#685: Dr. Shirley Sahrmann — A Legendary PT Does a Deep Dive on Tim's Low-Back Issues, Teaches How to Unlearn Painful Patterns, Talks About Movement as Medicine (or Poison), and More

Brought to you by AG1 https://drinkag1.com/tim all-in-one nutritional supplement, LMNT https://drinklmnt.com/tim electrolyte supplement, and Eight Sleep’s Pod Cover https://eightsleep.com/Tim sleeping solution for dynamic cooling and heating. Resources from this episode: https://tim.blog/2023/08/04/dr-shirley-sahrmann/ Shirley A. Sahrmann, PT, PhD, is Professor Emerita of Physical Therapy at Washington University School of Medicine https://pt.wustl.edu/education/movement-system-impairment-syndromes-courses/where-in-the-world-is-shirley-sahrmann/#:~:text=Shirley%20A.,of%20the%20Movement%20Science%20Program. in St. Louis, Missouri. She received her bachelor’s degree in physical therapy and her masters and doctorate degrees in neurobiology from Washington University, where she joined the physical therapy faculty and became the first director of their PhD program in movement science. Shirley became a Catherine Worthingham Fellow of the American Physical Therapy Association in 1986 and in 1998 was selected to receive the Mary McMillan Award, the Association’s highest honor. She is a recipient of the Association’s Marion Williams Research Award, the Lucy Blair Service Award, the Kendall Practice Award, and the Inaugural John H. P. Maley Lecturer Award. She has also received Washington University's Distinguished Faculty Award, the Distinguished Alumni Award, the School of Medicine’s Inaugural Distinguished Clinician Award, and an honorary doctorate from the University of Indianapolis. She has also received the Bowling-Erhard Orthopedic Clinical Practice Award from the Orthopaedic Academy of the APTA. She has served on the APTA Board of Directors and as president of the Missouri Chapter. Her first book, Diagnosis and Treatment of Movement Impairment Syndromes https://www.amazon.com/Diagnosis-Treatment-Movement-Impairment-Syndromes/dp/0801672058/?tag=offsitoftimfe-20, has been translated into seven languages. Her second book, Movement System Impairment Syndromes of the Extremities, Cervical and Thoracic Spines https://www.amazon.com/Movement-Impairment-Syndromes-Extremities-Cervical/dp/0323053424/?tag=offsitoftimfe-20, has been equally influential in promoting movement diagnoses. Please enjoy! * This episode is brought to you by LMNT http://drinklmnt.com/tim! What is LMNT? It’s a delicious, sugar-free electrolyte drink mix http://drinklmnt.com/tim. I’ve stocked up on boxes and boxes of this and usually use it 1–2 times per day. LMNT http://drinklmnt.com/tim is formulated to help anyone with their electrolyte needs and perfectly suited to folks following a keto, low-carb, or Paleo diet. If you are on a low-carb diet or fasting, electrolytes play a key role in relieving hunger, cramps, headaches, tiredness, and dizziness. LMNT http://drinklmnt.com/Tim came up with a very special offer for you, my dear listeners. For a limited time, you can get a free LMNT http://drinklmnt.com/Tim Sample Pack with any purchase. This special offer is available here: DrinkLMNT.com/Tim http://drinklmnt.com/Tim. * This episode is also brought to you by AG1 https://drinkag1.com/tim! I get asked all the time, “If you could use only one supplement, what would it be?” My answer is usually AG1 https://drinkag1.com/tim, my all-in-one nutritional insurance. I recommended it in The 4-Hour Body in 2010 and did not get paid to do so. I do my best with nutrient-dense meals, of course, but AG1 https://drinkag1.com/tim further covers my bases with vitamins, minerals, and whole-food-sourced micronutrients that support gut health and the immune system. Right now, you’ll get a 1-year supply of Vitamin D free with your first subscription purchase—a vital nutrient for a strong immune system and strong bones. Visit DrinkAG1.com/Tim https://drinkag1.com/tim to claim this special offer today and receive your 1-year supply of Vitamin D (and 5 free AG1 travel packs) with your first subscription purchase! That’s up to a one-year supply of Vitamin D as added value when you try their delicious and comprehensive daily, foundational nutrition supplement that supports whole-body health. * This episode is brought to you by Eight Sleep http://eightsleep.com/Tim! Eight Sleep’s Pod Cover http://eightsleep.com/Tim is the easiest and fastest way to sleep at the perfect temperature. It pairs dynamic cooling and heating with biometric tracking to offer the most advanced (and user-friendly) solution on the market. Simply add the Pod Cover http://eightsleep.com/Tim to your current mattress and start sleeping as cool as 55°F or as hot as 110°F. It also splits your bed in half, so your partner can choose a totally different temperature. Go to EightSleep.com/Tim http://eightsleep.com/Tim and save $250 on the Eight Sleep Pod Cover. Eight Sleep currently ships within the USA, Canada, the UK, select countries in the EU, and Australia. * [07:12] A brief terminology primer. [13:00] Why Shirley's first book is so influential among physical therapists. [15:54] The correlation between lifestyle and health hasn't always been obvious. [18:16] Low back pain: not a diagnosis, but a symptom. [20:41] The trouble with overdeveloped abdominals. [22:32] What's my problem? [30:14] The Movement Systems Syndromes (MSS) approach. [31:29] The wrong walk home. [33:01] Correcting bad habits. [35:00] Psoas it goes. [37:03] Other commonly repeating culprits. [40:36] Pump handle and bucket handle. [43:41] The body follows the path of least resistance. [48:00] Anterior superior iliac spine (ASIS) [49:20] How Shirley examines a new patient. [55:11] Assessing athletes vs. non-athletes. [56:18] Dynamic neuromuscular stabilization (DNS) [57:49] Collapso-smasho and squeezo-smasho. [59:10] Correcting low shoulders. [1:05:26] Stretching: yes or no? [1:09:56] Addressing my abdominal stiffness. [1:16:28] When the spine doesn't want to go along for the ride. [1:18:38] How has Shirley made it to 86 with her physical and mental health intact? [1:34:32] What men should know about femoral retroversion. [1:38:44] If it walks like a duck... [1:41:11] Managing symptoms of Scheuermann's disease. [1:42:49] Parting thoughts. * For show notes and past guests on The Tim Ferriss Show https://tim.blog/podcast, please visit tim.blog/podcast https://tim.blog/podcast/?utm_source=podcast&utm_medium=podcast&utm_campaign=podcast-description. 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Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

• 0:00Tim Ferriss?

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• 0:41Tim Ferriss?

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• 1:22Tim Ferriss?

  Again, that's eightsleep.com/tim to save $250 on the Eight Sleep Pod Cover.

• 1:31Tim Ferriss?

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• 2:15Tim Ferriss?

  And it relates to a bunch of stuff like a hormone called aldosterone, blah, blah, blah, when insulin is low. But suffice to say, this is where Element, again spelled L-M-N-T, can help. My favorite flavor by far is citrus salt, which, as a side note, you can also use to make a kick-ass, no-sugar margarita. But for special occasions, obviously. You're probably already familiar with one of the names behind it. Rob Wolf, R-O-B-B, Rob Wolf, who is a former research biochemist and two-time New York Times bestselling author of The Paleo Solution and Wired to Eat. Rob created Element by scratching his own itch. That's how it got started. His Brazilian jiu-jitsu coaches turned him on to electrolytes as a performance enhancer. Things clicked and bam, company was born.

• 2:59Tim Ferriss?

  So if you're on a low-carb diet or fasting, electrolytes play a key role in relieving hunger, cramps, headaches, tiredness and dizziness. Sugar, artificial ingredients, coloring, all that's garbage, unneeded. There's none of that in Element. And a lot of names you might recognize are already using Element. It was recommended to me by one of my favorite athlete friends. Three Navy SEAL teams, as prescribed by their Master Chief, Marine units, FBI sniper teams, at least five NFL teams who have subscriptions. They are the exclusive hydration partner to Team USA Weightlifting and on and on. You can try it risk-free. If you don't like it, Element will give you your money back, no questions asked. They have extremely low return rates. Element came up with a very special offer for you, my dear listeners.

• 3:41Tim Ferriss?

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• 4:15Speaker 01

  Can I ask you a personal question?

• 4:17Shirley A. Sahrmann?

  No, I would have seen an appropriate time.

• 4:21Speaker 01

  I'm a cybernetic organism, living tissue over metal endoskeleton.

• 4:33Tim Ferriss?

  Hello, boys and girls, ladies and germs. This is Tim Ferriss and welcome to another episode of the Tim Ferriss Show where it is my job to deconstruct world-class performers from all different disciplines. My guest today is Shirley A. Sarman, PT PhD. But before we get to her bio, let me just explain. Shirley is a legend in the physical therapy world. She has influenced some of the top performance coaches in the world. She's also 85 years old, going on 86, and is not only razor-sharp mentally, but in excellent shape physically. So she walks the walk. So let me get to the bio and I will also give you a bit of 101 on some of the terms that we'll use in the conversation. Shirley A. Sahrmann,

• 5:18Tim Ferriss?

  PT PhD, is Professor Emerita of Physical Therapy at Washington University School of Medicine in St. Louis, Missouri. She received her Bachelor's Degree in Physical Therapy and her Master's and Doctorate Degrees in Neurobiology from Washington University, where she joined the Physical Therapy Faculty and became the first Director of their PhD Program in Movement Science. Shirley, and she asked me to call her Shirley, became a Katherine Worthingham Fellow of the American Physical Therapy Association in 1986 and in 1998 was selected to receive the Mary McMillan Award, the Association's highest honor. She has also received Washington University's Distinguished Faculty Award, the Distinguished Alumni Award, the School of Medicine's inaugural Distinguished Clinician Award, and an honorary

• 6:00Tim Ferriss?

  Doctorate from the University of Indianapolis. She has received as well the Bowling Erthhardt Orthopedic Clinical Practice Award from the Orthopedic Academy of the APTA. She has served on the APTA Board of Directors and as President of the Missouri Chapter. Her books are iconic. They have been the initial domino that has toppled over, so to speak, the enthusiasm, the ignition for many people to get into the field of movement science and physical therapy and performance coaching. Her first book, Diagnosis and Treatment of Movement Impairment Syndrome, you may have heard Eric Cressy mention this. A hugely influential book for him, has been translated into seven languages.

• 6:45Tim Ferriss?

  Her second book, Movement System Impairment Syndrome of the Cervical and Thoracic Spines and the Extremities, has been equally influential in promoting movement diagnoses. And in this episode, we do a deep dive on low back pain. And that is something that for the first time, really, I have been struggling with for the last, let's just call it nine months or so, could be a bit longer. And we do get into the weeds with regard to anatomy, particularly as it relates to the back stuff that I mentioned. So I'd like to go over a few terms before we start the interview, so you don't have to wonder what they are and feel like you need to pause to look them up. You can get through the interview without listening to my definitions, but some of them might be helpful. Also, if you're a kinesiologist or professional, please excuse these very simplistic and possibly

• 7:30Tim Ferriss?

  slightly off definitions, but they'll help a lot of people. So the first one is the iliac crest. What is that? That's the uppermost border of your pelvic girdle. So you can think of the pelvic girdle as that large bony ball that you see in the middle of a skeleton hanging in a science classroom or something. You can feel your iliac crest if you press your thumb into the top of your hip. That sort of bony ridge is your iliac crest. The tensor fasciculatum, and I've heard many different pronunciations of this, and the fact of the matter is, no one really speaks Latin correctly, because we don't know if it was, you know, veni vidi vici, or veni vidi vici. For those who get that reference, I came, I saw, I conquered.

• 8:12Tim Ferriss?

  So anyway, it is better known and abbreviated as the TFL for a lot of people. So the TFL is a muscle at the outside, very outside portion of the thigh at the very top. So you could think of it also, people think of it as a hip muscle sometimes. You use it to balance your pelvis when standing, walking, or running. If you ever give someone a piggyback ride and a muscle gets super sore on the side of your hip, that is probably at least including the TFL. You also use the TFL for abducting your hip or pulling it away from the midline of your body compared to adducting with two D's, which would be pulling it toward the midline. One way that I remember that, abduction, it's like an alien abduction, taking you away. So moving the, say, leg away from body, abducting, bringing the thigh in.

• 8:58Tim Ferriss?

  Adduction, so like an adductor machine at a gym, one of those Susan Summers thigh master type machines would be that. We also talk about muscles that assist in lateral rotation. Lateral rotation is rotating away from the center of the body. Medial rotation is rotating towards the center. So imagine if you turned your feet outwards to look like you were duck footed, that would be lateral rotation out to the sides. And then if you turn them inward to be pigeon toed, that would be medial rotation of both femurs inward. All right. Psoas major. I also mentioned psoas major. That's spelled P S O A S major. That is a large muscle that joins the upper and lower parts of the body. And it also contributes

• 9:42Tim Ferriss?

  to a lot of lower back pain. It connects to the inside of the lower back. And if you were to take, say, your four fingers and move them four inches to either side of your navel and then press in, say, four inches, that would probably touch your psoas major, which is why massage therapy that addresses it can be so uncomfortable. For you chefs out there, or hunters, or people who might recognize this, this would be the equivalent of your tenderloin. So if you're wondering what a tenderloin is, it is this muscle in many animals. And there may be other ways to use that butchering term, but psoas major, tenderloin,

• 10:21Tim Ferriss?

  there you have it. Used mostly for posture and so on. We also get into stenosis as it relates to my spine. So stenosis is an abnormal narrowing. And I have some stenosis around L4, L5, which is in the lumbar spine or lower spine, which puts pressure on some nerves there and causes all sorts of pain. The thoracic spine is more of, say, the middle of the back. And kind of you just think between the shoulder blades for simplicity. Okay, last, and I could say not least, but who knows, these are all kind of equivalent and useful. You have supine versus prone positions. Supine is lying on your back. Prone is lying on your stomach.

