The Truth About Manual Therapy with Dr. Nick Torres

You're listening to the PT Profit podcast, episode number 85. Today I'm sitting down with Dr. Nick Torres, and we're discussing all things manual therapy.

Are you ready? Let's get started.

Hi, I'm Beverly Simpson, former fitness manager turned online personal training business owner. And this podcast is where smart fitness professionals, including trainers and clinicians, discover how to increase client performance and movement, package and position their products and services and get out of their own way so that they can increase their revenue to live a life that they love without sleazy sales. Welcome to the PT Profit Podcast.

What's up, coach? Thank you so much for pushing play on another episode of the PT Profit Podcast. I'm your host, Beverly Simpson, and if this is your first time joining me, thank you so much for hanging out with us today. I'm super excited to bring to you Dr. Nick Torres, who is known as the manual man. Today we got into all of the things manual physical therapy, how it differs from traditional physical therapy, talked a lot about his journey. We explored controversial topics like foam rolling, stretching, when you should do it, if you should do it, what you should be looking for. And we talked a lot about his journey from study studying under Dr. Greg Johnson to opening up his own facility in New York. So without further ado, let's go ahead.

And roll that interview. What's up, Nick? Thank you so much for joining me on the show today. How are you doing?

Pretty good. Cool.

So let's just go ahead and dive right in. Can you please share with me? And for those of you listening a little bit about who you are, who you serve, and how you got there.

So I guess the short story of that, because I can make it a very long story, but the short story of that is I went to PT school in Brooklyn. So I'm a New York native, Queens born and raised, but I went to school in Brooklyn. Liu Brooklyn, to be exact. Went there. While I was going to PT school, I started learning about particular manual therapy courses. So I kind of dived headfirst into manual therapy, which is kind of like a subspecialty of physiotherapy. So I started learning different techniques from those courses. Soon as I graduated, I started using all that stuff, saw the amazing results from manual therapy, was working in a couple different clinics, kind of like, you know, the PT mills, you know, we were familiar with, which is like kind of like 30 minutes if that per patient, and kind of run you in, run you out really quickly. I was sick of it after about a year, moved into another place. It was about 45 minutes, I got a little better and then I got into another spot, it was an hour. And then finally, probably around three years into my profession, I was able to open up my own practice, which I have now currently for two years. And there I treat as long as I want and it's amazing. And so I focus on manual therapy. Also postural restoration, which is from pri, which is another kind of subspecialty within the world of training. It's not just for physical therapy. It's actually allowed for trainers as well, which I know you're familiar with too.

Yeah, for sure. So I definitely want to dive deep into that. And I got two follow up questions. Number one being what led you to be so specialized and specifically, what are the differences between manual, manual therapy and what I would know traditional physical therapy to be?

Yeah, it's a very common question. It was just over the weekend I was with my wife's family and they were like, we know you're a physical therapist, but do you specialize in anything? And I said, well, I specialize in manual therapy. And they're like, what? You know, a whole table of older people, they're like, well, what is that? I have no idea. Because no one never heard of this manual therapy before. The term is getting popularized a little bit more. It's become more common, but it's still. We're kind of in the, in the bushes in the background right now. We're head, we're popping our head up. But basically manual therapy is basically hands on techniques that I utilize to restore function, restore range of motion of joints, improve posture. It's really specific stuff. So it's like, it's not a massage, right? People are like, oh, so you get massages now? I'm like, no, I don't give massages. Don't come to me, don't come to my clinic, my office and say, hey, can you just rub deeply into my back? Because that's what I really feel like I need. And it happens a lot. And I'm like, no, like I'm going to assess you and based on my assessment, I'll see what we need to do. Maybe it is some deep tissue work on the myofascia of your back, but maybe it's other stuff and most times it's not what they think they need. So yeah, so it's a lot more specific. So we're mobilizing not only soft tissue, like muscles, but we're also mobilizing joints. Very specifically, we're mobilizing actually Bones, I can mobilize different bones, which is something that I learned from these courses. Institute of Physical Art is the name of the, of the school of thought that I kind of go through their courses and learn this stuff.

Okay, so, but, but the manual component is hands on, correct?

Yeah, yeah. And I guess from your question you said, well, how's that different from physical therapy? I guess that we just learn more in detail about the hands on approach where on traditional physical therapy you learn a little bit of it, but not a lot. Soon to know specific techniques like how. I know now. So say, for example, when I went to PT school, we did one course, just one course. So say, for example, there's around like six to seven courses a semester, right. And then you have around two to three semesters a year. So we learn only in one course out of three years of my, of my PT schooling, one course of manual therapy. So if you just graduated from PT school, you're only going to have that little much of a background or knowledge in it. So then if you want to learn more, then you go to manual therapy courses. And that's what I did.

How did you get into physical therapy?

