298: Injury Rehab & Prevention; 7 Functional Movements & Dry Needling - Dr. Carlos Berio

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ELLA Hey, you're on air with Ella and today I bring you my friend on air and off Dr. Carlos Berio. Hi Carlos, how are you?

Dr CARLOS Hi Ella, thank you for having me.

ELLA Carlos, I need you in your own words to tell everybody who you are and what you do.

Dr CARLOS Okay, great. So my name is Dr. Carlos Berio. I'm the owner of Spark Physiotherapy. We're an orthopedic and sports physical therapy practice in Alexandria, Virginia. We've been doing this since around 2009 in a way that I think is a little bit special. So a lot of handholding, our practice is very much heavy on rapport, building relationships

ELLA and really just pressing people forward to become their own best self-advocate for their health-seeking habits. Well, that's your version. My version is that you are my chief torturer or torture in chief, whatever you want to call it. All right, okay. I can speak to the handholding and in all honesty, my listeners know that I have been dealing with frozen shoulders since July of last year. So we're on month 10. We're working on month 11. It's been a maddening journey, but I finally found help when I came to your practice and it was so transformative for me that I knew right away that I needed to talk to you on the air. We needed to talk about not necessarily we'll touch on adhesive capulitis, which is the fancy name for frozen shoulder. We'll talk about that briefly, but I have covered that a bit. I want to talk today with you about some of the specific modalities that help with that. But then let's zoom out for people who hopefully never have to deal with that and talk about things that are relevant to, I don't know, people who have bodies, people who play golf, people who play tennis. How's that sound? That sounds terrific. I'm all for it. Okay, tell me a little bit about you because you are a well-rounded gentleman. And I just want to get some of your experience on the table here.

Dr CARLOS Well, thank you so much. That's a terrific compliment. I started my journey in around 1998 when I began my personal fitness career. Several years working in commercial gyms, things like that, personal training clients. And as I gained more formal education, I started working with some, what would you consider, more high level movers, people whose bodies were their livelihood, they were playing sports in college or they were getting ready to go to the professional ranks. And so that happens less often, of course. General population rules the world. And it's really just as exciting for me to see someone who's never picked a bar up off the ground to do so with comfort as it is to watch my seven foot two basketball player gain three inches on his vertical. There's no difference in what gives me life in my journey here. But around 2006, I had my own personal training company, a strength and conditioning business that I was running on my own. Along the way in 2006, I picked up physical therapy as a new career path, sort of one that was going to be complementary to the workout I had already done. But one of the things that I had been seeing was clients asking me questions about their pain. And, you know, I was being honest with myself that my lane kind of ended when I can't cue it out because of the way I'm saying things or if I can't give you a very easy little tip and it makes it better, there's something else happening here. And I knew I had a blind spot. So I went to go fill it. In 2009, I graduated as a physical therapist and rebranded my strength and conditioning company to Spark Physiotherapy. And we've been running ever since. It's my baby. It's my curse. But it's the way I get to meet and interact with some of the most amazing people. It's been an honor.

Yeah, spoken like a true entrepreneur, actually. Tell me about Brazilian Jiu-Jitsu.

Dr CARLOS Oh, yeah. That is the art of folding someone's laundry while they're still in it. So you could think of it if you've ever seen a wrestling match, an actual wrestling match, not the WWF or whatever that has to do with the leotards. But the end game actually happens when you have gained such a position where you have all the ability to move and your opponent has none. And so you consider it like athletic chess. It's not a high impact sport. It is not a ground reaction sport, which we'll talk about later. But certainly it allows me to maintain some competitive athletic activity in my older age as I get away from things that bash my body into the ground. OK, but you're involved in another combat sport, which is you're the dad of twin girls. Yes, yes. And I'm very excited that they're getting into it. A couple of nights ago, my daughter, Ella, had come home and learned something new. She said, can I show you? Absolutely. It was bedtime. Like, I don't care. Let's go on the floor. So much fun. And it's a great way to learn just your physical body, your limits and what you kind of can stand up to.

ELLA OK, well, I might give that a try, but first I need to be able to, you know, move my arm. So come on, let me see. Let me see. Let me see. No, we're not doing that on video. It's a HIPAA violation. I'll take it. OK, I have touched on Frozen shoulder and I don't want to bore people by mentioning it, you know, every other show, Carlos. But just to set the stage here, could you just explain what adhesive capsulitis actually is?

Dr CARLOS Sure, sure. So the ideology, the cause of how this happens is actually really not well understood. What we know is that anything that can exacerbate the inflammatory cascade, especially in this area, but even systemic inflammation can kind of trip this. And it isn't by itself something that happens and then suddenly, bam, your shoulder doesn't move. You begin to feel this pain, the sensation of restriction or loss of mobility. And then many times as human movers, we go, well, maybe I should protect this. I probably should just make sure I don't do anything that hurts. And in many cases, that's OK. But this is not one of them. I actually have given many, many talks in front of groups of surgeons. And I said, I want every surgeon in the room here to answer this question. Raise your hand if you've ever had adhesive capsulitis. No one raises their hand. I would challenge anyone. I would bet my license to ask their orthopod if they've ever had one or knew an orthopod had never had one. And they would say no, because our knowledge is somewhat protective against pain. So if my shoulder began to hurt and it was in the ways that were typical that would eventually become an adhesive capsulitis, I'd say, boom, I'm up [raises arm]. I'm right up right away. Immediately. I'm not letting that happen. And it's that fear avoidance cycle that I think what we do on we kind of consider the next gen PT side of things that really gives the whole picture of that healing process and allows folks to, you know, maybe get OK with and this is going to take a while. If it doesn't take two years, I did good. If I take less than 18 months, great. If I get less than a year, hey, you did a good thing. That's a good place to be for people to have a good relationship with pain. Understand that pain by itself is not the barrier. It is information. And we have to just know what to do when we receive that information. If you don't know, contact somebody who's got that information.

ELLA Yeah, I'm going to say right now that I'm not your doctor. Carlos is not your doctor. And so we're not advising you. But one thing that I have learned is had I fought through the pain, so to speak, and kept my arm in motion, I could have shortened this journey by a lot. That's great to know now. But the truth is, when this is happening to you, you don't know what it is. I actually thought I had a tear because I was doing some shenanigans the day before. So I actually thought I was doing handstands and I had a push up contest with my son and I won. So it's obviously been totally worth it. But I thought that I tore something. And of course, if you tear something, you're going to arrest it. And what you have taught me is that, well, we learned that's not what it was. But if I had kept it moving, it wouldn't have frozen so solid. I mean, when I tell you it froze, you guys, I was completely incapacitated. And now my muscles are muscles that basically haven't been used in a year.

Dr CARLOS Yeah, no, it's true. And the thing that if I could go back in time, anything that kind of kicks off that inflammatory cascade can start this process. And maybe you also had a systemic thing. Maybe there was some illness going on. Maybe there's some underlying reason for your immunity to be disabled for a small bit. Who knows? Our bodies go through these changes constantly. Our immunity goes up and down. Our overall fitness, our ability to just rotate your head. You know, these things are not static things. If you don't use those abilities, they go away. So, you know, if we can kind of encourage that for more people, they can seek out the edges of their mobility and know when that information is there to be able to do something active so they can avoid these restrictions and pain. What does your immune system have to do with these musculoskeletal issues, Carlos? I mean, inflammation is something your body reacts to with the same systems as I got a cold, I had a virus, I got a flu. So when we can keep our gut healthy, when we can keep our sleep hygiene up to date, when we can have proper hydration, we are doing so many amazing things to eliminate many problems that plague folks throughout their lives.

