Barbell Shrugged - Avoiding Major Surgery and Staying competitive with Dr. Ray Gorman- Active Life Radio #2

Episode Date: July 19, 2019

Dr. Ray is the director of staff at Active Life. He works with one on one clients and is responsible for coaching the staff. If you have heard of the Active Life Immersion program, Dr. Ray runs that too. The dude is a stud!   A neuro surgeon told her she needed spinal fusion, an orthopedist agreed, and a physical therapist couldn’t help. Now she power cleans over 200# and she never had surgery. What happened between the scary prognosis and the heavy clangin’ and bangin’? Give it a listen.    Minute Breakdown:   0-10 - How did you know she didn’t need surgery? 11-20 - He told his wife to hide his gun. 21-30 - Is an anterior pelvic tilt bad? 31-40 - Turning off a false alarm.  41-50 - Even the smallest improvement can lead to the largest.  51-60 - What does the future look like?   Work with an Active Life Coach like Ray at activeliferx.com/shrugged Find Dr. Ray at @RayGormanDpt

what's up everybody welcome back to active life radio on the shrugged collective network i'm dr sean pastuch i'm your host and today we're joined by our director of staff at active life dr ray gorman the conversation that ray and i had today was about one of our clients who was in her young 20s when we first met her she's still in her young 20s when we first met her. She's still in her young 20s, but when we met her, she had some back pain and the recommendation that the people who she was seeing was surgery. And I'm not just talking about any surgery. They wanted to fuse her spine. This is a girl who is very athletic, has been active her entire life, and was actually a fairly elite CrossFit athlete as well. Getting a spinal fusion surgery, for those of you who don't

know, would have been a massively invasive procedure to the lifestyle that she wants to live. We would never encroach upon the instructions given to one of our clients by their doctor. We're not a medical service, and I want to make that clear before we start. This client was not interested in getting the surgery. She had given up on the thought of working with a physical therapist because that wasn't working for her either, and she had now come to us and asked for help and asked if we could get the job done. During the podcast with Dr. Ray today, we talk about exactly why we were confident to take her on as a client and what we did from day one to now, about eight months later, and where she's at, as well as what the future looks like for her. If what you hear today is something that relates to you, if it's something that rings a bell of

yourself or somebody else who you know that needs to hear this podcast, please make sure that you're sharing it with them. If you're so inclined that you want to seek the kind of help that this client got, by all means, feel free to head to activeliferx.com slash shrugged. And you'll find all kinds of options to work with us right on there. No more wait. Let's get you to the show. Dr. Ray. Dr. Sean. Pleasure to be here.

Welcome back. Thank you. When I say welcome back, Dr. Ray has been on the Active Life podcast. This is actually his first time on Active Life Radio on the Shrug Network. So, Ray, we're going to talk about this client of ours who we're going to name today because we're not going to talk about her specifically by her name. So let's call her, what do you want to call her today let's call her jane jane yeah it's a good name it's like general you know it doesn't really like so for all you

janes out there your name is pretty generic it's i mean it's general okay so we're gonna go with jane the pay the client's name excuse me it's not a patient it's a client her name is jane would you start our audience off kind of with where we met Jane and what the deal was? So we had the pleasure of meeting Jane, which is an awesome name, by the way, for all the Janes out there. It's like, yeah. Top of the list. Really good. And we actually got to meet her in person at a seminar at CrossFit Mayhem. And it's very, very unusual, I'd say in our market that we meet our clients before we actually start working with them, because we truly do believe that having that in-person assessment of their movement and in

person look at, at just kind of how the movement patterns fit and what the client is doing gives the coach a great idea of where to start with the client. So that was the start of meeting Jane. So this is why, for the record, for many of you who are listening to what Dr. Ray just said, and you're like, wait a minute, I thought you guys work with people remotely. I didn't know we had to come see you in person. You don't need to come see us in person. In fact, we don't have a clinic. We don't have an office. We don't have a gym. This is why when people have cases that are too severe for us to take on, we recommend that they go see a physical therapist in person. If we had met Jane online and she described to us that a neurosurgeon had told her that she needed spinal fusion,

an orthopedist had agreed, and a physical therapist said that they couldn't help her, we might have been more trepidatious to take her on as a client. Would you agree? That's very true. So this was one of those fortunate situations where we got to meet the client in person prior to starting. So she comes to us, and essentially she's now there as a coach. She's at a workshop where she wants to learn how to assess her clients as a coach. And she's kind of resigned to the fact that she might need spinal fusion surgery.

Yeah, it was pretty much, it was kind of sad. It really was, seemed to be running out of options, seemed to be desperate for a solution that didn't involve going under the knife. And after having the conversation with her, it was pretty apparent that we could help without that option on the table. I want to make sure people who are listening to this understand what goes into that decision. Because I think that for a lot of people, there's this fear around being told that they need to have surgery for something.

And surgery is not necessarily a bad thing when surgery is required. So what was it about the way that Jane talked to you and what she told you that made you believe, okay, you know what? Because she's willing to have surgery what she told you that made you believe, okay, you know what? Because she's willing to have surgery if she has to, but she wants to do everything she can in the meantime. So the risk is really not there. She understands she might be a surgical candidate and the likelihood of us

making her worse is extremely low. What was it specifically that allowed you to say, okay, based on these things, it's unlikely that we're going to make this any worse and unlikely that surgery is the best remedy? The first thing was kind of the mechanism of injury. What do you mean by that? What is the mechanism of injury? The mechanism of injury is the way that her symptoms started. And unfortunately, it started after a chiropractic visit now that is no bash on chiropractors at all i think that there's definitely a place for that kind of intervention