So physical therapy kind of like landed on my lap. I wanted to be a physician. I wanted to be a medical doctor. So I went to. That was originally when I went to Queens College. Shout out to Queens. I went to Queens College. I love that school. I got all of my courses that I thought would get me into medical school. And I was a naive young kid, like, yeah, I'm just gonna take these courses. I don't need to speak to an advisor, you know. And then after I took all these courses that I thought would be good for medical school, I went to my advisor. I was like, hey, I'm ready to apply for medical school. And they were like, no, you're not. Like, you got a lot more court. Like, she was like, these courses that you take that you've taken, they are not accepted in medical schools. So then I had to make a decision. Do I want to go back for two more years to take a bunch of more courses, or do I want to do something now? And I asked her, like, well, what do what, what, what can I do with this? What I have now? And she said, you know, pt, ot, Speech pathology, stuff like that. And I looked into it and PT was, was more my vibe.

Yeah. So it almost, you know, it was fate.

Yeah, it was basically. Basically, yeah, it was a lot of fate. And I, you know, I, because of, I've been a student Athlete my whole life. When I was in school I played football. So through like Pop Pop Warner, like as a young kid into like high school, into college, I played football. So I was injuring myself here and there. I, I fractured my scaphoid bone, I tore my rotator cuff on the field. So I've been to a lot of injuries and that also showed me how impactful physiotherapy can be if you do it the right way. So I met some really good pts and I met some really bad pts and the difference was so extreme. But I was like, I think that this profession can really need a lot more good pts and I decided to try to be one.

That's awesome. And I think that's true too for personal training. Although your barrier of entry as a PT is a little bit, is much more extensive than training but you're still, but I think it's true for all industries across all the boards that you're going to have people that are at the top and people that are just getting by.

So yeah, and I'm talking about like trainers versus PTs. It's funny because like when I first graduated PT I was like, me and trainers have nothing in common, right? But then like the more like now that I'm like around five years into my profession, it's like I see that there's a closer and closer distance between what I do and what really great trainers do. I think that what the issue that I was having was that I was seeing trainers who really didn't care that much when I first would look into the training world and I was looking at more from an outside perspective. And now that I have trainers in my gym that we kind of work together, I'm like, we basically do the same thing. I just, I just can do some hands on work with them. But training wise, neuromuscular wise, connections wise, strengthening all the stuff that I work on, they do as well. So it's like, it's really the same thing, more so than I ever thought before.

Well, it's so interesting that you bring that up because for me I tend to see trainers fall into at least, you know, I'll speak to me and my experience and going through my progression of training is that when you first they come, the barrier of entry can be so low. At first they're like, oh, I just love working out, I'm going to be a trainer. And then those trainers have a lot, you know, a big learning curve and then the ones that start to really get into the biomechanics and movement.

Yeah, yeah.

Because there becomes this almost this fear of collaboration because they think, oh, if I have. And so they almost try to be an amateur clinician, not recognizing that if you just build relationships with high level people, high level PTs, high level trainers, that's going to serve your client as opposed to feeling like, oh, I'm not good enough or they're going to find me out that I can't do it.

It's just not 100%. That's so true. And it's speaking from experience because I have trainers who I basically will say, like, I see a patient and I'm like, hey, like, you need a straight strengthening program and you need to see someone consistently. Whereas for me, you can see me maybe like once every two to three weeks, you need to see someone maybe two to three times a week on a strength training straight program. And so I recommend, and I refer those type of patients to my trainers. And the trainers and I, we developed a relationship where they feel comfortable now. And you can see when I first like developed that relationship between me and the trainers, it was like they were a little scared of me to talk to me about certain things. And like, now that we develop better relationship, like, you know, our relationship has definitely improved. But also the patients and the clients that we see together, they're like skyrocketing with their function, with their strength or all their gains because it's like now we're working together as opposed to working separately and trying to find a way to mingle our ideas.

Yeah, collaboration is, in my opinion, undervalued and so important. So. So I'd love for you to talk a little bit about your process. Like, can you tell me a little bit about, you know, who you see? Are you, do you see gen pop? Are you seeing athletes? And what are, what's your process? And from assessment to building your programs.

I see everyone I see from my youngest patient right now is 13 years old. He just turned 13. He's a basketball player. I've seen him since he was probably 11. He's a friend, he's the, he's the son of a friend of mine. And it's pretty, pretty cool seeing him grow up and utilizing some of the stuff that I teach him because, you know, the stuff that we do is like light years beyond what his friends are doing who are also like 13, 14 years old. So it's fun working with someone very young. And then also I see older people as well. I see my oldest patient is probably 87, like that. So the thing about it Is, I would always say, is when you are really great at what you do, you end up treating not just patients, you end up treating families. Because once you're good at what you do, that person then wants you to see their uncle, their father, their grandfather, their son, their daughter. And it's like I'm seeing the whole family now as opposed to just seeing just one person. And then that allows me to really treat from young to old.

