Episode 26: Understanding Mobility and Flexibility

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• Joe Gambino
• Joe LaVacca

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Summary
In this episode of the Beyond Pain podcast, hosts Joe Gambino and Joe LaVacca discuss the differences between mobility and flexibility, how to evaluate the success of rehabilitation, and the importance of personal goals in physical therapy. They share personal updates, including Gambino's recent fatherhood, and LaVacca's travels to Slovenia. The conversation delves into how to program stretching and mobility work for clients, emphasizing the need for individualized approaches based on each person's unique anatomy and goals. The episode concludes with a call for listener feedback on the topic.

Takeaways
Everyone has goals when they seek treatment.

Pain can take a long time to resolve even with good treatment.

Mobility is how you move actively, while flexibility is passive.

Stretching can be programmed if there is a tissue limitation.

Guarding can block flexibility and needs to be addressed.

Progress can be measured in terms of activity levels, not just pain relief.

There is no one-size-fits-all approach to movement.

Understanding anatomy is crucial for effective rehabilitation.

Client feedback is valuable for refining treatment approaches.

Future discussions on mobility and flexibility will be welcomed. 

Transcript

Joe Gambino (00:00)
Welcome back into the Beyond Pain podcast. I am one of your hosts, Joe Gambino, and I'm here with Dr. Mr. Joe LaVacca Mr. Backwards Hat today. loving it.

Joe LaVacca (00:12)
Yeah, I think I also think you are just the host I don't even think you are one of them I think you I think you're the host I think you're the lead guy

Joe Gambino (00:19)
No, no, no, we are co-hosts. We're co-hosts. do this. We do this bad boy together. Every single week, at least when we release them, because I know we, you know, I mean, I just had a baby, so we didn't record it for two weeks and you were traveling. How was your trip, by the way?

Joe LaVacca (00:34)
I know, well that's what, well that's a secondary thing. I want to congratulate you and the family and to all our listeners out there. Mr. Joe Gambino welcomed in a brand new baby boy, which was a week ago, two weeks ago.

Joe Gambino (00:40)
Thank you.

In between about a week and a half bill Tuesday Tuesday will make two weeks 24th Mm-hmm

Joe LaVacca (00:51)
September 24th and he is back already ladies and gentlemen. Committed to his craft, not willing to let you guys down, brand new baby, everything and this man is here for you. He's here for us, I should say.

Joe Gambino (01:00)
That's right.

Yes, yes, I'm here. I'm here for the 10 YouTube subscribers that I know we have listening

Joe LaVacca (01:17)
Hey Ted, that's like a 300 % jump from last month. So, I mean, YouTube starting to take off? Joe?

Joe Gambino (01:25)
I'm seeing it, man. Let's do it. Let's do it. But anyway, back to, well, tell me about your trip first and then we'll finish our introduction.

Joe LaVacca (01:33)
Okay, so the trip I went to Slovenia a couple of weeks ago. It was a Hidden I think the definition of a hidden gem. I always wondered what those places are actually like and I think I finally understand it was recommended to me by a client of mine so Again, special thanks to her. I already reached out to her I think I got a center like a bouquet of flowers or something because it was just so such an untapped

country in terms of the beauty of it, the offerings of nature there. There was some beautiful countryside. The city was absolutely lovely in Ljubljana. And then because it's right there on the Adriatic, we got a little day on the coast. So I can actually say I dip my foot or touch my hand in the Adriatic sea, which was nice. And the flavors of Italy and Germany and the old Yugoslavia kind of coming and blending together there.

If people are looking for a hidden gem, look no further than Slovenia. And it is between Italy and Croatia, because I didn't know where it was on the map either when it was recommended to me. But Courtney and had a blast. yeah, you know, I want to, I told you I want to get my own color pins on that board and just start, you know, put myself where I've been on that map of the globe behind you.

Joe Gambino (02:42)
You know, you could have just asked me. could I could have told you from back here.

Well, if we travel somewhere together, maybe we can get like a black pin somewhere and we can put them up here. I'm glad you enjoyed it. You're making me want to go. I mean, I love to travel.

Joe LaVacca (02:57)
Yeah, exactly, exactly. This is gonna be a blue and yellow pin or something.

Joe Gambino (03:12)
closest I've been is Spain and France.

Joe LaVacca (03:15)
Yeah, yeah, just a hop, skip, and a jump, man. And you're there. Hop, skip, and a jump.

