What If The Real Treatment Is The Experience

Manual therapy is full of confident stories: tight fascia, “alignment,” trigger points that must be released, posture that must be corrected. Then real life shows up and ruins the script. People feel better for a day, or a week, or not at all, and yet many still say massage is essential. We dig into that tension with Paul Ingram of PainScience.com, a former massage therapist known for skeptical deep dives that still leave room for nuance.

We talk about what massage therapy can reliably offer without pretending it’s a mechanical repair job. Anxiety and depression relief comes up as a standout, evidence-based benefit, and we explore why that matters for chronic pain, suffering, and threat perception. From there we wrestle with the messy data on movement and exercise therapy: sometimes helpful, often underwhelming, but still a long-term play with huge side benefits for health, function, and resilience.

The conversation turns to “therapy theater” and the ethics of the stories clinicians tell. Is it ever OK to sell posture analysis if the client loves that narrative? Where’s the line between an engaging experience and a harmful myth that creates fear, dependency, or wasted money? We also get concrete: what new grads should stop saying, what they should start doing, and why the sensory experience, warmth, consent, and personalization may be the real foundation of effective hands-on care.

If you care about pain science, chronic pain, trigger points, placebo ethics, and building a better therapeutic alliance, this one is for you. Subscribe, share it with a clinician friend, and leave a review with your answer: what belief about manual therapy did you have to unlearn?

Transcript

Welcome And Paul Ingram Intro

SPEAKER_00 0:00

Hello, everybody, and welcome to another episode of the Sensory Approach to Immanual Therapy Podcast. I'm Shore Levine. And today's guest is Paul Ingram, who many of you may know from PainScience.com. He's a former massage therapist and a writer and author, specifically on the Painscience.com, which is where he spends most of his time. And welcome, Paul. I'm glad to have you here today. Thank you. Nice to be here. Now, I don't think I've spoken to you several times on the phone and on Messenger, and we've texted each other quite often in the past, especially when I have questions about some of the classes I create. But this is actually the first time we meet face-to-face virtually, and I'm excited about that. I don't think I've ever told you how I got interested in your material, and I wanted to actually start the podcast with that. No, I don't remember that. How did you get interested? Yeah, so in 2012, I remember reading your posts on MFR and Trigger Points. Yep. And that was like, you know, the bread and butter of my practice. That was 99% of my practice. Easily 99% of my practice. And I remember after reading them being less upset with you, which I know is a common occurrence. Standard, really. But more upset with the profession and frustrated because I remember having this crisis of faith moment. And for my listeners who've listened to the podcast I did with Michael Hamm, it's actually titled The Crisis of Faith because it was something that I remember having. And it was like, what have I been lying to my clients about? What have I been saying? And from that moment on, it really led me down the idea of, okay, let's study neuroscience. Let's see what touch does to the brain. Let's see how interaction what it does to the brain. Let's see what context does to the brain. Let's see how we can help our clients that have nothing to do with our hands, because that's just one component of our, what I call the theater of intervention or the theater of therapy. And so I just want to say thank you because it really, it really opened up my eyes. And I imagine it's the same thing for a lot of people. And even though you probably do get, like you said, standard frustration, possibly even trolls or hate mail, I'm sure there's also a large population of people who hear your stuff for the first time and it sits in and it helps lead them on a journey of more exploration into what they're doing and where this profession can move forward. So I just want to say thanks to start, because that's that's great.

SPEAKER_01 2:29

You're welcome. Thank you. Thank you for joining the team.

SPEAKER_00 2:35

And then it leads me to wonder what made you do it? What made you have that crisis of faith? Was there a specific paper? Was it just one day you woke up and it was like, oh my God, this is just I just can't believe we've been doing this. What what was the epiphany moment for you that made these changes?

SPEAKER_01 2:53

Criticizing over quackery provoked such strong reactions, was so triggering for some people that I began to get curious about why I started asking questions about everything, precisely because I was being told to stop. So the the attempt to silence me had exactly the opposite of the intended effect.

SPEAKER_00 3:35

Okay, well, that's that's pretty great. Now, you were a massage therapist, and I know one of the biggest things that I know I get this question, and I'm not near as I would say informed, outspoken, or possibly even concrete in my thoughts. But I know I also still get people saying, well, how do you still do massage then if you're talking about it this way? How do you still, you know, talk, how do you still have a clinic and stuff like that? Yep. And I know you don't, but but I could. You could, exactly. What is it that makes you still go? Okay, we have this big body of evidence that shows that what manual therapy is is not what we thought it was. It doesn't detoxify, it doesn't do it doesn't do XYZ. Our mechanical forces are not significant enough to do whatever results are, especially a lot of the stuff that's still being taught, not only in baseline education, but especially even in continued education. And yet, you even talk about it when you're posts, you still like massage.

SPEAKER_01 4:36

Yeah. So I I still buy massage and and I would still happily supply massage if it worked for me professionally to do so.

SPEAKER_00 4:45

So, where in your brain, I mean, these two opposing forces, which at least they seem to be opposing forces. Yeah, yeah. It's an illusion. How do you yeah, how do you reconcile them? How do you bring them together in a place where therapists who are sitting there and riling against what you said, you get to say, hey, look, no, just because this is true doesn't mean massage therapy isn't true as well.

Reconciling Skepticism With Loving Massage

SPEAKER_01 5:07

Yeah. Yeah, massage feels fantastic. It's inherently pleasurable and relaxing. And there are good reasons for that that don't have to have anything to do with the traditional explanations for why manual therapy works. It's it just we were just focused on the wrong thing I was in my career. And actually, let me let me qualify that a little bit because I I'm I am weirdly on the fence about trigger points. And my career was entirely based on doing trigger point therapy for 10 years. But I don't entire I don't entirely regret entirely basing my career on trigger points. I think there is value in trigger point therapy as an experimental treatment, properly framed, humbly, with informed consent, with avoidance of the greatest risks, including the risk of wasting money. Properly framed, I've got no problem with doing trigger point therapy. But most of the value that I think I delivered to clients was coming from the therapeutic interaction, from the time that I spent with people, the curiosity that I showed, the compassion that I demonstrated, the pleasant sensory experience above all. We know that in fact the only truly evidence-based benefit of massage therapy, the only thing that we can we can say with confidence, we can point to and say, yes, that is definitely, you know, essentially a proven benefit, is the reduction of anxiety and depression. And that's not a small thing. It's not. No, it's huge. I mean, you think it's think about how hard it is to treat anxiety and depression by any other means. I mean, having any impact on it at all is fantastic.

SPEAKER_00 7:03

And and if you look at like pharmacologically, the the impact financially of anxiety and medication. And I mean, I know in some countries, like when I used to live in the US, if somebody said I was getting burnt out, it was like, well, tough luck, go to work anyways. Now, here in here in Quebec, the you know, we say épisodement French and we say burnout, and people get burnt out, and it's it's accepted that your organization is going to allow you to take time. It starts with a minimum of three weeks and it can go much further than that, but it does become part of the culture to say, hey, we we understand as part of it. And you think anxiety, depression, mental health issues like that is that is impactful to say the least. So if it can't do anything else and it only does that, that's already an incredible imprint.

SPEAKER_01 7:47

Yes, even if that was literally the only benefit, it would still be arguably superior to talk therapy.

