[SPEAKER_02]: Hey, it's Jordan from Barbell Medicine.

[SPEAKER_02]: Now this episode preview is from exclusive content that regularly goes out to our Barbell Medicine Plus subscribers.

[SPEAKER_02]: In addition to exclusive content, Barbell Medicine Plus subscribers get early access to episodes and products, at free listening, discounts on products and services, and the ability to ask Dr.

Barakie and I questions, all for about the cost of a cup of coffee each month.

[SPEAKER_02]: And in case you're wondering, the first month is free to join head over to barbellmedicine.com slash plus and sign up to be a barbell medicine plus member today that's barbellmedicine.com slash plus.

[SPEAKER_02]: Alright, thanks for your consideration, onto the show.

[SPEAKER_02]: Welcome back to the barbell medicine plus podcast where we bring modern medicine to strength conditioning and other items depending on what you asked us so let's just let's just get into it.

[SPEAKER_02]: First one is on flu slash COVID vaccine questions.

[SPEAKER_02]: Good thing is because it's only going out on supercast barbell medicine plus podcast.

[SPEAKER_02]: We're not going to get flagged and just get, you know, a bunch of hate messages.

[SPEAKER_02]: So.

[SPEAKER_02]: This question says, I did a quick search on the forum and found some things from about 2021.

[SPEAKER_02]: So apologies if this has been asked, slash answered before, but it is the season to get these.

[SPEAKER_02]: This individual says, I, without fail, have the same symptoms after the COVID booster every single year, but Nerna in my case.

[SPEAKER_02]: My joints hurt, I have headaches, sweat, muscle aches, like delayed onset muscle soreness, and generally feel like garbage.

[SPEAKER_02]: These are all things that, in my day-to-day life, of training four to six days a week, I do not have.

[SPEAKER_02]: What's that about?

[SPEAKER_02]: Is my immune system doing its thing in the least pleasant way possible?

[SPEAKER_02]: I remember that there was some guidance when these rolled out to avoid pain killers slash fever reducers, like ibuprofen.

[SPEAKER_02]: Is that still the case?

[SPEAKER_02]: Would really love to have some of these medications.

[SPEAKER_02]: Next year.

[SPEAKER_02]: This year I scheduled my shots after my Friday session, which is my last session of the week, but are there any reasons to not train after the shots?

[SPEAKER_02]: I've generally pushed through if I happen to have a training session the day of or after the shot.

[SPEAKER_02]: I remember there being some weird guidance to avoid activity for a week or some such nonsense from the early vaccine rollouts, so likely outdated.

[SPEAKER_02]: Long question, but yeah.

[SPEAKER_02]: adequate adequate, especially because it is the season.

[SPEAKER_02]: So we did cover some of this, I mean, granted, that was podcast up so 96, which is, yeah, I guess 20 episodes ago.

[SPEAKER_02]: Yeah, 300.

[SPEAKER_02]: Yeah, so and it is interesting, maybe just in a side, like people will bring up topics that we've covered before, for example, and be like any new thoughts, which is a reasonable question, especially if something is like, but we try our best if something is like, [SPEAKER_02]: practice changing, which is the fancy doctor speak for like, hey, look, we thought this before now based on new evidence we think this we try our best to update that and if they're like no news is kind of good news with respect to most of our material I won't say all because there's some stuff floating around out there.

[SPEAKER_02]: I'm sure that's over a decade old that I wish I could, you know, update in any case.

[SPEAKER_02]: Symptoms like joint pain, headaches, where at these muscle aches, they are certainly signs of your immune system mounting a response to, in this case, the vaccine.

[SPEAKER_02]: Your body's basically learning how to fight the potential viral infection without you having to get sick from an actual infection.

[SPEAKER_02]: So it's more controlled, but this is well characterized.

[SPEAKER_02]: So this is not like that one weird thing that happens to you and you alone.

[SPEAKER_02]: happens to a significant proportion of folks not all folks obviously and so yeah you can feel like you have delayed onset muscle soreness general feeling not so hot your immune system's doing it's thing release inside a kind it causes inflammation signal other [SPEAKER_02]: molecules to come play.

[SPEAKER_02]: You get these systematic effects.

[SPEAKER_02]: But again, this is more of a controlled type of experience than what we would predict from an active viral infection.

[SPEAKER_02]: I did some digging on this as far as, you know, should you avoid ibuprofen or anti-paradox anti, you know, fever medications.

