#26 - Load Progressions and the Rehab Continuum with Dr. Tom Teter, Part 1

FAKTR, spelled F-A-K-T-R, stands for Functional and Kinetic Treatment with Rehabilitation. Over the past decade, this unique approach to treating pain and dysfunction has been utilized by healthcare providers on 6 continents. Serving as a framework that guides clinical decision-making in patient visits around the globe on a daily basis. With this podcast, our goal is simple: to bring the best and brightest in clinical education to the forefront and empower practitioners with cutting-edge, evidence-based content that improves patient outcomes and inspires healthcare providers to continually evolve their approach to treatment. In each episode, we will feature a training or interview with some of the top minds in healthcare in a short format that is easy to consume. to digest with actionable information that you can implement into practice right away. Let's get started. Hi guys, welcome to a new episode of The Factor Podcast. I'm your host, Jessica Riddle. If this is your first time tuning in, welcome and thanks for listening. Today we kick off a new training titled Load Progressions and the Rehab Continuum with Dr. Tom Teeter. The rehabilitation and training processes share similar goals during the strategic application of load to biological organisms. In this 2-part training, Dr. Teeter will discuss the principles of developing a systematic approach to bridge the gap between rehab and fitness. He'll also talk about how to create a concurrent process for rehab utilizing this systematic model. Dr. Tom Teeter is the owner of Engineering Athletes, a manual therapy and performance enhancement clinic that focuses on integrating movement-based rehab and functional performance training. With more than 15 years of experience in strength and conditioning and clinical practice, Dr. Teeter has treated and trained thousands of athletes at all levels of skill and ability. Dr. Teeter holds a bachelor's degree in exercise science from Missouri State University, as well as a doctorate of chiropractic from Cleveland Chiropractic College. With his extensive experience in rehab, Dr. Teeter holds numerous certifications within the industry that have helped him develop injury prevention training protocols, to assist his clients in reaching their peak physical potential. Dr. Teeter is also the developer of FACTORS Rehab to Fitness Course, a 25-hour virtual course offering that provides a blueprint for fitness programming that bridges this gap between where rehab ends and fitness begins. Without further ado, let's cue up the intro music and get started with today's training.

Thank you, Jessica. Welcome everyone. Today I wanted to spend a little time talking about load progressions and the rehab continuum. This is one of the many topics that we talk about in our Rehab to Fitness course, but I find it to be something, or at least a conversation that a lot of chiropractors and students really either don't necessarily understand that well or just kind of leave out of general conversations in their clinical practice. So we're going to talk a little bit about load progressions, what those are, and how they apply to the rehabilitation continuum. I, in my practice, work with a lot of athletes, and I know at least a lot of you on this webinar would like to work with athletes. And there's a lot of challenges that we find when we're trying to work with athletic populations, whether that's not having an integrated support team or having silos of different types of practitioners that aren't working together. But there are many, many challenges when you're working with high-level athletes and athletic populations. The hardest thing when we're working with athletes is to get our athletes back to full function in the shortest amount of time possible. If you're working particularly with high-level athletics, sometimes there's a timetable when you have to get them back. And so there's a lot of stress on getting them back to full function as quickly as possible. So some of the current challenges we see in sports medicine, and these are 2 of the big ones that I tend to see over and over, is that typically clinicians only treat the side of the patient's pain. And clinicians usually release the patient from care way too quickly. And we're going to touch on each of those as we go through the presentation. We really need to shift our focus. And where a lot of times people will only treat the site of the patient's pain— a patient says their knee hurts, that's where they're going to receive treatment— we need to shift our focus to, instead of treating pain, to restoring function. The end goal of any rehab program should be to optimize the individual's ability to move and control their own body weight through fundamental movement patterns and to produce force during their chosen activity. Arriving at the end of rehabilitation as accomplished by restoring the individual's ability to control basic movement patterns with the right amount of force at the right velocity for the appropriate duration. Now, I would say this not only applies to athletic population but the general population, people that come into your office. I think unfortunately, because chiropractic has historically been a pain-based model, that when the patient's pain is gone, that's when they typically get released from care. And they may not be back to their full function, which we will touch on later. And because of that, they're not aptly prepared to go back to their individual sports appropriately. So we need to shift our focus from treating