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30: Mastering Physical Literacy with Dr. Chris Raynor, MD
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Mastering Physical Literacy with Dr. Chris Raynor, MD
Welcome to Episode 30 of the Movement Logic podcast! In this episode, Sarah is joined by Dr. Chris Raynor, orthopedic surgeon, sports medicine specialist, and founder of Human 2.0, an integrated healthcare and fitness facility in Ottawa that holds a “Movement Is Medicine” philosophy.
Sarah and Chris discuss how he managed to avoid surgeon stereotypes, why avoiding pain at all costs is not the answer, how to determine if surgery is the right approach, PLUS your Instagram questions answered!
- The difference between discomfort and pain, our tendencies to interpret all pain the same way, and the need to better interpret this “low level language” to make better movement choices
- Whether myofascial manual techniques are really making as much difference as we think they are
- How and when he steers patients away from surgery and towards strength and mobility work instead
- The frustrations he faces with non-musculoskeletal doctors who instill fear of movement in their patients through their own lack of knowledge
- How the conservative world of orthopedic surgeons is slowly changing with the newer generations to emphasize mobility and strength for themselves and their patients
StableKneez (Dr. Raynor on Instagram)
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Transcript
Embracing Pain as a Guide
00:00:00
Speaker
Some people think that they should have no pain ever. Like in any amount of discomfort is ridiculous pain. And that's just unrealistic. Again, pain is not necessarily the enemy. It's always the messenger and sometimes pain is your friend because it's telling you where you need to spend more time.
Introduction to Movement Logic Podcast
00:00:21
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yoga, movement, and physical therapy worlds, we believe in strong opinions loosely held, which means we're not hyping outdated movement concepts.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.
Guest Introduction: Dr. Chris Rayner
00:00:56
Speaker
Welcome to episode 30 of the Movement Logic podcast. I'm Dr. Sarah Cort, physical therapist, and I am here with my very special guest, orthopedic surgeon and sports medicine specialist, Dr. Chris Rayner. Dr. Rayner is co-founder of Human 2.0 in Ottawa, an integrated healthcare and fitness facility that holds a movement is medicine philosophy. They offer a wide range of interventions and resources, including orthopedic evaluations, physical therapy, group training,
00:01:25
Speaker
corporate wellness and as I personally was delighted to find a mobility practice geared towards motor heads like myself so that we are best prepared for the physical demands of riding a motorcycle. In essence, Dr. Rayner and his wife Amanda are running the kind of PT practice that many in the US would love to work at with physical therapists, massage therapy, strength training. Typically in this country, in the US, when there is a doctor overseeing a facility like this, it's called
00:01:53
Speaker
physician-owned physical therapy services. And these practices live in an ethically ambiguous space, as there are concerns around physicians practicing referral for profit, essentially upselling types of PT treatment following surgery to increase their own personal income.
Ethical Concerns in Orthopedics
00:02:11
Speaker
But what Dr. Rayner is doing is different. When patients come to him for an evaluation,
00:02:16
Speaker
He may well discourage surgery in favor of a movement-based intervention that asks a lot more compliance and discipline from the patient, which already puts him in a whole different category than a lot of orthopedic surgeons out there and is why I wanted to interview him.
00:02:31
Speaker
Today we're talking about surgeon stereotypes, how to determine if surgery is the right approach, strength and mobility training, plus your questions from Instagram answered. So Dr. Rainer, thank you so much for coming on the Movement Logic podcast. We really appreciate it. Not a problem. Thank you very much for the invitation. I often say to people, I'm amazed.
00:02:53
Speaker
anytime anybody wants to hear me speak. I'm very opinionated, but yeah, I'm amazed and I'm humble that people would like to hear what's inside my head and think that it's of value. So I greatly appreciate the invitation and thank you very much.
00:03:11
Speaker
It's our pleasure. I kind of just want to jump right in with this. I want to address the stereotypes that a lot of movement teachers, yoga teachers in particular, have sort of come to believe about orthopedic surgeons and what their mindset is.
Dr. Rayner's Evolving Practice
00:03:25
Speaker
Here we go. Number one, orthopedic surgeons only want to do surgery because when you have a hammer, everything is a nail. Number two, orthopedic surgeons don't think that physical therapy can help or help enough
00:03:40
Speaker
And I have personal experience with this. I found it surprising. Number three, they don't think, orthopedic surgeons don't think pain can be relieved with movement, let alone with strength training.
00:03:51
Speaker
And then number four, they're resistant to changing their opinion about any of these things. So you don't seem to be any of these things. And I'm wondering if you ever were. If you were, what changed for you? And if not, how did you develop your career and your practice so that you were able to create something like human 2.0? Obviously, I was a classically trained orthopedic surgeon.
00:04:15
Speaker
And when I went through the program, I learned to have a relationship with physical therapy that most other orthopedic surgeons do. What I have discovered once I went into practice myself was that there were shortcomings in that sort of classic relationship with that classic model.
00:04:38
Speaker
and that I needed to make some changes. I'm very much a problem solver and so if something is not working or I don't like the way that it is working, I think how can I change this and how can I make this better? My current stance on orthopedic surgery versus physical therapy stems from a combination of things. So some of my classical teaching
00:05:02
Speaker
but also my experience afterwards as an orthopedic surgeon in the classical model and disappointment with the results that patients would get.
Innovative Patient Rehabilitation
00:05:12
Speaker
It also stems from my own experience as a patient of orthopedic surgery.
00:05:17
Speaker
and seeing what things worked, what things didn't work with post-operative rehab and how I could do things to make myself either rehabilitate better or faster. In addition to that, my experience as a personal trainer and a fitness coach
00:05:34
Speaker
And then finally, my experiences as a multidisciplinary musculoskeletal care facility owner, right? So our facility human 2.0 is, as you mentioned, it covers a gamut of services. And when I first came to
00:05:59
Speaker
to decide to open that facility, I did it out of frustration. And so the classical teaching is I'm an orthopedic surgeon, I do surgery. And then when the surgery is done, I hand them over to you, physical therapists. And I don't tell you what to do. I go ACL reconstruction, physical therapy, go. And then you do your thing. They come back to me for follow up and I monitor their progress.
00:06:23
Speaker
And then at the end, once I've deemed them appropriate for discharge and return to sport or return to their activity, then I discharge the patient. So that was the model that I learned and so that's what I did. And when I first came out in the first couple of years, you know, I'm learning my craft and I would send people out and at that time I was doing
00:06:44
Speaker
a crap ton of ACL reconstructions. So this applies to many different surgeries and procedures that I do, but ACLs was this thing I was doing a ton of at that time. And I would see the whole spectrum of people who respond, and some people would respond well, some people would respond poorly. You know, I recognize that as a surgeon, I'm learning my craft, and so not every single operation is going to be, or technically perfect.
00:07:09
Speaker
But there were times when I would look at a case, I'd review the notes and I'm like, I'd look at the x-rays, everything, everything about that case was perfect. When I left that OR, that person had a cool range of motion. The knee was stable and extension stable and flexion. And then I followed that patient up and they would get substandard results. The knee is stiff. I'm like, what is going on? And so I just kind of would file that in the way of the back of my brain and I'd carry on. Just keep saying to myself, I gotta get better, I gotta get better.
00:07:38
Speaker
But then after doing that for a few years, I start to notice patterns, you know, cause then I ask people, what are they doing for physio? They tell me, and then I'll say, oh jeez, they're really not doing much. And they show me their little sheet of exercises. And I'm like, this is not enough, man. This is not, this is like, this is bad. So then I started to make little changes and I would write on the physiotherapy requisition. Okay, ACO reconstruction, they need to have active physiotherapy exercises, no modalities, blah, blah, blah.
00:08:08
Speaker
there was a marginal improvement, marginal improvement. And then, you know, but I'd still keep asking people. And so then they'd tell me and I'm like, God, I need to be more specific. So then I would write, you know, active, progressive exercise therapy, no modalities, no machines, flexibility, blah, blah, blah, strength, blah, blah, blah. And I would be like, I'm right out of page. And I was doing this all the time. And it slowly got better, but it still wasn't enough. And I kept coming home complaining. And my wife,
00:08:37
Speaker
got sick of me complaining, and then one day she said, you know, stop complaining, do something about it. I'm like, you know what, you're damn right, I'm gonna do something about it. And I'm not thinking that I know more than a physiotherapist, I don't want to tell them how to do their business, but I want my patients to have a good result. And part of this is selfish, because if I do a technically sound surgery, my patients have a good result, that looks good on me, right? And I don't want to do a good surgery and then have them have a crappy result, and then people go, oh, he's a crappy surgeon.