• 11:02Tim Ferriss?

  If you've ever wondered what a supinated grip is, or a pronated grip, supinated is Palm up and you can remember that because if you want to pour soup into your hand, you have your palm up. Okay, so that is supine. And honestly, learning the basics of anatomy and the basics of some medical terminology is, I think, one of the best, absolute best investments you can make in your health, because then you can talk the talk with professionals and they take you more seriously. They give you better advice. They give you the straight scoop. So this is all a very good investment of time. You can find a glossary of these terms and more in the show notes for this episode at tim.blog. And I do want to mention one other thing. If you want an incredible rotating view of

• 11:45Tim Ferriss?

  different muscles, like the QL, we talk about the quadratus lumborum, that's sort of this square-ish rectangular muscle in the lower back area that is sort of the grand central station of all sorts of things. If you want to see anything, the psoas major, check out the Essential Anatomy 5 app for iOS and Android and you can see all of this. You can also see the circulatory system and all sorts of other things. It's a great app. Really enjoyed it. And there are short YouTube tutorials that I recommend taking a look at if you end up downloading it. And that was referred to me by professional drummer Dave Elich, who helps people improve their mechanics, technique, and much more. And

• 12:28Tim Ferriss?

  there you have it. So if you want a video to go with this, I did record a video of this conversation and I get up and walk around and she does an assessment with me live. You can go to my YouTube channel, youtube.com/timferriss, and that will have some helpful graphics and so on overlaid into the video. Okay, that's quite a bit, guys, but I think it is a helpful prelude. And now, without further ado, please enjoy this wide-ranging conversation with Dr. Shirley Sarman.

• 13:00Tim Ferriss?

  Dr. Sarman Shirley, welcome to the show. It's so nice to have you with me today and I can't wait to ask a whole host of different questions. So, thank you for making the time.

• 13:11Shirley A. Sahrmann?

  My pleasure.

• 13:13Tim Ferriss?

  And I'd like to begin perhaps with the connective tissue that led to you being on the show today, which is a friend of mine and a well-known, suppose the label "performance coach" could be applied. He also has a background in physical therapy, Eric Cressy. He works with many Major League Baseball players, has a high degree of success with pitchers specifically. But he has written, and he also mentioned to me, that Diagnosis and Treatment of Movement Impairment Syndromes is probably the book, and I'm quoting him here, is probably the book that has influenced me more than any other in my career. It's worth every penny. I'm curious why it is that this book seems to have been so revolutionary

• 13:58Tim Ferriss?

  for him and many others. What would you say explains that, or differentiates that book?

• 14:05Shirley A. Sahrmann?

  The one big objective in it, I've actually been a physical therapist for over 60 years. And during all of that time, I've been through different eras of changes in physical therapy. And where I've sort of gotten to is how movement basically induces pathology. And part of that, trying to explain that and how it works, is also developing diagnostic categories that direct physical therapy treatment. So, what this book was about was a first attempt to really put together diagnostic categories that are based on movement, and movement as an inducer of musculoskeletal problems. Also, kind of working on the background

• 14:49Shirley A. Sahrmann?

  of what are the tissue adaptations that contribute to this. So, it really was an organizational attempt to identify, for in the first book, we covered the...

• 15:02Shirley A. Sahrmann?

  The back and the shoulder and the hip. And so I guess the shoulder is one of the things that he must have been particularly interested in if he's dealing with pitchers. And the shoulder is really quite complex because you've got that shoulder blade as well as the glenohumeral joint. And it's not as easy as muscles just turn on or turn off appropriately. They've got to really be well coordinated. So I think that putting together this kind of information in a way that could be understood by a whole variety of people. In fact, I was so slow in getting it out that I was grateful that there was the internet and Amazon selling things because if it would have only been sold in medical bookstores, no one like Eric would have ever found it.

• 15:47Shirley A. Sahrmann?

  So that was one of the advantages of being a slow writer. And of course, I learned more while all of that was happening too.

• 15:54Tim Ferriss?

  How did that attempt, or maybe not attempt, how did that organizational approach and also the maybe reframing of movement in the way that you just described differ from what came before or what was predominant at the time?

• 16:09Shirley A. Sahrmann?

  To be perfectly honest with you, Tim, it's not like this insight has been taken over by even the large majority of the people in my profession. It's still a bit of a struggle to have people move in this direction for a whole variety of reasons. But typically, and even though I wasn't there when physical therapy was first started, I wasn't too far behind. But typically, the role of the physical therapist was the doctor figured out what the problem was, made the diagnosis, and the physical therapist really provided treatment for what I think could fairly be called the symptoms or the consequences of that problem. In fact, I am old enough that I actually saw polio patients.

• 16:50Shirley A. Sahrmann?

  The vaccine had just come out about when I was entering physical therapy school. So we had a role in providing the therapy for the doctor's identified condition. And that's very different than what I'm proposing or have proposed with this book. And I think the other thing that's so important about all this, and I'm sure you are a reflection of this, is in the old days, no one thought lifestyle had anything to do with your health. I always like to point out this story. My family cooked with so much Crisco, I don't know how my blood flows.

• 17:27Shirley A. Sahrmann?

  And if the green beans were too healthy, we had bacon grease to put on them, you know.

• 17:33Shirley A. Sahrmann?

  But I was, I was very fortunate. I worked with a physician for a while who, who was really leading the way and showing about the role of exercise and nutrition. He did what is really called translational research, showing the cellular changes in animals and then also running studies in older people. And it was like an amazing insight for me to realize that your lifestyle had something to do with it. So I think that's behind what's slowly emerging as seeing movement play a different role. It's, I think what I'm like to get across to people, it's not inevitable what's going to happen to you, that you can do things via lifestyle to improve what your outcome's going to be.

• 18:17Tim Ferriss?

  I would love to come back to, I believe, and I don't want to misquote you, but something you said, which is the treatment of symptoms. So many offices are treating symptoms, perhaps not root causes. And I have read, and you can't believe everything you read on the internet, so please correct me if I'm getting this wrong.

• 18:36Shirley A. Sahrmann?

  I said a new saying.

• 18:41Tim Ferriss?

  That you've, that you've described low back pain as not a diagnosis, but a symptom. And could you just speak to that? Because I, as someone who currently for the last maybe six to nine months, has had a very perplexing constellation of symptoms that I describe as low back pain. This, I think, will resonate with many people who are listening. So would you mind elaborating on low back pain as a symptom and not a diagnosis?

• 19:10Shirley A. Sahrmann?

  Well, I mean, just what you're saying. You're saying it's low back pain. You're just telling me that you've got pain and you're telling me where you've got pain. That is clearly a symptom.

• 19:20Tim Ferriss?

  Yeah, right.

• 19:23Tim Ferriss?

  I am from Long Island, so sometimes I ask the silliest, silliest of questions, but got to start with the basics.

• 19:28Shirley A. Sahrmann?

  Well, the nice part is you can actually get reimbursed for making that big clever diagnosis. So even without an MD degree.

• 19:39Shirley A. Sahrmann?

  But where I would be looking at that problem, and I have an idea of what your problem is.

• 19:44Tim Ferriss?

  Wow, okay, already.

• 19:46Shirley A. Sahrmann?

  Just because, we can talk about that.

• 19:48Tim Ferriss?

  Okay.

• 19:48Shirley A. Sahrmann?

  I mean, I don't want to sound too glib about it, but what I would be doing is naming your low back pain by the movement that most consistently causes your symptoms, and by changing that movement reduces or eliminates your symptoms. Then I'm talking to you about a real cause of the problem. Now, it's not going down to the tissue level and saying, well, you know, it's a disc or facet joint or any of the rest of it. But here again, in some ways, when you have a problem like that, you can't say in the back that one tissue's at fault, because a lot of tissues have to change if you're having pain coming from your back region.

• 20:31Shirley A. Sahrmann?

  So, the expertise of a physical therapist needs to be, what is the movement that's either causing or exacerbating that problem?

• 20:41Tim Ferriss?

  So, I'm curious to, well, maybe we can dive into, you said that you thought you might know what my issue is.

• 20:48Shirley A. Sahrmann?

  That's because I know you're a big exerciser.

• 20:51Tim Ferriss?

  Yes, yes, indeed.

• 20:52Shirley A. Sahrmann?

  And do you know, I mean, do you want me to just give you a ballpark idea?

• 20:57Tim Ferriss?

  I do, absolutely.

• 20:59Shirley A. Sahrmann?

  Well, because, would you believe that abdominals can get to be too much, like, overdeveloped?

• 21:05Tim Ferriss?

  You know, it makes some intuitive sense, but it's not something you hear many people talk about.

• 21:09Shirley A. Sahrmann?

  I know, I know, I know. Even within the community of physical therapists, people are really exercising big time. I mean, high-intensity exercise is super popular. I'm all for it because it'll increase our patient load.

• 21:26Shirley A. Sahrmann?

  But, one of the things that happens when your abdominals are overdeveloped, because what happens when muscles hypertrophy, they become stiffer, and muscles are like springs. So, they have a, I mean, I'm using the mechanical word of stiffness. And so, when the abdominals get to be too much, they increase the compression on your spine. And so, the way you can check me out on this is if you look to see, if you take a deep breath, if you go from maximum exhalation to maximum inhalation, you should be able to change the circumference of your rib cage about two and a half to three inches. And if you can't really do that, then it means that the stiffness of your abdominal muscles is so much, it's adding to the compression.

• 22:09Shirley A. Sahrmann?

  And then if you have any kind of asymmetry, if, for example, if you put your hands on your iliac crest and one iliac crest is slightly higher than the other, then you're basically, your spine is in a side bend. And if it's in a side bend and you're squeezing on your vertebrae, they're not happy because they aren't lined up as optimally as possible. Do you see what I mean?

• 22:30Tim Ferriss?

  I do, absolutely.

• 22:32Shirley A. Sahrmann?

  Okay. So that's the ballpark idea. That also reflects how we're looking at these problems. What is it about the way you move? What is it about the way you've exercised or done things that cause the symptoms?

• 22:44Tim Ferriss?

  I would love to spend more time on this, selfishly of course, because the reason I am sitting and not standing for this interview is because of this lower back pain.

• 22:54Shirley A. Sahrmann?

  So it's worse when you're standing than when you're sitting?

• 22:57Tim Ferriss?

  It is worse when I am standing. Now, I do have, I guess, well, we can jump right into the weeds. I have a transitional segment, if I'm using the right terminology, in my lumbar. So I do have quite a bit of excessive lower back sway or atypical lower back sway.

• 23:15Shirley A. Sahrmann?

  When you say sway, do you mean an increased curve?

• 23:19Tim Ferriss?

  Increased curve, yeah, like lordosis and kind of guts hanging out and with that anterior pelvic tilt, right? Standing and slow walking, say, walking through a museum, tend to aggravate it the most. My brother has the same thing. Although, in the last six months or so, when I sit on a very hard surface, like a hard bench or something like that, it also causes this pain. I have had imaging, but maybe we could talk about imaging, how you see some people who look like they've gone through a mulcher on their back MRI, but they're asymptomatic.

• 23:55Shirley A. Sahrmann?

  Right.

• 23:56Tim Ferriss?

  And then you have the opposite.

• 23:57Shirley A. Sahrmann?

  That's the whole point.

• 23:58Tim Ferriss?

  So I do have some stenosis around like L4, L5, but the pain feels to me localized around the SI joint. The relief, if this is helpful, I know we're getting a little technical for some folks, but the relief that I've had in the last week was actually from seeing a chiropractor. There's a high degree of variability with chiropractors, but he works with a lot of athletes. And he put me on a machine that provided some traction. And he said, I think it's actually that you may have a disc. Pressing on a nerve that runs past the SI joint, so you're misattributing the cause to the SI. And I've had quite a bit of relief. But to answer your question, standing, slow walking, combined with standing, like going through a museum or a cocktail

• 24:38Tim Ferriss?

  party, sitting on hard surfaces, those are the three things that hurt. Brisk walking does not hurt. And actually, that type of, and this is a primitive interpretation, but sort of repeated stretching of the hip flexors, if I'm getting enough terminal hip extension, feels really good to the back. Those are a few of the things.

• 24:59Shirley A. Sahrmann?

  Have you put your hands on your pelvis to see when you're walking, if it rotates?

• 25:04Tim Ferriss?

  I have not. I would love to know how to do that properly.

• 25:08Shirley A. Sahrmann?

  It's not rocket science. You know where your pelvis is, you know where your hands are. Just because very often, when your hip flexors are not even just not short, just stiff, stiffer than your back, as you walk, it rotates your pelvis. And that's where you're going to be getting your symptoms from. And evidently, when you go fast enough, you're not staying static and you're causing enough equal movement. But that would be the big thing. Can, when you, when you stand up and you're in this anterior tilt, can you contract your abdominals enough to get out of the tilt?

• 25:42Tim Ferriss?

  I can. Yeah.

• 25:43Shirley A. Sahrmann?

  And then does that decrease your symptoms?

• 25:45Tim Ferriss?

  It does decrease my symptoms. So if my back is bothering me, I'll very often do basically a forward fold or a full squat and then round my back and get into that flexed position. The flexed position and even mild extension does not bother the back. If I do a compression test, like a heel drop test, or I pull myself into a chair, it's standing straight up. And with compression, that shows that that type of intolerance. And I get that pain kind of directly on the lower spine.

• 26:13Shirley A. Sahrmann?

  The other thing to try, Tim, is when you stand up, Put your feet apart, separate them out and see if that changes your symptoms.

• 26:21Tim Ferriss?

  What is that doing?

• 26:23Shirley A. Sahrmann?

  Number one is this little thing I referred to before, if one iliac crest is higher than another, and it's a test for what we call relative stiffness. So, one of the big hip flexor that's problematic is called the tensor fasciculata.

