10. Dan Pope, DPT, OCS, CSCS - Building Resiliency Through Rehab

Hello everyone, I'm Dr. Darsha Shah, and I'm Dr. Altamash Raja, and welcome to Medicine Redefined, a podcast where we will explore the often overlooked but necessary components of health, what we consider to be the fundamentals. We will investigate topics and practices that can give you and your patients the best chance to optimize a healthy lifestyle. It's time to move the needle forward and put the health back in healthcare. Before we get into this week's show, a quick word from our sponsor. Contract diagnostics is to firm 100% dedicated to physician contract reviews. They provide a service that all physician families will need at least one time in their careers, most likely a few additional times as well. I love this company as they've helped over 10,000 physicians understand not only what they are signing, but what risks they are taking for their family. All contracts are reviewed by an in-house attorney and presented in a simplified way back to you. Using custom documentation, composition data, and times outside normal business hours, they make it easy for you. Don't need a contract reviewed. They can even just consult you on the fairness of your current composition structure or your contract renewal. All packages are flat priced so you know what you will pay upfront. Residents and fellows can even make interest fruit payments over time. So look them up at doctorpodcastnetwork.com, slash contract diagnostics or call 888-574-5526 or info at contractdiagnostics.com. Our guest today is Dr. Dan Pope. Dan is a physical therapist and performance coach at Champion Physical Therapy outside of Boston, Massachusetts. He works with everyday athletes, active individuals, and those competing at the elite level. As an orthopedic clinical specialist and certified strength and conditioning coach, and across foot level one coach, his expertise lie in helping people train through injury around injury as well as coming back stronger after an injury. On a personal level, Dan was a division one collegiate polevolter at my alma mater. He was a state and national level champion in strongman competition and has been competing in the sport of fitness over the past decade. So he's one of those folks who has definitely walked the walk. But most importantly, he is a genuinely awesome dude and someone who I've looked up to for the past few years. In this episode we talk about building relationships among healthcare providers across the spectrum of rehab, optimizing training during and after injury, augmenting the healing process, and my personal favorite is famous salmon shakes that turn him into a national champion. That's right, just hearing about it will give you some serious gains. I absolutely loved picking his brain and unfortunately we were limited on time, but there is so much more we wanted to talk about so I'm going to bug him to come back because we couldn't get enough and I'm sure after listening to this episode, you're going to agree that we need more of Dan Pope on this show. So without further ado, please enjoy our conversation with Dr. Dan Pope. All right, what's going on everyone? Today we have a special guest, Dan Pope. Dan, how you doing today? I'm doing phenomenally well. Really really good. Awesome, awesome man. Well, I've been following you for a little bit. I know Altamash has been now for about three to four years. He's been loving your content, but to the people out there listening to us that don't know much about you, can you tell us a little bit about yourself? Who is Dan Pope? Oh boy, yeah, good question. So I'm a physical therapist and I have a big background as a strength conditioning professional, personal trainer, whatever to call it, and I always say I'm a meathead. I just really, really like exercise and always have and that's what's kind of pushed me into this path today. So I work full time for the most part as a physical therapist, but to be honest, it's a cash-based practice. We're out of network and I can kind of do whatever that I want to do. So I've had some patients today where I was looking at their Olympic weightlifting technique and writing a training program for them, and I had some other people that were a couple of weeks post-op, rotator cuff, and I'm rehabbing the rotator cuff, and then eventually we'll get into a fitness program at some point. So I try to bridge the gap as much as possible, and I really, really love educating people, mostly other physical therapists, other coaches, about how to do the same. How do they get their patients or clients out of pain into fitness, and how do they keep them kind of pain-free for the long haul and keep them exercise and keep them moving, I guess. Yeah, keep them away from you guys, just kidding. No, no, I mean, that's our hope. I mean, we talk about, Tarshan, I talk about preventative medicine all the time, and ultimately I tell people, I'm like, listen, you know, if, yeah, we're tongue in cheek when we say, yeah, we'd be out of a job, but I mean, the fact of the matter is people do stupid things, I do stupid things all the time, there's going to be a need, there's lots of other things that we do, which kind of leads me to the next question is, why physical therapy? You know, I know you mentioned your meat head, I've seen some of your strong man videos, they're pretty epic, but why physical therapy, why not just continue to go down to performance coaching pathway? Yeah, that's a great question, you know? And I do ask myself from time to time if that was really the right path, you know? So when I finished up at Rutgers University, which I guess we both went to, which is awesome, go Rutgers, I knew that I wanted to be an exercise, and the logical first choice was personal training. I'd already worked as a personal trainer for years in undergrad, and I started doing that full time afterwards, and I got to be honest, it's awesome, I really loved it. And one of the things I was finding was that everyone kind of had some sort of injury, you know? I was working with a bit of an older population at the time, I was also working with a bunch of athletes, and people get hurt from time to time. And a couple of things I noticed, for one, I really wanted to be the person that was able to help these folks. I just didn't like that I had to send everyone away, and two, I was sending them to local physical therapists that were telling them, hey, of course you got hurt, you shouldn't have been deadlifting, you're like, oh, kettlebell swing, that's why your back hurts, you know, or you hurt your shoulder because you pressed overhead, you know? And that was