matter of like and I hate to say this but it's a matter of like how much is that person willing to do to get maybe good enough with their symptoms. How much investment are they willing to put in even if it means things aren't going to be perfect? And that that is a hard pill to swallow. And I think that is something that really takes time, patience, meeting the patient where they're at so that they have the opportunity to really kind of like not be put off the journey because it's it's sometimes a very daunting journey.

Yeah. Fear can also play a role.

Oh,

the the fear of success in the pain journey.

Yes. play a role

when there is that apprehension about actually like I don't want to say defeating the beast as it were but like really confronting the the nature of things of like actually getting better having opportunity. There was a patient I worked with for quite some time uh when when she was very young she had a a whiplash injury and it started to cascade. Many of her symptoms, though widespread, were really very much rooted in fear. Which is not to say that this was like a mental construct, but that fear perpetuated like a physiological response in her body to where it was it was a tugof-war once we finally got her on the path to where she was actually able to do much more than she was before.

There were these times where we'd have a session and it was just like this dread of like what that meant and the sort of fear of the unknown because it was especially chronic pain could be in its own strange way familiar and comforting at a certain point. and ridding yourself of that or trying to like tamp that down can be its own kind of like apprehension because you're entering into a new world.

Yeah. I think at a subconscious level at least know pain is deidentifying. Um a lot of patients lose their sense of self. uh they they struggle so much to find a diagnosis, they become so desperate to get some explanation or some answer to explain what they're going through that they're almost too happy to have a diagnosis. So much so that they claim it as part of their identity.

And once once you've then claimed and internalized that disorder as your identity, it defines who you are if if you let it. And then if you're going through a process to extract and remove it, there's going to be some subconscious emotional kickback.

Absolutely.

And I I think the other piece of it is if if you have been through this process and you recognize that things are getting better, there's an overwhelming fear of what happens if it doesn't work? What if it comes back? What if I put all this energy in and it doesn't stick? And then the other side of that coin is what did all of this mean? Like what did I just go through? What what have the past several years been and who am I now?

And how do I readjust my life? And you know,

absolutely. Th this is something we encounter in the maintenance phase almost always whenever there's complex chronic pain because most of the patients aren't necessarily expecting to get there and and they're blindsided by the anxiety that just settles in,

you know, if if up to this point they were on a mission, right? Going through discovery, going through treatment, it's mission driven. They're at war, right? So very focused. But then as soon as that's done and they have time to step back and consider what have they been through? Who are they now? What does this mean?

Being a warrior in peace time is a very different proposition. Yeah,

a lot of people know that too well.

So, yeah, this is this is a real challenge and and we work directly with pain psychologists, but of course the physical connection with the emotional experience with pain is so so actually physical. So absolutely it must be part of the work to recognize that that connection and and coach patients through their awareness of that connection. I I love how you put all of that and I will probably not do it justice by the the segue out of that like yes the heart of that because like so much of that is deeply profoundly emotional psychological like there's so many components there that are so deep and worth considering with that one vital component that seems maybe minute by comparison is is that functional identity.

Um, which I think is it kind of goes hand in hand of like both that that mentally mentality of like you know really identifying with your diagnosis can be its own like kind of trapping of like okay this is me I kind of understand me if that's going away I'm not sure if I understand me in the same concept in terms of like physical therapy especially from like a functionbased approach oftentimes as I'm sure you've seen like with with pain there is going to be inhibited inhibi inhibited in function and like often like in the even the simplest standpoint of like people with back pain their stabilizers of their spine tend to fire less well in the presence of that pain.

So just from a simple standpoint all right that's not as well controlled mentally on the homunculus like we we start to get this potential smudging effect where it's like the body no longer kind of recognizes that ability to use those components. So part of the physical therapy process there uh especially kind of in the the approach that we take is really trying to restore not only the mechanical capacity of the body to move where it needs to but the neuromuscular function to have it be actively able to contract.

very importantly initiate movement not just valitionally but like if somebody hits you on the subway and knocks you to have your actual body be able to respond and initiate to that which a lot of people lack restoring that function so that there is like control there's a danger sort of response in the body but then also getting the valitional strength and endurance back in but then really retraining that person through whatever range of motion they're lacking whatever motion or functional activity they need to doing?

