[SPEAKER_00]: Welcome back to the Barbell Medicine podcast where we bring modern medicine to strength the conditioning and strength the conditioning to modern medicine.

[SPEAKER_00]: I'm your host, Dr.

Jordan Faganbomb, and on this podcast episode, we're going to do a medical mystery case.

[SPEAKER_00]: It's a real medical case.

[SPEAKER_00]: It's in the scientific literature.

[SPEAKER_00]: We'll ed you attainment for you.

[SPEAKER_00]: And we're going to do a little twist on this one.

[SPEAKER_00]: I'm going to be playing the role of the patient, so a little acting generously, chairedably using the term acting, so we'll see how good Dr.

Baraki is when he puts on his clinicians' hat, and also we got a quack watch from the New York Times.

[SPEAKER_00]: So that's going to be fun.

[SPEAKER_00]: On the other end of the line is the second most handsome Dr.

North America doctor Austin Baraki.

[SPEAKER_00]: What's going on, man?

[SPEAKER_01]: Hey, interesting, unexpected twists.

[SPEAKER_01]: So this hopefully this works out or at least provides the desired entertainment that people are looking for.

[SPEAKER_01]: But I'm doing all right.

[SPEAKER_00]: Yeah, people really just wanted me to to play the patient.

[SPEAKER_00]: I think this, you know, the people have been saying that.

[SPEAKER_00]: Everybody's been saying it.

[SPEAKER_00]: No, gosh, I just need, I want to get off the internet.

[SPEAKER_00]: This is an aside to the podcast and it's right.

[SPEAKER_02]: Yeah.

[SPEAKER_00]: I just, [SPEAKER_00]: The problem is, here's what's wrong about my brain.

[SPEAKER_00]: Now look, there's a lot of stuff that's up there that questionably, you know, maybe needs more therapy, less therapy, I don't.

[SPEAKER_00]: Something to change.

[SPEAKER_00]: But if I see something that is wrong, [SPEAKER_00]: And I feel like it's getting a lot of traction, like a lot of views, potentially harmful, like the stakes are reasonably high.

[SPEAKER_00]: Man, it's really hard for me to overlook that.

[SPEAKER_00]: It doesn't mean that I want to get into like a confrontational argument, but if I can provide some like steering or correction or, you know, politely worded feedback, I feel like I've been better about that over the last like ten years, you know, as I've, as I've matured.

[SPEAKER_00]: So the latest one has to do with this notion of leptin resistance, which is a, [SPEAKER_00]: If you guys, if you're listening to this and you don't know what left in resistance is, great.

[SPEAKER_00]: Don't worry about it.

[SPEAKER_00]: Just tune out, black out for like the next, you know, two and a half minutes, but left in is this hormone.

[SPEAKER_00]: It's, it's best characterizes like maybe eight.

[SPEAKER_00]: a short acting sort of appetite regulator in most folks.

[SPEAKER_00]: It is in the body floating around proportional to the amount of body fat that you have.

[SPEAKER_00]: So the less body fat you have, you have low levels of leptin, the more body fat someone has the higher levels of leptin.

[SPEAKER_00]: People have and it's been thought that if a person were to gain a significant amount of body fat, well, the leptin levels would go up and that this particular hormone, which again, usually in the short term acts as sort of like a [SPEAKER_00]: a satiety hormone or like stop eating.

[SPEAKER_00]: That was this thought, right?

[SPEAKER_00]: And so, oh, if you have all this extra body fat, your leptin levels are high, it should go to your brain and stop you from eating more.

[SPEAKER_00]: That theory's been around for twenty five years.

[SPEAKER_00]: There's effectively no evidence in humans supporting that line of thinking.

[SPEAKER_00]: Even when you give people a lot of like extra leptin exogenous, leptin through the medication metroleptin and other sort of agents that have been tried to manipulate this leptin axis, if you will, are leptin hormone.

[SPEAKER_00]: It doesn't work.

[SPEAKER_00]: People still eat.

[SPEAKER_00]: It doesn't tamp down your appetite.

[SPEAKER_00]: In fact, what we've learned is that individuals with very low body fat, whether it's starvation, anorexian nervousus, stuff like that, they have very, very low levels of leptin.

[SPEAKER_00]: And that is a very strong appetite stimulant, very, very strong.

[SPEAKER_00]: And so, yeah, that's how it works.

[SPEAKER_00]: It just doesn't seem to do much when it's high.

[SPEAKER_00]: And even these new like GLP-one receptor agonist, so ozampic, with gov, trisepotide, et cetera.

[SPEAKER_00]: They actually lower leptin levels.

[SPEAKER_01]: Actually, I didn't know that.

[SPEAKER_00]: Yeah, the recent meta-analysis came out a few months ago, twenty something studies, lowers leptin levels.

[SPEAKER_00]: It's more of like a, you know, hey, you didn't know this.

[SPEAKER_00]: Well, there you go.

[SPEAKER_00]: It doesn't, that's not the way it works to tamp down appetite because you would think if anything, oh, you lowered leptin.

[SPEAKER_00]: Oh my gosh, people's appetite should be much higher on these medications.

[SPEAKER_00]: Turns out it's just, that's not really how leptin works.

[SPEAKER_00]: And so, [SPEAKER_00]: providing a little bit of feedback about this this idea left in resistance is the cause of obesity and it's not will power I'm like well we agree that will power isn't like the main thing that's changed over the last fifty years with the tripling of the obesity rates [SPEAKER_00]: but it's not due to left and resistance.

[SPEAKER_00]: Because that is really it.

[SPEAKER_00]: No evidence in human to show that it happens.

[SPEAKER_00]: And oh, no, yeah, does look at what GLP one receptor agonist do.

[SPEAKER_00]: I'm like, yeah, they actually lower left and levels, which is kind of the opposite of your theory here.

[SPEAKER_00]: And so, and then I was called a wellness influencer, which I guess I've been called worse.

[SPEAKER_01]: Sure.

[SPEAKER_01]: I mean, how do you feel about that characterization?

[SPEAKER_00]: I don't, I guess, you know, it's like, the people say it in a disparaging way where it's like, right.

[SPEAKER_01]: I think that's the issue.

[SPEAKER_00]: Yeah.

[SPEAKER_00]: Yeah, you're medically trained, but now look at you.

[SPEAKER_00]: You're a wellness influencer.

[SPEAKER_00]: And I'm like, [SPEAKER_00]: Am I wrong though?

[SPEAKER_01]: Our physicians wellness influencers, if you take the terms literally, you would hope.

[SPEAKER_00]: You would hope.

[SPEAKER_00]: It's just weird.

[SPEAKER_00]: I'm like, I'm like, if somebody says something that is far outside of their area of expertise, and it happens to be incorrect and potentially harmful.

[SPEAKER_00]: Like I do think it needs to be corrected.

[SPEAKER_00]: I just wish that I had a better story about leptin rather than like, oh, look, here's the data.

[SPEAKER_00]: So you just, you know, [SPEAKER_01]: Yeah, it strikes me as being very analogous to the carbohydrate insulin kind of theory.

[SPEAKER_01]: It's like people have this idea.

[SPEAKER_01]: Here's what insulin does.

[SPEAKER_01]: It, you know, causes storage of things.

[SPEAKER_01]: Therefore, when it goes up, things are stored that includes body fat, so don't eat carbs, insulin goes down, fat goes away.

[SPEAKER_01]: And it's like, that's a nice, neat, tidy story, similarly.

[SPEAKER_01]: left in, you know, proportional to body fat.

[SPEAKER_01]: And so when it's very high, et cetera, et cetera.

[SPEAKER_01]: And so here's the implications of my model.

[SPEAKER_01]: And it's like, okay, that's like a theoretically kind of tight explanation.

[SPEAKER_01]: Now let's test it.

[SPEAKER_01]: And when both of those things have repeatedly failed to be predictive of outcomes in humans, both the carbohydrate insulin model has, you know, not been well supported.

[SPEAKER_01]: And neither has this left in resistance model or kind of theoretical explanation.

[SPEAKER_01]: So you just trash them and move on.

[SPEAKER_01]: Yeah, instead of getting wedded to it and like basing your identity and your business model and your practice patterns all around theories that, you know, don't work.

[SPEAKER_00]: That's the other thing.

[SPEAKER_00]: It's like this particular person is not in the health or fitness scene.

[SPEAKER_00]: They're just like, left in resistance.

[SPEAKER_00]: Why don't people more people know about this?

[SPEAKER_00]: And I'm like, well, if anything, left in resistance has been like promulgated by [SPEAKER_00]: Well, this people like in the low carb world like that's like the whole thing So like and people who like should know about left and resistance Do generally know about it and they're like yeah, this isn't really the thing similarly to like oh you just got to keep insulin levels low.

[SPEAKER_00]: It's like yeah, well GLP one receptor agonists actually increase insulin and cause massive weight loss [SPEAKER_00]: Oops.

[SPEAKER_00]: Oops.

[SPEAKER_00]: Yeah.

[SPEAKER_00]: It didn't work out.

[SPEAKER_00]: Anyway, a few announcements before we get into this week's podcast.

[SPEAKER_00]: One, we just released the second generation low fatigue templates.

[SPEAKER_00]: There's a series of templates.

[SPEAKER_00]: Previously, it was all like, like, maximal strength focused powerlifting focus, but now I've put four separate, sixteen week programs and they get a three day powerlifting program.

[SPEAKER_00]: four-day per week powerlifting program, a power building program, any general strengthening program, because if you're like, hey, maybe, I want to stay a little bit further away from failure.

[SPEAKER_00]: I want some more opportunities to train without having to go to the well every single time, but I don't, I'm not a powerlifter, what do?

[SPEAKER_00]: Well, here you go.

[SPEAKER_00]: I got you covered.

[SPEAKER_00]: I revised all the programming.

[SPEAKER_00]: So now it's more responsive to the individual based on their performance potential for the day, how they're feeling, et cetera.

[SPEAKER_00]: So they get the correct training load.

