Sensory Approach to Manual Therapy
Sensory Approach to Manual Therapy
Revamping Communication for Better Clinical Outcomes
What happens when the clinical application doesn't match the research results? Musculoskeletal specialist Ben Cormack joins us to explore this critical question and offers his invaluable insights into the world of therapeutic presence in clinical practice. We promise you'll uncover the gap between statistical effectiveness in studies and the real-world outcomes in practice. Dive into the exploration of randomized control trials, the magic of natural recovery, and the often-overlooked contextual effects that shape patient outcomes. Plus, we discuss the fascinating phenomena of placebo effects—sometimes dismissed as mere ‘happy accidents’—and consider how to harness their potential to elevate patient care.
Our conversation takes a closer look at the powerful mechanisms activated through treatments such as exercise and manual therapy, and how these can mimic each other by engaging similar pathways in the brain. We rethink the traditional views on inhibition and examine how placebo effects, driven by context and belief, can be as active as any other treatment component. Insights from expert Luana Coloca highlight the surprising potential of placebos when properly understood and applied. We also emphasize the importance of transcending traditional patient interviews, advocating for meaningful clinical conversations that truly consider the lifestyle and goals of each client, all while employing the biopsychosocial model for holistic care.
Communication stands at the heart of effective therapy, and this episode sheds light on enhancing these skills to foster genuine connections and maintain essential boundaries. Through personal anecdotes and expert perspectives, we stress the significance of professional growth and self-preservation for balanced therapeutic practice. We explore the benefits and challenges of interdisciplinary approaches in medicine, weighing the roles of generalists versus specialists. Whether you're seeking to improve your clinical practice or just interested in thought-provoking discussions about enhancing therapeutic alliances, this episode offers valuable insights and actionable advice.
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Hello everybody and welcome again to another podcast with the Sensory Approach to Manual Therapy. Today my guest is Ben Cormack and I'm excited to talk to him. Today we're going to talk about essentially therapeutic presence and what it means to interact with our clients. I've been a big fan of following Ben since about 2018 is when I got introduced into some of his material from Paul Ingram on the painsciencecom blog. Paul and I go way back and are very close. I've taken classes from Ben online in 2021, his research course. Ben's a musculoskeletal specialist in England. He started Corconet in 2011. He's a well-known figure in the physio and recovery and rehab and exercise world and welcome, glad to have you, oh, thanks for inviting me.
Speaker 2:That sounded very British, didn't it?
Speaker 1:It did Winter-sensually British and you are British, so you can sound as British as you need to be.
Speaker 2:Yes, I identify as British.
Speaker 1:Fantastic. So one of the things that made me interested in speaking with you is that the more we get into evidence, the more we get into research in manual. I even did one with Michael Hamm on the crisis of faith in medicine right now between what research tells us is effective and, as clinicians, what we see is effective, and the two don't always align.
Speaker 1:And I wanted to kind of pick your brain a little bit on that subject, where we sometimes come across this idea of we have a piece of paper that says doing this number of exercises, doing this manual therapy technique, doing XYZ version of treatment, is supposed to be effective, and we as clinicians, we provide that to our patients or our clients and they don't get the results that we're looking for. And there's this disconnect between what research tells us is effective versus in the clinic. What we're seeing is effective tells us is effective versus in the clinic what we're seeing is effective. And I wanted to see what you think about where that disconnect lies between the research and the applicable portion in the clinic yeah, sometimes I think we misunderstand what research is trying to do.
Speaker 2:So there's a couple of things that happen there.
Speaker 2:So, so the idea let's say we have something like a randomized control trial where we're looking to look at two interventions. Let's say we have exercise and we have manual therapy, and we would like to know which one's better, you know, or which one works in inverted commas, you know, which is a very loaded question. So the first thing that I think we have to understand is that what we see in clinic isn't just the effect of treatment, and this is something that I talk about quite a lot when I teach. The point of an RCT is to identify how much of that change is due to treatment. So let's say, you get a patient, they have eight out of 10 pain, and six weeks later they have one out of 10 pain, and so their pain is reduced by seven out of 10, right, and I'm just making numbers up and I can do that because I'm British and what we have is we have this seven out of 10 change, but what an RCT is trying to tell us is how much of that is actually due to treatment.
Speaker 1:And that's the whole point. Natural recovery, course of injury, all that kind of stuff, yes.
Speaker 2:Yes. So you know, what we do is, we have these two groups and we would like to know between the two groups, what's the difference. So we can go. Oh my God, manual therapy is better than exercise. Exercise is better than manual therapy.
Speaker 1:My biases are or they're better than pain medication, or they're better than no exercise or rest or recovery, whatever you want to choose Whatever you want to choose.
Speaker 2:So there was a piece of research that came out recently looking at back pain treatment. So about 50% of what you'll see over the course of 12 weeks, which is a general time period you'd see in research over the course of 12 weeks, about 50% of the change will be due to natural history, which is just how the condition on average waxes and wanes. About 30% might be specific to the treatment and then about 20% is what they talk about as being a contextual effect, which we could also call non-specific. That might be who we are, how we interact, all these other things that we discuss.
Speaker 1:Environmental placebo, whether they like your treatment or not, whether they trust you or not, whether they're stressed in life, not stressed in life. X, y, z, yeah.
Speaker 2:These would be contextual and there's a number of papers that came out in life, not stressed in life X, y, z. Yeah, these would be contextual and they think that, and there's a number of papers that came out in 2024, actually, or in 2023 as well, that actually I think there was three or four that all came out with very, very similar numbers, which, kind of you know, points in the right direction, I think.
Speaker 1:That 20% is actually really interesting. I teach a class called I Am Placebo Positive and it's about the unknown contextual components of placebo as an intervention, which is a very ethically gray shady area. Should placebo be considered an intervention? And scientifically absolutely not, of course not Clinically. If it gets you better, why the hell not? Right Like you're getting better? And the interesting thing is there was a meta-analysis that came out that talked about the effect of placebo care being 14% to 20% effective. If 20% is that contextual, significant number? All of a sudden the idea of placebo becomes relatively important into care.
Speaker 2:All of a sudden, yes, I am going to throw a spanner in the works, absolutely.
Speaker 1:This is a conversation.
Speaker 2:Because I do sometimes think placebo is a happy accident.
Speaker 1:Absolutely, I would agree. And the question would be research then would say if it's a happy accident, how can I make that happy accident not be an accident and still be happy?
Speaker 2:Yeah, how can I maximize the possibility?
Speaker 1:I think it would be terminology that I would be more comfortable with, and I think that's where context, environment, expectation all play into it. Sorry, I just jumped on your train of thought there.
Speaker 2:No worries. So yeah, so if we look at the 50% would be the natural history, 30 percent would be the direct effect of treatment and about 20 percent would be, hopefully, a happy accident. That makes it sound like an unplanned pregnancy, actually doesn't it?
Speaker 1:I don't know if those are always happy accidents be accidents.
