Ned Dowling: I don't know. They're dead. Um, maybe they may, as much as you know, as much as I've harped on pain, pain is there for a reason, right? It keeps us from doing things that would cause harm. I'm guessing that zombies, being dead, don't feel any pain. So, they're walking around in this really, like, inefficient, stumbly, whatever thing, and they don't know any better because they're not getting that feedback from their nervous system to tell them that they need to do things any differently.


Carolyn Ford:Happy Halloween. We're going off-script a little bit today to talk about the ultimate machine. AI and robotics have spent decades chasing what your body does without thinking: grip, balance, dexterity, self-repair. A robot needs about 5 minutes to fold a t-shirt, and a new fabric stumps it completely; I can do it in under 4 seconds. In the robot Olympics, the sprinters are fast, right up until they literally hit a wall. So, the most advanced machine you own is the one you're sitting in, and most of us never read the manual.


My guest is Ned Dowling, physical therapist and director of the Cyclist Clinic at University of Utah Health. We get into why rehab always takes longer than you think, and what's actually wrong with zombie posture. 10 years ago, Ned fixed my knees by fitting my bike, so I asked him what was really going wrong. He started with the one rule that explains almost every ache you've ever had.
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Ned Dowling: I should probably start with, like, my guiding philosophy as a physical therapist, and that has become also as a bike fitter. The root cause of all musculoskeletal symptoms, I think, is ultimately an imbalance between load being placed on the body and the body's ability to tolerate load.


So, when we ride a bike, we have load. We have load from pushing on the pedals to make ourselves go. We have load from what the bike does to us biomechanically. So, as we go around the pedal stroke, our feet are on the pedals, but our butt's still on the saddle. So, what happens to the body as we go around the pedal stroke? What happens to the body, or what does the bike ask us to do, and what is our solution to sitting on the saddle and reaching out to the handlebars?


So, in traditional physical therapy, we tend to focus a lot on the tolerance side of things. So, that's helping the patient's body adapt and become more able to withstand loads—better capacity. That could be a strength thing, a balance, a stability. Sometimes it's just tissue tolerance for load. So, traditional PT, we work very much on the tolerance side. I approach the bike fit from the load management side.


So, without going back and looking at my notes from our visit, was it really 10 years ago?


Carolyn Ford: I think it was. I think I've known you for 10 years, Ned.


Ned Dowling: Okay. No, I do not remember what was going on exactly or what I did to the bike to make it better, but that's kind of where I'm approaching the bike fit, as I said, from that load management side of things. So, I, as a bike fitter, I'm not looking at performance or aerodynamics as my primary thing. I might have those in mind depending on the patient that I'm working with, but I'm trying to make the bike more biomechanically efficient. And that's not necessarily a physical therapist bike fitter approach; that is kind of the approach that most bike fitters are going to take anyway. But whatever it was that we saw in your position on the bike, there was something that I didn't like and there was something that I changed. And if it worked, then it tipped that balance where it decreased the load enough that your tolerance then was above that threshold, and you were able to go out and do your rides and not have your knee pain.


Carolyn Ford: Yeah. And when I get knee pain now, I remember the things that you told me. I have to place my feet at a very particular spot on the pedal. You also made some adjustments to where my saddle was in relationship to my handlebars, and it did—it made a big difference.


So, let's talk about our audience. A lot of our audience is like me; we sit at our desk most of the day and look at a screen. So, let's talk about what's happening with the knees from sitting. The transition from sitting to standing to walking—even if it's not that they want to go out and ride a mountain bike, they just need to be able to walk after sitting all day without pain. What should we be doing as we're sitting all day?


Ned Dowling: Uh, not sitting all day! That might be the first thing that you should be doing.


So, yeah, I'll back up a sec and kind of revisit this load versus tolerance philosophy that I sort of said, "Well, that's the root of all musculoskeletal symptoms." Well, generally, musculoskeletal symptoms are pain, right? People come in to physical therapy or they go see their doctor because they're having pain, and pain is ultimately a defense mechanism. It's a body's way of keeping us from doing stupid things or from doing things that would cause harm to the body. And self-preservation is pretty high on our list of human priorities.


So, when load exceeds tolerance, the body is going to perceive that as a threat, and so that threat will elicit a pain response. That's nerve receptors from a part of the body communicating with the brain and saying, "Hey, I don't like this. Make them stop." And so that pain often gets us to stop doing things.


So, on the low end of that spectrum of load exceeding tolerance, something hurts. There's no tissue damage. If we take you and get an MRI, we're not necessarily going to see any indication of an injury. On the high end of that, there's injury, right? If there's a lot of load put on the body, then we break bones, we tear ACLs, we have bigger issues.


