Dr. Nathan Kadlecek, PT
Is a physical therapist committed to providing high quality health information, largely focused on lower back pain and the gross overuse of diagnostic imaging, medication, surgery, low quality treatment methods, and the over-diagnosis of pain conditions. He's also a powerlifter, pain nerd, macro-scale thinker, and wants to help you think differently about pain, healthcare, and life.
I’ve uttered this phrase. You probably have too.
Not getting 8 hours of sleep? You should start. In a recent podcast interview with Peter Attia, MD and Matthew Walker, PhD they discuss over a three part series just about everything when it comes to sleep. Matthew Walker is the author of “Why We Sleep: Unlocking the Power of Sleep and Dreams.”
You can also follow him on twitter where he has tons of tips and data to help you sleep better and deeper:
Want to greatly reduce your risk of cancer, Alzheimers, dementia, heart disease, high blood pressure, diabetes, low energy, and much more? Then you should REALLY consider getting 8 hours of sleep.
Sleep and mental illness are also very closely intertwined. For people struggling with depression, anxiety, and other mental illness, it’s likely that sleep has also been affected. As they discussed, this is likely in a bidirectional manner, too. Lack of sleep leads to higher anxiety, and higher anxiety typically leads to worse sleep.
From personal experience, when I get < 8 hours of sleep, or if it is broken up due to the neighbors dog barking, or loud people, or a multitude of other factors, I will 100% be more anxious during that day and of course, more tired.
This is why I think it is so important to make sure to keep our sleep as consistent as possible in terms of our evening winding down routine and to control what we can control. We can’t control the noisy neighbors or dogs or random alarms that go off at 2:33 am. What we CAN control are our habits prior to going to sleep.
Each of us likely has a different guilty pleasure before going to sleep which could be hindering our depth and length of sleep. Here are a couple:
Blue light + electronics before bed:
I tend to read on my phone or scroll on instagram before bed which not only keeps me awake longer from the blue light but also keeps me up later, sometimes as much as 30-45 minutes which significantly cuts down on my time asleep. This also applies to TV. I know a lot of people have a TV in their room and it’s how they wind down, however, if you are struggling with sleep, it may be time to switch up this habit. What’s more important, living longer and healthier, or catching one show?
If you are drinking that beloved afternoon caffeine this could be causing you to not sleep as deeply. Caffeine blocks the adenosine receptors which are required to help you fall asleep. Instead of adenosine binding to these receptos, caffeine does, which prevents us from feeling sleepy.
As much as I love having an ice cold beer or some wine an hour or so before bed, it ain’t great for sleep. While alcohol and THC will help individuals fall asleep faster (in some cases) you end up not reaching the same depth of sleep. The deep sleep component of sleep is where we experience more of our memory solidifying from the day prior.
Have you ever felt incredibly HOT after a large meal? I’m talking about physically sweating and feeling a bit uncomfortable -- usually after eating an entire pizza. I love a great meal, however try to...
As nice as it is to be in a cozy room, it’s not great for staying asleep as we’ll often wake up in a sweat. I am very temperature sensitive and I always love when winter comes around (in California) as my room will be a perfect temperature (mid 60’s) to help keep me asleep for longer.
Americans are only getting 6.25 hours of sleep on average which is a large reduction from what it used to be just two decades ago. In order to function at our highest possible level, 8 hours is recommended.
From an evolutionary standpoint, sleep seems to be very disadvantageous. If we were sleeping back before we had shelter, this made us very susceptible to predators (so sleep could get us eaten). For our species to survive mother nature must have a VERY GOOD reason for keeping sleep as a core portion of our life.
If you want to greatly greatly greatly reduce your risk of Alzheimers, mental illness, and a host of other diseases, START OPTIMIZING YOUR LIFE AROUND SLEEP, not the other way around.
BAD HABITS. We've all got em'. The worst of them all are the ones that cause us to lose an hour or more of sleep! What are some things you do to help you fall asleep faster and sleep deeper?
My poor sleep hygiene is typically tied to me reading my phone IN BED for 30-45 minutes (or scrolling through instagram). I've made a committment to putting my phone outside of my room OR putting it on the other side of the room to prevent me from looking at it while in bed. I've done this in the past and it has worked absolute wonders for me!
The benefit of not looking at your phone screen and reading right before bed is it limits blue light exposure, AND if you're like me and your brain is constantly going, it allows you to wind down vs. gather more information that inadvertently makes you think while trying to fall asleep.