[SPEAKER_02]: Yeah, you can take these like I'm not giving you medical advice.

[SPEAKER_02]: This is not medical advice, but yeah, there was maybe some concern that that would blunt like the response of an individual to the vaccine, but that hasn't panned out.

[SPEAKER_02]: So carry on, should you want to do something like that?

[SPEAKER_02]: And last thing, and this is probably where we'll spend the bulk of our time on this question is like, [SPEAKER_02]: There's no reason to avoid training after or before a vaccine.

[SPEAKER_02]: In fact, we covered this on our previous discussion of immunizations and training, there's maybe some like potential benefit there with like not only blood flow, but stimulation, the immune system, better surveillance or whatever.

[SPEAKER_02]: So I don't know, how confident do you feel that that is something that occurs.

[SPEAKER_02]: Meaning that if you took a thousand people, right?

[SPEAKER_02]: and you put half of them in a group that trained immediately after they got a vaccination and the other half did not.

[SPEAKER_02]: Do you think there would be significant difference in like immunogen, you know, the immunologic response and potential like infection risk down the road?

[SPEAKER_02]: Yeah.

[SPEAKER_00]: Yeah, I was wondering, as you were laying that out, knowing where you were headed, I was waiting for the pause that happened because the key element of that question is right where you paused to think about what outcome am I paying attention to?

[SPEAKER_00]: Yeah, right.

[SPEAKER_00]: So I remember when we did that original podcast, number 96, and we talked about this, [SPEAKER_00]: I found that evidence reasonably convincing as it related to the effects of activity around the time of administration of an immunization.

[SPEAKER_00]: But what I don't recall off the top of my head as it was several hundred episodes ago was the outcome that was being measured.

[SPEAKER_00]: For example, we can measure antibody tighter levels.

[SPEAKER_00]: So how like you're blood circulating blood levels of [SPEAKER_00]: There's all obviously going to be a significant increase in the short term no matter what if you are responding to an immunization.

[SPEAKER_00]: you can measure it long-term, how much of it persists versus how much of that antibody wanes, which tends to happen with a lot of immunizations.

[SPEAKER_00]: And that's not necessarily a bad thing, or it doesn't even necessarily mean that you have lost your immunity to something because memory cells can wake back up and restore higher levels when needed with some things better than others.

[SPEAKER_00]: That's why boosters are only needed for some conditions and not necessarily others.

[SPEAKER_00]: Or is your outcome not going to be some serologic measurement like this, but rather what's your risk of infection at all?

[SPEAKER_00]: Or is it going to be what's your risk of symptomatic infection?

[SPEAKER_00]: Or is it going to be what's your risk of hospitalization?

[SPEAKER_00]: Or is it going to be what's your risk of death, right?

[SPEAKER_00]: So we have all these different tiers.

[SPEAKER_00]: And obviously death is the one that we care about the most followed by like critical illness and hospitalization and disability as a result, followed by symptomatic infection, followed by any infection, followed by like what are your blood levels?

[SPEAKER_00]: importance if you're a patient, right?

[SPEAKER_00]: And so am I confident that like exercising after a vaccine versus not exercising after a vaccine?

[SPEAKER_00]: Is going to have a large impact on your ultimate risk of death from the infection?

[SPEAKER_00]: Pretty tough for me to feel confident in that.

[SPEAKER_00]: In general, much less because we don't actually have that kind of direct evidence that would be exceedingly difficult to prove.

[SPEAKER_00]: But on the other hand, at the opposite end of the spectrum, do I feel more comfortable if the idea is like, hey, if you're able to do some vigorous activity around that time, it may be at boosts your short term, immunologic response, and you might get some higher antibody titers or something.

[SPEAKER_00]: Yeah, maybe slash probably now how much of a relationship there is between those, you know, near, nearer term outcomes and like the more significant ones we care about of like symptomatic infection or hospitalization death, that is unknown.

[SPEAKER_00]: Yeah, all this is to say it's an interesting thing to point out like all the different outcomes that you could look at.

[SPEAKER_00]: But more importantly, I have no concerns about you exercising around the time of the vaccine.

[SPEAKER_00]: I think that people in general are overly cautious about this sort of thing, including after an actual infection.

[SPEAKER_00]: We've talked about this before too.

[SPEAKER_00]: This risk of be a paracarditis, or myocarditis, or something.

