173. Why Rehab Fails—And What Truly Heals | Jeremy Boyd, PT, DPT

Welcome to Medicine Redefined, a podcast focusing on helping you reclaim ownership of your health. I'm Dr. Darsha, and I'm Dr. Altamasharaja, where you're host, here to challenge conventional practices and uncover the stories behind pioneers shaping the future of medicine. Our conversations not only focus on the individual level to dissect common practices for health optimization, but also zoom out to enhance systemic change. Join us as we look to break the status quo, move the needle forward, and put the help back in health care. Our guest today is Dr. Jeremy Boyd. Dr. Boyd is the founder of Triaffected Therapeutics, a sports rehabilitation and performance practice with three locations in the Southern New Jersey and Greater Philadelphia area. He is both residency and fellowship trained and board certified in orthopedic and sports physical therapy. As a fellow of the American Academy of Orthopedic Manual of Physical Therapists, he demonstrates advanced skills in diagnosing and treating complex neuromusculoskeletal conditions, utilizing a comprehensive approach that integrates advanced manual therapy and psychological considerations. Dr. Boyd's expertise is trusted by elite athletes from the NFL, NBA, MLB, and the Olympics, and he has a particular interest and focused on ACL injuries and rehabilitation within his practice. On a personal note, I've known Jeremy for over three years, and I consider myself to be an extremely lucky individual who has known world-class physical therapists, one of whom was a prior guest, Dr. Dan Pope, and Jeremy Boyd is also in that class and a class of his own. This is a conversation that's been long overdue, and in this conversation, we'll talk about one of the polarizing topics in social media, and that is the role of manual therapy within musculoskeletal medicine, and what the research actually says. We talk about how to tease out whether the patient has failed rehab or whether the rehab actually failed the patient. This is a concept that I've stolen or borrowed from Eric Cressy and something that I make sure to emphasize with any individual that I'm working with. We then talk about the critical role of therapeutic alliance in long-term patient outcomes, again a concept introduced and talked about often on this podcast, and then we briefly touch on the downsides of social media as I alluded to before, and the misinformation in rehab and health care. One of the new concepts that I learned from Jeremy is the importance of dosing rest in high performance. We often talk about dosing stress and dosing exercise, but what we fail to recognize is the importance of rest and recovery, and how do we actually implement that in the individual who is unable to turn it off. Lastly, we're going to leave you guys with some practical advice for health care, practitioners, for physicians, clinicians, and anybody working with individuals with musculoskeletal elements and how you can evaluate the quality of a rehab program and ultimately determine how to ensure better long-term outcomes. Without further delay, please enjoy this discussion with Dr. Jeremy Boyd. Dr. Jeremy Boyd, welcome to the show, man. Thank you for having me. I feel like I've had to twist your arm to get you on here. I've only been asking you for maybe 18 months, so I'm surprised. Even earlier today, I texted you, I was like, hey, it's still happening, right? I was like, how's the jury's going to happen? Dude, I want to get right into it, right? I think one of the things that I was thinking about what I want to talk to you about, I know you and I have had these conversations offline, I don't know, for tens and 20, 50, 100 hours maybe, and I was thinking, what are some of the things on social media in the rehab world, which is where we all live? What are some things that are really polarizing, and you're the king of it depends, and so I'm going to challenge you to ultimately arrive at an answer towards the very, very end and maybe give the listener something actionable about that, but take your time if you got to get there. I want to start with manual therapy. It seems to be a bit of a cornerstone of how you guys practice. Why is it so polarizing, that topic of manual therapy amongst physical therapists in general on social media? Why is that so polarizing? Yeah, my opinions of why it's so polarizing, I like to play Devils Advocate on both sides of why some people will be at one side of the fence where there are proponents of it and completely against it. Big thing is starting off with the evidence and research, especially looking at our larger studies of like SystemAck Reviews and Metanalysis, the evidence for especially the long term effect in this manual therapy isn't quite there. So I think that's what a lot of people hang there on, they'll be able to bath water, it's okay if it doesn't really make any long term benefits or you don't see anything, any significant difference at nine or twelve months, why even apply it and everything like that to play on the other side of things is what are, what the studies are they utilizing for this? It's very difficult to, it's true homogenous studies when it comes to manual therapy, really anything in research, but if you look at these large studies, they'll have some where they're describing the manual therapy, some they don't, they just said manual therapy so that what could that be, could that be self tissue, could it be joint mobilization manipulations, some are very sham and what we were saying before is that it's almost impossible to have an actual sham, a factor of a sham comparison when it comes to manual therapy, especially if you're putting your hands on an individual, just deviate even for the sham ones, they'll just be like, oh, they put their hands on the individual, but they apply a force or a thrust or anything like that in the manipulation studies, but just doing that, just putting your hands on an individual in a, I guess, a space of where someone's caring and trying to heal you in a sense, as an effect in itself, we'll have a neurophysiological effect. That's, I think where a lot of the issues are and also in research is they tend to look at manual therapy and isolation, where it's manual therapy versus exercise versus education and not seeing, oh, a more effective than in those interventions. Now there are studies that do say that, but then you have other studies that say the exact opposite, but yeah, so that's the tough thing, but when you combine manual therapy with exercise or educational, which are like the pillars of physical therapy, that's when you see it, it's being the most effective, that's when you see it's, oh, manual therapy plus exercise is better than just exercise alone or exercise in education. There's a lot of studies, other than that, the shoulder, lateral ankle sprains, that prove that that addition of manual therapy is the exercise and not the kick that does help people get better faster. So that's it from our research standpoint. I believe those are the big, polarizing sort of things is what research are we looking at and what's it's own. Yeah, a couple questions. I'm trying to come at this with a very beginner mindset. So you mentioned a couple techniques already for what manual therapy can include joint mobilization, salt tissue work. It sounds like there might be a spectrum here, right, in terms of how aggressive somebody can be from a manual site. One is, can you explain that spectrum, how much intervention can we put when it comes to manual therapy? So if somebody who isn't familiar with at least physical therapy and how much there is to it, what are the main components of manual therapy? And then secondly, when we look at the research, what are the main and outcomes that we're trying to look at in the main endpoints to really compare manual therapy versus some other intervention? Good. Yeah, that's a great question, Darcia. So yes, very large spectrum, especially worldwide. You're seeing anywhere from, I don't even know if Reykjis considered, I've seen it. I had a professor try to bring it in as a form of manual therapy. That's a bit of a stretch if you don't know what Reykjis is really not actually touching a patient's like laying your hands a couple inches away for them and trying to move their energy flow. Not very evidence-based, I am a reiki level two practitioner for just one to learn. I don't know if that's exactly in the scope of manual therapy, but some research will lump that in. But ultimately, it's a hands-on intervention or the practitioner is flying with the intent to, for the most part, it should mostly be utilized in the effort to decrease pain and likely probably in the same kind of bucket range of motion, improve range of motion through the individual. Typical ones are soft tissue mobilization, which is anything of the massage or instrument assistive, like people say scraping or using plates and that sort of thing, to a joint mobilization, which is applying a force through a joint whether it's spinal or the periphery. You can do that statically and that's just a standard joint mobilization or you can do it while the person's moving, that'd be a mobilization movement or something that's a newer kind of push is what we call symptom modification procedures. So the person's doing a movement, let's say squat and they have a pain with their squat. Let's say in fear medial knee pain, you're performing a joint mobilization as they're squatting and seeming