Joe Gambino (03:18)
That's it. I know. The babies have been making it little bit harder to travel further because we're concerned with time zone changes and sleep. That's the big one. But otherwise, but anyway, you can find this podcast on social media, Instagram and the YouTube, cupsofjoe underscore PT on YouTube and on Instagram.

Joe LaVacca (03:26)
Of course. Yeah.

Joe Gambino (03:44)
Beyond Pain podcast. can also find us individually. I'm at Joe Gambino DPT and LaVacca over there is strengthinmotion underscore PT. Feel free to reach out. more than happy to have any conversations about anything that you'd like to chat about. And today we are talking about mobility versus flexibility. How much do you need? But before we do, Joe, I have a question of the day for you. It is from me actually prompted by a conversation I had.

with somebody on Instagram just this morning. And the person was telling me that he was he's some low back pain. He was seeing a chiropractor for two years and he had just stopped because he felt like they just wanted a regular customer and not really trying to help them. So my question for you is for people who are listening, especially I assume that most of the people listening have some sort of pain and been dealing with it for a while. How do they know?

if their rehab is successful or moving them in the right direction or how should they, how can they figure out, well, maybe I need to reevaluate things.

Joe LaVacca (04:53)
Yeah, I think, well, number one, everyone has goals when they seek you and I out or really any practitioner. So from your first visit to your second or your third or your 10th or whatever your program might be, do you feel like each week or each visit, you are moving towards those goals in one way, or form? Now we've talked a lot on the podcast with pain being very complicated, pain taking a long time. I think

In terms of the conditions we've covered when we've talked about foot pain or knee pain and even our episodes on back pain, these things do take a really long time to resolve even when you are getting really, really good treatment. So does your provider have a plan that matches your goals? Number one, I would say does your provider also give you tools to manage your symptoms?

or manage your behaviors or lifestyle on your own as well? Or is that clinician or clinicians, I should say, because you could be going to a group of people, are they just doing things to you? Meaning you show up, you get maybe laid on a bed or a table, you get heat and stim as just sort of a regular occurrence, then there may be a little bit of hands-on, maybe there isn't. But if they are doing things to you,

There are probably some combination of hands-on, maybe it's acupuncture, maybe it's cupping, maybe whatever the flavor of the month is at the clinic. And then you're just sort of then sent on your way. So what did you learn from those interactions? What did you walk away with? And if the answer is you're not learning at your sessions and you're not walking away with tools that will actually help empower you, I think those are probably the two biggest things I would look for.

What would you say about that? Do you agree?

Joe Gambino (06:53)
Yeah, I like that. think, you know, goals is a huge one. I spend a lot of time asking people their goals. I know some people have a hard time figuring out what they are. I have that conversation a lot, especially people in pain. I feel like goals for them are all around. How do I get out of pain? And they almost lose sight of like what they can actually do with their bodies. So I try to let them open up and give me something more than I just want to get out of pain. I think.

Joe LaVacca (07:14)
Right.

Joe Gambino (07:22)
progress, you know, you should see something change relatively quickly, whether it's your movement, whether it's a short term change in your pain. There is usually something that happens within those first couple of weeks that tells you that, okay, I think things are going to move in the right direction. It's rare that nothing happens over the course of a few weeks. So if you're seeing zero change, probably want to reevaluate.

And then something that I think rehab should always challenge the person so similarly to like what you're saying with learning Not just like are you learning something about your body or movement or whatever it is, but it should Physically challenge it maybe not so much in the beginning if like I'm starting you off and we need to bring down pain I'm not gonna challenge you I'm gonna do the things that make you feel good to bring down that pain system but then as the pain comes down I need to start to

Joe LaVacca (07:56)
Mm-hmm.

Joe Gambino (08:18)
challenge your body in certain ways to make it more resilient and knowing what your goals are, why we like the first thing you said was goals. First thing I said was goals. If I know you want to be able to get back to playing golf and playing 18 holes, or you want to be able to go on a golf trip with your buddies and be able to play, you know, 36 rounds in a weekend and you can't right now hit, you know, more than like five shots without your back being in pain. Well, knowing those stresses allows me to know what kind of

Joe LaVacca (08:25)
Yeah.

Joe Gambino (08:47)
what I need to get you back to, right? So there has to be a component of how strong you need to be, how mobile you need to be, what can you do? And then what does the return to golf perspective start to look like so we can build up tissue tolerance with the sport? challenging you, seeing some sort of progress in the beginning, then knowing that having like really, I would say like does your provider even know your goals? I know there are some providers who don't really even ask these questions. They don't really understand how

the person's pain really impacts their lives. And if they haven't gone through that and like asked you, how is your pain impacting your life? And what are you looking to accomplish? And where do you want to be? And they don't have those pictures. Any sort of rehab is just going to be the only paint at the wall. You need that to have like a clear set plan for recovery.

