 Welcome back to Movement Matters on Think Tech Hawaii. I'm Christine Linders, your host and physical therapy orthopedic clinical specialist. I'm broadcasting remotely today as we continue to hunker down the slowest spread of COVID-19 in our community here in Hawaii and worldwide. I've been home and out of the office now for three and a half weeks and I am honored to have a super guest today because of all she's done and contributed to the physical therapy profession. Dr. Mary Massery has been a physical therapist for over 43 years, achieved her doctorate in physical therapy as well as her doctor of science and has been invited to give over 900 presentations in the United States as well as 18 countries abroad. Her research pioneered the concept of managing trunk pressures as a new way to visualize core stabilization. She earned the highest of honors at the American Physical Therapy Association Awards, the Florence Kendall Practice Award for Outstanding and Enduring Contribution to the profession of physical therapy. Let me welcome Dr. Mary Massery to talk about the diaphragm and how to use it not only to breathe but to enhance posture and balance and decrease reflux and low back pain. Welcome Mary and thank you so very much for joining us on Movement Matters today. You're welcome Christine I'm happy to be here. How how are you doing in Chicago and your family is everybody safe? Yeah everybody is safe here and I think for the most part everyone is adhering to the guidelines. Nobody wants to get this disease so people are being pretty good pretty respectful and we're just going to have to navigate it as as the virus lets us and then see see what happens. I think everyone's going to be pretty nervous when they really say you can go back to work it'll be like uh can we should we how about if we like you go first and I'll go second. That's the concern um so how have you been staying busy at home? I understand there's a favorite thing you have to do while you're hunkering down is that right? Well there's several things there's one my daughter and her husband and two very young kids uh two-year-old and a newborn baby. Yeah they live in Chicago down in the heart of the city and they moved up with us we're in the suburbs to quarantine with us so they could get some extra help and also because we have more space you know I'm in a suburb so there's more green areas there's forest preserves etc and in the city they close everything so poor two-year-old would have nowhere to go so that's one and my favorite thing because I get to have the two-year-old and the baby girl that's wonderful and the other is that I have to bake bread all the time oh I mean why why not right you're gonna do something during quarantining so I get up and I make bread and now the two-year-old Archer gets up and says grandma make soda bread with Archer and like how are you gonna say no to that so yeah that's been that's been really fun to uh kind of picked up back up uh I used to make bread a lot and I got too busy and and just didn't make it very often and now now I'm doing it about every other day. I love it I was looking at that picture he's the two-year-old he is so adorable and congratulations on the new child. Thank you thank you. So I met you briefly in a seminar in 2017 in New York I went down for one day because I said let me take this course I've been wanting to take one of your courses for a long time and I was trying to validate some information on the trans or subdominous that I wrote this book on which I thought would publish then and it's gonna thanks to the COVID-19 I'm going to be able to get it published eventually in the next month but I was so fascinated at your seminar I just did the one day then and then I eventually went to South Carolina and took the three-day but the diaphragm I just really had no idea how many miraculous functions it had and you've been studying this for forever what fueled your passion to start looking into diaphragm pastoral control like how did you get there? I know isn't that kind of funny like why what would you do that? I went to physical therapy school at Northwestern which is in Chicago and I went very specifically because they taught PNF okay and for those who don't know that it's proprioceptive neuromuscular facilitation it's just one way to approach exercise but I had had two knee surgeries as a teenager and the first rehab was horrid I went once I crawled out to the curb in front of the hospital and sat on the curb and cried until my mommy picked me up and then I went home I'm like okay that's it I'm never going back to PT that's the pain and torture part right that they blame us for being right? It was definitely a pain and torture and it was actually really inappropriate if it happened today I'd be like okay I'm yanking your license anyway it was a long long time ago so then about a year later I needed the other knee to have knee surgery and went to the same doctor but did not go back to that hospital for PT so I went to a different hospital and when the therapist came in and outpatient I was like this like ready to karate chop her if she came anywhere near me and so she said are you a little defensive? I said no I'm very defensive and she was like okay then let me just take a look at your knee and I'm like no you can look at the other knee and she's like okay fine I don't need to look at the knee that just had surgery I'm like good because I'm not going to let you touch it and then she started to use PNF and what was then my good knee and it made my bad knee start to move and I said oh that's really cool and it doesn't even hurt what are you doing what is it called and she said it's called PNF and I said where do you learn it she said northwestern I said okay I'm going to be a PT and I'm going to go to that school so that's unbelievable yeah so I applied to one school because it never occurred to me as a stupid young kid it didn't occur to me that maybe they didn't want