#122 - Why Progressive Overload Is the Missing Link in Rehab with Dr. Todd Riddle, Part 1

Performance tech is everywhere, but here's the uncomfortable truth. Most clinics don't have a tech problem. They have a decision-making problem. Welcome to The Factor Podcast, where we talk about the stuff they didn't teach you in school, how to grow your practice, refine your clinical skills, and get better results for your patients. We're here to help you navigate the real-world challenges of being a healthcare provider. From delivering top-notch patient care to running a business that doesn't run you into the ground. Whether you're fresh out of school or scaling your practice, we're diving into effective cutting-edge treatments to get patients better faster. We'll also talk about business strategies and tactics to help you work smarter and not harder, and the mindset shifts required to thrive as a top performer in your field so you can build a career you love without burning out. If you're ready to learn what works— and what doesn't— from leading experts, industry innovators, and respected clinicians across a wide range of specialties, you're in the right place, my friend. Let's dive in. There's a big difference between learning a technique and understanding a system. In today's episode, we're pulling back the curtain on the Factor Rehab methodology. Not the marketing version, not the surface-level explanation, but the actual framework that drives how we assess, load, and progress patients. Because here's the truth: Factor is not a soft tissue technique. It's not just instruments, it's not just cupping, it's not just movement. It's actually a progression model. And if you've ever wondered, why do we treat through painful movement, or how do we decide when to progress a patient? If you've wondered, what does progressive overload actually mean in a rehab setting, and why do so many clinicians stop at function instead of Building performance? Well, then this episode is for you. In part 1 of this 2-part series, Dr. Todd Riddle, our Director of Education, breaks down the evolution of FACTOR from technique-based roots to a full rehabilitation continuum, why progressive overload is the missing link in most rehab programs. He'll also talk about the difference between treating a condition and treating a person, And how static, motion, resistance, function, and performance fit together inside the FACTOR system. You'll also hear why we believe pain during exercise isn't automatically the enemy and how to clinically differentiate between someone who's injured and simply having some sensitivity. If you've taken a FACTOR course before, this will deepen your understanding. And if you haven't, this will give you a behind-the-scenes look at how the system actually works. Let's step inside.

The idea here is to give you a little bit of a background about what Factor is and the kinds of things that we're affecting with patients. We're going to be reviewing pain science and how it applies to Factor. There's some nice symmetry between the current literature and the The concepts that we cover within a factor course. We're going to discuss how factor affects the musculoskeletal system and all of the things that apply there, so muscles, fascia, skin. And we're also going to discuss how factor affects the nervous system. Again, some great symmetry between the two there. We're definitely going to be discussing a lot of information about progressive overload both here and in class because And at the end of the day, that's really what rehabilitation is about, is starting a patient where they're at as an individual and working them through progressive overload, managing their load so that we can make them more resilient to everyday life. And obviously, we're going to learn how to progress through the factor concepts. First things first, we have to discuss what factor is, or the factor system. Historically speaking, factor was very much a course centered around soft tissue rehabilitation. Our co-founders, Dr. Hyde and Dr. Dorr, were both Graston instructors that discovered through their teachings and through the use of the Graston Technique that if you applied movement to soft tissue rehabilitation, that patients had better outcomes and tended to get better a little bit faster. So Factor at its foundation levels was very technique-oriented. But I do want to make the distinction here that as time has passed, Factor has started to incorporate a lot of different ideologies, a lot of different thought processes, and has moved away from being very focused on soft tissue therapy, so to speak, and has incorporated a great deal of assessment and a great deal of exercise, really removing the technique name from it. So it's not— it's definitely not a technique course. It's a methodology for patient progression and overload, as I've said previously. We are going to combine, still staying true to our foundation, soft tissue techniques with exercise to promote healing and restoration. But we've also added a great deal of assessments and some very targeted exercise To improve the overall outcomes for patients. What's really important here is that we utilize a patient's presentation. I think a lot of times as rehabilitation specialists and caregivers, we get caught up in trying to treat a condition as opposed to trying to treat an actual person that has a condition, and there is a distinction there. So we're going to look at a patient's presentation, we're gonna look at their health status, we're gonna take their physiology into account when we're trying to establish a treatment plan. Pain and dysfunction