#87 - Body Mechanics with Ti Pence, Part 1

Hi guys, welcome to another episode of the Factor Podcast. I'm your host, Jessica Riddle. Welcome and thanks for listening. If you're a healthcare provider in the physical medicine space, Your body is one of the tools of the trade that you use more than any other in your practice. Whether you're performing joint manipulations, soft tissue treatments, needling, or using any variety of treatment modalities, your physical ability to perform is the most common denominator of the success of your practice. And while there's no shortage of courses that can teach you about various techniques and treatments, there's very little attention given to the biomechanics and ergonomics involved with preserving the physical health of you, The healthcare provider that's administering care. And that, my friends, is the focus of today's episode. In this 2-part series with Dr. Ty Pence titled Body Mechanics and Beyond: Crafting a Sustainable Manual Therapy Practice, we will discuss the importance of alignment and conservative force generation techniques when performing joint manipulation. Dr. Ty Pence will highlight the key red flag mistakes They can quickly lead to overuse injuries, resulting in those above-the-belt soreness days, and can develop into career-ending injuries over time. So hit the pause button, grab something to take notes with, and be sure to download the PDF visual guide that I've linked for you in the show notes. These 2 episodes are one every manual therapist should listen to more than once. Let's cue the intro music and get started.

Thank you. Thanks everybody for taking time out of your day. I really appreciate it. It's an honor to be talking to you all. This is always the part where I am not such a fan of, is talking about myself. This slide is just to say I've been doing martial arts and chiropractic for a really long time. I've done it— chiropractic in just about every venue you can do chiropractic in, and I've been doing martial arts since I was 15. So I do understand the idea of generating force and understanding levers. And I'm going to try to use that knowledge to help you guys practice longer and have better practices, hopefully. So what we're talking about today, first I'm going to discuss mechanics. If you don't have the form right, it's kind of hard to go faster. If you can't relax into the form and the speed, there's no way your palpation is going to be very good. I know for some of us we're not talking about what we say grade 5 manipulation or adjusting. We might be using it for some soft tissue techniques. Same principles really apply. It's just force over time. Now, when I type in something like Road to Mastery, there's this implied idea that somehow I'm telling you from some level of mastery, and that's not it. I've just spent a lot of time trying to understand this stuff, and hopefully this brings all of us to a better understanding that we can one day all achieve some level of mastery. But I don't know any sport that the top levels of the sport aren't really focused on improving the basics. So that's kind of what I'm trying to talk about today. Just cautionary, because I hear this a lot from a lot of different fields. You'll get these folks who'll say something like they're a master or a ninja or a Jedi or something like that. Please, please be cautious of those. There's no such thing. We're not. That would imply that somehow we've gotten to the edge of knowledge, and we aren't. We got a long way to go. I'm just trying to help us move forward on that in the little way I can. I know I saw someone from— Katie from Toronto. God, Canadians do such good research. So we got how many injuries happen in a year as chiropractors. This is kind of the reason we're having this talk, is there's a lot of them. Here we go. Ironically, notice what's not on there. We don't have lower extremity injuries from doing this stuff. It's all low back and up. Now, how did these— how did these injuries happen? Positioning and performing manipulation. The other part that's kind of a bummer is these providers had pain for more than 30 days and they were still practicing, which means It started hurting and they kept doing the same thing that hurt over and over. Theoretically, maybe they changed everything immediately, changed how they were practicing, but that's generally not the case, and that's not the way it played out in this study. Since we're talking about form and structure, we really have to start out with how we put our feet on the ground. For those of us who have been through either physical therapy or chiropractic courses on manipulation, It seems like every place I have gone to and every person I have seen discuss this starts off with putting their hand on the patient, and that's just not the way we do it. You don't hand someone a basketball and tell them to shoot it without understanding mechanics and then just tell them to figure out mechanics on the fly. You wouldn't do the same thing for any other sport. You wouldn't put someone in a boxing ring and ask them to just start punching and then work on their punches. That doesn't make any sense. But that's generally how we do it as physical medicine providers. So I'm going to try to do something a little different and start with the foundation of how our form should be built, which is from our feet. That X is where we're aiming to do manipulation or adjustment or whatever you