Episode 23 - Golf Rehabilitation And Fitness with Graham Claytor
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Episode Summary
If you live or work in the Carolinas, you probably either play golf or have a friend or loved one that plays. Golf is an excellent sport for children and retirees alike and a popular activity for competitive exercisers that don’t want to strain their bones and muscles in high-impact sports. However, golf can also lead to its fair share of aches and pains, so today’s episode focuses on preventing and treating golf-related injuries.
On this episode of Back Talk Doc, our host Dr. Sanjiv Lakhia welcomes Graham Claytor, PT, Director of the Physical Therapy at Carolina Neurosurgery & Spine Associates, to explore his golf rehabilitation and fitness programs. While Graham admits physical therapy wasn’t a childhood dream, a combination of family and educational experiences ignited his passion for patient work.
After several years in private practice, Graham met professional golf agent Thomas Parker, catapulting him into his niche in golf rehabilitation and therapy, “look, I have a lot of guys that need this kind of specific golf treatment and there’s not really anybody around here that’s doing this. There are places in Florida, whether it’s a golf mecca, there are places in California, but there’s not really this niche in Charlotte.” (7:28)
Graham explores his TPI certified program, The Golf Rehabilitation and Fitness Program, his typical patients, and a number of recommended exercises. He also reveals the preventative benefits of the golf rehab program and available recovery resources for patients, “any of Greg Cook’s stuff is very good. And any of the Sea Island golf pro guys that are trainers down there, Randy Myers, some of the golf fit pro apps are very good to go see. (31:28)
To learn more about Graham Claytor’s Golf Rehabilitation and Fitness Program, visit https://www.cnsa.com/our-services/golf-rehabilitation-and-fitness. For more information on Dr. Sanjiv Lakhia and treatment options for back issues, visit backtalkdoc.com.
If you enjoyed this episode with Graham Claytor, check out our episode on Health Care and Spirituality, with Dr. John Welshofer.
Back Talk Doc is brought to you by Carolina Neurosurgery & Spine Associates, with offices in North and South Carolina. To learn more about Dr. Lakhia and treatment options for back and spine issues, go to backtalkdoc.com. To schedule an appointment with Carolina Neurosurgery & Spine Associates, you can call us at 1-800-344-6716 or visit our website at carolinaneurosurgery.com.
If you live or work in the Carolinas, you probably either play golf or have a friend or loved one that plays. Golf is an excellent sport for children and retirees alike and a popular activity for competitive exercisers that don’t want to strain their bones and muscles in high-impact sports. However, golf can also lead to its fair share of aches and pains, so today’s episode focuses on preventing and treating golf-related injuries.
On this episode of Back Talk Doc, our host Dr. Sanjiv Lakhia welcomes Graham Claytor, PT, Director of the Physical Therapy at Carolina Neurosurgery & Spine Associates, to explore his golf rehabilitation and fitness programs. While Graham admits physical therapy wasn’t a childhood dream, a combination of family and educational experiences ignited his passion for patient work.
After several years in private practice, Graham met professional golf agent Thomas Parker, catapulting him into his niche in golf rehabilitation and therapy, “look, I have a lot of guys that need this kind of specific golf treatment and there’s not really anybody around here that’s doing this. There are places in Florida, whether it’s a golf mecca, there are places in California, but there’s not really this niche in Charlotte.” (7:28)
Graham explores his TPI certified program, The Golf Rehabilitation and Fitness Program, his typical patients, and a number of recommended exercises. He also reveals the preventative benefits of the golf rehab program and available recovery resources for patients, “any of Greg Cook’s stuff is very good. And any of the Sea Island golf pro guys that are trainers down there, Randy Myers, some of the golf fit pro apps are very good to go see. (31:28)
To learn more about Graham Claytor’s Golf Rehabilitation and Fitness Program, visit https://www.cnsa.com/our-services/golf-rehabilitation-and-fitness. For more information on Dr. Sanjiv Lakhia and treatment options for back issues, visit backtalkdoc.com.
If you enjoyed this episode with Graham Claytor, check out our episode on Health Care and Spirituality, with Dr. John Welshofer.
Back Talk Doc is brought to you by Carolina Neurosurgery & Spine Associates, with offices in North and South Carolina. To learn more about Dr. Lakhia and treatment options for back and spine issues, go to backtalkdoc.com. To schedule an appointment with Carolina Neurosurgery & Spine Associates, you can call us at 1-800-344-6716 or visit our website at carolinaneurosurgery.com.
Intro: 00:01
Welcome. You're listening to Back Talk Doc, where you'll find answers to some of the most common questions about back pain and spine health brought to you by Carolina Neurosurgery & Spine Associates, where providing personalized, highly-skilled, and compassionate spine care has been our specialty for over 75 years. And now, it's time to understand the cause of back pain and learn about options to get you back on track. Here's your Back Talk Doc, Dr. Sanjiv Lakhia.
Sanjiv Lakhia: 00:35
Thank you for downloading this episode of Back Talk Doc. As many are aware, during these times, technology has been a bit of a challenge, and we recorded this episode remotely. I'd like to let you know that there are several instances during the episode where the audio is not as crisp and clear as we typically like. However, I think the information is good and I'd like to get this out to you as quick as I can, so we're going to go ahead and release this. I hope you find it informative and thank you for your understanding if it is not of the audio quality that you're typically used to when listening to our episodes. Enjoy the episode.
Sanjiv Lakhia: 01:17
One of the benefits of living and working in the Carolinas is the beautiful, almost all year round warm weather. And a lot of our listeners and patients at Carolina Neurosurgery & Spine Associates take advantage of that through outdoor activities, for which a top activity is golf. Golf is big time in this area. I see a lot of patients on a week-to-week basis whose primary goal is for us to keep them upright and pain-free, so they can enjoy their life, enjoy time outside playing golf with friends and family.
Sanjiv Lakhia: 01:53
And to address that we have developed at our group a really unique golf specific spine rehabilitation. I'm going to be interviewing spine protocols and keeping people healthy, active, and upright so they can swing the club and just really enjoy all the opportunities we have in Charlotte and the surrounding areas. So Graham, welcome to the show today.
Graham Claytor: 02:15
Thank you for having me. I appreciate it.
Sanjiv Lakhia: 02:18
Graham, for those who don't know you real well, I know basically you're kind of the guy in the area for this issue, but for those listeners who don't live in the Carolinas, can you give them a brief introduction to a little bit about your academic background, your clinical background and just your overall path to physical therapy?
Graham Claytor: 02:37
Yeah, so I can't sit here and say that I wanted to be a physical therapist when I was 10 years old. I'm the son of a lawyer, and I knew that I didn't want to be a lawyer, I'll put it that way. By doing summers at a law firm, I knew this was not where I was going to go. So I was always a guy who didn't need to be behind a desk. I needed to be on the move. I liked medicine, I liked patient care, I liked people, and I just started narrowing stuff down. I don't have the old-fashioned story of where I was hurt in a baseball, basketball game in high school, went to rehab and said, "Oh, this is a career for me." I didn't have that.
Graham Claytor: 03:15
What I liked about the therapy field, again, was the fact that I was able to spend time with my patient, to go through the journey with my patients. I spent a lot of times in nursing homes, having grandparents that went through Alzheimer's and that, so I spent a lot of time there looking at that part of rehab, which was intensive, not only physical, but the mental part of that too. So those are the kinds of the things that got me going on what this field was about.
Graham Claytor: 03:42
But you fast forward, and I went to college at the University of Chapel Hill and majored in sports medicine there and furthered my education at East Carolina University and got a, what was then a master's program there that has now transformed into a doctorate program, which is pretty much everywhere in the field now. And after I graduated there, I went to into a private practice, and so that private practice taught me a lot of different things.
Graham Claytor: 04:08
It taught me how to be involved in the community and what patient needs were, how to go out and pound the pavement. And how to, again, interact with different orthopedic issues that people had, not just spine care. And so I got a plethora of knowledge doing the orthopedics in the private practice side, but I also learned some of the business sense and what it takes to be in a private practice too.
Graham Claytor: 04:35
Fast forward a year and a half later, I get a call from Dr. Jerry Petty, who is a alumni [inaudible 00:04:43], closing in on 60 years of practice here in one of the Mount Rushmores of this [inaudible 00:04:51] Mount Rushmore. And he called me and said, "We're [inaudible 00:04:57] of neurosurgery right down the street and it's going to grow and it's going to grow for years and as many patients as we send you it'd be a lot better if you were down the hall versus down the street."