Joe LaVacca (09:33)
Right. Right. Now I totally agree. And even when you mentioned how things change, I think a lot of the people that I see week in, week out, it's not even so much that their pain changes, but attitudes and beliefs change. So I took a course this past weekend and the instructor was actually Ben Cormack, someone we know, I think, and both follow. So great guy. And he presented some, some interesting research on flares and how people

qualify or quantify a painful flare by sometimes not even describing their pain. It's just a lot of the overwhelming extra stressors that happen in their lives. So to your point, know, if people are listening and they're going to clinicians and they're like, you know, my pain's still the same. I'm just doing more. You know, that's progress. You know, I think that's definitely progress. You know, being able to cope, build your bigger life bubble, even if your pain bubble is kind of staying somewhat stagnant because

The thing that I continue to reinforce with clients is, look, look how much more you're doing, right? Remember, or the fear that we had with a lot of this stuff, and you're showing that you can tolerate without any negative impact. And hopefully we can continue to see the benefits of pain come down. I don't want anybody to be in pain, obviously, but I do know that it's just so complicated that when you say someone focuses on just that pain relief, well,

It's so day to day, Then Monday when they feel good, well, hey, I can run a marathon. And then Tuesday, I don't feel good, so I don't get out of bed. It's like, there's just too many variables with that. So I do like what you said there, but I also want to point out to people that progress could just be doing more and staying in the same amount of pain too sometimes.

Joe Gambino (11:16)
Yep, I know, I think that's you to nail on the head with that. So shifting here to the actual topic of the day, mobility versus flexibility. How are you defining the two? you, everyone, I mean, I feel like if you go on 10 different.

providers pages, you know, you're gonna get 10 different answers So how are you defining it? We'll see if it lines up with me because we haven't really I don't know when the last time we even had a conversation like this was And then we'll take it from there

Joe LaVacca (11:35)
Yeah.

Yeah, I think, you know, first is sort of like in the in the words for me, right? So flexibility, maybe how much can you bend or how much can you tolerate passive forces or maybe passive positionings, passive positionings, excuse me. So for me in the clinic, dealing with people in a lot of pain, flexibility might fall under the guide of range of motion.

for a lot of clinicians and maybe even a lot of clients are used to, right? So we can kind of maybe sub or interchange those words. The things I'm looking for with flexibility with people is if you move passively or I move you passively, let's just say a straight leg raise is always like the easiest example for people. So you're laying on your back, you have either maybe a strap, a towel, some sort of apparatus around your foot, or maybe the clinician you're working with is just taking your leg and

raising it up in the air. These would be examples of our passive range of motion or maybe our flexibility. How much we're bending or tolerant of force. So I think of things now where can we actually access this sort of idea of passive flexibility or are we being limited by active guarding? And maybe I'll do a better job clarifying that. So when people come in

We talked about this over and over. There's a lot of fear, there's a lot of increased stiffness, a lot of tension in tissues. When you're meeting people for the first time, maybe you're just not as trusting of me as we should be, or should be, as we could be potentially. So if you're guarded, then my sort of passive range of motion for you is gonna be really different than how you move actively, which would then be mobility.

So you might actually have more trust in yourself moving yourself. So for me, mobility, how you move actively, flexibility would be more of this like bend property. How do you move passively? And I think we could probably break down deeper into those categories with clients, but is that a fair way that you break it down? Is it more of a passive? How can someone move when there is an assist versus how do they move on their own or?

Do you like a better way to quantify it?

Joe Gambino (14:15)
No, this is pretty much how I quantify it. It's flexibility is your passive. It's just a point A to point B, something assisting you to get there, whether it's a partner stretching you, using gravity, you're using a band, whatever it is to get into the position. And then mobility is your body's ability to bring it into that position or even just being able to produce force in those positions. So that's kind of how I would kind of break that down.

Interesting. I will actually, because I know there's a debate on, know, stretching, it's becoming kind of demonized in a sense. So where do you fall as far as how you're programming both of these qualities into your clients' routines?

