Table of Contents
Take your golf, fitness, and rehab knowledge to the next level
It can be easy to get lost in the noise with all of the potential treatments, exercises, models, and more, when it comes to anything in the rehab and performance field.
Is there a way to put everything together? To use a wide variety of methods and be targeted with execution.
That, folks, is what few people do to the level of Dr. Mike Kay, and I’m juiced up to have done a podcast with him.
In this podcast, you’ll learn:
- How Mike went from accumulating rehab tools to developing rehab principles t
- How and why vibration plates, tiger tails, and needling can create CRAZY movement changes
- How to make better decisions clinically and when to look at sensory systems
- Why static postural assessment isn’t so bad after all
- How infrasternal angle archetypes can impact the golf swing
- The best ways to train for better golf and baseball performance WITH MINIMAL COACHING
- What the big keys are for basketball performance
- How to get the most out of home exercise programs
- Building a cash pay physical therapy practice
- How to balance entrepreneurship with family
Look below to watch the interview, listen to the podcast, get the show notes, and read the modified transcripts.
and the audio version:
Learn more about Mike
Movement, in general, has always fascinated Dr. Mike Kay. Following this passion, Mike received his Doctorate in Physical Therapy from Chapman University in Orange, Ca. After graduation, Mike has worked in pediatrics to high levels of sports performance. Mike also has experience working in a cash pay environment and has spent time developing performance models for a private equity company.
Today Mike works in Scottsdale, AZ running his own company, Kay Performance Physio. He continues to work on implementing specific exercises and manual therapy to help alter complex dynamic movements. He also consults with many high-performance teams to get the best outcomes for their clientele.
Here are links to things mentioned in the interview:
Dr. Mark Heisig – The ND that Mike works with.
Bill Hartman – Daddy-O Pops himself. My mentor.
Elevate Sports Performance and Healthcare – Where ya boi works
Myotape – I use this to help reduce mouth breathing
Mute Nasal Dilators – These are great for increasing your ability to nasal breathe.
Does the Mute Nasal Dilator Help With Sleep? – My review of the mute nasal dilator.
The evolution of Mike’s practice
Mike Kay: I got out of school and start practicing. Working on a regular sort of ortho place and just you look around and it was like, “Alright, I am going grab every tool that I can, obviously I am going to dry needle, I want to learn how to manipulate all these sorts of things,”
Suddenly, you have all these tools, but you do not really know when to use any of them. As you grow, you try and figure out how do these certain things work? Then you find different coursework, you find your blogs, right, your blog was a big part of my sort of journey into a more nuanced world
Zac Cupples: I think we have all gone through like the tool accumulation phase, because, well, this person needs a Phillips screwdriver instead of a flathead. What was that transition like to go from, “I have all of these things to now, I have this comprehensive model?”
Mike: Just realizing that I did not know why I was using any certain tool. You just following along with whatever coursework you took. But then you look at it and realize there aren’t any principles behind any of this stuff.
That’s all I strive for now, developing first principles. If you have those, then the tools don’t matter. Because nothing works every time but understanding why a given tool may work has become powerful.
Zac: So, over the period that you have done some learning on your own and just applying some of the stuff to your supreme clientele, what would you say your big principles are? What are the first principles of Dr. Mike Kay?
Mike: Much of it comes back to physics. It’s a bit of a buzzword, but physics applies to all systems.
Having a wide interest in reading has led me to picking up patterns and seeing what works in different fields. But there are certain things that that are going to be universal constants in multiple fields. Many fields have common physics principles like how things expand, how things compress. It has to apply to human systems. Also, non-Newtonian fluids, viscoelasticity.
Utilizing vibration plates to enhance movement
Zac: You’ve taken these principles and applied to many interventions I wouldn’t have thought of ever using again. Tiger tail, really? But then when you explained it, it made a whole lot of sense or the vibration plate and things of that nature.
There are three things I’d like to hear how you apply them:
- Tiger tail
- Dry needling
Let’s start with vibration.
Mike: Energy has got to propagate via wave. It does not matter if it is sound, whatever, it does not matter what we are talking about.
A vibration plate just a very cool way to just propagate energy. So, it just depends on what you are trying to elicit. So, from a compressive and expansive model, there are certain waves that are going to be more expansive, there are certain waves that are going to be more compressive. Lower hertz are more expansive (creating more space), whereas higher hertz are more compressive (reducing space).
From there, you visually look at where the wave propagation stops on a person when they are on the plate, choose an intervention to influence that area, then retest. It seems to get better afterwards.
Zac: So, when you see a decrease in the wave propagating into specific areas, so what does that visually look like? So obviously, you see kind of just like some, some rippling of sorts of the skin and the tissues, but then when you go to an area that perhaps is restricted at a specific hertz range or you just seeing a lack of movement there, or is it the wave, the duration or the amplitude of the wave reduced?