pain to restoring function. And what we can see in this diagram is as we see function improve, pain inherently in most cases will decrease. But it's not necessarily true in the converse, whereas if we only treat pain, that doesn't necessarily mean that we're restoring function. So if we appropriately restore the patient's function, we can effectively start to decrease their pain. So we need to have a shift in our focus from treating pain to restoring function. The other thing we tend to see in athletics is there's a big gap between what we would classify as sports medicine and sports performance. Or if you look at this diagram, on the left, you're going to see what's the rehab professional, and on the right, you're going to see is what's the fitness professional. On the left, we're treating pain and we're using rehab to hopefully restore function. And on the right, it's strength conditioning and maximizing performance. But in most models, in most academic settings, whether it's at a university or a professional team, there's usually a gap between those 2 professions. And because of that, patients aren't always restored to their normal function effectively and quickly, and they end up potentially having the opportunity to get reinjured. So that's what we're trying to avoid. So if we do our job right, there is no gap between rehab and fitness or rehab and training, hence why we have the name of our course, Rehab to Fitness. I like this quote, the principles of rehabilitation and training are the same. The only difference is the starting point. And the principles that we use for rehab and the principle we use for training are exactly the same. We have the principles of specificity, overload, and progression. Specificity. Are we using the right intervention on the right person at the right time? Are we being very specific? about what we're trying to accomplish. Overload is just making sure that we're using greater and greater intensity each subsequent time we come back to this intervention to achieve the optimal outcome that we're looking for. And progression is intensity must become progressive every time in order for greater improvements to occur. Now, if we look at these principles of specificity, overload, and progression, these apply not only to things we do in rehabilitation, but also what we do in training. So there really is no— very little difference in the concepts of Rehabilitation and training, the only difference is truly the starting point. And this is another quote that I find to be very appropriate for our conversation. Rehab and training are a concurrent process if you have the appropriate model. What I find for most clinicians that I speak to, even clinicians who are working in multidisciplinary environments, is they don't necessarily have the appropriate systematic model. And so rehab and training aren't happening concurrently. What ends up happening is you have someone that goes through rehab and then is done, and then training picks up. But if you have the appropriate model, both of those things can happen simultaneously, and that's where you have the opportunity to get people back to function quicker than if they were happened separately on their own. So if we are going to try to do our best to improve people's function, we have to have a very specific rehabilitation process And the 3 things that I've identified that we use in our process is having a continuum of care, having a clinical audit process, and having specific load progressions. If we look at this idea of continuum of care, continuum of care is, if we just think of a line going across a page, on the left we have what we would classify as sports medicine. Sports medicine is typically treating pain and it's clinical management, but we're using rehabilitation to restore function. So people are coming in in pain, We are using rehab or therapy to restore their function. We're using low threshold inputs, usually through neurological stimulation, to improve movement competency and to get them back to baseline. They're in a hole and we're trying to get them back to normal. Now, once they're at normal, if we keep going along that continuum, we're going to go to the right side of this continuum of care, which is performance enhancement or sports performance. This is typically where we're doing things which we would classify as fitness, To improve function. We've— in rehab, we've taken you out of the hole back to normal. And in fitness, we're trying to improve the function that we've just gained for you. So we're using high threshold outputs and usually gaining towards increasing physiological adaptation. And we're trying to improve fitness capacity. So again, this is all a continuum of care along a spectrum or a line. So we need to have at least both elements in our practices in order to effectively work with athletic populations. Now, if we look at this diagram here, they're talking about the rehab spectrum, but I like this because it's describing that continuum or line that we discussed. But on the left side is our sports medicine things. We're trying to protect you from things that are either going to be painful or loads that are not tolerable. So you're going to use things like manual therapy, education, low intensity or low volume, low threshold inputs to either work around the pain Or get them back to equilibrium. And then on the right, we're trying to expose them to load. We actually want to use higher volume intensity of training and load to actually give them the opportunity to adapt through physiological adaptation, but that takes time. So if you look at the