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May 24, 2023

The TRUTH about Blood Flow Restriction (BFR) with Kyle Kimbrell

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Dr. Yoni Rosenblatt: Wanna welcome Kyle Kimbrell onto the True Sports Physical Therapy Podcast. Kyle, super excited to have you on. First of all, tell me that I pronounced your last name correctly.

Kyle Kimbrell: You actually nailed it, man.

Dr. Yoni Rosenblatt: Hell yes.

Kyle Kimbrell: And it's funny because over time I've kind of defaulted on occasion to just say Kimbrell 'cause it's a little bit easier to see that and it's a little bit easier to enunciate. And so just depending on circumstance, I'll say that. 'Cause otherwise people go, is he mumbling? I don't know. You know, so yeah, you absolutely nailed it.

Dr. Yoni Rosenblatt: As a guy named Yoni. I'm sensitive to that, so.

Kyle Kimbrell: Well, I was about to ask. [laughter] I didn't know if it was Yoni or Yani. I was like, it's gotta be one of the two, but...

Dr. Yoni Rosenblatt: Baltimore O Yoni.

Kyle Kimbrell: Yoni.

Dr. Yoni Rosenblatt: Yeah, there you go. So now you can't screw it up. So Kyle, you have done unbelievable things with the blood flow restriction front on the blood flow restriction front. I'm excited to have you on to really educate us on that. So why don't you start by giving us some background on how the hell you got to where you are today and what today looks like for you.

Kyle Kimbrell: Sure, yeah. Today, it looks like me sitting at home [laughter] answering a lot of clinical questions for people and helping to produce content for the Owens Recovery Science brand, if you will. I manage their social media. So like yesterday, it's like tweet this or what. And then we have a few different little groups that we try to kind of engage with. So answering questions in those different platforms. And I got here because I was a clinician for well, let's see. I had been a PT practising in a traditional kind of outpatient setting for about 12 to 13 years before I met Johnny.

Dr. Yoni Rosenblatt: Just treating, 12 years of just treating.

Kyle Kimbrell: Yeah, man. Grinding it. Yeah.

Dr. Yoni Rosenblatt: Hell yeah. And how busy was that clinic? When you say standard, what does that sound? What is that? 

Kyle Kimbrell: So when I started there we were one every, or excuse me, three every hour. So on like 20 minute increments. And then when we... We were partly that way because, and we would double book as needed. We were partly that way 'cause the clinic was so small and when we expanded we had more space. And so we could hire more people and we could spread people out. So then we went to one every half hour evals every hour. And that flowed, that flowed great. Funny enough, like there were times where I actually felt like the care was maybe even better than that little tiny spot seeing three an hour, but you could always see everything. So you kind of had eyes on and it was easy enough to engage. So there was that, but yeah, I did that for a long time.

Kyle Kimbrell: Took students, I'm a credentialed clinical instructor, so did all that and that was kind of my foray into teaching. And then when I met Johnny Owens he came out to our clinic to teach all of us BFR back in late 2015. So we were actually the first public course that he did. And got to know him that way. Started doing like little in-services for him with various different sports teams around the Los Angeles area where I'm located. And then talking to different clinics and physician groups and whatnot about the technique and just, and then just kind of implementing it clinically in our clinic. And that just kind of snowballed to where I started teaching for Johnny. So the last three years of my time in clinic, I actually spent all my vacation to travel [laughter] to go teach...

Dr. Yoni Rosenblatt: To teach.

Kyle Kimbrell: People how to do this BFR thing and then thank god Johnny goes, Hey man, you know, I think probably we could just bring you on and just kind of have you do this if you were interested in maybe getting out of the clinic. And I said, you know yeah, that sounds like a good idea. And it's been great, and I miss the interaction with patients. I miss seeing people get better, but I still am engaged clinically 'cause I'm constantly answering questions for people and trying to help them implement this BFR thing better.

Dr. Yoni Rosenblatt: Yeah.

Kyle Kimbrell: And speaking at conferences, teaching still, that kind of thing, so.

Dr. Yoni Rosenblatt: Yeah.

Kyle Kimbrell: Yeah, that's me.

Dr. Yoni Rosenblatt: And it's working. I mean, man, the gospel is really spreading. It's really...

Kyle Kimbrell: I love the gospel.

Dr. Yoni Rosenblatt: BFR gospel. [laughter]

Kyle Kimbrell: I've seen that a few times. It just cracks me up, spreading the gospel of BFR. Okay.

Dr. Yoni Rosenblatt: Yeah. It's really awesome. And so it was brought to my attention, I wanna say like right around 2015 also maybe 2016 when I had a clinician working at our clinic and saying like, we gotta do this BFR thing. I'm like, what the hell is that? You know, I don't know what that is. So obviously we've come a long way from that, but let's kind of define our terms. Tell me what blood flow restriction means to Kyle Kimbrell.

Kyle Kimbrell: It means adding some type of restrictive device on a proximal limb. And I say it that way because it's been done in a lot of different manners. I am of course biased towards how we teach it, which is to actually use like a high grade tourniquet system that's validated, that's reliable. And measuring the pressure at which to use. So that pressure is essentially the point. I like to call it like the one-rep max of the vascular system. 'Cause it's kind of what it is. You don't give somebody a resistance exercise without dosing that exercise in some way, which means individualizing it. And the absolute best way to do that is a one-rep max. So we always, before we ever do BFR, we have someone lie down, we apply this cuff to their limb on the device we use, the Delphi device, we just push a button and it has technology that's been validated against duplex ultrasound to where it can sense when blood flows completely shut off into the limb. And that gives us this one-rep max number, if you will, or what is typically called 100% limb occlusion pressure.

Kyle Kimbrell: Then we apply pressure to that limb based off of that maximal number. So typically in the lower extremity we use a 60-80% range. And we give that range because it's been... A lot of different pressures have been used within the literature. We really kind of think that as we're seeing more and more come out, the way things are shaken down is there's kind of this load pressure seesaw where if the load that you're using with an individual is really light and you still want BFR to really be as effective as it can be, then you might need to use a little bit higher pressure. So maybe up closer to that 80% range. But as you're able to start kind of progressing load, then it looks like maybe you can drift that pressure down into that 60 to maybe even a 50% range, that's lower extremity.