Mike: Yeah, it just changes. You see the wave not move specifically in an area. The wave dies in the area that a person can’t create a specific wave. They can’t expand in a given area.
You can intervene in multiple different ways. You can use the vibration plate to see if you can then put someone in a position to drive the wave into that area, but it is not much different than other treatments.
Say a wave dies at the inferior angle of the scapula, you could also use a landmine press. But you could also put their hand on the vibration plate, and then a quadruped position, and depending on what I am trying to get after, and get the wave there, it is the same, it is an exercise. It is just a principle to drive energy to a certain area that might not be getting the propagation of the wave.
Zac: Have you seen the reduced propagation in specific areas also correspond with table testing?
Mike: Yeah, for sure. If you have someone who is really extended and the pelvis is anteriorly oriented, and the wave dies at the waistband. They often have an external rotation limitation in that area. Am I leading myself a bit? Yes. I want to.
Zac: We inevitably must operate under some type of bias. Everyone has bias. And if you do not have a bias, you are not going to be able to make decisions.
Mike: Yeah, and I think it comes back to intent. How specific can you be?
I will look at video of someone I looked at six months ago and then I look at him with these eyes that are six months later, I am like, “Man! How did I miss that? That is glaring.” But six months ago, I never would have seen it, and even if someone pointed out to be, like, “Nah” I do not get it. But it is time and the study and understanding and looking at and seeing that many more people, having that many more interventions, you are looking at there, now you are like, “Oh, I tie this together.”
fI am sure you would have it all the time where you are like, “Oh, that client I had four years ago,” like, “I cannot believe I missed that one.”
Zac: I have to send an apology letter to my patients from the previous year.
Mike: Yeah. It will be a lot of letters.
Using a tiger tail to enhance mobility
Mike: If you asked me about foam rolling or Tiger Tail a few years ago, I’d say “Yeah, if it feels good, do it, I do not really care,” It is not like I was never like an anti-foam roller.
Either way, you just need to understand what you are trying to change. For example, someone who has an externally rotated proximal tibia, you can do all your joint mobs and hands-on stuff and that works great but lying a tiger tail on the tibia and trying to turn it into internal rotation also works. You can get way more leverage.
My theoretical intent is to produce force on the level of the bone, as the bone can imbibe fluid and has relative motion Perhaps that externally rotated bone now has lost relative motion at that proximal tibia. So now you are increasing its ability to imbibe a little fluid, and now that proximal tibia has some relative motion, and you have also chilled some of the muscle around the area. Then I back up that motion with exercise
Zac: So, when do you elect to utilize something like that versus just a classic manual technique versus exercise?
Mike: There is nice carry over at home because the client or patient can use the tiger tail themselves, and it’s easy to understand. It may give enough loading to elicit a more lasting change. Maybe we only need to change something, you know, a millimeter, a percentage point. Whether whatever is happening, I do not pretend to know, but you get enough people coming back with feedback and saying “yeah, you know, my end-range knee flexion, it feels a lot better,” and then you look at before and after pictures of something, again, with leading eyes: “Oh, it is way better now!” Maybe it is, maybe it isn’t, but the outcome is there.
Zac: You can throw peanut butter on someone, but if it makes them feel better and they get better motion, it is totally fine.
I like the idea of using the tiger tail because I sometimes struggle with a person needing a particular intervention, say creating that proximal tibial internal rotation, but they do not have the motor competency to get that with a particular move. There are so many other steps they need before that. The tiger tail seems like a way you could almost get that person to skip a step to get the relative motion change that you are desiring when they might not have the motor competency to get there themselves.
Mike: At least get them in the neighborhood, and in an easier way to implement.
Should you start distally or proximally with treatment?
Mike: If I want to get a quick buy-in for someone and you know that they just do not have near end-range knee flexion with that twist or it is painful there, I might just talk to them and just lay on their tibia for 5 to 10 minutes and then see if it changes symptom-wise, then go proximal. I want to get a change as quickly as possible. Sometimes going proximal doesn’t get the immediate symptom change, then you must work hard to get their attention back.
That said, either way can work. There isn’t a great answer on where to start. I think it’s a little bit of the person’s personality with their measures as well.
Zac: It is hard, especially when you are in cash pay practice. You want to make as big of an impact as possible, as quickly as possible, so you can get buy in, so they know they are in the right place, and it can be hard when you know what they need, but maybe that does not always lead to an immediate result, and so sometimes going distal or local can be helpful.
Mike: Yeah, and again, like if you create a large enough effect locally, you can get proximal changes rapidly, so there are plenty of times where you can, if you create a large enough influence at that knee, you could change someone’s respiratory mechanics. So, there is no right answer.
Zac: It seems like generally those proximal changes happen when you are doing more, I see it more in the lowers in comparison to the uppers.
I do not know about you but changing foot orientation or dynamics leads to a lot more change proximally, but I do not always see that in the hands or the elbow, and I do not know why that is, I do not know if it is just kind of like a gravity-based thing or what. What’s your experience?
