Hi, guys. Welcome to another episode of the Factor Podcast. I'm your host, Jessica Riddle. Welcome, and thanks for listening. If you're a health care provider in the physical medicine space, your body is one of the tools of the trade that you use more than any other in your practice. Whether you're performing joint manipulations, soft tissue treatments, needling, or using any variety of treatment modalities, your physical ability to perform is the most common denominator of the success of your practice, and while there's no shortage of courses that can teach you about various techniques and treatments, there's very little attention given to the biomechanics and ergonomics involved with preserving the physical health of you, the healthcare provider that's administering care, and that, my friends, is the focus of today's episode. In this 2 part series with doctor Ti Pence, titled, The Body Mechanics and Beyond, Crafting a Sustainable Manual Therapy Practice, we will discuss the importance of alignment and conservative force generation techniques when performing joint manipulation. Doctor Ti Pence will highlight the key red flag mistakes that can quickly lead to overuse injuries resulting in those above the belt soreness days and can develop into career ending injuries over time.

So hit the pause button, grab something to take notes with, and be sure to download the PDF visual guide that I've linked for you in the show notes. These 2 episodes are one every manual therapist should listen to more than once. Let's cue the intro music and get started.

Thank you. Thanks everybody for taking time out of your day. I really appreciate it. It's an honor to be talking to you all. This is always the the part where I am not such a fan of is talking about myself. This slide is just to say I've been doing martial arts and chiropractic for a really long time. I've done it chiropractic in just about every venue you can do chiropractic in, And I've been doing martial arts since I was 15, so I do understand the idea of generating force and understanding levers. And I'm gonna try to use that knowledge to help you guys practice longer and have better practices, hopefully.

So what we're talking about today. 1st, I'm gonna discuss mechanics. If you don't have the form right, it's kinda hard to go faster. If you can't relax into the form and the speed, there's no way your palpation's gonna be very good. I know for some of us, we're not talking about what would say grade 5 manipulation or adjusting. We might be using it for some soft tissue techniques. Same principles really apply. It's just force over time.

Now when I type in something like road to mastery, there's this implied idea that somehow I'm telling you from some level of mastery, and that's not it. I've just spent a lot of time trying to understand this stuff, and, hopefully, this brings all of us to a better understanding that we can one day all achieve some level of mastery. But I don't know any sport that the top levels of the sport aren't really focused on improving the basics. So that's kinda what I'm trying to talk about today. Just cautionary because I hear this a lot from a lot of different fields. You'll get these folks who'll say something like, they're a master or a ninja or a Jedi or something like that. Please please be cautious of those. There's no such thing.

We're not. That would imply that somehow we've gotten to the edge of knowledge, and we aren't. We got a long way to go. I'm just trying to help us move forward on that in the little way I can. I know I saw someone from Katy from Toronto. God, Canadians do such good research. So we got how many injuries happen in a year as chiropractors. This is kind of the reason we're having this stock is there's a lot of them.

Here we go. Ironically, notice what's not on there. We don't have lower extremity injuries from doing this stuff. It's all low back and up. Now how did these how did these injuries happen? Positioning and performing manipulation. The other part that's kind of a bummer is these providers had pain for more than 30 days, and they were still practicing, which means it started hurting, and they kept doing the same thing that hurt over and over. Theoretically, maybe they changed everything immediately, changed how they were practicing, but that's generally not the case, and that's not the way it played out in this study. Since we're talking about form and structure, we really have to start out with how we put put our feet on the ground.

For those of us who have been through either physical therapy or chiropractic courses on manipulation, It seems like every place I have gone to and every person I have seen discuss this starts off with putting their hand on the patient, and that's just not the way we do it. You don't hand someone a basketball and tell them to shoot it without understanding mechanics and then just tell them to figure out mechanics on the fly. You wouldn't do the same thing for any other sport. You wouldn't put someone in a boxing ring and ask them to just start punching and then work on their punches. That doesn't make any sense. But that's generally how we do it as physical medicine providers. So I'm gonna try to do something a little different and start with the foundation of how our form should be built, which is from our feet. That x is where we're aiming to do manipulation or adjustment or whatever you wanna call it.