Anxiety Relief As A Real Benefit

SPEAKER_00 8:01

Well, and then it leads to the next question. So let's say it treats then like we know that it helps doesn't treat anxiety, it helps reduce anxiety. And so let's say we're now reducing anxiety, and then you go, well, what's your anxiety about? Well, you can have anxiety about family, finance as well. But one of the big ones, which I know you talk tons about and possibly talk to the point of fatigue, but also probably till the point of interest, anxiety around pain. Yeah. Right. So, like if you can reduce anxiety, I guess the next question is does that help pain? And it's a it's an interesting question because the research would say, yes and no. Some people are in the absolutely the allostatic load camp, which I fall into, which is going to be the culmination of your lifetime and the perception and the brain's interpretation of it, can enhance your pain experience. And then there's others who say no, pain is a separate experience. It can't be this conditioned thing, it can't be this thing that is enhanced through mental the boot and the nail boot guy is a good example of that, right? So like there are these theories around it, and yet if we know anxiety is reduced, it may not reduce your pain, it may reduce the suffering, which is pain adjacent, but not technically pain. So if it can reduce anxiety and depression, where does that, you know, where does that bring us when it comes to the mechanistic nature? Because now anxiety, depression, these are not going to be mechanistic. They're going to be outcomes. And yet pain tries to be explained mechanistically. So, and and most massage therapy, especially when we're in school, is taught, even all manual therapies, as mechanistic. You put your hands on someone, you apply force here, with this amount of pressure, you move in that direction, strain, counter-strain, inhibition, all that kind of stuff. If anxiety, which are these conceptual things and mental state things, have an effect, what is the effect then of massage therapy or manual therapy on the mechanistic nature of the body?

SPEAKER_01 9:55

Mm-hmm. Via the reduction of anxiety.

SPEAKER_00 10:02

Via the reduction of anxiety, which is a good starting point, because then it's a conversation which is theoretical or philosophical in nature. It's not going to be proven. It's going to be, well, maybe these are the outcomes. And then the other part of that question would be, no, the actual impact of your hands on the ball, which is a harder one for us, I think, to answer what it does, easy to answer what it doesn't do.

SPEAKER_01 10:22

Yeah. Um I I mean, I still have I still hold some hope with regards to trigger point therapy. Uh, that there is a that there is an effect there. Uh and the reason we haven't got the evidence is not necessarily because of the absence of an effect, but simply an absence of the evidence. That's fairly common in alternative medicine. We often don't have enough of the right kind of research to answer a question properly, which allows um quacks to keep keep making claims, but also allows legitimate hope to be sustained uh up to a point. Um so I hold out some uh hope. I have I have some optimism remaining for some of the possible effects of actually putting your hands on someone's uh tissues. Um but not a lot. I mostly assume that the experience of massage and what's good about it is about having a fascinating sensory experience. Uh that all of the mechanisms are neurological. Um whether reduction in anxiety reduces pain, uh, and we can dive in, you know, we can and probably will dive into more detail on any of these points. I'm trying to sort of get some highlights in here. Uh uh the i it seems very clear to me that we don't have the evidence to say what the effect of anxiety on pain is. I think it's extremely clear that anxiety can go down and pain can go on. Anxiety can can leave and pain can stay. I've seen it, I've experienced it. Um there's definitely nothing magic about reducing anxiety. Uh it doesn't suddenly make pain go away. But that doesn't mean there's no effect. Um, and it doesn't mean there can't be a profound effect in some cases. Uh, but we're definitely lacking the evidence, and uh evidence of absence is piling up. There is more and more there are more and more clues in the evidence that simply reducing the perception of threat or anxiety or fear or uh fear avoidance doesn't do it. And i i in some ways, even some of the big wins, um uh for instance the restore trial of cognitive functional therapy, widely regarded as good news, as a good news study, uh it showed you know substantial increases in function, uh, but not pain. People got a lot more confident, but they didn't get a lot less hurty. And there's a fair bit of evidence like that piling up now as well.

When Movement Helps Pain And When It Doesn’t

SPEAKER_00 13:19

So let me ask you about that, because I I I find that to be one of the more unique points, because a lot of times manual therapists they'll I I feel inappropriately tout their treatment as the reason somebody gets better. And oftentimes I feel, and I think I've read it once on your blog, uh manual therapy might give a temporary um alleviation of symptoms, which gives them confidence to go be active. I theorize my my theory would be okay, massage therapy or manual therapy in general gives them confidence to move, and the movement helps them improve. The movement is likely the thing that's gonna cause reduction in pain, reduction in inflammation, change of fluid dynamics throughout the system, change of stress on the tissue, allowing for healing to take place, especially if they move within limits of discomfort and things like this. But that's not massage therapy helping. That's massage therapy easing to give them confidence. Now, it seems almost like a a lot of people say, oh, it's a moot point. I don't think it's a moot point. It means movement is the thing that helps them. A healthy lifestyle is the thing that helps them the most. You're just giving them a window into that. You're you're opening a door for them just to do that, as opposed to, oh, what you're doing is the is the cure or the treatment method. So do you find that the research around movement therapy, exercise, walking, being active, or even rehabilitative in nature seems to have similar black sheep as manual therapy? Oh, the pain research doesn't show that movement helps, or the pain research, you know, this the research shows that movement does help XYZ.

SPEAKER_01 14:57

Yeah, it's a real mixed bag. It's real good news, bad news. I mean, basically, what you we're getting to there is does increased activity uh and exercise treat pain? And uh and the the general answer is um no, there are lots of kinds of pain that just aren't gonna budge because you get more active. Um but like manual therapy itself, there do seem to be some benefits for some kinds of pain. Um and we know that when people get more active and more fit, they do better with osteoarthritis, for instance. Um and we we essentially see exactly the same pattern um with manual therapy and exercise therapy. Um kind of, you know, good news, bad news, there are results, but they're also kind of underwhelming. And so you you'll see posts from experts and influencers um pushing both ways and saying, Great news, everybody, exercise helps. And uh and then the next day you'll see, eh, exercise doesn't really do anything, not really. Um so we're kind of the same dilemma. You know, what what do we make of this? You know, yeah.

SPEAKER_00 16:12

I think I think one of the only differences is that let's say movement doesn't help with pain, being more active seems to have other health benefits, cardiovascular, you know, fat loss, adipose tissue, increase in VO2, increase in oxygen, increase in dopamine from being outside, maybe a connection to nature. There are all these that you may not get with manual therapy. And so even if the results of exercise therapy are still, you know, good, bad, all the secondary effects seem to be really good for you, like decrease in dementia, increase in bone density, all these things like that. So that it seems to be like the good category might outweigh the secondary effects than the bad category.

SPEAKER_01 16:56

Yeah. And it's it's a long game. This is uh, you know, with manual therapy, we're talking very much about, you know, are are are you better within days, weeks, months at the longest. Uh, but with exercise therapy, we might want to look at a completely different window. And most of the research focuses on, you know, short to medium-term effects of exercise. And and even the longest-term studies uh have, you know, more or less maxed out at a year or two. Um, but the reality is it may take much longer. It is perfectly plausible that a serious long-term five-year plan to increase fitness could lead to substantially reduced pain uh with a wide variety of conditions. That's possible. No one's ever tested that. That's that study hasn't been done, and it may never be done.

SPEAKER_00 17:53

Yeah, it would be costly and effective, and a lot of variables and hard to isolate, and almost almost imaginable to think of an institution that'd be willing to put money towards that. But it's an interesting point because I do a lot of personal training programs for my clients as well. You know, they're in pain, they stop moving, they stop being active, and now they have a reduction in symptoms, and suddenly they want to start being active again, and they go do something and they do it like most therapists see across the world. They do it like when they were not injured. And they think, oh, I was lifting 80 pounds, I'm gonna go lift 80 pounds, and then they get re-injured. And so we do we do programs that are specific to get back to weight training where you can be active again with lower risk of injury.

unknown 18:35

Right.

SPEAKER_00 18:35

And I tell them, don't think in terms of weeks or months. Think in terms of the change is so gradual that within one year, 12 months to 18 months, you'll sit there and you go, Wow, I really feel different, but when did it happen? And it's so subtle that in theory, by the end, you go, you have the result, but you can't point back to a day and go, oh, that's the day my life changed. It's I just suddenly started feeling better over time. And that's that long-term gain with exercise.

SPEAKER_01 19:02

And it's not just long-term, it's also, and I'll swear to really emphasize this, it's really fucking difficult. It can't, it can't be overstated that this is something that many people will never achieve. Significant weight loss, significant increases in muscle strength, significant increases in fitness. These are very hard jobs. Those are really difficult goals, and many people will fail at them, or their progress will be so slow and so erratic over 10 years. They're demoralized. They're demoralized at multiple points and remoralized at other points. Um and it will, and the point here is it will be completely unclear 10 years down the road when they're finally doing better, whether or not the fitness was the thing.

