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Episode 35: Therapeutic Movement Through an Anti-Fragile Lens
943 Plays1 year ago
Welcome to Episode 35 of the Movement Logic podcast! In this episode Laurel sits down to talk with an old friend and colleague Dr. Caitlin Casella, DPT. In their conversation, Caitlin shares about her journey from yoga teacher to movement teacher to physical therapist. Laurel and Caitlin get into a multi-faceted discussion around the goals of rehabilitation, and how unfortunately sometimes the rehab process can fall short in fully preparing people to get back to the activities of their life after injury. Laurel & Caitlin discuss why this happens, and then ways that Caitlin works to help her patients better bridge the gap between rehab and getting back to the activities that give their lives meaning.
You will also learn:
- What exercise intensity is and how, as a physical therapist, Caitlin gauges the appropriate intensity for her patients, which tends to be a lot higher than they expect!
- What the concept of graded exposure is and how it’s both similar and different from the concept of progressive overload.
- What it means to see the human body through an anti-fragile lens.
- How the beliefs people have about their joints like “I have bad knees” or “there will be wear and tear” has made people afraid of exercise and rehab modalities like strength training and impact loading.
- How Caitlin works with two types of people: those who get hurt because they did too much too soon, versus people who get hurt because they are deconditioned.
- That working with some level of pain is better than movement avoidance, a sedentary lifestyle, and the deconditioning that brings.
- How Caitlin motivates patients to get moving even with some amount of pain.
Caitlin’s PT clinic in NYC Practice Human Physical Therapy
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Transcript
Caitlin's Journey: From PT to Practice Owner
00:00:00
Speaker
Hey folks, Laurel here. I am popping in before the episode starts my talk with my dear friend and colleague Dr. Caitlin Cassella because we recorded this episode last year a long time ago. I don't actually even remember when. And since recording this episode, Caitlin has taken a big leap
00:00:23
Speaker
in opening her own physical therapy practice in New York City. In fact, when I interviewed her, she was a PT on staff at the clinic and has since bought it and is now running it herself. The name of the clinic is Practice Human. It's an interdisciplinary studio in the Nomad neighborhood on West 27th Street. If you're in New York City, definitely check it out. We'll link her PT clinic for you to check out in the show notes.
Introducing Movement Logic Podcast
00:00:52
Speaker
Welcome to the Movement Logic podcast with yoga teacher and strength coach Laurel Beaversdorf and physical therapist Dr. Sarah Court. With over 30 years combined experience in the yoga, movement, and physical therapy worlds, we believe in strong opinions loosely held, which means we're not hyping outdated movement concepts. Instead, we're here with up-to-date and cutting-edge tools, evidence, and ideas to help you as a mover and a teacher.
00:01:29
Speaker
Welcome to the Movement Logic Podcast. I'm Laurel Beaversdorf and I'm here with a very special guest, Caitlin Casella. Caitlin is a physical therapist as well as a multidisciplinary movement teacher. Her offerings include and have included yoga asana, various contemplative practices, strength training, self-massage, and somatic practices. Of course, now she is a physical therapist applying rehabilitative movement practices
00:01:56
Speaker
for her patients. In her bio, Caitlin writes that her aim is therapeutic, and it is to make movement physically accessible to the general population and more widely available to folks across socioeconomic backgrounds. She strives to educate about the science of the human body while making space for the unknown. Of all the movement teachers out there, my path most closely aligns with Caitlin's.
Caitlin's Multidisciplinary Movement Approach
00:02:18
Speaker
I first met Caitlin when we were doing our 300-hour teacher training together in New York City, I think it was back in like 2007 or 2008, and we spent many years working together as teacher trainers. We followed similar paths in terms of teaching interests even. We both started teaching self-massage around the same time. We offered self-massage and restorative yoga workshops together, and Caitlin and I collaborated on her teacher continuing ed, Crossfade.
00:02:43
Speaker
We've even completed many of our prerequisite requirements for PT school together. Caitlin ended up following through and becoming a PT and I, I had a baby. Needless to say, I'm really looking forward to this conversation with my movement nerd sister from another Mr.
Caitlin's Transition from Theater to Physical Therapy
00:03:00
Speaker
Caitlin Casella. Thank you for joining me today, Caitlin.
00:03:03
Speaker
Thank you, Laurel, and thank you for that introduction. It's great to talk to you. Yeah, as always. So let's start off with telling or sharing a little bit about how you got started teaching yoga and then made this transition to teaching, and I'm going to use air quotes here, movement, and then transition to teaching or rather practicing physical therapy. Give us a little timeline.
00:03:30
Speaker
review. Okay. So the history is I well, I've always loved to move. I was like a very physical child outdoors all the time. Just like till the street light came on. I was out there. I was in the yard. I was like skating around the block.
00:03:49
Speaker
I loved as a kid, like did gymnastics for a while, did various dance disciplines, but never got really deep into either. I just kind of did it for fun and for interest. And when I started to get into theater, I gravitated towards the style of dance classes that were not so much to be a dancer, but to be a good mover on stage. And so I loved like tap and modern and rolling on the floor, kind of contact improv stuff.
00:04:17
Speaker
I came to New York City for theater. I ended up majoring in theater for set design. But all the while I was doing yoga classes all over New York City back in the day when we had that class pass, class book thing that was on paper. I remember that on paper where you could go to classes all over the city. So I became kind of enamored in exploring multiple styles of yoga at the time in New York. And it was a very different yoga world.
00:04:47
Speaker
then this was like 1999 to 2003 when I was an undergrad and then when I graduated I got a desk job at a design firm and it was intense, intense
00:05:04
Speaker
Hence
Yoga as a Refuge and Career Transition
00:05:05
Speaker
hours at a computer doing design illustration on a computer, I developed all kinds of pain and discomfort and issues in my back and my neck and my wrist and my eyes. And I would sneak away from that work to go to yoga classes that felt really fulfilling and
00:05:27
Speaker
nurturing for me at the time in the physical aspects, but also just in the, um, the aspects that allowed me to kind of settle and, um, Center myself at the end of really long days. Um, and that's sort of what took me from the desk job that I, I hit a point where I just couldn't really tolerate it anymore. And I saw what my bosses were doing and I thought, Oh, that's not really what I want to be doing. So there was nowhere for me to go with it.
