#3 - Integrating Fitness into Clinical Practice with Dr. Tom Teter, Part 1

Hi guys, really quickly before we get started with today's episode, we are excited to announce that finally, we have resumed live in-person courses in limited dates and locations. So in 2021, we are hosting 12 Factor Rehab System in-person courses in cities throughout the US. And we really hope to resume international course dates by the end of this year and starting into 2021. Also, the Rehab to Fitness course and the Factor Peripheral Nerve Entrapment courses are each still being offered in a fully virtual format online, but we are excited to announce that we are planning for a few select in-person course dates later on in the year. So for more details, keep an eye on our event calendar at factor-store.com, or you can always check out the event calendar link in the show notes. 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 digest, with actionable information that you can implement into practice right away. Let's get started. In today's episode, we will be discussing how to implement fitness into clinical practice with Dr. Tom Teeter. Dr. Teeter is the developer of Factor's newest course offering, Rehab to Fitness, a course that bridges the gap between rehabilitation and fitness by providing a blueprint for the why, the when, and how of fitness programming with appropriate regressions and progressions for patients at all levels. As the owner of Engineering Athletes, a manual therapy and performance enhancement clinic, Dr. Teeter's primary practice focus is on integrating movement-based rehab and functional performance training. With over 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, and has also become a sought-after expert witness in court cases that involve fitness and injury due to his expertise in injury prevention and Performance Enhancement. In this 2-part training, we will be discussing the increasingly blurred line between rehab and fitness. After all, they both involve exercise, so how are they really different, and how are they the same? Also, how does fitness fit into the continuum of care? Dr. Teeter will be answering these questions along with discussing best practices for establishing fitness as an additional service offering for your patients, In part 1 of this 2-episode training. Let's get started.

My name is Dr. Tom Teeter. I am a practicing chiropractor in Kansas City, Missouri in the United States, and I wanted to talk to you guys a little bit about how you can integrate fitness into your clinical practice. Fitness is a hugely important part of the things that I do with my practice, and I'm going to explain to you exactly why I think it's important and how you can utilize fitness as part of your practices. So some of the most common questions that we tend to get about fitness and how you integrate that in practice when we've been teaching our course is really understanding what is the difference between rehabilitation and fitness? Why do most of our rehab programs fail? What is the role of fitness in our clinical practices? And how do we integrate fitness into our treatment plans? Now, the first thing we have to understand is the difference between rehabilitation and fitness. Rehab is really the process of restoring movement function in order to either reduce pain or have them be able to perform a specific task. And then fitness is really about improving movement function that you already have in order to accomplish a specific goal or a task. So whereas rehab is designed to really bring your movement competency back to normal through making short-term changes in neurological motor control, Fitness is designed to take your movement capacity to a higher level by creating long-term physiological adaptation. And this is really the thing that most people need to understand, whereas the things that we do, clinicians in our treatment rooms, are really about creating short-term windows of opportunity through some type of low-threshold stimuli for neurological changes in motor control. And fitness, we're trying to take those windows of opportunity And load-specific patterns in order to get long-term physiological adaptation. And a good rehab program must have both movement competency and capacity in its use. Now, one of the other things that we really have to think about when we look at rehab and fitness again is that movement competency is the ability to move free from dysfunction. So that's having normal movement and normal control of movement. Competency is all about measuring the quality of your movement function, whereas with fitness, it's about capacity. And capacity is really defined as the ability to express strength, during fundamental movement patterns of daily activity. So capacity is a measure of the quantity of movement function, and we need to have both a qualitative and a quantitative approach to movement when we're addressing people through rehabilitation. Now, in a general sense, rehab and training should be concurrent processes if you have the right model. I think one of the challenges that we have as clinicians, particularly in chiropractic, is that we typically only want to focus on one piece of the puzzle, which historically from our profession has been joint manipulation. That is one piece of a There's a spectrum of loading threshold that needs to be addressed. And so if we have the appropriate model, we can address both rehabilitation and training at the same time, because ultimately rehab is just training when you're