Mike: Because we walk on our feet, wave propagation system distal to proximal is going to be more selected. From an evolutionary perspective.
Zac: Absolutely! Well, just affecting your weight bearing through those areas, it should have how much more substantial effect in comparison to things you would do upstairs.
Mike: Yeah, have him crawl, put them on, give him a heel wedge for his hand.
Zac: I have done that or give him an arch support and put a towel underneath their hand.
A novel way to use dry needling
Mike: If I think a tissue is concentric, I am just going to drop a needle in an area and try to get some expansion. If I think tissue is eccentric and they cannot create the contraction that I want, then you throw a little bit of electricity into it. So, it is basically as simple as that. It demystifies the whole process, because needling can be very mystical.
Mike: I mean, it is, and you get a lot of emotional change to it, and there is people who get a big emotional releases from needling because it is, I mean, obviously, you are penetrating skin, you got a big deal, like you have to be serious about it too, but for me, it is like I am trying to make it as simple as possible, just so we can apply it across multiple people, multiple concepts of different types.
For example, let us go back to the knee. If I have a VMO that is eccentric, maybe I will put a needle in it and give it a little electricity and then try to reorient the femur over top of it, so now the person has a better starting line.
Suppose you have a right-handed golfer who cannot turn into his left side, and he has got a posterior left compression smashed forward. You might think outside of the box and maybe look at his foot. Perhaps he can’t make his right foot hit mid-propulsion. Looking at his back you may see a smashed left scapula, his left thorax is smashed. You know what, let us try putting a couple needles in his medial gastroc. See if we can get that to chill out, and then see if we can get a better push there, and now maybe we have some more space in the left side. You can look at this very broadly.
Cupping has also been useful!
Zac: I have been messing with some cupping a bit with some of my supreme clientele. It is actually a great way to induce expansion.
Mike: It’s great. That is awesome.
Zac: Such a local expansion thing.
Mike: Yeah, there are so many cool things you can do with cupping, and I used to blast people with cups, but now you have a much more targeted cupping approach and I manage to try, you know, again like a left scapular area, along their helical angle, along their fiber angle and then you know, on the left side and maybe throw a couple on the right back side of the pelvis, like you can get some expansion and all of a sudden, the guy can turn left, It’s possible.
Zac: And save your hands, Good lord! I have been getting killed lately, because I get so many people who have the super squished scapula up against the rib cage and trying to rip that open, but you can change someone’s life if you could get it to come off, but there are some people where it is just like, you cannot do that, but I could totally see something like cupping.
Mike: Yeah, lift it up, and just do some move motion cupping there, and you know, it softens things up, and then you have a chance to maybe get your hands underneath there too. Put them in sideline and do it.
Zac: That is not a bad idea at all. You might have inspired me to do some more cupping. You know, and that is one thing I like about you. A lot of people poopoo different interventions, but if you have a good thought process behind it, you can justify a lot and have a good reason to do things and you probably will get better outcomes and then just doing like a blunt instrument approach of I am going to cup everyone, and we will see what happens.
Mike: Anything I pick up I try to demystify it. It does not make you necessarily super popular with certain tribes, but I think it is helpful to broaden who you can help. If people don’t know what your background is, that’s a good sign.
Visual and vestibular influences on movement
Zac: When do you consider more cranial-based interventions?
Mike: I tend to go there if I have to. If nothing is sticking despite compliance, or if there was a previous concussion history. Other red flags. I refer to the naturopath I work with, Dr. Mark when I suspect that. He has some very cool interventions. He’ll see some parallels to me. “Oh, he has a hard time creating an expansion in his left field,” and I could not get left external rotation back on this guy, that kind of stuff, so you will see some of these tie-ins, which is super cool,
I have had people where you are working on them, and you are just not getting things back and you realize like let us take this person outside and give them more expansive field and suddenly, the range of motion stuff comes back to, so like it is, yeah. I mean, there is so many inputs in the system. But I typically will go there if I am not getting the changes that I am looking for.
Zac: What indicators do you have for vestibular referral? VOR?
Mike: Yeah, and again, not my area of specialty, but you might see certain beating nystagmus. So, you look for different nystagmus like overshooting of visual tracking, and then from our perspective, it is like, you know, this person has created an orientation of like, this world exists over here, but this world over here does not exist to him. So, you are going to lose certain range of motions, because they will not get certain range of motions back, but these things will correspond with certain types of nystagmus, the ability we talked about earlier, the ability to converge, the ability to diverge, right, all this sort of stuff, the ability to expand, the ability to compress.
Dr. Mark has a nice assessment, where you can keep doing all these sorts of things and just looking at it enough, like if you have me watch someone’s eyes, I would be like, “I do not know if that is a nystagmus. Which way is that? I do not know.” Yeah, like your eye did something funny there, I do not get it, but he has got an eye for it. Just like if you have me watch a golf swing, or someone throw a baseball pitch, I pick up on stuff.
