E40 | Bill Hartman

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Bill Hartman, PT is the go-to guy in the fitness and rehabilitation industries when all other methods have failed. Clients from all over the United States and from countries such as Japan, Australia, Bulgaria, Canada, and the United Kingdom have traveled to Indianapolis, Indiana to seek his talents. Bill has degrees in Movement and Sports Science from Purdue University and Physical Therapy from Indiana University.

Bill is the co-owner of the Men’s Health Magazine Top 10 rated and Women’s Health Magazine recommended Indianapolis Fitness and Sports Training (IFAST) and IFAST Physical Therapy where he works with a variety of clients from high profile professionals to weekend warriors. He is a former columnist for Men’s Fitness Magazine, and he has also done a stint as the Men’s Health Muscle Guy while being a popular contributor to MensHealth.com. Bill has been a featured speaker all over the United States and internationally including the Perform Better Functional Training Summit and the Boston Sports Medicine and Performance Group. Bill has contributed to some of the top selling sports training products over the last 10 years and is the co-creator of the industry topping Assess and Correct: Breaking Barriers that Limit Performance DVD. Bill is currently a member of the Men’s Health Advisory Board and is a frequent contributor to Men’s Health Magazine. He is also a former member of the International Youth Conditioning Association Advisory Board and contributed a chapter to the Developmental Essentials: Foundations of Youth, the official textbook of the International Youth Conditioning Association regarding strength and power training for young athletes.

Topics Covered:

1. Parallels between Bruce Lee’s martial arts philosophy and critical thinking
2. Is the compartmentalization of learning necessary for “flow”
3. How are models of thinking useful? How are they limited? 
4. Does the current diagnostic framework in rehabilitation make sense?
5. The influence of pathology on clinical reasoning in rehabilitation
6. “Return To Play”
7. Protocols vs. constraints-driven programming
8. Can “clinical reasoning” be learned without experience/context?
9. What should rehabilitation providers absorb/disregard from constructs like anatomy, biomechanics, pain science, #justloadit, manual therapy
10. When to zoom in vs. zoom out in education

Links of Interest:

• Bill’s Website
• Bill’s Instagram
• Bill’s Twitter
• Bill’s Facebook

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Episode Transcription: Doug: [00:00:00] Alright, Bill. Thanks for coming on. So you've been out here before and we've had a lot of private discussions about, you know, models and clinical reasoning, and these are things that maybe can't be captured or obviously answered in any kind of format, let alone an hour podcasts. But I also know that you're also, a big fan of, you know, mixed martial arts and Bruce Lee. So I think a good analogy to get this going is the idea that, you know, Bruce Lee created this system of systems that he called Jeet Kune Do he's famous for saying, you know, take what's useful disregard what's useless. So when it comes to, you know, if we kind of like an, whether it's like treatment and a clinical scenario, or, coaching and a performance scenario, we have this complex, chaotic environment. The ideal is this flow state where you're just kind of going, and then Bruce Lee's case, you're just fighting and you're not thinking about, okay, I'm doing Western boxing now and now I'm switching to jujitsu. It's very seamless, but do you think that even in the clinical setting, that that flow state being the ideal, where you kind of come to transcend these, these models and these different constructs, do you think it's possible to achieve a flow state without compartmentalizing information and breaking them down into these very constrained boxes. So other words, I guess I'm asking, can we, is it possible to learn without doing that, in your opinion? Bill: [00:01:26] That's a really good question. You know, the way that we build our understanding, I think has a lot to do with why we, we compartmentalize in the first place. So, so it is a defense. That's the one thing that we want to recognize about compartmentalization is that it is, it is uncomfortable to try to hold multiple ideas in your head at one time. And so compartmentalization makes that easier for us. So it is, it is a reliever of stress. It is, it is a protection against trying to, rationalize to potentially useful, potentially equal elements and put them to use. And so again, I think that's what we have to recognize first and foremost, is that, is that, if we do recognize things as being so different, then the first strategy would be to compartmentalize. If we can start to look at things as one big entity you know, we're where people would say that it would be more integrative, right? So, an integrative fighting system of, of many systems that were brought together and, and instead of seeing them as, as separate things, if we can start to see things as being more unified than I, I think that that we don't have to do that. But I think it's also very, very difficult to, to build such a model from the ground up that it does take a great deal of time and it is still uncomfortable. All you have to do is, you know, be a clinical instructor on the, on the first go round, and you will recognize the, the difficulty that, that students will have of grasping things in, in the reality of the clinic because as we as practitioners went through that ourselves, we become more comfortable because what we see is many things, having done things through repetition and, and an orderly fashion that allows us to, at a glance, we see something that, that it would take the student seven or eight different looks or different perspectives. We see that as one. But that was done through, a great deal of investment of time and effort, which was, again, it's uncomfortable. And so I don't think we have to compartmentalize. I just think it might be one of those things that we do to try to make life just a little bit easier. Doug: [00:04:01] Yeah. Because it's very easy to look back retroactively at something like even traditional martial arts. I remember, and I'm sure you remember like the original UFC where like every guy had a style and it was like the TaeKwonDo guy versus the jujitsu guy versus the barroom brawler. But I don't get the sense, and even going back to like Bruce Lee and that he never bad mouth. He doesn't say like, Hey, judo is no good to jujitsu is no good. Kickboxing's no good. Western boxing is no good. Like I don't know if Jeet Kune Do would have been possible without those things and I'm sure that there's going to be a point where somebody, you know, the next Bruce Lee is going to look at Jeet Kune Do as being overly robotic and constrained. So I guess, you know, there's always like this idea of progress with models, but I think you've talked about this, like, I guess, how can we be like agnostic about models because, and you and I have had private conversations where we've talked about, okay, like we can, we can bash on certain things. But even going fundamentally back to the concept of models, like, and you touched on it, but what's, what's good about them? Cause it's really easy to say, okay, like the model doesn't account for all of these contextual things, but fundamentally even using them in the first place. You mentioned kind of safety. Can you elaborate on that a little bit? Bill: [00:05:18] Well, again, it just becomes comfort. It's like trying to hold multiple ideas. So if we, if we associate everything that we learn with what we have previously understood or what we think we understand, then then to add on to that. It's always the comparison. And so again, so there's an element of compartmentalization in that. It's like, I know this, I understand this. I am comfortable with this. For me to super impose something on top of that, I have to see the relationship to make it comfortable for me to take that bit of information in and then eventually to utilize it if I see it as too extreme. So if I see, you know, the, the, the, the battle between systems, then that's where the discomfort. It really starts to arise and then I become defensive and I push that information away even though something about that may have been useful. So what we want to do is we want to see these things like where the commonality lies. So if we're talking about clinical reasoning or we're talking about moving or we're talking about working with humans, what we want to say is like, okay. So if I have these two competing systems, but they're both working with the same system, how do I draw these things together? And so then that becomes this, this commonality. So again, if we're, if we're in the clinic, we're working with the human and movement, it's like, okay, how does this system see this representation of movement. How does this other system see this? And then can I draw some commonalities? The thing that you gotta be careful of this is just because someone has a system doesn't mean that it, that it is valuable. And so we have to be very, very careful of that. And that's something that you learn how to filter out. I think over time, this is where I build this, this bigger and bigger and bigger base of analogy. And I can, I can identify things that were being extreme conflict with that. Where, I've, and you've heard me say this before, it's like, you know, if you go to, to a course or something, and if they provide you some, some piece of information, if you don't have a defense against that, you will absorb that as a fact. Like you will take it in and, and so that's a big part of this is constantly building your base of analogy. And I think that that probably what we're talking about more than anything else is an evolution of, of learning really. It's like I have to learn something to compare to and, and so maybe initially we're looking at these things from a, from a compartmentalized structure. And then as I start this, recognize commonalities and my base of analogy does grow now so does