Peter Attia MD350 ‒ Injury prevention, recovery, and performance optimization for every decade
EVERY SPOKEN WORD
125 min read · 24,907 words- 0:00 – 1:37
Intro
- PAPeter Attia
You keep talking about making me a kickass 80-year-old.
- KBKyler Brown
Yeah.
- PAPeter Attia
I wanna be a kickass 40-year-old.
- KBKyler Brown
Yep.
- PAPeter Attia
What's the flaw in that logic?
- KBKyler Brown
If I'm gonna be an awesome 70 or 80-year-old, I kinda have to be an awesome 45 or 55-year-old. We're gonna be doing things now that make you crazy strong, that help your lean muscle mass, that burns your fat, all those health risk things, but you're also gonna be way more prepared for whatever life throws at you.
- PAPeter Attia
As a person listening to us who says, "Look, man, I've been not getting better."
- KBKyler Brown
Yeah.
- PAPeter Attia
Like, how do you help that person think about whether or not there's an underlying structural problem that needs a surgical intervention-
- KBKyler Brown
Yeah
- PAPeter Attia
... or a more direct intervention versus you're not being instructed to do the right things and/or you're being instructed and you're not doing it?
- KBKyler Brown
I think your rehab clinic needs to do more than just offer services. They need to offer a plan. The magic word of capacity is what it's all about. Are you building me back to what I wanna do?
- PAPeter Attia
If you're someone like me and you-
- KBKyler Brown
Mm-hmm
- PAPeter Attia
... who part of our CD involves probably walking on uneven surfaces one day.
- KBKyler Brown
Yeah. All of your training should account for that. If we're just doing bicep curls and calf raises, it's like I'm on these railroad tracks, but the minute you make me go sideways or rotate, it's trouble. What I always tell people to do is, like, look at your kids. Like, if you go to a coffee shop with your kids, I guarantee one of 'em will run and jump off a rock and, like, do a twist and land it. When was the last time one of us did that?
- PAPeter Attia
The pathway back isn't necessarily pain-free or injury-free. It's more of a trajectory that's gonna get better.
- KBKyler Brown
Pain does not always mean injury. Pain is your brain telling you, "Hey, I don't like what's happening here," but it doesn't always mean you're broken or busted. [upbeat music]
- PAPeter Attia
Hey, everyone. Welcome to the Drive podcast. I'm your host, Peter Attia.
- 1:37 – 10:42
The personalized rehab strategy for Peter’s shoulder surgery that sparked creation of a training program called 10 Squared
- PAPeter Attia
Kyler, wonderful to have you.
- KBKyler Brown
Yeah. Thanks for having me.
- PAPeter Attia
I wanna kind of, um, give folks a little bit of a sense of what you and I came up with a few years ago, uh, in the throes of my recovery from shoulder surgery, and why that kinda gave us this idea to take two things that seemed quite unrelated at the time, which, right, which was, was, you know, my recovery from an injury, uh, coupled with this idea that I'd been marinating around this idea of a, a centenarian decathlon in a marginal decade, and why we decided to kinda put these, the, the, you know, the best ideas or the themes of these together. Um, so how does that sound?
- KBKyler Brown
Sounds great.
- PAPeter Attia
All right. So, uh, let's see. You and I met four years ago, as soon as I moved to Austin.
- KBKyler Brown
Yep.
- PAPeter Attia
Um, and we were kind of just... I don't even remember what we worked on because I think it was just, like, preventative stuff, right? It was like-
- KBKyler Brown
Yeah, you, you really wanted me to come over, I think initially just doing some DNS stuff, like some routine maintenance things, and somewhere around the second or third, uh, visit, I, I was like, "Well, what's going on with this shoulder?" And that kinda kicked off this whole conversation because, you know, in my world, this idea of just doing one technique or providing one service isn't really a complete approach.
- PAPeter Attia
That's right. So y- you're right. We were probably a couple months in maybe-
- KBKyler Brown
Yeah
- PAPeter Attia
... and it was clear that I was nursing this bad shoulder. Um, and I knew what was going on because I had torn the labrum before. The diagnosis, I remember, was actually made in 2009.
- KBKyler Brown
Yeah.
- PAPeter Attia
I had my first arthrogram in 2009. For folks listening who don't know what that is, an arthrogram is an MRI where prior to you going in the scanner, the radiologist t- takes a needle about yay long, right, like four inches long, shoots the needle into the capsule, and injects contrast so that it really allows the MRI to show the labrum and how much it's detached, uh, from the glenoid fossa. Um, and so it was c- it was patently clear at that time I had a torn labrum. It was, uh, significantly torn, but not as torn as it would be, you know, 12 years-
- KBKyler Brown
Right
- PAPeter Attia
... or 13 years later. Um, but I had largely, uh, avoided surgery by, you know, doing as much as I could to strengthen the, uh, the rotator cuff. Uh, and frankly, I was afraid to have surgery.
- KBKyler Brown
Right. Of course.
- PAPeter Attia
That was the bottom line is I didn't want to trade one problem for another, meaning I didn't wanna trade pain and instability for immobility. And I saw that as the trade-off. [lip smack] Again, folks listening probably recall that I had a, uh, a podcast. I did a, a sit-down discussion with Alton, who is the amazing surgeon, Alton Barron, who ultimately did the repair. But what I was most impressed by in that experience, which turned out to be wildly positive, was that immediately you and Alton, uh, started working as a team, and m- maybe you can talk a little bit about what you guys decided to do in the six, I think it was eight weeks we knew prior to surgery. We scheduled it such that you could do something before then. What, what was that discussion like?
- KBKyler Brown
Yeah, I, I mean, Alton did an amazing job in a lot of ways, but one of the things as a rehab professional that I really appreciated was how he didn't wanna just cinch down that joint to where his liability was so covered that that shoulder would be strong, but you lost a ton of function. And I think that is one of the key things that he did for us was he did the right amount. He put the staples and the sutures in the right places to where that shoulder would be functional, and we got to your shoulder well before it became any kind of more significant structural compromise, so it was a really important window to do so. Um, but I do remember that conversation 'cause you had a, a date several months out where you're like, "I'm gonna have to use my arm a lot. I need to be strong."
- PAPeter Attia
Yeah, I ha- it was, it was, basically I needed to be able to hunt in September.
- KBKyler Brown
Yep.
- PAPeter Attia
So we backed out of that, said the surgery needs to be no later than March.
- KBKyler Brown
Yep.
- PAPeter Attia
It was January.
- KBKyler Brown
Yep.
- PAPeter Attia
And then the question was, should you do the surgery right away, or do you use two months to prehab?
- KBKyler Brown
Yeah.
- PAPeter Attia
And so tell me how you thought about that.
- KBKyler Brown
Yeah, no, I mean, that conversation was one of my favorites because I've done this before where if we know the big picture goal as well as the near-term surgical date, and then we reverse engineer, "Okay, I want to check off a certain amount of things preoperatively to where that joint is ready." And essentially in the most simple terms, what you're looking for in that situation, especially with the shoulder 'cause it's such a mobile joint, is you wanna make all the muscles around the shoulder just awesome. But we need to do so in a way that doesn't make the surgery, you know, more complicated or injure you more, right? And so we did a lot of things where we didn't only use technology like BFR- But we also used very aggressive approaches on your core stability, the way your scapula interacted with your ribs, and all these things have an effect on how my shoulder moves, and if my really mobile shoulder that has a torn labrum isn't stable and doesn't have a support infrastructure around it, you're always just gonna ask for more pain. But what-- the best thing about that is the day you got the surgery, we jumped on it really quick once things were healing from the surgery itself. All those other ancillary things were actually functioning really well. So now we only had to really target the shoulder itself because the rest of the human was really strong and ready.
- PAPeter Attia
Yeah, and, and so the things that I remember, which are probably fewer details than what you remember, is one, how much rotator cuff work we did ahead of time.
- KBKyler Brown
Yeah.
- 10:42 – 18:20
Training for the marginal decade: why precision & purpose are essential for quality of life
- PAPeter Attia
to this, right, I'm continuing to sort of refine my thinking around, um, the idea that we're all gonna have this marginal decade one day, and I... It, it does come across as sort of a depressing thought.
- KBKyler Brown
Sure.
- PAPeter Attia
Like nobody really wants to think about the idea that there will be a day when you knowingly or unknowingly enter the final decade of your life. Um, but at the same time, you know, to act as though it's not true won't make it not so. So, um, I think it occurred to me, um, that the more deliberate we can train for that last decade as though we are athletes, the more we can enjoy it. Because as I watch people in the final decade of their lives, and I've had the both privilege and curse of seeing a lot of it, um, I believe that the thing people complain most about is what's taken away from them physically.