Can they actually control it? Can they actually like engage with it? Because if they can't, all of us can have our dysfunctions. Dysfunction is a very normal state. But

comment,

yeah, it's but at the same time like we all for the most of us who are maybe not in a chronic pain situation, we can kind of get away with like, okay, I move this certain way. It's not perfect. Maybe my hip doesn't adjust appropriately. the local muscles maybe don't stabilize well, but I can kind of get away with it. Somebody whose system is so taxed and inflamed and sort of under constant stress and alert. That might be a huge component of like potential problem in their system, but also a lack of like identity of like what what do I do?

I don't know what you know this motion is foreign to me.

Yeah. And so trying to restore that so that they the person has as much as they can a real ownership over their movement, ownership of how their body responds to what they need it to do can help at least on some level kind of help with that identity of like all right, I know what to do here. I can engage in the correct way. And it's often sadly more than just, oh, this person needs to exercise. They just need to be stronger.

That is important. But if I had a nickel for every time I saw somebody doing an exercise poorly, that probably doesn't actually really help their system function.

I'm I'm sure as a personal trainer, you got much more than a nickel.

Yes. Yeah. I I I spent a long time getting annoyed.

So, how do you how do you accomplish that? How do you help patients develop this?

So, in part, it's through a lot of training to understand what the body should do. like as as the the founder of the functional manual therapy approach, he likes to think of it as being a a student of of motion of student of mo uh of movement and a how did he put it? A uh well he he very much loved the real deep analysis of of movement. He loved he still loves uh that aspect. He's a big fan of like and he incorporated into some of the style of Mosha Feldon crisis like awareness through practices

like really engaging in in terms of like what does the body

supposed to do and what does it look like when it's the most efficient really looking at people in their like maximal efficiencies top level athletes what is the body actually capable of not settling necessarily for what's normal how do we get you back to normal normal is a dysfunctional state like normal is often kind of the average

good enough.

Yeah, exactly. And it's like, okay, sometimes that's adequate, sometimes that is enough, but can't we push a little further? Especially if there's availability to get there. Can we go a little bit past that? So,

being a real like student of of how the body moves and also being a facilitator of of engagement and how the body does that. So how how we would typically approach it after like really trying to dig into the root of what is this person's issue like what are they having problems with? Is it is it from a trauma? Is it from a specific trauma? Is it from several traumas that combined together? Is there more of a systemic problem going on?

Uh possibly all all of them combined. trying to find the particulars of like, well, what is it in particular that they need from a from a physical standpoint? Like, what do they need to be doing? What are they having a hard time doing? What when they do it creates problems? Okay, let's break that down. Like, what is involved in that process? So, not just like in the case of a car accident, somebody maybe has a whiplash injury that occurs from that.

Okay. Well, what were they doing at the time of that impact? Were they looking in the rearview mirror? Was their foot on the pedal? Did their leg get jammed back? Were they maybe like twisting into the back seat to get something and their back was put into a problematic position? Trying as best as we can and not everybody's going to remember all the particulars, but like trying to get to the the root of what are the circumstances associated with their issue and really looking at the body under that lens of like well what's what needs to happen there that isn't happening there.

okay mechanically what's what's not moving? we got to get that moving better. That's that's common in most any manual therapy approach. But then once we have restored some mechanical capacity to things, is there control of that segment? And what is that control like? It's easy to say like okay like I can hold my arm here and press down and like I can maybe hold it possibly with some of the global muscles, the bigger muscles, but am I stable? Can I actually like perturb and have that rotator cuff of the shoulder actually like engage and stabilize in a way that really holds that arm fairly steady under that duress?

Or is it kind of like a jerky big response? Because the bigger muscles, they aren't as fine-tuned. They aren't as like finely adapted. For a lot of people, we need that more fine control. And so we utilize a variety of techniques but the main piece in functional manual therapy is utilizing propriceptive neuromuscular facilitation. Uh which is

can you tell us very specifically how you do that because I never would have guessed that manual therapy could restore propreceptive uh function and strength. It it is it's sadly not used as much any more at least in the full breath that it was developed and I don't want to claim that I use it in the full breath that it was developed but it was it came about uh out of collaboration between Dr. Herman Kat uh medical uh doctor and Maggie not a physical therapist uh back in the 40s was I think when they developed it and it was this it was kind of built around the idea of working mostly with like a neurologically involved population who really needed like facilitate as much like motor function as possible and it's for the most part utilizing patterns of motion of the body often like very narrow diagonals of motion not so much linear.