to get some symptom relief. So that'd be like a symptom modification procedure. All the way up to a manipulation, which is higher velocity thrust, mobilizations are graded non-thrust techniques, so we're not adding that extra. It's mostly what we call high velocity low amplitude thrust. So we're adding a more of a higher speed component and the spine thing of things that cause cavitations, which most people call those cracks and pumps. There's some other different types of phonanotherapy's neural mobilizations where we're trying to mobilize and move the nervous system. And some people also lump in things like dry enabling as well, which is probably the most aggressive, being it's the most invasive, getting to further depth, some of the tissues. So that's the whole spectrum. There's also other things that you can go on YouTube and get down a rabbit hole of like people using plungers and using xinaxes, I don't know if they're using x. Things get real bad. I guess they can just chop it off is what most patients say. Most of the follow up or the second part of your question is the intent is to, for most individuals, again, it's for pain relief, regillation standpoint. The research, I always encourage people, people as I mean my students or anybody that mentor, Drolbaoski, who's a physical therapist who does a ton of research in the mechanisms and the physiology in me in therapy. It releases an article, I think once every couple or five years or so, it goes really into the weeds, like the signs behind manual therapy, or certainly some other mechanisms at play. It does have an effect on the cardiovascular system. We know that the doing mobilizations actually can lower your blood pressure. There's studies doing manipulation at the CT junction, can increase excitability around the rotaire cuff musculature or paroscampular muscles. Lumbar spine can increase activation temporarily for 20 minutes and the gluteals and the quadriceps. You could play with that, as far as I'm using, for someone who's in a strengthening phase of sorts. But ultimately, most of the research, it's more towards the intent of relieving pain. You entered some of the methodological flaws with the studies in terms of when people are particularly in social media, the nasares, there's two camps. The people who are firm believers and they might be practitioners who are actually implement manual therapy, such as yourself, recognizing that there is a rule and for every intervention, as you highlighted, and it's very unique to the person in front of you. I want to maybe just talk to or understand the people who don't use it because they don't think it works, because of the reasons that you mentioned, these studies don't really show that the evidence doesn't really support it, blah, blah, blah, all that kind of stuff. Why do you think, if you've had these conversations at either conferences, these are your colleagues? Why do you think they're coming at it? Why are they attacking it? Because the fact of the matter is, majority of the people that you talk to, patients I'm talking, individuals who are hurting in an pain, they'll tell you that there's something therapeutic about that. They don't know why, they don't know what, there's something therapeutic about it. Hell, if it wasn't, you would not have as many businesses and massage therapists and parlors, et cetera, and that's important of that as well. I want to understand the folks who are attacking this. Some are very respectable individuals, some I'm a fan of on social media, I follow the content, they put the group content, and I'm just curious, I have some thoughts and I'm curious what yours are of why they attack it. Yeah, yeah, it goes into polarizing, and some people, I think the biggest part is people have stuck in their biases, they find out what works for them and they do it, and again, everything's in contact, so I always tell my people I'm out there and everything like that, this works for me, doesn't necessarily going to work for you, let's say a cervical manipulation, it's definitely, it's based off of, I guess, even the aura of my presence, how I communicate things, so it works for me in my situation and everything like that. But the naysayers, and I'll say this, it's a really good also podcast, I think it was Jared Powell's Chad Coke, and they framed it in verse Adam Niggins, who's one of the largest naysayers of against manual therapy. I love that you wrote him, I'm sorry, I was actually thinking of Adam Mekent as I was talking about this, he's great, I'm a huge fan of him, but he just trashes manual therapy so much. Yeah, they trashes it and mace look, mostly especially from his perspective, and again, less than to the conversation between the two of them, and again, Adam Mekent does a great job of reading through the research and everything like that, and highlighting things and empowering people, I love his saying, can't go wrong with getting strong, and I do truly believe that, I truly believe in making people more resilient, just a more robust, just makes life better, but it's like, how do you get to that? If someone's in such a exquisite or high levels of pain, and just lets us load them up, could that make it worse, can that make them drop off? We always like, especially research, it's, oh, there's a drop off, we'll just count the people who are in, why did that drop off happen? Maybe that person was in so much pain, they clearly come up for the fall-up and the studies are fall-up sessions and everything like that, so it's something to consider everything like that. We know with chronic pain, like the number one reason people get into chronic pain is how intense the acute pain was, is one of the biggest predictors of chronic pain, so can we help out these individuals and maybe avoid chronic pain, and I think that's where most of the manual therapy is most effective in those earlier stages, but a lot, especially me, Gens, and some other ones out there, it's a lot of the old thought process of manual therapy, it was so rooted in some of our biomechanical beliefs of, oh, this in there is rotated, you're see ones rotating, you see two, I've got to rotate it back, and I'm the guru, you've got to come back to me, and potentially a lot of the one, just the thought viruses you can plant based off of that, oh, this is that, is rotated because I term I have the wrong, what happens if I term I had wrong again, or I sneeze wrong, whatever it may be, and we just don't really, especially as a practitioner, especially physical therapy, chiropractorors, whatever it may be, especially when we're doing a physical exam, we go rely on the liver, the validity to be able to assess these, my little biomechanical faults, when there's really no evidence to support that, I think that's where a lot of it gets thrown on the bus, so a lot of manual therapies, unfortunately, I didn't with some beer monitor of sorts of them, correct this or do this, and he begins as a really appreciate that, and I appreciate that as well, is there certain things that I would say, you have to loosen this up, or everything like that, or the old school, certain profession, like you have to get XYZ manipulated for the, once a week for the rest of your life, that's not really true at all, so I think a lot of the hate on it is because of that, does it exactly are individuals, and the thought is that, oh, this person fixed me versus it going through its natural course of healing, I fixed myself, these, it's a gurus who were the cures versus how we really should be is the guide, and helping people to cure themselves or heal themselves. So I think that a lot of it, there is some thoughts of that, especially in the social media world, where people are selling courses and everything like that, where you can say, oh, many of therapies trash, this doesn't work, by my courses that aren't hands-on courses that anybody in the world can access and that sort of stuff. So there is that too, I always throw that in, it's who's making these claims, you know, I like them, again, all the different individuals, again, I told from me, those are some great points that he said, and then I'll pull from my China cook or Josh Pleylin or Mulligan and all these sort of things, I can choose the best of everybody. Yeah, social media obviously has so many different echo chambers, and sometimes that's a good thing, right? When you have a variety of opinions, it can foster debate with podcasts, like you mentioned, Instagram, all these different places where people can go and start seeing different opinions. We might be taken a little bit of a turn here, and maybe we go into another topic, but I'm curious, how much has social media changed the way you have practiced with your clients? Or by his first say, your client's coming in and saying, hey, I fall out of weekends and this is what he says, how do you navigate what you're learning through social media and then putting that into action? It's a great question. So for me, I'll start off with it gets me personally, because it's all that mean I'm just kidding. But yeah, I guess by the time social media became a thing, especially from the education, space, and physical therapy, I was already, I guess, well rooted in other forms of education. And I already knew who to follow and who is the most respected people of our field. So that that kind of helped me filter through things. And it kind of goes back to what I was saying before, I start following all these physical therapy influencers, researchers, big