WEBVTT 00:00:00.149 --> 00:00:00.769 There we go. 00:00:00.789 --> 00:00:01.209 All right, 00:00:01.710 --> 00:00:03.190 when most people think about physical 00:00:03.230 --> 00:00:05.251 therapy, they picture injury, 00:00:05.312 --> 00:00:07.593 something that happens after the damage is 00:00:07.633 --> 00:00:07.892 done. 00:00:08.273 --> 00:00:09.054 But for Josh Kidd, 00:00:09.093 --> 00:00:11.996 physical therapy lives much earlier in the 00:00:12.016 --> 00:00:12.375 story. 00:00:12.736 --> 00:00:14.737 Josh works with people whose jobs leave 00:00:14.776 --> 00:00:15.778 very little room for error. 00:00:16.856 --> 00:00:17.538 fighter pilots, 00:00:17.919 --> 00:00:19.300 special operations personnel, 00:00:19.861 --> 00:00:21.943 while recovery and performance and 00:00:21.963 --> 00:00:23.847 decision-making all have real 00:00:23.887 --> 00:00:24.728 consequences. 00:00:25.147 --> 00:00:26.489 He's also shaping the next generation of 00:00:26.550 --> 00:00:27.992 clinicians as a faculty member, 00:00:28.051 --> 00:00:29.655 researcher, and residency director. 00:00:30.054 --> 00:00:30.315 Lately, 00:00:30.355 --> 00:00:32.258 his work is focusing on a concept that 00:00:32.317 --> 00:00:33.299 sounds simple, 00:00:34.345 --> 00:00:35.706 but carries big implications, 00:00:36.006 --> 00:00:37.186 directional preference, 00:00:37.226 --> 00:00:38.667 how the body responds to movement, 00:00:39.027 --> 00:00:40.707 and what that response can tell us about 00:00:41.088 --> 00:00:43.607 healing, readiness, and performance. 00:00:43.908 --> 00:00:44.128 Today, 00:00:44.148 --> 00:00:45.569 we're talking with Josh about what 00:00:45.628 --> 00:00:47.848 directional preference really is, 00:00:48.250 --> 00:00:50.289 why it matters beyond the spine, 00:00:50.770 --> 00:00:52.551 and what the current evidence reveals, 00:00:52.850 --> 00:00:54.051 not just about treatment, 00:00:55.151 --> 00:00:57.051 but about how clinicians think. 00:00:57.572 --> 00:01:00.393 So let's get Josh Kidd in the studio. 00:01:00.533 --> 00:01:01.773 Josh, welcome to your episode. 00:01:02.911 --> 00:01:04.612 Hey, thanks. 00:01:04.632 --> 00:01:05.253 It's a pleasure to be here, guys. 00:01:05.272 --> 00:01:06.433 I mean, setting the bar pretty high. 00:01:06.474 --> 00:01:07.953 That sounded pretty cool in the intro, 00:01:07.995 --> 00:01:08.515 right? 00:01:08.555 --> 00:01:09.614 Let's go back first. 00:01:10.115 --> 00:01:12.337 How'd you get to do all that stuff? 00:01:12.356 --> 00:01:13.236 And we'll get to the stuff. 00:01:13.257 --> 00:01:13.456 But like, 00:01:13.716 --> 00:01:15.477 what was sort of the thirty second career 00:01:15.537 --> 00:01:16.899 arc to get to where you are now? 00:01:17.941 --> 00:01:18.400 Yeah, it's funny. 00:01:18.421 --> 00:01:19.581 I think you really overhyped the bio, 00:01:19.602 --> 00:01:20.563 so I appreciate that. 00:01:21.463 --> 00:01:21.884 No, it's funny. 00:01:22.424 --> 00:01:23.045 Like most BTs, 00:01:23.084 --> 00:01:25.186 I started off and wanted to go into 00:01:25.227 --> 00:01:25.707 orthopedics. 00:01:25.847 --> 00:01:28.209 I wanted board certifications. 00:01:28.290 --> 00:01:29.811 Started to go that route just as a 00:01:30.031 --> 00:01:32.293 basic clinician in a normal outpatient 00:01:32.313 --> 00:01:33.073 orthopedic practice. 00:01:33.875 --> 00:01:34.855 Had the opportunity to buy in, 00:01:35.135 --> 00:01:36.316 become an owner in that practice. 00:01:36.436 --> 00:01:38.138 So started to grow in that realm. 00:01:38.177 --> 00:01:40.180 And I'm like, man, I love outpatient. 00:01:40.700 --> 00:01:42.022 I want to continue to foster this. 00:01:42.042 --> 00:01:43.382 We're bringing in a residency program, 00:01:43.403 --> 00:01:44.123 bringing in mentors. 00:01:45.515 --> 00:01:47.496 um in in residence and enjoying my time 00:01:47.557 --> 00:01:48.897 and then these funny things called 00:01:48.917 --> 00:01:50.278 third-party administrators started to come 00:01:50.298 --> 00:01:52.259 around right and then my administrative 00:01:52.319 --> 00:01:54.840 burden started to scale and i'm like i 00:01:54.881 --> 00:01:56.081 don't know how i feel about this so 00:01:56.121 --> 00:01:58.382 much and so i decided um hey i'm 00:01:58.403 --> 00:01:59.924 gonna get out of this and i wanna 00:01:59.963 --> 00:02:02.125 my thought was go cash pay i'm like 00:02:02.165 --> 00:02:03.165 i want to go cash pay i want 00:02:03.186 --> 00:02:04.225 to set my fees i want to treat 00:02:04.266 --> 00:02:04.986 patients i want to treat them 00:02:06.123 --> 00:02:09.664 And so sold my practice and was doing 00:02:09.685 --> 00:02:09.925 that route. 00:02:09.944 --> 00:02:10.985 And I got a phone call from a 00:02:11.025 --> 00:02:12.245 good colleague of mine who was, 00:02:12.305 --> 00:02:13.286 I knew he was doing something with the 00:02:13.306 --> 00:02:13.725 military, 00:02:13.885 --> 00:02:14.725 but I didn't really know what it was. 00:02:14.746 --> 00:02:16.325 I thought he was just hanging out and 00:02:16.366 --> 00:02:17.346 chatting with a few guys. 00:02:17.366 --> 00:02:18.467 And he calls me up and says, hey, 00:02:19.407 --> 00:02:20.387 I work with the military. 00:02:20.486 --> 00:02:21.387 My company's growing. 00:02:21.546 --> 00:02:22.687 I need quality assurance. 00:02:22.907 --> 00:02:24.348 I know you run residency programs. 00:02:25.027 --> 00:02:26.587 I know you have a solid foundation and 00:02:26.627 --> 00:02:27.748 I want to practice the way, 00:02:27.829 --> 00:02:28.908 I want all of our guys to practice 00:02:28.929 --> 00:02:29.288 what you do. 00:02:30.288 --> 00:02:33.170 and he says um and I said okay 00:02:33.830 --> 00:02:35.372 um and he goes but I know that 00:02:35.391 --> 00:02:36.332 you're busy he didn't know I saw my 00:02:36.353 --> 00:02:38.153 practice he goes I know that you're you 00:02:38.174 --> 00:02:39.235 know you're occupied your business so do 00:02:39.254 --> 00:02:40.675 you know anybody that could do this and 00:02:40.735 --> 00:02:42.877 I said well actually I do and he 00:02:42.896 --> 00:02:44.837 said who's that I said it's me you 00:02:44.858 --> 00:02:45.239 know what he did 00:02:46.038 --> 00:02:46.677 He hung up on me. 00:02:46.758 --> 00:02:48.359 He goes, I got to call you back. 00:02:48.799 --> 00:02:49.400 And it was so funny. 00:02:49.419 --> 00:02:49.719 I get home. 00:02:49.740 --> 00:02:51.319 I talk to my wife and I'm doing 00:02:51.340 --> 00:02:52.501 this cash pay transition thing. 00:02:52.540 --> 00:02:53.320 And I said, hey, 00:02:53.341 --> 00:02:54.421 I got a call from Randy today. 00:02:54.861 --> 00:02:56.282 And he goes, and she goes, 00:02:56.323 --> 00:02:56.723 what do you want? 00:02:56.742 --> 00:02:57.002 I said, well, 00:02:57.022 --> 00:02:59.084 he wanted to pitch me a job to 00:02:59.104 --> 00:02:59.824 work for his company. 00:03:00.625 --> 00:03:02.504 And she said, well, what'd you say? 00:03:02.525 --> 00:03:02.866 And I said, 00:03:03.186 --> 00:03:03.966 I told him I was interested. 00:03:04.286 --> 00:03:04.626 What do you do? 00:03:04.665 --> 00:03:05.687 I said, he totally hung up on me. 00:03:06.826 --> 00:03:07.927 I didn't get it either. 