injured. We're using low threshold stimuli to try to open up a window of opportunity to allow you to get back to loading activities of daily living. What we have to also think about is I think we have pigeonholed ourselves into this situation where our patients think that rehab is about us fixing their problem. And really we know that the outcomes for those situations aren't necessarily as good, is if we take the approach to rehabilitation that we're going to show patients what they can do for themselves. We don't want people to necessarily have to come back to us over and over and over again. We would much rather give them some things that they can do for themselves. And so that they can get on the road towards self-autonomy and progressive loading strategies that are ultimately going to affect their health. We want to show them some things that they can do for themselves, not have them come back over and over again. To have the fix-it mentality. Another thing that we have to think about is why do most rehab programs fail? And I think usually what it boils down to is one of these 4 reasons. It's either the clinician focuses on the side of the problem instead of identifying the source of the patient's complaint. Clinicians either end their rehab programs when the pain is gone, because pain is the last thing to show up and it's always the first thing to go away. And because they end their programs too early when pain is gone, they fail to fully restore function before they release their patients from care. And because of this, they never ultimately increase a patient's tolerance to load. And I think that's one of the most important things we have to consider. I've always said this in some way, shape, or form, but if your rehab program does not start to look like resistance training, you're doing it wrong. There is a time and place for manual therapy and passive modalities, but the purpose of those interventions is only to open up windows of opportunity for progressive resistance loading to occur so that we can make long-term physiological change. So when we look at why programs fail, I think the majority of reasons is because most people and most non-contact musculoskeletal injuries occur because people are either underprepared or overstimulated. Now, underprepared is the patient is not prepared for the loads that they're tolerating on a daily basis, whether that's activities of daily living or sport. And because they're not prepared, most of the time they're also being overstimulated, meaning they're just doing too much activity Too often or too soon. So really, fitness is the method and the vehicle by which we can better prepare patients to tolerate larger amounts of load, which ultimately will decrease their incidence of injury. If we look at that from a different perspective, it's not always the load that breaks an individual down, but it's the load that their body is not prepared for that is the problem. Meaning that because most people come into either work or sports situations underprepared, it's not that load that ends up being the problem. It's the fact that they're not fit enough to be able to be resilient to those forces and stresses, and ultimately they get injured. Ultimately, most injuries occur from either doing too much too fast after doing too little for too long. So this goes back to the too little for too long— is you're underprepared, you haven't been doing things to be physically active to make your tissues resilient to stress, and because of that, then you start into activity in a volume or intensity that's too much, and you're doing it too often, and then ultimately you have the onset of pain. We also have to think about how we go about fitting fitness into our practice. Now, there are a large number of my colleagues that typically want to only do the manual therapy portion of care, and that's totally fine. But really, in order to ultimately get people back to normal function, you have to look at all of these things, rehabilitation and fitness on a spectrum. Again, rehabilitation is to reduce pain and restore function so that patients can do activities of daily living. But one of the major goals of our treatment process should be to eliminate What is known as a patient's activity intolerance. And activity intolerances are movements or activities that a patient needs or wants to do but can't because they're having pain or dysfunction. An activity intolerance could be things from activities of daily living to very specific sport or fitness-related activities. When we talk about an activity intolerance, typically where we'll pick up this information is through our history during the first part of our examination process. I will typically ask someone, what is it that you want to do but you can't because of pain or dysfunction? And they might say, I want to be able to squat down and pick up a box, or I want to be able to bend over and pick up my grandkids, whatever that activity intolerance is. And you mark that so we can come back to it later, and I'll show you specifically what I mean in a minute. So the primary goal of our treatment process is to prevent the potential for reinjury, and the best way we can do that is by finding their activity intolerance and then progress them through load, which we're going to talk about momentarily. At the end of the day, rehabilitation should prepare athletic populations to tolerate loads and velocities across a full spectrum of force-velocity curves. And this is essential for returning injured