What that means is no matter how our feet are angled toward the table, and the table doesn't have to be in that direction up and down. It can be you could be at the end of the table, the foot of the table, wherever. But you're trying to get it in between your feet. Now your feet your feet might be at an angle, like a 45 degree angle rather than parallel to the table, or they might be perpendicular. It doesn't really matter. The the issue is, is that contact point, that place you're putting your hand in between your feet, at most, that x of where we're trying to contact would be lined up with the front foot, but not ahead of it. The reason for this is as you're standing there, the weight distribution has to be on both feet. If the place that you're trying to contact is ahead of the feet, it, by definition, puts the weight almost a 100% on your front foot.

It's very hard to generate power like that and not get injured. So okay. All of these different angles are just some. I had to pick a few because, obviously, as I'm going through this, you could line up and work your way around the table as far as all kinds of different options for manipulation, which is gonna work better or worse for different people, different providers. But any of these, this basic mechanic should be true. The place that you're aiming to contact should be in between your feet or at most lined up with your front foot. Now that we've figured out where to put our feet in line with where we're trying to move something, now we gotta figure out how to generate some level of force that's gonna get that region of the body to move. I guess I'm just trying to prove my point.

They just had people do maximal lower limb and upper limb like a bench press and a squat. And then measured force as far as different techniques and basically punching techniques. Upper body strength really their their ability to bench press had no correlation to strength as far as power in their punches. Their lower leg strength is what define that. We all know this in martial arts. Anybody who's been in martial arts or who's watched enough UFC or boxing or kickboxing or anything knows if you see a guy swinging guy or gal swinging with their hands where their arm looks detached from their body and the force is obviously coming from their upper body, not their lower body, they're gonna be slow and they're not gonna be as powerful as someone that's swinging from their whole body. But I say this because it's obvious, and yet very few people practice this when it comes to manual therapies. There's 3 ways that you can generate force.

One of them is going from your back foot to your front foot, forward translation. 1 of them is going from your front foot to your back foot, backward translation, and then rotation. Now every almost every time I talk on this, someone tries to argue with me that there's some other way to do it. They learn some secret technique out of the mountains of somewhere from their guru that says that they've got this magical way of doing it. Okay. If it works for you, awesome. But for most people, these are really the 3, and you can kind of combine the translation and rotation. But we would be getting into the weeds on where that really defines itself as a combination rather than part of rotation.

If we have time at the end, maybe we can go into some of that if you guys have questions. Just to sum this up again because it it bears repeating, and I guess I'm repeating this because I so commonly see the opposite of this, and I rarely see this. Where I see this is in practitioners that and providers that have been doing this for a long time and they're still doing it. Most of the time, if you've made it, well, at least to where I am in the profession of 20 years or so, you've either figured out some mechanics or you broke yourself and you've had to, like, choose a different path as far as how you're gonna treat patients. I guess the take on there is if you do see somebody that is of retirement age still doing manual therapy on a regular basis and they aren't totally injured, you gotta pick the brain as much as possible. They're doing a lot of things right. Now that we've got how to generate force, we wanna figure out where the maximal place to put that is. And we've kind of talked about this in a 2 d format, and I realize that this is also 2 d.

But hopefully, this has a little bit more 3 d understandings. I don't like taking 2 films on an x-ray of what you're trying to do here. I'm also speaking broadly about all of this stuff first because all everybody that I talk to has a different way that they practice, where they practice, how they practice, what kind of patients they are seeing in their practice, all what type of body type they have. It's gonna change what techniques they use, I guess. It's all gonna change how these principles are applied in your own practice. That doesn't mean that they don't apply. They still either apply or you're probably gonna hurt yourself or you've already hurt yourself. The question is just, can I speak broadly enough that in the beginning, when you take this idea home to your own treatment room and start breaking apart how you're doing stuff, can you see how these things could be applied? And that's why I'm talking about them broadly first.