practice owners, whatever it may be. And just kind of look at and always take things, just like I'm reading a research article with a grain of salt, just seeing what is a beneficial thing versus this person's trying to trash something or throw under the bus or whatever it may be. I was able to do that, but social media is great. And especially from I picked up hands-on techniques from social media, whereas like, well, that one looks cool. Let me see if I try to try on the students. I was like, wow, it worked. I did try it multiple, many multiple times before I implement my patients, like I'll get patients like, well, so you're just testing things out of us. To some degree that we do that, but exercises, especially advanced biometrics, great strength of conditioning programs, so there's a lot of awesome resources out there. I just tell people diversify and everything like that. You don't want to just go and blindly follow somebody, again, usually that's a lot of these influencers and then their own biases and stuff to it. From a patient perspective, no, if it's helped or harms people, I've had a patient recently that straight up said to me, actually, after a little bit, we just got into a random conversation about it. It was talking about how the classic could do these for the straight-carrier back pain exercises or modalities and tried those. It wasn't getting any better. And then that added more fear to her system. It was that she didn't get any better and the hopelessness started to increase as a result of that. She wanted to follow this mega person or whatever it may be and why it worked for me. Is there something more serious that you're wrong with me? So those sort of things, I think that, especially those absolutes, like, oh, this is going to work for everybody or to do this is the only thing that works that I think I've never been a big fan of that, people have always asked me, like, why don't you do a certain series to help out ABC themes and I used to do it because there is no example. If we had an exact package for the cure and the sore pain, that would be out there as common knowledge. You probably learned in a score or something like that, but the complexities of every individual of pain is impossible to just package up. You can say, hey, there's some commonality. Yes, we probably should host up ACL and that sort of stuff. There's highly likelihood that we're going to have some weakness and after a few of the quadriceps and hamstrings, you should probably do some quadriceps. I had to strengthen exercises, but maybe there are some other ways that a particular patient needs to work on or some other different avenues, like maybe that person doesn't want to strengthen those muscles because they have such a high fear around their knee that they don't want to move it. So I need access that first versus just putting these out there. The person tries, they flares up their knee and then they're thinking to step back. So that's probably the negatives of it from a patient perspective. I've had some patients where they've picked up some good nuggets here and there, especially from things where people put out like the one big benefit of social media is starting up our patients and starting to pick away a lot of the fear of association with like pathologies, especially herodists and the skull tears, the small, the rotaire cuff tears, or a lot of that's coming out where it's just like you can get to an asymptomatic state with these conditions. So I think that's good at getting out there and starting to educate people like you are not doing for this, that you could be active and be healthy despite having this pathology or diagnosis. So I think that's the real benefit from it, but yeah, that's just it. One of the things I like to tell my trainees, really anybody that I'm in a relationship where I'm educating them, sometimes even the patient is, it's very important for us to go through this journey. This intervention that I might do for you, it's really important for us to pair this up with a good quality rehab program and I'm very specific with the verbiage I'm using because I want to emphasize the importance of a good quality rehab program. And I have some ways that I try to make that point where somebody goes to physical therapy that come back to me, I always make it a point to tell my trainees, hey, I want to know where they went and what they did and how long, right? I want to know the very specific to the rehab program because we can't assess if the rehab worked or not, if we don't know the quality of the rehab. And I have some thoughts in my mind of how to do that and I give that to my trainees. So I have a two part question for you. In your opinion, what are the components, some of the key components to a good quality rehab program from your perspective? And then what advice, what things can you give clinicians, physicians in particular, who are seeing patients after rehab, where they can assess if a patient's been to a good quality rehab program? So that's a great two part question. I'll answer. So the first question is basically just what you're saying is what defines a good quality rehab or what people should look for, ultimately a practitioner, physical therapist, and sometimes now we're having chiropractors become part of the rehab space. I thought trainer, so I don't care what profession you're a part of that you bond with and that cares about you. And likely with that, you're going to need some continuity of care. So one, maybe two practitioners at a practice, so you're not like bounce around seeing four to five different individuals, especially for the, because we treat or we should treat with a some degrees of a biopsychosocial approach. I think all components of pain have a psychosocial element to it, regardless of the simplicity of it. It always chalk up ankle sprains is a simplistic injury and everything like that, but even that hat is rooted in some cognitive and some social elements, especially for an athlete. So I think having one practitioner or one main practitioner there talking to you, understanding you is probably the most paramount thing. There are studies we call a therapeutic alliance in physical therapy, which I actually believe is stolen from nursing. You can be a very relatively mediocre clinician, but have exceptional therapeutic alliance and your outcomes will be really good and vice versa, the opposite. You can be really, if you can be a phenomenal clinician, but your therapeutic alliance, your ability to bond with someone is poor, your outcomes will be so that's just I think that's the most paramount thing. And then there you should be making steady progress, your program should evolve with your progress. So a lot of virtually is stigma or the normal physical therapies you start on a program and then three, four weeks go by and you're still doing relatively the same thing. Well, it should change, you range of motion, change, your goals progressively change. So the program should change as well. So seeing that evolvement go through things, I think is especially a big piece in making sure that you're a game challenge, I think is the main thing. It's like you want to want to be pushed in some degrees, obviously in those earlier stages, we have the on the fire situation, so it may not be as most really intense exercises, but taking those stages just moving around is intense enough, but you should eventually get challenged so we can building up more resiliency, ideally, hopefully get you out stronger than you've ever been. So I think those are really the main moments and just make sure there is also a psychological side of things. It's a second part is you said what a physician should be asked for or yeah, so one of my favorite quotes from Eric Cressy, I think I saw him on Twitter talk about it one time is we also say the patient field rehab and he talks about how it's that's typically not the case, they had bad quality rehab and the rehab failed the patient. So that's stuck with me for, I don't know, five, six years since I saw him post that. And how do I assess if the patient failed rehab or rehab failed the patient, it's critical for somebody like me because if we're going to decide that we're going to move on to the next step in the conservative management algorithm, whether that's injections, as you mentioned, whether it's going to be orthobiologics, whether it's going to be a surgical consult, we need to assess if that first intervention, which was rehab that we had agreed on, did it work or did it not work? And if it didn't work, why did it not work? As a physician, what are some questions we might be able to ask the patient because that's really what it is, right? We have ideally it's you have that relationship like you talked about the arctic illness, you have that with the physical therapist as well where you guys can communicate. You and I do that. Your team does that with me all the time. I love that. But maybe the physician doesn't have that. Maybe they're not willing to pick up the phone and get that sign out from the physical therapist. What are some ways that they can gauge the rehab? Yeah. So I guess right from the top, just what are you doing at rehab is a good start. If it's the outdated approach, they put a hot pack and I ride the arm bike for 15, 20 minutes. I think that right there is a red flag, tell that person go for a way. Chris Carroll. You've had some of our PT's, he'll go on an hour long rent on the upper extremity bike there, button. And so