00:03:07.948 --> 00:03:09.427 So he calls me two days later and 00:03:09.448 --> 00:03:11.528 he says, hey, he goes, I'm sorry, 00:03:11.568 --> 00:03:12.750 I just couldn't process all that. 00:03:12.789 --> 00:03:14.389 He goes, I was looking for one thing. 00:03:14.409 --> 00:03:15.211 And then when I found out it was 00:03:15.270 --> 00:03:15.471 you, 00:03:15.550 --> 00:03:17.731 I had just told this big gamut of 00:03:17.771 --> 00:03:18.391 things I wanted to do. 00:03:18.412 --> 00:03:18.632 He's like, 00:03:18.671 --> 00:03:19.793 I want you to come work for us 00:03:19.832 --> 00:03:20.913 and I want you to run this thing. 00:03:20.953 --> 00:03:22.993 And so it just kind of happened by 00:03:23.014 --> 00:03:24.814 happenstance how I fell into it. 00:03:24.854 --> 00:03:26.295 And I would say it's probably the coolest 00:03:26.316 --> 00:03:26.996 job in the world, man. 00:03:27.015 --> 00:03:27.216 I mean, 00:03:27.496 --> 00:03:30.578 the population we get to serve is amazing. 00:03:30.638 --> 00:03:32.098 Our teams are usually set up what's called 00:03:32.157 --> 00:03:33.158 an HBO team, 00:03:33.239 --> 00:03:35.139 so a human performance optimization team. 00:03:36.039 --> 00:03:37.341 And foundationally, 00:03:37.381 --> 00:03:38.842 it's usually about five different types of 00:03:38.882 --> 00:03:39.301 providers. 00:03:39.322 --> 00:03:40.141 So there's a PT, 00:03:40.782 --> 00:03:41.763 there's an athletic trainer, 00:03:42.144 --> 00:03:43.123 there's a strength coach, 00:03:43.604 --> 00:03:44.784 there's a sports psychologist, 00:03:44.844 --> 00:03:46.006 and there's a nutritionist. 00:03:46.746 --> 00:03:48.426 And we're basically embedded within a 00:03:48.467 --> 00:03:49.668 special operations unit. 00:03:50.127 --> 00:03:51.588 And our job where I'm at is to 00:03:51.628 --> 00:03:53.969 take care of sixty four special ops guys. 00:03:54.270 --> 00:03:56.170 And we get all the toys and we 00:03:56.191 --> 00:03:56.771 get all the time. 00:03:56.831 --> 00:03:58.151 So I don't have to bill anything. 00:03:58.633 --> 00:03:59.073 I treat I mean, 00:03:59.112 --> 00:03:59.893 I got a guy right now. 00:03:59.932 --> 00:04:01.274 He's going he's got a quad tender repair 00:04:01.294 --> 00:04:02.615 and I'm with him for like three hours 00:04:02.655 --> 00:04:02.955 a day, man. 00:04:03.115 --> 00:04:03.455 Wow. 00:04:03.936 --> 00:04:05.395 So the ability to practice at the top 00:04:05.415 --> 00:04:07.758 of our license has been pretty special and 00:04:07.777 --> 00:04:08.377 it's been rewarding. 00:04:08.937 --> 00:04:09.179 And again, 00:04:09.218 --> 00:04:10.679 I don't have to deal with those pesky 00:04:10.860 --> 00:04:12.120 third party administrators anymore. 00:04:12.159 --> 00:04:15.141 So that's been the original shift into 00:04:15.201 --> 00:04:16.783 kind of the human performance realm. 00:04:17.142 --> 00:04:17.963 And it's been fantastic. 00:04:17.983 --> 00:04:18.363 All right, good. 00:04:18.384 --> 00:04:19.204 We've got context. 00:04:19.244 --> 00:04:20.584 But now let's drill into for the 00:04:20.625 --> 00:04:21.466 clinicians out there. 00:04:21.505 --> 00:04:22.805 Let's drill into this. 00:04:22.846 --> 00:04:24.728 You're working with special operations 00:04:24.767 --> 00:04:25.307 fighter pilots. 00:04:25.528 --> 00:04:26.689 We sort of set the stage there. 00:04:27.108 --> 00:04:27.288 Yeah. 00:04:27.389 --> 00:04:28.310 These people do not have time for 00:04:28.370 --> 00:04:28.949 guesswork. 00:04:29.069 --> 00:04:31.391 The first time someone ever framed when I 00:04:31.411 --> 00:04:33.312 was a PT student with this podcast, 00:04:33.372 --> 00:04:34.692 his name was Rich Westrick. 00:04:35.634 --> 00:04:36.533 Rich said, listen, 00:04:36.855 --> 00:04:38.214 if you train triathletes, 00:04:38.254 --> 00:04:39.935 you know when the race is, 00:04:39.995 --> 00:04:40.857 what time of day, 00:04:40.937 --> 00:04:42.218 likely what the weather's going to be. 00:04:42.257 --> 00:04:43.577 You know the exact course. 00:04:43.598 --> 00:04:45.098 He goes, 00:04:45.119 --> 00:04:46.500 people don't have that in operations. 00:04:46.740 --> 00:04:47.740 You don't know when the bell's going to 00:04:47.821 --> 00:04:48.521 ring, right? 00:04:48.781 --> 00:04:50.401 So these people do not have guesswork. 00:04:50.903 --> 00:04:52.764 Where did directional preference become 00:04:52.824 --> 00:04:55.625 something so central to your clinical 00:04:55.665 --> 00:04:55.906 thinking? 00:04:56.045 --> 00:04:56.646 How'd that happen? 00:04:57.406 --> 00:04:58.367 Yeah, it's how we came into the unit. 00:04:58.387 --> 00:04:59.747 So I sat down with the commander basically 00:04:59.766 --> 00:05:00.627 day one and I said, okay, 00:05:01.187 --> 00:05:02.769 where can we have the biggest change? 00:05:03.028 --> 00:05:04.310 And he broke it down and they track 00:05:04.350 --> 00:05:04.689 everything. 00:05:04.850 --> 00:05:06.050 Every metric is tracked on these guys, 00:05:06.071 --> 00:05:06.230 right? 00:05:06.250 --> 00:05:07.591 And they said, hey, you know, 00:05:07.612 --> 00:05:07.951 believe it or not, 00:05:07.971 --> 00:05:09.033 my biggest problem is back pain, 00:05:09.052 --> 00:05:09.653 neck pain, right? 00:05:09.692 --> 00:05:11.254 And so my background, you know, 00:05:11.274 --> 00:05:13.156 I'm the director of the McKinsey 00:05:13.175 --> 00:05:14.055 Institute's residency program. 00:05:14.096 --> 00:05:15.377 So that's kind of the Kool-Aid, 00:05:15.396 --> 00:05:16.398 a little bit of the Kool-Aid I'm drinking 00:05:16.418 --> 00:05:17.017 for preference here. 00:05:17.057 --> 00:05:18.499 And so I said, okay, 00:05:18.559 --> 00:05:20.000 we have a specific way we can target 00:05:20.060 --> 00:05:20.240 this. 00:05:20.399 --> 00:05:21.641 And I said, let's just start tracking. 00:05:21.661 --> 00:05:22.360 Let's look at metrics. 00:05:22.401 --> 00:05:24.122 Let's see if we can change the prevalence 00:05:24.161 --> 00:05:24.322 here. 00:05:24.362 --> 00:05:24.641 And so 00:05:25.603 --> 00:05:27.524 Based on what the unit leadership wanted, 00:05:27.884 --> 00:05:28.425 we said, okay, 00:05:28.485 --> 00:05:30.427 let's go after spine pain because that was 00:05:30.586 --> 00:05:31.668 similar to outpatient. 00:05:31.728 --> 00:05:32.728 Everybody thinks it's going to be all 00:05:32.749 --> 00:05:33.249 different. 00:05:33.709 --> 00:05:34.250 It's spine pain. 00:05:34.269 --> 00:05:35.550 And a lot of times it's when they're 00:05:35.591 --> 00:05:38.012 not doing their training and doing their 00:05:38.033 --> 00:05:38.492 missions, right? 00:05:38.512 --> 00:05:39.533 They're not really getting hurt out there 00:05:39.553 --> 00:05:39.834 too much. 00:05:39.853 --> 00:05:41.514 It's more when they're back home and 00:05:41.535 --> 00:05:42.915 they're more sedentary and less active. 