Nerve-driven heel pain, graded exposure and why rest backfires

What do we need to do to get people better in general? And I started thinking about with immunology or just with kids who are exposed to chickenpox and all of these vaccinations they give them and so on. Whether you believe in vaccinations or not, I don't really care, but just exposing them to bouts of the pathogen when they're younger so they can have a strong immune system so they're more resilient. Obviously, each kid can get sick because the exposure to that pathogen might be too much. So within movement here, I kind of consider the same thing. If we expose them too quickly to something, whether it be weightlifting, deadlifting, running, jumping, then we end up possibly passing the tolerance point of whatever tissue gets pissed off.

You're listening to the Restoring Human Movement podcast, where movement experts discuss the latest evidence-based practices to help you and your clients move with mastery. And now, your host, Dr. Sebastian Gonzales. Hey guys, this is Dr. Sebastian Gonzales, your host for the Restoring Human Movement podcast. Thanks for joining the movement. If this is your first time listening to the show, this show is mainly targeted at more advanced patients, ones that are taking an interest in their body and how to improve themselves through loading as well as treatments and so on in different parts. So I've scattered a couple episodes here and there about a little bit more patient-friendly terminology, but also to the healthcare providers who are looking to improve their practice and just kind of be a little bit more open-minded about things that there are out there.

And the podcast today is just a solo one, and actually one thing I thought I would cover today is more of my experience of the things I've learned through podcasting. I mean, I've been through over 125 episodes now. I've learned a lot. I've interviewed a lot of people, and I've had a couple aha moments as well. And I thought I would share some of those with you today. So hopefully if you haven't listened to some of the old shows, then you go through and listen back to them as well. So I'll be referencing a few. I'm not quite sure how many I'll get through today. But I'll start to elaborate how that podcast and speaking to that person changed my practice, changed the way I think about injuries, changed the way I think about the human body, and how it's improved my patient care.

In case you're really wondering what spurred this type of podcast today was that so every once in a while I do get emails from listeners. And thank you, everybody, for your emails and feedback and every single bit of mail that I get via Instagram or email, I really do take it to heart. And I listen to things you guys have to say, and it really keeps me going. So it's always nice to hear that you guys are liking stuff on the other end because, I mean, there are, at this point, I think we've been staggering around 1,000 downloads or so per episode. Some of them get up there a little bit more. But for the most part, I mean, I feel very special that I'm speaking to 1,000 people.

So I got this email the other day, and it was from Stephanie up in British Columbia, and she said, I'm a big fan of your podcast. Thank you so much for all the content. I find it unbelievable that you're able to put it out or to put it out. It's so refreshing to hear so much of what you have to say. I can't tell you how helpful it's been in my practice. Okay, enough gushing. And then she went on to a lot more, and we had a little bit of an email thread back and forth about some of the things that she's looking to do in her practice. So I thought, after I wrote that, I thought, hmm, how has this podcast changed my practice?

So that's what spurred me to do with something like this. And don't worry, if this is your first show, then I'll always like this. I interview industry experts as well as reflect a little bit more of easy terminology for you guys to share with your patients. Or if your patient's listening, you should get a little bit more easy terminology stuff that is more healthcare-related and recovery-related rather than me self-reflecting. So if this is also your first show, too, I typically like to share a little bit about myself, mainly because I believe that if you watch nighttime TV like Jay Leno or Conan O'Brien, you typically go on because you like the person, and then whoever they interview or whatever they talk about is just a bonus, all right?

Eventually, you get to the point where, I mean, if they had crappy people all the time, you probably wouldn't like them. But hopefully, if I'm showing a little bit more about me, and if you like me as your host, hopefully you'll tune in more and start to learn more about healthcare and sports injuries and recovery and so on. So here we go into that little bit. Now, recently, I know a lot of you have probably done 23andMe, and this is not a promotion for 23andMe. I haven't done it, and I'll tell you the reasons why. Number one, I think it's a big scheme. I think it's a big... So, by the way, just if you're all listening, all of a sudden I disappear off the face of the earth.

It's probably because this was a scheme, all right? I think it's everyone trying to get all their information public voluntarily and give it to the government. I don't know. I'm a little bit more off the grid, but here's something I observed recently, because I started thinking about, like, how do we know this is all accurate? I know there are going to be researchers this, and we do it this way, and blah, blah, blah. So, recently, someone told me that 23andMe found out that their mother was 50% Jewish. And I thought, cool, great. And then so, a week went by, and I started thinking about it more.

I said, Jewish? How does that work? Jewish is religion or culture, right? I know it's both, and let's just say Christianity. So, Christianity is a religion. How can you tell, how can a blood test tell what your religion is? So, I started thinking more. I'm like, so, do they mean Israeli? Do they mean from that region? How can you tell that someone is 50% Jewish? Can you tell that they celebrate Hanukkah by a blood test? Can you tell that their family is not religious, but they celebrate the Jewish culture? How can you tell that? So, it really makes me think, like, what is the validity of this test, period?

So, I never had one personally done, and I've never seen a result. But it makes me really think. So, if you guys have had it done, I know a lot of you have. What else is on there that didn't make any sense? Or actually, am I stating this correctly? Because, again, I've never seen it. Does it actually say you're 50% Christian? You're 50% Muslim? You know, you're 50% you like clam, your family liked clam chowder? I don't think we can tell this stuff. And maybe I'm wrong, but someone explain this thing to me. All right, back to the content. Now, the first episode I'd really like to highlight is, and I've been exposed to this a couple times, and I'll tell you kind of context of those as well.