Graham Claytor: 05:09
And so I met with the group of guys here and I went over exactly what I thought a physical therapy practice looked like. My thoughts on patient care, my outcome abilities, how to grow a practice business models, niches that I thought were going to be there, one of those being golf which we're going to talk about.
Graham Claytor: 05:29
And then I started digging in my heels and working on the architecture with our architects here, working on the computer side, the next gen side, and organizing that for physical therapy. So basically Mary Kleiniger and the doctors here said, "We want to start a physical therapy practice. We know a little bit about it to be dangerous, but we don't know much about it, but we want you to have it." So I was an excited, but a little bit scared 27 year old physical therapist who was handed this golden ticket. We ran from there and I'm still digging and trying to grow this place. That's the cliff notes if you will, of where this physical therapy clinic practice is here at Caroline Neurosurgery, 15 years deep.
Sanjiv Lakhia: 06:09
And we'll talk about the golf program here, but you've been instrumental in that. What was kind of, or what's your interest or background in golf? Do you enjoy playing quite a bit? Do you have some experience with that from a personal side?
Graham Claytor: 06:21
So yes. I think as we all kind of move from our twenties and thirties and say, "You know what? I probably shouldn't be playing three days of basketball a week or being the weekend warrior playing football," especially if you have a wife and kids and you're scared of coming home hurt. So I said, "Well, this whole, like you said earlier, this area is booming with golfers and private and public clinics and access." And that just kind of started piqued my interest in my mid-thirties and I started playing a lot more. You kind of dabble a little bit in college, but that's just more of a kind of a side thing. You just play every now and again in between classes or something like that. But because everything is so easy around here, I started playing a lot more and it piqued my interest.
Graham Claytor: 07:05
Furthermore, I ran into and I can fast forward a story here, I ran into a gentleman who came to see me named Thomas Parker. Thomas Parker is the agent, if you will, for a lot of professional golfers and him and I actually met on the basketball court and he is a Wake Forest grad. And so he has a lot of Wake Forest professional golfers he sees amongst others.
Graham Claytor: 07:28
So he came in here and saw what I did with physical therapy and then he kind of gave me an idea and said, "Look, I have a lot of guys that need this kind of specific golf treatment and there's not really anybody around here that's doing this. There are places in Florida, whether it's a golf mecca, there are places in California, but there's not really this niche in Charlotte." And you have places like Quail and Charlotte and Myers Park and all these places that have these good golfers and some of the professional golfers are moving here simply because of the hub that is the airport here.
Graham Claytor: 08:01
So a lot of family guys were moving here so they could easily travel with the golf on the PGA Tour. So he came in and he brought me a handful of guys ranging from Webb Simpson to some other guys that once Webb got it in here and he got a couple of friends to come in here and then that kind of spread like wildfire. So we get some webb.com guys. Webb.com is basically the tour right below the PGA tour. Saw a lot of those guys ended up seeing a couple of LPGA or even some of the Symetra tour again, which is the ladies' version of the webb.com. And then now again, on a regular basis, we do see, I've seen the Russell Henleys, the Charles Warrens, the Harold Varners, the Webb Simpsons and those guys come in here on regular to go through our golf program.
Sanjiv Lakhia: 08:47
That's fantastic. So we have, what's called a TPI certified program. If you go to our website, we have a specific website for this, www.golfrehabandfitness.com. And we'll put that link in the show notes. You'll see that we're TPI certified. So explain to another doc or even a patient who's looking at that, what does that exactly mean?
Graham Claytor: 09:11
I will rewind a little bit. So we talk about the professional golfer [inaudible 00:09:16], but mainly what you alluded to earlier is that we've see a lot of John Does and Jane Does that come in here that are nine to five computer workers or other jobs where they're on their feet or things like that, but they also play golf and that's one of those things that they really want to do. And there was no real way to just... We didn't want to just do regular spine care with these people. We wanted to add that niche. And that niche was say, "All right, let's take therapeutic exercise. Let's take dynamic exercise. Let's take our normal back exercise progressions and throw a twist in there and let's get some golf specific routines for people."
Graham Claytor: 09:54
So I started building those golf specific routines and those were based on physical deficits for people, physical limitations, what do those look like? And I built my exercise routine based on things that I knew, like if you were coming over the top or you were early extending, these are terms that people use that are golf hindrances in a golf, a golf pro would know these terms. And again, they go furthermore with, I said early extension, but whinging or C-postures or S-postures.
Graham Claytor: 10:26
These are all kind of common terms that golf pros use that are again, limitations in the golf swing. So, but credit to the golf pros because they know these things, but what they needed was somebody like myself, as far as an anatomical professional to go through and diagnose why physically people have these deficits in their swing. And then you fast forward years later and they beat me to the punch, but TPI is a Titleist Performance Institute. And it's this big institute probably as big as something like a Google or Amazon out in California.
Graham Claytor: 10:59
And they took this group of board members ranging from therapist to chiropractors, to golf pros, to data analysis, to biomechanists, and they came up with this elite program where they were going to train people like myself to become Titleist Performance Institute certified. And what that does is help diagnose these golf pro limitations that they give out to their clients and bridge that gap, if you will, between golf pro client/patient and then medical professional. So it's a genius idea.
Sanjiv Lakhia: 11:35
It sounds like they beat you to it. If you had done that first, you'd have a lot more time to be playing golf.
Graham Claytor: 11:42
That's right. That's exactly right. So I had my sheets and sheets of exercises and things that I was doing, but then they got to it faster, but I'm glad they did because they got it to the masses and people like myself and even some of the other therapists here and even podiatrist John [inaudible 00:11:57] and his practice has gone on to be TPI certified. So now you can kind of look online and look at a search and TPI will be one of the first things that pop up and then look and see if you're certified, which is a really elite certification to get with the titleist performance and the fitness that you need.
Graham Claytor: 12:14
That is a great certification to have. It helps bridge that gap like I said and it helps get people involved when they look on the website, but quite frankly, nowadays there are YouTubes and there are apps and there are all sorts of things, but I'm, again, I'm kind of showing my age here, but where I got most of my learning and most of my referrals was going out to these clubs, introducing myself, doing free clinics, roaming the ranges, getting to know the golf pros, having them trust me with their clients.
Graham Claytor: 12:45
And that was the, and still is the best way that I learned. And that's the biggest thing that honestly, that I have learned from TPI outside of the general information on exercises they recommend in diagnostics and the physical screening that we take people through with this. They give you a 10 and 12-part screen to take people through and learn that with ranking scales and whether you pass/fail some of these.
Graham Claytor: 13:09
But what I really learned, again, dating back to when I even told you I was in private practice is to pound the pavement. And so I would blindly call these guys or get in with one of the docs here to let me introduce to the golf pros. And so I'm learning from the mecca of golf pros around here, which is these guys come from Sea Island. If you haven't heard of that, that's really the place where these golf pros around here and in the country go and get trained.
Graham Claytor: 13:35
And so if you take the analogy of the Bill Belichick and all the coaches that have been under Bill Belichick's wing and gone on to be NFL coaches, this is kind of what Sea Island does. And they spread these golf pros around the country and they're at Quails and they're at Charlotte's and they're at Sea Pines and they're all over. And if you can get information from them, it's gold. And over the years we built relationships seeing those referrals from them and me sending them patients as well. And it's been really good to build our program.
Sanjiv Lakhia: 14:07
Okay. So two questions then. Who is the golf rehab program for? So describe kind of a typical patient or scenario. And then secondly, kind of walk someone through. Let's say, they're coming to see you, their back's hurting, but they want to play. And within a week or two what can someone expect when they come into the office, how would a kind of a golf rehab evaluation differ from a traditional PT consult?
Graham Claytor: 14:35
So the good news is any golfer can come in here and get into our golf program. The better news is that you can put anybody in the golf specific program and they'll have better back outcomes because we're combining some of those safe rotary movements that are combined in your activities of daily living, whether you're a golfer or not. So I can do the golf program with just about anybody. I mean, we do it on NASCAR drivers because they turn left for a living, but they also have rotary and physical deficits. I do it on 15-year-olds that are going to get scholarships to Stanford to play golf and I do it on 90-year-olds that are playing from the senior tees and just want to shoot their age. So anybody can be a part of this program and that's the beautiful thing about it.