If You Ask These Questions; You'll Find a Great PT
It’s too difficult to find a physical therapist who’s actually good at what they do. I hear this all the time, “i’ve gone to a few physical therapists offices before and it was just the same old stuff over and over again,” or “I was really tired of getting passed off to aides and only being seen by the therapist for 10 to 15 minutes.” This is an unfortunate reality at a lot of PT clinics in the country. Good news for you is that I am going to be going into exactly how to find a great physical therapist near you, and, if you’re not happy with your current provider, how to find a better one.
For those of you strapped for time...
Here is your TL;DR version:
Groups of physical therapists who are great at what they do:
A few qualifiers:
Do you trust the person you are working with or potentially working with? Like with any relationship, the relationship you develop with your physical therapist or rehab professional is incredibly important. If you don’t trust this person, how can you expect the rehab process to be effective? Developing trust is faster for some than others. I’ve worked with clients who come in and we instantly hit it off, immediate trust. For others, it takes a few sessions before that person feels confident in the plan we’ve set forth.
I’ve also worked with people who end up not having as much trust in me and we didn’t have a great outcome. I find that this is likely the single most important aspect of the rehab process, what we rehab professionals call the “therapeutic alliance.” Have we jointly created a therapeutic alliance, a team approach, that will help you reach your goals, and are we on the same page.
I’ve been in clinics where the only thing I hear therapists saying are negative. As a colleague of these individuals, I can tell you, it’s terrible. It’s even worse for the patient as they are then working with someone who is burnt out, apathetic, and not giving 100%. Thankfully i’ve worked at clinics and hospitals where the therapists are the most positive people i’ve ever met and you can see this manifest in the patients lives, too.
When you have an injury or are dealing with severe pain, it’s important that the person you are working with be incredibly positive. While working through pain is not necessarily something we desire to be doing on a daily basis, it becomes a lot easier when you have a positive and uplifting coach working with you to guide you each step of the way.
Keeping up with the research
Do they have a practice of keeping up with the research? This one is a little harder to gauge from a patient perspective because you’re likely not that familiar with physical therapy research. A few questions i’d ask the therapist would be “what are recent continuing education courses you’ve taken,” “what are your favorite research journals to read,” “any recent studies that you found interesting?” You could also ask who some of their favorite researchers are.
These are a few questions I would ask your therapist to see if they truly keep up with the literature. To really be certain, ask a few different therapists the same questions. If you do this, you’ll be able to get a better idea of different practices and commonalities between each PT.
Do they talk straight with you and say “I’m not sure, i’ll get back to you on that?” I’ve found that the absolute best physical therapists that i’ve worked with are comfortable with saying “i’m not sure,” to the patient. Many times, people want to know how long something is going to hurt for, how long it will take to get their shoulder range of motion back, how long before they can start running again, among many other questions. The reality is that we can’t predict a lot of things, especially timelines.
In my experience, the best response to these questions is something along the lines of “i’m not sure and I can’t predict exactly when things will change, however we know based on ‘X’ that most people see a return to ‘Y’ within this date range.” Ranges are much more accurate as each individual will recover at a different rate. And… to some questions, we just don’t know.
High Volume Clinic “PT Mills”
These clinics are called “Therapy Mills.” I can’t tell you how many people come to me and say, “I really didn’t have a good experience at my last physical therapy clinic. I was one of four people that the therapist was seeing and I had no idea what I was supposed to be doing. They just put me in a corner and I stretched while they worked with someone else.”
Personally, I don’t think this should be happening, UNLESS it’s a sports clinic with multiple athletes recouping at the same time who understand what they are supposed to be doing. The most important parts of rehab are the understanding of what you should be doing and then actually doing it. If there are 3 or 4 people being seen an hour by one therapist it’s almost impossible to completely understand why you’re doing what you’re doing, there just isn’t the time to explain to each person and then correct it.
It’s possible you will still get better by going to a clinic like this, however, it really waters down what the rehab process could be in terms of you completely understanding your pain/injury, what the plan is, and how to properly execute it.
Minimal Time with Therapist
Like I said above, if the therapist is seeing >3 patients per hour then it’s likely you’re only going to get 10-15 minutes with them. I usually spend 10 minutes just catching up with the patient to see how they’re doing! Lol.
