There we go.
All right,
when most people think about physical
therapy, they picture injury,
something that happens after the damage is
done.
But for Josh Kidd,
physical therapy lives much earlier in the
story.
Josh works with people whose jobs leave
very little room for error.
fighter pilots,
special operations personnel,
while recovery and performance and
decision-making all have real
consequences.
He's also shaping the next generation of
clinicians as a faculty member,
researcher, and residency director.
Lately,
his work is focusing on a concept that
sounds simple,
but carries big implications,
directional preference,
how the body responds to movement,
and what that response can tell us about
healing, readiness, and performance.
Today,
we're talking with Josh about what
directional preference really is,
why it matters beyond the spine,
and what the current evidence reveals,
not just about treatment,
but about how clinicians think.
So let's get Josh Kidd in the studio.
Josh, welcome to your episode.
Hey, thanks.
It's a pleasure to be here, guys.
I mean, setting the bar pretty high.
That sounded pretty cool in the intro,
right?
Let's go back first.
How'd you get to do all that stuff?
And we'll get to the stuff.
But like,
what was sort of the thirty second career
arc to get to where you are now?
Yeah, it's funny.
I think you really overhyped the bio,
so I appreciate that.
No, it's funny.
Like most BTs,
I started off and wanted to go into
orthopedics.
I wanted board certifications.
Started to go that route just as a
basic clinician in a normal outpatient
orthopedic practice.
Had the opportunity to buy in,
become an owner in that practice.
So started to grow in that realm.
And I'm like, man, I love outpatient.
I want to continue to foster this.
We're bringing in a residency program,
bringing in mentors.
um in in residence and enjoying my time
and then these funny things called
third-party administrators started to come
around right and then my administrative
burden started to scale and i'm like i
don't know how i feel about this so
much and so i decided um hey i'm
gonna get out of this and i wanna
my thought was go cash pay i'm like
i want to go cash pay i want
to set my fees i want to treat
patients i want to treat them
And so sold my practice and was doing
that route.
And I got a phone call from a
good colleague of mine who was,
I knew he was doing something with the
military,
but I didn't really know what it was.
I thought he was just hanging out and
chatting with a few guys.
And he calls me up and says, hey,
I work with the military.
My company's growing.
I need quality assurance.
I know you run residency programs.
I know you have a solid foundation and
I want to practice the way,
I want all of our guys to practice
what you do.
and he says um and I said okay
um and he goes but I know that
you're busy he didn't know I saw my
practice he goes I know that you're you
know you're occupied your business so do
you know anybody that could do this and
I said well actually I do and he
said who's that I said it's me you
know what he did
He hung up on me.
He goes, I got to call you back.
And it was so funny.
I get home.
I talk to my wife and I'm doing
this cash pay transition thing.
And I said, hey,
I got a call from Randy today.
And he goes, and she goes,
what do you want?
I said, well,
he wanted to pitch me a job to
work for his company.
And she said, well, what'd you say?
And I said,
I told him I was interested.
What do you do?
I said, he totally hung up on me.
I didn't get it either.
So he calls me two days later and
he says, hey, he goes, I'm sorry,
I just couldn't process all that.
He goes, I was looking for one thing.
And then when I found out it was
you,
I had just told this big gamut of
things I wanted to do.
He's like,
I want you to come work for us
and I want you to run this thing.
And so it just kind of happened by
happenstance how I fell into it.
And I would say it's probably the coolest
job in the world, man.
I mean,
the population we get to serve is amazing.
Our teams are usually set up what's called
an HBO team,
so a human performance optimization team.
And foundationally,
it's usually about five different types of
providers.
So there's a PT,
there's an athletic trainer,
there's a strength coach,
there's a sports psychologist,
and there's a nutritionist.
And we're basically embedded within a
special operations unit.
And our job where I'm at is to
take care of sixty four special ops guys.
And we get all the toys and we
get all the time.
So I don't have to bill anything.
I treat I mean,
I got a guy right now.