[SPEAKER_00]: It's like, yeah, there's probably a non-zero risk.

[SPEAKER_00]: And everybody gets to weigh this risk and benefit for themselves.

[SPEAKER_00]: But [SPEAKER_00]: You know, I think that if you are somebody who is of such, uh, you know, risk, uh, intolerance that you're going to say because of this, uh, to minuscule risk of getting myocarditis, uh, after a blue or a COVID infection because I exercised, like there is no way that you should ever be getting in your car to go in.

[SPEAKER_00]: Don't drive.

[SPEAKER_01]: Yeah.

[SPEAKER_00]: Like, you know, that's, that's, that's, [SPEAKER_00]: It's an incoherent kind of risk benefit calculation there to hold those two things at the same time.

[SPEAKER_00]: So, yeah, those are some of my thoughts.

[SPEAKER_02]: I have two additions and more just like, hey, you said this and I kind of want to add on.

[SPEAKER_02]: Yeah, I guess I can't call that an addition.

[SPEAKER_02]: I feel very confident that exercising around or directly after vaccination does not impair the response to that.

[SPEAKER_02]: I feel very confident about that.

[SPEAKER_02]: minimally, perhaps, moderately confident that exercising after vaccine may improve short-term, you know, markers of, you know, the immunization working, as far as, like, serial logic levels go.

[SPEAKER_02]: And I have no confidence that it's actually going to, like, affect somebody's chance of not only getting a symptomatic infection, but also, like, subsequent outcomes from that.

[SPEAKER_02]: The second thing is about this concern over exercising either after a vaccination or after an infection.

[SPEAKER_02]: And I'm of the opinion that generally speaking, our public facing message should be, do you do not need to be restricted from exercise after you're feeling, you know, [SPEAKER_02]: to go exercise after an infection or after a vaccination that should be the public facing message and my caveat like would be if you're very well trained you exercise regularly I don't care like if you want to take a little bit of time off you don't feel your best and whatever I'm more accepting of that than people who do not currently participate regularly participate in exercise because those people I just want you to get started and however I can interface with you [SPEAKER_02]: It's like a quality improvement project for people health care professionals administering vaccinations.

[SPEAKER_02]: If they were like, hey, by the way, you should exercise after this.

[SPEAKER_00]: Oh, yeah.

[SPEAKER_02]: I'd be serious.

[SPEAKER_02]: Just something like that.

[SPEAKER_02]: Because people were like, wait, what?

[SPEAKER_02]: Or like, if you saw a physician after an infection, and you were just like, you're following up.

[SPEAKER_02]: And they were like, and by the way, you should exercise today.

[SPEAKER_02]: Just to sort of like, nudge people in that direction.

[SPEAKER_00]: Sure.

[SPEAKER_00]: Sure.

[SPEAKER_00]: I'd be interesting thing to link it together as like a necessary, not even though it's not strictly necessary.

[SPEAKER_00]: You know, if there's stronger evidence that it would boost or protect somebody, if we could get that evidence, then you could make a more compelling case that that ought to be introduced.

[SPEAKER_00]: Sure.

[SPEAKER_02]: I just feel like every time you interface with the healthcare professional, you know, if somebody's not currently exercising, just maybe you should exercise.

[SPEAKER_02]: Yeah, you should exercise and maybe eat vegetable today.

[SPEAKER_02]: Something.

[SPEAKER_02]: Something.

[SPEAKER_02]: Next question.

[SPEAKER_02]: We're talking about dead lifts for hypertrophy.

[SPEAKER_02]: Of the big three, why do you think the deadlift is so contentious in regards for being a good exercise for hypertrophy when the Romanian deadlift is often regarded as a staple for hamstrings in a hypertrophy-focused program?

[SPEAKER_02]: Obviously, there are differences in the movements, but surely not enough for these to be an opposite ends of the game's spectrum.

[SPEAKER_02]: I agree.

[SPEAKER_02]: Okay, next question.

[SPEAKER_02]: Yeah, as far as why this is so contentious.

[SPEAKER_02]: I think there are like four major like areas of concern that are all lumped into one when people say I don't don't don't do deadlifts for hypertrophy.

[SPEAKER_02]: One is this concern over injury risk.

[SPEAKER_02]: The second is this lack of eccentric focus within most deadlifts, how people perform them, right?

[SPEAKER_02]: It's mostly focused on the concentric, the way up and down is like, let's set the bar down, don't drop it.