But when I had Justin Dean on, Dr. Justin Dean, he's a chiropractor, on episode 51, we were talking about plantar fasciitis foot problems with runners, and he was presenting the idea that there's a possibility that plantar fasciitis is not actually plantar fasciitis, or actually that the pain on the bottom of the foot is actually not from that. And I know that with a lot of healthcare providers out there might think, well, maybe it's sciatica. Well, maybe it's not even that, right? Because it's in the inner part of the foot he's talking about, right around the heel. The typical presentation that you guys see with heel pain, maybe it's not actually the plantar fascia, right?

So he provided a little bit of thought where he said maybe it's an issue with a nerve. I think we talked about the medial calcaneal nerve, but more in, and I know we talked about the saphenous nerve. So the saphenous nerve, if you haven't looked at anatomy book in a while, it tracks in the inner part of the thigh, all the way down to the inner part of the leg, or the shin, and down to the inner part of the ankle. So he said that there's a possibility that some of these cases aren't actually, they don't need actually tissue care down there. They don't need, you don't need to beat up the plantar fascia.

You don't need to roll out the plantar fascia. And you might not even need to do even short arch exercises and so on. Maybe it's just a simple thing where we unload the nerve. And we started talking about the concept of dermal traction, or skin rolling. And if you've been listening this far, and you've heard a lot of episodes, we talked about skin rolling a couple times already. They do have a website called Dermal Traction Method. It was developed by Justin Dean and Philip Snell. I've had Philip Snell on as well. And they basically show you different spots you can roll the skin, and it unloads the subcutaneous nerves, the nerves under the skin, to really make the area feel better very quickly.

So I remember my first time after talking to him with this, and I had a plantar fascia person in. And I started to, actually I took a suction cup at the time and put it around the inner part of the medial malleoli, or the posterior aspect, kind of around the tarsal tunnel. And I just kind of grabbed it right there and had him walk around. Or I said I put the suction cup on him and had him walk around. Previously, walking around was painful, and all of a sudden the pain was gone. And so I wasn't really addressing anywhere on the actual foot. I was more above it. And so just to kind of play devil's advocate, I kept moving the thing up.

And I got it all the way up to about mid-shin inner part, obviously kind of around where the saponous nerve is going. And it kept improving. Like it always started feeling better. And the person was like, what the hell is going on here? I'm like, that's a great question. So it really enlightened me with that. And I remember that there was one time where we, me and Cody were hanging out, and someone was talking about numbness in the fingers, into the fourth and fifth finger. And so he grabbed them right around like the elbow, inner elbow, where the ulnar nerve comes down. And he said, hey, just grab the skin right there.

If it's tender, maybe just make it roll a little bit. So there had been a couple times where I've been exposed to it already. And I know we talked about it with Maine syndrome as well. But I really didn't take it to heart and do a lot of it until I started realizing the power of it by talking to Justin and then applying some of it in my office. Now, there's another episode, I think it was 119, where I talk about a case where someone came in with neck problems. I pulled in the skin around Herb's Point, just behind, or just the front part of the SCM. And it took their pain away too. Some people with headaches into the, behind the eye, where typically we treat the suboccipital group, if you just grab the bottom area, kind of like on the very last chunk where the skin is, or where the hair is, and pull up on the hair just a little bit and lighten the skin off the skull, sometimes that takes it away.

And it was just crazy shit. So it's really changed my thought with when I should apply tissue work to the areas where I'm applying tissue work. It only works part of the time. But I found it work with a variety of cases. I've had a medial hand numbness decrease with that by putting it kind of around the tunnel of Gion. I've had neck pain, shoulder pain, that mid-back ache that everyone says they have just into the T-spine area, and they're always rolling that thing out. That thing decreases too, surprisingly, and not even in the spots that you think. I've had, personally, I've had extension-based spine pain, which is decreased in the lumbar spine with the same, similar thing.

So considerations of maybe main syndrome. And even areas around the knee into the infrapatellar nerve, which then goes into the patellar tendon area. That thing tends to unload as well. So it's all surprising stuff because it really helps me navigate where I want to go in my session with that person. And it really challenges that person's thought of what is creating this condition. So why don't we go into that little interview section right here where you can probably see, I'm like, hmm, that's interesting. And just see if you guys have the same experience. So I take a neurocentric approach, which basically means that I assume it's the nervous system generating the pain.

The nervous system is what leads the pain. But I assume it's a nerve irritation until proven otherwise. So with the foot, the two big nerves that you need to consider is the tibial nerve, which is what a surgeon will go in and release on these chronic plantar fasciitis cases. They'll go in and loosen up that tibial nerve. Why can't I think of the room there in the heel? Like a medial calcaneal or something? Yeah, that's what I'm thinking of, which is a branch off the tibial nerve. At 7 in the morning, I need more coffee. And the one that I have particularly been trying to push in the social media in the last couple of years that I've got ridiculed for is the saphenous nerve.