I’ve worked in clinics like this in the past and it’s too hard to gauge patient progress if you only get a short amount of time with them. If the PT has a physical therapy assistant (PTA) on staff, that’s great. The PTA is also a licensed professional that works in a similar capacity to what a physician assistant (PA) does for a physician.
Each of these team members should be spending adequate time with you, at least 30 minutes so that you have ample time to ask questions and get the work in.
Which brings me to my next point… if you’re only being seen for 10 minutes there is no way that anyone can sufficiently answer your questions. I don’t care what any healthcare provider says, that’s simply not enough time, especially during the initial evaluation and first follow up to help you understand exactly what’s going on.
Largely Passive Treatment Sessions
Ice, heat, massage, dry needling, cupping, scraping, and other modalities can be helpful to reduce some short term symptoms, but if you are getting some rendition of these every single treatment session, particularly at the end, the clinic is probably just doing this to bill for it. That’s a waste of your time and a waste of insurance dollars on something that’s not really needed (in most cases).
Like I said, some of these modalities can be helpful in the short term, but what I see way too often is that people become dependent upon these and start to believe that these are the cure for their pain or injury. It’s not accurate and rehab sessions should be focused on helping you understand the rehab plan and ultimately building self-efficacy, or the ability to cope and learn long term solutions.
Are They Familiar With Treating Your Specific Concern?
This is not the end all be all, but ideally your therapist has at least some experience working with your specific concern. For general pain concerns in major joints such as the shoulder, hip, knee, neck, and mid/lower back, most PT’s have tons of experience with this. When it comes to specific foot injuries, hand injuries, jaw pain, women and men’s health issues, neurological conditions, among others, it is more important to find someone who is comfortable and confident with these. There is a bit more specialization and complexity with that list.
Find a therapist who you:
If you do most of these above you’re going to have a successful experience with your therapist!
What has been your biggest frustration when working with a physical therapist?
Having fun with workouts is a must...
I haven't done these in a while but they are challenging!
I find that it's easier for me on fists, some prefer with hands flat. If you can't reach the floor enough to push through you can also elevate your hands on books.
Which exercise are you trying to get better at?
"Uncertainty always creates doubt, and doubt creates fear."
Oscar Munoz — CEO, United Airlines
(personal opinions aside of this guy — I like the quote)
Uncertainty is a beast. “I’m really worried about this pain getting worse, I don’t know what to do. Will I need surgery?” he said. A past client of mine sent me a message on Instagram asking if I had some time to talk about a recent knee injury.
He ran. It popped. He got scared. What do you think happened?
Before I get into it, let’s talk about what he said first. “Will this get worse?” I think I get this question more than baristas at local coffee shops get the question “what’s the wifi password.” It’s a great question but it really is only a surface level question. Why are you worried the pain will get worse? Have you or a family member had previous experiences of something like this getting worse? Getting down to the root causes of the fear of this uncertainty is incredibly important.
To battle this uncertainty, people have tried many things… the “sure-thing principle,” was proposed by L. J Savage, an economist as a way to deal with uncertainty. Here is an excerpt from a great book “Made to Stick:”
"A businessman is thinking about buying a piece of property. There’s an election coming up soon, and he initially thinks that its outcome could be relevant to the attractiveness of the purchase. So, to clarify his decision, he thinks through both scenarios. If the Republican wins, he decides, he’ll buy. If the Democrat wins, he’ll do the same. Seeing that he’d buy in either scenario, he goes forward with the purchase, despite not knowing the outcome. This decision seems sensible—not many people would quibble with Savage’s logic.
After this initial stream of logic, two other psychologists, Amos Tversky, and Elder Shafir had a different idea. Their example is as follows: "For instance, imagine that you’re in college and you’ve just completed an important final exam a couple of weeks before the Christmas holidays. You’d been studying for this exam for weeks, because it’s in a subject that’s important to your future career. You’ve got to wait two days to get the exam results back.
Meanwhile, you see an opportunity to purchase a vacation during the holidays to Hawaii at a bargain-basement price. Here are your three options: You can buy the vacation today, pass on it today, or pay a five-dollar fee to lock in the price for two days, which would allow you to make your decision after you got your grade. What would you do? You may feel some desire to know the outcome of your exam before you decide, as did the students who faced this choice in the original experiment.
So Tversky and Shafir simply removed this uncertainty for two groups of participants. These groups were told up front how they did on the exam. Some students were told that they passed the exam, and 57 percent of them chose to go on the trip (after all, it makes for a good celebration). Other students were told that they failed the exam, and 54 percent of them chose to go on the trip (after all, it makes for good recuperation).