me it's like well I want you so you know you should want me because I'm going to be amazing you know we have that in common I applied to one school too and I actually didn't get in the first time I applied like late admission no I was already there and but they said but if you you know I was being an actuary at the time they said if you get a this grade in your anatomy class then we'll accept you in the summer so I just I did and I got in but I didn't I didn't think for a second they wouldn't take me at great grades I was doing great in school and why apply to more than one school I was already there all right so anyway in school I I was very interested in neuro orthopedics hadn't really been invented yet which was hysterical that's a whole different story but the last class that I took so it's was a one-year program and then you did clinicals that's just the way it was set up in 1977 so the last class at the end of the day was cardiopulmonary I was taught by Donna Fraumfelter who was amazing teacher and still teaching so she graduated in 1969 so she's been a PT for over 50 years and she's still teaching in Chicago so for those of you out there listening if you ever get a chance to take a course or hear a lecture from Donna Fraumfelter make it a priority anyway yeah well you should have her on your show there you go okay anyway Donna gets there the first day and and it's spring semester it's the last class of the day and she said what are you guys going to be going into as therapists you know pediatrics or outpatient, inpatient, etc and she's having us all raise hands and she said well let's see if any of you need to learn cardiopulmonary because I didn't hear anybody say they were going into cardiopulmonary therapy and you know that she's pulling your leg you just don't know how she's going to do it and so we're all looking around like yeah that's right we've never even heard of cardiopulmonary she said well of the patients you're going to see in pediatrics and outpatients and all the rest how many of them have hurts and lungs and we just looked at and she's like well then you all have to stay and learn so I like it I loved it so for me by default by default I learned cardiopulmonary by one of the country's best teachers so I left northwestern with two primary focuses one was breathing and one was neuro and then my first job was at the rehab institute of Chicago which was primarily adult neuro to start with eventually pediatric and particularly spinal cord entry that's what I started on and I just looked at every one of them when I came in I'm like okay I don't know anything because I'm a new grad but what I can see is none of them are breathing efficiently what can we do about it and the thinking at that time was more along the lines of they're going to wind up with pneumonia but it's okay they go back to the acute care hospital they work on airway clearance they you know make them better and send them back and I just looked and I said okay again I don't know anything yeah but wouldn't it make more sense to try not to have them get sick and they said okay kid your job you wanted I was like oh my god you guys are being so nice I didn't realize they were being nice they were dumping all the patients on me and I'm thinking they are just so kind to really be concerned about my career development but the beauty of that was since nobody wanted to treat patients who had pulmonary problems it gave me one after another after another until I could really see patterns and to see the multi-system involvement and to look at breathing in a very different way so it wasn't what I set out to do but it's what happened because that was my background and I've always been a puzzle doer and a detective yeah so it just fit right down my line I mean yeah that's that's so impressive I love it the figure of things out it's it's something that kind of fueled me to study the different things that I've studied too is I like to I like to figure out how I can help people even if I don't know how and I think you've just really killed it with that so this this I got to talk about the soda the soda can soda pop and model we have a picture of that if we can throw that up there this uh was a great explanation of how the trunk pressures work and I think from my experience I don't know that I ever really thought about vocal folds my I did the same thing I was into rehab my first job for the first four and a half years was acute rehab I worked with strokes and spinal cord injuries and vent wean programs and burns and things like that but we would have people talking and we worked with speech therapists who were training the swallow and all that kind of stuff but I never really thought of it like you've presented it and why I was doing the things that I was doing to try to gain that pastoral control with either talking or until I took your class the why and so can you explain this soda can sure sure one of the things that was very apparent to me very early on is that you can't treat breathing as if it is separate from the rest of the body I mean it's just when you actually say it out loud it's embarrassing to say it out loud of course of course breathing is part of everything we do since it's there 24 hours a day for our entire life so it just forced me to look at patients from more of a multi-system perspective you know was the problem really neurologic or did the neurology cause an impairment to cardiopulmonary and cardiopulmonary was now the major problem or did it travel to a different body system so eventually when I went to graduate school I was trying to really help people understand this more in terms of how to put it into a whole perspective and our final assignment in my doctoral program was to come up with a model of pastoral control and you had to present it to your classmates into some esteemed colleagues and it was it was a big deal and my my classmates made me go last because they said you're entertaining I'm