and deficits are going to be used to guide how we dictate treatment, but then also how we provide a load management program. And then finally, movement and progression is going to be the key to this, this approach to the FACTOR concepts. So here we're going to focus a lot on movement, but certainly in class, if you have not taken one yet, we are going to cover a lot of exercise. If you If you have taken it, again, this will be a nice kind of review of, of how we incorporated movement into rehabilitation. So let's talk a little bit about how pain can affect exercise. Clearly, all of us are familiar with the idea of pain, but a lot of us are not familiar with the idea of exercising through pain. And that's one of the hallmarks of the FACTOR concepts, is helping someone recognize that— Many times their pain, while it seems to be limiting and debilitating to them, that actually exercising through the pain can be very helpful. It is a fundamental ideology for us to treat the patient in a painful or dysfunctional position or movement. So I often use in class the old adage, if it hurts, you know, do it. A lot of times we'll have patients that come to us and say, hey, it hurts when I do a squat, my knee hurts or my hip hurts. And in the past, many of us have decided that that was probably a bad idea to move it if it hurts. So we would tell them to rest or lay off of it. Well, times have changed significantly, and there's a growing body of evidence that suggests having people move through pain, to exercise through pain, can actually be very helpful. Again, use the example of a patient being injured versus hurt, because this confuses a lot of people, especially patients. If you're going to have them move through pain, well, are they injured? Which means if you have them move through that injury, is it going to make it worse, or does it just hurt? And there is a big distinction there. Injury suggests that there's some other physiological mechanisms at play that if we don't mind those mechanisms, we can actually make them worse. Whereas hurts, we now are just dealing with a painful sensation. We're dealing with a movement or a Static position that's causing pain, but it's only because of a sensitive nervous system, and moving it isn't necessarily going to cause more injury or harm to the patient. So it is important to make that distinction, that if you feel like movement or treatment is going to create more harm than good, then clearly we have clinical decisions to make there to not move patients through injurious movements. But again, you know, just kind of a quick review of research here. We have protocols that use painful exercises do offer a small but significant benefit over pain-free exercises in the short term. So what we're going to discuss in course, in, in a FACTOR course, is how we move someone through a painful or dysfunctional movement, and they get benefit from that in the, the short term. So we do want to see progression away from those painful movements, meaning Either the, the movement gets better and the pain gets better, or we have to pick better exercises or ways to have them move through that. So pain during therapeutic exercise for chronic musculoskeletal pain does not need to be a barrier to a successful outcome. And that's a big mind shift for a lot of patients because many times they've been dealing with a painful movement.

Mm-hmm.

For so long that they feel like they can't do normal exercise. They feel like they can't get out and go to the gym or go for a walk or ride a bike. And what we're here to say is that with a little bit of imagination and a little bit of ingenuity, you can have patients back out and doing the things that they love by actually having them move through painful motions or positions. So what's interesting about the Factor Concepts, obviously, as any good program would go, they've evolved a bit. Previously, or historically, the Factor Concepts started off with treatment in a static position, and these would all be positions or situations where there was pain. So statically speaking, during your assessment, you were able to create some sort of discomfort or pain. Perhaps maybe their knee hurts just sitting there, or low back hurts just sitting there, and we would provide treatment statically because that was the most appropriate position to start the patient. And from there, once we had normalized the pain, we would ask them to move it around. Okay, well, it feels better now. Let's move that body part and see if it hurts. And sometimes it created pain, so we're going to treat them through a painful movement. Once we had normalized that movement, then we're going to load it up. We're going to give it a little bit of resistance, whether that's with using a TheraBand or that's using a light dumbbell or a kettlebell. Whatever the case may be, we're going to use some sort of external load or resistance to see if we can provoke discomfort. And again, once we've normalized that, we would move into more functional movements. Perhaps it's doing lunges or squatting or— Recreating things that they may do on a daily basis. And again, the attempt would be there to normalize that. And then eventually we would, would have rounded out the factor protocol historically with some kind of proprioceptive exercise. But as time has moved on, it's made more sense that proprioception is inherent to every single one of these concepts. So instead of leaving proprioception as the 5th component or concept, we've adapted it to make performance the next component or concept because we don't feel that it's appropriate to stop a person's plan of care