spectrum, we want— in rehab, we're trying to protect people from things that might be harmful while we're restoring function. And in fitness, we're trying to expose them to load to create long-term physiological adaptation. So the next thing you need outside of a continuum of care is a clinical audit process. And the clinical audit process that we came up with has 5 components. Now, some of these are things that you might have learned in chiropractic school. I find that there's a lot of pieces that are missing from most people's approach when they look at their audit process. So we've identified patient profile, needs analysis, patient examination, treatment plan, and activity restoration, or I like to better call it, this is your discharge criteria. And we're gonna go over these individually. So your patient profile, Is your chief complaint. You're looking at mechanism of injury, their past medical history, any primary concerns, and any activity intolerances and treatment goals. So for those of you who are in chiropractic school, this is what you're learning in taking a patient history. The main thing that we change, or that I change when I create a profile, is this idea of an activity intolerance. To me, this is the most important part of the history because what an activity intolerance is, is it's the thing that the patient can't do. But wants to do, but they can't because they're in pain or have severe dysfunction. So I need them to tell me, what is the thing that you want to do but you can't? I want to be able to run. Cool. And then we can match that to their treatment goals and say, well, how far would you like to run? I want to run a marathon. Awesome. So we can make a specific treatment goal based on their activity intolerance, and we're also going to tie their activity intolerance into the progressions that we use during rehabilitation and training. So The biggest piece that I find that people leave out of their patient profile is this idea of an activity intolerance. But our patient profile essentially just tells us who the patient is, gives us their history, and what they want to do. I want to make them tell me what it is they want to do so I know best how to use our time together.

Today's episode of The Factor Podcast is sponsored by Rehab to Fitness. Rehab to Fitness is a course for healthcare providers and fitness professionals to learn how to progress clients and patients from rehab into a functional fitness program. In this virtual course offering, Dr. Tom Teeter takes complex physiological concepts and makes them easy to implement. From the basics of fitness to advanced programming techniques, participants leave this course with a specific and practical blueprint that they can begin applying immediately in practice. The information included in this class has helped both general fitness clients and high-level athletes achieve their peak physical potential and remain injury-free. If you are truly interested in integrating fitness into your current systems, then this class is for you. To learn more about this 25-hour online course offering, visit our virtual learning platform at online.sports-seminars.com. Or visit the link in our show notes to take 10% off of your registration using promo code podcast. That's P-O-D-C-A-S-T. And be sure to visit the website at online.sports-seminars.com. Now, back to the show.

Patient profile, what the— who the patient is and what they want to do. Then we do a needs analysis, and this is the biggest piece I think that clinicians leave out when they're working with athletes. Most people jump right into— from history into examination, but I need to know the things that are in detail. What are the things you need to be able to do? If the patient profile tells us what you want to do, then I need to know what that entails. So we go into a very structured needs analysis. So we'll typically look at a sport or activity analysis, which is just the general guidelines of your sport. Like, for instance, if we use soccer, how long is a soccer match? How long is the field? What's the percentage of running? We get a very generalistic breakdown of the sport. I want to know the most common injuries. And then I also want to know what are the movement requisites, the fitness requisites, and any skill requisites you need to perform that sport for your position. And then ultimately what we do is look at any key performance indicators for your sport. What are the things that we measure success in your activity or sport? And we look at all of these things, and that tells us— our needs analysis tells us what the patient needs to be able to do. Our profile tells us what they want to do. The needs analysis tells us what they need to be able to do. Then we go into where most of us pick up, which is our patient exam. And when I do my patient exam, I'm not here to try to tell you how to do yours. I'm just telling you what I think works very well with our system and athletic populations. The first thing we do is our evaluation. And usually we're looking for mechanical sensitivity. Where does the pain exist? And we want to be very specific. So we'll use things like orthopedic testing or neurological testing. And these are all things that you would have learned in school. And then from there, once we've identified where the pain is, then we'll look for any contraindications to care. We will look for any red flags, even might start looking at yellow flags. But here's where I start looking at red flags. Is there anything that tells me that this person should not be treated? And then if there is red flags or areas of