00:09:06
Speaker
you know and I know that what I do for the surgery is like five to 10% of the rehabilitative process. The remainder is what they do afterwards, how compliant they are, what they're doing, what their level of determination is. So I finally said, okay, I got to open up this facility.
Non-Surgical Patient Care
00:09:25
Speaker
So I did that. And I had the great fortune when I opened my facility of hiring a trainer who was
00:09:33
Speaker
doing a lot of CrossFit, but then he was kind of switching over from CrossFit to Mobility. And he was my head trainer. And he opened my eyes to sort of the mobility world. I was like, wait a minute, like this is what you guys are doing. This is what you're doing for the fitness people in our class. But this stuff, I could use this for my patients. How will we start doing some of this over here for the patients? We'll scale it down.
00:09:58
Speaker
because they're a rehabilitation and they're not training or elite training. We'll scale it down to their level, but let's do these same things. Started to do that and started to see results. And I was like, oh my God. Then the light bulb went off. It's like, hey, I gotta think differently about what I'm doing. So that kind of led me along this path that I'm on now, focusing on a mobility-based approach to health, wellness,
00:10:25
Speaker
rehabilitation and performance training. You know, I'm in the midst of probably about 80-90% done for a course that I'm putting together for physios called Apex. And it's going to cover all of these principles. But in my
Emotional Management in Medicine
00:10:42
Speaker
mind,
00:10:43
Speaker
Rehab training, performance training, they're all the same thing. I do, because in our realm, in my realm, we do all the same thing. I don't care. I have professional NFL players, NBA players. I have Olympians that train with us. And then I have the average people who work out with us or the average competitive athletes that train with us or work out with us. We do the same thing for everybody.
00:11:08
Speaker
We either scale it up for the people who are elite or we scale it down for the people who are rehabbing. But we do the same thing for everything, for everybody. And so now in my mindset, I played high level of football, varsity football, and then I went to the CFL in Canada. So our version of the NFL, it was very short lived, mind you, but I went to the show as a competitive athlete. Like everything's about training and how to improve your performance.
00:11:34
Speaker
And so in my mind, everything is a sport. And I don't care whether the sport is for grandma who's 95 and she just wants to be able to get down on the floor and play with her grandkids. That's her sport. I look at everybody as an athlete and I'm going to make every athlete the best damn athlete for their sport that I can.
00:11:55
Speaker
So in my mind, surgery is just one part of this spectrum and it's only one of the tools. There are so many other non-surgical tools that we can do either pre or post surgery.
00:12:10
Speaker
or to avoid surgery in some cases, my experience in all those different areas has kind of led me along this path that has made me think differently than my colleagues. And I know that I'm a little bit of a unicorn in orthopedic surgery, but there are two things that let me know that I'm on the right path. And we've had our facility
00:12:32
Speaker
facility. This is going into the eighth year. So number one, when I was training, I didn't get along with all of my instructors. So all of the, the senior surgeons that were teaching us, and there was one, um, in particular, he and I are like mortal enemies, right? It's like, if I see him on the street, it's on, right? And so that guy, and he, he doesn't like me and I don't like him, but because I'm, my office is the gym, I'm seeing patients that come in
00:13:00
Speaker
Some of my patients go there, but they're not all my patients. There are lots of other patients from all across the city. We're a city of a million, and there's like 60 orthopedic surgeons in town. There are times when patients will be in there, and the therapist may ask me a question, which is another one of the benefits of being in this multidisciplinary place. They can just directly ask me a question because I happen to be there, even though it's not my patient. So they'll ask me questions all the time. And I started to notice, every once in a while they'd ask me a question, they'd say,
00:13:30
Speaker
Oh, this person had a knee replacement and it was done by a surgeon, so and so. And I'm like, but I know, I don't like him, but I know exactly what he wants and I know what he expects. And I'd say, oh, well, you know, this is, I trained under him and this is kind of what he would do. And I started to notice that more and more we're seeing patients from him. And if he will go to the extent to take his patient
00:13:55
Speaker
that he wants to get a good result for and send them to his entity to get that. That tells me we're doing something right, right? So that was number one. That's the first thing that lets me know that I was doing something right. And then for the first several years that we were open,
00:14:13
Speaker
Lots of orthopedic surgeons knew about my place and they were like, oh, what are you doing? Like, why are you spending money doing that? Well, you should just buy a cottage and blah, blah, blah. And they thought, it's a dumb idea, dumb idea, right? Like, why would you do that? Because we are not like the United States. And so there is this ethical gray zone of owning a place like this and nobody wants to get involved with that. However,
00:14:40
Speaker
Just at the tail end of COVID, on the other side of town, a group of five orthopedic surgeons from another hospital just put up a place. It's not fully identical because they haven't completely drunk the Kool-Aid. It's 80% the same.
00:14:59
Speaker
as our place. And I'm like, oh, I thought you guys thought I was stupid before. But now they're kind of, because the results speak for themselves. Surgeons, not only the guy that I don't like, but there are other surgeons that they send their problems to us, right? And why would they do that? Because they get better. It's like, oh, they've been over here, been treated, things haven't worked. Let's send them over to Chris's place and oh, now they get better.
00:15:27
Speaker
So both of those things tell me that it's a very, you know, tacit approval from the community that some people are starting to sort of see the light. Yeah. And we're seeing that. I mean, I'm seeing that here in Los Angeles as well with different surgeons that have sent me patients or just relationships that I've sort of built over the years.
00:15:53
Speaker
By the time that you have people that come to you, let's say for an evaluation, they've come to you potentially for surgery. Whereas it seems to me like your approach a lot of the time is to help people who don't need or wouldn't benefit from a surgery to not do it and instead do the work that they would benefit from. What do you do when there's the opposite? You have someone who actually would benefit from a surgery, but they don't want to do it.
00:16:20
Speaker
When I was a junior resident, uh, I learned what, you know, are the appropriate surgical indications for different conditions. Right. And, um, so when I saw something, I remember a particular example. I saw a young man who had a fractured calcaneus and this was a young, healthy, active guy.
00:16:39
Speaker
And I said, yo, you need to get this fixed because and oddly enough, or interestingly enough, he was a motorcycle rider. He was riding a little beyond his limits on the street. He ended up offing his bike into the woods and he hit a tree and he was remarkably good, but just had this calcaneus fracture. And so I said, hey, you know, the surgical indications for this, like this needs to be treated operatively.
00:17:06
Speaker
And I remember trying to convince this guy, and he was a little bit of a hothead. And he was like, no, I'm going to be fine. I heal fine. Blah, blah, blah. And I remember trying to argue with him. And then I said, you know, he was in his late 20s. He said, oh, let me talk to your mother and all this kind of stuff. I was trying to convince him. And then I had, when I was giving report to my senior, he said, listen, our job as surgeons is to give people information.
00:17:34
Speaker
and try to steer them in an appropriate direction. But if not, then it's okay. And he said something that I always remember. He said, when you leave at the end of the day, what does your calcaneus look like? Is it your calcaneus? And he said, no. Your calcaneus is fine. Your leg is fine. You're just there to give information. And if they want this surgery, then you can help them.
00:17:57
Speaker
For people, there are people who come to me, I have both ends of the spectrum. I have people who are non-operative and they're convinced they need a surgery and I have to convince them otherwise. But there are people who I know they need surgery and they say, no, no, no, no, your surgeon, all you want to do is cut, cut, cut, cut. So I'm like, listen, I'm just here to give you the information.
00:18:19
Speaker
going to help to facilitate your journey to recovery, one way or the other. In my own personal opinion, this particular problem would require a surgery to help you get to where you want to be and the result that you want. But if you do not want that, I'm cool with that, right? Because at the end of the day, I'm going to walk home and I'm going to be fine. You can choose to do the non-operative route if you want, and I will support that, right? At some point, I'd say to people,
00:18:48
Speaker
whenever you are ready, this is elective surgery when it means you can elect to do it or not to do it. And so when you are ready, you will let me know because I don't want to take a patient against their will, try to convince them, have surgery, and then they have a complication and then it's like, oh, see, I told you. No, no, no, no, no, no.
00:19:12
Speaker
I'll say, look, this is what I think should happen. But if you are not for that, no problem. We'll treat it in whatever way I think is appropriate or whichever way it is that you want. And then when
Patient Perceptions of Pain
00:19:26
Speaker
you deem that that has failed and you want to proceed with surgery, you can let me know.
