The Psychology of Pain | Dr Tom Walters

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For hundreds of years, pain was believed to be this sensory phenomenon that came from your tissues of your body. That really has changed through this research. A lot of it was on phantom limb pain, on people who had lost a part of their limb but still had pain. That piece of the body is not there anymore, so you can't think of it as just coming straight from those tissues.

They could not have a signal from the hand that didn't exist.

Exactly. And so that research really drove a lot of the changes of thinking about pain as sort of more of a top-down, an output of the brain.

Board-certified orthopedic physical therapist and strength and conditioning specialist, Dr. Tom Walters.

He's also the author of Rehab Science: How to Overcome Pain and Heal from Injury.

And has spent almost 2 decades teaching people about human movement, pain science, and how to effectively recover from injury.

They took people and they touched the back of their with a metal rod. The metal rod is the same temperature all the time, but they adjusted the meaning associated with it. So in some people, they would show a blue light, and some people they'd show a red light before touching their hands. And of course, when people saw a red light, they would say more pain. The brain is perceiving it as even more danger.

Why is that important for you?

For a lot of people in my world, it's actually that they go in and see a healthcare provider who tells them, oh, you've got severely degenerated discs, you've got the spine of a 70-year-old, or You've got this meniscus tear. We have lots of research showing that that creates a lot of fear and anxiety and actually worsens outcomes in rehab and in physical therapy.

How do you help people work with that fear?

I would say the biggest thing is—

Tom, I think about your expertise a lot and the power of the mind-brain interface and the way that we organize ourselves, our psychological experience and our physical experience in life through our bodies and through our minds. And so I'm excited to have this conversation with you because you've been studying the body and pain and injury and optimization for a long time. So thank you for spending the time on this conversation.

Well, thanks for having me here. I've listened to your podcast quite a bit over the years. I just honestly really appreciate the authenticity and kind of the the deepness that you bring to really connecting with people. And I think you and I were talking before we got on here, just your background as a sports psychologist and working with athletes, it's so complementary to what I do. And we were just saying that, I mean, I could imagine if patients came in to have the two of us together in a room with them, like you just said, to cover the mind, body, and the physical side. I mean, it is like the dynamic duo. So thanks for having me.

I'm stoked to do this with you. What do you hope that people will take from this conversation?

I think the biggest thing for me is that people come away from a conversation like this understanding pain and injury, how they're similar, how they're different. And then there's so much fear and anxiety and worry that goes around pain, understandably, and injury. And I think some of that can be mitigated when you understand pain and injury a little bit better. I know for me, I always feel really grateful that as a physical therapist, if something happens That causes pain or an injury, I don't get as worried about it because I can kind of think, oh, anatomically, or this region of my body, or this is where it's at, this is what I was doing. I can have a pretty good hypothesis to what's going on. And I think listening to a podcast discussion like this, even just in an hour, you can kind of learn what are the different types of pain, what are the different types of injuries. And that really helps people, you know, anything in life, like if you don't understand it, it creates more fear and worry. And I think when you just have a little bit of some of those base-level ideas of, again, what are the different types of pain, what are the different types of injuries, it helps you go down, you You can kind of go down a particular path and you can kind of have a jumpstart on how do I manage this?

Great. Types of pain, your relationship with it, and ways to manage it. And I think it'd be useful to also operationalize what pain is, what it's not, some of that stuff. And when you think about why you got into this field and you've invested so much of your time, energy, talent into it, what was the reason that you got into this field?

It really boiled down to being an athlete in high school. I was a martial artist and gymnast. Pretty much my whole life was in taekwondo. I originally thought I would just open a martial arts school, and that was kind of my path. And I had knee surgery when I was 16. I actually was born with my kneecap in 2 pieces, and it was just a small floating piece. But every time I would land from a jump in gymnastics or in taekwondo, my knee would really hurt and it would kind of buckle. And so I had this piece of bone taken out, and back then, it's so different today. We get people moving right away, but I was immobilized in a straight knee brace for 6 weeks, and I just atrophied and deconditioned. And I remember taking that thing off at the end, and it was just, it was so horrible to see my knee.

Is that my leg?

Yeah, it looked like my knee, just because of how much muscle mass I had lost, my knee looked like a softball or something, and I couldn't bend my knee past 90 degrees. And so I went to physical therapy after that. And in high school, I was really into just exercise science, and that's what I studied in my undergrad years, but it was really focused, I was focused on using exercise for performance in high school and in college. And I think after that surgery and going through physical therapy, it opened my eyes to using exercise and movement to rehabilitate the body. And that really was the motivation to go down the physical therapy kind of educational path. Yeah.

Tell me about your parents. What did they do?

Yeah, so I have kind of an interesting upbringing. I grew up with my mom and stepdad, and my mom is a psychiatric nurse practitioner. And so I actually spent a lot of summers working in the psychiatric ward of our hospital in Montana where I grew up in Billings. And so I spent a lot of time with her kind of understanding different mental health disorders. And then my dad was a social worker. So our discussions at home at the dinner table were just all around different psychological and social aspects. And so, a health emphasis, but really from that standpoint, I think I really became the physical component to the physical health, 'cause my parents really weren't exercisers. They didn't have a great movement practice. They didn't even really go on walks. They didn't strength train, which was so foreign to me 'cause I was such an intense athlete in high school. But I did really appreciate those discussions because it opened my eyes to kind of these other aspects of health. I didn't realize it in high school, but now looking back, it's such a huge part of how I interact with patients.

At the dinner table is a biopsychosocial conversation.

Exactly.

Which is the interaction that most of us operate in. So, okay. All right. So what was the main argument at the household?

I don't know that it was an argument, but it was, I think, a topic of kind of passion for my parents. My dad was a social worker for the Department of Family Services. So he took people's kids away. Mm-hmm. And so that came with a lot of stress. And I think my dad, and it was hard for him to separate that from work to coming home. So at the dinner table, that would leave him on edge. And as a kid, I remember, you know, he's my stepdad, a lot of great qualities, but I'd gotten a lot of, I had a lot of arguments with him as a teenager. And I think he had a hard time looking back on it, removing that stress. And I heard you even talk about your practice of when you come home, sitting and taking a breath before you go in.

Before I go into my sanctuary.

Which is amazing, 'cause I needed to hear that, 'cause I'm not always good. I work from home and I don't always take a, you know, it's easy when you're stressed to let that boil over into the people around you, your loved ones. And my dad, I think that was probably the biggest area where arguments could come up. It would be his stress associated with his job. And I mean, my dad, we'd get death threats, calls. We had to take our phone number out of the phone book back when there used to be phone books. It was a really stressful job for him. And that would come into the household and he would be stressed. And I remember I'm naturally a pretty glass half full type person, but I remember as a kid, I would just at the dinner table be like, so how was your day? And I remember my stepdad, sometimes he'd just be like, he'd just be almost angry that I'd ask a question, I think, so— Light. with such a light kind of— he's just a kid. You don't have much stress going on. So that was probably the biggest argument.

Yeah, I would imagine that when people are struggling with that level of intensity at work and having a hard time sorting out that level of suffering for people and trying to solve and do the right thing, and then coming home and having a buoyant kid, meaning you, that it would be difficult to feel seen. The reason I bring that up is because you've spent so much time seeing other people and really trying to understand them. I wanted to get to a bit of the origin story of why you've dedicated so much time to really understand how to move people through a difficult experience, which is pain. And so when people are struggling, and I'm not saying your dad was struggling, but he had a lot on his plate, right? Mm-hmm. Dealing with people that were in those types of dire situations. It's a heaviness that can come with that. When anybody is consumed with their own internal struggle, it's nearly impossible to see another person, right? And so when somebody is in physical pain, it's really hard to be benevolent and compassionate and kind and thoughtful when literally you've got signals coursing throughout your body, you know, from your brain to your brain saying, you know, this is not right. So do you think we kind of hit the nail on the head a little bit about why you care so much about this field and why you've made such a difference in it, is that there's an internal experience that was important for you to sort out?

Yeah, I think that probably is a big part of it. It's so interesting to think about where these things come from. My mom is probably the most empathetic person I know. I mean, people instantly— we'll be at Subway and people are instantly telling her their story and just sharing everything. And I think biology, environment, how much of those things Obviously, they're both shaping you. I look back on it, not like you said, not maybe feeling seen by my dad. And there's an aspect of what I did in the early stages that I've been working through as I've gotten older of seeking validation. Like, that's been something that I really cared about when I was younger. And it slowly— it's still there, obviously. I think we all have it to some degree, but it really drove me a lot.