concern, let's say I test someone's ACL and I think they may have an ACL tear. If it's necessary or warranted in your clinical opinion, this is also where you might decide to refer them for special imaging or a medical referral if that's warranted. Now, if there's no contraindications or red flags, then we're going to go into our screening of breathing. I think breathing is one of the most important things we should check. I think it's what most, almost everyone that comes into our clinics are going to do poorly. And it's the thing that we do more than anything else in our lives on an every single day basis. We, we breathe up to 20,000 times a day, I thought I read somewhere. So we need to check and see if they have any abnormal breathing. If they don't, that's going to deter them from having the ability to stabilize their spine. It's going to alter leg tension relationships. It's going to increase their perception of pain. Like, these are all things that could be affected by abnormal breathing. So have a screening process for breathing. And then we're going to go into our assessment. Now, I will tell you, and I'm not afraid to say this in any capacity, is I use the SFMA. I know not everyone uses that variation of assessment, but for me, it's been the most systematic way for me to have a system of checks and balances for my work. And it works extremely well in our model. Now, I have my colleague, Dr. Riddle. He doesn't really use a lot of the SFMA per se, but we usually end up in the same spot. And that's okay. As long as you have a systematic way of assessment, I'm totally fine with whatever you use. But what we're really looking for with our assessment is painless dysfunction. Is there somewhere in the body that is not doing what it's supposed to? And this tells us why you may be having mechanical sensitivity elsewhere in the body. As an example, if you have knee pain, that might be where your mechanical sensitivity is. Maybe we have— I'm making this up, but maybe we have an MCL sprain or we have patellar tendonitis where maybe when we start doing our assessment, we determine that the reason why that's happening is because they lack ankle dorsiflexion. So So mechanical sensitivity tells us where the pain is, and the painless dysfunction tells us why. It could be somewhere completely removed from the site of pain, or it could be an adjacent joint. You'll never know. And then once we find that painless dysfunction, then we're going to break it down into local biomechanical testing. We're going to do our joint or our tissue palpation to see if those joints or tissues are moving the way we'd like them to. And then from there, we're going to come up with our diagnosis. Now, and when I create a diagnosis, I always have a structural diagnosis and a functional diagnosis. And that the structural diagnosis tells me where there's the problem, and the functional diagnosis tells me why. So that's our patient exam. And our patient exam tells us what the patient can currently do, what is their current capacity right now. And then what we try to do from what they want to do and what they can do and knowing what they need to do is come up with a plan to get them from where they start to where they need to end. And that's where our treatment interventions come in. Now, in Rehabilitation, there's some consensus that there's about 6 stages of care when you're working with athletic populations. I've identified these 2, 3, 4, 5, 6 stages, and they start with acute management into foundational kinematics, motor control, functional integration, progressive kinetics, and fundamental capacity. We're going to talk about these in detail in a second, but these are the 6 stages along that spectrum of that line we talked about that athletes need to go to To get back to full function. And then in each of these stages of care, there are interventions that you may be already doing that fit in that are gonna appropriately help you treat this patient within each stage of care. So once we go through our evaluation, then we're gonna start treating the patient. And treatment intervention tells us what we are going to do with each individual patient. So what we're doing from an intervention perspective. And then finally, we look at discharge criteria. And our discharge criteria is looking at the presentation of pain. Do the patient have pain? Yes or no. Do they have normal range of motion? So if they don't have pain and they have normal range of motion, then we can start looking at some higher threshold tests. Now, I use— for quantitative testing, what I use is the Y-Balance test. I want to see if they have dynamic assessment of motor control. And then if they can do that, I want to put them in some higher threshold outputs through the qualitative testing, which what I use is the Functional Movement Screen. Now, if they can pass both of those things with normal movement competency, with no pain and normal range of motion, Then if their sport or activity dictates it, I may do some capacity testing. If you need to be able to run up and down the soccer field or run the length of the soccer field to play your sport, I may want to test that to see if you can do that within what your normal variants are. And then finally, we take all that data and we compare it back to your norms. So if you can normally run the field— I'm making this up, I don't know what a good number is— but if you can run the field in 15 seconds and you're still at 25, Then we may know that you need some more fitness or work capacity before we release you back to full activity. So we need objective discharge