00:05:55
Speaker
And that's when I did my yoga teacher trainings and started teaching yoga. And yeah, and had a pretty amazing, fulfilling career at that, traveling and teaching yoga teacher trainings. And I'm super grateful for all of that. Yeah, yeah. It really wasn't. But it ran
From Yoga to Physical Therapy: New Challenges
00:06:17
Speaker
its course. And I hit a point where
00:06:21
Speaker
I became less interested in yoga asana or the limitations that I felt, the constraints and limitations that I felt were put upon me within the studio and the training system that I was teaching in. I kind of had a reckoning where I felt like I wasn't
00:06:42
Speaker
holding that practice responsibly anymore in terms of focusing so much on the physical and weaving in other elements and into the physical practice and not teaching so fully the other facets of the practice. And I just was ready for something else, something different. And my body was ready for something different on a physical level.
00:07:10
Speaker
I feel really kind of privileged and resourced that I was able to make the pivot to fulfill my prerequisites for PD school, go to grad school for physical therapy at that time, because it felt like it kind of saved me from having to figure out what to do next. It gave me a thing to do
Learning New Modalities in Movement
00:07:32
Speaker
next. Was it kind of like starting over or was it a continuation or an expansion of sorts? That's a good question.
00:07:40
Speaker
Oh, it felt like a starting over in that I felt like I had acquired like this blank campus that I could begin studying in earnest.
00:07:54
Speaker
multiple movement modalities from the source of those modalities. And what I mean is I pulled way back away from any kind of yoga hybrid movement systems. And I was like, if I'm going to learn kettlebells, I'm going to go to a strong first kettlebell trainer because I like that style of kettlebell skill training. And these people know it front to back.
00:08:17
Speaker
if I'm going to study somatics at the Feldenkrais Institute in New York. I think this is actually a conversation we had at one time. I remember there was a yoga with Feldenkrais class on the schedule.
00:08:29
Speaker
And at one point we had a little chat about that and I was like, I don't know if I really want to check that out necessarily. And I remember you agreeing and kind of saying like, yeah, I feel like if I was going to go learn Felton price, I want to learn Felton price and not the like hybrid that tries to bring that into a yoga asana practice as well. And so I.
00:08:47
Speaker
I started to embrace like, will you talk, I listened to your first episode and you're talking about digging a lot of shallow holes versus kind of going in and digging deeper holes and really learning the thing. So I did feel like freed from kind of this, I no longer felt like I had to incorporate everything I learned into yoga somehow, freed from the idea that I had to try to make yoga
00:09:15
Speaker
anything and everything and things that it actually is not to meet my needs. Um, and I felt like I could just kind of like explore totally different and new ways to stress my body, to move my body. Um, and like skill, skill acquisition is like,
00:09:35
Speaker
kind of, oh, I'm sure you've been through this, kind of a wild trip of like, just the motor patterns have become so ingrained and so familiar with yoga asana, kind of breaking out of those grooves, and moving in completely different ways, was like, kind of liberating and great for me. But then I also do still, to answer the other part of that question, I do still feel like I bring so many elements of the
00:10:02
Speaker
yoga practice with me into my treatment as a physical therapist and the somatic practice, like just a little bit more of the like contemplative. I could say mind body elements, but at this point I feel like mind and body are like to use those as separate words is doesn't really mean anything anymore to me to use those as separate words, but just kind of treating a whole system, energetic, emotional, behavioral, environmental, social,
00:10:32
Speaker
everything that's wrapped up in our physical neuromuscular skeletal being.
Are PT Exercise Prescriptions Robust Enough?
00:10:40
Speaker
That was a really wild answer. I loved it. I loved it, of course. So you transitioned out of just calling yourself a yoga teacher, but you did bring a lot of what you learned while practicing and teaching yoga with you into
00:10:57
Speaker
the multidisciplinary offerings and PT practice. And yes, we've had many conversations, Caitlin, all over New York City in many different contexts because we've known each other for so long. And I know we've spent a lot of time talking about physical therapy as we were both kind of on
00:11:18
Speaker
track to pursue education in physical therapy, doing our prerequisites together. I believe we've talked several times in different contexts around physical therapy exercise prescription. And, you know, I like to think a lot of, you know, I work with Sarah on this podcast, a lot of what she does is teach movement. She's also a movement teacher, but she's doing it through the lens of physical therapy and rehabilitation. But PT, specifically PT exercise prescription,
00:11:47
Speaker
the exercises that physical therapists give to their patients, or exercise programming within PT, how it isn't robust enough to create adaptation in the body.
00:11:57
Speaker
That, or it's not sufficient, to raise someone's tolerance threshold beyond what's required of minimum daily demand. What I'd love to do, because we're really big on defining terms on this podcast, is I'd like to ask you to give us your off the cuff definition of what robust means, what adaptation is.
00:12:19
Speaker
And then what do you mean by tolerance threshold? So yeah, that's three terms and I will remind you of them. So robust enough. So exercise prescription slash exercise programming within PT is often not, not always, but often not robust enough to create adaptation. What is robust enough mean and what does adaptation mean in this in this context? Yeah. So robust enough is entirely dependent on the individual and their history of exposure to various
00:12:49
Speaker
forces are there like loading history there what what forces of has their body and their tissues and their nervous system been exposed to in the past. Where are they on their rehabilitation journey meaning are they in a very kind of acute and painful and irritable stage of their recovery or they kind of like
00:13:10
Speaker
feeling pretty good and pain free day to day. But there are certain things that they have apprehension with or kind of fear of going back to doing some of the things that they have been doing before because there's some
00:13:22
Speaker
just hesitancy in terms of like maybe I'm going to re-injure myself or any number of things that just kind of happen early in the rehabilitative process. I think that's kind of like first to look at that and say like where is this individual at right now through that process. And then
00:13:43
Speaker
To create adaptation, we need to do something that is just a little bit beyond what the body's typically used to doing in day to day. So there are certain exercises early on that can just kind of facilitate trust of motion again that are very kind of low grade.
00:14:07
Speaker
mild exposure to forces so that the nervous system just says like like okay you've got this you can do this it's like testing out this is a thing that oh I thought that would hurt but actually I'm doing it now and it doesn't hurt it's like kind of overcoming some of this movement avoidance that might be sticking around that's pretty like
00:14:28
Speaker
like low threshold, low grade intensity. But it's trying out things that your body isn't used to doing or hasn't been doing in a little while. Once people get over that hump of apprehension because they think it might hurt and movement avoidance and their range of motions, pretty good. Their strength is pretty good for just getting through their daily demands. This is where
00:14:53
Speaker
things get a little tricky, I think, for physical therapists. Part of it, unfortunately, is that things get a little tricky in getting insurance to cover, taking people up beyond what's required of their daily activities. It's a problem. And it's important. And I feel like it's something that really our medical industry should be more interested in because it's a really key thing in preventing recurrence of injury or ongoing chronic
00:15:22
Speaker
problems.