my filtering system now, like my BS detector, you know, is, is much more, accurate, if you will. And you know, if we want to use Bruce Lee as the example, he started with a martial art, he, I mean, it was a very, very specific, rigid martial art and it was his recognition of that rigidity, even though he may have been superiorly prepared within that, that art to defend against any number of things. He recognized that, that his restriction and depth of understanding of that one art allowed him to recognize the fact that there are weaknesses in, in restricting that, that perspective and saying that this is it. We can never say that there is always, always a better model available to us. We just either haven't been introduced to it or we didn't recognize it ourselves yet. Doug: [00:08:49] Yeah. And there's a lot there to digest. So the first thing you're kind of alluding to as all these models are kind of like dots on the map. And when you're talking about as an overall framework that allows you to connect those dots. That's essentially the BS filter that you're talking about, right? Going back to like the Bruce Lee analogy, you know, he started out in wing Chun Kung Fu, and I think that what made him evolve was that he got in a lot of fights and he realized the limitations of that one model because he didn't start out planning. He started out learning a traditional martial arts. Then he got into fights where you realized like, wow, like there's other things I have to be prepared for. And when we're talking about like the clinic, I know people always talk about clinical reasoning. I don't know how much it can actually be taught in an academic setting because you don't have the context. You haven't gotten in enough fights. But you're, you're talking about like you're seeing similarities, right? Because it can be very hard initially. Remember how overwhelming it was. You know, you've learned about the 10 different kinds of knee patients you're working with. So it's like the knee replacement person, the ACL person, the meniscus person, the instant, the patellofemoral tracking person. After a while, you kind of realize that they're fundamentally all really the same. They just have different constraints, right? So. And I think people get frustrated, myself included, because there was a point where like, you know, I'm going to all these courses, I just want it to expedite the process. But what really did it was I think just treating people kind of being in the arena, so to speak, and then just making sure that I wasn't so dangerous that I was hurting people. But you kind of have to make, make those mistakes. So, I mean, we started, we're having kind of like an ideal, you know, conversation here. We're not worried about like, regulatory constraints and legalities. Just for starting out utopian right. But in this utopian environment, I mean, if you want it to, to clone a, a PT that could work for you, that you could sell your practice to, would you start out having them take classes at an academic setting where they just watch you treat for six months or a year to get that context. And then so do you think we should start, we starting with the theory first and then the practice, the practice and then the theory to get context or is there a kind of a, a hybrid that we should be doing? Cause I think that the traditional programs are very heavy on theory initially, no context. And then you have to almost relearn that language in a contextual environment. Bill: [00:11:09] So, so here's, here's the dilemma that you run into.  And again, I had my 25th student in the last eight years that just wrap things up not too long ago. And in the simplest of things that, that you would expect somebody to know and understand have been forgotten. It's not their fault, it's just the way that the programs are structured where they, they throw you know, heavy duty doses of physiology and gross anatomy at you, and then it's like, okay, here's where stuff is. Here's how this stuff works as a separate system. And then when it comes time to integrate all that stuff they have, they have, unfortunately, because of the way that they learned that out of context, it's very difficult for them to remember or, or, apply it. And, and so, so what we're talking about here is the difference between the stuff that you can write down, which is explicit information. And then the tacit, which is very very difficult to explain to anyone, because it is experiential, in its foundation. And so without that, without the tacit, then you're just regurgitating stuff that, that will seem meaningless to you. Now you can get the answers right on the test per se, but, but when it comes time, so the real test where you're working with the individual and you're dealing in a complex atmosphere where there's tremendous number of influences and a tremendous number of unknowns, then, the, the book learning, if you will, has a limited value. It doesn't mean that it has no value, just means it has a limited value. And so I think that that your, your mention of, of this hybrid approach of, of sort of, it's, it's kind of OTJ when you think about, it's like, you know, it's like, and you've heard me talk about the plumber thing before too, where were they learn primarily through an apprenticeship model where they are literally on the job from, from the get go. And, and I think that if, if we were ever going to evolve the profession that, that, that we are involved in be with the scope that we have, it would be so much more ideal to be in the clinic from day one, and to see these things in representation. Now when you do learn anatomy, you're learning it within a context and then it becomes more meaningful. And so that information is then retained. Yeah. Because again, we're attaching something that's very, very powerful, which is this experience. So there's emotions involved which again ties a lot of things together, which you know, when, when it's almost like a, like a forced upon you scenario of regurgitation where it's like, okay, here's a piece of information. I want you to memorize this piece of information and then spit it out on the test. And if you spit it out the right way the way we want it to, you'll get a really, really good grade. When the reality is, it's like the good grades are, are basically, you, understanding how to manage outcomes in a clinic, and I won't say to be successful because you just don't know whether you're going to be successful or not. The goal is to take new information and be able to integrate that into the situation and then take the next step forward as successfully as you can and if you can't, then obviously to determine, well, is there a reason that I cannot move forward? And then that's when we start to send people to other people, right? So I have to send you to the doctor, or I have to send you to some other form of profession that may have an influence in this situation. And now you become, the, the true manager of the situation. Doug: [00:14:45] So that's, that's a great segue to the next thing that I wanted to talk about within the confines of like physical therapy and rehabilitation, where we're learned a certain way of diagnosing. And it's typically the medical model because there's like, for a variety of reasons, you know, many of them political. Physical therapists want to identify as medical providers. So they diagnose like medical providers when in reality, the scope of practice of a, you know, at least the non MD is that they can't directly treat or address pathology. All they can do is, you know, try to maximize function within the context of that patient's goals and values. Right. And then, you know, things like the pathology might be a constraint, but you're not addressing it directly. So to me, this is kind of where we start from, because if you're not, if you're a diagnostic framework or you know, our constructs are, I guess not conducive to the thinking that's going to drive the right interventions, then you're, if you're starting from the wrong place, they're going to finish in the wrong place. So to what degree do you think physical therapy and rehabilitation needs to totally change the manner in which they diagnose? Because the reality as you know, I've seen tweets where it's like. You know, if you're a physical therapist, you need to know the difference between a type one and a type two impingement. And I'm kind of like, I don't actually think that I do at all. I just think that like as long as you have some kind of an idea of how to assess a joint and know what's what's possible, and you can feel like this is a, a pathological joint or not, and then you just work around those constraints. So to me it's like, okay, how do we, how do we figure out if this person belongs in, in my office? And just being able to identify pathology, it doesn't even matter what it is. I don't need to know what the exact pathology is. I think it's more important to be able to identify it because if you think that's the driver of the symptoms or the lack of function, then you refer out. Now, obviously it's much less sophisticated to do it that way. I don't know if it warrants as many classes, but I mean, you know, in your ideal world, like how do we go about even what would be your diagnostic, systems, so to speak, in, in, in the context of rehabilitation, physical therapy, that kind of thing? Bill: [00:16:55] Well, I think you actually hit on it in your statement that you said, we have to consider what's possible.  