Hi, guys. Welcome to another episode of the Factor Podcast. I'm your host, Jessica Riddle. Welcome, and thanks for listening. In today's episode, we wrap up our 2 part series titled Body Mechanics and Beyond, crafting a sustainable manual therapy practice with doctor Ti Pence. In part 1, we learned about the importance of alignment and conservative force generation techniques when performing joint manipulation. We also talked about the key red flag mistakes that can quickly lead to overuse injuries resulting in the above the belt soreness that can develop into career ending injuries over time. Today, doctor Pence will teach us his 90, 90, 90 rule for shoulder, elbow, and wrist positioning.

We will also learn the optimal way to configure your treatment space for maximum efficiency and comfort and why it is important to be able to generate force through fluid balanced movements. So whether you're new in practice or are a more seasoned practitioner that knows exactly what I mean when I say above the belt soreness, Be sure to listen up and take notes. Let's cue the intro music and dive in.

Now let's quickly try to get through some entries. Another really cool study. I was gonna break this all apart in the results section, but the summary was so good. I this also violates my, like, don't put a whole bunch of words on one slide. But, man, every part of this is useful. The scary part to me is that the number of years in practice is considered a risk factor. And the risk factor is when in the first 5 years of practice. This is when you haven't gotten conditions out of seeing patients.

You still got the bad mechanics you were probably taught in school. This is not to talk negative about how to teach mechanics in school. If I was in there trying to force you from quarter 1 to learn good mechanics, you probably wouldn't see the value in what I was trying to teach you. You don't see it until you get injured. Unfortunately, that happens in the 1st 5 years. And, ironically and there is some obvious argument here. The most common way that this happens is doing some sort of side posture, low back manipulation. This is one of the most common things that any provider does who's doing manual medicine in their practice.

So it's not shocking that that's the most common way to do it. The way we can improve on that is that if you watch how people perform these low back manipulations, there is frightening things that people do that are setting themselves up for injuries. First one, clamshelling. I don't know a better way to explain this, but if you're just falling over at your hips or your low back and hoping that gravity is going to solve the problem of how to generate force through your patient, you are destroying your low back. The only other thing you're doing is giving yourself whiplash as your neck is bouncing up and down all day. You're doing it worse if your neck, if your head is over the patient. So if your head ends up on the opposite side of the table of your feet, by the end of the manipulation or the technique you performed, you're going to hurt your neck. It's just a matter of time.

That's clamshelling. Really, if you've got back pain or neck pain when you're adjusting or manipulating patients, you're probably doing this. This is just too great a picture to not talk on for a minute. If instead of a pool table, we put a patient under this guy, it would look like a lot of what practitioners are doing in their own practice. They're all on their front foot. They're not using their back leg as a way to generate extra force by contacting with the leg and rotating or using it to to create rotation in the low back. It's just sitting up there. They're hinging on their front hip.

How are you gonna generate power like that? And then the next part that's the most awesome part of this, look at where their arm is. If I took a lot of people out, meaning people, meaning patients, if I took the patients out from underneath providers, lots of their arms would look like something crazy like this. You you're gonna hurt your shoulder or your elbow or your wrist or all 3 doing this. Don't. I know someone taught you some cool method and you got something to make an audible pop one day and you decided this was a miraculous move. Please stop. You're gonna hurt yourself. Top speed golf.

I love you for this photo. This is fantastic. Don't chicken wing. Although we just came from what I would call, like, a very bad version of a low back technique. The worst chicken wing situations I've seen are in when you're working on a neck and it's terrible. When someone ends up throwing their elbow out to the side in order to get motion at the region they're trying to move, it generally also creates this really wonky thing with your hand where it not only bends towards your pinky or ulnar deviation, but it also creates flexion of your wrist. Now if you do both of those, you're going to hurt yourself. The wrist should be a way to transmit force through it, not let the force deform the joint.

