Throwers shoulder rehab: shoulder blade control, stability and threat

Probably the most dramatic example was a young man at Oregon State University who was diagnosed with patellar tendonitis for eight years, and indeed he could not walk up and down stairs without having pain and taking him through three sessions of what I just mentioned using an unloader and then actually overloading the tissues through heavy weightlifting using mostly isometric contractions. But in three sessions, which by the way is a week, he ran pain-free, and every year he still sends me a postcard thanking him, et cetera, et cetera. 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. It's Dr. Sebastian Gonzales, your host for the Restoring Human Movement podcast. Thanks for being part of the movement movement. As you heard the little snippet, I have a guest on today. His name is Guido Van Ryssegem again. I've had him on once before. He's an athletic trainer. And he talked about attractor states last time as well as the dynamic systems theory. So we're going to cover a little bit more into that today. And this is actually an interesting podcast because part of the stuff that we talk about in regards to Pro Chiro Online is no longer available.

So you can find Guido, though. I will tell you how to find him at the very end here. But just know that any reference we make of Pro Chiro Online, we've actually dismantled the platform, and so it's not going to be anymore. So I started releasing all the stuff that I made seven, eight months ago as a release of Module 2. So the whole point of this podcast is for clinicians and patients alike. Hopefully the communication is really seamless and easy and just more storytelling and kind of getting the point. So it's friendly to both. And so I believe that clinicians can get better at communicating what we know and what we expect the patient to do and what's going on with him, as well as patients can understand a little bit better about what is happening with them.

So common communication when all possible. Guido is really good at telling stories. And so think of it like we're all having a beer at a bar, and our friend who's there with us, who makes corrugated boxes for a living, decided to get a Belgian Strong Ale. I decided to get a Modelo to keep it to my roots. Negro, not Blanco. Blanco, I think. Forget the other one. Anyways, and you decided to get a local IPA, which is on tap, which is from Green Cheek. Shout out to Green Cheek. Good brewery. So, as always, I'd like to share a little bit about myself in regards to a personal story in the podcast, not because it's like, whoa, look at me.

It's more of that I'm hoping that you guys like your host. And I do believe that people listen to Howard Stern or they listen to Rick Dees because they like them. They like the information. I know it's not the same, but it could be the same. And it won't matter because it's about the host. So, I hope that you guys are like you when I'm putting out there. And please suggest this to another clinician or a patient who might benefit from hearing it. It's the only way this podcast will get out. We don't do any promotion. There is zero budget for actually promoting it on any social media. So, the only way you're going to hear it and hear more of it is if you share it.

So, thank you for doing that. We'll get on to the story and then straight on to the information and interview with Guido Van Ryssegem again. So, if you haven't met me before, if you take a good look at my face, you'll see under my nose there's this little tiny slit or a scar, actually, I guess. It's kind of like in the indentation line under the nostrils. And it's not that big, but people have asked me how I got that before. And so, actually, so the story goes is I don't remember it because I was younger at the time. And so, as I was growing up, we had this little TV set. I want to say it was like a 13-inch, you know, rabbit ears on the side.

And there was a turn dial. And if I can remember correctly, I thought we had it on kind of like a coffee table type of thing that was probably about, like, what, two feet high or so. And it was on the other side of the room. And so, I remember actually growing up that we would go over there and you had to click to change the dial, you know. I guess if you're under 30 years old, you might not have this experience. But I do remember clicking and turning those dials. And so, I guess when I was younger, I was running around, I think I was like two or so, and I hit my face. I ran to the edge of the coffee table on it.

And so, my parents took me to the hospital because, like I said, I had blood on me and so on. And so, they, I guess at the time, they just basically put a Band-Aid on the thing and said, he's going to be fine. Take him home. And so, I think the Band-Aid or the whole experience cost him at the time, it cost him 50 bucks. And so, that was the $50 Band-Aid basically is the remedy to the thing. And I came out with a little scar. So, that is my story about the $50 Band-Aid. And now, we're going to get into the content. So, okay, so we're going to start through again and just, we're going to interview Guido with the aftermath of everybody watching all the stuff they already saw on ProChiro.

And I thought this would be a good opportunity just to kind of clean up clinically how we can use these strategies that you really, that you proposed in there. Hey, Guido. Hi. Well, thanks for, you know, having me on this again. This is a real pleasure. Yeah, it's fun. I like talking to you every time. You always have something good to say. I think. Well, I sure don't know. So, after we did, so we did the recording about, it was almost a month ago now. Do you have a single thing that you kind of thought like, I should have added that if we're talking about neck, upper quarter, shoulder-based symptomology?

To be truthfully honest with you, it's, you know, it's like a month later now and I've been crazy busy. Just to let you know, just to let you know my schedule, came from Portland, Oregon, flew to Vail, Colorado, presented there at a conference right after Mark Verstegen. This was on proprioception. That same night, I flew to Seattle, did a workshop with Michael Lee. And the next morning, I flew to China, stayed there for about three weeks. Flew to Brussels, saw my family for four days. Back in Brussels, saw my wife when we went to Greece for two and a half weeks. And I got home yesterday and I got a hell of a jet lag.

And you just didn't think about me at all? Every time I raised my glass filled with wine or ouzo, I was thinking about you. Okay. Perfect. That's what I needed to hear. To be honest with you, I can't remember if I missed anything. Okay. But I'm sure, you know, what we're doing here today, we'll fill in the blanks. Okay. And so I did a little beta testing with one of my interns here. And I said, watch these videos. Tell them what you think. And so they really liked the retraction stuff. And then I think they had a lot of questions when it came to the shoulder blade. We did internal external rotation of the shoulder.

And they're like, well, again, they're like, I thought we learned these already. So how do we apply those types of things? Was there a major question? And when we went through some clinical, when people came in, they're like, you know, like, how would you use this with this patient? You know? So I guess the roundabout answer is, if there's a clinician that hasn't been using the style of care yet, what is maybe a first thing they would want that you'd suggest that they try? Well, let me answer the first question, you know, on your students looking at the video. The reason that most people think they are familiar with shoulder internal and external rotation exercises is they typically then focus on, you know, the rotator cuff strengthening exercises.