but it just happened to be the way that this started she had an adjustment and all of a sudden had this nerve pain in her legs and it just didn't fit the mold of what I have seen in my experience as a physical therapist of who would require a spinal fusion. Why not? Who would? Somebody with unrelenting nerve pain that shoots all the way down their leg and has tried and failed conservative intervention. And by conservative intervention, I mean physical therapy, any sort of injections, everything conservative on the table. The one thing that I always tell clients who are

considering any sort of surgery, but there's a chance that something conservative will help them, is you can always have surgery, but you can never unhabit. So let's exhaust every single conservative option that we have before we even have this conversation again. Yeah. And I want to one more time, make it clear. If you've been told that you need surgery by multiple doctors, you've gone to physical therapy and it didn't work, we shouldn't be your next call. We're not a medical company at Active Life. So solving these problems for probably 90% of people, it would be irresponsible for us to take that call online. What we want you to understand is this person really never needed to be in the neurosurgeon's office at all.

They needed a better understanding of what was going on in their own body so that they could better explain, essentially, what they were feeling. Because a lot of what I understood was fear. A lot of fear. I think a lot of heightened awareness of the situation. It also was kind of a factor against her that she works in the medical community. So it was really easy for her to get in and see people per recommendations. So there wasn't really a time to let the body calm down and just kind of get back into this homeostasis of what normal is. It was hyper-awareness of the situation going on in her back,

going into the doctor, and now you get this, hey, I think you're going to need surgery, a spinal fusion. That doesn't sell your nerves at all. No, it certainly doesn't. And I'll give you, as an audience, an example of someone who we worked with in clinic at Active Life when active life was a clinic who did need spinal surgery this patient at the time came into the clinic and essentially he had extreme low back pain that shot down to the bottom of his feet it was so severe that this man who was an ex-police officer told his wife to hide his gun.

That's how much pain he was in every single day. And I want you to think about that. You wake up in the morning, you have a little bit of pain running down the back of your leg, in your low back. And if you don't know what is going on, there's most definitely an opportunity for you to begin to panic. What is going on? Is this serious? Is this permanent? Do I need surgery? And all those things can run through your head. And the less that you know, the more scared it makes sense for you to be. This man who needed spinal fusion surgery had pain that was so severe that he described it as lightning bolts shooting down his leg to the bottom of his feet the moment he sat up in bed in the morning. He had his wife hide his gun. If you don't understand the innuendo, he was afraid he would

kill himself. He was in so much pain. Not everybody who needs spinal surgery is going to be that intense, but it's going to be closer to that than I can work out. Right. It only hurts when I X, Y, Z. And that's where we found Jane. Right. And one of the reasons why you bring that up is because at the seminar, in between teaching coaches how to do assessments, she was doing a lot of stuff still. Handstand walking, handstand pushups, a lot of carries, sled pushes. So it's like your level of function is really high. It just baffles me that the

consideration for this was on the table. Right. This wasn't a David Wright situation, for those of you who watch baseball, where if you want to have a shot at a professional career you need this surgery to prolong it this was a 20 something year old woman who could do most things except when the volume got too high or the intensity got too high it gave her pain to her hip right yeah and one of the biggest things that we talk about with our athletes is load got too high or the intensity got too high, it gave her pain to her hip, right? Yeah. And one of the biggest things that we talk about with our athletes is load versus capacity. And within that load, think of load as everything that your system is interpreting. So weight training, sprinting, but also stresses in life, your work, getting up and just having nagging injuries that you've dealt with growing up. You know, you rolled your ankle as a kid, you sprained your knee once,

those things all start to build up in that capacity line. And so for her being in this heightened state of fear was really a big contributing factor towards that. Well, so, okay. So, so part of the reason a big part of the reason why we both decided that, okay, we can help this person. She does not need to run to an operating table is because we saw her walking on her hands with her feet hanging over her butt in extension, right? Which is a terrible position for somebody typically who's going to need spinal surgery, especially a fusion surgery, I should say.

And she had no issue with it. She was doing, if I remember right, some lightweight work. And like you said, pushing the sled, it was, it was clear that she had some stuff going on that was bothersome and that it wasn't severe to the point that she had been told it was. So how do you start working? Cause she was your client is your client. How do you start working with a client like that? When everything else that they've been told is that nothing that you're about to do is going to work. Right. So, I mean, for me, it all starts with just getting the history of what's going on. Pretty typically when somebody just tells you their story and can understand that you're listening, they're going to start to feel better right off the bat just because you've gained their

trust. Well, so what do you mean by that? I mean, I think that if most people go to a doctor's office or work with a coach, the coach or doctor is listening. To a degree. I believe that there's a statistic out there that when a client is in a doctor's office, they're interrupted once every 17 seconds. So is the doctor really listening? Is the person really listening? And again, this isn't a bash on anybody professionally. It just happens to be a symptom of what the traditional health care model is. For us, it was, hey, we've got two days. Tell me your story. Tell me how you feel after you move. I'll keep coming in and checking in on you. Is it getting better

as you keep getting assessed? Is it getting worse as you keep getting assessed? So after getting her subjective history, it was really just about taking the movement screen and interpreting it. Yeah, and I think that what you're speaking to there is as much, or if not more, the client feeling heard as the client being listened to. And what I mean by that is she can talk to a doctor. She can talk to her coach. And if the coach or doctor doesn't appropriately demonstrate that they understand what she described and have a solution for it, then the person who told the doctor or the coach might feel like, okay, I said what I needed to say.

I'm just not sure that they understood me. And despite the fact that you, the doctor, the coach listened, doesn't mean that you communicated that you understood. And I think that that's what you did really well with her was, you know, I understand you're afraid of this. You feel that. This bothers you. You've been told this is a huge problem.