once you have improved their function. It is important to continue to build their capacity above and beyond what they were prior to their injury. So if you're working with an athlete, it's always important to restore function, but is there more that you can get from that athlete? Or if you're dealing with a police officer or the UPS guy. It is important to restore their function, but is there more that you can get out of them to help improve their performance of their daily activities even more? So what we've done here is developed what we call the Factor Rehab Continuum, and it looks like a periodic table. So hopefully most of you are at least familiar with the periodic table. It is a list or a table of elements where we lay out their atomic weight and have them categorized by their weights and their specific properties. And what we've attempted to do with exercise or with therapeutic interventions is to do something very similar. So we have this categorized in the blue boxes across the top as categories for load. AM stands for acute management, obviously the things that we could apply Uh, to an acute injury or a— an exacerbated injury. Uh, then as we move from left to right, we can move into foundational kinematics, which means exercises or treatments that would help to promote mobility, motor control to help promote stability. And then as we move further to the right, functional, uh, integration, which means we work on strength and general preparedness, progressive kinematics, and then— Finally, working on building capacity at its highest level. So what we've done is basically categorized these treatments, and again, these are kind of arbitrary numbers, but we're trying to get a point across here that in your acute management, you can offer things such as education, taping, lasering, perhaps doing some nerve flossing, vibration, or compression— or rather percussion. And eventually it's going to become necessary to increase the load. So our first category starts with education at number 1. There's no stressful or physical load to the body, but it's still a necessary component of the acute management spectrum. And then as we move through whatever our acute treatments are, it's going to become necessary to move over to treatments or interventions that start to focus on mobility. So we could do myofascial decompression. Acoustic wave therapy, joint mobilization. Again, the numbers that we've assigned to them are arbitrary. They're numbers that we feel provide some sort of stress to the body. And the idea that is, we— if we move from 9 down to 15, it becomes an increasing amount of load or stress to the body. So what we're seeing here is an overload or a progression of treatments that start with acute management and work all the way through the factor concepts to improving a person's performance. So the treatments or the interventions in yellow would be things theoretically covered in a factor course. The interventions in the white column would be those that are discussed in a new course that we have coming out called Rehab to Fitness. So for those practitioners that are interested in taking their skill level above and beyond just providing therapeutic rehabilitation, and then actually want to get into more advanced exercise prescription, Rehab to Fitness will cover the interventions that we have listed here on the white. But what we're really trying to get across here is the importance of progressive overload. It is our opinion that many therapists and many chiropractors, um, caregivers do not provide enough in the way of progressive overload and therefore don't help to have patients build the necessary capacity to, one, prevent future injury, but also, two, to allow them to improve their performance above and beyond what they had prior to their injury. So a few minutes ago, I discussed that FACTOR is not a technique course. However, it is important to restate here that there are a lot of techniques that fit or treatments that fit within the factor concepts. I think one of the most valuable parts about our concepts are people with varying backgrounds and varying experiences and varying education can benefit from using the factor concepts. So as you can see here, this is by no means an exhaustive list, but there are a lot of different techniques and treatments that do fit within the FACTOR protocol. So those of you that are trained in cupping, we will cover this in class, but those of you who are trained in cupping, cupping fits in here. Obviously ISTM fits in here. DNS, for those of you that are DNS practitioners, DNS actually fits into the FACTOR concepts. Things like laser or even blood flow restriction, shockwave therapy, all fit into the FACTOR concepts. So again, the value here is that if you are trained in a specific style of rehabilitation, it fits within the factor concepts, again, trying to progress someone through load management or progressive overload. So how do we get through the factor concepts? So we've covered them first: static, motion, resistance, function, and finally performance. And again, the idea behind each of those concepts is something would be wrong with a patient In that particular concept. So maybe they have a problem statically, or they have a problem with a specific motion, or they have a problem with resistance when they're doing exercise. The key here is a proper assessment, finding out why they have those problems in the first place, getting to know and understand who your patient is. As I said earlier, we are treating people, we're not treating conditions. We're treating a person with something going on, and therefore