• 26:36Tim Ferriss?

  Yes.

• 26:36Shirley A. Sahrmann?

  Iliotibial band.

• 26:38Tim Ferriss?

  Mm-hmm.

• 26:38Shirley A. Sahrmann?

  And it's an adductor. So if you put your feet apart, so your hips are abducted, it takes the stretch off of that band.

• 26:46Tim Ferriss?

  Ah, mm-hmm.

• 26:47Shirley A. Sahrmann?

  And any kind of asymmetry that you would have, particularly with the transition vertebrae, would be playing into the symptoms. Do you see what I mean?

• 26:55Tim Ferriss?

  I do.

• 26:56Shirley A. Sahrmann?

  And then if you put them together and your symptoms increase, then you would know that that's what's playing a role in doing this.

• 27:02Tim Ferriss?

  So I'll add a few more things, just because this is a rare opportunity to get to talk with you about this. So my TFL is very, tends to be very tight and sensitive.

• 27:13Shirley A. Sahrmann?

  Yeah, that's, that's right, yeah.

• 27:14Tim Ferriss?

  The piriform is also very tight. A piece of this that may or may not be helpful, but what gives my back also some release is working on the, very specifically, the iliacus and then some of the adductors, so on the inside of the thigh.

• 27:28Shirley A. Sahrmann?

  Now, I don't know how you do that. Tell me what that means.

• 27:32Tim Ferriss?

  Well, having someone really dig into the abdomen to have me say, extend the leg.

• 27:39Shirley A. Sahrmann?

  It's not you working on it, somebody else is.

• 27:40Tim Ferriss?

  No, it's somebody else working on it. And then, it's not very pleasant for people who are listening. And then, some of my adductors, I don't know if it's magnus longus or whatever, but also very tight and seemingly potentially weak. But to come back to the height, maybe the asymmetry of the iliac crest, my right side seems to get hiked up a lot, and doing wall sits to try to press them maybe back into some symmetry seems to alleviate some of the symptoms as well. I don't know if any of this makes any sense.

• 28:11Shirley A. Sahrmann?

  You've just confirmed one of my thoughts is that if your right iliac crest is higher than your left. But then I would also bet that your right TFL is stiffer than your left. So if that's playing a role, then when you put your feet apart, your iliac crest should level out. That should help with your symptoms.

• 28:27Tim Ferriss?

  So historically, when I've been recording podcasts, I basically end up in that really wide stance. And so I think I'm. Now, is that, I mean, that's useful for maybe temporarily relieving the symptoms if I'm recording a podcast. In terms of corrective measures, let's just say using your.

• 28:44Shirley A. Sahrmann?

  Have you ever tried anything where you're in the quadruped position?

• 28:47Tim Ferriss?

  I have actually, a long time ago, I did a lot of movement in quadruped position. But I would be curious to hear what you have in mind.

• 28:54Shirley A. Sahrmann?

  Part of what happens when one iliac crest stays higher than another, and I'm not, to be perfectly honest with you, I haven't quite figured it all out yet, but there's some adaptation of the other hip muscles. And I've just found that if you do this in quadruped, you just rock back.

• 29:13Shirley A. Sahrmann?

  Often it will improve the asymmetry.

• 29:16Tim Ferriss?

  Huh. So basically being on hands and knees?

• 29:18Shirley A. Sahrmann?

  Hands and knees, right, and let your hips drop to about 90 degrees. You don't have to go back all the way. You just need to go back a little bit and go back by easily pushing with your hands. Because otherwise, if you activate your hip flexors, it could pull it, contribute to your problems.

• 29:35Tim Ferriss?

  Right.

• 29:35Shirley A. Sahrmann?

  And then, can you tolerate prone?

• 29:38Tim Ferriss?

  Yeah, I can tolerate prone.

• 29:39Shirley A. Sahrmann?

  And then you need to just do, like, just flex your knee. And then you need to laterally rotate your hip. So you're letting your knee flex to 90 degrees and then let your foot go in towards the other leg. That's lateral rotation.

• 29:53Tim Ferriss?

  Yep.

• 29:54Shirley A. Sahrmann?

  And that kind of motion will help to elongate the TFL.

• 29:58Tim Ferriss?

  Interesting. And you're doing that leg by leg?

• 30:02Shirley A. Sahrmann?

  Yeah, yeah, one leg at a time.

• 30:03Tim Ferriss?

  One leg at a time. Okay.

• 30:04Shirley A. Sahrmann?

  Yeah, yeah, do everything bilaterally.

• 30:07Tim Ferriss?

  Mm hmm. Yeah. Okay. Very interesting.

• 30:09Shirley A. Sahrmann?

  So you can try those, try those things.

• 30:12Tim Ferriss?

  I will. I will do, I will do both of those. So let's, if we zoom out just for a moment, thank you for that, by the way, we may come back to it. How would you describe the movement systems syndromes approach? So the MSS approach? What would the sort of lay description of that be?

• 30:31Shirley A. Sahrmann?

  In 2013, the American Physical Therapy Association adopted the movement system as its identity. And to me, what's really important about all of this is. Then it's a way of trying to say to the public that there is a body system called the movement system.

• 30:49Tim Ferriss?

  Mm hmm.

• 30:50Shirley A. Sahrmann?

  And it's not like the traditional anatomically defined systems like the cardiovascular system, or the musculoskeletal system, or the nervous system. It's a system of systems. But that's just like, in my mind, the immune system, which nothing is more important in medicine these days than the immune system. And it's a system of system. It uses many of the different organs in its function. Metabolic system is the same way. And so when you think of it as running from subcellular all the way up to how do you move in your environment, movement is critical. When movement stops, everything stops. And so I think, in some ways, to me, it's like a parallel to the nutrition system.

• 31:35Shirley A. Sahrmann?

  Because we take for granted doing it. And yet, there's right ways and there are wrong ways. And so the whole idea of this is to realize that movement does involve a system. And just like we were talking about before, movement, if you have a lesion in a system, like you have rheumatoid arthritis or something, or you have a stroke, then you've got pathology in your movement. But as I indicated, movement can also induce pathology. In fact, we know if people don't move enough, they develop the metabolic syndrome and other kinds of things, because for lack of movement. So how important it is to move, this is related to the lifestyle issue, and doing it right.

• 32:19Shirley A. Sahrmann?

  One of the things I always loved doing with patients was saying, so who taught you to walk? And they say, nobody. And I say, that's the problem. Just because you're doing it doesn't mean you're doing it right. You're just doing it. Just like you, if you're walking and you're getting lumbo-pelvic rotation, that's playing into your problem.

• 32:37Tim Ferriss?

  Right. And also, if I don't have, which I don't think I do, this is one pattern of diagnosis with me that I think is accurate, that I don't have much terminal hip extension, so when I walk, I'm using my lower back to fake hip extension. Yeah.

• 32:54Shirley A. Sahrmann?

  See, that's what I'm saying. And you really can't do that. I mean, there's no way you won't keep injuring your back if you keep walking like that.

• 33:02Tim Ferriss?

  And how do you re-pattern or help people to adopt so that they can use it subconsciously, new motor patterns or new movement patterns? Because I've been doing this for god knows how many decades.

• 33:16Shirley A. Sahrmann?

  Well, not that many. You don't look that old.

• 33:18Tim Ferriss?

  Thank you. Thank you. I appreciate that. My new best friend.

• 33:23Tim Ferriss?

  How do you help patients to get to that point where they've changed something as fundamental as how they walk?

• 33:30Shirley A. Sahrmann?

  In my mind, it's twofold. In one, we know it takes a while, just like if you're learning a sport or you're learning to do anything, it takes time and it takes attention and it takes specificity. And so, one, it's just like we're talking about with you, what are the most important kinds of exercises? What are the issues that are an impediment to doing it the way you should do it? What are specific exercises that can help you and minimize those? And then, what's really important is showing you in your everyday activities what you should do. For example, if you already know that your hip flexors, you're calling it the iliacus, is problematic, then even when you're sitting, making sure you're not pulling with your hip flexors to stay forward.

• 34:15Tim Ferriss?

  Yeah, I'm probably doing that right now.

• 34:16Shirley A. Sahrmann?

  I know. I've been watching you.

• 34:21Shirley A. Sahrmann?

  It's how you even roll over or get out of bed. We go through every one of these things, teaching you in your everyday activities, so that it does become automatic. But, you know, it obviously takes participation on the patients or the subjects' part as well to learn it, and then you know it's going to take time. I think it's important for people to realize they can't just do 10 repetitions or three sets of an exercise and then they're going to move differently. I think that's been part of what's been picked up in my book, is that you have to bring people along, show them how to do that, and that exercise won't change the way you move. You have to change the way you move, and that can improve how muscles function.

• 35:01Tim Ferriss?

  You mentioned the psoas. I'd actually like to come back to the psoas. In my particular case, because I have been an aggressive athlete, or was for several decades, and accrued an impressive number of fractures and surgeries and so on, I get manual

• 35:13Shirley A. Sahrmann?

  Oh, really?

• 35:14Tim Ferriss?

  Oh, yeah. So I get manual therapy once a week, some type of soft tissue treatment. And what I've found for me personally is it seems like psoas major and so on, when someone does a manual release, for whatever reason, when they get sort of inside that pelvis a bit more to what I've been told is the iliacus, that's when I feel the most symptomatic relief for my back. But the psoas seems to hold some importance. I don't know if you could speak to that, but in terms of the role of psoas overactivity as it relates to back pain, is that something that you still feel is something people pay too little attention to?

• 35:54Shirley A. Sahrmann?

  I don't think it's always the cause, but it can certainly be an exacerbator, because the psoas attaches to the lumbar vertebrae, and it also attaches to the intervertebral disc. It's a muscle that's constantly pulling on your back and pulling it in sort of a translation motion. Iliacus is attached to your pelvis, so it's not directly acting on the vertebrae the same way the psoas is. In fact, people that truly have a herniated disc and they're in that acute phase, I try to have them do nothing with their iliotibial muscle. If they want to lift their leg up, use your hand to lift your leg up, to put your shoes on, or to cross your legs, or get into the car, or something if you're

• 36:35Shirley A. Sahrmann?

  sitting down already. So you minimize that use. And just like we were talking about in quadruped, if you are in quadruped and you want to rock back, you will probably use the psoas to do it. And that's why I suggested to you to push with your hands, so you go back and you don't use that muscle. Well, these are small samples of what I'm talking about as far as identifying what are the factors that are contributing, and how do you change that in your everyday activities?

• 37:01Tim Ferriss?

  Yeah. What would be some other repeating culprits that you see? Let's just say someone has the symptom of low back pain. You take them through an assessment or identify that they have an overactive psoas. What might be some other low-hanging fruit with respect to helping them to identify common patterns or positions that contribute to that overactivity?

• 37:29Shirley A. Sahrmann?

  In some ways... I would be looking more specifically at which particular movements do it.

• 37:37Tim Ferriss?

  Okay.

• 37:37Shirley A. Sahrmann?

  And then try to identify, for example, it would be hard for me to believe this, but if you're hip flexors, and it makes a difference, like the tensor fasciculata is a hip flexor, but it has a rotational component that's much stronger than the soas does. The soas has more anterior pull.

• 37:55Tim Ferriss?

  Yep.

• 37:56Shirley A. Sahrmann?

  The tensor fasciculata is going to pull more on the pelvis. And I will tell you that in my judgment, and I don't think I'm way off on this, at least 70% of the people with back pain, it's because their hip's not moving optimally. And you said it yourself, my hip is not moving and then it bothers my back. Well, that's exactly what goes on. And it doesn't take some big structural fault to have that, just a difference in the passive tension. So usually with younger people, if I'm going to generalize about back pain, it's related to their spine flexing, because when you're younger, you're more flexible.

• 38:32Tim Ferriss?

  Mm-hmm.

• 38:33Shirley A. Sahrmann?

  And I think the other thing that's tied to that while we're talking about the hip is they're identifying more and more that hips, what they call femoral acetabular impingement, hips aren't flexing as much. There's structural changes going on. So if your hip only flexes 90 degrees, then you want to bend over, you're going to do it much more in your back because your hip's not doing it. So I want to know all the things that relate to flexion. In the older person, then it's more related to extension, just like the stenosis thing. Stenosis is, that's when you really can't extend. That's why you see old people walking bent over, why they need a walker when they're bending over. And then the element of rotation.

• 39:17Shirley A. Sahrmann?

  And because it's not just, is it one iliopsoas that's problematic or both of them, one tensor that's pulling more strongly than the other? And that's the passive tension, not just the active tension. And that's what you have to know.

• 39:32Tim Ferriss?

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• 40:16Tim Ferriss?

  subscription purchase. So learn more, check it out. Go to drinkag1.com/tim. That's drink A-G-one, the number one. Drinkag1.com/tim. Last time, drinkag1.com/tim. Check it out.

• 40:36Tim Ferriss?

  Now, you were asking about my breathing and the deep breath. When I met with Eric, and I could be totally screwing up this terminology, so you may need to rein me in, but he had me take off my shirt and he, I think it was at a very low, it might be high, but infrasternal angle. So I have a bit of a depression in the chest. I have a very minimal ability to expand my rib cage. I'm a belly breather and I've had a number of people note that it's likely when I breathe, I kind of rotate my entire rib cage backwards, which also causes that excessive, exactly, that excessive hinging

• 41:17Tim Ferriss?

  at the lumbar. What do you do with somebody who's got this type of predicament or pattern?

• 41:25Shirley A. Sahrmann?

  Usually, as I was saying before, if your rib cage doesn't expand, then it's often because your abdominals are too taut. And so, one of the ways is to elongate them. So, arms up over your head and taking a deep breath.

• 41:40Tim Ferriss?

  Mm-hmm.

• 41:41Shirley A. Sahrmann?

  And just, you probably know that with breathing, you've got two modes of movement. One, they call pump handle, and the other is bucket handle.