Most of the anatomical textbooks that we use show the saphenous nerve ending, say, mid-calf. And the saphenous nerve is cutaneous nerve that if you look at nerve block research and surgical anatomy literature, it can go all the way down to the base of the first metatarsal or the first big toe. So it needs to be considered an arch pain and ankle pain on the medial side of the inside. So those would be the two areas that I would look at first. Because if you have a nerve that's irritated, it's going to alter the way you move. So it's going to give you... You're going to waste a lot of time doing, say, something like the SFMA because you're going to see a protective movement pattern that may not be present once you relieve or remove, in theory, the thing that's causing the protective movement pattern in the first place.

So I would have limited all that first prior to doing something like the SFMA. So how would you explain... Because I know people are probably thinking, well, we're still talking about plantar fasciitis. We're talking about the plantar fascia. What does the nerve have to do with it? And then explain how you address the nerve before testing movement. Well, what does the nerve have to do with it? Well, let's look at it from a running-specific perspective. Runners tend to be skinnier. They tend to do repetitive stress. And they tend to do an exercise that is in the anaerobic state, which means... I mean, sorry, aerobic state, which means they are constantly using oxygen.

Well, nerves get irritated in certain specific instances when there's a high tensile or compression load and when there's lack of oxygen. Well, when you're running, your nerves are constantly being stretched and compressed, which is one mechanism that gets them irritated, such as, say, a disc herniation on the nerve root causing... And the low back causing sciatica. That's the easiest one that everyone knows. Sciatica, pain down in your leg and the low back. Well, when we're looking at it from the foot, that same thing happens. If you have poor control of your foot, you're going to have a rapid stretch and compression of the, let's say, the nerves on the inside of the foot, the tibial nerve and the saphenous nerve.

So, and then you have lack of oxygen. So, you have rapid stretching from poor control of the foot, potentially, and the nerves not getting that much oxygen because you're running up the side of a mountain. And then compound that with how do nerves protect themselves from compression and stretching, well, compression mainly. Fat. So, runners tend to have less fat. The next episode that I really took to heart was 91. That was with Michael Shacklock. And I've taken a course through him. It was great. So, if you guys have the opportunity, go and take a course. He's from Australia, so it's a little bit harder to get him to the States here, but he does a little bit of circuits here and there.

He has an advanced course coming up here that, if you haven't taken it already, you probably should. But you can't take it unless you take the first one. So, the first one, he goes a little bit more into theory. And so, in this podcast, we talk a little bit more about theory because I've already taken his course. I didn't, I mean, I wanted to know a little bit more, but I wanted to know really what he's excited about. And the very tail end, I ask him about what he has been considering as an interesting thing with nerve-based conditions or just neurology overall. And he kind of mentions in a nutshell that nerves can adapt.

And I'll show you that clip here in a couple minutes. But he says that nerves can basically adapt a telescope. And over time, kind of like if you're trying to improve mobility or range of motion in a joint, you have to expose it to it a lot. So, it kind of made me think that, although, not like, it made me kind of rethink flexibility. And in the past, I don't want to actually, I'll retract that a little bit. Flexibility, mobility, whatever, I'm talking about the same thing. Flexibility as a general concept is fairly, I don't want to say dead to me, but I don't use it a ton. So, let's just say increase in range of motion.

So, it made me really think that when we're doing things like PNF stretching of like a hamstring, we're actually improving the nerves' pliability. And it makes it so it, for the most part, can go further without being traumatized. But as a general concept, and this made me really think about what are we doing with these people overall to get them better? Like, what do we need to do to get people better in general? And I started thinking about with immunology or just with kids who are exposed to chicken pox and all of these vaccinations they give them and so on. Whether you believe in vaccinations or not, I don't really care.

But just exposing them to bouts of the pathogen when they're younger so they can have a strong immune system so they're more resilient. Obviously, each kid can get sick because the exposure to that pathogen might be too much. So, within movement here, I kind of consider the same thing. If we expose them too quickly to something, whether it be weightlifting, deadlifting, running, jumping, then we end up possibly passing the tolerance point of whatever tissue gets pissed off for whatever reason. Maybe it's just overall, like say you have someone like jumping, you know, for two hours one day and they haven't jumped before in 20 years.

You might have a bilateral Achilles and patellar tendon just light up, right? Maybe that same person has the right side light up, not the left. So, maybe the tolerance was too much for the right, not the left. Why is too much tolerance, we don't know. But from a rehab and integration back in the sport perspective, I would think I would want to expose that tendon to that movement or that load, which is going to be exposed to anyways. So, if they're a professional jump roper, maybe we should start getting them slowly back into jump roping. But overall, I think humans should just be resilient. Like, I did take an antibiotic recently for something, but I took them a lot when I was younger as a kid and I generally try to stay away from that kind of stuff now because I believe the body can heal itself and it can be resilient if you let it.

But I think my personal thought with that is when you hit a certain tipping point, maybe we need to intervene and help out a little bit or else you're going to die. But when it comes to this movement, maybe we start exposing them slowly to other stuff like not just weightlifting, not just robotic movements, but also to getting them into a sport. I like to think about taking them into a reactional-based sport and my analogy for a lot of people would be like, so I'll grab my baseball bat in the office and I'll say, what is the perfect swing, right? The ball comes down the middle, I hit it, it goes out of the park, that seems like a perfect swing.