Speaker 2:Yes, okay, fair enough, yeah, um, so, so what? When we come back and we say, well, I saw this massive change in my patient or my client over this 12 weeks, the really what can? What research is asking is how much is specifically due to treatment, and that's why these numbers are often much smaller. So then let's say we take two treatments that are effective, one being manual therapy, one being exercise. Now can you see why you're not maybe likely to see a large difference between those two things, because there's not that much margins.
Speaker 1:Yeah, absolutely. And 30% could be left down to. If it's exercise motivation, were they rigorous? Did they do their exercises, did they do them correctly, did they do them at the right speed, dosage, resistance, all that kind of stuff. And if it was manual therapy?
Speaker 1:One of the things I teach because I teach manual therapy classes is stop going deep, because what's the first thing that happens when you potentially go too deep? You re-instigate the pain cycle pain vigilance, pain catastrophizing, and now the treatment's too aggressive. So there's a similar concept of if treatment is not done in a way that is most likely to lead to positive outcomes, then it likely won't lead to positive outcomes. So your 30% is less effective. If exercise is done in a way where it is least likely to lead to positive outcomes, it won't lead to positive outcomes.
Speaker 1:So I always understand I have learned to understand over time how the two seem so similar, and it's always been one of those things that's interesting to me.
Speaker 1:I was just reading your post the other day about you don't like talking about treatment, so sorry for this little section of the podcast.
Speaker 1:It was something that was always interesting to me because somewhere in the past 15 years, exercise and manual therapy have come to hit heads as one is better than the other, and as a manual therapist who is also a personal trainer and does exercise and exercises himself, let alone most of my clients who exercise I've never understood why there are odds with each other, similar to evidence-based medicine and patient-centered care. The two should be integrated, not opposing. Even though I understand why they oppose, there is a way to bring the two together, and to me it's like manual therapy followed by exercise or exercise followed by manual therapy is where that 30% chance is the most likely to occur. Why wouldn't you give your client or your patient the best chance of recovery, give them every tool possible to come out with a positive outcome, as opposed to saying this is the tool, say, take all the tools, these are all going to help you Do anyone that you feel an affinity towards?
Speaker 2:going to help you do anyone that you feel an affinity towards? Yeah, I think that may come down to something different, which may be what is the mechanism or mediator of effect? Absolutely does that make sense? So? So I think that one of the things that we don't often consider is how are our treatments actually having an effect now in? In one sense, you could say, the acute effects of exercise and the acute effects of manual therapy are probably stimulating similar mechanisms, descending inhibition, opioid type mechanisms. You know this is how we get acute. You know nociceptive, what could we call it? What would be inhibitor?
Speaker 1:Yeah, you'd mainly be getting dopamine and endorphin responses from the feel-good sensation of touch and the feel-good sensation of exercise, and both on their own. It's interesting because inhibitory nociceptive is. It's a good descriptive text. It's not a good, accurate text. It's more that dopamine and endorphins become so stimulated that our nociceptive responses are. They're not inhibited because they're not technically shut down, they're just not as engaged, whereas the other two are more present. Therefore our feel good sensations in our body are higher when we go oh, that's, that was a positive outcome. And with the feel good responses we get hope, we get motivation, we get self-determination, all these other contextual things that lead to that was a positive experience.
Speaker 2:Yeah, I think we do get some antinose-susceptive stuff going on as well. We get things like GABA, which is obviously an NMDA agonist, which is an inhibitory. We get opioids, we get cannabinoids stimulated by the periaqueductal gray rostroventromedial medulla. You know these are. These are quite well-known descending pathways.
Speaker 1:Yeah, so I think it's one of those interesting subjects in Sarah Stavard's book the Phenomenon of Pain. He talks about how this nociceptive inhibition he always questioned is it inhibitory in nature or is it overactive in another area where that becomes the dominant feature In neuroplasticity? We often talk about nerves that fire together, cells that fire together, wire together, and the theory is you don't stop something from firing, you make something else fire so powerfully that it becomes the source of information, and the other one is still present, just not as powerfully present. And so it's always that inhibition has always been one of those words for me that has had this really difficult.
Speaker 1:This is not really what the podcast is about, but it's a great conversation. It's always one of those things that has a different, a difficult way of defining exactly how the brain functions, because dominant function. The result is the exact same. We have an inhibitory function as a result, but it's more out of active firing in one region, as opposed to under fire or not under fire, because that's the right term, but less something stopping it from firing. Not sure if that makes sense.
Speaker 2:Yeah, potentially. I mean, maybe that's what we see with things like diffuse noxious inhibitory control, where one stimulus is greater than another stimulus, but there are some inhibitory and facilitatory stuff that goes on with both treatments and so I think that actually would placebo or the placebo effect, you know, which I don't like. I much prefer the idea of you know, dan, dan Mormons kind of more contextual context. I much prefer that you know, and it's funny with processing and stuff.
Speaker 1:I wasn't a big fan of placebos. And then I just did a series of three podcasts, one with I don't know if you know who Luana Coloca is. She's a. She's a doctor out of the University of Maryland, an Italian lady who's kind of like currently the godmother of placebos on the planet. She's probably one of the most well-recognized researchers on placebos and she was my last guest on the podcast and I wasn't a big fan of placebos until I spoke with her and I realized and same with this guy, sel Shavard, who wrote the Phenomena of Pain book, and it kind of got me thinking. You know, just because I'm not a fan of it doesn't mean it actually might not be something that's relevant. And it made me start thinking a little bit differently, because the longest time I kept saying placebos are things we want to avoid. They want, they're things we want to try to get rid of in research as a control, as a variable and things like that I think I think my issue with placebo.
Speaker 2:you know, if we look at the actual definition, it would be this idea of something that's inert that creates an effect. But if we actually look at context, will we start to understand that context always has an effect? But if we actually look at context, will we start to understand that context always has an effect? So my problem isn't with the placebo per se. I think it's more that we see something as inert when it's obviously not inert.
Speaker 1:And I think that was the moment for me when I shifted my mentality around placebos. When one of those doctors they told one of those people, they said whether mentality around placebos, when one of those doctors they told one of those they said whether you like placebos or not actually doesn't matter, they're happening. The only difference is if you are someone who likes placebos, they are likely to be more effective. If you don't like placebos, they are likely to be less effective. But they're still present and to me that was an amazing, enlightening moment of well, if I think it'll work, it actually seems to be more effective. If I think it won't work, it still works. It's just less effective and that, to me, shows they're definitely not inert and they're present. It's just based on so many variables that they're hard to create and replicate so many variables that they're hard to create and replicate.
Speaker 2:Yeah, so if we took a sugar pill, there is nothing in a sugar pill that has analgesic properties. That's the inert part. But the context and the ritual of taking the tablet becomes the active component. And again becomes the active component. And again, if we look at these kind of inhibitory mechanisms, or just mechanisms, exercise, manual therapy and context, or placebo or whatever you want to call it, I don't see why they don't all act in a very, very similar way. What would be another mechanism?