athletes to high performance levels. Now, what this means in a very simplistic perspective is that we need to, before we release patients from care, we need to have them to be able to tolerate the forces and the velocities of movement that they do in their sport. If we don't, ultimately, if we just stop when pain's gone, then they're going to eventually get reinjured. And it's important that we continue to use progressive loading to make sure that that doesn't happen. So one of the other things that we have to think about is how fitness and the role of fitness and how it fits into our practice. In my opinion, your treatment plan is not finished until your patient is number one, out of pain, and number two, able to perform the required activities of daily living or their preferred activities at their normal levels, which means— That fitness should be a huge part of all your rehab progressions. If we use fitness appropriately, this allows clinicians to continue progressing load until they have reached the patient's maximum relative function, which means they can perform their activities of daily living. The whole purpose of fitness is to be able to improve our patient's tolerance to load. So we don't want to shy people away from this concept of load. We would much rather have them utilize load and fitness to improve capacity so that they ultimately don't get hurt. And then what we also know about fitness that I think is a huge piece of the puzzle is that fitness is the number one means by which we can improve health. And so if not only can we get people out of pain, get them moving with normal function, and be able to perform activities of daily living, but this has massive carryover and implications to their overall health. And so fitness really can be a huge part of the puzzle for Particularly clinicians who practice chiropractic. Really, injury prevention is about increasing the load absorption capacity of the tissues involved with movement. If people are underprepared, meaning they haven't stressed their tissues physiologically to create long-term adaptation, and then they do too much, then ultimately they're going to get injured. And so we can use progressive loading to bridge things that we're going to do in our treatment rooms on the table, Remember, those things are meant to be short-term changes in neurological motor control to open up windows of opportunity for movement that allow us to load patterns that create these long-term physiological changes that allow improved capacity so that people don't get hurt. So injury prevention is a huge part of what we do, but we have to use load in order to accomplish that task. Now, one of the things that I always talk about when I teach is that when we use this idea of rehab and fitness, there seems to be a disconnect between Where rehab ends and where fitness starts. And the methodology that we use to teach this idea is that your last progression of rehab, the last thing you do in the treatment room, should be your first regression into fitness. And if we utilize that mindset, both of these things can happen concurrently, and there's not a gap that we need to bridge. If there's a gap that we're bridging, then we're obviously doing it wrong. So we need to use load progressions and a systematic continuum in order to make sure that we're getting the patient from rehab into fitness to accomplish long-term Adaptation. This is one of my favorite sayings. Rehab professionals need to understand that injuries are not treated lying down on a medical table. Rehab must be task-specific while performing real-life activities. I think it's easy early on to get trapped into the idea that when people are lying on the tables and we're performing some type of intervention, that is making the change necessary for pain to go away and function to be restored. But really, those things only happen under the force of gravity, under load. And so we need to use the things that we're doing on the medical table with treatment in order to get them in a position where we can do task-specific real-life activities, because that's what's going to create long-term adaptation. So the big question becomes, how do we integrate fitness into our rehab or clinical practice or return to activity program? And really what you have are 5 general stages of care for return to activity. Now, the first is looking at the pain generator. We typically call this putting out the fire. So you want to do something to reduce the patient's pain. Now, this may be your intervention. This may be some type of other passive intervention that you may see has relevance to decreasing pain. This could also be medication, but you want to do something to put out the fire so that the patient is reducing their pain. Secondly, we want to address the individual motion segment. Now, this might be a joint fixation. So we want to restore joint motion, or it might be that a tissue is stuck and we want to make it more extensible so that layers of muscle can slide against each other so they have normal range of motion. Either of these are things that would be addressed through a specific motion segment. And then once we've got normal input afferently to the brain, then we want to work on number 3, which is motor control. So we want to have proper input from the joints and tissues. We want to have the brain process that information in the form of a motor pattern, and then we want the brain to create output. And output is motor control. And that's the third piece of our puzzle.