So, in something like knee pain that develops while you sit for a long period of time or when you get up after sitting for a long time, on a very basic level, it's a nervous system response, and the body is saying, "Hey, I'm not so sure about this." On a more biological, physiological level, we could look at it and say, well, a joint that is not moving is "drying up." And that's a somewhat appropriate, somewhat metaphorical way of saying that our joints get most of their nutrition from the synovial fluid that is sloshing around inside the joint.


So, the old saying of "motion is lotion" means that joints moving keeps that synovial fluid moving around. It's covering all the cartilage inside the joint and getting nutrients to everything. If we're not moving, then that synovial fluid is not sloshing around. And "the joints can get dried up" is the wrong term because they're not actually drying up, but it then makes them less ready to handle load once we do get up.


If we're sedentary, our muscles aren't doing anything, and so we ask them to go from 0 to 60—from doing nothing for hours on end to now all of a sudden they need to support our body weight as we get up and move around. So, more than anything, the knee pain is just a bit of a shock to the system that it's not quite ready for, and it's just saying, "Hey, hold on a moment. I'm not quite ready for this."


Carolyn Ford: So, it's like when we first get up in the morning, you know, we're feeling a little stiff in the lower back and the knees. And I sound so old because I never used to feel this way, but it's because we just need to—it goes away after being up and moving for a little bit. So...


Ned Dowling: Yeah, and that is pretty darn normal. We don't think it's normal because when we were 20, it didn't do that. When we were 30, we feel our bodies didn't do that. But, you know, we get into our 50s and there it is, and it's probably going to be like that, if not more so, the rest of our lives. But it's not necessarily an indication of anything that's wrong; I think it's just a normal part of the body getting older.


Carolyn Ford: All right. Well, let me go back to—you said don't sit all day. So, I've got a standing desk that goes up and down. I've got a treadmill belt that I move up and down, back and forth, because usually my body will tell me—it's usually my butt that starts to hurt, and so that's when I know it's time to stand up. What do you think of—what's the best way to remind yourself to move?


And along those same lines, you remember a few years ago the saying going around that "sitting is the new smoking"? I would really like you to weigh in on that one. Should I just take up smoking since I'm sitting all day?


Ned Dowling: Yeah, and all the other things that you could do that are correlated with disease and not necessarily causing disease. But, yeah, my standard recommendation for people who are welded to a computer all day is to change position frequently. So, being able to go between sitting and standing every 30 minutes. And that is very much going to require a timer—an alarm going off—because you're not going to think to do it that frequently.


Most people who have a standing desk will sit until they can't take it anymore, and then they'll stand until they can't take it anymore, and then they'll sit until they can't take it anymore. And the problem with doing that is if your body is telling you that it's ready to change position, you've already pushed it too far. Your butt is not hurting—like you wouldn't call it pain—but it's still nerve receptors that are sending that signal to the brain that's saying, "Hey, tell her to move. This is not good. We don't like this anymore. Tell her to do something about it."


So, if you push it to that point, then you've already pushed the body a bit further than it really wants to tolerate that load. So, we try to break it up. And I don't know that standing is necessarily better than sitting; it's just different than sitting. And when you're at a computer, you don't have a whole lot of choices on how you can stay at the computer, be productive, but yet still do things that are good for your body, because our bodies like to move.


So, if you're changing position frequently, I think about it as like if we're in the gym, we're going to do sets of repetitions of an exercise, right? We're going to do bicep curls or back squats, and we're going to break it up into, let's call it, three sets of 10 repetitions. And we're going to break it up like that because you can do more work, heavier weight, if we break it up into three sets of 10 than if you go 30 repetitions all the way through, because you're going to fatigue out a lot faster if you go 30 repetitions all the way through versus stopping after 10 and taking a couple minutes to recover, and then stopping after another 10 and taking a couple minutes to recover.


So, each time you change position, it's a different stimulus on the body, or a different load on the body. So, it can recover. I don't know, your butt can recover from sitting while you're standing, and then your feet can recover from standing while you're sitting back down.


It also, I think, changing position that frequently is going to catch you if you drift off into a posture that I'm going to call a high-load posture. I'm not going to say that there's necessarily a good posture or a bad posture, but you know, the kind of slumping, and I could be on my mouse and...


Carolyn Ford: I know it well!


Ned Dowling: ...and yeah, so, you know, even if we're standing, we can drift into that, but then your alarm goes off and you change positions and you get yourself all sorted and start out pretty good, and then it kind of drifts off with time. But if you can stay out of that higher-load position, or you spend less time in that higher-load position, then the accumulated effect over the workday is a bit less.


Carolyn Ford: So, you recommend literally setting a timer, like every 30 minutes, and the timer goes off, you change positions?


What do you think about the walking—the walk? Like, I've got the treadmill belt that I move up and down. Or even—I tried the pedal things that sit underneath my desk; I hated it, that immediately got donated. But I do like the treadmill.


