214. How to Stay Mobile and Avoid Falls as You Age: Balance, Stretching, and Core (Training Series, Part 5)

0:00 Welcome to Medicine Redefined. I'm Dr. Ultima Sharajah. And I'm Dr. Darsha. Let's put the health back in healthcare. If you're a high performer who wants a clear plan for longevity, performance, and staying active with fewer setbacks, and you want to work with me directly, you can book at refininghealthrx.com. All right, let's jump in. Dr. Shals, back to put a nice bow on this five episode series for people. And I think this is the one that hopefully we'll be able to shine because this is right up our alley with respect to its clinical applicability.

0:41 I'm going to need you to make sure that I'm not getting too far into the weeds and I'm staying and keeping it simple. Our target has been for most people. to stick in that 30 to 35 minute range. That was the whole point. I don't know if we've been successful thus far, but here we are. Maybe a little over. Yeah, we'll try to make it happen. As always, let's start with the nomenclature. I think that's really important because a lot of these things get changed interchangeably. So flexibility is how far a joint can be moved. People understand this. How do we get flexibility stretching? But it could be by someone else or by gravity, right? So to attain that flexibility. Mobility, a slightly more important concept, is how much of that range of motion you can control. So, Max Schenck, all the way back in episode 23 and 24 in the archives, remember that?

1:23 Eamon talked about this active-passive gap, which is so critical. We'll talk about balance. Most people understand that. But in a nutshell, this is keeping your center of mass over your base of support. Critical. Last episode, we talked a little bit about falling. We'll dig deeper into that. And last but not least, stability. So this is controlling your position when life hits you, when something tries to move you out over your center of mass. This could be a stumble, a carry, a reach for you when you're trying to get that last little bit. I just started watching the Rafa stuff, by the way. In that World Cup, the Davis Cup, they showed Roddick serve at 214 kilometers per hour. That's- What is that mile prior, like 150?

2:05 Probably. Just take somebody's head off. Yeah, that's crazy. Insane. MPH. 132. That's not even his fastest. I mean, he was serving 148, consistent 150 maybe. Yeah, yeah, I know. Crazy. Talking about power and everything. All the ball is ball, the right stability, stuff like that. Tennis. We talked last episode a little bit about change of direction, lunging for a ball. So out of all the four of these qualities, the things that make up mobility, stability, balance, and flexibility, which one do you feel it limits you now at your ripe young age of 34? Question. Maybe stability.

2:46 I think I've lost that quite a bit. Just from not playing as many sports. Not playing basketball as much technically. Yeah, I'd say stability, balance. Yeah, perhaps the most important. Are you pretty limber? Are you pretty flexible, generally speaking, or no? Yeah, my shoulders apparently, I did a jiu-jitsu class, and they're like, dude, we can't even submit you because your shoulders are just, they just keep going back. They're like, I don't know. Yeah, and I was like, oh, okay, I didn't know. Interesting. Well, that's cool. When was this jiu-jitsu? Probably a couple months ago. We were doing some classes, yeah. Love it. stability arguably the most important one and people sometimes will think about stability i think in the rehab world it can be mischaracterized as oh bracing your core strategy for low back pain and that is one strategy part of stability but this is really controlling the positions you can actually use so one would argue from a safety injury prevention standpoint the most important let's start with falls and hip fractures because i think that is what we left off that little bread and This is arguably the most important thing.

3:50 People have talked about this a lot, have given it appropriate attention, but when you actually start digging into the literature and looking at what the studies show, it's actually pretty scary. I think this is one of those things that's talked a lot about on the interwebs, and it should be talked about even more. Is it when you, depending on what paper you look at, again, some of the literature review I was looking at, all the way back in the 90s, this one paper I came across, Pocari 1999 said that most hip fractures following a fall in one Finnish hospital studies resulted in a day most fractures were following a fall and up to 98% in this. And the CDC numbers attribute 88% of hip fracture emergencies and hospitalizations in adults 65 and older to falls.

4:30 CDC older pages will stay above 90%. So this is pretty well recognized, but not... practiced well enough for elderly population. I have this conversation with my patients all the time where they don't want to use an assistive device or they're like, it's okay. Everybody's furniture walking in the house and they're like, I just need it when I go and it's okay, I'm quickly running to the car. I'm quickly doing this. I'm like, that's exactly when you're going to. And half of them are anticoagulation. I don't want to open that can of worms. But I wish I could emphasize, like, again, you don't want to do that and fear monger anybody. You see a lot of this in the inpatient rehab unit. Talk a little bit about your conversations about the importance of fall prevention and the...