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Now, once we have proper input and muscular output, then we want to work on improving strength in our fundamental patterns. And this is number 4, fundamental performance. So this is where fitness starts. So if you can see this continuum of care, 1, 2, and 3 are things that we do as clinicians. We want to put out the fire, we want to restore joint and tissue motion, and we want to restore motor control. Once those things have happened, now we have to take the next step to improving strength to create long-term adaptation. So we work on resistance and progressive loading. Then number 5 is fundamental advancement. Now, fundamental advancement is where we start to improve strength and power. So we're getting a little further into the force velocity spectrum where we're looking at rate of force development. And then number 6 is advanced performance. Where we're trying to work on improving conditioning and motor skill acquisition. So we can literally take someone, let's say we're working with an athlete, from pain all the way to advanced performance if we follow the systematic process of stages of care. The other thing we have to think about again is that most clinicians stop their rehab program after the motor control part. After 1, 2, and 3, they've put out the fire, the patient's no longer having pain. Now remember, pain's the last thing to show up, but the first thing to go away. So the patient's no longer having pain, they've got normal joint and tissue motion, and they've got proper muscular output with motor control. That's usually where most clinicians stop, but usually the reason why people got there in the first place is their inability to tolerate load. They weren't prepared, they were underprepared and overstimulated. So if a patient has not gone through all the appropriate stages of care, then we're going to stop too early, and ultimately they will have a high potential for reinjury. So again, fitness is the vehicle by which we can bridge the gap between therapy and rehab, which we're doing in our treatment rooms, and performance from a musculoskeletal perspective. Ultimately, everything we do in rehab has the exclusive purpose to open up neurological windows of opportunities to load specific movement patterns. Now, we can improve movement capacity— is really the only way we can Save a motor program in the brain after we have rendered passive care. So this goes back to the idea of suggestion where I said treatment and rehab therapy is really just to open up these short-term windows of opportunity for movement so that we can load movement patterns to create long-term adaptation. Again, we have to use load progressions to ultimately get the outcome of achieving pain-free movement with no dysfunction and compensation in order to make people resilient to stress. Now, if you look at that on this particular spectrum, you can see— and this isn't obviously my favorite way to suggest this, but if you look at this diagram, you can see on the left we're going to call that rehab, and on the right we're going to call that fitness. On the left, when someone has painful movements or things we need to protect them from, these are red light activities that we say you probably don't want to do this, or maybe if you're going to do this, we're going to modify it. Now, when someone is on the left end of the spectrum with rehab, usually we're using low volume, low intensity, Low threshold stimuli, and this is usually in the form of any passive modalities or manual therapy. And we're really trying to work around and correct movement dysfunction to reduce pain. As we go along that spectrum, at some point we're going to have to introduce higher threshold stimuli in the form of load. So these are going to be things that we're doing with strength resistance training and fundamental movement patterns. These are going to be higher velocity, higher load movements, and we're going to expose them to stimuli to make them more resilient to stress. Ultimately, when you have patients, they're probably going to start somewhere on the spectrum, and it's your job as clinicians to determine where that is and determine if you need to work backwards or forwards. And I'm going to show you how to do that in a second. The goal of every patient interaction should be to promote activities that increase resilience to stress, develop durability to changing environments, and enhance longevity by improving physical autonomy. What this means is we need to get people moving better so that they can actually participate in fitness, because that's ultimately what's going to give them the most longevity and proper health throughout their lifespan. So if you look at this idea of fitness, fitness is the only way we can create permanent changes to movement competency. It is the only way we can increase a patient's tolerance to load. It is the only way we can help a patient eliminate their activity intolerances. Remember, those are activities that they want to do, but they can't. It's the only way we can assist a patient in preventing the recurrence of injury. The