00:05:43.857 --> 00:05:45.377 we um we started to look at the 00:05:45.398 --> 00:05:47.119 data and we said okay let's utilize 00:05:47.199 --> 00:05:49.180 directional preference as an avenue to 00:05:49.281 --> 00:05:51.401 assess but then also determine prognosis 00:05:51.882 --> 00:05:53.524 and we've actually been collecting some 00:05:53.543 --> 00:05:55.004 pretty cool data on it which i'm happy 00:05:55.024 --> 00:05:56.406 to share with you as we move forward 00:05:56.446 --> 00:05:58.286 here but that's really what's at the stage 00:05:58.346 --> 00:05:59.869 sit down with commander he says i got 00:05:59.908 --> 00:06:01.410 a problem with spine related issues you 00:06:01.430 --> 00:06:02.730 know we have we've had high level 00:06:02.750 --> 00:06:04.011 therapists in here before taking this 00:06:04.050 --> 00:06:05.812 approach i said well let's let's try 00:06:05.833 --> 00:06:07.334 something different here and see what we 00:06:07.353 --> 00:06:08.795 can do and you know we've got four 00:06:08.814 --> 00:06:10.136 years now of training down and it's 00:06:10.456 --> 00:06:11.336 actually trending in a pretty good 00:06:11.357 --> 00:06:11.716 direction 00:06:12.093 --> 00:06:13.333 What's that commander's background, 00:06:13.372 --> 00:06:13.814 just briefly? 00:06:13.834 --> 00:06:16.935 Is it a healthcare background or not? 00:06:16.995 --> 00:06:17.675 No, no, man. 00:06:17.694 --> 00:06:18.995 The reason I ask is it sounds pretty 00:06:19.016 --> 00:06:19.815 damn informed. 00:06:20.555 --> 00:06:20.755 Yeah. 00:06:21.036 --> 00:06:21.677 Well, 00:06:21.697 --> 00:06:22.656 his job is to take care of those 00:06:22.697 --> 00:06:22.857 guys. 00:06:22.896 --> 00:06:24.557 And so he works side by side with 00:06:24.577 --> 00:06:25.177 the HBO team. 00:06:25.218 --> 00:06:26.637 He's worked side by side with the flight 00:06:26.658 --> 00:06:27.319 docs, right? 00:06:27.918 --> 00:06:28.819 And in flight medicine. 00:06:28.858 --> 00:06:31.639 And so he needs to keep status on 00:06:31.680 --> 00:06:33.180 who's green-lighted and who's red-lighted 00:06:33.240 --> 00:06:34.440 on his teams because he'll have to move 00:06:34.461 --> 00:06:35.161 pieces around. 00:06:35.661 --> 00:06:36.622 One guy's not operational. 00:06:36.641 --> 00:06:38.403 He's going to have to swap somebody into 00:06:38.423 --> 00:06:40.122 that unit because everybody has a sniffing 00:06:40.202 --> 00:06:41.204 role within the unit, right? 00:06:41.704 --> 00:06:43.125 And so it's his job. 00:06:43.225 --> 00:06:44.225 It's his job to stay on top of 00:06:44.285 --> 00:06:44.384 it. 00:06:44.564 --> 00:06:46.625 And the crazy part is he actually has 00:06:46.685 --> 00:06:48.545 overall say of if this guy gets to 00:06:48.586 --> 00:06:48.887 go or not. 00:06:49.026 --> 00:06:50.127 Right. 00:06:50.146 --> 00:06:50.947 With no medical background, 00:06:50.987 --> 00:06:52.187 it was fascinating to me. 00:06:52.627 --> 00:06:53.507 But, yeah, I mean, 00:06:53.528 --> 00:06:55.209 that's his job to to make sure he's 00:06:55.249 --> 00:06:56.389 on top of every one of those guys, 00:06:56.449 --> 00:06:58.689 both from a physical, mental, 00:06:58.990 --> 00:06:59.610 family style. 00:06:59.649 --> 00:07:01.050 I mean, operational style. 00:07:01.110 --> 00:07:01.350 I mean, 00:07:01.610 --> 00:07:02.911 across the gamut on each one of these 00:07:02.932 --> 00:07:04.151 guys, he basically has a profile. 00:07:04.803 --> 00:07:05.665 All right, you mentioned Kool-Aid. 00:07:05.685 --> 00:07:06.805 Let's talk about some Kool-Aid and 00:07:06.826 --> 00:07:07.507 different flavors, right? 00:07:07.526 --> 00:07:08.848 We'll get a little bit into the Kool-Aid. 00:07:09.269 --> 00:07:11.011 For someone who's heard the term but maybe 00:07:11.050 --> 00:07:12.471 never fully got it or maybe they need 00:07:12.492 --> 00:07:13.552 to hear it from you one more time, 00:07:13.913 --> 00:07:16.536 how do you define directional preference? 00:07:17.372 --> 00:07:17.612 Yeah. 00:07:17.651 --> 00:07:18.612 So directional preference, you know, 00:07:18.632 --> 00:07:19.093 I look at it, 00:07:19.853 --> 00:07:20.874 a lot of people will look at it 00:07:20.954 --> 00:07:21.754 as, you know, 00:07:22.295 --> 00:07:23.475 an exercise and we look at it as 00:07:23.495 --> 00:07:23.915 assessment. 00:07:24.016 --> 00:07:24.456 So for us, 00:07:24.495 --> 00:07:25.255 what we want to be able to do 00:07:25.315 --> 00:07:26.557 is, is when you, 00:07:26.776 --> 00:07:28.718 when you look at it at the basic, 00:07:28.757 --> 00:07:29.939 basic foundation, 00:07:30.038 --> 00:07:32.901 it's directional preference is a specific 00:07:32.940 --> 00:07:33.380 movement. 00:07:33.980 --> 00:07:35.081 You can move any joint. 00:07:35.701 --> 00:07:37.142 Most research is on the lumbar spine, 00:07:37.163 --> 00:07:37.903 some on the cervical spine, 00:07:37.923 --> 00:07:39.343 but a specific direction, 00:07:39.384 --> 00:07:40.625 you can repeatedly move a joint. 00:07:41.788 --> 00:07:43.254 to end range in which you will see 00:07:43.293 --> 00:07:43.875 two things happen. 00:07:43.896 --> 00:07:46.202 You'll see an improvement in pain and 00:07:46.223 --> 00:07:47.747 you'll see an improvement in mechanics or 00:07:47.786 --> 00:07:48.067 function. 00:07:48.088 --> 00:07:49.252 So range of motion, strength, 00:07:49.903 --> 00:07:50.884 their ability to do something that was 00:07:50.923 --> 00:07:51.584 previously painful, 00:07:51.605 --> 00:07:52.605 and now that pain resolved. 00:07:53.024 --> 00:07:54.105 But that movement has to, 00:07:54.805 --> 00:07:56.886 that improvement has to last, right? 00:07:57.245 --> 00:07:58.447 And so it's not, hey, 00:07:58.726 --> 00:07:59.927 I can move you around a little bit 00:07:59.966 --> 00:08:03.668 and get some exercise-duced hypoalgesia, 00:08:04.168 --> 00:08:05.689 and you're going to feel better, right? 00:08:05.749 --> 00:08:07.389 Exercise-duced hypoalgesia. 00:08:07.749 --> 00:08:08.668 It's not just that, right? 00:08:08.689 --> 00:08:09.189 It's not just, hey, 00:08:09.209 --> 00:08:10.110 I move a little bit, I feel better. 00:08:10.410 --> 00:08:12.310 It's moving you in a specific direction 00:08:12.651 --> 00:08:13.750 that makes you feel better. 00:08:14.110 --> 00:08:16.271 And a lot of that's ascertained from the 00:08:16.291 --> 00:08:16.831 history in the exam. 00:08:17.752 --> 00:08:18.773 So now let's go the opposite. 00:08:18.833 --> 00:08:19.713 Now that we know what it is, 00:08:20.413 --> 00:08:21.353 what are some of the most common 00:08:21.394 --> 00:08:23.315 misconceptions clinicians have about it? 00:08:23.336 --> 00:08:24.196 What are the things that, 00:08:24.896 --> 00:08:26.718 that Josh is most of the time correcting 00:08:26.757 --> 00:08:27.939 and saying, well, 00:08:28.079 --> 00:08:29.540 actually not that it's actually more like 00:08:29.579 --> 00:08:29.779 this. 00:08:30.834 --> 00:08:31.754 Yeah, no, the big thing, I mean, 00:08:31.774 --> 00:08:33.054 I think a lot of people think it's, 00:08:33.294 --> 00:08:36.855 you know, for some things to be, 00:08:36.895 --> 00:08:37.836 and this is where the limits of the 00:08:37.855 --> 00:08:38.235 nuances, 00:08:38.255 --> 00:08:39.216 we can talk about the research we've 00:08:39.235 --> 00:08:39.596 looked at, 00:08:39.636 --> 00:08:40.956 because there is some discrepancies about 00:08:40.976 --> 00:08:41.817 the definition of it. 00:08:41.836 --> 00:08:43.798 And that's what we aim to try to 00:08:43.837 --> 00:08:44.898 clear up with some of our stuff we 00:08:44.918 --> 00:08:45.457 were looking at. 00:08:45.918 --> 00:08:47.499 But, you know, a lot of people think, 00:08:47.558 --> 00:08:47.759 hey, 00:08:48.519 --> 00:08:48.719 You know, 00:08:48.798 --> 00:08:50.059 if I move in one direction makes me 00:08:50.100 --> 00:08:50.519 feel better. 