Graham Claytor: 15:22
And furthermore, we take normal, regular therapeutic exercise and again, we put that twist on it. So now we do multiplanar movements and we do this 10-part screen, which I'll talk about in a minute. And we do multifunctional T box exercises, pre-round warmups. We can plug this data, the screen into the TPI website and it spits out individual programs via video that people can have access to permanently.
Graham Claytor: 15:50
So it's really neat on the things we do. And we also look at the swing. We don't dive into that too much. I'll leave that to the golf pros, but if they tell me a specific deficit, I can look at their swing and kind of say, "All right, well, this shoulder may be a problem or this mid-back may be a problem or your hamstrings may be tight because of this," and the golfers really like that because it's now tangible. It gets them more out of the lesson.
Graham Claytor: 16:13
So a lesson is, if you've ever taken a golf lesson, they look at a few things and give you, let's say drills to work on. But if you look at that in anatomically to fix some of those deficits that the golf pro defines for you, you just seem to get more out of it because sometimes the golf pros get cold feet. They'll call me and say, "Hey look, I've got a guy who's 73 years old, has got back pain. I need him to rotate more and I'm afraid because I just worried about his back. He hasn't seen anybody. And so we're kind of at this kind of crossroads. We're in a plateau here on our golf lessons and I don't want to him to keep coming if I can't get him to do what I want. Can you take him for two or three weeks and work on safe rotation?"
Graham Claytor: 16:58
So John Doe comes in here and I take him through our 10-part screen, which varies in the range of toe touch to an overhead deep squat, to a lat mobility test, to a glute test, to a shoulder range of motion test, to a cervical spine test, to a wrist test, to a foot and ankle test, to a balance test. And you combine all these, this data in the pass/fail sequence, and you define what these golfers can pass or fail.
Graham Claytor: 17:32
And then you start digging in from there. What are the exercises that I want to do if you pass or fail a squat or you pass or fail a glute strengthening test? And I can give you five or six exercises that I think you need to strengthen those glutes. I see you for three or four weeks as the golf pro wanted me to. I send you back. You now rotate and have more confidence in your swing. Your back pain's better. You can rotate more and everybody's happy. So it's really neat to see this stuff in action.
Sanjiv Lakhia: 18:01
To clarify, you are working with patients, clients to look at what we call biomechanical, maybe imbalances that could adversely affect a swing, but you are not working with people to improve their swing and improve their golf score?
Graham Claytor: 18:20
That's exactly right. Although a lot of my patients come in and that's the first thing they want me to do. So they asked me, "What am I going to do to lower their score?" I don't dive into that. And that's kind of the separation we have between us and golf pros. We never want to interfere with that just like we never want them to interfere with basically exercise prescription or anatomical or pathological diagnosis. They stay in their lane and we kind of stay in our lane, but we do do some crossover, but yes, our bread and butter is the biomechanical swing. And what anatomically can we fix to improve that swing without changing any sort of the technical part of the swing. We're not training them.
Sanjiv Lakhia: 19:02
And this could almost be a good form of preventative medicine. If you're a primary care doctor listening to the podcast today, and you have patients come in for an annual physical, and you're asking about their activity levels, and they mentioned that they're into golf, it sounds like a referral to the golf rehab program could be a great way for patients to prevent injury. Would you agree with that?
Graham Claytor: 19:23
That's exactly right. I mean, that's why most people say, well, they're the cusp of retirement. "What are you going to do in retirement?"
Graham Claytor: 19:30
"Well, I'm going to play a lot of golf."
Graham Claytor: 19:32
"Well, when's the last time you played?"
Graham Claytor: 19:33
"Well, I haven't played in a long time. I've got kids, I had a job and now I've got buddies that are traveling, or I've joined a club or I just want to play in a league and I want to make sure that my I'm able to do this three or four times a week."
Graham Claytor: 19:47
I mean, we get those kinds of requests, but we also get a ton of post-op requests. What is the data out there for post-op? That's the real, that's the big kind of money question there is, "What can I do with somebody with a post-op microdiscectomy laminectomy or a post-op fusion in their neck or back, and how do we get these people back on the golf course?"
Graham Claytor: 20:12
There really, once upon a time was not that much data out there. It wasn't definitive. It was kind of ballpark. Maybe do this at three months and maybe try this at four months and then maybe we clear them at six months. It all just depends on how the patient feels and what a scan say. Some of that stuff has gotten more defined, which is good, but we're still kind of in that gray area and I can kind of compare it to concussions a little bit. Concussions, we think we know a lot, but there's still a lot we need to know.
Graham Claytor: 20:41
I can say the same thing with return to golf after injury or returning to golf after a post-op spine surgery. You look at professionals like Tiger Woods, right? Well, Tiger Woods had multiple microdiscectomy and now the guy ended up getting a fusion. Did he go back too soon after these microdisectomies? The Monday morning quarterback could probably say, "Yeah." What we thought was as normal maybe the two or three months, maybe not normal for professional golfer who bangs a thousand balls a day. Somebody with a fusion, can they go back in six months, nine months? Well, generally more there's old P lifts that we did that was, that's more like eight or nine months, but now that we do these T lifts, it's less muscle to retract and less time to heal. Then they can go back a little bit sooner.
Graham Claytor: 21:27
So there's still some preliminary data that doesn't necessarily... it's getting better, but it doesn't necessarily define week-by-week and month-by-month, what you should be doing. So we try to define that for our patients as best we can. So we do swing progressions, meaning at a couple of weeks, you shouldn't play, and then maybe you grab your [inaudible 00:21:47] irons and then maybe you start to hit balls in the backyard, hitting blades of grass, no divots. And then maybe you play nine or maybe you go to the range. And so we define those specifically for people for swing progression.
Graham Claytor: 22:00
So that's about as close as I get to the golf swing and lowering scores that we really try to week-by-week and even day-by-day with some people tell them what they can do in the swing to get back from a progression point of view.
Sanjiv Lakhia: 22:12
So biomechanically, what is it about golf that puts the spine under stress?
Graham Claytor: 22:17
Well, as much as we want to try to... We always talk about neutral spine and what is neutral spine. We try to get patients in as best neutral spine as you possibly can in the golf swing, but no matter how you look at it, you are in a forward position with a little bit of stress on your back, because you're not in that neutral spine. One of the biggest things we tell people is the perfect storm for back pain is bending, lifting, twisting, right?
Graham Claytor: 22:43
Well, a little bit in that golf swing, you are bending a little bit. You're hinging at your hips. You're not necessarily lifting. You're lifting a club, but you're also can swing at speeds of let's say 60, 70 to these golf pros swinging over a hundred miles an hour. And you do have some inertia when you hit the golf ball, right? And you even have some inertia if you take a proper divot.
Graham Claytor: 23:05
So technically golf can combine those bending, lifting, twisting. We just got to make sure we control that and work on those movements that are natural in the golf swing as best we can. It's the same thing we would do in somebody who returned to tennis or returned to any other sport. We just have to build the muscles within that movement and hope that their swing and their anatomical fixes allow them to play with less stress as we can.
Graham Claytor: 23:35
The disc, as you know, is made up of that water, jelly donut material. And as we age that jelly donut turns more into a hardened crab meat. Well, you don't disperse forces as best as you did in thirties and forties. So those are the people that generally come in. We're starting to get a little bit of that evidence that have some arthritic change and they're swinging and by hole seven and eight they start to get stiff. Well, what do those people, what can they do to get themselves through a whole round? And that's where I go back to some of these pre-rounded T box exercises that we define for people.
Sanjiv Lakhia: 24:08
In terms of exercise. What do you recommend as complimentary? So someone who plays a lot of golf, but also wants to just stay generally active, are there some good general fitness exercises that can compliment their golf specific training?
Graham Claytor: 24:26
Absolutely. So, in general posture, flexibility, core strengthening, balance coordination. I mean, those are the things that are required to play golf. And then you can kind of peel it into layers here. Is it a 15-year-old female versus a 15-year-old male? Is it somebody who's starting to play golf versus somebody who's been playing for years? Is it somebody with an underlying condition like arthritis or stenosis versus somebody who has a normal looking back and we want to prevent things?
Graham Claytor: 24:59
So yeah, we have to define what those exercises are, but we really want to get a detailed flexibility program generally for my men and we want to get a good core strengthening glue program generally for my women. And that's just kind of the anatomical makeup. Most of men's problems on the golf course are back pain and sometimes that golfer's elbow, tennis elbow pain, but most of my women that come in here that have golf, let's say call them golf injuries or chronic problems are generally peripheral issues because that generally can be a weak spot that ends up in more women. So wrist injuries, elbow, feet, knees. I see more of those in my women than my men. So I'm generally stretching my men and core strengthening my women.