That's great. Now are they typically, did they get hurt, are they injured, did they have surgery? Or is it all the gap?

So, yeah, it's all different really. Say, going back to my younger patient, he deals with some ankle instability stuff where he sprained his ankle a lot, you know, some lower back issues because the position of his pelvis is a little tilted forward. He's learning how to kind of stabilize that pelvic girdle. Right. And as you're younger, you're growing, so your bones are growing, your muscles are kind of trying to catch up. So you're playing that game as well. And then I don't, I see some post op patients, meaning like, you know, after surgery they'll come to see me, but many times what I'll say to them is say, you know, go to see your insurance based physiotherapy because you can see them once or twice every week. You can get, you know, the traditional physiotherapy which is, you know, like the, the ice, the stem, the heat, a little massage, a little strengthening, very like locally, and then come to see me once every like two to three weeks because it's really hard for me to see someone right when they get post op, like right after surgery because they should be seeing someone more consistently. But I have a cash based practice and with my cash based practice, it's a little, it comes a little bit more financially harder to do that.

So people come and see you for, you know, once or twice and then you solve their problems?

No, no. So it'll usually it's. That's something I'm still working out with my business right now. I see patients throughout, so like I see patients long term and once their pain is gone, I still see them more so for the maintenance of it. So it's not like I'm seeing patients one or twice and I'm like, okay, like, you know, I solved your pain. Bye, bye. It's more so like, okay, well your pain is better now. And now let's work on really maintaining and sustaining the positions that we've created within your body. Within your alignment. And let's get stronger because at the end of any type of pain people have, especially when it's chronic pain, there's some sort of strength issue. There's an asymmetry going on within their body regarding their strength. So their right, you know, adductor, the right inner thigh might be overdeveloped and their left adductor might be underdeveloped. And we'll do some things in the first sessions to reposition stuff, but if you want to get that figured out long term, you need some sort of long term strengthening program for that left abductor. And it becomes a lot more than that, but it's just kind of the general gist of it.

I see. Okay, so this is going in just a little bit of a different direction, but bringing back to the manual therapy component that you know, are talking about. I'm curious and knowing your PRI background, I'm curious your take on things like foam rolling and myofascial release, things that, that patients can do at home and what your position is on it and what you think we can use those tools if we should at all?

A hundred percent. And I think that answer is yes, you should be using that 100%. Like, you know, a lot of people are like, yeah, I foam roll. And I'm like, do you really foam roll though? Like, a lot of times people will consider like, you know, soft tissue work. They do like foam rolling or lacrosse ball, things like that nature. And they'll do it for like five minutes. And like, okay, I'm good for the rest of the week. And I'm like, no, you should be doing that probably like three to four times a week. And longer than just five minutes. It should be like, you know, upwards of, you know, take like a half an hour and see how much you can get done in a half an hour. But really it's, I see that there's a commonality of people that like think they're doing the right things, but they're just not doing enough of it or they're not being as specific as they need to be. So like going back with like foam rolling, you can just roll out your back going back and forth on a foam roll, or you can, which I show is you can be very specific about which area you're targeting and trying to find different trigger points within that, that area. And then my whole thing is breathing. So I'm like, you got to take deep breaths, try to contract your core as you're doing your foam rolling. And it's like Things that people usually don't talk about, but it really makes or breaks both rehab and also maintenance work. Right. I don't really have any pain right now, but I'm always doing foam rolling, like I said, three times, four times a week, just for maintenance, to keep that good alignment.

So it's interesting and I'd love for you to talk more about that in terms of what people miss, what most people miss when it comes to this. And the reason why I'm saying that is because I feel like foam rolling has become controversial because there's people that tend to have a dogmatic approach where it's like, no, foam rolling is the worst, or you, you know, foam rolling is the way to be. And trainers like laying with their, you know, their clients on the floor, rolling around for an hour. So, yeah, navigate that.

I think that the answer to that is don't do it during the session with them, because that's almost like a waste of opportunity of time. But I would say show them what to do. Be as specific as possible. Record them on their phone, doing it the way that you want it to get done, and say, okay, now you're going to watch this video and you can do the same way three times a week when you're not with me because you want to prime that independence with them. And if you're just, oh, let's just foam roll today, they become dependent on you. And they're not going to do it if you're not there, and they're not going to do it if you're not telling them what to do and you're not doing it with them. But if you start priming their independence and be like, hey, you know what? I'm going to show you how to do it this one time. We're going to record it so you don't forget it. And I want you to rewatch it and do it just like how we did it together three times a week. And then you can just make sure that they're adhering to that. Like, oh, are you doing your foam rolling? Okay. And you'll always know. Trainers, therapists always know if people are doing the right or wrong things when they're not with you, you know?