00:19:33
Speaker
I will say to those people, now, in the interim, if there is a deterioration of your condition, that will take your chance of success from whatever it may be, 90%, 85%, whatever, to say 55% or 40%. And so you should be aware of that.
00:19:52
Speaker
But they are the one who is in control. We have to obtain consent from them before we can take them to the OR. So my job is not to convince. My job is to provide information and then to support and guide them through their journey. Yeah. I think sometimes I was struck by what you're talking about as far as like, it's not my calcaneus, it's their calc. My calcaneus is fine, right? We walk away at the end of the day. I think one of the things that
00:20:20
Speaker
maybe all sort of clinicians in general compared to, you know, a lot of people who listen to this show are non-clinicians, but movement professionals, let's just say. And I think sometimes it can be sort of, we can, clinicians can be cast in a sort of uncaring light sometimes, but I think the really important thing for people to know is that you, I mean, the number of people that you see, the number of people that I, like, I can't take my people home.
00:20:46
Speaker
It's the fastest way to just burn yourself out and be left with nothing. I have had some interactions with patients that were very emotional for me during my junior career and even later on.
00:21:10
Speaker
Um, but the, you, you quickly learned that like on an average week, um, let me see, in my plaster clinic, I'll see 80 patients. In the average week I'll see, um, I will operate on 20 people and I will, um, see in the clinic or in emerge over 200, maybe 300, 200, 250 patients every week. Right. And, um,
00:21:38
Speaker
If I allowed myself to become emotionally invested in every one of those patients, I would be burnt out in a second. Not only that, I would not be able to do my job. People think this is very callous, but I will tell you,
00:21:57
Speaker
Um, I like when people, I'm very laid back. And I said to you before we started filming, what you see is what you get. I'm just, I'm just chill. I'm pretty relaxed. Uh, although I'm a type eight personality, but in inter like, you know, interpersonally speaking with patients, I'm very chill. Um, and I'm friendly and easy going with my patients in the clinic. Um, if I see them out on the street, whatever, right?
00:22:25
Speaker
The moment that I step into the OR and I shut the door, well not quite when I shut the door, but the moment that they've had their anesthesia and the drapes go up, done. I'm not interpersonally involved with anybody. I become a machine.
00:22:43
Speaker
and I have a technique and a process I have to go through and they just become another job to me. And the reason is because like I have to put those emotions away because I have the plan in place and I know what I'm supposed to do, but oh hey, I'm doing my plan and I'm hitting the femoral implant, crack. Oh, the femur breaks.
00:23:13
Speaker
Like I can't be going, oh, this dude is my friend. Like that, I now it's like, oh, I have a femur fracture. I got to figure out now how to take this elective case, which is now turned into a trauma case and figure out how to get this person the best result possible. Or if I'm in a trauma case,
00:23:36
Speaker
and we're doing dissection, boom, an artery. There's a cut artery. I don't have time to be emotionally invested. I need to become a robot for that. And it's like, oh, cut artery, pressure, plant, dissect, find the tear in the artery, repair the tear in the artery, get back on track, and do it in a reasonable amount of time so that this patient doesn't get an infection and they don't have a problem because of anesthetic.
00:24:04
Speaker
That means I need to be like very methodical, very analytical and very cool during that time. So I have this ability to put those things in a closet in the back of my mind during my procedures and what I need to. And then when I'm done and everything's good, I can open up the closet and human Chris can come back out and we're all good.
00:24:35
Speaker
Yeah, exactly, exactly. It's the sort of skill, it's a skill to be able to do that, I think, and I think some people find it easier than others. It's the same sort of skill that makes, I think, some people good in an emergency and other people not good in an emergency because your ability not to like run around freaking out and in fact just sort of like look at the facts of the situation and be like, okay, what needs to happen here right now?
00:25:00
Speaker
understanding the difference between that skill versus this idea that you then have no emotions whatsoever, ever, and you're just this robot surgeon. It's a challenge, I think. I've had orthopedic surgery and I have a hip replacement, and the person who did it is a brilliant surgeon with absolutely zero bedside manner, which in my experience has been many in orthopedics. Not all, not all, not all, but plenty.
00:25:29
Speaker
But I also myself was able to look at that situation and be like, well, do I want the person who is probably the best in this city of Los Angeles at this surgery doing it? Or do I want someone who's going to like stroke my arm? And I'm like, well, I don't need, you know, personally, I don't need the arm stroking. I need the like, you know, skill set.
00:25:51
Speaker
I think it just depends sometimes on people's people's needs and what they're able to you know how they're able to take care of themselves I do see and I've been thinking about this in particular more and more lately because I'm sort of seeing more and more of it I have patients that I see who have had surgery upon surgery upon surgery upon surgery not you know sometimes it seems like they're they're almost addicted to it or they only believe that surgery is the thing that's going to fix whatever's wrong and
00:26:19
Speaker
These are also then the patients that are not getting better with movement interventions, but I hesitate to think that the movement intervention is not useful because I'm using all of my tools. Sometimes it's people who've had multiple spine surgeries, but it's not limited to multiple spine surgeries. I have a couple of people that I work with. It's almost like the patient has come to believe that
00:26:49
Speaker
they are, for whatever, you know, physio-biological reason, a special case, and I don't mean that in a rude way, but like, there's something that's like, there's an asterisk next to them, and the only thing that works for them is surgery. None of this other, they've tried everything, and the only thing that gets them better is surgery.
00:27:06
Speaker
What's your take on this? Are there really, are there people out there who really need these multiple surgeries or is part of the problem this repetitive surgical intervention that may, you know, maybe not the individual surgery, but the collection of surgeries are creating maybe more problems in the end?
00:27:27
Speaker
So I think that the answer here or one of the answers stems back to something that you just mentioned for the last question and that what it is that we do as surgeons and how it is received really depends on what the patient's needs are. And it could be physical needs, i.e. surgical needs, but also psychological needs, right? And so I have some of these patients myself and every time I see them,
00:27:56
Speaker
their name on the chart like before clinic I like I die inside a little bit because I'm like oh my god they're back again like what now one of the things that I used to get crap for all the time as a resident is that I take too long with patients and this is for a number of reasons to make a long story short I had made a promise before I started I was never gonna leave I didn't want patients to ever leave my office and without understanding and without me giving them time so I allow people to
00:28:25
Speaker
the opportunity to speak, sometimes,
Unique Rehabilitation Techniques
00:28:29
Speaker
oftentimes to my detriment. But for these people, I will spend an inordinate amount of time trying to convince them, yo, you are not broken. There are other ways to deal with this. We can do this. You can try this. I just saw one yesterday where I said,
00:28:48
Speaker
You know, these are the non-operative measures that we can do. And all of these things, if you did these things and you committed to them, you would find that they would make a difference. But there's always an excuse why they couldn't. And they believe themselves to be special case. Oh, I tried this. I worked hard. And I'm like, well, what did you call worked hard? Well, I did this exercise one day.
00:29:11
Speaker
Like, bro, what do you think one day is gonna do for you? Like, I said, you need to do this, you know, four times a week and you need to do it consistently over six weeks for a change to even start. There are these people and I think it is, it just takes one person from a surgical standpoint to give in.
00:29:31
Speaker
to feed that belief. And then after that, the rest of us, including that surgeon, were done. Because then you've cemented that idea in their head. And then no matter what you say, for the most part, they're not going to believe. And yeah, it's tough. And I try to resist these people as long as I can.
00:29:52
Speaker
And I try to convince them to go the non-operative route. But the other aspect of it, and this is more so the case for you in America than it is for me, we live in a very litigious society. And so people, especially in the United States, are
00:30:10
Speaker
quick to sue for anything. And so, you know, as physicians, one of the things, we are trying to do what's best for the patient, but we're also trying to avoid getting sued, right? And so I will have the lower threat, like if I have a consult, usually what'll happen is you'll get a consult for this patient and you'll see them. And then during your history,
00:30:35
Speaker
taking, you'll see, you'll learn that they have been to see five other surgeons and they've been turned away from all of those surgeons. And you are the last hope. And in my mind, I'm thinking, how can I extricate myself from this and not get sued? And sometimes, and I will admit to this, sometimes I have said to myself, you know, man,
00:30:59
Speaker
The imaging doesn't show anything. I don't think there's anything. I don't think they need surgery, but I'm going to offer them a diagnostic arthroscopy because that is the only way they'll believe, right? And a diagnostic arthroscopy in terms of surgery, relatively low risk. And so for me to stick a camera inside their knee and look and say, yeah, you know what? As I suspected, there's not anything going on.