5:14 Yeah, you're right, man. Oftentimes, I see patients who come back probably with multiple hip fractures, right? They did the right now with their left. Or if I see a patient with a left, let's say I first started, which was about two years ago, I'll see them for a right hip fracture now. So I do see oftentimes patients come in with both hips now being fractured and then needing replacement. The hip is a very complicated joint and everyone responds to it differently. And I've heard other orthodontists and other people tell patients, like, the hip is super complex when it comes to pain and restoring itself and trying to get the therapy that you need. Again, we're going to talk about insurance and whatnot, right? Because the way I talk to my patients is whether you're a hip fracture or whether you're a knee replacement insurance is pretty much going to give you the same amount of time while you're here with us.

5:57 And that's unfortunate because with the hip, we probably need to take more time when it comes to fall prevention, understanding your home situation, understanding your social support, understanding your diet and what we need to do to now prevent future fractures, but to also get you strong enough to where you feel confident living by yourself or living with your loved ones and doing the things that you were once doing. Yeah. Yeah, my conversation, especially with hip fractures, I talk a lot about social determinants of health because I do bring up those stats about how they're over the age of 65. You're looking at mortality in the next five years, 50% possibly, or rehospitalization, which I believe is like 60% in one year. And it's not, again, meant to fear monger, but it is to help wake up their caregivers.

6:38 Because a lot of times you'll see blame and be like, oh, they just got up too quickly or they didn't follow up with endocrinology when they should have. They knew they had osteoporosis, whatever it might be. So yeah, a lot of my conversations are about how do we set up for a successful discharge? What are the things that we have to do now to take care of when you get home? And that sometimes changes the discharge disposition. So oftentimes patients will go to an assisted living facility rather than going home. Yeah, so much to follow up on there. But I actually had a very difficult conversation with my dad this week and trying to explain to him the importance. My mom had a fall not too long ago, and she's young, right? She's just under the age of 60. But, you know, talking about securing the home, rugs, right, loose rugs, that kind of stuff, like with every single passing day, that we need to be cognizant of this and how do we make the environment safe?

7:29 And the first thing my dad said when I was talking about I presented the data like this and he was like, oh, I don't want you to tell her that because he's going to get it at him. I'm like, I understand that. I agree with you. And that's why I'm not having the conversation with her. Although, but yeah, with the caregiver, like you need to understand this is, some people are, it's challenging. It's the most challenging caring for your loved ones is that's why it's better that it's coming from you as opposed to talking to somebody, talking to their mom and stuff. But the reality is probably a lot of patients, people who are listening to them, maybe they're not the ones who are going to be most at risk for falls. And maybe this does make you think about your mom and your dad or somebody older in your life and maybe don't throw them studies like the one that I'm going to review. I'm going to talk about good ways to do that. But there are so many things that you could try to figure out, like what are their constraints right now?

8:10 Is it more of a weakness issue? Is it more of a balance issue? Is it more of a, is it a combination? Is there a visual issue? So let's talk about the good news, right? There was a Cochran review that I came across in 2019. I posted about this last month. They pulled together more than 100 randomized trials in older adults living at home. Average age was 76. So this is figure nine for you, Josh. And they looked at balanced functional exercise, which cut the rate of falls by about 24%. So that's awesome, right? But the reviewers rated that as high certainty evidence, which is great. But the program that combined resistance training with balance and functional exercise cut it by 34%, right? So the combination, this is why the thing about, okay, it's not just power.

8:51 It's balance training. It's what's going on inside your ear, your vestibular system. It's looking at your vision system. I'm not even including medications that drop blood pressure and things that make you delirious and things that might make you sleepy. But proprioception is another big one as well, right? So think about this, somebody who might have something called diabetic neuropathy. As you get a little bit older, you lose your sense of space, your feet in terms of how you can feel. And this is why people who have really severe diabetic or advanced diabetic neuropathy, they might have stepped on a nail and not known about it. So that's where the diabetic footwear comes in. So there's so much more to the fall thing that I think goes beyond just, okay, they couldn't move their foot fast enough and therefore we should train power.

9:33 We got to figure out where that leakage is almost to speak and train that quality to bring up the whole floor if I could. Mixing metaphors here. But you get what I'm trying to say, right? Yeah. And so I think that that's the good news is like, hey, we can attack this fall situation, the fall prevention thing from multiple angles. And if you do that, you're going to have better outcomes than just training one domain. That make sense? Yeah. Yeah. Yeah. So I think that was like pretty encouraging. Okay. Let's just attack all of that. Yeah, and I think this actually fits what I see in clinic. Again, I do more outpatient stuff. So it's like trying to pick people, okay, assistive device, like how can we troubleshoot and do that? The other interesting thing is, man, is I wonder if you see this is like... Almost 100% of the patients that I see who are using a cane are using the wrong extremity.