What is different in my approach is that based on the dynamic systems theory, a tractor state model, most people with shoulder pain or any disability around their shoulder, they will have a lack of the scapular thoracic stability. So within the dynamic systems concept, it means that the attractor state in people with or had even in the past a shoulder problem or shoulder limitations, they need to retrain the correct attractor state. And in this case, it means they need to tell their patient to retract and depress their shoulder. So tons of evidence. I mean, we're talking 50, 60 good research articles have shown things that people with shoulder pain have used, for example, predominantly their upper trapezius to stabilize their shoulder blade.

And so the most common solution to that problem is you, you get them into the correct attractor state, which is retraction and the pressure of the shoulder blade. Then they will pull on the band or use a dumbbell or whatever apparatus they're using to so-called strengthen their gluteal cuff muscle. And so just a thought with that too is I'm going to guess I know what you're going to say, but are those specific exercises you've shown the only way to do it? Or is there a variation of different exercises to do it with? Oh, that's a very good question. So the workshop, I introduced people to the most common attractor state problems.

And I've been debating for several years now to actually split up my workshops into, you know, what's called body parts. I've tried it in the past. It wasn't successful, meaning I got a lot of people showing up for the shoulder and nobody shows up for the knee, for example. So going back and forth and putting things in a big packet, because ultimately even research now shows that people with shoulder pain or had shoulder pain, their posture control will be off. So let's say balance, you know, so when you put them on one foot and you tell them to close their eyes, their posture control is limited based on, you know, I mean limited because it's, they had a shoulder problem.

So the more and more I study this stuff, it's pain, it's threat, it could be psychologically even, I don't want to get too much into detail on that, but it doesn't need to be completely, you know, a functional or a structural problem that is their issue. It just changes the whole system. And that's why, you know, as we're going through this interview here, I want to explain a little bit more what dynamic systems theory is in this attractor state concept. So to answer your question, with enough experience, and that's why some people, you know, have taken my workshop like four times. I got one guy taking it six times.

And he's like, every time I show up, I learn something more, I can apply something more, I can ask some specific questions. The majority of individuals will benefit from the exercises I brought forward in San Diego at the workshop. But it is still the clinician's job to evaluate the result of the change in the attractor state. Got it. And so what I mean, you know, what I mean by that is this, it might be purely driven by pain, or there might be a labral tear. Well, we're not going to necessarily then change the attractor state permanently by one or two exercises. We'll have to tell the individual they have a structural limitation.

They have to practice that attractor state exercise consistently, probably on a day-to-day basis. So that gets me into what we're getting into later is my athletes. So, you know, my athletes are constantly competing with problems. And so I cannot necessarily change their attractor state permanently, but I'm going to teach them what they can do, or their therapist, their athletic trainer, their chiropractor, whoever they see on a day-to-day basis as their clinician, what should be done, because I see a temporary change in pain, range of motion, and even performance, but it might not necessarily last.

So my task is often very challenging when I work with these elite athletes, because I show up, I do what I do, but then I need to leave. I am not their clinician that they can depend on on a day-to-day basis. But hopefully that'll answer the question. You try the attractor state exercises, you should see an immediate change, but you might not necessarily see a change that is permanent, although the majority of individuals will have a permanent change. And just to, I'm brainstorming to break things down for a, like case-wise, let's just say someone has, they have that labral tear, or they have a, let's just say their shoulder is quote-unquote unstable, past dislocation, something like that.

And so I would imagine that that attractor state they're migrating towards is something that you're constantly fighting against, but also it's creating a symptom, but it's going to keep migrating that way. Does that sound correct? That is correct. In some individuals, and especially in the example that you gave, you know, we know that a dislocation has a very traumatic injury. I had the pleasure of years ago when I worked for the Texas Rangers, Dr. John Conway, which in my opinion, probably the smartest guy I've ever met in my life, him and I would go down to Naples, Florida, and we, he would practice some surgery, surgery techniques on some fresh cadavers.

And we started literally kind of, you know, messing around with what if, what if, what if. And one of the questions I asked him one time is that, you know, what really happens when one of my athletes now dislocates his shoulder anteriorly, because that was the most common problem. And he said, well, let's experiment this on this fresh cadaver. I'm going to show you what happens to the structure when that shoulder dislocates. And literally that anterior clinohumeral capsule just exploded. I mean, it, it was unbelievable. It was traumatic as heck. And so basically in this example, this was a, not an unstable person, not with a lot of laxity.

Uh, he had a normal anterior posterior glide, inferior glide. So it was kind of the, the ideal person that has the first dislocation. Uh, that anterior capsule just pretty much went to shreds and it just blew away that, you know, that some of my, my athletes could return to full activity, uh, and not even have any surgery. So these, these shreds would basically overlap itself, scar tissue healing phase started to occur. And it made total sense to me at that point that it often took them a year, year and a half sometimes to return back to full activity. So in that scenario, the sucking forces within the glenohumeral joints that we normally have in a non-dislocated shoulder, uh, totally is, is gone.

And in my opinion, there is no proof that it would ever return, even if these individuals would have like a repair of that tissue. So we're losing, that person is losing now a fundamental capacity to stabilize. So yes, that person needs to then progress through their exercises. And often in the shoulder scenario, they end up with what they typically call rhythmic stabilization exercises to increase stiffness within the muscle tendon and, and, and capsular tissue. And we'll have to continuously, uh, on a, on, in a baseball player, especially on a day-to-day basis, do the attractor state exercises.

Okay. But I have lots of athletes that were basically written off as you will never return to full activity at this level, uh, that did return. And a majority of my, my private, uh, uh, elite athletes are actually individuals that have been written off. So they've been released, whatever sport, football, soccer, whatever it is, uh, sprinters, and they've been told that they will not be able to return to full activity and applying these strategies. Uh, actually a lot of them are able to return to full activity. Okay. And, uh, so you mentioned something back there to the, uh, the rhythmic stabilization.