[SPEAKER_00]: All of the condition work has been massively overhauled as well to make sure that not only are people meeting, the current physical activity guidelines for conditioning, but they're also attending to improve their performance with respect to endurance tasks.

[SPEAKER_00]: And it was previously like an eighty-five something page ebook, like my treatise on programming strictly for strength.

[SPEAKER_00]: Well, now it's swell to over a hundred and ten pages, including stuff on hypertrophy, conditioning, program design relating to those things and further expansion of the trouble shooting sections.

[SPEAKER_00]: I think it's my best work yet.

[SPEAKER_00]: I spent a lot of time on it.

[SPEAKER_00]: I'm pretty proud of it.

[SPEAKER_00]: Yeah.

[SPEAKER_01]: You sure did.

[SPEAKER_01]: Congratulations on the effort.

[SPEAKER_01]: And get that up there.

[SPEAKER_00]: Thanks.

[SPEAKER_00]: I've tried to pat myself on the back of my mobility sucks.

[SPEAKER_00]: So I have to do it.

[SPEAKER_00]: It is linked in the show notes below.

[SPEAKER_00]: You can go on to the website, check that out.

[SPEAKER_00]: And if you're on the fence, you get a free one week sample.

[SPEAKER_00]: If you're a barbell medicine plus subscriber, you get, I believe it's a three week extended sample of all the four different programs just to see if one catches your eye, you like it.

[SPEAKER_00]: So check, check that out.

[SPEAKER_00]: And we do have a seminar coming up.

[SPEAKER_00]: It's in September.

[SPEAKER_00]: We are sponsored, sponsored, going.

[SPEAKER_00]: So if you're on the fence about attending a live in person seminar for us, well, you should, you should act now.

[SPEAKER_00]: The link is in the description below.

[SPEAKER_00]: It's in San Antonio September twenty at the twenty first.

[SPEAKER_00]: Get to train with us on Friday.

[SPEAKER_00]: It's going to be a good time and I hope to see you there.

[SPEAKER_00]: All right, we're going to go to a quack watch.

[SPEAKER_00]: And I didn't send you this because it's a mystery case.

[SPEAKER_00]: And so that would, you know, if I sent you the outline before the mystery case, you'd see what it is.

[SPEAKER_00]: And that would be relatively unfair.

[SPEAKER_00]: So you're going to get this in real time.

[SPEAKER_00]: And I want to get your live reaction.

[SPEAKER_00]: So this was published in the New York Times.

[SPEAKER_00]: I believe it's like a wellness newsletter they sent out.

[SPEAKER_00]: And I don't have statistics on this, like how many people subscribe to this newsletter.

[SPEAKER_00]: I suppose it's a lot.

[SPEAKER_00]: I think I don't know this.

[SPEAKER_01]: I'm on the largest media organizations out there.

[SPEAKER_01]: Yeah, I bet it's a large number of people who saw whatever this is about to be.

[SPEAKER_00]: So here's the first line from this newsletter.

[SPEAKER_00]: There's also published on their website.

[SPEAKER_00]: And I quote, as I write this, I'm wearing a large heating pad on my back like a cape.

[SPEAKER_00]: Why?

[SPEAKER_00]: Because when I parked my car at the grocery store, I made the mistake of twisting around to grab shopping bags from the back seat.

[SPEAKER_00]: to go on about how she has this author's head low back pain.

[SPEAKER_00]: And then she says, so I thought it might be helpful to focus on how to prevent back pain in the first place.

[SPEAKER_00]: And I've asked orthopedic doctors for their best tips.

[SPEAKER_00]: Now, Dr.

Barackie, you are very, very familiar with the literature on low back pain.

[SPEAKER_00]: You have treated a lot of individuals low back pain.

[SPEAKER_00]: You have worked through low back pain on your own.

[SPEAKER_00]: I would go so far as to call you a subject matter expert on low back pain.

[SPEAKER_00]: Now, if you had a question about low back pain, [SPEAKER_00]: orthopedic doctors your first to your first pick.

[SPEAKER_01]: Generally not, you know, this is not intended to throw shade at orthopedists out there like by and large.

[SPEAKER_01]: They are no haycombs.

[SPEAKER_02]: Yeah.

[SPEAKER_01]: Right.

[SPEAKER_01]: They're generally quite good at what they do, meaning the skill set that they are trained for, which involves slicing and dicing to improve.

[SPEAKER_01]: you know pathologies of various you know orthopedic structures and joints joint replacements for example i would one hundred percent interest they will train orthopedist you know they're also even further subspecialties out of orthopedics who i would trust with their you know realms of expertise be it ortho oncology or hand surgeons or various other other niches but back pain by and large [SPEAKER_01]: is a non-surgical problem.

[SPEAKER_01]: And so, going straight to a surgeon for, you know, opinions on this, it's not to say that they're unreliable for this, but just that there's going to be a little bit more variation in the quality of advice that you're going to get from someone who might, you know, spend most of their day operating on patients for a problem that by and large does not require surgery.

[SPEAKER_01]: There are certainly situations with respect to back pain that do require surgical intervention.

[SPEAKER_01]: Sometimes purely orthopedic related issues be its final fractures, certain discarneated herniation type situations that do benefit from surgery, definitely like other forms of cancers and other infections and things like that that can get into the spine.

[SPEAKER_01]: But common low back pain, which is what this article author is speaking on, is not something that really needs an orthopedic surgeon to be involved at all in their evaluation or management.

[SPEAKER_01]: And so you run the risk of something that is very commonly seen when going to specialists in a given area is you end up getting commentary ideas advice that are subject to their own selection bias.

[SPEAKER_01]: And so this is, for example, where, you know, in recent years as pickleball has gotten much more popular, you started to see all these articles about how injurious pickleball is.

[SPEAKER_01]: And it's like, you know, they're interviewing people who see people with injuries, not all the people who are out there doing great and improving their health and function and feeling well and, you know, various things like that, right?

[SPEAKER_01]: If you go to an ER doctor and you're like, can you tell me your opinion on fireworks?

[SPEAKER_01]: And it's like, [SPEAKER_01]: If there are people who only see the really bad stuff that happens when things go wrong with fireworks, right?

[SPEAKER_01]: So there are certainly many of them who have that insight into what is the selection of my population and try to like consciously counter that bias with like bigger datasets than just their own experience.

[SPEAKER_01]: But I think that's hard to do for a lot of clinicians and is not the default setting.

[SPEAKER_01]: When a lot of times when you go to clinicians, they're going to tell you what they know based on, especially the further out they get from formal training, you're going to get less and less evidence base and more and more experience based, which is just unfortunately the way it is unless they go out of their way to stay up to date on evidence and things like that.

[SPEAKER_00]: Yeah.

[SPEAKER_00]: Yeah.

[SPEAKER_00]: I mean, I don't think that this particular author is like an investigative journalist.

[SPEAKER_00]: Although I would [SPEAKER_00]: if I would want that.

[SPEAKER_00]: And then I would want them to think about this, say, okay, look, if I'm trying to write this thing about low back pain, who would I ask?

[SPEAKER_00]: And you could say, well, maybe asking, oh, surgeon.

[SPEAKER_00]: Sure.

[SPEAKER_00]: You know, on with P to surgeon.

[SPEAKER_00]: Yeah.

[SPEAKER_00]: Yeah.

[SPEAKER_00]: Maybe should ask a physical therapist.

[SPEAKER_00]: Sure.

[SPEAKER_00]: And maybe I should ask, maybe like a clinician researcher, like hybrid that those actively involved in low back pain research.

[SPEAKER_00]: Like to me, that would be like the [SPEAKER_00]: three horsemen, like, great.

[SPEAKER_00]: Sure.

[SPEAKER_00]: Yeah.

[SPEAKER_00]: But it's kind of like, like, Fox News the other day asked, like, Texas mom about high fructose corn syrup, the cane sugar.

[SPEAKER_00]: It's like, how did you arrive?

[SPEAKER_00]: Like, these are the expert anyway.

[SPEAKER_00]: Yeah.

[SPEAKER_00]: So that's, that's my first gripe, but like, okay, let's, let's suspend this belief.

[SPEAKER_00]: Maybe this is a great thing.

[SPEAKER_00]: And we're just, this is actually a positive quack watch.

[SPEAKER_00]: Sure.

[SPEAKER_00]: Dr.

Arthur L.

Jenkins, a third great name, by the way.

[SPEAKER_00]: The neurosurgeon in New York City, who specializes in spinal surgery to your point, he says to avoid bending, lifting, and twisting the BLT as he calls it.

[SPEAKER_00]: This maximizes the stress on the disc, making it more likely to rupture as a spine surgeon I would never do it.

[SPEAKER_00]: And you know that a phrase, look, the guy came up BLT, or he catchy, right?

[SPEAKER_00]: And pretty quick, that's been said a lot to patients.

[SPEAKER_00]: Hey, don't BLT, you gotta avoid it.

[SPEAKER_00]: I, as a neurosurgeon, would never do it.

[SPEAKER_00]: Completely ignoring the fact that as you interact with the environment around you, you most certainly will have to bend, lift and twist, not only separately, but also at the same time.

[SPEAKER_00]: Can you imagine trying to go about your daily life without ever bending, lifting and twisting at the same time?

[SPEAKER_01]: Yeah, I mean, I imagine this neurosurgeon just goes about his day like living in a very tight corset that allows him to do none of those things with his thorax and he just remains rigidly upright and doesn't move actually has a series of assistants who carries him.

[SPEAKER_00]: from room to room and like I do do this thing.

[SPEAKER_00]: Yes, when lifting an object, make sure both feet are planted and your weight is evenly distributed.

[SPEAKER_00]: Then lift from your legs instead of your arms and back, said spine surgeon at the hospital for special surgery in Manhattan.

[SPEAKER_00]: So there's a second surgeon.

[SPEAKER_00]: those that's not terrible advice like you I guess in order to produce force against the ground your feet would have to be on the ground so that is a physics lesson that we all needed in this newsletter.