I have had providers show me this technique in the air. They they didn't even need a patient. They just showed me I asked them how show me how you do it on a NET manipulation, and they demonstrated this exactly like that. I said, hey. I could help you with that. This is not it's alright. I've been doing this for a while. That's like the most common response, and it's really frustrating.

If you wanna practice until you wanna choose to retire rather than when your body wears out, please please please really work on your form here. The reason I've worked so much on form, and and it seems like I didn't talk about speed and relaxation and palpation is because of how much emphasis I was putting on it. And I wasn't putting emphasis on the other parts that were going to come with it. The way you generate speed is by relaxing more. When you're working with your feet into generating force, it will start out slow and clunky. The more you get used to understanding how you generate your own force, that relaxation into that motion is how you generate more speed. Then the more you relax your arm, the faster it can go. Think of it like a whip, not as a baseball bat.

Once you can relax that hand, then you can get sensory input from it as you're moving something rather than just feeling like you've got this tight thing you're trying to push into resisted tissue. Lastly, the way you get really good at palpating stuff is a very simple message that a lot of people don't use. When you palpate and find some region that feels like it's not moving the way it should compared to other areas around it, use the body mechanics you know how to do, use the technique you generally do, then palpate afterward and ask yourself, if I hadn't have just done if I hadn't just manipulated this joint and I was first going through this area of the body, but I think I need to do it again. You can also ask patients and see if the pain is reduced. That is helpful in the beginning when sometimes you don't trust your own palpation. But that circle of palpate, deliver a technique, palpate again with honest feedback to yourself is how you get better and you you allow your hands to get better and better. If you just tell yourself, I heard it pop or I did something, so therefore it's better, you're not listening to the sensors that are telling you information. Until you listen, you won't become a better listener.

And then now we're down to our last bit, which is questions. I know we've only got about 5 minutes left. I've set aside extra time if people end up with a lot of questions.

Thank you so much. And that is no worries. We always leave a little extra time for a lot of great knowledge. That was a wonderful presentation, and I know there's things that you guys are gonna be able to take away and into your practice. I did have a few questions here. Someone was asking about if you could give us kind of an idea of some of the biggest mistakes that you see, because I know you've taught students before, that you see students and new doctors making when it comes to kind of setting up their space for success? I know you talked about table hype, and I I feel like that's one of those things that if you start out with bad habits, they're kinda hard to break later on.

Oh gosh. Okay. So I could answer that in a very theoretical manner, but that doesn't really apply. Most students coming out have very little control over their initial practice space. Meaning, they probably didn't pick their own table. They haven't picked a room that fits the dynamics of, like, how tall they are. So when they spread when they place their feet in the positions they need to for different techniques they use, they're not, like, hitting a wall or there's something in the way. But that is first.

Whatever you have to work within there, work within the parameters of it to start moving it around so that as you move through the techniques that you use every day, you're not bumping into something. Something isn't stopping you from doing from moving in the way that you're you know would be a better way to move. Now with that space part, errors that I always see, and it doesn't matter what's well, actually, let me back up. The most common one that I see that as far as space goes is if someone can have their own table in the practice they are in or if it happens that there's a table that is adjustable in the practice that are that they're in, which is awesome. Having a table that can go up and down will allow you to keep that wheelhouse area where you need it for different patients depending on how what their body looks like. So that is awesome. And it definitely allows you to practice longer in the day if you have a a table that's that that can work with you. If you're getting one that's stationary, don't get one at your that that's really low.

The volume of care you're providing anytime while you're in school is very small. You're gonna go through that same number of patients in a couple of months of practice. Meaning, what feels good as far as maybe doing 1 in a morning probably isn't gonna feel good when you scale that to 10. Having something down at your really low is an old idea in in practice, and I I a lot of ideas that have been around for a long time are brilliant. This just happens to be one that only fits certain body postures, body mechanics, and it's not a good idea. So trying to get that table as best as you can, and that might mean that you need to build some sort of base on the bottom that goes underneath the table that elevates the table up so that it's at the right height for you in in the room that you're using. The other one that I see a lot is they'll be so focused on what they're trying to do with their hands that they'll end up putting their face as close to their hands as possible as if that will speed up the sensory signal from their hands to their brain. Don't do that because you destroyed every body mechanic in trying to achieve that.