want to call it. What that means is no matter how our feet are angled toward the table, and the table doesn't have to be in that direction up and down, it can be— you could be at the end of the table, the foot of the table, wherever, but you're trying to get it in between your feet. Now your feet, your feet might be at an angle like a 45-degree angle rather than parallel to the table, or they might be perpendicular. It doesn't really matter. The issue is Is that contact point, that place you're putting your hand, in between your feet? At most, that X of where we're trying to contact would be lined up with the front foot, but not ahead of it. The reason for this is, as you're standing there, the weight distribution has to be on both feet. If the place that you're trying to contact is ahead of the feet, it by definition puts the weight almost 100% on your front foot. It's very hard to generate power like that and not get injured. So, okay, all of these different angles are just some. I had to pick a few because obviously as I'm going through this, you could line up and work your way around the table as far as All kinds of different options for manipulation, which is going to work better or worse for different people, different providers. But any of these, this basic mechanic should be true. The place that you're aiming to contact should be in between your feet, or at most lined up with your front foot. Now that we've figured out where to put our feet in line with where we're trying to move something, Now we got to figure out how to generate some level of force that's going to get that region of the body to move. I guess I'm just trying to prove my point. They just had people do maximal lower limb and upper limb, like a bench press and a squat, and then measured force as far as different techniques in basically punching techniques. Upper body strength, really, their ability to bench press had no correlation to strength as far as power in their punches. Their lower leg strength is what defined that. We all know this in martial arts. Anybody who's been in martial arts or who's watched enough UFC or boxing or kickboxing or anything knows if you see a guy swinging— guy or gal swinging with their hands where their arm looks detached from their body and the force is obviously coming from their upper body, not their lower body, They're going to be slow and they're not going to be as powerful as someone that's swinging from their whole body. But I say this because it's obvious, and yet very few people practice this when it comes to manual therapies. There's 3 ways that you can generate force. One of them is going from your back foot to your front foot, forward translation. One of them is going from your front foot to your back foot. Backward translation, and then rotation. Now, every— almost every time I talk on this, someone tries to argue with me that there's some other way to do it. They learn some secret technique out of the mountains of somewhere from their guru that says that they've got this magical way of doing it. Okay, if it works for you, awesome. But for most people, these are really the 3, and you can kind of combine the translation and rotation, but we would be getting into the weeds on where that really defines itself as a combination rather than part of rotation. If we have time at the end, maybe we can go into some of that if you guys have questions. Just to sum this up again, because it bears repeating, and I guess I'm repeating this, Because I so commonly see the opposite of this, and I rarely see this. Where I see this is in practitioners that— and providers that have been doing this for a long time and that are still doing it. Most of the time, if you've made it, well, at least to where I am in the profession of 20 years or so, you've either figured out some mechanics or you broke yourself and you've had to like choose a different path as far as how you're going to treat patients. I guess the take-home there is if you do see somebody that is of retirement age still doing manual therapy on a regular basis and they aren't totally injured, you got to pick their brain as much as possible. They're doing a lot of things right. Now that we've got how to generate force, we want to figure out where the maximal place to put that is. And we've kind of talked about this in a 2D format, and I realize that this is also 2D, but hopefully this adds a little bit more 3D understanding, kind of like taking 2 films on an x-ray, of what you're trying to do here. I'm also speaking broadly about all of this stuff first because all— everybody that I talk to has a different way that they practice, where they practice, how they practice, what kind of patients they are seeing in their practice, all What type of body type they have. It's going to change what techniques they use, I guess. It's all going to change how these principles are applied in your own practice. That doesn't mean that they don't apply. They still either apply or you're probably going to hurt yourself, or you've already hurt yourself. The question is just, can I speak broadly enough that in the beginning When you take this idea home to your own treatment room and start breaking apart how you're doing stuff, can you see how these things could be applied? And that's why I'm talking about them broadly first. All right, this wheelhouse concept, I don't know if that's the best way to define it. It would be where you