Um, can you, can you explain that a little bit for everybody? Sure. So my attractor state exercises are based on, uh, several concepts. And one of them is neutral joints, which, uh, Punjabi, for example, was the individual that brought that forward in the literature. So the first phase is we need to have these individuals return to neutral joint. If you are a clinician, uh, you can use manual therapy techniques. Uh, if you're not a clinician, uh, you can use so-called mobilization exercises as also than strengthening exercises. Uh, once they're in neutral, then I'm going to start applying strength training principles.

So typical overload patterns and so forth for them to now return to full activity, especially if the activity is a explosive, an explosive, powerful level, like throwing a baseball as hard as you can, they need to have a return of what we call normal neuromuscular control. Uh, so my whole KI attractor state concept is based on several models that all fitting into this, in this attractor state concept. So returning to neuromuscular control requires, uh, typically a rhythmic stabilization activity. So they're moving very fast, uh, trying to approach actually their competitive speed level, uh, using several apparatuses.

So in the thrower, uh, my exercise, I like to keep them as simple as possible is basically tubing, rubber band. They're holding it in their hands. Uh, they're attaching it to the fence if they're on a baseball field. So, you know, years ago, we basically went to the hardware store and bought some dog clips and that attached that to a rubber band. And so they were able to attach it to a fence. They were able to attach it to a variety of apparatuses they had available around them. So they weren't restricted in getting into a weight room or whatever. And now they're moving their arm. Uh, hopefully the video can make sense to internal and external rotation pattern.

And, uh, in the elite, I will actually then evaluate their, their shoulder height, how much shoulder abduction, all the different joints, uh, positions, uh, pre-injury need to be studied. So in my baseball days, it was relatively easy. We had videos available and we would then basically analyze those patterns. We would turn them back into that same pattern. And now over time, they're learning to speed up that pattern as quickly as possible. Okay. So actually there's, go ahead, go ahead. No, no, go ahead. So the, uh, the, I think, so I'm, I'm, I'm reflecting on with, so my current baseball team right now, it's just a bunch of, you know, 35, 40 year old dudes trying to not get hurt during the week or on Sunday.

And a couple of them show up with J bands and like one guy in particular, he's been using a J band for God, like it takes him literally, um, I'm not exaggerating innings to warm up his shoulder, he says all the time. And, um, so I guess my question is, is when you're, when you, when you're, when you're having someone use something like a tubing thing, is there progressions of steps to get there or can someone just go into the tubing? Because I feel like with this guy, the tubing ain't working kind of thing. I know he might have a different problem, but, um, is there a way to cue, um, uh, uh, you know, shoulder retraction or depression with that?

Or do people just pick up the darn tubings and just start flying with them, you know? Right. Well, ideally you do a first and evaluation to see if this person actually could get into the rhythmic stabilization exercises right away. Uh, in this individual, I'm not sure, but as long as he has enough range of motion, as long as there is sufficient strength, all he's lacking is just coordination by actually moving the tubing faster and, and it's, it's interesting that you brought this example forward. So the first time I had an individual, it was a closer, I was with the Baltimore Orioles. I can't say the guy's name, but it was a closer and he had shoulder surgery done.

He was in his early forties. And this was basically in the career kind of stuff. Uh, he saw Jimmy Andrews in Birmingham, Alabama as a follow-up of surgery and slash rehabilitation. And I, uh, this guy typically also took him too long to warm up the throw. Well, as a closer major league baseball, you got to be ready. I mean, in the shortest amount of time, especially if the game is on the line and you're, let's say you're short of the lead is in trouble and they're pulling you in to try to save this game. So him using a lot of time to get ready to pitch was a major problem. And one of the issues to potentially release him, it just took too much, took too long.

And so, uh, I basically, he was one of my first elite guys where I used this rhythmic stabilization, uh, uh, methodology on, and it decreased substantially his warmup time. So when he went to Jimmy Andrews and Jimmy says, how are you doing? He said, well, I'm freaking awesome because I'm doing this exercise that this Guido guy told me how to do. You're always Guido guy, aren't you? Yeah, I'm the Guido guy. And, uh, Jimmy Andrews, you know, the, you know, great guy that he is, he basically told the guy, you know, show me what the heck you're doing. And he said, well, give me a band. And, and so, uh, 15 minutes later, Dr. Andrews called me and said, uh, you need to present this at the, at the ASMI baseball injury conference.

Uh, so yeah, in a guy in his forties, uh, going through substantial rehab, it actually helped him to return to major league baseball. And he had another two years of his career, which at his age was quite exceptional. So to answer your question, I, I think it can be used with any individual that needs to warm up faster or produce some, you know, the, the exercise is going to increase muscular stiffness. Their velocity sometimes will go up. So even with this guy, uh, typically when they come back from that kind of surgery, you cannot return to full velocity. It takes them too long. And at his age, you're not going to wait three more years to see if you can throw hard as he used to, um, help that it also helped accuracy.

So control where the ball went from there on out. I mean, you can see a million videos on YouTube, people doing this type of exercise. Uh, so the whole attractor state concept continues in its rehabilitation and performance methods. And then eventually the athlete or the individual, even if it's grandma need to be able to do some rhythmic stabilization, of course, at her, his level, uh, that is specific to the demands of the athlete or the non-athlete. I think we talked about this in your workshop before, but for, for people individually, how long will the results of some attractor state exercises last?

Ooh, very good question. It's tough questions. All right. To be honest with you, we don't know, but what I've been playing around with for the last two years is looking at the concept of muscular stiffness. So more and more do we see research that shows that an increased muscular stiffness will improve performance in athletes that need to be explosive. So muscular stiffness is still a relatively, um, vague concept, but in, in simplified terminology, what it means is that if your muscles are stiffer, they're more responsive. And in a, if they're involved in a joint like the glenohumeral joint, because of their increased stiffness, so contractability, they will also then help to stabilize that glenohumeral joint.