Kyle Kimbrell: Upper extremity, we use a pressure range of 40-50%, it looks like 40%. It's kind of the lowest you can go in terms of BFR pressure and it really accomplishing what it needs to accomplish, which is basically causing you to fatigue much faster than you typically would with the traditional exercise. And so that's really the win on the rehab side of things, like from a physiology perspective, we know that in order to get muscle to get bigger and to enhance its ability to produce force, we have to make it very tired. We kind of have to push it to its limit, which is it's adaptation in general no matter what we're talking about, whether it's we're learning something or we're trying to get the human body to respond in a certain way, you have to push a limit at some point. And that's basically what we do with resistance exercises.

Kyle Kimbrell: We create a bunch of fatigue. And so if we can create that fatigue with a lighter weight with BFR and the use of this cuff, and maybe not having to do as many reps either, then that's a pretty big win for those folks that are in pain that might not be able to lift a heavy weight. And in some cases we're even just like pedaling a bicycle with cuffs on either leg or walking on a treadmill and if somebody's pretty low level, even that stimulus might be enough to get them a little bit of muscle, certainly improve their endurance, but maybe even improve their strength at some level as well. So there's kind of a range of ways that we use it, but the basic principle is apply a cuff, individualize that pressure, individualize whatever exercise stimulus you're giving and what you'll accomplish is this person's gonna get tired way faster than they normally would. And that's a pretty big win.

Dr. Yoni Rosenblatt: Yeah.

Kyle Kimbrell: In a lot of different ways, but definitely in rehab.

Dr. Yoni Rosenblatt: Yeah, I love that. So I usually sum it up when I'm pitching this to patients because it does sound terrifying, especially post-op day one and we'll get into that is this is gonna make, number one, it's pretty uncomfortable, but number two is it's gonna make things that are normally very easy, very difficult. Your body is going to respond by laying down more muscle tissue and you're gonna grow muscles bigger and faster and that's gonna get you to where you want to go quicker.

Kyle Kimbrell: Yeah.

Dr. Yoni Rosenblatt: And then it's like, okay, let's hit the gym. How'd I do with that?

Kyle Kimbrell: I think that's great.

Dr. Yoni Rosenblatt: That make sense? Okay, great.

Kyle Kimbrell: Absolutely. Yeah.

Dr. Yoni Rosenblatt: I'm glad I have not.

Kyle Kimbrell: Unless you're working with an engineer and then you gotta kind of go a deeper dive. [laughter]

Dr. Yoni Rosenblatt: Yeah, try not to do that. So for many reasons I try not to do that. Okay. So but you did say a lot of interesting things there, which because you talked about your system and so when this employee came to me and said we gotta get this BFR machine, I'm like, okay, sounds cool. How much? 

Kyle Kimbrell: Yeah.

Dr. Yoni Rosenblatt: And then he told me how much it costs and I'm like, dude, that's more than the car I'm driving right now. So I think that first system was six grand, something like that.

Kyle Kimbrell: Yeah.

Dr. Yoni Rosenblatt: Do I need to use that computer? Does it matter what brand BFR I use? Does it matter?

Kyle Kimbrell: Yes. Yes and no. Yes and no.

Dr. Yoni Rosenblatt: Okay.

Kyle Kimbrell: I mean, if you look at the literature, the early papers, were done when the BFR literature was really starting to expand. That device was a KAATSU device which is still a pretty expensive device in the grand scheme of things. But it's built a bit differently. So it's not a surgical tourniquet. In fact they have on their website, not for clinical use basically. So it doesn't meet FDA regulations or whatnot, that kind of thing. But then there are other devices out there. Some of these studies have used knee wraps, which I... The people that pioneered that work have said, Do not use this clinically. I think if there's anything I really discourage it's the use of like rogue bands or knee wraps or that sort of thing 'cause you have no way of controlling the pressure that you're giving to the limb. And that's been shown kind of time and time again. Then there are other devices that have no way of individualizing pressure that are out there. And those devices are basically built to not ever fully occlude no matter how much pressure you put in them. The problem with that is you just have no way of really providing the exact same stimulus to everybody that comes through your space.

Kyle Kimbrell: And I see that as a real problem. I mean, last I checked, we get evidence-based pounded into our head and I'm like, well, if I can't determine how much pressure needed, then how am I really being objective in evidence-based? I have a problem with that. But that doesn't mean that those devices can't, at some level provide enough of a restriction pressure to accomplish BFR. It's just you have no way of knowing like what that number is.

Dr. Yoni Rosenblatt: Yeah. As proportioned to their occlusion.

Kyle Kimbrell: Yeah. So you just... It's kind of a guessing game. And I think that someone that's really skilled with exercise, they could probably figure that out and they could figure out how to figure it out pretty fast. If you're treating a patient every half hour, I need to be able to like move and be... So that doesn't work for me. Then there are other devices that can create full occlusion and you typically are measuring them with a handheld Doppler. So the only limitation there is that, some of those devices don't have different size cuffs. They don't have a decent range. And so there's potential for maybe the cuff to kind of overlap, which could introduce a pressure gradient. It could cause the cuff to kind of slip when you're moving, that kind of thing. That's definitely something that I've seen happen. And it introduces a little bit of human error. Anytime you are having to measure and listen and pump up, there's gonna be some human error there versus a system that's computerized and validated, basically against two ways. So when I say duplex ultrasound, that means the Delphi device is validated against not only an auditory sound, but a visual stimulus as well. So they kind of confirmed on both ways that okay, this is accurate.

Dr. Yoni Rosenblatt: Yeah.

Kyle Kimbrell: And that's the one that I really like. That's the one that I've used my whole career. The reason I like it is because if something goes wrong, I can defend every decision I made with that device. It's made by a tourniquet manufacturer that's been... That basically has all the patents on all the technology that's used in all the surgical grade tourniquets for the last 40 years.

Dr. Yoni Rosenblatt: And I guess that's why it's a goddamn fortune, right?

Kyle Kimbrell: Yeah. Well, so it's funny you say that because I get the price question all the time. Like, why the hell is it so expensive? And I'm like, well, look at it this way, like we all kind of understand the drug market and how drugs are developed, but they're required to do that, right? They have to put in on all that R&D and then they have to make up their profits on the back end. The medical device market isn't regulated that way. And so what's happening is you have a lot of these companies that have seen this BFR thing become very popular. They've rushed to market and they've not done their R&D, they've not done their work. And in fact, in some cases there have been patent infringements already. And essentially the consumer is paying for their R&D.