Let's try these things and see if they make you any better. And so because I want to start getting some really good specifics on this, when Ray says as the assessments go on, let's see, as you move over the course of two days and one of our assessments the way that we at one of our workshops excuse me the way that we work is the clients at the workshop the coaches at the workshop go through and assess seven other workshop attendees fully top to bottom they do one assessment on seven different people then they do another assessment on seven different people until they've assessed assessment on seven different people then they do another assessment on seven different people until they've assessed it's the same seven different people through nine different assessments and then they become the client so they get those assessments done on

them as well so we knew that if jane could get through all of the assessments she could move absolutely and then it becomes a question of okay well why is it problematic when loaded If Jane could get through all of the assessments, she could move. Absolutely. And then it becomes a question of, okay, well, why is it problematic when loaded? Right. And that's what I wanted to explain. Yeah. So essentially with her assessment, it was full range of motion for the most part.

One of our assessments is called the standing lumbopelvic flexion test, where essentially you're standing up nice and tall. You're reaching down with your knees extended, touching the floor with your fingertips, ideally. And what we found there was full range of motion, a little increase in some nerve symptoms that kind of went into her glute region. Nothing that really shot down the leg, nothing that gave a lightning bolt feeling. And typically for me, the closer something is to a person's low back, the less worried I am about it. So since her symptom really only went down to her glute region, it was relatively low risk to take her on as a client. Let's talk about that for the people who are listening who don't understand why you said that.

What Ray was just describing is what we call focalization of pain versus the opposite, which would be called peripheralization. Let's try saying that three times fast. Right. Of pain. The difference being if somebody has a low back injury and the pain is in their low back, that's actually a good thing. We would rather see somebody feeling a seven out of 10

pain in their low back than a three out of 10 in pain all the way down their leg. Absolutely. So why is that? It basically shows us that hypersensitivity to that nerve is getting less. The irritation going on in that system is getting less. And it's just a kind of an indicator that we like to use to track progress, even though it can be scary that the symptoms are getting worse. Oftentimes, it requires bringing that client back to reality and saying, no, this is exactly what I'm looking for. It means we're trending in a positive direction. Which by the way, when explained to a client, I've seen over

and over again, take a pain from a seven to a five in a conversation. Yeah. Kind of like we talked about before with that just kind of initial history, you're getting some of that fear and uncertainty taken away. Hey, why is this getting worse? It's actually not getting worse. It's getting better. And I want you to know that. Totally. It's like if you told the client, I expect your knees to hurt after you do this thing, you're going to feel on the outside of your right knee.

And then they do the thing and they feel on the outside of the right knee. They're like, oh, yeah, that's exactly what you said was going to happen. Where if you didn't tell them and they did it, they'd be like, hey, why am I getting pain on the outside of my right knee? Then no matter what you tell them, it becomes, is he just saying that to cover it up? Is it more severe than he's letting me believe? Getting out in front of things like that can be major. Now, to stay on the path there, I want people to understand that there's a major difference between how we look at this from a coach perspective and how you would have looked at this in a clinical perspective.

And what I mean by that, Ray, and I hope that you can explain it better than I can because I'm not getting the job done right now, is you are able to explain to her this is a good thing. It means it's more in your back than it is in the nerve or in the disc or running down any kind of issue like that. In the clinic, that becomes something that we're explaining in a very diagnostic way, where it's probably if it's running in this path, that becomes something that we're explaining in a very diagnostic way, where it's probably, if it's running in this path, it's the L5 nerve root, if it's running in this

path, it's the L4 nerve root. When we're working with a client, it's just this is less severe than that. Yeah, it's taking away the clinical feel of it, the way that you're communicating with a client in terms of, look, it doesn't really matter why this is happening. It's just a good thing that it is. So let's run with this progress. And I think one of the things that we often see when we're coaching for clients is that everybody has kind of a litmus test. They have something that bothers them. And no matter how everything else improves, if that one thing keeps bothering them, they're going to say, oh, I'm not progressing at all. And so part of the coach's job is to circle back and say, well, remember when

before you couldn't walk up the stairs without any pain? Remember before you couldn't hop on the rower without any pain? You're doing a lot more stuff with less issue. That's progress. What's up, Shrug Nation? Are you enjoying this episode? I bet you are. I'm going to keep this brief. We'll get you right back to the show in a moment.

In the meantime, if you're interested in anything that we're doing at Active Life, make sure that you head to activeliferx.com slash shrugged. You want to be a better coach. You want to help your clients better. You want to get out of pain, but you don't want to go to the doctor or miss the gym. Activeliferx.com slash shrugged. That's where you need to be.

We'll see you when you get there. Turn pro. Here we go back to the episode. Yeah, I can relate. I recently had a day where I had, I've been training, my mode of training recently has been martial arts as opposed to barbells and squats

and things like that just because it's kind of the phase of life that i'm enjoying i have three kids now all of them are girls and i don't need a 17 year old boy coming over and beating the shit out of me in my own house in 16 years so i've been learning how to defend myself and offend others when necessary and one day i just I threw way too many punches with my right arm, way too many. It was, it was probably a 4x volume from any previous day of my life, which was never that high, and the next morning I woke up, and I was like, whoa, I, I can't scratch my own ass, so forget about trying to wipe it. Right. After the morning, after the morning duties uh d-u-t-i-e-s

or d-o-o-d-i-e i guess it doesn't matter it's spelled the same it's the same word um and if i didn't know where that came from and if i didn't know that the way it felt as i moved it more it felt better i might have been a little bit nervous about something like that and as the day went on i was like okay well this is, this is feeling better today. I'm going to feel better tomorrow. I'm going to feel better the day after that. I need to not do the things that aggravate it. I need to just keep moving it though. So that's kind of a segue into what we did with Jane right away, because now you have to start her moving. You have to start her actually getting better. What do you do? Right right so just kind of giving

a little bit more pertinent information the the other test that stood out was her prone heel to butt which essentially we're taking that client putting them flat on their stomach and and doing what you could envision as a quad stretch but we're actually looking at a muscle that crosses at the hip and the knee and can drive the low back into extension. And so one of the things that I noticed with her was after the test... Hold on. I just want to stop you. I want to make sure that people...