00:08:50.980 --> 00:08:52.020 I got to move them in the opposite 00:08:52.061 --> 00:08:53.741 direction and it's got to make them worse. 00:08:54.062 --> 00:08:55.163 And you don't always see that. 00:08:55.243 --> 00:08:56.923 And sometimes with specific patient 00:08:56.942 --> 00:08:57.443 demographics, 00:08:57.504 --> 00:08:58.543 you will and you won't see that. 00:08:58.583 --> 00:09:00.384 So that's necessarily not always the key. 00:09:00.705 --> 00:09:01.985 And then there has to be a lasting 00:09:02.025 --> 00:09:02.405 change. 00:09:02.586 --> 00:09:02.725 Right. 00:09:02.745 --> 00:09:03.626 I mean, for example, 00:09:03.726 --> 00:09:04.346 I have low back pain. 00:09:04.366 --> 00:09:04.506 Right. 00:09:04.527 --> 00:09:05.368 I'm a general person. 00:09:05.388 --> 00:09:06.048 I have low back pain. 00:09:06.587 --> 00:09:08.448 What do I normally like to do? 00:09:08.489 --> 00:09:09.049 My back's hurting. 00:09:09.070 --> 00:09:09.970 I want to lay down. 00:09:10.110 --> 00:09:11.250 I want to put some pillows under my 00:09:11.270 --> 00:09:11.671 knees. 00:09:12.150 --> 00:09:13.211 I want to get a recumbent position. 00:09:13.751 --> 00:09:14.513 I'm going to feel pretty good. 00:09:14.552 --> 00:09:14.712 Right. 00:09:15.784 --> 00:09:17.886 that directional preference and i say no 00:09:17.927 --> 00:09:19.248 because what happens once you come out of 00:09:19.268 --> 00:09:20.369 that position you stand back up what 00:09:20.389 --> 00:09:22.770 happens pain comes right back right so 00:09:22.791 --> 00:09:24.432 there has to be some lasting change and 00:09:24.471 --> 00:09:26.214 carry over and what you should see is 00:09:26.234 --> 00:09:27.914 you should see this gradual progression to 00:09:27.955 --> 00:09:30.076 improvement as i continue to do more of 00:09:30.116 --> 00:09:31.639 the movement i get better and better and 00:09:31.658 --> 00:09:32.820 better not hey it feels good when i 00:09:32.860 --> 00:09:33.759 do it and then it kind of comes 00:09:33.820 --> 00:09:34.660 back so we kind of got to do 00:09:34.681 --> 00:09:36.241 it again and then it feels better but 00:09:36.261 --> 00:09:37.302 you go through this repetitive cycle 00:09:37.322 --> 00:09:38.784 that's not it right so it's got to 00:09:38.804 --> 00:09:41.005 be lasting and it's got to be sequentially 00:09:41.086 --> 00:09:41.547 improving 00:09:42.596 --> 00:09:43.937 Yeah. 00:09:44.057 --> 00:09:44.118 Uh, 00:09:44.177 --> 00:09:45.519 you're jumping into some research with 00:09:45.558 --> 00:09:47.139 some pretty big names, right? 00:09:47.419 --> 00:09:48.760 Part of a recent scoping review in 00:09:48.801 --> 00:09:49.522 physical therapy. 00:09:49.662 --> 00:09:49.861 What, 00:09:50.363 --> 00:09:52.203 what question were you trying to answer 00:09:52.264 --> 00:09:54.024 and how that, what, what, 00:09:54.105 --> 00:09:54.966 what answer did we get? 00:09:54.985 --> 00:09:57.246 Yeah, that's a good, 00:09:57.307 --> 00:09:58.687 I think like similar to most scoping 00:09:58.707 --> 00:09:59.769 reviews, I think you're going to find out. 00:09:59.788 --> 00:10:01.070 So we were, we were, 00:10:01.309 --> 00:10:03.130 when you look at the clinical practice 00:10:03.152 --> 00:10:04.932 guidelines and you look at systematic 00:10:04.952 --> 00:10:06.153 reviews around directional preference, 00:10:06.614 --> 00:10:07.394 it's all over the board. 00:10:07.715 --> 00:10:08.855 Some systematic reviews say, Hey, 00:10:08.895 --> 00:10:09.755 this is beneficial. 00:10:09.836 --> 00:10:10.716 Others say, no, it's not. 00:10:10.736 --> 00:10:11.216 Some say, Hey, 00:10:11.236 --> 00:10:12.278 this is good for chronic pain. 00:10:12.697 --> 00:10:13.739 Maybe a Q, some say, no, 00:10:13.759 --> 00:10:14.519 it's not good for anything. 00:10:14.559 --> 00:10:16.542 And so our aim was to look at, 00:10:16.701 --> 00:10:17.022 you know, 00:10:17.042 --> 00:10:18.743 when you look at previous scoping reviews, 00:10:18.764 --> 00:10:20.384 they looked at your level of training and 00:10:20.424 --> 00:10:21.485 being able to identify it, right? 00:10:21.525 --> 00:10:22.667 Is this generalizable or do you have to 00:10:22.706 --> 00:10:24.488 go so far down this rabbit hole that 00:10:24.528 --> 00:10:26.129 it's not even going to be beneficial to 00:10:26.169 --> 00:10:26.470 do that? 00:10:26.509 --> 00:10:27.671 And so we just want to look at 00:10:27.691 --> 00:10:28.272 the definition. 00:10:28.292 --> 00:10:29.452 We want to say, okay, 00:10:29.472 --> 00:10:30.433 maybe it's not the level of training. 00:10:30.453 --> 00:10:31.695 Maybe it's how people are defining it. 00:10:31.715 --> 00:10:33.615 So what we did was a large scoping 00:10:33.655 --> 00:10:33.876 review. 00:10:34.994 --> 00:10:36.755 And we looked at all the research that 00:10:37.035 --> 00:10:38.236 used the word directional preference. 00:10:38.777 --> 00:10:39.317 And we want to know, 00:10:39.357 --> 00:10:40.019 how do you define it? 00:10:40.499 --> 00:10:41.039 Like, what was it? 00:10:41.100 --> 00:10:41.899 If you're saying, Hey, 00:10:42.181 --> 00:10:43.261 it has no effect or, Hey, 00:10:43.302 --> 00:10:44.283 it has this amazing effect. 00:10:44.383 --> 00:10:44.602 Okay. 00:10:45.082 --> 00:10:46.364 How did you define it to say, 00:10:46.565 --> 00:10:47.846 to determine what it was and what you're 00:10:47.865 --> 00:10:48.066 doing? 00:10:48.326 --> 00:10:49.527 And we found out, I mean, 00:10:49.888 --> 00:10:50.587 there was a mishmash. 00:10:50.648 --> 00:10:51.908 I mean, we, 00:10:51.950 --> 00:10:53.171 we started off with a fifteen thousand 00:10:53.211 --> 00:10:53.650 studies, right? 00:10:53.691 --> 00:10:56.052 Broke it down and went into full review 00:10:56.113 --> 00:10:58.034 on one hundred and forty nine studies and 00:10:58.075 --> 00:10:58.956 of those hundred forty nine. 00:10:59.690 --> 00:11:00.890 We found that people had there was one 00:11:00.910 --> 00:11:03.272 hundred fifteen different definitions that 00:11:04.371 --> 00:11:04.991 is all over the board. 00:11:05.293 --> 00:11:07.614 And in twenty two percent of them didn't 00:11:07.634 --> 00:11:08.433 even have a definition. 00:11:08.714 --> 00:11:10.034 They said we do directional preference, 00:11:10.075 --> 00:11:11.095 but we're not going to tell you what 00:11:11.134 --> 00:11:11.335 it is. 00:11:11.455 --> 00:11:11.615 Right. 00:11:11.875 --> 00:11:12.176 Wow. 00:11:12.875 --> 00:11:14.976 So which we found intriguing. 00:11:15.017 --> 00:11:15.197 Right. 