[SPEAKER_02]: Third is maybe a more global or systemic muscle loading kind of nature of the regular deadlift compared to the RDL which is more like focused on the posterior chain.

[SPEAKER_02]: You could make maybe that argument, not strong argument, but [SPEAKER_02]: unargument, and then concerns over fatigue.

[SPEAKER_02]: And so I think between injury risk and concerns over fatigue, that's what most like, quote, science-based lifters might refer to.

[SPEAKER_02]: So let's go through each one of these.

[SPEAKER_02]: I think the concern over injury risk would get your take on this Dr.

Barackie.

[SPEAKER_02]: I think this is misplaced because it assumes within this context that an RDL has a significantly lower risk of injury than the regular deadlift.

[SPEAKER_02]: And I don't know that to be true.

[SPEAKER_02]: In fact, I would say, again, if you took a thousand people who are untrained, you gave them the same program, one group did the RDL and the other group did the regular deadlift, I would predict they would have the same injury risk at the end of a year.

[SPEAKER_02]: Is that sound reasonable, do you?

[SPEAKER_00]: Sounds like a reasonable starting hypothesis.

[SPEAKER_00]: Yeah, I'm convinced that there would be likely.

[SPEAKER_02]: No, the lack of eccentric focus, that is real, the way the most people perform their dead lifts.

[SPEAKER_02]: So yeah, most people with a regular deadlift, whether it's sumo, conventional, whatever, the up, you're just working, trying to get the weight up.

[SPEAKER_02]: And then when you set it down, it's not really under.

[SPEAKER_02]: Much control other than you keep your hands on the bar, whereas the RDL and a stiff leg a deadlift, for example, both have a more controlled e-centric, which you would predict is probably better for high-perrophy, just you're getting a paired e-centric and concentric movement.

[SPEAKER_02]: I would predict that to work a slightly better for high-perrophy than no-e-centric, for example.

[SPEAKER_02]: to test that.

[SPEAKER_02]: So you would have to test it.

[SPEAKER_02]: That's my starting hypothesis, but to test it, you would have to have people do like a conventional deadly for the same rep sets, proximity failure, et cetera, and then drop every rep compared to the RDL, which would be performed with like a 210 tempo or something like that.

[SPEAKER_02]: Yeah, the more global versus local muscle group loading, I think that's made up entirely.

[SPEAKER_02]: Like people are like, I feel my hamstrings more when I'm doing RDLs, then when I'm doing regular deadlift, so I'm like, well, yeah, cause the eccentric component is slower.

[SPEAKER_02]: Not because the lift itself is like loading different muscles.

[SPEAKER_02]: It's the same muscles, just more eccentric focus.

[SPEAKER_02]: So I think that's more of the second.

[SPEAKER_02]: But this fatigue and certain thing, this to me is the most, [SPEAKER_02]: It's it's just annoying mainly because people are like all deadlifts are uniquely fatiguing and I'm like well yeah compared to like a biceps curl right and if we think about things that generally would increase fatigue have your weight.

[SPEAKER_02]: more volume, more muscle mass being activated, or you loaded sure, but like there's a limit to how far you can get with that.

[SPEAKER_02]: So for example, if you would predict that fatigue levels would be lower from the squat compared to the deadlift, they both work a similar amount of total muscle mass, the deadlift though, use more weight, [SPEAKER_02]: right and so you would predict that any marker of fatigue that is validator we think is reasonable to track it would be higher after squats and multiple studies at least two that I've linked here in the show notes show that's not the case you're like okay well those are both a lot of muscle mass let's let's give more extreme example how about the bench press [SPEAKER_02]: versus the deadlift.

[SPEAKER_02]: And so one way to track fatigue would be like, look, if you do a session of deadlifts, compared to a session of bench press, how quickly does your force production potential come back afterwards?

[SPEAKER_02]: You would predict a less fatigued exercise for force production to return more quickly and a more fatigued exercise for force production to take longer to come back.

[SPEAKER_02]: And when that's tested, that doesn't show up either.

[SPEAKER_02]: So, [SPEAKER_02]: I don't think these fatigue concerns are particularly useful when picking a hinge variation because you're not picking between a biceps curl and a deadlift.

[SPEAKER_02]: You're picking between a deadlift and a Romanian deadlift or a deadlift and a stiff leg a deadlift or a deadlift and a hip thrust.