00:31:22
Speaker
And so we'll now need to default to the conservative option. I've done that, but usually when I do that, I will sort of make a deal with the patient. Okay, despite what the imaging shows, what the physical exam shows, what everybody else has said, we're gonna make a deal. I'm gonna do a diagnostic arthroscopy and I'm gonna look inside because you are sure that something is going on.
00:31:50
Speaker
But I will do that only on the condition that in the event that it shows nothing, that this non-operative course of treatment that I have recommended for you, then you're going to do that. And if they're agreement, then I will take them to the OR. And how often
Redefining Rehab Intensity
00:32:04
Speaker
do they then follow the non-operative course of treatment?
00:32:07
Speaker
maybe between 50 to 60%. But it's probably better that those are better odds than they would have like they wouldn't have done it anyway. Had I not right, they just went to another, they would have just kept surgeon shopping until they found somebody who was going to just do what they want. Yeah, it's frustrating. And there is obviously with pain and what we know about pain science, there's an entire biopsychosocial component to it that has nothing to do sometimes with any actual physical ailment. And
00:32:37
Speaker
You know, from my side, I mean, as a PT, I was thinking this one patient that I saw only twice because the first time I saw them, it was a very lengthy eval because we had to go through a history of doctors and surgeries and things that didn't work and people who let her down and all this kind of thing. And there was this idea that I was going to be the one somehow that was going to finally help her. And I was like, oh, boy. And then we had one session.
00:33:06
Speaker
And I mean, this person was so severely deconditioned was the real problem. And of course having pain because they have absolutely no strength in their body was sort of my big takeaway. I did one session, we did some extremely gentle, non-weight-bearing, non-resistive exercises because I was like, well, this isn't what this person needs eventually, but this is my way in, right? I've got to convince them that I'm going to not hurt them. And then I never saw them again.
00:33:36
Speaker
because they then had their pain again, and their doctor said this was too hard for them, and I was like, how is, okay, anyway, I just get irritated thinking there's something, but it's that idea, like you said, it just takes the one person, right, who kind of like champions that idea that this is too dangerous, this is too hard, you shouldn't be doing this, you're quote unquote special for that reason, and it really does kind of put the rest of us in a really tough position. It just gets frustrating.
00:34:06
Speaker
Listen, I get frustrated with that as well. And I have both from the viewpoint, oftentimes I think there are some therapists that are who are enabling in that way, but also family physicians. And I'm more so frustrated with the family physicians because I think to myself,
00:34:29
Speaker
bro you're not even a specialist man you you know you know next to nothing about musculoskeletal care and you're going to tell this patient oh this is too hard shut up and like and it's like then i gotta but they have the the the trust relationship with that patient right so then i have to figure out how to explain to the patient without
00:34:54
Speaker
encroaching upon that trust relationship that they've established with their physician and say, no, actually, you know, I disagree that that's too much. And here are the reasons why. And I try to explain, but that frustrates the hell out of me. Right. You know, at one point as a competitive athlete, my mindset was always bigger, faster, stronger, bigger, faster, stronger.
00:35:15
Speaker
work harder. But as I've gotten older and then as I've had more of a mobility focus, it's more about trying to correct deficits, address weaknesses, and with a focus on longevity. But I still do tend to push people way harder than their non-MSK physicians would think is appropriate. And for many of the reasons that you said, I have so many people
00:35:43
Speaker
where I say pain and people think pain is one thing, where pain is not one thing.
00:35:49
Speaker
There are different types of pain and pain is telling you different things at different times. And I say to patients, well, do you have pain? And what is the quality of the pain, nature of the pain? Well, it just hurts. No, it doesn't just hurt. When does it hurt? How does it hurt? Because all of these things mean something different. And you just mentioned something about, oh, this patient was so deconditioned.
00:36:15
Speaker
And trying to explain to somebody, yo, you don't have pain because you're broken. You have pain because you're weak AF. The only way you're not going to be weak is to be doing strength and conditioning.
Advancements in Orthopedic Technology
00:36:29
Speaker
And guess what? Because you're weak, that strength and conditioning is going to suck. And it's going to cause you discomfort, right?
00:36:38
Speaker
And you need to be okay with that. And by the way, discomfort isn't the same thing as pain. I have these conversations frequently. You know, one of the biggest things that I try to get across to them is that not all pain is bad. So pain is a language.
00:36:54
Speaker
Pain is a low level language that the body uses to communicate with your higher level of consciousness. It's telling you something and the message is not always the same. So people need to become accustomed to pain.
00:37:11
Speaker
And then they need to start to learn to interpret the language, to learn, well, what is this pain? What type of pain is it? And what is it trying to tell me? Because the pain will tell you what you need to do. And the pain is not, the answer to pain is not always just stop and run away, right? That's rarely the answer, right? The answer is usually something else. The person I was speaking about before
00:37:39
Speaker
when she then asked her physician, it was like, oh, I'm in pain.
Skepticism Towards Fascia Therapies
00:37:43
Speaker
She called her position. He said, you can't do that. I was like, well, this patient walked in the door of the clinic and then laid down and did some exercises and then walked out the door of the clinic. And you're telling me the part where they lay down and did some exercises was too much? Like from a physics standpoint, that doesn't make sense. So there seems to be a really big
00:38:05
Speaker
disconnect between to your point sort of non-musculoskeletal certain doctors and ones that are just or those of us that are more sort of focused on that. For everyone listening, I found Dr. Rayner on Instagram, you know, when they just send you videos of like, you'll like this. And I was like, oh, I do like this. You were doing some mobility drills in between surgeries and doing some work on your wrists and getting in some exercises.
00:38:30
Speaker
And I looked at that and I was like, this man is a unicorn because I have sat in on surgeries and I have never seen anyone doing this. So is this sort of practice like what you're doing? Is it the sort of thing as you were describing about when you set up human 2.0 where at first you're maybe getting a little bit of a side eye and then maybe some other surgeons or other people are
00:38:51
Speaker
joining in with you, you know, or is this becoming more common that orthopedic surgeons are sensing that just like lots of other people, medical dentists, other people have these sort of like repetitive positional overuse and that they could stand to take better care of themselves. Is that getting more common? Like, I still think that I'm a unicorn. And I think that in most of my cohort,
00:39:17
Speaker
at least in people who trained at the same time as me or before me, that most of those people are very classical in terms of their belief system and what they do. And so I think for most of those people, they look at what I'm doing as being crazy. However, for some of the younger surgeons who are
00:39:39
Speaker
who have just recently completed their training or are going through their training now, they are starting to see things differently. And they're starting to see the value of that. And part of that, I think, is social media. When I started my social media, my goal was to educate the population. And I wanted to educate the general population. But I also, one of the things that I've done in the past, I have a teaching degree. And so I'm not at a teaching hospital, although we do occasionally have residents
00:40:08
Speaker
medical students so I don't really have the opportunity to teach anymore but I still want to teach I wanted to use social media as a way to educate the general population but at what I have found in my because I read the comments on my YouTube videos there are so many medical students so many physical therapy students
00:40:28
Speaker
chiropractic students, orthopedic surgery residents, sports medicine residents that follow what I'm doing and love what I'm doing, that I know I'm planting the seed in the new generation and I'm helping them to understand that what we learn in the textbook, it's more than just that.
00:40:47
Speaker
It is something else beyond that. If I think about my own hospital, most of the surgeons, I'm really the only surgeon that's doing what I'm doing on a surgical day, in between cases, whatever. But now I do have nurses who follow me on social media at our hospital.
00:41:06
Speaker
get down. I'm never doing a workout. What I'm doing is I'm injecting movement into my day because I think that's the way that it should be. The value of movement throughout the day supersedes the value of doing concentrated workouts. And so I have them doing stuff throughout the day and I will tease them
00:41:28
Speaker
Oh, you know, like you had to grab that thing. That was a chance for you to do your, your A to G squat, right? Like let's see your full, full depth squat. And so now I have nurses that are, that are doing that and it's kind of a game or, and we're joking with each other, but I see them doing stuff and I have, you know, uh, one of some of my anesthetic colleagues, um, you know, they have a little bit more sedentary time during cases and I can see when I'm not
00:41:55
Speaker
paying attention to what I'm doing. I got to wait for an instrument or whatever and I look up behind the curtain and there they're doing stretches or they're doing squats or they're doing whatever. Orthopedic surgeons are very conservative. I would not expect to see a, you know, other than the people who are training now they've sort of seen the value through social media.