[SPEAKER_00]: I don't know about your weight being evenly distributed because like what if picking up something or interacting with the environment forces you into a posture that your weight isn't a hundred percent balanced over your midfoot.

[SPEAKER_01]: Yeah, I mean, I think if we wanted to be maximally charitable to this guy that if he is advising against, you know, high effort lifting in very awkward positions to which you are unaccustomed.

[SPEAKER_01]: Yeah, there may be some risk of some discomfort associated with that because you are unaccustomed to that sort of thing, but.

[SPEAKER_01]: If you went in the other direction and you said that anytime somebody does follow that advice, right, that they are not going to experience back pain, well, that are rehab team would argue otherwise, because we have lots of folks who, you know, have gone about their lifting careers, following what would be considered kind of best advice for like deadlift training.

[SPEAKER_01]: For example, their feet are planted on the ground.

[SPEAKER_01]: They have the symmetric set up.

[SPEAKER_01]: The bar, the load is as close to their [SPEAKER_01]: You know, shins, as you can get it, trying to maintain your center of mass and everything all aligned and following that, and sometimes people still develop Baptist comfort.

[SPEAKER_01]: And so I think that there are variables that can be manipulated to, you know, that may contribute to an increased risk of Baptist comfort, or that may lower that risk.

[SPEAKER_01]: I think that our advice historically has typically been in the realm of [SPEAKER_01]: prepare for the thing you're trying to do and try to be prepared for those kind of things, whether in the gym or in day to day life like exposure is worthwhile and don't try to bite off more than you can chew in a lot of these situations.

[SPEAKER_01]: And beyond that, if you're still well prepared for something and you still develop some some backache, sometimes things just happen and these things are not always one hundred percent within our control.

[SPEAKER_01]: And sometimes even people who never do any of these things, be it bending or lifting or twisting, [SPEAKER_01]: or don't at least recall an incident with one of those activities, they still develop potentially very debilitating back pain.

[SPEAKER_01]: And so, you know, I think that there is like a charitable way to interpret this, but at the same time, it's not the way that we typically try to communicate around these topics to patients because it tends to generate [SPEAKER_01]: Relatively deeply seeded kind of hyper vigilance around movement and we're trying not to, ideally you go about your life not really having to think about every, you know, postural detail or something like that, right?

[SPEAKER_01]: Constantly, twenty four seven.

[SPEAKER_01]: That's not realistic in the same way that you should ideally not have to think about, you know, every calorie that is either entering your mouth or being expended by your body, like ideally we can set up your [SPEAKER_01]: daily habits, your dietary pattern, your food environment so that you don't need that constant hyper vigilance to everything.

[SPEAKER_01]: It kind of a similar concept when it applies to movement.

[SPEAKER_01]: And so these types of pieces of advice, I think are [SPEAKER_01]: Not as helpful as I think that this physician suspected it would be when he provided the quote.

[SPEAKER_00]: Yeah.

[SPEAKER_00]: The third surgeon is Dr.

Patel is a spine surgeon at Northwestern Medicine.

[SPEAKER_00]: He often sees patients vote running into trouble with activities such as pickleball, paddle tennis and golf.

[SPEAKER_00]: There it is.

[SPEAKER_00]: He says flexibility is key.

[SPEAKER_00]: So build in a warm up and stretching routine.

[SPEAKER_00]: For example, with golf at a low back and chest stretch, every three holes as an avid golfer.

[SPEAKER_00]: No.

[SPEAKER_00]: The dumbest thing I've heard, like one, it this presupposes that doing regular, we'll call it flexibility exercise, just some sort of guided.

[SPEAKER_00]: You know, flexibility training reduces the incidence of low back pain, which is not the case.

[SPEAKER_00]: And in fact, when people get a little overzealous with stretching, and they actually cause more, more symptomology.

[SPEAKER_00]: But on the course, if I was playing with a person in every three holes, they went through this whole routine, I'd like, dude, what do you do it?

[SPEAKER_00]: Yeah, like this is ridiculous.

[SPEAKER_00]: They, uh, further say, don't overload your carry on bag.

[SPEAKER_00]: Uh, that's not a motion that most people do every day.

[SPEAKER_00]: So be mindful not to overload your luggage.

[SPEAKER_00]: I personally never take a carry on bag on planes anymore.

[SPEAKER_01]: Wow.

[SPEAKER_01]: That's a remarkable.

[SPEAKER_01]: Instead of like, [SPEAKER_01]: Maybe get strong enough to wear, handling a carry on is a trivially easy task for you, just never going to never move anything over your overhead.

[SPEAKER_00]: This is like the doctor advice like, hey, if that hurt, don't, never do it.

[SPEAKER_00]: Ever, ever.

[SPEAKER_00]: Yeah.

[SPEAKER_00]: Where as we come back from a different perspective, it's like, look, I want you to have to the extent it's possible unrestricted movement, you know, you could do whatever you want, unfettered access to the entire conical behavior of the movement library that is so far exists in, you know, human history.

[SPEAKER_00]: I want you to be ready and be able to do all that.

[SPEAKER_00]: Fit for duty.

[SPEAKER_01]: Yeah.

[SPEAKER_01]: I want you to be seventy eighty plus years old and still able to lift your carry on into the overhead bin with no issues and no assistance from anyone else.

[SPEAKER_00]: Like have a carry on.

[SPEAKER_00]: to be able to travel, and to be able to lift in the overhead luggage.

[SPEAKER_00]: And then finally, and you knew this was coming, steer clear setups.

[SPEAKER_00]: They may put a lot of stress on the discs of your spine, core strengthening exercises such as planks, pilates, swimming, and yoga.

[SPEAKER_00]: And also the elliptical machine are a lot healthier for your back in general.

[SPEAKER_00]: We're personifying the back and back health, spine health.

[SPEAKER_00]: I mean, [SPEAKER_00]: This is like, it's like a low back pain, no sebo bingo card.

[SPEAKER_00]: You got like, you know, reductionism to just a disc injury, despite most of the low back pain not being related to a disc.

[SPEAKER_00]: You've got this, you know, biomedical model where oh, there has to be an injury to the disc, the ligga something.

[SPEAKER_00]: And that's what caused the pain, which again, most low back pain is specifically not.

[SPEAKER_00]: Nothing about doing more movements to like prepare yourself, where things that you might face, but instead just avoid more things, and then disc, disc, disc, disc, disc.

[SPEAKER_00]: And it's like, people already, even if they're not in the fitness space, and even if they've been exposed to some of our material or material like ours, [SPEAKER_00]: You hear disc injury disrupture.

[SPEAKER_00]: It's still kind of triggers.

[SPEAKER_00]: It's scary.

[SPEAKER_00]: Don't want that.

[SPEAKER_01]: Yeah.

[SPEAKER_00]: And you got all of them here.

[SPEAKER_01]: Yeah.

[SPEAKER_01]: I mean, this is that you could you could madlive this as Dr.

Miles likes to do and fit in, you know, running and your knees.

[SPEAKER_01]: It could be tennis and your elbows or your shoulder.

[SPEAKER_01]: And it's like, yep, all of those sports that, you know, deliver a particular stress.

[SPEAKER_01]: a little bit more bias towards a particular body area.

[SPEAKER_01]: People may be more susceptible to discomfort or overuse syndromes in that area.

[SPEAKER_01]: But the solution is not to just [SPEAKER_01]: withdrawal from that activity forever because it has the potential to contribute to some, you know, pain experience, but rather it's like be mindful of the dosage, be mindful of your tolerance, your capacity, and if something crops up here, the tools that you can use to self-manage and get better through that, which is what we aim to, the messaging that we aim to put out there instead of just never do this thing.

[SPEAKER_01]: Because the solution there is just withdrawal from all activity, [SPEAKER_01]: because all activity delivers some sort of physiologic mechanical stress to the body somewhere.

[SPEAKER_01]: And it's like, well, that doses off, you might get some pain.

[SPEAKER_01]: And that's the certainly a good way to avoid, you know, maybe the spine surgeons operating table for a discectomy, but it's also a great way to end up in the primary care office or the ER with a complication of cardiovascular disease because you develop metabolic syndrome from not, you know, moving for, you know, a large portion of your life out of fear.

[SPEAKER_00]: Yeah, I guess my question to you is now this is it is theoretically answerable if the data set existed, but but I've been actively looking for something like this and there's just not a lot of data on this, but my my speculation here is that if you took two groups of just twins identical twins and you split them right down the middle one group one side one group of identical twins on the other side.

[SPEAKER_00]: If the one group identical twins, they do not exercise.

[SPEAKER_00]: They don't lift weights or whatever.

[SPEAKER_00]: Any of that.

[SPEAKER_00]: In the other group, well, there they are resistance training, they're exercising, whatever.

[SPEAKER_00]: And you compared low back pain incidents in both groups.

[SPEAKER_00]: I actually think they'd be pretty similar.

[SPEAKER_00]: The only study that exists like this is mostly on with cardio only where the one cardio group was doing like six hours a week of conditioning the other group remain insufficiently active and the number of injuries, including low back pain was the same for the normal groups.

[SPEAKER_00]: And so it's like I don't know actually that avoiding these things reduces your risk of low back pain.

[SPEAKER_00]: I think in fact, [SPEAKER_00]: If you're avoiding all of these things to include exercise that would directly stress your low back in any sort of way, it actually just leaves you under-trained and maybe more vulnerable.

[SPEAKER_00]: Not to say that you need to be like have the super robust sort of, you know, strength and muscle mass, but whatever in order to prevent low back pain, but at least it prepares you for the movement more than sit on the couch.

[SPEAKER_01]: Yeah, it may just be tried off since shifting risks around instead of developing an overuse syndrome from maybe lifting a little bit more than you're ready for too much too soon.

[SPEAKER_01]: It leaves you undertrend and underdeveloped so that turning around to grab something out of the back seat or car is too much too soon.

[SPEAKER_01]: You know, and so you end up ultimately in a similar place.