• 41:50Tim Ferriss?

  I'd love for you to elaborate on that. Yeah.

• 41:52Shirley A. Sahrmann?

  Okay. Well, pump handle means your, the front of your chest, your sternum is going up, like a pump. And bucket handle is like the sides expand.

• 42:01Tim Ferriss?

  Mm-hmm.

• 42:02Shirley A. Sahrmann?

  And so, with arms up overhead, you want to really think about lifting your chest as well as pushing your rib cage out.

• 42:09Tim Ferriss?

  Laterally, you mean?

• 42:10Shirley A. Sahrmann?

  Yeah, laterally, like it's all going up. And then, yeah, yeah, can you, can you do that? Can you take?

• 42:18Tim Ferriss?

  Yeah, it's, uh, yeah, I don't have much. It doesn't do much.

• 42:21Shirley A. Sahrmann?

  No, no.

• 42:22Tim Ferriss?

  As it stands right now, yeah.

• 42:23Shirley A. Sahrmann?

  That's what you need to do. And then, here's the other thing, that if you stand with your back against the wall, and then you try to do a side bend, butt, butt, butt. You want to make sure the side bend, you're moving through, that the axis of rotation's through your chest, not in your lumbar spine.

• 42:40Tim Ferriss?

  Yeah, make my symptoms worse.

• 42:42Shirley A. Sahrmann?

  And you want to be sure, Tim, that you don't just pull yourself over. You want to try to fall, like you've got a heavy elbow. In, in other words, don't contract the muscles on the same side, but try to get these to elongate. So like you're falling over, more passive elongation rather than an active contraction. Now, you're not going to go real far initially, unless you've got a really heavy elbow.

• 43:08Tim Ferriss?

  So the axis of rotation should be, or the, or the fulcrum should be in the middle of the chest?

• 43:13Shirley A. Sahrmann?

  Yeah, right. And don't, I always like to say, I don't care how far you go, I care how you get there. And so, don't push it for big range, and just make sure you're not moving your lumbar spine, and that you're doing your thoracic spine.

• 43:25Tim Ferriss?

  And are you breathing in those positions, or is this stretching your intercostals? Or what is the, the objective of the?

• 43:32Shirley A. Sahrmann?

  The objective is to elongate those abdominals that are not.

• 43:34Tim Ferriss?

  Oh, I see.

• 43:35Shirley A. Sahrmann?

  The other thing is, just even when you were doing this, you don't have any symptoms at all when you're sitting there, right now.

• 43:41Tim Ferriss?

  I have a little, a little tightness in my low back. I am sitting in, in a chair with lumbar support.

• 43:48Shirley A. Sahrmann?

  Why do you do that when you have too much lumbar curve anyway?

• 43:52Tim Ferriss?

  Well, because I've noticed that for whatever reason, symptomatically, I get relief with a small amount of, of lumbar support. If it's a flat back chair and I end up kind of falling forward and flattening my back, it, it ends up hurting me much more later.

• 44:07Shirley A. Sahrmann?

  Yeah, because you're getting a translation motion. I could, but okay, what if you put your arms up over your head and take a deep breath? Does that decrease your symptoms at all?

• 44:14Tim Ferriss?

  I would say doesn't noticeably, I don't have any severe symptoms right this instant, but doesn't worsen it for sure.

• 44:23Shirley A. Sahrmann?

  And, but it doesn't make it any better either?

• 44:25Tim Ferriss?

  It might lessen it slightly. The degree of pain right now, I would say is pretty low, so it's hard for me to

• 44:30Shirley A. Sahrmann?

  That's good. And, and again, if you look at it from the standpoint, the more you move someplace else besides your back, the better off you're going to be.

• 44:40Tim Ferriss?

  Yeah, definitely.

• 44:42Shirley A. Sahrmann?

  That's part of the whole strategy is make sure, because usually the problem is that motion that's problematic is occurring during all of your activities. The body follows the rules of physics. It takes the path of least resistance. So if it's easy to move there, it keeps moving there. And that's what you're trying to change, to make it easier to move at other places where you should be moving more.

• 45:07Tim Ferriss?

  This seems to me to be very, very, very important. So would you mind just saying that again, just reiterating that the body follows the path of least resistance? So if you have a worn groove, you have to, and it's leading to pathology, you need to sort of grease a different groove. Could you, could you just speak to that? Because it strikes

• 45:24Shirley A. Sahrmann?

  You're doing a beautiful job yourself. I don't think you need me.

• 45:27Tim Ferriss?

  Well, you know, I'm great at pontificating. I just need to change my movements.

• 45:32Shirley A. Sahrmann?

  Okay.

• 45:34Shirley A. Sahrmann?

  Father Superior.

• 45:36Tim Ferriss?

  No, I just, you know, I talk a good game. I just have to fix my movement patterns and my breathing. But I like how you phrase it. I mean, it's the body is going to take the path of least resistance.

• 45:48Shirley A. Sahrmann?

  That's it. Exactly.

• 45:50Tim Ferriss?

  I'm going to follow these, these exercises. I will do, I'll experiment with the elongation. I wanted to add one more data point, which is if I do, for instance, Pilates classes with someone who's very technical, if I'm in that flexed position, which tends to be more comfortable for my back, if I'm experiencing a lot of symptoms.

• 46:11Shirley A. Sahrmann?

  You tell me, are you supine?

• 46:12Tim Ferriss?

  I am supine, yes.

• 46:15Shirley A. Sahrmann?

  Okay, you're supine?

• 46:16Tim Ferriss?

  Yep.

• 46:17Shirley A. Sahrmann?

  And then what are you going to do?

• 46:18Tim Ferriss?

  Well, if I'm doing, basically what I'm, what I'm trying to sort out for myself is if the overly contracted abdominal resting state can contribute to the symptoms of experiencing, what I have also experienced is if I do a workout that seems to be focused or is focused on a lot of core musculature and pelvis work and so on, that my low back doesn't bother me for a few hours after that workout. And I don't know how to interpret that. Maybe these things are not at odds. Maybe they can both be true for different reasons.

• 46:52Shirley A. Sahrmann?

  Well, I mean, it depends what your workout is. What would be bad in the long run is if you're doing a lot of holding your legs up and moving those, moving those around while you're supine, because again, you're going to be using your iliopsoas and it's going to be pulling on your back. The big thing is for you to be able to contract, I'm getting the picture from you that I didn't have before, that here you are with an increased lumbar curve and that your lower abdominals aren't as taut. In lower abdominals, I mean external obliques, not just the ones that are, are lower. And when you contract those muscles. That they tend to flatten your back and decrease your symptoms.

• 47:31Tim Ferriss?

  Yes.

• 47:32Shirley A. Sahrmann?

  And so that would be to me what the advantage is when you're supine and starting to do the exercise. What would be not the long run good is if you're holding your legs up and trying to do something with your legs while you're holding that position because you're you're building in too much activity from the iliopsoas. So if anything in that position, I would just have you slide your leg down and try to keep your pelvis from tilting. Put your hands on your, I'm sure you probably know what ASISs are, anterior superior iliac spine.

• 48:05Tim Ferriss?

  I do, on the front of the hip.

• 48:07Shirley A. Sahrmann?

  Yeah, yeah. And just make sure they don't tilt.

• 48:10Tim Ferriss?

  For people who are wondering, could you just describe what that is?

• 48:13Shirley A. Sahrmann?

  It's a little bony prominence on the front of your your pelvis and some of your major hip flexors attach there. But it's also an indication of what your pelvis is doing as far as tilting forward or tilting backward. And in your case, what you want to do is not have it tilt forward. So the importance of that exercise would be that you can move your legs without your pelvis tilting anteriorly. I wouldn't put a big load on them. I would only have them slide down like you're sliding your heel along the supporting surface. Get it all the way down on one leg with no tilt. See if you can do the same thing with the other. If you have difficulty from what we've talked about before, if you take them out in abduction,

• 48:55Shirley A. Sahrmann?

  you should be able to get them down easier because your tensor is going to be pulling on your pelvis as well.

• 49:01Tim Ferriss?

  Right, so for people listening, if I'm interpreting this correctly, if your legs are separated, so you're more, your legs end up more in a snow angel type of position as opposed to directly in front of your hips. Now, is that a predominantly a diagnostic or is it also a training move that's sliding the heel?

• 49:18Shirley A. Sahrmann?

  All of the above, all of the above. I mean, that's the nice thing about going through an exam in which you're looking for this path of least resistance, the motion that is occurring too readily because it'll occur too readily with all of the activities. It goes back to what we were saying before. Then you try to make sure that you're either not getting that motion or you're moving where you should be moving. When you're taking people through the exam, and I think this is what's so valuable, is you're also showing them how to be in charge of their symptoms. Because nothing is more scary than here comes the pain, what did I do? How did I do it? How do I get out of it? And if you're showing people, if you go this way, it hurts. If you do it this other way, it doesn't hurt. And that's helps also with people following the program that's

• 50:03Shirley A. Sahrmann?

  recommended because their symptoms are, they're in charge of them and they know what to do to decrease them.

• 50:10Tim Ferriss?

  This personal experience has been incredibly frustrating, kind of horrifying, because it's the first time in my life. If you tear a labrum in your shoulder, or you break a, break an arm, or break a collarbone, it's oftentimes reasonably straightforward, or it seems that way. Whereas with this lower back pain, I would feel better for three days and then I would wake up and I would just be in incredible, like eight out of 10, nine out of 10 pain. And I could not identify what the cause was. And there've been times when my QL and my external obliques and so on are so locked up in the paraspinals that I can stand for a few minutes and I have to sit down, find something soft. And that's

• 50:50Tim Ferriss?

  not the case right now, but the recurrence of symptoms has been so unpredictable on some level. And a friend of mine who's in the medical profession said, oh, how long have you had that? And I said, nine months. And she said, well, you technically qualify for someone with chronic pain. And I was like, oh, my God, is this the new normal? This cannot be the new normal, which is why I appreciate you taking so much time speaking about this. When someone comes in and they have not identified anything, they come to you for help, or someone who's trained in your system, what does the exam look like? What does the session look like?

• 51:30Shirley A. Sahrmann?

  First, it's looking at what they look like. I mean, for me, it's just like if I saw you standing, I would know a whole lot more than just looking at you sitting. Because all of these things that we've talked about indirectly, I would see immediately. So one is just looking at alignment. And believe me, that's, that's a roadmap to a whole lot of things. And I think it's also worth noting that it's why people stand the way they stand is to minimize energy expenditure. So you can see what the passive tensions are, which are reflective of how hypertrophy to muscle is. And then it's simple motions, Tim. Have people forward bend? Does their back flex too much? Does it not reverse its curve?

• 52:12Shirley A. Sahrmann?

  With you, and how, how much do their hips flex? And typically in men, there's more of a problem of excessive lumbar flexion than there are in women, just because the center of gravity is higher, the hips are stiffer, et cetera. So, how do they forward bend? How do they rotate? Because many people will twist rather than be, really be able to rotate. And then side bending. Does it hurt? Where do I see the motion?

• 52:38Tim Ferriss?

  Now, by twist, you mean their pelvis follows them instead of that sort of?

• 52:42Shirley A. Sahrmann?

  No, that, see, that's, that's the other thing that's interesting is because, I'm sure with you, that people have looked at what your range of motion is in your hips. But when you're standing, you don't have that same range of motion. Your pelvis won't rotate on your femurs the same amount. So, one, does your hips not move and therefore you have to move in your back more? Because your pelvis isn't rotating. Or is it asymmetrical? And then the other thing is that actually ironically, if your abdominals are really good, instead of sort of rotating off more of an axis, though it's not perfect, your trunk shifts over. Because if your trunk shifts over in a twisting motion, it's because your abdominals won't elongate easily. And then which one of these motions causes symptoms?

• 53:27Shirley A. Sahrmann?

  When I see that it's bad, I will correct it. For example, if you had pain side bending, then I'd put my hand above your iliac crest, have you side bend again. And if I've blocked it and you don't have pain, then I know that that motion occurring there is causing your pain.

• 53:44Tim Ferriss?

  The movement of the pelvis or the iliac crest?

• 53:48Shirley A. Sahrmann?

  The movement in your back. And the same thing, if, if you bend over and there's no pain, but you come back up and you lead with your back rather than your hips, then that causes pain, then I know, again, that extending is causing your symptoms. And then if your symptoms, as you have reported, get better when you bend over, again, I know that extension's causing your symptoms. And then I go through little tests in supine to see the length of the hip flexor muscles. I look to see what your symptoms are in supine. If you have symptoms, just like you sort of suggested, if we flex your hips and knees, you ought to be more comfortable than when they're down straight. If I abduct your hips, I know that what's causing it that way. You see what I mean?

• 54:32Shirley A. Sahrmann?

  So I will passively move your hips to see what the range is. Make sure it's passive, and then I'll have you do it actively to see if that elicits symptoms, show you how to change it. So I'm going through an exam, looking for that movement that shows up consistently. If I stop it or improve it, the symptoms go down. So we do in supine, side lying, prone, quadruped, sitting. Watch people walk. Everything that gives them pain, they get in and out of their car, how to roll, how to go up and down stairs, whatever activities would give them pain, I'll go through them.

• 55:11Tim Ferriss?

  Is the assessment largely the same for athletes versus non-athletes?

• 55:16Shirley A. Sahrmann?

  That's a really interesting point because in some ways, people have a hard time because I'm looking for little baby things. You know, ironically, there's really good research that's been done by Linda Van Dylin. And these movements that cause the symptoms occur very early, and they're only a few degrees. And so sometimes with athletes, I've had the issue that, well, these are just baby things and they don't really matter. But they do matter. You've got to stop that, and then you can build on bigger ways. There's a therapist by the name of Robbie Ohashi, who's put these into, it's like a movement spectrum, that's not the exact words, I'm blanking on it right now, where you do

• 55:58Shirley A. Sahrmann?

  isolated exercises, combined exercises, and then putting them together for your sport, you know, whether it's tennis or whatever. And he's seen a lot of athletes. And that's the whole idea, is that you get somebody to correct the little bitty movements, and then you build on the more complicated, the more demanding movements.