SPEAKER_00 19:55

Yeah, chances are they'll associate it to the last thing they did.

SPEAKER_01 19:59

The last three months quite likely. Yeah.

SPEAKER_00 20:01

The last three months of my life is the reason I got better. Yeah. Not in the last 10 years of my life leading up to those last three months. Yeah. Yeah. And and I and you said it right there. It's a tough job because, you know, like I worked with a lot of high-end athletes. Well, that's their job. They they take care of their body for a living. And they're still not pain-free. Let's let's not assume that's a good thing. Yes, let's be clear.

SPEAKER_01 20:20

Just because they're fit, which is another another basic argument, isn't it? Just just keep it too much.

SPEAKER_00 20:27

They're really not. But for everyone else who has a full-time job in a family, suddenly, oh man, that's and or like it can maybe they can't afford gym, but they also can't afford free weights, you know. So suddenly it's more than a job, it's inaccessible almost.

SPEAKER_01 20:42

Yeah. Yeah. Yeah. In this economy factor for increasing fitness, which is why it was zimbic matters. This is why the uh semiglutide counts, because it helps people um achieve that metabolic upgrade um that is for all intents and purposes it it's impossible for a lot of people. It's let's call well, let's say let's not say impossible, let's say inaccessible. Or or extremely difficult. Yeah, exactly. So difficult that in practice, 90% of people will fail.

SPEAKER_00 21:19

Unattainable.

SPEAKER_01 21:20

Mm-hmm.

The Long Game Of Fitness

SPEAKER_00 21:21

Yeah. So when when you speak about the exercise stuff and you think about the long-term gain, right? Let's see one, two, three, four, five years out. Yeah. One of the one of the consistent theories, I don't know if you are familiar with the book How Emotions Are Made from Lisa Barrett Fellman. She talks a lot about the prediction theory behind the brain and things like this. But one of the things that is talked about in that book a little bit is the resilience of the brain. And it's one of the common things that is more hypothesized than exercise theory, which is you're enhancing resilience. And as your resilience increases in theory, be it pain threshold changes because perhaps you're more resilient to it. It's one of those leaps in logic kind of thing. It's not a direct this, therefore, that. It's a leap in logic. But even if it wasn't just related to pain, let's say it's related to mental state, let's say it's related to energy balance, let's say it's related to motivation throughout the day, that long-term gain. Is it possible that resilience is the thing that might be changing the most? The habit-forming behavior of consistently pushing your boundaries, consistently pushing your limit to get up and be active, to eat healthy, to change your lifestyle over time. And that experience is what's allowing the brain to say, okay, focus so much on this resilience or this resistance or this effort that similar is it just being distracted away from the other experiences of discomfort? It's more a philosophical question. It's definitely not a study or anything. It's more is that is that possibly something that's happening in the brain? Because a lot of my theories are just theories and they're theories only. And I wonder if resilience might be the result behind exercise change.

SPEAKER_01 23:02

Yeah, I mean, it's possible. It's it's plausible. I I've got no problem with the idea out of the box, but I also immediately see some problems with it. Having a toe in the world of chronic illness, um, I'm well aware uh of how many people are extraordinarily disciplined and yet nevertheless struck down. And uh the world of chronic illness is full of stories of people who were highly resilient, highly motivated, very functional people, without really the slightest indication that they uh might be susceptible to illness as a character flaw. Well, I mean, it sounds ridiculous when I put it that way, but that's sort of deliberate. But that that's it that's exactly how it does get framed. Um chronic illness patients without obvious explanation for their illness or pain are in fact diagnosed as having a character flaw effectively. They are treated like that. And uh and so uh to circle back to your question, um, it's pretty clear to me that people can be highly resilient and yet continue to have pain, just like they can get a lot of great manual therapy, just like they can do a lot of fitness. Um uh resilience is manifestly evident in lots of patients with ongoing serious health issues. Um but that doesn't mean it's impossible that it is the mechanism by which fitness does good over time. It could be very hard to study, though, I imagine.

SPEAKER_00 24:53

And I think I think you're you're getting to a point that I've often wondered, and I I'd love get your insight on this. When we're talking about chronic pain, so let's say somebody has like, so I've had I had my ACL redone in 2007, and I had both my meniscus, I still run, I ran a half marathon this summer, I'm bone on bone, and and and I had a flare-up in the fall, and I've had knee pain for 20 years. Technically, what you would call chronic pain. Sure. But I've also gone through extended periods of time ever since I started, especially specifically weightlifting and working out, where I have no pain whatsoever. And I think possibly, I'm wondering if pain science in general is missing enough. Yeah, I know we have no susceptible, neurogenic, and neuroplastic and all these other and acute and subacute and chronic and rehabilitative pain, all these terms for pain, which is definitely overwhelming and also under, I think, still not enough at the same time. My question would be when you talk about people with chronic, when you talk about people with chronic pain, like you're talking about with illness and stuff, yeah, like someone with chronic, non non-specific chronic low back pain, right? If they find relief, let's say from resilience, let's say from exercise, let's say from manual therapy, some version of intervention. And then somebody else has, let's say, Crohn's or fibromyalgia, you name, you name the reason for their chronic X insert X name, right? Okay. One one gets better and one doesn't. And let's say there's two large pools of data. Some over here get better, some over here don't get better. Is it possible that pain, even though it's an evolutionary role, is it possible that it's behaving differently in these individuals versus these individuals, even though in theory the human behaves pretty similarly across the board when we look in the big scale of evolution? You know, red blood cells tend to do the same thing, white blood cells tend to do the same things. We have not uh abnormalities, but most of them tend to do the same thing. Is it possible that chronic pain sufferers aren't finding improvement? Is it possible that we haven't fully understand the mechanism of their pain yet and that it needs a new category for it compared to those who are finding improvement?

Why Chronic Pain Comes And Goes

SPEAKER_01 27:09

Yeah, okay, sort of two questions in one. Yeah, of course it's possible. Um whether or not it it lines up with people who seem to get better and people who don't. I'm gonna go with probably not for that one, because there are too many variables. And we're we're you know, I I think biology is destiny, and there are lots of hidden biological and pathological variables that determine whether or not we get sick and whether or not we get better, most of which are unmodifiable, out of our control, and more to my point, out of our awareness. We have no idea why it comes and goes in most cases, I suspect. Um you spoke of your pain coming and going over the years. Sometimes you have fairly long periods of remission. I think you are associating those with periods when you were more active at the gym.

SPEAKER_00 28:09

Yeah, usually. Usually they're more related to my leg being strong.

SPEAKER_01 28:13

Let me give you a counterexample. Um, my father is a um a veteran. He was shot uh and his femur was shattered by a bullet, just bone chips from knee to hip. And he has had many complications over decades from that, um, and uh uh including severe osteoarthritis of the knee. He goes into periods of remission for a year or two at a time. He's had over the last 15 years, he's had about you know five good long patches relatively pain-free. And every time he flares up, he's kind of panics and he thinks that's it, it's never gonna get better. And I remind him, no, it it comes and goes. And he's he's baffled by that. Why would it come and go? Like, why wouldn't it just get worse and worse and worse? And why wouldn't it just get better and better and better? Or that, right? And I and I it's my general answer to that is that I think mostly pain um rises and falls with the tide of metabolic changes that are just as complex as the movements of the oceans, that predictable and aggregate vaguely, but you know, any given day, who knows what you're gonna get out there. And uh, and so that's you know, he he's never he's never been to the gym, but his pain too comes and goes. Yeah. And uh, and so I think it it's it's conceivable, but I I don't think there's much hope that we're going to line up uh uh people who seem to get better with uh one identifiable biological factor pattern.

SPEAKER_00 30:07

Well, and uh you actually almost just actually contradicted with the last thing you just said, which is metabolic. You know, like that would be one thing. It's just it's one big thing. You know, like interoception essentially is one really big animal. And so it's like, is it these markers, is it these proteins, is it these molecules, is it this behavior, is it these hormones and flare up? You know, it's it's it's it's almost too large of a component to count, but it is also one thing, which is essentially you as a human.