Both those who passed and those who failed wanted to go to Hawaii, pronto. Here’s the twist: The group of students who, like you, didn’t know their final exam results behaved completely differently. The majority of them (61 percent) paid five dollars to wait for two days.
Think about that! If you pass, you want to go to Hawaii. If you fail, you want to go to Hawaii. If you don’t know whether you passed or failed, you. . .wait and see? This is not the way the “sure-thing principle” is supposed to behave.
It’s as if our businessman had decided to wait until after the election to buy his property, despite being willing to make the purchase regardless of the outcome. Tversky and Shafir’s study shows us that uncertainty—even irrelevant uncertainty—can paralyze us."
Heath, Chip. Made to Stick (p. 36). Random House Publishing Group. Kindle Edition.
Isn’t that fascinating?? Due to uncertainty that was created, over an outcome they had literally 0 control over, they still wanted to wait until they had all the answers. And… once they did, they chose to go to Hawaii regardless of the outcome.
A similar study was done which posed two three scenarios, go to one of your favorite musicians, study for your test, or watch a new movie that’s out. The group that only had two choices, a larger percentage chose to go to the movies vs. study. BUT, when posed with two “fun” choices and studying, a much larger percentage chose to stay and study. This illustrates how sometimes when we have too many choices, even only three, it can be a bit overwhelming and we’ll choose something that we don’t really want.
I think these scenarios apply fairly well to the rehab process, too, specifically when dealing with the uncertainty of what might be ailing us? Is it a muscle, a ligament, a bone, a nerve, is something out of alignment (I don’t believe this BTW), or is it something else? There are so many competing theories as to WHAT is the cause, and how do we find the exact cause of my pain. The amount of options tend to paralyze us and we go with the choice that "comfortable," because at least we "know what we're getting."
If we only knew the exact cause in every case then we could be sure that the pain would not get worse, right? You’d think so but it’s not that simple… let’s talk about back pain for a second. Once cancer, inflammatory disorders, infection, fracture, and other red flags have been ruled out, it’s very unclear as to what specific structures are contributing MOST to the pain experience. This is largely in part to the complex nature of pain, meaning it is a combo of biological, psychological, sociological components which we simply aren’t able to measure down to a singular level of specificity (yet).
And finally, circling back to our friend with the knee that popped; he heard this pop while running, was fearful of what could have happened, and then the uncertainty, coupled with things he had read created more fear.
The conversation we had determined it wasn’t swollen, it hurt to extend it, and it had only been about 1 week since the incident. There was no instability whatsoever and the pain was tolerable. This definitely wasn’t an ACL tear (something this person was worried about), and also, even if it was a meniscal tear (also unlikely), it was way too early to even go down the route of talking injections or surgery.
When something happens that we don’t expect and aren’t experienced in dealing with, we often jump to conclusions and choose interventions that may not make the most sense. We jump to the craziest conclusions and often the worst case scenario. Next time something happens in your life that you don’t have much experience with, try to resist that urge to jump to the worst case scenario. Find someone who knows what they’re talking about and get their perspective!
It’s totally normal to find uncertainty unnerving — and sometimes clearing up uncertainty with “what it’s not” is the best thing we've got!
I’m curious… how do you deal with uncertainty? Do you fear it, or do you come up with solutions to address it?
Spinal stenosis is something that can be treated or managed conservatively in many cases.
Here's an excerpt from a 2016 Cochrane review, detailing their conclusions of a study comparing surgical vs. non-surgical care for spinal stenosis.
"We have very little confidence to conclude whether surgical treatment or a conservative approach is better for lumbar spinal stenosis, and we can provide no new recommendations to guide clinical practice. However, it should be noted that the rate of side effects ranged from 10% to 24% in surgical cases, and no side effects were reported for any conservative treatment. No clear benefits were observed with surgery versus non-surgical treatment. These findings suggest that clinicians should be very careful in informing patients about possible treatment options, especially given that conservative treatment options have resulted in no reported side effects. High-quality research is needed to compare surgical versus conservative care for individuals with lumbar spinal stenosis."
As you can see, surgery should be a last option, not first line defense. Side effects reports were from 10%-24% whereas non-surgical treatment was 0% complication.
Do you or someone you know have spinal stenosis?