tough, because oftentimes, you know, these people wouldn't even return back to me. Like, you're the one that got me hurt in the first place, and I was like, you know what, that doesn't seem very true to me, you know? And what I asked myself at the time was, do I need to be a physical therapist to be very good at helping other people with her injuries? And I know there's a lot of folks out there that are trainers, you know, massage therapists too maybe, maybe there's a blend of the two, because those guys kind of do walk the line of rehab slash, you know, performance, you know, would that be the best route for me? Because I really cared about Andrea when I learned more about it, but in the back of my, you know, head, I kept on asking myself, like, what is really the best way to learn how to help people in pain? Who are the folks out there that do this every single day of their life? What is education they go through in order to be at that level? And that's really physical therapist, chiropractors, you know, physicians if they're doing rehab every single day. So I just felt that if I wanted to be as good as I possibly could be, you know, which is important to me and important for the people I was working with, I kind of had to go down this pathway of becoming a physical therapist. And yeah, there's a lot in physical therapy that's not related to what I do on a regular basis, but I do think that going the route of a physical therapist is probably the most powerful thing I could have done for my own learning and also for helping other people that I work with regularly. So. Dude, that's pretty awesome. Were there any specific, like injuries? Did you ever go through some devastating injury? We've had some, some guests on here. I remember we recently talked to David Ote from, you know, PPSC, I know you kind of followed John Russen's work. And he talked about this significant back injury he had when he was 17 years old. Being a strong man competitor and I guess we probably competed at higher levels. So did you ever go through personal struggles where you were like, okay, I've had to rehab myself and that's why they can, I'm very close to this and I can understand a little bit more, maybe empathize with my patients a little bit. Yeah, for sure. You know, I'm not the, the stereotypical like tour my ACL and then had an awesome experience with a physical therapist and then decided like this was the career that I wanted. To be honest, I had heard myself a bunch of times, it still do, you know, it's kind of crazy. The amount of injuries I've gotten and that sounds terrible because it sounds like I'm just niddy and I hurt myself all the time and in some ways, maybe that's true. And every time I get hurt, I'm like, this is a great opportunity to know what other people kind of experience and also, you know, work about getting myself into a better place so I can help my patients a little bit better. But I had gotten a few injuries. I competed at Rutgers, I was a track and field guy, I was a polevolter. And I hurt my shoulder pretty badly at one point and it was a combination of polevolting and probably doing a little too much stuff in the gym. And I ended up going to a physical therapist to try to help me out and to be honest, I didn't have a very good experience and I can't put that on the physical therapist. A lot of it was me being young, kind of dumb, biggie go, physical therapy was expensive the time when I went there, they just kind of ultrasound my shoulder and have me do exercises that were probably 10 times easier than I've already been doing, you know, and I wasn't really willing to kind of back off and kind of push forward. But I think the big thing was that the physical therapist there and I, we just didn't jive, he didn't really build a rapport with me, I didn't feel like he understood my problem and I just didn't really trust him, I guess, and a lot of that was my fault, to be honest with you. So I didn't have a great taste of physical therapy in my mouth and then you combine that with having tried to take my clients when I was working full-time as a transition coach and sending them to another physical therapist and that therapist also telling me, you know, the same thing that the physical therapist told me back when I was 17 that I disagreed with, you know, I just, I didn't really like the idea of physical therapy in general. But what's funny is that when I graduated and started doing personal training full-time, what I found is that the type of professional you are is going to be based around how much you enjoy it and your passion for it and there's going to be kind of poor, I'm going to use a work poor, I guess, personal trainers is also going to be poor physical therapists, there's going to be poor physicians, poor firefighters, poor plumbers, all that. So what I found is that there are really, really good trainers out there and I started trying to network with them. There's also really, really good physical therapists and I started to network with those folks as well. And when I started to understand it's like, wow, physical therapy is actually an awesome profession, but there's a huge difference between what I've experienced initially and then what can be, I guess. So that really changed my thought process and then that kind of drove me a little bit more towards the physical therapy route. Yeah, I love that. I mean, I think what you're talking about, we know that all, again, in any profession, you know, if there's a spectrum, right? I mean, all physicians are not created equal even just within physiatrist, sports medicine, cardiologist, whatever, it kind of spreads across all those things. Yeah, I mean, dude, I share very much the same experience that I'm lucky enough that I've never had a fracture, never had a torn ACL like some massive acute trauma despite all the sports I've played, but it's been so many chronic little overuse injuries here and there, back tendonosis, that kind of thing that have just impaired what I'd love to do, which is train. In fact, both of us have a mutual friend, Dewey, who works in the same facility as you and he's been in my coach for the last two months, two years, excuse me. And I'm always text, I'm like, man, this one doesn't feel good or this was hurting or this causes this. How can we modify this? And I'm sure he's probably telling you or thinking, man, this guy's just annoying and anything I program, he doesn't tend to love. No, he's a good dude, but that's kind of been the case for me. So that was my inspiration to pursue this, understand it a little bit more, and then also be able to relate to our patients. And what I will say that