Because you have to be able to see it. So she's laying on her stomach. We grab her ankle and press her heel to her butt. Correct. And what we're doing when we do that test that we call the prone heel to butt test is we are stretching a muscle called the rectus femoris. It's the one that we're focusing on. It's the only hip flexor that starts above the hip joint and ends below the knee joint. So it crosses two joints. Correct. Your other two hip flexors are called your psoas and your iliacus muscles. For those of you who've heard of the iliopsoas, that's the complex that we're talking about there. Rectus femoris is not one of those. Correct. So when we

pull the rectus femoris taut, what can happen is if there isn't enough range of motion, because it attaches to the pelvis, it can force the entire pelvis to dump forward like an anterior pelvic tilt, which puts the spine into extension and can cause pain if there's an issue there. Now, carry on, please, Ray. Yeah, so that was kind of her pertinent movement screen findings that really related to her back in any way. So then from there, it becomes, let's start seeing what you can do. Now, I didn't run her through a full test like we typically do. We typically run

a 10-day test that includes a movement screen, full strength screen, and we're also looking at endurance-based strength systems versus strength systems as far as movement patterns go. And really with Jane, it was kind of unremarkable from a discrepancy standpoint, but it was very remarkable from a quality standpoint and a subjective feel of, well, this side felt much harder. It felt like I was working three times as hard, even though I was only one rep shy. And so phase one for her was really just starting to get her moving again, giving her guidelines of what she can do, and then focusing on increasing the quality of movement before we progress to anything more aggressive. So how do you progress the quality? Is it just rep after rep after rep? I think one of the big things for me is looking at quality of movement as a variable in linear progression.

I think that where people get kind of caught up and lost is, oh, it's week two. I've got to add two reps or I've got to add some load. There's no harm in repeating work with an emphasis on quality. The important part to it is you have to relate to your client why you are repeating. So I'll put a note in, and we use a medium called True Coach that we communicate with our athletes with. I'll actually put a note that says repeating intentionally for quality, giving them some indicators on what I want them to focus on.

And what that does for those of you who are listening to this, who might be coaches as well, is if you cut and paste a workout from week one to week two or week 17 to week 18, wherever it is in the program, and your client sees it and you don't address repeating this on purpose for this reason, they might assume or question, are you just being lazy? Did you even look at what I did? So it's always valuable to communicate that so you you you tell her you want to see quality improvement and that takes how long for for you to start to be like okay we can progress and load and other things we did that for a couple weeks it wasn't anything crazy and then once that quality started to improve i was looking for more subjective quality as far as what she was feeling in the comments that she was leaving. The way that I decide whether to progress somebody based on subjective measures

is really just what is their perceived response. So if they say, hey, I smoke this, I'm going to progress it. If they say, hey, this was really hard or the last set was hard, I might keep them there one more week. So we were about four weeks until we started to add a new thing. She started in November. We started to progress her front rack step up. We started to progress her side plank work. And then once we got into January, we started a squat and hinge progression for her. So before we get to the squat and hinge progression, how did you choose? I know you touched on it earlier that the quality was off left to right.

Why step ups first though? Why didn't you look at single leg hinging? Why didn't you look at carrying? Why didn't you look at standard hinging? What made you say, okay, we're going to start here? And I'm asking you that because most of our clients, as Ray said earlier, go through a thorough 10-day full-body strength, stamina, skill assessment. And in this case, it wasn't warranted because that would have blown the client up. So what made you decide step-ups was the way to go? Yeah. So we actually started with a variety of single leg work. I thought that just giving her pelvis and her hips a little bit more freedom to move and not be locked in bilaterally would really help out with desensitizing the system and kind of building confidence and comfort.

So I actually did have her doing a really light single leg RDL, but just to above the knee. So we're already starting a hinge progression, but the client doesn't really know that this is our pathway into hinging. What I'm really trying to do is I'm trying to reconnect her brain into a movement pattern. And then that is kind of one pillar. The next pillar is with a front rack step up, I'm able to load much heavier. So I can actually get 65, 75 pounds through the leg and I'm not causing residual symptoms that last over a day.

Got it. So now you start to progress to a hinge and squat pattern. What's that look like? So essentially the way that I like to start doing those things is going from a unilateral progression to a bilateral progression. And then when I get into hinging, it's really simply just a matter of graded exposure to new ranges of motion, new movements. Stop talking science to me. So graded exposure meaning if you were deathly afraid of swimming, not learning how to swim, but deathly afraid of swimming, I wouldn't start our first lesson by tossing you in the deep end

because that's probably just going to send you into this insane fear response. You're never going to come back and you're going to tell everybody that I tried to kill you. Even though my mom threw me in the deep end to teach me how to swim. To teach you how to swim is different.

Okay. Now, the way that I like to relate graded exposure with movement in this analogy is day one is going to be explaining to you what we're going to do. It's going to be talking about the movements that you might be fearful of. It's going to be talking about swimming. And then at the end of that session, we might have you looking through the window at the pool. That's day one. The next time we bring you in, we're out on the pool deck. So essentially we're starting to gradually expose you closer to that fear response. Then it's going to be, let's get one toe in the water. That's all I want you

to do. One toe in the water, you can death grip the rail. Then it's going to be let's get one toe in the water that's all i want you to do one toe in the water you can death grip the rail then it's going to be one foot in two foot in and the way that we start to equate that with movement is let's start with a single leg rdl let's progress that to a pvc rdl where we're limiting range of motion and were you choosing to do that so in such a graded way with the single leg hinge because the hinge is what scared her the most? The hinge was absolutely what scared her the most. Okay. Yeah. Yeah.