- KBKyler Brown
Yeah.
- PAPeter Attia
Now, there are lots of people in the last decade of their life that are lonely because, you know, they were miserable sons of bitches and their family [laughs] -
- KBKyler Brown
Right
- PAPeter Attia
... you know, they don't have family or friends.
- KBKyler Brown
Yeah.
- PAPeter Attia
Like all of those things. There are many people whose cognition has failed them long before their body has failed them, and that can be very distressing. But if, if I'm really thinking about this in terms of large numbers, more than two-thirds of people, um, I would say in the final decade of their life, when they're really thinking about what's impacting the quality of their life, it's this.
- KBKyler Brown
Yeah.
- PAPeter Attia
It's the physical part. It's, "That's the thing I've lost that I miss the most." And, and sometimes it could simply be freedom from pain, but more often it's restriction of activity.
- KBKyler Brown
Yeah, totally.
- PAPeter Attia
So you... I mean, but, but I, I mean, that's my biased experience. You see much more of this. Tell me what you think.
- KBKyler Brown
Yeah, I'm, it's really analogous to the pro athletes I've worked with as well, where it's really interesting to see these mature athletes who've been playing their sport eight or 10 years, and they're starting to kind of look this reality that their career is gonna be over. And they start recalibrating how they train 'cause they start thinking about the long term. And what's really fun for me is when they start to get that perspective of it's not just about this weekend, it's about the long game here. And I think, to your point, a lot of people out there have the best intentions, and they're maybe even working hard, but there's no precision. It's, nothing's accounting for their specific details, their nuances of their joints, and how they m- move, and how their body feels when they move, and their trust in their body, and all these variables, right? And a lot of people are, either want to put in the effort and don't know where to start, or a lot of people are putting in the effort, but it's not calibrated.
- PAPeter Attia
Yeah, and I kind of even began to observe that in myself, which was there were a lot of activities that I was doing where I was doing them because I'd historically always done them.
- KBKyler Brown
Yeah.
- PAPeter Attia
Right? Like-
- KBKyler Brown
We fall in a groove
- PAPeter Attia
... this is a type of exercise I enjoy doing.
- KBKyler Brown
Yeah.
- PAPeter Attia
This is a tur- type of workout I enjoy doing.
- KBKyler Brown
Yeah.
- PAPeter Attia
Um, and then I had to kind of take an honest assessment of some of these and say, okay, for every activity, just like for every investment, there's a risk and there's a reward.
- KBKyler Brown
Mm-hmm.
- PAPeter Attia
And the way you might think about investing in your 20s is probably different from how you maybe should be thinking about investing in your 60s or 70s or beyond. And similarly, the risk and reward changes over time.
- KBKyler Brown
Mm-hmm.
- PAPeter Attia
Um, so for example, when you're 20, the risk is just inherently lower because you have better tissue, right? You, you, you, you know, you... We could go through all the reasons why, inflammation-
- KBKyler Brown
Yeah
- PAPeter Attia
... senescence, like everything that changes as you age reduces tissue quality. Um, and younger people, I'm sure you see this all the time, can just get away with doing things incorrectly. In fact, I, I'm... Would you agree that sometimes some of the most gifted athletes actually have horrible patterns of movement, but because they're so gifted-
- KBKyler Brown
Yeah
- 18:20 – 24:59
The Centenarian Decathlon: how training for long-term capacity enhances both current & future quality of life
- PAPeter Attia
Um, which actually gets to this, the idea that people listening to us are probably very familiar with, which is the Centenarian Decathlon.
- KBKyler Brown
Yeah.
- PAPeter Attia
Right? So- Um, have you, uh, give me some of the things on your Centenarian Decathlon.
- KBKyler Brown
Yeah, I think, uh, for me, um, wrestling with my kids, which means getting down on the floor, having the flexibility, wrestling with my grandkids.
- PAPeter Attia
Wrestling?
- KBKyler Brown
Yeah.
- PAPeter Attia
That's big, man.
- KBKyler Brown
Just like play, right?
- PAPeter Attia
Yeah, yeah, yeah.
- KBKyler Brown
Because I, I saw some-
- PAPeter Attia
Not a pile driver.
- KBKyler Brown
Yeah. Well, yeah, we, depending on the kid, you know?
- PAPeter Attia
[laughs]
- KBKyler Brown
If they're my grandkids, maybe. But that's definitely a goal of mine is, is that bonding that you get when little kids are wrestling on the ground, and I saw my dad recently doing that, and I thought that was really cool. You know, he's over 70 and he's on the ground, you know, messing with my three-year-old, and it was just cool to see, and that, that's how I added that to my list. I was like, "That's really cool that..." It was hard for him, right? It wasn't easy, but he got down there and he could do it, and he didn't suffer from it.
- PAPeter Attia
Yeah.
- KBKyler Brown
And that's, that's one of mine for sure. Um, as you know, I fell in love with rucking over the last couple years, and so I want to be able to really crank out some mileage, especially in national parks as I get older. I'm not looking to be an ultramarathoner per se, but I really want to be able to hike long distances, probably with a pack on it.
- PAPeter Attia
What's... So if, when you're in your marginal decade, how many pounds would be your expectation? Do you want to be able to do, you know... But give, give me some numbers. How many miles? How many pounds?
- KBKyler Brown
Yeah, I think my numbers will be a little distorted 'cause I'm a pretty big guy, you know? I'm 6'3", over 200, so I should be able to carry at least 20 pounds-
- PAPeter Attia
Okay
- KBKyler Brown
... without worrying about it too much for four to six miles.
- PAPeter Attia
Okay. I like that goal.
- KBKyler Brown
Yeah, I mean, I want to be reasonable about it.
- PAPeter Attia
And this is on what kind of terrain?
- KBKyler Brown
So I would like to be able to, not too, uh, technical. Like I'm not thinking boulders and rocks. But I'd definitely like to go hills, up and down, um, dirt track, all that kind of stuff without having to worry about it.
- PAPeter Attia
Okay. What else?
- KBKyler Brown
Um, you know, another one is I l- I grew up being an athlete. My youngest seems to be the more inclined to be an athlete. So as I age, I want to be able to hang with him as long as I can, so that means throwing, hitting a baseball as long as possible. Who knows how their careers will evolve from a athletic standpoint, but odds are they're not gonna be pro, so I really want to keep that base to where I can keep playing with them as long as I can. But to me, it's all about being able to still play with the grandkids, 'cause family is one of the most important things out there, and if your grandpa is sitting there and can do cool stuff, I think that serves as a great role model. Whereas if you're suffering from an injury, you're not healthy, then they want to hang out with you, but at the same time, kids want to go do stuff, and I don't want to be left out.
- PAPeter Attia
Yeah. I, I agree. I think, um, as much as I, I think there are probably examples where, A, you know, the wise old grandpa or grandma can sit inside-
- KBKyler Brown
Yeah
- PAPeter Attia
... and tell stories to the kids. I mean, there's, there's value in that.
- KBKyler Brown
Yeah.
- 24:59 – 33:07
How the shortcomings of conventional rehab & performance systems led to the creation of 10 Squared, a personalized training model focused on long-term physical capacity & individualized care
- PAPeter Attia
Let's fast-forward a little bit. Basically, as I'm kind of getting better from the shoulder thing and realizing how fortunate I feel to have had this experience where, you know, I've known Alton for a while, then I met you, it's this kind of great connection, um, I sort of say, "Hey, man, what do you think about this idea of we, we kind of build this separate little, um, business that just focuses on the training piece, uh, that's outside of my practice, outside of your practice-
- KBKyler Brown
Yeah
- PAPeter Attia
... but integrates it with everything that's necessary to train a person for the marginal decade?" So you bring in all of the cardio training. You bring in all of the strength and conditioning. You bring in the coaches to integrate the whole thing. So okay, we're doing that now.
- KBKyler Brown
Yeah.
- PAPeter Attia
Um, of all the things we do in 10 Squared, I still think that your domain is the hardest for people to wrap their heads around. I think people understand, "Oh, yeah, you guys, you guys will help me get a high VO2 max, and you'll-
- KBKyler Brown
Yeah
- PAPeter Attia
... boost my zone two, and you're gonna make me stronger, and blah, blah, blah." How do clients look at you? What do they, uh, what do they, what do they figure is going on with you?
- KBKyler Brown
It's funny you say that 'cause they al- it always takes them like the assessment takes, you know, m- two days.
- PAPeter Attia
Yeah.