The utility of static postures
Mike: I have looked at a lot of static posture, something I would have poo-pooed five years ago.
Zac: What made you shift do you think?
Mike: I think thinking for more of an expansion and compression model, again, it is a snapshot in time, a part of the story. It can also give good before and afters.
Zac: I think a lot of people think that this is going to be forever, and I am stuck like this, and if you can show them that they can change something very quickly, that should give them credence that that is not true, and they do have adaptability as a human being to be able to change to whatever it is they want, change their current situation.
How do you see that, the statics transferred to some of the dynamic postures that you specialize in? I know you work with a lot of golfers and baseball players. Do you see that it is a good correlation if a certain person presents with, say they got kind of your classic upper crossed syndrome, do you see that manifests a lot in dynamics of maybe say, baseball or golf?
Mike: You look at some of the range of motions of some of these high-level athletes have, and you are like “How the heck does this person do anything?” And they just do, then you put a club or a baseball on their hands, and you are like, “Wow, that is one hell of an output.”
But I think we have to understand this is like looking at a system as being expansion or compressive and creating a shape to get a desired result. So, what we are measuring is not necessarily what they are using.
Our table tests are limited, but then having an understanding what is happening maybe under this table test can be very empowering. Like if this person does not have a certain arc or range of motion, you know they must be using a certain shape to create a certain desired output. Like it is the opportunity maybe for them to create a more healthy pattern, instead of creating, like a right-handed golfer cannot get to his left side. So, for him to get to his left side, he creates this massive right-side bend instead. A lot of people who have made millions of dollars doing this. I am not saying it is bad, but maybe if they could bring that left scapula down a little bit, and to help him create more little left posterior expansion, they could do it easier, and maybe they do not even notice a difference, Which would be the sweet spot, maybe they will not notice the difference, but you are just getting a better distributed load and maybe they are a little bit healthier? Or maybe they are on the verge? We do not know where the line is.
We have no idea, but there are certain things when you measure someone enough and you get to know them, you know, like, okay, I need this person, and he needs to have this strategy to move.
Zac: I find it hard to believe that you have golfers who do not notice things, because if there is one population that notices every little change is definitely golfers.
Mike: Pretty close to.
Zac: Oh, yeah, I can only imagine that as well, because any changes in their body is, it can lead to substantially cool things in the positive or the negative.
Mike: I have definitely made mistakes. I look at someone’s table tests and their posture, and you are like, did a good job on this one and then you get a text two days later, and they are like, I hurt at place where I have never hurt, and my game is terrible, it is worse, and you are like, “oh, what did I do? Or did I do anything?” You have no idea, like, do not really do anything? I do not know, but I’ll debrief, take ownership, and see where the next step is.
Zac: Yeah. So if you have someone who maybe you have gotten a lot of good changes on the table, in the times that it has led to negative things, what do you feel like the disconnect sometimes is like perhaps, you know, I have a golfer right now who was dealing with some shoulder issues, just could not rotate at all, especially like pretty much T4 up was on a lock, but he was plopped out everywhere else, and then we have made some nice changes, but his swing is definitely different. He just got to get used to it.
Mike: There is time to download that new freedom of movement. When you see a dynamic pattern change where I think it is typically positive, and I will tell someone to wait it out is when you see maybe they will swing more on an access path or like a pattern that is going to be more related to their body type. So, like a narrow, you are going to want to see a more vertical shaft with a narrow, A narrow pitcher, you are going to want to see a tighter turn, but you got to think about the pattern they were using before that maybe they had not created the local adaptation at specific area that might be now uncomfortable, because now there are throwing this way. It may overload certain tissues. Especially if you have someone who has a lot of speed and power. So you may have to create local adaptations quickly.
Zac: Well, I think it gives you some educational pieces with them as well. Opening up this range of motion is not bad, but we may need time to prepare your body to use it.
I’m glad you said that, because I just think of a lot of people where we have given them stuff and then they end up hurting worse afterwards. It’s not that you don’t want to take away the strategy that made them great.
Mike: Alright, they think it can still be great.
Zac: Yeah, it is like really, like, we are not that good first off, but I could see now where, well it is just that they might not be prepared to utilize this in a manner that is most effective, because they are still driving 90 miles an hour.
Mike: The speed that they are generating, they are just not prepared for it in this position, because we know it is going to be context specific. They likely need to adapt to a new position.
How different body types can influence range of motion in a golf swing
Mike: It can also be helpful to move away from absolute movement amounts and focus more on ratios. Instead thinking I got to get 60 degrees of hip external rotation (ER), 40 degrees of hip internal rotation, thinking more like I have got a wide infrasteranal angle (ISA), he is never really going to have huge expansion position, but the problem is, if I get too much internal rotation (IR) on them, they may not have much separation. Versus what a narrow infrasternal angle (ISA) is going to need a larger difference in ratio and wider.