only way we can improve a patient's ability to perform specific tasks, And the only way we can bridge the gap from rehab into performance. So fitness is a huge piece of this puzzle, and I think we need to start thinking about what we do as clinicians in the form of load instead of being the type of clinician who's only out to fix pain. The biggest question that we get when we teach our courses is, how do we apply fitness into our rehab progressions? And first, we have to think about this from a very simplistic perspective: rehab versus training. To me, they're the exact same thing. The only difference is the starting point. With rehab and training, we're going to use progressive overload. We're going to use the general adaptation syndrome or specific adaptations to impose demands to increase strength and resiliency. The difference is the starting point. With rehab, people are starting in pain, they have dysfunction, and we're using low threshold stimuli to open up those windows of opportunity. With fitness, typically they shouldn't have pain, they should have a relative baseline competency of movement, and we're using higher threshold stimuli of load to help them Become more resilient to stress so that they can ultimately perform some type of terminal task. So rehab and training are really the same thing. We're just at a different starting point. And that's what you can see here. The goals and principles of rehab and training are exactly the same. The only difference is the starting point. The other thing we have to consider is a lot of times clinicians want to ask, what's the best exercise? And ultimately there is no specific exercise that works for everyone. The thing is, you just have to give the right amount of stress to the right person at the right time. How do you pick the right exercises and load for your rehab progressions? This is one of the hardest things I think most young clinicians have challenges with. So if we look at this idea, how do we pick the right progressions or load? Number one, we have to find the person's activity intolerance because this is task and sport specific. So let's say, for example, hypothetically, someone has knee pain. I'm making this up. Someone has knee pain and they say, I'm a basketball player, And I want to be able to jump, but I have pain and I can't jump because it hurts. So our activity intolerance is jumping, and that's where we're going to start. Now, once we know what they can't do, then we're going to pick a movement pattern that directly correlates to their activity intolerance. So for the purposes of this conversation, if you can't jump, then jumping is just changing levels, and that would be a squat pattern. So once we find out they can't jump because it hurts, they have a squat pattern, That needs to be loaded, then we're going to pick an exercise, and this particular exercise is going to be the squat. Then once we've picked an exercise for the pattern we're trying to load, then we have to find the right landing spot for that particular exercise, and then slowly and systematically progress the patient towards capacity. Now, for the purposes of this conversation, I'm going to leave out things that we would do from a rehab perspective to improve mobility or motor control. Those are things we're going to work on. So hypothetically, maybe this person has an ankle dorsiflexion restriction. And we are going to manipulate that joint and try to mobilize it to improve afferent input. So there may be some things you're working on through rehab, but those things can work simultaneously while we're working towards loading patterns. Now, when we start looking at what patterns we want to load, there's numerous conversations on the internet and social media about what are the appropriate patterns related to movement and fitness. This is just some options, but the ones that we typically use are pushing and pulling in the upper body, squatting, which is changing levels, hinging, which is hip-dominant motion or hinging at the hip, twisting, which twisting we talk about is rotation and resistance to rotation in the core. And then we have locomotion, and ultimately locomotion is lunging and stepping because locomotion is walking or running. So our patterns that we load are push-pull, squat, hinge, twisting, and locomotion. Now we know that those patterns need to be loaded. So once we've picked our pattern in this conversation, we have our squat pattern. When performing any exercise for rehab, we must ask 2 questions. Are they having pain and are they maintaining integrity? Now, one of the questions that we've been struggling with when we apply this in our clinical setting is sometimes as tissue's healing, we need it to move, but it's going to hurt. And so how do we decide what level of pain is acceptable with movement and when we need to stop? And so if we look at this on the spectrum of 0 to 10, which is our pain scale, anything below 0 and 3 to me is a green light. Yeah, it's a little uncomfortable, but we can keep moving through the motor pattern. If somewhere's in that 3 to 6 range, it's a yellow light. We want to proceed