put a cookie jar, kind of right there next to your abdomen. If you're trying to open it, it would be kind of where you're aiming for a golf— sorry, not a golf swing, a baseball swing. Same general area of where you want your hands to generate the maximum force. You wouldn't have your hands way up next to your neck. That wouldn't make any sense. You also wouldn't try to have your hands way down at your knees when you're trying to move something. That also doesn't make any sense. So where you're trying to locate this person in 3 dimensions is, well, kind of right next to your hips and below your rib cage. And then in front of your feet a little bit, but not too far in front of your one foot or the other. This will make more sense when we start talking about the upper body and how we relax into things, but we need to discuss this first kind of as a flow. This is what it looks like if we put a table in there. Sometimes that visual helps. I intentionally put that table somewhere around the knees. That allows there to be some space above that table to assume like a patient isn't 90 pounds like most of the TikTok videos of people manipulating other people. And so that, that height, which is going to determine also how far away the patient is, is going to be slightly higher than the table, which will put them right about in that spot that you want to move something in. If you have the table very low because you think, I'm a short person, I need it down way past my— at my ankles because that will help with gravity, you need to rethink how you generate force. That idea implies that somehow you're short but weigh an insane amount of weight, like the core of the earth type weight, where you can just drop your body on somebody and get motion. For most people, I don't think that's a practical way of doing things.

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Once we've got a patient in a place where we've set up our feet so that the place we're trying to move is somewhere in between our feet, And if they're high enough up that they're— that the place that we're trying to contact is somewhere in between our hips and our rib cage. Now we need to make sure that force that we started generating in our legs that transfers through our core into our shoulder gets out our hands into the patient. In order to do that, we have to make the shoulder part of the body rather than moving independently. This is where things go awry often with providers. The reason I'm talking about the shoulder independently of the rest of the upper extremity is because how important it is. If you don't engage your shoulder in a way that pulls it down before you try to drive force through it into the patient, the force is— good old Newton— is going to go back up into your hand. And it's going to go back into your shoulder. You're going to feel it in your shoulder if you don't compress it first. Also, you're going to end up losing that force as it pushes up your shoulder, and you're not getting the maximal force into the patient that you were working hard to derive from your feet and your hips into your shoulder. Now let's kind of dive into the whole upper extremity, but it's going to be the shoulder included. I use this 90-90-90 rule. Because it's easy to remember. Really, when we're talking about this, it should probably look like the 45-90-85 rule, but nobody wants to remember that. So we're going to go back to this 90-90-90 rule and talk about it for a second, and then I'll tell you why it should probably look more like the other one. The reason there are ranges on this that are so big is because different ways of manipulating patients Dictate a different way that you're placing yourself in relation to the table, how your arm is going to move in order to generate the force needed, because it's moving with the body, not because your hand or arm is moving independent of the body. That being said, the basic rule says you really should not be abducting your shoulder more than 90 degrees, which means bringing your elbow up away from your rib cage. You should not have your elbow Extended fully, so slightly less than extended, and then it shouldn't bend more than 90 degrees. If it bends more than 90 degrees, the force will translate directly out the elbow wherever you're going. The only exception to that is if the elbow happens to be the contact point for what you're trying to do. In that We'll say elbow and forearm, that whole region. If you're contacting somewhere in there, then it doesn't matter what angle it's on, that's where the force is going through anyway. So that's the only exception there. Other than that, if your arm is completely straight, your elbow is completely locked out, that again is just going to send force right in your shoulder and probably hurt your elbow as well. Next, the 90-degree wrist rule. Really, that 90 degrees of wrist extension really only applies to a couple types of techniques that I can think of. I've studied a lot of them. I'm sure someone's going to tell me something where there's an exception, and I always love to hear about those because there's no such thing as ever knowing everything when it comes to all the different ways one provider can use a technique. Or use many techniques to adjust various patients. So I'm always willing to— if someone wants to tell me some version where this is not true, let me know. It's when you're driving force into a flat palm. If that wrist