Um, there's selectively some use of that, but like like essentially, and this is sadly how like PNF gets taught in schools these days, if it's taught at all, which is like we get a pattern out here, we move the arm out to the side, we move the arm in like so. Yeah, kind of. Not really. But often times we're looking at combinations of movements that wind up the muscles in a like three-dimensional way. winds up the tissues, winds up the bones in such a way that really like there's a a unified tension that is potentially able to be produced there.

So things can really kind of like like wire and fire together and then using manual inputs through the therapist to either assist, guide or resist to sort of like stimulate motor responses in the system. There's also for areas that are like a little unable or like really having a hard time firing, there's a use of what we call a radiation, which is where we take a stronger segment of the body, something that's actually like able to do its job mostly well, and sort of trying to connect those two pieces.

So, for example, a common one we use is like the pelvis and the shoulder. Let's say that my shoulder has a really hard time like shrugging up or something like that. What I can do is I can put an input into the pelvis, build a bit of a contraction there. It's usually like through very light resistance. It's sort of like it takes some skill and nuance to like really craft a place to where you are inviting that patient to fire without a whole lot of thought process going into it.

It's like for example like when PNF is not working well, it's usually the therapist's fault, not the patient's fault because it's a matter of like finding what works for that person. How do I get them into a position like, okay, holding right there. I can kind of have them keep their pelvis in that position. They build a tension and we just sort of keep that engaged at a low level because that tension will kind of like spread through the body a little bit and not in a big global guarding kind of way because that's not what we're looking.

I don't want the lats to just come in and like they're really compressing. It's more just like nuance trying to get the whole body to connect and then I can put a contact into that shoulder that's maybe not firing so well and just kind of linger but I place my hands in such a way of like what's the direction I'm trying to improve. I like not unlike a weight machine. It's like you you move in a path. You kind of know the path that you're trying to get the the segment to move.

You engage that. you facilitate it from another segment and you kind of build and wait for a connection to form. Takes time sometimes.

So this is almost like stroke rehab techniques that you're applying to sports medicine.

Yes. Yeah. Like and I wish I was better with the history because I could there's probably some interesting connective tissue that goes through it all.

Um but yeah, this and there are many techniques. This is just the one that I've, you know, spent my time training in. So, we're trying to use these methods and like they do kind of equate, you could almost kind of call them in the realm of like something that looks like strength training, but really it's not about that. I don't care about making somebody big and strong through PNF. It's really about like how do we get this person to fire and or relax an area.

That's a that's also a common one that's very important with somebody with a sustained pain issue

is that often the body is like held in more rigid kind of like holding patterns. Yes, absolutely. So even just getting some of the tissues, the muscles to like relax and then we have some other techniques for that. Like there are some techniques in PNF that will help with that. But often times we're using PNF as sort of like a how do we get this to fire but fire in a connective way where like the trunk actually has a big hand in being the initiator of movement.

For a lot of us who've gotten dysfunctional, we tend to move more distally. we like sort of create tension through our hands or our feet when in truth it's often best and most efficient when we create that tension initially here through an initiation response and it sort of spreads out for our ability to move more freely through the extremities.

So when you're approaching something like TMJ dysfunction, do you start with the core or tell me about your approach?

That that's an excellent question. It depends. It's always on my mind. Um but that yeah that's that's an excellent question. The you can actually look at that in terms of like even breaking up like pressure systems of the of the system into like individual core components. So there is a pressure system through here that's available through like glottal closing that you can kind of get very similar kind of responses. Now, do you need that for everybody with a TMJ issue?

Like potentially, but it it depends on what's going on there. So, instabilities for one, yes. Like that is one of the first places we go. like if there's like just a tremendous amount of like off-axis like anterior translation of the of the jaw with opening if there's like you know laxity or like a lot of extra mobility in the upper cervical spine of like yes I want not only the ability of like all that musculature to fire well together but like segmentally control motions.

Um, so one sort of like pressurizing technique that kind of you could argue it's kind of core like in terms of like jaw opening to help keep centration at the joint is often we'll we'll place the tongue on the hard pallet just behind the rug there and create a little bit of a pressure system back here which often just automatically allows for more onaxis motion of that. So that might be something where it's like, oh, that may be a home program for somebody their first few sessions like, okay, we got this a little more centered.

I want you to recognize when that's centered and I'll have you just like start to push the boundaries of that, but making sure that the joint stays stable with that. So, in answer to your question, like yeah, like core responses and that that may go deep like often times like I I do care if I'm working on somebody's foot like I want to make sure that force transmits through that person's body up to the other side well and it connects as best as possible because it's going to affect so much through the rest of the body.