• 56:18Tim Ferriss?

  Do you have an opinion of, I've not experienced this personally, but something called DNS, I think it's dynamic neuromuscular?

• 56:27Shirley A. Sahrmann?

  Neuromuscular stimulants, yeah.

• 56:28Tim Ferriss?

  Yeah, and because it seems like they build based on some... Sort of motor skill development chronology from childhood. So you do, you'd start with supine or prone and then move to like one to crawling or something like that quadruped and then kneeling and so on. Do you have any perspective on this?

• 56:47Shirley A. Sahrmann?

  To be perfectly honest, I think you're already grown. So I

• 56:53Tim Ferriss?

  Okay, got it. Yep. Certainly. If my shiny paint would is any indication, then yes.

• 56:59Shirley A. Sahrmann?

  Looking at your well shaved head, I'm always reminded of what my father used to say, who was also bald from an early age. And he would always say, grass can't grow on a busy street.

• 57:11Tim Ferriss?

  That's hilarious. I'm definitely gonna, definitely gonna use that. Yeah, no, grass cannot grow on a busy street.

• 57:21Shirley A. Sahrmann?

  I don't think you need to stage it like that. That's why I go through the, the whole exam and look at the sort of the finished product that needs some fine tuning. The thing we talked about in the beginning and that movement causing pathology and the fact that it's really your everyday activities that cause it in the first place. And so that's why you've got to change the way you're doing basic things. You know what I mean? And look at that because that's what caused the problem. That's what you need to change.

• 57:49Tim Ferriss?

  What is, I believe you call it collapsosmashoh?

• 57:55Shirley A. Sahrmann?

  Where did you get? I didn't put that down. Well, there are two, there are two farms here. It relates to this fact that what we talked about already, that the spine suffers from compression type things. And in the older individual without muscles, it's collapsosmashoh. And younger individuals like yourself or others who have done a whole lot of abdominal exercises, I call it squeezeosmashoh. Because, because the passive tension from those muscles is adding to the compression. And the older people are people who are hypermobile, then it's kind of collapsing down without enough support. So, you know, it's not good if you don't have enough muscle and

• 58:38Shirley A. Sahrmann?

  it's not good if you have too much muscle. It's what's in between that's most important.

• 58:43Tim Ferriss?

  How do you find the Goldilocks amount of?

• 58:46Shirley A. Sahrmann?

  No pain and they look great.

• 58:50Tim Ferriss?

  Keep fine tuning.

• 58:52Shirley A. Sahrmann?

  And the other thing is, you know, obviously, we aren't all built the same. I think that's one of the other important things is looking for structural variations and building that into the assessment. That's the part that's tricky. People don't always pick the right parents, and when they find out, it's too late to go back.

• 59:10Tim Ferriss?

  All right. So let's talk about perhaps other common pathological patterns. I've read that you've said or written perhaps that most people wear their shoulders too low. Could you speak to that and perhaps also mention what corrective measures can be taken? What does it mean for people to wear their shoulders too low?

• 59:33Shirley A. Sahrmann?

  Well, it means that they should sit up at an angle that is about six degrees or so higher. And often you see when you don't look so bad, but when people have done a lot of weight training, that's one end of this game, you'll see that their shoulders look really dropped. They look lower so that the end of their shoulder isn't sitting up. If you know that there's the cervical vertebrae between C6 and C7, you should have, that's about the level where your shoulders should be. If that's way down, or you can look at your clavicle and you see that there's not this six degree angle.

• 1:00:12Tim Ferriss?

  Oh, I see. So the clavicle should from inside to outside have roughly a six degree upward angle?

• 1:00:18Shirley A. Sahrmann?

  It should have a little tilt to it, should be upward angle. Right, right. So it could be too low. And then the other way I like to talk about it is just the weight of the world, the husband, the children, you know, the bra straps, all of that pulling down. And women's shoulder girdles aren't as stiff. What's important about this is it's not only a factor of what it does to your shoulders, it also does a number on your neck. Because the muscles that help to hold your shoulder blades up attach to your cervical vertebrae. And the really big important thing on trying to address that is using, I think, the muscle that's called this, that's named the serratus anterior. The serratus anterior attaches to your rib cage, and it can act like a sling. So it

• 1:01:01Shirley A. Sahrmann?

  attaches to your rib cage and to your shoulder blades. So it's like a sling that can help to hold your shoulder blades up and take some of that load off of your cervical spine, as well as put your shoulders in the right position. And having your shoulders sitting at the right position is important for the glenohumeral joint, for all of the shoulder joint motions to work without subjecting them to too much injury.

• 1:01:27Tim Ferriss?

  So it seems like perhaps in weight training, I don't know if this contributes to the slope shoulders and maybe the flat or downward angle of the clavicle, but the advice to depress and retract your shoulders is common, right?

• 1:01:43Shirley A. Sahrmann?

  Run them up.

• 1:01:44Tim Ferriss?

  For any number of exercises. And I recall meeting with Eric and what he has a lot of his athletes do, and this is very individual dependent, so I'm not making a blanket recommendation and I'm not speaking for Eric. But for instance, as he has someone maybe retract on some type of standing pulling motion with say some type of cable machine, he'll have them reach forward with the opposing side. And it seems to me that there's less of that kind of fixed depress and retract, retracted position in a lot of what he recommends. Is working on the serratus anterior, doing exercises for the serratus anterior enough to correct that downward sloped angle in people who have that as the current state of affairs?

• 1:02:27Shirley A. Sahrmann?

  Number one is also you have to be sure when people have worked out, now it depends upon again what their workout routine is, if there's somebody that hangs and does chin ups. One of the things can be the latissimus dorsi, is this big muscle. And people do lap pull downs, et cetera, or they do climbing things or hanging things. And that muscle will pull your shoulders down. So you've got to make sure that that muscle hasn't gotten too short and that you can get your arms up over your head in the first place. Number two is what you really want to do is use the upper trapezius. And the exercises where you're down here is using the rhomboids and the middle trapezius.

• 1:03:07Tim Ferriss?

  And just for people who are listening, this is like a rowing motion?

• 1:03:11Shirley A. Sahrmann?

  Yeah, anything that where your arms are below your shoulders or at the level of your shoulders, you're using muscles, they pull your shoulder blades together, but particularly the rhomboids downwardly rotate.

• 1:03:26Shirley A. Sahrmann?

  So it's gonna make it more difficult to get your scapula to upwardly rotate and to get the upper trapezius to work. So one of the things that is probably more effective is actually, I like to start people off, and I think that's the other thing that when I look at what recommendations there are on the internet, they never show people where to start. It's like, do this exercise. Well, not everybody's ready to do that exercise. They've got to get ready to do it the way that's recommended. But if you can face the wall and slide your arms up the wall, and then once your arms get to shoulder height, particularly when they're lower, then you shrug a little bit

• 1:04:08Shirley A. Sahrmann?

  to get them up, and then you try to lift them off while holding your shoulders up.

• 1:04:13Tim Ferriss?

  How far are you standing from the wall?

• 1:04:15Shirley A. Sahrmann?

  Oh, you're right up, right up there facing.

• 1:04:18Tim Ferriss?

  Okay, got it.

• 1:04:19Shirley A. Sahrmann?

  Right up there facing. Your elbows are flexed, you're sliding the little finger side of your hands up there to get it. And then if you just let your shoulders drop, you've gained nothing. But you've got to also hold them up as you lower your arms.

• 1:04:32Tim Ferriss?

  Keeping your shoulders up as you do this exercise?

• 1:04:35Shirley A. Sahrmann?

  Right, keep them up. Get them up to where they should be worn, not closer to your ears than your iliac crest.

• 1:04:41Tim Ferriss?

  Mm-hmm, got it. And that would be, so you're looking to keep the shoulders in the position where the clavicle is angling up, yeah, slightly?

• 1:04:50Shirley A. Sahrmann?

  Yep, yep. The other thing is, it just makes such common sense. You can't spend the rest of the day having them hanging down either. So you should have a chair that has armrests on it so that they're up when you're, you've got your armrests up. If you have to stand a lot, you can put them on your hips. If one shoulder in particular is problematic, you can support it with the other hand. I mean, so, again, exercises will mean nothing if you don't follow through. If you're doing even 20 minutes of exercise, but you're spending 12 hours with your shoulders hanging down, it ain't gonna work.

• 1:05:26Tim Ferriss?

  What is your position on, and I know there are many different types, but stretching? This can be a controversial, sometimes polarizing topic, but could you elaborate on how various forms of stretching should or shouldn't be used in healthy and rehabilitating populations?

• 1:05:44Shirley A. Sahrmann?

  Number one is really understanding what you're meaning by stretching. I've talked about this as we've gone on through this, but I keep using the term stiffness because I feel like I was sort of misled during my early days as a physical therapist when I didn't use my own sense of looking carefully because we were told that certain movements occurred because a muscle was too short and it needed to be stretched. I'll give you an example. The example we talked about already, if you're on your back and you slide your legs down and your pelvis tilts forward, your hip flexors are too short. Well, actually, what it is, is the struggle between the tension from your abdominals

• 1:06:29Shirley A. Sahrmann?

  and the tension from your hip flexors. So stretching your hip flexors is not going to fix the lack of tension in your abdominals. And so what I find is that most often there aren't muscles that are short, there's a relative stiffness problem. So improving the stiffness of your abdominals will elongate your hip flexors.

• 1:06:51Tim Ferriss?

  Yeah, it's a relationship, not just an isolated muscle that you need to stretch.

• 1:06:56Shirley A. Sahrmann?

  Right, and it isn't the length of the hip flexors that's the problem, it's the passive tension from those muscles. Because when you're sliding your leg down, that muscle isn't that active anyway. And if it's related to the length of the muscle, it shouldn't occur until you get to the end of that muscle length. And that's not when the tilting occurs. So there's all these things that just don't make sense. So what I've found through these numerous years of experience I've had is that there's many more problems with relative stiffness than there is with muscles really being short. Now... If it's really short, then you also need to find out what's making it short. Because it doesn't just like, oh, I think I'll go short today.

• 1:07:40Shirley A. Sahrmann?

  It's a matter of what is your activity? When I'm teaching courses, I have a great picture of a, of a young man who has really short, he has big curve like you're talking about, an increased lumbar curve. Clearly, his hip flexors are short and he's a cyclist. Well, you usually don't see that kind of alignment in a cyclist. You usually see a, a flatter back. But if I didn't let him use toe clips, he couldn't move the pedals around. So he moved the pedals by flexing rather than pushing. So that's why his hip flexors were short. So it wouldn't matter how much you stretched him, if every time he went out to ride the bicycle, he's using his hip flexors all over again in a shortened position.

• 1:08:23Tim Ferriss?

  So he's basically in that rear half of the rotation of the pedal. He's pulling with his hip flexors.

• 1:08:28Shirley A. Sahrmann?

  Right. Instead of more pushing than just the lifting. So what is it that people are doing that's causing that muscle to get short? Other examples, and again, I find it so interesting about what intensive weight training is doing because if you're lifting, I've actually examined young women who are lifting twice their body weight. Well, you know, how many muscles do you use if you're lifting twice your body weight in a deadlift? Like every little muscle you've got in your body. Well, what happens is you end up training all of those muscles to come on and they don't just go off. So they walk stiff legged because there is too much activation of these muscles.

• 1:09:09Shirley A. Sahrmann?

  And so they can't stand and have muscles relaxed because everything comes on. It, it doesn't say, I'll only come on when I'm weight training. You've trained them to come on. And now you've got much more output for a given muscle than you would otherwise. So it's, it's too much. So you've got to learn also how to not activate them as much as you're learning how to activate them. I'm not against any of this. It's just that you need to know what all the additional factors are that take place with this training. So it's a long answer to the question about stretching, but my big point is you've got to figure out what's making it short. That if you need constant stretching,

• 1:09:52Shirley A. Sahrmann?

  You've got a problem with what's active, what's making it short that has to be addressed.

• 1:09:57Tim Ferriss?

  So I've been advised, and it seems to help a bit, but to do a fair amount of, say, hip bridging or glute activation alternated with, say, hip flexor stretches. And if I have, in addition to that, the stiffness in the abdominal muscles contributing to this low back presentation, right, these symptoms I'm experiencing, could you just remind me of how I would then work on that abdominal stiffness? I could do the overhead breathing and the side bends, but-

• 1:10:30Shirley A. Sahrmann?

  That's for, that stiffness. But again, what you're telling me, and again, I haven't seen you standing, but-

• 1:10:35Tim Ferriss?

  I could stand. We're also on video.

• 1:10:37Shirley A. Sahrmann?

  Okay.

• 1:10:38Tim Ferriss?

  Would you like me to stand?

• 1:10:39Shirley A. Sahrmann?

  Yeah, please, please.

• 1:10:41Tim Ferriss?

  And I can tilt the camera as needed.

• 1:10:43Shirley A. Sahrmann?

  Okay. And yeah, pull up the shirt so I can see.

• 1:10:48Shirley A. Sahrmann?

  Okay. Now turn sideways for me.

• 1:10:53Shirley A. Sahrmann?

  Oh, yeah.

• 1:10:55Shirley A. Sahrmann?

  Oh. No, no, no. I mean, you, I don't know what you're talking about. Your tummy's sticking out.

• 1:11:00Tim Ferriss?

  Oh, well, yeah. I mean, like, if I want to look kind of in my second trimester, I can-

• 1:11:05Shirley A. Sahrmann?

  Now, is that, which one's the real you?

• 1:11:08Tim Ferriss?

