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FC2O Episode 22 - Eyal Lederman
33 Plays4 years ago
Eyal Lederman has long been recognised as a leader in the field of Manual Therapies. Often a lone voice in the wilderness, he has led a crusade against many of the engrained beliefs and conclusions in the rehabilitation field.
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Transcript
Importance of Movement in Recovery
00:00:00
Speaker
Is it disc? Is it facet? Is it muscle? Is it ligament? It doesn't really matter a lot because if it happened within a certain amount of time, let's say within a week or two, you can suspect that it's likely to be a recovery by repair and they all benefit from movement. You end up doing the same treatment basically, which is wonderful because a clinic is a very complex environment and
00:00:28
Speaker
We really want to simplify it a lot and that allows you to do this huge jump.
Introduction to Dr. Al Edelman
00:01:03
Speaker
Dr. Al Edelman is our guest this week on FC20. Al has been an important voice in the manual therapies, calling for a more active approach to helping patients recover from or adapt to their presenting conditions. Al is not shy of controversy and has written many papers over the years questioning key tenets within the manual therapies, from the use of manipulation, to the benefits of core stability, to what he terms the fall of the postural-structural biomechanical model in manual and physical therapies.
00:01:31
Speaker
In this dialogue, we explored many of these areas. Now, I'm always keen to respect my guest requests, and in this instance, Ale has asked me to edit out a number of sections, totalling about 30 minutes. So the podcast is a little shorter than normal, and you may notice a slight lack of continuity here and there. My hope is that we will be able to meet again down the line to revisit some of these more challenging areas of discussion. Enjoy the show. Here we go.
El Lederman's Journey and Research
00:02:07
Speaker
All right, so welcome to another edition of FC2O with me, Matt Worden, and my guest today, El Lederman. Thank you, Matt. How are you doing, El? Yeah, I'm very well. Thank you for the invitation to speak. Well, thank you for coming along. I should probably let people know this is our second attempt because we had a bit of an issue the first time around.
00:02:24
Speaker
So thank you very much for coming back again. I think, you know, I really loved the last time we had a chat. There was so much great information in there. So I'm excited to go back through some of that again. And we're going to try and just do a
00:02:39
Speaker
a fairly brief introduction. So I think, you know, what I'd like to do, Elph, I know many people will know who you are and know of your background, but I also will have some listeners who don't know too much about your background. So if you could just give us a quick rundown of, you know, how you got into osteopathy, and then sort of where that led led you from there. Okay. Starting with life as a yoga teacher, and got very interested in bodies and how they work. And I found out that about the time I found about osteopathy,
00:03:09
Speaker
I got very curious about it and eventually came to London to study it. I finished in 86, so I've been in practice for a long, long time. And I still work in practice. Soon after I graduated, I also started doing research that eventually led to doing a PhD.
00:03:32
Speaker
the time there were no PhDs in osteopathy. So it was a collaboration between King's College London and the British College of Osteopathy at the time. And that was, I think, one of the first kind of collaboration between the two professions. But I also run the Center for Professional Development in manual and physical therapies. So we run courses throughout the year.
00:04:01
Speaker
So I spent a lot of time there. I'm still involved in research. I just finished a PhD dissertation. Someone finished a doctorate looking at functional movement to levitation for people who had knee replacement.
Functional Exercise and Rehabilitation
00:04:18
Speaker
And this was done at Stanmore at UCL, the orthopedic hospital. So that was last year. Yeah, I'm now looking for another project.
00:04:28
Speaker
So if anyone's got any ideas? Yeah. Well, I got the ideas. If anybody's got the money. The money. Yes, exactly. Yeah. Okay. So does that, am I right in saying, so was that a second doctorate or was that a doctorate you were working a lot on? No, this is, I was supervising. Yeah. An osteopath who she was doing at Yelena. She was doing her doctorate and looking at functional rehabilitation.
00:04:55
Speaker
Yes, okay, okay. Yeah, something we'll talk about probably during the podcast. Yeah, perfect, perfect. And also, I'm not sure if you mentioned your books, but you've, you've written several books. Yeah, I've written the fundamentals of manual therapy was the first book that was written in the early 90s. It was due to my frustration with osteopathy to the point that
00:05:21
Speaker
There was very little information on how techniques work, the physiology of techniques, what happens with them. How do they affect the body? Information was very, not well understood. I wasn't happy with that. And I had to clarify for myself, and that was the consequence of the book. And then it got into the science and practice of manual therapy, harmonic technique, the new homoscular irritation, which was a new take on movement rehabilitation.