getting to know who they are is absolutely crucial. So doing a good history, doing a great evaluation, having a conversation with your patient, learning who they are, learning what their goals are, is going to be paramount to putting, putting together a great treatment program. It is important to recognize, though, that it's not always necessary to start with the static concept. Many of us have treated patients where they only started to experience pain when they moved something, or they only started to experience pain when they gave it a little bit of resistance. So we could start at a different concept and work from there based upon how that patient shows up in our office. We progress once we have normalized pain or function. So if you begun a patient in the motion concept, they had pain with raising their arm over their head, but you were able to change that pain or reduce it to the point where you felt comfortable progressing them, then that's what you, you would move them on to the resistance concept. So you would move from motion to resistance once you changed the pain and/or the function of that shoulder in this instance. We would regress a patient if we're creating more problems, if we're creating more dysfunction, if we're creating more pain. Sometimes this is a little bit difficult to pick out because it's not always clearly obvious if you've created more pain. Sometimes, obviously, a patient will tell you that they're having more pain than when they first started. But again, this is where having open conversations and educating your patient about what they should be expecting is crucial to their overall outcomes. You should never try to progress through all of the concepts in the same visit. As you can see, you will see here coming up in a little while, that progressing a patient through is going to be based entirely upon where they're at in the healing process. And it would be foolish to suggest that you could progress a patient in one visit through the static part of the protocol all the way up through function. So what you may find is that you have to treat a patient statically, meaning on the table, doing some dry needling or doing some joint manipulation. Whatever the case may be, you may have to do those things for a couple of visits because of their overall health status or their injury status. But eventually you'll want to get to a point where you're starting to move them, where you're focusing on mobility. And then again, eventually you're going to want to Get to a point where you're starting to give them some resistance or some external load. So each one of those may represent a couple of visits with you for that patient. And again, one more time, you're treating a person, you're not necessarily treating a condition. I think it is really important to discuss what pain is. I think everybody has an idea about what it is, but if never really stopped to consider the components of what goes into pain. Well, if you look at the definition of it, it's an unpleasant sensory or emotional experience associated with or resembling actual or potential tissue damage. There's a lot to unpack with that, that definition. don't really take into account the emotional component of pain, meaning how it makes the patient feel, but also the things that may drive a patient's pain that are emotional— old memories, old sounds, old smells. Yes, it can get that complicated when it comes to trying to sort out a patient's pain. Now, the other thing we need to unpack there, and this is going to be something we'll take some time with, is Is it actual tissue damage? Is it perceived tissue damage? Or we could also replace tissue damage with threat. Is there an actual threat, meaning there is imminent harm coming, or is the patient just perceiving that there is harm and therefore they're getting pain associated with that perception? It is a very personal experience influenced by the BPS factors. Now, BPS, we're going to discuss here in a minute, stands for biopsychosocial. So a person's experience with pain is going to be driven by biology, it's going to be driven by their psychological status, but then also social characteristics of their life. This will be another concept that we discuss quite heavily: pain and nociception are not the same thing. Pain is an output of the brain, and oftentimes that gets misconstrued as pain is in our head. No, pain is an output that comes from information sent to the brain via nociceptors and various parts of the nervous system. It's actually a complicated process that I'm oversimplifying a bit here, but nociception is the information that is sent to the brain. The brain, once that information is received, then bounces it around various places in the brain to attach Emotions to it, to attach experience to it, so that the body has a point of reference, the brain has a point of reference, both now and in the future. Now, the problem with this is that oftentimes the brain can misconstrue what is actually happening. So this goes back to the original definition: is this a perceived threat, or is this an actual threat? And is the brain interpreting this in a way that is useful to us and gives us useful information about whether or not we are in imminent danger or if this is just a loop that is creating pain but there's no actual threat. A patient's report of pain should be respected. Very early on in my career, I didn't take a patient's pain complaint as serious if I couldn't validate why that patient was having pain in the first place. That didn't mean that the patient wasn't in pain. It just meant that I did a poor job of trying to figure