10:16 You see this. I'm sure we learned, you learned about it. Like opposite hand saying they're like, yeah, the A pattern's not. Right. They're doing ipsilateral, right? So for those who don't know, like if you have a quote unquote bad right knee or bad right hip, and you're walking with a cane to offload that, you shouldn't have it in your right hand. That's the ipsilateral extremity. It should be on the contralateral because that's a normal pattern of walking. I did learn not too long ago that not everybody appreciates that. This one patient I spent like 30 minutes having this conversation with and I got a terrible review afterwards on it. He made me safer. I think that's what the ruse is. Amazing. Anyways, let's come back. I'm not there at all about it. So I think the point with that is that strength belongs in the plan.

10:58 It just can't be the whole plan. So we have to look at a bunch of other things. And I think we had talked about maybe in the strength series of the ACSM 90 to 119 minutes, but really for healthy adults. the biggest balance gains come earlier on. I think for most folks they do, but within three months of training, three sessions a week, roughly 90 minutes to two hours a week. So again, that total time required is actually quite low. Again, I recognize that our listeners aren't 76, maybe some are out there, but this is talking to that caregiver that somebody who is like me and you or our parents might be in that 70. So anything to add to that, bud?

11:38 No, no. Do you do any specific balance training as part of your program? We will at times. Paces are high enough level. We'll get a phone pad out there. I meant you specifically. Oh, me specifically. Balance training. No, I haven't in a while. I think the last time I was probably doing it was med school. Had a little bit more time then actually, which is funny. I just messed around with BOSU balls maybe or just, yeah, phone pads, things like that. Cool. Awesome. All right. Shall we switch to mobility? Let's do it. So stretching, as I mentioned, is trying to get into range, you know, exceeding your range of motion to access more range of motion. I think mobility is far more important. There's so many ways to access this.

12:20 And across when we look at studies, multiple studies, more than 70 studies, again, this one paper that I looked at 2024, that stretching works for range of motion. static stretching and contract, reflect or contract relaxed stretching rather, it's also called PNF stretching, proprioceptive muscular facilitation. These types of stretching, specific stretching modalities or techniques rather, they'd be ballistic or dynamic stretching. So ballistic stretching would be when people like bounce at the end of touching their toes or dynamic stretching would be walking like leg kicks and stuff that we would do a lot of the track warmups. Technique specific, like that can help you access more range of motion, but if you can't control that range of motion, then to me, it's a moot point, right? Where you're wasting time.

13:01 in terms of what you can do. And it doesn't, the study showed that it doesn't significantly change how people do down the road because you don't end up keeping that. Like you'll get looser for the next couple of minutes, but you're not lengthening your muscles. You're not lengthening those sarcomeres over time. So what's even the point? And so, The other point would be, and this is a lot of purists will say, well, you don't need to do any stretching at all because if you do strength training through a full range of motion, it does just as well as about stretching. And the studies, when they compare head to head, that actually turns out to be pretty true. So I think I've evolved, right? Again, somebody coming from a corrective exercise background, going into PM&R, sports medicine, recognizing at the age of 15, this is where I was headed.

13:45 For better or for worse, having injuries earlier on, this was part of the program. I've shifted. So now it's when we're looking at, I had mentioned earlier on that I'm pretty time poor and we're thinking about the constraint driven life and how do we implement? Well, yeah, you have to have a lot of hours in the week that we're going to think about stretching. So I almost put no energy into this, almost no significant person. And I would even say, argue that most athletes, unless maybe you're a gymnast and stuff, or like a ballet dancer, your time is probably not better spent. The reality is most people who are doing a lot of stretching are the ones who are really good at stretching and don't need stretching. And the ones who need the stretching don't actually need the stretching. They need more mobility and they need more stability.

14:28 And so there are a couple of schools of thought of how to hone in that mobility. FRC, functional rate conditioning, you're familiar with this. And I think you've implemented this in your life at some point, right? Yeah, it's like cars for the hips and things. That is a subset or component FRC. And so this is where something, actually you'll like this, but actually maybe before I connect that dot for you, this was built by this Canadian chiropractor, I think, Andreo Spina. And it was developed around that gap that we talked about that again, shout out to Max Schenk again, this active passive gap. So the range you can reach versus the range you can control, like where most of the injuries happen. And again, Max had talked about.

15:09 I would love to get Max back again. That was such a great conversation. But CARS controlled articular articulations, controlled articular rotations, slow full circles through one joint, what that might look like. Alison Grimaldi argued that maybe we shouldn't be doing that because you're exposing the whole rim to labial pathology. But again, so context is everything. Other part components of function FRC are these things called pales and rails. So this is progressive and regressive angular isometric loading. So this is hard isometric holes at the end range. So you can expand that end range and you can build strength at that end range. So this would be a level up from cars. Cars, you're going through that range and you're trying to do slowly. Here now you're trying to build strength at that end range.