00:15:25
Speaker
One piece of it is kind of hard to get into this next stage where we're doing exercise that's robust enough to raise this tolerance threshold. But I think it boils down to identifying what someone is going back to in their daily life once they're like fully back to doing all the things they had been doing pre-injury and saying, okay, they can get through all of that, no problem. But what if you have an exceptional day? What if one day you just end up having to do a lot more than you typically do in one day?
00:15:55
Speaker
What if you encounter some kind of situation where all of a sudden you're exposed to a lot more force or a lot more load and your body has been used to and hasn't experienced those kind of forces in a very long time. Right. I'm thinking of like things like air travel where you're going to be running across the airport with your heavy suitcases. Yeah. Things like your, you know, your child or your dog had to be carried for much longer.
00:16:23
Speaker
you move to a new, I don't know, location and you had to load up all your stuff in a truck. Yeah. That kind of thing. Yeah. Yeah. And these are the things that I hear again and again, when I take a history from a patient, when they show up in the clinic as well, I went on a bachelor weekend and I played a lot of sand volleyball, which I never do. A heavy duffle bag around the airport and you know, on and on and on.
00:16:49
Speaker
Yeah, things happen. Right. Yeah. And so I would love to see like all humans get to a place where, you know, they're kind of trained at a threshold that is higher. We provide a buffer, right? Right. Between what you need to get through your day to day and what you can withstand beyond that, that is not going to create a problem for you afterwards or right.
00:17:17
Speaker
So exercise prescription at a certain point, once they're past the acute and really kind of irritated stage of being in pain, right, needs to actually become more intense, more challenging, more effortful to build up their body's tissues. That's the adaptation part. So these exercises need to be robust enough or they actually need to challenge
00:17:40
Speaker
the body's tissues enough so that their tolerance threshold is actually above what their minimum daily demands are because there are days that are above the minimum, right? There are days that kind of stretch a little closer to the medium or the maximum, right? All right, cool, thank you. So I would love to know, like, are you able to, in the capacity that you provide physical therapy, are you able to
Helping Patients Build Resilience After Injury
00:18:11
Speaker
to work with that constraint with regards to physical therapy, how do you help your patients take that next step after that acute phase to know how to continue to build their bodies more resilient and to increase their capacity? Do you work with them directly? Do you refer them out? What do you do?
00:18:34
Speaker
And this is, again, it's like it varies based on what they have as their health care resources. And I mean, because I do work at a clinic that is in network with just to, you know, I feel like this context is kind of important. I work with a clinic that is in network with some insurance companies. We accept Medicare. We do see a lot of patients self pay.
00:18:58
Speaker
So it depends on what they get in terms of how far we can go to bridge this gap between their rehabilitation and PT and going back to much more intense activity if it's someone who is going back to that. What I strive to do with everyone, because I think it helps everyone bridge this gap, is to get them really well educated on an exercise program that they can do themselves and feel really confident doing themselves.
00:19:26
Speaker
And sometimes we get really creative with ways that they can do that just at home or with the things they have around the house or the things they have access to in their community. Some people have well-equipped gyms and know their way around the gym. But depending on those factors, I do try to get everybody some kind of program that is going to take them a little ways beyond the stuff that we're doing in PT.
00:19:49
Speaker
Um, you know, so like if we're kind of calming things down with some light resistance band exercises to get, get back some trust emotion, I don't want them to keep doing those light resistance bands exercises after about the second or third week. I want to start loading them up with just a little bit more force through their bodies. Um, so in the clinic, I do use a lot of weight. We have a cable machine that I make good use of. I use kettlebells a lot with my patients. Um,
00:20:16
Speaker
since the pandemic, a lot of people do have some resources at home, like some dumbbells that they can use and some things they can do to load themselves up a bit. So I make sure that they have like enough that they can do that's going to be challenging for them to get through like two or three sets of 10, you know. So that we're getting to that place where, I mean, I feel like so many
00:20:41
Speaker
therapeutic exercises or PT exercises are the kind of things that somebody could just like watch a show on Netflix for 30 minutes and potentially do that exercise for 30 minutes straight without a rest. It's like, if you're doing that, this is the wrong exercise for you, right? It's just not gonna do anything for you. It's a waste of everybody's time. And so I do try to get everybody to a place where I see them challenged in front of me.
00:21:09
Speaker
They know what it means to be challenged. Like they know what it feels like to do a bent over row and go eight.
00:21:19
Speaker
Ooh, nine, that was a little iffy. Oof, just squeezed out that 10th one. I don't want them to feel what that is, know it, understand it, and be able to recreate that themselves.
Role of Intensity in Exercise Adaptation
00:21:31
Speaker
Yeah, it's so funny that you mentioned watching something on Netflix. I've been thinking lately about intensity and how we know the different realms or stratospheres of intensity that we've entered into with regards to exercise. And I find that when my workouts are intense,
00:21:48
Speaker
whether it's weightlifting or running, I've started running again, kettlebelling, plyometrics, whatever it is, I can't listen to a podcast because I, on those last stimulating reps or whatever, when I start running faster for an interval, I stop listening. I don't have the cognitive capacity
00:22:05
Speaker
to be able to follow a train of thought, I actually can only think about what it is that I'm trying to accomplish in the moment, which is like completing the set or just keep running, right? So yeah, I think that this idea of exercise intensity being important, maybe we could talk a little bit about what intensity is actually. It's defined different ways. You know, I'm studying for the CSCS and I've seen intensity defined as
00:22:35
Speaker
Um, you know, proximity to a one rep max, right? So if you are your one rep max, this is theoretical amount. We've talked about this on the podcast, um, before, but it's a theoretical amount that you can lift one time and one time. Oh, it's a very heavy weight. And the closer you get to picking up a weight that is your heaviest possible weight, the higher the intensity, right?