Speaker 1:Exactly so. For me, I think the best argument for that concept and I'm agreeing with you, so I don't know if argument is the right word, I guess the best discussion is for me it's foam rolling. There's so much science around foam rolling about how it's not powerful enough to break apart collagen. It takes 64 kilonewtons of force to change collagen against manual directions. Foam rollers can't do that and it takes time and dependency to create this creep and the stress and the tissue. And we don't really have that capability with a foam roller. And yet you kind of get better when people use foam rollers.
Speaker 1:They constantly say that's the thing that helps me feel the best, the XYZ, and I think similar to what you're saying, the idea that they're taking care of themselves, they're doing something for themselves, post to help them recover, post exercise, post treatment, post stretching, whatever it is. That contextual component satisfies the brain. In a way it says well, even if mechanically what you think is happening is not happening, the brain is still really enjoying the experience and that's going to help the recovery process more and more and more. And that, for me, is also why exercise and manual therapy, though they seem recently to be butting heads even in science and even in research, one is better than the other. I've never understood it, because they've both been this component of not only recovery from just general life but even especially from injury, and I've always seen them as really well melded together more than separate, and I think contextually is really the reason for that.
Speaker 2:Yeah, I would say I'm going to caveat that by saying in the shorter term. Now there was some really interesting I think. Uh, chad cook did an interesting piece of research looking at chronic effects of exercise and manual therapy on the immune system. Right so, over the longer term, if we would like to and we know that you know immune function might be quite a big deal in things like chronic pain, you, we know that changes in epigenetics and immune function could be quite a big deal there. One thing I will say is, with chronic effects of manual therapy, I think we are less likely to see things like epigenetic change, whereas exercise may have greater epigenetic potential effect on health and that type of thing. But in that short-term, acute phase I don't see them as very different.
Speaker 1:Usually one of the things I teach in my classes is I encourage therapists to remember that three and a half months is your window. You have three and a half months to create the most possible change when a client sees you for the first time. After that three and a half months to create the most possible change when a client sees you for the first time. After that three and a half months, the most change that's going to be happening is now them on their own, with exercise. You have three and a half months to create knowledge base where they know how to move, when to move, how fast to move with resistance. But the manual therapy creates a safety environment where they feel, oh, I'm feeling stronger, I can move. And if I, if I do, hurt myself, oh, I see my therapist next week. I feel confident that I can go and do my exercises and if I get hurt, I have a safety mechanism, I have a safety net, and that three and a half months gives their brain a chance to say this is a new habit and then for most of my clients, therapy's done.
Speaker 1:Three and a half months you should be, you shouldn't need to see me anymore. If you choose to see me. Thanks for the money. I will gladly give you a half months. You shouldn't need to see me anymore If you choose to see me. Thanks for the money. I will gladly give you a session that makes you feel good for an hour. The effects are not going to last weeks, they're not going to last months, they're not going to last days, they're going to last hours and that's about it. And now your exercise should be where you find your health. But in those first three and a half months I really find that creates that, especially for people in chronic pain who are like I, haven't been able to lift an object in the past 15 years, and then you tell them okay, go move, and they go. I don't feel safe doing that. No-transcript.
Speaker 2:Yeah, I mean we could argue that. Well, not argue. I probably agree that. I think that most many of the effects that we have aren't even treatment related. They are person or people related, and it's about building confidence. It's about helping people make sense of their problem. Make sense of their problem. It's about you know, making sure that someone has the skills to you know, helping, support, self-management, building self-efficacy, these type of things, and I think you can either do that with lots of treatments or destroy that with lots of treatments. That isn't relative to treatment. It's relative to the relationship you build with people, and that's why I say I'm not actually that bothered about treatments. I think that treatments are the most boring part of the discussion because they take away from things like relationship, supported self-management and these type of things, because, if you think about it, we are being very us-focused, not very them-focused.
Speaker 1:I absolutely agree. It leads perfectly into the next question that I wanted to talk to you about, that interview process, because it's easily one of the things that I learned, both from taking some of your classes but also from a few other therapists and also throughout time, was I've moved. I mean, yeah, I think about 15 years ago I moved away from the hour long massage to, if it takes me 10 minutes to do the hands-on portion or it takes 90 minutes to do the hands-on portion, I don't care. What I care about is making sure that before we move to the hands-on portion, first of all I understand what the person in front of me is going through. I understand the stresses in their life, I understand their injury, I understand when it happened, how it's replicated when they have discomfort, how intense it is, descriptive text, how it makes them feel, what they're looking to achieve out of the treatment and out of recovery, when they feel better, what are their goals ideal movement, adls, all those kinds of things and oftentimes that interview process which you know for a massage therapist in North America I don't know if it's the same in England, but historically it's 55 minute massage, five minute turnover, next client, 55 minute massage. You know, and I don't do that and I and most of my most of my clients or most of my um students don't do that kind of treatment anymore. We've moved into this.
Speaker 1:Like I think I had a new client yesterday and the interview process took 45 minutes, which less than 15 minutes to do hands-on portion, and when she walked away she said it was the best she'd felt in three years and the treatment wasn't the important part. Now, without the treatment, she probably wouldn't have feel justified in her payment if all I'd done is sit there and talk and understand her injury, her mechanism for discomfort. So for me the treatment was still valuable because it gives her that oh, he is going to touch me, we are going to get some work done, oh, and I have some exercises now to do. But that first 45 minutes is where she goes. They understand me, they care, they listen, and I wanted to talk to you about that interview process because that's something that you tout and promote so much. So I just wanted to pick your brain on that subject a little.
Speaker 2:So I just wanted to pick your brain on that subject a little. Yeah, so I call it a clinical conversation and the reason being is because you know, interview is quite a common word. But who likes going for an interview? So I like to call it the clinical conversation because I think an interview tends to bring connotations for me anyway personally of you know having to answer questions and a power dynamic as well, and if you want to create connection you have to ditch the power dynamic that's. You know, one of the most important parts of communication and connection is not having a power imbalance, because that skews that. So I call it a clinical conversation, but you know that may just be being picky um, I don't know if it's being picky, I I think appropriate wording has importance.
Speaker 1:You know, like one of the things people talk about with fascia is they say fascia has, or the body has, layers. We don't have layers, we we're not. You can't pick the skin up without affecting the tissue beneath it. We have densities of tissue that are a continuum, but when you think layers too long, you start treating as layers and that's inaccurate. You can't physiologically do that. So I think actually having those changes in words, even though some people think it's minutiae, those minutiae kind of separate you from just a general practitioner. They make you an expert, they make it an art form, they make it an expertise more than just eh, I'm working today. So to me I like the fact that it's a clinical conversation, because that actually changes, definitely gets rid of the power dynamic instantaneously.
Speaker 1:It's just a talk.