ELLA Well, this will sound idiotic to you, but I just really in all my years of training, really never made a connection between my immune system and how I thought of it. I'm using air quote marks because what I meant by that was like, am I getting a cold? Have I gotten the flu in the past two years? I never connected that. I started to learn to connect that to my gut health and understand how much of our immune system is housed in our gut, actually, physically, literally. And what I did not appreciate is that the weakened immune system equals excess inflammation equals more injury. I never made that connection. I wonder if anyone else is making that connection with me in real time.

Dr CARLOS Yeah, that is there are correlations between those things because you have a weakened immunity does not necessarily mean you're going to see excessive inflammation. However, if you also have a high inflammatory diet, you're not sleeping enough. You're you're you're sedentary and you're so you're not moving throughout these large ranges of motion, moving the ends of muscles and and the connective tissues that contain a lot of the signaling system for the endocrine rest of your body to produce the and the analogistic chemicals, the recovery chemicals. This is all part of the whole moving thing that I think more folks really just need to understand. Your body is a very complex bit of moving parts. You have control over every one of those parts.

ELLA OK, so last sort of word on frozen shoulder before we move on. Am I to understand then and we'll broaden this, but am I to understand that that is in very practical terms, that is just such intense inflammation that you can no longer move your arm in your shoulder because of your shoulder joint?

Dr CARLOS Yes, shortest answer would be yes, that capsule that has gotten so hot and so short and so contracted. And now every bit of the musculature that is around there is also taking part to join this protective mechanism. So part of care for adhesive capsulitis is knocking some of that irritability down. That can be gentle modalities that could be gentle, gentle mobilization. And then part of it has to be aggressive mobilization against the soft tissue structures that are the static stabilizer, the actual sack around the glen or the around the head of your humerus that holds this all together. That winds up and that is what we need to move and get free so that your shoulder can move more freely.

ELLA When I found you, one of the first things that we did was we engaged dry needling therapy and I would like you to explain it. I'm going to explain it as mid evil torture that I'm now addicted to and love. You don't like it when I say torture, do you?

Dr CARLOS No, but I get it. I totally understand. I get it.

ELLA It is something else. But trigger point dry needling is the most effective thing that I have done. I am so glad I found it and you. Can you please tell us what it is and why it works?

Dr CARLOS Sure. I will begin by telling you what dry needling is not. It is not acupuncture. I have zero knowledge on any meridian. I don't know what a chi is. I don't give a crap where your flow goes. None of that. I want to know what is causing your pain, what is stopping your mobility, and I want to address it in the fastest, most efficient way possible. And in my experience, I have found dry needling to be just the most easy to deliver, simple to teach technique for releasing tension through soft tissue, specifically muscles. It essentially is a massage inside of the muscle. I think a better name for it would be intramuscular therapy or intramuscular manual therapy, because in this case, I'm just using a tool to get deeper than my fingers or my elbows or whatever could possibly get. Now, also, I mean, I want to get into some of how much your audience will tolerate the nerdy parts of this, but I do want to get into some of that. But the idea that if I use the tip of my finger to get to the depth of a muscle, let's say a hips muscle, in your case, like a lats muscle, you have thick muscles and then the muscles are not right on the surface. You have your skin, you have a fat layer, you have layers of connective tissue, you have layers of other tissues, and then they invaginate one another and they have to slide and move as a whole. Now, if I put my finger on your skin and then I press down, I'm impacting every single thing from the surface of your skin all the way down to that area. And the surface area of my finger is much bigger than the surface area of the tip of one of these needles. I'm not forcing mobility to occur when I use dry needling as a technique. I'm using your nervous system to get mobility to occur. And so what you would feel when you're having a treatment like this is you really wouldn't feel the needle. They're very small. But when you get the tip of the needle to the depth of the area in that muscle, there will be a local twitch. And that local twitch is similar, actually exactly the same neurologically, as a spinal reflex. The same kind of thing when your doctor caps your kneecap or the patellar tendon on the table and they're testing your reflexes. It's exactly that mechanism. And the reason we know it's that mechanism is because this area of muscle is being told to contract. We see jitter. We see electrical activity that is telling this area of muscle differently from other areas within the same exact muscle. Hold. We want you to hold. Please hold. And we tend right now the prevailing understanding of why is if we have instability in an area of our body, other parts of our body can say, well, let me just do that. Let me just do that job. So we need to first get normal mobility of these soft tissues to then teach good coordination, good strength, good endurance to get back all the way well motion. So from before this was ever a big problem. So we're trying to reset muscle tissue. We're trying to drop pain because those trigger points directly lead to myogenic pain. But that pain is also known to really rapidly diminish. And then the restrictions in mobility diminish as long as we can teach the proper coordination.

ELLA Yeah, I mean, it's a very intense process, but it's very brief, like very, very brief. And then just as the end user, if you will, I'll say that the needles are so fine that that's the only thing in my mind comparable to acupuncture. The needles don't hurt going in and the needle is not the issue. It's the twitching and the release that is so very intense. And then it's like that “hurts so good” thing. You know, it's working.

Dr CARLOS Absolutely. You know, when it works, it works near immediately. That's the thing I tell folks. You know, we don't you don't dry needle everything, you know, folks who and this is probably the best free advice I can give anyone is when do I know I need dry needling as well? If you can point with your finger to one place and it hurts like, oh, it hurts when I do that. Oh, it hurts when I do that. This is a problem right there. This is something going on right here. But if you go and this is very common, you know, Doc, I have my shoulder hurts, but like it's just aching. The whole thing hurts in my brain. I say, OK, she has touched her medial deltoid or anterior deltoid or biceps or brachialis. OK, so now let me go test them all. If I can't make those hurt when I ask those individual muscles to work under a heavy load and you go, no, no, no, no, no, that's my pain. OK, well, your pain lives here, but the cause does not live here. And then what happens? I start poking around some of the posterior cuff muscles and suddenly they go, oh, I feel the front of my arm. I go, ah, that is referral pain from your infraspinatus or from your teres minor or whatever. Every muscle has a known referral pain pattern. So if it's a small cuff muscle that rotates your arm out, we know that muscle hits you here most often. If you have a neck upper trap trigger point, those people complain of headaches and my head in the back hurts. And I got a headache right on top of my head. But they don't go, you know, my trap is killing me. But when you grab it, they go, oh, what's that? That's where your head is coming from. And so that's part of what we learn along the process as therapists, as dry needling technicians, as a little bit. You might consider expert myofascial folks, but that really fills the gaps for a lot of folks who are sort of stuck in between a real injury to a small tissue and like everything else that occurs.

ELLA Well, I'm going to go ahead and guess that you work with a lot of baseball players. Sure, sure do. So now I want to zoom out and we can draw a line under adhesive capsulitis. We can leave that. Thank you all for coming. Now let's zoom out and talk about folks who play golf, who play tennis, who move their bodies in any way or who want to, Carlos.