00:22:55
Speaker
but intensity could also be defined for example speed training is the faster you're running the more intense right and and so in in terms of like what we're able to sense about the intensity of an exercise a lot of times it just comes down to our subjective experience like how hard do you feel that you're working a lot of times it's
00:23:13
Speaker
It's notated as like a one out of ten, right? Are you at a five? That's like right in the middle. Are you a seven? You're working pretty hard. Are you a nine? You're working really, really hard. You've stopped listening to the podcast, right? Intensity affects adaptation. Maybe we can talk a little bit about how do you find the right intensity for the person you're working with.
00:23:36
Speaker
It feels a little bit like, you know, first you got to get to know the person you're working with. You got to get to know their history of, you know, exercise and physical activity. And then when you're starting them off, like, how do you know what intensity is the appropriate amount to start off with? And how do you know to increase that intensity safely over time? How do you approach, you know, working with different individuals and exposing them to intensity?
00:24:05
Speaker
Yeah, that's a great question. I mean, I think I tend to do quite a bit of
00:24:12
Speaker
And we usually talk about graded exposure, meaning gradually progressing intensity or gradually progressing weight over the course of weeks to months to create adaptation. But I like to give my patients some graded exposure over the course of PT visit. So I will have them do an exercise with a fairly lightweight. So they've got a little bit of load that just kind of helps with sense of direction.
00:24:37
Speaker
say they'll do it they'll do an exercise five to ten times just to be like this is the motion prepare yourself like how does that feel is there anything alarming in terms of how how this feels is like very low intensity to just do a few to learn the motion um no feeling good okay we got it like you you understand that your body understands that motion like so like i think that's a little piece of adaptation too that
00:25:06
Speaker
gets overlooked is just the motor learning aspect. We think of it a lot as mechanically building up thickening tissues, building up muscle, things like that. But you're just kind of like demand on your nervous system and your skill training to learn it, learn the thing. So that's the first piece of it. And then once that starts to feel comfortable, people can start to feel comfortable with gradually increasing loads.
00:25:35
Speaker
So then I'll, you know, sometimes I'll take the weight up three times within a visit just to like give them a little bit of exposure to like this 10 pound dumbbell.
00:25:46
Speaker
lift that up off the floor, put it down now. How about this like 15 pound kettlebell? And then what about a 30 pound kettlebell? And then people really quite quickly will say like, oh, I didn't think I'd be able to lift that. I feel fine. That was great. They'll be kind of shocked that they can lift 30 pounds with one hand and be like, oh.
00:26:08
Speaker
I'm good. And then it's it's just like an entryway to say like, so so like, we're not going to hang back with that 10 pound dumbbell for like six weeks, you know, because I want to know within a visit, like, that looks too easy. Let's try this. Let's try this. Let's try this. And just give them a little bit more exposure to those higher forces earlier on.
00:26:32
Speaker
That's pretty cool. So there's a couple of questions I want to ask. First of all, this phrase of graded exposure, I find we hear this phrase a lot in the context of rehabilitation practices, but it sounds a lot to me like progressive overload. And I know that you know what progressive overload is. You obviously also know what graded exposure is. Maybe we could talk about how these two phrases terms are the same and how they're different.
Graded Exposure vs. Progressive Overload
00:27:01
Speaker
Hey everybody, Sarah here. Back in 2017, when Laurel and I started Movement Logic, we felt that movement teachers were being shortchanged by the available continuing education options out there, and we wanted to fill that gap. Now here we are five years later, and I'm very proud of the tutorials we've created so far.
00:27:19
Speaker
What's really exciting is, together with Jaisal Parikh, we're launching a free hips mini course video series for you. In the movement world, the hips and the SI joint get a ton of attention. But at the same time, we see loads of injuries and misinformation all over the place. So what's going on? Clearly, there's some sort of disconnect and an information gap happening.
00:27:40
Speaker
As some of you might know, I have had several hip surgeries, including a hip replacement about 10 years ago. I don't blame my yoga practice for it because there's a meaningful genetic aspect, but I certainly don't think that my years of deep hip openers particularly helped.
00:27:56
Speaker
in large part because the way I practiced leaned into my hypermobility instead of working on the stability and longevity that my body really needed. There's a lot of unlearning for a lot of us to do around things like hypermobility, SI joint pain, sciatica, yoga butt, and other hip-related concerns. So, with that in mind,
00:28:16
Speaker
Laurel, Jason, and I have created a free hips mini course video series for you, in which we address these topics and more, including gender bias and inclusivity, whether we store emotions in our hips, and why demonizing the SI joint is not particularly helpful.
00:28:33
Speaker
Right now, you can sign up for the free mini course. If you're interested in learning a more thoughtful approach to movement solutions for yourself and your students, the link to sign up is in our show notes. Or if you follow us on Instagram at movement logic tutorials, the link to sign up is in our bio. Graded exposure. I find we hear this phrase a lot in the context of
00:28:57
Speaker
rehabilitation practices, but it sounds a lot to me like progressive overload. Maybe we could talk about how these two phrases terms are the same and how they're different. Sure. Yeah. Yeah. So progressive overload, this is the way I know it and think of it is specifically dealing with like intensity of like wheat,
00:29:23
Speaker
or forces, whereas I can see graded exposure maybe applied more broadly or to other situations or other tasks and environments. And I think that kind of speaks to what I was saying about adaptation too, how I feel like graded exposure could capture any exposure to like any number of challenges to the system.
00:29:53
Speaker
Even like visual vestibular like motor and skill training. So you start with something simple and then you make it more complex.
00:30:07
Speaker
as opposed to just increasing? I mean, I guess, yeah, that's a good question, actually. Well, I was wondering, actually, let me run this by you and tell me what you think. So is graded exposure typically used in the context of rehabilitation, specifically in helping people to overcome painful experiences with movements, with particular movement scenarios? And so the idea is that you,
00:30:31
Speaker
you allow them to complete the movement or the task but maybe in like for example a different relationship to gravity where you've really off-loaded like the weight of the limbs somehow so that now when they go to raise their shoulder up like one example I've heard is like if someone has pain when they lift their arms straight up over their head
00:30:52
Speaker
an example of graded exposure might be to have them hold on to a pole, right? And then to squat down. So their arm is raised up overhead because their body is moving down and their hand is affixed to the pole. But actually you've completely kind of changed the emphasis on the neuromuscular patterning. But voila, look, your arm is overhead and there's no pain. And what you're then doing is maybe retraining
00:31:21
Speaker
their nervous system to perhaps not always predict that this position of the shoulder is going to result in pain. Because I think, and maybe you could speak to this, a lot of why we have pain has much more to do with our expectations than it does our ability to actually complete a movement or our body's biological health. We just expect the movement to be painful, and that actually brings on the pain.