Ned Dowling: Yeah, I've never used one. For better or worse, my job, I don't sit still long enough to need one. I'm not sure how well you can walk on a treadmill and, like, use the keyboard and the mouse at the same time.


Carolyn Ford: You have to do it very slowly, Ned. Like, literally two miles an hour. It's super slow. I often will do it during meetings. It also helps me stay awake.


Ned Dowling: Yeah. So, I mean, if that's the thing where you're having a conversation, you're in on a meeting, you're not having to be active at the keyboard and the mouse, I think that that's a great idea. You know, if you have the option of being on your meeting on your phone and getting outside and walking during the meeting, I think is great. Or if you're on phone calls, to get away from the computer and move around.


You know, that's kind of the other strategy I've heard called, like, "exercise snacks." You're not going to be able to get away from your desk for an hour or two to go to the gym or to go for a walk or a run or a bike ride or something, but you could get away and do 10 minutes of exercise and then come back to your computer. And that could be things that you don't need a whole lot of equipment for: squats, step-ups on your stairs—something simple, but something to just get the body moving and get it away from that static positioning.


Carolyn Ford: You know, I used to do walking meetings all the time until Zoom came into vogue, and then when it really got bad was COVID when everybody went to work from home. So, there's like at a lot of companies there's a rule that you have to be on camera, and so those walking meetings went away for me. And it's been—I need to figure out how to bring those back because they were actually really productive. I think better when my body's moving. I can't do it for all meetings, but they were really good. So, I need to bring the walking meetings back.


Ned Dowling: Yeah, I think that's a great idea. I actually would have thought that with the switch to all this remote stuff during the pandemic that it would have allowed for more movement. But because you've got to be on camera...


Carolyn Ford: Yeah! I used to take people with me in my ear all the time. I would walk, and I haven't—I rarely do that anymore.


What about when you—is there a difference between men and women rehab time recommendations for certain injuries? Does it matter?


Ned Dowling: Yes, no, maybe. In my mind, it's very individual. I think about the individual in front of me in the clinic much more than I think about male or female, or an age exactly, or an occupation, or an activity level. Those things are all—I'm going to take it all into account, but it's going to be on an individual level.


So, in a very general sense of, like, male versus female, we have some statistics of like ACL tears. Women tear ACLs at a much higher rate than men. They also re-tear ACLs at a higher rate than men. Have—do we know why? No, we've yet to figure that out. There are theories, but we're also not very good at predicting ACL injuries in the first place. So, we've yet to really draw anything better than correlations. We certainly have no known causality of being able to identify who's going to tear an ACL and who's not.


But if I have someone who—maybe I'll frame it this way: We are in Salt Lake City, Utah, which is a huge ski destination, and we see a lot of ski-related injuries. Skiing is very good for business in the physical therapy and orthopedic world! So, we kind of have a lot of skiers with ACL tears, unfortunately. Then we have patients who have had an ACL tear, and typically surgery, who are not skiers. They're kind of what the rest of the country is going to see, which are predominantly cutting sports: soccer, basketball, volleyball, ball sports, cutting sports—not skiing.


So, to me, the difference there is the skier who tears an ACL, the biggest cause of that is unlucky. They're skiing down a hill, they've got this big long ski that is attached to their boot with a binding that may or may not release, and they make a mistake and they fall, and...


Carolyn Ford: You don't even have to make a mistake, Ned! You just catch an edge like every time. It's never my fault.


Ned Dowling: That is—that is unlucky, right? Unlucky! You catch an edge, you twist that—that ski turns into a gigantic lever arm, and it twists the knee and you blow out your ACL. There was nothing that you inherently did wrong. Now, maybe you could be better as a skier, or maybe you shouldn't have taken that last run down the hill when you were tired, but everybody said, "Let's do one more run," and you went for it. But I generally consider those unlucky. So, we're basically starting from scratch, and we need to rehab you.


The athlete who comes in with a torn ACL from dribbling the ball down the court and planting the foot to change direction, and the knee kind of collapsed in and it overloaded the ACL and that tore—that was the athlete's fault. Nobody knocked into them, nobody kicked them in the knee. It was a non-contact injury. They lacked the movement coordination, control, and strength to prevent that knee from collapsing and that ACL from tearing.


So that person, we don't need to get them back to where they were before injury; we need to get them better than they were before injury. The skier, we could probably get them back to where they were before injury and that would be fine.


So, that's kind of an example of how I'm going to look at the individual who's in front of me, more so than a male/female thing.


Something that may play into the male/female thing a bit more is we're finally getting research on the effects of menopause on musculoskeletal symptoms. And what we're seeing is that menopause sucks and it ruins everything. Pretty much, that is what the research says!


Yeah, the changes in hormones in your body are affecting not just your hot flashes, and your emotions, and your ability to sleep, and all the things that I will politely say my wife is not dealing with right now, but it can also affect your muscles, your tendons, your joints. And that is going to decrease your body's tolerance for load.