But realistically, when I'm playing baseball, there is no perfect swing because the ball might be outside, I might be spinning differently, maybe I have to react to it differently, maybe I'm off balance, maybe I'm poking it to the right, maybe I'm pulling it to the left, maybe I'm bunting it, you know? So there's all these different things and really what is kind of a telltale thing or what makes this occur is my reaction to the object. So I like to push people a little bit more into the exposure of a reactional sport when possible after they've started to really accumulate their tolerance to load in their weight training.

So I like to think when we eventually expose them to load, eventually we have to expose them to non-loaded variety of movements. And we can get them to do things like dance and play baseball and throw a ball and things of that nature. Or we can give them a nice choreographed thing, kind of like Tai Chi. But I know some people, they don't want to think that much and I don't really want to think that much either. So I'd rather just play a sport. So kind of retracting back on this clip that I'm going to have of Michael Shacklock, it made me really think about not just the, so the nerves also have to be exposed slowly to things too.

And it seems like just for me as a general concept, a graded exposure to a lot of things will help out not just muscles, not just tendons, but also nerves, your nervous system. It'll help out a lot of things. So immune system and so on. So let me play that clip for you here. One of the things that I'm really keen on is a study that was done recently where they found, did you mean your neurodynamics? Oh, anything. I was in your neurodynamics. I knew you were going to tell them about your smoker. Yeah, I've got a really good kamado at the back here that I'll get going soon. A ceramic kamado, yeah.

There's a study done where they looked at the elasticity and the extensibility of peripheral nerves in different regions along its course. And this is something I wrote about in 1995. My contention at the time was that the nervous system is not mechanically uniform in its behavior. It's specific. It has variations along its course according to the local needs. And this study, and it's on the website, neurodynamicsolutions.com, is a feature article if you want to read it. But basically what they showed was that a nerve between joints, so a long part of the bone, the extensibility is different from across the joint.

And they tried to relate it to Sunderland's proposal in the 1970s that the protective mechanism of axons in nerve was produced by the connective tissue of nerves. So epineurium, perineurium, and so forth, which is all logical. So the extrapolation was that nerves will be tighter with its more connective tissue in the nerve, or they'll be less extensible, less elastic. Well, this was not. This was the other way around. Was it more connective tissue, was it more elastic? Well, it's actually the amount of connective tissue did not correlate with the lack of extensibility of the nerve at that location.

So what they found was across joints, the nerve was much more extensible. Between joints, it was less extensible, independent of the amount of connective tissue in the location that they were investigating. So across joints, there was more connective tissue, but that didn't make it less extensible. In fact, it was still more extensible across joints. That's not the telescoping phenomenon, then? It's something different? That relates to it. It relates to it. Now, as you straighten your knee, for instance, you expose the tibial nerve behind your knee to much more elongation force than you do the tibial nerve down the leg or the sciatic nerve up in the thigh.

So what the tibial nerve does is it responds to its local mechanical effects. And so it's not just about connective tissue. It's about what it does, how it functions, what it needs. Do you think then is that – I'm just – I'm thinking about like developmentally, like a lot of the body will adapt to the stresses put upon it over time? Yes, probably what happens is a bit more friction there, so it develops more connective tissue, but because it's stretched more, that softens and it has a viscoelastic response. So there's many mechanisms. But for me, that's really important for rehabilitation because how we move produces local effects on the nerve.

And if we change our movement, we are likely to change the local effects on nerve and therefore the nerve movement. And the balance of functions along the nerve is specific to the individual. The next one we're going to cover is Tom Michaud in 94. I finally learned how to say his last name. Tom Michaud, if you haven't heard of him already, he wrote a book called Human Locomotion. And actually, funny, he drew all the pictures in it. I have to admire the guy for that. But his storytelling ability was amazing. So the thing I learned most from him was he's a smart dude. He's written very technical stuff.

Like that book is heavy, not just in regards to how thick it is, but it's just heavy reading. It's technical shit. There's a lot of biomechanics. And when I've interviewed Tom, I listened to a couple of podcasts he did before. And it was interesting to see how he kind of edged you to the point of like tolerance of like you're thinking about external rotation and adduction and blah, blah, blah. And all of a sudden he pulls it back to a nice story. And the exposure, I guess, if we're going to go on to exposure again, sometimes it's just too much. And I think about like when I had my dog, I went to have the dog taken, so the lady took a look at, the vet took a look at her knee.

She had a canine cruciate ligament, CCL problem, and she was limping. And so the vet was very good, spent like two hours, two hours examining the dog, fitting Maggie for like a brace and so on. And I appreciate all the time she spent, but at the end I literally had to go in to sleep. She was talking about a lot of things, and I had to digest it and retain it and really make use of it. And it was challenging. So as I went through the interview with Tom, you see how he nicely blends from technical stuff to storytelling and being a real human and kind of having that common language that we should have between patients and clinicians to make sure that they know that we understand where they're coming from and we can communicate and be able to explain what they need to understand through their own terms.

And it's nice when the person meets us partway too, but they don't always do that. So that was amazing to hear from Tom. And I think, Tom, if you're listening to this, I think you should do a lot more podcasts. I know that it took a long time for us to set up our thing, and I know you're a busy dude, but I think you would do fantastically well. We can sell more books and we can get people to really start reading and following you because you're a smart guy. He's a DC. So everyone should check out session number 94, and I'll play a little clip here so you can get a gist of how darn good Tom is at this stuff.