00:11:15.216 --> 00:11:15.836 So what does that mean? 00:11:15.897 --> 00:11:16.077 I mean, 00:11:16.118 --> 00:11:17.018 I think it means that we need to 00:11:17.038 --> 00:11:19.698 look at what is a more concise definition. 00:11:20.038 --> 00:11:21.259 And I think there's different ways to go 00:11:21.299 --> 00:11:23.581 about looking at that to determine, OK, 00:11:23.821 --> 00:11:25.142 how do we actually define this? 00:11:26.283 --> 00:11:27.984 And then how does that definition 00:11:28.024 --> 00:11:29.306 translate into clinical practice, 00:11:29.326 --> 00:11:30.067 but also research? 00:11:30.547 --> 00:11:31.168 And I think, I mean, 00:11:31.528 --> 00:11:32.489 we see this all over the board. 00:11:32.528 --> 00:11:32.690 I mean, 00:11:32.710 --> 00:11:33.791 I know there are similar studies have been 00:11:33.811 --> 00:11:35.572 done looking at what is manual therapy, 00:11:35.753 --> 00:11:35.932 right? 00:11:35.952 --> 00:11:36.994 Because that's still some of these things 00:11:37.014 --> 00:11:38.054 that's ill-defined, right? 00:11:38.115 --> 00:11:40.638 And so we've tried to follow along those 00:11:40.658 --> 00:11:41.058 same lines. 00:11:41.078 --> 00:11:42.801 So hopefully if we can get a more 00:11:42.860 --> 00:11:43.822 uniform definition, 00:11:44.360 --> 00:11:45.720 then we can research it and then we 00:11:45.740 --> 00:11:47.061 can also use it as a clinical tool. 00:11:47.520 --> 00:11:51.341 You almost maybe half already answered my 00:11:51.402 --> 00:11:52.863 next question, but I got it queued up. 00:11:52.883 --> 00:11:53.962 So I'm just going to answer it anyway. 00:11:54.602 --> 00:11:56.964 How did those inconsistencies in research 00:11:56.984 --> 00:11:57.923 you were just talking about, 00:11:58.484 --> 00:11:59.445 how do they show up? 00:11:59.485 --> 00:12:01.184 What do they look like in everyday 00:12:01.225 --> 00:12:01.705 practice? 00:12:01.745 --> 00:12:02.806 If we don't even know what, 00:12:02.865 --> 00:12:04.265 if we're not even agreeing on terms here, 00:12:04.285 --> 00:12:04.586 there's no, 00:12:05.025 --> 00:12:06.346 we're not going on the same dictionary. 00:12:06.366 --> 00:12:07.586 So I'm using a word one way or 00:12:07.606 --> 00:12:08.807 a term one way and you're using another. 00:12:09.086 --> 00:12:10.648 How's that show up in practice then? 00:12:11.556 --> 00:12:11.716 Yeah. 00:12:11.755 --> 00:12:11.936 I mean, 00:12:12.115 --> 00:12:14.437 I think when you it can cause people 00:12:14.476 --> 00:12:16.236 to potentially abandon it early and say, 00:12:16.277 --> 00:12:16.677 hey, sure. 00:12:17.336 --> 00:12:17.517 Right. 00:12:17.937 --> 00:12:18.136 I mean, 00:12:18.177 --> 00:12:19.138 we looked at some of the studies and 00:12:19.158 --> 00:12:19.658 some of the studies. 00:12:19.697 --> 00:12:19.878 I mean, 00:12:21.057 --> 00:12:23.077 when you look at let's just say the 00:12:23.518 --> 00:12:24.918 treatment based classification systems. 00:12:24.979 --> 00:12:25.178 Right. 00:12:25.538 --> 00:12:26.399 They have different subgroups. 00:12:26.438 --> 00:12:26.538 Right. 00:12:26.558 --> 00:12:27.879 We have this manipulation subgroup. 00:12:28.119 --> 00:12:29.759 We have the stabilization subgroup that 00:12:29.779 --> 00:12:31.080 are based on some clinical prediction 00:12:31.100 --> 00:12:31.379 rules. 00:12:31.639 --> 00:12:33.259 And then we have this exercise specific 00:12:33.279 --> 00:12:33.460 group. 00:12:33.500 --> 00:12:33.720 Right. 00:12:34.000 --> 00:12:35.640 Which is essentially based on directional 00:12:35.681 --> 00:12:36.061 preference. 00:12:36.660 --> 00:12:37.201 Well, in their study, 00:12:37.221 --> 00:12:38.241 what they would do is they would say, 00:12:38.282 --> 00:12:39.783 okay, if you had pain down your leg, 00:12:40.243 --> 00:12:42.524 you do ten forward bends, ten back bends, 00:12:42.924 --> 00:12:44.166 and if it didn't change the symptoms, 00:12:44.426 --> 00:12:45.567 boom, you're out of there, right? 00:12:45.606 --> 00:12:46.408 We looked at other studies, 00:12:46.427 --> 00:12:47.368 and we're like, no, we did that. 00:12:47.607 --> 00:12:48.668 But then we lay the person down, 00:12:48.688 --> 00:12:51.230 and we would do that prone press-up that 00:12:51.270 --> 00:12:52.451 everybody is synonymous with, 00:12:52.491 --> 00:12:53.052 like McKenzie. 00:12:53.072 --> 00:12:54.153 But then they would be moving the hips 00:12:54.613 --> 00:12:55.974 and doing these gapping techniques and all 00:12:55.994 --> 00:12:56.955 these different movements, 00:12:57.355 --> 00:12:58.655 and they were finding a higher prevalence, 00:12:58.716 --> 00:12:58.916 right? 00:12:58.936 --> 00:13:00.376 So the question is like, okay, 00:13:00.397 --> 00:13:01.738 we're not even doing this the same. 00:13:01.798 --> 00:13:02.999 And so if you look at one of 00:13:03.019 --> 00:13:03.818 these studies and say, okay, 00:13:03.859 --> 00:13:05.080 I'm going to bend them forward ten times 00:13:05.100 --> 00:13:05.821 and back ten times, 00:13:06.100 --> 00:13:07.942 If that's the only one study you read, 00:13:07.961 --> 00:13:09.003 you're probably going to abandon things a 00:13:09.023 --> 00:13:10.683 little early versus you read that other 00:13:10.703 --> 00:13:11.705 review and it says, hey, no, wait, 00:13:12.105 --> 00:13:13.807 there's so many different movements that I 00:13:13.826 --> 00:13:15.628 need to implore before I can move on 00:13:15.668 --> 00:13:15.967 from, hey, 00:13:15.988 --> 00:13:17.369 this isn't going to exhibit directional 00:13:17.409 --> 00:13:17.769 preference. 00:13:17.809 --> 00:13:18.009 Right. 00:13:18.931 --> 00:13:21.011 And how it's defined. 00:13:21.111 --> 00:13:22.173 Also, 00:13:22.312 --> 00:13:23.614 we saw some variability in the clinical 00:13:23.634 --> 00:13:26.196 practice guidelines for the low back pain. 00:13:26.216 --> 00:13:26.375 I mean, 00:13:26.395 --> 00:13:27.937 we looked at the first one guidelines that 00:13:27.956 --> 00:13:29.519 came out and directional preference had 00:13:29.538 --> 00:13:30.538 this A level evidence. 00:13:30.639 --> 00:13:30.840 Right. 00:13:31.653 --> 00:13:33.413 And then when you looked at the revision, 00:13:33.894 --> 00:13:35.434 it had this B-level evidence, right? 00:13:35.455 --> 00:13:37.816 So we broke down those studies that they 00:13:37.855 --> 00:13:39.976 looked at and we found varying themes 00:13:39.996 --> 00:13:41.618 within those definitions as well, right? 00:13:41.638 --> 00:13:44.539 So we basically identified a few specific 00:13:44.559 --> 00:13:45.700 themes that must be present. 00:13:45.840 --> 00:13:47.500 And if based on the research and then 00:13:47.561 --> 00:13:49.701 also based on this thematic analysis we 00:13:49.741 --> 00:13:51.923 did in addition to our scoping review. 