[SPEAKER_00]: Yeah, if New York Times contacted me and they say, hey, you want to review this, just for, like, accuracy, whatever, they're like, yeah, so I think this is mostly harmful, net negative.

[SPEAKER_00]: It does not provide a lot of actionable advice for folks that would actually make them healthier.

[SPEAKER_00]: Instead, maybe we should do some stuff on pain education, like what it actually means to have low back pain, what it doesn't mean it's probably not a disc injury, most of the time unless you have these certain signs.

[SPEAKER_00]: And then which case, yeah, it's okay to be concerned and be evaluated.

[SPEAKER_00]: Let's introduce maybe the virus like social model.

[SPEAKER_00]: Let's talk about exercise, like what you can do, find an entry point.

[SPEAKER_00]: All sorts of stuff.

[SPEAKER_00]: But yeah, no, no, no.

[SPEAKER_00]: Let's just, you know what?

[SPEAKER_00]: Let's just talk about not lifting, look, you know, not having luggage.

[SPEAKER_00]: Never BLT?

[SPEAKER_00]: Yes.

[SPEAKER_00]: Great sandwich, by the way.

[SPEAKER_00]: And yeah, if you're going to blast us out to like a million subscribers, I think the other responsibility to do a good job.

[SPEAKER_01]: Yeah, here's an interesting kind of corollary to this.

[SPEAKER_01]: If we were to translate this into a different clinical setting, instead of talking to a spine surgeon about back pain, for example, let's say you went to an obesity medicine physician about their best tips to manage or avoid, you know, developing obesity.

[SPEAKER_01]: The analog of I just don't carry a carry on is.

[SPEAKER_01]: Yes, so I just don't eat.

[SPEAKER_01]: I just don't eat.

[SPEAKER_00]: Yeah, that's the analog of this.

[SPEAKER_00]: The way that I avoid with I avoid gaining weight is I actually don't take in any energy and it's pretty full proof.

[SPEAKER_00]: There you go.

[SPEAKER_00]: Yeah, just don't eat.

[SPEAKER_00]: Eat.

[SPEAKER_00]: Let's move more.

[SPEAKER_00]: Thanks New York Times.

[SPEAKER_00]: All right, so we're going to get into the mystery case now before we do, again, just to remind folks is a real case.

[SPEAKER_00]: Any jokes, any humor is purely for the entertainment portion of the edutainment, sort of the word we made up.

[SPEAKER_00]: Also, I'll be playing the role of patient.

[SPEAKER_00]: So this is a little twist, Dr.

Brock is going to have to treat me like his patient.

[SPEAKER_00]: So maybe more respect than normal.

[SPEAKER_00]: And I also do have to predict whether or not you're going to get this.

[SPEAKER_00]: And get this, I'm defining this particular type with not only the diagnosis.

[SPEAKER_00]: but why it happened.

[SPEAKER_00]: So a little house type type thing.

[SPEAKER_00]: So I'm gonna say that you, no, you're not gonna get it.

[UNKNOWN]: Okay?

[SPEAKER_00]: Yeah.

[SPEAKER_00]: All right, so let's get into this.

[SPEAKER_00]: So Dr.

Baraki is on call in the hospital in his hospital.

[SPEAKER_00]: And he gets a, he's chart checking as he normally does, particularly in the emergency room.

[SPEAKER_00]: We'll see, look, and I got somebody coming to me, like, what's going on?

[SPEAKER_00]: I have to go to ED.

[SPEAKER_00]: And he sees that there is a patient who's been in the emergency room for a couple of hours.

[SPEAKER_00]: It's a twenty-two-year-old male, the four-day history of fevers, difficulty, swallowing, and throat pain that's been associated with shortness of breath.

[SPEAKER_00]: And he thinks, man, I'm about to get a page from this.

[SPEAKER_00]: And, serendipitously, boom, page your goes off.

[SPEAKER_00]: It's the emergency department.

[SPEAKER_00]: They want Dr.

Barack, and he come down and see this patient.

[SPEAKER_00]: I am playing through all of the patient.

[SPEAKER_00]: My name is Torque Luith, and my friends call me T.

So, Dr.

Barackie, [SPEAKER_00]: Take it away.

[SPEAKER_01]: All right, T did.

[SPEAKER_01]: Did you pull your name from like a key and peel sketch?

[SPEAKER_01]: This sounds like one of those kinds of names.

[SPEAKER_00]: Exactly.

[SPEAKER_00]: I am a subscriber to the fandom website for key and peels experts West challenge.

[SPEAKER_01]: That's correct.

[SPEAKER_01]: Perfect.

[SPEAKER_01]: All right, T.

Well, tell me in the best way you can.

[SPEAKER_01]: What's going on today and what brought you in?

[SPEAKER_00]: Well, before we start, are you Austin Barbell Medicine?

[SPEAKER_01]: Yes.

[SPEAKER_00]: Oh, my God.

[SPEAKER_00]: I watch all of your stuff.

[SPEAKER_00]: I send your meme all over the place.

[SPEAKER_00]: I'm so happy that you're my doctor because you get you get I'm a lifter you know I'm a lifter bodybuilder so not really your cup of tea but I have been competing in bodybuilding for a few years yeah I don't know it's really weird like four days ago right before workout I have a normal pre workout meal so you know protein shake [SPEAKER_00]: and some oatmeal, and I went to the workout.

[SPEAKER_00]: It was legs, so it did some squats, some Romanian deadlifts, some hamstring curls, and everything was fine.

[SPEAKER_00]: Lifted normally.

[SPEAKER_00]: came home, eight dinner, normal dinner.

[SPEAKER_00]: But that night is kind of weird.

[SPEAKER_00]: Yeah, I started feeling like not so good.

[SPEAKER_00]: I thought, man, maybe I have a fever, but I don't have a thermometer.

[SPEAKER_00]: So I actually had to like, you know, Amazon Prime that to myself.

[SPEAKER_00]: And yeah, it said a hundred one, which I think is high.

[SPEAKER_00]: And then I noticed when I try to eat again later, because you know, six meals a day, trying to keep that metabolic furnace going.

[SPEAKER_00]: Yeah, I hear you.

[SPEAKER_00]: Yeah.

[SPEAKER_00]: It was tough, like I couldn't really eat.

[SPEAKER_00]: It was hard for me to chew and even harder to swallow because it was painful.

[SPEAKER_00]: And so then I thought, oh, I could just do like another protein shake.

[SPEAKER_00]: You know, I gotta get my protein in.

[SPEAKER_00]: But yeah, it was even hard with like, to drink like the protein shake, which was just liquid.

[SPEAKER_00]: So I didn't, you know, I didn't feel like any food was getting stuck or whatever, but I thought, man, this is weird.

[SPEAKER_00]: So I just went to bed.

[SPEAKER_00]: But that was four days ago.

[SPEAKER_00]: And every day it's kind of gotten a little worse.

[SPEAKER_00]: Like it's just hard for me to eat because of because of the pain.

[SPEAKER_00]: I can't really swallow.

[SPEAKER_00]: Yeah, I don't know.

[SPEAKER_00]: So four days now, I've had this fever.

[SPEAKER_00]: It's worse at night for sure.

[SPEAKER_00]: And I can't really eat.

[SPEAKER_00]: And I'm really worried that I'm going to lose all my gains because I can't eat.

[SPEAKER_00]: So that's why I can't hear.

[SPEAKER_01]: Okay, great.

[SPEAKER_01]: Glad you came in.

[SPEAKER_01]: This does sound like something that needs some medical attention.

[SPEAKER_01]: And you're doing some great acting so far as an, as an aside, is it fair to me to assume that this patient would be as fluent in their speech as you are right now?

[SPEAKER_01]: Would they be able to speak in complete sentences like this or would the symptoms that they're having, the throat pain, difficulty, you know, swallowing things that would that make it so they're not able to speak as clearly, fluently and breathe comfortably while they're talking.

[SPEAKER_01]: Breaking the breaking character here.

[SPEAKER_00]: Yes, or whatever.

[SPEAKER_00]: There's no report that the patient had any difficulty speaking or given a history, so I'll just assume that he can speak normally.

[SPEAKER_01]: Okay.

[SPEAKER_01]: So that's the first reassuring thing in terms of, like, how much of an emergency am I dealing with here?

[SPEAKER_01]: Do I have imminent concerns about this patient's like airway and complications from some sort of infection or something like that in the throat?

[SPEAKER_01]: So moving on.

[SPEAKER_01]: So yeah, I'm glad you came in and important that you noticed these symptoms like the fever and difficulty swallowing and things like that.

[SPEAKER_01]: Have you had any vomiting during this period?

[SPEAKER_00]: No, I haven't thrown up.

[SPEAKER_00]: I actually haven't been sick to my stomach at all, which I think is because I haven't really been able to eat anything.

[SPEAKER_00]: So I'm just really hungry to be honest, but I'm afraid to eat because it hurts, you know, that's fair.

[SPEAKER_01]: But you have been getting some fluids down.

[SPEAKER_01]: It sounds like at least shakes or have you stopped drinking any fluids as well.

[SPEAKER_00]: Yeah, like this morning, I tried to have a little bit of water and it was actually pretty painful to swallow.

[SPEAKER_00]: Like I thought maybe I had like strep throat or something like that with the fever, not really being able to swallow comfortably.

[SPEAKER_00]: So a little bit of water, but nothing, nothing with any calories in it.

[SPEAKER_00]: So okay.

[SPEAKER_01]: And before this four days ago, you were, sounds like you were feeling great, like you're normal self, never didn't have any signs or issues at that time.

[SPEAKER_01]: Dude, I've been crushing the gym lately.

[SPEAKER_00]: It's been so awesome, but yeah, it's just really weird.

[SPEAKER_00]: Like, I don't know, man.

[SPEAKER_00]: I, okay.

[SPEAKER_00]: Yeah.

[SPEAKER_01]: Ever had anything like this before?

[SPEAKER_01]: Never is the first time.

[SPEAKER_01]: Okay.

[SPEAKER_01]: And any symptoms anywhere else in your body that you've noticed, like, painting your chest or rashes or anything else?