00:42:16
Speaker
I would not expect to see a large contingent of orthopedic surgeons changing or adopting that kind of lifestyle or whatever until there was some big paper
00:42:28
Speaker
that you know are multiple papers that were shown it and you know i'm not again i'm not an academic guy um so i'm i'm not doing that research because there there are certainly you know that we are doing repetitive tasks and there are things that i think about all the time you know like when i think about my own practice i we
00:42:47
Speaker
more prefer doing arthroscopy than I do prefer doing open procedures, although I do knee replacements, hip replacements, and trauma cases. And that's just simply for the one reason, like I noticed that I have, I'm looking down, so I'm six-two, and everybody else in the OR usually is shorter than me. So either they all gotta stand on stools, or I gotta have a table down low, which means I'm doing this all the time.
00:43:15
Speaker
There are times I'm kind of like, what the hell is wrong with my neck? And then I realize, oh yeah, I was looking down like this for eight hours.
00:43:22
Speaker
Whereas when I'm doing arthroscopy, I'm looking at a TV screen, right? I'm working down here, but I'm not paying attention to my hands. I'm looking at the screen. And that's like so much, I love arthroscopy days. I'm looking straight ahead. I'm standing up, I'm looking straight ahead. Yeah, you're like, this is a surgery that's not gonna also take a toll on my body. Sort of as an adjacent question, some of my most uncoordinated
00:43:49
Speaker
poor propriocepting patients are doctors. It's just kind of across the board. Is this related to that kind of conservatism that you were talking about as far as changing habits or was this just like nobody ever talked about like, hey, this also applies to you and you need to work on your own fitness? Like what are they not teaching in medical school? Well, there's such a
00:44:14
Speaker
Such a, uh, an extent of knowledge that we need to learn. Like we spend so much time reading, either reading, operating, or seeing patients and emerge that there's relatively little time for fitness.
00:44:27
Speaker
Having said that, I know a lot of my colleagues, they have their various hobbies and stuff like that. But I think it is very important for us to not only maintain our fitness, but in addition to that, to master our physical literacy. Although we need to learn a lot and know a lot. At the end of the day, if I just boil it down to brass tacks,
00:44:56
Speaker
I'm a technician and I'm a glorified carpenter. But the thing is, I'm a carpenter on the inside of the body. It's a very complex machine. And I work with very fine instruments and the tolerances of joints and bones is mere millimeters. And so it's important for us to be very dexterous, right? And I know several colleagues of mine
00:45:26
Speaker
that are brilliant. They are super smart, right? They know everything that there is to know about their particular aspect of orthopedics. But I would never have them operate on me. And I would never send anybody that I cared about to them for surgery. Not because they don't know their shit. Has nothing to do with that. It's just that I've seen what their hands are like. You know, I may not be the most well-known orthopedic surgeon
00:45:54
Speaker
in the academic realm because of, you know, I'm not publishing articles or whatever. In the medical realm, the way that you know that things are, that you are doing things well is when medical colleagues will ask for you to do their surgery or they will send their family members. Like when people send me, when like, you know, they send me their mother to operate on their mother.
00:46:24
Speaker
right then I know okay that that's that's what I need to know right so but to come back to your your point the dexterity matters I don't think people all understand
00:46:40
Speaker
the importance of that and especially as I said my cohort and older but I think that the younger cohort is starting to see the light and there's also been a push recently in the last five years for orthopedic programs in both Canada and the US to switch to a more competency based model.
00:47:05
Speaker
Okay, so before you just went through, you did year one through five, then you write the exam, you write an exam every year, you write the exam at the end, if you pass the exam, then you become an orthopedic surgeon, you go to your fellowship, and then off you are to the races. Now, they don't want to make it a time-based thing anymore. Time-based loosely, but more importantly competency-based.
00:47:27
Speaker
So until you've demonstrated certain skill sets, you cannot progress. And so with that, there is a little bit more of a focus on physical skills, manual skills. That also has influenced a little bit more of a shift in that direction. And the final thing that I'll say on that is that, and so one of the things that I'm always telling myself is if I'm going to top the top, I need to walk the walk.
00:47:50
Speaker
And I don't wanna prescribe any exercise for a patient that I can't do myself. It is a point of pride for me that I am trying to develop skills, whatever it may be, handstands, you know, strip muscle up, ring muscle ups, planche, whatever. I'm trying to develop skills for myself. I'm 53 years old. But I'm trying to develop skills for myself that I think all humans should be able to do.
00:48:17
Speaker
I'm trying to demonstrate to my patients that this exercise is so important that I think it's important for me to do. And I don't want to hear you whining about, oh, it's too hard. I can't do it or whatever. Because look, here I am over here doing this, right?
00:48:34
Speaker
And I love to say to patients, they talk about rehab after surgery and oh, this is hard, I couldn't do it, blah, blah, blah. And then I say, oh, by the way, did I mention to you that I've had five knee surgeries? And yeah, here's me doing this thing. And here, let me show you this video on YouTube where I'm doing this thing that I told you to do and you can't do it yet at five weeks. And here's me doing it three days after surgery. Come on, let's get with it. Sarah, I'm gonna totally change the topic here because I have three questions for you.
00:49:03
Speaker
Why do yoga teachers have so much hip flexor pain? Why are yoga teachers who tend to be quite hypermobile so tight all the time? And how the heck can all these yoga teachers with yoga butt get rid of their yoga butt aka proximal hamstring tendinopathy? How does this work? Like what's the deal?
00:49:25
Speaker
So that's a lot of questions all at the same time and that would be very hard and take up the length of this entire episode for me to answer. So the good news is I'm not going to have to do that. And the reason why I don't have to do that is that we already made a entire tutorial. Five hours. Five hours. Keep it forever. Forever. Review as often as you'd like. As often as you'd like. Five continuing education credits with Yoga Alliance. Those are
00:49:53
Speaker
Important maybe I mean that's up for debate, but anyway. We've done a bunch of tutorials. This is our sixth tutorial and Incredibly it was overwhelmingly our most popular Tutorial when we first launched it last year does this relate to the three questions that I asked you it absolutely does because this tutorial gives really practical
00:50:14
Speaker
answers in the form of movements and exercises to help you understand if these things are happening to you as a practitioner or as a teacher or to your students why they might be happening and what you need to do to help. And it's not only those things. Wait, what were the ones that you said?
00:50:30
Speaker
Well, it was hypermobility, hip flexor pain, and yoga butt. There are more though, right? So many more. We talk about SI joint pain. We talk about tightness. Just feeling tight all the time, even if you're not hypermobile. Sciatica! IT band syndrome. All of these things that are very common for teachers and are exceptionally common for our students as well. Yeah, and it's not just the practical exercises that potentially address some of the symptoms that students might be experiencing.
00:50:56
Speaker
that help fill in the strength gaps that might be contributing to the problem. Spoiler alert. There are some strength progressions that include kettlebells and barbells in this tutorial. There is also some exceptional anatomy instruction. Thank you, that was my part. And so we're putting it all together with the science, the theoretical,
00:51:19
Speaker
and the practical to help you actually have more solutions to offer your students and to be of service to your students in a way.
00:51:27
Speaker
that speaks really quite directly to a lot of the problems that they are going to probably come to you with as it turns out. So why are we talking about this right now? Because we're having a sale. We've actually we've actually discounted this course. You can buy it at a discount, which is less than full price. So we've actually discounted this thing more than 25 percent, which is probably the best sale we've ever had on a single tutorial, wouldn't you say? Definitely. Yeah. So if you've been
00:51:57
Speaker
Wanting this tutorial, if you missed it the first time around, you should snap it up quick because this sale will end. It will go back to full price. So it was around $130. Now it's $100. So just in case you don't know, it's me, Sarah, but also Jason Perique, who is a genius and the co-host of the Yoga is Dead podcast, which I highly, highly recommend you check out. So.