And I don't think that that, that representation has existed, at least not, not as well defined in the current system of education that's being provided people in, in our aspect of care. So when you think about a, like a, a model that considers things separate, right? So if I, if I look at a muscle and fascia and bone and ligament and tendon and water and fluids and air and all of those things as separate entities that are not, again, like I said before, not as this integrated whole. If we don't consider all those things, then, I will lack something in my model that may actually be, a source or an influence that is a benefit for me to consider. Right? If, if I look at an isolated structure like so I get a diagnosis from say a doc and it comes back and it's like, okay, I have such and such a tissue change or whatever. Okay. If that is truly the diagnosis, I mean, this truly the limiting factor I can do absolutely nothing. It's like so and so this is, and this is the battle that we fight when we do get those patients that do come from a physician with all good intentions, but they give them a label and they say, you have a, and then whatever that a is that that follows. Then this person comes in and says, I have a herniated disc for an example. It's like, okay, great. You want to see the MRI? No, not really. Cause it doesn't really change anything from my perspective. It's not that I don't take it into consideration. It's not that it's not in an, you know, an, an element, in, in the back of my head as I'm moving forward. But. That's just a constraint. And then the question mark is, is it significant enough of an influence that it's going to interfere with our ability to recapture what ever it is we're trying to recapture? Whether that is comfortable movement or whatever, which is typical in our situation, why people would come to us. And, and so, again, looking at what is possible, it's like, okay, does this interfere? If it interferes. And, and we can eventually figure that out, I think to some degree. Then we, we have to also recognize like, okay, this is beyond my scope. I can't do this. Right? And so again, I think that expanding the model, putting things into a much larger context where everything is working together, provides us an element of, of that understanding and allows us to look for, and I think you mentioned pattern recognition as, as being one of the primary elements. That's what we do. That's what, you know, you go to a physician and you have like a sore throat or you know. Whenever they're looking for signs and symptoms, they're combining those into a situation. They don't know why you have that. They just know that these symptoms kind of go together. This medication goes with the, with those kinds of symptoms. And so what we want to do is we want to have a model associated with movement that is, that is similar and respect is like, okay, if I see these limitations, then I understand that I have these influences that are potentially, creating this, this presentation that I'm working with, and then how do I alleviate those? Or how do I make the, the, the influential change to restore what I perceive as what's possible? So, so I, I think that the, again, the restriction comes in and the model in and of itself, which is, I mean, 30 years into this is totally different from where, where, where I started, thankfully, thankfully. And, and I, but I think I could have gotten here sooner, with a, with a different structure as to how, how we, you and I learn. We got an element of it near the end of our educations in the clinic where you were finally placed into this context and a mentorship sort of apprenticeship type of model. But imagine how good you could have been had you started there day one. And superimposed all of the explicit information and, and see it demonstrated in real time, in real life from the get go.  I, I can only imagine how much better you would be coming out as a clinician. Doug: [00:21:24] Yeah, and I'm not saying this to be critical of the way that like medical doctors diagnosed because it actually, it works for them because they're supposed to be treating pathology. Right? I'm talking about the direct access. You know, you're the first person to see this patient with hip pain, and it's like, okay, what's the diagnosis? Well, you get pinching in your hip when you squat, like, you know, and even with these diagnoses, like how do we define them? Right? Because you can define something like FAI based on an xray criteria. But functionally to me, FAI is, can my interventions get this person to squat without pain? If the answer is no, and I and I assess the joint and it feels pathological, which is totally subjective, and something that I wasn't able to, to detect until I assessed a lot of hip joints, no matter how much I could regurgitate the criteria on a multiple choice test. So to me it comes down to is it pathological or not? And this is where the trial and error thing, and you talk about this, where you don't know what the diagnosis is until you try something, because based on having treated however many hip patients, if the things that you do that normally work, that get that person to go into deep hip flexion without pain don't work, and you still feel that same bony end-feel when you assess the joint, which is again subjective now, you know, okay, there's probably a good chance that this is a pathological condition that I can't influence with my toolbox, and then it goes from a functional construct to a pathological. I just don't know how we rushed that. I mean, but I think the point of this conversation is that people need to be encouraged that like it actually is a lot simpler than it's made out to be, but it's also, it doesn't make it easy. Bill: [00:23:02] No. No, because we're so, we're, so what we do, so what we do is we actually just, we have to, we have to understand the probabilities, right? So somebody comes in with this subjective complaint of pain in the front of their hip crease, and it was like, okay, well what are all the possibilities? Okay. So if it, if it's pathological, I'm of no use. Right? So I can set that one aside. Initially. Right. And so now I'm just looking at, okay, what influences these possibilities. So based on my, my acquisition of information from the patient, from some, whatever evaluation you use, I determine what may be the limiting factors. I try to alleviate those limiting factors and again, based on probability. So I have done a number of interventions over the last 30 years, and so I have built up some, some, currency, if you will, in regards to what I think will work under these circumstances. Right? And so there's the three in the first year and 30 years it's like, I'm just have more stuff. I've failed more times than everybody else, and therefore I am able to narrow probabilities a little bit more effectively than somebody that does not have the, the, the task experience that I do. And that's literally what we do because we have too many unknowns. We can't identify things from the simplest of tasks, we can't identify structures in and of our, on our own. I don't have x-ray vision, right? There are certain things that will be a little bit more obvious than others, certainly. But again, even that's acquired through through experience to identify, okay, what is more likely under these circumstances? And so we're always just playing with probabilities. And it sounds like it's a, it's a crap shoot, but it's really not. Well, you know, I was talking to our, our buddy Brian Shawn about this, and he goes, he goes, but you kind of know when you do something because the rate of is is, is so much better. It's like, well, I'm just better at narrowing the probabilities because I still don't know what the ultimate answer is going to be. But you know, if I would say that, you know, 76% of the time when I do something under these circumstances, I'm successful. I kind of know what I'm going to do. And when that doesn't work, there's a 24% chance that it's going to be something else that I can't do anything about. And that's kind of how we work and we have to respect that. It doesn't mean that it's, like I said, it's not a total crap shoot and it's not trial and error. It's just, that's how you manage complex situations is you have to understand how to take a piece of information. I intervene and I take that response as the next piece of information as to how I step forward. And now I can further narrow those probabilities. And then we just go as far as we possibly can under those circumstances. And that's, you know, and I, you know, some people would say that, well, that's not black and white enough for me. I'm sorry. But that's just the reality. We live in the gray, we live in unknowns, and we don't even know what all the unknowns are under most circumstances. Doug: [00:25:56] So that's. That's a great point where we don't really know and there's some humility involved. But at the same time, patients come to a medical provider because they want an answer. So you know, when somebody says, and I'm not talking about like the obvious case where you break your leg in a car accident and that's why your leg hurts, you know, where it's like obvious cause and effect. So in these cases where it's not obvious cause and effect, and it's not like a clear pathological driver. How do you ethically navigate that when a patient asks you, why does my back hurt? Or why does my hip hurt? Like do you, do you say, I don't know. Do you say, I don't even know if that's the right question because it doesn't matter. Cause I think fundamentally it actually. It doesn't matter. That's not in my head. Does it hurt? Bill: [00:26:39] Yeah. It doesn't matter so much. Right. But, but for them, they, they, one of the, if you look at the hierarchy of needs of the patient, one of the reasons that they come to see you is they want to know why. Right. And I think it's fair for us to say, it's like we can narrow the possibilities and then we, and then we have to be incredibly truthful. It's like it could be this, it could be this, it could be this. And if it's this, then I can't help you with that. Right? And again, that's why, that's why the experiential element of what we do becomes so important and so powerful. And probably why it should start from, from the get go is so that people do get comfortable with that. Because as new students come out, they are afraid to admit that they are, they are unsure. Right? Because they think that that negatively influences the, the perspective of the, of the patient. You can be unsure, but you can offer up potential solutions that will be satisfying for that individual, right? If I can narrow it down, it's like I can't be certain of this, but here's what happens under these circumstances. So as I move your hip into this position and you feel that discomfort, here's what we know. We know that