Now, there's some research on it, but the problem is at this point, as far as I know, there is no direct way to measure muscular stiffness. Uh, you can do an H reflex study, for example, to give you an idea on the stiffness of the contractability of muscle, muscle and tendinous tissue. Uh, but there is a very simple apparatus out there called a myotone. So it looks like a, it's like a pistol and it measures resistance. Now, of course, it's quite subjective, you know, how you hold it and et cetera, et cetera. But from a practical, practicing clinician like myself, using it on a, on a more frequent basis, I have a pretty good idea on progression in stiffness.

So although it's not a good apparatus to measure it directly from a scientific perspective, it can, I can, I can now measure progress in stiffness. And so what we know is we can increase stiffness and in the trained individual, and most studies, unfortunately, are done on bodybuilders. Uh, and I'm, I don't mean bad bodybuilders, but you know, it's only in bodybuilders and not in people not so well trained, their stiffness can last much, much longer than the research shows. So if you work with a bodybuilder or a power lift or anybody that lifts weights on a decent level, if they don't train for 24 hours, it's not like their bicep, tricep becomes a wet noodle.

It's still stiff. There's still this tone in their bicep and their tricep. Very trained individuals, again, the bodybuilders, you can see, you know, that that stiffness will last for longer than 72 hours. And I, and I think an individual like Chris Duffin, he can pretty much become bedridden because he gets sick and it doesn't look, it doesn't mean that he's going to look like me 72 hours or a week later, you know, he, he still will have some tone there. So to answer your question, it's somewhat subjective, but you can still notice a difference in stiffness. So in a non-trained individual, it will require training to obtain stiffness.

And that's, you know, one of my methodologies, that progressive exercises includes strength training. We need to get stronger. And actually the research shows that if we increase muscular stiffness and we measure the muscle spindle sensitivity in the laboratory in non-trained individuals, it lasts at least two hours, but that's not good enough. Right. I mean, we don't want to be a wet noodle two hours later. We still want some muscle tone that also is going to, you know, not only make us look better, make us perform better, but also supports joints. So even old people, you know, osteoarthritis, for example, arthritis in their joints, often you'll see that they have very poor stiffness in the muscles around the joints that they're having issues with.

And if you get them onto a strengthening program, they're, they're decreasing their symptoms and they're getting better. They're able now to walk longer, maybe you're getting out of a chair they couldn't do before. So it's a continuum based on which individual you work with, how much stiffness do they have when you start working with them? How much stiffness do they need to obtain to give back to performance? And in grandma that might be getting out of a chair to go to the bathroom, first an elite baseball pitcher needs to throw 102 miles an hour. Okay. I got a couple of questions. I'll hit this one first.

Cause so when you said, um, someone walking with osteoarthritis, they, they have a lack of stiffness with, but they may feel stiff. Does that sound? So you know what I mean? The feeling of the stiffness, but they don't have stiffness. Um, is there a, what do you think about like with the, um, I guess the symptom of being stiff? How does, how would this addition of stiffness reduce the symptom of feeling stiff? All right. Damn, all tough questions. Oh, I'm glad you can still hear me. I put, I brought that microphone down. Uh, but a very, very good question. So part of my dynamic systems attractor state model incorporates information around the concept called movement variability.

So when we have an injury or had an injury, we decrease our degrees of freedom or the degrees in this scenario, in, in this example, the degrees of joint mobility. So if I have arthritis in my, in my knee, in my, whatever, uh, in my knee joint, let's say, you know, patellofemoral joint indirectly because of pain, maybe friction forces when I'm bending my knee will automatically, my, my, my body will automatically protect itself and decrease the amount of range of motion that I have now in that joint. So it's almost like, you know, you want to protect the body, but at the same time, that protection model is actually a disadvantage over time because it will decrease the amount of range of motion that I have.

That's why these people often feel stiff. They can't move anymore, or they have a very hard time moving or even worse. They're afraid to move. And that's a whole other packet. This part of my, my workshop is fear and I'm believe system. I can talk about this for days and days and days. What do they believe is limiting their problem? It's a very important question we should ask all our patients because that belief is very real to them. It's like believing in a God, right? It is real for them. No scientific evidence available, but very, very real for them. You cannot ignore belief system. So in, in the older individual, increasing now movement variability, exposing them to unloaded weighting exercises, for example, showing them they can actually move.

They can squat. They can pick up something off the ground when we offload them a little bit. And typically with my elite athletes, I use an unloader. Zuni was the first company out of Japan to build one and we can offload them up to 60%. So I'll give you a real example in my baseball scenario. I can, I can use his name. Juan Gonzalez, for example, when I was with the Rangers, sprains his ankle. Well, he's one of our top outfielders and one of our top hitters in those days. So he's slightly limping coming into the training room, hooking him up now to our unloader. So it's basically a cable system with a vest around his body.

I can offload him and ask him when he's walking on a treadmill, limping, you know, his pain. I ask him, Juan, tell me when your pain is 50% better. So at about 40% offloading his body weight, he goes, well, yeah, this feels a lot better. Now tell me when it's 90% better. Bingo. So I offloaded him about 60% of his body weight. He feels no pain now whatsoever. And he's walking with, not scientifically, but visually with a normal gait pattern. So the older individual doesn't have that available. They get stiff because they move in a stiff pattern. Does that make sense? Now, so option number one is we need to introduce that individual to environments, again, a dynamic system concept that is non-threatening to them.

Could be an unloader. Could be partial off-weighting. Could be even you holding their hands. You know, you make it simple if you do some home exercise with them and show them that they can actually move pain-free or less painful through their ranges of motion. That will be the first step, in my opinion. Second step now is this individual needs more muscular stiffness. The strength is going to help them to support their body weight. So the stiffness component has two things with this individual. I am stiff because I have a structural problem. I have a disease in my joints. And B, I am stiff because I can't move.