00:52:22
Speaker
make sure that you click the link in our bio, head on over to the page that tells you all about what's included and snap it up before it's gone. One of the populations that I work with is older women. And I see time after time that they need to get stronger. And I actually just had a recent
00:52:42
Speaker
patient just so frustrated because they were seeing another physical therapist and they were actually getting weaker. They were shuffling more, they were stooped more because they were given exercises to do that were just far too easy. They were given the little pink dumbbells or the yellow resistance band and they were told three sets of ten
00:53:05
Speaker
and they could do three sets of 10 in their sleep. A lot of people are afraid of hurting themselves with strength training, I think. I think people get this idea that they could really do some harm to themselves. But what I see is that, in particular for our older patients, they're more likely to hurt themselves by not banking the balance and strength benefits that come with weight training. And I end up having to do quite a bit of reeducation
00:53:35
Speaker
for people. Is that something that you find yourself doing as well? At our facility, we have like what we call a master's class. Some people don't like us to say older or seniors or whatever. So we call it master's class. But basically it's a little bit of a toned down version of what we do in our regular class, but we still do the same. We don't do CrossFit, but we use some of the ideas from a CrossFit model and in that like we have programming of the day.
00:54:01
Speaker
Okay, and so every class all day long everybody's gonna do that same programming We scale it up for some groups because they're more advanced and we scale it down for other groups So for the master's class, they'll do the same programming or aspects of the same programming and we'll scale it down But we still want them to lift we still want them to do resistance exercise one of the main indicators of health and longevity is a degree of lean muscle mass and
00:54:29
Speaker
right in your in your older years and so there is only one way to develop lean muscle mass there is there are no two ways about this and so the little sheet that freaking drives me bonkers right I literally just tore one up yesterday bonkers it's like like yo this is way too easy
00:54:53
Speaker
And it needs to be progressive I tell patients if you do the same thing if you go to a therapist and you do the same thing two days in a row and it hasn't changed.
00:55:04
Speaker
said, you need to find another therapist. Cause I said, no workout should ever be the same. It should always progress. And I said, they could either increase the number of reps, increase the number of sets or increase the duration of time. Those are the three easiest things. But I said, it should always change. It should never, no one should ever give you a sheet and say, oh, this is it. And then this week you're doing that, next week and the week following, you're doing the same thing. That's a complete waste of time and money. So people should be,
00:55:33
Speaker
um lifting all the time and I have to convince people of that and people go oh you know while I walk and I'm like walking is is I said that's not even it is exercise but I said it's so generic non-specific and not directed towards the deficit that you have yeah I'm great I'm glad for that you're doing it but that's not helping right you know this particular problem that you've arrived with has a
00:56:03
Speaker
specific deficit that we need to address. And being generally active throughout the day or walking does not address that deficit. And so you can do those things, but you're going to continue to have difficulty if you don't do these specific exercises. And lifting weights should be part of it. Every therapy session should look the same as a workout. I think of everybody as an athlete.
00:56:30
Speaker
And so it should be as if you were training for a sport. You should be sweating when you leave. You should be short of breath when you're doing this stuff because you're working hard. And the body adapts to specific stresses that are imposed upon it.
00:56:49
Speaker
And if you do not impose a particular stress on the body, there is no need for it to adapt, no need for it to change. And so if you are working within your current functional envelope, the body does not pay attention to you because it's like, well, I can do that already. So you need to step outside of your zone of comfort. You need to step outside your abilities in order to
00:57:18
Speaker
stimulate change in growth in the body. And that means lifting weights or doing resistance training. And it means working hard. Absolutely. And to your point as well, one person's working hard is not the next person's working hard. So there is a scale to it. Yes.
00:57:39
Speaker
And I think the same way I think about rehab to elite athlete is just a series of progressions of difficulty in various ways. And that's really it. And I think the part where people get stuck often is when you're in the rehab end of it, when there's pain, I found it difficult both to convince patients sometimes, but also to convince colleagues
00:58:05
Speaker
that that doesn't mean that they shouldn't be strengthening. That doesn't mean they shouldn't be doing something that's hard for their body.
00:58:14
Speaker
I don't know if you have thoughts about that in particular that you might want to share, but that seems to be a bit of a sticking point. It's like, well, if they're in pain, we have to take it really easy and maybe we just do some massage, but a reluctance to then also make the person effort in any way. Part of the fault lies with the therapist because the therapist themselves
00:58:36
Speaker
And like, I understand why they would do this because the therapist doesn't know, you know, what surgery or how the surgery was done. You know, what are the complicating factors? No, they don't want to do something that's going to break something or wreck the surgery, whatever. I get that. But on the other hand, they have to recognize just as do physicians and the patient that not all pain is the same. And so you need to really get specific about
00:59:06
Speaker
what is pain, what type of pain it is, when it occurs and what that means. So I will routinely say to my patients, when you're going to be doing this exercise, I expect there to be some discomfort. So discomfort to me is, you know, and I use a pain scale that is purposely outrageous because as you said, pain, not everybody's pain is the same and everybody's pain tolerance is not the same, but we can all pretty much agree on what's outrageous.
00:59:36
Speaker
So I'll say to people, on a scale of 0 to 10, where 0 is no paint at all, and 10
00:59:43
Speaker
is the amount of pain where it is so bad that you are gonna give me $1,000 out of your pocket right now to cut that extremity off in front of you with a rusty butter knife. It sounds crazy, right? But like you can imagine like how bad it would have to be for them to say that, right? Or to say, yeah, I agree to that. On that pain scale, when you are working out, you may have discomfort
01:00:12
Speaker
and that discomfort may be around a six or even as high as a seven. Anything above that, stop. But if it's six or seven where it's bad enough that it makes you want to say to me, stop talking, doc. I need to concentrate on this so I can breathe. I said, I'm cool with that. If you have that or less, keep going.
01:00:39
Speaker
Right? If it's more, then you should stop. And I also talked about the quality. I said, if you have pain that's super sharp and it occurs during the activity and persists after the activity, we don't want that. So if you have discomfort that occurs while you are doing a thing, but immediately after you stop, it goes away. I said, I've got no problems with that. Carry on.
01:01:07
Speaker
right anything that lasts persists afterwards that's a sign that you're doing too much or if it's you know eight nine or ten getting to where like you can't function you can't breathe whatever then that's too much but anything short of that is fine and it just means you need to just concentrate
01:01:31
Speaker
manage your breathing and work through it because that tells me that you are working at that threshold of, yeah, I'm getting to the boundaries of what my body can tolerate, but that's also where you need to be spending time, right? And so I say to people that five, six, seven to me is discomfort, eight, nine, 10 is pain, and five, six, seven, you should run towards discomfort and run away from pain.
01:02:02
Speaker
Right? Because the discomfort, as far as I'm concerned, that's telling you where you're either tight, you're weak, or a combination of the both. Right? And we should always be working to correct those things, weakness and tightness. I think that's for a lot of us, that is a real reframe of a concept of not only the pain scale, which I personally really don't like at all, for that reason, because everyone could, the people, I either get patients who say,
01:02:31
Speaker
my pain is 10 out of 10 and then I'm doing like an insanely hard eye roll inside my head, but keeping it to myself. They're talking to you like this and they say it's 10 out of 10 or it's 15 out of 10. I said, bro. Like you don't understand the scale. Yeah, you don't understand. You did not understand the assignment. Okay. It's not 15 out of 10.
01:02:50
Speaker
or I get a lot of people who say I have a really high pain tolerance and I also I know I do that face as well because I'm like I promise you A you don't and B it's not a great thing actually you know like so you will understand this people who if they're non-msk people and they're listening to this right now that is the number one red flag right there every time you hear that come out of people's mouths
01:03:19
Speaker
you instantaneously know it is the opposite, right? Like I have a high pain. Oh my God. No, no, no, no, no, no. It's almost 100% true, right? And the people who say this, so they'll have fibromyalgia or some other kind of complex regional pain disorder, or they'll have a frozen joint.
01:03:41
Speaker
or they'll have a number of narcotic allergies, right? And if you have a number of allergies to pain medications, what does that mean? That means that you have been exposed to all those different pain medications. Somebody has actually prescribed those to you to try to control your pain and they have found that you were allergic. And now, a lot of people who have allergies to narcotics, if you really delve into it,
01:04:11
Speaker
and you look at their medical charts, often the time those people, they don't have allergies to all those narcotics. What they've done is they used a whole bunch of narcotics, it didn't control their pain, and then they've said to their physician, who oftentimes is not necessarily well-versed on narcotic analgesics and MSK issues, oh, I have this side effect, I have this, I have that, and they go, oh, you're allergic to that.