So, that's not a—how should I put it? It's not a coffin nail, but it's something that we need to take into account, and we need to be aware of, and that means that we probably need to do even more work from a load-tolerance side.


I think for some women, it's another reason for them to look into hormone therapies. As a physical therapist, I'm not sure that I would recommend hormone therapy purely based off of musculoskeletal symptoms that may or may not be strongly influenced by menopause, but if it's one of multiple things, then it's probably worth considering.


Carolyn Ford: So, you're saying hormone therapy helps support those joints that might be getting weak during menopause? The show just went down a whole new route!


Ned Dowling: I mean, that is some of the theory, and I wouldn't use the word "weak"; I would say "decreased tolerance for load." So, what does that mean physiologically? I'm not sure, because I'm not so sure that we know this yet. We're doing enough research to see this link between menopause and an increase in musculoskeletal symptoms, but we don't have direct causality yet to say, "Oh, as your estrogen decreases, then your joints become more arthritic." We don't have that connection.


So, again, that's where I try to frame everything in a load versus tolerance thing. If the changes in hormones are going to affect tolerance, then the body's just going to be more susceptible to load. And again, when load exceeds tolerance, then it's going to trigger a pain response.


Carolyn Ford: Hormones aside, men or women aside, I'm just thinking about like when I go to the gym. So, there are some days where—rarely anymore—I don't feel my knees when I'm doing lunges. But I've wondered, especially lately, like when I'm doing lunges specifically, and it hurts sometimes, and I keep doing them. Is that good or bad? Like, when do I listen to my body that's saying stop? Like you said, pain is a security measure for us. But I don't want to stop moving, so where—how do you find that balance?


Ned Dowling: Right, and exercise doesn't need to be pain-free, exercise doesn't need to be painful. It's not necessarily a "no pain, no gain" thing, or there's a difference between musculoskeletal pain and suffering.


Like with endurance athletes, I try to draw this distinction, because people who get on their bikes and ride for hours up the canyons around here, or go out for long hard runs, you know, we're kind of in that because we want the heart rate to be through the roof. We want to taste blood, right? We want to suffer. That's very different than your knees hurting when you do lunges. The suffering goes away as soon as we stop. Now, the pain in your knees might go away as soon as you stop as well, but both of those are really the body trying to tell us to stop doing things, right? Like, even when you're pushing hard on the bike, and your heart rate is up there and you're suffering, and you start having those thoughts of like, "Why am I doing this?"—you know, that's your brain trying to get you to stop, just in a rather roundabout way.


But in a lot of exercise, I would say a small amount of musculoskeletal pain that calms down within a couple hours is not a big deal; I wouldn't worry about it. But it needs to be only low-grade pain, and it does need to calm down pretty quickly. That pain is something that we would like to mitigate, we would like for it to go away, we would like to be able to build up the tolerance to be able to do that exercise and not have the pain.


It may be that the exercise that you're doing is too hard. It may be that the way that you're doing that exercise is putting additional load on the knees that doesn't really need to be there, so that's kind of a form thing.


It's tricky in our setting as physical therapists because, again, I can sit here and tell you that, "Oh, this is a load versus tolerance thing, and we need to improve your body's tolerance for doing lunges." And you say, "Okay, how are we going to do that?" And I say, "Well, we're going to do some exercises." Well, exercises are load, right? So, I'm telling you that the answer to improving your body's tolerance for load is to load the body.


But we need to do it in a fairly Goldilocks way. If we make the exercise too hard, if the porridge is too hot, then your body's not going to like that, and load is going to be exceeding tolerance by a fair bit and it's going to complain. If we undercook it, if the porridge is too cold, if we don't make the exercise hard enough, then we don't get any adaptations in the body.


So, ultimately, what we're trying to do with exercise is stimulate these adaptations that then lead to improved tolerance for load. So, I would probably tell you, if the pain with lunges is pretty intermittent—one day is totally fine, another day is kind of painful, and there's not really any pattern to it—as long as that pain is low-grade and it calms down quickly, then I would continue with the exercise. If it's the sort of thing where every single time you do the exercise, it's painful, then we need to either ditch that exercise or change how you do it.


Carolyn Ford: All right. I want to go back to—you mentioned posture and how switching positions reminds you to either stand up straight or sit up straight. Honestly, just being on with you, I'm like, I've got to sit up straight cause he's my PT, he's going to see if I'm slouching!


But what about other things, like the big—what are the big balls that they sit on? What are—not Bosu balls?


Ned Dowling: Oh yeah, like a physio ball, or Swiss ball, or exercise ball.


Carolyn Ford: I hate them! Like, I can only tolerate them for a few minutes, and I finally just—I was like, "No, I'm not doing that." So, is there something that you would recommend other than regular movement? Like, what myths are there about posture? What do you recommend? What should your posture be?