[SPEAKER_02]: And I'm like, I predict these all to globally cause about the same amount of [SPEAKER_02]: The focused eccentric component, though, may be more useful for high-perrophy with an RDL or a stiff-legged deadlift over the way that people mostly perform deadlifts.

[SPEAKER_02]: But ultimately, it's the silly premise to me, because you got to pick one exercise, and I'm like, why aren't you doing most more exercises?

[SPEAKER_02]: Because that's what I would generally pick for high-perrophy.

[SPEAKER_02]: Use multiple exercises to work the muscle group of muscle groups of interest from different angles, relatively large range of motions for all of them.

[SPEAKER_02]: and get somewhat close to failure and go from there.

[SPEAKER_02]: But picking one exit like the one exercised through the mall.

[SPEAKER_02]: It should have been RDL or regular deadlift.

[SPEAKER_02]: I'm like, poor canola Stos, wow, why wouldn't you do both?

[SPEAKER_00]: Or because of the fact that they involve so much muscle mass, that can also be broken apart such that if you had no interest in performance of a particular lift, [SPEAKER_00]: if you had no interest in function in your daily life, but you were purely of the interest of hypertrophy and particular muscle groups.

[SPEAKER_00]: You also don't even have to deadlift, you know, like you could become an exceptionally competitive bodybuilder.

[SPEAKER_00]: I'm sure without training.

[SPEAKER_00]: the deadlift very much by training a lot of these muscle groups more more individually.

[SPEAKER_00]: Neither of us would claim to be body builders.

[SPEAKER_00]: We have experienced some hypertrophy over the course of our training career, but that's not been like the primary focus, but you could also why not snatch grip RDL?

[SPEAKER_00]: Why not snatch grip deadlift?

[SPEAKER_00]: You can get even more range of motion about the hamstrings and the low back.

[SPEAKER_00]: Why not do deficit snatch grip RDL?

[SPEAKER_00]: Like you could take [SPEAKER_00]: or you could do prone hamstring leg curls or all sorts of other single leg things.

[SPEAKER_00]: The thing is with respect to hypertrophy, you have enormous options.

[SPEAKER_00]: That's the nice thing about bodybuilding and hypertrophy oriented training.

[SPEAKER_00]: There is absolutely nothing that you have to do or that you can't do.

[SPEAKER_00]: You can do absolutely anything.

[SPEAKER_00]: What sucks more about competitive powerlifting is you have no choice but to squat bench press and deadlift within certain arbitrary rules.

[SPEAKER_00]: And if you don't like that too bad, if you can't tolerate that too bad, if an injury limits you from doing those movements to the competitive standards too bad.

[SPEAKER_00]: But in bodybuilding, none of that matters.

[SPEAKER_00]: You can achieve a lot of hypertrophy in all sorts of ways without any consideration of rules of how I got there or which exercises I didn't do.

[SPEAKER_00]: And so, yeah, similar to your thoughts on the premise here, I'm just like, this is not something that I can serve myself with at all because you can hypertrophy in tons of other ways.

[SPEAKER_00]: And I don't even really think of them as building that particular outcome in a unique way.

[SPEAKER_02]: Yeah, yeah, it's one of the interesting maybe pushbacks against that is you know some guys the talking face over somebody else's video It would be your video this video if you say you don't have to deadlift and then somebody's head pops up Stitching I mean, you know like why is it then that all like top level bodybuilders started out You know do and heavy deadlifts and squats and bench press or whatever, and I'm like I have a perfectly rational and likely true response to that [SPEAKER_02]: when you get bit by this resistance training bug, whether you end up as a body builder, a power lifter, strength, and enthusiast, whatever.

[SPEAKER_02]: It's just the all kind of enter in the same funnel.

[SPEAKER_02]: It's like, get big, get strong, get jack, all this other sort of stuff.

[SPEAKER_02]: And you kind of get lead into these movements, which have this arbitrary importance across most enthusiasts for the gym, for some, [SPEAKER_02]: relatively long period of their life.

[SPEAKER_02]: Whether or not that's better or worse, we don't know.

[SPEAKER_02]: It just seems to be that like the track from untrained to like Jim Rat is pretty much the same.

[SPEAKER_02]: Oh, you start with the interest in the big compound lifts.

[SPEAKER_02]: And then you specify later on, perhaps, or you burn out and you never lift again, like whatever.

[SPEAKER_02]: Those are the two kind of athletes.