Zac: Could you expand upon that a little bit more, Mike? So, when you are talking about ratios, and maybe we can use like, let us say, a golf swing as an example, let us say we got two right-handed golfers and one is a stereotypical narrow and the other is a stereotypical wide, and let us just isolate it to backswing mechanics and maybe we are talking about the various rotations that we need at the hips, Because, you know, they have to keep the foot planted, so they are probably going to be some IR going on, but then as I am turning, I am getting some ER, so what do you mean by that, if I have those two archetypes, talk to me a little bit about the ratio?
Mike: Your narrow is going to be a better turner. It does not mean a wide cannot turn, they do turn, but they are just going to turn in a different way.
If you start losing ER on a narrow, they are going to lose their ability to create that relative turn, and then you are going have problems, because they are going have a harder time superimposing more IR, because they do not have a system that can create that downforce.
If you have a narrow with 65 degrees of hip external rotation, you know, you look at his IR, let us say he has got 10 degrees of hip IR, that is an oriented pelvis, I want more IR on that guy, and maybe we lose a little bit of ER when we do bring him back into better position, but so we are just trying to create, like, maybe a 60:30, especially if the guy is a Ferrari, the guy is like lots of speed, But I want to hold on to that expansive position. So, like, you may have it made up of 2:1 ratio.
They are also going need more time to build pressure. So, they center pivot, they are going turn straight over the ball. They are going turn right over the top of it more.
A wide is really never going maybe have full shoulder flexion just because of where their helical angle is. So, maybe they do not have the full hip ER, maybe they are going to live at like 45 degrees of hip external rotation, and then, but let us say they have got 40 degrees of hip internal rotation, like there is no space there. That is the person that, that is everything moves together, and you get into the different sides and everything we can get a better idea of their shape, but first off thinking is like, you are not going to get any separation in a rotational sport, we are trying to create some semblance of separation, the narrow is going to separate typically really well, and the wide is not going to separate so well. So, the closer those two numbers start running together, to me, I think of like, you have not lost the ability to create a gradient.
Zac: So, would you almost rather in the case of a wide, someone, like more amount in one direction and less amount in another when we are talking about a swing?
Mike: Good question. Yeah, so like wide has got 40 degrees of hip IR, let us say if you have got a bunch of hip IR, and it is the same as their hip ER. So, then I think that with that much IR, so they lost a lot of the ER, so they are going to increase, their IR force on the ground is going to get longer and longer. So, their propulsive phase is going to get longer and longer, which may increase injury risk.
It does not mean they cannot create a ton of force, but their propulsive phase is going to be a lot longer and with an implement-related sport, I want it super tight. I want that thing to blink and gone. So, you know, that brings you into training thought, like how would you train that wide? The worst thing I would want to do is bury him into more internal rotation. So, you know, you are thinking about, like, more load for this guy is a big problem. But you may want to get more yielding out of them. Make them more elastic to create that separation. You might not get a ton, but enough.
Maybe a better exercise for this guy would be sprinting. That gets you a reactive ER. A quick amount of force into the ground. This may narrow up that IR and get more expansive ER really quickly. Because if you lay him into the ground as he swings to the ball, he is going to compress, because he does not have the ER, so he is going to compress to try to create the shape to hit the ball. So, you are going to get a lot of the right-side bends, you are going to get their pelvis orientations, you are going get all these sorts of things, because we know he does not have it at the hip. He is going create this adaptation somewhere else.
There are plenty of guys who are wider guys who have nagging injuries all the time and the result for them is like, I just need to get stronger, but it is like you are just driving more IR, they do not need more IR.
Zac: How do you educate people on that is not the necessarily the need, especially, like we have some golfers right now, they work with us, but then also they got to do their back squat to gain some weight, so they can hit harder?
Mike: They get that they are swinging a very light implement, And in order for them to generate power into the club head, there has to be a quick stop. If you explain it to them, I think, they seem to get it. But it is hard for some of those guys to let go of a back squat and there is nothing wrong necessarily with the back squat in certain cases, certain times, but you know, maybe you give them another alternative. Something like a safety bar or elevating the heels. You do not want to rip their binky away.
Zac: And most of the elite golfers are not. They are not these specimens of athletes.
Mike: No. They turn well, they turn well in space. A lot of them are really good at darts, really good at billiards.
There are great athletes in golf, do not get me wrong, for sure, but the precision of the sport likely self-selects a population that is probably not the fleetest of foot, but it does not mean they cannot be hell of a turners.
Zac: Alot of them move well in a variety of positions. I would argue with some of these rotational sports, it is really the pinnacle of putting a lot of things together from a movement perspective in comparison to others, I mean, just the coordination, the ability to put all of the joints in your bodies in particular positions to hit a little fricking ball really far is just…
Mike: Yeah, it is. I mean, you watch that stuff on slow motion, and you watch the repeatability of these guys what they can do over and over again, because I mean, we are in Vegas and Scottsdale, there are so many good players. You just walk into any range, you go on any mini tour event, and there are guys that are some of the best players you have ever seen, but will never make a dollar playing. It’s incredible what little separates the goods and greats.