Yeah. So your profile for that was high achievement. So you became the classic high-performing athlete, right? What level black belt?

I was a second-degree black belt.

There you go. Competing, probably thinking about the Olympic path. That's right. PhD, fill in the blank. Your writings are extraordinarily in-depth. We talked earlier that it's not a textbook in every university. I'm surprised that it's not, actually. So you've adopted the high-performance characteristics eloquently. So why is that important? Because you're trying to solve something. One, most of us are trying to solve our own early stuff, so check the box there. But you're also trying to solve something else for people. What are you trying to solve?

I think at a base root, I'm just trying to help people solve pain. I mean, that's really been the motivation from the start of all of this is pain causes a lot of suffering. And it's really hard for me to see people in that. And I think I come at it from not only the Interventions I teach, the manual therapy, exercise, and movement, but really at a base level, just education. Like I said, just helping people understand pain and injury. There's so much suffering that's reduced when you understand these topics a little bit better.

So let's open that piece up. What is pain? What are the types of pain? Eventually getting to what you want people to be able to do with pain.

Yeah.

Reducing pain, dealing with pain. So, but what— start basically, what is pain?

Yeah, so pain, if we look at it from a definition standpoint, is talked about being an unpleasant sensory or emotional experience. So I like to highlight those 2 words, sensory and emotional, because most people think of pain as just purely a sensory phenomenon. So it has an emotional component to it. And then the other key thing to pick up on, so an unpleasant sensory or emotional experience that's associated with actual or potential tissue damage. And so again, most people think if I have pain, I have tissue damage. So that is true for a lot of people. You sprain your ankle, you probably have actual tissue damage. You stretched or tore ligaments in your ankle. And in most cases, that's going to create pain. But you also can create pain, and we see this in research studies, if you make people believe that there's going to be tissue damage. So the potential for tissue damage. So the brain, we talk about now, for a long time, Yeah. For hundreds of years, pain was believed to be this sensory phenomenon that came from your tissues of your body. So if you slammed your finger in the door, you would turn on pain receptors, and you'd have a pain signal go up pain pathways to the pain center in your brain. And that really has changed through this research. A lot of it was on phantom limb pain, on people who had lost a part of their limb but still had pain. You have pain in a part of a limb, in an arm or in a foot, that piece of the body is not there anymore. So you can't think of it as just coming straight from those tissues. And so that research really drove a lot of the changes of thinking about pain as sort of more of a top-down, an output of the brain. And so that's where you can really get into this potential for tissue damage causing pain. And there are a lot of cool studies where they visually manipulate people into thinking that something dangerous is happening to them, and then they will report pain.

Open that up. It's a phenomenal indicator of the power of our mind. Yeah. With what you're talking about is the power of suggestion and manipulating somebody to use their imagination to protect themselves. And it is the fastest kind of well-greased slippery slide that you can imagine because our brains are designed for survival. Um, and scanning the world and finding all the potential threats or actual threats is a full-time job. This is why, for me, I stand on the tallest table I can find to say, hold on. You got to train your mind, your psychology, your heart, your software, if you will, to have a chance of working with this incredibly powerful hardware, the brain. So the brain is the hardware, the mind is the software. You have to really spend some time under tension to work with your psychology to give yourself a chance. And so I love where you're going to take this because just the suggestion of damage.

Yes.

Creates, fill in the blanks.

Yeah, exactly. Well, one great study that I love to highlight is one where they took people and they touched the back of their hand with a metal rod. It's such a great study. And the metal rod is the same temperature all the time, but they adjusted the meaning associated with it. So in some people, they would show a blue light, and some people they'd show a red light before touching their hand. And then they'd, of course, like people associate blue with cold, red with hot. There's a meaning attached to it. And so they'd ask them, how much pain did you have with this stimulus? And of course, when people saw a red light, they would say more pain. The other interesting thing is that they would sometimes let people look at the rod touching their hand, and sometimes they'd have them look away from being touched. And if you looked at the rod touching your hand and it was a red light, it'd be even more painful. And this is exactly why, like, you'll hear a lot of times when kids get shots, tell them to look away because our vision is such a powerful piece of information. When, like you said, we're looking to detect threats or scanning all the time. The brain's always looking. So for a lot of people, if they look at tissue damage, it creates more pain. It amplifies that signal. The brain is perceiving it as even more danger. And so that was such a cool study.

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Why is that important for you?

I think for me, it's all about meaning. So when I talk to patients, it's anyone I interact with who's in pain, I am trying to spend time listening to their story and their history and kind of finding out, well, what does this mean to you? And

what does the knee pain mean to you? Exactly. What does the low back pain mean to you?

Yeah, and usually it's around something that they can't do in their life, right? That they're worried they're not going to be able this anymore. I can't run anymore. Or I need to be able to bend down and pick things up at my job, and I'm worried I might not be able to do that anymore. I've got young kids and I've got to pick them up. So it's usually they're extrapolating out to what this pain might limit in the future for them, what it might mean. And so you're trying to uncover that meaning to help them sort that out. As an early PT, I wasn't very good at sitting and listening. I just wanted to talk about this stuff. I still don't always listen, but it's really important because you can just go down a particular road with someone from a treatment standpoint and never really be addressing the fears or thoughts that they have. So you have to, you really have to uncover what the pain means to them.

And you were talking about earlier, so you talked about the sensory piece, the emotional piece, and then you talked about real and imaginary pain.

Yep.

Can you open the difference up between those 2?

Yeah. In the definition, I'll talk about actual or potential/imaginary pain. So actual tissue damage is when you can identify That a tissue actually has been injured in your body. So say you have an X-ray, you've got a broken bone. Say you have an MRI and you ruptured your Achilles tendon, something like that, something that can actually be detected. Or of course, you could cut your skin, something you can visually observe as well. So most people are going to understand those actual tissue damage leading to pain, which it doesn't always. And I know we're going to talk a little bit about the distinction between pain and injury. You can definitely have tissue damage without pain. A lot of people have woken up with like a bruise and you have no idea, didn't hurt, you don't know where it came from, but there's—

At the end of their life, for some reason, they have a scan on their back and there's a ton of discs.

Exactly.

And they've never had back pain.

Those studies are amazing. They literally take asymptomatic, pain-free people, put them through MRIs. I mean, almost half of the population have meniscus tears, bulging herniated discs in their back and in their neck, labral tears in their hip and shoulder. I mean, degeneration all over the body. So those all kind of fit into that actual tissue damage. And then potential tissue damage is anytime you think something is going to cause pain, and then that belief having the ability of actually creating pain. So that could be, for a lot of people in my world, it's actually that they go in and see a healthcare provider who tells them something, probably after looking at an MRI or an X-ray, And they tell them, oh, you've got severely degenerated discs. You've got the spine of a 70-year-old, or you've got this meniscus tear, or you've got a, whatever it is, fill in the blank, something on an MRI that they classify as an injury. And then they express that in a way to the patient that the patient then correlates their symptoms with that finding. And so now they've attached some meaning that my pain is due to this thing on the MRI. And for a lot of people, we have lots of research showing that that creates a lot of fear and anxiety and actually worsens outcomes in rehab and in physical therapy.

It happened to me twice. Once with a problematic neck injury I had. It was a chronic pain for a long time, probably 2 to 3 years. And somewhere in that journey, an MD in a white coat looked at the film with me and his eyes got big and he's like, oh, this is serious. Are you okay? I was like, no, I'm not okay. That's why I'm here. And I know instantly, I was like 23 or something, instantly I got worse. It accelerated all of my protection mechanisms because the expert, and I've just got a thorn in my side about like, hey, listen, you need, you meaning people that have a position of expertise in their lives, you need to honor that. Because your responses and reactions are imprinting beliefs with other people that I didn't have the mechanism to be able to discern. That's his experience, doesn't— and his experience as an expert does not need to be my experience as another person. So I didn't have the ability to do that. And so this goes for leaders as well. This goes for parents. This goes for anybody that has a position of influence, is that your response and reactions dramatically shape in benign and subtle ways The belief systems about people's potential. And if you're not thoughtful or unaware of it, we create a wake of potential damage. And so I had it twice, once for my knee and once in my neck. And I'll tell you, for my knee, it was a mutual friend of ours, Peter Park, who— so I'll just tell the story really quickly, is that I had an MR of my knee and the doc put it up and he goes, oh yeah, what's the— it's a fat pad.