we're closing that space, and so if that space closes too soon. For this reason or that reason, then this is something that we're going to be very, very successful with because in most circumstances, in most circumstances, we can address these things very easily. If it's this, this, or this, then it's going to be a much more difficult time, or I need to send you back to the doctor, and this is one of those scenarios where you would refer it back out. So I think that's the way that you explain these things. I think that there, that expresses it with an element of competence. It's like I have narrowed it down to these things. Right? And I think that that becomes a very, very effective way and a very truthful and honest way to do it, rather than making a leap and saying, Oh, it's this, as if everything is obvious and this is the difference between complexity and something that is very, very simple. You know, it's not like if you watch a basketball player come down and for a rebound and he lands on somebody's foot and he gets an inversion sprain, you can speak with great confidence that you, that you've got a really good idea as to what just happened, right? You look at, you look at the cardinal signs and you say, okay, so it's either a baby sprain or it's a really severe sprain. You saw it happen. It's kind of obvious as to what this really, really is. But if somebody comes walking in up the street and they go, yeah, I just had this, this ankle pain that just kind of started, no, it didn't have any trauma or whatever, whatever. It just kind of started on its own. That's a totally different scenario, that, that we have to be comfortable with in stating like, okay, here are the possibilities. Here's what we've narrowed down through an assessment. Here's the intervention I would like to do. It's going to give us more information and allow us to be a little bit more certain as to what's going on and whether we can be successful with this or not. Doug: [00:29:38] Yeah, I think it obviously demands a level of trust from the provider because I found that I speculate a lot less than I feel theorized a lot less about why things hurt, and fundamentally I'll say, look like, you're, you're here because your hip hurts when you squat. The burden is on me to do things with you that allow you to hurt less when you squat. So without even theorizing about why the hip hurts, it's like, look, let's try a couple of things and you tell me if what we're doing is working. Now I've got my like assessments and you can break things out and you can assess the hip and look for things like more flection and internal rotation. But why are they there? And I kind of like letting them drive it. And then I, I, cause I think ultimately, it's less of that they want an answer, then they just don't want to hurt or whatever. The goal is like, I can't, I can't do X. Well, we have a process to get you from A to B and you're a part of that process. And ultimately, like you tell, you tell me whether you know what we're doing is working or not. And that's where like you can't separate the intervention from the assessment for the diagnosis because with the right interventions, that becomes diagnostic therapeutic. And now if the interventions, you know, work so to speak, now that the patient's probably less concerned about why, because you gave them an answer without answering. It's like, well, clearly you can get better without us knowing with a hundred percent certainty what the root cause is. Cause everybody wants a root cause. But oftentimes. There isn't, but I don't think I was confident enough earlier in my career to say, look like I don't, I don't really know. Let's try some stuff. And at the end we can, we can figure it out. We can get into the why more, but at this point it's just pure speculation. Bill: [00:31:18] Right, right. I mean, it's just a matter of being process oriented. Right. Versus versus saying like, okay, I, what people see is, is based on their, their experiences and their, and their perspective. So you're a kid, you fall off your bike, you scrape up your elbow, you kind of know why the elbow hurts. Right? Again, we're going back to the obvious situation. What, what, what the patient may be looking for in our situations now is they say, well, if I can attach a diagnosis to it, then that gives me the confidence that there is a solution. And what we need to do to let them understand this, that you are now part of a process. And so everything that we do as an element of discovery that gives us more information. We're narrowing, like you said before, we're narrowing our probabilities and this was going to get us closer and closer to what you might consider the ideal outcome. And again, I think that's a very fair way to do this without having to make a leap into, to, sort of blame something, via diagnosis. Doug: [00:32:21] Okay. And then as far as like, you know, protocols go, cause that's, that's a big thing in our field. Right? You know, I think initially the intent is like you don't really know what you're doing, so we're going to give you a protocol. So, you know, week two, you're doing this. At week six you're doing this. But kind of the more you go along, the more you're like, wow, it's actually more confusing to be that bounded by something. So, I mean, you know, and this is always, most of these discussions come down to you don't want to be in the chaos side of things. You want to be in the rigidity side of things. If you're overly protocol-driven, you're rigid. If you have no framework, no structure, no protocol, then you've got nowhere to start from. So how do you think we navigate that? I mean, you know, we've talked about this and our thought was kind of like, you should have the absolute like, do not do these things because they're so like, Hey, for the first three weeks after a surgery, don't do passive range of motion beyond that. But as long as they're not violating those absolutes, everything else is kind of fair game, but I think that it's one of those, it's a centralization problem, right? People don't, aren't comfortable delegating authority because you know, they don't want to leave all of that gray. But how do we, how do we navigate that as far as protocols go? Because it's so overwhelming when you're like, this person's different. This person is different. I mean, right now I'm working with somebody who had a diving accident and has a cervical spine fusion, has some neurological constraints, and earlier on I would have been like, what am I supposed to do for somebody who has this level of spinal cord injury and now it's like, look, I'm not going to magically make that, you know, facilitate that neurological return. That just takes time. That's a constraint. And ACL surgery is a constraint. When a joint is a constraint, it's easier to see the similarities now, but for a newer, for a newer person who doesn't have the reps, what kind of guidance would you give them to navigate structure versus autonomy? Bill: [00:34:10] Well, you just use, just use an extreme example of, you know, somebody breaks their arm. Okay, I have to protect that for a certain length of time. And then after that I need to slowly reintegrate that element back into this human. But prior to that I, there are many things I could be doing. I have three other extremities. I have a body, I have, I have other systems that will influence this. And if I can create a favorable environment, then as soon as I am now able to reintegrate that, that, that element, in this case, the broken arm back into it, then I have everything that I could possibly have done in place that will produce a more expeditious, outcome as, as well. And so I don't see any difference in the broken arm example versus any other constraint. And so you take like any ACL, repairs, like, okay, there's certain things that we know about this situation. Okay. So I know that there are certain stages where I need to be a little bit more protective, But beyond that, I, I have other elements of the system that are trainable to a very high degree under this circumstance. So as long as I respect the protective element, and understand graded activities, because that's essentially a great portion of what we do when we're restoring elements, especially in the fitness realm or, or the, the return to play, if you will, is that there are so many different things that I could be doing. Whereas if I'm told that you can't squat. You know, the classic, the classic stuff, you know, or, or they're saying, do this or do that. When there's so many things that could be infinitely more influential. Again, it's literally, like you mentioned, it's like, it's just a constraint. It's just something that we work around is something that we know is an influence that we respect. And then we do everything else that we possibly can. Doug: [00:36:13] Yeah. And that's obviously like, you know, it's a relationship issue between the surgeon and the rehabilitation provider where I can understand like if I was a surgeon and you went to school for that many years and that's your good work, you don't, you don't want people screwing that up. But at the same time, you know, we have providers want some autonomy and choice. And I think it just seems like the reasonable middle ground is like if you're the surgeon, what are the absolute things that you just don't want violated? And then at that point, if you have to micromanage beyond that, you're probably referring to the wrong provider because ultimately, you know, you just can't, you can't script out the whole thing. I mean, I don't, you can't script the rehab Bill: [00:36:48] Nore is that their role? Right, right. I mean, that's, that's our role and to have that understanding and, you know, it would be a, it would be a, a great world to live in if you did get an order like that, that, that, you know, gave whatever procedure was performed and said, just avoid this. Doug: [00:37:07] Yeah. At the same time, it's like, as a physical therapist, I'm not telling the patient, you know what kind of surgery they should push for when they go to see the MD. It's like the surgeon should know more about that than me, and if they can't make that choice, then