  This is probably the real me. This is the real me. This is, this is how I would stand. If I were standing at an event, I would probably try to tuck my hips a bit to take pressure off my back.

• 1:11:17Shirley A. Sahrmann?

  But you see, you, you don't have an increased lumbar curve. You've got an increased thoracic curve.

• 1:11:23Tim Ferriss?

  The, you'd be like the kyphosis on the back-

• 1:11:26Shirley A. Sahrmann?

  Yeah, yeah, yeah. And, and part of that kyphosis, yeah, right, right up there. Yeah. And part of that kyphosis comes from your rectus abdominis pulling down on your thoracic spine.

• 1:11:36Tim Ferriss?

  Interesting. Right here.

• 1:11:38Shirley A. Sahrmann?

  Yep, yep. Yeah. And see, when you, when you lean back like that- I'm telling you though, the rectus and the, and the other abdominals become your anti-gravity muscles, so they're constantly being used.

• 1:11:49Tim Ferriss?

  Hmm, meaning that I'll lean, I lean back and then these are pulling me forward?

• 1:11:54Shirley A. Sahrmann?

  Yeah, you lean back to get away from those, but you need to, the, the rectus needs to be a little bit longer.

• 1:12:00Tim Ferriss?

  Okay, this needs to be a bit longer.

• 1:12:02Shirley A. Sahrmann?

  And to decrease, and the best way for you to do that is to, to do the quadruped thing and then let your thoracic spine go down.

• 1:12:09Tim Ferriss?

  Now, so that would be almost like the cow, no, no, the cat of the cat cow, I guess, sort of, as I'm on my hands and knees.

• 1:12:17Shirley A. Sahrmann?

  All you need to do is think about letting your chest go towards the floor and like you feel the load on your shoulder blades.

• 1:12:23Tim Ferriss?

  Mm-hmm.

• 1:12:24Shirley A. Sahrmann?

  Okay. Now, let, let me watch you just easily, like you're gonna contract your tummy to pull it in. Yeah, see, you do sway back, now, okay, stop.

• 1:12:32Tim Ferriss?

  Yeah, this.

• 1:12:34Shirley A. Sahrmann?

  Now, you, you, you did lean back.

• 1:12:36Tim Ferriss?

  Yeah, if I'm gonna, like, I'll.

• 1:12:39Shirley A. Sahrmann?

  But, don't, don't, that's it, that's better, that's better. Now, do you have any symptoms like that at all?

• 1:12:43Tim Ferriss?

  No, there's a little bit of tightness here, but it actually, uh, it doesn't, it doesn't bother me right now.

• 1:12:49Shirley A. Sahrmann?

  Yeah, okay. Yeah, and, and it looks like your hips are fairly straight, so go ahead and turn, put your back to me, so I can just see, put your back to me for a minute, and put your hands on your iliac crest.

• 1:13:01Tim Ferriss?

  Getting my, my index fingers on my ASIS.

• 1:13:04Shirley A. Sahrmann?

  Now, with, yeah, with, with your hands like that, it looks like, they don't look so bad to me. Let's do what we talked about before, put your feet apart and let's just see what happens. Does that, if that changes your symptoms at all?

• 1:13:14Tim Ferriss?

  Yeah, it, uh, it seems to help. I'm wearing very slippery shoes, so I'm doing a little bit of.

• 1:13:19Shirley A. Sahrmann?

  Is it better?

• 1:13:20Tim Ferriss?

  Yeah, it's better. I would stand, this, this would, this would help if I was, like, recording a podcast. What would help even more is if I put my one leg up on something, if I stepped on something.

• 1:13:33Shirley A. Sahrmann?

  Yeah, yeah, yeah. Does it matter which leg?

• 1:13:35Tim Ferriss?

  Right leg, because where I, where I feel most of the pain is sort of localized around this bony process here.

• 1:13:43Shirley A. Sahrmann?

  Right, right, yeah, so that is gonna be the, the tensor on that side. Now, let me do you one more thing, just bend over and come back up.

• 1:13:49Tim Ferriss?

  From the side like this?

• 1:13:50Shirley A. Sahrmann?

  Yeah.

• 1:13:51Tim Ferriss?

  Okay.

• 1:13:53Shirley A. Sahrmann?

  Well, yeah, see, now, you need to work a bit on how you come back up from

• 1:13:58Tim Ferriss?

  Okay.

• 1:13:59Shirley A. Sahrmann?

  forward bending, so that it's, and don't worry about going over that far.

• 1:14:03Tim Ferriss?

  Okay.

• 1:14:04Shirley A. Sahrmann?

  You need to come up with your hips and less back. As you finish off your back, you sway back and do too much back extension.

• 1:14:12Tim Ferriss?

  Oh, when I get to the top, you're saying?

• 1:14:14Shirley A. Sahrmann?

  Yeah, about the last.

• 1:14:16Tim Ferriss?

  So hinge more at the hip?

• 1:14:17Shirley A. Sahrmann?

  Thirty, forty percent.

• 1:14:18Tim Ferriss?

  Is that what you mean?

• 1:14:19Shirley A. Sahrmann?

  Just think about going over and coming back up by making your hips extend.

• 1:14:24Tim Ferriss?

  Okay.

• 1:14:27Shirley A. Sahrmann?

  Hold it there. Now, hips, just come back up with hips, hips, hips, hips, hips, yeah. That was better. Yeah, just, yeah, and try not to let your back sway back. You use the momentum of your upper back coming back to finish up.

• 1:14:41Tim Ferriss?

  I see, I get a little like.

• 1:14:43Shirley A. Sahrmann?

  And then you get a little extension and that's not good.

• 1:14:45Tim Ferriss?

  Okay, got it.

• 1:14:46Shirley A. Sahrmann?

  Yeah.

• 1:14:47Tim Ferriss?

  Anything else that I can, yeah, I mean, I can do more, certainly. This is helpful.

• 1:14:52Shirley A. Sahrmann?

  If you can easily practice, you've got those, the lower abdominals or the external obliques, they're the ones that tilt your pelvis. And if you just easily practice tightening those, but don't work hard at it so that you sway back.

• 1:15:05Tim Ferriss?

  So this is the external obliques and then what was the other musculature you mentioned?

• 1:15:11Shirley A. Sahrmann?

  I'm saying don't sway back, just easily try to tighten them so you get a little bit of a pelvic. Yeah.

• 1:15:18Tim Ferriss?

  Yeah.

• 1:15:18Shirley A. Sahrmann?

  Plenty.

• 1:15:19Tim Ferriss?

  Yeah, okay.

• 1:15:19Shirley A. Sahrmann?

  Now, are you good that way?

• 1:15:21Tim Ferriss?

  Yeah, I'm good. I'm good.

• 1:15:22Shirley A. Sahrmann?

  Yeah.

• 1:15:23Tim Ferriss?

  And this would be in a standing position, when I would have just a little bit of tension in the external obliques.

• 1:15:28Shirley A. Sahrmann?

  You do that as much as, as much as you can.

• 1:15:30Tim Ferriss?

  Yeah.

• 1:15:31Shirley A. Sahrmann?

  Because, you see, it eliminates your symptoms. That's all you need to do.

• 1:15:34Tim Ferriss?

  Yeah.

• 1:15:34Shirley A. Sahrmann?

  And then work on that little increased thoracic kyphosis.

• 1:15:38Tim Ferriss?

  Mm-hmm. So, or, or I'm, I guess, reducing this kyphosis by lengthening.

• 1:15:43Shirley A. Sahrmann?

  Yeah, if you decrease that, then you won't sway back so much.

• 1:15:46Tim Ferriss?

  I got it.

• 1:15:47Shirley A. Sahrmann?

  And, and if this, if your rectus abdominis elongates better, you won't have that tendency for a thoracic kyphosis.

• 1:15:55Tim Ferriss?

  And to extend then elongate the rectus abdominis, for people listening, this is like six-packs, right? The stuff running down the, the front of the abdominal. Oh, sorry, I, yeah, that's right, I'm, I forgot about the microphone over here.

• 1:16:10Tim Ferriss?

  That to elongate the rectus abdominis, I could get in that quadruped position and basically drop my chest to the floor as I'm pushing my hips backwards.

• 1:16:20Shirley A. Sahrmann?

  Just in that position, just let it go down. It's amazing how much you can improve your alignment and it looks like you could change pretty readily. And the big thing, so we started off because you were doing the bridging exercise. I wouldn't be tempted to do that.

• 1:16:36Tim Ferriss?

  Okay.

• 1:16:36Shirley A. Sahrmann?

  One, you'll do a much better loading of your gluteal muscles by that bending over and coming back up with your hip extensors.

• 1:16:43Tim Ferriss?

  Yep.

• 1:16:44Shirley A. Sahrmann?

  And if you tighten it there, there's also a tendency for the glutes to actually posteriorly tilt the pelvis, but the spine doesn't go along for the ride.

• 1:16:52Tim Ferriss?

  Could you say more about that, please?

• 1:16:54Shirley A. Sahrmann?

  This is one of my guilt trips because many years ago I was working, to get the point across, I'll tell you my little story.

• 1:17:01Tim Ferriss?

  Yes, please.

• 1:17:01Shirley A. Sahrmann?

  I was working with this older woman, I thought old was my age now. And so she did have spinal stenosis. And I was working on sit to stand so she didn't have any symptoms. And I had her try to tighten her abdominals and she was doing pretty good. And then I said, okay, now let's tighten your gluteal muscles as you get up. Well, she did that and she got pain shooting down her legs. And the reason being that your gluteal muscles, as you know, attached to the pelvis. So if they posteriorly tilt the pelvis, but if the spine doesn't want to go along for the ride, it stays there and you get a translation motion between where the pelvis is moving and the vertebrae are not moving.

• 1:17:46Tim Ferriss?

  Right. The gluteal muscles are basically pulling the pelvis out from under the spine in a sense.

• 1:17:52Shirley A. Sahrmann?

  Exactly. Not a good idea. Now, if your spine moves easily, then that's all right. And you can get the same effect. If you would put your hand where your spine is and tighten your glutes, you'll see your spine doesn't move. You see what I mean? If it wants to go along for the ride, it'll go along for the ride. But the problem is those people where it doesn't want to go along for the ride, and you're going to be one of them.

• 1:18:14Tim Ferriss?

  Hmm. So in what ways do I need to be careful then?

• 1:18:18Shirley A. Sahrmann?

  I mean, I just don't think that's a good, a good exercise for you.

• 1:18:21Tim Ferriss?

  Got it. The bridging.

• 1:18:22Shirley A. Sahrmann?

  Bridging.

• 1:18:23Tim Ferriss?

  I feel especially if I do bridging, single legged, but even double legged. I remember it's been recommended to me by a number of PTs and I've told them all like, guys, this really bothers my back.

• 1:18:34Shirley A. Sahrmann?

  Yeah, yeah. And it's arching your back. It's not a good plan.

• 1:18:36Tim Ferriss?

  Yeah. Okay. I'll skip those.

• 1:18:39Shirley A. Sahrmann?

  I would skip those. When do you have time to do all this?

• 1:18:42Tim Ferriss?

  I don't. I don't. That's, that's honestly surely been one of the compounding factors that has been so frustrating is not only am I getting very often entirely different diagnoses, but I also get 37 different programs and there's just no way that I can fit them in. And many are probably conflicting also.

• 1:19:02Shirley A. Sahrmann?

  Right.

• 1:19:03Tim Ferriss?

  I've found the movement focused approach to make a lot of, at least intuitive sense to me. If, if our entire conscious experience of reality is modeled on a brain that is evolved to move us through space, it just seems to make sense that that is the variable to pay a lot of attention to because it's not just a variable, but a system of systems, as you put it, much like the immune system. So it makes a whole lot of sense. Now you just mentioned older woman, but she's now my age. Would, would you mind sharing your age, but also your own self-care, I suppose, routine? What do you do to keep as sharp and as in shape as you are? I would love to know more about that.

• 1:19:48Shirley A. Sahrmann?

  Next month I'll be 86 years old.

• 1:19:49Tim Ferriss?

  It's incredible. It's just amazing. I would never guess in a million years.

• 1:19:54Shirley A. Sahrmann?

  I'm so lucky. I'm so fortunate too, because I don't mind saying both of my parents had dementia and I've now exceeded their ages, both in life and in dementia. Right now I don't know that I have any.

• 1:20:06Tim Ferriss?

  I would not think you have any. Very, very sure.

• 1:20:08Shirley A. Sahrmann?

  So far, so good.

• 1:20:09Tim Ferriss?

  So far, so good.

• 1:20:11Shirley A. Sahrmann?

  As I told you that, number one, choosing to be a physical therapist. And also, I was very fortunate because, growing up, I refused to grow up and I played sports in my day. It's when are you gonna grow up and stop all that stuff? And that was very good. We also didn't have air conditioning and we only had one car. So instead of paying more for a bicycle than a car, I had to ride a big old bicycle and ride it everywhere. So I happily, you know, laid down enough bone and enough muscle in my early years. And then, the physician that I encountered, who was part of the Department of Medicine at Washington University in St. Louis, his name was John Hollis, he started bringing in the lifestyle issues.

• 1:20:54Shirley A. Sahrmann?

  And as a physical therapist, even though I got a PhD in neurobiology, because I wanted to solve the motor control problems of the stroke patient, I stayed very physically active. I started really running and doing things when I started my PhD studies and after encountering this physician. And learned a bit about nutrition, breaking all the family tendencies. And then, again, learning about musculoskeletal problems, even though I was really interested in working with neurological patients, people with spinal cord injury, head injury, stroke. I'd always had this tendency to look at how people moved and I totally tried to figure out why they were moving the way they were moving, etc.

• 1:21:38Shirley A. Sahrmann?

  And got involved with musculoskeletal patients and they started getting better. So I had to figure that out. And then I applied my own ideas to myself. I don't know how folks that you wanna get up, but there are really some funny stories.