So this is, it's like dating. You don't meet somebody at the bar and be like, hey, you're cute. Want to get married? You know, you got to get them ready. You got to prime everything up. You got to make the nice dinner. You got to wear the nice shirt. You got to ask the parents, you got to do all the right things first. So that's kind of what we were doing here with getting her acclimated to these different things.

And what happens when we do that is essentially the body is getting more information. So the brain is getting more information from the extremities, from the spine saying, oh, okay, I wasn't sure if we could do that or not. And now that you've shown me that we can, I'm not going to drive pain to it when you do it in an uncontrolled environment. Right. We're essentially turning off a false alarm. Yeah. So the other analogy I like to use, it's very helpful when you can talk in terms of something that is non-scientific. If you have an alarm on your door and it's supposed to go off when the door opens, but now it is so sensitive to movement that it goes off when the wind blows. That's a hypersensitive alarm. That's essentially what our brain is doing to these patterns, to these movements.

The actual movement isn't going to cause us any harm, but our brain is saying, wait a second. I need to pump the brakes on even going into this range of motion because we might blow up. Yeah, it's the dog that used to bark when someone came to the door. Now it barks every time someone walks by the house. Absolutely. Same idea. So great. So now you're getting aed exposure into the hinging.

She starts to do well with it. What's next? I want people who are going through something similar to understand the progression that they might be able to go through themselves. Yeah. So we started out in the end of November. And actually I'm looking at some notes here. And January 1st, so beginning the new year, we began her dead year progression, her dead lift progression. I combined those two. Okay. So she was like what, five and a half, six weeks into

things. Yeah. So it wasn't, it wasn't that long of a time, but you know, it's, it's hard for people to be patient when, um, when there's uncertainty involved. Yeah. And I think that that's where the coach's job comes in to actually provide some of that certainty. You know, how long did you tell her to expect this to take prior to feeling like it was doing the job? Oh, that's always such a hard question to answer because it's different for everybody. No, but in this case, did you tell her?

In this case, it was more, it's really going to depend on how you feel. It was easing the nerves of days that, hey, this didn't feel great when I did it. And it's, okay, let's see how you feel tomorrow. Let's not worry about this tonight. Yeah, you're irritated. I need some irritation in order to drive an adaptation. Yeah, and I know that we also had her sign up for six months to start.

Yeah. It was, look, this is going to be a minimum of a six month long process so let's not if you're dealing with an issue like this and you pay a coach you pay us you pay someone in your gym you pay your physical therapist whoever it is to help you and you're doing it visit by visit month by month what happens is every month you audit did i make enough progress to make this worth paying for again right and the the unfortunate truth is you're the worst judge of that. And it's the old adage of so many people quit right before they reach their goal.

You don't know. So you might go a full month, not feel any better, but be demonstrating progress to your coach, to your practitioner. And they're like, no, no, no, we have to continue going. If you stop there, you set yourself up to believe that you can't be helped without a major change, and that's dangerous. Yeah, the other thing that I want people to know is, um, we're not solely focusing on getting this injury in the past. Um, we were working on shoulder strength and I'm actually looking at another note from here that she's still hitting PRS in this timeframe of what she PR and her ring muscle ups 10 in a row. So strict or kipping, kipping, but we're making great progress. And so

it's, it's, you're not going to lose as much fitness as you think you're going to lose. And one of the thoughts that I've kind of been dwelling on is, um, I don't know if people are ever out of shape. They're always just in the shape that they're in. Because I remember looking back to being in the best shape of quote unquote the best shape of my life and things were still hard like i still felt out of shape yeah right so when do you actually ever feel like you're in shape in kind of the crossfit realm i don't know that you really do yeah i can tell you that when i when i anyone who's ever trained any kind of um combat sport can probably tell you that the first day that they did it,

no matter how fit they were, they were like, what the fuck? Six seconds in and you're like, why am I gassed? So it's all relative. So I'm surprised she didn't have pain with the kipping. And I'm surprised that you let her do the kipping with the extension and tolerance in her low back. How did that come about? Once we were in this, in this phase, the extension wasn't really bugging her anymore. Okay. So it's starting to reintroduce and, and my, the way that I interact with my athletes is always, I want to take away the least amount of work that I need, and then we'll get more aggressive scaling things back, modifying things back. But for her, it was, hey, let's actually try putting this back in.

Well, I think that that's a really big point that you make there that a lot of people miss. We don't add stuff. We don't take somebody who's got low back pain and be like, okay, cool. We're going to add these six exercises to your program, and that's going to solve your problem. We're going to add volume to your problem, and that is almost never the case. Right. So you have to be ready to do some of the things that you haven't been willing to do, including taking some of the things that you're currently doing out. Yeah, it's always going to be short-term sacrifices for long-term gains. If you look at training maturity,

training age, and you think about like, if I removed six, eight weeks of training, it's not going to make that big of a deal in the long, in the grand scheme of things. You've seen plenty of athletes who take time off from training patterns and because they have matured as athletes, come back into the gym and start moving more weight like it's like me today on the bench press dude you were repping them out killed it but that's training maturity that's training age it's the time spent in the gym not just your time total so it becomes really important really valuable to decipher that and have that conversation with athletes yeah and for those of you guys who are at home right now wondering,

because it's probably a burning question for you, and I want to make sure that you have the answer to it. I was repping out 135 for reps on the bench. I think I did 20 reps in about 30 seconds. You crushed round one. Let's not talk about anything else. We're going to go on the front of the net. Yeah. Just round one was great. 20 reps in about 30 seconds. So for those of you out there, still got it. And if you're laughing at 135 as a weight, whatever.