He's going he's got a quad tender repair
and I'm with him for like three hours
a day, man.
Wow.
So the ability to practice at the top
of our license has been pretty special and
it's been rewarding.
And again,
I don't have to deal with those pesky
third party administrators anymore.
So that's been the original shift into
kind of the human performance realm.
And it's been fantastic.
All right, good.
We've got context.
But now let's drill into for the
clinicians out there.
Let's drill into this.
You're working with special operations
fighter pilots.
We sort of set the stage there.
Yeah.
These people do not have time for
guesswork.
The first time someone ever framed when I
was a PT student with this podcast,
his name was Rich Westrick.
Rich said, listen,
if you train triathletes,
you know when the race is,
what time of day,
likely what the weather's going to be.
You know the exact course.
He goes,
people don't have that in operations.
You don't know when the bell's going to
ring, right?
So these people do not have guesswork.
Where did directional preference become
something so central to your clinical
thinking?
How'd that happen?
Yeah, it's how we came into the unit.
So I sat down with the commander basically
day one and I said, okay,
where can we have the biggest change?
And he broke it down and they track
everything.
Every metric is tracked on these guys,
right?
And they said, hey, you know,
believe it or not,
my biggest problem is back pain,
neck pain, right?
And so my background, you know,
I'm the director of the McKinsey
Institute's residency program.
So that's kind of the Kool-Aid,
a little bit of the Kool-Aid I'm drinking
for preference here.
And so I said, okay,
we have a specific way we can target
this.
And I said, let's just start tracking.
Let's look at metrics.
Let's see if we can change the prevalence
here.
And so
Based on what the unit leadership wanted,
we said, okay,
let's go after spine pain because that was
similar to outpatient.
Everybody thinks it's going to be all
different.
It's spine pain.
And a lot of times it's when they're
not doing their training and doing their
missions, right?
They're not really getting hurt out there
too much.
It's more when they're back home and
they're more sedentary and less active.
we um we started to look at the
data and we said okay let's utilize
directional preference as an avenue to
assess but then also determine prognosis
and we've actually been collecting some
pretty cool data on it which i'm happy
to share with you as we move forward
here but that's really what's at the stage
sit down with commander he says i got
a problem with spine related issues you
know we have we've had high level
therapists in here before taking this
approach i said well let's let's try
something different here and see what we
can do and you know we've got four
years now of training down and it's
actually trending in a pretty good
direction
What's that commander's background,
just briefly?
Is it a healthcare background or not?
No, no, man.
The reason I ask is it sounds pretty
damn informed.
Yeah.
Well,
his job is to take care of those
guys.
And so he works side by side with
the HBO team.
He's worked side by side with the flight
docs, right?
And in flight medicine.
And so he needs to keep status on
who's green-lighted and who's red-lighted
on his teams because he'll have to move
pieces around.
One guy's not operational.
He's going to have to swap somebody into
that unit because everybody has a sniffing
role within the unit, right?
And so it's his job.
It's his job to stay on top of
it.
And the crazy part is he actually has
overall say of if this guy gets to
go or not.
Right.
With no medical background,
it was fascinating to me.
But, yeah, I mean,
that's his job to to make sure he's
on top of every one of those guys,
both from a physical, mental,
family style.
I mean, operational style.
I mean,
across the gamut on each one of these
guys, he basically has a profile.
All right, you mentioned Kool-Aid.
Let's talk about some Kool-Aid and
different flavors, right?
We'll get a little bit into the Kool-Aid.
For someone who's heard the term but maybe
never fully got it or maybe they need
to hear it from you one more time,
how do you define directional preference?
Yeah.
So directional preference, you know,
I look at it,
a lot of people will look at it
as, you know,
an exercise and we look at it as
assessment.
So for us,
what we want to be able to do
is, is when you,
when you look at it at the basic,
basic foundation,
it's directional preference is a specific
movement.
You can move any joint.