Sanjiv Lakhia: 25:50 Y
ou mentioned earlier kind of a 10-point screen. Do you want to dive into that a little bit? Yeah.
Graham Claytor: 25:55
So, for example, I would do, let's take just one or two and dive into it. Let's say somebody who has a C-posture and you can imagine a C-posture at set up. C-posture means you're have a rounded C looking back, right? These are guys that have a little bit of extra weight up front, or they sit at a computer or they have a tight thoracic spine, or they have tight anterior chain muscles, or they're just, again, lower quarters, tight, et cetera. So they kind of set up in this rounded posture.
Graham Claytor: 26:27
Well, if you have that, then your chances of doing other things like not getting full rotation or blocking your down swing or coming over the top are greater. And plus you put more stress on the spine. If you're not in that normal lordotic posture as we call it. So it just sets you up for escape routes. And those escape routes generally will come with other injuries somewhere else, plus putting stress on the spine.
Graham Claytor: 26:56
So again, what do we do with that C-posture? Well we work on proper. We know we work on the foam rollers or we work on what neutral spine is for that person. We work on pelvic, neutral pelvic tilt testing, we work on core strengthening. We try to get maybe some weight reduction if we need to. And we show them videos, either golf pro what that C-posture looks like and so we start diving in from there. That's just a simple test.
Graham Claytor: 27:23
The other thing is overhead deep squat, overhead deep squat is a great test because it's multiplanar. So we look at a squat. What does a squat look like? A squat can be different for a lot of people. Do you stick your butt out, do you stick your butt in? Do you put your weight on your heels? Do you put your weight on your toes? We have professional athletes that come in here that have trouble with a deep squat. And that should be one of the first things an athlete can do is get their butt below their knees and be comfortable there with a neutral spine, but it's surprising what you see in these.
Graham Claytor: 27:51
So we'll pick up deficits, whether, again, it's if you put your arms over your head in that particular movement, whether it's a lat tightness or a shoulder pain or a mid-back thoracic spine, that won't let them stay in neutral spine or the hips, won't let you go all the way down. We have a arthritic hip or a tight hip somewhere. The knees won't let you go down. You have ankle mobility issues. You can't dorsiflex, you have tight calves, or you just don't have the coordination to do these multiplanar movements.
Graham Claytor: 28:21
And so that's one of my favorites to do because there's so many exercises that I can give people and a ton of recipes that we can work just on that movement. And so there's a lot of guys that come in here that are just starting off playing golf, or they're on that webb.com that I talk about that don't have trainers or access to people like myself and they're traveling in hotel rooms because they're grinding, trying to make the tour. So we have to do a lot of these movements and exercise prescription for these guys in hotel rooms.
Graham Claytor: 28:51
And so we give them a lot of these things to do. They're not only screens, but they can be exercise prescription to try to fix these movements. So there are assessments that we give people, but they're also exercise fixes to fix that deep squat. These movements that we do are now being performed at things like behind the scenes at NFL combines and professional sporting events that if Cam Newton walks in the room and say, "Cam, before you sign this big contract, can you touch your toes? Can you turn left? Can you turn right? Can you overhead deep squat? What does neutral spine look like for you? What is your shoulder range of motion?"
Graham Claytor: 29:26
And so these are behind the scene things they do at combines now. So it's garnering a lot of steam. These multiplanar selective kind of functional movement assessment, TBI assessments are given to anybody, but they're given to athletes as well for any [inaudible 00:29:44] sport.
Sanjiv Lakhia: 29:44
I think it just speaks to the injury risk or injury prevention idea here. Just demonstrate you can have normal free-flowing range of motion through some of these dynamic movements. I think this is a really good service for people who are listening who are in a golf or thinking about it. It sounds like a great way to... It's almost like if you're looking to buy car, let's say a used car. You want to take it to your mechanic, have him check it out before you buy it, seeing here, looking at under the hood from a mechanistic perspective, working with an expert of [inaudible 00:30:20] exercise prescription, and about probably a more enjoyable pre-season and potentially better success on the golf course.
Graham Claytor: 30:29
Well, a lot of people that come in [inaudible 00:30:35] some physical exercise and maybe define what these limitations are before you start going out for the season, or before you get this golf lesson, because more than likely, you'll get a lot more out of your golf lesson and you'll feel better about playing because you've already taken that physical step. And we may, not only just the golf program, but we may say that for people that are just wanting to get into yoga or Pilates. Why don't you try these movements, make sure you can do them so you can participate more, feel better about it, and you prevent injury.
Sanjiv Lakhia: 31:07
Graham, are there good resources on YouTube or even textbooks that you would recommend for other physical therapists who are listening or other practitioners or lay public, just to learn a little bit more about maybe some of these TPI assessment tools or more on the biomechanics or the basic science of the golf swing?
Graham Claytor: 31:28
Well, yeah, I mean, outside of the TPI and certainly the selective functional movement assessment, which TPI is one of the founders of that selective functional movement assessment. And then now what that's professional sports and TPI has taken that movement assessment and kind of tweaked it to make it more sports specific. So any of Greg Cook's stuff is very good. And any of the Sea Island golf pro guys that are trainers down there, Randy Myers, some of the golf fit pro apps are very good to go see. Some of the books that I read about golf injuries are very good.
Graham Claytor: 32:02
I'm a gadget guy, too. I love the gadgets that come out. So we have a lot of gadgets here that I think are very good to kind of use when you warm up, whether it's an elbow trainer to keep your elbow in proper place or the orange whip, that's more of a speed. That's kind of an orange ball, weighted ball on the end of a long pole that people swing to warm up. Or we had these smash bags where we kind of hit and say, "Hey, I know you're a little bit nervous about taking a divot when you get back out there, I got this bean bag that's fun to use for people."
Graham Claytor: 32:31
We have clubs that are weighted so you can feel the weight evenly when you take a club back and down to the ground to see whether that distribution of the weight of the club should be. We have clubs that break midway through a swing. So if you don't maintain that good tempo, momentum, and neutral angle and swing plane, then it'll break. And so there's gadgets everywhere and all my golfers generally have no less than 15 gadgets because they think it all helps their score, but I'm a gadget guy too and I think all that stuff helps.
Sanjiv Lakhia: 33:03
Fantastic. I think [inaudible 00:33:05] you're breaking down a little bit of the science behind the need for a golf rehabilitation program and certainly some of the details surrounding ours, so I really appreciate that.
Sanjiv Lakhia: 33:15
As we wrap up the episode, I want to be respectful of your time. Obviously you've got a wealth of knowledge about health and fitness. Would be curious to know and if you could share with the listeners maybe some insights about your own personal health routines and some of the favorite tools you use to promote wellness in your life.
Graham Claytor: 33:31
I'll be realistic. I was a three or four times a week basketball player and was playing with guys in their twenties, thirties and forties until a couple of things happened. And I think basketball was one of the better things, just because it's fellowship, it's high interval intensity training, it's skillful, and there's nothing that really could mimic basketball.
Graham Claytor: 33:52
But as we know, as we get older basketball injuries are very real. I'm more scared of what my wife would do to me if I got hurt going home, playing basketball with an actual injury. I now do a lot of stuff where I'm doing still high interval stuff, whether it's, I may play one day a week of basketball where I'm pushing and then you really have to get creative, right? So what are you doing at home to try to mimic some of those speed things that you used to do and getting the cardiovascular?
Graham Claytor: 34:21
That's certainly a proponent of non-impact exercise, but let's be honest. Some of that loses its flavor every now and again and you need something else to kind of get your mind going. So I'm always in the yard playing basketball with my boys or plugging into soccer and doing those dads things that can still kind of get you in shape. And then you're always looking at your, the things that you need to eat properly and to keep yourself from injury or at least injury recovery and we try to do a good job of doing that.
Graham Claytor: 34:48
But again, where we are in the world today, things getting a little bit tougher and you have to get a little more creative on what you're doing as far as cardiovascular and being conscious of what you're putting in your mouth. But it's certainly a proponent to our patients who ask about anti-inflammatories and natural ways of doing it and safe and proper diets and how to... what's the best for men and best for women? So we do get those questions. So not only do you want to preach it, you want to live it as well.