00:31:51
Speaker
So graded exposure is, though, this incremental increase moving toward this real life task that would, in the past, provoke pain. But now we're trying to actually retrain maybe your body, your brain, to not feel that movement as painful. Progressive overload, and this is a way of loading the body. I mean, anytime you move on planet Earth, you're loading your body. But progressive overload is applied typically in strength and conditioning.
00:32:20
Speaker
And I feel like there's a lot of crossover because in progressive overload, we're also kind of.
00:32:25
Speaker
changing in gradually making something more difficult over time, but slowly. And we're exposing the body slowly over time to loads so that we adapt. I guess maybe the connection is that adaptation is change that takes place in our bodies. And there's so many different ways that we can adapt, not just by increasing bone density, increasing muscle force production,
00:32:53
Speaker
increasing, you know, tendon thickness or stiffness or whatever it is. But we can also adapt in terms of our pain response. Oh, yeah, definitely, definitely. Yeah, that's huge. So thank you for sharing how you apply graded exposure
00:33:14
Speaker
within the course of a PT session it reminds me so much of I know we both were trained to sequence initially yoga classes in a particular way where we would build up to a peak pose and it sounds a little bit like the way we would deconstruct that peak pose and then sequence the class from simple to complex starting with like lower, load, simpler movements that kind of
00:33:39
Speaker
were sort of similar in some components to the peak and then gradually over time kind of building students up to being able to do this more complex posture. It sounds a little bit like graded exposure now that I think about it. Yeah, yeah. Well, I think as you talk about that more, those are some great examples about just kind of like movements that provoke
00:34:00
Speaker
someone's pain symptoms and kind of finding another way in like I use the phrase sneaking in the back door a lot like you're just like kind of sneak into that motion but a different way. It also just makes me think about how like some of those things serve as just a really good
00:34:20
Speaker
entry point to progress things along a little quicker. So I think of my example of increasing from 10 to 15 to 30 pounds within a session, it's not like I think somebody got stronger to be able to progress from 10 to 15 to 30 pounds, but it's like, where am I starting? What is this person's capacity right now? And I'm mostly underestimating.
00:34:45
Speaker
this person's capacity right now and I think even for those like painful movements like I I kind of just like don't really let my patients be like
00:34:56
Speaker
I can't do that. It'll hurt. But can we find those ways in where it's like, look at you. You just did that. Did that hurt? No. Well, OK, there's a place to start. So it's like, can we find the starting point that is a little bit more used to use robust again, but a little bit more robust starting
Overcoming Exercise Fears
00:35:16
Speaker
point? Because I just I kind of see things through this anti fragile lens of like
00:35:24
Speaker
Let's assume that we're capable of more than we think. Yeah. Try it and see what happens. Right on. I mean, obviously like within reason of safety as a clinician.
00:35:38
Speaker
people's bodies can tolerate that after some evaluation and working with them over those first like acute weeks of rehab. But yeah, like I think people can find that they're capable of a lot more than they think. And I think there's probably a lot of trainers and therapists out there who
00:35:58
Speaker
could find that their clients are capable of more than they think, given just the right levels of entry points to then progress slowly and gradually from there. But you got kind of started a higher level sometimes, I think. Yeah, I totally agree. And I love how when we were talking through what graded exposure is, that we're exposing people to loads.
00:36:26
Speaker
and shifting those loads, maybe progressively overloading those loads over time, we're grading that increase. We're also potentially grading their exposure to what were in the past painful experiences movement-wise and showing them, showing their nervous system that see this is, it's safe here, it's safe for you to be here, but we're also grading exposure to the way they see themselves, the way they think about themselves. It's so interesting because it's all actually connected.
00:36:57
Speaker
And I think sometimes as maybe movement teachers and maybe even physical therapists, we get really potentially caught up in grading exposure for the purpose of affecting the tissues, but we're always
00:37:11
Speaker
we're always affecting everything else as well. And so the language that we use and the expectations we have and the assumptions we make as that second person in the room with that person, the way we reflect back to them, what we think they are capable of really matters actually as much as the cues we use and the exercises we choose. Yeah, yeah, for sure. I mean, and that's so big in kind of the chronic pain world too, is just getting that level of,
00:37:41
Speaker
confidence that like, I'm okay, I can do this thing, I'll be okay. Kind of get over the hump of a lot of that avoidance. That psychological element, that confidence is really key. Yes, absolutely. All right.
00:38:02
Speaker
So let's actually talk a little bit about confidence or maybe lack thereof. What are some of the fears that you've come across your people, your patients, your students having around exercise?
Debunking Exercise Myths
00:38:13
Speaker
Specifically, I'd love to talk with you about strength training and maybe impact loading. What do you notice people are worried about? Where do they feel like they and their capacity might actually fall short, not that their self-efficacy is perhaps a little bit lower than it
00:38:32
Speaker
than it should be. They can't see themselves lifting that weight. They can't see themselves engaging in that form of exercise. They're afraid. What do you notice about that? Well, I think there, I think there's a lot of myths out there about like wear and tear on the joints or
00:38:59
Speaker
Like, you know, there are certain activities that are seen as inherently risky or dangerous to our bodies.
00:39:11
Speaker
like running, for example, running, jumping, you mentioned impact loading. I think that's one that especially, um, as people haven't done it for a very long time, um, start to become a little more fearful of that. Uh, and also like, and lifting heavier weight, I think there's, there's definitely a little bit of a barrier there for some people to like see that, you know, I have patients a lot that are like, my dog is 35 pounds. I pick up my dog. And, and that is like a wiggly.
00:39:42
Speaker
squirming, awkward, load. And then I give them a 30-pound kettlebell and they're like terrified of like a hot kettlebell. So I think also people do a lot more in their day-to-day than they realize. But then somehow when it's framed in like a deliberate exercise context, they start to become fearful that they're gonna hurt themselves for any number of reasons. And also just like a lack of confidence in like,
00:40:10
Speaker
I'm probably not doing this right. My alignment is bad. My form is poor because I don't know what I'm doing. You know, these are like the kind of things I hear that get said a lot by patients. And then especially I think patients who are working with osteoarthritic changes
00:40:31
Speaker
hear phrases like oh it's bone on bone and you know like some of these like these language that is pretty fear inducing um and a lot of times just inaccurate and inaccurate and um and not helpful for for instilling that kind of confidence that someone needs to really get going with more robust exercise um and then and then also just you know i tried to dispel those myths with some of my patients that
00:40:59
Speaker
You know, things like, like low or running. I can't run as bad for my knees. I have bad knees. Uh, Oh, this is a wear and tear on my joints that, you know, there's been a lot of recent research that has shown that, that people who are exercising and exercising at very high intensity levels.