15:50 And then you want to strengthen in that new range. That's kind of what you're doing now. Here's what I thought was cool. If you look at figure 10 and for people, this might not be important for the listener, but for my osteopathic students, when I look at these, I just think I'm like, oh man, this is muscle energy kind of right. And the different types of muscle energy, and maybe as a professor, I talk about this a lot more. So when you think about PAILs, progressive angular isometric loading, that's post-isometric relaxation, a specific type of muscle energy. Whereas the rail, which would be the secondary thing after PL would come in, that's reciprocal inhibition. So what that would look like for people if they wanted to implement that. So let's just think about we're doing hamstring. Let's say you take your hamstring to N-range of motion. You put it on a table.

16:30 You raise it really high. And you're like, man, okay, I'm N-range. Now at N-range, after sitting there for a couple of minutes, about two minutes or so, now you would... put a little bit of force and so you'd contract that hamstring. So you would push the heel into the table. That would be pale, progressive angular isometric loading. After doing that, then you would flex your hip flexor. You would try to lift up your heel off the table. So that's your... you are activating the opposite muscles and you're really building a lot of that control. So I think that's a fantastic technique, but I love the fact that you had this connection with osteopathy and whatnot. A lot of these concepts actually is really fascinating who you talk to. PNF stretching, like I talked about, I remember going to my professor, you'll find this funny, going to my professor as a first year, because as a CSCS, this was a testable concept during the NSC exam.

17:19 I was like, hey, look, this is PNF. Yeah, osteopathic doctors made this thing and then everybody else still is, you know, I'm sure. Depends on who you talk to, right? It's just like Max Schenck said that he developed yoga way back in the day. Anything on that? Because were you doing cars at some point as part of your thing? I was for hips a little bit. Just kind of loosen up. I had really tight hip flexors and things. And I think I was following Beth Lewis a little bit and just bearing it up a little bit of just getting more mobile. So I do a lot of Kelly Starrett's coaching app that he has on the phone. Also again. Yeah, shout out to Kelly. Yeah. Yeah. A lot of desensitization, which I find super, like that is the number one thing I find super helpful, that desensitization and just loosening up myofascial release.

18:00 Oh, you're talking about like foam rolling and that kind of stuff. Foam rolling. And then there will be a lot of muscle energy that he does, especially in his app. He does a lot of muscle energy. Well, how? Tell me how. Just exactly what you're talking about. Oh. Contract, relax, pushing it out. Yeah. Yeah. Yeah. Part of your stretching. Yeah. And you do this in the evening before you go to bed. Before workouts, typically. Before, yeah, just for that desensation. I find that I get more made of motion, but I'll try to do whatever. I just need to do it once a day. Yeah. That's great. Which brings us, so that's an amazing segue into our next topic there. So there was this idea for a long time that short static stretching or static stretching before training is a bad use. So you're shaking your head, you know this. It's going to actually rob you away from your power and your speed.

18:40 And you don't want to do that. Poo, no dynamic workout, dynamic workout. In fact, I, when I started football as a freshman, we were doing a lot of stretching in a warmup. A new trainer came. Sophomore year, we switched a full dynamic workout. My senior year, we were back to stretching again. And it's like pendulum, right? And what it turns out is actually, the literature shows, yes, it does affect it, but it's, if you keep those static stretching to 60 seconds or less, it's nearly negligible, especially if you follow it up with some type of dynamic warmups. So what that might look like, you want to stretch your hamstring because it makes you feel better, by all means, go do it. Especially if it's what you're describing is it's going to have a neuromodulation effect where it's going to reduce tone, you're going to feel better. Great. If you do a couple of sprints afterwards or some high knees and maybe some box jumps, it's not going to matter.

19:24 Not unless you're like, again, Usain Bolt, you're on blink, maybe it matters, but for me and you, probably. What do you think about that? Tell me if this is true. I heard you don't static stretch before because it changes the neural input essentially into the muscles. Yeah. if you're doing do strength training, you don't static stretch because you actually have decreased strength because I guess, again, quote unquote, lacing the muscles and then the neural input is going to... Yeah, that's exactly what I'm talking about right here. So both power and strength, that was the idea. Now, if you're going to sit there and you're going to hold your stretch for three, four minutes, let's say you're going to a squatting session, you're going to stretch your quads for two minutes, each quad, two minutes, each hamstring, and then you're going to go right into squatting in your warmup, you're going to have a problem.