If you want to get closer to the signal as far as paying attention to what your hands are telling you, close your eyes. Nobody's looking at you when you're trying to move stuff on a patient. If they are, that's probably feels pretty awkward, so closing your eyes will also help. But if you close your eyes, you can focus on what your hands are telling you far better than trying to get your eyes closer to your hands. Does that answer that?

That's a great point. And I think a lot of people, especially those of you that are hands on providers, I mean, there is so much that comes from that touch and that sensation. That's a great tip though. Like, remove one of your other senses. Remove the visual, close your eyes, and then that definitely opens you up to kind of being able to get more in touch with things. But that's interesting, and that's something that I'm sure a lot of providers may not even realize they're doing is sometimes they're getting closer and messing with their own body mechanics as opposed to just using that sensation to kinda take that additional sense out of there. And that there was a second part of that question that was also asking about things that you see that are sometimes really bad habits to break that maybe when a student comes out of school, they're exposed to various different techniques, and I'm sure it takes a while for you to kinda hone in on the things that that work best for you as a provider and the best ways that you find to kind of get into your own groove, what advice would you give for those students that maybe they've been exposed to a variety of different techniques, every guru's telling them this is the best way, Maybe even their instructors are telling them, no. Don't do it this way.

Do it this way instead. What is that advice that you give so that they can kind of figure out what works best for them for the type of provider they wanna become?

Okay. So I'm gonna follow-up on on a little bit even even expand on what you're just saying, which is a lot of times, you'll get from one course to another, one provider one teacher teaching them one mechanic and how to do something. And then the next term, having the next teacher saying the previous one doesn't know what they're talking about or this is the only way to do it. Half the time, students come out of the school with some hodgepodge of various techniques that they've they kinda learned sort of as they were going through in order to get through the exams, but haven't even spent the time to figure out what works for them. That's really unfortunate because in school is probably the safest time to put the most practice time in where you can be the most honest with yourself about getting good feedback from the other students you're practicing with or the patients that are there understanding that they are working with students rather than some rather than when you're in practice. The second piece of that is true of any competitive martial art. Any like, god, there's so many examples of this. We'll just cut down to the basics here.

What you want is one technique that you do the best of any other technique, and it should feel more natural than the other ones for you For each region you're trying to do manipulation on, that should be your go to technique that you should spend the most time mastering. Once you feel like you've gotten a good handle effect, meaning you could perform that technique on a number of patients of various body sizes, then practice one alternative technique that is counter to that one. It needs to be somehow different. If that one involves a push, then you want something that's more like a pull. Having the patient in a different position, seated versus lying down, face up, face down, something like that. But you want at least two ways to do some things. If the first doesn't work, you can try the second. If you have a whole toolbox of techniques that all are mediocre, then it doesn't matter how many techniques you have.

You're mediocre. You need to be good at 1 so that you can do it all day without injury. Then you take those 2 and start figuring out how to modify those for different scenarios. If you find true holes between those two where you don't have a solution, that's when you would try to learn a new technique from somebody else. Is that

I love that. Yeah. I love that. I think that's huge. That's the whole jack of all trades or master of none. And you're right. I think that's something that we also encourage, especially those docs that are looking to go into business for themselves. Like, figure out what it is that you wanna be the best in the world at, whatever that is.

And then set your sights on that and achieve that as best you can instead of, as you mentioned, what does it matter if you're gathering a lot of mediocre skills? Because at the end of the day, it just waters down what you're doing and and you become a a mediocre provider, which I don't think anyone goes into into any profession and says, I wanna be the most mediocre at this I could possibly be.

Man, I hope not. Right.