goes into hyperextension, meaning more than 90 degrees, and you're doing that often, say like on the lumbar spine or the middle of the back, the thoracic spine, You're gonna injure your wrist. It's just a matter of time. Now, the reason I say the 45-95-85 rule is in most cases you really shouldn't come anywhere near 90 degrees with your shoulder. There are very few situations where you might want to do that. If you try to depress your shoulder, contracting all the muscles underneath, contracting your lats and everything else, Trying to get that shoulder to go down and then try to abduct to 90 degrees, meaning bring your elbow away from your body, you'll notice at some point you can't keep the shoulder depressed anymore. That is where you've lost the linkage between your arm and your body, and now you're going to have to muscle it. Most of the time it's easier If it's somewhere between that 15 to 45-degree range, it allows the force to just travel a lot easier. It's easier to relax into that. The body can stack on itself, so you don't have to work as hard to get that power through there. The 95 means somewhere over 90 if we're going through the full range of motion of an elbow, meaning it's not more flexed than 90 degrees. I don't know how people— I know I'm talking to a diverse group, so some people are going to measure this differently, but the general is just from flexion to extension. So as we're going from flexion to extension, it should be more than 90 degrees and not 180. I know how hard this is for a lot of people when I say this because a lot of folks, the main way they do certain manipulation is by bending. is by straightening out both elbows and then just putting their body weight into their hand contact. They're likely getting away with it, or else they wouldn't fight me on this, but it just feels very awkward for most folks to bend their elbow a little bit if they've gotten used to having a very straight elbow. You're gonna have to practice. This is not something you just like bend your elbow one day and go, oh, I got it, and start working on patients. It It's something you probably want to practice beforehand, and we'll get into some practice ideas depending on how much time I've got. But you're going to want to practice this before because this, this will feel weird. You will feel like now you're collapsing your elbow, or at least this has been something I've been told, that now it feels like you're losing connectivity of your elbow into your body because it doesn't feel locked in. Yep, that's kind of the first stages of that. And then as far as the 85 for the wrist, the way I described that hyperextension, meaning it forced your wrist into more than 90 degrees, you probably didn't start at 95 degrees. Some do. There's some, but not a lot. Most folks start almost at that 90 degrees, and then as they derive force into the patient, that hyperextends the wrist. There's a trick to this that you can do as well as just making sure that your wrist is not completely at a right angle to the body. And that is, if you contract your thenar and hypothenar, or try to bring— try to push your pinky and your thumb into the patient so you're contracting the bottom part of that hand there. If you get those muscles to engage before you drive force into your hand, It really won't let you go past that 90 degrees, and it creates padding for your wrist, which is probably where you're going to hurt yourself if you're not abiding by this rule. So it's a trick you can try to practice. It— I just can't overemphasize how useful it is and how little effort it takes to start implementing it. It just means when you're practicing this, For the first few weeks, maybe even a month, you're gonna have to be mindful every time you put your hand flat on a patient that you have to take that extra step and contract those muscles. It might slow you down. So now, how do we train all this at home? There's no such thing as going from, hey, let me just show you the right way to do it. There isn't the right way to do it. Anybody who tells you that there's a right way to do it is only speaking to what they have found that works for themselves with their patient population. No matter how cool that person might seem to you, do not buy into the idea that that's the only right way or that's the way that's gonna work for you. You have to be mindful about what your body tells you and what you see working in your practice. That's kinda how that evidence-based medicine thing works. So figure out what motions you're using the most. Once you've got your top 3 or 4 that you're doing every day, start breaking those down. Don't do all of them at the same time. This is a bad idea. If you do all of them at the same time, you're going to get frustrated because now you're bouncing off of patients where you used to be able to get things to move easily. Don't do that. Pick one. Generally, the one that feels most uncomfortable for you, or the one that you feel needs the most work. Start there. It's already annoying to you. Start with that one. Then figure out where your feet are when you're actually doing this thing. Realize, like breaking apart a golf swing, as soon as you start messing with this, everything's gonna feel weird. The other example is like if you're trying to solve a Rubik's Cube, you get one side to work. Obviously, you're gonna see— you're gonna make a mess out of some of the other sides in the process.