[SPEAKER_00]: Yeah, I mean, they're generally appealing things.

[SPEAKER_00]: They are easy to compare one to another, but within person and across people, they generally can enjoy pretty rapid progress, you know, just into the plates over plates at the beginning.

[SPEAKER_00]: Whereas assessing your hypertrophy progress as a beginner or something, especially if you start out with an excess body fat, it's like, man, it's going to take a long time before we can totally feel confident that you're making tons of progress.

[SPEAKER_00]: And so, yeah, I get the appeal of, like, yeah, you're dead.

[SPEAKER_00]: If you want to 350 pounds in the first three months of your training or something like that, neat, that's a very appealing thing.

[SPEAKER_00]: Whether a decade later, when you step on to a bodybuilding stage, whether that was [SPEAKER_00]: You know, heavily influenced by your first few months of training the deadlift, probably not, you know, by that by that point in your training career.

[SPEAKER_02]: So yeah, I agreed moving on recovery chances in terms of a non-traumatic injury, hey, were you ever on student doctor network when you were I probably not because you got directed mid so you're like didn't have to I was aware that it existed, but I never needed it as a resource for myself.

[SPEAKER_02]: So if you're not in the health care, if you've never went to medical school, whatever, that means you're well adjusted and hats off to you.

[SPEAKER_02]: If you were, and you are familiar with student doctor network, I'm not about to tell you anything you don't know about this for the people who don't know what I'm talking about.

[SPEAKER_02]: This was a forum, I think it's still an active forum where people apply into either medical schools or residency programs would basically be able to interface with other folks doing the same thing or people who have previously done it.

[SPEAKER_02]: And there was just these laundry list of threads.

[SPEAKER_02]: every single fall.

[SPEAKER_02]: That's the prime like interview season and the title would be chance me for getting into medical school and you'd post your MCAT, your science GPA, your extracurriculars and whatever, and then people would say no chance.

[SPEAKER_02]: No shots.

[SPEAKER_02]: For the record, I undertook this in 2011 and everyone said no chance.

[SPEAKER_02]: You got no chance of getting accepted to a med school.

[SPEAKER_02]: Would you say they said you had no chance?

[SPEAKER_02]: I showed them.

[SPEAKER_02]: That's right.

[SPEAKER_02]: They said I know chance I said it was done.

[SPEAKER_02]: Anyway, so that's that when I saw this question.

[SPEAKER_02]: I go, oh interesting call back So this question says what's your take on the permanency of non-traumatic injuries like disc herniations or sciatica?

[SPEAKER_02]: The context here is that this person says I have colleagues at my IT job dealing with chronic back pain and their doctors are pushing the classic narratives [SPEAKER_02]: of degenerate disc disease, pinch nerves, and bad posture being the root cause of irreversible damage.

[SPEAKER_02]: Now I know that this wear and tear or body as a fragile machine model is outdated and generally helpful, but I'm just curious if there would be some extreme scenarios where incorrect posture or very asymmetrical movement patterns would cause permanent issues.

[SPEAKER_02]: Outside of a severe traumatic event can a person truly cause permanent structural breakdown just by moving, quote, incorrectly, over time, or is it more that the damage seen on imaging is often just a normal, poorly correlated part of aging, and the pain experience is largely driven by factors like load management, fear of avoidance, beliefs, or other biological, bio-psychosocial stressors.

[SPEAKER_02]: Basically, when people talk about being permanently broken, are they describing a busted piece of hardware, the spine, or a software issue, the nervous system's threat detection that can be rehabbed with graded exposure and education?

[SPEAKER_02]: I think this person already knows the answer to this question.

[SPEAKER_02]: And like, we could just ask this.

[SPEAKER_00]: I mean, this is complicated.

[SPEAKER_02]: So it is, but I'm just saying, like, with the nomenclature, the verbiage being used to it.

[SPEAKER_00]: Oh, they've clearly listened to us before.

[SPEAKER_00]: Yeah.

[SPEAKER_02]: Uh, so my initial take when I read all this a couple of times, I was like, just ask the people what they mean.

[SPEAKER_02]: But like, in this case, your colleagues, hey, you're telling me about your back pain and your doctor said that you have degenerative disc disease or whatever from these movement patterns.

[SPEAKER_02]: What, what does that mean to you?

[SPEAKER_02]: Because that's kind of how I would start this conversation with the patient.