Ned Dowling: Yeah, the explanation that I will often use, or the analogy that I will use, is if you pick up a bowling ball and you grab that thing with three fingers, right? As long as you hold the bowling ball right over top of your forearm, it's really easy to hold on to. But as soon as you tip that thing forward, it becomes really hard to hold.


Our heads are kind of the same way. So, as long as the head is stacked over top of the spine, it's pretty easy for our bodies to hold this thing upright. But as soon as the spine starts to flex and the head tips forward, it now becomes a lot harder on the body to hold the head up.


Carolyn Ford: So, correct posture is all about keeping the head sort of stacked over top of the spine, right?


Ned Dowling: Yeah.


Carolyn Ford: But I get tired in like my belly, and I want to slouch!


Ned Dowling: Yeah, so that becomes the—you know, in physical therapy, we have long been accused of being the posture police, and there was a time when we blamed posture on everything. And I don't think that posture is—posture is load, right? So, there are people who can slouch all day long, and they don't have any problems. Maybe they will down the road, but for now, like, they don't have any problems, so I can't really complain about that.


It becomes, again, a load management thing. So, things like the really swank ergonomic chairs, they're going to help support the body to maintain that kind of more neutral alignment. Sitting on the physio ball will force you into that neutral alignment, because if you start to slouch on that thing, the ball will just kind of dump you, right?


But like, the difference between those two things: the ball is making you do all the work, so your core muscles, your postural muscles, have to work to keep you in that position. And it's something that you have to train.


Carolyn Ford: Give me ripped abs if I do it every day?


Ned Dowling: Yes, guaranteed or your money back!


If that's buy-in, then take it. It will make you stronger because you have to hold yourself up, but you're not going to be able to pull the ball out of the closet, and then sit in front of your computer all day tomorrow, and feel totally fine with it. Yeah, you're going to be cooked after an hour, because your body is not used to that kind of workload being put on it.


So, if you spend 10 minutes on the ball, and then stand, and go to the chair, and then go to the ball, and kind of not only have your sitting/standing routine, but then mix sitting on the ball in with that as well—you know, you start with 10 minutes at a time, but do it five times through the day, and then you add five minutes each day. Maybe then you get to where you can spend half an hour, 45 minutes or something on that ball and be comfortable with it. I would still want the timer to go off and you stand up for a bit, even.


So, the other chairs that you don't see so much anymore, but they were kind of popular in the, I guess, in the '90s, were those kneeling chairs.


Carolyn Ford: Oh, that didn't have a back to them!


Ned Dowling: Yes, those things were great. I don't know what happened to them, I don't know why they went away, but they were great because they really put you into that neutral position, but by having the shins up against the pad, it allowed your lower body to do some of the work to keep you there.


Carolyn Ford: All right. All right, well, we're going to take a break and thank our sponsors, and we'll be right back.


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Carolyn Ford: Welcome back. I'm here with Ned Dowling, physical therapist and director of the Cyclist Clinic at University Orthopedic Center. Before the break, Ned walked us through my knee story, how a bike fit adjustment kept me on the trail instead of off of it, and we busted some myths about posture and workplace ergonomics. And coming up, we're going to get into my shoulder rehab and everyday habits that actually keep a body durable... and what Ned is seeing in real...




Coming up, we're getting into my shoulder rehab and everyday habits that actually keep a body durable and moving.


All right, Ned, we are in the middle of rehabbing my shoulder. This is an old—this is another old bike injury. This happened—you looked it up—three years ago. It didn't even hurt when it happened. I remember very specifically what happened: I took a sharp turn, I came off my bike—I don't even know how—and I barely, like, tapped down. I don't even remember coming all the way off my bike, I remember tapping down. And a few days later, my shoulder was just killing me. We rehabbed it, it got better, and then this summer it flared back up. I mean, and we're talking about pretty typical injuries: knees, like joints, right? Shoulders—you rehab this injury all the time.


Okay, so when you're rehabbing any injury, but let's talk about these typical ones like this shoulder injury, what's a typical rehab time? What should people expect? Like, how fast should it heal?


Ned Dowling: They should expect it to take a lot longer than they think it's going to take; that's probably a good starting point. It's a question everybody wants to know: "When's it going to get better?"


And I think when I came out of PT school 20-plus years ago, we had these timelines. We would think about everything in terms of biological healing. So, we would say, "Okay, a muscle injury, you know, those heal pretty quickly, that have good blood supply—six weeks to where it's feeling pretty decent, and 8 to 10 weeks and you're probably really good to go." A tendon injury, that's going to take a bit longer. Tendons have less good blood supply. We're looking at 12 weeks minimum, maybe 16 weeks. And we framed it very much in this biological context.