00:13:51.982 --> 00:13:54.125 And so depending on where you're looking 00:13:54.144 --> 00:13:54.784 and how they're defining, 00:13:54.804 --> 00:13:56.686 it's going to clinically going to drive 00:13:57.025 --> 00:13:58.907 what you do or how quickly or don't 00:13:58.927 --> 00:13:59.626 quickly abandon it. 00:13:59.647 --> 00:13:59.746 Yeah. 00:14:01.846 --> 00:14:05.389 um so how does this approach how does 00:14:05.649 --> 00:14:07.750 directional preference let's bring sort of 00:14:07.811 --> 00:14:10.032 both of the things that you do together 00:14:10.133 --> 00:14:11.734 the research directional preference and 00:14:11.774 --> 00:14:14.195 working with athletes or you know tactical 00:14:14.254 --> 00:14:16.376 athletes tactical operators what does this 00:14:16.397 --> 00:14:18.378 approach offer when time matters i mean 00:14:18.398 --> 00:14:20.719 you just said you operationally this is 00:14:20.879 --> 00:14:22.340 money this is effectiveness this is 00:14:22.421 --> 00:14:24.022 readiness what does that approach offer 00:14:24.042 --> 00:14:25.341 when time matters with those types of 00:14:25.361 --> 00:14:26.143 people you're working with 00:14:26.664 --> 00:14:26.904 Yeah. 00:14:26.924 --> 00:14:28.025 Let's put some context around that. 00:14:28.066 --> 00:14:30.567 So within the unit for our guys, 00:14:30.587 --> 00:14:31.489 depending on what level of training they 00:14:31.528 --> 00:14:31.749 have, 00:14:32.029 --> 00:14:35.091 it's going to cost between one point two 00:14:36.153 --> 00:14:37.634 to about one point nine million dollars to 00:14:37.653 --> 00:14:38.355 make one of these guys. 00:14:38.414 --> 00:14:38.634 Right. 00:14:39.034 --> 00:14:41.096 Government has a down to a dollar figure 00:14:41.236 --> 00:14:43.538 in its four thousand three hundred twenty 00:14:43.558 --> 00:14:45.721 dollars and some odd cents per day that 00:14:45.740 --> 00:14:46.782 these guys aren't operational. 00:14:46.822 --> 00:14:48.123 OK, so they track this. 00:14:48.182 --> 00:14:48.363 Right. 00:14:48.403 --> 00:14:49.803 And they look at the cost of not 00:14:49.823 --> 00:14:51.245 being ready and they know. 00:14:51.426 --> 00:14:53.527 And so there's huge incentive to get these 00:14:53.547 --> 00:14:55.089 guys back to duty quickly. 00:14:55.969 --> 00:14:57.370 And every one of these guys has to, 00:14:57.390 --> 00:14:59.533 no matter what service you're in, 00:14:59.552 --> 00:15:01.254 they have to be able to pass some 00:15:01.274 --> 00:15:03.136 sort of operator fitness test, right? 00:15:03.457 --> 00:15:04.619 And every branch is a little bit different 00:15:05.038 --> 00:15:06.701 to be on status to be operational. 00:15:06.740 --> 00:15:08.363 And so if they can't pass that due 00:15:08.383 --> 00:15:09.484 to pain, due to whatnot, 00:15:09.725 --> 00:15:10.645 they don't get to go, right? 00:15:10.725 --> 00:15:12.006 And then they start costing money for the 00:15:12.027 --> 00:15:12.368 government. 00:15:12.768 --> 00:15:13.067 And so... 00:15:14.044 --> 00:15:15.326 the intent for us was like okay how 00:15:15.346 --> 00:15:17.226 do we get these guys back right now 00:15:17.586 --> 00:15:19.447 when you look at you know it's basically 00:15:19.488 --> 00:15:21.629 sports specific PT we have this whole 00:15:21.669 --> 00:15:23.071 battery of tests we can use for a 00:15:23.110 --> 00:15:24.692 lower extremity injury right like I hurt 00:15:24.731 --> 00:15:26.332 my knee um you know I can look 00:15:26.352 --> 00:15:27.653 at hop testing I can look at Y 00:15:27.693 --> 00:15:29.014 balance I can look at all these different 00:15:29.034 --> 00:15:30.676 metrics say okay you're ready to go okay 00:15:30.716 --> 00:15:32.197 you've passed this let's put you in the 00:15:32.216 --> 00:15:34.057 test let's make sure you're set same with 00:15:34.077 --> 00:15:36.139 the upper extremity right but the question 00:15:36.198 --> 00:15:37.840 is like they already told us our biggest 00:15:37.860 --> 00:15:39.000 problem is spine related issues 00:15:40.352 --> 00:15:42.214 what return to sport testing is there for 00:15:42.335 --> 00:15:44.615 spine related issues, right? 00:15:44.655 --> 00:15:45.256 Nothing, right? 00:15:45.297 --> 00:15:46.317 And so what we started to do was, 00:15:46.378 --> 00:15:46.597 okay, 00:15:47.018 --> 00:15:49.419 let's see if we can use directional 00:15:49.460 --> 00:15:53.623 preference as a performance metric to get 00:15:53.643 --> 00:15:54.043 them back. 00:15:54.264 --> 00:15:55.484 Because what we were doing is we were 00:15:55.504 --> 00:15:56.684 defaulting back to more of this 00:15:57.145 --> 00:15:58.886 traditional pathoanatomical diagnosis. 00:15:58.907 --> 00:15:59.807 They come in, we say, hey, 00:15:59.827 --> 00:16:00.989 you got a grade two, 00:16:01.009 --> 00:16:02.149 you got a grade one or two lumbar 00:16:02.168 --> 00:16:02.450 strain. 00:16:03.090 --> 00:16:04.051 you know you're going to be shut down 00:16:04.091 --> 00:16:05.832 about three weeks to six weeks depending 00:16:05.852 --> 00:16:07.355 on the severity of it right well now 00:16:07.375 --> 00:16:09.456 what we've done is okay let's put you 00:16:09.476 --> 00:16:11.558 through our exam right we do a basic 00:16:11.700 --> 00:16:13.380 ompd exam looks nothing different than 00:16:13.421 --> 00:16:15.003 anybody else going to do and then we 00:16:15.043 --> 00:16:16.625 throw in this repeated movement testing 00:16:16.664 --> 00:16:18.466 with it and if they exhibit directional 00:16:18.506 --> 00:16:20.708 preference we actually use that as their 00:16:20.749 --> 00:16:22.751 guideline to if they're ready to return 00:16:22.792 --> 00:16:24.352 back to duty right and so 00:16:25.114 --> 00:16:25.955 We know that, like we said, 00:16:25.995 --> 00:16:28.998 directional preference is moving them in a 00:16:29.038 --> 00:16:30.899 specific direction that reduces pain, 00:16:30.938 --> 00:16:32.860 that decreases their pain and improves 00:16:32.880 --> 00:16:34.542 their function. 00:16:34.562 --> 00:16:36.063 So what we've done is we've basically 00:16:36.104 --> 00:16:37.725 broken down component movements of their 00:16:37.884 --> 00:16:39.486 fitness tests that they have to pass. 00:16:40.246 --> 00:16:41.067 And once they come in, 00:16:41.128 --> 00:16:42.328 if they exhibit directional preference, 00:16:42.509 --> 00:16:43.509 we get the pain resolved, 00:16:43.730 --> 00:16:44.931 we get the mechanics restored. 00:16:45.818 --> 00:16:48.820 We then go test specific parts of that 00:16:48.860 --> 00:16:49.159 test. 00:16:49.179 --> 00:16:50.600 And if they pass that without a 00:16:50.640 --> 00:16:52.880 reproduction of pain or a loss of 00:16:52.900 --> 00:16:54.542 function, we green light them. 00:16:54.861 --> 00:16:56.523 And we've been tracking the data now for 00:16:56.582 --> 00:17:00.323 four years and we're getting our guys back 00:17:00.344 --> 00:17:03.105 to duty about thirty six percent faster 00:17:03.565 --> 00:17:05.506 than we were four years ago. 00:17:05.645 --> 00:17:05.786 Yeah. 00:17:06.086 --> 00:17:07.826 I mean, it's you know, it's upwards of, 00:17:07.866 --> 00:17:10.047 you know, eighteen to twenty two days. 00:17:10.146 --> 00:17:10.287 Right. 00:17:10.307 --> 00:17:11.587 And so you can times that number. 00:17:11.607 --> 00:17:11.768 Right. 00:17:12.208 --> 00:17:13.890 So, you know, so in that same tent, 00:17:13.910 --> 00:17:15.270 cause these programs cost the government a 00:17:15.290 --> 00:17:15.810 lot of money. 