[SPEAKER_02]: I'd be like, what's your understanding of this condition?

[SPEAKER_02]: and just let them go and they may in fact reflect that right back to you and say look I've been moving wrong my whole life I've been sitting wrong stand and wrong my whole life and I've caused this irreparable irreversible damage in my spine Which is causing me this pain and the follow-up question would be and so what does what do you think that means for your prospects for moving You know pain free in the future and they may say well look if it's irreversible I can't do anything about it.

[SPEAKER_02]: I'm likely to be in pain the rest of my life.

[SPEAKER_02]: I'm like oh shit That's the worst possible outcome there.

[SPEAKER_02]: Is that kind of makes sense to you?

[SPEAKER_00]: Yeah, I mean, these things always end up being very individual and super unique and almost always interesting conversations that I have with people when I get a sense of upfront.

[SPEAKER_00]: What are their beliefs?

[SPEAKER_00]: Where did they come from?

[SPEAKER_00]: What are they basing that level of confidence on if they have a confident self-assessment?

[SPEAKER_00]: on these things and then trying to find ways to get my foot in the door to gently they call it what do they call it like a compassionately compassionate confrontation I think is the phrase that is something like this in this literature where it's not like I'm coming at you and attacking you and telling you that your beliefs are bullshit but rather trying to identify ways that I can kind of like I said get my foot in the door and maybe challenge some aspects of your thinking.

[SPEAKER_00]: I mean, if I took my initial thoughts on this question is like by and large for the majority of situations, yes, I'm in agreement with the kind of implied understanding in this question because it reflects a lot of what we've talked about before, right?

[SPEAKER_00]: Where a lot of this is not necessarily the primary pathology that is permanent and irreversible and these folks are destined for lives of debility.

[SPEAKER_00]: But that is not a universal, right?

[SPEAKER_00]: So there are situations where somebody might be uniquely predisposed to some sort of pathology.

[SPEAKER_00]: So just to give some examples, people, we know that people with certain forms of connective tissue disorders, [SPEAKER_00]: They are at higher risk of various chronic pain syndromes.

[SPEAKER_00]: There's probably some biology there, right?

[SPEAKER_00]: That might not be something that we can easily modify or control at this time.

[SPEAKER_00]: That doesn't mean we don't try to rehab them using a comprehensive biosecsocial approach, but there might be something unique about that situation that basically is an additional challenge for us.

[SPEAKER_00]: or somebody has osteoporosis.

[SPEAKER_00]: And they end up experiencing as a result, multi-level, vertebral compression fractures, or something like that, like, okay, you know, sometimes those are asymptomatic, interestingly enough, but sometimes they're not, and they might need to be addressed.

[SPEAKER_00]: Or somebody is, you know, due to their history, or due to some genetic variables or something like that, uniquely predisposed to develop like accelerated osteoarthritis.

[SPEAKER_00]: Right.

[SPEAKER_00]: Again, these are some things that I'll ask you.

[SPEAKER_00]: Yeah.

[SPEAKER_00]: So these are all things that the clinician has to try to us out is like how likely is it that this finding this thing that I'm seeing is correlated with their experience and what other levers can I modify to try to impact their experience.

[SPEAKER_00]: And if I am like maximally pulling on all those other levers and I'm not making progress, then maybe that's a period where we do need to entertain [SPEAKER_00]: that much more direct pathology directed treatment of like a, yeah, a joint replacement or something like that might be the way to go like that can change the course of people's lives to get a hip replacement or a near placement for like severe symptomatic osteoarthritis so it's just quite complex and and that's why I think that working through these issues requires.

[SPEAKER_00]: clinicians who are educated, who are informed, who are experienced, who are good at having these conversations, who are good at listening and interacting.

[SPEAKER_00]: And it sounds like the types of clinicians that these folks are working with are generally failing one or more of those criteria.

[SPEAKER_00]: It's just hard to find somebody who's very good at having these conversations and helping people work through these types of things.

[SPEAKER_00]: I'm a shill for big physiatry or PM&R doctors.

[SPEAKER_00]: Although, as with everyone else, I've worked with some who are not awesome, but by and large, the PM&Rs who I have interacted with over the years, I've enjoyed quite a lot.

[SPEAKER_00]: One who is aware of us, and in our sphere, if somebody is, I think he's at NUSC, is Jim, Dr.

Jim Ubanks, fantastic.

[SPEAKER_00]: He's been on the podcast before.