01:04:42
Speaker
And oftentimes, you know, we will, when we're in the OR, when we will have these patients and they'll be allergic to so many different things. So like we have no choice in the OR, but to give them something to which they're allergic, right? Because otherwise we can't give them any analgesic. And many times, almost all the time,
01:05:07
Speaker
We'll see they're not allergic to it. They have no reaction. Once they're under anesthesia and they don't know that they're getting that thing, we give it to them to control their pain. They have no issues. Right. But it's because they've been exposed to a whole bunch. Some people think that they should have no pain ever.
01:05:27
Speaker
Like in any amount of discomfort is ridiculous pain. And that's just unrealistic. Again, pain is not necessarily the enemy. It's always the messenger and sometimes pain is your friend because it's telling you where you need to spend more time.
01:05:43
Speaker
Absolutely. Oh, this has been so great. Thank you. I have a couple of more questions from Instagram that were submitted. The first one was, do replacement parts come in different shapes and sizes? Yeah. So in the past, most implants came in sort of generic sizes and generic shapes. They
01:06:05
Speaker
would have one sort of shape. Say, for example, the next gen knee implant. Okay. So that's a Zimmer Biomet near placement implant. It's kind of middle of the road implant. Okay. In terms of features, quality, and price. And it's one of the most commonly used ones in North America. So the next gen implant has a basic shape.
01:06:29
Speaker
Okay, but it has different sizes because obviously the next gen implant that goes in my knee is not going to be the same size that goes in your knee. And so that was up until maybe the last five to eight years or so. And then we start to have 3D printing technology. What you found with the advent of 3D printing technology is that you could then now start to make custom
01:06:55
Speaker
implants and not only could you make custom implants you could make custom cutting jigs for those implants because in the past with the generic sizes we had implant or we had cutting guides one set of cutting guides for everybody and we cut to certain angles certain dimensions and then we slap on these generic implants different sizes but generic implants
01:07:23
Speaker
But now with 3D printing technology where you can print implants and you can print guides to match your specific anatomy, now you can, if, we don't do this in Canada because of the price and because we are a universal health care system, but in the United States, you can do this. If you have the money, you can pay to have a 3D,
01:07:49
Speaker
CT scan of your joints done and then from that they can build and 3D print specific jigs that are designed to match your anatomy and you can custom tailor certain alignments based on computer referencing and the 3D model of your skeleton
01:08:19
Speaker
And then they can create custom jigs for you and custom implants that mimic your native anatomy and are custom designed to you and that have jigs that will cut to you. So that's something that has occurred over the last sort of five to eight years. It's not in widespread use, again, because of the cost. That's very cool. I didn't know that about the 3D printing. That's a really interesting development. Yeah.
01:08:49
Speaker
And I think in the future, as the cost of 3D printing comes down, that would become a more widespread option. And I actually have an idea I want to pitch to Elon Musk.
01:09:03
Speaker
because he's got all the money in the world kind of around that. But I need to get a larger social media following first so that he can actually notice who I am. And then I can pitch it to you. Maybe we can brainstorm some other billionaires, because I would like you to find someone maybe a little more, I don't know, a little more stable behaving, perhaps. I'm not sure. Anyway. He has become rather erratic.
01:09:32
Speaker
I think there's a handful out there close to or at his level that are much more below the radar that might be an easier person to work with. Okay, so the next question from Instagram is, when there is a herniated disc, do doctors prefer surgery or exercises for hernia resorption? The disc material, disc contents generally are not resorbed.
01:10:02
Speaker
They generally are not resorbed. They will usually hang around. There might be a small degree of resorption, but in my experience, I've just found that they hang around and they can move around.
01:10:17
Speaker
once they've been externalized outside of the disc, and sometimes they become sequestrated in the far lateral recess, but they generally don't get resolved. Now, whether or not we do surgery really depends on the patient's findings. So the thing that people don't understand about spinal surgery is that spinal surgery is almost, it's rarely indicated.
01:10:43
Speaker
We almost always try to treat people non-operatively before they go to spine surgery. And I would say that it's probably maybe 20% of the time or less that surgery is indicated. And most of the people are trying to treat non-operatively with exercise and other modalities.
01:11:07
Speaker
The only indications for spinal surgery are loss of bowel bladder function, so cauda equina. The loss of sensation or loss of motor function
01:11:25
Speaker
in a particular nerve root distribution. People come all the time and go all my legs are weak blah blah blah this is weak and they tell you and it's not in any recognizable pattern that that we don't we don't treat that with surgery because that's more psychological than anything else right. But if we can if you have loss of sensation or loss of weakness and we
01:11:48
Speaker
do a testing and that's all that's the L3 distribution that's the L5 distribution that tells us there is a specific nerve that is compressed we can decompress that. So, loss of biobatter function, loss of motor sensory function in a particular nerve root distribution.
01:12:06
Speaker
intractable pain, okay? And we, like back pain is as harsh as this sounds. I tell people all the time, surgeons, we give a rat's ass about back pain. We don't care. 95% of people in their adult life are going to have at least one episode of mechanical back pain lasting six weeks. To be honest, we don't care about back pain. Not because we don't care about it, but because for issues that we mentioned before, everybody's perception of pain is different. You know,
01:12:35
Speaker
And so what is terrible pain for one person is mild discomfort for somebody else. And so pain, generalized back pain, that doesn't mean anything to us, but intractable back pain that has failed all other kinds of treatment, including epidural, nerve blocks, all kind of whatever, and is associated with osteoarthritis of this pain, spondylitis, spondylolisthesis, or some other structural problem.
01:13:03
Speaker
That's a surgical indication. And finally, structural instability of the spine.
01:13:11
Speaker
that's an indication for spine surgery like osteomyelitis of the spine so infections of the spine that result in structural loss of structural integrity or also cancers whether they be cancers of the the bony elements of the spine or metastatic disease from somewhere else that has compromised the structural integrity of the spine
01:13:34
Speaker
That's an indication for surgery. Anything else is not an indication for surgery. It's funny, I read my comments all the time on my videos.
01:13:43
Speaker
People are like, oh, yes, surgeon, all you want to do is operate, blah, blah, blah. What about all these people, all this back surgery? We don't want to operate on backs. And none of us want to do that, not even spine surgeons. We don't want to operate on backs. Surgery is like the ultimate last resort for back pain. And only after they feel everything else and they keep coming back and bothering the crap out of us, right? It's not, back pain is not an indication. So unless they have one of those indications,
01:14:16
Speaker
from the viewpoint of disc to encourage disc resorption, because like I said, that almost never happens. MRI these people later, five years later, if they haven't had surgery, the disc has not been resorbed. The disc has lost height and the herniated fragment that came out has just either been scarred down to the dural tissue around it,
01:14:39
Speaker
it's being treated non-operatively.
01:14:43
Speaker
or it has moved its way into a lateral recess where it can either cause worsening symptoms or it's moved to an area where there's a little bit more space and it's not impinging on it. Thank you. I just want to take that last five minutes of what you said and just put it on repeat and drive around in my car with a bullhorn and just play it to the entire city. I tell that to people all the time, man.
01:15:13
Speaker
All right. Here's the last one from Instagram. How do orthopedic surgeons or maybe the field itself view the concept of biotensegrity? You have to tell me what that is. I don't know what that is. So, okay. So this is sort of from the world of fascia and the idea of the model of how fascia behaves in the body. Buckminster Fuller came up with this biotensegrity model, which is just sort of like a structure for one of a letterbird better word that
01:15:43
Speaker
is it has a tense tensegrity to itself. It has a like the like a drop of water has a sort of tense to itself. Right. In the world of sort of fascist studies in particular, they talk a lot about the fascia of the body as having this bio tensegrity. Is that something that I mean, my my experience when I was in PT school, and at the time I was sort of starting to learn about what fascia was, and I was doing more studies around it. And even in the world of PT, they were a little bit like,
01:16:12
Speaker
Well, ha ha ha, that's fine, but that has nothing to do with anything. So is that something that, I mean, I don't know if surgically that comes into consideration, is that something that
01:16:24
Speaker
you take into consideration when you're working with people from a movement standpoint? So, first of all, I'd say I don't think this is widely known about in orthopedic circles or thought about orthopedic circles at all because this is my first time hearing about that. And this is me being an orthopedic surgeon who also is kind of a mobility
01:16:46
Speaker
And now I haven't heard that particular model I have heard of different thought processes and ideas around fashion. Several of my therapists are certified in active relief.
01:17:02
Speaker
or active release which is a technique which is based around the fascia. I think it plays less of a role than people think. From my perspective the fascia is it provides two roles. Number one it encapsulates muscles and number two it separates muscle planes and and to me those are the
01:17:30
Speaker
the fundamental roles that it serves. And that's what I see when I'm going and I'm performing surgery and I'm trying to access various compartments. So that is my interaction with it. Now, how do I think that it behaves or contributes to various musculoskeletal problems?