[SPEAKER_00]: Yeah, it is interesting that you mentioned that I've, like, they wouldn't have mentioned that.

[SPEAKER_00]: I didn't really want to worry about it.

[SPEAKER_00]: I thought I'd think about it when we're about it, but I haven't had in a little bit of chest pain.

[SPEAKER_00]: Mostly, if I do happen to eat something or drink something, if I get it down, it does seem to hurt like right here, like right in the middle of my chest.

[SPEAKER_00]: But yeah, other than that, it seems to go away a few hours after I try to eat something, but yeah, I've had some of that, too.

[SPEAKER_01]: Okay, and then any problems, so I mentioned something like any rashes or are you having any problems rearnating, for example?

[SPEAKER_00]: No, been going to the bathroom just fine, although probably less.

[SPEAKER_00]: Yeah, now that I think about it, say, you know, I used to have a two gallons a day guy and just I haven't really been able to do that.

[SPEAKER_00]: So like, [SPEAKER_00]: I don't know, I probably go in the bathroom less, but nope, no issues with that other than that.

[SPEAKER_01]: Okay.

[SPEAKER_01]: And then last couple of questions I saw from the ER board that you were having some shortness of breath going to experience back to say.

[SPEAKER_00]: Yeah, it's mostly when I'm trying to eat or drink.

[SPEAKER_00]: Like, I don't know that I'm like choking.

[SPEAKER_00]: Like, that's not like the axe.

[SPEAKER_00]: I don't feel like it's getting stuck per se.

[SPEAKER_00]: But like, it's just not going down how it should.

[SPEAKER_00]: And I feel like [SPEAKER_00]: Right afterwards, yeah, I'm a little shorter breath, but otherwise, like sitting here, I feel fine.

[SPEAKER_01]: Okay.

[SPEAKER_00]: Any cough?

[SPEAKER_00]: No cough?

[SPEAKER_00]: No.

[SPEAKER_01]: Okay, gotcha.

[SPEAKER_01]: All right, could you, I'll probably come back with some other questions related into what's going on right now, but I'm curious if you have any other medical problems, anything else that you've ever been told you have, any other things you see doctors for?

[SPEAKER_00]: No, I don't take any medications.

[SPEAKER_00]: I haven't seen my doctor since like I was a kid, but you know, yeah, don't take any medications.

[SPEAKER_00]: I don't have any medical diagnosis that I know about, and I call my mom.

[SPEAKER_00]: I was like, hey, if you ever like had this, she said, no, you need to go to the ER.

[SPEAKER_00]: So the ultimate kind of went to the emergency room.

[SPEAKER_01]: Yeah, probably pretty good advice right now.

[SPEAKER_01]: Okay, and aside from the medicines, what about supplements?

[SPEAKER_00]: Uh, I mean, yeah, a little bit, you know, I listen to your podcast and a huge fan.

[SPEAKER_00]: Love your guys stuff.

[SPEAKER_00]: Uh, now you probably won't like this because I've been taking a multi-vitamin, you know, for some years, but it's the same multi-vitamin.

[SPEAKER_00]: Okay.

[SPEAKER_00]: Whatever.

[SPEAKER_00]: And then, uh, yeah, I take, I take free workout, but again, big fan.

[SPEAKER_00]: So it's third party tested.

[SPEAKER_00]: So I like I'm pretty pretty, uh, clear on that, but yeah, pre workout, where every workout, uh, I don't take it on my off days when I, when I just do some walks, you know, because got to stay lean, got to get ready for this next bodybuilding show.

[SPEAKER_01]: Okay, very good.

[SPEAKER_01]: And then my last question, at least right now, before I'll break character and give some thoughts, is it?

[SPEAKER_01]: And tell me about your sexual practices.

[SPEAKER_00]: Oh, yeah, like I broke up my girlfriend a few months ago.

[SPEAKER_00]: She just didn't get it.

[SPEAKER_00]: You know, like I was in the gym twice a day.

[SPEAKER_00]: She said I didn't have like time to spend with her or whatever.

[SPEAKER_00]: So yeah, not not really active, I guess for the last few months, but [SPEAKER_00]: Yeah, no problems down there, you know what I'm saying?

[SPEAKER_00]: Never had any sexually transmitted infections.

[SPEAKER_01]: Not that I know of, no.

[SPEAKER_01]: Okay.

[SPEAKER_01]: All right, very good.

[SPEAKER_01]: So, uh, well, I guess pause here if that's accepted.

[SPEAKER_00]: Yeah.

[SPEAKER_00]: Yeah.

[SPEAKER_01]: The idea that you had for this.

[SPEAKER_00]: Yeah.

[SPEAKER_01]: Yeah.

[SPEAKER_01]: All right.

[SPEAKER_01]: So we have this twenty-two-year-old kid who is seemingly previously completely healthy without any known medical issues coming in with four days of fever and this syndrome that is really centered around the throat relating to swallowing with some other associated symptoms that so far I'm interpreting as mostly kind of consequences of that initial issue.

[SPEAKER_01]: For example, he points out that the shortness of breath that he's experiencing is really just associated with when he's trying to get stuff down.

[SPEAKER_01]: The chest pain is just associated with when he's trying to get stuff down.

[SPEAKER_01]: And so I'm not interpreting those as like separate symptoms of shortness of breath or chest pain, like we have maybe in some of our other mystery cases.

[SPEAKER_01]: It is really quite centered around the mouth throat type area in associated with a fever, which is evidence of inflammation.

[SPEAKER_01]: And so I think that, you know, at the moment, that leaves me in a position where I'm kind of comfortable applying a label to this patient, like a working diagnosis of acute pharyngitis.

[SPEAKER_01]: Now, acute pharyngitis is not what I would call like a final diagnosis or a terminal diagnosis.

[SPEAKER_01]: It's a description of a syndrome.

[SPEAKER_01]: You can get pharyngitis from all sorts of issues.

[SPEAKER_01]: They can be due to infections.

[SPEAKER_01]: Lots of different viral infections and bacterial infections.

[SPEAKER_01]: He even mentioned one himself, like strip throat.

[SPEAKER_01]: But more often, this is due to all sorts of different viruses, mononucleosis, all sorts of things can be associated with pharyngitis and throat pain.

[SPEAKER_01]: And again, there's a long list of bacterial infections.

[SPEAKER_01]: And part of the reason I asked about sexual history and practice, for example, is that gonorrhea can cause a pharyngitis.

[SPEAKER_01]: And that's also why I asked about urinary symptoms.

[SPEAKER_01]: So there are some reasons behind asking those questions.

[SPEAKER_01]: This is a demographic where that would be a, you know, [SPEAKER_01]: not too unusual of a presentation of Gana Cockle, fair and joyous, for example.

[SPEAKER_01]: But it seems to be relatively low risk even though I didn't go into as much detail on sexual history on this podcast, as I would in person with a patient like this just for the sake of our audience.

[SPEAKER_01]: And since I don't think that's where you were leading me.

[SPEAKER_01]: But aside from infections, there are other things that can present with pharyngeitis, you know, this kind of inflammatory syndrome centered in the throat.

[SPEAKER_01]: There are cancers, lymphomas, and leukemias can present that way.

[SPEAKER_01]: There's all sorts of autoimmune conditions that can do this.

[SPEAKER_01]: The most characteristic is called stills disease, one of my favorite and most interesting kind of diagnoses that I've caught a couple times over the years.

[SPEAKER_01]: This can also show up with certain forms of like drug-induced hypersensitivity syndromes can present this way.

[SPEAKER_01]: And so that's kind of why I asked about supplements as well.

[SPEAKER_01]: If there's some sort of a drug contaminant or something like that, that can manifest in this way.

[SPEAKER_01]: And then thyroid disorders can be in the neck, but kind of patients can interpret it as being in their throat.

[SPEAKER_01]: So thyroiditis and things like that, which we would look for some signs of when we move forward a little bit.

[SPEAKER_01]: So I think that first and foremost, with these types of cases, acute pharyngeitis for a couple days, fevers, difficulty swallowing.

[SPEAKER_01]: The first thing we need to think about is, is there an infection in the throat?

[SPEAKER_01]: And more importantly is there an infection that requires kind of more urgent evaluation.

[SPEAKER_01]: So is this patient have like an abscess like a peritonsular abscess or some pocket of pus or something that can be potentially damp, you know, a threatening to their airway, their ability to breathe and speak.

[SPEAKER_01]: That's why I was paying attention to those things once people are [SPEAKER_01]: no longer able to swallow their own saliva for example and they start drooling it's like okay this is this is getting real bad and so a lot of these patients you know what will certainly move on and get some vital signs and in physical exam take a look in the throat feel feel around the neck [SPEAKER_01]: But a lot of times patients like this end up in addition to getting some initial basic labs if they're in an emergency department setting, they might get a contrast at CT of the neck.

[SPEAKER_01]: If there is sufficient concern to look for things like that, and it's not just a run-of-the-mill presentation of something like strep throat.

[SPEAKER_01]: A lot of the times these are just viral sore throats, but this patient has persistent fevers for a few days.

[SPEAKER_01]: He does not have a cough, and all of those are things that can't fit with strep throat, for example.

[SPEAKER_01]: So among the more likely diagnoses that I'd be thinking about first, [SPEAKER_01]: While also knowing that this is a mystery case and it's probably something a little bit more interesting, but trying to make it as realistic to what would happen in real life.

[SPEAKER_01]: So that's kind of my initial thoughts here.

[SPEAKER_01]: So if it's okay, I'd like to move on and if you were able to pull data and give me a sense of what are your vital signs patient and tell me about your physical examination of your throat and neck and things like that.

[SPEAKER_00]: Sure, yeah.

[SPEAKER_00]: So let's give you some some data here.

[SPEAKER_00]: So vital signs are significant for an elevated heart rate to a hundred and ten beats per minute is fever in the emergency room is a hundred one degrees Fahrenheit.

[SPEAKER_00]: Otherwise normal blood pressure is normal.