That being said, obviously, you have a lot of experience with various different techniques that are out there. And depending upon how specific you wanna get with things, do you feel like that there are some techniques that are a little more problematic from a body mechanic, from a practitioner injury standpoint than others or some that are better left to kind of try to conquer after you've been in practice for quite a while and gotten comfortable with other techniques before you try to add that one to your tool belt?

I definitely have spent some time learning all kinds of different techniques. And the reason that I'm saying to focus on one is because I was the Pokemon collector of techniques, thinking that I'm gonna become good by by learning from every person who ever has a different technique. And somewhere in the middle of my schooling, I found myself not able to do basic moves because I I just couldn't I couldn't separate the techniques in my head. And I put some weird Frankenstein version of the technique together, and it it took a while to take that apart. As far as saying one technique or another is by, like, a name technique is worse than the other, that doesn't it it it doesn't pull apart that easy. The easiest way that I can say is start with the ones that involve simple mechanics, that don't involve very dynamic motions with multiple appendages. For example, if you're trying to get the low back to move by having your leg on the ground, your other leg connected with the patient at an angle, your arm on another angle contacting the low back and the upper arm doing something else, that's a lot of moving parts. That's not where you wanna start.

You wanna start with simple motions, straightforward, things that don't require a lot of dynamic understanding of motion in order to perform the technique without hurting yourself. I know that I see a lot of providers eventually learn one of these techniques and can show it really well, and then they show it to a new graduate who has a much simpler form of how they do it, their own technique. And that is working for them right now. And the young student will then try to mimic that very complicated maneuver that only works because of years of of getting to that space. And we don't even know if that other doc is if that actually is working for that other doc. It just happens to be working through that doc in the moment when they're demonstrating to that student.

Absolutely. And I can say firsthand, I've I've seen that time and time again, and I think there's so much value, as you mentioned earlier, in seeking out providers that have had a long career that you know do a lot of adjusting to learn from them because there's a lot of wisdom in that. And if they've done so successfully, both from a patient outcome standpoint, but then also successfully from a, hey. Their their body is still able to do this decades later, that there's something to be learned there for sure. Someone else is asking about hypermobility and how that may factor into what you do as a provider. Obviously, all of us know that hypermobility has a big effect on joint movement. It can have a big effect on loading joints and things of that nature. If you are a hyper mobile mobile provider, what should you modify or how do you kinda take that into consideration when it comes to mastering your manual therapy?

Oh, I this is this is one that hits close to home. Man, I wish someone had told me about this before I became a chiropractor because I from 6 to 16, I was a gymnast, and I am I am crazy like my thumb. I don't know if you can see this on here, but it just bends all the way backward. Like I got all the like bendy parts like my it I've done just about every terrible sports thing you can do to a shoulder. So I've had all kinds of fun as far as hypermobility goes. Hypermobility becomes more of an issue when you're trying to engage the muscles around that joint to get that to transfer that force through it because the muscles are already working hard to try to stabilize that joint. If you're challenging the joint in a way that you know your body doesn't move well, you're not gonna sustain a practice in that. There are many moves that involve a thumb, for example, for me that involve pushing, like, pushing where my thumb is pushing into the patient.

I don't do those because my thumb gives out, and I end up hurting the capsule. If you have a hypermobility somewhere else like the cervical spine, then you're gonna be much more cautious about whipping your head forward over a over the table. Generally, if there's some sort of hypermobility in your SI joints or your low back I'm sorry. Your lower extremities, doing the form right generates the right type of muscle contracture. So that shouldn't be a problem in the lower extremities. I'm sure someone will show me where I'm wrong on this. But and I'm totally like, please do. But even being a gymnast, like, that that shouldn't be an issue if you're doing this right.

No. That's that's huge. And as a as a Bendy person myself, I totally understand that there are some constraints there for sure, and it's interesting. I didn't realize how much hypermobility affected me. Although, I mean, I was the kid in casts because I had nursemaids elbows that would pop out. Like, that was that was my childhood. But as an adult, I didn't realize how much that affected things until I started weight training and doing hit training and realizing that heavyweights and speed are just not great for hypermobile people. So I think that's an interesting takeaway here for the providers that are listening or for the students.