Yeah, I'd love for you to expand on that. How do you measure whether or not the rolling is productive?

So that's a good question. So rolling in particular, for me, I think about it as, like, roll out until the areas that you felt were, like, really tight and really tense. Many times it's like, it's hard for me to breathe in those positions. Like say if I'm rolling on my back and I go into like an extension moment of my mid back and I'm like, oh, I can't breathe. Oh my God. That's where you should be trying to take deep breaths. Engage your core, angle that foam roller in a position where you're kind of really kind of fulcruming that trigger point and then do it until that feels better. Do it until that area is okay. I can, I can breathe here fairly normally. I can chill here and relax here and then repeat that for every trigger point that you find in that area. So say for example, when I grab my foam roller, I'm like, okay, I'm going to do my mid back today. So I do my mid back and I'm going to hit. I usually go start at the lower neck and I'll start working my way down one inch at a time down from my lower neck all the way down to like where my kind of like where my rib cage ends, like around my mid lower back. And I'll try to hit every inch and assess if that area is tight, restrictive, painful, hard to breathe. All those things that you feel when you have that myo fascia or joint immobility. And then I work through it. So every inch, I work through it, work through it. And so I'll probably pick around like maybe like five different spots and I'll breathe deeply, maybe like five deep breaths. Repeat that maybe three times for each spot and that's it. You just have to, have to structure it. It's almost like people like with, with training, right? When you train someone as specific as possible, it's not just, I'm just going to take any weight, I'm just going to do as much as I can and put it down. Like, no, we have to structure it. We have to organize it in your brain so you know exactly. You're doing it the same way or improving in it every time you do it.

Now are you thinking about the position when you're on and position specifically pertaining to the relationship between the ribcage and the pelvis? Are you thinking about that when you're on the foam roller?

Because, you know, so say for example with the mid back thing I was talking about. So imagine, just imagine right now I'm on my back, I have the foam roller behind me long ways, right? And I'm kind of doing that extension through my back. And a lot of times people will like to drive their hips up higher as they're pushing back towards extension. And I say, no, don't do that. Let your hips drop down and like, have them hover above the floor so that you're mobilizing your rib cage almost in front of your pelvis, if that makes sense. Because if you drive up your hips too high, your rib cage becomes behind your pelvis. And many times, this is where people are usually stuck in their posture. If I throw it this way, many times people are hanging out with their rib cage leaning backwards and they're all their weights on their heels and their pelvis is in front of them in an anterior tilt or just kind of sheared forward. When they do the foam rolling, I make sure, I say, well, drop your hips down so that your ribcage can be in front as you're mobilizing it. And the pelvis is like a little bit behind you.

So I even think, like, even as I'm listening to you speak, that most people are on the foam roller in terrible positions. Like, you have to pay attention to that 100%.

It's something that you need to cue. It's something you need to practice with your patients or your clients. It's not something that you're like, okay, you know, initial consultation. Do you foam roll? Yes. Okay, check. It's not just a check mark. You gotta, like, go through it with them and make sure they're doing it the right way.

Okay, so now you see those people, like, speaking of myofascial release, you see those people with those gun things?

They're like, yeah, the theragun things.

Yeah, yeah. What is that? Is that something? Is that a gimmick? What is that?

It's not a gimmick. It was designed initially for a different purpose, and then it was marketed differently than what it was designed for. So it was designed initially to be almost as if you're waking up muscles to prime them for contraction. So that kind of repetitive vibration is used in physical therapy already. But we usually do it with our hands or we'll do with, like, different instruments. But it's to kind of wake up muscles, right? To kind of prime their contraction or prime their awareness of that muscle. And so that's what it originally was designed for, was almost pre or post workout to prime or kind of wake up muscles. And then it then turned into almost like a recovery. Like, I'm going to do it. Like when I'm feeling sore, you know, I worked out, the next day, I feel super sore. I'm going to hit myself with a theragun because it feels good. But that's that's, that was the, that's the wrong way. Because now you're priming that muscle test to contract or to wake up. So short term, when you're doing that, that muscle is contracting, contracting, waking up, waking up. And if you do it too much, it ends up falling back asleep and like relaxing. Right? Those, those muscle cells. And neurologically it becomes a relaxation because you're doing it now. If you do it too often and too much, you're, you're gonna, you're gonna put that muscle to sleep and then when you actually need it, it's not gonna want to wake up. So it's like they're playing. The people are playing a game with this. Like, uh, I think because of the way it was marketed, that's like, okay, well I'm going to use it for like more of like soreness or relaxation or rehab. But really it's was more developed initially.

For the priming of activation and activating especially that neuro. The, the neural relationship, essentially.