Kyle Kimbrell: And so what you see now is like new device every year or so, and there's small little tweaks and weirdly enough, they all start kind of looking more and more like a Delphi system. But I heard this funny thing on that topic the other day and I, 'cause it was somebody saying like, if you're buying a product and somebody's telling you, oh, they can do it cheaper, they can do it cheaper, they can do it better, da da. That means you are the product, not what they're selling is, you are the product. And I went, oh, this is exactly...

Dr. Yoni Rosenblatt: Yeah.

Kyle Kimbrell: From my perspective, the BFR market, we have a product that's been developed and it's been shown to do all this stuff. And there's this other market where all these physical therapists and athletic trainers and strength coaches are, they're the product now. And these companies are just kind of learning off of them. So, yeah.

Dr. Yoni Rosenblatt: Yeah. Cool...

Kyle Kimbrell: That's why it's so expensive. It's just been around.

Dr. Yoni Rosenblatt: Listen, I think that makes a lot of sense in terms of that R&D and the back investment to get it to where it is. Anecdotally speaking. I refer to it as the real BFR. I have it in a few of the clinics and I have the handheld one, it's a different ballgame. I mean, compared to what you feel, I love its ability to really squeeze down during rest and kind of relax a little bit during work. Obviously, you don't get that with the handheld stuff.

Kyle Kimbrell: Right.

Dr. Yoni Rosenblatt: And I love the whiff of the cuff, which I know there was a bunch of literature coming out on how important that is, not just to hold it in place, but an actual occlusion and Delphi freaking nailed that. It's comfortable, it stays there. It really does its job. So we're still using the same original that I dumped all that money into and what I would love is, let's get... Is Johnny behind you, if we can get higher reimbursements for this thing.

Kyle Kimbrell: I know, dude, yeah.

Dr. Yoni Rosenblatt: Dude, make that happen, Kyle.

Kyle Kimbrell: We are. That is... It's certainly an ultimate goal. It's tricky. It's really tricky.

Dr. Yoni Rosenblatt: No kidding.

Kyle Kimbrell: Yeah. 'Cause I mean, if you think about like name me another profession in the United States economy that has not seen an increase in what it has paid for its services in the last 30, 40 years. You're gonna name physical therapy. I don't know that you're gonna name another one.

Dr. Yoni Rosenblatt: Yeah. Listen, it doesn't exist except for PT. And what's crazy is I have this conversation all the time because when I sit down and do reviews or we're talking comp structure.

Kyle Kimbrell: Yeah.

Dr. Yoni Rosenblatt: The PT... I'm a PT, like I wanna get paid more. Like my life costs more today than it did yesterday. But it's really hard when Blue Cross just laughs at us. So if Owens could fix that, I'm happy to invest in Owen.

Kyle Kimbrell: Dude. If we could fix that, there'd be a lot of things that would get a lot better for a lot of us.

Dr. Yoni Rosenblatt: So true. By the way, are patients included, and...

Kyle Kimbrell: Yeah, 100%.

Dr. Yoni Rosenblatt: Yeah, you're absolutely right about that. I think that's an entire other podcast to talk about. Talk to me about rep scheme, when you're using your BFR and it's been, when you talk about being ingrained in our brains, it's 30, 15 times three, right?

Kyle Kimbrell: Yeah. Yeah.

Dr. Yoni Rosenblatt: Where'd that come from? Do you still live on that and die by that? And why do we need to keep doing it?

Kyle Kimbrell: Yeah. So it kind of comes from studies where they have said, all right, we're going to do as many reps as we can until we can't do anymore, and then we're gonna let you rest a little while and you're gonna repeat that. And so what ended up kind of shaking out over time is seeing that if you get like an 80% pressure and a 20% load and you have a group of people do four sets to failure, then they end up doing about 75 repetitions. Now the split looks a little different, probably more like, hey, we did 40 reps in that first set, and then maybe it shrunk down to 13 and maybe 10, but in total it was 75. So over time we just kind of saw people breaking it down 30-15-15-15.

Dr. Yoni Rosenblatt: Isn't that weird because you're a CS guy or you're a strength guy. We don't use that when we're imparting a strength and conditioning protocol where we say, here's your number of reps, everyone's gonna do this. We really vary it depending upon our goals. So talk to me how that fits together.

Kyle Kimbrell: Yeah, in the end my goal is kind of that last set for the person to almost not be able to finish. And over time we'll get to where the last two sets typically, they can't finish. So my goal is really an effort goal with this intervention, getting that person to what we would probably call like momentary muscular failure. It definitely looks a little bit different than some sort of a strength program though. It looks totally different there, and that's, I think maybe that's where sometimes you'll get pushback from the strength and conditioning community a little bit, but then of course you put a couple cuffs on their... [laughter]

Dr. Yoni Rosenblatt: They do 50, right? 

Kyle Kimbrell: Legs if you ask them to squat and they go, oh, okay, I get it now, because all of a sudden it feels like they've got however much weight on their back so, yeah.

Dr. Yoni Rosenblatt: But is it worth kind of thinking about your goal? I'm always preaching, pick a goal for the session. You can't accomplish everything in a given session. If your goal is strength for that session, strength, we're not talking activation, we're not talking endurance. Like do you pick that applicable rep range, use LOP appropriately, use increased resistance appropriately, and you're gonna live in that given rep range as opposed to 75 reps, which depending upon your reps break, that sounds to me more endurance.

Kyle Kimbrell: Yeah, but the thing with endurance is, you typically are kind of relying on kind of that aerobic system and your, the type 1 fibers, and really when we put this cuff on you, we limit your ability to use those pathways to produce the energy that create muscle contractions. So the thought is that first 30, we kind of run you out of oxygen and the muscle, and now you start having to use your storage sugars, your lactate and that kind of thing to produce ATP. So the thought is that we get you into some of these type 2 fibers by kind of front loading everything with like a 30 rep scheme. Now, if my goal for a session, kind of going back to that original part is strength, BFR is probably not gonna be my first, it's not gonna be my first choice. I'm going to choose to lift someone heavy, because I think that increasing strength is multifactorial. It's not just about force production, especially if we're talking about a multi-joint movement, there's some improvements in efficiency that need to also occur in order for somebody to get "stronger".