Sanjiv Lakhia: 35:16
Yeah. And I, like you, actually played basketball for about 20 years and then my low back just kind of quit on it. And now I'm relegated to trying to dominate my 14-year-old and 10-year-old in the driveway. And frankly, I'm having more fun now than I did when I played growing up. The one thing about sports that you can't duplicate in the gym, it's the competitiveness of it.
Sanjiv Lakhia: 35:39
So for some people who really like the competition and challenge, as you get older, letting go of some of that can be difficult. Some of the things that I do personally to keep myself physically fit without harm is I've really gotten into, purchased a really high quality fitness trampoline. So I can do a tremendous amount of high-impact aerobics on that and it doesn't hurt my joints at all. Certainly I use the elliptical machine. I have one of those, and then I'll still occasionally run a little bit, but the joints will talk to me when I do that as well.
Sanjiv Lakhia: 36:09
I think at the end of the day, it's just about, it's really not about, I've said this before, it's not about really what you do. It's just being consistent with it. And I like your idea of kind of integrating that into your life. I mean, staying active with your kids is activity, it's movement, and it's going to promote certainly bonding with your family as well as keeping you healthy. So keep up the good work.
Sanjiv Lakhia: 36:30
And I want to thank you very much for your time today and sharing tremendous amount of information regarding the golf rehabilitation program. And again, if you're interested in learning more, go to www.golfrehabandfitness.com. We'd certainly love to see you in the office and get yourself checked out, prevent injury, and enjoy a sport that you all love. So Graham, thank you for your time today.
Graham Claytor: 36:50
Thank you very much. I really appreciate the invite. Appreciate the referrals and the confidence that you always send our department and I know that this is an important subject. And just like you said, at the beginning of this, we are in a growing golf mecca here, so it's an important service that we can offer to pretty much anybody. So I really appreciate your time.
Sanjiv Lakhia: 37:10
All right, you're welcome. Thank you.
Outro: 37:14
Thank you for listening to this episode of Back Talk Doc, brought to you by Carolina Neurosurgery and Spine Associates with offices in North and South Carolina. If you'd like to learn more about Dr. Lakhia and treatment options for back issues, go to backtalkdoc.com. We look forward to having you join us for more insights about back pain and spine health on the next episode of Back Talk Doc. Additional information is also available at carolinaneurosurgery.com.
Welcome. You're listening to Back Talk Doc, where you'll find answers to some of the most common questions about back pain and spine health brought to you by Carolina Neurosurgery & Spine Associates, where providing personalized, highly-skilled, and compassionate spine care has been our specialty for over 75 years. And now, it's time to understand the cause of back pain and learn about options to get you back on track. Here's your Back Talk Doc, Dr. Sanjiv Lakhia.
Sanjiv Lakhia: 00:35
Thank you for downloading this episode of Back Talk Doc. As many are aware, during these times, technology has been a bit of a challenge, and we recorded this episode remotely. I'd like to let you know that there are several instances during the episode where the audio is not as crisp and clear as we typically like. However, I think the information is good and I'd like to get this out to you as quick as I can, so we're going to go ahead and release this. I hope you find it informative and thank you for your understanding if it is not of the audio quality that you're typically used to when listening to our episodes. Enjoy the episode.
Sanjiv Lakhia: 01:17
One of the benefits of living and working in the Carolinas is the beautiful, almost all year round warm weather. And a lot of our listeners and patients at Carolina Neurosurgery & Spine Associates take advantage of that through outdoor activities, for which a top activity is golf. Golf is big time in this area. I see a lot of patients on a week-to-week basis whose primary goal is for us to keep them upright and pain-free, so they can enjoy their life, enjoy time outside playing golf with friends and family.
Sanjiv Lakhia: 01:53
And to address that we have developed at our group a really unique golf specific spine rehabilitation. I'm going to be interviewing spine protocols and keeping people healthy, active, and upright so they can swing the club and just really enjoy all the opportunities we have in Charlotte and the surrounding areas. So Graham, welcome to the show today.
Graham Claytor: 02:15
Thank you for having me. I appreciate it.
Sanjiv Lakhia: 02:18
Graham, for those who don't know you real well, I know basically you're kind of the guy in the area for this issue, but for those listeners who don't live in the Carolinas, can you give them a brief introduction to a little bit about your academic background, your clinical background and just your overall path to physical therapy?
Graham Claytor: 02:37
Yeah, so I can't sit here and say that I wanted to be a physical therapist when I was 10 years old. I'm the son of a lawyer, and I knew that I didn't want to be a lawyer, I'll put it that way. By doing summers at a law firm, I knew this was not where I was going to go. So I was always a guy who didn't need to be behind a desk. I needed to be on the move. I liked medicine, I liked patient care, I liked people, and I just started narrowing stuff down. I don't have the old-fashioned story of where I was hurt in a baseball, basketball game in high school, went to rehab and said, "Oh, this is a career for me." I didn't have that.
Graham Claytor: 03:15
What I liked about the therapy field, again, was the fact that I was able to spend time with my patient, to go through the journey with my patients. I spent a lot of times in nursing homes, having grandparents that went through Alzheimer's and that, so I spent a lot of time there looking at that part of rehab, which was intensive, not only physical, but the mental part of that too. So those are the kinds of the things that got me going on what this field was about.
Graham Claytor: 03:42
But you fast forward, and I went to college at the University of Chapel Hill and majored in sports medicine there and furthered my education at East Carolina University and got a, what was then a master's program there that has now transformed into a doctorate program, which is pretty much everywhere in the field now. And after I graduated there, I went to into a private practice, and so that private practice taught me a lot of different things.
Graham Claytor: 04:08
It taught me how to be involved in the community and what patient needs were, how to go out and pound the pavement. And how to, again, interact with different orthopedic issues that people had, not just spine care. And so I got a plethora of knowledge doing the orthopedics in the private practice side, but I also learned some of the business sense and what it takes to be in a private practice too.
Graham Claytor: 04:35
Fast forward a year and a half later, I get a call from Dr. Jerry Petty, who is a alumni [inaudible 00:04:43], closing in on 60 years of practice here in one of the Mount Rushmores of this [inaudible 00:04:51] Mount Rushmore. And he called me and said, "We're [inaudible 00:04:57] of neurosurgery right down the street and it's going to grow and it's going to grow for years and as many patients as we send you it'd be a lot better if you were down the hall versus down the street."
Graham Claytor: 05:09
And so I met with the group of guys here and I went over exactly what I thought a physical therapy practice looked like. My thoughts on patient care, my outcome abilities, how to grow a practice business models, niches that I thought were going to be there, one of those being golf which we're going to talk about.
Graham Claytor: 05:29
And then I started digging in my heels and working on the architecture with our architects here, working on the computer side, the next gen side, and organizing that for physical therapy. So basically Mary Kleiniger and the doctors here said, "We want to start a physical therapy practice. We know a little bit about it to be dangerous, but we don't know much about it, but we want you to have it." So I was an excited, but a little bit scared 27 year old physical therapist who was handed this golden ticket. We ran from there and I'm still digging and trying to grow this place. That's the cliff notes if you will, of where this physical therapy clinic practice is here at Caroline Neurosurgery, 15 years deep.
Sanjiv Lakhia: 06:09
And we'll talk about the golf program here, but you've been instrumental in that. What was kind of, or what's your interest or background in golf? Do you enjoy playing quite a bit? Do you have some experience with that from a personal side?
Graham Claytor: 06:21
So yes. I think as we all kind of move from our twenties and thirties and say, "You know what? I probably shouldn't be playing three days of basketball a week or being the weekend warrior playing football," especially if you have a wife and kids and you're scared of coming home hurt. So I said, "Well, this whole, like you said earlier, this area is booming with golfers and private and public clinics and access." And that just kind of started piqued my interest in my mid-thirties and I started playing a lot more. You kind of dabble a little bit in college, but that's just more of a kind of a side thing. You just play every now and again in between classes or something like that. But because everything is so easy around here, I started playing a lot more and it piqued my interest.
Graham Claytor: 07:05
Furthermore, I ran into and I can fast forward a story here, I ran into a gentleman who came to see me named Thomas Parker. Thomas Parker is the agent, if you will, for a lot of professional golfers and him and I actually met on the basketball court and he is a Wake Forest grad. And so he has a lot of Wake Forest professional golfers he sees amongst others.