I hate to sound like a broken record, but I'm going to keep coming back to this load versus tolerance thing, because I'm not chasing necessarily a biological healing thing; I'm chasing a tissue tolerance thing. So, in the case of a tendon that's gotten irritated, we just need that tendon to be able to handle the load that's being put on it and not complain about things. So, whether that means that we're going to see changes, like if we do an MRI before we start rehab and then an MRI sometime down the road, are we going to see changes in that MRI? Maybe, maybe not.


I'll use the example of myself: A few years ago, I had a muscle strain in my calf, my soleus muscle. Had a little tear in it from running, and I went to see one of our sports med docs to do ultrasound imaging of it. The ultrasound he could do in the clinic is cheap and easy versus getting an MRI. And I was pretty sure what happened, cause, you know, I'm a good physical therapist, so I diagnosed myself! But when I saw the physician and he did the ultrasound, he was like, "Yep, okay, there's the tear." I said, "Okay, I'm going to be a good physical therapy patient, and it's a muscle, so 6 to 8 weeks, I know this is going to be doing better." I said, "So should I come back and see you in six weeks and we'll ultrasound it again, and if the tear is gone, then I'm good to run?" And he said, "No, the imaging doesn't mean anything with regard to symptoms." He said, "You could come back in six weeks and we could ultrasound it and we could still see a tear, but you could be running without any pain. Or the tear could be healed, but yet you still have pain when you run."


So, the imaging gives us some information, but it doesn't tell us how the body is going to respond to things. So, again, we're just looking for improvements in tissue tolerance and how it's going to handle load.


So, I have had patients come in with shoulder pain, and I give them a few exercises, and they do those exercises diligently. They come back in a couple weeks and say, "My shoulder pain is significantly better."


Carolyn Ford: Mm-hmm.


Ned Dowling: Hey, that's great. I can do the same thing to somebody with very similar symptoms, give them the same sorts of exercises, they come back in two weeks and they're mad at me because the exercises made their shoulder worse. I'm like, "Okay." In that first patient, we got the prescription right; we gave the body just enough stimulus to create the adaptations to be able to handle load better. In the second patient, I overcooked it; the exercises that I thought would be okay ended up being not okay, and the body didn't like it. So then we have to kind of recalibrate and figure out a different path forward.


So, it's really—it is the question that every patient that I see wants. They want to know, "When am I going to get better?" And I don't know! I can try to ballpark it, but generally, I just don't know.


Carolyn Ford: I did yoga teacher training about 20 years ago, and during the training, they said an injury you should plan on about a year to recover. And I just thought that's insane, there's no way that an injury is a year! And I'm one of your chronic patients; you're constantly helping me rehab something. It just seems to, like, rotate around my body. But a lot of my injuries, it is honestly about a year.


And the other thing that I've learned from you is I don't ever get mad at you if the rehab doesn't work, but I've learned that, you know, we try something for a few weeks—usually you have me do it for a couple of weeks. And that's the other thing: I'm a very good patient, I do my rehab, and if it doesn't work, then we try something new and see if it gets better.


But what about preventing these injuries? Are there everyday habits that we can do, especially for the knees, and shoulders, and lower back? Would you say those are like the number one injuries that you rehab for?


Ned Dowling: Yeah, that's probably the bulk of it. Knees, shoulders, low back, and neck are probably the top ones in there.


Carolyn Ford: So, what are some everyday habits that people can adopt to maybe help prevent the injury?


Ned Dowling: Move. Movement is probably the main thing, and move in the right amount, because we can overdo it very easily as well.


I mean, I see both ends of the spectrum: I see patients whose symptoms are, I think, a result of their body being very underprepared for living on Earth and dealing with gravity, and I see patients who are overdoing it with exercise and training. They're running more than their body can handle, or they're riding their bike more than their body can handle. And I kind of put those into—I call those "training errors," really, because it has less to do with their body's tolerance and more of just the quantity of load that they're trying to throw at it.


There's a certain amount of mobility that we need to maintain. You don't need to be a yoga guru and be able to put your foot behind your head, but there's a certain amount of mobility that we need for everyday life, and there's a certain amount of strength that we need for everyday life.


Again, as your physical demands go up, then those demands are going to go up with it. As we get older, we need to spend more time in the gym doing dedicated strength training, because our bodies are not going to be as willing to endure the whatever we throw at it. You know, it's, "I think I'm going to go do this on Saturday and go do that on Sunday," and just sort of whatever sport comes along, we tackle. We get more and more into a—hate to call it a rut, but we sort of get to where our bodies are going to tolerate what we have trained it to tolerate. And the adaptations for a different sport can come, but they're going to come much more slowly than when we're younger.