Kyle Kimbrell: So if I'm trying to increase somebody's strength with BFR, I'm definitely going to be, I might not, I'm gonna probably use that 30-15-15 as a framework, as like a goal, but I'm gonna choose my loads and my pressures, so that they're definitely failing early in that second set of 15 and in that third set of 15. So I'm really gonna push my limits in terms of like, how can I load this, right? So I might look at more like a 40% load and a 60% pressure in that scenario, and if that's the case, they're probably like, whoa, you know, 10, 12 reps in that second set, and I'm fine with that because I got the effort piece in there.

Dr. Yoni Rosenblatt: Yeah. Yeah. And okay, so that speaks really well to this 30-15-15-15 is a guide, but you just sounded like a really good strength coach when you explain that is depending upon what you want your outcome to be, you're gonna change the stimuli.

Kyle Kimbrell: Absolutely. Yeah. Definitely.

Dr. Yoni Rosenblatt: Okay. Okay. Awesome.

Kyle Kimbrell: Yeah, it's not like a protocol that you can just like plug and play, which I know it's nice to have those when you can, but that's just not really what we do in general. We're always kind of tinkering and finding what's best so...

Dr. Yoni Rosenblatt: Love that. I feel like the best ones do, so...

Kyle Kimbrell: Absolutely.

Dr. Yoni Rosenblatt: Yeah, I appreciate you kind of working through that. Tell me... Well, let's talk difference between lower extremity, upper extremity.

Kyle Kimbrell: Okay.

Dr. Yoni Rosenblatt: Do you feel that the cuff concept is as effective upper extremity as it is lower extremity?

Kyle Kimbrell: I think it kind of depends on what muscle group you're working and what movement you're working. I think in the physical therapy world we end up really treating a lot of shoulder in the upper extremity, and then some elbow and some wrist hand. And so I think from that perspective, maybe BFR is probably a little bit more valuable in the lower extremity just because it can address the vast majority of the things that we see. When you start getting into the shoulder, it's tougher with exercise. Now there's some data recently showing like if you get that 50% pressure, that actually you can't increase muscle recruitment proximal to the cuff. But I find, at least from our practise, I was always fighting range of motion for people. And so I was like, man, I can't [laughter], like I haven't put this cuff on them, but they're not able to work their muscle through a large enough range that it really even matters, so we kind of avoided that. I didn't avoid it. We just didn't see us using it as quickly and as easily as we would in the lower extremity.

Kyle Kimbrell: But for things like tennis elbow or like a golfer's elbow, those things man, we're able to see really great pain reductions pretty quickly. So that's been, for me, the win that I see in those two populations is that ability to really substantially impact their pain and see that change within a visit, two visit, three visits. So on those fronts, I see it really kind of providing a lot of help. And where we haven't really seen things go is kind of like wrist hand. There's very little work on that out there, but think about like, how hard is it to actually fatigue the intrinsics of the hand or some of those, it's like virtually impossible. But with the addition of BFR, you can take like your little manuals and things like that that you might do for say, a thrower or maybe somebody after like carpal tunnel. And you can actually work those muscles hard, which you really pretty much can't do...

Dr. Yoni Rosenblatt: Very hard to. Yeah.

Kyle Kimbrell: Without BFR.

Dr. Yoni Rosenblatt: I've seen that work beautifully. I think that that's a great point. I've also seen it really well in the plantar fasciitis, achilles tendinopathy stuff. Where we're like, how many towel crunches can you do before a patient looks up at you and they're like, "What am I doing?" Right. So actually making that hard and challenging, and like you said, recruitment wise, I've definitely seen benefit. Walk me through physiologically what you think is happening to have the effects proximal to the cuff?

Kyle Kimbrell: Well, I mean, in a multi-joint scenario, what we really think is happening more than anything is you are fatiguing those muscles that are distal to the cuff that act as primary movers. And then that's just kind of forcing you to use the muscles above the cuff more than you typically would with that movement, and at least kind of maintain the quality of the movement that you're after. If we start talking muscles that solely lie above the cuff, like say rotator cuff muscles. That's a harder one to explain. [laughter] It's really hard to explain. And so, I don't know because... You've done it, I mean, when you do like say external rotation with BFR, your hand still kind of starts to fatigue a little bit.

Kyle Kimbrell: So I don't know if there's something there with just the, neurologically, the fatigue there is kind of forcing you to feel fatigue proximally, maybe. The overriding thought that people always kind of point to is they feel like that cuff kind of acts like a funnel and you get some sort of like a retrograde sort of restriction of blood flow. So as long as you're kind of close to the cuff, but still proximal, you still might be getting some blood flow restriction. Even though, like from a straight plumbing perspective, it wouldn't make any sense.

Dr. Yoni Rosenblatt: Yeah, yeah.

Kyle Kimbrell: That's what people point to the most. No one funny enough has actually studied that.

Dr. Yoni Rosenblatt: Dude, let's do that. I want to know that. I want to be able to put a cuff on a pitcher and say, this is gonna help your rotator cuff tendinopathy. And here's how I know that. Can I answer that today, or no?

Kyle Kimbrell: I don't think we can answer it today, [laughter] but there is a actually a study just published out of Houston Methodist on throwers. So it was done on the Rice baseball pitchers. Now, they weren't treating them clinically, but they were studying. They looked at EMG, they looked at fastball velocity, they looked at throwing mechanics, and they looked at spin rate. And everything in the BFR group was really positive and significantly different. Now, they didn't let them publish all of the results. There were some reasons they didn't publish the velocity and the spin rate. But mechanically they actually looked better those groups because presumably they had less fatigue, less pain in the arm.

Dr. Yoni Rosenblatt: I'm dying to know the spin rate piece.

Kyle Kimbrell: Those are the...

Dr. Yoni Rosenblatt: That's fascinating.

Kyle Kimbrell: Yeah, I'll see if I can get it for you, man. I don't know if... I don't... Yeah, they didn't publish it, but yeah, it was small.

Dr. Yoni Rosenblatt: I don't care. That's fascinating. And the Methodist produces some awesome PTs. We employ some of them who are just absolute studs, specifically baseball based. So that would be super interesting. I love hearing that. Just tell me how I can be a piece of that research. That is awesome. Tell me how...

Kyle Kimbrell: You gotta get a multi-site thing going, man, that'd be awesome.

Dr. Yoni Rosenblatt: I'm working on it. I'm working on it.

Kyle Kimbrell: Alright.

Dr. Yoni Rosenblatt: Okay. So tell me the two biggest mistakes you see PTs make using your BFR.