00:17:15.911 --> 00:17:16.872 So it's like, okay, 00:17:16.912 --> 00:17:18.333 how do we incentivize to keep these 00:17:18.373 --> 00:17:18.713 programs? 00:17:18.733 --> 00:17:19.513 Cause they're so valuable. 00:17:20.035 --> 00:17:20.355 Um, 00:17:20.375 --> 00:17:21.955 but they have to demonstrate some sort of 00:17:21.976 --> 00:17:23.477 value, right? 00:17:23.617 --> 00:17:24.878 Now I'm going to make you think an 00:17:24.979 --> 00:17:26.519 answer bigger, no pressure, 00:17:27.200 --> 00:17:30.163 but if the profession did a better job 00:17:30.242 --> 00:17:31.864 leveraging directional preference, 00:17:32.285 --> 00:17:33.526 what could change you? 00:17:33.546 --> 00:17:34.946 That was my question that was queued up 00:17:34.967 --> 00:17:36.607 a minute ago, but you sort of, you're, 00:17:36.847 --> 00:17:37.969 you're putting numbers to this. 00:17:37.989 --> 00:17:38.309 You're like, well, 00:17:38.329 --> 00:17:39.871 if these guys are four grand a day, 00:17:40.050 --> 00:17:40.090 um, 00:17:41.048 --> 00:17:42.951 It might be smaller if you're just a 00:17:43.010 --> 00:17:44.231 podcast host, right? 00:17:44.251 --> 00:17:45.573 But to me, that's a lot. 00:17:45.613 --> 00:17:47.795 So what would you imagine or how would 00:17:47.835 --> 00:17:49.316 you explain it to a student if the 00:17:49.336 --> 00:17:50.958 profession did a better job leveraging 00:17:51.038 --> 00:17:51.417 this? 00:17:51.938 --> 00:17:53.559 Man, what would that look like? 00:17:55.099 --> 00:17:55.641 Yeah, I mean, 00:17:56.801 --> 00:17:58.064 I guess I'll say the caveat, right? 00:17:58.104 --> 00:17:58.584 So, you know, 00:17:59.105 --> 00:18:00.366 a little bit of bias here, right? 00:18:00.386 --> 00:18:01.627 Because I teach for the Institute. 00:18:03.190 --> 00:18:04.070 I'm going to put that out there. 00:18:04.090 --> 00:18:05.272 But, you know, I think, 00:18:05.373 --> 00:18:06.413 like I tell all my students, I say, 00:18:06.433 --> 00:18:07.154 you know, 00:18:07.174 --> 00:18:08.616 this method works for me because it makes 00:18:08.636 --> 00:18:09.258 sense in my head. 00:18:09.618 --> 00:18:10.660 It doesn't mean you need to do this 00:18:10.700 --> 00:18:11.201 method, whatever. 00:18:11.721 --> 00:18:14.102 framework works for you that that you want 00:18:14.122 --> 00:18:15.522 to implore your patients that you can 00:18:15.603 --> 00:18:17.844 that's that's evidence-based do it all i 00:18:17.864 --> 00:18:19.263 encourage people to do is yeah just put 00:18:19.304 --> 00:18:22.025 in repeated movements and identify if you 00:18:22.065 --> 00:18:23.766 can look for directional preference based 00:18:23.806 --> 00:18:26.948 on these criteria because if you do i 00:18:26.988 --> 00:18:28.448 mean a patient is going to get better 00:18:28.667 --> 00:18:31.009 i mean when you look at there's again 00:18:31.048 --> 00:18:32.509 you look at the guidelines it's still a 00:18:32.529 --> 00:18:33.750 to b level evidence so there's a high 00:18:33.790 --> 00:18:35.730 level evidence for this right nice part 00:18:35.750 --> 00:18:37.692 about it is a lot of it the 00:18:37.731 --> 00:18:39.012 patient is able to do independently on 00:18:39.032 --> 00:18:39.313 their own 00:18:39.853 --> 00:18:40.073 Right. 00:18:40.452 --> 00:18:41.693 And so you're starting to build this 00:18:41.733 --> 00:18:43.054 self-efficacy for the patient. 00:18:43.273 --> 00:18:44.515 You're starting to empower the patient. 00:18:44.595 --> 00:18:45.535 Right. 00:18:45.555 --> 00:18:46.674 To be able to treat themselves. 00:18:46.694 --> 00:18:48.296 So we're looking at decreasing, you know, 00:18:48.336 --> 00:18:49.895 more chronic related problems. 00:18:49.915 --> 00:18:50.997 We're going to look at decreasing 00:18:51.057 --> 00:18:52.576 recidivism of problems because they're 00:18:52.596 --> 00:18:53.396 self-managing it. 00:18:53.477 --> 00:18:53.656 Right. 00:18:54.258 --> 00:18:55.657 The cool part about the system, too, is, 00:18:55.837 --> 00:18:55.998 you know, 00:18:56.097 --> 00:18:58.338 it's this cause and effect check recheck 00:18:58.979 --> 00:18:59.278 system. 00:18:59.338 --> 00:18:59.538 Right. 00:18:59.778 --> 00:18:59.939 I mean, 00:18:59.979 --> 00:19:01.559 patient tries to bend forward and they got 00:19:01.599 --> 00:19:02.559 pain shooting on their leg. 00:19:02.579 --> 00:19:03.560 They do repeated movements. 00:19:03.621 --> 00:19:04.540 Also, they bend forward. 00:19:04.921 --> 00:19:06.260 Hey, it's not my leg anymore. 00:19:06.480 --> 00:19:07.882 You think the patient's happy or not? 00:19:08.021 --> 00:19:08.241 Right. 00:19:08.483 --> 00:19:09.955 they can feel an immediate change. 00:19:10.608 --> 00:19:12.170 And you don't have to create much buy-in 00:19:12.210 --> 00:19:13.030 for that, right? 00:19:13.451 --> 00:19:15.613 And so one, the ability to, 00:19:15.673 --> 00:19:16.794 like we're demonstrating to accelerate 00:19:16.814 --> 00:19:19.537 recovery, but two, to empower the patient, 00:19:19.557 --> 00:19:20.537 to decrease recidivism. 00:19:20.576 --> 00:19:21.858 So we're looking at decreasing overall 00:19:21.878 --> 00:19:22.659 healthcare costs. 00:19:22.679 --> 00:19:24.461 We're looking at decreasing overall 00:19:24.480 --> 00:19:26.201 chronicity of problems and more downstream 00:19:26.221 --> 00:19:27.542 related issues that we know are so 00:19:27.563 --> 00:19:28.423 associated with that. 00:19:28.483 --> 00:19:30.726 So I think there's power in it, right? 00:19:31.606 --> 00:19:33.087 If, and like I tell everybody, I'm like, 00:19:33.188 --> 00:19:35.009 just put it in, you do you, 00:19:35.029 --> 00:19:36.090 but just throw it in your exam, man. 00:19:36.230 --> 00:19:37.251 And you will start to see, 00:19:37.592 --> 00:19:38.712 you'll start to see change, right? 00:19:39.093 --> 00:19:40.334 and then you just see what that fits 00:19:40.354 --> 00:19:43.257 within your own treatment system if you 00:19:43.277 --> 00:19:45.078 could leave clinicians we'll do your we 00:19:45.098 --> 00:19:46.921 call it the wow your words of wisdom 00:19:46.961 --> 00:19:48.682 if you could leave clinicians with one 00:19:49.663 --> 00:19:52.005 shift in how they think not just what 00:19:52.045 --> 00:19:54.347 they do as much kool-aid as you want 00:19:54.367 --> 00:19:56.849 in this answer that's that's allowed after 00:19:57.170 --> 00:19:59.432 this episode what would it be what would 00:20:00.093 --> 00:20:01.453 one shift in how they think that you 00:20:01.473 --> 00:20:03.115 would you would suggest not just in what 00:20:03.135 --> 00:20:04.156 they do but how they process 00:20:04.977 --> 00:20:06.017 You know, I think the biggest thing, 00:20:06.076 --> 00:20:06.278 you know, 00:20:06.298 --> 00:20:06.917 and I try to do this all the 00:20:06.938 --> 00:20:08.518 time is be open-minded, right? 00:20:08.538 --> 00:20:11.339 Understand that one thing doesn't fix 00:20:11.400 --> 00:20:11.980 everything, right? 00:20:12.019 --> 00:20:13.160 If there was one thing to fix everything, 00:20:13.180 --> 00:20:14.121 we'd all be doing the same thing. 00:20:14.141 --> 00:20:14.340 Sure. 00:20:14.601 --> 00:20:15.721 There's all these different things out 00:20:15.741 --> 00:20:16.122 there, right? 