That's okay.

That's part of the process. Start with the feet. Make sure that the feet are abiding by the rule that you're not somehow leaning way over on one side or the other. That's first step. Then how are you actually generating force in this patient? That's critical. Be honest with yourself. It's okay if you want to tear apart what I'm saying or believe that I'm just making stuff up. That's fine. Don't lie to yourself. That's crazy. Watch how you generate force. If you generate force from moving from one leg to another, okay, use that. If you're rotating and that's how you're generating force, use that. The only additional thing that I will say is there is moves where you have one leg contacting the patient And that leg is using the patient's leg as a lever in order to generate force. So one of your legs isn't actually on the ground, but acting like it is in the way that you are translating force through that or rotating in a way that's using that leg. That is still that rotation or translation. When we get into injuries here in just a second, you'll understand where I'm going to draw the line here as far as when that's working for you and when that's not. Once you can generate force in your arm, however, however those angles work out for you and the way you're moving that body, your arm should be able to be relaxed through that motion. What that means is wherever your contact is on your hand or your elbow or somewhere else, whatever that contact point is, you should be able to drive that force from your legs through your body into that point without contracting your hand too much. It's other than what we were talking about with the wrist. It should be that your hand should stay relaxed as you're doing that. That will tell you that you're doing it right. The more you have to contract more muscles just to feel like you've got this move to work, in most cases, the more you do that, The more likely it is that you're gonna hurt something. The reason I say that is because you're generating force that's going up through the body and then getting stuck somewhere in the arm. That arm is resisting that force. That's where you're going to have injuries happen. That's what I mean by relaxing the arms. Can you generate force and then relax the arms in a way that you can keep working on your speed, how much force you can translate through that motion you're doing? And still keep your arm linked to your body and relaxed. There are so many ways to practice this at home. It could easily be a very long one-day discussion on all the ways to practice this kind of stuff at home. So we're not going to condense it all into here. And besides, everybody here that I'm talking to, I'm sure, has different stuff they're working with in their clinic as far as resources. So I'm going to try to keep it as something that could be used in a lot of different settings. I don't know, I'm sure someone's going to come up with a— with some sort of example of something where it doesn't work, and that wouldn't shock me. If you happen to be a chiropractor who has one of those tables that when you push on it, it will collapse, meaning it will drop into itself, and you can adjust the tension so that You can create more resistance to you pushing into that. That's awesome. That is a great way to practice all of this stuff because you don't have a patient yet in front of you. You can work on getting yourself to where your hand is in that location, your feet are in the right place, you know what kind of force you're trying to generate, you've got the location of where you're trying to move that.

Mm-hmm.

body part in between your feet and at your wheelhouse. And then you can practice over and over again trying to perform the way you use your body and see if you can't relax into that more and more. The more you can relax, the more comfortable you feel in doing that, the more force you can generate through that. If you don't have one of these tables or have no idea what I'm talking about, They do have these portable ones that I believe are called speeder boards, but those are just small versions of exactly the same thing. The only issue is the smaller the one you get, the less tension you're going to be able to generate. The good news is usually they don't cost that much, so you won't feel that bad when you finally get really good at this and you start breaking them. I'm sure someone who's mechanically inclined could see that there might be an invention here somewhere as far as training, but There's a lot of ways to do this. I've heard old chiropractors talk about practicing this with empty beer cans. I am not suggesting that. I'm just saying one could be creative in how they do it. Bands also work. Connecting bands to different locations and using resistance bands in order to work on how you move through that motion, also really good. Lacrosse balls, any type of weighted ball if you want to work on like cervical adjusting or Or like a side posture, like where you have the patient on your side and you're trying to rotate them, you can use a ball to try to figure out how to contact that and drive into that ball without having the ball just roll away from you. The key is, is that whatever you're doing with your hand is really a prop just to get you to drive in to practice with your lower extremities. Going back to the beginning, just to make sure— I know that in order for someone to get a new concept, we have to repeat it a number of times. So I'm trying to do that. What we covered