01:17:53
Speaker
From what I see when I operate in the fascia, so if I operate on a patient for the first time, the fascia is a pristine tissue, it's just very thin, it looks like tissue paper, moves very well, you can separate it from the muscle very well, the muscle slides over it very nicely. So that's native fashion. But if somebody's had surgery, and in particular a surgery that goes into or into a muscle belly,
01:18:21
Speaker
Right? Then we have to disrupt the fascia, right, to do that. Or if they've had some kind of traumatic, you know, femur fracture, tibia fracture where the bone edges have cut the fascia. Then the fascia is no longer pristine and we start to see some scarring and some adhesions of muscle tissue to the fascia.
01:18:48
Speaker
So normally the fascia is separate and it will slide. But in those cases, there is some adhesion. And so I think there probably is some utility, some, to doing work to try to address those adhesions between the fascia and the muscle. But people who think they're doing a ton of fascia work,
01:19:17
Speaker
Um, I think that they're kidding themselves. Um, that I think it's having less results than, than what they believe. And because I can see like, just how difficult, like say, for example, I did an anterior approach on somebody four months ago. Uh, anterior approach, total hip arthroplasty.
01:19:40
Speaker
And so for people who don't know, the anterior approach is the one surgical approach that we use that we don't cut through muscles. We cut the fascia over tensor fascia lata, and then we pull the muscle aside, and then we cut the back of the fascia. So we come through the front, pull the muscle aside, go through the back, put the rectus off to the one side, tensor fascia lata, and vastus lateralis to the other side.
01:20:09
Speaker
Bang, we're right down on the capsule. So no disruption of muscle tissue whatsoever. So that, and I love that approach just because of its beauty and it's hard to do technically, but from a anatomic point of view, it's so simple. Now, so this guy, I made a technical error. And so normally the stem should be in, should be anti-verted by about 15 degrees.
01:20:37
Speaker
And in this particular case, just for whatever with the bone, the way that I had broached it, I was off by a few degrees. That meant that it was a little bit more anti-very towards the front and it's a little less stable than it would normally be.
01:20:53
Speaker
Usually we don't have a problem with stability with the anti approach. So anyway, this guy went discharged from the hospital and he had some issues in physiotherapy and he had a subluxation of the stem, the femoral head during physiotherapy. So I brought him back. And so when I went back to do the revision,
01:21:11
Speaker
The amount of scar that was there, like I hadn't done anything to the muscle, but the amount of scar that was there in that fascia and then in between the muscle and the fascia was quite significant. Almost to the point where it was like a little bit hard to tell where the interval was. After his initial surgery, it had only been like a month after his initial surgery.
01:21:33
Speaker
So like I'm directly on it. He's during that whole time. He's been doing physiotherapy He's been doing everything and yet there was a ton of scar there, and I just think Yeah, these techniques. I just think are not as powerful as people think and I just think probably people are just gonna be as well suited just by doing a
01:21:58
Speaker
concerned, consistent program of flexibility and some manipulations, some massage the area just to help break things down. Number one, I don't think people are as limited by fascia as some people might say. And then number two, I don't know that these techniques are as fruitful as people think them to be.
01:22:28
Speaker
But I'm having I'm seeing this with a limited knowledge of the particular techniques. And I'm just speaking more from what I see when I'm actually, you know, looking at a gross specimen, I have a person open and staring at fashion.
01:22:45
Speaker
And I think, I mean, this is one of the things that we try to do here on our podcast is, you know, we, my co-host Laurel and I both have very strong opinions about lots of things, but we try to hold them loosely so that when we learn new things, we're able to replace those opinions with a more accurate, maybe more up to date, things like that. So the world of, of fascial study is seems to be just sort of, as much as people like to think that science is just facts and those facts are
01:23:11
Speaker
never changing. I think one of the things that those of us who who try to stay on top of things know that that's just not true. And especially in the world of the study of fashion, I think we're still learning. You know, so I think it's hard to for sure, for sure. And I think the one thing that people have to understand. And so we saw this very much during COVID. The general population doesn't understand science. Science is a process. It's a process of discovery. And we are trying to get towards the truth.
01:23:37
Speaker
And it's not the truth changes, it's just that as we learn more about whatever particular thing we are studying, we start to learn what questions to ask, because the previous questions that were asked were not perhaps specific enough, or pointed enough, or directed enough, or they were directed in the wrong direction.
01:24:00
Speaker
So we start to learn what questions to ask and we also start to have better instruments and better tools with which to analyze the results if you think about say telescopes.
01:24:14
Speaker
the original power of the first telescope compared to the power of the James Webb's telescope are orders of magnitude different. And so the science that you could ascertain using the first telescope is much different than what you can ascertain with Hubble or the James Webb telescope. People go, oh, you can't trust the scientists, they're lying. No, they are revising their opinion
01:24:41
Speaker
based on the new information. And so my understanding of fascia has to do with what I do as a surgeon, but science may show me
01:24:53
Speaker
at some point in time as there is more data that it has more effect than I think or whatever. And I'm prepared to revise my, like what I think of now is my current position based on my current knowledge, right? But if something comes along and changes my knowledge, I am not so set in my beliefs that I cannot change my opinion
01:25:23
Speaker
based on knowledge. Where I am today as an orthopedic surgeon, if somebody had said to me while I was in my residency, oh, you're going to have post-operative patients who have had shoulder surgery, you're going to be showing them how to do handstands in the gym as part of the rehab.
01:25:43
Speaker
um I would have said you're man get out of here quit your your I don't know what you're smoking but I'm not having any part of it right um but I do that now uh because I've learned that teaching handstands well is all about scapular control right and to me the scapula is the stage upon which the shoulder acts if I want someone to have
01:26:09
Speaker
good shoulder function, I need to first teach them how to have good scapular function. And I can't think of a better way to do that than to teach people how to do a handstand. Not because I want them to do a handstand, but when you are learning how to do handstand,
01:26:27
Speaker
you need to learn how to retract, depress your scapula. You need to learn how to have active
Conclusion and Call to Action
01:26:34
Speaker
core. There's all these things that are just, these are all things that I need to teach people who are rehabilitating from shoulders how to do. So why don't I just teach them this task and then they will get all of those things as a byproduct.
01:26:49
Speaker
And as a bonus, they learn how to do a hands down. As a bonus, they learn how to do a hands down. I want to thank Dr. Raynor so much for joining us today. Could you let us know what's the best way for people to find you? My main platform is on YouTube. So I'm Chris Raynor at Chris Raynor MD on YouTube. I'm on Instagram as well at stable knees with a Zed.
01:27:11
Speaker
And I am on TikTok, Dr.Chris, C-H-R-I-S, Raynor, R-A-Y-N-O-R, and they can find me on those two platforms. Thank you so much, Dr. Raynor. It's really been a pleasure and I've learned tons listening to you and I'm sure that our listeners will too. I'm going to keep an eye out for anyone in the US who might be doing something
01:27:30
Speaker
even remotely as cool as what you're up to out there in
Upcoming Apex Course Announcement
01:27:33
Speaker
Ottawa. Well, listen, like I said to you before, so I'm about 80 to 90% done for my first course that I'm going to be offering to physiotherapists called Apex. And it's basically all of the principles
01:27:50
Speaker
that we've discussed today and about how I think physiotherapists should work. So that I'm gonna do the course and then I'm working on a Apex certification. And so that of course will have CME points that's associated with it. So that's something that I'm working on and my goal for that is to share this movement-based
01:28:19
Speaker
rehabilitation philosophy with physiotherapists and trainers around the world and then potentially have people who are become certified in it and then people who can you know become teachers and trainers in that so that's something that you know my wife keeps saying to me you gotta have a date to get this done because you keep dragging it on so I told her so I'm shooting for the end of January
01:28:49
Speaker
to have my first course. So that's something that's coming. So hopefully that will be out in 2023. And if all goes well, maybe I will come down to Los Angeles and offer it in Los Angeles. We would be lucky to have you. Thank you so, so much. Not a problem. I appreciate it. Thank you very much for the invitation.
01:29:14
Speaker
Thank you so much for joining us on the movement logic podcast. It helps us out so much. If you liked this episode to subscribe and also to rate and review either on Apple podcasts or wherever you listen to podcasts.