We see a fair number of patients with hypermobility spectrum disorders. Eller's Danlo syndrome and of course the the hallmark of this group of conditions is impaired propriception.

Can you tell us um when you start working with a patient who's globally hyper mobile

and intrinsically maybe has a weak core and has lots of tight muscles from guarding and progravity posture. Yes.

Uh where do you start? Oh, and it is somewhat simple, but it's like it it depends where that person needs it and where there might be regions of like greatest concern of like again like upper cervical instability. It's like, you know, we we need to work on those structures and making sure that that's as stable as possible. I would say for a lot of people with more of a global presentation maybe there's no like main [gasps] area of concern like often times I want them to have what like what we term in functional manual therapy like a core first response so it's working on that ability for the system to initiate without necessarily like a conscious voluitional effort because a lot of people walking around with a hyper mobility it's like often times they're It's sort of just a normal state of being where they're kind of hanging on their their ligaments.

They're kind of relying on their more passive structures as best they can for for some kind of stability. I want there to be a little bit more of just an everyday constant engagement there. And so where we might start other than just purely through like some facilitator techniques of like exercise is alignment, joint centration, these kind of things like what provides opportunity for the system to just fire better. Um, one way we often will think about it is like let's say somebody who's like they're pretty laxed, maybe they're sitting in like a very anterior pelvic tilt.

They're kind of hanging on their facet joints in the back, which means they're kind of like in this extended posture because it's stable, not maybe healthy for long-term use. But part of what we want to do is for core firing and for core initiation, I want sort of the the muscles of the of the diaphragm to preferably be like over the abdominal contents and preferably in sort of like a direct opposition to the pelvic floor. So, we want to create sort of like a there's there's an analogy that sometimes we use like a a can of uh soda or something like that where it's like we want sort of that pressurized system of like a closed can of soda, it's just almost impossible to compress.

But as soon as you have like a a leak, if you crack that top open, [snorts] it's very easy to compress. M

sort of the idea here is like if we get the muscles of the diaphragm over the abdominal contents, the organs, the visca, and like not only will that help in just sort of like the nice general mobilization of the viscera itself, but then you're getting the muscles of the pelvic floor to oppose and have a similar action of like you've got the weight of the visca settling into that. So there's a gentle tensioning push back. So like those kind of muscle structures tend to give like a low level of like engagement when you get that oppositional force there.

Now part of what we're looking for with initiation is like is your body kind of ready to go without a lot of extra bells and whistles at some kind of provocating incident like some kind of sudden motion. So these the idea hopefully is that when these structures kind of oppose each other, not only is the spine probably in a much more balanced alignment, not only are we kind of like getting less biomechanical strain through the body, but then you've got a little bit of like base tension available, then if something kind of bumps into you, you're a little bit more available to potentially fire better through your stabilizers with that alignment.

So often times early in the process, I'm looking how can I help this person get their alignment improved and then how can I get their core and their their localized stabilizing musculature to actually like fire well and like strongly. So we want to kind of like build the amplitude on that. Um, I might take it a step further is like kind of like exiting just sort of the trunk region like are there other areas in the body like where the joints are like poorly centered like one that we often look at is like the hip is like is the hip fully like firmly like on axis in the in the joint space or is that maybe kind of like a little push forward common one of course of like the shoulder for a lot of people a lot of anterior laxity for a lot of people often something that will come along to the party with that is a like a restriction of soft tissue through the back aspect that's actually inviting that to further go forward.

And so part of the process is like okay can we get that tissue to get a little bit more pliable, a little bit more out of the way. Can we like center that joint so that then motions really they don't have to work as hard to do the same activity as you otherwise might be reaching for something on a shelf. So a lot of it and this is a lot of ground just in that initial kind of thing but that's initially what I'm looking to do is like how how do I improve alignment how do I enjoy like improve joint centration how do I improve so that you know stabilizing musculature is in a prime spot to be fired and then how do we like increase the amplitude of what that person can bring to the table in terms of their physiological effect like can those muscles then fire with some gusto and do it well and with endurance.

I think you've just summarized the core of physical therapy for EDS. That's fantastic.

Hopefully. So, yeah. And of course, EDS is a a wonderfully complex thing where it's like, and I again, I don't want to pretend to be able to like navigate all the avenues of it because everybody presents in a different level there and like how you respond to certain treatments. Um, [sighs and gasps] can be somewhat inconsistent, but at the base of it is yes, trying to get that that propriceptive, that kinesthetic awareness, really trying to make sure that there's adequate control of each needed segment so that there's just sort of the best possibility and the least amount of excess stressor component to that person's system.