20:09 You've robbed yourself. However, if you stretch each hamstring for 30 seconds, stretch each quad for 30 seconds, and then you do a couple of cars for your hips. Let's say you do a couple of bodyweight squats, a couple of walking lunges. Maybe you do some clamshells and some glute bridges as part of your warmup. Then you'd get into a couple of jumping jacks. And then you're going to do a couple of your warmups. You're perfectly fine. You know what I mean? And that's exactly the concept that I was talking about. At this point, it's like, okay, if it feels good, let's do it, right? Because mentally getting people ready as well is an important thing. And if you're dealing with injuries, just like you had talked about, is somebody who is apprehensive, you're going to have a shitty squat performance.

20:49 So if you can tone down the nervous system a little bit, it's fine, which is why. So I think we have listened to Andy Galpin a lot. I'm a big fan of him, but sometimes he'll talk about deregulation at the end of a workout. I just want you to sit there and breathe. You're a go-go. You gotta turn down so you can show up. Well, in the right person, we might do that before the workout. Why would you wanna induce a parasympathetic state before? Because If you're too turned on, like you can't do a good job. So I guess maybe if I had to use a car analogy, it's like if I'm going, if I'm in a Ferrari and I'm racing and I'm going 250 miles an hour or maybe F1, I didn't watch that thing, but someday I will.

21:31 If I'm F1, I'm going too fast around the bend, I'm not going to be able to control that car. So I think that matters too, is you have to bring it and have to understand the athletes. For most people listening, this is not going to matter. But since you asked the question, I think. Yeah, absolutely. So anything else you want to add there about mobility? Anything worth mentioning or elucidating for the patient or the listener, I suppose? Not much else. I mean, I think, again, I think it could be a great pain relief technique. This is what I talk to my patients about a lot of times is doing mobility and even getting a little noodle because oftentimes they're in bed and I'm like, just roll out your quads, go sideways, go back and forth, different input in there. We talk about this a lot when patients get a getup.

22:12 We talk about amputation. desensitizing because those nerves are running through and they're fired up and they're trying to everything's mapped to your brain and so it's how do you change the input how do you change that signal from the muscle to the brain so that you feel more comfortable in those end ranges of motion in those different movements that you want to perform in yeah Yeah, the warmup part is really interesting. I'm really passionate about this. And I think I've talked to multiple people on social media. They say, oh, you don't need to do a corrective exercise and stuff. And I don't want to get too much into that. It's whatever seems to work for you. Yes, if you make it a 30-minute warmup, that could be problematic. I have done that in the past. But you also don't do any type of stuff in the workout to do this activation. That's probably also not good. And this is where you have to figure out what works for you.

22:54 And somewhere in the middle is the answer. So I think I have this framework that I like. I call this like R3P or it's like a rep system. So we try to reduce is R1, which is going to be some type of soft tissue myofascial stuff. Then we are going to restore some range of motion. And that could look different things. So do you ever use the voodoo floss bands that Kelly Starra talks about? Yeah, I do here and there. If I'm really sore. Do you want to tell people what that is? Yeah, it's like a really tight resistance band, almost like a grippy thing. And you pretty much wrap it around your muscles at a certain tension. You hold it on there. It almost feels like blood flow restriction, but it's just really tight, compressing the muscles and it creates a little bit of friction onto the skin and fascia as you do like a squat, for example, and it's really tight around your quads.

23:41 Yeah, and it could be really any joint, right? You said love to do up your knees and shoulders. And the idea is that it's almost a form of occlusive training. So as soon as you take it off, you're going to have a bunch of blood flow in there. And so that's going to help you restore range of motion. I've talked about countless times the importance of blood flow. And then for me, number three is recruit. So now it's activating muscles. So if you're going to go into a bench press session, then maybe you want to really quote unquote wake up our cuff, right? And people will do some silly things in the gym, but maybe we'll do it some isometrics and ERI or let's get that infraspin is firing a little bit better. Let's wake that subscap up because it's an anterior stabilizer of the glenohumeral joint. Let's wake up the periscapular muscles. So that might be recruit. reduce, restore, recruit, and then PS prime.

24:23 And this is where I'm coming in with my power stuff. So if I'm going into a heavy bench press set, we might do some chest press, like with a med ball, or we might do some explosive plyometric pushups or something. So that's what has worked for me. And again, biases, I'm seeing somebody who has some, I'm not seeing patients who don't have, or I'm not seeing even athletes who don't have some ache and pain, right? You're in the game, you've got something. So I think that's where the myofascial stuff works really well. On that note, we'll maybe just talk a little bit about stability and we will close this series. So I think that we've done its diligence here. I think it's worth mentioning that because this is another tested debated topic on social media. I want to give shout out to Dan Pope a lot.