- KBKyler Brown
And we're looking under the hood a lot in a lot of different ways. And it's funny how they evolve, like, their perspective of it because, you know, what I was kinda forced to do in my career was become this... You know, I had, I had experience working with teams and all that other stuff, but I kinda became an off-season person for these athletes. And, and by default, I had to almost become a strength coach, not because I wanted to or that was my goal, but because, um, these athletes needed that bridge from, "I'm injured," to, "I might be injured," to, "Hey, I've got the green light for performance." And that spectrum we're always... All humans are moving up and down that spectrum based on our recovery and all these variables, right? So what's been fun at 10 Squared is I get to do all the assessment I want, and it's not really a clinical assessment, right? On the one hand, we're of course looking at things that either have pain or that, uh, individual member has had a previous injury with, and we're accounting for that, and we're making sure that's on track or could be improved, and we add those things. But then I also get to play around and look at what else is weak. What is this individual at risk for? So one example is we have a client who loves to surf. He's got a shoulder issue. So by default, surfing and swimming on a surfboard is a different position than a traditional freestyle stroke, so we had to make his shoulder uniquely robust in certain directions, and so that's part of his strength program. One of my biggest pet peeves in the rehab world is when people give someone 30 exercises that are really tedious and boring and, and no human sticks to that. They might do it for a week or two, but if it's not bridging to what they love and what they wanna do, it won't get there. So if we can bake in having, making, uh, ensuring that all the strength training won't make 'em worse and then also make sure that we're baking in their little corrective exercises or improving the gaps, that's where you make a huge difference into how someone feels but also how they can perform.
- PAPeter Attia
So what are, what are some of the things you see that, um... And, and I'm not asking this to be critical of, of what other rehab professionals do.
- KBKyler Brown
Of course.
- PAPeter Attia
But, but as a, as a, as a person listening to us who says, "Look, man, I've been kind of not getting better."
- KBKyler Brown
Yeah.
- PAPeter Attia
Like, I've, I've had fill-in-the-blank injury, right?
- KBKyler Brown
Sure.
- PAPeter Attia
So I've had tennis elbow that won't get better. I've had lower back pain that's just not getting better.
- KBKyler Brown
Yeah.
- PAPeter Attia
I've had shoulder pain that's not getting better. Um, how, how do you help that person think about whether or not there's an underlying structural problem that needs a surgical intervention-
- KBKyler Brown
Yeah
- PAPeter Attia
... or a more direct intervention versus, you know, you're not being instructed to do the right things and/or you're being instructed and you're not doing it? Like, h- how do you walk somebody through that tree?
- KBKyler Brown
Yeah. That's... Obviously, it's a heavy lift with a lot of details. I think the first rule is the medical community, so your orthopedic surgeon or your neurologist and then your rehab pro, have to be in sync and have a relationship.
- PAPeter Attia
And how often is that happening?
- KBKyler Brown
Um, I mean, it's very rare. Like, what's really interesting is the philosophy and the individual just spirit of either the surgeon or the rehab pro, they have to be kinda committed to the service-oriented field. Like, if they're just doing it for money, they're gonna do scale, and they're gonna do, like, the PT mill that there's four clients with one therapist, and that therapist is probably doing the best they can, but they're just kinda outnumbered, right? And they're not accounting for those four different people all at once. So first off, it has to be one-on-one, right? Like, you cannot tell me that you're rehabbing you the same way you could rehab my grandma who had a shoulder issue.
- PAPeter Attia
Wait. Are you saying that... This is gonna sound like an ignorant question.
- KBKyler Brown
Yeah.
- PAPeter Attia
Are you saying that in some facilities-
- KBKyler Brown
Yeah
- PAPeter Attia
... one PT will work with multiple clients at the same time and put them-
- KBKyler Brown
Yeah
- 33:07 – 43:19
Case study: how personalized assessment & treatment at 10 Squared helps uncover the root causes of injuries
- PAPeter Attia
you guys do that? So, um, uh, I never, I didn't ask her in advance if we could do this, so we might have to edit this out of the [laughs] of our discussion.
- KBKyler Brown
Sure.
- PAPeter Attia
But can we use my wife as an example?
- KBKyler Brown
Oh.
- PAPeter Attia
So my wife is a client at 10 Squared, right?
- KBKyler Brown
Great example.
- PAPeter Attia
So, so, uh-
- KBKyler Brown
Yeah
- PAPeter Attia
... so Jill's a runner.
- KBKyler Brown
Yep.
- PAPeter Attia
Uh, like a little deer.
- KBKyler Brown
[laughs]
- PAPeter Attia
Runs, runs, runs, runs, runs.
- KBKyler Brown
Built for it.
- PAPeter Attia
Yeah.
- KBKyler Brown
Yeah.
- PAPeter Attia
And, uh, so, so I, I don't... I'm pretty hands-off. I'm very hands-off anything that has to do with her, actually-
- KBKyler Brown
Smart, yeah
- PAPeter Attia
... by design. Um-
- KBKyler Brown
[laughs]
- PAPeter Attia
Can you [laughs] can you tell us a little bit about her?
- KBKyler Brown
Yeah.
- PAPeter Attia
And, and what did you learn when you did an assessment of her, and how did that impact how she works with the other members of the team on the cardio side, on the strength and conditioning side?
- KBKyler Brown
Yeah, other than saying that she's a saint for having signed up with you, you want me to talk... Okay.
- PAPeter Attia
Yeah. [laughs]
- KBKyler Brown
Um, yeah, so Jill was a great example of she had some pain when she showed up. Um, and again, I'll just talk about in detail and she can delete it if she wants. But, um, Jill's a really great example because she had some pain when she showed up. So my job immediately is evaluate that pain. Is that a structural insufficiency? Are we worried about a real injury here, or is that just an annoying nuance, right? Based on the testing I did, so I did my clinical exam, but way more detailed than I normally would in my private practice because at 10 Squared we have the time, right?
- PAPeter Attia
Yep.
- KBKyler Brown
And we wanna remove con- confirmation bias, so we don't want me to just say, "Oh, your hamstring hurts. Let's do, order an MRI." Like, let's test it six ways and in a smart, conservative way, and if all six of those indicate that, then we're gonna do an MRI, right? So with Jill, we saw some proximal hamstring issues. She's, of course, like you mentioned, endurance athlete. Her profile, her demographics, her running history all pointed to there might be a tendinopathy there. And then based on my testing, it reinforced that. So I said, "Let's get an MRI. Let's really evaluate this tendon," because we knew in the near term, within a year, she wanted to run Boston. And as a injury person, I saw this as, look, she's okay now, but it hurts. Once we start stacking up her mileage, that thing's gonna get in the way.
- PAPeter Attia
Well, there's another detail here that I do recall, which, uh, obviously you recall as well, but it might be worth pointing this out to the listener. So she normally only runs one marathon a year.
- KBKyler Brown
Right.
- 43:19 – 51:32
The role of the “core” in movement & injury prevention, & the importance of training stability before strength
- PAPeter Attia
Let's, let's talk for a minute about the, the, the core. Like, a- again, I hate the term-
- KBKyler Brown
Sure
- PAPeter Attia
... because it's so misused, but the way we talk about it is probably most closely aligned with how DNS thinks about it-
- KBKyler Brown
Mm-hmm
- PAPeter Attia
... dynamic neuromuscular stabilization. So maybe just say a moment about it through, through the lens that we think about the core as a cylinder-
- KBKyler Brown
Yeah
- PAPeter Attia
... um, as opposed to, quote-unquote, "abs."
- KBKyler Brown
Yeah, exactly. I think that's the starting point that I wish everyone could automatically understand, is that if you have really prominent rectus abdominis, that six-pack, that has nothing to do with how you stabilize your trunk, especially if I'm doing things in multi-planes, like tilting and rotating. So it's not just your obliques either, but it's the deep stabilization system that not only pressurizes with our diaphragm, the pelvic floor, but it's also all the small muscles up and down my spine, including, like, multifidi. Do all those muscles kick on and create stiffness in the right way at the right time? I think a lot of times people are accidentally over-coached into thinking they only need stiffness 'cause the, the second step to that is, okay, now I can activate that deep stabilization system. I have that bracing. I'm pressurized. I'm using my transverse abdominis, all these other structures down there. Now can I do that with motion, right? And that's where you start looking at, like, someone kicking or running or throwing. Like, that needs to be a dynamic system, not just a stiff system. And I think a lot of people, they don't have the first one, so they see a ton of these exercises like the DNS three month or, um, you know, dead bugs or whatever else you wanna call them, that create kind of deep core stabilization. But they don't see the next step after that, which is, okay, now how do I maintain that pillar and that strength, and then I get a free shoulder blade or a free hip to move? And, you know, one of our shared clients, um, he had a lot of radicular nerve pain from a disc issue, and he was convinced, you know, he had some of that. But one of the most fascinating cases for me in recent memory because with him, we were able to actually find a trigger point that referred pain that mimicked that radicular nerve pain. So when we l- literally pressed on his glute minimus, he got a referral that he thought was attributed to his back, right?