Alright. This wheelhouse concept, I don't know if that's the best way to to define it. It would be where you put a cookie jar kind of right there next to your abdomen. If you're trying to open it, it would be kinda where you're aiming for a golf I'm sorry. Not a golf swing. A baseball swing. Same general area of where you want your hands to generate the maximum force. You wouldn't have your hands way up next to your neck.

That wouldn't make any sense. You also wouldn't try to have your hands way down at your knees when you're trying to move something. That also doesn't make any sense. So where you're trying to locate this person in 3 dimensions is, well, kinda right next to your hips and below your rib cage and then in front of your feet a little bit, but not too far in front of your one foot or the other. This will make more sense when we start talking about the upper body and how we relax into things, but we need to discuss this first kind of as a flow. This is what it looks like if we put a table in there. Sometimes that visual helps. I intentionally put that table somewhere around the knees.

That allows there to be some space above that table to assume, like, a patient isn't £90. Like most of the TikTok videos of people manipulating other people. And so that that that height, which is gonna determine also how far away the patient is, is gonna be slightly higher than the table, which will put them right about in that spot that you wanna move something in. If you have the table very low because you think I'm a short person, I need it down way past my at my ankles because that will help with gravity. You need to rethink how you generate force. That idea implies that somehow you're short but weigh an insane amount of weight, like the core of the earth type weight where you can just drop your body on somebody and get motion. For most people, I don't think that's a practical way of doing things.

Once we've got a patient in a place where we've set up our feet so that the place we're trying to move is somewhere in between our feet. And if they're high enough up that they're that the place that we're trying to contact is somewhere in between our hips and our rib cage. Now, we need to make sure that force that we started generating in our legs that transfers through our core into our shoulder gets out our hands into the patient. In order to do that, we have to make the shoulder part of the body rather than moving independently. This is where things go awry often with providers. The reason I'm talking about the shoulder independently of the rest of the upper extremity is because how important it is. If you don't engage your shoulder in a way that pulls it down before you try to drive force through it into the patient, the force is, good old Newton, is gonna go back up into your hand and it's gonna go back into your shoulder. You're gonna feel it in your shoulder if you don't compress it first.

Also, you're gonna end up losing that force as it pushes up your shoulder and you're not getting the maximal force into the patient that you were working hard to derive from your feet and your hips into your shoulder. Now let's kinda dive into the whole upper extremity, but it's gonna be the shoulder included. I use this 90, 90, 90 rule because it's easy to remember. Really? When we're talking about this, it should probably look like the 40 5, 90, 85 rule, but nobody wants to remember that. So we're gonna go back to this 90, 90, ninety rule and talk about it for a second. And then I'll tell you why it should probably look more like the other one. The reason there are ranges on this that are so big is because different ways of manipulating patients dictate a different way that you're placing yourself in relation to the table. How your arm is going to move in order to generate the force needed because it's moving with the body, not because your hand or arm is moving independent of the body.

That being said, the basic rule says you really should not be abducting your shoulder more than 90 degrees, which means bringing your elbow up away from your rib cage. You should not have your elbow extended fully. So slightly less than extended. And then it shouldn't bend more than 90 degrees. If it bends more than 90 degrees, the force will translate directly out the elbow, wherever you're doing. The only exception to that is if the elbow happens to be the contact point for what you're trying to do. In that, we'll say elbow and forearm, that whole region. If you're contacting somewhere in there, then it doesn't matter what angle it's on.

That's where the force is going through anyway. So that's the only exception there. Other than that, if your arm is completely your elbow's completely locked out, that again is just gonna send force right into your shoulder and probably hurt your elbow as well. Next, the 90 degree wrist rule. Really, that 90 degrees of wrist extension really only applies to a couple types of techniques that I consent of. I've studied a lot of them. I'm sure someone's gonna tell me something where there's an exception, and I always love to hear about those because there's no such thing as ever knowing everything when it comes to all the different ways one provider can use a technique or use many techniques to adjust various patients. So I'm I'm I'm always willing to If someone wants to tell me some version where this is not true, let me know.