Dr CARLOS Yes. Well, everything starts with finding out where the line is right now. I don't care who you are. You're a professional athlete at 40 or you're Tom Brady or you're me coming in the door. I got to figure out where on this continuum between pain and performance you are because everyone is on that continuum every second of every day. You can move yourself up that continuum of being very well rested by having a good meal the night before by spending 20 minutes to warm up and say, yeah, now I'm ready to golf. And you can shove yourself down to the pain side of that continuum by sitting still, getting to your round five minutes for tea time and having a bad dinner the night before. You're not on the good side of that spectrum. And so when we see anyone, we say, OK, where are we now? And where do we need to be going? What is the goal here? Do you want to be the criterion level golfer? But now your back is getting in your way. OK, so now we've established a baseline. And anytime someone comes in, I think what a good plan should always be. We should have a movement plan and then a pain plan or an inflammation plan. Or what do you do with the information your body gives you when it's run out of steam, when you've got more endurance, when you're out of strength, when you've run that last hole and you did a little bit too much on that swing and now like, oh, that didn't feel good. Do you stop or do you absorb that information and then make a small adjustment? And that is what we teach folks to do the most is become very good advocates for themselves. Say, OK, I got the info. This is the next step so that I can press forward. And sometimes it means I'm done. This means today I have met the line, but that's OK. As long as I don't cross the line in a week, that line is going to be further down the line down the road.

That's what you want to do. That's how we get progression. That's how we move people further and further away from the pain side on that continuum.

ELLA Well, let's go back to the individual because I happen to know that you and I share a belief in common. And that belief is that getting older does not mean getting feeble. It does not mean getting weak. And like I just reject that as an excuse for me personally. That's just not a belief I choose to accept or live out in any way. If you could just download a belief or a motivation for people, what would that look like and sound like to you?

Dr CARLOS We get old when we stop playing. Period. I'm like a kid. I enjoy moving around. And I wanted this cool little sidebar. I was in the bathroom with my daughter helping with teeth time, brushing teeth and getting ready for bed. And she asked, Daddy, why do you exercise like this? And I said, well, you know, I exercise a lot, but I enjoy my body. It's like and daddy wants you to learn how to enjoy your body because you don't get more of these. This is one - you got to protect it. And you have no idea the capability you have. You're never, ever going to end that journey. So it's always, you know, this is never ending quest for more and more. And like you said, aging only happens when we kind of stop having fun. We get these responsibilities. You have kids, you have a job.

ELLA You don't have to do it all. But what you do should be done well with expertise and should be progressive so that we never age and we can always remain playful. Well, I don't know how this will translate over the air, Carlos, but I would love for you to describe several functional movements that we should all be able to do. And if we are not able to do them smoothly, that is an indication to us. What pops into mind for you when I say that?

Dr CARLOS Oh, certainly. There's seven specific ones that we test everyone, actually. So everyone can do this. I will do my best to be clear when I speak here. So there are seven main movements and we do our screening. First will be the neck and head. What I'd like everybody to do is sit nice and tall in their chair, keep their jaw closed and attempt to touch your chin to your chest. And what you should have is the chin's ability to go all the way to the chest, not any space between your chin or your sternum. And you shouldn't see much rotation or side bending. And that just means like your head turned sideways. Yes, I'll go. Should they touch? Should my chin? Okay, mine doesn't. And so there are many violations. Well, hey, you're the one shouting it out. There are many reasons we can or cannot do these things. I'll get to that in the end, because this is actually one of the main reasons we use this screen is very, very useful at telling us what we're going to do for this patient. All right. So we've just done cervical flexion now, jaw closed, everybody looking up as high as possible. So you should have full almost 90 degree extension with no side bending or rotation and shouldn't hurt you back right now. So just right down to the front of your clavicle, your collarbone or front. And you should be able to do that without elevating your shoulder or opening your mouth. And Ella just did both.

ELLA You open your mouth and elevate your shoulder. Great. Wait, wait, wait, wait. I want to try again. Do it again. Okay. Chin to basically your collarbone. Okay. Yeah.

Dr CARLOS And so you saw that elevation there. Yeah, you did. You did. You did.

ELLA Damn it. Little better on that side. Okay. Now I felt it.

Dr CARLOS Now up and over. Touch your opposite shoulder blade with your arm. Okay. You know, you do that one. You do that one. Good. Now underneath like you're trying to reach up and back.

ELLA Wait, I'm trying. Okay. Describe what we just did.

Dr CARLOS So we went up and over, to over our head to our opposite shoulder. And so your elbow should point mostly straight up and down and you shouldn't have to rotate very much. You do it. And then you reach up behind you like you're trying to scratch that spot on the back of your head.

ELLA Like you're trying to hook your bra.

Dr CARLOS Yeah. Oh, yes. Exactly.

ELLA Okay. My arm. This arm does not do that yet.

Dr CARLOS And that's going to be the last functional range of motion to gain with what you have had to go through with adhesive capsulitis for sure. All right. So now we've done our cervical screen and our shoulder screen. We've seen functional internal rotation and functional external rotation. Now, if you don't have all of those, there's lots of reasons why pain can go as low as the lower back. Actually, I've seen patients who lack shoulder flexion. And in order to get more height, they just arched their back and did it for so many years that they realized they didn't realize that it was a shoulder problem. They said, I have back pain.

ELLA So they can't raise their arm all the way is what Carlos is showing us. So they've actually been relying on their back to arch to do the rest. Yes.

Dr CARLOS And that patient came in just with back pain. He did not have any shoulder complaint. And when I said, all right, let's see you move around and can you move your shoulder more? No, this is how high really. So guess how much we looked at his back. We just treated his shoulder, got flexion, and goes, “my back pain went away”. As it turns out, the knee bone is in fact, connected to the thigh bone. OK, so simple. All right. So you've done all the upper body now. Now, everybody's going to stand and you're going to attempt to touch your toes. You can round, you can get as far down as you like. It doesn't really matter as long as your knees are extended and you can get to your toes with your fingertips. Now, sometimes you need a couple of bounces. You need a couple of, you know, a couple of seconds. That's OK as long as you get there. And the cool thing about a lot of these tests is if you do it a couple of times because you're not sure if you've got it, if you can do it, it'll get better and better and better. And if you can't do it, it'll actually get worse. So it's a cool thing to test it a few times. All right. So now you've touched your toes and you should be able to do that on both legs or that is with both legs feeling the same and both knees straight. Now you're going to raise your arms up in the air and you're going to go backward as far as you can. So your shoulders should be able to extend your thoracic spine, your lower spine, your hips should all be able to extend. And you shouldn't lean or feel like one side is tighter than the other. So that's kind of like the yoga pose where your hands are pointing to the sky and then you arch your back while you're very, very vertical. OK, yes. And that one, though, making sure to allow the hips to move forward. That's very important to think about there. All right. Now we have rotation. So hands are down to your side, standing with your feet together. You're going to rotate your head and your shoulders and your hips as far around as possible. And you want to see about 90 degrees of total motion, but even motion of top and bottom.

ELLA OK, when you're doing that. So basically we're standing and we're twisting. Did you say our hips twist with us or they stay pointing forward?

Dr CARLOS Hips twist as well. The only thing in this screen movement that doesn't move are your feet. So even your knees are going to see some rotation. That's all fine because your knees do provide some rotation moments in certain motions. OK, and we got two more single leg stance, which everyone can sort of visualize. You're standing on one foot, 10 seconds, both sides. Eyes open is one test. Eyes closed is another. We were trying to eliminate a very important part of your balance mechanism to see whether or not old ankle, knee or hip injuries have disabled your body's ability to feel yourself in space. So as soon as you close your eyes, you rely only on the mechanisms in your foot, ankle, knee and your hip to tell your brain, where am I? Is that proprioception? You got it. That's awesome. Yes. And then the last one is overhead squat. So deep overhead squat with arms extended overhead. It is by far the worst one to see people do. It's always bad if there are any if there's anything going on in other parts of the screening. But it's a good one because it really shows full mobility, like having a nice vertical overhead squat shows extreme amounts of hip control.

ELLA Carlos, sorry to interrupt you. Can you explain more about what a perfect squat looks like? Because I actually don't think people know that. So if you'll get that on the table and then finish your thought.