Yeah, that's a really great question because over the past, like I'll make a new exercise device once every two years for something. I made an ankle rock board that inverts 20 degrees, inverts 10 because that's the foot your range goes through. I originally got the idea just as a way when that Reber paper came out 20 years ago, I treated a lot of runners, and Reber showed that the biggest force deficit in a runner, muscle deficit, was in their peroneals. That's the reason that they slow down. That's the reason they're not as fast as they go into sprinting speeds. And a friend of mine was running on the beach, and he was going south on Cape Cod, and he asked me which muscle was sore.

And he ran for a long distance, and I said, because you were going south, your left foot would be inverted, so your peroneals would have been tight. And he said, yeah, the outside of my left calf is killing me. And then I thought, if you could make like a jump platform that was inverted bilaterally, because you couldn't have someone run on a can because one side would be inverted, one side would be inverted. So I made this wooden platform that was three feet by two feet that was pitched 20 degrees, and I just had people do jumps with weights on it and land it. But there was a risk of ankle sprains on that, so I kept playing around with the angles.

And then I just kept tilting the shape around to have it become smaller and a little more pitched. And then with all the, you know, I've always done eccentric and concentric loads for Achilles disorders. And then I found that paper on toe strength and then Goldman's paper showing that when the toes were exercised in a length and position. So I just kept adding pieces of clay to this platform until I came up with a shape that was right. Then I made it as small as I possibly could. Then getting the durometer of the foam right was impossible because it has to give more under the toes. So I ended up after having it manufactured, I had to have it remanufactured with a gouge out beneath the central grind where the toes are so your toes would compress more, but the peroneals would stay under tension.

And then for older people, I made the gouge at the base so that when they lean into it, it would give under the tips of the toes so that they could increase their anterior fall envelope. And that's that thing when you stand up. Most falls, people who aren't familiar with falls in the elderly, 40% of people over 70 fall annually. And most falls happen at the initiation of the gait cycle when you start to walk. So if you just stand up, balance, and then keep your arms at your side and just lean forward with a straight spine and torso, you feel the tips of your toes pushed down. Some people, now that I've been doing this thing for a while, I can go to like a 40-degree angle forward.

The distance you go is called your anterior fall envelope, and it's determined by toe strain, particularly hallux strain, big toe strain. And that's what I really set out as a goal with that thing to strain them. But then you saw all the stuff with improved running performance. When that article by Peke came out showing that older masters runners, and these were, you know, guys in their mid-30s, and they were slowing down, 11% decreased force output in the foot and ankle. I had just previously read the article by Booth where they talked about how our genes were developed to respond only to activity.

Satellite cells sit on the side of muscle fibers, and if you don't stress it to a certain threshold, they don't rebuild. So that's what made that article so fascinating. I just had finished reading Booth saying we need to exercise because hunter-gatherers don't get age-related muscle wasting like we do. I mean, you lose almost half of your muscle fibers between 50 and 82, and it's avoidable. And you can use lightweight. That whole thing, American College of Sports Medicine says you have to do four sets of 10 and 90% full effort. When those fibers start disappearing, when you're in your 50s and 60s, they're replaced with scar tissue and fat.

And so if you attempt to lift 90% full effort, you're going to tear stuff. And what they showed in multiple studies starting in 2017, all you have to do is do 35% full effort, four sets of 25, with a 30-second rest in between. You can't take a long rest because that short rest allows for an increase in pressure inside the muscle that shuttles blood out of the muscle, like squeezing a wet sponge. That forces you to recruit your fast-twitch muscle fibers, which are the only fibers that can get by without oxygen. And it's recruitment of fast-twitch that produce muscle repair and remodeling. So it's a really simple technique that, you know, they had one study of the elderly where they had them do a protocol like that.

There were 90, almost 90 people in the study. Only two dropped out because no one gets hurt. And at 30% full effort, most of the protocols take five minutes to do. Okay, the next one I'd like to address is, it's a recent one, it's 117. This was with Dr. Cameron Marshall. We talked about concussions. One thing that I thought was really cool with just human bodies in general is it seems like, and this is a general statement, is that movements should occur, exercise and challenges should occur sooner than you think. And so we kind of go through on this that when I first learned more about concussions through the DACVSP program, we were going off the premises that we should get the people to rest.

No lights, no cell phones, no TV, just lay in a dark room for 24 hours until symptoms started to change for the better. And then we progressively get them back into play. And Cameron, Dr. Marshall, really challenged this, and he proposed some research that showed that people, especially with chronic concussion symptoms, seem to really respond well to exercise. So eventually they started to bring this more into acute cases. And it seems like, whenever all possible, movement is medicine. Seems very simple, right? And movement starts to get blood to the brain to help it repair. And it was just fascinating to me that, I know that for me, I don't manage concussions, and probably because, I mean, some of you probably listen to this, you're thinking, yeah, you don't know shit about concussions.