Yeah, it's all neuro. Right. So that those vibrations and those kind of deep stimulus, that's not, that's not for the muscle itself. That's all for the nerves and the nervous system connection to your brain from that muscle.

So is that a tool you would say don't touch?

I say use it before or after workout. Don't use it the day after when you're resting and you just feel sore. For then when you feel sore, foam roll. When you feel sore, do your pri breathing. When you feel sore, do some active stretching. But go for a walk, right? Something lighter with intensity. But don't hit yourself with a theragun because long term it's actually going to be detrimental to your nervous system.

Okay, interesting. Can you expand a little bit more on what you mean by active stretching? Because I feel like that's another controversial topic that goes hand in hand with the foam roller. You hear people like, no, stretching is bad. So what do you mean specifically by stretching?

So active stretching, What I mean by that is basically using some sort of activation of muscle, like contraction of a muscle either while you're stretching that muscle or activating a muscle that is the opposing muscle group of the one you're stretching. So for example, if I wanted to stretch my quad many times for my quad stretches, I'll have people lie on their back on the edge of their bed or like a table and drop their leg down off the edge of that bed and stretch their quad out, which is kind of going towards that hip extension, knee bend, position. But I'll have them squeeze their glutes and their hamstrings as they drive the thigh downwards. So they're activating the hamstring and the glute while they're stretching the hip flexor and the quad. And that once again, going back to the nervous system, if I want to elongate a tissue more, it would be easier if I activated the opposite muscle. And that opposite muscle turning on is going to naturally cause the one you're trying to stretch to relax better. We call it reciprocal inhibition. It's just like a nerve nervous system kind of reset button. But we use that little, like, trick to allow the tissue to actually get lengthened longer when you're stretching it, as opposed to if you didn't activate a muscle, you're just like stretching out your quad. That muscle is going to be more stubborn and more difficult to lengthen as opposed to if you activate it, the opposite muscle, or even activated that muscle while you're doing it.

So when people are trying to just stretch out their hamstrings, what are they really doing?

So, you know, we talk about pri, right? So pri, postural restoration. And the big takeaway I got from that early on, and these are the courses that I'd said initially that I kind of was thinking taking. And I still take PRI courses, by the way. But the initial, the foundational courses, they really stress saying, don't stretch your hamstrings, because when you stretch your hamstrings, you're stretching something that's already too long. Right? So, and I'll explain that to the viewers very, very simply. But basically we have a pelvis. So picture your pelvis is like exactly straight, exact. The easiest way to make it is like a box. Imagine it's like a wooden box, and that box is exactly upright, straight. Many times people have their box tilted forward. And when that box rolls forward, the hamstring, which connects to the back of your pelvis, if that box rolls forward, that hamstring becomes overly short, stretched, and it feels like it's tight because of the fact that it's in that stretch position. Imagine if you take a rubber band and you pull a rubber band and stretch it. That rubber band is going to be very taut, but it's not necessarily short, it's actually too long. So we have to then instead, so say, for example, if you were to stretch that right, and that's already too long, it's going to go even longer. And that box that was to the forward is going to go even more forward. Now, so obviously you're going in the wrong direction. You want to go from the box going this way to a box going more upright, which that would require more of a posterior or a backward tilt. And so that's what we usually reinforce. We say, well, you don't need to stretch your hamstrings. You actually need to activate them in a posterior tilted position. Because if you activate them, they'll naturally shorten. And if you activate them in a posterior tilt, you're kind of restoring that position of your pelvis.

That's so good. So now I'm going to throw a wrench in here. Okay. Because you're like, okay, here we go. So I'm sorry I'm putting you on the spot. But yeah, I'm a mom, right. I'm a mom of two kids and I little kids. They're six and six and four. And so when I was in that postpartum stage, you heard so much about making sure we didn't as moms, specifically that we didn't overly posteriorly correct. Because we to carry our babies in the front. And I don't mean in the baby, I don't mean like in the belly, I mean like holding the toddler and that we would come, we would balance that weight by pushing her. Oh, by pushing our pelvis forward. So I was, every time I was training in that season, I was like, don't, don't over tilt. Don't over tilt.

Yeah.

So curious. Like, how have you had. Is that true? Is that true? How do you navigate that with your postpartum moms?