Zac: And it really is consistency. That is the key. When I was in basketball, anyone, I mean, even today, anyone can drop 40 in a game, but the greats do it day in and day out, and I think it is the same thing with any sports at that high of a level, is it is how consistently can you hit it this way and hit it where it needs to go every time regardless of whatever club you are using.
Mike: Yeah, and I think maybe the hand that we can influence on that is giving someone a little bit more movement options so that they have a little bit more bandwidth and more variability in order to make appropriate swing.
Transferring training adaptations to the sport
Zac: I remember when I was in basketball, I think one reason, especially on the D-League, where we got good transfer was me and one of the assistant coaches worked well together.
Suppose a guy needed to pronate their right foot, we’d drive basketball drills that would force that action. How do you do that on a baseball and golf perspective?
Mike: Yeah, similarly. You have a coach that the person respects, the athlete respects, and you work together with them.
This is a mistake that I still make today, where someone will come in and they will set me, I always say I need a video of your swing, which many aren’t used to a physical therapist asking that. But I just that want to see certain things and you just show them certain things like see when you take the club away, see how that right knee just starts rolling out right away like that, that is going to cause a power, you are not going to pull the rubber band quite as well, you are not going to create the load that you want with that position. Speaking the language of the player helps.
I got a basketball player who did not have full shoulder flexion, and you are like, I bet when you shoot, you tilt your head this way. He is like, I have been working on that for years,
But getting that dynamic change over time is challenging. It is picking the right exercises, the right influences, the right amount of time, all those sorts of things. And I think the more and more like we can integrate, like, on to the field or and to the context of the person, you get closer to what you are trying to do, and also like we have to understand that I am trying to mimic forces, not necessarily the motion. I think the idea of forces transfer much more than some specific movement.
Zac: The force is strong with you you might say. So, how does that change your exercise coaching and cueing if you are thinking more forces than the movements and maybe in the case of, if you got an amateur or not even that, someone would say amateur or someone who just enjoys golf, you know, you need to make a little tweak to that?
Mike: I had a gentleman who was having a hard time creating like the left yield, like he could not quite get into his left side. When he went left his ribcage would pop forward. Then everything else was trying to create the downforce.
So I gave him a little bit of a heel to give him a little better chance to yield, and then we are going to try to sort of slowly mimic the forces. So, maybe, I will start with a fake med ball toss to teach deceleration. That could progress to a dynamic left setback, kettlebell catch. From there, a med ball release slam, then maybe you grab the water bag, now you are really amplifying the forces. So, you are slowly, and if he is check, check check, I am taking video of everything is, he is check, still good, still good, still good. Now, we know he has the capability to create these amplifiers, to deal with these amplified forces. The harder he can then push right, he can deal with larger forces of the left side.
A common thing you see is people with a weak right propulsive foot, They just do not want to push, because everyone is told, I cannot slide. Well, the reason you cannot push is you do not have anywhere to push to, and you cannot deal with the forces. So you create space, then amplify the forces into that space. Now they can push like crazy in the right side, and now that right SI joint is not painful, that sort of stuff, and then right neck is not painful, because now they do not have to do this, they can actually create downforce IR on the left through the left side, but you started it from like, create the space, and then slowly amplified forces in said space to then now can I push into that space.
Zac: So, you are almost using just various implements to drive it as opposed to utilizing a lot of external or internal cues to elicit the particular move with the hope being and it certainly does that it transfers to the terminal task?
Mike: Yeah. I am all for good internal and external cue, And oftentimes, they work really well, But then sometimes, too, it is like, they might feel something, but what shape are they creating to create that feel? There is a lot of ways to get a feel.
But at high speed, I do not want you to feel really anything.
Zac: You do not want to be thinking either.
Mike: I want impulse, I just want to shorten that impulse is much like boom, boom, boom, boom, boom, as quickly as you can, because you are basically you are creating the adaptation.
Zac: I have to get a water bag one of these days, man.
Mike: They are fun. There is a lot of cool things you can do with them, I mean, from just the sensory feel of someone turning to their right and feeling the guts slam, and getting that sensation. “Oh, I see, that is what you mean.” That is why I need to still hold on to the inside part if my foot, because if I do not, it is just going to swing me around the outside, and I do not really get that slosh feeling back, So, you are not creating a backstop for it, and then and then they get the sense of, okay, then I need to create the timing of the slosh to the other side. So, you can do it from like a sensory thing, but I like it mostly for like trying to amplify forces, like slamming it down and you feel the smash of the water. So, you get the sort of the slow delay and then you got to wait for it.