What's it called? Yeah, the infrapatellar fat pad.

Infrapatellar fat pad. Patella.

Infra.

Infra patellar fat pad. That was a mouthful. And he goes, oh, you crushed it. You must be a skier. I said, yeah. And he goes, yeah, yeah, that thing's cooked. He goes, ah, there's not a whole lot we can do for it. You know, like you're just going to have to kind of suffer through it. And he said, um, you know, you should, you should really strengthen your body around it. I was like, what do you mean? Like I'm doing plenty of fitness work. So Peter Park, I don't know, it was a couple of weeks later, like worked up and down my IT band and just kind of grabbed it like a friend, you know, he grabbed it and he's like, Dude, why don't you work on your IT band? And so sure enough, rolling out my IT band, which is now I'm in your lane, right? Um, which seems so simple and so painful, by the way, that my knee doesn't click like the way it used to. And I know that if I'm off my game on my IT band, that naturally gets kind of tight because I am a professional sitter at this part of my life, that if I don't get that thing right, the knee pain comes back.

Yeah.

So when you hear those 2 pieces of that story, what comes up for you?

Yeah, it's frustrating. It happens so much. And like you said, language, communication, it's such— it's so important as a healthcare provider, any of those other, anyone that's a person of influence. I think sometimes we look down on, we used to always look down on communication majors in college, but man, communication is so important everywhere. And if you have any kind of influence, I'm a parent as well, I have 2 daughters, and I think you have so much power over people. And unfortunately, healthcare providers, most of the time unintentionally, Harm people. It's what we talk about as the opposite of the placebo. It's the nocebo.

Nocebo.

Yeah. So the nocebo is causing harm through your language, the messaging you're passing on to people.

Explain that though.

Yeah. I mean, a placebo is when you are able to create positive effects in someone through suggestion. Like you say, the classic examples are sugar pills, but you tell someone this pill has these properties and it's going to help with these symptoms. And just believing that, people get better. We see this actually, some cool studies in physical therapy, in orthopedic surgery and physical therapy, where they took people who had meniscus tears in their knee. Everyone on MRI had a meniscus tear, and they told people upfront, some of you are going to have a real meniscus surgery, some of you are going to have a fake one. So everybody knows that going into it. But then what they do is they go in, some people get the real arthroscopic surgeries, just have those little portal sites. If you've ever seen a meniscus surgery, just little holes so you don't have a big incision. They put those sites on everyone. So everyone coming out of the study—

A small little stitch.

Yeah, so you don't know, but people who didn't have the surgery reported the same reduction in pain as the people who had the real meniscus surgery. So surgery is talked about sometimes as being one of the most powerful placebos, because somebody is doing something invasive to your body. It's not just someone telling you, it's not like me just telling someone, this exercise is going to make you better, or foam rolling your IT band is going to make you better. Of course, there's probably a placebo Most interventions, sometimes some of these studies will say up to 50% of medical interventions have some placebo mechanism. And I think surgeries can be a really— Not to say all surgeries have placebo.

So obviously you and I both go to the same place here. The power of the psychology to impact the actual behavioral experience is—

Huge.

It's phenomenal. Okay. And a nocebo?

Nocebo is just the opposite. So it's some message or suggestion that's negative and leads to harm in people. And so Most of the time in this world, it's amplifying pain. So it's exactly the 2 scenarios you mentioned. This is what most people encounter. They have a scan, and then they either read the report that the radiologist writes, which sounds really scary if you just go down and read their conclusion. It's all these words they don't understand, which creates fear by itself. And then it sounds horrible. I've got stenosis and bone spurs, and what does this all mean? And half the time, it's just age-related changes that we see in pain-free people. So—

And if I don't do something about this, I could rupture my spinal cord.

Exactly.

Which is not actually the case for most people.

The number of sinister kind of serious cases when people have pain injuries, less than 1%. That's a really serious, scary red flag. We'd call it a red flag type symptom or condition. Most stuff people can manage with just time, the right mindset, kind of education and knowledge, and then exercise movement, different strategies that go into this. But I think that's the big one in terms of the nocebo is that Again, usually it's unintentional by healthcare providers who aren't trained in this side of things, in the psychological effects of their language and how that impacts symptoms.

Most people writ large are not trained here. And so let's take your insights and learnings from research on the body influenced by the mind, and the body influences the mind as well. It's bidirectional in that case. And just keep the framing of nocebo and placebo. And how would you help leaders and then parents use that insight to lead better and then parent better?

Some of this stuff is tricky because I think it requires some preparation before you go into conversations. If it's a really important conversation, I think it would be good to set aside time to plan out and think about your communication strategy. How are you going to go in? What words are you going to use? Words are so important. We have so much research in the clinical world on certain words. The word chronic is, for example, we used to use that all the time, chronic pain. If you study people, the word chronic to them means doom and gloom, that they're never going to get better. So even a word like that, that we used forever—

What's a word you use differently?

Now we use persistent pain, or sometimes people will talk about the technicals, like nociplastic, but it's still related back to that chronic pain. But I think if somebody's a leader or a parent, again, myself having 2 kids, there are times I think think where you might go into talk about a topic that's a little bit more tough, and if you just rush into that, you're going to resort back to communication strategies that could be potentially harmful and maybe fall into that nocebo side of things. And I think it's worthwhile to not put yourself in a situation where you just kind of fall back to your defaults.

Yeah, I would say it's probably something similar to, that's not going to work. Susie, I hear you, but that's just not going to work. As opposed to like, what do you think the upside downside? What, what, what, let's open this up. Let's talk about it. You know, where, where do you naturally think that, you know, this could win and where do you think it could be problematic? Like just instantly saying, not going to work. Or, oh, that could work now. This is on the placebo side. Oh, that could work now. Like, even though you're like, I'm not totally sure, but I think it could have a chance, but you want to, you want to bake in a little bit of a belief system in a non-consequential let's say, setting. There's a good discussion in psychology about is it ethical, unethical to have a strong placebo effect with a client or to use placebo interventions, if you will. You know that there's no evidence that what you're saying is actually going to stand up according to research. However, the way you say it, you are now using one of the greatest interventions, placebo. Where

do you stand on that? Because it's the same in physical therapy.

It is the same. I'm trying to ground everything that I say in something that can be backed.

Yes.

And if there was a moment, it was a very dangerous environment, high consequence, real physical injury was on the line. The athlete and I had done a lot of work. He was radically scared in this moment. And he looked to me with these big, huge eyes in the moment before the moment. And I had a call to make. And so I used the placebo. I didn't lie, but I used the intervention To point to all of the things that could be amazing, and all he needed to do was this one thing. There was some grounded factual basis I was in, but I was emphatic of the one thing was the unlock for the all things. I didn't know that. Nobody would've known that. It was a tough one. So I'm going to err on the side of using factual-based knowledge as opposed to one of the greatest interventions, which is just in my head gets really messy. The line between a placebo and a lie,

a

placebo and making something up, it's really, you know, that feels like there's a manipulation in there that I'm not comfortable with. So where are you with that?

I'm exactly the same. As best I can, and of course everything hasn't been studied, but I try to fall back on what is the evidence around this. And in the physical therapy world, it's nice because you can test things. You can do these sham-controlled studies where you have groups who, just like the meniscus study where you could have somebody get the real intervention and then somebody get the fake kind of one, the sham intervention. And I think those have been really helpful in figuring out which interventions actually have some efficacy behind them and aren't mainly placebo-driven. One example in the physical therapy world that a lot of people will be familiar with is that you use your insurance, you go to physical therapy, probably at the end of your visit, they're going to do ultrasound on you. They rub the little thing on, they put gel on you. Yeah. There are studies on ultrasound showing that if they don't turn the machine on, but rub the— they don't turn the machine on at all, but rub it on people, they get better just as if the machine were on. So I don't use ultrasound at all anymore. I don't really use any modalities. I just focus on exercise, education, manual therapy. I stand in the same kind of spot as you is, and obviously the situation you talked about, that's a much higher stakes. I'm not having that kind of situation come up with people. What really bothers me is I will see sometimes clinicians, and people listening to this may have had this experience, there are some clinicians that will, use placebo and nocebo sometimes to get you to keep coming back for treatment. And unfortunately, this happens more often than it should in the musculoskeletal kind of pain world.

For example?