It's when you're driving force into a flat palm. If that wrist goes into hyperextension, meaning more than 90 degrees, And you're doing that often. Say like on the lumbar spine or the middle of the back, the thoracic spine. You're gonna injure your wrist. It's just a matter of time. Now, the reason I say the 40 five, ninety five, eighty five rule is in most cases, you really shouldn't come anywhere near 90 degrees with your shoulder. There are very few situations where you might want to do that. If you try to depress your shoulder, contracting all the muscles underneath, contracting your lats and everything else, trying to get that shoulder to go down, and then try to abduct to 90 degrees, meaning bring your elbow away from your body, you'll notice at some point you can't keep the shoulder depressed anymore.

That is where you've lost the linkage linkage between your arm and your body. And now you're gonna have to muscle. Most of the time, it's easier if it's somewhere between that 15 to 45 degree range. It allows the force to just travel a lot easier. It's easier to relax into that. The body can stack on itself so you don't have to work as hard to get that power through there. The 95 means somewhere over 90 if we're go if we're going through the full range of motion of an elbow, meaning it's not more flexed than 90 degrees. I don't know how people.

Yeah. I know I'm talking to a diverse group, so I some some people are gonna measure this differently. But the general is just from flexion to extension. So as we're going from flexion to extension, it should be more than 90 degrees and not 180. I know how hard this is for a lot of people when I say this because a lot of folks, the main way they do a certain manipulation is by bending, is by straightening out both elbows and then just putting their body weight into their hand contact. They're likely getting away with it or else they wouldn't fight me on this. But it just feels very awkward for most folks to bend their elbow a little bit if they've gotten used to having a very straight elbow. You're gonna have to practice.

This is not something you just, like, bend your elbow one day and go, oh, I got it, and start working on patience. It it's something you probably wanna practice beforehand, and we'll get into some practice ideas depending on how much time I've got. But you're gonna wanna practice this before because this this will feel weird. You will feel like now you're collapsing your elbow or at least this this has been something I've been told. Then now it feels like you're losing connectivity of your elbow into your body because it doesn't feel locked in. Yep. That's kind of the first stages of that. And then as far as the 85 for the wrist, the way I described that hyperextension, meaning it forced your wrist into more than 90 degrees, you probably didn't start at 95 degrees.

Some some do. There's there's there's some, but not a lot. Most folks start almost at that 90 degrees. And then as they derive force into the patient, that hyperextends the risk. There's a trick to this that you can do as well as just making sure that your wrist is not completely at a right angle to the body. And that is if you contract your thenar and hypothenar or try to bring try to push your pinky and your thumb into the patient so you're contracting the bottom part of that hand there. If you get those muscles to engage before you drive force into your hand, it really won't let you go past that 90 degrees. And it creates padding for your wrist, which is probably where you're gonna hurt yourself if you're not abiding by this rule.

So it's a trick. You can try to practice it. I just can't overemphasize how useful it is and how little effort it takes to start implementing it. It just means when you're practicing this for the 1st few weeks, maybe even a month, you're gonna have to be mindful every time you put your hand flat on a patient that you have to take that extra step and contract those muscles. It might slow you down. So now how do we train all this at home? There's no such thing as going from, hey, let me just show you the right way to do it. There isn't a right way to do it. Anybody who tells you that there's a right way to do it is only speaking to what they have found that works for themselves with their patient population.

No matter how cool that person might seem to you, do not buy into the idea that's the only right way or that's the way that's going to work for you. You have to be mindful about what your body tells you and what you see working in your practice. That's kinda how that evidence based medicine thing works. So figure out what motions you're using the most. Once you've got your top 3 or 4 that you're doing every day, start breaking those down. Don't do all of them at the same time. This is a bad idea. If you do all of them at the same time, you're gonna get frustrated because now you're bouncing off of patients where you used to be able to get things to move easily.

Don't do that. Pick 1. Generally, the one that feels most uncomfortable for you or the one that you feel needs the most work, start there. It's already annoying to you. Start with that one. Then figure out where your feet are when you're actually doing this thing. Realize, like breaking apart a golf swing, as soon as you start messing with this, everything's gonna feel weird. The other example is like if you're trying to solve a Rubik's cube, you get one side to work.