- PAPeter Attia
Mm-hmm.
- KBKyler Brown
So that was a window towards, okay, that's a muscular issue. That's not your spine causing trouble. And then we gave him these stabilization drills which helped that glute just kind of relax for once. What we see all the time in the clinic setting is muscles are meant to be a muscle. My bicep is meant to contract and relax. It's not meant to be a shoulder stabilizer. But if my stabilization isn't doing its thing, then that bicep and the trap and all these other muscles try to help. And that's where we lose freedom of movement because your body's essentially perceiving a little threat, a little instability, and so it tightens other structures up. So then I see people coming into our office saying, "Will you dry needle this or work on me or do soft tissue work?" And you're like, "Yeah, but that's gonna be a..." They go to the stretch place. That's gonna be a six-hour benefit, but if we activate this deep stabilization system and get all the parts moving in unison and in sync, all of a sudden those m- movement problems go away, and you're much more robust and strong.
- PAPeter Attia
Yeah, there's so much I, I wanna say on this, and I, I don't wanna lose the thread, but I'll, I'll, I'll, I'll sort of say two things that are... that seem unrelated, but they're, they're, they're quite related. The first is, um, I wish there was another word for stability that didn't imply static.
- KBKyler Brown
Yes.
- PAPeter Attia
Because stability and apli- it, we just, we, we, we, we sort of think of that as things that are not moving.
- KBKyler Brown
Yeah.
- PAPeter Attia
Right? So rigid, stable, et cetera.
- KBKyler Brown
Yep.
- PAPeter Attia
But the truest way to appreciate stability is kinetic stability.
- KBKyler Brown
Mm-hmm.
- PAPeter Attia
That's why in the book, um, which I know you haven't read, but if you do read it one day... No. [laughs]
- KBKyler Brown
[laughs] I've been too busy.
- PAPeter Attia
Yeah, I know. Um, I... In the, in, there's the section of the book where I write about stability. The analogy I use, much against the desire of my publisher [laughs] who hated it-
- KBKyler Brown
Yeah
- PAPeter Attia
... um, was that of a race car. 'Cause again, you're thinking like, "How does a race car explain stability?" But if anybody's driven a race car, or if you haven't, if you can take my word for it, one of the fundamental differences between a race car and a street car is that in a race car, you're transferring much more of that horsepower to the tires than you are in a street car.
- KBKyler Brown
Mm-hmm.
- PAPeter Attia
In a street car, a lot of energy seeps out because the chassis is not very stable.
- KBKyler Brown
Right.
- PAPeter Attia
And you might say, "Well, why?" Well, in the case of a car, it's 'cause it's more comfortable.
- KBKyler Brown
Yeah. Yeah.
- PAPeter Attia
You know, race cars are not being optimized for comfort, they're being optimized for performance. If you're optimizing for performance, you actually want more stability in the chassis and the suspension so that you're transmitting more force to-
- KBKyler Brown
Yeah
- 51:32 – 55:48
The layered assessment process used at 10 Squared to determine whether a person is ready to perform dynamic movements
- PAPeter Attia
W- what is it that you see? So when a client comes into 10 Squared and you do an assessment-
- KBKyler Brown
Mm-hmm
- PAPeter Attia
... how do you gauge how far they are away from being able to do the dynamic movements? How are you gauging, how are... What are you testing? What are you looking for to say, "Yeah, this person could start doing plyos"? Like, for example, one thing I love doing, uh, it's kind of one of my... I don't have this on my Centenarian Decathlon list because w- we're being so strict about that only having 10 things.
- KBKyler Brown
Yeah.
- PAPeter Attia
But I have kind of a side list of things that I wanna be able to do. Like, I wanna know how late in life I can maintain certain metrics.
- KBKyler Brown
Mm-hmm.
- PAPeter Attia
And one of them is how late in life can I still do a broad jump of my, my height?
- KBKyler Brown
Cool.
- PAPeter Attia
So why is that something I enjoy doing? 'Cause it combines two things.
- KBKyler Brown
Mm.
- PAPeter Attia
It combines the, um, concentric strength and power to be able to leap.
- KBKyler Brown
Mm-hmm.
- PAPeter Attia
But even more importantly, and at least as difficult, is it requires the eccentric strength to land-
- KBKyler Brown
Yeah
- PAPeter Attia
... and decelerate really quickly.
- KBKyler Brown
Yeah.
- PAPeter Attia
Um, so how do you know when you look at someone if they're ready to do that, for example?
- KBKyler Brown
Yeah, so w- we did a ton of work, and, and the literature and the science is out there to a degree for you stack things on top of themselves, right? So you start with isometrics, and you progress people to more kind of in, um, explosive or compound movements, right? So let's assume that I don't have any injury risks at all.
- PAPeter Attia
And you would determine that based on just my history?
- KBKyler Brown
Uh, no, and testing.
- PAPeter Attia
Okay.
- KBKyler Brown
Yeah, history, testing, demographic risk. There's a lot of variables we look into for having concern about-
- PAPeter Attia
Okay
- KBKyler Brown
... like musculoskeletal injury. That's number one. Um, but yeah, every person is different that way, and we've had people come in who've had multiple surgeries and injuries, and then we've had other people come in who they're high risk for injury, but, um, overall they're a pretty good package to work with, right? There's not a lot of medical concern, if you will. Um, so ignoring all the medical side of it, you basically... I really like following the principle that the exercise is the test because y- we basically look at everything about four to five different ways. But if I watch someone do, um, let's say a wall squat-
- PAPeter Attia
So just to be clear, people understand, a wall squat is just the, it's level one, it's isometric
- KBKyler Brown
... isometric load. You're, it's what we all used to do in, like, high school practices-
- PAPeter Attia
Yep
- KBKyler Brown
... where it burns your quads and your patellar tendons. And we can even set you up to where you're in the right position.
- PAPeter Attia
Okay.
- KBKyler Brown
So that's gonna tell us, A, comfort with the position, number one, right? Can they even get there?
- 55:48 – 59:50
Case study: the rehab plan designed to treat a hamstring injury while preserving fitness & preventing reinjury
- PAPeter Attia
Okay, so let's go back to Jill for a minute. So we, we have this diagnosis, which is, okay, we've sort of figured out why your knee is hurting.
- KBKyler Brown
Mm-hmm.
- PAPeter Attia
Um, we now have a radiographic diagnosis-
- KBKyler Brown
Yeah
- PAPeter Attia
... that completely comports with what's being seen on the physical exam-
- KBKyler Brown
Yep
- PAPeter Attia
... on symptoms. Uh, these are stubborn injuries.
- KBKyler Brown
Yes.
- PAPeter Attia
So what's the... What was the next step?
- KBKyler Brown
So the next step was immediately, you have to have a parts approach first, right? If I have a damaged part, we gotta make sure does that need intervention or not? How are we gonna address that? So with Jill, we knew her foundational, like, underlying movement patterns or dysfunctions, if you will, that were contributing to that. So we put a package together for her program that was all of those underlying structural functional issues that didn't make the hamstring worse. We started building those right away while we considered platelet-rich plasma, and she actually ended up going for it to create essentially regeneration of that tendon at the damaged site, which she did perfect with. We had to have a lot of come to Jesus conversations about you cannot run too soon. If we're gonna go through all this trouble and financial cost, we want to make sure that that can heal as much as it can. So everything we did in her programming was to ensure we didn't flare that up, and then conversely, we really communicated with not just the strength team at 10 Squared, but also her physical therapist off-site and her running coach. And all of us had to put together this six-month plan where her running coach didn't accidentally flare it up, right? Because he does have a window to everything we're doing. He definitely needs to talk to the PT, as did we, to where she could, quote, "get medically cleared."
- PAPeter Attia
I should know this 'cause I live with her.
- KBKyler Brown
[laughs]
- PAPeter Attia
But I don't remember exactly how long she actually had to stop running, and I, I, I mean, I know that it was right after the first and second PRP injections.
- KBKyler Brown
Yeah.
- PAPeter Attia
But does eight weeks sound about right?
- KBKyler Brown
Yeah, so because of her timing for the race, and, and she wants to run Boston, we had a little extra runway. So the more healing time you can get, the better. We have a lot of people who are, like, really impatient, dying to get back to running.
- PAPeter Attia
Yeah, if you're a pro athlete, you might not have that luxury.
- KBKyler Brown
You don't have that luxury, right? But that's what's been fun for me about 10 Squared is I don't have all these environmental constraints. I could just get to look at people.