00:05:51
Speaker
which was the consequence of my research. My own PhD research was into the neurophysiology of manual therapy. Do manual techniques have any effect on motor control, motor system? The bottom line is they don't. We need to have an active approach and that kind of led to this new approach in osteopathy. Yeah, fantastic. And that led also to the functional stretching.
00:06:20
Speaker
a book also because the sciences were demonstrating that clinical stretching were not that effective and that we need to look at it in a completely different way. That was the consequence of that kind of research that came around. I'm now struggling to write my sixth book and that's about
00:06:41
Speaker
functional exercise prescription. The idea is how to exercise without exercising. Can we use normal human movement, i.e. daily activity to rehabilitate people? That's largely because people don't do a strength and conditioning exercise. It's very difficult to convince patients who may need it, have a dramatic need for this.
00:07:13
Speaker
There's very little compliance and adherence to this kind of advice, or kind of turning the whole thing upside down and looking at it. Any human activity can be amplified or attenuated in some way to provide physical challenges for the habitation of movement.
00:07:33
Speaker
So this is my big passion at the moment. Yeah, great. And it sounds like a lot of the information I've been reading in the literature, pain neuroscience and so on, is really talking a lot about the idea of a meaningful task and identifying meaningful tasks and then building the rehabilitation around that. And that sounds very much like what you're... 100%. Yeah, yeah. One of the first questions I ask my patients is what would you consider to be a successful treatment? What would you?
00:08:03
Speaker
one part of this treatment. And that's it. That's what determines the whole programme. Yeah, yeah. Yeah, right, right. And so I know you just touched on it in your sort of introduction there. But, you know, one of the first things I remember picking up from you was this idea that, you know, it relates to relates to treatment as well as to rehabilitation, to some degree, but the idea that passively applied techniques
00:08:33
Speaker
like most manual techniques with with the odd exception so I think you might say MET for example or contract relax type techniques do have an active component to them obviously but but a lot of other techniques such as mobilization manipulation articulation massage NMT STC soft tissue technique you know that they are very much passive and so you know can you can you
00:08:58
Speaker
just explain why that's a bit of an issue in the longer term.
The Process Approach in Therapy
00:09:03
Speaker
Because obviously that's been the way people have been treated for many, many years, isn't it? Many decades. And that's part of the problem that we have in osteopathy. We didn't have as a consequence any kind of rehabilitation or exercise prescription management of patient. So the treatment was mostly a passive treatment. And very rarely in the past, osteopaths used to give exercise.
00:09:27
Speaker
When I was a student, there was no active component to the course. We didn't know what exercise we should give our patients. And only in the last year of osteopathy, we had physiotherapies come and teach us what is a kind of traditional physiotherapy exercise. But otherwise, we had zero input. And so when I started doing my research into the neurophysiology of immunotherapy, I started scanning all the other methods
00:09:56
Speaker
And seeing that there are problems everywhere, that's not just for osteopathy, but even the methods that were used in physiotherapy and so on, they needed updating, basically, to develop problems. And this is where I'm at now, which is kind of developing functional approaches. But the essence of it is that you can't learn movement
00:10:26
Speaker
or enhance it in any way or develop it if you are not actively doing the movement. It's in the same way that you can't learn movement while you sleep, it just wouldn't happen. You need to be actively engaged and collecting the movements. So this kind of correction and creating the maps for the movement is an active process. It doesn't happen with passive stimulation.
00:10:56
Speaker
It's actually a very long story, but basically that's the essence of it. So adaptation in any kind of neural system is an active process. You need to be actively doing something to facilitate this kind of plasticity. If you do passive techniques, all we are doing is providing feedback to the system, but it's not activated necessarily. It's not responding.
00:11:23
Speaker
doing something about this feedback, which is that's the important bit. You need an afferent, an input, but you also need the same kind of afferent output. Yes. And you have to couple them together. Yes. Yeah, absolutely. Which creates an interesting phenomenon. If you learn something one more day, and they're doing it that same day, walk across a plank with your eyes shut.
00:11:53
Speaker
If you learn to do it with your eyes shut, once we ask you to do it with your eyes open, you might not be as good as doing it with your eyes closed. It will take you to readjust again. So what I'm trying to say is the sensory information that comes in and the output have to all the time be coupled together. That's why there's no transfer of sensory information.
00:12:18
Speaker
So what you learn in one activity doesn't necessarily transfer to another one. Now, you know, part of where we're sort of leading the discussion is that, of course, your most recent, I guess, concept that you've developed is this process approach, I believe. I mean, you're probably developing new stuff all the time, but this is what your focus has been on fairly recently.