[SPEAKER_00]: Rather than, you know, I think you have a worse chance of getting exceptionally good, non- [SPEAKER_00]: uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh [SPEAKER_00]: most of these folks understanding of their condition is inaccurate and unhelpful and it is the job of a competent skilled empathic clinician to help assess that understanding and gently massage it in a more favorable direction to generate more optimistic kind of views on their prognosis and getting them moving and things like that while also entertained in the possibility that yeah there might actually be some tissue level pathology that actually might need to be addressed more [SPEAKER_00]: there are some like I don't want to over-generalize and say like most of these persistent paint things are in your head because that's not a good way to frame this or to think about it.

[SPEAKER_00]: There are certainly situations where it's like now this person's got cancer in their spine or they got compression fractures or they have like [SPEAKER_00]: real advanced osteoarthritis that is not just like, you know, expected age-related changes for whatever reason and that deserves some consideration and shouldn't be prematurely dismissed just because they listen to a lecture on the BIOS like a social model or something like that.

[SPEAKER_02]: Yeah, yeah.

[SPEAKER_02]: I wanted to do a brief chat about the idea that maybe non-traumatic injuries like discarnations or sciatico would be permanent and then also talk about this like incorrect posture thing just briefly and move on.

[SPEAKER_02]: So with the first the first question, you know, what's your take on the permanency of non-traumatic injuries like discarnations or sciatica?

[SPEAKER_02]: I think the overwhelming evidence from both our clinical experience and the scientific literature suggests that for the vast majority of people, the answer is no, these things are not permanent.

[SPEAKER_02]: Present that's presenting with a discharneation, well non-surgical management leads to full resolution in four weeks increasing to 90% of patients within three months and so again That just speaks against the idea.

[SPEAKER_02]: But this is permanent.

[SPEAKER_02]: You're always going to have it.

[SPEAKER_02]: It can never get better It's probably not the case for these two specific examples [SPEAKER_02]: And then this idea that are there extreme scenarios where incorrect posture or very asymmetrical movement patterns could cause permanent issues.

[SPEAKER_02]: And I think to maybe get at the crux of this question, it seems like we would need to start with a generally healthy, generally like.

[SPEAKER_02]: full unrestricted movement that a person had and then over time by the way of them exercising, moving, sitting, standing, whatever, they somehow developed into this decrepit individual who can no longer move correctly.

[SPEAKER_02]: And I cannot think [SPEAKER_02]: of any way or mechanism that may be true, short of some severe like anatomical changes, either from a surgery and you know, but again, that's not really what we're talking about, some sort of trauma that required surgery or a mobilization for a long period of time, which is not really what we're talking about here.

[SPEAKER_02]: And so I think about some classic examples of asymmetrical movements, like golf, bowling, in cricket, tennis, et cetera, they all show adaptations to short of the spine, but also other aspects of the body that are not symmetrical.

[SPEAKER_02]: not symmetrical, whether these persist indefinitely after cessation of that sport or training for that sport is unknown, but they don't really appear to cause pain while people have these asymmetrical adaptations that make them better at their sport.

[SPEAKER_02]: It's not a bug, it's a feature of participating in this sort of training.

[SPEAKER_02]: So, I would push back against both of those things, compassionately.

[SPEAKER_02]: But I don't know, it sounds like in your situation, you know, maybe you're asking like, what to do about this, do I interject and if so how?

[SPEAKER_02]: I think if they ask you, you know about it, right?

[SPEAKER_02]: It seems like they're telling you about this.

[SPEAKER_02]: And so I think where I would maybe flip the switch is if they said, what do you think?

[SPEAKER_02]: And that would be a good way to get your foot in the door to say something like, well, tell me how, what do you understand about this?

[SPEAKER_02]: That's probably how I'd start.

[SPEAKER_02]: Rather than leading over, you know, beating somebody over the head with educational materials, that's really not going to be well received most of the time unless somebody's opening the door for you, I think.

[SPEAKER_02]: Yeah, reasonable take, here.

[SPEAKER_02]: All right, that is a wrap on this free sample of our bonus content that regularly goes out to our barbell medicine plus subscribers.

[SPEAKER_02]: Again, to join head over to barbellmedicine.com slash plus, and sign up to be a barbell medicine plus member today, that's barbellmedicine.com slash plus.

[SPEAKER_02]: Thank you so much for listening, we'll catch you guys next time.