- PAPeter Attia
Right. When you're training for an event that's 30 years from now-
- KBKyler Brown
You have time
- PAPeter Attia
... you don't have to, you don't have to take shortcuts.
- KBKyler Brown
Yeah. Let's take a breath and be really detailed, right? And so with Jill, um, the, the PM&R docs and the physiatrists will always kinda give you different amounts, but usually two rounds for her issue. Um, so you do one round of PRP, basically do nothing, and then you do another round about two weeks later, and then you slowly let that heal, and you start to add physical therapy. So with Jill, total time, we were doing a ton of stuff around the area of the injection right away. Like, that's imperative. You don't stop everything. You just protect the area, and you train everything else. So that is gonna be one of the reasons why we get a lot of success with her. Um, and then back that up with we really did targeted physical therapy for that site to promote the healing. So the physical therapy side, they're using, um, a ton of things like BFR, dry needling where necessary, everything you can to just help those parts heal, foster that growth hormone, foster that protein synthesis, build that muscle up without a lot of force in the tendon, all those w- things that a traditional physical therapist that knows what they're doing, um, they can crush that.
- PAPeter Attia
Yeah, and she for eight weeks had to swim.
- KBKyler Brown
Yeah. So she was pleasantly open-minded. It's hard for every athlete to not do their sport. I get that. Um, but I've delivered that medicine over and over [laughs] for a long time. And so she swam, so she didn't lose any true cardio, right? She, yes, she lost a little bit of running strength, but someone with her background and her base, and then keeping everything else really strong, she's gonna hit the ground running, and she's running now and doing really well. And so I always say I have two athletes. I have the athlete that I have to encourage, like, "It's okay." Those tend to be more your traumatic, acute, like ACL-type people, where you gotta show them in the lab and show them in the gym that it is okay. "Keep pushing. You're good." And then I have the other athletes where you have to hold them back, right? And so Jill's gonna be that one, like, "Let me go, let me go," and we have to play bad cop just enough where science supports that, so where she doesn't flare it up again, 'cause we need her to have a nice, smooth progression. I'd rather her be really balanced and athletic and strong and feeling good on race day, not, like, a bunch of junk miles and that tendon in the knee starting to hurt her again and stuff like that.
- 59:50 – 1:04:52
Training approach for clients with minimal training history
- PAPeter Attia
All right, so let's, let's pick another type of, uh, client-
- KBKyler Brown
Mm-hmm
- PAPeter Attia
... that you'd see at 10 Squared, which is, um, maybe somebody who comes in who doesn't have a great training history.
- KBKyler Brown
Yeah.
- PAPeter Attia
They, they don't have... They've never really been an athlete.
- KBKyler Brown
Right.
- PAPeter Attia
And but, but they, but they, the thesis really resonates.
- KBKyler Brown
Yeah.
- PAPeter Attia
They, they sort of go, "You know what? Like, I get it, man."
- KBKyler Brown
Yeah.
- PAPeter Attia
Like, this is... Like, I feel fine now, even though I'm not particularly athletic, and I'm not training a lot, but I'm young enough that it hasn't caught up with me yet.
- KBKyler Brown
Yeah.
- PAPeter Attia
You know, I'm in my 40s or whatever.
- KBKyler Brown
Yeah.
- PAPeter Attia
Um, but y- I now accept that when I do my test, like, 'cause those people don't typically do very well on the assessment, 'cause it-
- KBKyler Brown
Right
- PAPeter Attia
... exposes just-
- KBKyler Brown
You can't hide.
- PAPeter Attia
You can't, you can't hide from not having done the work.
- KBKyler Brown
Yeah.
- PAPeter Attia
Um, so how do you think about, like, where to start-
- KBKyler Brown
Mm-hmm
- PAPeter Attia
... when there is so much work to do? So you talked earlier-
- KBKyler Brown
Yeah
- PAPeter Attia
... about, you know, this is on the second floor, this is on the first floor-
- KBKyler Brown
Yeah
- PAPeter Attia
... this is on the penthouse, this is in the basement. We're gonna focus on the basement. But what do you do when everything is first-floor basement?
- KBKyler Brown
Yeah, so great question. I think number one, we gotta build the habit. So that's a big part of this, is when your coach is basically in contact with you every day as much as you want to help bend and twist and develop that formula t- so where that person's actually encouraged to do it, they enjoy it, they like it. I've had people tell me, "Yeah, this core stuff makes sense, but I just hate getting on the floor." Okay, we gotta pivot and change the program, right? Because if I just try to convince you to do an exercise that you hate doing, it's not gonna last. That's number one. Number two is we wanna really mitigate the risks of injury, because those just... You get some momentum going on the psychological habit side, and then, "Ugh, I pulled my hamstring. I'm devastated," right?
- PAPeter Attia
Mm-hmm.
- KBKyler Brown
So we gotta get those foundations going. But then usually we look at the medical risk side. So some people, the CPET test was terrible, right? Their VO2 numbers are bad. You know, in our society, you gotta have a good heart. We wanna get that off the table from a risk factor. So we'll probably really put that routine cardio in in a manner in which we don't flare up the things that could create an injury. So one client we had recently, he didn't know it, he didn't bring it up. He's never had leg or foot issues at all. But his testing, his calves, he's a big fall risk. His calves are crazy weak. His balance wasn't good because he didn't have strength, and he's definitely a high risk for an Achilles.
- 1:04:52 – 1:09:34
How to train foot reactivity, tendon resilience, & explosive capacity in a safe, progressive way
- KBKyler Brown
backwards. That's a bummer.
- PAPeter Attia
Yeah. This idea about foot reactivity is so important, right? I think, um-
- KBKyler Brown
Oh, yeah
- PAPeter Attia
... I've been much more attentive to it in the past couple of years.
- KBKyler Brown
Mm-hmm.
- PAPeter Attia
And I've noticed the number of times when I've lost my footing and regained it.
- KBKyler Brown
Yeah.
- PAPeter Attia
So I've never had a fall.
- KBKyler Brown
Yeah.
- PAPeter Attia
You know? Never, it's never resulted in anything, 'cause it's been, it's been caught.
- KBKyler Brown
Yeah.
- PAPeter Attia
But I keep thinking to myself, like, this is the type of slip that can be devastating, and I, you know, I don't know how long I'll... Like, I don't know how long, 'cause these are really type II fibers that are doing it, right?
- KBKyler Brown
Yep, yep.
- PAPeter Attia
And the type II fiber's atrophying as we age. And is, is the jumping, is, are the types of jumping things that we do sufficient to preserve that? Like, what... You know, if you're someone like me and you-
- KBKyler Brown
Mm-hmm
- PAPeter Attia
... who part of our CD involves probably walking on uneven surfaces one day.
- KBKyler Brown
Yeah.
- PAPeter Attia
So being it, whether for you it's rucking, for me it's maybe going out and hunting or something-
- KBKyler Brown
Sure
- PAPeter Attia
... like that. Like, you're not walking on pavement.
- KBKyler Brown
Right.
- PAPeter Attia
Um, and you're not even just walking on, like, beautifully manicured grass.
- KBKyler Brown
Yeah, it's slanted to the side. It's g- it's like pebble gravel.
- PAPeter Attia
Yeah. Yeah, like you're always gonna lose your footing somehow-
- KBKyler Brown
Yep
- PAPeter Attia
... and you have to be able to regain it.
- KBKyler Brown
Yep.
- PAPeter Attia
Um, what are the most important exercises that you need to be doing to maintain all of the characteristics of, of tissue and nervous system to preserve?
- KBKyler Brown
Yeah, I think the best way to answer that is more principle-based. So I think, um, number one is we behave in a three-dimensional space. So this idea of only doing calf raises, my toes pointed straight ahead, insufficient, right? 'Cause to your point, there's gonna be moments where my toes are out, or one toe is out. So we wanna do all these strength exercises in multi-planes of motion, and that doesn't mean even in a static position. But that's like a lunge, lunging to the side, lunging backwards. Like, you wanna train in a three-dimensional space, number one. So all of your training should account for that. If we're just doing bicep curls and calf raises, it's like I'm on these railroad tracks, but the minute you make me go sideways or rotate, it's trouble, right? So three-dimensional, number one. Number two would be to get motor unit recruitment, right, to really make sure that those muscles are firing, you need to do really heavy loads or things that are really fast, right? To get that nervous system to, like, wake up and respond. The problem with that is not a whole lot of us are ready for that. So what you usually start with is really long hold isometrics. So we put you in these different positions and find ways to resist that and pull and create stiffness and remodel those tendons.
- PAPeter Attia
Mm.