If you haven't done some of those hypermobility tests on yourself like you do on your patients, turn that mirror around and take a look at yourself and see if there are some considerations that you have to make for your own hypermobility and and how you handle your joints and loading them in that respect. My final question for you has to do with some of the work that you've done treating overseas and in international areas. I know you've worked in other countries before. You've treated athletes around the world. Have there been any things that you've picked up along the way or that you've learned from a manipulation standpoint that have been very unique and not necessarily taught here in the US, but things that you have incorporated into your own practice practice that you may have picked up from other providers from other countries.

Yeah. I oh, okay. So I gotta start this question. I this becomes kind of a canned thing that I respond that I respond to all these questions with Because I've just learned this is how it plays out for me, I once I figured out what type of move was working for me as far as the low back, I thought that one of my teachers had taught me that move. And in fact, I was citing that instructor as the one who had taught me this technique. And then I don't remember what brought me to go past that instructor about something about that. And he looked at me and was like, I've never seen this before. I've never taught this.

I don't know where you got this from. And so somehow that transition of, like, what I thought I learned versus what my body found to work well and then what I actually manifested on the other side of that has made me weary about saying, oh, I learned this from so and so because I might have seen a technique that then my body adapted to the way I work best. And now it's technically my technique described probably 100 of years ago, if I've read through enough of the old textbooks, just slightly differently with old ways of describing it. I think the best way that I that I can describe that as far as, like, working from all over the world like that. And, like, the the Japanese spine surgery clinic was definitely an eye opener because it's just you don't have patients. You don't get to work in that kind of close proximity to a spine surgeon where you're both trying to solve a problem in the same space very often. Even if you're in a hospital, you're not in the same office. And working with different athletes yeah.

There's, gosh, there's, oh, gosh, there's such a list of this. Different ways to to work on with the feet when it comes to people like landing on a trampoline versus someone who's got cerebral palsy and how you wanna change how you work with that person. How you wanna modify that that athlete's care based upon which muscles they're actually using, not what to the average person is functionally correct. I think that's probably the biggest one, and that ties into something that that one cycling expert someone who fitted bicycles to athletes was having it on top of me and said, hey. You know how how how I can tell if I've got a real pro or just an amateur who I'm fitting this bike to? And I'm like, okay. I I'll I'll play. Tell me. He said, an amateur, whatever I do, no matter how uncomfortable they are, will accept it as fact because they they trust me to be the expert.

A pro, no matter how good I do at fitting that bike to that rider, will spittle with it until it feels right to them. I think that's really the biggest take home is do you make sure that when you're working with a patient, a, you understand that you're the mechanic outside of the vehicle trying to do the best at fitting this vehicle to the driver as possible. But then getting the feedback from the driver, meaning the individual, as to how that feels and works with them, and maybe what looks functional is actually nonfunctional to that athlete. And maybe that asymmetry is functional to that athlete. And figuring out how to help that athlete move in that non normal way that is very functional to them, if that makes sense.

Absolutely. And and I could see how that's certainly the case amateurs. And and we had a great conversation about this on our podcast recently where we were speaking with 2 providers that treat elite level athletes. And that was one of the questions that we discussed was, how is it different treating those that are your amateur recreational versus your pros? And interestingly enough, the amateurs and the recreational athletes were less inclined to listen to the provider straightaway than those that are at the pro and the elite level because they realized that that provider has something of value to give them to give them that competitive edge. One final question for today, and I always love to ask this of our presenters, because I feel like you are kind of on the cutting edge and and leading the charge when it comes to manual therapy in terms of health care providers really looking at how they're utilizing manual therapy in practice and doing it so that they can have longevity. If you had a crystal ball and you could look in that crystal ball and look 5, 10 years into the future and see where manual therapy is evolving, and that means manipulation, whether it's a chiropractor doing it, a PT, etcetera, where is it heading? Where is it going? What do you think you'll see more of in the future, and what do you hope that we'll see more of in the future?