Things have changed. I know, I get that. I don't manage concussions. It's not something that I typically do. I'm familiar with the stuff, but I really don't. I wouldn't see myself as an expert in concussions. But it was interesting to see with something like a brain injury that you think that we baby these people, you actually don't, you know? And babying them tends to make them a little worse. And I know this is probably a hot topic, but I've considered this with pregnant ladies, you know? And I know that looking at old movies and TV shows, as soon as you see someone's pregnant, you start to say, oh, no, you shouldn't be doing that.

Don't lift anything. Don't. Like, you need to rest. And like half the time, you can't even see a belly on these ladies yet, and all of a sudden, people are telling them to rest and take it easy. I tend to think that's more of a deconditioning thing. I don't think it makes it so we end up seeing these people, these ladies come out with all these post-pregnancy problems, you know? I know this is a much broader topic than I'm talking about now, so I'm just going to propose it as a theory. So anyone working with mother-baby out there, don't hold this as in stone. But just from my observation, I see that people tend to baby people who have injuries.

And pregnancy is no different. Concussions are no different. People tend to say, hey, maybe rest it off. Other people, I like this theory, rub some dirt on it and just keep moving. Walk through it. Eventually, the body, I think, think about this. Why does a limp happen? Like, if you hurt your ankle, why do you start limping? The body's pretty damn smart. It just tends to start offloading an area so it can repair. Now, that first aid process there, I think we talked about it a couple podcasts ago. That first aid process is there for a reason. It's there because you need that to happen. But it's a very acute time frame.

After that, your body, or say that tear in that ankle, has the ability to transfer loads. We need to start getting weight back on it. Now, there might be a little glitch in the system where the body tends to not want to load on it. But we have the responsibility as healthcare providers to get these people moving again, at least get them walking, at least get them carrying stuff and coming up and downstairs and starting to feed themselves and all that kind of jazz. So, my thought is that the body is not stupid, okay? It'll offload areas when need be. But also, too, that whole thought about listening to your body and knowing what it needs, sometimes it's good.

Sometimes we can take it a little bit too far. And I know that I personally had an incident about a year or so ago where I was making beer in my garage. And I dropped this big old glass five-gallon jug of beer. And it didn't go very far to the ground. It only fell about three inches or so. But it shattered and it actually opened up right around my left ankle's medial mileoli. And I can literally see the tendons in there. I actually couldn't walk on it for about a month for various reasons. But eventually when I could walk on it, it was a little tender and I slowly exposed it to that weight. And eventually I got into squatting.

And I didn't go jumping. I didn't go running right away. But now, today, it's interesting to see that it no longer hurts, right? It hurt like bloody murder. It felt like my ankle was going to explode when I put weight on it. But the body's smart. The pain's there as an alarm. And I couldn't load onto the foot, so I shift to the other side or I crawl. So, what I learned from this snippet, which I'll play for you, is that movement is medicine. Literally. And sometimes you have to force the correct medicine on people because there's a lot of biases that they'll have, that they've been told, that what they've read, all this old information that was kind of hindering them from progressing forward.

So, maybe that old information is good, but it was good for a period of time. Remember, there's that first aid process. And if you, actually, if you heard the other podcast as well, I mentioned my book. So, part of my book is mentally getting these people ready to apply movement as medicine. So, there's a lot of times people that will, they'll fear that if they don't rest for a month, then their ankle will never get better. There's a fear that, and Dr. Marshall talked about it with the podcast 117. People will say that when they came in, they did everything they possibly could for the concussion, and it's not getting better.

What the heck can you do for me? And he's like, what'd you do? And he's like, oh, we rested the whole time, as needed. No cell phones, nothing. Didn't even do homework, you know. So, at what point are we making our patients worse, or sorry, are the patients making themselves worse by fear and these thoughts, these biases of what they think should be applied to their body? So, sometimes we need to be the bigger person and kind of force them back into daily life and movement. We're basically like sharks, in my opinion. You have to keep moving a little bit or else you don't get air into your gills.

And I've even thought before that, so, say like with walking. So, we know that lymph, the lymph fluid from the foot and ankle, like people with edema down there, you got to get the foot and ankle moving because there's this natural pumping effect. Lymph doesn't come up unless you have the muscles acting like it's kind of like a squeeze pump. So, to even think about like with chewing or talking, like what is the secondary thing that's occurring there? Like, when you chew, maybe you're mobilizing the muscles of, or sorry, mobilizing the nerves of your face. Maybe you're producing saliva. You know, there's a lot of things, secondary things.

I know Michael Band in 95, he talked about the pumping of the diaphragm. It's not just for respiration and not just for the theory of supportive intra-abdominal pressure, but maybe, he said, it also pumps lymph up. So, all these other things occur. So, when you're moving and walking, maybe it improves your digestion, right? When you're moving and walking, maybe it improves blood flow to your brain, which helps the concussion. Maybe when you're walking, it starts to slowly progress load onto the foot and ankle. Maybe when you're walking, you walk with arm swing, it starts to mobilize the spine from the mid-back, which helps unload some neck problems.

So, overall, I'd say my thought when I talked to Dr. Marshall 117, again, the clip is coming here, is that movement is for more things than you think. So, let me play that clip right here. You know, it might be the day or two after they saw that doctor and went, oh, shit, I didn't ask him this. And, you know, am I allowed to exercise, for example? Which they probably should have been doing, but now they didn't ask, so they're going to wait six weeks now to start something, right? Whereas if they're seeing me, I'm going to see them, you know, probably once a week for the first couple weeks to try and get them going on something.