Speaker 2:Yeah, and I do the same with the terminology of education. I call it knowledge coaching, because what I want to do, what I'm doing, is helping someone understand what I understand. I don't know if I'm educating them like a teacher. Again, you create that kind of power imbalance, but I think when it comes to the let's call it an interview, just for the sake of whatever you can say conversation, I like that yeah but I suppose it depends on what your aim of that conversation is.
Speaker 2:The aim of the conversation for me was always diagnostic. I was taught to recognise signs and symptoms, to then turn around and say this is my working hypothesis. I've heard you have pain at night between two and four. You know. Blah, blah, blah.
Speaker 1:Or you know, statistically, based on, based on your age, your problem, mechanism of injury, how it happened.
Speaker 2:Statistically, this is your most likely concern yeah that's what signs and symptoms, pattern recognition, to put that into some form of diagnostic working, hypothesis-y type of thing, right? So I actually think there are three parts of the clinical conversation. The first part is that more diagnostic type of process. What is this problem?
Speaker 1:here right, If they say they have low back pain, did they also happen to lose control of their bladder?
Speaker 2:Exactly Well, diagnostically a very important detail.
Speaker 2:Yes, the first thing is I'm safe. You know I am minimizing the probability that there is some form of serious pathology. Whether that's fracture, whether it's you know, cauda equina, whether it's you know whatever else, you know it's cancer. Yeah, exactly, Exactly. Is it an infection? Blah, blah, blah. But of course the likelihood of that is low. But you know, the probability is one part of that diagnostic procedure.
Speaker 2:But at the same time, I'd like to know is there something serious or is there something specific? Is it ridiculous? Is it fracture? Is it something that we can say there's pain in the calf, it's shooting down the leg? That's likely to be the probability of some kind of disc herniation. I want to know that. But then there's two other parts that I think are really important. Now the second would be what I describe as wider life listening. So that would be who is this person? What do they enjoy? What are their valued activities? What do they want to achieve from this process? What do they want to get back to doing? What is their family life like? What is their work, stress, et cetera?
Speaker 1:How much has this potential diagnosis affected their ability to live their ideal life?
Speaker 2:And that is the point of the BPS model. I've published quite widely in that area and the point of the BPS model wasn't always a diagnostic model or a pain related model. It was a person related model. It was finding out, not as much how has this life affected this problem as much as how has this problem affected this life. And that's the original kind of Engle philosophy and Peabody and all these other people in the background.
Speaker 1:Which, speaking of semantics, about like interview versus conversation, that is an important semantic. It's not. How does this life affect your problem. It's how does the problem affect your life?
Speaker 2:That is, and for me.
Speaker 1:I think for me that was probably the biggest change that I ever had in my clinic, where I started seeing first of all better results. But also where I started seeing first of all better results, but also where I started being more motivated to be a therapist, was when I started seeing it that way, when my brain took the switch from not oh, your problem is your life and everything around it is circumstantial. It was more no, your life is a bigger life and the problem is circumstantial. And for me it switched the way I treated people, but it has also changed the results of my clients that I found Well, I think that probably you know there's that great.
Speaker 2:You know no one cares how much you know until they know how much you care. And I think that if people know that you are interested in this broader, wider perspective, well I think they think they think well, this person cares they give up whatever.
Speaker 1:They give up what you can swear that's fine, but I'm a londoner.
Speaker 2:We swear like sailors, so you know this person gives a fuck right, yeah, and then I think here it's called bedside manner.
Speaker 1:It must be the same for you guys, but it's like for doctors, it's called bedside manner. If they have a good side bed bedside manner, it must be the same for you guys, but it's like for doctors, it's called bedside manner. If they have a good bedside manner, it shows that they care about the person in front of them.
Speaker 2:Well, actually I read somewhere and this may be highly inaccurate that in the US doctors get sued more for bad bedside manner than they do for kind of medical negligence.
Speaker 1:Medical malpractice.
Speaker 1:There was that, yeah and that might be wrong, I don't know, I haven't read that, but there was another one that showed that if a doctor gives a diagnosis while touching the client hand or foot and spends 15 minutes with the client within contact, versus somebody giving the diagnosis without contact, that individual was 30 more likely to recover with a positive prognosis. Okay, just just by touching them, which it leads so much to this idea. Okay, was the touch? Is it the fact that it's a biopsy? Is the fact that they're caring? Is the fact that they're present? They spend 15 minutes? So many unknowns, contextual, environmental things? Absolutely yeah, it's that. 20%.
Speaker 2:Yeah, absolutely so. I suspect that if someone feels like there's more connection, they're more motivated to change behaviour or they're more motivated to do so. I think there's a lot of confounders in there. But I also think there's an important lesson to take from that If someone cares, is that likely to create more of a positive therapeutic environment? And you know that would be that kind of ecological aspect, wouldn't it that? That kind of you know, environmental approach is that if we create an environment that's positive, are we more likely to have positive outcomes.
Speaker 2:And there's one last point that I think is really important. So we've got this element of the interview being diagnostic. So that would be hypothetical deductive reasoning. Right, that's what I was taught Then. Number two would be this wider life listening. But thirdly, this idea of listening to make the other person feel heard and fundamentally that's the most important is not because I could listen to you now, troy, and I could be doing this, but I'm listening. I could be whirring away in my mind about your diagnosis, but you could walk away and say, well, they didn't listen and I have been listening. So I actually think one of the most powerful things and this is the point of things like active listening is that you are showing someone that you're listening, and we don't always consider that active engagement is a big part of that.
Speaker 1:So I think you had a post a couple months or weeks ago, I can't remember, I think it was months ago about when a client tells you a story. That's not your opportunity to tell them your story.
Speaker 2:I don't remember it, but I say a lot of stuff, half of it's rubbish, and I forget it anyway.
Speaker 1:It was a post that was interesting because people come in and they'll say, okay, let's say undiagnosed low back pain, or like the lady that I was telling you about yesterday. She came in, she's had undiagnosed low back pain for a very long time now and the first thing that she feels safe with is me sitting there saying, just so you know, like I lost the disc between L4, l5 when I was 16 years old from two nails puncturing my spinal column and I had sharp, debilitating back pain for 20 years. I'm telling them my story so they understand. I know what it's like to live in a shitty scenario. But at the same time, since I read that post, I've wondered, when I say those things, if I'm like it might have been you, it might have been Adam, it might have been Paul, it might have been someone else, you know someone else I was listening to. But I remember thinking how much do I use my stories to take over the conversation versus let their story be affirming, let them know I'm here, I'm with you.
Speaker 2:Yeah, I think there's probably for some people and this is the dynamics of conversation, you know it can go. It's like going for a first date, isn't it? And I've been married for many years, by the way, I'm not, uh, I don't have much experience in first dates in the last 18 years, but it's like going for a first date or just meeting someone for the first time. The dynamic of a conversation has so much flow to it that you know you never know how something is going to be interpreted. So for one person, it could be like, oh my God, this person has experienced something I've experienced. It could be like, oh my God, this person has experienced something I've experienced. You know, they know what I'm going through.