BFR is a great way to increase your training volume without having to add in a bunch of heavy heavy volume, particulalry if you are dealing with pain or injury associated with lifting heavier. If you can lift heavy, lift heavy, however this is one way to receive a similar training intensity to maintain your work capacity.
Have you used BFR before? What'd you think?
Ever heard of blood flow restriction training (BFR)? Essentially, some blood flow is restricted, the workout is harder at much lighter weights, and you can still realize hypertrophy and strength gains.
Who is this good for? Bodybuilders and powerlifters looking to increase volume but keep load and mechanical stress lower, older adults dealing with osteoarthritis who have a hard time performing heavy leg exercises due to pain, pre and post ACL tear for extra hypertrophy work on atrophied quadriceps.
There are plenty of other people who could benefit from BFR, too! Shoot me a message if you're interested in working with me, and getting some BFR training/rehab.
BFR is not approriate for everyone, of course, and if you can lift heavy without pain, then lift heavy. This will not necessarily help you get stronger if you're already able to do that.
"The quest for more success and status (for the sake of success and status) often leads to the slow erosion of meaningful relationships" - ME
A perpetually happy, exciting, pain free life. It seems like this is what we all want. There is a catch though... we don’t want to put in the work. There is another catch... we won’t always be happy, life won’t always be exciting, and pain will come and go.
I’ve been thinking about this quite a bit as of late. When reflecting on conversations I’ve had with friends, family, and patients, I recognize most people are trying to reach an idealized life without struggle or pain. This type of life is exulted on social media, TV, from our friend groups, even our family. Scroll for two minutes on Instagram and you’ll no doubt get bombarded with perfectly edited photos of people, homes, and other trinkets.
We want the perfect marriage, the perfect body, the perfect family, the perfect job, the perfect home. We are obsessed with perfect scores on tests, saddened when we are less than perfect. This also leaks over into our expectations of others. We expect others to be perfect, to be without fault, and when a mistake is made we ruthlessly jump to conclusions that they were acting out of malice. We expect perfection of others yet expect others to take us as imperfect. This obsession with perfection also ties into how we view success.
Success and wealth go hand in hand with this perfect life, so society says. Many of us want this success and wealth, however, I’ve observed two things: 1. We want wealth but are envious but also spiteful of those who have it, 2. We expect that if we had wealth, life would be infinitely better and we would be exceedingly more happy. It’s true, that people living in poverty would have a better life with more wealth, and increase in happiness, to a point. It is not true, that massive amounts of wealth lead to a greater and more fulfilling life. There are plenty of people who are wealthy and miserable, routinely logging 60+ hr work weeks and sacrificing everything they care about.
In the past couple years, I’ve interacted with hundreds of business owners and entrepreneurs, and individuals in the workforce who are so focused on building and growing their business, progressing in their career, and working seven days/week for months, sometimes years at a time. This sacrifice of time with family and friends often leads to burnout and the severing of the relationships that they initially got into business for. Many business owners got into business as a way to a better life for them and their family but it turned into an all consuming force that has wreaked or is wreaking havoc on their relationships. I see this all too often with professionals. The quest for more success and status (for the sake of success and status) often leads to the slow erosion of meaningful relationships. If you are this person, stop. Stop and read this paragraph again.
Why are you working so hard? Hard work, embracing struggle, and being persistent is certainly necessary for any type of success in this life, however, the priority should not be these things. Could you accomplish the same if you also maintained healthy relationships with your significant other, friendships, and family? (This question was rhetorical, of course you can). Hard work does not equal smart work. Let’s not be consumed by the struggle and the act of working hard. Let’s prioritize our relationships and the positive impact we can have on others. If we do this, we’ll likely be able to accomplish more than we ever thought possible and to live a life filled with meaning and purpose.
Nathan Kadlecek is a Doctor of Physical Therapy, health nut, powerlifter, and seeks to answer somewhat unanswerable questions.
The scapegoat for so much back pain.
Could a disc herniation be the cause of pain? Sure.
Could it be other things as well? Yep.
True symptomatic disc herniations are actually quite rare AND most people will be able to recover from these without surgery.
Many people think that in order to feel better the disc must "heal" or resorb. This is not always the case.
Many of us are actually living with disc bulges and herniations and we don't even know about it.
We don't need to fear herniations so much!
What are your thoughts? Have you had a disc hernaition in the past, were you able to recover from it? Would love to hear your experiences!