SPEAKER_01 30:37

Yeah, it's a real mixed bag, it's real good news, bad news. I mean, but basically, what you we're getting to there is does increased activity uh and exercise treat pain? And uh and the the general answer is um no, there are lots of kinds of pain that just aren't gonna budge because you get more active.

SPEAKER_00 31:01

Um but like manual therapy itself, there do seem to be some benefits for some kinds of pain, which which kind of brings me back to something you spoke about earlier, which again, like you said, we're probably gonna del go into it a little bit more, which was the therapeutic alliance. You know, like if it is just one person, an interoception is this internal experience with a metabolism and all these other things, but impacted by the external world, you know, like if I see a bear, I have cortisol spike, I have adrenaline spikes, right? So my interoception is definitely affected by the exterior world. But if I also walk into a massage room and I see and I smell lavender and I hear music that makes me think of a relaxing massage, I may all have some may also have an opposite aspect.

SPEAKER_01 31:50

I was just gonna say, I hate lavender.

Therapy Theater And Ethical Storytelling

SPEAKER_00 31:52

Exactly, right? For me, it's patchouli. For me, it's patchouli, like no way, man. Oh, it doesn't do it at all. Lavender, I don't mind, but I also lived in the south of France and it makes me think of all those beautiful moments. So the question then would be if the metabolic behavior, my the neuroimmunology, the metabolism, the hormones, my wife is going through perimenopause, I know you recently had a post about that. You know, like all those, all those internal factors that are playing into it, should the theater of therapy not be trying to, instead of putting my money into spending education, professional development on what I can do with my hands, the next modality, should I not then be spending it on every magician's trick in the book to make that therapeutic alliance better? Make that charisma the most powerful thing in the room. And if it means rock and roll or a yellow wall or a rainbow-colored art to allow everybody to feel safe because it's a safe space, does it mean I need windows and plants? Like, should I not be therefore spending my money on the therapeutic alliance because that could affect their interoception behavior? Yes. Fair enough. There you go. Care to elaborate? Any idea, any insights on this?

SPEAKER_01 33:15

Yeah, I mean, I think I think that's the game. I think there if the term therapy theater, you know, has a bit of um a bit of a stick, uh a bit of a stink on it, um, because it essentially comes out of critical analysis and skepticism. The implication being that the theater or the therapy is just theater. Um, but uh in the same way that it's there's nothing just about reducing anxiety and depression. There's also nothing just about an ethical theatrical, a non-deceptive theatrical experience. Now, maybe this is very tricky and weird. It gets, you know, there's there's some fun ethical questions in here. Um, you know, what we go to the we go to the literal theater to be entertained by a story that is a lie. It didn't really happen. Even if it's a fiction, right. But we love stories and are deeply moved by them. I was watching uh Taskmaster in New Zealand last night with my wife, and uh there's a there's a contestant on uh season five who's um an autistic lady with a PhD in theater studies, and my wife says a PhD in theater studies. What's that? And I've got a background in theater.

SPEAKER_00 34:35

Means she did a lot of plays.

SPEAKER_01 34:37

I don't my I could I could only respond, you know, with uh a nerdy shuly hun theater matters, theaters, you know, telling stories is a really important part of life. That's there's a lot there. There's a very rich history to storytelling, and it merges with healthcare. Uh, stories are important in healthcare. We talk, um, you know, again, kind of kind of coming at it from the skeptical angle. Um there's often a dismissive um uh tone regarding the quote-unquote narrative of a therapy, the story that is told about uh what's going on and why. And the reason that it tends to be a negative you know implication, the the insinuation that a narrative is bad is because a lot of the narratives are shitty. They're stupid narratives.

SPEAKER_00 35:35

So a lot of the narratives we're to we're taught in school that the narratives are modalities, that the narrative is what I'm doing to your body, and that's that's not the narrative. The narrative is the experience being essentially co-written between two individuals. Yeah, and I and I think that's a hard thing to get students to understand.

SPEAKER_01 35:55

And and my point is that it's not that that it does the problem, isn't with narrative itself, it's with specific narratives, uh, in the same way that there's you know, you don't go to a bad movie and say, well, all movies suck because that one was bad, or because every movie I've seen for for the last six months has been bad, therefore um all of cinema must be terrible. Um there is such a thing as a good narrative. And uh and there are there are good ways to create therapy theater and ethical ways to do it. And for me, the baseline is do whatever you like as long as you're as long as you're honest, and as long as the the person has a pleasant experience. If they have a nice like that's the bedrock. If as long if there's nothing else, if there's no other benefit, they can still walk away and say, well, at least it was a nice hour. Um begin with that bedrock and then see if you can build up to something you know better, uh, essentially leveraging the idea that that you um framed your question around, which is that maybe uh interoceptively things get interesting if the experience is rich enough or fine-tuned enough to the person, uh, in the same way that you can watch a bad movie and have absolutely no emotional impact or benefit from it, but then the next movie you see changes your life. You're you're you're never quite the same again in a good way. Uh, you can be deeply and profoundly inspired by the right story, and that can probably happen in massage as well. And it's not because uh a fascial distortion was banged out of someone's back, but because they had a profound sensory experience that changed their impression of themselves. Um, so I think therapy theater can be made into a virtue and in fact should be the point.

SPEAKER_00 38:17

So let me, I I just a few things I want to go into. One is going to be ASMR later on, because we talked about you know the feel-good sensations in the body with interoception. And I've had several podcasts on ASMR, and I actually teach an ASMR massage. Because I happen to get I have I happen to get ASMR responses. So I teach an entire Hato class, eight-hour class about essentially getting the chills with no relief. And people have taken it, it's it's one of my favorite versions of treatment. Like I would rather a back scratch from my wife or my kids than a massage any day of the week if I'm in if I'm in pain, just scratch my back, everything, everything is better. The whole world is better. Great. But but going to the narrative of the stories, using some of the examples you use, which I understand are just you know on the spot. So it's it's not a fully refined theory, but let let's say it's a horror film. I hate horror films. I love suspense, I love thrillers, comedies, Taskmaster is one of my favorite shows, all that kind of stuff. But my wife, she doesn't care for Taskmaster, and she doesn't like action films and stuff like that. So my question would be if that's the case, and let's use fascial distortion method, since you had said fashion distorted. If I go get a massage and I get results and and I like it, and let's say they do posture analysis, which people know that I'm completely, I think posture analysis is bullshit, whatever, that's fine. So if I go get a massage for the first time, or chiropractic or PT or any version of manual therapy, I'm gonna use manual therapy from now on interchangeably with all those terms. Um and I get posture analysis and I like that story. Yep. It's the type of story I like to hear. It's the John Wick, it's the story I like, and I walk away going I enjoyed it. Yeah, does that mean it was bad? Is that good theater? Is that good theater?

SPEAKER_01 40:06

Is telling people what they want to hear, good theater?

Placebo Questions And High Stakes

SPEAKER_00 40:11

It's a good qu to me, it's a good question because when it comes to research, no, not at all. Not at all. But I'm also a clinician. I'm not I'm not only interested in research, I'm interested in outcome. Yep. Now, if I give them the story of the posture and they walk out going, hey, I felt better, does the ends justify they walk out going, that's a story I relate to? And and and I it's a it's a philosoph again, it's that ethical question of does the ends justify the means, even if you're upfront and honest, the whole idea of you know, open label or not. If I say to them, hey, by the way, I don't know if the research behind posture is really validated. Theories are that it doesn't do what it says it does, but we're gonna go ahead and do a postural analysis on you anyways. I'm I'm telling them and I don't think it's real, and then I do it anyways. I tell them I don't think I can find a trigger point because I don't think I can, and yet I go ahead and I do something similar to trigger point therapy. I don't think myofascia can be stretched by mechanical forces and that I'm gonna go ahead and do some version of that because it elicits a sensation in the brain. If the client or patient latches onto the story and they enjoy it, who am I as a therapist to say, my story is not good for you, or you don't like the story, or here's a different story, one that you may not like as much? Does the outcome not justify it?