criteria that we can use to determine if the person's function has been fully restored. So discharge criteria tells us when exactly we can release the patient from care. So the big question is, we started talking about this and teaching it in our courses, how do we choose the appropriate interventions? And there's a lot of different responses to that. Each clinician is going to have their own idea of how and why they're choosing each intervention. But to me, the main thing that's always stuck in my head is we have to use biology as a guide. Now, biology is the branch of science that primarily deals with structure, function, growth, and evolution of organisms. So everything we do is about biology, no matter if we want to realize it or not. But hold on, I have a question. Where do you start with treatment when there's already known tissue damage with chronic pain? Let me answer that, Caesar, at the end, because I think I'll get through that. As I answer some of the rest, but if not, I'll come back to it. When we're talking about biology, in my mind, everything that I think about is from a biological perspective. And so, I had to try to create this semblance of there has to be some things whether we're a chiropractor, a physical therapist, or an athletic trainer or coach that we all agree upon that relates back to biology because if we can't even agree on that, then each of our perspectives are going to be lost in translation. So, I came up with 15 thoughts or universal truths, as I call them, that I think we can all agree upon. The first one being that humans are biological organisms and thus must abide by the rules of physiology. Secondly, number 2, through evolutionary design, Homo sapiens were designed to perform a variety of very specific tasks and thus have a very specific hierarchy of needs. And, we'll talk about that at the end. Number 3, The further humans stray away from our intended function, the closer we get to pathology and disease. If we were designed to be able to move and rotate our thorax, but because we're sitting in kyphosis all day long and we're not doing that, that puts us closer to pathology or disease. So the further we get from our intended purpose, the closer we get to pathology. And then number 4, everything we do in rehab and fitness is about the application of load to the biological organism. To me, this is the number one thing I concern myself with every patient and fitness interaction that I do, is everything that we're doing is about the application of load to biology. Number 5, when the load or challenge is applied to the biological organism, the human body responds in very predictable ways, or we, as we know in physiology, the general adaptation syndrome. Number 6, in order to elicit specific adaptations, load must be applied to the organism in very specific amounts, or Specific adaptation to imposed demands. Now we're starting to see anatomy and physiology merge together in a way that leads us back towards biology in the sense that whether we're doing rehab or fitness, we have to be concerned about how the body's adapting through general adaptation syndrome. We have to make sure we're being specific in our load application to get the adaptation that we're looking for. Now, when we're doing that, number 7, when applying load to the body, we must seek to understand the minimum effective dose necessary to elicit physiological adaptation without violating the individual's maximum tolerable limit. This is about dose-response relationship. So for instance, if someone needs 5 minutes of manual therapy to stimulate the adaptation we're looking for and we give them 25, that might be 20 minutes more than their maximum tolerable limit or what they needed to get that adaptation. So we have to be very specific, whether it's through rehabilitation or through fitness, about the dose of the stimulation that we're giving each individual person. Number 8, as we attempt to continue to evoke adaptation in the organism, we must provide chronic and repetitive exposure to progressive stimuli. This is all about progressive overload. Number 9, everything we do in regards to motion in the body comes down to the expression of force. We need proper joint motion and we need proper length-tension relationships for the sarcomeres to overlap in a meaningful way that moves a joint. So everything comes down to the expression of force and force is just torque around a joint. Number 10, in order to provide sufficient amounts of force, joints may be able to explore the entirety of its range of motion. If you need to produce force, you need proper link tension relationships. And if you're in a joint position or you have a lack of centration and you don't have proper link tension relationships, you're never going to be able to, no matter how hard you try, produce sufficient amounts of force. This is one of the reasons why I think movement competency is so important to athletics. If you need to be able to express full range of motion in the ankle in dorsiflexion and you don't have it, not only are you going to compensate and potentially lead to energy, but your force outputs are going to be diminished in a meaningful way that maybe it doesn't allow for skill acquisition to become successful. So these are these ideas of biology that are starting to tie back together. Number 11, in order for tissues to be able to produce force in a very specific joint position, it must have experience producing force in those positions, meaning If I need to go to 180 degrees of shoulder flexion to do a kipping pull-up, I better have had experience putting my shoulder