• 1:21:52Tim Ferriss?

  Oh, let's do it. Oh, yeah, no, we love funny stories around here.

• 1:21:55Shirley A. Sahrmann?

  Well, and it really related to doing this quadruped little exercise. So one sort of funny story was, I was really poor, going through getting my PhD, because I didn't have any income and was living off of a minimum amount of money. And so I didn't get to buy new clothes very often. And I had a pair of slacks that I was wearing for a long time and a friend actually took me out to play golf, and it was an older woman at that time, and we're out playing golf and she says, you know, Shirley, you've got your pants on backwards. And I said, you know, I'm working on my PhD, I think I oughta be able to know how to put my pants on.

• 1:22:34Shirley A. Sahrmann?

  And so we started looking at the darts and sure enough, I had them on backwards. Well, before, before my alignment was such that they looked all right. But now that I was doing this quadruped exercise, they didn't look all right. They were, they were looking funny because I had changed the curves in my back and my buttocks. And so that's why she caught the idea that I wasn't wearing my pants right.

• 1:22:58Tim Ferriss?

  Which quadruped movements were these?

• 1:23:00Shirley A. Sahrmann?

  It's just the idea of being in quadruped and just letting your back go down and then rocking back.

• 1:23:06Tim Ferriss?

  Yep.

• 1:23:07Shirley A. Sahrmann?

  I tended to ride the bicycle. I was a catcher for three different softball teams. So I was really in a posterior tilt with a really flat back and I had never really gone the other way.

• 1:23:20Tim Ferriss?

  And just for people who are listening, if you don't know, just to imagine, if you imagine the pelvis as a bowl of soup, posterior tilt, you're kind of pouring soup out the back of your pelvis, just for people.

• 1:23:31Shirley A. Sahrmann?

  Holding it in the middle.

• 1:23:33Tim Ferriss?

  Yeah, yeah, right. Yeah, got it. Okay.

• 1:23:35Shirley A. Sahrmann?

  And so your back, your whole back goes kind of flat then.

• 1:23:38Tim Ferriss?

  Hmm. And when you're pushing your hips back, you're facilitating more of a natural curve in the, in the lower back.

• 1:23:43Shirley A. Sahrmann?

  Well, I was, you know, getting my hips to bend and yeah, letting my back go down. So I was getting more of a curve and I think also decreasing a bit of a tendency towards a thoracic kyphosis. The, the other thing that was really interesting, I used to bowl, you know, like with a bowling ball.

• 1:23:58Tim Ferriss?

  Yeah.

• 1:23:59Shirley A. Sahrmann?

  And while I was in my PhD program, which took me six years, I didn't have any money to bowl. And so when I went and got my bowling ball out again, I had to change the finger grips because I had stretched my finger flexors out. And so the finger grips no longer fit me because my fingers were, were longer.

• 1:24:18Tim Ferriss?

  So could you explain that? So your grips had been molded to fingers that were?

• 1:24:22Shirley A. Sahrmann?

  My fingers were always flexed from everything I did.

• 1:24:25Tim Ferriss?

  Right.

• 1:24:26Shirley A. Sahrmann?

  And I never really thought about stretching them out. And so when you're in quadruped.

• 1:24:30Tim Ferriss?

  Oh, right, right, right.

• 1:24:32Shirley A. Sahrmann?

  Stretching those all out.

• 1:24:32Tim Ferriss?

  Right, okay, I see, right. Instead of, so for people who are listening, because we're making movements with their hands and gestures with the hands, instead of being in sort of the keyboard position, we're going to make the video available as well, but some people will only hear audio. So instead of being in sort of that keyboard, you know, hawk talon position, when you're in quadruped, right, as if you were doing a push-up, but not that push-up position, if your hands are flat on the floor, then you're going to be stretching those flexors.

• 1:24:58Shirley A. Sahrmann?

  Stretching across the wrist and across the fingers, yeah.

• 1:25:01Tim Ferriss?

  Mm-hmm, yeah, got it. So you had to change your bowling ball, that's wild.

• 1:25:05Shirley A. Sahrmann?

  Yeah. And then the other thing is, I had always worn my shoes off so that they were going off to the side, and after I did this few years of this quadruped rocking, I didn't walk in the same way, and I didn't have my, shoes weren't worn off to the side from just walking.

• 1:25:21Tim Ferriss?

  Oh, interesting. So worn off to the side, you mean the shoes on the inside were worn, or on the?

• 1:25:27Shirley A. Sahrmann?

  Yeah, like the outside of the right and the inside of the left. So there were all these little changes that took place, just from improving my alignment, partly with that. So to go on to answer your full question, so what do I do these days? Guess what, I still do quadruped. I don't go all the way back and sit on my heels. And I also want to tell you about one thing people need to know about that exercise. And then I do push-ups, modified push-ups. And then in prone, and I think that if you could do this carefully, it'd be good, is in prone, I flex my knee, so that my leg, as much as possible, is falling on my thigh.

• 1:26:05Tim Ferriss?

  You're laying down on your chest, you...

• 1:26:08Shirley A. Sahrmann?

  Yeah, I'm laying down, face down, bend my knee.

• 1:26:10Tim Ferriss?

  Well, you bring up one knee.

• 1:26:11Shirley A. Sahrmann?

  And I try to get my leg, just one knee, to fall back on my thigh, because I don't want to hold it bent at 90. In other words, if you bend your knee, you can go to 90 degrees. If you go more than 90 degrees, your leg is falling on your thigh.

• 1:26:25Tim Ferriss?

  I see, your lower leg is sort of falling onto your hamstring.

• 1:26:28Shirley A. Sahrmann?

  Yes.

• 1:26:29Tim Ferriss?

  Okay, got it, okay.

• 1:26:30Shirley A. Sahrmann?

  That's your thigh, yeah.

• 1:26:31Tim Ferriss?

  Yep, and so, right, and so you're...

• 1:26:33Shirley A. Sahrmann?

  And so then, in that position, then I lift my thigh off of the floor. I do hip extension, but not high, there's only 10 degrees of motion, but it's a way to stretch, it's a way to use your gluteal muscle, because you can't, if you use your hamstring, you'll get a cramp.

• 1:26:52Tim Ferriss?

  Yep.

• 1:26:52Shirley A. Sahrmann?

  You'll get a bad cramp in your hamstring. So just a little bit of hip extension to use my gluteal muscle.

• 1:27:00Tim Ferriss?

  How many repetitions are you doing on each side?

• 1:27:02Shirley A. Sahrmann?

  I just do 10 repetitions on that, on one side, and then 10 repetitions on the other.

• 1:27:07Tim Ferriss?

  And you're doing roughly 10 repetitions of the quadruped rocking as well? I'm not sure if that's the right.

• 1:27:13Shirley A. Sahrmann?

  Yep, yep, and 15 pushups.

• 1:27:15Tim Ferriss?

  Got it.

• 1:27:15Shirley A. Sahrmann?

  15 modified pushups. Modified is your knees are bent. I don't go to my toes.

• 1:27:19Tim Ferriss?

  Mm hmm. Got it. Okay. All right.

• 1:27:23Shirley A. Sahrmann?

  And then still in the prone position, knees flex to 90 degrees and then I do hip rotation in both directions, letting my lower leg come in and then go out.

• 1:27:34Tim Ferriss?

  Right. So just if I can translate and please, uh, correct me if I'm getting this wrong, but you're bending one, you're laying on your chest, one leg bent to 90 degrees and basically windshield wiper with that lower leg on each side.

• 1:27:48Shirley A. Sahrmann?

  But I do both at the same time.

• 1:27:49Tim Ferriss?

  Oh, you do both at the same time. Okay, I see.

• 1:27:51Shirley A. Sahrmann?

  Yeah, so they're not quite, you know, one's maybe 80, the other maybe 70, because it doesn't take all that long. And then with my knees extended straight, with my lower extremities straight, I alternate doing hip extension, but I think about using my gluteal muscle. I think about activating my gluteus maximus. And again, only about 10 degrees of hip extension. And then in that same position, I do hip abduction. In other words, one leg out to the side 10 times, because you use your gluteus medius and that better if you're working against gravity and extension than you do when you're supine. Supine, you tend to recruit the tensor too much.

• 1:28:35Tim Ferriss?

  Oh, I see. Mm hmm. Got it. And is there anything that, that follows that abductor work?

• 1:28:42Shirley A. Sahrmann?

  Then I go supine, turn over. And I think this is really, you know, I'm pretty good about not having a kyphosis, but in supine, I adduct, pull my shoulder blades together and slide my arms up over my head, so that my arms are all the way up over my head as much as I can. And I'm on a hard floor. And I'm starting with my hips and knees bent. Arms up overhead and then slide one leg down, slide the other leg down. And believe me, for an older person who's got a tendency towards collapso-smasho, just getting yourself as stretched out as possible is so important.

• 1:29:21Tim Ferriss?

  Hmm, yeah.

• 1:29:23Shirley A. Sahrmann?

  I mean, really.

• 1:29:24Tim Ferriss?

  Sounds like for me with my kyphosis, that would also be important.

• 1:29:29Shirley A. Sahrmann?

  Yeah, and the biggest worry is going to be with the older person that if you have a kyphosis, you're not going to be able to get your arms on the floor all the way up over your head. And you don't know pain, you don't want any pain on top of your shoulder because that's not going to be a good plan. So they may need to have a pillow up there when they're first starting so their arms don't go all the way back because you want to avoid any kind of pain on top of your shoulder. But happily, I can, I know how to do it and I can do it. And then I do actively hip and knee flex, bring one knee towards my chest, put it down and the other one, and 10 times with each leg. And then with one foot on the floor, I do a straight leg raise.

• 1:30:14Shirley A. Sahrmann?

  I don't tighten all my thigh muscles so that my knee is perfectly straight and I turn it out a little bit so that I don't use the tensor. But if I rotate it out, you'll use the psoas more. And I think about tightening my abdominals. I have had a significant problem and I don't want to put too much stress on my lumbar spine from the iliopsoas. I want to use it, but I want to protect my back. That's why I have one foot on the floor.

• 1:30:44Tim Ferriss?

  I see. That's why you're doing one leg at a time?

• 1:30:47Shirley A. Sahrmann?

  Well, yeah, certainly one leg at a time.

• 1:30:48Tim Ferriss?

  Now, so, so could you just reiterate, so given the past lumbar issue, why you would want to engage the psoas instead of the TFL in this case?

• 1:31:00Shirley A. Sahrmann?

  I mean, it's a good muscle to use. I need to be able to flex my hip, but the tensor... It has a real low threshold for activation. I mean, interestingly enough, if you would scratch the bottom of your foot, the first muscle to go off will be your tensor fasciculata. No kidding. Wild. Yeah. In fact, I think it's so interesting because I've tried to contact the World Health Organization because all over the world, the tensor is run amok, but they don't want to listen to me. They're not returning the calls. You know, I know. And it's this little bitty, wimpy muscle, and you say, how can it cause so much trouble? But it sure does. You know, it plays a role in what happens to the knee, plays a role in what happens to the back and the hip. I mean, it's an evil thing.

• 1:31:45Shirley A. Sahrmann?

  Anyway, but you know, an interesting thing, one of my colleagues was doing a study and we actually had a student that did not have a tensor fasciculata. No kidding. Just, yeah, we didn't throw her out of school or anything.

• 1:32:02Shirley A. Sahrmann?

  But anyway, I couldn't wait to do all the tests that we do to look for the length of the tensor. And she was a, you know, a fair athlete. So it wasn't like it had been sitting, not doing anything, if it was there. And I did all the tests and they were negative, which was kind of supportive to me that indeed the tensor does do things that aren't so kind to the rest of the body. So anyway, all that to say, that's why when I do the straight leg raise, I try to laterally rotate my hip because I'd rather use the psoas. And it's not causing me any problems. Clearly, if I thought I was injuring myself, I would not, would not do that. And then I do one other thing with one leg straight and the other foot on the floor

• 1:32:43Shirley A. Sahrmann?

  so that my knee is bent, my foot's on the floor, I let my leg go out to the side. And that's my way of trying to work on controlling rotation with the trunk. My leg goes out to the side, it wants to rotate your pelvis, but contracting your abdominals prevents that rotation. So that's another way I'm trying to work my abdominals. And then I stand up and I'm so proud of myself because I can get up from the floor without any difficulty.

• 1:33:11Shirley A. Sahrmann?

  And many people at my age or many years younger than that can't do that. And put my back to the wall and then do what I was telling you to do, arms up overhead and do, do the little side bend thing.

• 1:33:22Tim Ferriss?

  And you do this every day?

• 1:33:24Shirley A. Sahrmann?

  I do. And I walk three to four miles a day.

• 1:33:28Tim Ferriss?

  Amazing.

• 1:33:29Shirley A. Sahrmann?

  And sometimes ride a stationary bike.

• 1:33:31Tim Ferriss?

  Mm-hmm. Well, these are things I'm paying more and more attention to. I'm so impressed.

• 1:33:37Shirley A. Sahrmann?

  But let me tell you one thing now, Tim, that the Podropad, as much as I love it, and I think it's important whether you have a shoulder problem, a cervical problem, et cetera, is that one of the things that's a problem, though, is, and it can be for several reasons, but again, the tensor is one of them. If you rock back and your hip immediately rotates, in other words, I've found this in some patients, that as you rock back, your hips should just flex. But if you are monitoring the femur, you can sometimes see that it immediately rotates. That is really bad. And the reason why it's really bad is because it's rotating in your knee joint, too.

• 1:34:19Shirley A. Sahrmann?

  And that's a good way to set yourself up for an ACL tear, anterior cruciate ligament. And I think people should be monitoring that, anybody that's doing that. One of the things that helps is if you slightly laterally rotate your hips. You know, many people, particularly men, come with what we call femoral retroversion. Do you know what that is?