I should refer to different surgeons, kind of. So, you know, there's these relationships that have to be navigated. You, you mentioned there the return to play thing, and it's such a big buzz word and I don't, I don't get it. I mean, frankly, because return to play just means what did it take to play in the first place? But you had an injury, which is a constraint. So how do we demystify this whole thing? Because it's become such, it's almost like propaganda at this point where I don't, it's become a meaningless sort of term, and I don't get why all of a sudden because somebody, somebody got hurt. Now we pay attention to their preparation, but we didn't before. Bill: [00:37:54] Yeah, I don't, I don't see the big, I don't see the big deal either. Like I said, unless, unless there's some element from, a procedure that is, unchangeable. Right, right. And those are symptoms, but again, that doesn't really change the game very much at all anyway. It's just another constraint to work around. You know, why is it different? Why is it different when you're, you know, six months post ACL? Versus, I just came off of one month, lay off, because I just started my off season. Right. And, and so I needed to rest. So again, we, we, all we have to do is we have to say, okay, for you to be effective in your sport, I need you to achieve these levels. Doug: [00:38:38] Yes. Bill: [00:38:39] And that's it. That's, that's, that's literally it, right? Your ability to change direction, your ability to do, hop on one foot sprint at a certain rate, produce this much force. I mean, we've always done those things with our quote unquote healthy athletes and, and so I don't think it is any different. It's just like, okay, you're just starting from this point a instead of the other point a, and then we're still going to close the gap under those circumstances. I think that that again, it, it becomes very protocol-ish to say that return to play follows this structure when the reality is people are going to progress at different rates all by themselves, and we have to respect that. And again, it always comes down to that, that N equals one thing. Because if we put everybody on the same return to play structure, it's just like trying to put everybody on the same program and expecting everybody to have the same outcome when the reality is it doesn't work that way. Doug: [00:39:38] Yeah. I'm not trying to say that like getting a hip surgery versus a knee surgery there aren't unique things we need to those procedures, but no one ever, no one ever acknowledges the similarities, right? Because if you're a midfielder in lacrosse, whether you got a hip surgery or an ACL surgery, ultimately your sort of program or your scheme should funnel into the same thing. So it's just different in the beginning. But what we see is we see all of these, you know, like these linear things, none of which are connected. But if we're talking about return to play protocols, like no one's really talking about, okay, like there's different constraints in the beginning, but they ultimately have to converge based on the demands of the game, the demands of the game dictate return to sport. But it just seems like we're reinventing the wheel anytime somebody has a procedure because we haven't really defined well, what does it mean to be prepared in the first place? So maybe we're just, you know, cause people are healthy. We just assume, well, like. We're lucky they, they, they can play so they're good. But we haven't really thought about like how do we know when they're ready to play? And these are things that require, I think, a blend of objective and subjective, Bill: [00:40:38] Right. Yeah I mean when things go successfully, we don't ask enough questions. Yeah. Right. And, what we really need to do is establish a process. And that process does not have to be unique. It just has to respect what the constraints are. And so people that are apparently healthy still have constraints. They still have secondary consequences associated with everything that they do. So not all good. All things that we apply are good things under every circumstance. And again, we've always respected that from the fitness side of things, if we can call that, you know, preparing an athlete for their sport in general. But it always seems to be a little bit more special when, when they're coming off of a rehab situation, when the reality is it's, it's really the same rules. Doug: [00:41:31] Yeah. And I love what you said there. And again, it comes down to, to process because you know, when the outcomes are good, which in the context of rehabilitation is the guy didn't get hurt, the girl didn't get hurt, that we did a good job. But conversely, people can get hurt and you could have done everything right. So I'm not saying outcomes aren't important, but you know, like the aviation world, the military, like they're debriefing after every mission, even the successful ones. And they're trying to refine the process, which probably doesn't happen enough in our field. Bill: [00:42:01] So when you have the ideal outcome. What could we have done better? Yeah. What did we do wrong? Was there someplace that we could have saved time? Is there something else that we could have done with and gotten the same outcome? Like these are the questions that we ask when we screw up or when things don't go as planned. When the reality is, is if we ask, just make it a process and not look at things as like, Oh, this was good, or this was bad. It's just like, this is just what was. It doesn't change the way that we should perceive. These things will be much more successful. We'll have many more answers. Most likely we'll be able to narrow the probabilities even even better than we did before. And then we can apply these things regardless of circumstance. Doug: [00:42:48] Yeah. And I think that we probably overreact when things go wrong and underreact when things go well, that's like somebody gets hurt so we have to totally abandon everything that we've been doing. And if you have enough trust in your process, you're going to realize that like you probably are going to take some casualties, so to speak. Bill: [00:43:04] It comes down to decision. If it's decision making, which, which again, it decision making should not be based on on a successful outcome or a failure. It is a process that you utilize to make a decision. So you could, you could do everything perfectly. And people, have a horrible outcome, you could do, everything incredibly poorly and that individual, for whatever reason, overcomes that and still appears to be successful. and so again, it comes down to refining your processes, and that's where we need to be focused on. It's, it's not the good or the bad. It's like, how did we arrive at these decisions? And then if we get better at making decisions in general, we will tend to have better outcomes. Doug: [00:43:52] Yeah. There's no better reminder of that than what's going on now where with this virus, right? Like there's so many unknowns, so we don't even know what the outcomes are because you can give somebody an antibody test, we can't even solely trust the results. So it's really about like looking at processes under uncertainty and the, we don't even know like what the outcomes are going to be because this is such an evolving process. Bill: [00:44:18] So, but again, so, so there's a key word right there. It's evolving. It's actually every time we get a new piece of information, we have to take that into consideration and then say, okay, how does this affect our, our perspective and how does this affect what the probabilities are? Because again, bought me a book not too long ago, from Annie Duke, who's a professional poker player and, and what she's talking about when we're making decisions, he says, we're playing poker. We're not playing chess. Chess is very structured and has very defined outcomes. We are playing, we're always playing poker. So we always have a probability that we have a desire for, and one that we probably don't have a desire for and both are still on the table. So even though I might have a 76% chance of having the outcome that I desire, there's still a 24% that that I won't. And it doesn't mean that you made the wrong decision if you fall into that 24% it just means that there was a lot of influences here. There's a lot of factors involved, and luck is a real thing. And so again, you could do everything right. You can make the best possible decision and still fall into that 24% failure. Doug: [00:45:27] Yeah. And you could have a 19 in Black Jack, and if you don't get another car and you could lose it, you know? Bill: [00:45:30] But yeah. So that's, so that's unfortunately what we're playing. But again, people are uncomfortable with that because it is, it's in the gray and, and, and we do have to learn how to get comfortable with that because that's literally how we work. Doug: [00:45:45] Yeah. I mean, it's easy for us to do that because we work for ourselves. We don't have to answer anybody. We don't need like these BS metrics to justify it. And so I get in hierarchies and larger organizations how this becomes problematic because we kind of work in a utopian environment. So I'd love to hear your thoughts on breaking down some, you know, some of these various models or martial arts, so to speak, in our field. So kind of like, you know, if you were to ask Bruce Lee, what do you like and not like about Judo, what do you not like? And not like about Western boxing? We'll start with, you know, our field. I can kind of anatomy a model or a pillar. That, that anatomical model and I know that you've got some, some, some passionate thoughts on this. So what do you know, what does anatomy good for and not good for in the context of rehabilitation performance? That kind of thing. Bill: [00:46:36] Well, so I talked about dead guy anatomy is a representation of how we actually move, and that's just not the reality. It is a representation is, is unfortunately not the representation. When, when you're, when you're looking at a cadaver and because of, I mean, all you gotta do is ask me like, what are you made out of? And they go, well, you're, it's like two thirds