like hey that's not fair and they were like well but you are entertaining so we're making you go last because we're all stressed out I said I don't really think that's fair because that means I have to go last they're like oh well so what so I went last and I used a model that I was trying to be very doctoral in it so there were lines and graphs and arrows and everything else and I put the central nervous system right out in front and my classmates said but you don't really believe that I'm like guys it's a neurodoctorate so we're talking neuro they're like but you don't believe that you believe cardiopulmonary and physiology drives all motor behaviors we all know that from you so if your model doesn't reflect what we know you to truly I'm like okay I'm ready to rip my hair out this is the end of the doctoral program I'm going to kill them but it was actually great because they were forcing me dig deeper how is it that you're going to explain what you really believe happens and and that is absolutely true that physiology drives everything we don't have to walk we don't have to talk we don't have to play volleyball yes we must we must breathe we must eat we must pee poop and sleep and that's actually all we have to do so I went home I went home from that presentation a very frustrated that I'd spent so much time on it my kids had just come home from college we're sitting in our kitchen we've got a recycle bin right there because everybody was in and out with friends and they're taking their cans of pop and throwing them in the recycle bin and it just hit me it's like wait a minute I know exactly what I need to show them I said sorry I have to go write a dissertation I'll be right back I love it was hours and hours I rewrote my entire postural control model it's like it's really all about pressure and that was the like epiphany on how to be able to explain it so once you look at that model and I don't know if your colleague can bring that back oh there it is yeah okay so if you don't mind leaving that there for a minute if you think of a soda pop can you know that it's it's only strength is really the pressure that's within because the the can itself is very weak you could crush it if the top top is open yeah it's very thin but it actually is functionally strong because of pressure so you have the diaphragm in the center you've got the thoracic cavity and abdominal cavity beneath it you've got to have two other valves or any pressure within the can would just fall out anytime the diaphragm moved so your diaphragms your internal valve you look at the vocal folds on top they're the ones that depending on what you need how much air do they let leak out it's like the neck of a balloon so anywhere from oh it is it is so you know the vocal folds are in position to either let the air passively fall out or to close it that's breath hold or to be somewhere in between and that's voicing is really a a typical explanation or example of it then you come all the way down to the pelvic floor if I don't have a valve on bottom anytime I cough sneeze yell push I'm gonna lose pressure through the pelvic floor or anywhere else where I have a breach and pressure that was an absolute epiphany and it really allowed me to show people that core activation is way way way beyond the stomach muscles that's what everybody thinks of I gotta get my core activated that means doing a plank it's like it does not maybe what you need is pelvic floor or vocal folds or intercostals or diaphragm or maybe you need the stomach muscles or back muscles or maybe you need to learn how to control all of them together so that your pressure is modulated the way that you needed to perform that task to support your physiology as well as your motor skill or from being a top level athlete to maybe the old person just trying to go from sit to stand that is so brilliantly put from such a super guest I'm gonna rewind this I'm gonna rewind this Mary and I'm gonna quote that and stick it in my mastery section of my book oh that's like such a great explanation and so brilliant to come up with a soda can but let me let me ask you this cuz I'm dying to know I have a visual person were they crushing the can and throwing it in the recycle bin or were they just throwing the empty can in there no they were crushing it they were crushing it and they were stomping on it they were doing stupid college things which is to hit it against your frontal lobe and I'm looking I'm going do you really want to decrease executive function I don't think that's a good idea you should not be smashing it against your cranium I mean that's that's scary I've never done that but also you know I'm not a macho guy right and I'm pressing people so I just looked at them and I said yeah well you guys might think you're strong but your mom is so strong that she can crush metal in her bare hands and then that was the epiphany it's like right but I can only do that and there's no pressure from within so if we're not looking as as pts when we look at poor stabilization and we think stomach muscles stomach muscles we're doing an incredible to service to our patients and a great example of that would be my patients with cystic fibrosis they clearly have lung disease so I'm going to be doing true cardiopulmonary you would think of classic cardiopulmonary work with them but they're also going to be very likely to wind up with stress incontinence unless you prevent it they have abs of steel because they cough 50 100 200 times a day so cough cough cough cough they've got really strong abs that's not the problem the problem is you're squeezing the cylinder in the middle but you didn't roll up the bottom of that can so thinking like a tube of toothpaste if you squeeze it in the middle the pressure is going to go down and the pressure is going to go up so until recently which would have been maybe the last 10 to 20 years which is pretty recent for cystic fibrosis it was about two-thirds of