I want to shift gears and ask a

an easy lowball softball question for you. [clears throat]

I appreciate it. It's not infrequent that patients say, "Why can't I just go exercise on my own? Why do I need a physical therapist?" Or, "Oh, I have a personal trainer. Can't I just tell them what I need to do?" So, having been both a personal trainer and now a physical therapist, uh, can you highlight some of the key differences of what you offer as a physical therapist that a personal trainer might not be able to?

That's that's a wonderful question. I will try not to get on a high horse about it because it's it's a [gasps and snorts] it's a a point of concern that I have that my profession is somewhat moving into a realm of glorified personal trainers. um there's much less of an emphasis on some of the other aspects of care and it's like there's a lot of like exercise protocol that is just like thrown at people and on a certain level like I I am a proponent of that.

I'm I'm a huge fan of exercise. It's it's tremendously beneficial, [sighs and gasps]

but not exercise in isolation for everybody.

No. And it's like and if what what you're getting out of it and like one it's like and this is kind of the the through line of most everything is like

specificity like we need to be specific with what we're trying to achieve. What are we looking for for this person? So if all we needed was just exercise like yeah sure go work with a personal trainer, go work like in a general PT practice. Okay. Um but most of the time people who are in pain have systemic issues, chronic pain. There's a lot of [sighs] specific needs that we need to address. Where is the weakness? What is the weakness?

What with? How does it relate to their function? Like exercise. I mean, if you like to exercise for the sake of exercise, like I do, it's like great, that's nice. But like it ideally should be purposeful. It needs to serve a purpose and hopefully that purpose is beyond just vanity. How does it fit into the task that that person is having a hard time with? And oftentimes when they are weak in a component, when they go off on their own or go to their their regular personal trainer or something like that, the body finds the path of least resistance.

So oftent times they will find a way. I I work with many people who are like tremendously strong. They're often very strong in their dysfunctions. They have cultivated a compensation like tendency that they are really good at bypassing the thing they need to get to the functional outcome that they're kind of looking for. It's just not efficient and it's often problematic. So having somebody there who can recognize the difference for starters of like what is an actual like functional exercise that actually addresses the problem that we're trying to address and then how do we break that down into a step-wise progression.

That's something else that I I often have some qualms about in terms of like how to progression physical therapists and I apologize if I offend anyone with this, but like often physical therapists are terrible at progressions. Um I hope I'm wrong with that more these days, but really having an understanding of like what a person's more optimal ability is and knowing the path to get there. How do you build the parts to meet the whole demand? Uh, and oftentimes that's just sort of that's that's nuance.

So, for example, let's say somebody is just like, "All right, I want to get back to squatting." It's like, "All right, I have some trouble with squatting. Like, I want to get back to squatting. Why can't I just, you know, squat in the gym? I'll just grab some weights and I'll I'll squat." Maybe that person on evaluation, you look at them like putting weight through their leg and like all right, maybe one side they can put weight through the body and you know body doesn't really adjust.

It's like it's it's nice and centered and they shift to the other leg and like so the hip kind of has to like shift out to the side or their knee kind of turns in or the ankle kind of collapses. Well, that that person either there might be some mechanical reasons why that's happening, but there also might be an inability from a neuromuscular or motor control standpoint of actually putting the pieces together to put weight through the body in an efficient way. So, yeah, I could have that person squat and they'll get stronger, but then three years down the road, they're going to wonder like, "Yeah, I still have this problem and I'm stronger, but like, so what I might do with that person is actually take them through a progression of like, all right, let's take, you know, the floor and weight bearing out of the out of the equation.

All right, what's missing in there?" It's like, is there something not working in your pelvis? Is your pelvis not actually engaging into that position? Is there some kind of limitation in terms of like how that hip can like settle into the socket? Is there like a little shear in the knee that's like not allowing congruency of the knee? Right, we address those mechanical needs. But then oftentimes when people have had a dysfunction, they don't know how to fire even if things are kind of like reentered.

So then tactically giving somebody something where they are learning to put weight into the ground. Sometimes as simple as just like all right, they have a hard time putting their right foot and like really engaging to really weight accept into the ground. All right. Maybe they practice just sort of like shifting their weight. Can they have like really push off one foot to the other foot and like really settle that weight in a way where they're not deviating out to the side?