Dr CARLOS Of course, of course. Yes. So a perfect overhead squat would be extremely vertical. So we're going hands overhead and the arms are in line with my ears. Now, I can't do a perfect overhead squat. Fortunately, one of our therapists can. However, the idea would be verticality from the arms to the chest to the hips with deep sitting into the pelvis. This should be comfort. This shouldn't look difficult and they should be able to come right up out of it with no problem

ELLA Where are your knees pointing? Forward. This is a very weird squat. We're not dead lifting here. No, no, no, no. This is a PT eval squat. Yes. It's like a medical squat.

Dr CARLOS Yes, this is an information gathering squat versus anything else.

ELLA Yes. So we are a pencil. Yes. Perfectly straight. And we are just sinking into our bend.

Dr CARLOS Exactly. Our back is not bending. Right. You're sitting it straight down. And so those are the seven tests that we look at across the board to discover one real important variable. Are we as physical therapists and strength and conditioning pros and movement people, are we going to be WD-40 for this patient or are we going to be duct tape?

ELLA WD-40 for those of you who are not in America is like a greaser upper. So to use your analogy, what is what? Like when does someone need more juiciness to create agility and mobility versus what is the duct tape scenario?

Dr CARLOS So duct tape is far more important in my experience and in the literature and what we see day to day for people's performance than WD-40. WD-40 is I can't touch my toes, doc. What's going on? My hamstrings are tight. My hamstrings are tight. I went to physical therapy and we stretched and we stretched and we stretched and my hamstrings are still tight. I say, OK, let's see you touch your toes. And they go to touch your toes and they say, see? All right. And then I'll take their leg and I push your leg up. And suddenly the leg goes further. All right. Well, that's interesting. Put your arms out like this. And then imagine somebody lying on their back with their arms in front of them. And I pull their arms over their head. I said, just hold here. What I'm doing is making your abs turn on. You can feel that. Right. Yeah. I feel my abs. Like if I let go, my arms will go. All right. Now lift up your leg yourself. And every single time it's invariable. Boop. Legs go straight up. And they go, wow. I said, yeah, did I make you more flexible there? But I didn't touch you. I made you stable there. I put duct tape around your core. And when you asked your hip to flex, it didn't pull a bunch of mush around first. It just moved your leg. But when you go to move, your body says you don't have control over that. We're not going to let you have all those degrees. You're going to stop here. And that's what happens. So instability can look just like tight. But I would bet my license that the next 10 people who come in here, nine are not tight. They're just weak. It's all the time here. And so we're duct tape a lot. We're not mobilizing and moving joints as much. It's certainly part of what we do, but we're always working on the strength and coordination and power side.

ELLA OK, yeah, you guys, it should also be said that you are performance personal trainers. So that should be put on the table. OK, last question here. And you really just touched on it. And I wasn't planning on asking you this, but I know and have experienced that core strength is like “ballgame.” And I mean, if you get injured, having core strength will help you get up. If you're getting older, having core strength will literally help you get up. Can you just talk to us about your version of that? And then what are some of the best exercises we can do to maintain our core? Because spoiler alert, it's not sit ups. Sorry, it's not sit ups. That would be really great. Nobody's sorry. Carlos, don't be sorry. I'm not sorry. No.

Dr CARLOS So I've gone a large part of my career saying there are three cores and think your axial core is most important. Now think about this. You have your spine, you're sitting in place. And if I were to put a brick on top of your head, I would squish all your discs together. I would squish your spine down. Great. No problem. Your body can handle that. Your body can handle that to a level you do not understand. Your spine is one of the strongest, most stable things we've got. And it's always been that way. So this idea that suddenly our backs are fragile is crazy to me. It is not a fragile thing. However, if you attempt to load it with your body, not in proper alignment, side bent, rotated a little bit, flexed for some weird reason. Well, now it's going to take work to hold those bricks overhead. And in this analogy, those bricks are just gravity. It's the world constantly trying to put you to the center of this planet. OK, we have to fight that constantly. And if we do it with neat, what I call quiet sitting postures and can comfortably go from posture to posture, we're good. Axially loading a bar on your back, a heavy thing in your hand. That's going to strengthen that “axial core”. But if you break it down more to break it down further, you have a core between your shoulder blades. You have a core in the middle of your pelvis and you have one right down the center of your body. And so all three of those working together make up that axial core, that squish proof system that provides a good area for your shoulder blades and your leg muscles to push and pull from just back to that patient who couldn't touch his toes. When I make him brace his tummy, suddenly he can move. All I did was take his pelvic core and squeeze it up and his trunk, his middle core, if you will, turn on so that when he lifted his leg, his pelvis didn't go toward his foot. That's how it should work at all times. And so when you prime a move like that and you teach and you drill a move like that, it becomes the way you move.

ELLA OK, well, I lied. That definitely was not my last question, because now I want to ask you in that case. What are your three if you can only do three exercises for the rest of your life? Yeah. OK, what are you doing?

Dr CARLOS Front squat kettlebell swing deadlift. Well, you didn't even hesitate. No, because it's not even close. Say them again. Say them again. Front squat. It doesn't get you with a bar, a dumbbell, kettlebell. Kettlebell swing. Deadlift. And it doesn't have to be the pure version of the Olympic deadlift. It could be a trap bar. It can be a version of a dumbbell. But the idea is those three motions incorporate every muscle and also allow you in certain volumes to work metabolically. So if you do kettlebell swing with a very, very, very heavy kettlebell, you do sets of five and really condition your trunk and your hips and your glutes and your hips. Great. But if you have a lighter one and do 50 and you maintain good technique, oh, man, that is a cardiovascular workout. That's cardio. We like the word cardio. We don't do cardio. Wait, you're saying hardio? Hardio. Yes. Hardio is what gets people to move. Hardio. I'm not standing on a treadmill walking for 50 minutes. No, not at all. We're going to do hard things again and again and again. Improve your cardiovascular exchange. Improve your overall endurance. Again, make you a versatile mover. So yes, the kettlebell can be just as good as the rower. And then deadlift with regard to how much input your sensor nervous system is getting. How much your body loves compression in your spine and in your knees that it's just it craves it. And so you think about what the deadlift does. It trains the squish, that squish core, right? Your axial core immediately. And if you're not keeping your shoulder blades back and your hips really, really well engaged, you're not moving the bar. So it's a low risk movement in that, well, if you do it wrong, it's just not going to go. If you do it right, it goes and you can progress.

ELLA And I love the idea. We've been talking about this a lot lately on the show and just people starting to lift heavy again or even just start to lift period. And I'm a big fan of getting someone to teach you how to do this with proper form because that is a long term investment, meaning that's an investment that lasts the rest of your life. And you can do it literally in one or two sessions. And it doesn't need to be somebody. You don't need a big budget to do this. You can go to a gym and have free access to these resources. You can go online. You can watch some of Carlos's or somebody else's videos.

Dr CARLOS I just implore you to learn the proper form because you will get so much more out of the function. Absolutely. Yeah. Moving efficiently also allows you to load quicker. Like if you want to make improvement, we have to be performing progressive overload. And muscle is quality of life. If you're not doing work, intentional work to increase your muscle mass, man, woman, dog, cat, you are going to age quickly.

ELLA You have to stay on top of muscle mass. Carlos, I cannot thank you enough for sharing your wisdom with us today. Where would you like people to find you and what can we share with them? Can we put some videos on here?

Dr CARLOS Can we not link them to some of your work? Absolutely. So you can find us at www.sparkphyisio.com. We have a filled out YouTube channel with a lot of exercise demonstration videos. We've got some funny stuff on there. We have a lot of fun. We enjoy every one of our clients on a very fun level and it comes across in a lot of what we do.