Obviously, you're gonna see you're gonna make a mess out of some of the other sides in the process. That's okay. That's part of the process. Start with the feet. Make sure that the feet are abiding by the rule that you're not somehow leaning way over on one side or the other. That's first step. Then how are you actually generating force in this patient? That's critical. Be honest with yourself.

It's okay if you wanna tear apart what I'm saying or believe that I'm just making stuff up. That's fine. Don't lie to yourself. That's crazy. Watch how you generate force. If you generate force from moving from one leg to another, okay, use that. If you're rotating and that's how you're generating force, use that. The only additional thing that I will say is there is moves where you have one leg contacting the patient and that leg is using the patient's leg as a lever in order to generate force.

So one of your legs is naturally on the ground, but acting like it is in the way that you are translating force through that or rotating in a way that's using that leg. That is still that rotation or translation. When we get into injuries here in just a second, you'll understand where I'm gonna draw the line here as far as when that's working for you and when that's not. Once you can generate force in your arm, however however those angles work out for you and the way you're moving that body, your arm should be able to be relaxed through that motion. What that means is wherever your contact is on your hand or your elbow or somewhere else, whatever that contact point is, you should be able to drive that force from your legs through your body into that point without contracting your hand too much. It it's other than what we were talking about with the wrist. It should be that your hand should stay relaxed as you're doing that. That will tell you that you're doing it right.

The more you have to contract more muscles to feel like you've got this move to work, in most cases, the more you do that, the more likely it is that you're gonna hurt something. The reason I say that is because you're generating force that's going up through the body and then getting stuck somewhere in the arm. That arm is resisting that force. That's where you're gonna have injuries happen. That's what I mean by relaxing the arms. Can you generate force and then relax the arms in a way that you can keep working on your speed, how much force you can translate through that motion you're doing and still keep your arm linked to your body and relaxed? There are so many ways to practice this at home. It could easily be a very long one day discussion on all the ways to practice this kind of stuff at home. So we're not gonna condense it all into here.

And besides, everybody here that I'm talking to, I'm sure has different stuff they're working with in their clinic as far as resources. So I'm kinda trying to keep it as something that could be used in a lot of different settings. I don't know. I'm sure someone's gonna come up with a with some sort of example of something where it doesn't work, and that wouldn't shock me. If you happen to be a chiropractor who has one of those tables, when you push on it, it will collapse, meaning it will drop into itself and you can adjust the tension so that you can create more resistance to you pushing into them. That's awesome. That is a great way to practice all of this stuff because you don't have a patient yet in front of you. You can work on getting yourself to where your hand is in that location.

Your feet are in the right place. You know what kind of force you're trying to generate. You've got the location of where you're trying to move that body part in between your feet and at your wheelhouse. And then you can practice over and over again trying to perform the way you use your body and see if you can't relax into that more and more. The more you can relax, the more comfortable you feel in doing that, the more force you can generate through that. If you don't have one of these tables or have no idea what I'm talking about, they do have these portable ones that I believe are called speeder boards, but those are just small versions and exactly the same thing. The only issue is the smaller the one you get, the less tension you're gonna be able to generate. The good news is usually they don't cost that much, so you won't feel that bad when you finally get really good at this and you start breaking them.

I'm sure someone who's mechanically inclined could see that there might be an invention here somewhere as far as training, but there's a lot of ways to do this. I've heard old chiropractors talk about practicing this with empty beer cans. I am not suggesting that. I'm just saying one could be creative in how they do it. Bands also work. Connecting bands to different locations and using resistance bands in order to work on how you move through that motion, also really good. Lacrosse balls, any type of weighted ball, if you want to work on like cervical adjusting or like a side posture, like where you have the patient on your side and you're trying to rotate them, you can use a ball to try to figure out how to contact that and drive into that ball without having the ball just roll away from you. The key is is that whatever you're doing with your hand is really a prop just to get you to drive in to practice with your lower extremities.