Oh, gosh. I I I I I love and hate this question.

It's a little little evil question there. Certainly.

Yeah. Yeah. Yeah. Yeah. Yeah. Yeah. Good one. I know I know I'm gonna offend people with this.

And I don't know. I guess the only thing I can say is I'm sorry if you're offended by my answer to this. It's it's not intended to be that way. It's just what I've seen from from my little location within physical medicine. What I see as far as a provider is more and more, it's not the degree that determines what the practice looks like. If you just walk into a practice, a private practice, at the top level, it's hard to discern what type of physical medicine provider you've walked into just by looking at what their office looks like or what they're doing in their office or the techniques they're offering. It it it could be a number of different providers. I think that is gonna probably continue to the point where it's more like people are picking from the same menu because the evidence is out there.

Everybody knows what things work for what conditions most of the time. It just makes sense to use those therapies for those conditions if you have access to them. Or you're gonna be referring out for those conditions and you're gonna be focusing on the conditions, the therapies that you have in your office are are able to be the most beneficial. So it's no longer gonna be a competition of, like, one provider versus the other or, like, one like PT versus chiro or accu or massage or personal trainer or what it's not gonna matter. It's just gonna matter what services you provide and are you really good at them. Sometimes, the way that a provider looks at treating a patient has merit. And some patients will choose one of us providers for that. I don't think that'll go away, but I think the old way of siloed lying is probably gonna go away.

All of us, really, whenever you put us together, we do better when we work together. I'm constantly working alongside acupuncturists and physical therapists and medical doctors. Synergy always results in better outcome for the patient, which means there will likely be a time when colleges and universities get on board with this, and private schooling of these things probably isn't gonna be a thing. It's probably gonna be where now incoming students have the choice of which university they're gonna go to and then which things they're gonna specialize along the track of something that's just called rehab or physical medicine. How long that's gonna take? I don't know. Things are going really fast, and they seem to be going faster and faster these days as far as knowledge and different schools competing with each other and needing to find new new curriculums to offer in order to stay competitive. So I'm not sure how that'll play out, but I don't see it staying the way it was for the generations before us. I don't.

I I think the reality that they got to experience and that they worked hard to get us to hear is going to rapidly change in a way that's going to be very uncomfortable for anybody trying to hold on to that style of practice.

No. I I would agree. That's definitely what we're seeing in the postgraduate space, and what we've been encouraging for years now is we're so much better together. It's really interesting even in a platform like this where you have a diverse group of professions that come together to share ideas and information. And getting everyone together in a room, you realize quickly that you do a lot of the same things, and there's certainly a ton of overlap when it comes to the scope of practice. Well, I think that's all of our time for today. Thank you so much, doctor Pence. This has been such a great presentation, and we really appreciate the discussion.

The Q&A was phenomenal, and, of course, your presentation gave us a lot of great take aways to take into practice and utilize with your patients.

That's it for today's episode. Be sure to visit our show notes for a link to the PDF slide deck from today's training for helpful visuals and diagrams. If you enjoyed today's episode, be sure to subscribe, leave a review, and share it with a friend. You can also visit our website at factorpodcast.com. That's faktrpodcast.com, and drop us a note or submit a question for today's guest instructor. We read each and every one, and your question might be featured in an upcoming q and a episode. With our next series, you're in for a real treat. In 2 weeks, we release our 3 part series where doctor Todd Riddle takes over the show for a fascinating interview with a true legend in the world of sports chiropractic care, none other than doctor Tim Stark.

In this 3 episode series, these docs will cover topics ranging from the evolution of sports chiropractic education to the importance of multidisciplinary care, and we'll get to hear doctor Stark's incredible story and the impactful work he has done serving in chiropractic education leadership in the USA, in Australia, and even in Japan. You won't wanna miss it. Episode 89 drops in 2 weeks. We'll see you next time.