Joe LaVacca (14:53)
Yeah

Yeah, I think that maybe dives into my little bit of a comment on this idea of guarding with passive range of motion. So if we are assessing someone or someone's being assessed and there is an actual limitation in the tissue, and again, I just keep it really easy when I'm explaining this to clients, if your actual hamstring was short, we should move your leg into a position. We should feel a certain quality happen.

We should probably feel gradual increase in tension through the backside of your leg. And then there probably are some acceptable norms that I would expect given your age, your injury, and things like that. So if you're meeting all these norms and we feel this gradual increase in tension and we want to improve that, well then I would say this might be more of a tissue limiter. I am totally cool with programming stretching for people.

I approach stretching the same way that we would strengthen conditioning. It's a stimulus. We want to increase the behavioral property of a tissue, in this case tolerance to length or tolerance to stretch. So the more we dose it with that stimulus, it should respond. Now it doesn't mean that it replaces strength or conditioning or anything else, but if that's something specific that we're trying to work on, then I have no problem dosing it specifically for clients. Now if we

sort of see pain or apprehension and I'm not feeling any increase in tissue stiffness or this gradual ramp up, well then I'm probably not gonna program stretching for people because they just showed me they're irritable in that position. So then to send them home with passive stretches, it's just gonna be like trying to pull your way out of a finger trap, right? It's just gonna get tighter and tighter and you're probably gonna get more more aggravated. So for those people with the

guarding that's blocking them from their flexibility. I'm going to approach that more as maybe, hey, maybe we need breath work. Maybe we need just aerobic exercise. Maybe we just need to do things to our point before to just get pain to calm down. And then maybe your range of motion or your mobility, how you express yourself actually gets a little bit better. I know we've taken a lot of the same courses in the past to promote different things with stretching and so on and different inputs.

And like you said, this is a big debate now in our field of how much stretching do you give people? So where have you sort of landed on, I guess, you know, creating plans of care for people when you see a flexibility restriction?

Joe Gambino (17:47)
Yeah, I mean, it just comes down to what they show in the assessment. Like to your point, like if I had somebody who was, you know, as you said, like, they feel guarded as you're trying to move them into a stretch. think one of the ways that I've kind of like grown as far as like stretching and mobility work goes is that it doesn't always need to be in range.

You don't always need to go like find this deep stretch and hold it for time. And that's what's going to create changes. The same as like kid style workouts, right? Like you do these hard workouts and assume that it's going to make a change because you feel something and you expect the same thing from your stretching. But in a case like that, like if you just brought them maybe like 10 degrees shy of where they are. Apprehensive and guarding and just let them hang out there and experience that position and produce some light isometrics.

Well, it's going to let that brain and nervous system start to accept it more. Right. So spending times in these like ranges of motion that are just on the border of pain or discomfort can offer benefit. think people don't train there as much and they just go straight to the end ranges. And sometimes it's just too much for your body to even handle. So I think growing from a mobility perspective that way is like the same, you know, again, the parallel to strength training.

which I see often. But yeah, again, good.

Joe LaVacca (19:09)
So do you think that, go ahead, do you think that people need a certain amount of, like, do you have normals in your mind or is it just very dependent on what people want to get back to?

Joe Gambino (19:21)
Yeah, it's very dependent on what people want to get back to. I do hold some norms in my mind. You know, I look at rotation of all joints and I think that there needs to be doesn't need to be quite what we would like our normal ranges, but they need to have some movement there, right? So they need to have hips that can rotate. They need to have a spine that can segment. They need to be able to create some sort of uniform curve, get at, you know, inter flexion and extension.

I do look at like the leg race race tests and I do Expect someone to be able to get their leg past their knee or you know At least you know like decently there and not have pain especially someone wants to deadlift I think people should be able to touch their toes. I don't think that's like a hard ask for a lot of people So there are things that kind of like that where I'm like, well, I would like to maximize Maybe you're not gonna get there, but I at least want to maximize whatever you can get and move you in that direction

Just so I know your joints and your body have the ability to move and disassociate and do the things that they need to do. So this way, when I'm asking you to squat or deadlift, I know that your body has something right where it can pull information from and produce force from and things like that. the thing when I'm saying like I have these norms in my head, like sure, if somebody doesn't meet them, it's not the end of the world. Pain and dysfunction are kind of like the really main things that we're focusing on. If it's not painful.

Do I really need to change it? That's always a debate in my mind. But I don't think that putting a little extra TLCs, those things, and trying to maximize some potential, I don't think there's any downside to it. So that's kind of how I go about it.