I think that more so, and I'm curious to hear your thoughts on this, is what we probably tend to see more so in musculoskeletal medicine, both of our professions, physical medicine, rehab, those chronic overuse injuries, right? When we talk about rotator cuff, send it up at the end, dysfunction, whatever you want to call it, impingement syndrome, I know there's a debate on that. All these things that are probably these aberrant movement patterns that are kind of below the symptomatic threshold, and then when somebody does a little bit too much, they tend to flare up. You guys recently talked about tennis elbow, that's a classical one as well. I mean, what are your thoughts? Do you think more people have that acute trauma, like slipping on ice having a fracture or is it more the chronic overuse stuff that that's what they go to therapy for? Yeah, I guess it really depends on what you specialize in. A champion where we do a lot of sports medicine, and we see a combination of all of these things, right? You see a lot of traumatic ACLs, meniscus pathology, that type of thing, but we also see a lot of overuse. And to be honest, for me, in my population, I see a lot of fitness type people, a lot of Olympic weightletters, powerletters, and you certainly do see traumatic injuries from time and time, but I think my bread and butter is really just overuse injury. These folks tend to have more overuse stuff going on, but you do definitely see traumatic injuries from time and time, it's just much less frequently, at least the people that I see, not necessarily just champion, because champion sees a lot of athletes that have traumatic issues as well. Yeah. It's good stuff, man. I mean, yeah, even me, I've had back issues my whole life, and you know, you have this concept of fitness pain-free, which sounds awesome, and I think a lot of people could benefit from that, right? Can you just explain what is fitness pain-free to you? How did it come about? What's your purpose, and what do you see it going? It's a farce, man. It's impossible. You can't attain it. So. You know, looking back on the name, fitness pain-free, I think it'd be a little more accurate if I was like, well, fitness with a little bit of pain, you know, because this idea of like never having pain ever is just, it's just not fair, you know? No pain in the Indian. What's that? No pain, no game. No pain, no game. Yeah. I guess we're kidding. No, we're kidding. We're kidding. Yeah. Yeah. The name, fitness pain-free, was kind of trying to blend what I was trying to do and kind of the expertise that I was chasing kind of at the time. So I love fitness, and I was doing physical therapy, and I wanted to try to get kind of pain-free fitness. How can we be a little bit better about exercising to keep us a bit safer over the course of time? And how can we kind of get our painful folks back to fitness, I guess? So that was kind of the name, you know, at the time. I wanted to be kind of obvious when people look at fitness pain-free.com and they're like, okay, this kind of makes sense, you know? In terms of like the website and kind of my business, that word, you're kind of asking what was the reason why I did that? Yeah, kind of just like how it came about, why pain more than anything, right? I guess as a physical therapist there's so many different things you can kind of focus on, but what drew you to, you know, getting people back into the gym and making them realize that, hey, we can do this, I'm sure with a little bit of pain, but way better than what it can be. Yeah, I don't know, fitness is something I've always really loved. And as a trainer, I just found so many folks that were in pain, and I found that there is a tremendous need to help these folks at the time. And to be honest, I think we've gotten way better. There's so many resources out there right now for folks that like fitness and have pain right now. Besides fitness pain free, obviously that's going to be the first one who's list. But at the time, you know, and this is like, I guess like 10, 12 years ago, there wasn't a lot of information out there for folks that had some sort of injury and wanted to get back to kind of higher level performance specifically in the gym, you know? There wasn't much information about there, about like is deadlifting bad for my back, you know, is bench press bad for my back? Should I press over head or is that going to call as injuries? You know, what's the deal with that? How do I make my fitness activities safer, you know, what actually is causing injuries? There wasn't much of that. So a lot of that was me trying to figure out what is going on. And the other part was I loved sharing, you know, the information that was learning. I really wanted to spread that, you know, to other folks out there kind of get these conversations going, build these networks, and you know, ultimately help the clients that I was working with, you know? Yeah. At the time, I really looked up the folks that were doing that. I remember not even just physical therapy related because, you know, Mike Ryanell was probably one of the few people doing it back in the day. But guys like John Barardi, I used to read a ton of his information. I used to love testosterone.net, T-Nation, T-Mag, whatever one to call it, said so many iterations over the course of time. And I looked up to the folks that were kind of these thought leaders that were kind of writing and talking about what they're thinking about from the injury perspective, prevention, kind of getting this, you know, they were starting these trends. We're talking about it, trying and experimenting on the room with their clients and patients. And then, you know, it was, it was just a really kind of fun and interesting dynamic. And I just want to be part of it, you know? So that's why I started kind of writing and doing fitness pain free in the first place. Yeah. Dan, that's awesome. I mean, we can certainly attest to that. We've learned a lot from just following you on social and also you're, I think that actually you can talk about your sale because I know today's the last day towards the end. But that's not good marketing then. You can't tell people that it's a sale all the time. Yeah, I don't want to go to my stuff. We'll work on it. It's an hour and never. People. No, so we'll talk about, I mean, obviously we want to get into, you know, training around injury, you know, and bouncing back and becoming more resilient. But you touched on this concept of bridging the gap, right, between rehab and performance, right? I don't know if that's a tagline for Mike, what he says, at least for some of his courses. But what