in that position before I start putting it under load. Because if it's the first time going into that position and it's under a high threshold force output, that's probably not going to end so well. So it's just something we have to keep in mind. Number 12, in order for movement to be successful, you must possess all of the physical requisites to perform the task. I think this ties really well into number 13. You must be able to demonstrate joint independence or motion before joint interdependence or movement. Now, what both of these mean is the physical requisites. If I'm going to do a squat, I might need some hip flexion, some knee flexion, and some ankle dorsiflexion, amongst many other things. But if I don't have one of those things, if I don't have joint independence at the ankle, the squat motion or interdependence and movement is not going to be successful. You need all the physical requisites to perform the specific task, and you need to be able to isolate joint motion before you integrate it into a movement pattern. Number 14, motor learning and skill acquisition cannot take place successfully in the presence of movement dysfunction. This all ties together. You need movement competency to have proper length-tension relationships to express force, and you need some relevance of force output in order for skill acquisition to take place. So if you can't dorsiflex the ankle, sprinting or any sprinting technique work you do or kicking the soccer ball is probably not going to be successful. And then number 15, the degrees of freedom a joint possesses, the greater movement variability that can occur during the execution of a movement skill. So if I only have the ability to move in this plane of motion, and let's say sagittal plane motion, but I, I only have one way to do a thing, whatever that skill is. But if I have freedom of my joint in all 3 planes of motion in the specific ranges I needed, Now there's multiple options of ways I can do that skill. And when you're only left with one option, but the circumstances fall outside that option with skill acquisition, or even in sport application, you're probably going to get injured. But if I have multiple ways to solve that movement problem, now there's less likelihood that there's going to be any detriment for the potential of injury, but also it's going to allow more success with skill acquisition because now I have multiple ways to move. So, when I look at all these things tying us back to these universal truths, I don't think there's anything in here that we could argue with. All of those are things that we can all agree that tie us back into this realm of biology. But in essence, everything we do in rehab and fitness is about the application of load to the biological organism. So, if we're going to talk about load, we might want to define it. And this is one of the areas in my practice where I spend a lot of my time is thinking about load And application and load monitoring. But load is the amount of external burden being placed on an individual. When we have this external burden being placed on an athlete, the body is going to respond internally in the form of stress. And stress is defined as the body's internal response to any physical, chemical, or emotional factors that disrupt equilibrium. So we have this external burden, our body starts to respond— general adaptation syndrome— it starts to respond in the form of stress. And as we keep applying this repetitive stimuli in the form of stress, the body starts going to resist it until it ultimately adapts, which is the process which brings the organism back to equilibrium. So load is— if we think of load, it's the amount of external burden being placed on an individual. And I want you to think about that as we talk about the rest of this presentation. And this is just a representation, a graphical representation of load. It's something that's being placed on the individual that actually has some meaningful impact. Now, the last thing we need in that rehabilitation process that we talked about is load progressions or a rehabilitation continuum. And I struggled with this for a long time because in the couple of years that I've been teaching my class at A Rehab to Fitness, or even when I taught at the university, it was really hard to talk to students about how we classify those stages of care and how we even classify the interventions that we're doing on individual people. And the one thing that kind of popped in my head one night, it was about 2 o'clock in the morning, is the idea of a periodic table. Now, the periodic table, if you're familiar back to high school science, is a way to classify elements based on their atomic mass, which is their weight, and their classification. And so I started thinking about how can I apply the idea of a periodic table to the things that we do in rehabilitation? And what I came up with was this idea of our rehab continuum. Now, if you look at the top of this diagram, you'll see along the top we have the 6 stages of care. We have acute management, foundational kinematics, motor control, functional integration, progressive kinetics, and fundamental capacity. If you look at the bottom, you'll see from top left, which is the least amount of load that's being placed on the system, and the bottom right is the highest amount of load. If you look back to the periodic table, This is the least atomic mass, and down here is the most atomic mass. So we're applying the same principles, but instead of mass, we're going to call it load, the amount of external burden placed on an individual. And so what we did