So for instance, say you have back pain and you have a practitioner who delivers a particular— a lot of times this happens with hands-on interventions like spinal manipulation, where someone's popping your back, or it could be massage. It can be both physical therapy and chiropractors is probably where you're going to come into this the most. But of course, that business owner is incentivized to have you keep coming back. each week and paying them. So if they can convince you that this intervention is the thing you need to fix your body, and if you don't keep coming back here, then you're not going to have this tune-up and you're going to get worse. Well, that just creates treatment dependency. And that's really not supported in the research that all of the musculoskeletal rehabilitation research pushes for self-efficacy. So most things in the human body in the—

Self-efficacy meaning a sense of internal power.

Internal power, exactly. And if you look at the research, most musculoskeletal conditions get better with time. And movement/exercise. Those 2 things have the best evidence. So clinicians will a lot of times take credit for things getting better when it probably was just time.

What is your position? It's a great insight. Time plus some movement. Yeah. Let's get into the movement pieces. But before we do that, what is your take on folks that like chiropractic adjustments and/or are not sure or are scared of a chiropractic adjustment?

I don't have any problem. The people who like that, there is evidence that is supportive of interventions we'd think of as being sort of more chiropractic in nature, especially manipulation, where they're popping you. And there is research showing that that can cause temporary reductions in pain and improvements in mobility. It tends to be short-lived in most people. So I'm fine with that as long as the message is right with it. If the message is this should be complemented with exercise and movement, and teaching the person how to manage the symptoms on their own, I'm totally fine with it. It just matters the message that comes with it. If the message is, you need to keep coming back here, this is the one intervention that's going to keep you healthy, it's completely inappropriate in my mind. People who are scared of it, you don't have to have that. You don't have to undergo that type of intervention. There's research supporting, so those kind of high-velocity manipulations we Or adjustments, they're sometimes called, where the body is popping. For the most part throughout the body, they're not dangerous. There are some situations in the neck where there have been kind of rare cases where people have serious adverse— have strokes or things after. So in the physical therapy world, we use manipulations like that in some cases, but there is research showing that you can do slow velocity, slow kind of safer mobilizations of people, and they have similar outcomes to the fast ones. So if you're a person who's You don't have to feel like I have to do that type of treatment. There's other options that all fall within that kind of manual therapy, that umbrella I've used before. Someone's using their hands on you.

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Okay, so let's talk about some of the physical movements that you're finding for professional sitters to be important.

Yeah, a lot of professional sitters. I am getting more like this too. A lot of it, sometimes it's just as easy as walking. Like, just try to get your 8,000, 10,000 steps a day.

It sounds easy. 10,000 steps is hard. There was a time in my life when I'm like, 10,000 steps, like, that's it? And now I'm like, boy, 6,000 was kind of hard to get today.

Yeah.

So I don't know. I mean, I am sitting more and traveling and, you know, than I would like to, but I have to make a concerted effort to get it in. I have to plan. It's not part of my lifestyle. So walking, you're pointing that to be an important intervention.

It's huge. Just general movement. I think most people who have pain, they just need more general movement. There's a lot of research to support that. Doesn't have to be, in a lot of cases, it doesn't have to be a specific rehab exercise. Those have their place, but sometimes it's just general movement. And I think a lot of people struggle with what you're talking about. The cool thing, I think, if you are someone who works at a desk, is get a standup desk and a walking pad and put that under your desk. And hopefully you can type. And it looks a little funny when people are on Zoom, they're kind of going back and forth, but it's so much better than sitting all day. We have a little dog that needs to be walked a lot of times, so that forces me to get out and walk. So, but, you know, I understand sometimes people have time constraints and it's not always that easy. The other thing from a movement standpoint is that you could just have in-place exercises. So you just take breaks from getting out Yeah. So maybe you can't easily go for a walk, but you could get up and do 10 or 15 chair squats. You could drop down and you could do pushups. You could have little weights where you could do shoulder press while you're sitting there. There's all kinds of mobility and resistance exercises that you could do. Most of the things I teach people don't require much equipment. There are little bands and weights, and a lot of it's body weight, especially like my background The gymnast or martial artist, almost everything is bodyweight. And that's very true of the physical therapy world. So we talk about it now in PT as movement snacks. So people get up a lot to go get—

Is there research on movement snacks?

I wouldn't say that language. There's a lot of— there's research around more just general movement and reductions in pain.

Yeah. So one of the things before we get to the reduction of pain is that from a psychological biological interface is that many people that I'm spending time with have or teams have a high stress or high workload. And I'm talking about consistent hits of acute stress, mostly for the most part, decently managed, but not necessarily optimized. Mm-hmm. And this simple little exercise of sitting up, this is a snack, if you will, sitting up, good posture, kind of the crown of your head pulling up into the clouds, And then just unlocking your shoulders. So up, back, and around. So getting the shoulder girdle to move, which I'm sure you can teach a little bit better here in a minute. And what I find is that if I go back 200,000 years ago and I put my chin forward and I had my fists up, and that's a fighting posture. And if I look into the UFC or I look into— there's a fighting posture where your chin is forward, It's down and your hands are up. And then I look at somebody carrying a cell phone. Their chin is forward, it's kind of down, they've got that posture, and their hands are up and they're typing or pressing whatever on the phone, scrolling. It sends this signal to the brain, hey, I think there's a threat. This is a fight posture. So we get that cascade to the signals throughout our brain saying, we need to run, we need to protect, we need to do something. So just getting that shoulder girdle to move, And getting the crown of the head to pull up, it can adjust the posture just a little bit where the chin hangs over the spine in a different way rather than protruding out. So when I say that to you, I don't know any research that I can point to, but I know it to be true for me. And it makes almost an instant realignment between my thinking, my brain, and the way that I experience the present moment. So when I say that to you, do you say, yeah, kind of quackery. It's a placebo, dude. Go be research-based. Or Would you say, yeah, all of that makes sense, and would you sweeten that or have me stop doing that?

No, I think there's aspects of that that make sense. I probably come at it from a different kind of mechanism than you do. There's plenty of research to show that just getting people out of— most of us are in these static postures throughout the day. We just default. That forward head kind of you're talking about where the head sort of slides forward, we're looking down, whether it's a computer or a phone. The problem that we really see with people in pain is We try to get across— it used to be for a long time that we'd say there was bad posture and good posture. That has completely gone away. Now it's just that any posture that you hold for long periods will tend to be more likely to create pain in the musculoskeletal system. So we say your best posture is your next posture. So just keep moving. So what you explained there from a mechanical, physical pain standpoint makes a ton of sense. Most people, their head's translated forward, their shoulders are rounded, which means their shoulder blades are protracted. Coming out of that position is going to offer a new novel stimulus to your nervous system. And so that is what the nervous system thrives on, is movement and novel stimuli. And so you have to imagine, like we said before, we used to think we had these pain receptors. We've found now in research that we have nociceptors, which are these free nerve endings all throughout the tissues of your body. They're basically danger receptors. Those will get activated if you don't move. You know, if you're in a position for long periods, say you're holding your head forward. When you hold your head forward, your head is like 15 to 20 pounds. The cervical extensor muscles on the backside of your neck, those muscles are on the back, they are isometrically contracting to hold your head. When you hold an isometric contraction, you naturally reduce blood flow to a muscle. And so the muscle becomes, we'll call it, it's called ischemia if you lack blood flow. When you have ischemia, you also become hypoxic, which means you have less oxygen. That will naturally activate nociceptors. Like our body detects danger if there's not blood flow. So when you move, that's one of the theories is that movement just continues getting blood to your musculoskeletal system and your skin and muscles have a ton of nerve endings.

Because I'm going at it from a stress management load. So an efficiency, like if you could just unlock your shoulder girdle a little bit, get your head posture in a more relaxed state is what I would suggest, that you are less expensive of an organism to run.

Yeah.

And I'm not even talking about the pain, but you add a layer to it, which is like, if you're stuck in a posture, there's going to eventually be some compensation, and that compensation could lead to pain.

Exactly. And you probably are physiologically less expensive because if you're holding a posture, you're contracting, and there's a physiological demand to that. And I think the other part you said too, just, it's not my area of expertise, but there are hormonal studies showing that when people adopt those kind of upright postures, it changes stress hormones. And so I think there is a whole other physiological side that's not just placebo that, you know.

Okay, good to know. Check. There's also another piece here, which is that you suggested there's no such thing as bad posture, or you're moving away from that language. That's totally new to me. I would have thought before you said that, I can totally spot when I'm in, I can feel when I'm in a bad posture and I'm in good posture, and I could spot it on other people. What do you mean there's not good posture, bad posture?