about, you know, bridging the gap between our side for the physician and the therapist, right? Because there's a spectrum, right? You got the physician. We refer to therapy. Then from there, you guys, guys, this amazing system at champion, where it'll go right to, you know, the performance side of it because we reached, again, David came here last time. He talked about something that I thought was really cool that, you know, when he gets somebody maybe post-op for after a hit replacement, maybe nine months down the road or something like that, he will actually call the physician and say, what was the approach? Was it an opposed to your approach, an anti-approach, you know, what might be some contraindications stuff like that? Which was a crazy concept to me because I never thought about it. You know, he was basically, we do this in medicine all the time. You know this because your wife's a physician. We give sign up each other all day every day, right? That's what we do. And that's essentially what that sounds to me. So talk a little bit about this. I know you guys have touched on this podcast about that communication between physician, to therapist, to coach, you know, how can we build? How can we make sure that these communications are going really well? Because ultimately it's going to be for the benefit of the patient. Yeah, for sure. I think you kind of, you know, already stated it. I think that communication is key. One of the things that's very challenging for you guys, you know, and I think physicians in general is that there's a lot of people that are extremely overburdened, you know. And as a kind of cash-based physical therapist, I give everyone my cell phone, you know, which is kind of crazy for a lot of medical providers. And I did that a little bit when I was working in network for basically an insurance-based physical theory practice. And that was a little crazy, too, because it gets to be ridiculous. You know, you don't have a life. There's so much going on. They're already crushing you with a ton of different patients. So, you know, you don't always have A, the time, or B, like the emotional energy, be on the data to actually try to do a better job, right? But the doctors I work with, one of the reasons I really love them is because they are great about communicating, and I do the same thing. So if someone is coming from a surgeon, which I like and trust, which is pretty much like most of the patients I see are from surgeons I like and trust at this point, because we've built that network over the course of time, I'll ask them, you know, I have a rotator cuff repair. I was like, hey, how was that tissue quality? Like, what do you think? Can I start pushing it at this point? You want to wait a little bit longer, you know, like with a couple of tenons involved, what was going on there? How did the surgery go? And they're great. And they get back to me and say, no, no problem. This is it. We just did this, standard approach, whatever. Or if there's something a little bit funky going on, they'll say, yeah, just be a little cautious with this. I'm not really sure what's happening there. Give me some feedback. If you think we should change something in terms of the rehab, then go for it. I trust you. So there's a lot of communication, I think, is really important to have, you know, understanding the surgery, understanding the approach, obviously, if it's like a hip replacement. So I think the communication really has to be there. Unfortunately, that's tough. You know, I don't think our system, as it is, our healthcare system is set up for success to be able to communicate with a physical therapist for every single patient that you have or vice versa. You know, you're already slammed with your evaluations or coming in. You don't have enough time to even communicate with a patient, let alone that patient's physician, let alone that patient's kind of coach or personal transfer it is. So it's certainly a challenge, and it goes the other direction too. So when I am getting someone from a personal trainer or coach, which we do a ton as well, as you know, with guys like Duesh and also individuals outside of champion, Duesh is one of the strength coaches that champion physical therapy where I work. I communicate some with those guys, and they help me with my rehab. I have a patient right now that had a high-tivial osteotomy. For the listeners, I don't know what it is. Basically, when someone has arthritis in one side of the knee joint, they'll either take a chunk out of the tibia or they'll open up the tibia to correct the angle and to allow the other side of the joint to take more stress. So the one that has a lot of wear is not being compressed on as much. And it's a pretty in-depth surgery, and there's a lot of pain afterwards, and it's just a long rehab. And I have a really good relationship with one of local trainers, coaches, and we work together, you know. Basically, I do the more painful activities where you have to be cautious in terms of pushing, and he handles some of the activities that are less risky, you know. And he's not doing physical therapy. He's just doing strength conditioning with this individual when it's safe to do so, and I'll do this stuff that's a little bit more risky where I'm supposed to do that as the physical therapist. So we have a lot of direct communication. And I do that every single day with my patients. So I think you already said it, that communication is absolutely key. You just have to kind of set up a system that works well for you, you know. I love that. Yeah, I think it's all about the system. And like you said earlier, you're a teacher. And I think having that ability to teach comes with great, you know, ability to communicate with patients and ensure that they're getting the proper information as well as your colleagues and things. But Dan, so let's get into fitness and pain. So, you know, as a physician, I think, you know, I want to say back in the day, but even maybe five, 10 years ago, oftentimes when people want to get injured, we would say, oh, you need a bed rest, right? Don't go back to your normal activity level. And now we're starting to see that change a little bit and we know that, hey, movements actually, you know, gradual movements, it's starting to help this pain. Can you kind of just talk about, you know, training while you're injured? What are some of the general principles that people should really know about at a high level? I can't let my seekers go, man, this isn't good, they understand everything we're doing. I'm just kidding, you know, I think that's, it's a beautiful thing because it's funny because