Now, I weigh 160 pounds. Give the guy a break. I don't care what an NFL linebacker who weighs 250 can do a 225 it's not even it's it's the same so what's next she gets back into hinging she's pring her muscle ups what do you do with her next yeah so so kind of at the same time we had started a a hinge progression a squat progression we were working on a little shift that was going on in the bottom of a squat that I think was more habitual than an actual strength deficit right to left. How did you work on that? Because I think the people who

are listening to this podcast are going to be like, oh, I have that. How do I fix it? Yeah. The first thing that you need to do is you have to rule out any movement screen findings that might be causing the shift. So is it the ankle? Is it the hip? Then the next thing we're going to look at is, is it a strength balance issue? So are you stronger on your right leg than your left? That's going to cause you to shift out of the bottom. The other piece is going to be, do you have the stability and comfort to sit in the bottom and then produce force evenly out of the ground? So doing holds are one of my favorite things for that. Okay.

So she had a little shift and you decided it was habitual because what? Because there was really no quantitative difference going on strength-wise right to left. Got it. Okay. So you fixed the hitch by? Yeah. And that took a while. How did you do it? We've been working on that for three while. How'd you do it? We've been working on that for three months.

How did you do it though? Um, by slowing her down. One of the biggest things that I think I see in the, in, in fitness athletes is wanting to rush the eccentric because it takes a, takes a lot out of you to do an eccentric rep, right? So what's going to be the fastest way, the most efficient way, let's drop down to the bottom of the hole. Let's bounce out of there. And then we'll just concentrically stand up in whatever pattern we start to get strong in. So oftentimes it's taking athletes and saying, let's expose you to some tempo. Let's decrease the load.

Let's increase the time under tension. Give you a slight hold at the bottom to let you just get comfortable and then allow you to actually focus on using both legs out of the bottom of the squat so as simple as intent as simple as intent every single thing that we did had some sort of intent behind it for jane okay so now by the end of what March, the hitch is gone. End of March hitch is gone. Um, we had since that time started her with, you know, a 65 pound deadlift. Well, now, now we're in March. Is she still hurting? Yeah. I mean, she is, she's still having slight issues. Um, so it's less, it's much less and it's more of an annoyance than it is a pain. It's more of, Hey, I can still do this, but it's bothering me.

And I find that at that point of the client's path, the interesting thing is impatience actually grows, at least from my experience. Yes. from being so obviously hurt and unable to do what they wanted to do before to making progress to where they can see the light at the end of the tunnel, and now it feels like instead of moving forward, they're on a treadmill, and they just want to get to that light so bad. So what do you do there?

Yeah, so I'm actually looking at March 19th. Sets of deadlift, 4x6, 135 from the floor. Absolutely no pain, best it's felt. Great. So we're riding out that progression. We're starting to build volume in things that might be more aggravatory, like running, running. And just as an idea for people, 135, what is this girl able to do?

I think she was in the high twos high twos low threes i think yeah yeah so so just so if you guys understand um unlike my bench press where that's impressive this is not an impressive number for her to to deadlifts off the floor yeah and and that becomes one of the issue. It's like, Hey, this is, you know, this is 30% of what I used to do. And it's, yeah, but it's 30%. It's 30% more than you could do when we started and you're doing it without pain, right? You're not going to overall become weaker. You're going to feel weak if you're hurting. So if I can just get you to feel better and then I can start building your progress and tolerance back up, I'm not worried about the weight. That's easy to say from a coach perspective, kind of having that experience under my belt, but I know that the strength is in there. So if I would have said build to a heavy three, my guess is she would have been able to push

90, 95% of what her prior deadlift was she's pulling 275 i told her to do that but that would have been grossly irresponsible on my part because i know that her tissues don't have that adaptability anymore so we're having to recreate and rebuild on those linear progressions just like when she was almost like when she was just starting to learn but now we have that maturity under the belt and we're able to progress it to tolerance and yeah and this is where i feel like most people make mistakes is they they've been out of the gym for a while they start to feel better they see the light at the end of the tunnel and instead of continuing to progress slowly towards it they sprint off the treadmill and fall on their face it's why the person who gets rhabdo in their abs

gets it when they come back from injury doing the same thing they did previously on the GHD sit-up. It's not the person who is in the gym working out every day. It's not the person who's not fit. It's the person who had a capacity, took time off, and went back at the capacity they were previously at. So we're keeping her doing less. It's March 19th. She's still experiencing some discomfort. It's less than before. She understands at this point, surgery is not going to be happening and there's got to be some frustration. Do you guys ever go back and forth on, yo, get the job done? Yeah, there was actually one day where we probably were in a three-hour text conversation.

The point where athletes start to feel really good is typically the point where they start to need the most guidance, kind of like you had just said. And it's really hard to, you really have to sell the value of what that last phase is going to look like. Because it's like driving a Ferrari 30. Absolutely. You don't want to do that. No, I know. That sounds boring.

What am I just on a cruise control? Why am I in a Ferrari if I can only drive a 30? So you're having to talk that athlete off the ledge of saying, look, I'm ready to rev the engine. I'm ready to go. And really it becomes we have to rebuild all of your capacity. And if we don't do that smart and slow, and when I say slow, I mean relative to how fast we can progress, but it's going to feel slow to

the athlete. There's always going to be a point where as a coach, you say, we got to test this out a little bit. And so it was probably about a month after that conversation. So getting into kind of end of April, beginning of May, where we said, all right, let's start to rev this engine. And, you know, to some degree, let's keep our fingers crossed and see how they go. And how'd it go? It went great. Tell me about that. So really, it's just starting to get into one of the things that we really focused on was knowing when she was ready to train hard. We use a lifestyle indicator. Check-in. Lifestyle check-in. Yeah, that we give to our clients.