Kyle Kimbrell: Just throwing the cuff on and pretending it's like Jesus' cloak is number one.

Dr. Yoni Rosenblatt: Okay. [laughter] There you go. And by Jesus, just explain it for the Jews in the audience. Jesus' cloak is a...

Kyle Kimbrell: Jesus' cloak is kind of a metaphor for, oh man, I'm forgetting, but there is a guy on a road and basically, through his faith, he's like, "If I could just touch his cloak I'll be healed," and...

Dr. Yoni Rosenblatt: It doesn't work like that.

Kyle Kimbrell: He touches his cloak and he's healed and so this is not something where, and I say that in all seriousness, I see it used in this manner a lot where basically a "clinician" [laughter] has put this cuff on an individual and they're just kind of doing something that clearly isn't working on improving the muscle quality, quantity force production of a muscle. It's just very obvious from either the movement, the exercise being chosen, the effort that the person's putting forth. That sort of thing.

Dr. Yoni Rosenblatt: Hold on, let me just shoot in there. Save that second one for a heartbeat. I would say, you know what else we as therapists or "clinicians" do a lot like the needling idea, right? Like, well, I'll just needle it and you're gonna be healed. Well, like, you gotta figure out when to apply these tools. That's why I love this conversation.

Kyle Kimbrell: Absolutely.

Dr. Yoni Rosenblatt: What's the best way to apply BFR? I could totally see it being Jesus' cloak. Like I always say, Kyle. It sounds like Jesus' cloak. What's the second, [laughter] the things you've taught me. What is the second mistake that you see him making?

Kyle Kimbrell: I think it's probably more the claims that people will make for BFR. They'll claim it heals bone faster, or they'll claim it heals tendon faster. Don't get me wrong, there's evidence to suggest that we're really doing some positive things for those tissues, but I think that we need to be a lot more careful with what we claim for things like, we know BFR will increase muscle size, increase muscle force production if you dose it properly and consistently over a set amount of weeks. We do not know if it accelerates tendon healing, like if, a disease tendon any better than just loading that tendon up does. We don't know that information. I'm not saying it can't, I'm not saying you shouldn't use it for tendon, but I'm just saying like, we gotta pump the brakes on some of the stuff that we claim it for it.

Kyle Kimbrell: But we definitely don't know about bone. Again, Methodist, they're the only group that has published a paper that is a longitudinal trial and actually looked at bone density and saw it really doing some positive things for bone. But that was not in a fractured scenario. That was in an ACL reconstruction scenario. So yes, BFR is definitely doing things that are positive for muscle. Generally if you do things that are positive for muscle, you're doing things that are positive for bone, but actually telling people that hey, it's gonna, or a physician referral or whatever, Hey, this is gonna do this or that for tendon or bone. It's just you're stepping out of lane, you know? You need to look at this as more of a way to address a skeletal muscle issue that the person in front of you may have. And that's gonna be a very positive thing for those tissues as well. But let's just kind of stop there, you know? Until we have good evidence to support that, I think we really need to be careful about what we claim for it.

Dr. Yoni Rosenblatt: Yeah. Now, can you back your way into those claims by saying, I'm gonna make that muscle bigger, stronger, or at the very least I'm gonna prevent it from atrophying the way it would cuff, and by way of doing that, you're gonna keep some type of load through the bone or we're not even there.

Kyle Kimbrell: Yeah, I think it's fair to say something like that. And I think it's fair to say, look at, all indications are we're doing really positive things for bone and keeping it healthy.

Kyle Kimbrell: I think that's fair, but just like, just stop there. It's okay. Like it doesn't have to, again, it doesn't need to be Jesus' cloak. I mean like we just, we need to be better about understand... I think 'cause I get, you know, taking kind of a 30,000 foot view a little bit. We get the question all the time about, hey, like I just got the question the other day. Hey Kyle BFR works for Hoffa's syndrome? And I'm like, Hoffa's syndrome? I don't think I've ever, I don't even know what that is. And it's just like, it's a fat pad irritation, which I'm like, I've never heard that term, but it's freaking medicine.

Kyle Kimbrell: So we gotta change the effing definitions and terms all the damn time I can't keep up. But people want to know like this is the diagnosis, that diagnosis, will BFR work? And I'm like, I don't know. Tell me how you're gonna use it. Tell me why you're gonna use it. Tell me why you're concerned with this particular diagnosis. Is there a safety profile issue? Let's reason through that. But I don't need a randomized controlled trial to tell me when to use BFR. I need to know that BFR can impact skeletal muscle in a positive way. And here's how I have to program BFR in order to do that. That's all I need to freaking know to figure out if it's gonna help the individual right in front of me. Like I don't, like can it help ACL reconstruction rehab? Well, hell yeah. And there's a lot of different targets there. Does it return on to play faster? Ah, I don't know about that.

Dr. Yoni Rosenblatt: Yeah. I don't know about that either, but you're making a good point with the Hoffa's fat pad syndrome where it's like use your goddamn brains, right? Like if you can tell me, and you can look at these RCTs to know it's gonna increase muscle size. Well, is that gonna help this pathology? If it is, then great. If not then no. I would think at least at this point, right? It's the same. It's very similar to the stuff I see on, someone comes in with a frozen shoulder, they've been going to another PT and they show up at our place and they're like, we've been doing all these rotator cuff strength stuff. I'm like, well what? Why would that help the pathology or presentation That's in front of you? That's not gonna increase your range similar here. Right. It's not gonna increase range. So, but if your patient can benefit from increasing strength, it sounds like BFR would be a good use.

Kyle Kimbrell: Yeah, exactly.

Dr. Yoni Rosenblatt: Thanks for getting me on. Yeah. Thanks for getting me on that soapbox. Okay.

Kyle Kimbrell: I know, I love it.

Dr. Yoni Rosenblatt: What... [laughter]

Kyle Kimbrell: Yeah, I love soapboxes.


Dr. Yoni Rosenblatt: What claim can I make confidently about BFR. And like, because when you talk about those parameters, you said like, we know it'll increase muscle size and strength. Well, what are the parameters I have to hit in order to confidently say it's gonna make your muscle bigger? 