- 1:09:34 – 1:19:15
Peter’s foot & ankle pain: how to diagnose, treat, & strengthen the lower extremities
- PAPeter Attia
even things out so Jill doesn't think I'm, I'm picking on her injury, let's, let's talk a little bit about my limitations. So-
- KBKyler Brown
Yeah
- PAPeter Attia
... so w- the thing that's probably been my biggest source of nag in the past 12 months has been foot, ankle. Like, let, let's talk-
- KBKyler Brown
Yeah
- PAPeter Attia
... a little bit about those injuries, why they're occurring.
- KBKyler Brown
Mm-hmm.
- PAPeter Attia
And again, they're not debilitating. They don't actually prevent me from doing a single thing.
- KBKyler Brown
Right.
- PAPeter Attia
But because I'm sensitive-
- KBKyler Brown
[laughs]
- PAPeter Attia
... uh, I just wanna know. Like, "Hey-
- KBKyler Brown
Yeah
- PAPeter Attia
... like, is this a harbinger of something?" And, and, and so what's your assessment of what's going on in my-
- KBKyler Brown
Yeah
- PAPeter Attia
... uh, and how would you even describe it? Would you describe it as my ankle? Would you describe it as my, you know, navicular-talar joint? Like, where, where-
- KBKyler Brown
Yeah
- PAPeter Attia
... is the actual issue in me?
- KBKyler Brown
So with you, um, without getting your foot out, y- you have a very mobile foot. So, you know, your swimming background, like, swimmers have really great mobile feet, right? Like, show me a, a soccer player who had their foot strapped in cleats for 10, 20 years versus a swimmer. Like, very different setups, right? Um, so it really speaks to how tissues adapt over time. Um, so your feet have a ton of motion in them. They are not restricted. You also do a lot of barefoot work in the gym, which is helpful for you. Your feet are actually pretty strong, too. Like, if we test your big toe and your smaller toes, you don't test outside the normal limits for strength requirements. But your biggest gap is that multi-positional stiffness and that ability to create force absorption through your tissues. And you're actually set up for that because you can move so much, right? You don't find those end ranges, either the bony end ranges or those tendons can't grab because there's so much play in that pattern. So what you accidentally do all the time is you'll go on a ruck or you'll go on a hunt where you're off-road and you're getting all these angles. You'll slowly flare up a tendon, and tendons are notorious for not hurting.
- PAPeter Attia
And thank you for not telling everybody the last cause of injury.
- KBKyler Brown
I would never. [laughs]
- PAPeter Attia
Just for the listener, I don't know why, but I somehow decided two months ago to pick up a pogo stick.
- KBKyler Brown
[laughs]
- PAPeter Attia
Like, never done it in my life.
- KBKyler Brown
Yeah, logical.
- PAPeter Attia
And somehow decided-
- KBKyler Brown
Hey, is that in the bonus Centenarian Decathlon for you, is like pogo?
- PAPeter Attia
Yeah, I was like, "I'm gonna add another activity-"
- KBKyler Brown
[laughs]
- PAPeter Attia
"... pogo sticking up and down the driveway."
- KBKyler Brown
Yeah, that's, that goes in the bucket of you should've called me first, you know?
- 1:19:15 – 1:29:20
How fear & perception influence recovery, what drives back pain, & when to choose surgery vs. treatment
- PAPeter Attia
Let's talk about something that you, you touched on a few minutes ago-
- KBKyler Brown
Mm-hmm
- PAPeter Attia
... which is around sort of fear.
- KBKyler Brown
Yeah.
- PAPeter Attia
Um, and we see this a lot. We see this in the medical practice where we have patients that are, you know, we're, where we're overseeing all their training. Um, and I, I... sounds like you see this at Ten Squared as well-
- KBKyler Brown
Oh, yeah
- PAPeter Attia
... where you have clients that are just coming in for obviously the, the training piece of this. So, um, is there, is there any kind of common thread to this, or does it come in all walks of life? It, uh, I've seen it in former athletes-
- KBKyler Brown
Yeah
- PAPeter Attia
... who are injured, but the injury is so bad that they just can never quite get back to... You know, they injure the back, and then they're sort of like, "They never quite wanna go back down that path," especially if they've had multiple re-injuries.
- KBKyler Brown
Yeah.
- PAPeter Attia
Um, I assume you see this in people who are not necessarily athletes. So, so what do you think is going on there, and how do you, how do you kind of work up the, the confidence to, to accept that the pathway back isn't necessarily pain-free or injury-free, but it's, it's more of a trajectory that's gonna get better?
- KBKyler Brown
Yeah, I love what you just showed there. The graph is, it's always gonna have peaks and valleys. Um, and, you know, when your brain perceives threat, whatever that could be, maybe your, you know, your dad hurt himself playing football, so you're scared to play football, right? But when your brain perceives threat, not only is your heightened awareness up, right, your nervous system is kicked up, but we're more sensitive to pain. So certain things hurt more when we're ill or when we're stressed than if we're not, right? And if we stick to just movement themselves, a lot of people are afraid of certain movements because it hurt me in the past, or they heard it could hurt them, or maybe they just haven't done it a long time, so they're nervous about it, right? So you can actually empower people if you show 'em there's a rational reason why that, that fear could be there or why that pain is there. Pain does not always mean injury. Pain is your brain telling you, "Hey, I don't like what's happening here." But it doesn't always mean you're broken or busted. Another thing to think about is your image isn't always, like, a, a death sentence, right? Like, if we MRI 100,000 low backs, there's gonna be wear and tear, especially if you're over 30 years old. Same goes for every other joint in the body. Does that mean we design your whole clinical plan around that? No. We really need to think about, okay, how much is there? What do they wanna do? What are their strengths? What are their weaknesses? All those things we already spoke to. So when there's fear involved, you really have to address that because the individual needs to know that, A, you have a plan for 'em, that you understand their fears, and then B, we gotta account for those fears in one way or another. So I mean, this is not data, but in my private practice, the amount of low-back, like, flare-ups, just your traditional back spasm, not a surgical candidate, just, like, high back pain but no damage, the amount of those people that have come in when their wife's about to go into labor or they, they're worried about getting fired from their job, where they have, like, an emotional, mental stress in their life, the amount of those people is infinite. Like, I've had thousands of people come in and go, "And my back flared up out of nowhere." And then you start to dive in, like, "What else is going on?" And they're really worried or stressed about something. So what the goal there is you can't always fix those external, cultural, psychological, emotional things, but we can address 'em and identify 'em. And sometimes they need therapy. They need other things to address those. But more importantly, we need to empower that individual and give them rational reasons why you're like, "Hey, this might be why you flared up in that glute or in that mid-back, and this is what we're gonna do about it." And if you outline those plans for people and give them the tools, now you've equipped them to actually help themselves. This whole game of I'm gonna take an X-ray of you and look, oh, there's one little bone spur, but now I'm gonna scare you into, like, a 40-visit package to my chiropractic clinic or something, that game needs to go away fast because the only thing you're doing is making people feel more frail, more afraid, and you're actually only helping the bottom line of your business. You're not helping that individual. So it's really about empowerment with education.
- PAPeter Attia
W- what is it that you would see when somebody comes in that would make you say, um, "Actually, we need to immobilize you," or, "We need to..." You know, like, what... Is that something that's only gonna be on an exam where you see a motor weakness, for example?
- KBKyler Brown
Immobilize how? Like, put 'em in a boot, or are you saying-
- PAPeter Attia
Uh, well, let's just... let's look at the lower back.
- KBKyler Brown
Okay.
- PAPeter Attia
So if somebody shows up with a lower back complaint to you-
- KBKyler Brown
Mm-hmm
- PAPeter Attia
... what's gonna make you say, "No, actually the answer is, you know, seeing a surgeon or-"
- KBKyler Brown
Oh
- PAPeter Attia
... um, "complete and total rest-"
- KBKyler Brown
Yeah
- PAPeter Attia
... or, you know. H- how are you... What is kind of your algorithm on people presenting with lower back pain?
- KBKyler Brown
Yeah, I mean, low backs are great. So number one is, and, and for the neuros out there, if there's weakness or you don't have bowel or bladder function and things like that, right away, get evaluated, right? Because the way nerves work, if, if there's pressure on nerves, it could, over time, create permanent damage. Now, a lot of nerve pain is sensory, right? It's that electrical sciatica-type stuff. It's that tingling and that weird thing like that. But the real number one that you look at is do they have weakness or do they have loss of some sort of, you know-
- PAPeter Attia
Control
- KBKyler Brown
... foundational control, right? That's when you gotta get integrated with neuro and orthos right away. Um, if we don't have that, now you're in the, like, decision-making domain, right?
- PAPeter Attia
So this means you're, you're gonna do the rectal exam, make sure-
- KBKyler Brown
[laughs] Yeah
- PAPeter Attia
... sphincter tone is there.