The classic example is you imagine that teenager, whoever it is, is slouching. And we used to label that, that would be the classic bad posture. We would've looked at a position, we could look at somebody in the airport or wherever it is and, oh, that's bad posture. And then if somebody was standing upright, shoulders back, That would be considered good posture. But the problem is, is that even if you take people and put them in sort of that good posture and you tell them to hold it, a lot of them will start developing pain because they're holding something without moving. It's another static postural position. So we say that no movement or posture is bad. If it creates symptoms, you likely don't have the capacity to tolerate that. So it's really a capacity problem. We want people to be moving, but if something— This is true of exercises too. If somebody Exercise and movement, if something hurts them, it's probably not— we really don't want to say that that exercise or movement is bad. It's just that person doesn't currently possess the capacity to tolerate that.

So let's take that idea and now talk about exercise from your lenses. My son has spent a lot of time in volleyball, and there's a posture in volleyball players. It's a bit rounded. Everything is a rounded posture. in volleyball. And so indoor is what I'm speaking about. And there's an overdevelopment in glutes and there's a rounded shouldering of the posture. Okay. So we went into this new trainer that I wanted to spend some time with. I heard really good things and he wanted to do some training. And the strength coach just was loading dysfunction.

Mm-hmm.

And I was like, whoa, this is the wrong place for us. So from that framework, when people want to exercise and they have a compromise, I think we all have a compromise. True. Okay. Like, and we have a compromise. It amazes me that more people don't get hurt working out. And here we are as folks in the health industry saying, yeah, you need to walk. It's not very dangerous to walk. Okay. For the most part. But then as soon as you do something in the gym where you're loading your skeletal system and your muscles are under some tension, How do you help people from a thoughtful standpoint avoid— it's a big word— avoid injury?

I would say the biggest thing is what we will talk about is load management now in physical therapy. So anybody who's done any strength training, they'll be familiar with the idea of progressive overload, right?

Before you go any further, how important is strength training for—

Huge. It's the number one. It's the number one thing.

That's why I'm asking this piece right here is like, how do we do it intelligently that you're not loading dysfunction? You're not You're not trying to do something to strengthen your body, but you're actually putting it in a compromised shape.

Yeah. If you had to pick anything from an exercise standpoint, strength training. Strength training is the number one if you look at the research in terms of preventing, reducing your risk of future injuries.

And you're defining strength training as?

Anything where you're using external load, you're targeting your tissues by adding external load to your system. It doesn't always have to be— your body weight can also be an external load. It's just that In that case, you're using gravity and the weight of your body. But usually people are thinking about dumbbell, barbell, bands, any of that stuff. Way more research to support that from an injury risk standpoint versus mobility, flexibility. Most humans have the necessary mobility and flexibility for daily tasks. It's great for marketing. There's a lot of mobility and flexibility, but unless you're a gymnast, you need to be able to do the splits or something, most people have what they need. From a strength training standpoint, if anybody has any strength training experience, And you work with a trainer or you have a program, you don't just go from day 1 not having any experience to adding 150 pounds to the barbell, right? You have to— this is where this principle of progressive overload comes in. You slowly over time add weight to the bar or with the dumbbells as your system adapts. That's the amazing thing about the musculoskeletal system. Probably why we don't see more injuries is its amazing ability to adapt. So that idea of progressive overload is actually quite similar to how we would think about load management So if you don't want to get injured and you're going in the gym exercising, especially when it comes to strength training, any type of exercise movement, it could be running. This applies to these kind of repetitive exercise types as well. You want to think about the amount of weight you're putting on your system, how much external load, but also the volume of that exercise. So this really ends up— volume really ends up applying to more aerobic athletes, like runners and swimmers and things. If you're starting a running program, you don't want to instantly go run 5 miles if you haven't run in years because you're likely going to suffer a running-related injury. It could probably not something serious that something tears, but you get Achilles tendinopathy or you start having gluteal tendinopathy or whatever it is, things will start hurting. It's not like there's an easy formula that works for everyone. There is a trial and error process of this, of figuring out kind of where the person's system at, paying attention. Symptoms guide a lot in physical therapy. You're paying attention to your symptoms, you're respecting that, and then you're deciding how you move forward based on how sore you are. Did you have any pain? And that's where this load management piece comes in. It's probably the number one thing we talk about in physical therapy right now is not necessarily, do you have the perfect exact exercise? It's more just about what does your training look like and how, what does that loading on your system look like? Can we get a picture of that and then figure out how to adjust it?

So without actually going and seeing a physical therapist or a certified strength coach or whatever, Are there resources that you can point us to? Maybe you have some yourself or maybe otherwise.

There's a lot to be said for just kind of paying attention to your symptoms. But even the question you asked before, most people do have compensations that we're just not even aware of. And a lot of times we can adapt around those. But when you start adding external load to your system, you do want to be more cognizant of where do you have compensations? Do I have sort of any weak links in particular movements or muscle groups that I should address? to help reduce injury. And I think, of course, probably the gold standard is having someone who's not going to use nocebo language. I think in looking at all the different fields, orthopedic physical therapy is a great one in terms of somebody who could even just assess you one time and sort of help you figure out, because they can go through and test you with their hands. They test each muscle group.

What protocol do you use personally?

For this type of testing?

Yeah.

So I will do a lot of this based on my hands testing people. So we call it manual muscle testing. So manual muscle testing does have limitations because I'm using my hands to compare the right side of the body to the left side of the body. So it's somewhat subjective because it's based on my strength. The great thing about the gym too, outside of like a physical therapist, maybe kind of finding real weak links for you is just having a really good strength and conditioning coach or trainer that's really well experienced because they can actually get objective data in the gym with the weights, right? Because the weight stack, whatever it is you're doing, the cable machine, the barbell, that is an objective piece of information that you can write down and track. And you can compare the person, you can test each movement in the body and compare right side to left side. Because a lot, most people don't know, our musculoskeletal system is really good at hiding deficiencies. You know, it's really good at, most people, you can go through and test things on them and find areas of weakness that they had no idea existed because the different muscle groups are coordinating, working together, and can hide things. We see this in physical therapy all the time. You could take someone who had knee surgery. A lot of people who have had Uh, knee surgery will demonstrate quadriceps muscle weakness and inhibition, but they will hide it. You can watch them walk as they start to heal and are getting better. They can hide that by compensating and loading the other leg more. They can use other muscle groups and they can hide an impairment like that. So, you know, if you're somebody who's just, you're pretty healthy right now, you don't have any pain, even I think right off the bat, just finding like a really good experienced strength and conditioning specialist, they can really help go through your body in a systematic way and identify weak links and then help you build a program. To address all the different movements.

I think what you're pointing to is important. What resources do you have? You have an app, but what does that app do?

Yeah. So I have the Rehab Science app. So my app is mostly focused on rehab from different conditions. So if somebody already has pain or injury, but I do like to mention the thing with rehab exercises that I think a lot of people forget, most people go to physical therapy and they are incorporating these exercises. And as soon as their symptoms are better, they just stop doing them. There's a lot to be said for using exercises from a prehab standpoint, an injury prevention standpoint. And so physical therapists will often be a little different than strength coaches, where we will target a lot of the accessory smaller movement patterns that go into a bigger movement pattern, like a squat or a deadlift. So for instance, like somebody might want to do a single leg squat, and we might watch them and see, oh, their thigh bone, their femur is moving inwardly towards the other leg, and that's called knee valgus. Well, to target that, we need to strengthen their hip abductors, the muscles, the glutes on the outside of their hip, gluteus medius and gluteus minimus. And so we will give people really specific, maybe a side-lying hip abduction exercise that targets those specific muscles. It's a really nuanced, isolated exercise that feeds into a squat pattern. And so that's where rehab exercises not only can have a rehabilitation stand— place, obviously, but they also can have that prehab standpoint where you're integrating them into a bigger—

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When you think about people in the kind of the strike zone of their professional career and they are spending a ton of time on their professional life, they want to be great at home and they know they need to be moving, but they're not doing it the way they once did. They're targeting 3 to 4 days a week in the gym and doing some movement. So it's super thoughtful. Yeah. Right? And somebody's got, let's say that they've got some tight hips, they've got some tight glutes, they've got a mid-back or low-back thing going on, and they're trying to figure out how to eat well, sleep well, and do all the things, but they've got some of that kind of classic symptomology. Nothing is really alarming in pain, But they know that they need to maintain this thing to stave off something and to be fit and healthy and vibrant. What would you suggest we all do in that case?