I'm afraid to move. So less variability available. Versus now we need to increase their muscular stiffness so they can support the joint. Okay. Two questions then. The first one I'm sure will answer very quick. When Juan had pain and you were done with him, how did he rate his VAS scale? Was it a 1 out of 10? Before or after? Oh, it was after. Was it a 1 or a 1 out of 10? I'm playing work. I got it. I got it now. He had a 0 or a 1. Oh, he had a 1. So... That's crazy. Even... This sounds nuts, mate. I saw the swelling in his knee decrease. And I've applied this principle in many individuals. Some of them even had an ankle sprain like 24 hours before.

It was blown up like a freaking frog, right? And they're limping like crazy. They got crutches on. And their physician has told them they're putting a mobilizer on them, etc., etc., etc. And with their permission, I basically said, listen, we need to try something different. You're an NFL football player. We need to play. You want to play, right? So let's take this thing off. Let's start offloading you. And let's see if somebody's offloading can actually help you. And this is, again, not scientific. I didn't measure that swelling or whatever. But the athlete is baffled, looking at their ankle and going, whoa, swelling is almost gone now.

So we don't understand all these problems associated. Are you still there? I've lost you on video. Oh, yeah, yeah. I'm still here. Do you see me okay? All right. Sorry. I can't see you, but can you hear me? I can hear you. And I can see you, too. Okay. No worries. I don't need to see you, right? Uh-oh. All right. Let's continue. So where are they going? Oh, yeah. We don't understand all. I don't know. I should say me. I don't understand yet all what happens when we, let's say, sprain an ankle. We have swelling. We have this level of disability and or pain. And then this responds to this threat, right?

The sprain versus removing the threat by unloading, for example, and not having any pain and seeing an immediate result in range of motion, even in isometric strength testing manually, even in swelling that is profound and almost immediate. And I've also seen similar results using neurodynamic techniques, doing neural glides, and seeing a decrease in, let's say, lateral ankle swelling, chronic, after a grade 2 plus or grade 3, whatever you want to call it, ankle sprain, that had damage done to the lateral and medial collateral ligaments. And where this athlete now sees me six months, a year, one guy, three years later, and says, I still have swelling and pain in my lateral ankle, and I can't do this, and I can't do that, and it destroyed my sports career.

Using some of these techniques like neurodynamics are also very helpful, although I don't completely understand how suddenly swelling is disappearing literally in front of your eyes in mere minutes. Now, a really quick break from the show. I want to propose an educational series to you guys, for you clinicians out there. This is not intended for patients. I recorded a webinar series a little while back. I recorded it. It's over 15 hours easily when you put all six parts together, but I broke them up into two, three-hour bits. We cover what I call the five-step patient care system, and I've developed this because I've been training interns, and this is a good way to organize thoughts for them, and also an easy way for me to teach, too.

And so step one is history taking, working diagnosis, physical examination, dynamic testing, and good exam flows, just really good, solid exam flows, knowing when to use them for hips and shoulders and backs and cervical and so on. Also, we do cover first aids, how to get people out of pain without having to use medications and really without even having to put our hands too much on them either. That's very empowering shit for people to be able to do stuff on their own. We also cover corrective exercises, which is number three, and when to use them, how to use them, which ones to use, how to cue them, how to coach them.

Then we cover loading. DMACC, Dr. DMACC, also covers a little bit into the other products we have on the page, too. That one is, if you want to go a little bit more into depth on number four, which is loading, Dr. DMACC covers that, again, in 12 hours of the low back one. Or sorry, no, it's two hours. Two hours of the low back one and another two hours of upper quarter and cervical spine. So, as you can see, I cannot fit it completely within the five-step series because it takes more detail than that. So, he covers it a little bit more thoroughly in there, but I do make introductions into it, and I do do some of my coaching and cueing style, too, which is a little bit different than his.

However, I want you guys to go through this and really take to heart what I'm going to say is, and take in the light that is intended. If you don't get this, shame on you. Shame on you because it is one of the most educational, useful, cheapest series that you can possibly get to improve your clinical knowledge. Again, I don't say that lightly, but I feel like a dick when I say it is, if you don't get it, I don't know what you're spending your money on. I don't know why you're going to all these other workshops that show only little tiny parts of things. And so, this is an organizational series.

I know a lot of you already know how to do tissue work. You already know how to do some stretching techniques. You already know some exercise techniques. Why do more? You might as well just figure out where you're missing things and learn that one. Learn how to plug in those things you already know. Many of you are very, very good at tissue work already, and you don't need to go to more. I know that I spend a lot of time doing a lot of tissue work. I don't need to learn a lot more. I probably need a little bit more, but not a lot more. I need to figure out where my competencies are lacking. And for many years, my competency was lacking in corrective exercise cueing and loading strategies.

And so, after plugging those things in, man, freaking game changer. Freaking game changer. Anyways, we cover hip, shoulder, low back, cervical spine, and referred symptoms. I'm going to share with you a review that we have on the low back one, taken by one of the people who went through the course as I taught it live. I highly recommend this guide to any chiropractor and physical therapist looking to up their game in treatment of the low back. The guide is a great supplement to anyone who likes crisp book protocols by Don Murphy. If you read those books and agree with the patient's needs to have better control of their own health, then you will love this.

Sebastian Gonzales gives you a step-by-step guideline of what to look for in examples of exercises for treatments that will be useful the next day, not just theories and concepts. Great. Well written. I like that. So, please go through there. Again, take my comments in the light that it was intended. I want everyone to improve. I want our profession to improve. I continue to learn people who have been around longer than me as well. And there's no need for everyone to struggle and try to reinvent the wheel. I know we get frustrated when our patients try to struggle through some of the easy stuff that you could teach them.