But they can continually ask me questions, and I can continually reassure them, which I think is kind of the benefit of having more frequent follow-ups with patients. Well, I know we're going to go full circle back to exercise at some point here, so that's a good point probably. But you said something on a different interview that I heard. It was you figure out the things exercise-wise that they can actually do successfully, not trigger their symptoms. I would assume, and you correct me if I'm wrong, but the first couple times if you're implementing exercise, you find some that are fail points, and then you find some that are successes, but it's a trial and error process.

Is that right? Yeah, I mean, with just cardiovascular exercise, I think it's one of the most important things, is just get people moving. And it used to be that you would rest, rest, rest, you know, after injury, and, you know, don't do anything. Just stay on bed rest. It's the same type of thing we used to do with patients with low back pain and neck pain. Put them in neck collars and tell them not to move. And, you know, but that's just, we found out that's the worst thing you do for somebody, and we're starting to realize that's the worst thing you do for somebody with a concussion as well, is to put them in this cocoon dark room therapy, which ends up making them more sensitive to light and more, you know, deconditioned than anything, and more depressed and more anxious and everything else, which then compounds and makes things worse.

And so in the acute phases now, we're learning that exercise is actually potentially beneficial or therapeutic even as early as the first day. Now, there's only been a couple studies on this, so we haven't gone to the point of full bore recommending patients start exercising that early, at least vigorously. So what we do in the first kind of 24 to 48 hours is we tell them to take it easy, but they can go on their computer, they can go on their phone, they can do some homework if they feel fine, they can do anything from a cognitive standpoint that doesn't provoke their symptoms to a significant degree.

If, I mean, if you're sitting there with a headache, but, you know, you want to watch TV and the headache is staying the same throughout, well, are you really doing any harm? Well, probably not, right? But if your symptoms start getting provoked, well, maybe shut it down. But one thing we will always tell them is to not just lie on the couch and do nothing. We want them getting up, going for walks, you know, doing household chores, provided they're not too strenuous. You know, if they're a kid, you know, clean your room, do the dishes. You know, you can vacuum the carpet. Like, it's not a big deal.

You can do a little bit of kind of physical activity, keep yourself moving and occupied. It's when people sit around and do nothing that they have the chance to focus on their symptoms and things like that. When you get a little bit further out, when you get into, you know, maybe a week or so after the injury, we're actually getting to the point now where we put people on the treadmill at the 10-day mark. And I think we're probably going to start doing that earlier and earlier, but we actually run them through a protocol. And that's when you get into establishing what their threshold is. So we'll put them on a treadmill and we'll gradually ramp up their heart rate through a walking test.

It's kind of a standardized test. It's called the Buffalo Concussion Treadmill Test. We'll put them on that, you know, within the first 10 days or so, if they're still symptomatic. If they're still symptomatic at 10 days, we say, okay, what can you do? Let's see what your physical capacity is. And we start working them out and then they get symptomatic, let's say, at a heart rate of 155 beats a minute or whatever. We say, okay, 155 is your threshold. So we don't want you working out at 155. We want you working out, you know, at less than that. And so generally the rule of thumb is 80% for non-athletes, 90% of their threshold for athletes.

And you want them to work out at that 90% rate so that they're improving that blood flow. They're getting the blood flow going, but they're not creating, you know, symptoms for themselves. And the same thing goes for the vision and vestibular type stuff. It's like, okay, well, what can you do? Does this make you symptomatic? Okay, we'll do it, but do it, you know, at this level, not this level yet. And then we'll progress you as things, you know, improve in that way. But I think the big thing is people tend to baby concussion patients. We really tend to, you know, back off on everything. And, well, don't do that if that makes you feel, you know, symptomatic.

And I think what we have to start doing is being a little bit more okay with symptoms. I think symptoms are, you know, a loose guide in terms of what you should and shouldn't do, but you shouldn't totally avoid it, completely avoid it because you end up kind of regressing in a way that I think is damaging. And I think that was the issue with exercise is telling somebody to rest and sit in a dark room and don't do anything. Well, now you have somebody, let's say, who are an athlete. They completely decondition themselves. And now any type of exercise, like walking up the stairs or going outside for a walk, provokes symptoms is because they're so out of shape by this point that even getting their heart rate up slightly makes them feel dizzy and nauseous.

Well, you know, it's like if you haven't worked out in a while and you go back to the gym and, you know, you have a hard workout. Well, it's kind of a great thing. I think, I do think you're right with, I know you have, we had back pain and neck pain and all that stuff where they tend to rest them excessively. I know there's the time and place for it, but I've noticed that people tend to have a lot of sympathy or empathy for people in injuries and they just tell them to rest and relax, you know. And I don't know, I think it disables the people, honestly. But there's that acute phase, which is obviously I think we're needed, but then the rest is like, just get them moving, you know.

But it's funny how it kind of comes full circle on that because I never, like, I know very minimal about concussions. I know enough to know that there's a scat and I know that I've done a scat a couple times, but I don't like managing, I wouldn't manage a concussion. But it's funny that it kind of comes full circle. It's like, okay, well, you're not moving. Why don't we just move you, you know? So I don't know all their tolerances though. Yeah, I mean, that was, I think that was, I mean, kudos to the guys in Buffalo for kind of going down that road because without them taking that chance and that idea, like it was, you couldn't even get a study like that pushed through like ethics committees because it was considered so common knowledge and best practice to just have people rest that even the idea of saying, well, why don't we try exercise was like a difficult thing to get pushed through ethics.