00:41:16
Speaker
that doesn't create any further degeneration of cartilage, that sedentary people have just as much osteoarthritis as active people, and oftentimes, actually, I mean, when you exercise, there are a lot of other health risks that are averted, there are a lot of other benefits, and ultimately, it tends to be
00:41:40
Speaker
better for decreasing pain and increasing function and independence if someone is exercising despite the fact that they have some pain from arthritis in their knees or whatever it is that they're working with. Absolutely. Absolutely. It's a net gain. It's a net gain. Totally. Totally. So a couple of things. One is it may be the case that people
00:42:05
Speaker
do get back into exercise. And, you know, maybe it's the person who played sports in high school, and then they decide to join an intramural league and play some basketball, right? And they end up injured, right? That's a different situation.
00:42:24
Speaker
than the person who has it in their mind already pre-programmed that any type of impact loading is dangerous, right? These are like two different issues. One is the myth, right? That impact loading is inherently dangerous. Or maybe it's strength training, right? Lifting heavy weights. Sure. Something other than pink 2.5 pound dumbbells, right? That's pink. Always pink.
00:42:53
Speaker
or, you know, running is dangerous because the wear and tear. It's different than somebody who actually makes an effort to start exercising, but then actually legitimately ends up in pain. And I'm sure that you've come across both of these types of people. I mean, I know I have. It's a little bit of the case of, in the second example, too much too soon.
00:43:20
Speaker
Where we just kind of jump in to the class at the gym or the pickup game of basketball, whatever it is. And actually, yes, that was a little bit or a lot more than you were ready for.
00:43:33
Speaker
And so this kind of goes back to our conversation around progressive loading and the importance of maybe starting kind of pulling back a little bit and starting with a lower intensity versions of that eventually higher intensity work, which is kind of what you're doing with your patients in the PT clinic, right? The ones who are athletic.
00:43:56
Speaker
who are injured, who come to you, who want to get back to that athletic activity again. Maybe they're runners, right? Competitive runners. You've got to take them from that place of getting out of acute pain to that level of robustness that's going to put them back doing the thing that gives their life meaning. I find it easier to work with those folks, right? Because they don't necessarily have fear
00:44:24
Speaker
They might not understand that they did too much, but then you talk to them and you realize that was a lot. You never hike, but then you went hiking for two hours. That was a lot. But it's harder to work with the folks who just
00:44:43
Speaker
have been told so many times in so many different ways, both subtle and overt, that exercise is dangerous, that various forms of exercise are dangerous. How do you address those types of fears? That's what I love to hear, because I find it very challenging.
Motivating Rehabilitation Through Loved Activities
00:45:02
Speaker
And this isn't a one-on-one context because we're both active on Instagram You know, we both have our soap boxes on social media where we're we're trying to spread the good news of exercise Right and like empower folks on a you know on that platform but like actually how do these conversations go one-on-one with folks who you you get the sense that like they actually have this this belief that
00:45:24
Speaker
about something about their body, about their body's capability, about exercise, some form of exercise in general. How do you go about addressing those fears? I think it all, for me, for working with patients who are either fearful or just unmotivated to do more, it really boils down to
00:45:48
Speaker
What in your life do you love doing that you can't live without? What do you want to keep doing for a long time? Good question. And how do we get you there? Because ultimately, people do not care about, oh, I can do split squats with two 18-pound cymbals.
00:46:10
Speaker
Yeah. But yeah, like, like, I hear you any split squats and it doesn't hurt my knees as much as it used to. What they care about is like, I mean, high work with patients in New York City.
00:46:25
Speaker
It's a demanding place to live physically to get through your day to day. If you want to go out in the world and do things, you have to walk city blocks. You got to climb stairs to get up and down a subway. If you want to go to that show or that museum or that event in that place, like not everything here, unfortunately not everything here is accessible. Like sometimes you've got to go up,
00:46:51
Speaker
five steps to enter the building. There are major physical barriers in a lot of places here, and there are a lot of folks
00:47:00
Speaker
living in fourth floor walk-ups. I mean, I have patients in their later 80s who live in third and fourth floor walk-up apartments. And if they're going to maintain their independence to live in that space and go up and down those stairs, that's a pretty motivating factor for those folks to understand. If you can do this many 12-inch step-ups,
00:47:26
Speaker
It's a lot more than your typical step, right? You're going to fly up those three flights of regular stairs that you have to go up and down three times a day, you know, and you can do it with groceries, right? Yeah. So like if you can do it holding these kettlebells, you can you can get up the stairs with your groceries and that's going to feel easy. And it's going to continue to feel like something that you can do and feel competent, successful doing and do with without pain or and I just kind of want to add this to the conversation or with
00:47:55
Speaker
minimal pain with the understanding that, you know, some people will have pain. Yeah. And to do exercise, despite the fact that it causes some pain, like we talked about with net gain, for a lot of people, that's preferable to avoidance, deconditioning, and going toward a more sedentary lifestyle.
00:48:17
Speaker
Right, because your life becomes smaller. Actually, I wanna follow up with that statement that you just made that, in fact, some people will just have pain in a second.
Normalizing Pain in Human Experience
00:48:25
Speaker
My question to you, Caitlin, first of all, I love that when I asked you about how you address people's fears around movement or exercise, that your first question was, what do you love the most and what can't you live without? What really positive way to spin that
00:48:45
Speaker
and to start really seeking out from people what they love and care about rather than what they're afraid of. In fact, I think that's like the best way to address fear is to just change the conversation and talk about love. Well, how do people ever come here? They say that this thing is more important than that fear I'm experiencing.
00:49:11
Speaker
And if I'm ever going to move forward and do that important thing or take that next step, I'm going to do it or I'm not either. The fear wins or I do the next thing. So, um, yeah, you train, you train. I see you in the gym, um, on Instagram. I know you're very active person. So Caitlin, my question is what, what do you love? What can't you live without? Why do you train? Why are you doing split stance lunges with 18 pound dumbbells?
