#123 - Pain, Plasticity & Performance: How Rehab Actually Works with Dr. Todd Riddle, Part 2

Our body is literally hardwired to want to regenerate under load. So that's why this is really important.

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 are in the right place, my friend. Let's dive in. Welcome back to The Factor Podcast. I'm your host, Jessica Riddle. Welcome and thanks for listening. Today's episode is part 2 of our 2-part series, Pulling Back the Curtain on the Factor Rehab System. In part 1, our Director of Education, Dr. Todd Riddle, made the case that progressive overload is the missing link in rehab. Not more tools, not more techniques, but better progression and better load management. Today, we go from framework to mechanism. This episode is titled Pain, Plasticity, and Performance: How Rehab Actually Works, because we're answering the real question: what's changing inside the body when rehab is done well? You're going to hear 2 main sections: First, Dr. Riddle will break down tissue healing phases and how they map to what we should actually do clinically— calm it down, make it move, make it strong— and talk about why models like peace and love fit the progression conversation. Then, we'll shift into fascia— why it matters, how it affects movement and sensation, and why densification is often a better term to use than adhesions. After a quick break, we'll slightly shift course and move into the nervous system and discuss afferentation, pain gating, neurogenic inflammation, cortical maps, and talk about how novel repeatable stimulus drives neuroplastic change. This episode is dense in the best possible way. If you're listening while doing something else, you might want to listen more than once And be sure to bookmark this one to take notes later. Here's Dr.

Riddle. This is a model of the inflammatory cycle. And as you can see there, we have our hemostasis, which is going to be the very first seconds of an injury, the internal components Of the injury. Maybe there's some capillary breakage and we get some bleeding into a specific area that's going to cause swelling and eventually will end up causing pain. Well, after a couple of hours, we enter into the actual inflammatory or the acute phase of an injury. Again, this could be going on for days or weeks. In this phase, our job is to calm it down. Many of you have probably heard that before. When we're in the acute phase, phase, or maybe even in the exacerbation phase of an injury, our job there is to calm it down. For FACTOR purposes, this would be the static phase. As they transition through the acute phase and into the proliferative phase, or what we could call the subacute phase, our job here is to make it move. So our focus is going to be on mobility. So if you'll recall back to the FACTOR rehab continuum, we talked about mobility being a very important component of the overload process. So we go from calming it down and protecting it to making it move. And then as they progress through that subacute phase into the chronic phase of their injury, this is where we see a lot of soft tissue remodeling and the maturation of the collagen that has been laid down. Our job there is to try to make it as strong as possible. So we have some very distinct goals within these phases that are actually going to help to drive our care. Now, to further help us there, there's a new acronym that hopefully many of you are familiar with. We've kind of left behind the whole RICE acronym, rest, ice, compress, elevate, even though it is, there are some components of it within this new model. I like this one a lot because it's actually a model that tells us how to deal with the acute components of an injury, but then also gives us suggestions about how to rehabilitate that injury. And it's called Peace and Love. And as you can see here, some of the components look very familiar. We want to protect the injured body part. We want to elevate the injured body part, but where this really grinds people's gears, so to speak, Is the avoiding the anti-inflammatories. It's been very popular in the past for people to want to pop an ibuprofen or take some kind of corticosteroid in order to stop the inflammatory process. But as we just discussed here a moment ago, we have to go through the inflammatory process in order to expedite healing. So taking a medication or having some kind of external intervention that slows inflammation Actually slows down the healing process, and that's not necessarily a great thing. So the recommendation would be to avoid anti-inflammatories, and this does include ice in many circumstances. We want to compress the injury and we want to educate the patient about their injury. What should they be expecting as far as the healing process of their injury? So, PEACE: protect, elevate, avoid anti-inflammatories, compression, and elevation. To rehab the injury, we want to give it some love. So we want to load it. And I love the fact that we're now starting to see load as a component of the rehabilitation process. We want to provide optimism. And again, that's just more education, give them some hope that things are going to get better. You can discuss ways that