ELLA Yeah. OK. Well, you guys, Carlos is not going anywhere. I see this man once a week. So if you have questions for Carlos or his killer team, who I love, shout out to Kristen and Matt, then send me your questions and we will get them answered. Carlos, thank you.

Dr CARLOS Thank you so much. It was great.

Well, that's your version. My version is that you are my chief torturer or torture in chief, whatever you want to call it. All right, okay. I can speak to the handholding and in all honesty, my listeners know that I have been dealing with frozen shoulders since July of last year. So we're on month 10. We're working on month 11. It's been a maddening journey, but I finally found help when I came to your practice and it was so transformative for me that I knew right away that I needed to talk to you on the air. We needed to talk about not necessarily we'll touch on adhesive capulitis, which is the fancy name for frozen shoulder. We'll talk about that briefly, but I have covered that a bit. I want to talk today with you about some of the specific modalities that help with that. But then let's zoom out for people who hopefully never have to deal with that and talk about things that are relevant to, I don't know, people who have bodies, people who play golf, people who play tennis. How's that sound? That sounds terrific. I'm all for it. Okay, tell me a little bit about you because you are a well-rounded gentleman. And I just want to get some of your experience on the table here.

Dr CARLOS Well, thank you so much. That's a terrific compliment. I started my journey in around 1998 when I began my personal fitness career. Several years working in commercial gyms, things like that, personal training clients. And as I gained more formal education, I started working with some, what would you consider, more high level movers, people whose bodies were their livelihood, they were playing sports in college or they were getting ready to go to the professional ranks. And so that happens less often, of course. General population rules the world. And it's really just as exciting for me to see someone who's never picked a bar up off the ground to do so with comfort as it is to watch my seven foot two basketball player gain three inches on his vertical. There's no difference in what gives me life in my journey here. But around 2006, I had my own personal training company, a strength and conditioning business that I was running on my own. Along the way in 2006, I picked up physical therapy as a new career path, sort of one that was going to be complementary to the workout I had already done. But one of the things that I had been seeing was clients asking me questions about their pain. And, you know, I was being honest with myself that my lane kind of ended when I can't cue it out because of the way I'm saying things or if I can't give you a very easy little tip and it makes it better, there's something else happening here. And I knew I had a blind spot. So I went to go fill it. In 2009, I graduated as a physical therapist and rebranded my strength and conditioning company to Spark Physiotherapy. And we've been running ever since. It's my baby. It's my curse. But it's the way I get to meet and interact with some of the most amazing people. It's been an honor. Yeah, spoken like a true entrepreneur, actually. Tell me about Brazilian Jiu-Jitsu. Oh, yeah. That is the art of folding someone's laundry while they're still in it. So you could think of it if you've ever seen a wrestling match, an actual wrestling match, not the WWF or whatever that has to do with the leotards. But the end game actually happens when you have gained such a position where you have all the ability to move and your opponent has none. And so you consider it like athletic chess. It's not a high impact sport. It is not a ground reaction sport, which we'll talk about later. But certainly it allows me to maintain some competitive athletic activity in my older age as I get away from things that bash my body into the ground. OK, but you're involved in another combat sport, which is you're the dad of twin girls. Yes, yes. And I'm very excited that they're getting into it. A couple of nights ago, my daughter, Ella, had come home and learned something new. She said, can I show you? Absolutely. It was bedtime. Like, I don't care. Let's go on the floor. So much fun. And it's a great way to learn just your physical body, your limits and what you kind of can stand up to.

ELLA OK, well, I might give that a try, but first I need to be able to, you know, move my arm. So come on, let me see. Let me see. Let me see. No, we're not doing that on video. It's a HIPAA violation. I'll take it. OK, I have touched on Frozen shoulder and I don't want to bore people by mentioning it, you know, every other show, Carlos. But just to set the stage here, could you just explain what adhesive capsulitis actually is?

Dr CARLOS Sure, sure. So the ideology, the cause of how this happens is actually really not well understood. What we know is that anything that can exacerbate the inflammatory cascade, especially in this area, but even systemic inflammation can kind of trip this. And it isn't by itself something that happens and then suddenly, bam, your shoulder doesn't move. You begin to feel this pain, the sensation of restriction or loss of mobility. And then many times as human movers, we go, well, maybe I should protect this. I probably should just make sure I don't do anything that hurts. And in many cases, that's OK. But this is not one of them. I actually have given many, many talks in front of groups of surgeons. And I said, I want every surgeon in the room here to answer this question. Raise your hand if you've ever had adhesive capsulitis. No one raises their hand. I would challenge anyone. I would bet my license to ask their orthopod if they've ever had one or knew an orthopod had never had one. And they would say no, because our knowledge is somewhat protective against pain. So if my shoulder began to hurt and it was in the ways that were typical that would eventually become an adhesive capsulitis, I'd say, boom, I'm up [raises arm]. I'm right up right away. Immediately. I'm not letting that happen. And it's that fear avoidance cycle that I think what we do on we kind of consider the next gen PT side of things that really gives the whole picture of that healing process and allows folks to, you know, maybe get OK with and this is going to take a while. If it doesn't take two years, I did good. If I take less than 18 months, great. If I get less than a year, hey, you did a good thing. That's a good place to be for people to have a good relationship with pain. Understand that pain by itself is not the barrier. It is information. And we have to just know what to do when we receive that information. If you don't know, contact somebody who's got that information.

ELLA Yeah, I'm going to say right now that I'm not your doctor. Carlos is not your doctor. And so we're not advising you. But one thing that I have learned is had I fought through the pain, so to speak, and kept my arm in motion, I could have shortened this journey by a lot. That's great to know now. But the truth is, when this is happening to you, you don't know what it is. I actually thought I had a tear because I was doing some shenanigans the day before. So I actually thought I was doing handstands and I had a push up contest with my son and I won. So it's obviously been totally worth it. But I thought that I tore something. And of course, if you tear something, you're going to arrest it. And what you have taught me is that, well, we learned that's not what it was. But if I had kept it moving, it wouldn't have frozen so solid. I mean, when I tell you it froze, you guys, I was completely incapacitated. And now my muscles are muscles that basically haven't been used in a year.

Dr CARLOS Yeah, no, it's true. And the thing that if I could go back in time, anything that kind of kicks off that inflammatory cascade can start this process. And maybe you also had a systemic thing. Maybe there was some illness going on. Maybe there's some underlying reason for your immunity to be disabled for a small bit. Who knows? Our bodies go through these changes constantly. Our immunity goes up and down. Our overall fitness, our ability to just rotate your head. You know, these things are not static things. If you don't use those abilities, they go away. So, you know, if we can kind of encourage that for more people, they can seek out the edges of their mobility and know when that information is there to be able to do something active so they can avoid these restrictions and pain. What does your immune system have to do with these musculoskeletal issues, Carlos? I mean, inflammation is something your body reacts to with the same systems as I got a cold, I had a virus, I got a flu. So when we can keep our gut healthy, when we can keep our sleep hygiene up to date, when we can have proper hydration, we are doing so many amazing things to eliminate many problems that plague folks throughout their lives.

ELLA Well, this will sound idiotic to you, but I just really in all my years of training, really never made a connection between my immune system and how I thought of it. I'm using air quote marks because what I meant by that was like, am I getting a cold? Have I gotten the flu in the past two years? I never connected that. I started to learn to connect that to my gut health and understand how much of our immune system is housed in our gut, actually, physically, literally. And what I did not appreciate is that the weakened immune system equals excess inflammation equals more injury. I never made that connection. I wonder if anyone else is making that connection with me in real time.