Zac: So, it is almost a progression for Mike, you catch your oscillatory isometrics.
Mike: I think so. I see it as being amplifying forces, depending on the weight or what you are using.
Zac: Are you utilizing that particular intervention for anything within postures of the swing, for example? So, you know, if I got someone who cannot get rotated into their left hip on follow through, will you be utilizing golf specific postures to get that? Or are you using other postures?
Mike: Yeah, I am a split stance guy, especially if they are narrow, because I want to tight turn. But that does not mean I will not put them in a golf posture and do variations of chops.
Movement needs of basketball players
Mike: Got to bring them back. So, you look at the, you take a look from behind, and you have got scapulars jammed together, about to squeezed right here, all that sort of thing. So, they are just screaming to come back, and you are not like, when you have someone who is that specialized, that highly adapted, you are not going to make massive change, nor would you want to. I do not think so.
Zac: Never would you get a full squat?
Mike: No. I mean, you heel elevate them.
Zac: They are not crapping in the woods squat though.
Mike: No, no, not like my squat. My squat is pretty good.
Zac: Yeah. Man, we should have a squat off. Yeah. We want to do a picture together.
Tons of heel elevated squatting and then also to just anything you can do to offset positioning. Single leg is just so fricking money. Because, well, anything that you can do that drive some semblance of rotation just seems to create that gradient. Allow them to get lower. Those have been some of the bigger things that.
Mike: Yeah, I mean, honestly, like any sideline positions with some reference underneath the pelvis, side of pelvis, like a half foam roller, and then teaching them to roll, create some sort of left yielding. I love using lazy ass rolling.
Zac: Nasal breathing, lazy ass rolling…
Mike: I think it is Feldenkrais.
Zac: Man, I would love to learn a little bit more from him and some of his stuff, these sorts of stuffs are kind of hard to find, maybe I just have not looked.
Mike: I have got some nice changes, crazy changes on people that I could not get anything on, where you just having the other side, and you must roll as lazy as possible. It is frustrating. We will just teach you to move without generating tension.
I think I have a couple of cues I have done better with some people as like you should mess this up and you should start over.. You should repeat and start over repeatedly on this, and if you do not, then you are not doing it. You should not be able to move role without screwing this up..
Zac: Yeah, I kind of have the same thing with some people when you are coaching them to do myofunctional therapy or different tongue exercises, because it is like, I need you to put your tongue in this position, you know, whether it is like the pointy tongue, Which is kind of hard to do, but then, the coaches, well figure it out, and it is repeat failure over and over and over again until you get it and then once you get it, it is like you can do it all the time.
Choosing the best home exercise program for patients.
Mike: Safe to fail. I am trying to pick the highest level of exercise that they could possibly do well. And there is no shortcut to that. There is just a lot of screwing up.
Zac: I think you want a higher level of competency that even if I could get 80% of it, they are still going get a good change.
Mike: Yeah, I mean, I think like both you and I utilize a lot of videos. So, we are in session, you will like at the end of it, it is like okay, you explain to me this exercise that you are doing here.
Zac: Yeah, I have been doing that. Really, I started doing that out of laziness. So, because I used to send my big summary emails. But I eventually got to a point where I couldn’t do that. So, I started filming. The nice thing is the patients have to talk through the steps. It’s money.
Mike: Then if they get nice changes, I know that if they stay consistent they ought to be able to maintain them. Something I do too every once in a while, and Bill has actually influenced me to do this, is basically tell people that, hey, in three days, I want a video of every single one of your exercises.
Zac: That is a good idea.
Mike: Yeah. Not everyone does it, depends on the person, But it is at least they know you care about this stuff, and selfishly I want to know if this works too because you will hit a streak, you are like “God, everything I do, nothing seems to be working,” and then you are like, “okay, these people are, that I am pretty sure they are compliant” and then or they are just not doing with the level of intensity and specificity they need to be doing things.
Moreover, people have got very busy lives. It is not a judgment, but it is from my selfish perspective is like, this is our life’s work, I want to know if what I am doing is working. I want to fast track this type of stuff, I want to learn, I want to help as many people as I can, I want to know if what I am doing is making an influence changing stuff.
Operating a cash pay physical therapy practice
Zac: Now you are a proud owner of cash paid practice. What has the transition been like from employee to employer for yourself?
Mike: Yeah, so I was cash paid practice within a gym and then employee of a certain model that did not work out, and then out into kind of on my own, really on my own now. So, I guess I have seen, you know, the different variations of it.
Zac: Yeah, it is like you were intrapreneur, employee, entrepreneur.
Mike: A lot more onus, like for me, it is great, I do not think I need that push, but I think when you have no other options, and you have got two little girls and a family to take care of, you better get going.
But also, I think my skill set has gotten significantly better in that amount of time, and I think it is from repetition, I think it is from having more skin in the game, all these sorts of buzzwords right, but it matters.