Joe LaVacca (20:57)
Yeah, I think for me, with the rise of social media and everybody talking about hip and turn rotation and your foot pronation and you're this and you're that, and I think sometimes it gives people even maybe like a false hope that they can magically change their structure or their anatomy. So whenever I'm hearing a person talk about what they want to get back to, it's always about shapes. It's a squat, it's running, it could be golf swings, right? But all these require shapes. Can you make the shape?

And the answer is always yes or no. Why can't you make the shape? But we talked about this idea of maybe guarding or is it a soft tissue issue? Sometimes it's just your anatomy. Your bones are structured a certain way. There's 8 billion people on the planet. That means there's potentially 16 billion different types of hips. So maybe you're just sort of like trying to fit yourself into a shape that doesn't match what your body's architecture lends it to.

Typically when I tell people that and I'm like, hey, well, don't squat so narrow, let your toes go out. Or, you know, here's a better way for you to think about your bench press setup. Here's a better way for you to think about your hinge. And you could just see the light bulbs go off. Like, well, I thought I had to do it this other way. And it's like, well, no, you could do it that other way. That's one option. But if you're a triangle and that shape is a square, well, you're never gonna fit into that shape appropriately.

So why don't we make that shape better for you, more accommodating for you, and then see what happens down the road with repeated input.

Joe Gambino (22:31)
Yeah, no, I like that. I mean, I definitely think that there's definitely no one size fits all for movement and that it needs to be adapted to the person and, you know, why fight yourself, right? When you can just make a subtle change that makes it more comfortable and now you can load it and actually work towards your fitness goals. it never made sense to me that you have to point your feet in this direction specifically with your feet only.

shoulder width apart for a squat when if you want a little bit wider or went a little bit narrow, I usually when I'm teaching it, I have people or I'm assessing and I have them try like three or four or five different foot positions and whatever feels best to them is what we're going to, if it looks good and feels good, then we're going to, that's going to be your, your signature, so to speak for squatting or whatever the movement is. so doing that and then working on a little bit of, you know, I

For me, honestly, mobility work and stuff like that is just things to help me feel good and joint health related. I think that it serves a large purpose in helping tissues be ready because you're just loading, like really my mobility work is just loading it pretty to failure and heavy in range positions. Unless I have some pain or something like that, I need to really build something. So it's just interesting. I always find this topic interesting because there's no.

I don't think there's really is an answer. I don't really think there's a standard. think that, you know, we have standards and it's good to maybe like use them, you know, towards some normals. But again, there are so many people that don't fit the normals and don't have pain, don't have issues. So why do we need to fix them? And again, it goes back to goals, right? If you can, you can squat and you can do everything you want to do. Do you really need to add a whole lot of mobility work on top? If you have a lot of pain, you can't get into those things. That may be something you want to maybe.

add a little bit more into. So just again, right? Like this is what goes back to the beginning of our conversation. What are your goals? Where's your starting point? And then what does that pathway look like? And then I think you can be specific when you have that versus like, you know, if you're just somebody who's throwing like a ton of mobility work and you're spending 30 minutes to an hour a day because you feel like you need it, you probably don't need that much. Well, I would say you definitely don't need that much. Like you can definitely shorten that up unless it's something you just like doing.

Joe LaVacca (24:42)
Yeah.

You

Joe Gambino (24:49)
And it just makes you feel better and it helps you for whatever reason. Anything else you want to add on that?

Joe LaVacca (24:55)
Well, no, think, like you said, I think there's a lot of things that we can maybe open this up to. Maybe this is a topic we can revisit. So I'd actually welcome, like we've been doing questions of the day, to those listening. Like, how do you think about mobility and flexibility? Do you think about it? How would you prioritize it? And, you know, give us some feedback. And then maybe this is a topic we'll come back to in a couple of weeks where we have a couple more thoughts from other clinicians. Maybe we can even find a guest to come on and talk about it specifically. So, yeah, I think...

We shared some ideas. I think it's definitely something that we come back to in a couple of weeks, maybe after a couple more people chime in. And we can hopefully come up with a solid answer for everyone. Consensus. That's it, man. Love it.

Joe Gambino (25:35)
Yeah, maybe that's, we'll just, that's it. We're going to come up with our answers and we're going to teach you to the world. That's it. All right, Joe, take us home.

Joe LaVacca (25:46)
All right, to everyone who made it this far, thank you so much. Joe, I love you. Listeners, we love you. And tune in next week for another exciting episode of the Beyond Pain podcast. Take it easy, everyone.

Joe Gambino (25:57)
Love it.