The other thing that we know that happens as we get older is the body's willingness to develop and hold on to muscle mass goes down. So, you know, when we're younger, we could get strong and we could stay strong for a long time without really reinforcing that. As we get older, we need to keep reminding the body that we need to hang on to these muscles. I think our bodies get in this place where priorities change, and our bodies care more about us just living from one day to the next versus excelling from one day to the next. So, we need to spend time in the gym doing strength training and maintaining that muscle mass.


Carolyn Ford: You know, one of the hardest regimens you gave me: You told me I wasn't getting enough downtime. You told me I wasn't giving my body enough time in between workouts to rest and recover. That was about six months ago when we were rehabbing my glute, and I told you what my routine was and you're like, "You're not taking enough time in between." And so I took it to heart. It was hard; I discussed it with my sister. I'm like, "Ned's crazy!" But then I did listen to you, and it doesn't mean I stopped moving—I walk every day, I go with my dog, Han Solo. And it's not a lot, you know, it's a couple of miles a day, but I stopped doing the really hard, like, "push it to an 11" workout every day, and it did make a difference.


So, all right, let's talk about wearable tech. What do you think of it?


Ned Dowling: It has its place. Its biggest use is in helping to identify those training errors that basically you just described. So, whether that is using heart rate—and I use heart rate whenever I train. I should say I don't use it when I do strength training, but anytime that I'm on the bike, that I'm running, that I am cross-country skiing, I'm using a heart rate monitor. And whether I'm looking at the heart rate while I'm doing it or later on, it can kind of quantify how intense that exercise session was.


The biggest use of it, I think, is in making sure that my low-intensity sessions are actually low intensity.


Carolyn Ford: It's hard to stay in the green!


Ned Dowling: It is. And, you know, especially I think where we live where it's very hilly terrain, it's hard to stay in a legitimately easy effort. And so heart rate can help with that quite a bit. Now, with heart rate, you need to know what that number means; you need to be able to frame it within training zones, and that's not a very easy thing to come up with, training zones.


Boy, the internet has exploded with this because Zone 2 is all the rage, and Zone 2—it's not everything, but I think the push with Zone 2 was really as a counter to the way that you were describing your workouts, of you just went high intensity every single day. And we just can't do that. Our bodies are not going to be able to recover from one of those sessions to the next to actually be productive with the load that you're going to throw at it from that next session.


So, heart rate to monitor things while you're exercising. And then I think heart rate variability has a good place in terms of helping you understand how your body handled the load of the day. And I'm going to call it "the day" because it's not necessarily just your exercise session that is training load. Heart rate variability is looking at your central nervous system's response to the stress that came on that day. So, stress can be exercise, stress can be work, stress can be family, can be school, can be relationships. Your nervous system doesn't care; it doesn't care where that stress comes from. It all gets basically poured into the same bucket, and if the bucket's not big enough to hold all of that, then your body's not going to be able to recover and be ready for strenuous exercise the next day.


So, that's a tech that I think can be really helpful if you are having a hard time monitoring whether you're training appropriately, or whether you're overcooking it or not.


Carolyn Ford: Yeah, well, I just like points, so I like to wear it because I like to win, and I can only win if I'm getting a lot of points!


Ned Dowling: Well, from an HRV standpoint, you're scoring points when you get it right. And this may kind of circle back to what I was saying with exercises and Goldilocks: If we're looking at exercise to—whether it's from a performance standpoint where winning a race is our goal, or whether it's just a staying healthy standpoint—we still exercise to stimulate adaptations in the body. And if we're constantly pushing it too much, then the body's going to lose its ability to make those adaptations. The recipe is really the load or the stimulus of the exercise plus the recovery equals the adaptations, so that recovery part is key. And in order to score points with your HRV, then you've got to recover just as hard as you exercise.


Carolyn Ford: Do you rehab every day? Or do you do something every day?


Ned Dowling: So, I do two sessions a week of—I call it "pay to play." My wife and I call it "broccoli." You know, it's good for you, but it doesn't necessarily taste good. And it is an hour each session of generally exercises that I give patients.


Carolyn Ford: Super boring! They're so boring!


Ned Dowling: It's massively boring! I can't stand doing it. It gives me tremendous empathy for my patients when I hand them a stretchy band and tell them to go do an exercise. But I'm right there with you. I do these things because I know that they're good for me, and they are things that are going to keep my body ready to handle the load that I'm going to put on it from the fun things, like running and riding my bike.


So, that's two sessions a week. I try to use a foam roller every day to work my...


Yeah, so this is probably in the computer-bound population a good maintenance thing to do. You know, we tend to spend so much time with our—you know, here kind of thing, and we need to try to get our spine to go the other direction. So, that can be something as simple as trying to arch back over a chair, but a foam roll works really well to lie on the floor with the foam roll perpendicular to your spine and try to arch back over the foam roll to get that thoracic spine extension. So, that's one mobility thing that I do every day.