Dr CARLOS Yeah, that is there are correlations between those things because you have a weakened immunity does not necessarily mean you're going to see excessive inflammation. However, if you also have a high inflammatory diet, you're not sleeping enough. You're you're you're sedentary and you're so you're not moving throughout these large ranges of motion, moving the ends of muscles and and the connective tissues that contain a lot of the signaling system for the endocrine rest of your body to produce the and the analogistic chemicals, the recovery chemicals. This is all part of the whole moving thing that I think more folks really just need to understand. Your body is a very complex bit of moving parts. You have control over every one of those parts.

ELLA OK, so last sort of word on frozen shoulder before we move on. Am I to understand then and we'll broaden this, but am I to understand that that is in very practical terms, that is just such intense inflammation that you can no longer move your arm in your shoulder because of your shoulder joint?

Dr CARLOS Yes, shortest answer would be yes, that capsule that has gotten so hot and so short and so contracted. And now every bit of the musculature that is around there is also taking part to join this protective mechanism. So part of care for adhesive capsulitis is knocking some of that irritability down. That can be gentle modalities that could be gentle, gentle mobilization. And then part of it has to be aggressive mobilization against the soft tissue structures that are the static stabilizer, the actual sack around the glen or the around the head of your humerus that holds this all together. That winds up and that is what we need to move and get free so that your shoulder can move more freely.

ELLA When I found you, one of the first things that we did was we engaged dry needling therapy and I would like you to explain it. I'm going to explain it as mid evil torture that I'm now addicted to and love. You don't like it when I say torture, do you?

Dr CARLOS No, but I get it. I totally understand. I get it.

ELLA It is something else. But trigger point dry needling is the most effective thing that I have done. I am so glad I found it and you. Can you please tell us what it is and why it works?

Dr CARLOS Sure. I will begin by telling you what dry needling is not. It is not acupuncture. I have zero knowledge on any meridian. I don't know what a chi is. I don't give a crap where your flow goes. None of that. I want to know what is causing your pain, what is stopping your mobility, and I want to address it in the fastest, most efficient way possible. And in my experience, I have found dry needling to be just the most easy to deliver, simple to teach technique for releasing tension through soft tissue, specifically muscles. It essentially is a massage inside of the muscle. I think a better name for it would be intramuscular therapy or intramuscular manual therapy, because in this case, I'm just using a tool to get deeper than my fingers or my elbows or whatever could possibly get. Now, also, I mean, I want to get into some of how much your audience will tolerate the nerdy parts of this, but I do want to get into some of that. But the idea that if I use the tip of my finger to get to the depth of a muscle, let's say a hips muscle, in your case, like a lats muscle, you have thick muscles and then the muscles are not right on the surface. You have your skin, you have a fat layer, you have layers of connective tissue, you have layers of other tissues, and then they invaginate one another and they have to slide and move as a whole. Now, if I put my finger on your skin and then I press down, I'm impacting every single thing from the surface of your skin all the way down to that area. And the surface area of my finger is much bigger than the surface area of the tip of one of these needles. I'm not forcing mobility to occur when I use dry needling as a technique. I'm using your nervous system to get mobility to occur. And so what you would feel when you're having a treatment like this is you really wouldn't feel the needle. They're very small. But when you get the tip of the needle to the depth of the area in that muscle, there will be a local twitch. And that local twitch is similar, actually exactly the same neurologically, as a spinal reflex. The same kind of thing when your doctor caps your kneecap or the patellar tendon on the table and they're testing your reflexes. It's exactly that mechanism. And the reason we know it's that mechanism is because this area of muscle is being told to contract. We see jitter. We see electrical activity that is telling this area of muscle differently from other areas within the same exact muscle. Hold. We want you to hold. Please hold. And we tend right now the prevailing understanding of why is if we have instability in an area of our body, other parts of our body can say, well, let me just do that. Let me just do that job. So we need to first get normal mobility of these soft tissues to then teach good coordination, good strength, good endurance to get back all the way well motion. So from before this was ever a big problem. So we're trying to reset muscle tissue. We're trying to drop pain because those trigger points directly lead to myogenic pain. But that pain is also known to really rapidly diminish. And then the restrictions in mobility diminish as long as we can teach the proper coordination.

ELLA Yeah, I mean, it's a very intense process, but it's very brief, like very, very brief. And then just as the end user, if you will, I'll say that the needles are so fine that that's the only thing in my mind comparable to acupuncture. The needles don't hurt going in and the needle is not the issue. It's the twitching and the release that is so very intense. And then it's like that “hurts so good” thing. You know, it's working.

Dr CARLOS Absolutely. You know, when it works, it works near immediately. That's the thing I tell folks. You know, we don't you don't dry needle everything, you know, folks who and this is probably the best free advice I can give anyone is when do I know I need dry needling as well? If you can point with your finger to one place and it hurts like, oh, it hurts when I do that. Oh, it hurts when I do that. This is a problem right there. This is something going on right here. But if you go and this is very common, you know, Doc, I have my shoulder hurts, but like it's just aching. The whole thing hurts in my brain. I say, OK, she has touched her medial deltoid or anterior deltoid or biceps or brachialis. OK, so now let me go test them all. If I can't make those hurt when I ask those individual muscles to work under a heavy load and you go, no, no, no, no, no, that's my pain. OK, well, your pain lives here, but the cause does not live here. And then what happens? I start poking around some of the posterior cuff muscles and suddenly they go, oh, I feel the front of my arm. I go, ah, that is referral pain from your infraspinatus or from your teres minor or whatever. Every muscle has a known referral pain pattern. So if it's a small cuff muscle that rotates your arm out, we know that muscle hits you here most often. If you have a neck upper trap trigger point, those people complain of headaches and my head in the back hurts. And I got a headache right on top of my head. But they don't go, you know, my trap is killing me. But when you grab it, they go, oh, what's that? That's where your head is coming from. And so that's part of what we learn along the process as therapists, as dry needling technicians, as a little bit. You might consider expert myofascial folks, but that really fills the gaps for a lot of folks who are sort of stuck in between a real injury to a small tissue and like everything else that occurs.

ELLA Well, I'm going to go ahead and guess that you work with a lot of baseball players. Sure, sure do. So now I want to zoom out and we can draw a line under adhesive capsulitis. We can leave that. Thank you all for coming. Now let's zoom out and talk about folks who play golf, who play tennis, who move their bodies in any way or who want to, Carlos.

Dr CARLOS Yes. Well, everything starts with finding out where the line is right now. I don't care who you are. You're a professional athlete at 40 or you're Tom Brady or you're me coming in the door. I got to figure out where on this continuum between pain and performance you are because everyone is on that continuum every second of every day. You can move yourself up that continuum of being very well rested by having a good meal the night before by spending 20 minutes to warm up and say, yeah, now I'm ready to golf. And you can shove yourself down to the pain side of that continuum by sitting still, getting to your round five minutes for tea time and having a bad dinner the night before. You're not on the good side of that spectrum. And so when we see anyone, we say, OK, where are we now? And where do we need to be going? What is the goal here? Do you want to be the criterion level golfer? But now your back is getting in your way. OK, so now we've established a baseline. And anytime someone comes in, I think what a good plan should always be. We should have a movement plan and then a pain plan or an inflammation plan. Or what do you do with the information your body gives you when it's run out of steam, when you've got more endurance, when you're out of strength, when you've run that last hole and you did a little bit too much on that swing and now like, oh, that didn't feel good. Do you stop or do you absorb that information and then make a small adjustment? And that is what we teach folks to do the most is become very good advocates for themselves. Say, OK, I got the info. This is the next step so that I can press forward. And sometimes it means I'm done. This means today I have met the line, but that's OK. As long as I don't cross the line in a week, that line is going to be further down the line down the road.