exercise can cause an injury, but it's also the same exact thing that's going to help you heal, you know, I think a lot of it comes down to the dose and one of the things I tell my patients is that, let's say you have a headache, right? And if you take two aspirin or two ibuprofen, your headache goes away, right? If you take the whole bottle, you die, right? You can't really blame the aspirin. It was the dosage that caused the problem and the same thing goes with exercise. So if you do a little bit of exercise, it's probably going to make you feel better and you'll get better with the course time and you kind of ramp up over the course time as needed. If you do too much, you know, it's like taking the whole bottle of aspirin, it may make you worse. So I almost never take exercise away from folks unless they have something that's like a little bit more sinister, like a fracture, we're like, okay, yeah, we need to take weight off of this because we know this thing isn't going to heal if we exercise. So a big part of my evaluation process is figuring out, okay, what are we dealing with? Is this something that we can load? And it's like 99% of the time it is. And then we just try to come up with a plan that allows people to continue working towards their fitness goals, right? And to be honest with you, I try to minimize changes in their exercise program as long as that program is well thought through, right? And it's going to be something that the coach who wrote the program was thinking about the athlete in terms of how much volume they can tolerate, their prior injuries, their goals, the amount of recovery they have. Because if I start making major changes to the training program, I'm kind of derailing their path to success, right? So what I do is I need to take away some of the exercise if that's what's continuing the pain problem, right? And I don't want to take anything away if we're not continuing the pain problem. So this happens all the time, and I'm sure you guys are running into it, like if someone gets hurt, right? And this happened. I was a coach. Last personal training job I had was as a cross-recoach. I did that for around six years. And it was funny because people knew I was a physical therapist. And after every single night coaching, I'd have like 10 people come up to me, like, oh, damn, it was all those bother me or like, damn my back's bother me. And you know, my advice for every single person was, okay, let's back off a little bit of the things that bother you. And as you start feeling better, the course of time, let's slowly ramp back into it. And I'd say that that was helpful for 90 to 95% of every single person that I saw. And I also told them, like, hey, if it's not getting better, then yeah, come see me. And then usually what happens at that point is I do the same exact thing. I start to back off. I just give them more guidance, better guidance on how to back off the things that are really given some trouble and ramp up, you know? And in terms of, go ahead, give it some. No, no, go for it. Yeah. In terms of general rehabilitation, I guess, I like to use the term unload initially when someone has an injury, but I actually don't think that's a great term to describe what I'm doing. Because oftentimes I'm actually adding more exercise to that individual, but I'm looking at the movements at that time that might be too stressful for them and modifying them. And it might just be decreased in the load. Maybe I'm changing the move in a little bit, maybe I'm going from a back squat to a front squat to a goblet squat if someone has low back pain. And I'm adding more stress to the spine in terms of additional course strengthening or whatever it may be. And if I think that there is a problem with their technique that's driving long term problems, I may modify that, you know? But in general, I really don't want to take away exercise because that's something that's going to help them heal. It's also something they love and there's a ton of positive benefits, right? So I'm going to keep doing that, make it's minimal changes I need and add some additional exercises to kind of push them along faster, you know? Gotcha. So when you're looking at programming and changing of the program, are you really looking at it from a mechanic standpoint or how do you know when you need to change whether it's the duration of the entire workout to whether it's decreasing the weight or decreasing the wraps or increasing the wraps? How do you kind of make that? Yeah, of course. It's kind of like art, right? There's lots of different art, very different, it's all beautiful, right? I'm actually not an art fan, I just made that up. I guess what I'm getting at here is that there's so many different ways to have success, you know? If someone that comes in that's like a little load intolerant for, let's say squatting, let's say that they can't get above 85% of their max and their back starts to hurt, I can very easily say, okay, let's increase the repetitions a little bit. So instead of doing sets of five, 85% of your max, let's do sets of like 10-ish because you can't use as much weight and they may be able to train without much trouble whatsoever, you know? The other piece is let's say someone can't tolerate 85% of the max on the back squat, but maybe they can tolerate 85% plus percent of their max for the front squat, right? So we just fix the problem with the different movement or we fix the problem with a different rep scheme, you know? There's a lot of ways to do that and it really, I don't know that there's one way that's better than another. I mean, obviously we haven't done any research in this regard, you know? But at the end of the day, I'm going to make the modification, it's going to impact their fitness, you know, as little as possible. Like I said, I don't want to make enormous changes and then I'm also going to cater to that individual. Like, part of it is like, what are their beliefs? What are you okay with? Are you okay with dropping the intensity? If they say no, it's like, okay, we'll keep the intensity high, but we'll do a front squat. If they're completely okay with it, then I'll maybe modify that load, you know? If they're, you know, two weeks out from a parallel to me, it's going to be very, very different than if they're A, not even a parallel, if they're B, they're in their off season, I can kind of change things up. So it depends a lot on the individual and the situation and I think what's important for physical therapists and coaches too, because coaches do this every single day is learn how to dose stress, you know? If you want to dial up the stress on the