seeing those sort of things or a lot of use of the low value modalities of like e-stem or ultra-sounding and these are things that we want thought worked in the 90s, maybe the early 2000s and the 80s, if that's how they're still practicing, you're starting to hear those signs like maybe this person, maybe rehab in this situation did fail then. And it's like going back to us and before how they challenge you, how they ask you to our things come along early, trying to modify the program to meet your needs out there. So I think those are the main things and looking from a patient perspective to the patient fail the rehab. The main thing is they did they show up sort of situation like a lot of times like people they've told to go to physical therapy and they still live in this fantasy world that people can go three times a week and have the time to do it and then also have time to do a home exercise program. And it's really almost unrealistic for a lot of individuals, they're busy, they're parent, they're working full time jobs, even kids now, you've thought at least the kids can do that sort of stuff, now they're again shuttled to three different practices, they have banned practice, they have chest club, whatever maybe, but they at least should have some consistency. Did you show, did you go, when will I see they do the things that you're saying, where you're trying to be pushed? And sometimes they are doing those things and progress isn't made. And I think that's it should be the PT probably making that call before like the follow up first bed. But at least maybe the physician doesn't need to get back to the PT, but at least a couple of weeks in, in rats, the PT's not seeing progress, obviously we want to see progress with everyone, but sometimes we do need to help live in this fantasy world life. You come through my doors, I'm going to carry it. And that's at the case, if that was the case, I'd have a line outside, wrapping around the town and driving a Ferrari, there's all these other beautiful interventions that can help with objects and surgery at the right time, even medication, if they're a medication or a bus and it's a time and it's placed for it, obviously, when I get people to wash me as easily as I can. But if we're not seeing progress that we're expecting to make, and it should be a valid on a session by session basis, but within a week, we're not seeing anything, but definitely within two weeks, you know, seeing progress, PT should probably be the one that's giving the physician heads up, at least the patient's trial, we're doing everything on RN, but it's not taking situation versus the physician just going, I don't know, but I think big ones are where you challenged more updated of interventions, especially from a loading standpoint, a lot of practices or keep using their bands as their main source of pushing the patient, even regardless of age, like we unfortunately, silo off the elderly and the geriatric, so yeah, that's okay for them, a reality of age should be squatting, deadlifting, blood pushes, so they should be challenged just as much as athletes themselves based off of their capacity. So listening for those sort of things, but immediately with the patients is that they show up, as long as they show up, I think that's all we can ask. If they're one of the individuals, let's say, I'll knock, like, runners, crossfitters, I love them, I do crossfit and I'll run as well. I have these tendencies as well, but where it's especially for an athlete's perspective, you're telling them, all right, you need to go to rehab and you need to listen to them, maybe ease off of your training regimen and then you go, you start talking to them and they're like, yeah, I've still got a crossfit, six days a week done where I was asleep, again, it starts to go on the patient probably too, so do you make the appropriate life cells modifications or rehab to be successful? So those are the big ones that they show up and they make the actual recovery. I want to double click on this idea of failing rehab as well as showing up. I practice an inpatient rehab setting and when I screen patients that come in, the one thing that I cannot assess most of the time is their motivation, their ability to participate in therapies and our goal is to get them back to their prior level of function as much as possible, but sometimes I might only have seven or 10 days to do that. They start all day one day too and we start to see that, hey, they aren't motivated. They aren't willing to put in the effort that it might take to get to where they need to be. Yet they're there. They're showing up because they can't leave, but they're not exactly participating in those situations. How much of the onus is on the patient? Like how do you view that concept of failing rehab and making adjustments? Because there's also times where I might have the patient returned for the second or third time and we might actually have to deny that patient because they quote unquote failed rehab the first two times, they're going through the cycle of hospitalizations, chronic disease. I want to understand, I guess, from your perspective, the fairness of that and how much physicians therapists can do to really get a patient where they need to be. That's a great question. So I work in inpatient rehab so I get a feel for it, but even in an outpatient and everything like that, a competitive spirit trying to always improve myself regardless of what comes in it. We get a lot of people who don't have that willingness to change. I always figure like what are the magic combination of things, of education points, of bonding points that I can say to get this person to make the footbed? Also at the back of my mind, no, they people are sometimes not ready for that, which was a tough pill for me to swallow. And I thought that they could get every once in a while. Adrian Leno was one of our exceptional researchers on pain science in the physical therapy space. He said himself, he says, some people are just not ready to change. Some people are not ready for the education and everything like that. And I believe Dr. Fatima that you guys, you just had, she made it point nine when I heard that on you guys podcast, like I say the same thing to my students is some people have to hit rock bottom. So sometimes they do need a second and third unfortunate go at it before they are willing to make them change. As clinicians, we're always going to try and, all right, how am I going to get this person to be motivated to do this sort of thing? How I get them obviously with their program, they get salient and important to them and everything like that. But even that sometimes is enough. But I think I'm fortunate hitting rock bottom is unfortunately a powerful motivator. I wish it wasn't the case. I know he's trying to get people away from the ice to say, oh, my freak out flyers back and down see as much of them because I believe them are cool early or odd, but so people, you know, I mean, it's a flaws me as a clinician or still like that where it's just like I'm giving them everything that should work, but it's not any, they're not making that change I was hoping for. And some people just, like tough for them, they almost negotiate with their lifestyle, you know, I'm telling someone, hey, they need decreased their workload and that sort of stuff and they get used to it and there's maybe some things on the back end that are motivated versus, especially from like athletics and weight loss and everything like that. So we can be saying all these sort of things, but in the back of their mind, no, I need to keep exercising to make sure I don't weigh whatever it may be. So sometimes they have to get them where the unfortunate does stop them for a long period time. It really settles in. So I'm always a believer in second and third chances. Sometimes people are four or five, I'll never give up on people, I know, I'd cement their strip sessions with some of my PTs where it's like a person like keeps coming and he's I don't know what to do. I'm like, you keep giving them the good word and one day, maybe we'll, you know, finally click, but make sure obviously they're screen and they're appropriate for physical therapy and they're, they have a good team around them, it's also supporting them. A lot of people, especially their traumas are so deep and eliminate time with their seven to ten days or hour or two in outpatient physical therapy, it's probably going to be unrealistic to really get down deep into those traumas. We try to try our best. I've had many three hour long sessions with people, but you're talking about stuff that's they, I mean, you're some of a big fan of me, I've tried, tried to keep giving them say their chains, as long as they're appropriate, they're certain situations where it's like they're not doing well because we're not the appropriate practitioner situation. Yeah. A while back, I remember maybe a couple of years ago, E. C. Sinkowski, she had posted on, and I'm not sure if you're familiar with her, but she's a nutritionist, previous guest here, really awesome shout out to her. Maybe I talked about, you know, people make changes in the nutritional habits, and I think something to the sort of where, you know, people change when they're sick and tired of being sick and tired, which is kind of what you're talking about, right? Hidden rock bottom. I remember hearing that the first time I was like, wow, that actually is really powerful. And we do need patients to be active