That's what you want to do. That's how we get progression. That's how we move people further and further away from the pain side on that continuum.

ELLA Well, let's go back to the individual because I happen to know that you and I share a belief in common. And that belief is that getting older does not mean getting feeble. It does not mean getting weak. And like I just reject that as an excuse for me personally. That's just not a belief I choose to accept or live out in any way. If you could just download a belief or a motivation for people, what would that look like and sound like to you?

Dr CARLOS We get old when we stop playing. Period. I'm like a kid. I enjoy moving around. And I wanted this cool little sidebar. I was in the bathroom with my daughter helping with teeth time, brushing teeth and getting ready for bed. And she asked, Daddy, why do you exercise like this? And I said, well, you know, I exercise a lot, but I enjoy my body. It's like and daddy wants you to learn how to enjoy your body because you don't get more of these. This is one - you got to protect it. And you have no idea the capability you have. You're never, ever going to end that journey. So it's always, you know, this is never ending quest for more and more. And like you said, aging only happens when we kind of stop having fun. We get these responsibilities. You have kids, you have a job.

ELLA You don't have to do it all. But what you do should be done well with expertise and should be progressive so that we never age and we can always remain playful. Well, I don't know how this will translate over the air, Carlos, but I would love for you to describe several functional movements that we should all be able to do. And if we are not able to do them smoothly, that is an indication to us. What pops into mind for you when I say that?

Dr CARLOS Oh, certainly. There's seven specific ones that we test everyone, actually. So everyone can do this. I will do my best to be clear when I speak here. So there are seven main movements and we do our screening. First will be the neck and head. What I'd like everybody to do is sit nice and tall in their chair, keep their jaw closed and attempt to touch your chin to your chest. And what you should have is the chin's ability to go all the way to the chest, not any space between your chin or your sternum. And you shouldn't see much rotation or side bending. And that just means like your head turned sideways. Yes, I'll go. Should they touch? Should my chin? Okay, mine doesn't. And so there are many violations. Well, hey, you're the one shouting it out. There are many reasons we can or cannot do these things. I'll get to that in the end, because this is actually one of the main reasons we use this screen is very, very useful at telling us what we're going to do for this patient. All right. So we've just done cervical flexion now, jaw closed, everybody looking up as high as possible. So you should have full almost 90 degree extension with no side bending or rotation and shouldn't hurt you back right now. So just right down to the front of your clavicle, your collarbone or front. And you should be able to do that without elevating your shoulder or opening your mouth. And Ella just did both.

ELLA You open your mouth and elevate your shoulder. Great. Wait, wait, wait, wait. I want to try again. Do it again. Okay. Chin to basically your collarbone. Okay. Yeah.

Dr CARLOS And so you saw that elevation there. Yeah, you did. You did. You did.

ELLA Damn it. Little better on that side. Okay. Now I felt it.

Dr CARLOS Now up and over. Touch your opposite shoulder blade with your arm. Okay. You know, you do that one. You do that one. Good. Now underneath like you're trying to reach up and back.

ELLA Wait, I'm trying to do my best. Okay. Describe what we just did.

Dr CARLOS So we went up and over, to over our head to our opposite shoulder. And so your elbow should point mostly straight up and down and you shouldn't have to rotate very much. You do it. And then you reach up behind you like you're trying to scratch that spot on the back of your head.

ELLA Like you're trying to hook your bra.

Dr CARLOS Yeah. Oh, yes. Exactly.

ELLA Okay. My arm. This arm does not do that yet.

Dr CARLOS And that's going to be the last functional range of motion to gain with what you have had to go through with adhesive capsulitis for sure. All right. So now we've done our cervical screen and our shoulder screen. We've seen functional internal rotation and functional external rotation. Now, if you don't have all of those, there's lots of reasons why pain can go as low as the lower back. Actually, I've seen patients who lack shoulder flexion. And in order to get more height, they just arched their back and did it for so many years that they realized they didn't realize that it was a shoulder problem.

ELLA They said, I have back pain. So they can't raise their arm all the way is what Carlos is showing us. So they've actually been relying on their back to arch to do the rest. Yes.

Dr CARLOS And that patient came in just with back pain. He did not have any shoulder complaint. And when I said, all right, let's see you move around and can you move your shoulder more? No, this is how high really. So guess how much we looked at his back. We just treated his shoulder, got flexion, and goes, “my back pain went away”. As it turns out, the knee bone is in fact, connected to the thigh bone. OK, so simple. All right. So you've done all the upper body now. Now, everybody's going to stand and you're going to attempt to touch your toes. You can round, you can get as far down as you like. It doesn't really matter as long as your knees are extended and you can get to your toes with your fingertips. Now, sometimes you need a couple of bounces. You need a couple of, you know, a couple of seconds. That's OK as long as you get there. And the cool thing about a lot of these tests is if you do it a couple of times because you're not sure if you've got it, if you can do it, it'll get better and better and better. And if you can't do it, it'll actually get worse. So it's a cool thing to test it a few times. All right. So now you've touched your toes and you should be able to do that on both legs or that is with both legs feeling the same and both knees straight. Now you're going to raise your arms up in the air and you're going to go backward as far as you can. So your shoulders should be able to extend your thoracic spine, your lower spine, your hips should all be able to extend. And you shouldn't lean or feel like one side is tighter than the other. So that's kind of like the yoga pose where your hands are pointing to the sky and then you arch your back while you're very, very vertical. OK, yes. And that one, though, making sure to allow the hips to move forward. That's very important to think about there. All right. Now we have rotation. So hands are down to your side, standing with your feet together. You're going to rotate your head and your shoulders and your hips as far around as possible. And you want to see about 90 degrees of total motion, but even motion of top and bottom.

ELLA OK, when you're doing that. So basically we're standing and we're twisting. Did you say our hips twist with us or they stay pointing forward?

Dr CARLOS Hips twist as well. The only thing in this screen movement that doesn't move are your feet. So even your knees are going to see some rotation. That's all fine because your knees do provide some rotation moments in certain motions. OK, and we got two more single leg stance, which everyone can sort of visualize. You're standing on one foot, 10 seconds, both sides. Eyes open is one test. Eyes closed is another. We were trying to eliminate a very important part of your balance mechanism to see whether or not old ankle, knee or hip injuries have disabled your body's ability to feel yourself in space. So as soon as you close your eyes, you rely only on the mechanisms in your foot, ankle, knee and your hip to tell your brain, where am I? Is that proprioception? You got it. That's awesome. Yes. And then the last one is overhead squat. So deep overhead squat with arms extended overhead. It is by far the worst one to see people do. It's always bad if there are any if there's anything going on in other parts of the screening. But it's a good one because it really shows full mobility, like having a nice vertical overhead squat shows extreme amounts of hip control.

ELLA Carlos, sorry to interrupt you. Can you explain more about what a perfect squat looks like? Because I actually don't think people know that. So if you'll get that on the table and then finish your thought.

Dr CARLOS Of course, of course. Yes. So a perfect overhead squat would be extremely vertical. So we're going hands overhead and the arms are in line with my ears. Now, I can't do a perfect overhead squat. Fortunately, one of our therapists can. However, the idea would be verticality from the arms to the chest to the hips with deep sitting into the pelvis. This should be comfort. This shouldn't look difficult and they should be able to come right up out of it with no problem.