25:03 He has a really great series about and I think some social media content on this in terms of looking at core stability and that does it help? Does it not help for back pain and what the trials show? And I think when people look at specific core stability target exercises, it beats general exercise for back pain in the short term. But at longer term stuff, 6 to 12 months, there's really no significant effect. So what I mean by that is, okay, you're doing bird dogs, which would be a low load motor control activity. Core stability exercise. So Stu McGill is a Canadian person. A lot of people reference him. Actually does phenomenal work. my first flare in 2018 that was somewhat debilitating. Game changer, back mechanic, good book, really patient friendly book, so highly recommend that one.

25:45 If you're a clinician, there are more advanced stuff that he puts out there. But yeah, so his stability program, the big three, the McGill big three, versus if you're looking at actual deadlifts and actual hip thrust and that kind of stuff, right? Long-term outcomes, really, there's not much of a difference. And so some people take that to look at, oh, you're wasting time. In fact, there's a... person who's been on here and just like pooh poohs these things all the time and so again i come back to context is everything with the device so you and i've talked about this a billion times over on this so you have to take that your consideration and what your body likes whether you apply it at the end of the day I've said this multiple times, the exercise that you'll keep doing is worth more than the perfect core program. So if you like the core stuff and it's going to keep you in the gym and it makes you feel better and you're going to show up, great, do that.

26:28 If you hate it, great, don't do it. That's what the takeaway for me is. Anything from you on that? I did 2010. I heard you made it on my disc. L5, I got epidural injections. It did anything for me. Therapy was, yeah, like you said, the big three, doing core work, also did nothing for me. What I did was strength training, getting back, doing deadlifts, and I was told never deadlift again. That was a common thing back then, whenever you already did it. But it was about being safer with it and actually building stabilized muscles. The load wasn't on my back. And that's what really saved me. And so I changed my tune as I was going through schooling and all that. Presumably you waited until it calmed down before you got back into like a ridiculitis or here and there.

27:10 I mean, I had sciatica like throughout it, but I just, nothing would help. And again, with my personality, it was kind of like, I'm just going to figure it out. Like I'm going to have to go through it. I'm going to figure it out and whatever it might be. But you started, you were 18 years old. So you're basically bulletproof at this point. Zero inhibition. So I'm just going after it. Yeah, no, it was funny that once I, because I always told myself, okay, I'm not going to deadlift more than 135. Not going to deadlift more than 155. Not going to deadlift more than 155. And I would just keep going. And now I'm like, wait, I could just keep going. And like you talk about parasympathetic, stop being so anxious, stop worrying about injuring myself when I'm not actually injured, when I'm not feeling anything. I'm like, wait, I'm feeling great. Let me just do this. And that's when I was like, wow, my back pain, Berkeley, it's still there, but it's nowhere near what it used to be.

27:57 You're about to open up a can of worms that I don't want to touch right now, but I do want to get an injury psychologist on that I've been trying to get him on the podcast because I think what you're talking about is constant of kinesiophobia and, you know, just fear of movement. And especially it's really common after injury and even more so after chronic injury because your nervous system gets rewired. And maybe we'll get Jeremy to come back if he has some time. But yeah, just to wrap up the core stability work, I... I wanted to ask, because I don't know if we've talked about DNS ever, because I was looking at the other different philosophies. P.R.I. Institute is a big one that's influenced me as a through Eric Cressy, because I've looked a lot of his work and Mike Weld, but DNS is something that people I've talked about.

28:37 Is that something that dynamic neuromuscular stabilization from Powell, Kolar's group in Prague, is that something you looked at? When you were following Beth Lewis? Because she talked about that. A lot. Kelly Surin, she talks about a lot in his program as well. So I know of it, but he incorporates a little bit of it. Yeah. So for those who don't know, this is something that's... Training stability through breathing and pressure in developmental positions. So it fits that point that stability isn't just bracing, you're putting yourself in compromised position. But the evidence is really underwhelming on this. So I didn't go too deep into it, especially for back pain. There's no stabilization approach that beats the program that you talked about in your personal approach. And I think that's so you have to figure out ultimately find a clinician or practitioner that you can connect with.

29:18 I would say is hopefully agnostic to the approach because I think what I've learned over time personally and putting it in practice is like there are a lot of paths to roam and they all get you there. So you kind of have to figure it out. With respect to testing, and then we'll wrap this up. I think that this one was really big on social media. I'm sure you saw this on TikTok is the sit to rise test. You stand and you go down all the way down and you stand back up. And I think a lot of people went down and they were sitting cross-legged. And if you're touching the floor with either your knees or your hands, you lose a point. Actually, it comes from a study. So this group in Brazil, they tested about, was this the one? Yeah, so this is a figure that I have here. 13 or 13, right? So the sit to floor rise.