Speaker 2:For another person, depending on how you do it, it could be this person is, you know, they don't know my experience. What are they telling me? So I think that it could work wonderfully with one person, terribly with another. But how do you know? That's the big problem about communication, and this is why the biggest part of communication skills isn't getting things right, it's adapting. And so when things go to shit, it's about thinking to yourself have I talked too much, have I said the wrong thing. How do I get this back?
Speaker 1:So let me ask you a question. So when I went to massage school, I did not learn observational techniques. I learned, you know, similar to what we talked about earlier learning signs and symptoms, diagnostic and all that kind of stuff. And we're not allowed doing diagnosis in North America, as massage therapists were. We're not allowed doing those so, but we're still taught. You know, look at posture, look at gait analysis, things like that. But before I went to massage school, I went to a program called special care counseling which was dealing with people with special needs, addiction or autism, neurodivergent things like that and we had, I think, in the three years that we were there, every year one of our entire semesters was taken up with observation, was learning how and communication, learning how to observe an individual, pick up an unsaid body language and also how to use your body language as a tool to communicate with them. Now what you're saying here is listening becomes part of that conversation and showing active listening. Were you ever taught you know body language, observational communication skill sets in your program?
Speaker 2:because I know that's not common here whatsoever, of course not, no, no, no, why, why, no, no, and yet, and yet this is a long time ago but and yet it becomes this key component to communicating do you know what this is where I think that part of being a good therapist, of whatever type, is just being a person, just being a good communicator, right.
Speaker 2:So are there some people that are just naturally good communicators, people who enjoy being around them, and are they going to gravitate into roles that maybe helps that and maybe that's where people get into things like massage therapy or acupuncture or any or these kind of less medical but still person focused roles. And actually it might be. That's why people seek alternative medicine because they do. They come in, they have connection, connection, they have an environment that's conducive to relaxation and and discussion and you build a relationship. And these are, you know, over a number of weeks, and actually I can 100, see why people seek alternative treatment outside of massacral type of treatment, because that's what they want, that's what they need for their problem. Maybe medicine is never going to solve their chronic pain, you know, because it might be immune-related and there aren't the drugs there or whatever. So seeking that help from somewhere else is fantastic for them.
Speaker 2:But I like communication, not because it makes me a better therapist. I believe it makes me a better therapist. I believe it makes me a better human. It means that I'm better at communicating with my family, with my wife, with my son, and I still fuck it up on a daily basis. But communication is about self-awareness and it's about trying and it's about thinking am I talking too much? Am I showing I'm interested? Am I trying to create connection? And the first point and rule of all of this stuff is just be aware and care. There you go. That sounds like something from the 70s about crossing the road, doesn't it?
Speaker 1:That's a good PSA announcement, but also to me, you're also describing, you know. I mean, I think the best way of describing it would be mindfulness, which is a term that-.
Speaker 2:You could call it awareness, couldn't you?
Speaker 1:Yeah, and every time I've looked up articles or, you know, listened to other podcasts about therapeutic presence, the number one consistent thing across the board has been mindfulness. Awareness is when you're in the room, you're mindful of yourself and the individual in front of you. It's a person in front of you and you're aware of their and they come in. They're anxious you find a way to bring them down. They come in they're lethargic and depressed you find a way to bring them up. You know a way to connect with the individual in front of you. And I think that mindfulness is so key to creating that awareness and that trust with the client or the person in front of you.
Speaker 2:So let's go back to the first question you asked me you asked me about where clinical practice and research differ.
Speaker 2:That's exactly it, I would agree. And one of the problems we have is we prize this research knowledge. You know, I, I know. Oh, rodney et al Not 2017 said who gives a fuck? Half of this is just knowledge tricks of people remembering shit. Right, people don't care about that. Do you know that?
Speaker 2:You know I could talk research methods and RCTs and all of these things till the cows come home, taught research methods and RCTs and all of these things till the cows come home, but I would hope that I've evolved enough to realize that that is not the knowledge that I think that makes people successful. But when you become a doctor or a surgeon, we prize the technical knowledge and the diagnostic knowledge. And when we look at research let's take the world of physio we look at research and we prize this research knowledge. And actually, sometimes the people who are the best researchers aren't always the best social people, or they aren't always the best at working with people, or they're not clinicians. Yeah, and that might exactly be what separates them. There's nothing wrong with that. Go to where your heart takes you and where your skills take you, but when we start to prize the knowledge of this is what it said in this RCT how do you actually care for a person?
Speaker 2:Then I think that that started to go in the wrong direction. And again, all of these skills. If we're selecting people to go to university into roles that require quite high academic grades, are we also making sure that they're suited in other ways to those types of roles?
Speaker 1:An example I often use in class is I'll take the average age of everybody in the class, so do you mind me asking how old you are?
Speaker 2:Absolutely. You have offended me. Now I'm joking. Go on, you guess, and then I'll tell you.
Speaker 1:I'm going to go ahead and say 43. I'm 45., 45. So you're 45, I'm 44. Right, there you go. So the average age of people who do podcasts on Friday, the 16th, at 1018 Eastern Canadian time is 44 and a half years old. And yet neither of us are 44 and a half years old.
Speaker 1:There's research versus clinical application. The information kind of applies but doesn't actually apply at all, and I think that's something people forget. When a client or a person is in the office, they go oh, you have low back pain. Well, the research gives us good statistical probability. If you're this age and this is your condition and this is what you've done and this is your active lifestyle and this is what you've been doing for X number of years, there's a probability that this is a good diagnostic and if we don't know what to do, if we were to treat you for that, you'd probably have a positive outcome. But it actually is just statistically relevant. It's not the actual person in front of you, and I think that's such an important detail and that's where that communication and that mindfulness comes in. It's I'm not treating a research, I'm treating an individual and I love that. I love how you tied it all together there.
Speaker 2:For me, that's great that I love how you tied it all together there. For me that's great, um, but I am going to put a little caveat in there. I am going to put a caveat because I I also think sometimes the argument and I'm not saying that you're making, I'm just saying there is an argument made that kind of, just because we aren't, we have statistical individuality, you know, and if you look at the ACT guys, haynes and all those guys, they're doing some kind of crazy stuff with statistics and you know these type of things Still doesn't mean that I still think we have to realize when things are statistically or mechanistically unplausible. Do you see what I'm saying?
Speaker 1:Because I think that we open the door sometimes yeah, if you can give an example, because that's an interesting way.
Speaker 2:Statistically unplausible yeah, let's say, we take chi meridian healing right or next week.
Speaker 1:My next podcast is with an acupuncturist, so this is going to be crystal chakra.
Speaker 2:Crystal chakra knitting or I don't know? Right, I'm going into the realms of craziness. Mechanistically, can we create a link beyond the happy coincidence, and is there anything research based that actually lets us say that that does have some efficacy, right? So is there plausibilityibility, is there some basis of efficacy?