water. It was like, okay, well that's a big deal. Right. I've never worked on a, on one of the, the fixed cadavers that had any water in it whatsoever. So right away, right away, my perspective is different. So I look at these things and I say, Oh, look, if I pull on these things, there's a bunch of levers there and so then we get the lever model, that's associated with that. So then I immediately have a type of math that goes with that to calculate forces. Well, here's the problem with that. That ain't reality. Not even close. And so now I have, I have a misrepresentation of how actually, how these things actually work, and therefore, when I even do calculations. So if you look at the biomechanical model, and they do, they use typical geometry to, to calculate out forces that exceed the tissue tolerance, right? So it's like, I remember the, If you, if you're in the NBA and you perform a slam dunk and you land on the ground, it's that term for this eight or 16 times body weight is the force. How on earth could you possibly withstand that if we're using normal geometry? So we don't behave that way. And so again, those forces are misrepresented. So, so again, if we're making decisions off of that type of a model right. Then we started with the wrong model. Our decisions will be wrong under many circumstances. It doesn't mean it's not useful under some circumstances. It just means that under reality, it's just not. And so I again, I prefer to, to, to try to use something that it's a little bit closer to what we actually are in regards to dynamics. Which is, you know, the compressive and expansion element of how we move through space and, and we're, we're much closer to, Oh, I suppose a worm than we are a cadaver in regards to how we actually behave. which means that then the, the anatomy needs to be, learned in context. So we touched on this a little bit earlier. This is why, you know, going through a semester of gross. Before you do anything, again, it's nice to know where stuff is, but I could have an app for that. I don't need, I don't need to spend hour upon hour dissecting out when, when I could just say, okay, this structure is here because I want to do my little highlight thing. You know my app, I know exactly where that is. But, but now move me into a context where, where I have somebody that is actually behaving in space and now I can say, Oh, I can see how this now relates. So again, much more useful representation than, than to to lay somebody on this lab. And like I said, pulling on tendons and saying, Oh, this does this. So we're going to call this a, it bends the toes. We're going to call it flexor digitorum. Right. Which again, not very useful, especially when it's out of context, because that's not what it really does when you're walking across the ground. Yeah. Sorry again. No, you, you go, you go. Doug: [00:49:48] No, I mean with, with regards to anatomy, I just look at it like there was a point during my first semester of PT school when I could literally identify every muscle, nerve, blood vessel in the body, and I would heinously fail the written or the practical exams now and then I've been treating and I feel much more competent clinically. So if what we're learning in that setting is truly useful, it should reinforce and if anything enhanced when you're actually applying it, right. The application of that anatomy made me know the cadaver stuff less. So even when it comes to things like manual therapy, if people are into that, we'll talk about that later. I don't wanna get too deep into it, but it's like to do a manual therapy technique. I don't need to necessarily know what that's called. I just need to know, like I can feel some kind of aberrant tone, I'm going to do a technique and as long as I know that I'm not on something that's really bad. Like if you're dry needling somebody, you don't want to dry needle the sciatic nerve, but it doesn't matter that you're identifying which deep hip rotator you're on? Probably not, except for it allows us to speak a common language, but I just don't know. To your point, I think that in terms of opportunity costs, cadaver... A cadaver anatomy is just not a great use of time and resources when you can use an app. I think for like a surgeon, if you're trying to do procedures on actual anatomy, on people under anesthesia, that's a different story. But, you know, it's a Rite of passage and it, so when a select people, it's kinda like in the military, you know, because you have an untrained person, the way that they weed people out is they make you crawl through mud and run around with logs. And it doesn't have actually, once you're, once you're a qualified soldiers, so to speak, before guys are going to Afghanistan or Iraq, they're not running around with boats on their head, they're doing things that look like their job. And I think anatomy is just an imperfect proxy for selecting people that have the determination to make it through a medical program? No, I'm serious. It's a, I think I'm trying to find something good about it. I think that's what it does. It's, it's a, a Rite of passage. But I, you know, as long as we're like acknowledged that and we're not, you know, we're agnostic. We're not saying like, it's really important because to your point, if we embrace that model too much, I think it can lead us astray. Bill: [00:52:00] Right. And again, it's like, it's not that it's not totally, irrelevant. It's just that its level of relevance is, is, is limited. It's just like any model, all models have a limitation. It's like, okay, so this is a representation of something. Okay. But, but again, it ceases to be useful very, very quickly. Right? And, and I think there are better ways to go about this, especially when, you know, we don't work under those circumstances, right? We have to have people that are live and moving and, and, you know, working against gravity and forces and et cetera, et cetera. And so, again, that would be a much more. A useful representation if we would, would emphasize that. It doesn't mean the anatomy's not important, but the begin like learning instruction by structure, by structure, but probably not terribly Doug: [00:52:47] depth that we have to learn. Bill: [00:52:49] Yeah. Yeah. It's like, you know, I did flashcards for every muscle and nerve and you know, all through school just so I could get through that because you have to memorize it. You have to pass the test. Doug: [00:52:59] So related to anatomy, the next thing would be biomechanics. If we talk about anatomy is kind of like. You know, just statically what's going on with the body and the structures involved. Biomechanics is sort of the movement or positional manifestation of that anatomy. Now there's a whole gamut of things, right? There's like the posture police where it's like, you know, if you have a plum line and you're deviant from the plum line, it's causal of all these things, but then you look at some sports and while people have idiosyncrasies, there's certain mechanical sort of truths that emerged. So how are our biomechanics useful, not useful to you clinically or in a, in a performance setting? Bill: [00:53:38] Well, so it's representative of, of the possibilities, right? So, so all I have to do is I have to have a representative model of what I'm shooting for, right? So again, the biomechanics are that representation. It's like how do you know when, when movement is better, besides the fact that the patient says. Oh, that's better. It feels better. Do I have a representation that can provide me some, some measure of information to know that I'm on the right track? So what if they, if, if I recognize the fact that, okay, so based on my normative model, a full motion has been restored, this person still has, has a complaint, then that might just be one of those representation that's now beyond my scope. Right? So I have to have those elements. So, so biomechanics provides me that foundation of understanding of like, okay, under, under most circumstances, this is my norm, that I'm comparing what I'm seeing too. Right? And it, and again, it is foundational, whether you, whether you want to appreciate it or not and I would say that, that, from the biomechanics standpoint, is using it as that representation of what is possible, not as a singular representation. So, so when you talk about things like, Oh, does posture matter? Yes. It does matter when it matters, right. Does it, does it, does a posture represent an absolute that somebody will, will feel a certain way? Absolutely not. That'd be, that'd be ridiculous to say something like that. But it may provide a piece of information in certain circumstances that becomes valuable, especially when we're talking about the ability to change, which is, you know, making people more adaptive tends to make them feel better. And so if I have somebody that has a representation where they demonstrate a lack of adaptability and it just so happens that they show up in a certain shape that might be useful. Right. But I, but I can't rush out on the street and go and start pointing at people and go, Oh, you have this, you have that, you have this. That would be kind of silly. Right. so again, it's just information and we have to respect where it, where it is valuable and where it might not matter. Doug: [00:55:46] Yeah. I'm saying try to, again, we're back to the early deterministic, but also overly annihilistic is to say that it doesn't matter, I think is also flawed. As well as you know, that it doesn't matter. Bill: [00:56:03] It's just information. It's just information. Is it useful? Maybe not right now. Is it useful later? Maybe it will be. Maybe it won't be. I don't know. It's like I, I'm, I'm, I, you know, I'm totally comfortable with that. That fact that, okay. It's just a piece of information. Doug: [00:56:19] I think that there's kind of a, a counter reaction counterculture to biomechanics because probably for the, most of the history of PT or rehab, it's been overly deterministic. And so the reaction to that, and you know, maybe this is one of those things where you have to have an overreaction to meet in the middle. I hope that's not true. That just seems historically to be the case. So now we have the pain science. So in your opinion, is there anything particularly special about pain that it warrants its sort of own science, if that's even a thing. I mean, and again, I think there's good things about it, but what's what, what do you, what do you take from it that's good.  