00:49:37
Speaker
I am loving my training right now. I'm having a lot of fun with it because I do it in very short bursts of intense exercise. I think you had sent out an email recently about how you can get it in in 20 or 30 minutes. And for me, that is so preferable. I love my gym, but I do not love to spend 90 minutes at the gym.
00:50:05
Speaker
I don't know how people do that. I spend other time at home doing supplementary things I love to roll on the floor. Anybody who's ever looked at my Instagram knows that I roll on my living room floor a lot and make videos of it. I don't do the down regulating, stretching, cool down type stuff at the gym.
00:50:30
Speaker
I go in, I do a quick warm up, I get into pretty high level of intensity workout pretty quickly. It takes maybe 20 minutes of that intense period until I'm doing some kind of finisher that pushes me right to that end of what I can do until I'm like done my basement or my gym is two basements down, high concrete steps. And I know I did it when like,
00:51:02
Speaker
There's like just enough in the tank to get up those two flights of the stairs to exit the gym and get up. I'm in a fifth floor walk up. So then I've got another four flights to get home.
00:51:17
Speaker
And like, I know I've like done it when I, you know, I have just enough to, to get myself home and you know, then I chill out for a second and I'm feeling good. And I'm like, okay, that was, that was my workout. So, you know, like I get it in, oh no, it's just twice a week at that intensity. For me, that's perfect. Yep. Yeah. It's a week, 20 minutes of intense workout. You're an embodied person. You have been your whole life and you've made careers out of your own, you know, interest in embodiment.
Caitlin's Love for Intense Workouts
00:51:46
Speaker
And so, would you say you work out because you love to work out? Or are you actually working out?
00:51:53
Speaker
for that thing that you ask your one-on-ones, what do you love the most? What can't you live without? Because for them, maybe, the idea is that we're working out so that you can continue to do what you love the most, whether it's live independently in your fourth floor walk-up, play with your grandkids, do the physical things of your life so you can really live your life in those physical moments. Do you work out because you love to work out? Or do you work out because you know that if you don't,
00:52:24
Speaker
You won't, you will suffer. Is it intrinsically motivating to work out or is it actually, is there some extrinsic motivation for it? For me, I work out because I love to work out, but I've only come to that in the kind of training I've done in the last maybe five or six years.
00:52:51
Speaker
I didn't use to love working out. I used to love, or I didn't, what I did for exercise, I didn't consider it working out. So I used to be more into like, it was really low loading. So it was like really long walks, lots of yoga asana. Um,
00:53:14
Speaker
like a little bit of like light string training with five and 10 pounds on bells. And I don't mean to say that that kind of tone to like demean that in any way for some people, that's exactly where they're at and perfect for them or a good place to start. Um, no weight shaming, but it felt like I was just, it all took a really long time. Yeah. I didn't never feel the kind of.
00:53:40
Speaker
energetic rush that you get or like the adrenaline rush or just all of the physiological things that occur when you do a more moderate to intense workout. I wasn't experiencing any of that. So I wasn't feeling those benefits. And I also wasn't feeling the benefits of my body. Like my body just kind of like hurt and ached all the time. Right.
00:54:07
Speaker
So then it wasn't until I started to do these shorter, more intense, more heavily loaded workouts that I started to love the way it felt in the moment, like I crave it. Love the way I feel afterwards and the next day. Love the way I feel in those other daily activities that I love and want to keep doing forever because I feel more
00:54:32
Speaker
comfortable and keepable and powerful and like I feel powerful. It's the feeling you're left with. And it's also the feeling of like putting on just like really loud pop music. You know it's like I think there's something very um
00:54:52
Speaker
nourishing or therapeutic for me and that's that I need that like as an outlet sometimes or just like to throw some like heavy medicine balls around. For me it's like a little bit of like working out some aggression I'll be honest when I go and do those workouts too.
00:55:09
Speaker
It just helps me be a little more steady and even the rest of the time if I can get a little bit of that out at the gym. Hallelujah. I agree. I'm working with a personal trainer right now and I did some medicine ball slams and his comment, he's doing remote personal training with me, his comment was, that was violent. I was like, yeah, it was violent. All right. I want to go back to my follow-up question with regards to your statement of some people will just have pain.
00:55:38
Speaker
And so my understanding is, in terms of our understanding of pain, is that before, or I'll just talk about my understanding of pain, before I thought,
00:55:53
Speaker
Pain is just something you shouldn't have. It's not normal to have pain. And you should do everything in your power to get rid of it. And if you can't get rid of your pain, there's something wrong with what you're doing. You're doing it wrong, right? Something is wrong. But now I'm hearing more and more from my conversations with Sarah, but also just
Approaching Pain with Curiosity
00:56:16
Speaker
listening around the edges to what people like yourself, physical therapists,
00:56:20
Speaker
are saying about pain, which is that no, actually, sometimes you just have pain. And actually, it's normal to have pain. And I find this statement, maybe five years ago, I would have thought what that's, that's like giving up. That's not that that's not that's not, you know, a positive approach to eliminating or banishing pain. But actually, now,
00:56:50
Speaker
having lived a little longer and worked with my own pain and worked with people who have pain popping up here and there. My husband, for example, has some pains that pop up here and there. My understanding that it's normal to have pain, what that means to me is that we don't need to catastrophize.
00:57:12
Speaker
and we don't need to maybe feel shame or we don't need to feel bad that we have pain because actually that just makes it worse, that it's actually normal to be in a human body and have pain in this life.
00:57:28
Speaker
And I find it actually kind of a relief, not saying that we should do nothing about it and not try to get ourselves out of pain, but that we don't need to try to be perfectly out of pain all of the time. And I find that those days when I do maybe have a little bit of achy, painy, twingy stuff showing up in my body, that when I remember that
00:57:49
Speaker
Yes, this is normal to have pain because maybe I did a little bit more than I usually do yesterday, and it will pass. It will be okay. It helps me not catastrophize and make maybe a mountain out of a molehill, but I understand too that some folks actually have a great deal of pain on a regular basis, and so I can't speak for them, and I'm sure that it's not great to have to feel that pain on a regular basis, but I'm wondering if you could speak a little bit to this almost, I feel like,
00:58:18
Speaker
mentality that is becoming a little bit more prominent now that we don't need to try to be perfectly pain free all the time and we don't need to catastrophize pain. Some people just have pain. Can you speak to that a little bit? Yeah. It's something I work with patients a lot in the clinic is, first of all, I encourage
00:58:47
Speaker
I encourage a variety of language and words to be used to describe pain, right? So like we use clinically a pain scale of 0 to 10, 0 is no pain, 10 is worst possible, a natural pain. Totally subjective, totally fluctuates day to day, totally depends on like
00:59:07
Speaker
what happened five minutes before you walked into that session, like what your mental state is like, right? I have a nine out of 10 pain today. You know, like, yes, you were experiencing nine out of 10 pain. That is layers of so many other factors that are creating that assessment for yourself right now, what your pain level is. And that's real, right? But it's so variable based on so many other factors.