Speaker 1:and I do think we still need those, even within understanding the average versus the individual and I think there we're beginning to, and I think that's a great example of improbable statistic relevance when it comes to clinic. But for me it's one of those things where we start getting into the realm of being in massage therapy. So you know, the ABMP published an article last year and there are 265 different recognized modalities in massage therapy. That's a lot. That's a lot.
Speaker 1:And I mean I started in manual therapy or in not manual therapy. I started in the world of caring, I would say as a Reiki practitioner. Now I haven't done Reiki in 15 or 20 years, but I started from the idea of spirituality and energy work and crystal ball healing and all those kinds of things. You know that's where, that's how I got into it. I've moved away from that, but that doesn't doesn't mean when I don't see that, I don't see it as a beautiful experience. I think the key difference and that is just something I try to tell my students is if I'm coming to see you to unwind, to have a stress reduction and to feel good, all of those things are beautiful and feel free and have fun and do them if I connect to it. But if I'm coming to you for knee pain because I can't move more than two flights of stairs. That's, I think, where suddenly it has to be. That's not the modality we're going to be doing today. We're going to be looking at medicine today.
Speaker 2:Because there isn't a plausibility or an evidence base. If you are stressed out, you're in pain, you're stressed out out. Those two things go quite hand in hand, right? Um? And I actually think one of the effects of acupuncture is you step, you've got a load of needles in you. You think, fuck, I'm not gonna move, I'm just gonna lie here in a dark room with these needles in me and suddenly my sympathetic system, or my parasympathetic system, kicks in and everything goes yep, right, absolutely yeah and down regulate down, regulate the nervous system due to environmental or my parasympathetic system kicks in and everything goes Yep absolutely yeah, and downregulate the nervous system due to environmental context.
Speaker 2:There's nothing wrong with that. But at the same time could lots of things have the same effect through the same mechanism, and that's where we get into the idea of nonspecific effects. And that's why, you know, I think, when we start to say, well, Reiki does this and acupuncture does this, actually I think that's where we're starting to get away from where we should be.
Speaker 1:And it's one of those things. The non-specific effects are something that, as a massage therapist, one of the things that's really interesting that I don't think a lot of people remember and I've had, you know, we talked about this and it's one of the questions I had for you about when you talk about the clinical conversation. So I'm going to lead this from two different points of view. With the clinical conversation, one of the positives to it is that the person in front of me feels heard, they understand. Oh, this clinician cares, they're thinking and they understand. So already I'm in safe hands. The downside as a clinician is I'm listening to this person, I feel them, I see them and I hear them. Now there is a higher risk Doesn't mean it's a guarantee, but there's a higher risk of creating an affinity towards the person in front of me. So now, if they don't get better, does it affect me as a human, or if they do get better, does it affect me as you? Transference, counter transference in psychological terms? And so the other component to that is approaching it from the other side, which is as a massage therapist.
Speaker 1:There are very few environmental, contextual situations where someone is undressed and being touched, if it's not your partner or doctor right and think of a massage like they're not always undressed, because sometimes they keep their clothing on, something like most of mine stay dressed, but normally you think of a massage. You're naked, maybe you're underwear on and you're under tables and you're getting touched kind of all over. You're avoiding the privates and that's about it. Most people who receive that version of touch and it's something we talk a lot about in massage school how to create, you know, healthy boundaries Most people who get that kind of touch end up creating a false relationship with the therapist where they go.
Speaker 1:I am closer to this therapist than I really am because they go. My partner touches me this way and a doctor touches me this way and my massage therapist, and they're the only three people on the planet who touched me when I'm mostly naked, and so they have this sense of trust and intimacy. So they open up and tell stories that massage therapist shouldn't be hearing, that we should never be hearing some of the stories that we hear, because they feel safe and feel trusted. So between me as a clinician, having a clinical conversation, creating the sense where I feel affinity towards the person in front of me, and then them being on the table dishing their soul out. Where do you find yourself creating that trance? And you're not a massage therapist, so you might not have that second component as much, but even the clinical conversation there is, that ability to feel close to them. So how do you create a healthy boundary where the person in front of you feels heard, safe and listened, but you're not also saying your outcome actually doesn't affect my day?
Speaker 2:Yeah, well, I tell you who I heard talk about this was I don't know if you know Jason Silvanale. Yeah, and I don't know whether we had this conversation in person or whether it was maybe online or whatever, and this has always stuck with me and it's this idea of you know you don't own their failures and you don't own people's successes. You know you don't own their failures and you don't own people's successes. And I actually think, if you're talking about clinical experience and I'm I've been around a while and I've been doing this for a while I think that's one of the things that experience teaches. It's not always making you a better massager or it doesn't always make you a better practitioner in a technical sense, but I think you learn to not get too high on your own supply or not get too down if it's not going.
Speaker 2:You know, I actually quite easily walk away from positive and negative situations now, simply because I think experience has taught me that that's what to do, and also a bit of self-preservation I don't need. You know, it's like being a manic depressive, isn't it? One minute's mania and you're up in the sky because someone got, you know, got a good result, and being down in that you cannot control that. So take the small wins, it's good. I mean, the other day I did get I I helped, um, I helped someone get a diagnosis of axial spondyloarthritis. They'd had back pain for about 15 years. They told me the symptoms and I said that's not musculoskeletal. I said go back to your doc. I wrote a letter to the doctor. The doctor said totally agree, went off and got the blood work and said this is autoimmune. And actually I did get high on my own supply a little bit for that, but that doesn't happen regularly.
Speaker 1:And I think if it were to happen, let's say, another 30 times, you probably would stop getting high on it. You start saying oh, it's just my clinical experience has led me to understand that X, Y, Z conditions are met.
Speaker 2:That's the likely probable outcome to understand that xyz conditions are met. That's the likely probable. For me it's very rare. If you were a rheumatologist it would be like breakfast and every day, yeah, yeah.
Speaker 1:So I think I think the clinical experience. It's funny because when we talk about clinical experience a lot most people think that means I'm becoming a better clinician, meaning I've, I've learned how to oh, I spotted patella from oral syndrome more accurately, I spotted it quickly and I knew to treat, or I knew not to treat kind of thing. But they don't correlate it to this idea of I'm creating healthy boundaries where I'm still able to create that connection. But I don't feel like it affects me personally.
Speaker 2:So I believe I have grown in my communication with my experience and my awareness of my communication. So I believe I am a better communicator. But I say this all the time when I teach I don't believe that I am any better at special tests today than I was five years ago.
Speaker 1:Yeah, would your wife think you're a better? Because that's the real test, right like it's the personal experience. Because I would say the same thing. My wife and I we've been together 15 years and we think we communicate better now, and I think a lot of it comes from all the neuroscience stuff I've learned. It's taught me how my habits of auto reaction, of anger well, where the fuck did that come from? Oh, that has nothing to do with you. That's me hitting my allostasis. I've hit my levels. That was.
Speaker 2:I need 10 minutes to go cool down before we keep this conversation going I mean, you could explain it for a neuroscience lens, or we could explain it through a behavioral lens. Do you see what I mean? And I and I would, I would probably it through a behavioral lens.