SPEAKER_01 41:36

Yeah. I mean, that this is going to a very clear place ethically. It's unavoidable. We're going to end up asking whether or not placebo is ethical. Oh, we can talk about that.

SPEAKER_00 41:50

I teach a class in placebos. I know how you feel about placebos, I know how I feel about placebos. And absolutely, I agree. Yeah, it's just even if let's say it's not even a placebo, let's say it has to do with anxiety and depression, which why they get better, sure. Mechanism, possibly placebo. Outcome, not placebo. We see that it seems to help. So even if we're thinking placebo open label or not, doesn't really matter. It's more if the story is something that they enjoyed, who am I to say, oh, you don't like the you didn't like the Marvel movies, you like DC more? Right, who am I to say that?

SPEAKER_01 42:26

I I mean that you can ask exactly the same question about much more specific medical interventions. Um that and that's why I say this is you know it inevitably going to end up at the placebo question, whether or not placebos are ethical. Because you can you could frame that question that you just asked me exactly the same way about medicines. And that you know, the the doctor says to the patient, well, I'm gonna, you know, we're gonna give you what you want, whether it's right for you or not, because that's the story you want to hear. Um, and uh and I think we have pretty good reasons not to practice medicine that way. And therefore, I think we have pretty good reasons not to practice therapy theater that way. Um the i i it there's a gray zone, there's a big old gray zone between overtly, you know, delivering a narrative that you essentially know is bullshit, um but you're doing it because uh you think it will evoke a response in someone, uh and that that response may be valuable, maybe, may be potent. Uh so at one extreme you've got that, where the the the clinician knows full well that they are um basically lying.

SPEAKER_00 43:50

Yeah.

SPEAKER_01 43:51

Um and at the other extreme, um you've got completely earnest, well intentioned. I sincerely believe that this story makes sense. Uh and uh and and may also um work for you.

SPEAKER_00 44:07

And it got it comes to a tricky point because if a patient goes to see the therapist who says quite clearly, I don't think this works, you know, and the client doesn't get better, and then they go see another therapist, as most people do, and then someone says, I do think it works, and they get better, and yet the research says it doesn't work, but they got better because they like that story. Did the first therapist not did the did the first therapist not do them a disservice by not giving them, you know, giving them the movie they wanted to see? Like you advertise Terminator and you won't show up and it's Rocky kind of thing, right? But it's just it's more, it's again, it's there's no right or wrong answer to these questions. It's just it's it's that philosophical thing of like where are we as a practice, especially since let's let's talk about higher medicines. Let's say it's you know it's medication or pharmaceuticals and things like that, or even a surgery or something like that. I think the answer in more modern medicine, it's a little there, the area of gray is smaller because the risk reward is so much higher in the risk category. If I cut you open and take this thing out of you, or I give you this medicine that's gonna fuck with your metabolism or your interobsession, outcomes could be quite severe. Higher stakes, yeah. If I massage you wrong, so you wasted your money. Okay, for some people, that is significant. Socioeconomic status is a thing, that's a big deal. But for most people, the it's not the end of the world. I'm not saying it isn't the end of the world for some. I'm saying for most people, they go, oh, it was it didn't take energy. So it's one of those things where the shade of gray is bigger because the risk reward is less intense in the manual therapy profession. So does that therefore make our storytelling does it change our approach, or is it more just, hey, if you have the report of the client, they're gonna get better. And if they don't have the report with you, they're gonna go see someone else. And even if their story research shows us that story isn't real, but if they have the report, then they're gonna find improvement. They're gonna find satisfaction.

SPEAKER_01 46:12

Oh, I like that. It's a it's an important distinction. I I you know it probably 80% of the people who say it worked for me, what they're really reporting is that they were satisfied, they were emotionally pleased with the experience, um and their suffering was eased somewhat. Um, but they the problem wasn't actually solved, and or it regressed to the mean and the therapy got the credit. Uh so in the majority of cases where people are satisfied because they were told what they wanted to hear, because the therapy theater suited their personality, suited their character, suited their um ideological prejudices, whatever. Uh right, remember that you know, some some, if you've got a white nationalist on your table, uh their the th the ideal therapy theater for them might involve saying terrible things about people of color. And that patient might be satisfied, and they might then go on to say, Oh, yeah, yeah, yeah, my that racist therapist really helped me. Um there's the quote. There's the quote in the title for the podcast right there. But it doesn't necessarily mean that they were helped. And one of the earliest skeptical observations of my career is that I would that this was boy, I would guess that it was actually one of my first two or three cognitive dissonances, you know, one of the very earliest signs that something was amiss, that there was something more that I going on that I didn't understand and I wanted to dig into, and that was how frequently people would say, Oh, yeah, my other guy does amazing work, amazing, miraculous, but I still really need help.

SPEAKER_00 48:02

For me, I it's one of the ones I I hear all the time like if you keep spending your money on the same thing and the treatment's the same and the results are the same, didn't Mark Twain say that's insanity? Like, what why are you oh yeah, I I've been seeing them for 10 years and I love it, but I'm not getting better.

SPEAKER_01 48:16

Yeah, I've never understood. What is it that they love? Well, they love a story that they're being told, but that story isn't actually quote unquote working for them in terms of medical outcomes. And it this is a really strong pattern. And of course, with clinician listeners, it's probably not a surprise to anybody. But if you're talking to a lay audience, people don't know this. They don't appreciate how frequently people say, uh, intervention X was amazing, it worked for me, I'm still fucked up though.

SPEAKER_00 48:45

Yeah.

SPEAKER_01 48:46

It's one of those things all the time.

Satisfaction Versus Solving The Problem

SPEAKER_00 48:49

It's one of the things I teach in my classes, which is you, you as a therapist, as a new therapist to a client or a patient, you have, I think you have a reasonable amount of time, which is for me is about three months. If you, if that client hasn't found the improvement that they're looking for, or maybe the satisfaction they're looking for, right? To have to have a to have a better quality of life. Yeah, then it's time for you to move on. It's time for that client to say, nope. And but it's also your job as a therapist to say, it's not working. But there's so many therapists, I mean, if they're financially constrained, they can't, they're not going to make rent, they need another client, right? So it becomes then it becomes self-serving. But it also becomes one of those things where it's like, I really think three months is an important, and and it happens to align with a lot of stuff around learning and things like that, and allostatic load and chronic pain is a three-month window. So that it happens to a line up with a lot of that 90 day stuff. But I really think that a lot of therapists have a hard time accepting that if they haven't helped the 90 days, it's probably not the right, it's not the right theater for them. They need it, they need a different film.

SPEAKER_01 49:52

Yeah, yeah. Uh, but how much therapy continues because the patient is enjoying the theater. And that uh, you know, I saw that pretty regularly in my practice. Um and I was quite diligent about trying to fire people after 90 days if if I didn't, if I wasn't satisfied with the results. Uh but yeah, I had a lot of patients who who would, you know, basically say, I don't care, I want to keep going because I like the show. I like the experience, uh, even if it's not you know, quote unquote, medically useful. And that speaks to the power of the experience, but it um but it also speaks to the fact that although the experience is motivating, the theater is motivating and inspiring, it may not actually be powerful in terms of clinical effect. Um and that I keep I keep thinking this as we go here, that that ultimately what we're talking about is okay, does good therapy theater, regardless of whether it's honest or dinner, dishonest bullshit or the opposite of bullshit or described or ethically or that it's informed or whatever? Whatever it is, I does the experience of being you know emotionally influenced by the therapy theater, does that work? Is that effective? Does that help people with their pain? Um and that question I think remains unanswered with a number of discouraging signs and some obvious logical flaws, but it also isn't completely out of the running. And I I think the really um the really tricky thing about it is uh what I call the unicorn hypothesis, which is that absolutely can work with just the right combination of factors and the right amount of skill. And I I I have I have nightmares, I have epistemological nightmares about how the hell would you ever prove that? What what if it's real? What if really skillful theater for the right patient is very medically potent, but it only happens to one in 10,000 patients, which means it's happening thousands of times around the world every year, but the vast majority of patients and clinicians are never experiencing it or only experiencing it incredibly rarely.