[SPEAKER_00]: O two sets are normal on room air as far as the physical exam patient does appear non toxic well nourished and he is alert and oriented.

[SPEAKER_00]: is head and neck exam, no lymph node swelling, no thrush, no focal deficits.

[SPEAKER_00]: The actual fairings looks pretty normal.

[SPEAKER_00]: His cardio pulmonary exam is also normal.

[SPEAKER_00]: He's moving all of his extremities well, no rashes or lesions node is on a skin exam.

[SPEAKER_00]: For labs, he did have a chemistry run sent in the lab, which is normal except for his creatinine was one point five.

[SPEAKER_00]: They also did a D dimer, which was five hundred ninety five nanograms per milliliter.

[SPEAKER_00]: Austin, hey, what's a D dimer?

[SPEAKER_01]: Sure.

[SPEAKER_01]: So a D dimer is a kind of a breakdown product of [SPEAKER_01]: blood clots.

[SPEAKER_01]: It is involved in the coagulation and kind of a cascade at the tail end once things start breaking down.

[SPEAKER_01]: So this is kind of a crude marker of like there is some kind of clotting happening somewhere in this patient's body.

[SPEAKER_01]: And I imagine, you know, I don't think that I would have sent this in this patient necessarily, but I wonder if they heard that he had chest pain and shortness of breath and sent a de-dimer.

[SPEAKER_01]: which is actually I would say a little bit unexpectedly elevated in this patient.

[SPEAKER_01]: I would expect it to be lower than it is.

[SPEAKER_01]: So now the question becomes what do we do with this thing, which is a common conundrum that people end up in when they order this kind of a test.

[SPEAKER_01]: I will also say it is interesting.

[SPEAKER_01]: It's reassuring.

[SPEAKER_01]: I was expecting, you know, it was plausible that we might find some swollen lymph nodes in this patient's neck or if we found thrush that would definitely open up a significant concerns about this patient's immune status because he has no other reasons to have oral oral thrush.

[SPEAKER_01]: The fact that his throat looks visually completely normal is not shocking, but I was expecting to see something there given the severity of his symptoms.

[SPEAKER_01]: And so if he's telling me he's having a lot of pain with swallowing and he's having this chest pain associated with swallowing, it's making me wonder, is this not so much a case of fairingitis, but does he have potentially a suffogitis?

[SPEAKER_01]: So there's something going on a little bit lower that I can't see just looking in his mouth.

[SPEAKER_01]: And a suffogitis has its own list of possibilities.

[SPEAKER_01]: A cute suffogitis is a little bit more unusual.

[SPEAKER_01]: It can be due to certain infections like Canada and viral infections and things like that.

[SPEAKER_01]: It can also be due to just like irritants to the esophageal kind of ecosah of the surface.

[SPEAKER_01]: If people have swallowed something, whether it be foreign bodies or somebody tries to self-harm or accidentally drink some bleach or something like that, that can irritate the esophagus and cause a lot of pain.

[SPEAKER_01]: with swallowing and pain in the chest after eating.

[SPEAKER_01]: So now I'm kind of entertaining.

[SPEAKER_01]: Is it pharyngeitis?

[SPEAKER_01]: Is it a suffogitis?

[SPEAKER_01]: Am I completely off-base?

[SPEAKER_01]: And I need to start looking completely someplace else in the patient's neck area to try to find where is the actual problem here?

[SPEAKER_00]: Yeah.

[SPEAKER_00]: Other labs that were in infectious panels, so he's negative for HIV, for cytomegalovirus, CMV, and negative for herpes, simplex virus, Hs.

[SPEAKER_00]: Some imaging was also performed that you have access to get an EKG performed that just showed sinus tachycardia, but otherwise normal complexes.

[SPEAKER_00]: And he had a CT chest done.

[SPEAKER_00]: Yes, because you were on that D dimer.

[SPEAKER_00]: You got to get a CT chest.

[SPEAKER_00]: That's what happened.

[SPEAKER_00]: Show no pulmonary embolism, but there was some circumferential distal esophageal thickening.

[SPEAKER_00]: So we'll pause there.

[SPEAKER_00]: Austin, do you have any further thoughts on this particular patient?

[SPEAKER_01]: Yeah, still a bit puzzling.

[SPEAKER_01]: If I go through these labs, it's great, and in a one point five, could be because he's not eating or drinking very much for a couple days, or could be, if he is well muscled, the test for that would be, give him a little fluids, especially since his heart rates up, and which could also be due to the fever, but see if it gets better.

[SPEAKER_01]: But I'm not terribly concerned about that right now.

[SPEAKER_01]: The fact that he's HIV-negative is helpful, because, again, esophageitis, infectious esophageitis, and things like that are definitely something we see more often in patients with compromised immune systems.

[SPEAKER_01]: Not much to say about the EKG, not terribly surprising.

[SPEAKER_01]: And so now we have this thickening of his lower esophagus.

[SPEAKER_01]: The question is, hey, what could that be?

[SPEAKER_01]: And B does that fully explain his presenting symptoms?

[SPEAKER_01]: I would say that it could explain some of the symptoms.

[SPEAKER_01]: So what kind of things can happen in the esophagus that resulted in this kind of visualized thickening on a CT scan?

[SPEAKER_01]: You can have kind of long-term thickening if there's some sort of like pre-cancerous, cancerous type process developing, which in general we don't really see in twenty-two year olds.

[SPEAKER_01]: It's something that can usually take quite a bit longer to develop.

[SPEAKER_01]: There are, you know, some infections that can happen in the esophagus that I alluded to earlier, not so much something that I would expect to see just on a CT scan or just in the lower esophagus.

[SPEAKER_01]: And there are some kind of autoimmune inflammatory things that can lead to esophageal thickening, but those also don't tend to show up so abruptly like this patient's situation did.

[SPEAKER_01]: The last thing is that I wouldn't expect something in the distal or the lower part of the esophagus that's right before enters the stomach.

[SPEAKER_01]: to cause tons of throat pain or pain with swallowing.

[SPEAKER_01]: Usually, that might cause some feeling of food getting stuck in the chest as it's trying to move its way down the isophagus and get in there.

[SPEAKER_01]: And so I'm a bit puzzled as far as how related this is.

[SPEAKER_01]: It can explain some of the symptoms, but I'm still reaching a little bit to try to figure out why is he having a fever?

[SPEAKER_01]: Why does his throat hurt so bad?

[SPEAKER_01]: And so the next things that I'd be thinking about here is do I need actually dedicated neck imaging, because a chest CT doesn't actually get a [SPEAKER_01]: totally sufficient assessment of the soft tissues of the neck.

[SPEAKER_01]: And do we need to ask a specialist to send a camera down whether to look in his throat and or in down his esophagus to see what we might find down there.

[SPEAKER_01]: I think those are probably the next couple steps.

[SPEAKER_01]: This patient would at this point probably get admitted to the hospital to undergo some of these things and because he was actively fevering when he came in and try to try to figure out what's going on here.

[SPEAKER_00]: Yeah, so they did send a camera down my throat.

[SPEAKER_00]: I guess it's an esophageal andoscopy.

[SPEAKER_00]: And that showed severe punctate ulcerations, linear ulcers and scattered linear gastric arrogens biopsy was sent.

[SPEAKER_00]: that showed severe chronic inflammation of the squamous mucosa with basal cell hyperplasia and lots of eacinophils.

[SPEAKER_00]: You can also talk to the patient, again, if you prefer, because at this point I'm going to have to ask you for a diagnosis at a cause.

[SPEAKER_00]: So, at the information that you have, unless you want to talk to the patient again.

[SPEAKER_01]: Okay, well, at this point, [SPEAKER_01]: You know, I'm curious, of course, always going to be how the patient's feeling and what his trajectory was like if he's been admitted to the hospital, has he had persistent fevers this whole time or what else could be going on?

[SPEAKER_00]: Nursing staff reports.

[SPEAKER_00]: So they started, you know, you because he hadn't been able to drink or anything, you started him on some IV hydration, you know, and the fever, the tachycardia, the elevated creatine all resolved with the IV hydration.

[SPEAKER_00]: But, yeah, what?

[SPEAKER_00]: What's up with this endoscopy report, you know?

[SPEAKER_01]: Sure.

[SPEAKER_01]: Yeah, so that endoscopic description is something that does raise concern for an inflammatory esophageitis.

[SPEAKER_01]: And so that, again, kind of like when I said, fairingitis is not a terminal diagnosis, but rather kind of a working diagnosis.

[SPEAKER_01]: And a lot of different things can cause inflammation in the esophagus to include infections and autoimmune conditions, being the top two things that I would think about.

[SPEAKER_01]: And this did not have the classic appearance that I would expect from something like Candidale esophagitis, which is something that is kind of like having thrush except all the way down to esophagus.

[SPEAKER_01]: Herpes viral esophagitis can cause punctate ulcerations, CMV esophagitis can cause linear erosions in the esophagus severe reflex can cause linear [SPEAKER_01]: kind of erosions and ulcerations in the esophagus.

[SPEAKER_01]: And so I'd be curious if this patient has maybe a history of like reflux type symptoms that he's never, you know, thought much of or didn't tell us about or if anything else, you know, if this rings a bell or we're talking about heartburn or I always go back and grill patients in this demographic about are you sure you're not taking any other new or different supplements or have you been trying anything new or differently to see if there if anything else rings a bell it comes to mind for them.

[SPEAKER_00]: Man, Austin, Barbara, Madison, that's crazy.

[SPEAKER_00]: You know, you mentioned that.

[SPEAKER_00]: I feel like an idiot.

[SPEAKER_00]: It's like, I've never had like Harper, at least what I think it feels like, but I'm telling you, man, like, you know, I've been taking this pre-workout.

[SPEAKER_00]: It gets third party tested, so it's like really good.

[SPEAKER_00]: You know, I don't think you're put guys podcast, but like, after I took it four days ago, it felt like [SPEAKER_00]: I don't know, like, I feel like my chest was on fire.