Speaker 2:Do you see what I mean? And I would probably go through a behavioral lens and I read a book recently called Super Communicators and one of the things it talked about was being on the same page. And so let's say you have a patient that comes in and they just want to tell you their story. They want to get something off their chest. They just want to tell you their story. They want to get something off their chest. They're frustrated, they just want to. You know, have their say. Charles whatever his face was, was talking about in the Super Communicators book is being on the same page with what you want from a conversation.
Speaker 1:Yeah, and sometimes we are not.
Speaker 1:We don't do that, yeah, and I think I think it leads also to that idea of um, you know, clinical or therapist, client person boundaries, where oftentimes more for massage therapists, but even for other people, I mean, you see it a lot in psychology where clients have unnatural attachments to their therapists and things like that I think what happens is they're not on the same page because it's left unsaid and it's one of the examples that I often use that don't leave it unsaid, make sure somebody understands I'm your therapist.
Speaker 1:These are, you know, like if somebody says something in a session and they're on the table and it's too intimate, I'll often be like I just want you to know, like I'm happy to hear that, but I want you to know this, that I'm not taking this personally. I'm making sure you understand that I'm hearing it, but I'm not going to address this or go into it in more detail because I'm not a therapist and this is my boundary. And I think one of the more entertaining examples of that is when men get erections during a massage. There are signs where it happens and sometimes it's a natural occurrence of the body, sometimes it's you were asleep and you woke up and things like that. Sometimes it's because they are aroused and they're idiots.
Speaker 2:Like in Friends.
Speaker 1:Exactly. But I think one of the funniest responses you can have to this and this is how I was trained to deal with erections on the table which is you stop the session, you look at the individual in the eyes and you say so I noticed you've had an erection, and it usually stops the moment pretty aggressively.
Speaker 2:But it's not left unsaid.
Speaker 1:And that's the key component. It's we are now on the same page. You have an erection. Is it because you're aroused? Is it because you're sleeping and you woke up? Do you need to turn over? Do we need to terminate the session? And it's the same page. There's nothing unsaid.
Speaker 2:So me and Adam had a discussion about this on the Better Clinician Project a while ago. We were talking about some psychological areas and depression and anxiety, and we were talking about when do you refer? And one of my boundaries is does it make me feel uncomfortable? And if it makes me feel uncomfortable, that's when I would say that's a boundary for me, that's something that I feel is better for someone else. So let's take suicidal thought. I had a patient. Well, I had a patient. Another physio sent me someone, um, and actually they, they were talking to me about some suicidal thoughts and I was like I'm just gonna stop you because I think this is yeah, I think this is something that needs to be explored.
Speaker 2:I'm happy to work with you, but it needs to be explored from another perspective as well, and actually it transpired that he was also working with someone about some of this stuff as well, and I was important yeah, I think.
Speaker 1:Thank god for that. I think suicide is one of those conversations that's. It's almost an easy example because everybody can sit there and say, oh, if it's suicide, I'm not qualified. They need to be with the therapist. This now needs to be a multi-disciplinary approach and we can still focus on their physiological symptoms, absolutely yeah but I think it becomes more complicated when we have examples like like I have a client.
Speaker 1:I had a client who I fired because I was uncomfortable with it, who, uh, talked about how her pain was the manifestation of being a median. A what story a median someone?
Speaker 2:who channels spirits from the undead? Oh yeah, okay, a medium.
Speaker 1:Yes, sorry, yes, and for me, I, I was like you know what I? This is the boundary for me, and that I won't have this conversation for any other reason than for me personally. It was. That's a cop-out. You, you're not taking the responsibility, you're using something. Now maybe they exist, I, I have no way to say that the metaphysical doesn't exist. There's no science to say it does, but that doesn't mean it doesn't. There's just nothing to say one way or the other. So I'm going to go ahead and say I don't know.
Speaker 1:But for me it was a hard stop.
Speaker 2:Yeah, I would probably say well, I probably can't help you. Then I would say my skill set doesn't. What did she say? It was Bad spirits. Did you say yeah?
Speaker 1:the spirits of the undead.
Speaker 2:Yeah, I would say ah, out of my skill set.
Speaker 1:You know, if they were spirits of the living, I could deal with it.
Speaker 2:Yeah, I would say I went to the spirits of the living day at uni, but I was ill that day, didn't get those skills and we're joking about it.
Speaker 1:But I think for any listener who doesn't like that we're joking about it. But I think I think for any listener who doesn't like that we're joking about it, feel free to write me, but I think what we're trying to get across is that if it is a boundary and it's something you're uncomfortable with, you have to find a way to make sure they understand this is not something that you're comfortable with and that makes you. It's part of that clinical experience. You learn your boundaries over time, with exposure exposure.
Speaker 2:Yeah, and actually a probably a less, uh, left field example would be spirituality, that some people believe that they've done something wrong, this is something that's punishing them. Yeah, you know, whether that be from a spiritual perspective or or, uh you know, higher perspective or more, you know, like a just a kind of lesser perspective, but again, those are areas that certainly I don't know if I'm particularly equipped to deal with.
Speaker 1:Yeah, and I think that's something that comes with that clinic, because then it also leads to that communication Same page If I'm not the person but it also promotes that idea of interdisciplinary approach. If I'm going to deal with your knee pain and you think your knee pain is coming from a spiritual component, well, I have a friend who does crystal healing, crystal bowl healing, so you go see them for that component and I'll come see you for the tracking component and then you can go see ben for the exercise component and between the three of us you'll get better. Now the only one, well, that was going to be my next question.
Speaker 1:So the last component I wanted to get at before I let you go was the interdisciplinary approach, which is we know where. That's where medicine is going. All the research shows us that no single therapist is able to handle the workload of the clients coming in, the patients coming into their offices, and that the majority of clients who seem to get better have a multitude of therapists. They're not just seeing one individual for everything, which leaves small communities kind of shit creek because they may not have the population density to encourage multidisciplinary approaches. It also leads to this component of clients are now stuck in a scenario where the research is showing us multidisciplinary is likely to lead to the most positive outcomes. But if that multidisciplinary approach some of it's public but some of it's private, where's this balance for the future in medicine? To say, well, we have to find a way to make it affordable. And yet it's not really research backed in regards to the mechanisms. But the research does show that the interdisciplinarian is the most effective.
Speaker 2:You are above my pay grade here.
Speaker 1:It's a question I have, for, I mean, it's kind of a question of the philosophy of the future of medicine, because it's something that pertains to all of us, but yet there's obviously no easy solution. Okay, let's go back.
Speaker 2:Let's rewind to the premise of this podcast. How does that interdisciplinary approach, how does that align with the ideas of therapeutic alliance and therapeutic presence? Because now you've got, can you have too many cooks spoil the broth?