- KBKyler Brown
Yeah, exactly right. [laughs]
- 1:29:20 – 1:32:08
Could AI eventually deliver an individualized rehab & training experience?
- KBKyler Brown
the human body's meant to move
- PAPeter Attia
Do you think this is scalable? I mean, I, I feel fortunate that, you know, we're able to take care of people where we have the luxury of doing this very bespoke approach
- KBKyler Brown
Sure
- PAPeter Attia
And yeah, you can, you can, you can integrate your strength and conditioning with your cardio, with your PT rehab, and all that stuff-
- KBKyler Brown
Yeah
- PAPeter Attia
... and it's all, it's all great. But, like, do you see a day when this could all be app and AI-driven, where any sing- any person out there, um, with any set of lower back symptoms could be provided with the feedback that they would need to, to take care of themselves?
- KBKyler Brown
If they execute, absolutely
- PAPeter Attia
How would you get the feedback? I mean, is that basically... Is it just, I just have to have good enough image recognition software that... Is, is that, would that be the, would that be a necessary step, that if you were using such a device, like an app-
- KBKyler Brown
Mm-hmm
- PAPeter Attia
... you would have to be able to set up your phone on a tripod to be at least-
- KBKyler Brown
Yeah
- PAPeter Attia
... able to capture you doing it? 'Cause the advantage of being able to do this the first few times with an actual person like you-
- KBKyler Brown
Mm-hmm
- PAPeter Attia
... is the cuing is so important.
- KBKyler Brown
Yeah
- PAPeter Attia
A lot of these exercises are not, um, they're just not natural
- KBKyler Brown
Yeah. Well, especially if you're that person who's suffering from that injury, then odds are you didn't perform these exercises well subconsciously, so that's what set you up for it, right? What, what is interesting is the, the video recognition software is getting fantastic. I've, I've demoed a few now where they're... Like, the AI is actually watching someone do movements and saying, "Hey, you know, this was too far out that way," or whatever. But that also goes in the bucket of everyone moves differently, right? Like, my femur length is different than yours, so the angles with which I'm gonna lunge are gonna be a little different. And so this idea that if you take principles and you know the symptoms and then most importantly you know how people react to really conservative loads, that almost tells you more than did their tibia rotate three degrees or not. I could care way less-
- PAPeter Attia
Yeah
- KBKyler Brown
... about three degrees of tibial rotation based on AI software and care way more about, "You know what? I did these lunges in this setup, and we activated some neuromuscular reaction to where my glute fired a little bit better. My knee felt way better," right? And then when people give us that good kind of f- qualitative feedback, now you know how to trim up that program. So I think the AI part of it's gonna be more that. It's gonna be less about, oh, what degree did it move, but more about how did you respond to each drill that's safe, and then we go from there, right?
- PAPeter Attia
Yeah, agree, and that's where ... training the AI is much more nuanced and complicated.
- KBKyler Brown
100%, 100%.
- PAPeter Attia
Yeah, image recognition is one thing, but it's-
- KBKyler Brown
Yeah
- PAPeter Attia
... knowing what to do with that information.
- KBKyler Brown
Yeah. Knowing am I gonna do an overhead dumbbell and a DNS three month and all these other nuances versus the legs, right? Like, there's certain cases that I'll do that one for one and the other for another, and it's, it's really a matter of knowing what you got to start with, and then we test it a little bit, and then we test it a little bit more. And then the outcomes are dictated by how do they respond to that exercise.
- PAPeter Attia
And
- 1:32:08 – 1:38:22
Kyler’s professional evolution from traditional chiropractic care to a performance-based rehab philosophy
- PAPeter Attia
why did you kinda gravitate towards this? I mean, we didn't really get into kinda telling people your story, but-
- KBKyler Brown
Sure
- PAPeter Attia
... you know, you went to chiro school.
- KBKyler Brown
Yep.
- PAPeter Attia
But then you immediately went out and did a sports medicine thing. You-
- KBKyler Brown
Yeah
- PAPeter Attia
... went and worked with the New York Giants. Um, why did you just opt into kind of the role you're doing now, which is much more in the PT rehab space-
- KBKyler Brown
Yeah
- PAPeter Attia
... than it is the r- what people, I think, assume of traditional chiropractic, which is here's a, here's a 40-adjustment schedule, uh-
- KBKyler Brown
Yeah
- PAPeter Attia
... you know, uh, y- you know?
- KBKyler Brown
Yeah.
- PAPeter Attia
And, and, like, I'm gonna crack... And, and again, I, I d- I don't have a point of view on that, but-
- KBKyler Brown
Sure
- PAPeter Attia
... but, um, w- well, yeah, what drew you more towards the, the side of things you're on now?
- KBKyler Brown
Yeah, I mean, I think it speaks to a bigger thing which, um, I'm really degree-agnostic in the sense that I, I hope someday in the future there's, like, a, a more clear, uh, certification or degree where there are chiros and PTs and, frankly, strength coaches. All three of those people I would trust way more to do a rehab and get someone better. Like, who would I send my mom to? I would send my mom to all three of those people if they have certain skillsets and, like, approaches, right?
- PAPeter Attia
Independent of degree or-
- KBKyler Brown
Yeah
- PAPeter Attia
... credential. Yeah.
- KBKyler Brown
Totally, 'cause, you know, the chiro degree was my baseline training. That's where my license is and all that, but the traditional view of what chiro is with the manipulations and the adjustments, like, you know, that's 5% of our week at my practice, right? We, our practice, we have chiros and PTs, but you can't really tell who's who because everybody's doing what we call is active rehab. So one of the things I always tell people, I don't care what their degree is, but if you're going to a rehab clinic and it's one-to-one relationships, so it's not group, but it's one-to-one, and they've got a bunch of weights in there as well as your traditional bands and stuff, now that's an indicator, okay, these guys are gonna build me back up to something actually strong, not just, like, make me come in here forever and do rehab purgatory where I do the same micro-drill over and over, right? Like, we gotta build over time. So I'm really agnostic to a degree, but yeah, that said, my story, I basically tried to create a residency for myself right out of chiro school, and back then it was really manual therapy based. I learned a ton. Um, we were... I was by far the lowest guy on the totem pole, which we all know how that works. Lot of time, lot of learning, but I was there to soak it up. And everyone always thinks that, like, pro sports is the top, right? Um, and it is in a lot of ways, but it wasn't really for me f- in terms of an official team relationship because I just didn't like that personal schedule, and it was pure chaos. Like, you'd spend a week fixing somebody up, and then they'd go out there and get blasted again, and you're like, "Oh, that's a bummer." It's kinda like when my son builds his tower of magnet tiles and then his sister knocks it over. It, like, the look on his face was me every Sunday.
- PAPeter Attia
[laughs]
- KBKyler Brown
[laughs] Um, so I really enjoy the off-season side. I really enjoy more the project. Um, and I really, like, realized early on that when you're only doing pain relief manual therapy work, there's a lot missing, right? We're not building people up-
- PAPeter Attia
Right. It's not active
- KBKyler Brown
... we're strengthening them. Yeah.
- PAPeter Attia
Yeah.
- KBKyler Brown
So that's when I just started doing this deep dive as much as I could and learning from as many people as I could about the foot and balance and, and neuromuscular training and all these other things to where, you know, it's a compliment at my private clinic when people are like, "What are you?" Like, we actually have people come in our office now who are like, "I need to go see my chiropractor later," and one of my other docs will be like, "Well, I'm a chiropractor." They're like, "What? I had no idea," and they've seen us for years. So we're probably supposed to identify ourselves better, but the regardless, we're solving problems.
- PAPeter Attia
Uh, what is the role for what most people think of when they hear chiropractic, right, the adjustments?
- KBKyler Brown
Yeah.
- PAPeter Attia
Like, um-
- KBKyler Brown
What does it do?
- 1:38:22 – 1:41:27
How 10 Squared provides precision rehab & training in a remote format
- KBKyler Brown
and making them stronger.
- PAPeter Attia
Okay, so let's kinda put this now all back together, right? We've kinda gone really deep down one of the-
- KBKyler Brown
Sure
- PAPeter Attia
... three pillars. Um, y- you now have c- basically two things you're trying to do. You're trying to do everything you're doing in concert with a broader agenda of creating a precision training program, not an exercise program, not a workout program, a training program for an athlete whose sport happens to be life.
- KBKyler Brown
Yep.
- PAPeter Attia
And you have to be able to do it with the strength and conditioning coaches, the cardio coaches.
- KBKyler Brown
Yep.
- PAPeter Attia
And then the other thing you have to be able to do is you have to be able to do this remote, because most-
- KBKyler Brown
Yeah
- PAPeter Attia
... of Ten Squared clients are remote.