women would have stress incontinence by the time they were in their later teams of course they didn't talk to their doctors about it because for teenage girls so who wanted to talk about it but when they did finally start talking about it they thought it was something completely separate from their CF it's like no you're coughing so think of it in terms of multi system it's because you had a lung disease which caused a neuro motor plan of I need to cough and I need to cough aggressively to keep my lungs clear which caused a musculoskeletal deficit of inadequate strength and support for the pelvic floor which caused an internal organ problem of inability to hold your urine so they're far more likely to get a urinary tract infection as well so if I'm the doctor I could treat the urinary tract infection or I could say huh I wonder why they get the urinary tract infection it could have a million other things because the root cause but one of the things that the doctor as well said therapist should be looking at is being that reverse detective I having urinary tract infection I'm going to ask some more questions oh yeah it does turn out they have stress incontinence but I know they have cystic fibrosis I know that's aggressive coughing and and excessively high intra-abdominal pressures rather than too low and be able to back that up to say there might be a physiologic reason for the UTI but there is definitely a physical contribution to that UTI as well it changes your entire practice because it forces you to find the real problem instead of saying I'm going to treat a shoulder problem because they came in complaining of shoulder pain or back pain or ankle pain it makes you look and say but is that the root is that the real problem I love it I love it I like what you said about the reverse detective thing I think it's so important to find the root cause and I mean absolutely and people are always asking me why are you working on this that's not where it hurts and I have to tell them but you know what we found is that this part stiff this is not moving this is not strong which is making this more vulnerable or not able to move and so we need to fix this so that doesn't have to cry out in pain and in this reverse detective that you're talking about I think is genius it's something that I always inspire other therapists and friends and students to to think about it with their you know if they're new and they're doing a new val and I tell them tell their patient this is a team and we're going to figure out why you're having this pain and so I think it's this this or this but you need to keep we need to have this conversation so we don't want to bark up the wrong tree when you're new you can't just find out the root and reverse detective it right away it takes experience and time and I know that and you know that yeah I try to tell them that like just you touch your patient about we're going to figure out the root cause of why you're having that pain it might not be where the pain is right or where the problem is my colleague Nikama Kerman who is one of my yeah she's one of my oh yeah you would have met her as your teacher for the full course yes yes so she's from New York and she is one of my faculty members and she just has a great saying that she heard from someone else and that is where it hurts it works so they come in complaining of shoulder neck back foot knee hip pain but that is very likely where it works where is it dysfunctional that is causing another place in your body to have to pick up the slack and do more work so it's just it's a great saying but just thinking along along those lines I I just submitted a presentation for the APTA on COVID so we're doing something called the PACER project which okay I wanted to ask you about that yeah it's called post acute COVID exercise every rehabilitation I had to go through it in my mind PACER P-A-C-E-R right so everyone's calling the APTA and calling cardiopulmonary specialists and saying if I get a patient who is a survivor of moderate to severe COVID because you're not going to get someone who was mild because they barely even noticed they had it but somebody who had a more serious case what are going to be the issues that I would have to think about and of course we don't know we don't know because it's novel but we're projecting what might be occurring and so in that video which will be posted later today on the cardiopulmonary and vascular sections YouTube page and Facebook and all those other mediums that I don't even know about but anyway the whole point from my perspective is that it's going to be multi-system and they're going to come in with something like low back pain and I'm going to say well is their diaphragm working it was paralyzed when they were at their sickest point you're going to have to strengthen their diaphragm as part of your low back pain program so it's being able to look multi-system how cardiopulmonary affects musculoskeletal and how musculoskeletal affects cardiopulmonary and all the other systems together but it makes it very exciting very exciting to be a PTI I still love my profession and I'm never going to retire and you're so good at so you're so good at that so Mary we we're out of time and I love I have to have you on again to so we can continue this conversation I love what you just said about the breathing and the back pain and I hope that the viewers today heard that message so I want to thank you so much for coming out I really hope I can convince you to come on maybe in two weeks when I'm on again and thank you thank you think Hawaii and our sponsors and donors for allowing us to be here today and during this typical time everybody please be safe do some breathing think about your diaphragm now and maybe maybe in a couple weeks or if I can convince Mary to come back on we'll give you some lovely inspiring breathing exercises to do hello hi everyone thank you so much Mary thank you you're welcome bye bye