Kyle Kimbrell: Yeah, I think you have to hit a 20% load. Like if we're just gonna go straight from the literature, you've gotta get somebody to that 20% load. And they're gonna need to do, if you're seeing them twice a week, two exercises for that muscle group using our 30-15-15 rep scheme. So like, say for example it's a quad. Quad needs to get bigger, needs to get stronger. You need to hit a 20% load. And I would say you should do a long arc quad and some sort of a squat type movement twice a week. And you need to keep that up for six to eight weeks. And in that time, if you go back and you retest force production, you retest circumferential measurements, you should see increases in muscle size, muscle strength.

Dr. Yoni Rosenblatt: Significantly more than if they weren't using a cuff.

Kyle Kimbrell: Yeah, yeah, yeah. Now, I mean, of course assuming that they can't just train traditionally. Yeah.

Dr. Yoni Rosenblatt: Okay. Okay.

Kyle Kimbrell: If that person could train traditionally, then I wouldn't say that the changes that you're gonna see are gonna be greater than what you would get with training traditionally.

Dr. Yoni Rosenblatt: Okay. Gotcha. And then I've heard you talking in the past about loading up the quad and the differences of the way the quad reacts with hip flexion versus extension.

Kyle Kimbrell: Yeah.

Dr. Yoni Rosenblatt: You know, anything to really share with the audience on that.

Kyle Kimbrell: I think the... So that's a newer concept for me. And I came around because I was working with a buddy of mine. I still work with him. And working with him after he had bilateral total knee. Now this guy [laughter], he is the physical embodiment of Mr. Clean. So he's like 6'5 bald, gotta turn sideways to get through a door because he's just like kind of an amateur bodybuilder. Has bilateral... Yeah. How old?

Dr. Yoni Rosenblatt: How old is he? Yeah, how old is he?

Kyle Kimbrell: He's... I wanna say he's about 56, somewhere in that range. He's a deputy Sheriff here locally and just great dude. Bilateral total knee. So his legs don't look great. He called me up because he's having, you know, he's getting discharged from traditional PT and he is like, dude, my quads are terrible. It's not even easy to walk really, but my range of motion is good. And he wanted to know if I could help him, if BFR might help. And I was like, well, let me just, I'll come look at you. We'll see. So long story short, start working with him. One leg is going along great, the other leg is not. And I listen to your a podcast with Lynn Snyder-Mackler, she was talking about, after ACL reconstruction, if they've harvested the patellar tendon, sometimes the tendon actually stretches out a little bit.

Kyle Kimbrell: And in order to address that, to really get the quad going, you actually need to extend the hip so that you get the rectus femoris more involved that you create some more passive tension throughout that complex. And I'm listening to this and I'm going, this sounds a lot like my buddy and I have not tried that. I had tried everything else under the sun. Like, I mean from me pulling him into full extension and him just trying to control the knee coming down, from shocking him with neuromuscular stem and BFR. I mean, I'm not a therapist that turns his brain off. I'm like, I gotta freaking figure out how to do this. And I was failing, which did not feel good. And then I heard this and I'm like, all right, I'm gonna try... This at least gives me something to try.

Kyle Kimbrell: So next time I see him, we go into their little rehab space at the Sheriff's academy and I lay him, I actually laid him down prone on a bench so I could kind of support that thigh. And I rigged up the cable system to tie off onto his foot. And I was like, all right, just kick and see if you can extend. And sure enough, I mean, immediately he was able to produce enough force to move 40 pounds or so, which he couldn't fully extend 20 pounds, like to 45 degrees in a seated position. So it was a huge difference in, his ability to produce force and fire that quad. He was like, oh my God, wow. How does that work? And I'm like, dude, I could try to explain it to you, but let's just roll with the fact that it's working.

Dr. Yoni Rosenblatt: Yeah.

Kyle Kimbrell: And so we started training him that way, and made a very big difference with him. I don't think you need to do that with everyone, but if you have someone where, like for example with him, he had passive extension, full passive extension, good infield, good flexion. You know, his knee feels tight to him because he has the sense that he can't control that knee. Right?

Dr. Yoni Rosenblatt: Yeah.

Kyle Kimbrell: So his nervous system's kind of giving him that sense, but his knee is not stiff at all. So if you see that, knee not stiff, but just can't like even do a quad set, try extending that hip and getting some tension...

Dr. Yoni Rosenblatt: Yeah.

Kyle Kimbrell: Through that rectus and that worked.

Dr. Yoni Rosenblatt: Well, I love that, dude. And that makes a ton of sense. It's like you... Like you said, you don't turn your brain off. So when you're looking at these things like think about old school origin insertion points and how that muscle is working dynamically. I'll tell you where you see this also, you see this post-op BTB ACLs when they're doing walking lunges, like that knee doesn't have a problem when it's anterior hip is flexed. You're using a ton of other stuff. When you load that quad with the hip extended when it's behind you, now all of a sudden their knee hurts and you gotta figure out how to train in that position.

Kyle Kimbrell: Yeah.

Dr. Yoni Rosenblatt: Because they have to be strong enough to support it. I think that feeling of the knee feeling stiff or sensing that it's stiff comes from, listen, they're living on a fake joint. We need those muscles to be supporting them, right? And if that quad is asleep, you better believe that's gonna feel uncomfortable.

Kyle Kimbrell: Yeah.

Dr. Yoni Rosenblatt: Kind of around their knee, or in the walking lunge.

Kyle Kimbrell: Yeah. And I think too, Yoni, just because you... Kind of staying on the ACL topic, one of the things that's really popular right now, and it's true, is this Arthrogenic muscle inhibition. But I think you can make a real mistake thinking that, oh, this is a scenario where this person's brain is not allowing them to control that muscle, and you haven't looked at everything. So I think you just need, like, just throw this into your routine of like, I'm gonna check this box, and if I extend that hip and they're unable to produce force, well then maybe it's more of like a brain thing or a nervous system thing. But if you haven't checked that you can't say it isn't.

Dr. Yoni Rosenblatt: Yeah, you're absolutely right.

Kyle Kimbrell: And I think that can be a pretty easy mistake to make just because there's a lot of popularity with the AMI stuff and whatnot.

Dr. Yoni Rosenblatt: Yeah.

Kyle Kimbrell: It's some cool work being done, but.

Dr. Yoni Rosenblatt: Yeah. Yeah, you're absolutely right. I think that's worthwhile. Okay. Tell me about IPC. What is IPC? What should we know about it? First of all, define it.