- KBKyler Brown
Yeah.
- PAPeter Attia
As you said, they come to Austin for two days, they do a whole bunch of assessments, they go away for six months, then they come back. Some of them go away for less, but-
- KBKyler Brown
Yeah
- PAPeter Attia
... y- you know, a lot of them b- they just, they go away for a year and they-
- KBKyler Brown
Yeah
- PAPeter Attia
... come back in two months 'cause they're out of the country and it's just not easy for them to be here. So how are you able to do this remotely? What are the challenges, and, um, what, what enables it to, to, to make sense?
- KBKyler Brown
Well-
- PAPeter Attia
What do they, what do they need when they're back home?
- KBKyler Brown
Yeah, that's a great... We get that question a lot because even, you know, before Ten Squared, like some of the athletes I would manage who travel a lot, like a couple of my golfers, you know, they would call me and say, "My back hurts," from the hotel room. And I had the luxury of knowing so much about them and how they moved and what their body looked like. I could take all that and then be like, "Well, what are the symptoms?" We rule out the scary medical stuff, and then we try some exercise, right? And we were able to get a lot of results for these athletes, and they were about to tee off in two hours and compete, right? So we've taken that model, and if we know... When we were designing the assessments at Ten Squared, one of the biggest themes was we need enough time to know as much as we can, right? Like, a lot of people want it to be faster, but we're like, "We need to have... That initial step needs to be so in depth that we are certain about all the factors of how you move and where you're strong and things like that." When I have that certainty and I'm not flying blind, and someone calls me and says, "You know what? My knee's really sore after doing these exercises," we either hop on a Zoom and just talk real quick, and I can actually test them on Zoom, because the exercise is the test. So many people think they need a doctor to do, like, a Lachman's test and pull on their leg. The story, their profile, and then how they respond to the exercise, that is the test. And so we can program exercises really effectively in a remote way to kinda probe the fence or test it, and if it responds the right way, we definitely can fix it quickly. I had a client this week, his shoulder was bugging him. We did a Zoom call, took about 20 minutes. We have our library at Ten Squared. I fired him off a few exercises. He messaged me, he's like, "Feels a lot better." He didn't have to go to the doctor. He didn't have to go anywhere. Now, obviously, if the story was different and I was worried medically, I'd concierge that in the sense of I'd find him someone local and refer out. But if I'm not worried medically and if we think it can respond to load, we're gonna load it, and a lot of times people are shocked that we can make their neck tension go away with an exercise in the same way that if they traditionally got a massage or something they'd get that relief. It has to do with what your body does when things are off, and if you load it, it'll actually respond more because your nervous system's involved as well.
- 1:41:27 – 1:47:52
How Peter resolved a severe back pain flare-up using DNS-guided isometric exercise
- PAPeter Attia
I wanna tell a story on that vein that I... is one of the most incredible experiences I, I ever had. This would've been in 2018 or 2019, and I had kind of the first flare-up I'd ever had of my lower back since 2000, right? When I had my-
- KBKyler Brown
This is surgery
- PAPeter Attia
... back surgery-
- KBKyler Brown
Yeah
- PAPeter Attia
... and all that nonsense. So I'd gone 18, maybe 19 years, maybe it was early 2019, um, without a single flare-up, and then it happened.
- KBKyler Brown
Mm-hmm.
- PAPeter Attia
I get the flare-up, and at the time I was working with this guy, it was my first person I'd ever met who did DNS.
- KBKyler Brown
Mm-hmm.
- PAPeter Attia
Um, and so I would, I had already learned about intra-abdominal pressure. We were doing all this stuff. In fact, when I went to see him, my back was totally fine. It was actually, I had tennis elbow.
- KBKyler Brown
[laughs]
- PAPeter Attia
So I had this tennis elbow-
- KBKyler Brown
Yeah
- PAPeter Attia
... and we, he figured out pretty quickly that my tennis elbow was completely due to my scapular instability.
- KBKyler Brown
Total, yeah.
- PAPeter Attia
And my chief complaint was when I do a lot of pull-ups, my elbow hurts.
- KBKyler Brown
Sure.
- PAPeter Attia
Like, I don't even play tennis, right?
- KBKyler Brown
Yeah.
- PAPeter Attia
So we had fixed all that, but I kind of was like, "This is amazing." Like, I wanna know what else is going on, and then independent of that, I get this lower back flare-up. And so I'm in there seeing him on one day when I'm in, honestly, like, about the worst pain I'd been in in years.
- KBKyler Brown
Mm-hmm.
- PAPeter Attia
Um, by the way, his training, by the way, is also a chiro. So he's-
- KBKyler Brown
Cool
- PAPeter Attia
... a chiro by training who probably hasn't done an adjustment in 20 years.
- KBKyler Brown
Sure.
- PAPeter Attia
Um, just doing DNS.
- KBKyler Brown
Yeah.
- PAPeter Attia
And I'll never forget the exercise he had me do, 'cause I was like, "I don't know how this is gonna work, dude."
- KBKyler Brown
Yeah.
- PAPeter Attia
So he laid me on my back, and he had me get into, like, an imaginary leg press position. You know those old-school leg press machines where you're pressing up?
- KBKyler Brown
Yeah, yeah.
- 1:47:52 – 1:50:55
How to identify & treat common joint pain (neck, back, knee, shoulder) & help avoid surgery
- PAPeter Attia
And so walk us through the framework, 'cause you've got an... I love your framework for how you approach these. So what's the framework?
- KBKyler Brown
Yeah. So first off, you know, kinda that bifurcation we talked about earlier where it, you know, are, do we need to consult an orthopedic or, or neurosurgeon, right? That's number one. So we're gonna assume-
- PAPeter Attia
So how do you make that decision?
- KBKyler Brown
The story, the incident, what it looks like.
- PAPeter Attia
Yeah.
- KBKyler Brown
Like, if we're talking knee, if, you know, they're a soccer player, they twisted it really weird yesterday, it's all swollen on the joint line, I'm more worried about the joint. If, conversely, if it's a runner where it's been kinda off and on for a long time, no acute incident, no joint line swelling, the pain is kind of vague, those are two very different presentations. So one's gonna be more, like, ortho consult, one's gonna be like, "Let's, let's tinker around as a rehab pro and see what we can do," right?
- PAPeter Attia
Yeah.
- KBKyler Brown
Um, so that's the first bifurcation, is basically playing doctor and being like, "What's the right path?" The other thing I really wanna encourage is that the best orthopedic surgeons in the world, like you spoke to earlier, they don't wanna do surgery or inject everyone right away. They're referring out all the time. And a lot of clinics nowadays have, like, a physical therapy clinic in-house, and there's all kinds of constraints with that. And the best orthos don't just give someone a list of every PT clinic in town. They're actually referring to different clinics based on that clinic's strengths and experience, right? Some clinics specialize in running, some specialize in strength training. Like, if your ortho is specifically searching out different PT clinics, that's a huge win and it's a great sign they know what they're doing. If they just give you a handout and they're like, "Go call somebody," that means they think all PT is the same and all rehab's the same, and it's not, right? So that's number one. Once we've got past that bifurcation of knowing that it's a rehab case, then the protocol really turns into, what is the safest and smartest way to create a change? W- maybe it's a manual therapy, maybe it's dry needling, maybe it's one of those treatments we spoke to earlier, or maybe it's a strategic load. That decision is a lot of times based on the patient's comfort, like how you read the room. Are they, they like cattle rancher dude who wants to push through pain and they're gonna go back to work tomorrow, or are they someone who's really scared 'cause their pain is high, right? We gotta build trust. We gotta get them some sort of pain relief to show that we're medically being responsible and making sure we're going the right direction. But then once we've created that change, then we start to load it. A lot of times, uh, if I have a joint that I know is permanently compromised, let's say someone with total knee replacement, I'm not gonna actually beat up the knee a lot. Traditional insurance-based rehab is gonna go after that joint 'cause that's the code that's associated with it, and they know they're gonna do that really well. What I'm gonna go for first is the foot, the ankle, the hip, and their pelvis in general, because if there's a lot of low fruit there, I can enhance the pelvis strength or the foot strength, and I can actually buffer that knee to where it doesn't have to work nearly as hard, and those people get a reduction in symptoms overnight.
- PAPeter Attia
Kyler, this was really a ton of fun. Enjoyed sitting down with you. It's not normal that I sit this far from you.
- KBKyler Brown
[laughs]
- PAPeter Attia
Uh, but at a distance, you look just as, as, as, as great as ever.
- KBKyler Brown
Devastating as always. [laughs] Thanks a lot. [upbeat music]
Episode duration: 1:50:55
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