There is a lot of cool stuff about it. I get to set my own schedule. I have more freedom, all these sorts of things, but they are also part of the game too, like you have to know what you are going to do in a day, otherwise you are looking at YouTube cat videos at 8:30 or whatever you are into.
Zac: How do you create that balance with business, family, and everything?
Mike: Yeah, well I am lucky enough to have a wife that is extremely supportive of what I do, and then realize it is a big part of my overall wellness. It makes me a better father. It makes me more present when I have time to do, you know, self-study or whatever.
But I have put in a lot of work to get here. I would go into the gym, I would see 5:30 AM’s five days a week and then work till 6 p.m. I felt like I had to take everyone.
But eventually you get to a point where you just aren’t where you want to be. Either your learning stalls, your health stalls, like if you are taking a wide enough perspective of like your overall wellness, it is just not where you want to be.
So, then if something is not working for me, I’ll change something. It is easier said than done. I have got a lot of ducks in order, like, again, I said, support a family, health, all these sorts of things, that not necessary everyone has. So, I am not trivializing and making it sound like it is simple, but I have set up my life and a career where I see five people a day, four people a day, and I really rarely will ever see more than that. I am not showing up until 9 a.m. usually.
I get up early, my daughters get up early, and I get a lot of my self-study reading or whatever done earlyish. I will see clients, you know, do some self-stuff, self-exercise, and I am home by 5. It is a pretty damn good day.
It doesn’t work that way when you are a new grad. A lot of work went into this. In cash pay, you are competing. People will not pay cash unless they are getting results.
Zac: You put in time in the beginning to be able to set up the system, and then yeah, and now it is, you burn the candle at both ends, man, I could not imagine going 5:30 to 6. I am more of a 9 to 9 or 9 to 11 kind of guy.
Mike: I am useless after about like 5:30 p.m., like when I have to focus and be present, like that type of stuff. I go to bed like at 8.
Zac: Oh, that is amazing.
Mike: Girls are in sleep by 7:30. I am in bed before night.
Zac: Wow. Rinse and repeat.
Mike: Yeah, but I am like, it is like my wakeness schedule has shifted, like I am up really early, And doing stuff, I am not productive in the evening.
Zac: The evening typically when I am most productive.
Mike: I can see that. Yeah, that makes sense.
Zac: But it is probably not a good thing, because then it impacts sleep because most of my productivity is on that wonderful screen over there.
Mike: Do you notice, is that helpful?
Zac: The blue blockers?
Zac: No, not really. Not as much as getting my teeth moved.
Zac: Yeah, that did not really seem to make a benefit.
Mike: They never moved the needle for me.
Zac: No. I do not know if the research is really holding up with some of the blue blocker, because it is probably the light itself that is the major issue, which.
Mike: Well, there is a lot of other ways light gets into our system I imagine because it is just here.
Zac: I would say like the biggest changes for me sleep-wise have been definitely the mouth expansion. If you can create more space, you get better airway and you do things to promote that. I also use Myotape and the Mute Nasal Dilators. But I have not figured out a way to offset the work stress. So, yeah, I might need to get five patient a day to train, that would be nice.
Mike: Yeah, I mean, it is helpful. Honestly, I think I deliver a better product for sure. I mean, there is no way you can be like, I understand the grind and seeing, seeing 10 people a day, and I used to be like, I see 10 people a day, it is very cool, but I was not delivering the specificity or the attention to detail. You cannot. There is no way you cannot.
Zac: it is just fatigue and especially if you can put like four good hours in a given day.
Mike: Yeah, like what can you really do when you are seeing person back-to-back to back? Like it is just, you know, just…
Zac: Or multiple in one hour?
Mike: Yeah, I think, I mean, I think about like how you started with ortho stuff, and you are doing 20-minute, 25-minute evals and then you have got two people exercising while you are doing this eval, and you are seeing someone in the second, I mean, it is just like, holy cow.
Zac: Did you work in that type of environment?
Mike: I did, yeah. I worked at a decent amount of places like that.
Zac: I have been lucky. All of mine has been one on one from the beginning. There was my residency, there was like, one time, where I saw two people and then I just, I would rather work late. So, I would work from like 8 to 7.
Mike: Well, it is the classic interview at a place and they say: “Oh, we are a different, patient centered place, but our bonus structure is how many people you see in a week.”
Zac: Well, it is unfortunate, because I think a lot of that is due to the system. If you are going to use insurance and reimbursements dwindling and then you have to see more people, but then you see more people, the quality of care is lower, and the research comes out that PT does not help with condition X, Y and Z, and then reimbursement gets lower, and then you got, this cycle continues. So, anything you can do to break the cycle, cash pay practice can fix it.
Mike: Yeah, yeah, it is not for everybody, but I could not imagine having to clock in and clock out.
Zac: I do not know, and I mean, I am only officially cash pay for a little over a year and it has just been a much better experience for myself, and the clients included.