out why that patient was in pain in the first place. Oftentimes, I tried to ascribe a patient's pain to something that was biological, meaning there was some physical evidence of why a person was in pain, when now we know that that's just not the case, that there are many other components that go into a patient's pain, again, including that emotional response. Pain can affect function. Obviously, this will change the way that a person interacts with the world socially as well as psychologically. The verbal description is only one way to express pain. Again, that's why it's important to watch the way that your, your patient moves through your clinic, the way that they sit down, the way that they stand up, the way that they walk. There are going to be things that will give you context clues about why a person is in pain. And it's not just about the way they discuss their pain, it's the little what I call metacommunications. It's the little intangible ways that they say something. They'll give you clues about what's going on with them. Maybe it's the tone of their voice, maybe it's a sense of sadness. So you'll be able to pick up things as you discuss with the patient what is going on with them. There's a great book that helps to educate patients as well as clinicians what pain is. It's called Explain Pain by Lorimer Moseley and David Butler. I highly recommend picking that book up if you have not had experience with it. It's a great and very, actually very comical read. I think you guys will enjoy it, but definitely recommend the book Explain Pain. Pain, if you're looking for a better way to help patients understand what pain is and maybe even give yourself a little bit of clarity on how to discuss it with patients. So let's talk about a little bit of pain science here. I mentioned a moment ago the BPS model, or the biopsychosocial model. This was introduced by Engel and Romano back in the '70s. It's a concept that has actually been around for a much longer time than the '70s, but they were the first ones to kind of sort it out and formalize it. Basically, they postulated that there's a complex interaction between the biological, psychological, and social factors of a patient's condition. So there are basically 3 components that we can and should be taking into consideration when discussing a patient's pain. It is very individualized to each person. And these components were never really meant to be taken in isolation, meaning they play off of each other. If you can assume for a moment that a patient with an acute injury— maybe they were in a car accident and injured their neck— well, there may be a very high biological component to their pain at first, meaning they sprained a joint, or maybe they had a muscle strain, or they've irritated some nerves. There's a biological reason for their pain. But at the same time, there may be a Psychological reason to it as well. I mean, that's a very stressful event when somebody gets into a car accident. So perhaps their autonomic nervous system has, has elevated to some degree. Their sympathetic nervous system has now engaged and hasn't quite come down yet. And then there's the social aspect of that car accident. Maybe they're worried about how are they going to get their car fixed? Are they going to be able to go to work? Do they have the resources, the money to actually even rehabilitate themselves through that specific accident? So there are a lot of things that play into it, but over the course of time, using the car accident as the example, the biological components of that accident should start to go away, meaning eventually the ligaments will heal, eventually the strain will heal. Eventually, the nervous system should start to calm down, but there may be a shift away from the biological component to the psychological component, meaning the person now has anxiety about driving their car, and maybe that's creating more pain for them. So you can see that there's a shift between the biological, the psychological, and the social aspects. Um, of a person's pain. So they were never meant to be isolated. They're also never meant to be static. So there's going to be some movement between them. And again, it's my opinion that many practitioners only focus on the biological components, and that's okay, but we can't disregard the fact that there's a psychological component to a person's pain and that there's a social component to a person's pain. the people that they're around, their support system. Well, so how does this apply to the factor concepts? Well, we have to identify where that pain is actually coming from. Oftentimes I'll refer to this as victims and villains. The victim is the, the part of the body that hurts, the area or the anatomy that a patient is complaining about as being painful. And the villain is the actual pain driver. And as we just discussed, Well, that could be a biological reason, it could be a psychological reason, and it could be a social reason. And your job as the practitioner is to identify what that is. Now, that doesn't necessarily mean that you're going to be the one to fix all of those problems, but it is your job to at least recognize it and then educate the patient about what their options are in regards to those pain drivers. So where it fits in with the FACTOR protocol, we were— we are going to focus primarily on the biological adaptation, meaning the biological parts of a person's injury. But again, that does not mean that we don't have the obligation to identify when there's a psychological aspect to their pain or a social aspect to their pain. So we're going to discuss how FACTOR