they can help to improve their self-efficacy and, and Give them some insight about goal setting and things of that nature here. Vascularization. So we want to be providing treatments that help promote blood flow into that area and exercise. So we want to start potentially with static care, but again, we should be progressing away from that the moment that the patient can tolerate some motion as part of their care plan. So initially we want to do some static care and then by the end of that acute phase, start to work in some motion. The mantra in my own personal practice is if a patient was able to walk or move in under their own power into my office, then we're going to be doing some kind of rehabilitative movement or motion during that particular visit. When we move into the subacute phase, again, we want to be firmly into working on motion and mobility, but also want to start to incorporate a little bit of range, rather some resistance work as well. So other treatments that we could be considering, some heat, myofascial release, instrument-assisted, again, compression, blood flow restriction training, all things that would be appropriate in the subacute or in the proliferative phase. And then finally, to help to remodel that collagen, the new collagen that has been laid down after an injury, we want to give it resistance and then start to work more on functional movement with that patient. And then eventually try to graduate them into More of a performance-based post-rehabilitation program. Maybe that's discussing the possibility of them hiring a personal trainer, or if you are a clinic owner that also has a gym as part of your clinic, then discuss with them the options of continuing exercise programs with you in your clinic gym. Now we're going to kind of transition some of our conversation over towards, I think, one of the most important components of the musculoskeletal system. And that is fascia. And why I think that's important is fascia was a highly disregarded organ within the body. For those of us that were fortunate enough to do any kind of gross anatomy dissection within the last 30 years or so, a lot of times we just cut through the fascia and entirely disregarded what the structures were or what its actual function was. And Now, as time goes on, we're starting to learn that fascia is immensely important to the function of our body because of its, its integration of both the collagenous connective tissue that it is, but also it is deeply innervated with nerves as well as highly vascularized with blood flow. So it's an incredibly important part of Our structure and the function of our body. And I really like this quote here because it kind of reinforces what we're talking about with factor, that structural disorders of the fascia can surely distort the information sent by spindles or muscle spindles to the CNS, and thus can interfere with proper coordinated movement. So when our fascia isn't gliding like it's supposed to, when it's dysfunctional, We send bad information to the nervous system, and therefore the output is going to be bad movement, or in some instances can be pain. So by trying to normalize the movement and the function of fascia, we can actually provide stimulus that is going to provide the brain with better information so that the output could also be better. We also discussed this within our peripheral nerve entrapment course. But this is where we would consider providing some sort of superficial treatment for soft tissue purposes. The whole idea would be that we could provide pain relief, affermentation, so giving good information back into the nervous system, or potentially even to work on scars at the superficial level. When we're trying to focus our attention and our treatment into the deep fascia, Obviously, we're going to have to press much further into the tissue, which can be quite uncomfortable for patients. So with Vector, what we recommend is adding movement into that pressure. Therefore, the pressure doesn't need to be nearly as much. Also, you're getting down into that deeper fascia by forcing it to move over the structures that it is encasing. Where we would consider using this, well, obviously it's going to be more with chronic injuries. We don't want to push deeply and hard necessarily. Into an acute injury. So we would, we would save our deep fascia treatments more for that late subacute or even the chronic phase of care. Why would we want to do this? Well, we're trying to affect motor control. We're trying to provide functional improvements of that tissue. It also helps to provide fibroblastic proliferation. So if you remember from histology, fibroblasts are what create collagen. So by putting pressure and movement or load into tissue, We are stimulating the production of collagen and the laying down of new tissue. Our body is literally hardwired to want to regenerate under load. So that's why this is really important. External tension could be massage. External tension could be soft tissue manipulation with an instrument. It could be shockwave therapy. So it's anything that puts stress into the body. Again, remember what we talked about with the factor rehab continuum. So as it