And essentially, we took that and we created a score based around it. So what we do for the lifestyle checking is the total hours of sleep. So that's anywhere from, you know, hopefully seven plus to 10. How was the quality of sleep? One being I could not sleep at all. Five being very restful. We took fatigue levels, so kind of a perception of how you feel, again, one to five, five being very fresh. We took nutrition into account and then we took in stress to account. So I think you could get up to about 28, 29. And for her it was, hey, when you're over, I think I gave her the number 21.

When you're over 21, we can go hard. When you're less than 18, we're going to run just a recovery day. Now, two questions to that. Number one, actually before I get to questions, anyone listening now knows that Ray doesn't have kids because he mentioned 10 hours of sleep. And that is just not happening and the second thing is did you tell her that the score that we wanted to see her at to go hard was 21 or is that what you kept in mind and I asked that because my fear in telling a client that who I know is a line you know like they're they're after it is that they're going to just figure out how to

get the math to 21 on their score yeah and and And, and part of that is, you know, if, if you want to lie, you're really only going to lie to yourself. It would, it would definitely depend on the client. With Jane, it was, it was pretty clear that, Hey, I want you to do this so that I can help you. Because if you don't, it's going to be the one thing that we look at at, were you being honest on this check-in. And it worked out phenomenally for her.

So we were able to start pushing the limits of intensity. We were able to start adding in more Metcons. We're able to keep going up into more of a strength progression. And while it's still not where she wanted to be, it was seeing the light. Do you take people in the Active Life Immersion course for coaches through the lifestyle check-in? Is that included? Yeah, we do.

Yeah, we actually talk about this case specifically of how we used it. Oh, that's cool. So for those of you guys listening who are coaches who are aspiring to what we like to say turn pro, if you want to work with clients who are looking to get out of pain

without going to the doctor or missing the gym or looking to train without the pain that typically frustrates them, the immersion course is essentially how we train our staff. It's the first step to being a staff member at Active Life and we offer it now to the general public so that they can learn how to do what we do

and our methodology can spread and clients can get helped all over the world. So ray teaches that and that's why i asked the question um and we actually give the um we actually give them this lifestyle check-in to use with their clients if they want it perfect created by dr katie harper active life staff and it was an awesome addition it was an awesome addition so get me an awesome addition. So get me close to current day. We were at the end of April and Jane is doing better. She's into her progressions.

What's next? Is she ever going to, like we're now recording this podcast end of June, 2019. When is it like, okay, you can go clean 200 pounds again because I follow her on Instagram and I've seen her clean,

I think 205 pounds again. Yeah. So we basically started that progression the exact same way we did with the deadlift. It was, let's start cycling some light barbells. And then, you know, kind of like I said, it became time to take the training wheels off once we established enough capacity. And I'll typically start my clients at a six to seven out of 10 RPE, rate of perceived exertion to build up to something that they're going to have plenty in the tank. And all that does is it gives me a floor. It gives me somewhere to start building up my weight. It gives me somewhere to start actually writing and programming that is not going to exceed what their nine or ten, you know, I don't want them to fail a lift on their first attempt back at a quote-unquote

max clean. Right. So that was it. We start overhead squatting. We start squat snatching. We start doing things that look more like what she needs to do and with adding new things comes new irritations and then we start that adaptation process all over again with with the new movements yeah so there's going to be the valleys again there's peaks there's valleys and that's that's life that's training we're six and a half months in now with her and at the point that we're talking about you know it's it's early june late may at the point that we're describing where the training wheels are off is that right? Yeah.

Okay. That's the first time she overhead squatted? So, you know, we had started building some capacity probably about a month prior to that, just with an empty barbell. Yeah. The point I'm making is that we don't use that as an assessment. Right. And it's because we've seen things like, I mean, remember Drew Canavero doing a pistol overhead with 1855 pounds he also did a pistol thruster with 185 205 yeah that was a squat clean thruster pistol that's

right that's right with 205 about four feet from the curb in front of my clinic at the time where had he fallen and dumped backwards he would have cracked his skull and died now his overhead squat looked beautiful. This guy was the best-looking squatter in the world. If you watched him overhead squat, you would just give him a pat on the butt if you were friends with him, pat on the back if you weren't. Even if you weren't friends with him, I feel like you'd give him a pat on the butt. You probably could because he's probably wearing some neon shorts

or something that just invites the slap. By the way, I'm not suggesting if you wear neon shorts, I'm going to come around and slap you. Joke. Maybe I should have left that one out, but either way. And he had excruciating knee and low back pain when he was doing that stuff. Yeah. So it's, it's, you can't look at a complex coordinated movement and, and decide what's wrong based off of how they perform it. Yeah. And, and one of the things that I think is really important is you can be strong and in pain. I mean, there are plenty of people who are ripping 600, 700-pound deadlifts

off the ground and feel like shit the next day. Well, and I think that people understand that. I think that what people understand less is that you can also have flexibility and mobility and be in pain. Absolutely. That's why you can't just look at one thing you have to take into account the whole system right and basically what are your low-hanging fruits right jane who we're talking about today could very easily do a standing i imagine um standing to backbridge you know some some crazy gymnastics stuff because of her history. And she didn't fail any of the movement screens, and yet here we were.