Graham Claytor: 07:28
So he came in here and saw what I did with physical therapy and then he kind of gave me an idea and said, "Look, I have a lot of guys that need this kind of specific golf treatment and there's not really anybody around here that's doing this. There are places in Florida, whether it's a golf mecca, there are places in California, but there's not really this niche in Charlotte." And you have places like Quail and Charlotte and Myers Park and all these places that have these good golfers and some of the professional golfers are moving here simply because of the hub that is the airport here.
Graham Claytor: 08:01
So a lot of family guys were moving here so they could easily travel with the golf on the PGA Tour. So he came in and he brought me a handful of guys ranging from Webb Simpson to some other guys that once Webb got it in here and he got a couple of friends to come in here and then that kind of spread like wildfire. So we get some webb.com guys. Webb.com is basically the tour right below the PGA tour. Saw a lot of those guys ended up seeing a couple of LPGA or even some of the Symetra tour again, which is the ladies' version of the webb.com. And then now again, on a regular basis, we do see, I've seen the Russell Henleys, the Charles Warrens, the Harold Varners, the Webb Simpsons and those guys come in here on regular to go through our golf program.
Sanjiv Lakhia: 08:47
That's fantastic. So we have, what's called a TPI certified program. If you go to our website, we have a specific website for this, www.golfrehabandfitness.com. And we'll put that link in the show notes. You'll see that we're TPI certified. So explain to another doc or even a patient who's looking at that, what does that exactly mean?
Graham Claytor: 09:11
I will rewind a little bit. So we talk about the professional golfer [inaudible 00:09:16], but mainly what you alluded to earlier is that we've see a lot of John Does and Jane Does that come in here that are nine to five computer workers or other jobs where they're on their feet or things like that, but they also play golf and that's one of those things that they really want to do. And there was no real way to just... We didn't want to just do regular spine care with these people. We wanted to add that niche. And that niche was say, "All right, let's take therapeutic exercise. Let's take dynamic exercise. Let's take our normal back exercise progressions and throw a twist in there and let's get some golf specific routines for people."
Graham Claytor: 09:54
So I started building those golf specific routines and those were based on physical deficits for people, physical limitations, what do those look like? And I built my exercise routine based on things that I knew, like if you were coming over the top or you were early extending, these are terms that people use that are golf hindrances in a golf, a golf pro would know these terms. And again, they go furthermore with, I said early extension, but whinging or C-postures or S-postures.
Graham Claytor: 10:26
These are all kind of common terms that golf pros use that are again, limitations in the golf swing. So, but credit to the golf pros because they know these things, but what they needed was somebody like myself, as far as an anatomical professional to go through and diagnose why physically people have these deficits in their swing. And then you fast forward years later and they beat me to the punch, but TPI is a Titleist Performance Institute. And it's this big institute probably as big as something like a Google or Amazon out in California.
Graham Claytor: 10:59
And they took this group of board members ranging from therapist to chiropractors, to golf pros, to data analysis, to biomechanists, and they came up with this elite program where they were going to train people like myself to become Titleist Performance Institute certified. And what that does is help diagnose these golf pro limitations that they give out to their clients and bridge that gap, if you will, between golf pro client/patient and then medical professional. So it's a genius idea.
Sanjiv Lakhia: 11:35
It sounds like they beat you to it. If you had done that first, you'd have a lot more time to be playing golf.
Graham Claytor: 11:42
That's right. That's exactly right. So I had my sheets and sheets of exercises and things that I was doing, but then they got to it faster, but I'm glad they did because they got it to the masses and people like myself and even some of the other therapists here and even podiatrist John [inaudible 00:11:57] and his practice has gone on to be TPI certified. So now you can kind of look online and look at a search and TPI will be one of the first things that pop up and then look and see if you're certified, which is a really elite certification to get with the titleist performance and the fitness that you need.
Graham Claytor: 12:14
That is a great certification to have. It helps bridge that gap like I said and it helps get people involved when they look on the website, but quite frankly, nowadays there are YouTubes and there are apps and there are all sorts of things, but I'm, again, I'm kind of showing my age here, but where I got most of my learning and most of my referrals was going out to these clubs, introducing myself, doing free clinics, roaming the ranges, getting to know the golf pros, having them trust me with their clients.
Graham Claytor: 12:45
And that was the, and still is the best way that I learned. And that's the biggest thing that honestly, that I have learned from TPI outside of the general information on exercises they recommend in diagnostics and the physical screening that we take people through with this. They give you a 10 and 12-part screen to take people through and learn that with ranking scales and whether you pass/fail some of these.
Graham Claytor: 13:09
But what I really learned, again, dating back to when I even told you I was in private practice is to pound the pavement. And so I would blindly call these guys or get in with one of the docs here to let me introduce to the golf pros. And so I'm learning from the mecca of golf pros around here, which is these guys come from Sea Island. If you haven't heard of that, that's really the place where these golf pros around here and in the country go and get trained.
Graham Claytor: 13:35
And so if you take the analogy of the Bill Belichick and all the coaches that have been under Bill Belichick's wing and gone on to be NFL coaches, this is kind of what Sea Island does. And they spread these golf pros around the country and they're at Quails and they're at Charlotte's and they're at Sea Pines and they're all over. And if you can get information from them, it's gold. And over the years we built relationships seeing those referrals from them and me sending them patients as well. And it's been really good to build our program.
Sanjiv Lakhia: 14:07
Okay. So two questions then. Who is the golf rehab program for? So describe kind of a typical patient or scenario. And then secondly, kind of walk someone through. Let's say, they're coming to see you, their back's hurting, but they want to play. And within a week or two what can someone expect when they come into the office, how would a kind of a golf rehab evaluation differ from a traditional PT consult?
Graham Claytor: 14:35
So the good news is any golfer can come in here and get into our golf program. The better news is that you can put anybody in the golf specific program and they'll have better back outcomes because we're combining some of those safe rotary movements that are combined in your activities of daily living, whether you're a golfer or not. So I can do the golf program with just about anybody. I mean, we do it on NASCAR drivers because they turn left for a living, but they also have rotary and physical deficits. I do it on 15-year-olds that are going to get scholarships to Stanford to play golf and I do it on 90-year-olds that are playing from the senior tees and just want to shoot their age. So anybody can be a part of this program and that's the beautiful thing about it.
Graham Claytor: 15:22
And furthermore, we take normal, regular therapeutic exercise and again, we put that twist on it. So now we do multiplanar movements and we do this 10-part screen, which I'll talk about in a minute. And we do multifunctional T box exercises, pre-round warmups. We can plug this data, the screen into the TPI website and it spits out individual programs via video that people can have access to permanently.
Graham Claytor: 15:50
So it's really neat on the things we do. And we also look at the swing. We don't dive into that too much. I'll leave that to the golf pros, but if they tell me a specific deficit, I can look at their swing and kind of say, "All right, well, this shoulder may be a problem or this mid-back may be a problem or your hamstrings may be tight because of this," and the golfers really like that because it's now tangible. It gets them more out of the lesson.
Graham Claytor: 16:13
So a lesson is, if you've ever taken a golf lesson, they look at a few things and give you, let's say drills to work on. But if you look at that in anatomically to fix some of those deficits that the golf pro defines for you, you just seem to get more out of it because sometimes the golf pros get cold feet. They'll call me and say, "Hey look, I've got a guy who's 73 years old, has got back pain. I need him to rotate more and I'm afraid because I just worried about his back. He hasn't seen anybody. And so we're kind of at this kind of crossroads. We're in a plateau here on our golf lessons and I don't want to him to keep coming if I can't get him to do what I want. Can you take him for two or three weeks and work on safe rotation?"
Graham Claytor: 16:58
So John Doe comes in here and I take him through our 10-part screen, which varies in the range of toe touch to an overhead deep squat, to a lat mobility test, to a glute test, to a shoulder range of motion test, to a cervical spine test, to a wrist test, to a foot and ankle test, to a balance test. And you combine all these, this data in the pass/fail sequence, and you define what these golfers can pass or fail.
Graham Claytor: 17:32
And then you start digging in from there. What are the exercises that I want to do if you pass or fail a squat or you pass or fail a glute strengthening test? And I can give you five or six exercises that I think you need to strengthen those glutes. I see you for three or four weeks as the golf pro wanted me to. I send you back. You now rotate and have more confidence in your swing. Your back pain's better. You can rotate more and everybody's happy. So it's really neat to see this stuff in action.
Sanjiv Lakhia: 18:01
To clarify, you are working with patients, clients to look at what we call biomechanical, maybe imbalances that could adversely affect a swing, but you are not working with people to improve their swing and improve their golf score?