So I don't necessarily. I definitely see postpartum moms. I never connected the idea of over posterly tilting for them. I would say that generally speaking, overly tilting or overly posterior tucking is a common situation that I come across with my patients that here they should be more of a posterior tilt and they end up going into too much of it or they go into not a true posterior tilt, but they end up just shooting, shifting your pelvis forward as they go to tuck their hips. And that's wrong because like I said before, a lot of times people have a position where their rib cage is, so they're backwards and the pelvis is forwards. Now, if I overly post their tilt, I can end up reinforcing that forward position of my pelvis, which the back is not going to like. Your hip flexors are not going to like that. Right. So it's going to cause pain. So a lot of times people come to me like, oh, like I post, I'M doing these posterior tilts like you told me to do, and I'm in more pain now, Nick. Like, what the hell did you do to me? You know? And I'm like, well, let me. Let me watch you do the exercise. I mean, let me see what you're doing. And the. And the common things that I see that are incorrect are they end up doing that posterior tilt as they shift their hips too forward. So imagine you're in your back, and you do a posterior tilt. Now imagine that posterior tilt. You do too much of it, and then you end up driving it forward. Now, that becomes actually compressive of the hip flexors in the front, and it overly stretches the back muscles in the back. So. So that's not good either. So, you know, it's. It's like they always say, like, you don't want too much of anything. So if you're an anterior tilt, you want to go into poster tilt, you don't want to go too much into a posterior tilt either. And then the second thing that I usually will see is people that will do a posterior tilt blind, meaning there's no muscles connected to that posterior tilt. They're just tucking their butts. But if you don't activate muscles like your hamstrings, like your glutes, like your core, if you're not activating those muscles with. While your poster tilting, then it just becomes a blind butt tuck. And when that happens, it's actually reinforcing all the bad stuff already. So it's like, you got to make sure that you're doing things the right way. It's not just about like, okay, same thing with foam rolling. Oh, do you. Foam rolling. Okay, check. Do you post their tilt? Check. Like, I have to run through all this stuff with people because, you know, nine times out of 10, they're either doing it wrong or they could be doing it better.

Yeah. So I want. I want you bring up an excellent point. And when you're talking about, you know, too much of anything is good, and you said, you mentioned that pain is also, you know, a signal. A signal for us to be like, oh, pay attention. Right. I always say pain means pay attention. This is true in business, too, by the way. But for. For me, how do you navigate between the differences between discomfort and. And doing something that your brain has not created that neural pathway for yet? And knowing that, like, oh, this is discomfort, that's going to put me on the right track versus oops, it's hard.

It's hard. It's hard. It's not easy by any means, especially people who have chronic pain, because in their minds, any pain is bad. And they've been in their pain, whatever would, like, maybe like, lower back or like, right hip, posterior. Right hip pain is a very common thing I always see. It's like, okay, well, I've had this pain for so long that anything that I experience that even resembles that pain, my mind is like, nope, I'm good. I'm not going to do this. And what happens is that those type of people, they end up not challenging their body enough, and they get stuck in their chronic pain because of their apprehension to try new things, experience new movements, challenge your body, push your body, you know, and it's hard to convince someone, hey, this is good pain, not bad pain. That's the hardest thing to do. And it takes rapport with your patient, with your client. It takes, you know, like. Like ABA connection, like, okay, well, this is bad pain. And then, you know, what does bad pain create for you? Whereas this is good pain. Now, what does good pain create for you? Like, there has to be a connection of, like, cause and effect almost for them to understand it and make rational sense of it, as opposed. Because for them, it's more about an emotional connection of like, well, emotionally, that pain that you're making me do right now is creating pain in my body. But if you actually think about it as something positive, and many times that pain is just really just soreness or fatigue or tightness of muscles that you're not really used to working. So I always try to say, like, well, they're like, I'll do. I'll do a technique, or I'll have them do an exercise. And they're like, oh, this causes me pain. And I'm like, let's talk about this. Like, what do you mean by that? And I'm like, well, it kind of. It's sore, it's tight, it's shaking. And like, well, that's. Is that pain or is that just the muscles waking up? Is that that's supposed to happen? And I always try to, like, say, like, well, let's. Let's. Let's separate the word pain from other stuff that you're experiencing. Because it's all not pain. It's all different things that you're perceiving in your brain, but it might not be considered pain. And that's where it really becomes, like, a really, like, give and take between you and the patient. Another I have patients read because reading is something that's really great for you to understand for some People, right? Some people are like, really like to read and like, oh, like, well, I can give you a book that will explain what we're talking about so they can go read a book. My favorite book is Explain Pain by David Butler. Love it. And with that book, you know, it's fun, it's cartoony, there's animation, and it really does a great job of explaining how pain is a perception from your brain and how you can kind of control that perception. So, yeah, it's definitely. That's a hard topic to talk about with patients.

Have you heard of the book the Great Pain Deception?

No.

Okay, well, it kind of.

Good.

I have not read it. I've heard lots of things, but I've heard talks a little bit about the. You know, are basically our. Our perceptions of what pain means and how it's. That our perception influences pain.