participants in the care. This is what I tell them now, right? Yes, I can inject your rotator cuff, tatted sheet, then it's going to help you temper early, but this problem is going to be a problem probably for the rest of your life, unless you do something to get a handle on it and do a maintenance program indefinitely. But I also remember, and I'll share this with you at the struggle that I had, because just before that, I had read a book, Change Baker, John Burrady, big fan of him, yeah. And there was this quote in here, which, man, it gave me all the good feels. And that, that concept we're talking about, people hitting rock bottom, it's almost to say, you can lead a horse to water, but you can't make them drink. John Burrady said great coaches make the horse thirsty enough that they want to drink. And that really hit me deep, right? Because I was like, man, that's inspiring, right? Like you're injecting some type of motivation into this person that they're going to want to change, right? And I was like, man, how, that's what I want to be. You want to be the change maker, right? That's just like he's been, I think the reality is we, as our recent guests, they'll talk about, we'll reach us a comfort and convenience is really infectious. And when things can be done to us, for us, hear that with Instagram gratification, not being patient, everything we talked about in terms of rehab, that process takes a while. Yeah. Or it's like six, 10, 12 weeks of an indefinite versus an injection and you'll feel pretty good in three, four days. You take all that into and it's not really a recipe that is designed or not a framework that is designed to get people into buying to their rehab process and be active participants. And I think the reality is you have to find the people, even those people that are already talking about who you might get thirsty enough to drink, they probably had something within them that you were able to light up like a spark, but if there's just no spark, if somebody just doesn't have buying and there's not ready for rehab, then they're just not ready. And when they do hit that rock bottom, like you talked about, they'll come back to you. And if they're lucky, they won't, but depending on how the musculoskeletal chronic disease burden is going and pain is, pretty much everybody does. So I think that's something that for the young physicians, young clinicians who are struggling with that, who are big into motivational interviewing and coaching, because that's really what we're talking about coaching, you're talking about coaching with your patients. I'm talking about coaching, that's something to keep in mind. Yeah. Super powerful. It's a great quote to try, send that out to the thief. So I've heard the, we can make the horse, we have the horse, the water, and then we can try to stop the horse's head in and try to drown it in the water, like that's the approach. Yeah. It's, I think that's where a lot of the fair appearance in bonding comes to play where if you have an incredible bond, especially with, I always say, what makes like the greatest clinician is that someone who can be so dive into research and the training and the mentorship that they forgore everything else in their personal life and that makes them, would make them the goat clinician physical therapist, or is it someone who has also, maybe isn't so forward to that, but has also a balance into real life sort of things, things that be tended bottom of people of similarities to. So sometimes it's just, you just need to find that right person that can like that spark. And so I'll be honest with patients and everything and so that's why I like having a team and like to also tree around, it's been a little bit since I've treeed around the other staff to the bounce around the other offices, but being around other people and they can hear like they're, we all have our own different style and that can attract someone to potentially make a different change if there was someone who's, they have one clinician and he's super like high energy and motivating, I remember everyone loves him, but the one patient young girl asked to not be with him, I mean, not love being with him and she's in the dumps, I mean, Kelly's 10 and ruptured and he was here and his patients thrive off of that, but it was not what she needed. So I mean, the swap and she eventually did a couple sessions with him when, I mean, her pistol is on vacation and stuff, but it blew my mind, I'm like everybody loves everyone my family to send them, but that was it, it was like she was here and he's here and that's something simple as that. Interesting, yeah, the energy mismatch, really, right, that's important too. I tell people that with we, I make so much, I encourage people to really improve their mental, I really, I'm a firm believer if you got street almost from between the ears and orphariate that it's accepts and we, it gives it to go therapy as the knock on and it's a jack of all trades master of none, some conversations like counseling and therapist and psychology, we can do manipulations and stuff like car practice and osteopaths, we can even eat them now, like active punctures, we can do a little strengthening conditioning, like off the straight thinking they're training trainers and so we can't even get knocked for that, but I really do think that's the beauty of us and it's this better, I get these skills a better, better, I get referring to individuals and picking up on these sort of things and I've done what really meant the health practitioners, it's all in bottom of that person, that person wasn't for me and never did it again. I'd say that's over 75% of the copper statistic of the individuals I refer to, like they try to once they they work for them and then they're shut it, it takes a while to find the right person, you know they guess for anything in evolved medicine, take the time to find that right individual that you bond with and hopefully they have an exceptional personality that works with and also exceptional clinical skills, hopefully get both, but I think that's or they is finding a person that works best for you. I love that reframe that you have though, I think maybe something I'm thinking through now as you're talking about this, I think maybe what makes you guys incredibly successful in the team that you've built is maybe because you guys are at the jack of all trades and master of none and maybe the reality is that most patients in rehab, that's what they need, they don't need a master of one trade, they need a jack of all trades because if you get them to, it depends on what phase of rehab that you get them to the world's greatest strength and conditioning coach, right, just high level person, but he doesn't know how to create that connection, therapeutic lines that you're talking about and then at that athlete's having a bad day off the outside of the gym and you can't get that person to get dialed in because you don't know how to have a conversation between the years that you talked about. By the same token, you paired them up with the greatest psychotherapist in the world who's had success with the high performers, all that kind of stuff, but there are two weeks post op hip and they need some mobilizations or some reason that you could talk to them all day and get their positive psychology and mind right, but that hip needs to be mobilized a little bit, right? We got to create some stuff there. So I think maybe for those like later stages of rehab and maybe not even rehab at that point, which is why I remember you and I talked about at some point, I was like, hey, you still do programming. You're like, nah, I think earlier on we do and then we start referring out and now you need to, I can carry this torch for a little bit, but now I need to pass this on to somebody who can better serve you because of what you need and I'll be here periodically for you to check in, but you can graduate, so to speak. Also I want to, I think that's also refreshing in this world, particularly of healthcare where everybody is so hyperspecialized and I'm curious to get your thoughts on this, is medicine, everybody, like I'm so, so specialized and everybody has done a fellowship at this point. The trend in physical medicine, rehab residents are not to go into practice, primarily go into a fellowship afterwards and it's, you come in, somebody comes in for pain and let's say you're a shoulder surgeon or shoulder elbows, I treat shoulder elbow. I don't treat the hands or I go see the hand guy and sorry, that's not my problem. You know what I mean? And human beings are very complex and you need to address all the facets to treat health overall. And so, yeah, I think that's a beautiful thing, I agree with you and I think that reframe is powerful. Yeah, yeah, it's actually my, it's actually my favorite quote because a lot of people don't know that it's an unfinished quote, but it's a Jack Mall trades master of none, but oftentimes better than a master of one. And so my leading principle in life honestly is to build range and I think there's a lot of anecdotes stories now, even some data talking about how if you're able to build range or able to have a diverse set of passions and skill sets, you're going to oftentimes become better and be at like quote unquote, the top dog in your field because now you are able to pull out some different tools from the toolkit to help and to build whatever you need to do. Great book. David Epstein called range, even the book