Most research is on the lumbar spine,
some on the cervical spine,
but a specific direction,
you can repeatedly move a joint.
to end range in which you will see
two things happen.
You'll see an improvement in pain and
you'll see an improvement in mechanics or
function.
So range of motion, strength,
their ability to do something that was
previously painful,
and now that pain resolved.
But that movement has to,
that improvement has to last, right?
And so it's not, hey,
I can move you around a little bit
and get some exercise-duced hypoalgesia,
and you're going to feel better, right?
Exercise-duced hypoalgesia.
It's not just that, right?
It's not just, hey,
I move a little bit, I feel better.
It's moving you in a specific direction
that makes you feel better.
And a lot of that's ascertained from the
history in the exam.
So now let's go the opposite.
Now that we know what it is,
what are some of the most common
misconceptions clinicians have about it?
What are the things that,
that Josh is most of the time correcting
and saying, well,
actually not that it's actually more like
this.
Yeah, no, the big thing, I mean,
I think a lot of people think it's,
you know, for some things to be,
and this is where the limits of the
nuances,
we can talk about the research we've
looked at,
because there is some discrepancies about
the definition of it.
And that's what we aim to try to
clear up with some of our stuff we
were looking at.
But, you know, a lot of people think,
hey,
You know,
if I move in one direction makes me
feel better.
I got to move them in the opposite
direction and it's got to make them worse.
And you don't always see that.
And sometimes with specific patient
demographics,
you will and you won't see that.
So that's necessarily not always the key.
And then there has to be a lasting
change.
Right.
I mean, for example,
I have low back pain.
Right.
I'm a general person.
I have low back pain.
What do I normally like to do?
My back's hurting.
I want to lay down.
I want to put some pillows under my
knees.
I want to get a recumbent position.
I'm going to feel pretty good.
Right.
that directional preference and i say no
because what happens once you come out of
that position you stand back up what
happens pain comes right back right so
there has to be some lasting change and
carry over and what you should see is
you should see this gradual progression to
improvement as i continue to do more of
the movement i get better and better and
better not hey it feels good when i
do it and then it kind of comes
back so we kind of got to do
it again and then it feels better but
you go through this repetitive cycle
that's not it right so it's got to
be lasting and it's got to be sequentially
improving
Yeah.
Uh,
you're jumping into some research with
some pretty big names, right?
Part of a recent scoping review in
physical therapy.
What,
what question were you trying to answer
and how that, what, what,
what answer did we get?
Yeah, that's a good,
I think like similar to most scoping
reviews, I think you're going to find out.
So we were, we were,
when you look at the clinical practice
guidelines and you look at systematic
reviews around directional preference,
it's all over the board.
Some systematic reviews say, Hey,
this is beneficial.
Others say, no, it's not.
Some say, Hey,
this is good for chronic pain.
Maybe a Q, some say, no,
it's not good for anything.
And so our aim was to look at,
you know,
when you look at previous scoping reviews,
they looked at your level of training and
being able to identify it, right?
Is this generalizable or do you have to
go so far down this rabbit hole that
it's not even going to be beneficial to
do that?
And so we just want to look at
the definition.
We want to say, okay,
maybe it's not the level of training.
Maybe it's how people are defining it.
So what we did was a large scoping
review.
And we looked at all the research that
used the word directional preference.
And we want to know,
how do you define it?
Like, what was it?
If you're saying, Hey,
it has no effect or, Hey,
it has this amazing effect.
Okay.
How did you define it to say,
to determine what it was and what you're
doing?
And we found out, I mean,
there was a mishmash.
I mean, we,
we started off with a fifteen thousand
studies, right?
Broke it down and went into full review
on one hundred and forty nine studies and
of those hundred forty nine.
We found that people had there was one
hundred fifteen different definitions that
is all over the board.
And in twenty two percent of them didn't
even have a definition.
They said we do directional preference,
but we're not going to tell you what
it is.
Right.
Wow.
So which we found intriguing.
Right.