• 1:34:38Tim Ferriss?

  I don't.

• 1:34:39Shirley A. Sahrmann?

  You probably have a femoral retroversion. It's a structural variation. And so the femur, as you know, has a head and neck on it. It's angled. Well, it's also rotated on the shaft. And in the ideal world, the average, not the normal, the average, is that that rotation is 15 degrees.

• 1:35:05Shirley A. Sahrmann?

  So the head and neck of the femur are pointing 15 degrees forward. Now, many men, it's not rotated. So what it means is that when you're doing your hip rotation, you go out a long ways, but you don't go in.

• 1:35:19Tim Ferriss?

  That's true for me, for sure. My internal rotation is terrible compared to my external rotation.

• 1:35:23Shirley A. Sahrmann?

  Well, but that's because you came that way, and it should never change. No, I mean it. And so you, and, and men need to know that. And so, in fact, that's a problem because if your tensor is really developed, you could be sitting in hip medial rotation when you shouldn't be. And if your glutes are really good, that'll also immediately rotate your hip when you're sitting. That's a problem. But one of the ways to, if you're trying to do the quadruped thing, is to turn your hip out a little bit when you're in the quadruped position. So your feet would come together a little bit closer.

• 1:36:00Tim Ferriss?

  Right, more of like a wrestling parter position, but meaning...

• 1:36:04Shirley A. Sahrmann?

  Yeah, I don't, I don't know, I never wrestle.

• 1:36:05Tim Ferriss?

  Yeah, I could, I can pick up the slack on explaining that then.

• 1:36:10Shirley A. Sahrmann?

  Not, not with a referee, anyway.

• 1:36:12Tim Ferriss?

  Okay. So the, right, right. So from the feet to the knees, it would just be making a very, very, very slight V shape. It's not a V shape. The lines would converge, in other words, right.

• 1:36:28Shirley A. Sahrmann?

  Yeah, your feet would be a little bit closer together.

• 1:36:30Tim Ferriss?

  Yeah, exactly. Mm-hmm. You're funny. All right, so that makes a lot of sense to me, and I'm certainly comfortable with that. What would it mean, or how would you read the movement pattern that I have of sitting and having my legs sort of splay open? That's also something that alleviates my low back symptoms. If I'm sitting in a chair, oftentimes I'll take my shoes off and fold them up on top of the chair. Restaurants hate this, by the way, so I do get chastised occasionally, but it alleviates some of my lower back issues.

• 1:37:08Shirley A. Sahrmann?

  Yeah, you're getting it fore and aft because you're probably in this, one of the syndromes I have of the hip, that I've described of the hip, because if your tensor's really developed, it's going to be holding your femur in medial rotation when you're standing because it's pull taught then. If your gluteals are really well-developed... When your hips flexed to 90 degrees, they become medial rotators too. So they're trying to hold your hip in medial rotation. And you're probably getting that twist on your back. So when you laterally rotate your hips, then you're taking that pull off of them.

• 1:37:41Tim Ferriss?

  Taking the pressure off of it.

• 1:37:43Shirley A. Sahrmann?

  Yeah, you're not getting that extra pull on your pelvis from those gluteal muscles being pulled so tight. And that's where you should be. That's your, your normal thing because you have femoral retroversion. See, and that's why, that's one of the things that's bad is because, you know, like when people go in and they're doing deadlifts and they say, well, make your feet point straight ahead. Well, many men in particular shouldn't have their feet pointing straight ahead because they have this femoral retroversion. And also when they do things that rotate, like play golf, their feet should be turned out. Because if they're straight ahead, they're at the end of their medial rotation range. So then it'll be the knee or the back or the hips that are gonna go. It's also interesting.

• 1:38:23Tim Ferriss?

  Yeah.

• 1:38:23Shirley A. Sahrmann?

  It's like the back is attached, the backbone's attached to the pelvic bone. You know, and I think to me, that's what's so valuable about being a physical therapist or looking at people. Because I can't, like an orthopedic surgeon, just look at the knee or I can't just look at the hip. Because it's the result of all of these interactions of the body. That's what's so important.

• 1:38:43Tim Ferriss?

  Mm hmm. And in a case like mine where if you look at family photos, right? Especially on my mom's side, the feet point way out. I mean, a lot of the guys stand like, you know, they stand like ducks. And now at the same time, I have been told, and I agree with this, that if one were to watch me walk, I have probably because I have at times the feet pointing out, very little sort of glute hamstring assisted hip extension. So I tend to bend at that lower back. Maybe I'm misdiagnosing things, but how would you sort of make sense of that? Would it be bad for me to try to point my feet a little more straight ahead so that I get better hip extension

• 1:39:26Tim Ferriss?

  using the gluteal muscles and the hamstrings versus the lower back? Or is that gonna be setting me up for knee problems?

• 1:39:32Shirley A. Sahrmann?

  Usually if you're not using your gluteal muscles, and that is because you're, you're swayed back. If you're swayed back, your line of gravity's behind your hip joint.

• 1:39:41Tim Ferriss?

  Right, right.

• 1:39:42Shirley A. Sahrmann?

  And if your line of gravity's behind your hip joint, you don't need your gluteals, those other muscles. So if you reduce that kyphosis, which isn't bad, it's just not helpful for what your condition is, and then you go forward. And then the other thing is, if you also push off, in other words, when you're walking, and this could be another way in which you're reinforcing what your tensor is doing. If you tend to walk by pulling your leg through, rather than pushing with your feet and letting it swing through, and if you push with your feet, you'll activate the extensors more. So the two things, the things that may be contributing to, and I'm not saying this is for sure, because I'm obviously not analyzing

• 1:40:25Shirley A. Sahrmann?

  you, but let's say if we paint a scenario that you're swayed back with a kyphosis, your line of gravity is behind your hip joint, I always call it, then the gluteals do not have good definition. I call it missing for lack of action. And so then, then you pull your legs forward with your hip flexors, you're just reinforcing the overuse of the tensor. But if you decrease your kyphosis, so your line of gravity is a little more running through your hip, rather than way behind it, and you roll over your feet and you push with your feet, and so you roll over so that you're pushing with the ball of your foot, and your leg swings out, you'll use your gluteals more. Just pushing instead of pulling, you want to chase your center of gravity, not pull it.

• 1:41:10Tim Ferriss?

  Uh huh. Yeah, this kyphosis has been with me since I was a little kid, and it's, I've tried foam rolling, manual release, strengthening the mid-back, but I have not worked on elongating the rectus.

• 1:41:22Shirley A. Sahrmann?

  You know, there's a condition called Sahrmann's disease, which isn't really a disease. If you had it, particularly, it happens in your teenage years, where you get a, you've heard of it?

• 1:41:33Tim Ferriss?

  No, I haven't heard of Sahrmann's disease, but I, ever since, I would say since I've been like 12, 13, I've had this kyphosis lordosis combo.

• 1:41:40Shirley A. Sahrmann?

  Well, then you've probably got Sahrmann's disease.

• 1:41:42Tim Ferriss?

  Oh, okay. I'll have to look it up.

• 1:41:44Shirley A. Sahrmann?

  It's S-C-H-E-U-E-R-M-A-N-N. And it's kind of a idiopathic compression fracture of the thoracic spine. It means you won't get rid of it.

• 1:41:56Tim Ferriss?

  Oh, man. Okay.

• 1:41:59Shirley A. Sahrmann?

  But I think if you just don't sway back more, and just stay forward a little bit, if you can make peace with that.

• 1:42:05Tim Ferriss?

  Well, I can try to work on the elongating of the...

• 1:42:09Shirley A. Sahrmann?

  Well, it's not going to change. The big thing is don't let it get worse.

• 1:42:13Tim Ferriss?

  Right.

• 1:42:14Shirley A. Sahrmann?

  Yeah, if that's what you have, yeah. I'm not saying that's what you have, but I'm saying.

• 1:42:18Tim Ferriss?

  Right. It's possible.

• 1:42:20Shirley A. Sahrmann?

  Yeah, because it happens around the teenage years.

• 1:42:23Tim Ferriss?

  So what would be the keys to not letting it get worse, would you say?

• 1:42:27Shirley A. Sahrmann?

  Don't have it increase. I mean, you can still do the same things, Tim, but just don't say, I will be absolutely perfect. I have to settle for kind of perfect instead of absolute perfect.

• 1:42:36Tim Ferriss?

  That's probably a good MO for most of my life, I would say.

• 1:42:43Shirley A. Sahrmann?

  Well, most of us don't get that close.

• 1:42:46Tim Ferriss?

  I'm probably further away than I would like to admit. So Shirley, this has been such a great conversation. We've covered so much. I've taken copious, copious notes. And certainly people can find your books, The Diagnosis and Treatment of Movement Impairment Syndromes, which has been translated into seven languages, as well as your second book, Movement System Impairment Syndromes of the Extremities of the Cervical Enthoracic Spines, has been very influential in promoting movement diagnoses. Is there anything else you would like to mention, anything else we should talk about, anything you would like to draw attention to with my audience, anything at all that you think is worth saying or discussing before we begin to wind to a close?

• 1:43:30Shirley A. Sahrmann?

  It's probably just a little repeat of all the things we've been talking about. It's been really great and generous of you to allow me to discuss your, your issues. But you know, what's really nice is here you are, somebody that's worked so hard to address all of these things with all the discipline that most people don't have. And it's still hard to get a straightforward story about what's going on and how best to suit you. And that's what worries me a lot. Number one is I look on the internet for exercises and most of them people can't do, and they're not taking into account the variations in how people are. I mean, here you've been through all this exam and nobody said you have femoral retroversia, which you need to know because you came that way, you need to stay that way. So I would like to see that there's more.

• 1:44:16Shirley A. Sahrmann?

  Respect for how difficult exercise is. It's not like, here's the way everybody should go out and do this one thing and then they'll all will be well. I'd like to see this recognition of movement is as complicated as anything else that the body does, that there is a movement system, a physiological thing. And that we should have diagnostic categories so that people, when they're consulting a physical therapist, get a diagnosis, just like when they go to any doctor. I mean, that's to me why you go to a doctor, is to get a diagnosis or find out what condition you're you're working on. I think that would do a lot to help reducing all this variability in in in treatment.

• 1:44:58Shirley A. Sahrmann?

  And I think helping people to understand how it's the way they do their everyday activities that causes the problem, and that those can be changed with with good direction. I can't help but say this too. I help a good friend who's actually on a dementia floor. I go to help feed her twice a day. And I look at all the other people, older people that are in assisted living. And the majority of them are there because they have physical disabilities. I'm older than most of them. And I think if people had a chance to address these things early on and with the discipline like you show, and good direction, we could cut down on and improve the quality of life. I know you've interviewed Dr. Atina.

• 1:45:40Shirley A. Sahrmann?

  And, you know, much of what he says, you know, medicine 3.0 or something. And if we did that with more care on exercise, and knowing how to do everyday activities and not just take them for granted, I think people could have longer, fuller lives. And, yeah, be as fortunate as I am.

• 1:45:58Tim Ferriss?

  Agreed, agreed, agreed. What a great conversation. I've learned so much, and I've taken so many notes. I have a lot to dig into. It's also given me some renewed optimism in terms of exercises that I can work with, movements, I should say, that I can experiment with.

• 1:46:18Shirley A. Sahrmann?

  I hope you'll get back to me if I can help further.

• 1:46:21Tim Ferriss?

  I will.

• 1:46:22Shirley A. Sahrmann?

  If you find out that these things are going along, I would be more than happy to.

• 1:46:27Tim Ferriss?

  Thank you.

• 1:46:28Shirley A. Sahrmann?

  Do this a little more formally.

• 1:46:29Tim Ferriss?

  Yeah, absolutely. I really appreciate it.

• 1:46:31Shirley A. Sahrmann?

  We can do it on Zoom. I mean, we can do it on this.

• 1:46:34Tim Ferriss?

  Yeah, I would, I would very much like to do that. So, thank you for the very kind offer and thank you for so kindly taking the time to have this conversation. I think it'll be really helpful to people.

• 1:46:45Shirley A. Sahrmann?

  As my dear friend Michael said, you are tremendous. I've really enjoyed talking to you and you do have a sense of enthusiasm and how to ask the right questions.

• 1:46:54Tim Ferriss?

  Thank you.

• 1:46:54Shirley A. Sahrmann?

  To make it fun for both of us.

• 1:46:56Tim Ferriss?

  Thank you so much. And for everybody listening, we will link in the show notes to everything we discussed as usual at tim.blog/podcast. And until next time, be just a bit kinder than is necessary, not only to others, also to yourself. And as always, thanks for tuning in. Hey, guys. This is Tim again. Just one more thing before you take off, and that is Five Bullet Friday. Would you enjoy getting a short email from me every Friday that provides a little fun before the weekend? Between one and a half and two million people subscribe to my free newsletter, my super short newsletter called Five Bullet Friday. Easy to sign up, easy to cancel. It is basically a half page that I send out every Friday to share the

• 1:47:40Tim Ferriss?

  coolest things I've found or discovered or have started exploring over that week. It's kind of like my diary of cool things. It often includes articles I'm reading, books I'm reading, albums perhaps, gadgets, gizmos, all sorts of tech tricks and so on that get sent to me by my friends, including a lot of podcast guests. And these strange esoteric things end up in my field and then I test them and then I share them with you. So if that sounds fun, again, it's very short, a little tiny bite of goodness before you head off for the weekend, something to think about. If you'd like to try it out, just go to tim.blog/friday, type that into your browser, tim.blog/friday, drop in your email and you'll get the very next one. Thanks for listening.

• 1:48:25Tim Ferriss?

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• 1:49:06Tim Ferriss?

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• 1:49:47Tim Ferriss?

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• 1:50:28Tim Ferriss?

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• 1:51:13Tim Ferriss?

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