Kyle Kimbrell: IPC is ischemic preconditioning, and it has a very clear definition, which I think is something that gets mistaken a lot in the BFR world. I hope that we're not responsible for some of that, but inevitably we potentially are. But if someone says to me ischemic preconditioning, what that means is they are applying a cuff at full limb occlusion, so 100%, and it is inflated for five minutes. It's deflated for five minutes, and that's applied three to four rounds. So, inflate five, deflate five, so like a one-to-one ratio.

Dr. Yoni Rosenblatt: And totally off, when you say deflated.

Kyle Kimbrell: Completely deflated. Yep.

Dr. Yoni Rosenblatt: Okay.

Kyle Kimbrell: So full reperfusion. The technique was discovered by some heart surgeons or cardiothoracic surgeons. I forget exactly their profession, but basically they kind of thought that that technique might be protective for heart muscle. And the reason that they were thinking that was because they're noticing that their patients, the patients that had little miniature heart attacks leading up to a big heart attack seemed like they had less heart damage than the ones that just had a big heart attack outta nowhere. And so they thought that maybe those little mini heart attacks, those little miniature bouts of ischemia provided some sort of protection. And so they studied that, and sure enough they found like, oh, if it's applied actually to the artery where the heart attack is gonna be given, then it provides a ton of protection.

Kyle Kimbrell: And so it gives you a lot of time in there to intervene, to restore blood flow, if you will. What we've seen over time is people have continued to kind of research that technique and look at all kinds different tissues from brain tissue to other organs, in terms of just the ability of that technique to provide some protection. And then over time we started seeing it work its way into being used to enhance performance in things like swimming trials and cycling trials and that sort of thing to now probably the newer area that it's being used as more of like a recovery type modality. So maybe in place of like a NormaTec or something like that. It's actually been shown to reduce the amount of creatine kinase that's released to reduce the amount of delayed onset muscle soreness from a task and to allow the restoration of force production to happen much faster.

Kyle Kimbrell: So we're seeing it used, especially like in football where there's this really intense event once a week and like after a game, getting on the cuffs running through in ischemic preconditioning protocol, and if you've ever done it, especially on the legs, it just, you get this kind of refreshed sort of feeling in your legs. I think people typically kind of call that a flush, if you will, is what's probably the most common terminology that you would hear. To me it just... It feels like you wet your leg [laughter] when it deflates, it's like...

Kyle Kimbrell: Did I just wet my leg? I don't know. [laughter] Yeah. But, yeah, that's ischemic preconditioning in a nutshell.

Dr. Yoni Rosenblatt: And does it have a place in our rehab center? 

Kyle Kimbrell: That's a fantastic question. And I actually started to answer that and I kind of forgot, while I was describing it. Not much of one in my opinion. It depends, I think it depends on your clinic setup and who you tend to work with. But like in a, like a traditional outpatient setting that I came from, I didn't really use it. Now, I say that and I think that the... Well, I know that an emerging area of its use is actually in like neurologic rehab, like after stroke or something like that. There are some potential nervous tissue preservation effects that can be realized and then maybe even like some motor learning aspects to that. And so that's kind of the forefront, if you will in that area.

Kyle Kimbrell: And then kind of going the other direction, there's a curiosity that I have that has not been investigated but I have Todd Davenport at University of Pacific. He is starting to look into this. He works a lot with people that have chronic fatigue. And one of the problems with persons that have chronic fatigue is their autonomic nervous system kind of freaks out when they do anything sort of active. An what we know is that exercise doesn't work. But the question is, could we maybe alter that metaboreflex with the application of a cuff and a release? And there is a study in healthy individuals that has shown that that is a thing. So we'll see from their work, if there's any maybe promise there and then.

Dr. Yoni Rosenblatt: Well, then my head goes to sending Dean Kremer off the field and let him put cuffs on and sit there while the Orioles rally. Let him go through this IPC, and now all of a sudden he's able to get back out refreshed and his Velo stays up, or his accuracy stays up, whatever it is. That's where my head goes.

Kyle Kimbrell: To be honest with you, I hadn't thought of that, but I think it's a great thought. This is why I get frustrated sometimes. People are like, "Oh, I took that class, I know how to do that," I'm like, "Dude, I learn something new all the time," like just now, I think that's a great application. We typically see it used on pitchers when they're done for the day, but like you said, why not go... We all know a starting pitcher their legs is what wears out a lot of times, if you think back... Like I grew up watching Nolan Ryan pitch in Houston, and then later down the road, Roger Clemens and Andy Pettitte, those guys, even though they were popping like growth hormone and whatever the hell else, [laughter] they still would complain about their legs.

Dr. Yoni Rosenblatt: It might have had effect.

Kyle Kimbrell: Yeah. It might have factored in just like the Astros might have been baying on trash cans.

Dr. Yoni Rosenblatt: Maybe, maybe.

Kyle Kimbrell: Maybe.

Dr. Yoni Rosenblatt: But maybe not.


Kyle Kimbrell: Maybe not, but... Yeah.

Dr. Yoni Rosenblatt: That would work, right? 

Kyle Kimbrell: No, I think it makes a ton of sense. Honestly.

Dr. Yoni Rosenblatt: It's just very interesting, I think in our clinic, unfortunately, reimbursement also pops the mind, but when you're working with high level athletes, so much of this is education. If they're already going home and putting the boots on, and you can educate around... Maybe there's something better we can do here, whether it be lower extremity, high extremity but the concept of IPC. Now, I've heard you talk about performance enhancement immediately following IPC, anything there that's worthwhile?

Kyle Kimbrell: Yeah, yeah, I think, again, it kinda depends on what sport you're talking about, like performance enhancement, probably the sports that you'll see that really matter the most in would be like a swimming effort or maybe a track and field effort or something like that, and it needs to be like a maximal kind of effort. If you're talking about some kind of sub-max long distance run, you may not really see anything, but like an all-out sprint, a 400 meter sprint, that kind of thing, or shoot a mile is basically a sprint at this point. Those types of activities, it looks like there's something there. The only kind of caveat is it does look like we might have some people that really do respond to this and others that don't. It's never really a huge negative in terms of the response, but there's just some that just don't and maybe even get a little bit worse, so.

Dr. Yoni Rosenblatt: Dude that... Yeah. But that's what spring training and preseason is for.

Kyle Kimbrell: That's when you figure it out.

Dr. Yoni Rosenblatt: That's when you figure it out.

Kyle Kimbrell: Exactly. You gotta figure it out.

Dr. Yoni Rosenblatt: I love it. Okay, so let me conclude with a lightning round, you ready? 