with caution. We may need to make some changes, but we may not. And anything 6 or above to me is a red light. And anytime we have a red light, we stop loading that motor pattern because there's something either structurally still going on or it's just too much progression of load. So we always want to know, are they having pain and can they maintain integrity? How do we know if we've got the right corrective exercise? First, again, ask, does the patient have pain with performing this exercise? And if the answer is no, then you're probably in the right spot. Then we have to ask the second question is, do they maintain integrity? But for the purposes of pain, if they have pain with movement, then the first thing we're going to do is reduce the weight. Now, weight is just a fancy way of saying the external load. So if we're having someone perform an exercise and the external load is causing pain, then we want to then change the range of motion. If it's not causing pain, then you were just using too much weight. Once we've reduced the weight and it still hurts, and if they're having pain, then we want to reduce range of motion. Now normally we'll cut the range of motion in half, and if it still hurts, then we need to move backwards to a regression where it puts them in the right landing spot. Because usually at that point, they're losing integrity. And that's too much of a load progression for them at that time. So then what comes down to is we have to understand what is integrity. Whenever we're putting someone through a motor pattern under load and the force of gravity with their body weight or an external resistance, we always use ABC. So integrity is alignment. Can you approximate the diaphragm over the pelvic floor? This is important for 2 reasons. Number one, because that puts you in a neutral position in the lumbar spine. And by stacking the joints, you're going to give them the most resistance to compression. And then number 2, by stacking and approximating the diaphragm over the pelvic floor, you're going to have optimal length-tension relationships in the musculature in the abdomen to utilize to create tension. Secondly, if the diaphragm is properly approximated over the pelvic floor, that's going to allow for proper contraction of the diaphragm, pushing air down in the abdominal cavity, which creates intra-abdominal pressure, and thus we get increased spinal stability. So joint stacking and alignment's number 1. Then secondly, we need to make sure they're They're breathing properly with diaphragmatic breathing to create intra-abdominal pressure and abdominal tension. And then third, once they're going through the motor pattern, we need to have— make sure they can control it with proper technique without any compensation. So if we're in the right landing spot for someone, it shouldn't hurt. Or if it is going to hurt, it's going to be in that 3, 4, or below. Those are our green lights. And then we need to make sure they have proper integrity. Can they stack the joints, breathe properly, and maintain control? If they cannot do all 3 of these things, then it's too much of a load progression, and the body's going to perceive that as a sympathetic stress, probably beyond their current threshold, and it's going to be ineffective. So remember, we have to find the simplest thing that they do well, and we're going to slowly and progressively make small and meaningful worthwhile changes. So always want to look at integrity. Again, there are no good or bad exercises, there's only progressions of load. So if we look at that, going back to our squat analogy, if we're going to say my person has knee pain, they're a basketball player who wants to jump but they can't, then we're going to do our interventions from a rehabilitative perspective to reduce pain and restore mobility and improve motor control. Now, once we've done that, we have to put them under load. So we're always going to start a pattern-assisted unloaded exercise, and I'll show you what the— what I mean by this in a second. We're always going to then go and progress to an unloaded exercise, then progress to a pattern-assisted loaded variation, a loaded variation, and then an advanced loaded variation. Now, what that looks like from just a general simplistic perspective is when we're talking about changing load, we have 2 options really. We can change body position, and that will thereby decrease stability requirements or increase depending on the circumstances and the task, or we can change resistance. So there's 4 different options. As far as changing stability requirements or changing body position, we can— let's say for instance, we're having someone in a standing position. Well, if the exercise can allow it, then we can go to a half kneeling position, which is half the stability requirements. If that's too much, we can go to a quadruped position, which is half the stability requirements. And then if the exercise allows it, you can work all the way back to supine or prone progressions, which is then half the stability requirements. Now, as far as load and resistance, we can go from an assisted pattern