So what does that mean?
I mean,
I think it means that we need to
look at what is a more concise definition.
And I think there's different ways to go
about looking at that to determine, OK,
how do we actually define this?
And then how does that definition
translate into clinical practice,
but also research?
And I think, I mean,
we see this all over the board.
I mean,
I know there are similar studies have been
done looking at what is manual therapy,
right?
Because that's still some of these things
that's ill-defined, right?
And so we've tried to follow along those
same lines.
So hopefully if we can get a more
uniform definition,
then we can research it and then we
can also use it as a clinical tool.
You almost maybe half already answered my
next question, but I got it queued up.
So I'm just going to answer it anyway.
How did those inconsistencies in research
you were just talking about,
how do they show up?
What do they look like in everyday
practice?
If we don't even know what,
if we're not even agreeing on terms here,
there's no,
we're not going on the same dictionary.
So I'm using a word one way or
a term one way and you're using another.
How's that show up in practice then?
Yeah.
I mean,
I think when you it can cause people
to potentially abandon it early and say,
hey, sure.
Right.
I mean,
we looked at some of the studies and
some of the studies.
I mean,
when you look at let's just say the
treatment based classification systems.
Right.
They have different subgroups.
Right.
We have this manipulation subgroup.
We have the stabilization subgroup that
are based on some clinical prediction
rules.
And then we have this exercise specific
group.
Right.
Which is essentially based on directional
preference.
Well, in their study,
what they would do is they would say,
okay, if you had pain down your leg,
you do ten forward bends, ten back bends,
and if it didn't change the symptoms,
boom, you're out of there, right?
We looked at other studies,
and we're like, no, we did that.
But then we lay the person down,
and we would do that prone press-up that
everybody is synonymous with,
like McKenzie.
But then they would be moving the hips
and doing these gapping techniques and all
these different movements,
and they were finding a higher prevalence,
right?
So the question is like, okay,
we're not even doing this the same.
And so if you look at one of
these studies and say, okay,
I'm going to bend them forward ten times
and back ten times,
If that's the only one study you read,
you're probably going to abandon things a
little early versus you read that other
review and it says, hey, no, wait,
there's so many different movements that I
need to implore before I can move on
from, hey,
this isn't going to exhibit directional
preference.
Right.
And how it's defined.
Also,
we saw some variability in the clinical
practice guidelines for the low back pain.
I mean,
we looked at the first one guidelines that
came out and directional preference had
this A level evidence.
Right.
And then when you looked at the revision,
it had this B-level evidence, right?
So we broke down those studies that they
looked at and we found varying themes
within those definitions as well, right?
So we basically identified a few specific
themes that must be present.
And if based on the research and then
also based on this thematic analysis we
did in addition to our scoping review.
And so depending on where you're looking
and how they're defining,
it's going to clinically going to drive
what you do or how quickly or don't
quickly abandon it.
Yeah.
um so how does this approach how does
directional preference let's bring sort of
both of the things that you do together
the research directional preference and
working with athletes or you know tactical
athletes tactical operators what does this
approach offer when time matters i mean
you just said you operationally this is
money this is effectiveness this is
readiness what does that approach offer
when time matters with those types of
people you're working with
Yeah.
Let's put some context around that.
So within the unit for our guys,
depending on what level of training they
have,
it's going to cost between one point two
to about one point nine million dollars to
make one of these guys.
Right.
Government has a down to a dollar figure
in its four thousand three hundred twenty
dollars and some odd cents per day that
these guys aren't operational.
OK, so they track this.
Right.
And they look at the cost of not
being ready and they know.
And so there's huge incentive to get these
guys back to duty quickly.
And every one of these guys has to,
no matter what service you're in,
they have to be able to pass some
sort of operator fitness test, right?
And every branch is a little bit different
to be on status to be operational.
And so if they can't pass that due
to pain, due to whatnot,
they don't get to go, right?
And then they start costing money for the
government.