spine because we want to get that thing strong and stable, what movements do that, you know? How do I do that? And if someone is too painful because they have low back pain of some sort, some variety, how do we dose down that stress, you know, and how do we bring that back up over the course of time? And if you understand those principles, if it's pretty well with general strength conditioning, you know? So it's, yeah, that's kind of the way I go about it anyway. And I love that. I mean, especially because you're not giving any specific tactics, you're primarily talking about strategy, right? And I think what Darsha alluded to earlier with what we used to propose after somebody injured their back was complete bed rest, immobility, and now we know that that's actually, if somebody goes immobility, the chances of prolonged disability are significantly higher for that type of person. It's interesting. Actually, just earlier this morning, I read this article, I pulled it up as calm, basically in doxamity, talking about how aerobic exercise and chronic low back pain can provide a similar relief to low dose morphine, right? I mean, obviously, we understand that pain, you know, is complex. The experience of pain is very subjective. But I think generally what you were talking about is, especially the CrossFit population, right? The sport of fitness. You know, these folks probably, they like training, right? For athletes and stuff who enjoy training, you know, they associate themselves, you know, there's a whole social psycho component to that. It's a rewarding experience. Maybe the sedentary individual for whom training exercise isn't a part of staple in their day to day, how do you even take a step back and set the expectations and get them to buy in that, hey, this is what's necessary. I'll give you a quick example, currently on an EMG rotation, I was doing some EMGs that had a patient yesterday coming with basically bilateral carpal tunnel syndrome symptoms yesterday and hadn't tried any conservative therapy. We know first line is splints and therapy and all that stuff. I asked, have you done this? This is, no, it doesn't work for me. It doesn't work for me. Have you tried it? No, it doesn't work for me. You know, again, this goes back to your point of, you know, I had a very limited time to do this procedure. So I didn't have the time to sit there and have the conversation with a white physical therapy. It's so important. But I regret it now because I think that might have done her more benefit. But when those patients do finally come to you, whether it's just, you know, because they're upset the doctor sent them or whatever, how do you get them to kind of buy in and set the expectations that this is not something that might get better in four weeks or five visits or whatever? I mean, that might be a loaded question. No, this is an awesome question. It's actually one of my favorite questions, you know, to be honest, and this is not really fair because obviously people are going to be seeing folks off the streets from time to time. But we built ourselves up over the course of time as kind of the go-to folks in the area for light crossfit problems, you know? So the surgeons that I know, the trainers that I know, they all like me, respect me, and then they're having some sort of problem with one of their clients. They say, go see Dan, he's the best for all these reasons, you know? And then you walk the walk and talk the talk. So when someone comes in and they say, you know, I was doing crossfit, like, oh, I crossed crossfit for six or seven years, you know? And I work for this company that's really popular in the crossfit world, you know? So all of a sudden, all these lights are going off, like, oh, my gosh, this person, you know, really understands what I'm trying to get back to, you know, like, oh, he knows this person. He talks to this person on a regular basis. Oh, that's crazy. You know, I always love it when a physician sends someone to me and says, like, on the best, because it's like sitting the golf ball up on the tee, you know, it's like, here you go, Dan, right? It's like knocks that out of the park. We know that therapeutic alliance is going to affect your outcomes, right? So if I just build a really, really good rapport with someone, I'm probably going to have a better outcome than someone who doesn't. I mean, I can't tell you the amount of times that someone came from another physical therapist and came to me and always asked, why? And say, well, what wasn't so good about your prior physical therapist and they'll tell me, and they'll say, like, oh, yeah, the guy told me to exercise and stop doing this. And in my head, I'm going, I'm going to tell you the same exact thing, you know what I mean? But I know that if I build rapport, I don't just sit there and immediately tell them something that goes against what they want to hear, then over the course of time, they're going to have a pretty good outcome, as opposed to me just saying, like, no, you need to do this, right? But I think this is, again, a little bit easier for me. I've set myself up into a situation that I think works better. I think being able to have the time to build that rapport is really, really important, you know, I'm a big fan of motivational interviewing you guys ever heard of that. So just taking the time to make sure that patient feels very, very hurt, right? Making sure that you're listening, opening questions, a lot of reflections, making sure that you're meeting their needs, asking a lot of questions about how I can help them, as opposed to me just kind of regurgitating, you know, or just saying exactly what I think that they need, and that tends to help, that tends to make a really big difference. I'm also in a nice place where I have multiple visits, so I just want to try to establish good rapport and continue that going down the line, you know? So I know that's hard and it's very challenging, but building that therapeutic line as much as you can, early on in relationship, establishing a really good connection and serving that individual, I think goes a long way. I love that. Yeah, talking about listening to the patient, it kind of just reminds us, again, we tend to, every time we interview an expert on here, there's a common theme about stopping, I mean, what's that stat that we always quote at 18 seconds before physicians starts interrupting a patient? I wonder if it's still the same. I suspect it's probably at best 20 because we've gotten a little bit better. But, you know, this Jody Patel, she came on, she talked about just, you know, spending an hour kind of getting, spending so much