so far is make sure your feet are in the right location, figure out which way you're generating force, make sure that where you're aiming at is in the right place, both in between your feet and vertically in between your hips and your diaphragm. There are some cases that deviate from all of those, but the exception should not be the rule. If you're deviating from any of these here There should be a very good reason, and it shouldn't violate a number of these things. It should violate maybe one. And then make sure those arms stay relaxed. You should not try to muscle through something. That generally not only gets you less force, but as an experiment, find someone that's going to be honest with you. And really contact somewhere that you would try to move. Don't move, don't do this, don't actually try to manipulate people like this, but just put your hands on them and contract as hard as you can with your upper body. And then relax as much as you can with your upper body and see which one the patient feels more comfortable with. They will tend to relax more if you relax more. So this is a double win for you. You're not only generating more force, You're also getting the patient to relax, meaning it takes less force to move the joint. And I know that what I'm talking about is trying to generate more force, and some might take that as I'm implying that we just need to generate maximum force on any region of the body we're trying to move, and that's not true. You can be very gentle, and you, you should be able to dial that forward and backward depending on what kind of patient population you have or what patient's presenting to you today. What I'm saying is you shouldn't generate 100% of your force from your feet and get 10% of that force out of your hand. Losing 90% of that force in your body is going to generate pain. So this is my rule. I generated this rule by doing the same thing that everybody does out of practice. So anybody that's a new student, they got out Or anybody that remembers their first couple of years out will understand what I'm talking about. I got out, I was seeing a bunch of patients back to back because I was low man on the totem pole, and that's how it rolled there. There was no discussion of mechanics. I blew out my wrist, my elbow, my shoulder in quick succession. Like, it was, it was bad. And there was no scenario where I could like stop, like just call in sick for a week to rehab. That wasn't going to happen. So this falls back to what we saw in that first research study. Providers keep practicing because there's not really an option a lot of times. So I made up this rule, and this has worked for me since then. I should not be sore above my belt or my waist. If I am sore, I have done something wrong. I need to figure out what I did wrong in my practice that day. That cannot happen. Tomorrow. I know I have succeeded at this because at the end of the next day, I should not be sore above my belt. I know this is a very simplistic way of doing it, and I realize that if I had everybody in a room and asked how many— if all of you were seeing patients all day, how many people are sore in their upper body at the end of the day? I'd get a significant percentage of people to raise their hands. I'm not trying to say this like bragging. That's not the intention of this. I'm just trying to show that I am living this example, which is I'm seeing more than 50 hours of patient care a week. I am treating that many people every week. Some of my days are 12-hour days, some of them are 10, some of them are 8, but then involve travel back and forth. And all of my patients is hands-on care. The area that I am most sore at the end of the day is my calf. It's never above My waist. The only time I've ever had this happen is when I let myself not pay attention to engaging my shoulder and I got sloppy and I gave myself impingement on my shoulder. This rule does work. Now, it's not going to work for fatigue if you're being crazy and not taking enough time to warm up in the morning, rest, and be honest with yourself that you're ready for another day. Obviously, even if you've got the best mechanics in the world, eventually you burn out. So I don't know what to say about that. Just be true to yourself about your own resilience.

That's it for today's episode. Be sure to tune in for part 2, where Dr. Pence teaches us his 90-90-90 rule for shoulder, elbow, and wrist positioning. We'll also learn the optimal way to configure your treatment space for maximum efficiency and comfort, and the importance of the ability to generate force through fluid, balanced movements. You won't want to miss it. Episode 88 drops in 2 weeks. If you're interested in learning more from Dr. Pence and would like to submit a question for an upcoming Q&A episode, please click the link in our show notes and drop us a line. We read each and every one, and we'll be sure to feature your burning questions when we have Dr. Pence back on the show. And if you enjoyed today's episode, be sure to share it with a friend and then visit our website at factorpodcast.com and leave us a review. That's factor, F-A-K-T-R, podcast.com. As always, I highly suggest you check out our show notes for links to additional free resources and special offers from our sponsors. We'll see you next time. Hey guys, if you like what you heard today, I encourage you to visit our website at factor 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 The best 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.