Don't make the same mistake they do. Don't let them go around on YouTube videos looking for solutions when you have an easy solution for them. So, p2sportscare.com slash products. You won't be disappointed. We'll see you on the other side. Back to the show. You know, there's a story actually that I had from a couple weeks ago that I think it might play well into this. It's a little bit of a tangent topic of what you're just mentioning, but definitely neurodynamics is important stuff. So, there was a gentleman that came in a couple weeks back, and so I treated him randomly for different things.

And he comes in with like, you know, kind of like how patients do. They're like, you think you're going to see him for one thing, and all of a sudden they're proposing something different to you within like a small block of time. And so, he had had loss of left shoulder range of motion and external rotation, and the right was normal, 90 degrees or so. And the other one, like we didn't do any measurements or anything, but it was like, let's just say the left one was like lacking 25% range. And so, he's like, dude, I've been doing mobility stuff for I don't know how long, and I just can't, it's been like two years, I just can't get this thing to go down.

I don't know why it's not going down. And so, we did some neurodynamic tests on him, and one just lit up his positive, and I said, oh, cool, let's just try. So, we actually tried the chin stuff that you showed on the thing that everyone probably just watched. Within 20 reps, he was able to, we tested again, he hit the floor, so he was on his back. So, he had 90 degrees external rotation at that point, and to my knowledge, two weeks later, it's still sticking. And so, it's interesting that I think as clinicians, we default to the structure of the shoulder very quickly, when that threat reduction, which you mentioned earlier, maybe it's easy to glaze over it, you know.

Oh, you got some minor neck stuff, no big deal, let's mess with the shoulder, you know. What are your, I know you said maybe we shouldn't go down the rabbit hole of threat, but I think actually it'd be useful for everybody. So, what do you want me to think about threat? Yeah, you talk about threat, and actually, yeah, I'll let you take that mic on that. Threat in regards to shoulder, loss of shoulder mobility, maybe. Uh-huh. Well, let me start by saying, so many individuals that influenced me looking at, especially if I see individuals with chronic problems, like your candidate, you know, two years plus.

And I've seen people, I had a professional soccer player, actually, from Ecuador, eight years after an ankle injury. He still could not run, and he was pretty much afraid. But, anyhow, the individuals that influenced me the most about looking into this more deeply, and then applying strategies around threat, are, of course, Mosley, you know. And how the brain changes with pain. And then, way back, explain pain model, and they've updated that model now. It's not Mosley, I can't remember who the heck wrote that book, explain pain. But, anyhow, it talks about threat and pain. And it blaffles me when my wife and I go to countries like Nepal, for example.

Every five years, we do something physically challenging. Last year, we were in Kyrgyzstan, you know, basically spent almost three weeks with the nomads up in the mountains and horseback riding, you know, some strenuous hiking and so forth. When I try to talk to these individuals, to a translator, and talk to them about things like pain and limitations that they have in their life, it always baffles me that these people don't even, often don't even know what is pain. You know, do you ever fall off your horse? Yeah, of course, I fell off my horse. They'll say, well, did it hurt you? And they say, well, you know, I made contact with the ground, and, you know, let's say my back hurt or whatever.

But I just stood up, and I had to go about my business. I got to go, you know, take care of my yaks, or I got to take care of my cattle, or I got to take care of my horses. And I think in our modern society, and I don't want to bash pharma, but big pharma has basically put a big spell on that, that, you know, you have pain, you shouldn't have pain. And then you take this pill, and pain will go away, and pain is bad, and, you know, and a headache. You got to do this, and you got this, and then you got to take that. And we live in, we, in our modern societies, are living in a structure that, you know, we have to go to work, and we got to do this, and we got to do that.

And if we have a problem, then we got to take a pill. And I think it's a learned behavior, or people just popping things, or, you know, go see clinicians that do things like acupuncture. I'm not saying acupuncture is bad, but there is this immediate response to pain is bad, it's a negative behavior, it's a sign of me being weak, so it's got to go away. And then I'm going to pop a pill, I'm going to go see somebody that makes that pain go away. While in these cultures that I've visited, that doesn't exist. They don't have a pill to pop, and they just move on with their life. And pain is a very interesting concept to them, to a point where they don't even understand what the heck I'm talking about.

Now, let's go back to Mosley, et cetera. He has a video, a YouTube video, where he explains he got bitten by a snake in Australia, I'll never forget this video. And it's one of the most poisonous snakes in the world. Now, he survives this bite, which, again, is an exception to the rule, most people die, get bitten by this specific snake. But to sum it up, what he basically says is this, I was walking through the bush, and I felt something on my leg, and then I ended up in the hospital. Since then, when he walks in the bush, something scrapes on his leg, he thinks about a snake. And so these are all learned behaviors.

So is threat. It is a learned behavior by our society, by our experiences, maybe our mom and dad. I see a lot of people overprotecting the heck out of their little kids for a variety of reasons. I have a grandson, and he's full of bruises because I don't protect him. He's a tough little guy. And, you know, he's got a bump on his head, but it's, you know, my response is, it's okay. You know, and then literally a minute or two minutes later, he just moves on and goes about it. While at the same time, I see a ton of parents overprotecting their kids, and the kids are scared. Part of it is our society makes us scared.

9-11, the boogeyman is there, and we can't have our kids outside playing anymore because they're sexual predators, et cetera. Anyhow, I don't want to get too much into that detail, but I think we're creating a society that has more, that is more responsive to threat than it should be. And it's probably already learned or taught to them from childhood. Some person, some older guy told me, we're having a very weak society where more and more young adults right now, you know, basically can't even wipe their own ass. And when I was still at Oregon State University over the years, I did experience that, where the last couple years I was there, young men and young women not having what I would call common sense.

They had to call their mom, they had to call their dad, about all kinds of things that I thought were completely irrelevant. But, yeah, threat is a big problem. I think it's a learned behavior, and like any behavior, it will repeat itself. And if we have a constant negative response to it, then that behavior will be actually strengthened, and it's just going to get worse and worse and worse. Based on that threat, I think we're seeing more and more people with so-called chronic injuries at Oregon State University. You know, I see students coming in, being told they have a patellar tendonitis because they have pain in the patellar tendon region.