Yeah, yeah. And it's like the one thing I'll say about that that I've learned in my readings and my learning of the material. It's like. It's almost like your. Your brain. Your brain has this homunculus, right? Homunculus is basically a part of your brain that perceives information sensory wise and motor wise, like muscle wise. And what happens sometimes is that there's a smudging of the homunculus. And what that basically means is that basically when you have this pain for a long time, your brain perceives that area not as the area, not as like your right hip. It perceives that area as just pain. You can't even sense that right hip anymore because when you think about that right hip, you think it automatically it thinks about pain. So that's smudging. It's like almost like. Imagine like if you're kind of a mirror and you kind of smudge your fingers across the mirror and it becomes like spread. So like, okay, well, I had right hip pain. Now it's actually right lower back and my hip and sometimes my knee also gets painful too. That smudging is just getting bigger where now you felt it in your right hip. And you can't see your right hip anymore. Now you just see pain there. And now that smudge is getting bigger and bigger going across from that area and spreading.

So, so interesting. That is like, I definitely, like, oh, I want to learn more about that for sure.

Yeah, yeah. Fun stuff.

Yeah, super fun. So I'm curious too, for your, you know, you were starting to talk about it. So I'd love to circle back to some of the common things that you often see in your patients. Just over and over. And if you were working with, you know, and as trainers and as clinicians, like, what are some of the like red flag signs that we should be paying attention to that we hear from our clients in order to be like, oh, we need to address that.

That's a hard question. There's some say again.

So I know it varies and I know there's so like, that's a big question. So just give me some common things.

You see like with like red flags with my patients or seeing that or things that I see with trainers.

Trainers.

With trainers. So I think that generally speaking, going back to the whole thing about pain, a lot of times when trainers have someone that's in pain, they will, he or she will move away from that area and be like, all right, you're in pain in your hip today we're just going to do all upper body stuff. And I'm like, that's not what you should be doing. You should be trying to problem solve their pain. Just because you're a trainer doesn't mean that you can't problem solve someone's pain. And that's what I'm saying. Like where I see great trainers, that's the missing link, is that they look at their client as like, okay, well, their body could be feeling good or feeling horrible, but I'm still going to train them in a way that's going to improve on their function, their body, their health, their well being. It's not just about like, okay, well we're just going to do some arms today, right? It's like, well, let me look at the whole entire body, let me look at their posture, let me see what's going on. Let me try to, you know, fix things as opposed to, let me just try to like build more bicep muscle. You know, it's looking at more of the bigger picture. And a lot of times with trainers, they're scared to look at the bigger picture. They're scared to look at someone's posture and be like, oh, I'm going to try to change this. They're scared to see if someone's in pain to even do anything near that area. Whereas for me, what I do like, okay, if someone has pain, I'm going to go around that area, I'm going to try to figure things out. And just as like I said before, that bridging of the gap between a therapist and a trainer, you guys can do the same thing as well. And obviously you can't do any sort of hands on techniques necessarily, but you can do A lot of problem solving with different assessments and different movement assessments and different assessments. You're doing with your hands that you're not actually doing techniques, but you're doing hands on stuff for assessing them. Right. We have a table, we have a massage table outside in the gym floor. And it's still hard for my trainers to get their patient or their client on a table and assess the. Assess different things because they're like, well, I'm just gonna. They're used to what they're doing. Like, I'm just gonna like run through their little program that we have them doing. But I'm like, well, let's. We can understand their body so much more if you were to assess them first, you know, so that's something that I'm still working on with within, within my gym. But yeah, I would say that that's. That's definitely the biggest, I would say red flag I see is that, like, people who have pain, they just don't want to do anything with that area and they rather just jump somewhere else.

It's so funny thinking about, you know, perception of pain. Trainers have it, and I think it's drilled into our head, you know, make sure that you're staying within scope of practice, Scope of practice. Not recognizing that there are things that they can do to navigate that discomfort and really deciphering the difference between chronic pain, discomfort and, you know, sharp pain, they need to go see someone about. Now you did talk about assessment. I am curious, like, what are some of your main assessment tools that you use in your gym that your trainers also use?

Yeah, so generally speaking, I do PRI assessments, which is on the table. I'm checking, you know, shoulder motion range of motion, which a lot of this shoulder range of motion testing, it shows us the position of the rib cage. So that's what I use it for. I do, I do pelvis or I drive. Like, it looks like a hip test, a hip range of motion test, but it actually is for the position of the pelvis. So there's different things that I'll do on the table. Range of motion wise with the patient, it's all passive. So they're not really doing anything. They're just chilling out there and I'm. And I'm checking different range of motions to get an idea of what position their rib cage and their pelvis is in space. And functionally speaking, one thing that I always will do is watch someone walk, because walking is like everything. So that's a habit that some of my trainers are trying to do as well. They'll have the patient, they'll have the client walk up and down the gym floor in the beginning of their session so they can get a. Get a little idea of what the person's biases are, what the person. What compensations they can see, what weaknesses they can see, what alignment issues they can see stuff like that. And that. That always comes better with time. So, like, there is. We do like this once a month training with me and the trainers. And so I'll go over walking with someone and then someone will walk and we'll talk about, what do you see, what do you see? Stuff like that. And I can see a lot more because I've been doing it consistently for like, five years. But it's just one of those things you just kind of got to build on. You just got to keep on doing it and just get your eye to look at specific stuff as the person's walking. And then you can start catching different things. So I would say walking is probably the number one thing that I usually would do with every single person with their assessment.