And what do you sort of disregard. Bill: [00:56:55] Well, I, I, I gotta I gotta steal something from Neval Ravikant when he was talking about, if you've got to put the word science in the title, it's probably not a real science, right? All we're talking about is, is an element of the human speciology so the pain science is no different from happiness, science or, or any other. Anything you want to attach to it, right? It is, it is an element that is an influence. The reason that pain gets so much attention, and I've said this a ton of times, is because it's an unpleasant sensation. You know, cause we don't study. We don't study joy the same way we study pain, right? I'm sure they do study joy to, to some degree, right? But, but pain gets a lot more attention because it's interrupts things to such a degree. And because of its unpleasant nature, we want to get rid of it. But if, if we, if we keep looking at it as if it's something that is so different from everything else, then I think we're going to be, we're going to be lost. What we want to look at as like, okay, when somebody has these situations, what are these adaptations? How does the system behave? What are the possible influences? But again, these are the same questions that I asked before because it's just part of the process of this whole thing, right? And so it's not that I would ignore it. It's not that I don't value it. Right. But, but again, it's just another piece of the, of the information that, that lets us know the status of this situation, right? It allows us to help. It helps us make decisions, but we can't, we can't. So, for instance, based on our scope of practice, people come to us because they're in pain, but our scope of practice really doesn't. Doesn't, set that as the, the direct outcome because we are movement related in our scope. And so once we have a representation of everything that we can possibly do, if the pain persists, that is no longer our situation. Right. And so they may need some other form of intervention to resolve that situation. And so again, it's just like I said, it's just a piece of information. We try to understand it the best that we can. We try to understand how it influences the situation, but it is, again, one piece of information. Doug: [00:59:06] Yeah. I mean it's, it's another constraint, just like getting ACL surgery that we have to work around. And the reality is it's, it's subjective and very poorly understood. So I think to overly focus on it can be problematic because what is it that you're chasing? And moreover, like if your identity as a movement professional is to work on functional outcomes, then how do you maximize function with pain as a constraint working around it? I will say that what, what you know, those sort of models and constructs did for me was they made me more careful about what I should avoid saying to people. You don't want to tell somebody, Oh, well you've got the back of a 90 year old, even though you're 20. That, that obviously creates, you know, a ton of potential problems and then people internalize these things. So I think that, you know, it did reveal some of the deterministic flaws in the biomechanical model, but if you take the pain science model too far, and now you're giving lectures for an hour about ion channels and just talking, but you're not doing things with people because they still need to be able to move and do things. That's why they're in your office. I think you could take either of those things to the extreme, but you know, I think the key takeaway from that model for me was at least like a much more careful about what I say, and more importantly, what I don't say. Because what we say can have you know, very profound consequences for people. Bill: [01:00:26] And again, that's just understanding, okay, how does this influence this situation? Right, right. Doug: [01:00:32] It's not unique to pain science. I mean, I got there and science people were emphasizing that, but it's not necessarily unique to pain science, but I think that in the context of our field, they're the ones that like are most, you know, kind of championing that message. And I give them. I give them credit for that. Bill: [01:00:47] Absolutely. I don't deny it. We, we've, we've been through many situations, you know, together and, and on our own and, and again, seeking out those resources for that reason. It's like, I need to understand how this is an influence. I need to understand where this is. This is most valuable. I need to understand how to manage this. But I can say the exact same things about everything else that we have talked about as well. Doug: [01:01:12] Yeah, I haven't been, since you're bringing that up, I'll admit, you know, when I goofed up with you and I was your student and it was when I was like just reading this stuff and probably being a little bit too enthusiastic about it and we had a patient with a really arthritic hip. When you get a hip replacement and telling him about like as a Migdal at all that like it actually backfired. Bill: [01:01:31] Not very helpful.  It's a powerful lesson learned. Yeah. So then. Doug: [01:01:40] Moving on from biomechanics, pain science. I think kind of a, a hybrid of those two things is like the, the just load it model where kind of the ideas, you know, everything is a matter of progressive overload. It doesn't so much matter how you do something as just, you know, you need to develop your tolerance. So that extreme example of that would be, you know, dead lifting a maximum weight. Because you can do it with, you can try to, and you're set up maximally around your lumbar spine as long as you progressively built up to it. Again, I think there's good things about it because you are resizing progressive overload and not being overly deterministic about biomechanics, but I think it neglects biomechanics. So where are you on the, just load it because to me it's like, all right, well load. What? Because in order to determine what it is that you're loading, you need it biomechanical or how components. Bill: [01:02:35] Right? I mean, so if we're, if we're talking about graded activities and things like that, I think that that's, that's a little bit more straight forward then, then to... I think when you, when you talk about, Oh, you just need to get strong, or, I don't even know what that means anymore, to be honest with you. or did you put load on it? The thing that we have to, we have to understand though, is, is that when, when we are focused on one thing. That there are secondary consequences associated with everything that we do. And so what are the secondary consequences of increased force production? So let's just call it force production for the sake of argument. Cause that's a little bit more of a, of a measurable concept versus like gym strength or something like that. It's like what are the secondary consequences of that? Right? And so again, so I have tissue tolerances they have to consider. I have, I have strategies that I have to consider. So I have behaviors that are, that are associated with, with me producing force. So I will produce force in very specific circumstances, in very specific ways. And so if, if I am, if my intention is to load a tissue to increase its resilience or, or, to enhance that structure. What are the secondary consequences? Did I take something away from something else that might be just as valuable if I'm talking about health or if I'm talking about performance, because there are many situations in performance where we slowly take things away from someone because you cannot raise performance. It is very rare situation that someone would be great at everything. And so let's just simple, simple gym strength or something like that. So if I raise your squat from 300 pounds to 400 pounds, what did I have to take away from you to do that? Did I take away something valuable in regards to your ability to move? So for instance, if I have to sacrifice shoulder range of motion or hip range of motion to get you to bench press more squat more, was that useful? Was it helpful or or was that secondary consequence? A negative? So we have to be very, very careful in how we describe these things. And we can't be, we can't have that singular perspective of, Oh, you just need to get strong. Because again, there are consequences to that, that may not be favorable under every circumstance. In some situations it may not matter. And in other circumstances it may matter a great deal. you know, if you took a golfer. You know, and you took away their ability to turn because you had to make them more stable to lift the heavy deadlift. That's probably a bad idea. Okay. Yeah. You're raised their strength, you, so you loaded them, you raised their force output, but now you've also created a consequence where they can no longer access a position that they needed to perform, and now maybe you're going to put load on structure or maybe they're going to create some sort of compensatory activity. And so maybe you just created a secondary consequence that is unfavorable. So I don't have any issues with the concept of loading. I just think that we need to be a little bit more broad in our perspective as to what's actually happening under the circumstances. And it's not just that aspect, like everything that we do, everything that we do as a secondary consequence, right? Me, me, reestablishing someone's range of motion can reduce their force production. Sure. Do they need that to protect themselves? So I always have to consider these things. Right. So that's why you have key performance indicators as you're moving someone through a process, whether they be a rehab patient, whether they be, be an athlete that's training for performance. We have certain elements that we say, I need to make sure that I maintain this because it is representative of their resilience, or it is representative of their