was I took the most common interventions for each stage of care and mapped them out based on a theoretical construct of what I thought their load would be to the biology. Now, I will tell you as we talk about this, this is not set in stone. This is a theoretical construct to be able to describe what we do and why we're using the interventions that we're using within each stage of care. But as I've talked with other professionals about this, the principles hold up back to our relevance to biology because now what we're seeing is a way that we can classify our interventions based on their load to— and how much burden they are to the biology of the human system. So as we talk about these individually, our first stage of care is acute management. This is Things that we might do for pain and swelling. These are a lot of passive interventions that you might have been taught during school. Now, the first thing we're always going to do is patient education. There's no burden typically for someone to sit there and have to listen to us tell them about their pain, use some principles of pain science, and just discuss the general aspects of their injury and pathology. The second thing we want, and we can start working on, is diaphragmatic breathing. Diaphragmatic breathing can help immensely with pain and function. And, there's very little burden to the system to have them actually retrain the aspect of breathing. We can do passive things like if there's a lot of swelling, we can do dynamic taping. For pain and swelling, we can do cold laser. If in your state it's applicable and you're trained appropriately, you can do dry needling and electrical stimulation or do those in combination like I know a lot of my colleagues do. And, some people have also used vibration and percussion almost like the Theragun. And then the end would— the last thing you could do in acute management would be nerve flossing. Now, I will also tell you, these are not all the interventions that are out there. What we try to do is just take the most common ones that we see and apply them to those stages of care and give them a load number, a load score. So these are things we do in acute management. And as you can see in the diagram, we might have things for Like here we see some bruising, so like swelling and bruising, we can use some dynamic taping, whatever taping methodology you find to be effective. I find dynamic tape the way Dr. Riddle teach it to be very effective for these types of things. You can use cold laser or any type of intervention you have in your practice. Here we see an example of dry needling with electrical stimulation, very good for pain and inflammation. And then some people again could use vibration percussion if you use that in your practice. And here we see an example of nerve flossing. So these are interventions that we use in acute management. And as we move through the next stage, here we see foundational kinematics. So there are a series of things in that stage of care that we can utilize in our practices. But the underlying principle of foundational kinematics is trying to increase mobility, whether it's joint or tissue mobility. So we could do things like myofascial decompression or cupping. You could do compression flossing or factor flossing. Which is just compression banding. You can do direction-specific movement or things like McKenzie. You could do acoustic wave. And we chose, even though acoustic waves is a passive therapy, we chose to put it in here because the sole purpose is actually to mobilize tissue. You could do joint mobilization or manipulation, whatever your flavor is. And then any variation of soft tissue mobilization, whether that's things like Stecco, using your hands, cross-friction massage, Active release, massage, or even instrumentation like using Factor instruments. Those are all things that would go under soft tissue mobilization. So you can see some examples here. We have myofascial decompression with cupping. We have Factor flossing up here at the top. We have direction-specific movement or McKenzie. You can see things like joint mobilization or manipulation, soft tissue mobilization with your hands, any type of manual therapy. Or instrumentation like using the Factor instruments. So these are all things that fall into foundational kinematics. And these are things to improve mobility.

That's it for today's episode. Be sure to tune in for episode 27, where we wrap up part 2 of this training and discuss the 3 parts of the rehabilitation process, the stages of the rehab continuum, and specific interventions within each stage of care. We will also talk about specifically what to do with patients who are finished with rehab but not necessarily ready to be discharged from treatment. You won't want to miss it! Episode 27 drops in 2 weeks, or 1 week for our Patreon subscribers. In the near future, we're also planning a few special Q&A episodes with past instructors and a few guest interviews coming up here this summer. So please be sure to click on the Q&A link in our show notes and ask any burning questions you may have. You can subscribe to The Factor Podcast on Apple, Spotify, iHeartRadio, or the podcast app that works best for you. Please give us a 5-star rating to help us grow the show. Every little bit helps. And last but certainly not least, be sure to visit the show notes for a link to download the PDF of today's full presentation, as well as learn about any special offers that we featured in today's episode. 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 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.