I think people can think about it from kind of different categories of exercise. I mean, that's helpful. And the areas you mentioned are super common, right? When you look at the hip, low back, mid-back, biomechanically, they'll work together. So there are different types of interventions you can think about. And that's great if you have 3 to 4 days a week at the gym. A lot of the things I'm going to talk about, You can almost think of as like a warmup before your main exercises, or even like sort of a cool-down. You could do them—

Is this 10 to 15 minutes?

10 to 15 minutes, yes.

Before, pre and post?

That's something people probably want to play with. There's some nuance there, and people are probably going to find the most benefit, but I'd say in most cases, probably pre, focus on that.

If you had 10 minutes pre and you did some kind of mobility movement dynamic stuff. Yes. Okay, be concrete there.

Yeah, so those things I would break down into what we call soft tissue mobilizations. So those are things like you mentioned with the foam roller T-band earlier.

Vibration or no vibration on the foam roller?

You can experiment with both. There is some kind of neat, interesting research out there on vibration and how it influences your nervous system. So to me, all these things are like an N-of-1 experiment. You just have to play with them and see. There's no harm really in trying things. People are always asking me, it's like, can I do this exercise? I'm like, yeah, just exercise is mostly safe. Test it one at a time. I think that's the thing is test one exercise at a time. Give yourself a little time to see how your symptoms respond.

Okay. So a little soft tissue—

Soft tissue So say you've got the tight hip and back, you could do things like what helps a lot of people, soft tissue mobilization to their glutes. So you can kind of sit on a foam roller or a ball and kind of roll in there for a minute or 2.

Find the spot or work around the spot?

I like to find the spot. It's good to kind of work the region, but what I usually find works well with people is to find the spot and then implement what we'll call sustained pressure. So you just kind of find that spot at a tolerable level. It shouldn't be killing you. You can hang out there. It's a discomfort that you can kind of tolerate. Take some deep breaths, and then I'll have people kind of hunt around. So just a few minutes doing that. I mean, sometimes people spend too much time on—

So like, say we're doing quads.

Yep.

How many passes in general are you suggesting on a foam roller?

Probably in the neighborhood of, if I'm thinking about myself doing it or instructing it to someone, they're probably going up and down, maybe it's 10 times. It's not a lot.

Yeah, yeah. I was going to say 5 or 6 times and then find a spot, sit on it for a little bit, see if you can tolerate and whatever you can tolerate, but you're trying to get your body switched on.

Yeah. I think for a long time, this got kind of hyped up. spent way too much time foam rolling. This should not be the main thing in your workout. Okay. So you've got soft tissue mobilizations. Foam rollers are great for the spine too, especially for the mid-back. You can kind of lay on it and roll, and it'll sometimes kind of pop, and it helps kind of ease things. After that would be your mobility and flexibility exercises, which we said you don't really want to spend a lot of time focusing on these unless you have a range of motion deficit, but they can be helpful if you have nagging kind of areas that are kind of tight or uncomfortable. Super helpful in those things. More from a pain reduction standpoint. It's more about getting rid of the symptoms and less about, like, I'm trying to become more mobile.

And do you have a protocol that you like, like C.A.R.S. or any of that stuff?

I don't. I think some of those are okay. They're out there, but I don't think you have to really get that fancy. I just— there's some basic stuff that you can learn. This is kind of just at base level, like physical therapy, kinesiology. It's not really—

And your YouTube channel is a great resource.

Has all these. Yeah. So like if somebody wanted a hip mobility video, I have a ton of those on there. The book, All of the programs in my—

Remind me of the YouTube channel.

It's called Rehab Science. And it's all broken down by playlist. So there's a hip playlist, shoulder, people can go find those videos. The book is, all the programs in my book and in my app too, phase 1 is all soft tissue mobilizations. So we start there. Phase 2 is looking at mobility, flexibility, and what we call neuromuscular control exercises. These would be the other things I would encourage people to think about. Like if you have a nagging kind of low back hip area, Stretching your glutes. A lot of times we'll teach people nerve mobilizations. A lot of people have nerve flossing where you're kind of doing these—

It's nauseating to me. Yeah. It just makes me want to throw up.

Yeah, it does to some people. You have to be careful with them because they can make some people feel nauseous. Some people will have a flare-up in nerve symptoms. So you find the right dosage. But for something like back, low back, and hip, sometimes doing a sciatic nerve mobilization, even if you don't have traveling sciatic nerve pain, can help reduce symptoms in those areas. So they're kind of these movements where you're moving one part of your body and then usually like your head and neck. So like the sciatic nerve, you're moving your ankle and knee in combination with your head and neck. And there are basically studies in cadavers where we can see that the nerves, they put pins in the nerves and can see that they slide. Those fall into that mobility flexibility. But again, you're using it sort of for treating pain and discomfort. And then last would be all the exercises that fall into kind of neuromuscular control and strength. Every rehab program should focus, like I said, on strength, gaining capacity. Your musculoskeletal system, even though we talked about how complex it is with your body and mind, it is still a mechanical system. And that system becomes more resilient by putting load on it and strengthening it. All the tissues in your body, your muscles, your tendons, your bones become denser, your ligaments become thicker. Even the discs in your spine, there's evidence showing that the discs of weightlifters are thicker and more resilient than non-weightlifters. So pretty much your whole musculoskeletal system will adapt to mechanical loading. And if you think about, if you want to reduce the likelihood that you break a bone or rupture a tendon, the stronger those tissues are, the better they are at handling force and not failing, the less likely you are to be injured. And the thing that's going to change those tissues is putting load on them with strength training.

And what about We're not jumping. I'm not jumping anymore. You got to get jumping.

We got to get you jumping.

I know that if I don't purposely, with the person that I spend time with, Ken Vick, as a strength coach, if he doesn't get me bouncing and moving with jumping and/or he's really switched on about the importance of rotation. So rotation and jumping for the elasticity. Can you talk about where you are in that as a level of importance?

Yeah, those are huge elements. Those types of more explosive kind of even plyometric movements, we'll call them, where your body's being forced to store energy and release it, are hugely important. If somebody's brand new to exercise or they've gone through—

This is not a place to start.

Yeah, not a place to start. It's like the end. If you think about climbing a ladder, first is kind of reducing pain, mobility, flexibility, strength, how much force can you generate? And then last is explosive movements.

And even in that last phase, he'll have me jump with bands. Yeah. Right? So it's It's not my full body weight. And then we'll take the bands off and then we'll do some load, body weight load. And then we'll do some actual moving around with weights.

That's perfect. Because you're getting kind of a whole regression progression. Yeah. Because even jumping explosiveness with your own body weight could be too much for some people. So you could even jump in a pool. You can do different things where you start with this, but those exercises, they're helpful on a bunch of different levels. One that has been researched more recently is increasing bone density. So jumping has been one of the primary interventions besides strength training for increasing bone density.

Does walking count?

No. Walking counts—

Does running count?

Not really.

Does rucking count?

To some degree, maybe more than those other ones. The problem with—

Does Pilates?

No. Does Pilates? Pilates a little bit, because if you have enough resistance—

If you're jumping on a Pilates resistance and if you're using some weights. Yeah.

If the weights are high enough.

Okay. But you're saying So put some weights in your hands and squat, bench, this, that, and the other, right? That's what you're saying is the load that you're looking for.

Yeah, it has to be a pretty strong load. I mean, it has to be, you think about the amount you can lift for a 1 rep max, you've gotta be getting up high enough that there's enough, a heavy enough muscle contraction that you're pulling on the bones with enough force to get them to adapt. Also, your muscles release these myokines, which are these molecules that circulate and help increase bone density. Those are released more as the

So we started the conversation saying you should walk, and then you say, yeah, but you should walk and you should load your skeletal system because you're not going to get the myokines and you're not going to get the resistance on the tendons and the whatever. So we need both.

Yes.

And do we need to do cardio on top of that?

Yes.

Okay. What is your position on REHIT as opposed to HIIT? Reduced exertion, high intensity interval training. So it's the intense bursts with resistance of like 30 seconds at a time. Where you are sprinting full out for 30 seconds with some tension on it.

So you have tension, you have some kind of load while you're doing something explosive.

Oh, I like that you're like, what is this? I understand it too. I think it's really interesting.