ELLA Where are your knees pointing? Forward. This is a very weird squat. We're not dead lifting here. No, no, no, no. This is a PTE Val squat. Yes. It's like a medical squat.

Dr CARLOS Yes, this is an information gathering squat versus anything else.

ELLA Yes. So we are a pencil. Yes. Perfectly straight. And we are just sinking into our bend. Exactly.

Dr CARLOS Our back is not bending. Right. You're sitting it straight down. And so those are the seven tests that we look at across the board to discover one real important variable. Are we as physical therapists and strength and conditioning pros and movement people, are we going to be WD-40 for this patient or are we going to be duct tape?

ELLA WD-40 for those of you who are not in America is like a greaser upper. So to use your analogy, what is what? Like when does someone need more juiciness to create agility and mobility versus what is the duct tape scenario?

Dr CARLOS So duct tape is far more important in my experience and in the literature and what we see day to day for people's performance than WD-40. WD-40 is I can't touch my toes, doc. What's going on? My hamstrings are tight. My hamstrings are tight. I went to physical therapy and we stretched and we stretched and we stretched and my hamstrings are still tight. I say, OK, let's see you touch your toes. And they go to touch your toes and they say, see? All right. And then I'll take their leg and I push your leg up. And suddenly the leg goes further. All right. Well, that's interesting. Put your arms out like this. And then imagine somebody lying on their back with their arms in front of them. And I pull their arms over their head. I said, just hold here. What I'm doing is making your abs turn on. You can feel that. Right. Yeah. I feel my abs. Like if I let go, my arms will go. All right. Now lift up your leg yourself. And every single time it's invariable. Boop. Legs go straight up. And they go, wow. I said, yeah, did I make you more flexible there? But I didn't touch you. I made you stable there. I put duct tape around your core. And when you asked your hip to flex, it didn't pull a bunch of mush around first. It just moved your leg. But when you go to move, your body says you don't have control over that. We're not going to let you have all those degrees. You're going to stop here. And that's what happens. So instability can look just like tight. But I would bet my license that the next 10 people who come in here, nine are not tight. They're just weak. It's all the time here. And so we're duct tape a lot. We're not mobilizing and moving joints as much. It's certainly part of what we do, but we're always working on the strength and coordination and power side.

ELLA OK, yeah, you guys, it should also be said that you are performance personal trainers. So that should be put on the table. OK, last question here. And you really just touched on it. And I wasn't planning on asking you this, but I know and have experienced that core strength is like “ballgame.” And I mean, if you get injured, having core strength will help you get up. If you're getting older, having core strength will literally help you get up. Can you just talk to us about your version of that? And then what are some of the best exercises we can do to maintain our core? Because spoiler alert, it's not sit ups. Sorry, it's not sit ups. That would be really great. Nobody's sorry. Carlos, don't be sorry. I'm not sorry. No.

Dr CARLOS So I've gone a large part of my career saying there are three cores and think your axial core is most important. Now think about this. You have your spine, you're sitting in place. And if I were to put a brick on top of your head, I would squish all your discs together. I would squish your spine down. Great. No problem. Your body can handle that. Your body can handle that to a level you do not understand. Your spine is one of the strongest, most stable things we've got. And it's always been that way. So this idea that suddenly our backs are fragile is crazy to me. It is not a fragile thing. However, if you attempt to load it with your body, not in proper alignment, side bent, rotated a little bit, flexed for some weird reason. Well, now it's going to take work to hold those bricks overhead. And in this analogy, those bricks are just gravity. It's the world constantly trying to put you to the center of this planet. OK, we have to fight that constantly. And if we do it with neat, what I call quiet sitting postures and can comfortably go from posture to posture, we're good. Axially loading a bar on your back, a heavy thing in your hand. That's going to strengthen that “axial core”. But if you break it down more to break it down further, you have a core between your shoulder blades. You have a core in the middle of your pelvis and you have one right down the center of your body. And so all three of those working together make up that axial core, that squish proof system that provides a good area for your shoulder blades and your leg muscles to push and pull from just back to that patient who couldn't touch his toes. When I make him brace his tummy, suddenly he can move. All I did was take his pelvic core and squeeze it up and his trunk, his middle core, if you will, turn on so that when he lifted his leg, his pelvis didn't go toward his foot. That's how it should work at all times. And so when you prime a move like that and you teach and you drill a move like that, it becomes the way you move.

ELLA OK, well, I lied. That definitely was not my last question, because now I want to ask you in that case. What are your three if you can only do three exercises for the rest of your life? Yeah. OK, what are you doing?

Dr CARLOS Front squat kettlebell swing deadlift. Well, you didn't even hesitate. No, because it's not even close. Say them again. Say them again. Front squat. It doesn't get you with a bar, a dumbbell, kettlebell. Kettlebell swing. Deadlift. And it doesn't have to be the pure version of the Olympic deadlift. It could be a trap bar. It can be a version of a dumbbell. But the idea is those three motions incorporate every muscle and also allow you in certain volumes to work metabolically. So if you do kettlebell swing with a very, very, very heavy kettlebell, you do sets of five and really condition your trunk and your hips and your glutes and your hips. Great. But if you have a lighter one and do 50 and you maintain good technique, oh, man, that is a cardiovascular workout. That's cardio. We like the word cardio. We don't do cardio. Wait, you're saying hardio? Hardio. Yes. Hardio is what gets people to move. Hardio. I'm not standing on a treadmill walking for 50 minutes. No, not at all. We're going to do hard things again and again and again. Improve your cardiovascular exchange. Improve your overall endurance. Again, make you a versatile mover. So yes, the kettlebell can be just as good as the rower. And then deadlift with regard to how much input your sensor nervous system is getting. How much your body loves compression in your spine and in your knees that it's just it craves it. And so you think about what the deadlift does. It trains the squish, that squish core, right? Your axial core immediately. And if you're not keeping your shoulder blades back and your hips really, really well engaged, you're not moving the bar. So it's a low risk movement in that, well, if you do it wrong, it's just not going to go. If you do it right, it goes and you can progress.

ELLA And I love the idea. We've been talking about this a lot lately on the show and just people starting to lift heavy again or even just start to lift period. And I'm a big fan of getting someone to teach you how to do this with proper form because that is a long term investment, meaning that's an investment that lasts the rest of your life. And you can do it literally in one or two sessions. And it doesn't need to be somebody. You don't need a big budget to do this. You can go to a gym and have free access to these resources. You can go online. You can watch some of Carlos's or somebody else's videos.

Dr CARLOS I just implore you to learn the proper form because you will get so much more out of the function. Absolutely. Yeah. Moving efficiently also allows you to load quicker. Like if you want to make improvement, we have to be performing progressive overload. And muscle is quality of life. If you're not doing work, intentional work to increase your muscle mass, man, woman, dog, cat, you are going to age quickly.

ELLA You have to stay on top of muscle mass. Carlos, I cannot thank you enough for sharing your wisdom with us today. Where would you like people to find you and what can we share with them? Can we put some videos on here?

Dr CARLOS Can we not link them to some of your work? Absolutely. So you can find us at www.sparkphyisio.com. We have a filled out YouTube channel with a lot of exercise demonstration videos. We've got some funny stuff on there. We have a lot of fun. We enjoy every one of our clients on a very fun level and it comes across in a lot of what we do.

ELLA Yeah. OK. Well, you guys, Carlos is not going anywhere. I see this man once a week. So if you have questions for Carlos or his killer team, who I love, shout out to Kristen and Matt, then send me your questions and we will get them answered. Carlos, thank you.

Dr CARLOS Thank you so much. It was great.