Actually, prone heel to butt was a little bit problematic, but that's not what people are associating with mobility and flexibility. They're looking at I can move well, generally speaking. And she had all this pain. She was going to get surgery. So how does this thing get wrapped up? So obviously we're not done with her yet. She's still a client and the anticipation, I know she bought six more months. Right. So the anticipation is she'll be with us for at

least a year, maybe longer than that thereafter. What's next? The phase that we're in right now is really trying to figure out what program she's going to go on for a conditioning. So we're trying out different things for her. I've made some recommendations of programs that I like, and she has tried some that are lower on the cost end and has not stuck with those. So it really just becomes finding what kind of Metcon conditioning stuff are we going to give? And my job becomes filling in the gaps of strength work that's actually fit to her profile. Right.

So essentially at this point, what we're looking to do is outsource the energy development to a different coach who is not an active life staff member. So we've referred clients to Brute Strength. We've referred clients to Training Think Tank. We've recommended clients to Invictus. We've recommended clients. Where else? I mean, I don't need to keep going through them. We've recommended clients all over the place.

We try to match the client up with the coach who we have a relationship with, who we think is going to be great for them. Absolutely. So what do you think the future looks like for her? Is she always going to have to worry about this? No, but I don't think she's always going to have to worry about it. I'm also not going to be surprised if it acts up from time to time. One of the things that I think is vital in the progression of kind of returning from an injury like this is not sending the panic meter off the charts when it happens again. It's really just saying, hey, I've been through a valley before. I know that it's going to be okay. And I know that when I come out on the other side, I always come out better and stronger.

So that's kind of the conversation from the emotional side of it is managing the expectation of I thought that this would never happen again. Well, unfortunately, our bodies are weird. They do weird things. They respond in weird ways. It could be something as simple as picking up a pen off the floor when yesterday you just hit a max deadlift. You know, it's, it's just the way it works. Yeah. I think that's great advice for people that, that, you know, what happens is once you've had an injury and a scare in a place, it almost acts like a scar that whether it's even there anymore or not, you always remember it was. And if in the future, you do something that exacerbates a symptom in the same area, it could be totally unrelated.

It could be something that's totally different, that is not invasive, that just feels really bad in the moment. And you immediately have the potential to take your mind back to, oh my God, it's back and I'm screwed. And that's a mistake. You know, we, we had, um, today we're walking through the city of Boston. We're here for a workshop at Invictus Back Bay. And one of our staff members, uh, Larry Geyer has one of his clients from back home. And he says, you know, this guy has never had any pain. He's a personal training client that Larry works with in person in New York. And he's like, this guy's never had pain.

And all of a sudden, he just told me today he has pain in his back, down both of his legs. Like, what is that all about? You know, and I'm like, what would you tell him? He's like, I just told him to wait until Sunday. And if he still has it Sunday to reach out to me. But weird that that would happen. And I think that it's would you tell him? He's like, I just told him to wait until Sunday. And if he still has it Sunday to reach out to me. But weird that that would happen. And I think that it's easy for somebody on our staff, somebody with the experience level of one of our coaches,

or maybe the coaches at your gym, to nonchalantly brush something like that off and say, look, things happen day to day that we can't explain. Sometimes you wake up and your neck is stiff for no reason. Your ankle feels weird. You know, give it a few days and see if it persists before you panic. Yeah. Or give it till the afternoon. You know, um, don't send your brain into this. Oh shit mode, send it into like, this is going to be fine. Yeah. Um, the, the real win and kind of the thing that I want to wrap this up with is the win for Jane isn't, it has nothing to do with the programming.

It has nothing to do with the outcome of fitness. It has everything to do with changing training habits, changing pushing through injuries when the goals don't line up with pushing through injuries. So the way that I know that I've won successfully with a client is when they start writing me messages like, hey, wasn't feeling good today, cut the volume back. And the unfortunate part to that is a lot of people are going to see that as copping out. And that's just a terrible way to look at it. Because if you're doing it for you, you're not copping out on anything. You know, it's the old mindset of, you know, the greats train hard on bad days too.

Right. You do. You train at a hard relative intensity to the way that you're feeling that day. Yep. Period. Our workout today, I was supposed to do GHD sit-ups, chose not to.

And I feel like every bit of a man, no problem with it. Yeah. I mean, it was great, man. You still got a good workout in and it doesn't matter. Like fitness is fitness.

Yeah. Let's just get fit and not worry about what we're doing. Yeah. Let's remember that we're doing fitness because our lives are too sedentary, generally speaking. Absolutely. It's not like we don't need exercise if we actually are exercising throughout our day. Correct. So we'll wrap the show up there.

Dr. Ray, where can people find you on the interwebs if they want to, besides obviously coming to ActiveLifeRx.com slash shrugged if they want to work with us? Yeah, Instagram, feel free to reach out, send me a message, Ray Gorman, DPT. And then also feel free to shoot me an email

at drray at ActiveLifeRx.com. That's D-R-R-A-Y at ActiveLifeRx.com. And that is extremely gracious of you to offer that. I hope that your inbox gets flooded with people looking for advice. R-A-Y at ActiveLifeRx.com. And that is extremely gracious of you to offer that. I hope that your inbox gets flooded with people looking for advice. As do I.

Yeah. So guys, it's been great. It's been real. It's been fun. And I look forward to talking to you again next week on the Active Life radio show on the Shrugged Collective Network. Till then, Turn Pro. Hope you enjoyed today's show. If you did,

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If you found the show inspiring, there was something about it that you would like to take action on. You want to work with Active Life. You want to find out if you're a good candidate to be the next Active Life testimonial. All you need to do is head to activeliferx.com slash shrugged. Find us there. We're looking forward to talking to you. We're looking forward to working with you. We're looking forward to your testimonial. Turn pro.