Speaker 1:I absolutely can. But also at the same time, maybe somebody doesn't like italian food, maybe they want chinese food totally, so that interdisciplinary approach might give them all over. On on a monday I went and saw ben and he talked to me about the biopsychosocial approach and I had an affinity. And then on wednesday I went and saw a doctor and they told me all the research about why this is going to be effective. And then on Friday I went and saw my friend who's a faith healer, and I felt safe and my stress levels diminished. And between all three of them I'm getting better, even though there's a portion of my identity that only relates to individually each one of them.
Speaker 2:Yeah, but also you now take that you know life, job, have people got the time to do that kind of so?
Speaker 1:we've got two sides. That's the question. There is no answer to this. Should therapists become everything for everyone?
Speaker 2:And obviously we can't. The question here is the generalist versus the specialist, isn't it, I actually believe, given society? I personally think that for the majority of people, seeing a generalist is probably more powerful, but I do think for some people an element of specialism or multi-specialism is probably necessary. Should everyone get multidisciplinary care? I do not believe that. No.
Speaker 1:I think you're describing similar to my thought, which is generalist, but the longer with clinical experience you're generalists you become a specialist in general health?
Speaker 2:Well, yes, you become.
Speaker 1:your general specialism becomes much broader and much wider doesn't it, and you gain an expertise in it to the point where now you can be more things for more people and you don't need this, yeah.
Speaker 2:I would regard myself as health literate, I would regard myself as fairly psychologically informed, I would regard myself as fairly decent at pain science, so as long as you're learning and you're growing. But if someone comes to me and they need, they have clinical depression, then they definitely need to see someone else. Um, and so I think, whether they do that with both of our care, whether they do that with me first, then someone else, or whatever, I don't know, but I do think this is the point of can you learn everything in a three-year undergrad, or even a three-year undergrad and a master's? That's why maybe the clinical experience isn't, let's say, my kind of field, msk. You'd call that the physio field mainly, wouldn't you?
Speaker 1:Let's say- it's funny, I would actually call it more than massage therapy field because it's musculoskeletal, and physios in north america tend not to do as much of the manual therapy or musculoskeletal and they focus primarily on just rehabilitation, exercise, ultrasound, dry needling and or ultrasound e-stem, and that's it. They don't do anything with their hands, and when you say musculoskeletal, all I think of is hands.
Speaker 2:Yeah, that's just interesting, is that right, okay, yeah, all right um, I would say that the the experience it sometimes allows you to broaden your skill sets wide enough is that you don't just learn test this, you know special tech signs and symptoms, special test treatment that would be the classic wouldn't it? So I do my interview pattern recognition I'm going to confirm that for a couple of special tests I'm going to wiggle it. Oh, it hurts, right, that's a shoulder impingement.
Speaker 2:Let's do 10 of these and five of these and you've got your 15 minute blocks 45 minutes later out the door that would be a narrow view of treatment, whereas I think as you go along in your experience, you broaden out and you realize the multifaceted parts of what you probably need. And I think that's maybe where experience comes. You're not better at your core treatment. Maybe sometimes you're better at understanding some of the broader things that go on as well, and I would personally say the thing that I utilized the most would be behavior change I think I really like what you said earlier about therapeutic presence.
Speaker 1:You know how being in the clinic with clinical experience didn't make you better at your tests. You got better as a clinician but you're like the favor test and the Obertest, the drop empty can test. Those are the same as they were 20 years ago.
Speaker 2:I've gotten better at knowing and they're still shit.
Speaker 1:They're still shit. They're as shit as they were 30 years ago. Yeah, as somebody who specializes in posture analysis, we're going to go ahead and do inverted quotes on that, or gain analysis. The test is going to be the same as it was a long time ago and I'm going to agree, it's still just as unfounded as it was back then, but your bias might be more entrenched. Exactly, your bias might be more entrenched, but what does happen is that, even if that test isn't changing, your ability to communicate what you see and your results to the client improves over time. And this is the interesting part about, I feel, interventions in general, especially when it comes to tests. Even if the tests don't seem to be well-founded in research, if you can communicate it clearly and create trust with the client, the clients are still getting results, and that, to me, is really interesting.
Speaker 2:Whether that 50% of time buddy, no, but that, to me, is still one of 50 of time, buddy?
Speaker 1:no, but that. That, to me, is still one of those things. That's so interesting is that, you know, like a client who comes in and says, oh my, like I you I mean every therapist hear this all the time oh, my posture's bad, I sit there and I'm I'm slouched in my chair with my inner, with my intake, with my clients I'm slouched, I don't care about my posture, and people say my posture is not good and it's like well, that's fine, let it not be good. I don't really care about that, but it's one of those things that people attach to and yet when they start thinking about postural care, some get better, some don't I am better today at making people feel better.
Speaker 2:Right, and what I mean by that is I'm not better today at helping pain. I'm better today at making people feel better.
Speaker 1:Yeah, even if they're still in discomfort Does that make sense. Yeah, even if they're still in discomfort. Yeah, they feel better and more motivated that their future is brighter.
Speaker 2:Or less worried, less fearful. I am better at treating people today than I was 20 years ago, but that doesn't always mean I'm better at helping their pain.
Speaker 1:I think that is probably, for me, the best way to describe therapeutic presence is that I'm better at making people feel better, not better at making them get rid of their pain, and I think to me that's part of being a therapist and being present with my client, but to me that's part of being a therapist and being present with my client.
Speaker 2:Many years ago maybe 2018, 2019, it all blurs into one. I was presenting at the San Diego Pain Summit and I did a session on patient-centered care or person-centered care, and someone said would you still do it even if the outcome measures of pain and disability never changed? And I said, absolutely. Can you measure effectiveness of helping another human being solely by whether you help their pain or not?
Speaker 2:And it's the same way of saying you have a cancer patient, measuring your effectiveness by who dies or who doesn't, you know if you work in cancer. Some of your patients are going to die Quality of life. Along. That way have you helped them.
Speaker 1:Quality matters.
Speaker 2:You haven't stopped them from dying, but you've helped them, and I think that's what we need to remember.
Speaker 1:I absolutely agree and I think that's probably we need to remember. I I absolutely agree and I think that's a. I think that's probably one of the most positive notes we can finish a podcast on. To me that's fantastic. Thanks so much, ben. Do you want to talk about any classes? I know you teach in germany soon. I do have quite a bit of followers in the frankfurt area, so if you want to talk about any of your stuff that you're teaching to promote your core kinetic, feel free. The better clinician project feel free. This is your moment yeah, I get.
Speaker 2:Just if anyone doesn't know me, I do a lot of teaching internationally. Uh, classes coming up. I think I'm in germany. Uh, beginning of september I'm in cyprus. Um, I am in new york, getting down back to the big apple, um, I'm all over the place. And something people might be interested in is the core kinetic mentorship program and we do a lot about therapeutic alliance and communication and these type of things. So, um, I think I'm quite good at teaching about that stuff, but I might be biased it's okay, confirmation bias has its place.
Speaker 1:Thanks so much, ben. I really appreciate it. Thank you for having me.