[SPEAKER_00]: I don't know, like, I've never felt anything like that.

[SPEAKER_00]: But, you know, I just, I got my work.

[SPEAKER_00]: I didn't want to go do any training.

[SPEAKER_00]: So, like, whatever.

[SPEAKER_00]: And it kind of went away when I was working out.

[SPEAKER_00]: But then, yeah, like, right afterwards, it was kind of hard to eat, but I still got it down.

[SPEAKER_00]: And they'd get just kept getting worse than I had the fever.

[SPEAKER_00]: Well, you know, the rest of the story.

[SPEAKER_00]: But yeah, that's the only thing I can tell you, man.

[SPEAKER_01]: Sure.

[SPEAKER_01]: Okay.

[SPEAKER_01]: So I have a couple, you know, kind of, I guess final, final thoughts here.

[SPEAKER_01]: One is, I think in the endoscopic report, you mentioned lots of Eosinophils.

[SPEAKER_01]: That is a very unusual and unexpected finding for most forms of kind of inflammation in the body.

[SPEAKER_01]: There is a diagnosis called eocinophilic esophagitis.

[SPEAKER_01]: It is most often thought of as an autoimmune type condition where these particular types of immune cells are activated and cause inflammation and esophagial symptoms.

[SPEAKER_01]: Again, they don't tend to present this abruptly in most patients with like fevers and all of a sudden developing the syndrome.

[SPEAKER_01]: It's more often [SPEAKER_01]: people having what I would call more like subacute to chronic kind of symptoms associated with eating, swallowing, sometimes this can lead to the development of things like strictures and stenosis in the esophagus that do lead to food getting stuck and things like that.

[SPEAKER_01]: So I'm curious about the potential diagnosis of esophageitis in this patient.

[SPEAKER_01]: But the other thing is we do have this unusually abrupt onset and we have this temporal association with this [SPEAKER_01]: patients, uh, new supplement use.

[SPEAKER_01]: And so could it be either that there is some ingredient in the supplement that can potentially trigger an eosinophilic response and eosinophilicosophagitis, or does the pre-workout product itself contain some sort of, uh, kind of mucosal irritant?

[SPEAKER_01]: As I mentioned earlier, the most extreme examples like when people drink bleach, [SPEAKER_01]: and end up with severe caustic esophageal injuries.

[SPEAKER_01]: Is there something in this product that is leading to this kind of like irritant inflammatory kind of mucosal response?

[SPEAKER_01]: For him to have fevers for days afterwards, unless he's been continuing to use this, even in that situation is like a little surprising to me.

[SPEAKER_01]: But I think that it's hard to ignore the temporal relationship there between this new exposure and this syndrome.

[SPEAKER_01]: So I'd be [SPEAKER_01]: probably doing two things, I'd be asking for him to provide the information about this product that he's been using and then start aggressively searching all of the ingredients and what is known or reported out there about it.

[SPEAKER_01]: I would also probably be looking for, are there any kind of case reports of this kind of thing happening before?

[SPEAKER_01]: Maybe I'll come across the very case report that you are pulling this from.

[SPEAKER_01]: And then definitely be talking to the pathologist who kind of reported [SPEAKER_01]: The results of the endoscopy talking to the gastroenterologist who performed it about their thoughts, particularly because like a gastroenterologist is somebody who would see a lot more cases of use in a philicosophageitis than I would.

[SPEAKER_01]: I'm aware of it and I see a handful of cases a year, but I'm not an expert in that condition, particularly with this type of presentation.

[SPEAKER_01]: So that's kind of where I am right now.

[SPEAKER_00]: Yeah, I'll give you one more shot as the cause and such.

[SPEAKER_00]: Because, you know, yeah, you get to talk to the gastroenterologist and to the path of pathologist and get a little report here.

[SPEAKER_00]: They call this an esophageal ulcer.

[SPEAKER_00]: They're like, like, the ocenophils are kind of funky, but like, this looks like smells like an esophageal ulcer.

[SPEAKER_00]: We don't know why.

[SPEAKER_00]: But that's what it looks like.

[SPEAKER_00]: We're calling it an esophageal ulcer.

[SPEAKER_00]: It's up to you, Doc.

[SPEAKER_00]: Figure out why, why does this patient have an esophageal ulcer?

[SPEAKER_00]: I was a twenty-two year old with the heck.

[SPEAKER_01]: Yeah, so this is where I'm probably at the, you know, I'm getting stretched at the limits of my typical experience.

[SPEAKER_01]: So in acute febrile syndrome with the presumed acute esophageal ulcer, you know, this is something that I would be starting to do some searching and talking to some consultants and some friends to seek out why so abrupt, why febrile.

[SPEAKER_01]: And yeah, that's, I think I'm kind of tapped out at this point.

[SPEAKER_01]: So yeah, what you got.

[SPEAKER_00]: All right, so this particular patient had an esophageal ulcer that was the diagnosis and the clinical team who wrote up this report concluded that it was from dry scooping his pre-workout had you ask the patient how he was taking the pre-workout he would say that he was dry scooping it.

[SPEAKER_00]: effectively he had ran out, patient reported, or whatever reported, that he ran out of the solvent that he was previously using.

[SPEAKER_00]: His pelvis pre-worked out and he was just dry scooping it for weeks leading up to this particular sentence where he had some [SPEAKER_00]: felt like heartburn to him and then subsequently had a fever and everything else and had to difficulties eating and drinking.

[SPEAKER_00]: He was started on a proton pump inhibitor, a PPI, and his diet was advanced while he was in the hospital.

[SPEAKER_00]: The patient was able to tolerate normal diet before discharge.

[SPEAKER_00]: He was continued on the PPI for eight weeks at four weeks.

[SPEAKER_00]: They did another endoscopy on this patient and it was basically normal at that time.

[SPEAKER_00]: So they're calling it [SPEAKER_00]: on a soft-a-geal ulcer secondary to dry scoobing his pre-workout supplement.

[SPEAKER_01]: Well, that is very interesting.

[SPEAKER_01]: It is puzzling in a bunch of ways.

[SPEAKER_01]: If he's doing this for weeks and then presenting that abruptly is interesting, that presumably is when the ulceration like reached some sort of a critical threshold, persistent fevers, though, is a little [SPEAKER_01]: surprising in that in that context, if there was never any sort of infectious complication that was that was identified.

[SPEAKER_01]: A lot of good teaching points from this, I would say even for like general medical trainees and students, you know, about the differential diagnosis, both fair and joyous and esophageitis in a patient patient like this, as well as autoimmune, I suppose, getting into esophageitis as well.

[SPEAKER_01]: Dry scooping, your supplements leading to ulceration, that is wild, so nice find.

[SPEAKER_01]: Good case, I suppose, when it comes to patients who use certain types of drugs, I'm certainly in the habit of always asking them how they administer them, because different drugs administered by different routes, whether inhalation or injection or anything like that can lead to dramatically different complications.

[SPEAKER_01]: The route of administration of a pre-workout supplement is, although I guess that's the same route, but just like the method is not something I've ever thought to ask specifically, are you raw dog in the supplement as they say?

[SPEAKER_01]: Or are you actually dissolving it?

[SPEAKER_01]: Maybe I'll have to think about asking that when that becomes relevant in the future.

[SPEAKER_00]: Yeah, there were a few other case reports.

[SPEAKER_00]: I found on some strange ways, not only just dry scooping, but also other ways that people have used to pre-work out self-mmant some people have snorted it and had, you know, nasal pharynx, you know, inflammation and other issues related to that.

[SPEAKER_00]: Makes sense.

[SPEAKER_00]: I also thought of like, what if you ever made like a pre-workout suppository, like you'd have a whole mother?

[SPEAKER_01]: potential list of complications or like a like a what if he made like a like a dip kind of thing you know like buckle absorption yeah you could and there are mechanistic reasons why you could promote all of these things to say why there's so much better because they're bypassing interrogator interapatic circulation and all sorts of things like that and and people who don't know any different would be like sure that sounds awesome what's to it yeah [SPEAKER_00]: Yes, let's talk about esophageal ulcers and dry scooping.

[SPEAKER_00]: It's pretty interesting stuff here, and I think, I don't know, I did think this case, like obviously this person was probably terrified and reasonably, you know, rightfully so.

[SPEAKER_00]: But yeah, I've had a found this one.

[SPEAKER_00]: I'm like, bro, you're your dry scooping and head.

[SPEAKER_00]: Anyway, okay, so an esophageal ulcer is a you know discreet break in the tissue lining the esophagus when we say mucosa is just the the cells that are lining the the organ in this case the esophagus the main cause most common cause is gird so gastrosophageal reflex disorder [SPEAKER_00]: usually from the lower esophageal sphincter that's just like little muscle that separates the esophagus from the stomach, it's either weak or it's inappropriately relaxing.

[SPEAKER_00]: And so you get this sort of caustic, acidic content of your stomach that gastric juice.

[SPEAKER_00]: interacting with the mucosa, the tissue of the esophagus, and that can lead to an esophageal ulcer.

[SPEAKER_00]: So you get an injury that way.

[SPEAKER_00]: The second most common cause of drugs, most commonly would be like a non-steroidal anti-inflammatory drug, something like that, ibuprofen or antibiotics, specifically like Dr.

Cyclean.

[SPEAKER_00]: That's pretty common, but the gird, causing this like, sixty, eighty percent of cases, drugs about twenty percent of cases, [SPEAKER_00]: Lots of different drugs, almost any drug could theoretically cause this, but as far as supplements go, there have been documented case reports of like L.

Argentine and caffeine causing this stuff, particularly in powder form.

[SPEAKER_00]: The ingredients of this particular individuals pre workout included malach acid, which also has been associated with acid induced injury, the pH of malach acid is two to three.

[SPEAKER_00]: Citric acid pure citric acid is a pH of one point five is very very acidic right water seven is neutral citric acid one point five that's very very acidic.

[SPEAKER_00]: Tartaric acid was also in the supplement that is a pH of one point six.