turns out, this external stress or load has a significant physiological response within the fascia itself, more specifically with the water that is associated with fascia. And there are 2 types of water, bound water, which is a good kind of water, and bulk water, which is the water that fascia just kind of sits in. And I like to use a bucket and wringing out a sponge as our analogy here. The sponge is the fascia and the water inside of the sponge is the bound water. This is the good water. This is the water that we clean with. This is the water that promotes cleanliness. The bulk water is the bucket water. It's the water that the sponge would sit in. It's also kind of the dirty water, so to speak. So we want to encourage bound water and the exchange of bound water, and we want to discourage bulk water, which basically means the fascia has become stagnant and not really moving. And it's getting an accumulation of metabolites and water that isn't really useful to the gliding of fascial surfaces. And the way that we promote more bound water and less bulk water is external load. Again, it could be all of those treatments that we just discussed, but primarily it's going to be through movement. So we can Help to promote the exchange of good water, that bound water, through movement and external load. This also stimulates the release of hyaluronan, which oddly enough is still very hydrophilic, which means it likes to have water attached to it. It's that bound water. Hyaluronan, if you're not familiar with that, is basically the WD-40 of fascial surfaces. It is promoted and released by something called a fasciocyte. And yes, When we provide external load, when we provide external stimulation, fascia sites produce hyaluronan. So again, I've said this several times. Our body is hardwired for movement. When it moves, it regenerates, fascia glides better, and everything just seems to work better. Now there's a term that I want to introduce to you to hopefully replace a term that we probably need to go ahead and let go of. And that's Densification, densification being the word that we should be trying to use more. It was a term that was coined by the Steckos, Antonio and Carla Stecco, who I previously mentioned. And basically densification is tissue that has become dehydrated, going back to the water analogy here, and just doesn't glide quite like it's supposed to. It becomes viscous. The hyaluronan becomes viscous in that area. And we get an accumulation of bulk water. We're not getting an exchange of water and we're just not moving well in that particular tissue. We call that densification. This is a more appropriate term than, say, adhesions. Again, the idea behind adhesion would be that we have tissue that has somehow become connected or stuck to itself. And quite frankly, there's really no scientific evidence in the literature to suggest that adhesions actually even exist. So, I prefer to use the term densification because it is a more accurate description of what is actually going on there. But when we also try to describe to a patient what we're attempting to do with our soft tissue treatments, we can describe it in terms of trying to promote glide and removing densified tissue, removing the compaction of that tissue, if we will, to try to get more water and better exchange of ions and other healing nutrients into that tissue. Densification is the term that I use with patients now, and hopefully you will adapt to that as well. Because again, I am a big fan of using words that actually describe what we're doing as opposed to words such as adhesion that theoretically don't even exist. And also use terms such as breaking apart adhesions, which I think can have a negative effect on a patient's beliefs about pain and what we're actually doing for them. So Highly recommend the use of densification as opposed to the use of adhesions. Well, fascia also has a very important component to it in that it creates tensegrity within the body. Now, probably have heard this term. If not, it's basically a series of continuous tension-resistant components, and that's the fascia, as well as a discontinuous series of compression-resistant components, and that's the bones. Basically what we're Doing here is tying together the fascial system with our skeletal system. And obviously that's going to be how it moves. When these 2 things work together, the fascia with the skeletal system, it allows our body to stabilize mechanically by balancing the compression with continuous tension. So what it basically means is when our fascial structures are working at their most efficient and optimal, We move better.

A quick pause before we shift from fascia and tissue mechanics into the nervous system. Up to this point, you've heard the hardware side of rehab: healing phases, remodeling, collagen, glide, and how load changes tissue behavior. Next, we're going to move into the software side of things: how sensory input changes perception, how pain gating works, how neurogenic inflammation can drive symptoms, and why better afferentation can improve movement and motor control. If part 1 of today was the blueprint, this next section is the wiring. We'll be right back.