time on history, history, history and intake and dorses, big and functional medicine, and that's kind of what they go back for as well. So I certainly love that. Yeah, again, harder to do in a 15, 20 minute visit. Let me ask you this though, specifically, going back to the strategies, I think that it's worth mentioning because I remember, I mean, you know, back of the day, like if I hurt my ankle, whatever, I remember going to the gym on crutches because I had this really severe, great three ankle sprain and training upper body and stuff. But people in the gym would be looking at me like, what is wrong with you, you know, or even my own family, my parents were like, you know, you shouldn't go to the gym and I'd say, I'm not putting pressure on this, like I'm doing it and that concept was just so foreign to them, right? So obviously, both of us took motor learning and undergrad and we learned about the concept of the opposite extremity training can help you bounce back from rehab. Talk a little bit about that. Let's say you get an athlete who comes in with just a really bad ankle sprain. Let's make it a fracture, right? Postoperative sees you. How would you modify the rehab process and still giving them the maximal benefit so you don't, you know, they don't have much of a decline in performance. Yeah, you got it. So let's say that they're a specific athlete. They'll say it's like a like a field sport like soccer or something along those lines. I kind of want their physical therapy to mirror what their training is supposed to be as much as possible, right? So this is an off season and they're kind of focusing on strength conditioning, right? And stronger and they're also working on maybe building like an aerobic base or something along those lines. I want to see if I can get their program as close as possible to that, you know, we can't load that leg, right? Or at least we can't stand on it, but we can train all the musculature around it. We probably can do things like knee extensions, hamstring curls, right? A lot of hip strengthening and we can train the other side leg for sure. We can train the upper body. And if we're allowed to do any sort of, let's say bike work with the physician who pays it, I think it's the fracture is not necessarily going to be affected by doing some sort of cardiovascular work. I want them to do as much as humanly possible because what's going to happen is that they're going to be decondition when they take the boot off and now they're more likely to get hurt and they're already way far behind because they were going to use that entire off season to get stronger, better condition, all that stuff. So I think first and foremost, when that person sits down and we're asking questions about their goals, you know, are you trying to go to college for soccer, you know, which year's most important for you? Can we back off of this for potentially? Let's see if we can do this as opposed to that. And then the rehab kind of goes backwards and trying to plan for that next up kind competition or whatever it is. It's important to them, you know, and then we do as much as humanly possible to try to prepare them for that while respecting the healing tissue, you know, for sure, talking about the healing tissue, how much of it is done, you know, in the gym with the program and how much of it is actually what they do outside, right, whether it's sleep, the food they eat, all those types of things. What are some of the tips that you tell your clients in terms of augmenting the healing process? Yeah, for sure. That's another good question, you know. Well, in terms of trying to recover well, if I think that an athlete is not recovering well because maybe they're not sleeping, maybe they're not eating enough, and I'll give them direct tips, you know, how many hours per night are you sleeping? If they're telling me I get like six to seven, I say, let's try to make sure you're getting more, you know, nothing that does happen. A lot of times with things like fracture, people will not be able to exercise and because of that, they kind of stop eating because they don't want to get fat, you know. So I, people are not great in terms of nutrition and I'm not the best, so oftentimes I'm referring people out, but just making sure that they're getting enough nutrition, they're not body weight drop, drop, drop, drop, drop. Of course, a lot of that is going to go away because you're not training, but the other piece is that you might not be eating enough to sustain some of the muscle mass in your body, right? I'm just counting people on that. Stress is another huge one. Oftentimes you get an idea of whether or not stress is a big player and someone's injury. Sometimes you don't, you know, I could be better about asking more questions about that, but just giving people some ideas on how they can limit some of the stress in their life. I find that that is one of the hardest things to counsel people to try to improve upon, you know, like a lot of the things that are stressed people most are very deep-seated and a very big behavioral issue that I don't often have the expertise to try to tackle. So again, we have people in our network that are a little bit better with that, you know, I know a bunch of nutritionists, I work with Power Monkey Fitness and they have a really good company, MP2 nutrition, and they cover a ton of that stuff, you know, they have good questionnaires, they try to figure out where those limitations are and they try to have, you know, objective goals that they're reaching, try to make sure they optimize all those parameters of health that are kind of outside of the just movement, you know what I mean? So what I will say is that in areas of my practice where I feel like I'm not the best person for someone, I am okay with referring out for that, you know, and that's one of those areas where I think I can give a few tips, but I'm not going to be the go-to guy for that, and if I think it's a big issue then I'm doing it to service to that person by not referring them out, you know. Sure. Yeah. No, I love it. It's got to be a holistic approach and I love that you refer out, you know, when need be, you know, I've recently just heard the episode of the mic vinyl show about your guys just take on massage guns, you know, and now we're seeing this huge boom with hyper, it was hyper ice and they're gone. I'm just trying to sell other companies out there. Can you tell me your thoughts on massage guns or your pro or your con? I've heard both sides of the story, but I would love to hear your take on it. Yeah, I'd say I'm mostly pro. I'm definitely not against it. I kind of see it