And so...
the intent for us was like okay how
do we get these guys back right now
when you look at you know it's basically
sports specific PT we have this whole
battery of tests we can use for a
lower extremity injury right like I hurt
my knee um you know I can look
at hop testing I can look at Y
balance I can look at all these different
metrics say okay you're ready to go okay
you've passed this let's put you in the
test let's make sure you're set same with
the upper extremity right but the question
is like they already told us our biggest
problem is spine related issues
what return to sport testing is there for
spine related issues, right?
Nothing, right?
And so what we started to do was,
okay,
let's see if we can use directional
preference as a performance metric to get
them back.
Because what we were doing is we were
defaulting back to more of this
traditional pathoanatomical diagnosis.
They come in, we say, hey,
you got a grade two,
you got a grade one or two lumbar
strain.
you know you're going to be shut down
about three weeks to six weeks depending
on the severity of it right well now
what we've done is okay let's put you
through our exam right we do a basic
ompd exam looks nothing different than
anybody else going to do and then we
throw in this repeated movement testing
with it and if they exhibit directional
preference we actually use that as their
guideline to if they're ready to return
back to duty right and so
We know that, like we said,
directional preference is moving them in a
specific direction that reduces pain,
that decreases their pain and improves
their function.
So what we've done is we've basically
broken down component movements of their
fitness tests that they have to pass.
And once they come in,
if they exhibit directional preference,
we get the pain resolved,
we get the mechanics restored.
We then go test specific parts of that
test.
And if they pass that without a
reproduction of pain or a loss of
function, we green light them.
And we've been tracking the data now for
four years and we're getting our guys back
to duty about thirty six percent faster
than we were four years ago.
Yeah.
I mean, it's you know, it's upwards of,
you know, eighteen to twenty two days.
Right.
And so you can times that number.
Right.
So, you know, so in that same tent,
cause these programs cost the government a
lot of money.
So it's like, okay,
how do we incentivize to keep these
programs?
Cause they're so valuable.
Um,
but they have to demonstrate some sort of
value, right?
Now I'm going to make you think an
answer bigger, no pressure,
but if the profession did a better job
leveraging directional preference,
what could change you?
That was my question that was queued up
a minute ago, but you sort of, you're,
you're putting numbers to this.
You're like, well,
if these guys are four grand a day,
um,
It might be smaller if you're just a
podcast host, right?
But to me, that's a lot.
So what would you imagine or how would
you explain it to a student if the
profession did a better job leveraging
this?
Man, what would that look like?
Yeah, I mean,
I guess I'll say the caveat, right?
So, you know,
a little bit of bias here, right?
Because I teach for the Institute.
I'm going to put that out there.
But, you know, I think,
like I tell all my students, I say,
you know,
this method works for me because it makes
sense in my head.
It doesn't mean you need to do this
method, whatever.
framework works for you that that you want
to implore your patients that you can
that's that's evidence-based do it all i
encourage people to do is yeah just put
in repeated movements and identify if you
can look for directional preference based
on these criteria because if you do i
mean a patient is going to get better
i mean when you look at there's again
you look at the guidelines it's still a
to b level evidence so there's a high
level evidence for this right nice part
about it is a lot of it the
patient is able to do independently on
their own
Right.
And so you're starting to build this
self-efficacy for the patient.
You're starting to empower the patient.
Right.
To be able to treat themselves.
So we're looking at decreasing, you know,
more chronic related problems.
We're going to look at decreasing
recidivism of problems because they're
self-managing it.
Right.
The cool part about the system, too, is,
you know,
it's this cause and effect check recheck
system.
Right.
I mean,
patient tries to bend forward and they got
pain shooting on their leg.
They do repeated movements.
Also, they bend forward.
Hey, it's not my leg anymore.
You think the patient's happy or not?
Right.
they can feel an immediate change.
And you don't have to create much buy-in
for that, right?
And so one, the ability to,
like we're demonstrating to accelerate
recovery, but two, to empower the patient,
to decrease recidivism.