30:00 And basically, you're starting off with 10 points. So you sit down on the floor and you get back up using the little support you can. So if you're touching your hands or your elbows or your feet or the side of your leg, you're losing a point. I did this earlier today, actually got an eight because going down, I lunge down and touch my knee and coming up and lunged down because I can't sit across like it because I can jack up hips. I'm old man hips. The good news is the way that they characterized the folks in, I think is eight to 10 was that the top performing group. And what they had showed is that every group down that you went, there was a, or there was a 21% higher death rate by every time you went down. Now, it's like a slope and it's relative risk.

30:41 So I don't want people to freak out that if you have a seven, like that doesn't mean that, you know, you're 21% like to die for somebody if you have an eight. Like, that's not what I'm saying. So this is another one of the things, the false proxy, right? People start training this. It's like, oh, was that all my chances of dying is went down. No, that's not what it's saying. And I just clearly show you the confounding factors of this is not assessing. They did control for. age sex and i think bmi as well but you're not accounting for things like what i just mentioned right somebody has hip arthritis or fai or something and they can't get into that position or just has maybe acetabular retroversion then that's or antiversion that's going to be really difficult i'd be curious to see what you do can you sit cross-legged yeah can you go down the floor without touching the floor should be able to do that i think so we'll try it i'll do it i'll do it now yeah do it i want to see it let's see i can do it So no elbows, no elbows, no...

31:33 I just did another one. I know I can't hear myself, but TikTok. My therapist made me do this. You do a plank. You put the cardboard on your foot and you have to bring it in front of you while you're doing the plank and then go all the way around like a 360. Like this? Plank like that? This? No, you can do whatever you want. He's doing it live, folks. Oh, yeah, that's good. There's a little momentum there. Those are watching on YouTube. Yeah. Darsh is getting his headphones back on. It's just right or left now. Now it's going to take like 30 minutes to put these on. Yeah, you did it. 10 out of 10. All right. Yeah, that's fantastic.

32:13 Yeah, so that's... Hey, you're going to make it, man. 100%. 100%. But it goes broken out. But the other test is the single leg stance. This was actually quite shocking. They... Another study, I think, out of the same lab, actually... where they looked at people, can you stand on one leg for 10 seconds without support? Can you take your other foot and you put it on the back of your calf? So our Rujo's group in Brazil looked at about 1700 adults. Again, older folks, 51 to 75. And about one in five people, 20% could not do this. 10 seconds, bro, 10 seconds. And so even after adjusting for age, sex, body mass index, other conditions, those who could not do this, do this, do that, died at 84% higher rate after about seven years.

32:56 That's scary. Again, these numbers, it's relative. So it just, it makes it sound much worse. But 10 seconds, that's a low bar, bro. That's a low bar. I would say this, this is something I sold for Max a long time ago and is one of his programs. Brushing your teeth, right? You got that two minute timer. If you got the thing, stand on one leg, one minute, brush your teeth, switch it up one minute. And over time, you could take it next, next level. I've started having my daughter do this now sometimes and she finally finds it fun. So you do the one leg. Then over time, you could switch it up. You could close the eyes if you're starting to crushing it. So now you're removing that input. And then, so you're challenging your balance, your strength, your vestibular system. You're removing the vision input and seeing how that plays a role into it. Can you train that?

33:37 You want to take it to the next level. You want to start doing some skill development as well. Start brushing your teeth with your left hand. So now you're challenging different parts of the brain. And I think things like this are important because when we go back to the, I think this was the VGSN paper that we talked about, Darsh, where they looked at tennis being the sport that influences longevity more than any other sport. And why is that the case? and I won't spend too much time on this, is because it's challenging so many different parts of your fitness, not only the actual physical fitness component, but also the neuromuscular control, the skill, the hand-eye coordination, all these things actually pay dividends down the road. And so that's what we're doing here, right? So if you can start introducing exercise or just these qualities that we're trying to develop for fitness into your every single day, Like the opportunities are endless, actually.

34:23 You could do this when you're cooking. Maybe you don't do it with a knife in your hand or you're cutting stuff, but because we don't want somebody falling and stabbing themselves. But yeah, you can play around with it. And I think that's something that is easy for people to do. And I encourage people to do that. What will you do to do? Bursher teeth tonight on your left leg? I started doing this while doing notes. I'm a standing desk at work. So whenever I'm prepping, I'll do one leg at a time. Yeah, you can't put too much weight in your hands, though, when you're typing, though. Well, I'll dictate. There you go. Opposite hand dictate. Super easy. Yeah. And then overtime close your eyes. That's awesome. Five episodes. One idea, man. Four qualities, right? So strength, power, aerobic fitness, not just VO2 max, mobility, stability.