mastery by Robert Greene. I think both of those really highlight in today's world where there's just so much out there that you can now learn and obtain. You talked about your, you just had a breakies certification, right? Just because you were interested in learning that, but that gives you an advantage because there's probably going to be some patient comes in and just says, hey, what about this? And you having also that easier philosophy a little bit will help you with your patients a little bit more. But I agree all times. I think everything is getting a little more siloed and I think we're starting to see the pendulum go the other way a little bit in medicine. I feel like most physiatrist now are actually going down more the general route rather than fellowship one because of the time of the investment and just the ability to have that lateralization. If I get sick of inpatient, I can go do outpatient, I can do injections, I can pad the option to do a lot of different things. But yeah, sometimes mastery, it blinds the practitioner, blinds the patient and they're not able to get everything that they may need. So I'm a big fan of being a general and it's coping out the field. Yeah. Especially with obviously it treat people pain out and I guess it specializes the gets in the physical therapy space I've with the residency went through a sports manual therapy fellowship. So that's even subsection of orthopedic manual physical therapy by chemist complex. It's multi factorial. So our treatments should be multi mold. So we should whatever we have some patients where it's I'll touch them at all. Exercise and some people it's I have a ability to just talk to patients. I've had without a doubt, I've had multiple two to three hour sessions where I never got them passed away in the room and have other patients come in and I'm like, I probably should have done some exercise at this point, but at that point that person needed some more conversation pieces. So that is a beauty of especially physical therapy where we have a space to be able to do all these things and have the squat racks and read that. So that always encourages the same thing that you guys say. I don't know if any prospective students physical therapists are listening in and everything like that. Typically the students that are like, Oh, I picked your place or want to go your place because you're a sports place and that's all I want to do. I can't remember any student of that thinking maybe one or two that were just dynamite, but typically the greatest students in my opinions, ones that we've hired and everything only. I just love this profession. I don't care if it's inpatient, geriatrics, pediatrics, they love it all and they take it piece for me. Well, I do think that's super beneficial, you can bring it to Chris Carroll who has a little private practice in spinal cord injuries and neural base rehab and strokes and all these sort of things, but he blends so much of what he gets on the sports and orthopedic side into that and they, you know, outcomes that are unforeseen in the field. I know Gastivic Kevin who's, I forget where some are in the Midwest where they have one PT for every, I'm being a jerk here, but like 100 miles for something on that major. So he has to know the cardiac system, integumentary, neurocognitive, all these sort of things and he's able to treat everyone, he's a phenomenal physical therapist as a result of that. So I do, if I can give any advice to the younger generations, it's to be open to everything because it's truly to treat the human, it's the whole system, so don't silently yourself off just to one point. Like you see, you know, push your knowledge and everything, you can't worry about it. I love it, man. I think what we're talking about is this, we're all in the business of helping people and you got to take out the tool, they need to take out in that time to help the person with the situation they're dealing with and typically try to do it and look at it from that point of view, you're going to have some success. Just a recap, I think the composer rehab program that you talked about, number one, and I'm not surprised at all, they talked about therapeutic aligns, so a building that rapport, creating connection and the powerful word with that patient, maybe the most important thing and then for better or for worse, progressive overload. So a varying program over time, not being stuck doing the same thing that you're doing today, a four weeks on this, something's not right, is that adequate, those two main components that you looked at, yeah, that's the main thing, like again, you want them to be challenged. I think that's most of the knock on rehab, it's like most people say, I could have just done it at home, sort of this situation and that's not how it should be, one, either paying with time or actually out of pocket or whatever it may be, find it, believe it, you should be given more than what you can do at home or what you can look up on. Definitely. I think one thing I would add is something that I do look for is part of the rehab program as homework. I'll have patients in the hall often do I need to go and rarely will I say somebody needs to go more than twice a week. Now, again, their exceptions to the rule, postoperatively, I had my hip done, I did my rehab with you full disclosure for the audience, I was seeing you three times a week earlier on. That's what we need, right? You need a higher dose and this actually, good segue into the next topic I want to talk to you about. I knew we wouldn't get to some of the stuff that we wondered, but that's okay. So dosing exercise and dosing rehab. So Dan Pope, we love him, he's been on here a couple of times, he sure, he didn't coin it. This concept of dosing exercise is what I learned from him is very important. Actually, I think what he talks about is dosing stress and we can talk about exercise being a physical stressor, maybe a psychological emotional stressor and you have to balance that with other stressors during your life and over time, you have to increase that dose so your body can be more capable and build capacity. You talked to me about something a while back and you were talking about dosing rest. It was mind blowing to me and maybe this is a bit of a cue where I think you were telling me about somebody who was going on a vacation and after two days, it was like an eight day trip or nine day trip and the person started losing their mind. This is somebody who has always go. Is that starting to ring about, yeah, why don't you go into that concept because I had never thought of it that way. So for that high performer type AA person that you take care of a lot, most of my healthcare colleagues, medicine colleagues, how do you dose rest? Yeah, which is a tough thing and a tough thing to negotiate as well. Once you start to explain things and having that story as a patient or having a patient like that, it's a lot easier. But we have these posters, they're called the Twin Peaks posters, can run and rip them off the wall. They can kind of show you guys or send it to you guys for the notes and they're writing like that. But it just, it explains like your capacity of stress, whether it's work stress, physical stress, mental stress, all these sort of things and when certain individuals, like you said, I mean, the providers, I see a lot of business owners, elite athletes where they're just always operating up here. It's one, a, one, you're just in that fight or flight sympathetic drive response all the time and which is probably most likely a big cause of why you have to come see someone like me or you so it's one of big threat to the individual because they're used to it of always operating like that, whether it's my business, I have to do all these sort of things or even something as simple as like the ultimate mom or dad who's, oh, yeah, four or five kids, I'm taking them everywhere, I'm working a full time job, whatever it may be. So say, hey, I need you to take a break or I need you shut down from the sport. One, that you're just going to set alarm bells. You're now changing their, you know, organized chaos and that's the one, you know, when we set off alarm bells, that's the increased pain sensitivity. So that's what you're going to make things worse. So to give things just like we dose anything else, exercise, pain, education, I used to give it like, for me, I'm like a full hour long after my evaluations and some people in helped with and then a lot of people were like, screw this guy and they were talking back to him because they didn't have the right dosage. So we have to give these little bite size, these crumbs for people to pick up the trail and then, okay, I'm picking up what you're putting down and it's starting to get a little bit better and everything like that. For those individuals that are like that, it's not everybody, for several people, you can just be like, okay, I need to take a week off and they're cool with it and buy your response grade for it. But those extremely high performers, it's just, hey, you're used to operating like this. I just need you kind of waved a little bit of a breaking and come right back and then we're going to extend that window. It's okay. Maybe just plan to and work at four o'clock versus eight o'clock and then we'll work from there. It's our situation and then by a lot of times we have that, like a negotiating piece for these individuals, work till four o'clock instead of being on the desk, I want you to go