So we're looking at decreasing overall
healthcare costs.
We're looking at decreasing overall
chronicity of problems and more downstream
related issues that we know are so
associated with that.
So I think there's power in it, right?
If, and like I tell everybody, I'm like,
just put it in, you do you,
but just throw it in your exam, man.
And you will start to see,
you'll start to see change, right?
and then you just see what that fits
within your own treatment system if you
could leave clinicians we'll do your we
call it the wow your words of wisdom
if you could leave clinicians with one
shift in how they think not just what
they do as much kool-aid as you want
in this answer that's that's allowed after
this episode what would it be what would
one shift in how they think that you
would you would suggest not just in what
they do but how they process
You know, I think the biggest thing,
you know,
and I try to do this all the
time is be open-minded, right?
Understand that one thing doesn't fix
everything, right?
If there was one thing to fix everything,
we'd all be doing the same thing.
Sure.
There's all these different things out
there, right?
But we tend to be closed off and
have our own confirmation and internal
biases, right?
Hey, I did all this training,
so I'm going to do this, right?
be open-minded, try other things,
you know,
that hopefully have some level of evidence
behind them,
fit them in your system because, you know,
there's value in what I do,
but I take so much from everybody else
as well.
I'm like, okay, how does this fit in?
Oh my gosh,
this was the last little piece I needed
to help this population that I've
struggled with.
So, you know, obviously I'm biased.
I'd say take a course, try it out,
but,
be open-minded about it.
Don't, don't just throw it out because,
Hey, I did a couple of these things.
I tried it once.
It didn't work.
Understand a little bit more,
understand it's more complex than what
people might think.
It's not just simple, straightforward,
forward bends or backward bends and, um,
explore a bit more, right?
Cause you will see, you will see change.
Uh,
what would some of those things that
you've tested and tried and, and,
and taken some things from,
this is where you can throw out just
names of courses.
We're not saying you're endorsing them,
but what are the things that you've tried
that you're like, Hey, I've tried these,
these different flavors of Kool-Aid I've
drank.
Yeah, I mean,
the nice part about the government is they
like to spin us up on everything.
So if there's something out there, I mean,
you know, I've been through BFR, you know,
I've been through dry needling.
You know,
I'm a I'm a strong first kettlebell
instructor.
I went through my USAW search.
You know,
my fellowship had a Maitland and Saruman
flavor to it.
Right.
So I do look at some MSI stuff.
You know,
I did take a master's in medicine.
orthopedic manual therapy that was more
osteopathic based right so you know
there's all kinds of stuff out there and
that's why i know this other stuff works
right um but sometimes you know i know
prior to i was probably before going
through a lot of that training and being
around these other highly skilled
clinicians i was a little closed office
you know and i would just shut other
things down like no that's not right but
yeah there is such an application i think
the more and more you you get better
at your craft the more you recognize hey
these other things do work you know it's
like every time i go to am and
i'm i'm learning so much from all these
other people right and um like okay i
can definitely see what that fits within
my system and why that would work but
then at the end of the day i
think if we're just nice to our patients
a lot get better too so you know
We need a course on how to do
that.
Josh,
you're going to lead that course on how
to be nice to our patients.
This is one of the reasons you just
highlighted without me having to ask,
why do we sit down with microphones and
put these things on YouTube and share them
and let them...
This is outside of membership as well as
this is show more than tell what the
value of membership is.
You're looking at a snapshot of Josh here,
but...
Someone like Josh goes to Aometer as a
member because they understand the value
in those things.
And those things are intangible.
I try to make this as tangible as
a podcast or a video could be.
Make it as tangible as you can because
that's where the value, in my opinion,
really is.
Right.
Awesome.
Well, hey, Josh, appreciate the time.
Hurry up.
Get back to work.
You're costing the government some money.
Get some people back.
And we appreciate your time here on Hands
On, Hands Off.
Hey, thank you so much.
It was a pleasure to be here.