Graham Claytor: 18:20
That's exactly right. Although a lot of my patients come in and that's the first thing they want me to do. So they asked me, "What am I going to do to lower their score?" I don't dive into that. And that's kind of the separation we have between us and golf pros. We never want to interfere with that just like we never want them to interfere with basically exercise prescription or anatomical or pathological diagnosis. They stay in their lane and we kind of stay in our lane, but we do do some crossover, but yes, our bread and butter is the biomechanical swing. And what anatomically can we fix to improve that swing without changing any sort of the technical part of the swing. We're not training them.
Sanjiv Lakhia: 19:02
And this could almost be a good form of preventative medicine. If you're a primary care doctor listening to the podcast today, and you have patients come in for an annual physical, and you're asking about their activity levels, and they mentioned that they're into golf, it sounds like a referral to the golf rehab program could be a great way for patients to prevent injury. Would you agree with that?
Graham Claytor: 19:23
That's exactly right. I mean, that's why most people say, well, they're the cusp of retirement. "What are you going to do in retirement?"
Graham Claytor: 19:30
"Well, I'm going to play a lot of golf."
Graham Claytor: 19:32
"Well, when's the last time you played?"
Graham Claytor: 19:33
"Well, I haven't played in a long time. I've got kids, I had a job and now I've got buddies that are traveling, or I've joined a club or I just want to play in a league and I want to make sure that my I'm able to do this three or four times a week."
Graham Claytor: 19:47
I mean, we get those kinds of requests, but we also get a ton of post-op requests. What is the data out there for post-op? That's the real, that's the big kind of money question there is, "What can I do with somebody with a post-op microdiscectomy laminectomy or a post-op fusion in their neck or back, and how do we get these people back on the golf course?"
Graham Claytor: 20:12
There really, once upon a time was not that much data out there. It wasn't definitive. It was kind of ballpark. Maybe do this at three months and maybe try this at four months and then maybe we clear them at six months. It all just depends on how the patient feels and what a scan say. Some of that stuff has gotten more defined, which is good, but we're still kind of in that gray area and I can kind of compare it to concussions a little bit. Concussions, we think we know a lot, but there's still a lot we need to know.
Graham Claytor: 20:41
I can say the same thing with return to golf after injury or returning to golf after a post-op spine surgery. You look at professionals like Tiger Woods, right? Well, Tiger Woods had multiple microdiscectomy and now the guy ended up getting a fusion. Did he go back too soon after these microdisectomies? The Monday morning quarterback could probably say, "Yeah." What we thought was as normal maybe the two or three months, maybe not normal for professional golfer who bangs a thousand balls a day. Somebody with a fusion, can they go back in six months, nine months? Well, generally more there's old P lifts that we did that was, that's more like eight or nine months, but now that we do these T lifts, it's less muscle to retract and less time to heal. Then they can go back a little bit sooner.
Graham Claytor: 21:27
So there's still some preliminary data that doesn't necessarily... it's getting better, but it doesn't necessarily define week-by-week and month-by-month, what you should be doing. So we try to define that for our patients as best we can. So we do swing progressions, meaning at a couple of weeks, you shouldn't play, and then maybe you grab your [inaudible 00:21:47] irons and then maybe you start to hit balls in the backyard, hitting blades of grass, no divots. And then maybe you play nine or maybe you go to the range. And so we define those specifically for people for swing progression.
Graham Claytor: 22:00
So that's about as close as I get to the golf swing and lowering scores that we really try to week-by-week and even day-by-day with some people tell them what they can do in the swing to get back from a progression point of view.
Sanjiv Lakhia: 22:12
So biomechanically, what is it about golf that puts the spine under stress?
Graham Claytor: 22:17
Well, as much as we want to try to... We always talk about neutral spine and what is neutral spine. We try to get patients in as best neutral spine as you possibly can in the golf swing, but no matter how you look at it, you are in a forward position with a little bit of stress on your back, because you're not in that neutral spine. One of the biggest things we tell people is the perfect storm for back pain is bending, lifting, twisting, right?
Graham Claytor: 22:43
Well, a little bit in that golf swing, you are bending a little bit. You're hinging at your hips. You're not necessarily lifting. You're lifting a club, but you're also can swing at speeds of let's say 60, 70 to these golf pros swinging over a hundred miles an hour. And you do have some inertia when you hit the golf ball, right? And you even have some inertia if you take a proper divot.
Graham Claytor: 23:05
So technically golf can combine those bending, lifting, twisting. We just got to make sure we control that and work on those movements that are natural in the golf swing as best we can. It's the same thing we would do in somebody who returned to tennis or returned to any other sport. We just have to build the muscles within that movement and hope that their swing and their anatomical fixes allow them to play with less stress as we can.
Graham Claytor: 23:35
The disc, as you know, is made up of that water, jelly donut material. And as we age that jelly donut turns more into a hardened crab meat. Well, you don't disperse forces as best as you did in thirties and forties. So those are the people that generally come in. We're starting to get a little bit of that evidence that have some arthritic change and they're swinging and by hole seven and eight they start to get stiff. Well, what do those people, what can they do to get themselves through a whole round? And that's where I go back to some of these pre-rounded T box exercises that we define for people.
Sanjiv Lakhia: 24:08
In terms of exercise. What do you recommend as complimentary? So someone who plays a lot of golf, but also wants to just stay generally active, are there some good general fitness exercises that can compliment their golf specific training?
Graham Claytor: 24:26
Absolutely. So, in general posture, flexibility, core strengthening, balance coordination. I mean, those are the things that are required to play golf. And then you can kind of peel it into layers here. Is it a 15-year-old female versus a 15-year-old male? Is it somebody who's starting to play golf versus somebody who's been playing for years? Is it somebody with an underlying condition like arthritis or stenosis versus somebody who has a normal looking back and we want to prevent things?
Graham Claytor: 24:59
So yeah, we have to define what those exercises are, but we really want to get a detailed flexibility program generally for my men and we want to get a good core strengthening glue program generally for my women. And that's just kind of the anatomical makeup. Most of men's problems on the golf course are back pain and sometimes that golfer's elbow, tennis elbow pain, but most of my women that come in here that have golf, let's say call them golf injuries or chronic problems are generally peripheral issues because that generally can be a weak spot that ends up in more women. So wrist injuries, elbow, feet, knees. I see more of those in my women than my men. So I'm generally stretching my men and core strengthening my women.
Sanjiv Lakhia: 25:50 Y
ou mentioned earlier kind of a 10-point screen. Do you want to dive into that a little bit? Yeah.
Graham Claytor: 25:55
So, for example, I would do, let's take just one or two and dive into it. Let's say somebody who has a C-posture and you can imagine a C-posture at set up. C-posture means you're have a rounded C looking back, right? These are guys that have a little bit of extra weight up front, or they sit at a computer or they have a tight thoracic spine, or they have tight anterior chain muscles, or they're just, again, lower quarters, tight, et cetera. So they kind of set up in this rounded posture.
Graham Claytor: 26:27
Well, if you have that, then your chances of doing other things like not getting full rotation or blocking your down swing or coming over the top are greater. And plus you put more stress on the spine. If you're not in that normal lordotic posture as we call it. So it just sets you up for escape routes. And those escape routes generally will come with other injuries somewhere else, plus putting stress on the spine.
Graham Claytor: 26:56
So again, what do we do with that C-posture? Well we work on proper. We know we work on the foam rollers or we work on what neutral spine is for that person. We work on pelvic, neutral pelvic tilt testing, we work on core strengthening. We try to get maybe some weight reduction if we need to. And we show them videos, either golf pro what that C-posture looks like and so we start diving in from there. That's just a simple test.
Graham Claytor: 27:23
The other thing is overhead deep squat, overhead deep squat is a great test because it's multiplanar. So we look at a squat. What does a squat look like? A squat can be different for a lot of people. Do you stick your butt out, do you stick your butt in? Do you put your weight on your heels? Do you put your weight on your toes? We have professional athletes that come in here that have trouble with a deep squat. And that should be one of the first things an athlete can do is get their butt below their knees and be comfortable there with a neutral spine, but it's surprising what you see in these.
Graham Claytor: 27:51
So we'll pick up deficits, whether, again, it's if you put your arms over your head in that particular movement, whether it's a lat tightness or a shoulder pain or a mid-back thoracic spine, that won't let them stay in neutral spine or the hips, won't let you go all the way down. We have a arthritic hip or a tight hip somewhere. The knees won't let you go down. You have ankle mobility issues. You can't dorsiflex, you have tight calves, or you just don't have the coordination to do these multiplanar movements.