out for a walk while you're on the show. It's our situation. So instead of fully cutting the cord and that's our stuff because again, it meets a lot of resistance. You have to bite size those and then start to extend that window and the buy ultimately wants to be anymore, but balance probably mostly it cares sympathetic state. But we if we do it too much too soon, it's going to, it's going to pose all the alarm bells to go. So a little bit by a little bit and you get a gauge as a clinician of like how much you can negotiate with the individual based off of what they say that I haven't taken a vacation in six years. Okay. Start off very little for those individuals that people like it's been a month or two. It's like, all right, why don't you take this week in a sort of situation. So I think it's super important. I think a lot of people, especially in the United States, where practice and just today's day and age, it's so go where we need to get into that or some of that kind of state because people are waking up, they're driving and then it's like they go to sleep thinking about the next day. Ruins are falling asleep. The ruins of hormones are produced. They can be growth hormone, it's a growth like factor. Those are getting disrupted. And then there runs in repeat, where is all is going to be a shooting up and everything like that. So we need to get them that state, but can't all be done. Is there anything you're recommending to your clients to get into more of a parasympathetic zone given that even if they're taking a break and they're type A, they might still be stressed in about the fact that they're not doing something or they might substitute exercise with another high stress chore. Yeah. Well, first things first, I tell them that they owe it to themselves because the most these individuals do not believe they deserve to have a break. Something's rooted, they're pushed when they're younger, to go whatever it may be. First thing we're out of that, get a dream between the ear situation is that they owe it to themselves. I always give the love, it's like they're internalizers, it's a lot of times people want to help out others. Those are the main ones. It's very rare, sometimes you get some maybe narcissistic individuals, but it's usually individuals who are just trying to help out others and they're like, oh, whether business owner, I'm going to do everything for everybody, oh, my, I always give the analogy of the airplane. I probably say this at once a week or something, when the airplane, when the mask comes down and they tell you to put it on the mask of your kid first before years, you have to put yours on before you put the cage or messing that up. Why? Because if you can't help yourself, then say put it on the kid first, you pass out and the kids in trouble, such and so forth, then you got to help yourself before you can help out others. So I say that right off the rip first and that usually gets home saying that it's the main thing and then you get kind of engaging things with what they're okay with doing it. Sometimes I'll start to say, yeah, while you book a massage or try and do a meditative walk and you just start to see it like glass over. All right, let's do just like a cardio sort of thing, like a bike ride or something of that kid. So again, you have to meet the patient that way and explain to people, it's like also the expectations around it's not, oh, they're going to take one day off or you're going to modify something and give yourself a little bit of a break and then, oh, your pain that you've had for the last years, three months is going to disappear, like no, that's not going to be a case, but it's a piece of the pie. I just try and meet the way I figure out something. So I get to tell people, maybe it's my biases of massage and manual therapy, I'm like, you get a massage every once in a while, it's good for you, maybe you'll pass out, like your little body work done, it's commonly environment, they smell, but you should try and tell people, there's a lot of gents in research for medication, I'll tell people, like, yeah, you may be like, clearly, the world, there's just completely blank and blank. Now, just getting a meditative state of where you're just devoting time for yourself to be, to your thoughts, to a so degree, but I'm trying to get to a peaceful state. So those are the ones I promote yoga, mostly because there is a lot of those makeup on and it's well, sometimes it's just like listening to music, jam, and now it's like, you want to find something just like the exercise mode, especially when I had treated it in a lot of population, it's always try to get people to be in different fitness, those are always a, that was a discharge call, now it's everyone's active, fitness, I have to get them back into it, but they're always like, oh, what do I do? I'm like, whatever you have enjoyment doing, that's a main one, I'll care what mode of exercise it is, as long as you enjoy it, you're getting consistently doing it. So whatever type of, I'll list off some parasympathetic based activities, whichever one kind of, it's home for you a little bit, go for that, you jam and out to music, go for it, walk, go for it, drive it around in your car, aimlessly, go for it, whatever it's your fancy, I said the same thing, you may miss the first couple of activities, but you'll eventually find something like, this is good for me, alluring whenever it may be, so that's a trial league, I think we're all familiar with the person, and in my family, I am that person where, you know, you, or somebody might say, like you talked about who has been hustling for five years, right? Just trying to start up a business, start up a family, young entrepreneur, young healthcare professional might be residency that you're coming out for five year residency fellowship, and then somebody says, okay, let's just, let's take a two week vacation off. You don't even know how to do that. As you said, organize chaos, like your system is used to that organized chaos, that's the baseline, and we know a big stressor for somebody is like a difference from their baseline where they're used to, right? That in itself is stressful. So if you're just used to go go and all of a sudden now, we completely changed that environment where you're not doing anything, that in itself can be problematic. You might find that you were coping and not having time to think through some emotions. Darshan, I've talked about this as, can you sit quietly by yourself? You might find that you have some scary thoughts when you sit quietly by yourself. You might have some loneliness that you weren't ready to handle, and that can open up different cantal worms might not be good. And so I think just micro doses initially and figuring out where that person is about that person needs, and then expanding on that dose, just like we talked about building exercise, progressive overload on training, but we also do a progressive overload on this parasympathetic. Chris Williams talks about, we did David Goggins type, nobody can rest harder than me. But I think before you get there, most of those type A people need to solely be introduced to that. And I think once you said it, I started thinking about it myself. I'm not that person who's go, probably no surprise anybody would listen here. But if I go on a vacation, by day three, I'm getting itchy. I'm getting real itchy if I haven't done some type of work. And I was thinking about this. I think Darshan recently posted on Instagram at some point about self love is, what is it that first thing that you need to do to get yourself going? And I love the train. And I want to train in the morning. There are some benefits that I think for me personally, because I have that out and then I'll have them in the back of my mind. But lately, just because I have some other projects on my plate lately, I think I've had this mental load of things that are to check off for various projects. Lately, what I found for me self love is, and thank you to Darshan for doing this is when I get first get up is I do not go to the gym. I still get up early, but I want to take care of the administrative stuff. Oh, there's products that I got to do. And then I feel so much better after work. And I come home and I can be engaged with my child and actually be there because I've taken care of the administrative tasks, but I can go to the gym afterwards too. I'm still training and doing that kind of stuff. And so at this point, Dara, say this, it's maybe even more important from a mental health perspective for me to take care of that. Then my training training is still, it's habitual. I don't have to get fired myself. I recognize the importance. That's like brushing my teeth. So I think that's one of the pieces you have to find what your dose is. And then what's the minimum effective dose, if I may say that, that you need to get yourself into that parasympathetic comfortably. And so that's great points. And knowing that they might get a little fight back sort of stuff, whether it's being alone and you're getting these thoughts and everything like that, or maybe increase symptoms, or it's just like anything else. That's why you be progressively a little bit of exercises or even manual therapy. That's progressive in itself. We start to push down a little bit and sometimes we get a little fight back. And that's okay. That's part of the healing process, a lot of the protection around things in the sense that to be around things. What are you