affects the nervous system, the musculoskeletal system, and even To some degree, the cardiovascular system. But we also need to be able to identify a patient's psychological components. What are their beliefs about their pain? What are their beliefs about their ability to overcome their injury? These are all very important aspects to a patient's outcomes. Are they experiencing fear avoidance? Are they going to want to exercise, or is their pain becoming a limiting factor to their ability to move? Are they experiencing depression and anxiety? These are things that can be identified through outcomes assessment tools. There's one in particular that I like to use with patients called the Yellow Flag Questionnaire, but there are a wide variety of outcomes assessment tools that can be used to help identify psychological drivers. And again, we can't leave the social constructs out. What, what is a patient's access to care? I think ideally we all have an idea about how many times we would like to see see a patient, whether that's several times a week or one time a week. Sometimes patients can't afford our recommendations for their patient care, and therefore we have to find a way to meet them in the middle based upon perhaps their financial capabilities. We also have to take into consideration their interpersonal relationships. Is a job stressing them out? Is Is school stressing them out? Do they have family problems? Have they recently experienced a divorce or loss of a family member that could be creating emotional strain as well? So again, all of these things need to be taken into consideration. However, what we will do with the FACTOR course is primarily focus on the biological aspects, because for most of us, that is our scope of practice. So within the FACTOR concepts, we have some specific things that we like to focus on here. Obviously, the patient. forthcoming and forthright about. We're really focused on the patient. Who are they? Getting to know them. We're also going to be focusing on the site of pain. Okay, if it's the knee that hurts, we're going to focus on treatment that revolves around the knee. But we also need to take into consideration how that knee pain, in this instance with this picture, could affect the person's low back. Could it affect Their shoulder, specifically if they're a throwing athlete, is their inability to move through a specific range of motion without pain, forcing them to move their trunk or their shoulder in a way that now creates a problem and potential injury for that other specific body part. Again, taking this picture into consideration, oftentimes people that have knee pain, we will find through examination, have a limitation in The range of motion in their hips, or perhaps as a throwing athlete, restriction in range of motion of the thoracic spine that again will force them to have to use other body parts disproportionately, such as the shoulder. And then finally, we're going to look for loss of function, and this could be weakness. Do they have weakness in their core? Do they have weakness in their feet? Again, all of these things we're referencing in relationship to this picture because it's a little bit easier to visualize how a throwing athlete that has weakness in their feet or in their legs may have to try to reproduce power or develop power in some other part of the body, and that's not necessarily the most appropriate way to go about trying to throw an implement. So as a quick review there, we want to get to know who the patient is. We're also going to focus on where they're saying their body hurts. We're going to look for loss of range of motion, and we're also going to focus on a loss of function. All of these things are fairly easily identified through an assessment, which is why in a course we go through very in-depth assessments so that we can get down to the bottom of who a patient is, where does it hurt, what stuff isn't moving like it's supposed to, and what's not functioning quite like it's supposed to.

Okay guys, so what you heard today is the blueprint, the progression model, the logic behind moving a patient from static through motion resistance to function, and then forward, progressing them into performance. But in part 2, we're going to go under the hood. We'll introduce the concept of rehab existing on a continuum and why progressive overload is a non-negotiable. We'll talk about how fascia and musculoskeletal systems actually adapt to load. And we'll talk about the nervous system response, such as afferentation, neuroplasticity, and pain gating, and what that means in real clinical practice. Part 1 today was the framework. Part 2 is the physiology. And if you want to understand not just what FACTOR does, but why it works, You won't want to miss it. Be sure to hit the subscribe button to be notified when the next episode is released in 2 weeks, and we'll see you in part 2. Hey guys, if you like what you heard today, I encourage you to visit our website at factor-store.com. That's spelled F-A-K-T-R-store.com to find out more information about all that we have to offer. We have a variety of online offerings as well as our hands-on FACTOR Rehab System course scheduled in cities around the globe. Be sure to also check out our event calendar and bookmark any of these upcoming live webinar dates coming up in the near future so you can join us live. And of course, the biggest compliment we can receive is for you to help us spread the word to your friends, colleagues, and classmates. You'll find all the important links as well as info about our sponsors in the show notes, so be sure to check those out.