But in reality, there was nothing to be found on diagnostic studies. And I started doing that when I was with the Baltimore Orioles. I had the luxury as medical coordinator to have access to an MRI machine, and basically at will. And then after I went to Australia, we had a diagnostic ultrasound. This is 1996. It was probably the first, second, or third one in the country. So if an athlete came in and he said, my patellar tendon hurts, or he said, it hurts in this location, the first thing I would do is put my diagnostic ultrasound, that patellar tendon, to see if it exactly was a patellar tendonitis.

And I'll tell you what, although they're baseball players, I'm not saying it's a different scenario in, let's say, long-distance runners. I didn't see anybody with a real patellar tendonitis on my ultrasound or when I put them in an MRI machine, if their agent demanded me to do that, for example, because they want to make sure there was no structural abnormality. There was pain in the patellar tendon region, and some of them had actually some level of disability, and I would say limping, because of it. But I couldn't find anything on MRI or diagnostic ultrasound. So my approach, my rehab now needs to change.

This is not a structural problem. I should not take this athlete through a patellar tendonitis rehab protocol, which, by the way, can take months. No, this is a threat problem. So I'm going to remove the threat. Typically, I would use an unloader. If I didn't have that available, I would put them in a swimming pool, unload their body, and basically make them move through their so-called threatening movement pattern, let's say running, and make them realize there was no threat. Thereby, there's no problem. They come out of the pool, come off the unloading machine, and they literally have a normal gait, and they jog.

Probably the most dramatic example was a young man at Oregon State University who was diagnosed with patellar tendonitis for eight years, and indeed, he could not walk up and down stairs without having pain, and taking them through three sessions of what I just mentioned, using an unloader, and then actually overloading the tissues through heavy weight lifting, using mostly isometric contractions. But in three sessions, which, by the way, is a week, he ran pain-free, and every year, he still sends me a postcard, thanking him, et cetera, et cetera. This individual was diagnosed by eight different individuals as patellar tendonitis purely because he had pain in the patellar tendon area, but there was no structural problem.

Yeah, it's funny that that occurs, actually. I don't know if I ever told you. So the watchers, if they're DCs, they know what the DACBSP credentialing system is, and so you have to do an abstract or a study or a meta-analysis or whatever, right? Yeah, and so mine, I actually have a diagnostic ultrasound, and so I went to a group of runners multiple times, and I said, look, I'm doing a research study on the accuracy of patient self-diagnosis. And so I said, if you feel like you have Achilles tendonitis, please come to my office, and I'll scan it, and I just want to see. And so someone raised their hand and said, what is Achilles tendonitis?

I'm like, that's a great question. I'm not going to answer it. If you believe you have Achilles tendonitis, I want you to come in. And so, lo and behold, this actually, the P score was not appropriate enough to make it valid because I didn't have enough subjects. Well over 50% of them were, there was no findings whatsoever of abnormality in the Achilles tendon at all. But they still have pain there, you know, and I think you're right on with all the, you expose them to non-threatening movements and so on. That's why I'm a huge advocate of like, I'll do less and less manual therapy or, you know, like, I guess I'll say coddling the patient.

But I'll try to put them through movements and coach them through and let them know it's okay. And that's where my practice kind of migrates towards just for those reasons, you know. Right. Well, and I think the belief system there comes into play as well. They've been told and believed they have a certain problem. So my first appointment, which is typically like 40 minutes, I probably talked to them for 30 minutes about the attractor state concept, et cetera, et cetera, et cetera. And I basically, my interview process is beyond their health history, et cetera, and reviewing their diagnostic studies and what has been tried before.

I ask them, what do you believe is going to make your, let's say, Achilles tendonitis feel better? And it's profound sometimes what their response is, what they say. Well, if you would be able to do this, then I believe my patellar tendonitis would be better. And that's often then what I will provide unless it's completely contraindicated, especially in an individual that is subjective to seeing. So I have athletes that are being sent to me by their agents. And, you know, the first question is, you know, why are you coming here to see me? And they, you know, nonchalantly say, well, my agent told me to come see you.

And you can see it immediately in their facial expression. They're not, they have no interest whatsoever to be seen by me. So even more important now to play into their belief system, what makes you believe that, what's important, what do you believe is going to make this better? And then what do you believe is going to make it worse? It's often a very interesting question to ask. It's also very culturally biased. So while I was in baseball, it was an amazing experience for me to work with individuals from all over the planet. Because belief systems beyond the God belief system is culturally, often culturally biased.

And we need to respect that. We can't just put on our, let's say, our American belief system onto our patients if they're culturally biased. So I had players from the Dominican Republic that believed they had to slaughter a live chicken and put blood on the baseball bat so their batting average would go up. Now, we might find that all freaking ridiculous. But for them, this was fact. This was reality. And so I think as clinicians, we need to play into this. Simultaneously, we as clinicians need to be culturally non-biased. For example, a flat foot. Individuals that live for generations on sandy soil, let's say native Hawaiians, aborigines, et cetera, or on swampy soils, let's, I'm typically saying now Southeast Asia, their foot has adapted to that terrain.

There's no way in hell we should slap an orthotic underneath them because they want to run. We might actually have to have a conversation with them to let them know they're not, that foot is not made to run long distances. And it's a major challenge in the U.S. because we have people from very different cultural backgrounds over here. And often they've been here for many generations and don't even understand their own cultural background. So this is a real example. University of Oregon, years ago, I was a grad student there. We started seeing shin splints problems in our defensive football players.

These were almost all of them were recruited from Samoa, et cetera, Hawaii. These young men were large in our norm, but not by their norm. So what was typically the preseason workout program? Running. Who ended up with shin splints? Those individuals. What did we do? We treated their shin splints. We taped them with all kinds of stuff, but we still made them run. Until I was finally able to have a conversation with the coach that was in charge of this running program and said, these kids are not made to run. Let's make them run in the pool. So it was basically then my job as a grad student, take all these guys into the pool.