00:59:34
Speaker
I really encourage my patients to pay attention to trends with activity and how they would describe in their own words what those sensations are because they're not always pain. There are a lot of bodily sensations that happen with exercise, with physical stress, with other layers of other stress in our system that
01:00:04
Speaker
Some people are like, no, it's not pain. It's discomfort. It's uncomfortable. It's whatever words they choose to use.
01:00:15
Speaker
what are those words for you and how does that behave in your life? What is the behavior of your pain, whatever you're naming it from day to day from one activity to the next? That's where we start. And then can we start to like have a dialogue about how those activities change your pain to make it or whatever you're calling it? I kind of like to think of
01:00:40
Speaker
like spice levels. I use good references for a lot of things because I like to cook. It's like it's like mild, medium, spicy. Is that like a habanero? It's also, you know, is it like a mild roasted jalapeno right now? It gives it a little more delight to the descriptors. Right. I love it. You're flipping it, man. I have a runner who their thing they can't live without and they love so much is running. Yeah. And
01:01:09
Speaker
They find that they can typically run five to six miles, but some days in that fifth, like after that five mile mark, it's like that, that mellow jalapeno that came on at three miles is like intensifying to like pretty spicy. Yeah. And then we started to talk about like, how long does that linger after your run? How quickly do you recover from that?
01:01:35
Speaker
Does that impede on any of the other activities you wanna do later that evening? Does it make it painful to sit around and watch TV and go to bed that night? Do you feel it the next day? Does it affect your run two days later? If someone reaches like a certain level that they're comfortable running with to complete that run and get home and they recover well from it,
01:02:04
Speaker
It's not impeding on any of their day-to-day activities. It's not intensifying two days later when they run again. If it's like got this steady state that they know well and understand,
01:02:19
Speaker
And they're like, I'm, this is happening and I'm cool with running despite this pain that I feel. I'm like, all right, good for you. Cause again, it's this conversation of like the net benefits of having that thing they do that they love. That is a great means of exercise. It's readily available to them. Um, all the reasons that that was good for their system, uh, outweigh like dealing with this little bit of.
01:02:44
Speaker
discomfort or intensity that arises at certain points in the run. So, I mean, that's just like one example, but you've got to apply that, I think, to a lot of other scenarios, like come to know it, describe it in your own words, and kind of have a relationship with it. Yeah.
01:03:02
Speaker
that lets you still do the things you love to do. It's like this character in your life. Yeah. And it doesn't necessarily have to be a terrifying character, right? Right. Right. It's just something you are actually curious about. Curious about. Yeah, that's a great way of putting it, for sure.
01:03:16
Speaker
I love that. I mean, just reflecting back to you, just some of the approaches that you take, I find are very positive and very rich in this curiosity provoking type, joy provoking questions that you ask to get more information, but also to maybe shift people's mindsets toward things like their body, their capacity, their ability, their pain,
01:03:46
Speaker
So, thank you for sharing yourself and your approach and your knowledge and this wonderful information with me today. I have one more question for you, well two more actually, and it can be related to anything, but what are you really excited about right now in your life?
Life in NYC Post-Pandemic and Patient Work
01:04:05
Speaker
Anything you want to share?
01:04:09
Speaker
That's a hard question. I don't know why. I mean, it's like, which things? There's a few things. I mean, well, related to this conversation, like I said, I am excited about the way that I'm training at the gym and the types of patient populations I'm working with and the work I'm doing with my patients. I'm also really excited about
01:04:36
Speaker
by life in New York right now. And since we've come through the pandemic, can't say we're out of the pandemic, but the ways I've kind of seen this city shift and I've been here the whole time and I've been with it the whole time, I am really loving and embracing the freedom that New York offers and has always offered to just kind of like walk out the door,
01:05:02
Speaker
meet up with people, see friends, be exposed to new things, try new things, go to events that expose me to ideas and whatever that I like haven't been exposed to before. So I guess I'm just kind of like re-exploring and rediscovering the city as it's constantly shifting, especially shifting so much throughout
01:05:25
Speaker
the pandemic and the phases that it's gone through here. I'm also really excited to not be in school anymore. Because that was rough at the end during the pandemic. Because we're all on Zoom, right? Yeah. A lot of Zoom you. Zoom you. As you know, a lot of prerequisites before that, it's very stressful.
01:05:54
Speaker
um, the way
01:05:57
Speaker
school and degrees and clinical doctorates are structured and this could be like a whole other conversation. There's just so many layers of stress wrapped up in all of it that were so unnecessary and so I'm really excited to be through it and working and feeling really like autonomous in my work at the clinic and I feel super fortunate to work where I work and with the people that I work with that I can
01:06:25
Speaker
treat the way I treat with other people who their philosophies really align with mine in terms of treatment and rehabilitation. And yeah, it's good stuff. Fantastic. Well, thank you. And final question, where can people find you and learn from you?
01:06:44
Speaker
My website is my name, CaitlinKosela.com. And then there's also Dotham Physical Therapy, which is the clinic where I'm treating here in New York City right now. And we're right in Midtown Manhattan on 27th Street.
01:07:00
Speaker
Fantastic. Thank you so much, Caitlin. It's been such a pleasure speaking with you. Thanks, Laurel. Good to talk to you. A note to you listeners that you can check out our show notes for links to references we mentioned in this podcast. And you can also visit the MovementLogic website, www.movementlogictutorials.com, where you can get on our mailing list to be in the know about sales on our tutorials.
01:07:23
Speaker
And finally, thanks so much for joining us on the Movement Logic podcast today. It helps us out if you did like this episode. Please subscribe. And then also rate and review in iTunes. We would be super appreciative of you if you would do that. Join us again next week for more Movement Logic and more of our loosely held opinions and strong muscles or strong opinions loosely held.