And this is where it helps. It helps when the patient has a good like body awareness, but sometimes we have to like cultivate that a bit of like recognizing when like, oh, you see how your hips kind of falling out to the side there. All right, we got to bring that back in. Now, there are lots of tools for that. I will admit like some trainers, some physical therapists are like really good at like using some sort of like feedback that helps guide that person.

Great. Like that is vital. But I dare say like 80 90 who knows how many% of like a lot of the general trainers out there probably not going to offer that bit of nuance and like really being that kind of student of movement of like oh I that doesn't look quite right or like we need something here. What do we plug into that? So often times it's it takes somebody who's just like possibly a little obsessive and compulsive about the the minutia to then dig into all right here's our here's our problem.

How do we chop that up into segments so that we can address this and build it sequentially in such a way where it's like before I ask you to put weight through your system with an external load putting weight into the floor are you able to actually like engage that in a nonweightbearing situation and then can I kind of build into where it's like you're starting to like I'm assisting you with weightbearing to where you can put weight into that and this is where some like PNF principles come in again where it's like you can help through resistant uh standing movements weight shifting movements.

So like really facilitating so that person knows like oh that's what it's supposed to feel like when I engage and having that awareness of like how your body is supposed to feel with when something is working actually efficiently that that will often help that person [clears throat] to understand where it's like oh I this is how it needs to be now I can go do this off on my own and because I know what to look for. Um yeah, ideally we we need the patient to understand what something should feel like but also what it should not feel like and have them really well established in those in those parameters before we can kind of go okay yeah go do your own thing get after it but like without some of that guidance likely that person's just going to end up back in my office.

If I can summarize, it sounds like

longwinded. Yes.

It sounds like what you're saying is most people have maladaptive patterns to some degree. Even our normal functioning is somewhat dysfunctional because we got to be good enough and there was no incentive to get better or awareness of the need to get better. And so if we do start down a path of exercise or some sport, if that maladaptive pattern is stressed, it may result in more dysfunction causing pain. And one approach is just to power through.

Yes. But perhaps a better approach is to break it down and granularly look at each piece of movement in the larger pattern, identify the dysfunction, correct that and then build back and retrain that synergistic pattern of activity.

Very nicely put very much more concisely than mine. Yes. is like you don't want to build strength to a dysfunctional pattern and it is a a challenge because often times people get really rooted in those patterns. So yes like we kind of it's almost necessary to then break it really down into pieces so that person has the opportunity to like rebuild it from scratch.

So any musician knows this too well.

Absolutely. If I'm studying a passage on piano, I can pound through it and not do that very well. And I can pound through it hard enough and long enough that I'll be able to do okay, but it's not going to be very good. And I certainly couldn't scale it.

Yes. Absolutely. And that is and and as with music like you and this this is also like true of so many things, but like motor control training is like the whole idea of like all right, we have this whole piece of music we need like I like I don't know how to just suddenly do all of it. Let's break it up into segments. Break it up into pieces. What are the pro, you know, pieces I'm having a hard time with.

Let's just focus on that little bit. Let's like really build that with repetition and like ideally start to challenge it with some resistance. Like, all right, maybe I'm starting with a slower tempo.

It's like, okay, this is not the tempo of the piece, but like this is where I need to be. change [clears throat] it up, get the crowd engaged.

And so really kind of like diving into the piece and then modifying, really getting specific of like, all right, how do we need to do we need to assist there? Do you know does somebody need to like really show me

or can I actually kind of do it on my own and I can like get a little push back. I can get like a little resistance to this. And through that practice, once you plug it back into the hole, hopefully that just really has retrained the system into a more optimist state. So the the the approach you're describing it sounds like it could be never ending. How how how and when do you graduate a patient?

Oh, that that is a very good question and often one that I I sort of propose to some of the people I see uh who have had like good success because like through this mindset of like when we're really chasing efficient or optimal function that is that is a never-ending pursuit. which is it is a conundrum built into it like okay theoretically we could just go on forever in my mind it's a matter of like when we're getting a person to their point where like they can do the things they want to do in the way they want to do them or modified in such a way that's realistic if there's like some kind of other limitation some kind of structural you know dysfunction or something that we we cannot bypass when we've got somebody to where it's like all right I can do the stuff I want to It's really a matter there of like, okay, we can we can switch to a maintenance kind of thing.