Stop Pathologizing Posture And Alignment

SPEAKER_00 52:15

The story I uh the story I use frequently for that is you know, we've all heard of that story who had TM the client who has TMJ pain and they put in an insole and their TMJ pain goes away. We all have that story. Chances are it's because it's happened once. But let's say it's happened once. Let's say it's far more likely that it's not the ankle causing their TMJ pain. It's happened once. And so it's like that unicorn theory. It's just because it happened once doesn't mean every client who walks in with jaw pain has this experience. But that's where it gets tricky because then in order to replicate that moment as a therapist, you kind of have to become a master of all trades. You have to become a true master of clinician. And and and you know, that's a lifetime experience. And even after a lifetime experience, you can't get it. You can't be on a like Friday, 5 p.m. Like, I don't work Fridays to start with. So let's say Thursday, 5 p.m. If I'm in my clinic, I'm not thinking of my clients, even if I'm there in front of my client. I'm probably thinking, like, God, I can't wait to be home with my kids, to have a drink, to relax, to cook a nice meal because it's the end of the week. So, how present are you truly? The same as every other job in the world when it comes to the end of the work week, you're just a little less present. So then the unicorn is even less likely to be hit. Get skittish. Yeah, yeah, yeah. So I am keep going. So but I was just gonna say I I feel like I could feel like I could do two or three episodes because I feel like the the way I enjoy this conversation with you is similar. Like I had Ben Cormack on a couple episodes ago, and him and I were talking, and it was similar. And with most of my client, or well, most of my guests, it's the same thing. I like talking about the philosophy of therapy because I think that's I noticed, yes. I think I think that's really where we see mastery, though. I think that's really where we see people going. I've gone beyond every client gets this exercise, every client gets this treatment, every client, the cookie cutter session goes away when you start thinking in terms of philosophy. So even though I think I could do several episodes of that with you, what I do I do want to respect the time that we have, and it's already been almost an hour. So, what I do want to ask is because I have a few other things I wanted to ask, and one was if you came across let's say you have a new student in front of you, graduate, a new graduate that comes comes to you. If you had to disperse two pieces of wisdom, one in the pro column and one in the con column, one saying, Okay, when it comes to manual therapy, please stop saying X. And when it comes to manual therapy, please start saying X or Y. Do you think you'd have a chance to summarize what those might be? I'm not I'm not asking for a sentence. It's more one in each column, one point in each column. Like like true because we could we could list all the research we want on how manual therapy is ineffective. Yeah, and we could get write-ins from people saying, look, I did this study in XYZ, and and then we'd have we'd be inundated with how it is in their in their in their research. Because research is really designed around a very specific question. And if you do it right, you'll get the answer you want, even if that's not the individual in front of you in your office. It's just a generalized theory. So if we really break it down, what's what's something that as manual therapists we have done as a disservice to our clients that we should probably stop communicating to them? And what's something that really is of service that could help them walk away and go, okay, yes, I feel like I've done something ethical and good, and that they will actually get something from this experience that's valuable.

SPEAKER_01 55:55

Yeah. I mean, I I think I almost can't avoid the answers. They're so uh particularly in the negative column. I think it's so obvious. I can't really imagine any other answer.

SPEAKER_00 56:08

I'm gonna go ahead and guess a word of structuralism. I might be wrong, but I'm gonna guess that works.

SPEAKER_01 56:13

Yeah, that would be my word, uh my umbrella term uh for that. But I but I'll but I'll dumb it down to uh posturology. Um stop pathologizing subtle uh alleged problems with posture, and uh and we can extend that just a little bit um to to broaden the umbrella to allegedly dysfunctional movement patterns. Uh stop pathologizing those. They're not the problem. So much evidence that they're not the problem. If it's subtle, it doesn't matter. So I I wrote a post, I think it's about a year ago now. Um the the gist of it was that the obsession with uh alignment and uh position you know dysfunction of position and movement and alignment is not just um still common, it's not just a powerful theme in manual therapy, it is completely and utterly dominant to this day, despite 30 years of research saying, uh uh guys, um there could be a problem with this.

SPEAKER_00 57:35

I I don't know what I've done in my algorithm, but for some reason, whenever I'm on Instagram or YouTube, all I get are sleep pillows that are supposed to be good for you, how you sleep is wrong, and I'm like, I don't think this thing is paying attention to what I really do because this is completely not the algorithm I thought I was printing onto the web.

SPEAKER_01 57:55

Yeah. And the the one of the main ways that I know that posturoogy um is still hopelessly dominant is social media posts and the public response to them and the professional response to them. Uh you get an almost unbelievable amount of enthusiasm and support for incredibly simplistic ideas in this category. Um any attempt to push back, anything that that uh um any attempt to uh criticize that way of thinking is hopelessly marginalized by comparison. Uh it is not unusual for me to stumble across social media posts that have hundreds of thousands of likes and hundreds or thousands of enthusiastic and uncritical comments for the most brain-dead, simplistic, obsolete garbage that you can find in this business. Um so it's yeah, it's crazy how strong it still is.

SPEAKER_00 59:08

And I like how you're avoiding the words uh red light therapy, cold therapy. I like how you're avoiding the words of all the things, but we all know what they are. We all know what they are: the bracelets, the things. I I love how you're being PC about it.

SPEAKER_01 59:24

Oh, I just haven't gotten to it yet. But but the obsession with alignment is the top of the list. If I if there was one thing that I could tell a new graduate to please avoid, please consider not contributing to that uh paradigm, not extending it for another generation, uh that would be the number one. The positive alternative in the other column is much less obvious, much harder, and I risk simply repeating myself and saying that I think that the sensory experience is the thing. Try to give people a pleasant experience, if nothing else. It almost certainly has some powerful benefits. Like, for instance, I suspect that the I don't know this, and I can't I don't think there's any research that can answer the question for us, but I strongly suspect that the easing of anxiety and depression in massage therapy strongly correlates with pleasant massage experiences, not challenging ones. Notes yeah.

Make Pleasant Sensation The Bedrock

SPEAKER_00 1:00:26

So there actually is a study that tries to correlate, and again, it's it's a leap in logic, but it tries to correlate the effects of C tactile affairing pathways on the effects of uh increase in oxytocin and dopamine, which would counteract anxiety and depression, but it doesn't necessarily mean that that's the reason, but it is one of the theories, and and it's you know, C tactile afferent pathways, they're they're expected very much in a massage session. And so it's it's it's a small study, but it's one of those things that might lead down that pathway of concrete mechanism. But again, mechanism, you know, my friend Justin Solis and Matt Gobby and Anna Rickenbaugh, they all say the same thing. Yeah, massage works, you know, like when you really boil it down, the mechanism we probably don't know. And and will we ever? There's a lot of variables, but does it work? Yeah, we see it works. And I I'm kind of a fan of that. It's simplistic in nature.

SPEAKER_01 1:01:21

I I I yeah. I mean, it is obviously there's you know tons of nuance. We can dissect that into many slices. Um I'm okay with in a casual set way saying, yep, massage works um because I've had profound massage experiences. I've got my own little, you know, got my own little uh uh bag of great anecdotes. Um, but I'm also reluctant to say, yep, massage works in a formal sense.

SPEAKER_00 1:01:51

Exactly. This was very much over drinks, yeah.