35:04 questions you want to ask yourself, just to recap what we talked about is, what do I want to improve? Start with the goal in mind. What can I actually repeat? Remember, build around the program that you're going to fall back to first, and then you can scale up. And you got to ask yourself, how am I going to know it's working? So you have a very specific event that you're training for. But as we had mentioned earlier, it's like, how are we going to recheck yourself at 12 weeks, 14 weeks, 18 weeks, whatever, within the gym, within the external load. But you can also, we haven't even touched on things like body fat percentage and that kind of stuff. Like we've talked about that elsewhere. And I got to say this is, again, constraints first. Decide what physical constraints you have.

35:44 Orthopedic stuff, people do a good job thinking about that. Decide time constraints life-wise, right? Like we are in this different era in our life right now. So maybe a lot of time training is taking a backseat. Allostatic load, something we had talked about a couple of episodes ago, really pay attention to things outside that are not in your control and how that's going to influence your performance and how much workload you take on. There's this concept of acute to chronic workload ratio that I wanted to talk about, but I thought I might get a little too much into the weeds today. And clearly I've failed my 35 minute mark here, but you got to think of it like medication, right? Minimum effective dose, maximum tolerated dose, and what's your ideal therapeutic dose for each of these domains? And then how do they all come in together?

36:25 That's it, man. That's all I got. Anything to add to that to close it? No, I like it, man. I think the biggest takeaway for me and for the listeners is obviously I think what our average listeners probably anywhere from 25 to 40. People may be like, I want to say brush this off, but haven't really thought about it. But what happens in 30 years? What kind of life do you want to live when you're 65, 70? What do you envision yourself doing? A lot of people like to travel at that age, right? They retire and they think about... go to Switzerland and hiking or whatever it might be. But are you going to be able to do those things? Are you actually going to be able to travel? Are you able to be around your loved ones, play with the people you want, be able to play the sport that you want whenever you age? So I think keep those things in mind and start training now. Having a higher ceiling now or a higher floor now will help you as those days come.

37:11 Yeah, I just want to echo that as well because I think I see this every single day. deal with more patients with chronic pain in the aging population. And we're going to continue to. We're really good at lifespan extension. GLP-1 is great for hard stuff like that. You and I have both talked about how they're going to cause muscle loss. Despite the myostatin inhibitors are going to be weak and we're going to create more problems. What that means is over time, people are going to start losing agency more and more. It's so hard as I'm taking care of somebody who is in their 50s and they just, I wish I could do this and I can't do this and I can't do this. And slowly, life starts taking things away from you, right? That curve of the last 10 or 15 years of most people's life is miserable.

37:53 They're in that nursing home. They have somebody doing stuff for them. Forget about ADLs, but the things that really bring them joy is traveling or seeing the world of playing with the grandkids and they can't. And yeah, this talk today was probably the boring stuff, but it's again, I mean, all of these are important and where you are in your training journey, it's going to be different things are going to be important for different people. But yeah, I think it's all about agency. I see this on every single day where patients are just frustrated. Now I can't do this. Now I can't do this. Now I can't do this. And I actually heard, I want to say this. Oh my God. So I was listening to the founders and I listened to David Sunder talk about Ed Thorpe. Ed Thorpe, amazing. I'm going to read his book.

38:34 But he made a point how invested he was in his physical fitness and his health. And he kept saying over and over, apparently in the book, every hour I spend exercising is one day less in the hospital. I love that. I love that. And that's how, that was his philosophy from a young age. This guy's one of the smartest, most brilliant people ever. Like really cool actually. Do you know about this guy, Ed Thorpe? I think I've heard Senator mentioned him on other podcasts. Yeah, you got, yeah, just check that out. You don't have to read the book. But yeah, it's really interesting like this, like he's made his money gambling and beating blackjack and that kind of stuff. Nice. Really cool stories. All right, we'll leave it there and we'll see you guys next time.

39:14 Sounds good. Let's follow. Thanks for listening to another episode of Medicine Redefined. If you enjoyed it, please subscribe, leave a review, and share with anyone who'd get value from it. To stay up to date on more content like this, follow us on Instagram, X, and TikTok at MedWeDefined. And if you prefer high yield, bite-sized information delivered to your inbox twice a month, subscribe to our newsletter. The link is in the show notes. Now, time for the ever so important disclaimer. This podcast is intended for general public use and is for educational purposes only. It does not constitute the practice of medicine, nor should it be construed as medical advice. No physician-patient relationship is formed and anything discussed on this podcast does not represent the views of our employers.

39:59 We recommend that you seek the guidance of your personal physician regarding any specific health-related issues.