And hopefully I've given them enough information, wherewithal, and like home program work to where it's like hopefully they can sustain that themselves and manage the ups and downs of like if they have flares or something like that, they got to know how to navigate that. But then from there it's like often a matter of like well I like to think of it as like preventative care. Like from there it's like all right check in with me from time to time just like you know 6 months a year later like stop back in.

Let's let's take a look. Are things kind of like still as they are? That's sort of like one pathway. But also it's to me a matter of like what is that person looking for and have they achieved that end? And like additionally like is that end realistic? Because like if we've set a realistic highle goal that really gets them to where they want to be and we're there sure there's more to do but like at that point it's more of an option for them of like all right if you want to do more I'm here.

We can keep going further if you have like other things you want to work toward. But like once we've kind of met those criteria that's that can be the end of the road. On the flip side, people with more kind of chronic systemic issues is like that might be a more winding road and maybe a less concrete one. And that's that's where you got to work with what are what are the patients expectations and what are they willing to invest in that process of like if if somebody like needs long-term care but maybe they can only afford or have the logistics to see me a shorter duration.

I want to give them as many home tools as possible as much like savviness in navigating this and hopefully like we haven't spoken much about it but like also resources you know in the wider scheme of healthcare of like who are people that they can consult with that can kind of help manage these situations whether it's like a clinic like Manhattan you know pain medicine whether that's like more on the psychological psychiatric side whether that's more pain processing kind of like things like I want this person to feel like they've got avenues so that they're not on their own preferably like even if they need something like more longer term and it's just maybe not realistic for them.

So it goes every which way I guess is my answer for that. My long-winded answer for that. Something I I think is quite important and and sat with me very much when I was a PT student. Uh, one of the criticisms I kind of received when I was doing clinical rotations, um, was that I I talked to the patients too much, which I found kind of a fascinating criticism. And I and I understand in my profession, it's like you want to be quick, you want to be concise, you want to, you know, especially in like a hospital setting, it's like we've got to

we've got 20 or 25 other patients to see like we all right, come on.

25 steps to discharge.

Yes. Exactly. Um, but something I think that is really vital in in physical therapy, but healthcare in general is like really somebody like when you go to see a practitioner provider, you want somebody who's listening to you, but also like dynamically asking you about your experience of like really delving into the ins and outs of like how did this start? What does it look like? How has it changed? When it's bad, what does that look like? when it's good.

What does that look like? Like how irritable are are things like do you have pain at mile 20 of a run or or do you have pain with like two minutes of sitting? Like all right, what is what is the experience of this person and like what went into it? Like what is what is their injury history? What is their surgical history? What's what are the ins and outs? and really trying to delve in not to just get like bullet points for the chart, but more like really trying to understand the nuances of what they are experiencing so that you can best and most accurately like go in for what is necessary.

And I like I I am a big proponent of like I want patients to know that that is a a sign of like you're probably in pretty good hands if you got somebody who's really interested in the whole dynamic of their experience. Um and I think I've I've seen enough like in my profession where it's like all right we got the we got the important bullet points but like it's not really going to inform so much the treatment. They've got a piece of paper that has a protocol on it that's like, "Oh, you know, it sounds like this.

We'll just kind of follow this protocol." And I really want patients to be advocates for themselves and kind of know kind of be attentive and often they know when it's in front of them of like, oh, this I yeah, this this is somebody who's interested in helping me, who's got my back and like understands that this is this is not necessarily just a simple straightforward thing that's going to be solved by an algorithm. So the question that you just answered,

how does a patient know if they're finding a good provider or not? [sighs and gasps]

An excellent question. Hopefully, it starts with somebody who is there to earn their trust, there to listen to them, meet them at their level, but then also in like taking their subjective history, taking objective measures and really diving into, okay, here's what I think is happening, but then like getting a response, a result soon. Like that is something I think a few too many people are willing to like go along for the whatever six week journey of physical therapy and I' I've talked to many where it's like yeah I did my six weeks of PT like all right well how were things like at the start like like how how did it change like how was your how have your symptoms changed oh no they've been the same all right did they do anything like what what you if you're getting the care you deserve you should be heard you should be treated as like valid in a non-judgmental way and for what their experience is.

You should have somebody who's like seems to be really invested in looking at like the nuances of things, but there should be some kind of early response,

some proof of concept.

Yes. There needs to be I mean not only for the buyin, but like that's also like proof in the pudding of like all right, this this actually has an effect. I want people to know that they there should be an effect from treatment and if there isn't all right maybe maybe the provider can like provide a rational like okay it hasn't responded yet because yada yada yada or like if that's if you're on session five and it's still like yeah well we haven't quite got that response you're probably in the wrong office.