Yeah. It sounds, as you're explaining it, like it has real potential, because I do think from a cardiovascular standpoint, sometimes it doesn't have to be what people imagine where I'm going out for a 30-minute run. You could have these really—

It'd be the exact opposite.

Yeah, just really quick.

It'd be 3 segments of 15 seconds where you are flat out, in those 15 seconds and then recovering for 2, 3 minutes and then flat out again and then recovering for 2 minutes and then flat out and then you're done. So it's like 45 seconds under great duress with like 6 minutes of recovery.

Yeah, I would imagine, because if you think about health and kind of longevity, right, we know VO2 max is such a big component. I think if you think about VO2 max, you know, it'd be interesting to, I've got a buddy who's an exercise physiologist that only studies this aerobic exercise side of things, but But to compare a HIIT type of high-intensity type of exercise versus a long and slow, it'd be interesting to see VO2 max, kind of how that changes within those 2. But I would imagine that probably has more influence than I'm going to go do a zone 2 slow run. Kind

of a junk run.

Yes.

There's interesting research around the zone 2 stuff right now as well. I mean, I think the net-net is, to your big point, is like, look, If you don't want to be in pain, get ahead of it.

Just try to move. Just have some movement.

Yeah. And now, can you take a lifespan approach? So I'd like for you to address the parent that says, when should my son or daughter be lifting weights?

The research on this is that starting weight training young, say like middle school, is not detrimental to the development of the musculoskeletal system, because that's what parents really worry about is, oh, is it going to injure their growth plates or something? So I think, of course—

How clear are you that putting a 12-year-old lifting weights that are not in a stupid way, but lifting weights is not going to shorten their growth plates or close their growth plates?

I mean, pretty much almost 100% certain. Yeah, me too.

And so where did this come from?

I don't know. I think it's some sort of—

Shorter gymnasts back in the '80s?

I don't know. I don't understand. I don't actually have any idea where it came from. If it's just some sort of myth, maybe it's just mechanically people imagine I think there used to be this idea that weightlifting was dangerous and kind of risky.

Yeah. And if you put all that weight on your spine, you're going to actually compress yourself and be shorter.

Which actually your system adapts the opposite. So you do have to be thoughtful about it, right? You don't want to just— I started weightlifting when I was in 7th grade, and I was so lucky that my PE teacher was a strength and conditioning. He's a CSCS. I learned, started with lightweight, learned good form. I mean, that's the thing with everyone is that We talk about in physical therapy, when you're learning a new movement, if you want to reduce injury, you need to start with motor control, which is movement quality. So how well can you move and control your body with no external load? So that might be, say you want to bench press, you want to start weightlifting and you're going to be new to a barbell bench press. Well, in the beginning, you could just be starting with, it could be pushups with just your body weight. You could be starting a pushup progression. You probably want to be able to do a certain amount of pushups before you really start trying to load a barbell.

By the way, pushups are not easy. People like, I don't know what percentage of the population can't do a pushup, but I'm sure it's pretty high.

It's pretty high.

Yeah. So, you know, like, I don't know, starting on your knees or like there's other—

Do tabletop pushups.

Tabletop. So you're taking some of the gravity kind of off.

Exactly. You can start on a wall pushup and hardly have any force. And then you just lower the height over time to where then when you can get to the ground. Now you don't have to start there. If you want to bench press, just start with the bar. The Olympic barbell's 45 pounds. If you've never lifted, start there and have a spotter and learn good form. You really need to learn. People underestimate how much muscle coordination goes into these lifts. I had this actually occur to me because I took a friend to the gym who's naturally quite strong, but he had no strength training background. And we were going to do incline dumbbell bench press. He had never done that in his life. And so I was slowly kind of testing him, but he was up doing the 50-pound dumbbells with me and I just didn't— he was fine while he was doing it. Well, it turned out it really strained his rotator cuff. He went on to have 4 months of shoulder pain that basically I caused.

Good job, doc.

Yeah, exactly. He tricked me. He was very strong and he controlled it well. I couldn't really see anything, but that was another example of load management and the importance of progressive overload. I shouldn't have let him start there. He tricked me. He looked good. He wasn't shaking, but his system didn't have the capacity for it. And I think just another example of where you've got to add in the movement quality. You think about those young kids, you've got And anyone, if you're new to exercise, whether you're a 14-year-old or you're a 65-year-old, have someone coach you and teach you technique first before you start adding external load. You want to add a bunch of force to your system if you don't have the technique.

How do you address people? I'm going to go back to pain, and they're listening to this conversation, they're like, one day, but my back hurts. How do you work with people that structurally on film, let's say that there's no There's no real thing that's getting in the way, but they've got pain. Okay? Something's going on that they feel pain. The signals are all lit up and they're, they're, they're not loving the way that they feel in life. And they want to move. They want to exercise. They're afraid of the, the state where they're not going to be able to lift their kids over their head or, you know, travel easily on an airplane, whatever it might be. How do you help them? And how can you help them in this moment take steps? Either psychologically and/or physically to address the state that they're in?

Right off the bat, reiterating what we talked about before, most conditions get better with time and not avoiding movement. That's unfortunately most of us, our protective response is to avoid movement when something hurts. And there's a ton of just problems that come from that. You could pick certain conditions like people who have a shoulder injury who don't move are more likely to develop frozen shoulder. You're more likely to experience a loss of mobility, deconditioning, atrophy, kind of muscle weakness. So I think right off the bat, it's encouraging people to figure out how they can keep moving where they can while respecting their symptoms. When you have pain, there's a flare-up line where your pain will be exacerbated. And so you're always playing with that flare-up line. And I always tell people that rehab is not this linear, rarely is it just this linear, I'm getting better and it's just perfect the whole way through. Yeah. You're gonna see a general positive trend, but everyone's gonna have setbacks and flare-ups, and you just have to not beat yourself up about that. You've gotta know, okay, I'm gonna try and test some movements. I'm gonna see what I can do today. I'm gonna do it in small doses, 'cause exercise and movement has a dosage just like medication. So you, we talked before about capacity. Capacity is just how much stress your physical body, your pain system can tolerate right now. And so you can push that capacity higher Gradual training. Like, sometimes we call it— we were talking about graded exposure in the pain world. It's like people who are like, have anxiety. If you're scared of snakes, right? You don't just hand the person a snake the first day. You might think about a snake, or you see a— watch a documentary on snakes or something. So if somebody has back pain, for instance, and it hurts when they bend over, we're not just the first day going to have them deadlift. You know, you're going to expose their system to gradually increasing increments in stress that challenge that same movement pattern. So people who are really severe, like say they've had back surgery, there's research where just having the person Even think about bending their back fires the same motor networks. So they start firing those, all those neurons for that pattern. And that can be the first step in that graded exposure process. So say you want to get back to exercising with your back, well, maybe you start there, and then maybe you start with similar kind of movements. So say maybe it hurts to bend over, maybe I'm going to start by just lying on my back and pulling my knees to my chest as like a mobility exercise that rounds my back, but it's a little bit different context and maybe it's less threatening to your nervous system. And then maybe you start doing the movement pattern, like you're just learning to kind of bend over gradually And slowly trying to touch your toes or seeing how far down you can go.

So I think this is where your commitment to your channel on YouTube, your book, your app is helping people move through this experience with some coaching, with some instruction. And then I'll add from the psychological side is that I'm going to use this language provocatively. You have to compete with your schedule. You have to compete with yourself. And I'm not saying like, Be aggressive with yourself. But I've got 20 minutes at the end of my day. I've got a mat in my room. I really work hard to make sure that I roll out a little. So I've got a ball, foam roller, a mat, and I'm getting in a runner squat. I'm kind of moving around. It's almost like a tai chi yoga mix. Sometimes it's just laying in rotation, but I don't know if I don't do it. I find myself over, I don't know, it takes maybe 6, 8 weeks where I start to feel a little bit more. Brittle's not the right word, but just less supple. And do you have a practice similar to that? And would you recommend that end-of-day type of mobility work for folks?

Yeah, very much. Listen, I know talking about this, this can sound overwhelming to people sometimes and very complicated. I think it doesn't have to be. You literally could just have a few minutes, maybe cumulatively you have 10, 15, 20 minutes throughout the day. It doesn't even have to all be at one time. It could be that end-of-the-day routine, maybe that helps you wind down, helps you sleep, and you also get your movement in. I personally don't have a practice like that only because I spread my movements out. I try to spread my movement out in little doses throughout the day. And then on the days I go to the gym, I also have that thing. But I think all of this can sound a little overwhelming to people, but I think the key message is just get some movement in. Most, most of the time when people come to see me, I only give them 2 or 3 exercises. It's not some overwhelming thing. So if you're somebody who has a little area that's uncomfortable or feels stiff to you, usually you can find just 2 or 3 things. It just takes a few minutes. Maybe you try to do it 2 or 3 times throughout the day, and each time it takes 5 minutes.