00:20:17.162 --> 00:20:18.442 But we tend to be closed off and 00:20:18.482 --> 00:20:20.303 have our own confirmation and internal 00:20:20.323 --> 00:20:21.044 biases, right? 00:20:21.263 --> 00:20:22.523 Hey, I did all this training, 00:20:22.544 --> 00:20:23.525 so I'm going to do this, right? 00:20:24.385 --> 00:20:26.826 be open-minded, try other things, 00:20:26.866 --> 00:20:27.147 you know, 00:20:27.188 --> 00:20:28.688 that hopefully have some level of evidence 00:20:28.708 --> 00:20:29.249 behind them, 00:20:29.528 --> 00:20:31.789 fit them in your system because, you know, 00:20:31.829 --> 00:20:32.651 there's value in what I do, 00:20:32.671 --> 00:20:34.551 but I take so much from everybody else 00:20:34.592 --> 00:20:34.912 as well. 00:20:34.932 --> 00:20:35.992 I'm like, okay, how does this fit in? 00:20:36.053 --> 00:20:36.532 Oh my gosh, 00:20:36.952 --> 00:20:38.233 this was the last little piece I needed 00:20:38.253 --> 00:20:39.974 to help this population that I've 00:20:39.994 --> 00:20:40.434 struggled with. 00:20:40.454 --> 00:20:42.957 So, you know, obviously I'm biased. 00:20:43.037 --> 00:20:44.376 I'd say take a course, try it out, 00:20:44.416 --> 00:20:44.557 but, 00:20:45.577 --> 00:20:46.478 be open-minded about it. 00:20:46.518 --> 00:20:48.239 Don't, don't just throw it out because, 00:20:48.278 --> 00:20:49.239 Hey, I did a couple of these things. 00:20:49.278 --> 00:20:49.759 I tried it once. 00:20:49.818 --> 00:20:50.298 It didn't work. 00:20:50.838 --> 00:20:51.920 Understand a little bit more, 00:20:52.000 --> 00:20:53.359 understand it's more complex than what 00:20:53.380 --> 00:20:54.019 people might think. 00:20:54.059 --> 00:20:55.220 It's not just simple, straightforward, 00:20:55.580 --> 00:20:57.861 forward bends or backward bends and, um, 00:20:58.040 --> 00:20:58.961 explore a bit more, right? 00:20:59.000 --> 00:21:00.521 Cause you will see, you will see change. 00:21:00.541 --> 00:21:01.321 Uh, 00:21:01.781 --> 00:21:02.882 what would some of those things that 00:21:02.922 --> 00:21:04.303 you've tested and tried and, and, 00:21:04.462 --> 00:21:05.542 and taken some things from, 00:21:05.603 --> 00:21:06.942 this is where you can throw out just 00:21:07.002 --> 00:21:07.663 names of courses. 00:21:07.683 --> 00:21:08.884 We're not saying you're endorsing them, 00:21:08.923 --> 00:21:10.243 but what are the things that you've tried 00:21:10.263 --> 00:21:11.484 that you're like, Hey, I've tried these, 00:21:11.525 --> 00:21:12.884 these different flavors of Kool-Aid I've 00:21:12.904 --> 00:21:13.144 drank. 00:21:13.815 --> 00:21:14.954 Yeah, I mean, 00:21:14.974 --> 00:21:16.076 the nice part about the government is they 00:21:16.096 --> 00:21:17.115 like to spin us up on everything. 00:21:17.155 --> 00:21:18.576 So if there's something out there, I mean, 00:21:18.935 --> 00:21:20.836 you know, I've been through BFR, you know, 00:21:20.856 --> 00:21:22.116 I've been through dry needling. 00:21:22.156 --> 00:21:22.356 You know, 00:21:22.396 --> 00:21:23.678 I'm a I'm a strong first kettlebell 00:21:23.698 --> 00:21:24.157 instructor. 00:21:24.198 --> 00:21:25.597 I went through my USAW search. 00:21:25.617 --> 00:21:25.897 You know, 00:21:26.898 --> 00:21:28.999 my fellowship had a Maitland and Saruman 00:21:29.019 --> 00:21:29.638 flavor to it. 00:21:29.699 --> 00:21:29.959 Right. 00:21:29.979 --> 00:21:31.720 So I do look at some MSI stuff. 00:21:32.839 --> 00:21:33.059 You know, 00:21:33.140 --> 00:21:35.280 I did take a master's in medicine. 00:21:36.796 --> 00:21:37.936 orthopedic manual therapy that was more 00:21:38.017 --> 00:21:40.778 osteopathic based right so you know 00:21:40.798 --> 00:21:42.059 there's all kinds of stuff out there and 00:21:42.079 --> 00:21:43.401 that's why i know this other stuff works 00:21:43.441 --> 00:21:45.862 right um but sometimes you know i know 00:21:45.882 --> 00:21:47.942 prior to i was probably before going 00:21:47.963 --> 00:21:49.483 through a lot of that training and being 00:21:49.505 --> 00:21:50.785 around these other highly skilled 00:21:50.805 --> 00:21:52.546 clinicians i was a little closed office 00:21:52.626 --> 00:21:53.727 you know and i would just shut other 00:21:53.747 --> 00:21:55.107 things down like no that's not right but 00:21:55.127 --> 00:21:57.509 yeah there is such an application i think 00:21:58.049 --> 00:21:59.792 the more and more you you get better 00:21:59.833 --> 00:22:01.335 at your craft the more you recognize hey 00:22:01.454 --> 00:22:02.936 these other things do work you know it's 00:22:02.957 --> 00:22:03.938 like every time i go to am and 00:22:03.978 --> 00:22:05.380 i'm i'm learning so much from all these 00:22:05.400 --> 00:22:07.663 other people right and um like okay i 00:22:07.682 --> 00:22:08.765 can definitely see what that fits within 00:22:08.825 --> 00:22:10.988 my system and why that would work but 00:22:11.008 --> 00:22:11.749 then at the end of the day i 00:22:11.769 --> 00:22:12.971 think if we're just nice to our patients 00:22:12.990 --> 00:22:14.373 a lot get better too so you know 00:22:15.461 --> 00:22:16.561 We need a course on how to do 00:22:16.582 --> 00:22:16.801 that. 00:22:16.882 --> 00:22:17.162 Josh, 00:22:17.182 --> 00:22:18.143 you're going to lead that course on how 00:22:18.163 --> 00:22:19.144 to be nice to our patients. 00:22:19.463 --> 00:22:21.005 This is one of the reasons you just 00:22:21.045 --> 00:22:22.546 highlighted without me having to ask, 00:22:23.246 --> 00:22:25.008 why do we sit down with microphones and 00:22:25.048 --> 00:22:26.709 put these things on YouTube and share them 00:22:26.729 --> 00:22:27.509 and let them... 00:22:27.528 --> 00:22:29.170 This is outside of membership as well as 00:22:29.590 --> 00:22:31.751 this is show more than tell what the 00:22:31.791 --> 00:22:32.772 value of membership is. 00:22:32.792 --> 00:22:34.233 You're looking at a snapshot of Josh here, 00:22:34.253 --> 00:22:34.334 but... 00:22:34.775 --> 00:22:36.375 Someone like Josh goes to Aometer as a 00:22:36.435 --> 00:22:38.458 member because they understand the value 00:22:38.478 --> 00:22:38.958 in those things. 00:22:38.978 --> 00:22:40.038 And those things are intangible. 00:22:40.599 --> 00:22:42.480 I try to make this as tangible as 00:22:42.500 --> 00:22:43.862 a podcast or a video could be. 00:22:43.922 --> 00:22:45.884 Make it as tangible as you can because 00:22:45.903 --> 00:22:47.365 that's where the value, in my opinion, 00:22:47.525 --> 00:22:50.106 really is. 00:22:50.267 --> 00:22:50.366 Right. 00:22:50.386 --> 00:22:50.567 Awesome. 00:22:50.586 --> 00:22:51.928 Well, hey, Josh, appreciate the time. 00:22:52.388 --> 00:22:52.848 Hurry up. 00:22:52.969 --> 00:22:53.730 Get back to work. 00:22:54.150 --> 00:22:55.691 You're costing the government some money. 00:22:55.711 --> 00:22:56.731 Get some people back. 00:22:57.252 --> 00:22:58.594 And we appreciate your time here on Hands 00:22:58.673 --> 00:22:59.314 On, Hands Off. 00:22:59.334 --> 00:23:00.494 Hey, thank you so much. 00:23:00.515 --> 00:23:01.256 It was a pleasure to be here.