ability to produce more force, which is what I wanted in the first place. Doug: [01:06:14] Yeah. And I think where it gets tricky, you know, cause I think to me like my interpretation of the just loaded movement is that, you know, the, the execution doesn't matter so much as the progressive overload, but it becomes difficult when you're trying to differentiate symptom relief from performance. And because it's a functional profession, we're trying to achieve a functional goal, which is performance, but we're also trying to reduce symptoms. So it's not clear. Well, it's not, it's not a line, right. It's a, it's a spectrum. So like if you've got someone who, let's say they just want to be able to run once or twice a week without pain, go for a three mile jog. They don't care about how fast they are. They've had no pain. If that person comes into eye care, how they run, probably not. But if someone, let's say, has had a history of hamstring strains and they want to run it, max velocity. I'm going to care a lot more about how they do it. Because if we look at the best sprinters, yes, there are idiosyncrasies among individuals, but there's also certain biomechanical patterns that emerge, right? So I think you have to look at the individual, and again, it's trial and error. Like you don't. It doesn't matter to what matters and you don't know until you try, which is not satisfying, but that's, that's the gray that we live in. Bill: [01:07:22] Yeah, and it's always going to come back to that. Every, every discussion like this was going to come back to that. It's like, okay, yeah, there's probabilities. Yes, it's gray. It's N equals one, right? It's like, what? What are your needs? What are you present with? Right. And again, people want black and white answers. It makes them comfortable and we just need to get used to being uncomfortable and be satisfied with what we are capable of doing. Doug: [01:07:47] Yeah. And I think reducing any complex human interaction to a hashtag is comfortable because it's only gonna figure it out. But none of these things, you know, three minutes, not a hashtag. kinda, you know, I'm coming up on time here, but what do you think, for you, I mean, throughout your career you've had periods where you've like really zoomed in and gotten very like rehab, movement centric, and then periods where you're zooming out. For you. I mean, I'm sure it's kind of more of a subjective thing, but like what makes you determine when you're going to do what. Bill: [01:08:18] It's kind of like, I hate hate saying this, but it's just kinda like how the river takes me sometimes. Right? And th there's certain things that, that capture your curiosity infinitely more so than, than other things. But I think that the reason that you do go, go, go in and out is because you're trying to say is like, okay, how valuable is this? And then you're not certain of that. Or like I said, just sometimes it's just fun. And, and that's acceptable, right. To, to just dig into something and really, really get a grasp on it. And, and I think that having been involved for, for three decades, the way that I learn now is just totally different from, from what I've done before. I actually picked up, what's his name? Michaud's Human Locomotion book this week, which is like a technical book that I haven't touched in though. Yeah. It's a great little book. It's like, and, and again, that's why it's still on the shelf, but it's like I just grabbed it because I had, I had a question about something and I just needed to, I needed the technical side of things, but, but I think that the further you get into this stuff and you start to layer upon layer upon layer. You know, again, like I was talking about expanding your base of analogy, there's, there's a certain element of, of like what else could be an influence here and what am I, what am I most confident with and do I need something else? And, and looking at the way that, that I've evolved my model over probably the last five years, six years. And you, you've gotten a taste of it, cause I used to send you a bunch of stuff on a regular basis as to what I was digging into at the time, you know, so you saw some of that, some of that evolve. but, but I think that that you have to dig into certain things to say, is this valuable? You know, does this fit? Is this in conflict? And so you have those questions that you have to answer. And so that's when you do kind of dig in and then you can zoom back out and you say, okay, so this is the whole thing as a representation, right? Where are the gaps? And so a lot of these things are identified as I teach. So again, having had 25 students over the last eight years or so, every time you teach something in, you teach it a little bit differently and you say something out loud or they ask a question, it allows you to say, Oh, you know what? I need to, I need to look a little bit deeper into that. And so you're, then that's your zoom in and then you kinda zoom back out and you say, okay, how does this affect everything else? And so I think it's always going to be this back and forth kind of a thing. Doug: [01:10:50] Yeah. And you kind of touched on it, talking about other things and models where everything comes to the expense of something else. So I think zooming out actually allows you to connect the dots, get that BS filter, but you need dots to connect. And that's the zooming in. I just found like for myself personally. To your point, like I just do what I enjoy and what's going to be fun. And you know, when it comes to learning and anything else, because if you enjoy it, they're going to retain it. If it's being imposed on you, like, which it often is in an academic environment, or it can just drain the joy out of learning. I find that I just like anything that's important that I've retained, I didn't even study for. Bill: [01:11:33] Right. Doug: [01:11:33] You know? And that's kind of happening now. Like if I, if I want to read something, I'll do it. And I used to kind of, if I started a book, I had to finish it. Now if I start a book and I don't like it, 10 pages in, I just stopped and I'm like, I don't feel guilty about that anymore. It's really, like you said, it's kind of going with the wind, which, you know, very unsatisfying earlier in my life to have somebody tell me that. But I think maybe you need a little bit of a base before you can even know, like gauge where the wind is blowing, so to speak. but that's kind of the evolution of it. Bill: [01:12:04] Yeah. But like, like I said, I, I, you know, the nice thing about learning is that there was always something else, right? There's always a next, and... your patient might say something to you, or a colleague might say something to you. And then that leads to curiosity. And then that leads to interest. And then that leads to the active investment of, you know, acquiring the information. And then it's like, okay, does this fit? Does it not fit? Do I need to spend time on this? Do I not need to spend time on this? And again, that. I, I, I'm in a constant state of that. I think we're always seeking, right? because we're always curious and we always want to know what's next. And, and the thing that would be, that would challenge people is, is don't, don't just follow the current, because that, that's a really bad way to go. Is, just doing what's popular. Because it, it, well, it may be useful. It also leads to just, what I call lateralization of information. It's like people learn things that are not in depth, and then they pass that information on and then it becomes the world's worst game of telephone. And, and, you know, I said this before, it's like you make a photocopy of a photocopy of a photocopy of a photocopy, and then by the time you get, you know, 10 of those deep, it's just very unclear as to what's really going on. And, and so I would prefer that people sought out the things that they are interested in. That they do find useful. And not, not say that, Oh, just cause this is novelty, this must be important. Right? Doug: [01:13:33] I think that's, it's a little bit of like, you know, David Epstein talks about this and range and even in the sports gene where, you know, obviously you don't want to have no structure, but I think that our culture is very, very structure grind. You need to know what you're doing and have a linear path. And maybe what a lot of us could benefit from is just being okay being directionless. You know, and I think maybe in a culture that was like a little, you know, kind of the opposite that, that didn't have any direction, then maybe it's better to be told to have more structure, but like, I don't know, we're in a culture that celebrates getting up at three in the morning and stuff like that. We probably could benefit a little bit more from like, yeah, just kind of go with the flow a little bit. And then if you do it, then you can reign yourself back in. Bill: [01:14:17] Yeah. Nobody has to tell you what to study. Right? They shouldn't have to tell you what to study, right? You should just be interested and then seek things out and then, you know, it's like you, if you want to go buy a shirt, you try on a shirt, you don't like it, you don't buy it. Right? If you like it, you maybe you get another shirt. Yeah, so it's kind of the same thing. It's like, okay, I study this. It's like, is this useful? Is this helpful to me? Or is it just a curiosity? You know, am I reading about, I'm reading about quantum physics. Okay. How useful is that to me? Well, maybe it is. It helps me think a little bit differently about things, and so then it becomes useful. Am I going to directly apply it as, you know, am I going to be concerned about what, what particle is, is flowing through me at the moment? And it's like, no, not really. It's like, where is that useful? Doug: [01:15:03] That was a, that was a lot of fun. That flew by. I've got to put my mask on over here. Thanks for coming on. I mean, we want to do this for a while. We probably had so many conversations we wished we'd recorded and we got, so, yeah, that's fine. Bill: [01:15:18] Thank you for having me done. Doug: [01:15:19] Yeah, absolutely. Thanks. Enjoy the rest of your weekend.