Graham Claytor: 28:21
And so that's one of my favorites to do because there's so many exercises that I can give people and a ton of recipes that we can work just on that movement. And so there's a lot of guys that come in here that are just starting off playing golf, or they're on that webb.com that I talk about that don't have trainers or access to people like myself and they're traveling in hotel rooms because they're grinding, trying to make the tour. So we have to do a lot of these movements and exercise prescription for these guys in hotel rooms.
Graham Claytor: 28:51
And so we give them a lot of these things to do. They're not only screens, but they can be exercise prescription to try to fix these movements. So there are assessments that we give people, but they're also exercise fixes to fix that deep squat. These movements that we do are now being performed at things like behind the scenes at NFL combines and professional sporting events that if Cam Newton walks in the room and say, "Cam, before you sign this big contract, can you touch your toes? Can you turn left? Can you turn right? Can you overhead deep squat? What does neutral spine look like for you? What is your shoulder range of motion?"
Graham Claytor: 29:26
And so these are behind the scene things they do at combines now. So it's garnering a lot of steam. These multiplanar selective kind of functional movement assessment, TBI assessments are given to anybody, but they're given to athletes as well for any [inaudible 00:29:44] sport.
Sanjiv Lakhia: 29:44
I think it just speaks to the injury risk or injury prevention idea here. Just demonstrate you can have normal free-flowing range of motion through some of these dynamic movements. I think this is a really good service for people who are listening who are in a golf or thinking about it. It sounds like a great way to... It's almost like if you're looking to buy car, let's say a used car. You want to take it to your mechanic, have him check it out before you buy it, seeing here, looking at under the hood from a mechanistic perspective, working with an expert of [inaudible 00:30:20] exercise prescription, and about probably a more enjoyable pre-season and potentially better success on the golf course.
Graham Claytor: 30:29
Well, a lot of people that come in [inaudible 00:30:35] some physical exercise and maybe define what these limitations are before you start going out for the season, or before you get this golf lesson, because more than likely, you'll get a lot more out of your golf lesson and you'll feel better about playing because you've already taken that physical step. And we may, not only just the golf program, but we may say that for people that are just wanting to get into yoga or Pilates. Why don't you try these movements, make sure you can do them so you can participate more, feel better about it, and you prevent injury.
Sanjiv Lakhia: 31:07
Graham, are there good resources on YouTube or even textbooks that you would recommend for other physical therapists who are listening or other practitioners or lay public, just to learn a little bit more about maybe some of these TPI assessment tools or more on the biomechanics or the basic science of the golf swing?
Graham Claytor: 31:28
Well, yeah, I mean, outside of the TPI and certainly the selective functional movement assessment, which TPI is one of the founders of that selective functional movement assessment. And then now what that's professional sports and TPI has taken that movement assessment and kind of tweaked it to make it more sports specific. So any of Greg Cook's stuff is very good. And any of the Sea Island golf pro guys that are trainers down there, Randy Myers, some of the golf fit pro apps are very good to go see. Some of the books that I read about golf injuries are very good.
Graham Claytor: 32:02
I'm a gadget guy, too. I love the gadgets that come out. So we have a lot of gadgets here that I think are very good to kind of use when you warm up, whether it's an elbow trainer to keep your elbow in proper place or the orange whip, that's more of a speed. That's kind of an orange ball, weighted ball on the end of a long pole that people swing to warm up. Or we had these smash bags where we kind of hit and say, "Hey, I know you're a little bit nervous about taking a divot when you get back out there, I got this bean bag that's fun to use for people."
Graham Claytor: 32:31
We have clubs that are weighted so you can feel the weight evenly when you take a club back and down to the ground to see whether that distribution of the weight of the club should be. We have clubs that break midway through a swing. So if you don't maintain that good tempo, momentum, and neutral angle and swing plane, then it'll break. And so there's gadgets everywhere and all my golfers generally have no less than 15 gadgets because they think it all helps their score, but I'm a gadget guy too and I think all that stuff helps.
Sanjiv Lakhia: 33:03
Fantastic. I think [inaudible 00:33:05] you're breaking down a little bit of the science behind the need for a golf rehabilitation program and certainly some of the details surrounding ours, so I really appreciate that.
Sanjiv Lakhia: 33:15
As we wrap up the episode, I want to be respectful of your time. Obviously you've got a wealth of knowledge about health and fitness. Would be curious to know and if you could share with the listeners maybe some insights about your own personal health routines and some of the favorite tools you use to promote wellness in your life.
Graham Claytor: 33:31
I'll be realistic. I was a three or four times a week basketball player and was playing with guys in their twenties, thirties and forties until a couple of things happened. And I think basketball was one of the better things, just because it's fellowship, it's high interval intensity training, it's skillful, and there's nothing that really could mimic basketball.
Graham Claytor: 33:52
But as we know, as we get older basketball injuries are very real. I'm more scared of what my wife would do to me if I got hurt going home, playing basketball with an actual injury. I now do a lot of stuff where I'm doing still high interval stuff, whether it's, I may play one day a week of basketball where I'm pushing and then you really have to get creative, right? So what are you doing at home to try to mimic some of those speed things that you used to do and getting the cardiovascular?
Graham Claytor: 34:21
That's certainly a proponent of non-impact exercise, but let's be honest. Some of that loses its flavor every now and again and you need something else to kind of get your mind going. So I'm always in the yard playing basketball with my boys or plugging into soccer and doing those dads things that can still kind of get you in shape. And then you're always looking at your, the things that you need to eat properly and to keep yourself from injury or at least injury recovery and we try to do a good job of doing that.
Graham Claytor: 34:48
But again, where we are in the world today, things getting a little bit tougher and you have to get a little more creative on what you're doing as far as cardiovascular and being conscious of what you're putting in your mouth. But it's certainly a proponent to our patients who ask about anti-inflammatories and natural ways of doing it and safe and proper diets and how to... what's the best for men and best for women? So we do get those questions. So not only do you want to preach it, you want to live it as well.
Sanjiv Lakhia: 35:16
Yeah. And I, like you, actually played basketball for about 20 years and then my low back just kind of quit on it. And now I'm relegated to trying to dominate my 14-year-old and 10-year-old in the driveway. And frankly, I'm having more fun now than I did when I played growing up. The one thing about sports that you can't duplicate in the gym, it's the competitiveness of it.
Sanjiv Lakhia: 35:39
So for some people who really like the competition and challenge, as you get older, letting go of some of that can be difficult. Some of the things that I do personally to keep myself physically fit without harm is I've really gotten into, purchased a really high quality fitness trampoline. So I can do a tremendous amount of high-impact aerobics on that and it doesn't hurt my joints at all. Certainly I use the elliptical machine. I have one of those, and then I'll still occasionally run a little bit, but the joints will talk to me when I do that as well.
Sanjiv Lakhia: 36:09
I think at the end of the day, it's just about, it's really not about, I've said this before, it's not about really what you do. It's just being consistent with it. And I like your idea of kind of integrating that into your life. I mean, staying active with your kids is activity, it's movement, and it's going to promote certainly bonding with your family as well as keeping you healthy. So keep up the good work.
Sanjiv Lakhia: 36:30
And I want to thank you very much for your time today and sharing tremendous amount of information regarding the golf rehabilitation program. And again, if you're interested in learning more, go to www.golfrehabandfitness.com. We'd certainly love to see you in the office and get yourself checked out, prevent injury, and enjoy a sport that you all love. So Graham, thank you for your time today.
Graham Claytor: 36:50
Thank you very much. I really appreciate the invite. Appreciate the referrals and the confidence that you always send our department and I know that this is an important subject. And just like you said, at the beginning of this, we are in a growing golf mecca here, so it's an important service that we can offer to pretty much anybody. So I really appreciate your time.
Sanjiv Lakhia: 37:10
All right, you're welcome. Thank you.
Outro: 37:14
Thank you for listening to this episode of Back Talk Doc, brought to you by Carolina Neurosurgery and Spine Associates with offices in North and South Carolina. If you'd like to learn more about Dr. Lakhia and treatment options for back issues, go to backtalkdoc.com. We look forward to having you join us for more insights about back pain and spine health on the next episode of Back Talk Doc. Additional information is also available at carolinaneurosurgery.com.