Um, so I'd like to say like patients should hopefully within like one to two sessions tops there should be some solid evidence of like aha we have

made a profound change in some way that demonstrates

and even if something flares as a result of that first or second step

absolutely

that's also confirmation. Can you speak about that? Oh, absolutely. That that is something I I often warn. Well, not often, everybody I warn, it's like, I'm looking for a change in your symptoms. Ideally, what you're looking for, a positive change in your symptoms, but a negative change in your symptoms still tells us a lot of information. It's not what I'm going for, but like how your body responds tells me a lot about what I should be expecting and what's needed here.

Yeah.

Um, and at the bare minimum, it just tells me nope, not that approach.

Yes. And it it's usually helpful for understanding the cascade of symptoms. I'm sure you see this all the time. We see it a lot where what the patient comes in with is not the primary issue, right?

They may come in with knee pain, but it's actually the hip instability, but they don't have any hip pain

or any any number of of

Oh, absolutely. Like that is that is a common thing that hopefully again physical therapy is getting out of the practice of like, all right, the script says they're in for a right ankle issue. That's all I'm looking at is the right ankle.

Yeah.

Taking away is like, well, maybe that person's like left rib cage actually can't like settle down and so they're like nerve root.

No, exactly. Like so

so many options.

There are so many things that we need to consider, but also in that for the buyin for the patient like all right helping them understand you came in with this and oftentimes that means like I need to not discredit like that thing. I need to often like put my hands on that that area that is their in their mind like that primary driver of of issues

and there may be a primary process there that's taken on a life of its own because of the dysfunction someplace else.

Absolutely.

Th those for me are some of the more challenging cases because I know what they're coming in with won't get better until I treat what's driving it.

Um but at the same I'll give you a good example. So a C6 ridiculopathy and rotator cuff. Yeah.

So, we'll see rotator cuff impingement, rotator cuff tears because the nerve is not functioning appropriately

and they may have had injections in the shoulder. Heck, they may have had surgeries in the shoulder that don't take, they don't get better because the nerve is still dysfunctional, right? So, they're not having any neck pain. They're not having classical ridiculopathy in the arm.

It's a little bit of a cell to say that it's the nerve in the neck that's the problem when it's just their shoulder that hurts. Uh so going we almost have to sometimes go through the process of okay let me inject your shoulder let's let's confirm that it's not your shoulder right so when your shoulder's numb and you still have the exact same pain it's the nerve in your neck that's irritated telling your brain that it is your shoulder but it's not actually your shoulder so there's there's sometimes a learning curve that we have to go through u sometimes for myself sometimes I don't realize it I may think it's the shoulder and then I only come to learn later that it was the neck Right.

There's a particular evaluation technique we use is like not quite as like surgically like diagnostic as that but we call it the the disinhibition series which is we use it to sort of establish a central driver of like peripheral weaknesses. So in that kind of same example like I'm seeing somebody's like their shoulders like has a really hard time like locking in and being stable. And so I take a look at their cervical spine and I see like is there any segment in there or multiple segments that don't stabilize well?

and I take them into a position where it's like they should be able to at least lightly engage there and oftentimes it'll be a few it's like wow that's that doesn't really kick in. So using some similar PNF principles like I facilitate that segment might take 30 60 seconds and then I often retest the stability of that that joint that structure a lot of times in these situations like suddenly that's a lot more stable. It's like, okay. It's like, it's a way not only for me to know, okay, there's a proof of concept, there's a central driver there, but it's a good example for the patient because they'll often feel like, oh, that's just like a lot more solid there.

Like, yeah, I didn't touch your shoulder.

I facilitated your neck and like there's something going on at your neck where your neck's not stable and therefore it's like creating this cascade.

Wonderful. Well, thank you for spending this time with us.

Can you please uh tell us how we can find you? How can we work with you? So, I uh work at a clinic called uh KFMT uh physical therapy. It is in Chelsea. It's on 19th Street. And uh I work with a fantastic team of other functional manual therapists. Um we are on Instagram and Facebook and all those good things. Uh it's yeah, KFMT Physical Therapy.

Thank you so much.

Thank you.

Thank you for joining us on another episode of Care Beyond the Pain. The pain journey is rarely a straight line. To learn more about how to navigate it, you may visit our website, manhattanpain medicine.com, or read our book, Pain Answered, found on Amazon. Until next time.