I stretch a little bit every day. As a 52-year-old guy, I'm not going to gain any mobility by stretching, but I am reminding my body that I need to have this amount of motion in my muscles. I need to take my muscles to their end range to remind the body that I need this, so don't take it away from me. Basically, that's how I see stretching.


Carolyn Ford: Okay, I knew we were going to go past time. Are you okay to go to the tech talk questions? Do you have time?


Ned Dowling: Yeah, I'm good.


Carolyn Ford: All right, good. All right, I'm going to take us to our tech talk questions. These are just rapid-fire, from-the-gut answers. So, you ready for your first one?


Ned Dowling: Go.


Carolyn Ford: Okay. If the human body got a software update today, what's the first bug you'd want patched?


Ned Dowling: Arthrogenic muscle inhibition.


Carolyn Ford: What the hell is that?


Ned Dowling: Yeah. So, amongst our body's defense mechanisms, the nervous system will sort of upregulate or downregulate muscles. Statistically, 80% or more people have experienced low back pain in their lives, right? With low back pain, we tend to get this spasming of the muscles in the low back; that is the body upregulating those muscles. It kind of puts the muscles on lockdown to theoretically support the spine, right, and to help—it actually tends to make things worse, but that's what it does.


Arthrogenic muscle inhibition is the opposite: It's when the nervous system turns off a muscle. So, we know that this happens at the knee; we have a growing body of evidence that this happens at the hip. That when there is pain or swelling, inflammation at the knee joint, the nervous system will decrease or try to turn off the quadriceps muscles. And so we get this kind of—I don't know, with your knee pain, did you ever have a sense where your knee was going to, like, give out on you?


Carolyn Ford: Yeah.


Ned Dowling: So that is the influence of the arthrogenic muscle inhibition. The defense mechanism part of your nervous system is trying to turn off the muscle. Meanwhile, the normal programming part is trying to contract the muscle when you go to put weight on your leg. And so, for this brief moment, you get this like—the knee wants to give out or sort of buckle on you. And then the normal nervous system part wins out, and the muscle contracts and then it catches you and you don't actually hit the ground.


But this is something that we have to deal with quite a bit in the physical therapy clinic. Whether that's a chronic knee pain thing like you have going on, or we see it quite a bit after knee surgeries—especially ACL reconstructions and total knee replacements—where the quadriceps muscles just don't work. And so every day that they're not really functioning, they're getting weaker and weaker and weaker. So, we end up with this huge deficit—this huge strength deficit—that the patient has to work really, really hard to get back. So, we need to get rid of that defense mechanism; it just doesn't work.


Carolyn Ford: I'm with you! Okay, zombies are famous for shuffling around with terrible form. As a PT, what's the single biggest thing wrong with zombie posture?


Ned Dowling: I don't know, they're dead! As much as I've harped on pain, pain is there for a reason, right? It keeps us from doing things that would cause harm. So, I'm guessing that zombies, being dead, don't feel any pain. So, they're walking around in this really, like, inefficient, stumbly, whatever thing, and they don't know any better because they're not getting that feedback from their nervous system to tell them that they need to do things any differently.


Carolyn Ford: Okay, so back to the pain—pain to a certain degree is good for us.


Ned Dowling: Yes. I mean, if we had no pain, you put your hand on a hot burner and it hurts, so you take your hand away, right? Well, if it didn't hurt, then you wouldn't know to take your hand away. Eventually, you would smell the burning flesh and maybe that would give you a signal, but I don't think that you would last very long if you didn't feel any pain.


Carolyn Ford: Okay. If you could 3D print any replacement body part anytime you wanted, what would it be? What would you upgrade first?


Ned Dowling: The knee. Yes, the knee takes a lot of load, and it's not engineered well enough to handle it.


Carolyn Ford: Oh, you'd just re-engineer it!


Ned Dowling: Yeah, it needs to be more stable. If we want to go down this biomechanics path, the knee joint itself is two bones that come together and are held together with four ligaments, and we expect it to work as a hinge. But those four ligaments can't keep it as a pure hinge, so it has some rotation to it, it has some anterior/posterior translation. It can go this way, it can go that way, depending all on how robust your ligaments are, how tight your ligaments are.


So, if the knee was more stable inherently, then it would probably cause problems a lot less. But maybe I'd be out of a job if we re-engineered knees!


Carolyn Ford: I don't think so! All right, well, Ned, thank you so much for joining us today.


Ned Dowling: You're very welcome.


Carolyn Ford: Last word of advice: What's the one thing that you want our listeners to remember to do from what we talked about today?


Ned Dowling: Change positions frequently.


Carolyn Ford: Thanks for tuning in. If you found this episode valuable, be sure to share it, leave a review, and smash that like button to help us reach more people who could benefit from the conversation. I'm Carolyn Ford. Tech Transforms is produced by Show and Tell and sponsored by Owl Cyber Defense. Until next time, stay curious and keep imagining the future.