Do you have any things that you're like, I'm not buying it? Like say Orange Theory or F45. Do you have any things that you're like, I'm not buying that? Or pretty much are you saying, no, just find a spot that feels right to you and go for it?

Yeah, I don't really, when it comes to pain and injury, if there's a focus, as long as there's some resistance training in it and you're actually having to work on strength, I'm pretty much okay with most things out there. I'd rather have people move a few times a week than not. So even when you look at back pain research, all of these different— they've done studies where they compare all these different exercise types, Pilates, yoga, strength training, mobility training, all of them are about equally effective in reducing back pain. So I think the key to me in all that is just find the thing you enjoy because then you'll do it consistently.

Speak right to the person that has back pain.

Yeah. If you have back pain, And just right along those lines, you've just got to find ways to move that you enjoy. If you enjoy that movement, again, strength training, it could be mobility flexibility training, it could be yoga, it could be Pilates, F45, whatever it is. If you can find something that doesn't totally exacerbate your symptoms, because you do have to respect your symptoms, if you can find something that keeps you moving that you enjoy, you are going to do so much for helping to get rid of back pain just because you enjoy it and you do it.

Not that you're doing this, but if you were to design an ideal movement approach to be able to live vibrantly in your life, what would you do across 7 days?

I'd walk every day. I would strength train 3 to 4 days a week. It could be as low as 2.

20 minutes is a minimum?

20 minutes minimum. Yeah. And it doesn't have to be— it really is probably going to be in that 20 to 30-minute range.

That's where I am.

Yeah. You don't need— if you even look at the strength and conditioning research right now, if you can Just get your major muscle groups in twice a week, you will maintain, and in a lot of cases, keep gaining strength and muscle mass.

Okay.

I think the strength and conditioning, that world has changed. Things have changed. It's become actually more manageable in some ways. Looking at those 7 days, those are going to be the things I'm really going to prioritize right off is just general movement. And it doesn't have to be walking, it could be cycling. You just need to be moving. And I think that 10,000 steps is a good goal for that general movement. And then prioritizing strength training. The good thing about strength training is that if you move through full range of motion, it is also accomplishing mobility training. So that's the thing I think people forget is that if you go in and strength train and you do half reps, then you're not taking your joints through full range of motion. But sometimes strength training is the most best mobility training because take for instance, like a deadlift pattern. If you have tight hamstrings, well, you could just stand there and do sit and reach. I mean, I did that for thousands of hours in gymnastics and in martial arts. And it can make you more flexible, but you can also do a deadlift and you're causing those hamstring muscles to contract eccentrically on the way down, which in some cases that is actually more helpful to people for gaining flexibility. So I think resistance training—

Oddly enough, some of the most flexible people I know are Olympic weightlifters.

Yeah. They have to go through that full range of motion and control it. They have all that great neuromuscular control. They know how to control their muscle through that full eccentric contraction. So I think if you just start with those 2, like say on a 7-day regular week, you try to walk every day, You try to strength train 3 to 4 days a week. Again, that minimum of 2, maybe have one day that is just, you're probably going to have a couple of days in there that are just off from strength training. And then if you want to bring in other things, I do think you want to be thinking about your VO2 max and your cardiorespiratory system. So for me personally, I like to do, I don't mind doing like kind of slow runs. I like running. It's good for my mental health as well. But I think even if you don't like long and slow, then think about the intensity. intervals like you mentioned before, because I do think if we talk to any exercise physiologist in that area, they would say that has probably equally or maybe stronger impacts on VO2 max.

There you go. And if you can put in there something that's really fun, like a swim or surf or basketball or something like that, and/or yoga.

Some play stuff.

Yeah, some play stuff in there. All right, thank you for reminding us of the importance of doing the simple things well and how important movement is. Thank you for reminding us about the science of nocebo and placebo. And a way to think about the types of pain that people have. And so is there anything that you want to make sure that we hit that we didn't hit yet?

I think this is good. There's so much we could continue to talk about. I hope that people can come away from this. I mean, I think the main thing for me is that people have kind of a mental roadmap for if they're in pain or have an injury. And I think the thing that I would just really encourage people around is Try to really understand pain and injury. They are different things, right? Like, something hurting doesn't always mean that something's damaged or you have harm in your body. And I think, like we talked about, if you've had an MRI and X-ray, just think of that as one piece of the puzzle and try to separate it from your— just take it in the whole kind of context of your symptoms and what you have going on. You know, I think at a base level, if people can just— there's so much evidence to support movement as an intervention for pain, almost any condition you look at, rehab, physical therapy, chiropractic, whoever it is that kind of helps you with your rehab, athletic trainers, whoever it is, it is the first line of defense across almost every research study for almost every musculoskeletal condition. So I think the cool thing about that is that with some knowledge and a little bit of exercise and movement that helps target the area, most people will get better with time. And I know it can be scary to people when they're in pain, but I just think just that encouragement to try to figure out how you can move, find a resource. Like I said, my book is a YouTube channel. There's videos for every condition on there. So people can just go, almost every video is just 3 or 4 exercises. It just gives you somewhere to start. You can help kind of get that pain coming down and then figure out how to address any impairments you might have, whether it's a mobility impairment or strength impairment that will get you back. Closer to kind of your normal function and health. And then think about all these things we talked about, which to me are like the things that keep you going in the long term, the steps and the strength training and all that other stuff.

When people are in pain, there's often a lot of fear about the pain continuing. How do you help people work with that fear?

Well, I think a lot of it is around the educational messages that we're talking about today. It's helping people understand that While this may seem really serious to you, that most of these conditions are going to get better even with time if you had no interventions. It's the truth. I mean, it's called the regression to the mean. You look at most musculoskeletal conditions, clinicians will take credit for things getting better, but most things just get better with time. When I'm working with people, I'm trying to help them understand that. And I think a lot of people, if they can just experiment with movement, just one movement at a time, that can really help boost your confidence. When you can, a lot of times you can find just one movement that really helps your symptoms. But it might not be the first, second, or third one you try. You just have to find the right thing. Like, you've got that low back pain, maybe it's a mobility exercise, maybe it's cat-cow, maybe it's a glute stretch, maybe it's the sciatic nerve mobilization. Oftentimes there's one or two exercises or movements that is the right thing for that person. And so I think you've just got to try to understand the pain, pull back on that fear, and just kind of talk yourself up a little bit and try some movements.

Yeah, I think that's the right approach, which is running some experiments to figure it out. Face it.

Exactly.

Address it. Move towards it. And I would also add to the, to the quiver is mindfulness-based stress reduction, MBSR. Dr. Jon Kabat-Zinn, uh, it was the founder of that, the idea. It's phenomenal, the research around it. So it's basically a practice of awareness to be able to become more connected with what's happening inside of you and what's happening in the world around you so that you can adjust accordingly. And so the findings around pain there for MBSR are ridiculous as well. So run some experiments.

Exactly.

Tom, thank you so much for your contribution in a significant way to help people live a more vibrant life. Appreciate you.

Thank you so much for having me. I know we just kind of touched on the surface. I always like to say, if there's a lot of nuance to this and everybody's symptoms are a little bit different, I'm Rehab Science on Instagram. People can DM me on there. Send them forward posts, things like that. They can go search the YouTube channel. There's so much out there. For 10 years I've been doing this. There's a lot of free content. I've covered every condition. So I'd encourage people, just like you said, face it, be proactive. So much about getting better is an active mindset. You have to have an active approach. Things won't tend to get better when you're just passive and you expect somebody else to fix you. You have to kind of take an active approach to pain. So those resources are out there and people can always message me.

Well done. Appreciate you.

Thanks, man.

Next time on Finding Mastery, what if peace isn't something We have to find, but something we learn how to return to. Dr. Mike sits down with world-renowned spiritual teacher and humanitarian Gurudev Sri Sri Ravi Shankar to explore what it means to truly master yourself, how to remain steady when life becomes overwhelming, and why meditation and the breath can be powerful pathways back to clarity, presence, and joy. So join us Wednesday, September 30th at 9:00 AM Pacific, only on Finding Mastery. Thank you.

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