They were doing all their cardio there and shin splints problems went away. And often, you know, we often don't keep that in consideration that some individuals are not made to do the things we think they should be doing because of their sport event. There's different ways to get cardio work done. And guess what? Running on land was not what, you know, what you're not supposed to do because their foot could not, and I should say their structure could not absorb that amount of force on a day-to-day basis. Well, we just, I got a bunch of holes if they want to dig that in my backyard. And that's, that'd be my attractor state exercise for them so they can run.

So the, so as we start to finish up here, actually we've gone, I hope everyone is okay. We've gone over in time, but I think this is all relevant to your practice. So obviously this, this pro-cour program is obviously we're given CEs, but at the same time, it's, it's, this is just useful stuff. So Guido doesn't, he, he doesn't get a role like that all the time, just half the time. Well, what, what can you tell everyone about your workshops, Guido, and I know that you have a couple different types. And so why don't you tell the listeners or viewers about each one and what they can expect to come away from with either of those at workshops?

Sure. So I would recommend that most individuals should start by taking my kinetic integrations attractor state concept workshop first. This is basically my brainchild that I've developed over the years. But within that workshop, I mean, if I would have to go through everything that is discussed in my eBooks, it would take literally a week. And that's what I'm currently doing now, mostly in China and Japan and Korea is long workshops to go through the whole methodology. So as an example, neuromuscular control was one of the topics discussed within that workshop, but it's briefly discussed. So is balance and posture control and proprioception is briefly discussed.

Why? It's a whole workshop in itself. So over the years, I've then developed workshops specifically based on those concepts. So I have a workshop on proprioception, for example, and I had the pleasure of presenting that at the Mountain Calm conference in Vail, Colorado, right after Mark Verstegen. He took a ton of notes and talked to me about it in depth afterwards. There's a paper on it. It's called The Myth of Proprioception that was written by Dan Kim. Dan was at that point a Korean student of mine. He's now a very established clinician in Canada, in Vancouver, BC area. And I had a pleasure to see him in Seattle, and we're going to update that paper because, of course, the research has, you know, there's more and more stuff that came out.

So in my opinion, this is going to blow away a lot of people, we cannot improve proprioception. But there's factors associated with proprioception and balance and posture control that we can improve, and that's the whole workshop in itself. Okay. I have a workshop on neuromuscular control. I have a workshop on movement variability. Those are kind of the big items. There's a couple more. You can see them on my website, kineticintegrations.com. I also have a very active Facebook page called kinetic integrations. What is currently the plan? I'm leaving to China next Wednesday. I'll be there for about, let's see, three weeks.

I'll be two days in Japan preparing for a workshop there in September and November to get me known in Japan. Then I'm going to go straight to New York. I have a workshop lined up there. After that, I'm presenting at the national conference of the National Straining and Editioning Association, which is a huge honor. Rhode Island? Is that where that one is? That's in Rhode Island on proprioception. It's 15 minutes. It's short and sweet, but it basically is all the scientific evidence and the rationale behind my exercise and my workshops related to that. Nice. What's the website again? I'm sorry?

What's the website again? The website is www.kineticintegrations.com. Good. We'll put a link under this as well so everyone knows. Yeah. I must admit, I'm not very active on that website. Next year, my wife and I are going to revamp all that. I'm just incredibly busy right now with China. Basically, I've started a private university there, which is a four-year program based on sports medicine and exercise science to prepare Chinese clinicians as also performance coaches in the future. And I'm doing a ton of workshops all over China, three locations actually next month, and two locations in Japan.

So, very busy traveling. Well, after this, people watch this, hopefully they're going to think, what the heck? I don't want China to have him. We need him. We're going to have more of him. I hate to toot my own horn. People that know me personally, I'm not a great self-promoter. I bought four books upon your advice. Oh, did you read those ones? Well, I haven't started reading them, but they're all going to go with me on the plane. Oh, good. I love it. And Ben's advice, because I was not realizing that there's a message to be told. I'm going to be 60 this year. The clock starts to turn backwards.

I'm not a negative person about it, but I start to realize that some of my stuff shouldn't be lost. Although I've influenced hundreds of individuals, especially when I was at Oregon State University, clinicians and non-clinicians through my methodologies. I realized that, you know, when I'm gone, I don't want the information to be gone. October 5th, 6th, right? You think so? Or 7th? No, October 7th, 8th. We'll be back in San Diego. We haven't decided yet on the topic, but, you know, it'll be fun. I think people that have taken my workshops find it simultaneously entertaining. You know, we shouldn't be all too serious all the time.

There's a ton of cases that come forward. And I just, you know, have a lot to share and want to see as many people as possible. Right on. Well, thanks for this. I know that you can't see me on camera because we had a technical issue, but for everybody who's watching, stare right into that camera and say goodbye. All right. Take care. Guido, thanks for being on. It's always a pleasure talking with you and chatting, and I always learn a lot. So, everybody, if you're looking for Guido's information, go to kineticintegrations.com, and that's how you can reach out to him and figure out where he's going to be.

He does workshops. He's got a book. He's got actually some free information online. This is pretty good. And he's got a little blog. And so, I strongly suggest you go over there and learn what Guido has to share because he's a smart dude. And as you can tell, he's had a lot of experience. So, I think that's going to be the best thing you guys can possibly do to learn more about that attractor state principle. Now, again, just to reiterate, Pro Chiro Online, which we kind of talked about in there, is no longer in existence. So, don't email me about that because I'll say it's no longer in existence.

But if you're looking for some of the information that is within it or what Guido had to share on that video, he actually has some of the videos that I'm not sure what he's going to do with them, but he actually has the videos. So, you go ahead and reach out to him about that. So, thanks for being part of the movement and thanks for supporting the show. Share it with friends. And again, all you got to do is click that little button at the bottom, review it, and then send that episode to a friend. Perfect. Thanks. That's the best gift you can give me. I'll see you guys next time.