Arguably, I think one of the most important parts of what we are affecting with our treatments, not to downplay what we are getting from fascia with the skeletal system, But neurology is a significant driver of how we function in our environment. Specifically, when we talk about the sensory input that we are providing through the factor concepts. Again, most of what the treatments are supposed to be doing, whether it's the soft tissue work or the movement, is going to be providing information externally into the central nervous system so that it can be interpreted by the brain. The better the quality of the movement, the better the quality of the treatment, the better the information is going to the brain, the better the interpretation is going to be. So we are going to create change to a patient by improving their perception. So the use of manual therapy or movement or tape or any one of a variety of interventions, again, that's not— this is why FACTOR is not a technique course. You can use so many different things. It's about whatever you have to affect a person, in this instance, their nervous system externally through the peripheral nervous system, and then eventually into the central nervous system. We call this afferentation or exteroception. So the things that we do from the outside of the body create an input, a stimulus that is driven to, through the peripheral nervous system into the central nervous system for processing and for Uh, interpretation. This also helps to improve proprioception, which, as we know, helps to improve movement and helps for us to interact with our environment better. It also helps to improve neuroplasticity, which is basically our bodies, or rather our brain's ability to learn and grow and reshape and remodel itself. This is incredibly important, uh, and it's actually fairly simple. From a theoretical standpoint to improve. We can do this through novel stimuli, novel stimuli being novel movements, different movements than what a patient is used to, safe movements that a patient is not used to doing. It is my belief and opinion that I think a lot of our injuries that patients experience come from them attempting to do things that they weren't previously exposed to. They weren't putting in enough novel movement. And therefore, uh, the neuroplasticity of their brain was relatively low. And that's actually fairly easy to defend because neuroplasticity is heavily tied into load management. The more neuroplasticity, the more learning that our brain does, the better it's going to be at adapting motor control to take on a variety of different movements. And as we just discussed earlier, Injury happens when a patient cannot, cannot manage load well. So by improving neuroplasticity and putting in novel movements, we can help to improve a patient's load management capabilities. On the flip side of that, if we don't do enough of this stuff, we see a loss of proprioception. We see a loss of internal awareness or interoception, which can lead to pain. So These external stimuli, whether it be the treatments or the movements, help us to rewire and remap the brain. Other things that we're doing through the FACTOR treatments obviously is to calm down the nervous system. Pain is a result of an angry or threatened nervous system, as we've discussed previously. So by stimulating mechanoreceptors that trigger the CNS, We can change perception. So by triggering alpha, A-alpha and A-beta mechanoreceptors, we can actually use those to downgrade or shut down nociceptors. Many of us would describe this as pain gating, as discussed with, or by Melzack and Wall. So we've got a lot of different treatments that can help to stimulate this pain-relieving effect. And again, I don't want to use pain as Synonymous with nociception, because remember, pain is an output, but we've got to affect the information as it's going into the central nervous system. So external treatments such as ice or stim or vibration guns, you name it, there's so many different ways that we can stimulate mechanoreceptors to kind of dampen the noise that nociceptors are creating. And therefore we can change a patient's pain perception. By utilizing neurology of the body. Another important topic that we do need to discuss that I think oftentimes is overlooked in many treatment programs is neurogenic inflammation or the inflammatory components of our nervous system. It is inflammation from the local release of inflammatory mediators of afferent neurons. So the neurons going into the central nervous system do have the capability of generating inflammation. Things such as substance P, CGRP, or calcitonin gene-related peptide, neurokinin. Again, there's so many different neuroinflammatory mediators, but they induce the release of histamine from adjacent mast cells. So this is where we start to see the pain and the inflammation and the swelling. To the affected area. This can assist in the restoration of axoplasmic flow that did or can reduce distal hypersensitivity. So by normalizing nerve flow, we can actually help to reduce hypersensitivity. And this is very evident when we discussed or will discuss in class Maine syndrome, which is basically an entrapment of the Superior cluneal nerve, or when we talk about SI joint dysfunction or apparent SI joint dysfunction, I would postulate that oftentimes it is an entrapment of the middle cluneal nerve that has become inflamed and looks very similar to an SI joint dysfunction. Again, all things that we talk about in class. But through our neuro, rather through our manual therapy, we can help to mobilize entrapped nerves. Again, something that we cover in our Factor peripheral nerve entrapment course. And obviously the goal here would