What are some of the common things you see when you watch people walk that they didn't realize.

With walking? Many times I see people not leaning enough forward and not sensing their big toe through the ground enough, where a lot of times people will walk and they'll walk with their rib cage behind their pelvis in front, and they're walking mostly on their heels, right? And very, very short, short step length. So they're not really getting into true hip extension because they're always. Their hips are always in front of them. That's something I very commonly see. So for that, I usually say to people, just, you know what? Before you even walk, just stand up and lean forward. Like, imagine like, this is like my whole body and this is like my feet. Your whole body. Lean your whole body forward until you feel you're about to fall. And when you're about to fall, drop your leg forward and continue to do that as you're walking. And their whole gait, their walking pattern will change because now they're trying to catch themselves from falling. And by doing so, they're feeling more of their big toe. They're driving more through a hip extension. They're getting a chance to feel their glutes and their hamstrings working. Because if you can picture, if your hips are always in front of you, you can never really get that glute and hamstring activation. So everyone's like, oh, my hip flexors are always so tight. My quads are always so tight. Why? It's because of that fact that you're always behind yourself. If you lean forward as you walk, you're giving the chance to let those glutes and hamstrings work to push you forward so many times. What I'll do is I'll take, like, a PVC pipe, right, and those plastic long sticks, and I'll. And I'll have someone stand in front of me and I'll say, okay, don't let me move you. And I'll push the pipe, like, into, like, them. And they're holding the pipe in front of them and like, okay. The only one. Okay. So they hold there. And I say, okay, now. Now push through me to walk. So now they're pushing through that pipe, and they're walking forward as I'm resisting them pushing backwards. So, like, that's really helpful. And that's why I love, like, say, for example, like, sled running. Right. Anything where you're pushing something forward as you're running is great because it's really hardwiring your brain to realize you need to be more forward and drive through things as opposed to that passive walking that people get stuck in.

Okay, I'm going to go and film myself walking so I can take a look at it.

Oh, yeah, it's fun stuff. I feel myself walking probably once every couple of months. I should probably do it more often. But it's just interesting because it's like, you don't realize these little things. And there was one time when I watched myself walk, I had my friend record me, and I was in this mean pelvic shear. Like, my pelvis was hanging out all the way to the right. And I had no idea that. And I had some pain in my lower back. But, like, I was like, oh, whatever. And I was like, well, that's why I have pain. It's because my pelvis is so sheared as I was walking. And it just gives you a different insight to your own body when you watch yourself. And running is good, too. So, like, record yourself running on a treadmill. That'll tell you light years of information about yourself.

I love it. Okay, so I definitely want to be mindful of your time. So for who want to learn more about what you do. Hang out with you. Where can I send them?

So. So my office is in Queens. Astoria. Queens, to be precise. It's. It's a. It's inside of Sage Fitness. Astoria. That's the name of the gym. One of my close friends is the owner of the gym. Danny and I am the owner and I run my PT practice inside called the Manual Man Physical Therapy and it's a cash based practice so you can go and see me for hour and a half slots so you can be with each other for a long time, one on one sessions. And you know you can use, you can use your credit cards. You don't. Doesn't have to be cash per se. People think cash, it has to be like dollars cash. It could be credit card, Venmo, PayPal, anything like that. If you want to catch me on some sort of social media, Instagram is my big one. It's the Manual man with underscore between the and manual and man. And then I also have my website as well and that's a link from my Instagram and I have, I just published my own ebook which I'm going to start marketing as well soon. But the ebook link is in the website. I also have different merchandise, like I have shirts. This is a shirt for mine here. Learn, Teach, Love, Heal. So that is also available on my website. Also available on my Instagram shop as well. Cool.

So we'll be sure to link all of that up in the show notes too.

Cool.

Okay, thank. Thank you so much for hanging out with me today. I really appreciate it. It was super insightful.

Yeah, it was awesome.

Thank you for listening to the PT Profit podcast. If you like this episode, chances are your friends will too. So it would be a huge service to us if you would please leave us a review and share with your friends on your social media channels. When you leave us a review, be sure to take a screenshot of it and email that screenshot to my team atinfo simpson fitness.com and we'll send you a very special Instagram podcast that will show you how to create compelling content so that your ideal clients come to you. And you go from wanting clients to a wait list of clients ready for your services. Thank you so much for listening and we'll see you on the next episode.