SPEAKER_01 1:01:54

Over drinks, I'll put it that way. And it's not a matter of being honest in you know one situation and dishonest in the other. It's a matter of you know, simplification versus nuance. Um, you know, works for what? Are they satisfied versus treated? Uh did their suffering reduce or did their pain? And you know, I'm very mindful of the fact that there are so so many people uh because I have chronic pain myself and I'm now part of that community. I know so, so many people who suffer from terrible chronic pain that massage has never put a dent in. Um and and so and you know, some of it in a obvious way, like you know, I'm trying to think of a condition that's just unambiguously never going to be successfully treated by massage, and I I I can't see one that was the first one that came to mind. But I know it's up there. It's uh let's put let's go with that one. It's up there. Um, but then there's also just lots and lots of examples of uh conditions that are at best very difficult to treat with massage, where the odds are not great, but yeah, maybe sometimes. Um so I'm very mindful of the fact that many chronic pain patients are not okay with saying, yeah, massage works, like, yeah, well, it didn't work for me because I'm still pretty much living in hell um uh despite my massage therapy. But many of those people, and this is critical, right? This is circling back to my point, why I'm putting that point in the in the positive column. What should a new graduate focus on? I am one of those people, and I've heard from many of those people who say, yeah, it's not changing my pain. I'm not getting treated, but I, you know, you can prime my massage for my cold dead hands. I want my massage therapy anyway. Why? Because the the reduction in suffering, the pleasant experience is precious. It's not treat, it's not treating their pain. That's a different thing. So, what does massage quote unquote work for? Um if we if we clarify and say, well, it it works for having really pleasant experiences. Oh hell yeah, it does. It can it really can do that.

Neurodivergence And Personalized Touch Preferences

SPEAKER_00 1:04:07

And and sometimes those pleasant experiences will be significant enough that somebody might get short to and medium-term results from them that's significant enough for them to go and be have a change of lifestyle. Yes. For most people, it's just gonna feel good for a couple hours, maybe a couple days, and then we move on. And yeah, to me, I I love that. I think I mean there's a reason my podcast is called the sensory approach to manual therapy, and that's what my business is called. It's it's literally like what do you say the sensory system? A little part of me kind of got all giddy inside because of like Yeah, I've been I've been talking about this for a long time, kind of thing. Hey, that's my brand. Exactly. That's that's exactly the point is that the sensory system determines what version of intervention you want. And you know, and we talked early about the theater therapy, it's almost like I happen to be neurodivergent, and I have a lot of my clinic here in Sherbrooke, I get a lot of neurodivergent individuals. And they all want very that's why I made that ASMR massage because they don't want the elbow, they want the nail scratch, and some who like the nail scratch, they just want the the who they don't want it, they want the elbow. And there's an entire theory that's beginning to gain a little bit of footing. Like I'm actually a big fan of this. I'm trying to follow it, it's so brand new, but it's essentially around phenotypes. Your phenotypes determine your skin tone, and your skin tone might actually be related to the version of touch you like. Low skin tone people like deep, firm pressure in the beginning. Once they feel safe, they like light touch. Sorry, sorry, low low tone people opposite. They like light touch in the beginning, finished by deep touch. High tone individuals, not muscle tone, skin tone. In the beginning, they like deep touch to feel safe. And once they feel safe, they actually only just want light touch. And I happen to fall in the light or the high tone category, and it's true. Like when I first go in for a massage, first touch, I want your elbowing.

unknown 1:06:00

Me.

SPEAKER_00 1:06:00

But after I like, I feel safe, just scratch me. Like, just go for the lightest possible feather touch. And I will love your. If you go deep for an hour, I'm like, but okay, session's over. I got I want to leave. And it's just interesting because I think there's an early development in in uh in some versions of intervention where they're starting to go, okay, neurodivergent is significant enough that we should be paying attention to the nuance of how these individuals are, you know, there's a reason we have sensory buckets and stuff like that. And so it's just, I think massage and manual therapy should be guided by similar guidelines. If their sensory system dictates that they don't like light touch, then don't do light touch. If the sensory system tells them they like light touch, do light touch. Their system that tells you what to do. And and that would be like what film be like, the theater kind of thing that they connect with.

SPEAKER_01 1:06:49

Yeah. Yeah. To use another metaphor instead of theater, imagine you've got your own personal cook, and their job once a week is to spend an hour cooking for you and trying to figure out what you love. What I love is your most satisfying meal. And I want manual therapists to know that the I I want them to make that the bedrock, the minimum, the the thing you go for that even if there's nothing else, at least you got that. But then on top of that, and this is important, I'm specifically saying this because I don't want to just be a stuck record saying your entire job is just to create pleasant experiences. I'm also assuming that by creating the most pleasant possible experience for your client, you are also potentially doing something more profound. Um if there's any potential for an effect on pain or or other important medical outcomes, that's where it lives. If there's potential for it, that's where it lives. Now you could come back at me and say, uh, actually, um certain medical outcomes might never be achievable without an unpleasant intervention. And yes, I'm I'm not gonna I'm not gonna categorically say that that's impossible, but I will categorically say it's unlikely.

SPEAKER_00 1:08:15

Yeah, I I can tell you right now, you can have really good ice cream without eating shitty ice cream. You don't you don't have to have bad ice cream to eat good ice cream. It makes you appreciate it more, but it's still just good ice cream.

SPEAKER_01 1:08:26

Yeah, and and and the problem with uh uh gambling on unpleasant sensory uh experiences in manual therapy containing some magic therapeutic ingredient is that uh your client gets nothing but a bad experience if you're wrong. The problem is that you're gambling and it's not a very safe bet. And what I see from the clinicians who are the most gung-ho about gotta break some eggs to make an omelet treatments is that the ego and the ideology is intense generally. They're true believers, they're faith-based, they're they're it's it basically they don't have a what I would consider to be a good idea about what works and why. And so I think that most things in that category are um uh low, they they are bad gambles. Uh not necessarily impossible, but not a safe bet in general.

SPEAKER_00 1:09:32

Yeah. And and it's hard too because our profession is really broken into. I mean, there was a post Julia DePonorio put up a post yesterday where she had essentially typed into AI, and you know, she put all these really good, you know, delineations around the answer, but it was essentially, can you talk to us about what the problems in the current massage therapy profession are? And one of them was it's essentially broken.

SPEAKER_01 1:09:56

There's a bunch of this going around right now, by the way. Yeah. Well, a lot of people asking AI to summarize the problems with their professions seems to be a bit of a trend.

SPEAKER_00 1:10:05

And one of the ones that she put up that I that I liked was that it's broken into essentially two fields, one which is the spa profession, and one is the more the medical or therapeutic or however else you want to term it. And it becomes complicated because someone who wants to do, like if you're looking for that sensory input, you can get it in both camps. But if you're doing the spa style environment, you're gearing the entire session specifically to patient satisfaction around the sensory system through visual, through auditory, through sound, through every everything about that experience is geared towards that. Now it may not be the right one, but at least they're trying. At least that's the intent. And when you go down the therapeutic route, you're almost it like I don't, because I only do therapeutic care. And because my podcast is called The Sensory Approach and Rider Theory, I I primarily focus on sensory input in my clinic. But I feel like most is not that. Most it's they they try to avoid the sensory impact and they say, barring your sensory system, we're gonna do XYZ. Yep. And and it almost seems asinine in nature, and it seems to be one of the complicated complications we have in the profession because the people pushing in our profession for more respect, more accreditation, more recognition is is by far that therapeutic branch. And yet they seem to be the ones ignoring the fundamental value of what touch therapy could be. And that's what it's that's why it seems so weird to me.

Spa Versus Medical Massage False Divide

SPEAKER_01 1:11:40

Yeah, or weird to me too. I mean, you're you're talking about a Venn diagram that in school the circles were separate. Like we are medical massage therapists learning how to treat people's flesh, and then there's those those trivial and ridiculous spa therapists who are only about the sensory experience. And from day one, I'm like, I'm gonna just kind of get those circles overlap them a little bit. A little bit. And you're what you're saying, and what we've been saying this whole thing is, but we just squished them together so that they're one thing. The um what absolutely drives me nuts about this dichotomy is that for different reasons, each camp, even when they're, you know, completely isolated, they are screwing up the sensory experience in different ways. They're both doing it badly, one of them by generally ignoring it, and the other by sticking to all kinds of aesthetic cliches and stereotypes and cookie cutter that just is just a just low quality, right? It's it's not the wrong idea, it's just really poorly implemented. The law of averages, and the law of averages, like and something I again like anybody who's over you know 40 is is starting to notice how more and more of their healthcare professionals are basically seem like kids. And I I had a spa massage a while ago. The the combination of their incompetence and their youth was just deadly for me emotionally. It's just like they they just instantly started doing it wrong, and I'm like, and all I can think is oh my god, they're just like the the the sheer tonnage of what this kid doesn't know about how to deliver a good sensory experience, a pleasurable massage experience. It's just there's no hope.