[SPEAKER_00]: Interestingly, there was a study that was conducted with the purpose of analyzing the pH, so how acidic the thing was of energy drinks and pre-workout beverages.

[SPEAKER_00]: Now of the twenty-something pre-workout powders that they analyzed, the way that they did the studies, they mixed them with water, which would make these things [SPEAKER_00]: less acidic, because water is neutral, pH is seven, and the pH range from three to four, when the water.

[SPEAKER_02]: Yeah.

[SPEAKER_00]: So imagine if it was not mixed with water.

[SPEAKER_01]: Sure.

[SPEAKER_00]: likely lower with being dry scoop and the transit is likely slower because now instead of it being the smooth sort of thing, it, you know, tends to go to your suffocates is, you know, we call it parastaltic contraction, just based like a rhythmic beating of the esophageal muscle to move stuff from top to bottom, get into your stomach.

[SPEAKER_00]: Well, powder is going to flow a lot more slowly and expose that mucosa that tissue.

[SPEAKER_00]: a little bit longer compared to something mixed with water.

[SPEAKER_00]: And so, probably direct cost to exposure, damaging the tissue here.

[SPEAKER_00]: I suspect that his lower-sophageal sphincter was intact and working fine.

[SPEAKER_00]: He just, you know, had been dry scooping this stuff for a while, and yeah, after a while, caused this ulcer that led to these sort of symptoms.

[SPEAKER_01]: Yeah, I had mentioned a couple times the idea of a caustic, you know, irritation, those are typically like more basic compounds.

[SPEAKER_01]: This is like a, it's definitely seems on the more acidic side and it makes me think of like, if you were to take a drug that is normally known to cause like pill us off of gitis and you try to crush it and you'd end up with like powdery form of the pill would probably, you know, do the same thing.

[SPEAKER_01]: So this is effectively that.

[SPEAKER_01]: Yeah, super interesting.

[SPEAKER_00]: Infections can also cause this, like you'd mentioned, not only herpes, the HSV, CMV, HIV, a bunch of other types of infections as well.

[SPEAKER_00]: You can get radiation, you know, that could cause upgel ulcer, various autoimmune diseases, various cancers, genetic conditions, lists are long, but most commonly drugs and [SPEAKER_00]: symptoms, heartburn, chest pain, usually not related.

[SPEAKER_00]: So non cardiac sort of chest pain, although there was a case report from dry scooping of an ST elevation, myocardial infarction, a stemmy, so heart attack.

[SPEAKER_00]: I'll help the five year old man from dry scooping.

[SPEAKER_00]: I'd be more concerned about what ingredients were in that, but yeah.

[SPEAKER_00]: But yes, you can get this heart pain, this non-cardiac chest pain, you can get difficulty swallowing, so that, call that dysphagia, you can get pain with swallowing, call that odinophagia.

[SPEAKER_00]: You get nausea, vomiting, lack of appetite.

[SPEAKER_00]: Usually when people have problems swallowing, it's painful.

[SPEAKER_00]: They're appetite tends to go down.

[SPEAKER_00]: It's like a learned sort of response.

[SPEAKER_00]: You can get bleeding.

[SPEAKER_00]: If the ulcer is actually bleeding, uh, we'll hematemesis if you're throwing it up.

[SPEAKER_00]: Melina.

[SPEAKER_00]: So if it ends up in the stool and it's take, you know, it's not a, we call it a brisk bleed.

[SPEAKER_00]: So if it's relatively slow, it can be dark in the stool.

[SPEAKER_00]: And if it's fast and a lot of blood's coming out, it can be bright red.

[SPEAKER_00]: We call that hematocesia.

[SPEAKER_00]: So you guys are learning a lot of medical terminology here.

[SPEAKER_00]: As far as evaluation goes, yeah, the upper GI endoscopy for both diagnosis and treatment can't be very useful here.

[SPEAKER_00]: Or people can do an esophogram or barium swallow for example.

[SPEAKER_00]: And as far as treatment goes, if it's bleeding to me, you got to stop the bleeding, protect the airway.

[SPEAKER_00]: Those are really like to, you know, most, most important things are off the bat.

[SPEAKER_00]: If it is gastrosophageal reflex disease or a gird, a proton pump inhibitor or other medications can be useful.

[SPEAKER_00]: If it's an infection, you got to treat the, the thing appropriately, whether it's an anti-viral or anti-botic, or fungus, and a lungle, although you have other questions, how did this thing end up there?

[SPEAKER_00]: Yep.

[SPEAKER_00]: If it's a caustic sort of cause, [SPEAKER_00]: First thing, you gotta remove the cost of agent.

[SPEAKER_00]: Secure the airway.

[SPEAKER_00]: You gotta make the patient NPO, so nothing by mouth due to risk of perforation.

[SPEAKER_00]: Yeah.

[SPEAKER_00]: If it's actively bleeding and you can advance the diet.

[SPEAKER_00]: It's tolerated.

[SPEAKER_00]: There's a whole, what's the scale?

[SPEAKER_00]: It's like a ag room or something.

[SPEAKER_00]: Like, it's a predictive model of how severe the ulcers, anyway.

[SPEAKER_00]: That's well beyond my training, but I did read that I go.

[SPEAKER_00]: Cool.

[SPEAKER_00]: Learn something else today.

[SPEAKER_00]: As far as complications that we would be worried about here is yet bleeding, perforation, if it goes untreated, stricture, which is a narrowing of the esophagus, so that sometimes requires a stent or surgery to correct.

[SPEAKER_00]: So dry scooping, you're like, all right, Jordan.

[SPEAKER_00]: To know nobody dry scoops, dude, like what are you talking about?

[SPEAKER_00]: One, it's super popular on TikTok and social media right now.

[SPEAKER_00]: A recent study out of Canada analyzed nearly three thousand young Canadian to work out and used a pre-workout, seventeen percent reported dry scooping in the past year.

[SPEAKER_00]: It's the big pearl here that they came out.

[SPEAKER_00]: Yeah, big take home.

[SPEAKER_00]: Don't dry scoops.

[SPEAKER_00]: Just add some water.

[SPEAKER_00]: Just add some water.

[SPEAKER_00]: Not difficult.

[SPEAKER_00]: Yeah, or like, don't take a pre-workout like whatever.

[SPEAKER_00]: Like we obviously make a pre-workout.

[SPEAKER_00]: I think that if you're trying to get the most out of your training, both performance-wise in a session and get the most gains from every session, short.

[SPEAKER_00]: A multi-engredient pre-workout supplement, which is the use of the acronym MIPS, could be useful.

[SPEAKER_00]: Just don't dry scoop it.

[SPEAKER_00]: And make sure there's no like bleach in it.

[SPEAKER_01]: Also, like you could get generally, generally, would avoid, you know, highly costing agents.

[SPEAKER_01]: So yeah, I suppose this practice involves just trying to swallow dry powder completely, which is I don't know.

[SPEAKER_01]: I can't believe people actually do this, especially at that rate.

[SPEAKER_01]: I will take creatine oftentimes in powder form, but then it is getting washed down with a [SPEAKER_01]: substantial amount of water afterwards rather than trying to dissolve it in a glass first.

[SPEAKER_01]: But just straight dry powder trying to like choke that down seems, uh, I don't know, very unpleasant to me.

[SPEAKER_00]: Yeah, I would be very curious of like the transit time of like pure powder.

[SPEAKER_00]: So no, no liquid at all.

[SPEAKER_00]: Also like choking hazard potentially versus like, aren't you did the scoop and then like a small little water?

[SPEAKER_00]: Right.

[SPEAKER_00]: Okay.

[SPEAKER_00]: What's the pH there?

[SPEAKER_00]: What's the transit time?

[SPEAKER_00]: And then like, okay, per manufacturer's instructions like twelve to sixteen ounces of water.

[SPEAKER_00]: Right.

[SPEAKER_00]: Yeah.

[SPEAKER_00]: Mix it up, you know, whatever.

[SPEAKER_00]: Then what is the pH and what's the transit time there?

[SPEAKER_00]: I mean, obviously the pH has measured by that other study with somewhere between three and four.

[SPEAKER_00]: So still pretty acidic, but because it's liquid, it's just not in your soft against very long.

[SPEAKER_00]: Right.

[SPEAKER_00]: So live a is likely, you know, made this a little more basic, a little more neutral.

[SPEAKER_00]: and then it just gets into the stomach and get nothing to worry about.

[SPEAKER_00]: But if it's stay in there for a while, particularly like these like granules of, you know, whatever.

[SPEAKER_00]: I mean, it seems plausible.

[SPEAKER_00]: Yeah.

[SPEAKER_00]: It seems plausible.

[SPEAKER_00]: Good.

[SPEAKER_01]: Good.

[SPEAKER_01]: Good.

[SPEAKER_01]: Fine, man.

[SPEAKER_01]: Good.

[SPEAKER_01]: I learned today.

[SPEAKER_01]: And I think our audience probably did too.

[SPEAKER_01]: Maybe if there's any that, seventeen percent in our audience, maybe they will rethink this practice if it's something they do habitually.

[SPEAKER_00]: Yes, they have TikTok also.

[SPEAKER_00]: Generally good advice.

[SPEAKER_00]: Yeah, right.

[SPEAKER_00]: That is a wrap here on the barbell medicine podcast where we bring modern medicine to strength conditioning and strength conditioning modern medicine.

[SPEAKER_00]: I'm your host, Dr.

Jordan Fagamum special shout out to Dr.

Austin Baroque for, uh, lessen us with his clinical acumen also for tolerating my, my acting chance.

[SPEAKER_00]: They are rudimentary at best.

[SPEAKER_00]: Before you guys go anywhere, please leave us a five-star rating and a review.

[SPEAKER_00]: It really helps drive traffic to our podcast so we can keep bringing you out of the latest nuance and health and fitness.

[SPEAKER_00]: Remember to here at Barbell Medicine.

[SPEAKER_00]: We'll get you next week.

[SPEAKER_00]: And every week, right here on the Barbell Medicine podcast.