as like supplements, you know. People always get excited like, what's the best supplement for me? It's kind of like, well, what's your training program? Are you sleeping appropriately? Like are you managing stress? Okay. You know, there's so many variables. They're probably more important than something like a massage gun, you know, that I want to make sure we optimize that as much as possible. The other thing is that people love those massage guns and we know it's probably pretty good for a short term release relief of pain. It's pretty good in terms of reducing soreness, which can be really helpful and people just absolutely love using them. So I'm okay with that. I'm not okay with people saying like, oh, this massage gun is going to fix your pain. I don't always like the marketing that these companies use. I feel like that's misleading. Like you already said, when someone has pain, they're already afraid to move. We're going to tell them now that you got a jam massage gun in there like, yeah, maybe that'll help you, but you have to start moving, right? Not necessarily massage gun is the answer. So definitely not against it. We have a whole bunch of vibrating tools, a champion that we use and people certainly enjoy them. But we're also in a situation we can optimize all those other parameters. We have a strengthening staff. We have people that do nutrition. We have massage. We have movement specialists. We can optimize all those things and then say, okay, try this out. I think it's going to help with your recovery. It seems to really help you out. I think it's going to give you a bunch of pain relief. Give it a go. And it really helps a lot of folks with that. So I love that, Dan. I mean, it's just another tool and tool belt, right? That's kind of what we're talking about. And yeah, I don't know why it gets to be like everything. It's also polarizing. But hopefully people can listen to this. And you guys have talked about it more than once on your shows. So we'll definitely link that in here. Dan, we know that you got a patient coming up and your squeeze in it. So we certainly appreciate over that. So before we let you go, I do want to hear a quick story, though, because I remember reading on your site, I guess back in your Meadhead days, technically you're probably still on Meadhead or heart. You know, when you're doing a strong man stuff, something about, you know, tuna and canned salmon milkshakes, I got to know what that is. Tell me. I highly recommend this strategy to be the best Meadhead you can be. Yeah. I don't even know where I got this recipe fun, to be honest with you, but I was a type of guy that got so excited by learning about some new fitness program or some nutritional program. I remember, like reading an article on Swedish meatballs, right? And thinking like, oh my god, they're so anabolic. And I can't sleep at night time. So I'm thinking about freaking meatballs. Like I'm just so, I don't know, into fitness and like nutrition, human performance, you know. So I read an article about tuna shakes, you know, and salmon is obviously good for you. And there's so many benefits. So I'm like, I just give it a shot, you know. So I think I was, I was using a variety of fish. I can't tell you you shouldn't blend up fish. First and foremost, should have known, you know. But yeah, you can put like a can of tuna inside a blender, throw some tomato, I don't know, juice of some sort, maybe some V8, a little hot sauce, if you like, maybe a celery stalk. Hit that blend button, maybe put some olive oil in there, if you're trying to gain weight, log that bad boy down, you know. Wow. That I might have just thrown up in my mouth right there, but were you in high school? A lot of this was done in high school, yeah. But I was pretty stupid in terms of trying whatever I read about through college, and then maybe a couple of years afterward too. I can't lie though, man. That story kind of hits home with me. So I know we got a balance here, but my second year of medical school, I was training for this like big bike trip and trying to lean out as much as possible. And so I was very much counting my macros, counting my calories. And I think it was towards the end of the day. I remember studying with one of my buddies and which to quick break to go eat. And for dinner, you know, counting my calories on my fitness pal, I only had like 45, 50 calories allotted left for the day. And I had to kind of still heat another 20 grams or protein. So I had unflavered branching amino acids. And then I was like, well, what? I don't have spinach left in here. And I looked in the fridge and I had red cabbage. So I blended red cabbage with branching amino acids, unflavered. If you ever had that, they were extremely bitter. And I took that thing down, and it was one of the most disgusting things. So much so that like I was almost throwing up. And as I walked up back up there, my friend just looked at me like, what did you have? And it smells horrible. And I was just like, do I explain it to him? And he was like, why? And I was like, man, I had to get 20 grams of protein. And this is the only way I could do it. So it might be the jersey thing in us. You come to Philly. We don't do any of that. So we don't make that disease when it comes to gaining muscle and being a meathead, if you will. And it's been a pleasure, man. Thank you so much. We just kind of scratched the surface and everything we can learn from you. Hopefully, I know you're a basic guy that we can kind of have you back. But before we let you go, and where can people find you on social media, your website? We talked about fitness pain free. Is that the handle for pretty much everything? That's a handle for pretty much anything. I've been blogging. I always say I blog furiously in my underwear, because usually I don't get dressed to blog. But probably about the past 10 years. I've got a ton of information on my website. You know, people don't love websites so much anymore, but there's a ridiculous amount of information there. I post very actively on Instagram. Also, the same stuff goes over to Facebook. I'm terrible at Twitter. Don't follow me there. But yeah, definitely check out Instagram and or my website. And I'm also have done some podcasts in the past. I'm playing on kind of releasing a new one in the future. So I'll be on YouTube, Spotify, all that stuff, underfamous pain free. So kind of the thing. Awesome. So we'll link to all that. Again, Dan, thank you so much, man. It was fun talking to you. And thank you guys. It was fun. Appreciate it. Man, what an awesome show with Dan. 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