Kyle Kimbrell: Okay, yeah, lets do it.

Dr. Yoni Rosenblatt: Quick answers as they pop in your head.

Kyle Kimbrell: Okay.

Dr. Yoni Rosenblatt: The best book you've read in the last five years and why?

Kyle Kimbrell: Oh God.

Dr. Yoni Rosenblatt: Quick answers.

Kyle Kimbrell: I don't know that I've read a book in the last five years.

Dr. Yoni Rosenblatt: I don't believe that for a second, Kyle.

Kyle Kimbrell: Am not a book reader, funny enough. I'll go Thinking, Fast and Slow 'cause it's sitting right here on my desk.

Dr. Yoni Rosenblatt: See that.

Kyle Kimbrell: That's a great... I at least started the book, I don't think I finished it.

Dr. Yoni Rosenblatt: Love it. I love it. Okay, where is physical therapy in 10 years? 

Kyle Kimbrell: Realistic or what I...

Dr. Yoni Rosenblatt: Realistic. That's what this pods about, man, you're talking to sports PTs, and my mission is to bring them real answers, not stuff that.

Kyle Kimbrell: Realistic, I think probably about where we are right now.

Dr. Yoni Rosenblatt: That is so depressing.

Kyle Kimbrell: I know. That is depressing. That's why I asked, realistic or not. [laughter] What am I trying to push PT to?

Dr. Yoni Rosenblatt: Tell me.

Kyle Kimbrell: I would say frontline orthopedic care.

Dr. Yoni Rosenblatt: Love it.

Kyle Kimbrell: You have an ankle pain, you go to see a physical therapist, and...

Dr. Yoni Rosenblatt: It's Australia. Dude, that's Australia. That's why it works there.

Kyle Kimbrell: I think that's what we should be.

Dr. Yoni Rosenblatt: Yeah. Why are we not there? Why are we not there? The American Medical Association?

Kyle Kimbrell: That's part of it for sure. They definitely are a barrier. Texas just now got I think direct access just recently.

Dr. Yoni Rosenblatt: It's insane. It's insane.

Kyle Kimbrell: And 'cause it's... Our healthcare system isn't about what is evidence-based and what is best for the patient, it's not what our healthcare system is about, it's about who has the money and the power. We see that, 'cause we already talked about insurance companies. They have money and the power and the physicians have the money and the power, and that's how our healthcare system works unfortunately, but yeah...

Dr. Yoni Rosenblatt: It's broken.

Kyle Kimbrell: I think we should be frontline.

Dr. Yoni Rosenblatt: Yeah. I agree with you. My pushback to that is, Man, is it easy to find information now compared to when I got out of school?

Kyle Kimbrell: Yeah.

Dr. Yoni Rosenblatt: And obviously, you gotta be discerning, you gotta get good information, know how to apply it, but at least it's there, and that should make us way better clinicians, just that learning curve should decrease. Now, can we turn that into patients getting better faster and insurance companies giving a damn? It's up to you, Kyle. I don't know. I don't know. I'll put that on your shoulders.

Kyle Kimbrell: Okay.

Dr. Yoni Rosenblatt: Good luck, let me know how it goes.


Dr. Yoni Rosenblatt: One piece of advice to the busy ass PT, just trying to keep up in a high volume clinic.

Kyle Kimbrell: Carve out a day in the week that you don't do PT. Make...

Dr. Yoni Rosenblatt: Good answer. It's a really good answer.

Kyle Kimbrell: Set off a day...

Dr. Yoni Rosenblatt: Yeah, I love it.

Kyle Kimbrell: We get a day every week.

Dr. Yoni Rosenblatt: I love that.

Kyle Kimbrell: If you do that, I think you can grind it, and I think you can grind it hard.

Dr. Yoni Rosenblatt: And I think they're also far more productive, you give yourself that day that respite, the rest of the week is far more productive, that's very mindful of you. How can all the awesome sports PTs that are listening to this pod, how can they find you and how can they learn from you?

Kyle Kimbrell: Twitter and Instagram are probably the two best places in terms of social media. My Twitter is @kylekimbrell1, and then my Instagram is @kylekimbrell because I was actually the first Kyle Kimbrell I like...

Dr. Yoni Rosenblatt: Well, that's funny I love it.

Kyle Kimbrell: You know what's funny? Is on Twitter, I found @KyleKimbrell, and am like, "I should be friends with this guy," and so I like friended him, messaged him, dude, totally ghosted me, no response, I'm like, "What an asshole."

Dr. Yoni Rosenblatt: Maybe he got the same thing from KyleKimbrell2 and three...

Kyle Kimbrell: I guess maybe so. Maybe he was just sick of it. He thought I just wanted his handle.

Dr. Yoni Rosenblatt: Another Kyle Kimbrell.

Kyle Kimbrell: I know.

Dr. Yoni Rosenblatt: I love it. I learned a ton during this pod, thank you so much for opening my eyes and hopefully the audience's eyes. We gotta get you on again, I thought this was just really great, so thanks for everything, Kyle.

Kyle Kimbrell: Thanks for having me on. It was a fun chat. I love it. I love like-minded people, people that are passionate, people that give a damn like Jimmy McKay says. I think that's what we need more of and that's how we move the profession forward, for sure, so.

Dr. Yoni Rosenblatt: Exactly.

Kyle Kimbrell: Yeah.

Dr. Yoni Rosenblatt: Yeah, get passionate. Awesome, Kyle, thank you so much.

Kyle Kimbrell: Thanks, Yoni. Appreciate it, man.

Dr. Yoni Rosenblatt: Just a quick note to everyone listening, thank you so much for listening, be sure to share this pod. It's been really exciting to see it grow. As our listenership grows and really communication grows, you can always reach out to us, True Sports PT on Instagram with the DM is the best way. With either questions, comments, concerns, tell me who you wanna hear from in the field of sports and sports physical therapy, and just tell me how we can do it better. Always interested in feedback. We're gonna be launching our ACL course, and it's really where the rubber meets the road and truly how we rehab ACL, at True Sports Physical Therapy, so look forward to sharing all the specifics with you about that, and as always, we're looking to add to our team, we're growing like crazy. We're now in Maryland, Pennsylvania and Delaware. We're looking for passionate, motivated sports physical therapists. Just shoot me a DM, again, True Sports PT. Just let me know what you wanna hear and if you wanna join us. Thanks guys.


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