SPEAKER_00 1:13:33

I I know for a fact that we're very close in age, and I think it's wonderful how old you sound right now.

SPEAKER_01 1:13:40

Also, get the fuck off my lawn. Um yeah, so I it I mean, I would have objected to that experience as a younger client as well, but I f I find it amusing now to notice as an older patient, and I go I go into that situation, and it's obvious to me that half the problem is just that it's just it's a kid. It's a kid, it's an inexperienced human who just doesn't know very much about how to create a pleasant experience for other humans. Uh great, great little story from my massage training and a formative one. Um, when I was uh in training, my very first night in clinic, in the student clinic, um, this was at uh OVCMT, and some people will know who I'm talking about. The owner of the school was my first client in the student clinic, which was you know intimidating or would be intimidating for a lot of people, but I was already an older student. I entered the profession fairly late, but wasn't too intimidated. He says to me, he walks in the room and says, Hi Paul, keep me warm or there's no point in me being here. Like just and the the the coldness and directness with which he requested warmth um was quite instructive, was a good lesson because it's heart, it's almost heartwarming. That's almost heartwarming how cold he was. He's he clearly had many experiences in the student clinic where the student didn't keep him warm. And that was essentially my first, you know, the sort of first direct lesson about the sensory experience might matter, right? And this was, you know, this was the guy who owned a school that was teaching massage therapists to be as medically and clinically minded as possible, you know, really, really trying to make it.

SPEAKER_00 1:15:35

And the first thing is a and the first thing he wants is to feel good.

SPEAKER_01 1:15:39

Is to feel good.

SPEAKER_00 1:15:41

It doesn't matter if I had a school on the yeah, first thing he wants, I just want to feel good.

SPEAKER_01 1:15:45

Don't really care what else you do, just keep me warm for God's sakes.

SPEAKER_00 1:15:49

You know, see on the option.

SPEAKER_01 1:15:50

Give me a bad sensory experience.

SPEAKER_00 1:15:52

My therapist knows that like before I get on the table, she has if if she's had someone on the table before me and the table heater's been on, she's got to take that thing off because it's too warm for me. Like I I get I cannot stand a hot massage. It drives, I feel gross. Oh, yeah, yeah.

SPEAKER_01 1:16:08

Oh, if you feel like you're getting sweaty when someone is rubbing you, oh yeah, or too oily of a session.

SPEAKER_00 1:16:13

Oh my god. And again, you know, you say some young therapists, like there's there's no way out of being a young therapist. Time and experience is the only thing. Like you just hands-on bodies eventually makes you better at understanding the sensory system. There's really no way to avoid that aside from asking them. And I think that's something people I have a series of classes called creating empathetic touch, and it's 16 hours in total. And one of the classes is four hours, and it's called touches communication. Touch is the communication tool. And it's like a lot of that is around hey, does this feel good? Does this, you know, your first couple sessions should be pretty question-filled, not to the point of annoyance, but definitely to the point of what touch do you like? And knowing that on their feet it might be a different touch than on their face. And accordingly, yeah.

SPEAKER_01 1:17:01

Yeah, and you don't want your personal chef leaning over your shoulder and asking how each bite is. How is that bite? Was that good? How about that? You know, uh in it's a get getting to a consensus about what works for someone is an art in itself. Um, the there's the thing, but there's also figuring out the thing. Um they're they're both an art. It takes a lot of social skill. Um, and uh and and this is this is why I start I've started to avoid young therapists, because they don't have that art. And I know that they're they're not gonna get there or not without a lot of hand holding, and I don't really want to pay uh your next bucket for that.

PainScience.com Deep Dives And Closing

SPEAKER_00 1:17:41

Your next hate mails are gonna be about ages of money. Yeah. Well, awesome, Paul. I really had a great. I mean, I I feel like I could do this once a month with you or something like that. I I really enjoyed today. I really appreciate it. And uh before we go, do you want to talk a little bit about your stuff so that if anybody most of my listeners will know who you are because I've mentioned your name in many of my other podcasts, but if they don't, do you want to talk a little bit about your stuff?

SPEAKER_01 1:18:08

Yeah, sure. Um I I I make my living doing this stuff. So at some point I it makes sense. It's wise for me to switch my focus from the subject matter to actually promoting my my stuff. Um, I sell books and I sell a membership program on Paintscience.com. It's an amazing thing that uh people pay me to criticize them. That's um that's my insane business plan. I never thought of it that way, but that is absolutely what you do. It is a it is a bizarre business, and it's bizarre that I managed to keep this plate spinning. Um the the idea is you know the value proposition for for the right customer is that I I sell nerdy deep dives into this subject matter. Um, if you're curious and enthusiastic about how all this stuff works, well, I got a busy mind and busy hands on the keyboard, and I write about it a lot, and I give away some of my best content to my members only. Um but the weird dark side of it is that I pretty routinely challenge the beliefs of my core audience. And it is not uncommon for me to lose money when I publish a post.

SPEAKER_00 1:19:32

I love how I love how lately you've been talking about how you're not completely opposed to the trigger points, because for people who have read your trigger point post, they would assume you are completely opposed to that.

SPEAKER_01 1:19:41

And let me clarify that actually, because this is kind of a fascinating phenomenon, and it's exactly what I mean. And it's you know, and this would be, you know, this is a selling point, right? This is this is why you should buy my stuff. It's a unique perspective. I am a fence sitter on trigger points, and my my most prominent article on this topic consistently gets interpreted by both teams as their own. That whoever's reading it thinks that I'm championing their side. So anti-trig anti-trigger point skeptics read what I have to say, and they're like, they're banging the table with enthusiasm. This is fantastic. And then people who like trigger point therapy read myself and like, see, this is a sensible approach to the topic. Um it's fascinating to me how many times over the years. This this, by the way, is rare. Most of what I write is polarizing, and I get hate mail about it from both sides. But the for whatever reason, specifically that trigger point article, which by the way, if you want to Google it, it's called Trigger Point Doubts. Um that article specifically seems to get love mail from both sides.

SPEAKER_00 1:20:58

And uh and you need to you need to write you need to write more of those just for your own self, self-soothing at night.

SPEAKER_01 1:21:05

Funny you should say that I try to, like I'm trying to learn from the letters. Like, why does it work with this article? Um But the the point is that I that's thanks to nuance. That's thanks to a very, very detailed, nuanced, honest attempt to understand the subject uh without um banging the drum for team skeptic or team quack. Um it's it's because I've just put I think it's basically because I put so much work into actually trying to understand and communicate the subject matter. And uh and it works. Anyway, so I sell books and I sell memberships at PainScience.com, and uh I do not have a ton of customers. 99% of massage therapists will probably never be members, but boy, the 1% special club, awesome people.

SPEAKER_00 1:21:59

And and I will say, for those of you who do decide to read some of his stuff, um bear with it. You're the first time the first time you read, the first time you read an article, you'll walk away riling against him or you'll rile against yourself. One of the two. You'll think you've been lying, or you think he's been lying. But read deeper, read more, and in the end, you'll come to a place of a really clear understanding of a larger picture of what we're trying to do, which is you know, Paul's been doing this for a long time. I've only been doing it eight years, and and there's there's a large group of large, a growing group, I should say, of of clinicians and authors and influencers are trying to help answer the question of not necessarily what's going on in the body, because that answer may be a little harder to answer, but more is it working and is it worth it? And if it is worth it, how do we make it the most effective? And that's a tough question to answer, but it's a worthwhile question to ask. And and I think it's one of the best things that I've seen about your stuff. So thank you so much for being here, Paul. I I really appreciate your time and your honesty and and and the laughter. It was a very, very fun moment.

SPEAKER_01 1:23:13

Thanks. Okay. Until next time then.

SPEAKER_00 1:23:15

Yeah, have a great day, Paul. Thanks.

SPEAKER_01 1:23:17

Bye bye.