Going back to the beginning just to make sure I know that in order for someone to get a new concept, we have to repeat it a number of times. So I'm trying to do that. What we covered so far is make sure your feet are in the right location. Figure out which way you're generating force. Make sure that where you're aiming at is in the right place, both in between your feet and vertically in between your hips and your diaphragm. There are some cases that deviate from all of those, but the exception should not be the rule. If you're deviating from any of these here, there should be a very good reason and it shouldn't violate a number of these things. It should violate maybe 1 And then make sure those arms stay relaxed.

You should not try to muscle through something. That generally not only gets you less force, but as an experiment, find someone that's going to be honest with you and really contact somewhere that you would try to move. Don't move. Don't do this. Don't actually try to manipulate people like this, but just put your hands on them and contract as hard as you can with your upper body. And then relax as much as you can with your upper body and see which one the patient feels more comfortable with. They will tend to relax more if you relax more. So this is a double win for you.

You're not only generating more force. You're also getting the patient to relax, meaning it takes less force to move the joints. And I know that what I'm talking about is trying to generate more force in and some might take that as I'm implying that we just need to generate maximum force on any region of the body we're trying to move, and that's not true. You can be very gentle, and you you should be able to dial that forward and backward depending on what kind of patient population you have or what patient's presenting to you today. What I'm saying is you shouldn't generate a 100% of force from your feet and get 10% of that force out of your hand. Losing 90% of that force in your body is gonna generate pain. So this is my rule. I generated this rule by doing the same thing that everybody does out of practice.

So anybody that's a new student that got out or anybody that remembers their 1st couple of years out will understand what I'm talking about. I got out. I was seeing a bunch of patients back to back because I was low man on the total bowl, and that's how it rolled there. There was no discussion of mechanics. I blew out my wrist, my elbow, my shoulder in quick succession. Like, it was it was bad. And there was no scenario where I could, like, stop like, just call in for a week to rehab. That wasn't gonna happen.

So this falls back to what we saw in the first research study. Providers keep practicing because there's not really an option a lot of times. So I made up this rule and this has worked for me since then. I should not be sober above my belt or my waist. If I am sober, I have done something wrong. I need to figure out what I did wrong in my practice that day. That cannot happen tomorrow. I know I have succeeded at this because at the end of the next day, I should not be sore above my belt.

I know this is a very simplistic way of doing it. And I realized that if I had everybody in a room and asked how many if all of you were seeing patients all day, how many people are sore in their upper body at the end of the day? I get a significant percentage of people to raise their hands. I'm not trying to say this like bragging. That's not the intention of this. I'm just trying to show that I am living this example, which is I'm seeing more than 50 hours of patient care a week. I am treating that many people every week. Some of my days are 12 hour days. Some of them are 10.

Some of them are 8, but then involve travel back and forth. And all of my patients is hands on care. The area that I am most sore at the end of the day is my cap. It's never above my waist. The only time I've ever had this happen is when I let myself not pay attention to engaging my shoulder and I got sloppy and I gave myself impingement on my shoulder. This rule does work. Now it's not gonna work for fatigue. If you're being crazy and not taking enough time to warm up in the morning, rest, and be honest with yourself that you're ready for another day, obviously, even if you've got the best mechanics in the world, eventually, you burn out.

So I don't know what to say about that. Just be true to yourself about your own resilience.

That's it for today's episode. Be sure to tune in for part 2 where doctor Pence teaches us his 90, 90, 90 rule for shoulder, elbow, and wrist positioning. We'll also learn the optimal way to configure your treatment space for maximum efficiency and comfort and the importance of the ability to generate force through fluid balanced movements. You won't wanna miss it. Episode 88 drops in 2 weeks. If you're interested in learning more from doctor Pence and would like to submit a question for an upcoming q and a episode, please click the link in our show notes and drop us a line. We read each and every one, and we'll be sure to feature your burning questions when we have doctor Pence back on the show. And if you enjoyed today's episode, be sure to share it with a friend and then visit our website at factorpodcastdot com and leave us a review.

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