be to help to reduce pain by reducing that inflammation. By providing these treatments, we can also help to affect motor control because neurons also, we have a bunch of neurons that respond to mechanical loading. These would be our Golgi tendon organs, which measure tension, muscle spindles that measure tension, our Pacini corpuscles that measure vibration. Again, we have a lot of different neurons that Respond to mechanical tension. Well, why are these things important? Well, we discussed it earlier. These things feed into our nervous system and give information about our body in the environment. Stimulation of them, or a lack of stimulation of them, can result in a change of our overall tone. So these sensory afferents in soft tissue connect to our gamma motor system. And if you'll recall, The gamma motor system is what sets the overall tone and tension of our body. So feedback to muscle spindles, they help to set reaction time. These muscle spindles help to set reaction time. So if we have too much feed into the muscle spindles, we tend to be hyperreflexive or hyperreactive. And if we don't have enough, we tend to be hypotonic and slow. So when we give affrontation, somatic affrontation, we can help to affect the overall tone of that gamma motor system by stimulating all of the neurons that we just discussed there. So spindles can provide better information about tension. Alpha motor neurons can then provide precise innervation for proper contractions. With better contractions, we have more opportunity for changing And optimizing movement. It's really kind of a neat concept if you stop to conceptualize how we can change a person's ability to sense the environment and change their ability to move through the environment through external stimulation. Another important concept here, these ideas of cortical maps and how these cortical maps can be smudged, a concept that's actually been quite around for quite a while. But taking into consideration these cortical maps, they help us to sense and act through the physical world because of our ability to take in information about what's going on around us. These flexible brain maps or the homunculus actually help us to interact with the world. But what happens when these maps become smudged, meaning the overlap of these barriers or these boundaries, we lose a sense of our body of itself and in how it interacts in space. So altered motor cortical organization, which is characterized by the number of discrete peaks and map volume. So the changing of cortical activation and organization was associated with severity and location of back pain. And all cortical smudging is, is oversimplified. It's basically a loss of sensation. It's a loss of The body's sense, the exteroception and interoception. And when we lose that, we can see significant increases in pain. So again, all of the things that we're trying to do with Factor through all of these treatments, through all of this movement, is trying to change the way that our central nervous system and our brain experiences itself in an environment. And I used this term earlier, neuroplasticity. Again, what we're trying to do is change the way that the brain and the spinal cord reorganizes itself. So take something that may have been dysfunctional, a smudged cortical map or an injury that has changed the way that the central nervous system is receiving information from the peripheral nervous system. We can do this through the activation of the brain through experience. A lot of times this is going to be movement. Novel, novel movements, having a patient move in a way that they're not used to moving or haven't moved because of pain. This requires a sensory stimulus or afferentation, but we can also use a bunch of different senses. So we can use sight as a way of improving neuroplasticity. We can use hearing as a way of improving neuroplasticity. We can even use cognition, quizzing someone as they're doing a movement to stimulate A variety of different senses. The key here is that the stimulus must be novel. It must be something that the patient isn't necessarily familiar with. It should be challenging and it should be repetitive, meaning they have to do this a lot and it should be a pretty fair challenge to them. New exercises that are different than the one that the patient is familiar with and are challenging are going to be the best way to go about improving neuroplasticity. And there's some really neat research to suggest that using external timing as a superior way of helping to improve overall functionality, meaning that instead of having them count out sets and reps in their head, that you have them working out to metronome, or you have them working out to a song that has a specific beat to it, that external timing is yet another way of improving neuroplasticity.

That's it for today's episode. And if you're thinking, okay, rehab is doing a lot more than I was taught, then good. That's the point. Here's the through line: load is the language of adaptation, and the nervous system decides how that load is interpreted. In this episode, you heard how tissue healing phases should drive progression, Why fascia matters for glide, force transmission, and sensory input. And how afferentation, pain gating, and neuroplasticity shape perception, motor control, and performance. If you got value from today's episode, be sure to share it with a clinician who might be stuck in symptom-chasing mode. And if you want to learn the FACTORS system hands-on, visit the link in our show notes To join our priority waitlist and be the first to know when a regional cohort opens up in a city near you. We'll see you next time. 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.