doing? Increase the pain, sense it to be early, sensitize the experience. So let's be like one, just communicating that with people, especially when things are, it's like it's by identity to be this. I felt that as well. It took me till, I don't know, probably year nine or eight or nine of practicing before I could like really relax, especially being a business owner, just have all the phones go to my, all the calls go to my phone and everything like that. So eight or nine years of practicing before I can actually start to truly relax on a vacation. Or it's like I wasn't answering things or sending the animals or chicken in and that sort of stuff. I still do it now, but it's, oh, I had to, but it was part of my identity. It was almost like I shouldn't be on vacation. It should be grinding and that sort of stuff. Even when I'm on vacation, if I'm grinding, I'm on the man for it. It's like great. I'll eat this. Yeah, sure. That's cool. And you have the Dave Goggins thought possible. What cost is that? Is it coming at the cost of the drive of being a sympathetic state? Is that going to affect my heart? Is it also going to affect my relationship? It does like halfway across the world and I'm thinking about work when I should be thinking about spending time with family. They'll pick up on that sort of stuff. It does take time to do that. And I think that's an important thing too. Like, especially rehab or boxed into the three times for each or four to six weeks of the classic script and that sort of stuff. And it's the deal of people with things for many years. Sometimes longer than I've been around as a clinician. I've had people with 30, 40 years of issues and everything like that to say, oh, this is just going to happen in this case that you're here. This is probably unrealistic, but we can make the small steps towards that little okay, you start spending five minutes by yourself situation. And then you'll start to see the value of it. And then when you as in a couple of years, maybe you're taking a vacation or you're working only 20 hour work weeks or something of that nature. Yeah. Yeah. It was a 20 hour work days, huh? Yeah, exactly. Hey, Darce, I got a question for you, man. You travel a lot here. Do you find yourself ever getting that edge that you need to do something work related? Yeah, absolutely. I still do. So it's funny. Like even during the day now, like I've noticed that if I get to write something on threads or if I get to put a content out there, then oh man, it's just like this wave of relief. Like I've accomplished something. And so even when traveling, I know going in, I try to make that like my D load week where I'm just not doing anything or I can just do a couple of push-ups and work out with Mira or something like that. So I try to go in purposely and say, Hey, this week is going to be a D load week from a trading perspective. But I do tend to write in my notes about things that I philosophize over that I can then come back once I'm back in the US or back home to then make content or then act on those things. It's going to actually steal that. I'm stealing that and repurposing D load because D load is in the context of training. But I think D loading from work, right? Let's look into see if that happened. Let's trademark that for us. But I think that's what we're talking about because yeah, I think completely abstaining from that. We don't want to necessarily abstain from exercise. We know that. And so we D load and every now and then take some time off. But I find myself if I just D load and you're decreasing intensity and also the duration on the vacation time, like everything seems to the vacation becomes much more enjoyable. I think when you have those high performing individuals, like they they have that itch that needs to be scratched or big fans of Alex are rosy and I'll let that guy talk about vacation ever. He went on a vacation recently. Yeah, but I wonder. Yeah, I like that. Jeremy, we could do this all day, man. And maybe we will. I think we'll have to bring you back for something in talking about the concept of none up. Hey, see I'll rehab in a feature. I think that's a very important from a sports rehab perspective. But tell us. I don't know if I even know this. You're a very thoughtful guy. You think about things are a deeply. It's apparent. And you mentioned a lot of training and years and decade more than decade of working with people. How did you even get here? What inspired you to go this route? You talked about the importance of just loving this profession. You're clearly one of those people. Why did you even pick PT? The question. I always loved this typical while the guys in physical therapy or male physical therapy always are interested in sports side. But so I was a huge. I just like to compete. I think there's really like knockout or basketball or soccer. So I always had a love for sports. So that's how I got into that. It was actually a lucky Google search. He puts words in medicine and somehow this is going back and now if it's got therapy popped up all the time. But it popped up and even though it existed, I'm not one of the more traditional PT's that suffered. They've got an injury and then how to go through physical therapy to find out about. Lucky and a shout out of the affect training at my school physicians that I knew there was something in the medicine world. Like to watch diagnosis from Erdogan Clarker. So I was always watching as a medicine seems awesome. So buying that out with sports would be like the best thing in the whole wide world. Yeah. I got a great opportunity to shadow Jersey physical therapy in Mark Rubenstein and just seeing the out that interaction was happening. I just thought it was a fun enjoyable environment with political excellence. It seemed to be occurring there and no marquee that definitely delivers that. I really know what I was loving at that time was that bond that was created and they see the progress over time. That was pretty special. They did push off that Instagramfication and it was more delayed and it caused more changes. I think more left life changes. And I didn't really have time if I was as fun and I got to combine the both of my like, well, so medicine sports. But it was really what sold me and it was really the bond I could see Mark and his patients building and that carried over into me and the more people I was around, especially that really looked at human side of things and really the logical side of things that really blending all that together in the deal that you don't forget. This is the way that we do physical therapy. It's the perfect spot for me where I can have long talks and that I can flip the switch and yell at a kid in motivational way to get yoked in the squat and be in performing the therapy and do you take the something of that nature and write some relief for somebody else. So it just does that whole combination of things. It's pretty special. It's probably how it treats the panacemal diamond sort of way. Absolutely, man. It's a good thing. Oh, God, God. So there's a non PG 13 version of what made me seal the deal and go into the PT, but I'll say that for off the air. All right. We'll definitely have the ear that. But yeah, I mean, it's definitely inspirational. Your story, your love for learning and how you can incorporate just all the different learnings of your journey to be the practitioner that you are. And so I totally understand why ultimately I spoke very continuously, very highly of you. And he kills me and sometimes on the things that he's learning through you. And so definitely appreciate you coming on here on educating me in our audience. And if they want to learn more about you, what are the social media that they should go to? What website should they go to find you? That's great. So I need to be better about my own personal social media. But on the decent doctor, which is the reason for decent is I'm always striving to be greater and better and everything like that. But I'm not saying it on that way in China. It's a, I love this profession because it's a lifelong learning profession. That's where the decent seat comes from. But so that I'm the decent doctor on mostly Instagram is about mostly what I utilize. My company's traffic, the therapeutics, which I have the pleasure of leading what I'd say is the strongest physical therapy clinicians arguably in the nation. So you can feel a lot from them and they're different styles of flavors shown up to them. So that's a traffic with therapeutic access on all the major once. If you guys have any specific questions, my email is jboyde and try to check the therapeutics.com, which is I know long, but feel free to reach out to me there or be in me always to help out you right. I met the feedback asking. Awesome. And no worries about the length. We'll put the hyperlink into the show notes. So that way, people can just click on it and ask us some questions. Yeah. Jeremy, this has been a true pleasure. Hopefully we can get you on again because I know there's some other topics we haven't discussed that I still have no idea what you guys are talking about with us. ACL stuff. I'm in for a treat. I guess if we're able to do a part two. Yeah, Jeremy, thanks so much again. So ladies and gentlemen, Jeremy Boyd. Like a dorscht. Thank you all too much. There's also a show. People doing what you guys are doing. Thanks, man. Thanks for listening to the other episode of Medicine Redefined. 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