unloaded, meaning no external resistance. So that would be assisted with their body weight. We can go to unloaded, which just means they're doing it with their body weight going through the motor pattern. We can do assisted and loaded, meaning we're adding external resistance, but we're giving them a little bit of stability and assistance. And then ultimately they're doing it loaded with only external resistance and no help. So if we look at that, going back to our squat pattern analogy, then what we would typically start with our load progressions are a TRX-assisted squat. Then we would progress to a bodyweight squat so that when you're using the TRX, From our estimation, it can take anywhere from 20 to 30% of your body weight away because you're using the straps to pull, and that helps you through the motor pattern. So we're going to do an assisted squat, but it's only with body weight. Then once that becomes too easy— and usually we determine that when you can do 1 to 2 sets of 10 repetitions with no pain and no loss of integrity. All right, if you're at 2 sets of 10, it's time to move beyond that. So then once we get from— we're going to take away the assistance and we're going to have you only do it with your body weight. Weight. So we're adding back 30% of your body weight. Then once you do 2 sets of 10 and you're not having any problems with no loss of integrity, then we're going to progress to a landmine squat. A landmine squat is where you take a barbell and you stick it in a fixed pendulum, and that barbell then is pressing into the pivot point. And so you can hold the barbell at your chest going through a squat pattern. So this is pattern-assisted because when you press the bar into the fixed pivot, it's giving you a little bit of stability. But we can also add load to the bar. So this is where we get pattern-assisted loaded with our landmine squat. Now, once you can do 2 sets of 10 with a relative portion of your body weight, then we take away the landmine and we're going to go to a kettlebell goblet squat. Remember, this is all still within our squat pattern. So this is just a loaded squat. Now, typically what we'll do is we'll do a single kettlebell goblet squat, then we'll go to a double kettlebell front rack goblet squat position. And then ultimately the task dictates it for athletics. With this particular example, we would go to a barbell front squat, which is an advanced load. So you can see here how— if I had some diagrams, but if you see how we had some pictures, we could do a TRX-assisted squat, a bodyweight squat, a landmine squat, kettlebell goblet squat, and then ultimately a barbell front squat. And we would take that same athlete— remember the 6 stages of care— advanced performance, with the last one would be doing sport. So we can use all of these progressions to get to advanced loading, because ultimately that is going to allow them to squat, to make those tissues more resilient to stress, to go back to jumping, And doing the activity related to our example, basketball. If we get through and they're able to maintain the pattern, we're working through our progressions. There's other ways we can make those exercises harder. Number one is always to increase resistance. Then you can work on increasing range of motion. You can make the base of support smaller, but in some exercises that's not always possible. And same thing with changing the center of mass. Sometimes with specific exercises, center of mass is just what it is. Now you can change the length of the moment arm, which is just moving the resistance further away from the axis of rotation. You can add dynamic changes at the basis or reduce the number of stability points. I don't necessarily like changing or using an unstable surface or changing— making dynamic changes at the base of support. You can reduce the number of points of stability, which is just changing your body position. Remember we talked about standing to half kneeling, half kneeling to kneeling, quadruped, and then supine and prone. And then you can change the intensity You can change the speed or you can change the volume. All of those are ways you can make an exercise harder to continue to get adaptation.

That's it for today's episode. If you have a burning question that wasn't asked by our live audience, please click on the Q&A link in our show notes to submit your questions for Dr. Teeter. We'll be sure to cover those on one of our future Q&A episodes. Also, be sure to tune in for episode 4 next week to hear the second part of this training where Dr. Teeter discusses how to use fitness as a form of maintenance care, the importance of loading correct patterns to simulate change, clinical red flags, and the importance of having a support team. You won't want to miss it. You can subscribe to The Factor Podcast on Apple, Spotify, iHeartRadio, or the podcast app that works best for you. Give us a five-star rating to help us grow the show. Every little bit helps. And remember to visit the show notes for a link to download the PDF of today's full presentation. 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.