And they started out with like really, really chronic patients saying, well, like rest isn't working. Let's, you know, get them exercising. And then just with like an eight week exercise protocol, they had like almost a full resolution in symptoms and like 70% of their sample or something. So then all of a sudden they go, whoa, okay. That was a fluke. Rest is better. Yeah. Like rest, rest obviously isn't working, but there's something here. And then that led now to, let's say, okay, let's try these people at a month. Then two months, then all the way down. And now we're getting to the point where the study's coming out showing like exercise on the same day of injury, you know, the day after is potentially beneficial.

So I think that, and this is only in the span of, you know, the past maybe seven, eight years that this has kind of gone this direction. And so I think we're, we're, we're on to something. Now, those are the snippets that we're going to go through today, obviously. And lastly, I want to remind you guys that if you haven't listened to the book, there's a book episode that I went through that I revealed some of the audio tape of, or the MP3 audio audible version of the book that I just, that I just put out. The book called I Will Beat Back Pain, Getting Into a Winning Mindset for Recovery. And the reason I created it again was because of my personal experience with back pain.

I've had a couple bouts of it and I learned a lot of things through it because I've been through it a couple times. That episode, if you're looking for it, is 123. And you can find that by going to the P2 site. Just type in 123 and you'll find it. But, I really think this book is needed. And I'm not just saying that because I'm selling it or Amazon is selling it rather. So, I'm saying it because we as healthcare providers have a lot of people who come into our office who have a spouse who doesn't want to get better. For whatever reason, they think that they're old. They think that they have something broken.

They think that because they had a disc injury, they should be this way forever. It's just interesting with all these different conditions how people are, they tend to just deload. They tend to kind of give up. And I totally get it when they think that their area is broken and busted. They think, why even fight it? You know? And they think that they're never going to have a normal life again. But the hard thing is, it's hard for that spouse. It's hard for the spouse to see the person suffer and not go on hiking trips and not wanting to fly on airplanes. Like, I was having trouble wanting to go to Italy because I didn't want to fly that far because the city was terrifying for, what, 12 hours, 16 hours, whatever it was.

So, and then not seeing people actually get back to the sport that they like. I wanted to get back to baseball and I did and I played the entire season without having a problem. But just playing also with the intensity and the desire that you want. I was able to dive. I was able to steal bases. I was able to do, I was able to hit. I was able to pull the ball. Missing the ball at the plate with a pull, with an inside pitch was a little bit scary to me because that's how I entered it the second time with the, when I was 16 in baseball. So, the book, the main intention of the book is that you guys can provide a little bit of inertia or the spouse can provide some inertia and help push that person into at least the right direction.

There is no corrections in it. There is no treatment. There is no suggestions to do anything. And I know that the people who have read some of my, the review version of the book said, hey, how come there's no treatment in it? Like, I kind of wish there was more treatment and like that was their feedback. And I'm like, in chapter one, I tell you, there is no treatment in this. This is literally getting people mentally to the point, where they will accept care because not everyone accepts care. Not everyone will go to a psychologist. Not everyone will even accept free care. I dare you, one of you guys, try to give out, or all you guys, try to give out free care to your sister.

Say, hey, for that foot problem, I want you to come in. Let me treat that foot. They will make every excuse in the book because they're busy and they live too far and so on. And so, they won't even, it's not always, it's not the cost. There's another mental barrier and that's what this book will help cross. And hopefully, the book will start, edge and break through that inertia to get them moving and hopefully, when they read the book and they do little exercises in it, the written exercises, they are supposed to goal set. They are supposed to tell themselves what are their biases and belief systems about their back pain that are hindering themselves from getting better.

They're supposed to do those exercises and that will hopefully unlock the friction that they have. Imagine a ball rolling down a hill. You have to push it off the hill but if there's too much friction, it'll stop. We don't want these people to stop. We want these people to get better. And I don't care about all this age stuff. I mean, I've had people come in and they're like, you know what? I don't think you understand. You're not old. I'm like, are you kidding me? I'm 36, all right? At 35, I thought that that was going to be the end of my athletic career and I feel better now than I have in years.

So, although I'm not older, don't tell them all your problems are from age because there's a lot of people your same age that have no problems and probably last year or a month ago when you had no problems, all of a sudden you weren't old but all of a sudden now you got to this next month and you're old. That's a mentality change, man. So, that's something we're addressing in this book. So, if you're looking to change a lot of lives, go to the links in the show notes. I'll provide a link to the book. It'll also be on the front page of ptsportscare.com. That is P, the letter, to the number, sports is plural, care.com or just go into Amazon and search I Will Beat Back Pain.

What I hope that you guys will do with this book is I hope that you will share them with your patients who have spouses that have back pain and I'm hoping they'll review it and have a good experience and come back to you guys for care. So, if you're willing to do that and take the gamble, handle it. Buy a book. So, I'll see you guys next week. Leave people better than how you found them and if you're dating, date an Eagle Scout. I'll see you later.