#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.

The personalized rehab strategy for Peter’s shoulder surgery that sparked creation of a training program called 10 Squared [3:00]

• A few years ago, when Peter was in the throes of recovery from shoulder surgery, he and Kyler had this idea to put together 2 things that seemed unrelated
  • His recovery from an injury
  • The idea of a Centenarian Decathlon in a marginal decade
    • [episode #261 goes into detail about the Centenarian Decathlon]
• Peter met Kyler 4 years ago, as soon as he moved to Austin
  • They worked on preventative stuff: DNS and routine maintenance
    • [episode #152 goes into detail about DNS]
• On the second or third visit, Kyler asked about Peter’s shoulder 
• And that kicked off this whole conversation because in Kyler’s world, this idea of just doing one technique or providing one service isn’t really a complete approach
• Peter had torn his labrum before
  • The diagnosis was made in 2009 when he had his first arthrogram done
    • This is a MRI where prior to you going in the scanner, the radiologist takes a needle about 4 inches long, shoots the needle into the capsule and injects contrast so that it really allows the MRI to show the labrum and how much it’s detached from the glenoid fossa
  • It was significantly torn but not as torn as it would be 13 years later
• Peter had largely avoided surgery by doing as much as he could to strengthen the rotator cuff
• And frankly, he was afraid to have surgery
  • He didn’t want to trade one problem for another
  • He didn’t want to trade want to trade pain and instability for immobility
• Folks listening may recall his discussion with the amazing surgeon Alton Barron on the podcast [episode #232] who ultimately did the repair 
• What Peter was most impressed by in that experience was that Kyler and Alton started working as a team

Talk a little about what you guys did 8 weeks prior to Peter’s shoulder surgery 

• One of the things as a rehab professional that Kyler really appreciated was how Alton didn’t want to just cinch down that joint to where his liability was so covered that that shoulder would be strong, but then have Peter lose a ton of function 
• One of the key things that Alton did was he put the staples and the sutures in the right places to where that shoulder would be functional (he did just the right amount)
• And Kyler worked with Peter to get his shoulder well before more significant structural compromise
• It’s a really important window to do so
• Kyler remembers that conversation ‒ Peter had a date several months out where he was like, “I’m going to have to use my arm a lot. I need to be strong.”
• Peter wanted to be able to hunt in September
• So the surgery needed to be no later than March

It was January, and the question was should he do the surgery right away or use 2 months to prehab? 

How did you think about that question? 

• That conversation was one of Kyler’s favorites because he’s done this before where if we know the big picture goal as well as the near term surgical date, and then we reverse engineer
• Okay, I want to check off a certain amount of things preoperatively to where that joint is ready
• Essentially in the most simple terms, what you’re looking for in that situation, is you want to make all the muscles around the shoulder just awesome
  • Especially with the shoulder because it’s such a mobile joint
  • But we need to do so in a way that doesn’t make the surgery more complicated or injure you more
• He combined a lot of things
  • Technology like BFR [blood flow restriction discussed in episode #179]
  • Aggressive approaches on core stability
• The way the scapula interacts with ribs and all these things have an effect on how the shoulder moves
• If the mobile shoulder that has a torn labrum isn’t stable and doesn’t have a support infrastructure around it, you’re always going to ask for more pain
• Once things were healing from the surgery itself, all those other ancillary things were actually functioning really well
• So now we only had to really target the shoulder itself because the rest of the human was really strong and ready

What Peter remembers 

• How much rotator cuff work he did ahead of time, particularly around supraspinatus
  • He got that muscle as strong as possible in 8 weeks
  • Anyone who’s gone through that type of rehab knows it’s uncomfortable 
  • You’re burning a tiny muscle that’s not used to working that hard

“The second thing that I remember and hands down the most important thing was what you and Alton decided to do postoperatively completely shattered everyone’s understanding of what we do with these patients.”‒ Peter Attia

• Peter didn’t have a slap tear, his labrum was hanging on by a thread 
• Traditionally a surgeon’s primary objective is to make sure that is never unstable again
  • Cincy it down really tight
  • The patient will be in a sling for 4-6 weeks, and that’s going to give it plenty of time to heal
• But you’ll never regain mobility, never regain the healthy range of motion, and you’ll probably atrophy away

⇒ Alton’s goal was to have Peter out of a sling in 24 hours

Kyler points out, “The broader picture here is what we touched on, the liability. And it’s really difficult for modern physicians and rehab pros to integrate.”

• Professional sports try to achieve this as well, but they have time constraints and all these other constraints with how many people they’re working with
• Ignoring all those layers, the most important thing is Alton and Kyler had these conversations in detail and Alton was really specific about, “Okay, did we get the training we talked about? Is that supraspinatus, the serratus anterior, all these other muscles that help stabilize? Are those really good?”
• Kyler had some metrics he was able to discuss with Alton, and Alton felt confident in the stability of Peter’s shoulder

The decision about no sling was based on the preparation they did and what they knew 

The other thing was Peter followed everything to a T 

“One of the big complications in rehab (athlete or not) is are people following the rules?”‒ Kyler Brown

• If we take this individual out of a sling, are they going to forget about it and all of a sudden go reach for the cereal or are they going to follow the rules? 
• Peter was definitely a rule follower
• So Alton and Kyler had high confidence in minimizing the risk 

Peter learned a lot the hard way from his first orthopedic surgery in 2000 

• He’s not even convinced he received post-operative instructions
  • And if he did, he didn’t read them 
• He was breaking every rule there were

Peter’s labrum repair surgery 

• The stakes were higher here in a way 
• Peter was very mindful
• When you have surgery, you tend to go on YouTube to learn all about it
  • He wanted to see everything: the post-operative, the rehab process

Post-surgery exercise 

• One of the big milestones you see for people with labral surgery is when they basically can dangle the arm and rotate a light weight
  • Alton was really clear, “You’re not going to be doing that for a while. We’re talking about range of motion without stress on the repair.”
• Very early on pre-operatively and post, we were able to do very gentle but targeted isometrics where there wasn’t complexity in the joint itself, but we were loading the tissues in a very articulate and specific way
• And that’s how you again put the support structure around it
• Kyler describes as the roll cage in a car, we want all the muscles around that to be ready to absorb force
• So those joint structures that are getting the staples or whatever else in there aren’t stressed
  • We don’t want to yank on those things while they’re healing

Training for the marginal decade: why precision and purpose are essential for quality of life [11:00]

In parallel to this, Peter continued to refine his thinking around the idea that we’re all going to have this marginal decade one day  

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