00:12:42
Speaker
And, again, within that, of course, what we were just discussing, the focus must be much more active and much less passive as far as the patient. Not necessarily. It depends on the process you are dealing with. Okay. So, let's go there for a minute and do a process support. What is a process support? The most kind of basic, if we had to somehow
00:13:09
Speaker
look at the bottom line of osteopathy, what osteopath do is we basically, we believe that the body has the capacity for self-retardery, self-health and so on. And that's the basis of everything we do from there on. What was missing for a long time is that we didn't identify what are these remarkable processes. How do people get better? How do people get better after an injury? How do people get better after a stroke or after immobilization?
00:13:39
Speaker
How will people recover after chronic pain? What are the mechanisms there? And so that's what I set out to do. Basically, there are three key processes associated with functional recovery. Functional recovery, let's define that first maybe, is your ability to maintain and carry out daily activity in some effectively, efficiently, and in some level of comfort, let's say.
00:14:09
Speaker
So that's functionality, that's what I mean by that. And so the return to functionality after some kind of condition depends on three different overall processes. So one is repair, the other one is adaptation, and the other one is modulation of symptoms or alleviations of symptoms.
00:14:36
Speaker
And they kind of, if you can imagine a VAN diagram, which you can probably put on there. Yes, I can do that, yeah. They all overlap, of course, so you can have several of these processes happening at the same time. So, in a process approach, we ask a very simple question. When a patient comes in,
00:15:01
Speaker
By which process is this individual going to recover the functionality? That's all yeah now if you can define that you're on to a winner Because there has been a lot of research around these three overall processes So we actually know a lot what we need to do in order to help people recover Mm-hmm. So if you look at so so we're looking at if how to create a
00:15:27
Speaker
ideal environments for each of these processes. What is the ideal stimulation for repair? What is the ideal stimulation and support for adaptation and for modulation of symptoms? And when I'm talking about environments, I'm talking about the environment, that outside environment, the physical environment,
00:15:51
Speaker
the person's relationship to their environment and their body also as part of the environment. So we're looking at psychology, behavior, culture, and all those kind of things. So this is what we are looking for. So when a person comes in, let's say a person came in with an acute disc problem. It's very clear that that's the case. And it happened in the last, say, two weeks ago.
00:16:19
Speaker
So I would immediately ask myself a simple question by which process is this person is going to recover? Is it adaptation, repair or modulation of symptoms? So now we are dependent on repair processes because they had some kind of tissue damage and this is what is happening there. But this is the main process. And the question then is, well, what does the research tell us about repair? What do we need to do in order to support repair?
00:16:49
Speaker
As a physical therapist, you know, keep on moving, movement. It's very, very important for that. Yeah. Amongst other things, but this is the most important key point. Sure. Now, if you start thinking like that, it actually simplifies your management a lot also at the same time, because repair is universal
Adaptation and Task-Specific Rehabilitation
00:17:11
Speaker
in the body. So no matter where there is tissue damage, there is a repair process going on.
00:17:18
Speaker
they all require the same management. You don't really have to have a tissue diagnosis anymore. So say the same patient came to your clinic with acute lower back pain. Is it disc? Is it facet? Is it muscle? Is it ligament? It doesn't really matter a lot because if it happened within a certain amount of time, let's say within a week or two, you can be highly
00:17:48
Speaker
you can suspect that it's likely to be a recovery by repair and they all benefit from movement. You end up doing the same treatment basically, which is wonderful because a clinic is a very complex environment and we really want to simplify it a lot. And that allows you to do this huge jump. So you don't have to have tissue causing symptoms anymore. You just need to guess
00:18:18
Speaker
which process may be taking place for recovery. No, the whole management would change dramatically if we had someone who's, let's say, had been immobilized in a plaster cast for two months. Once the plaster cast is off, we're no longer in the early phases of repair anymore. We're more in the remodeling or the other patient phase.
00:18:44
Speaker
Yeah. Before we jump into that, could we just elaborate a touch? I really like the way you're taking this. But with the repair side, when we've got this idea of an acute injury and the repair is fairly predictable from what we were just discussing, would you also incorporate other elements such as nutrition and hydration and sleep and those kinds of things? Or would you assume that that's kind of being handled
00:19:13
Speaker
by the patient themselves. Is that something you get into or you refer out for that kind of thing? Or do you not really consider that so much? No, it's fairly robust repair process. You really have to be malnourished or have serious chronic illness to affect your repair process. And that doesn't come in North London, not where I live.
00:19:40
Speaker
Okay, okay. So now I'm getting to those. Yeah. Also, you have to consider that the more information you give your patient, the more we are likely to confuse them. Right. Because we know that 80% of the information that given after the session is forgotten. Yes, yes. And is remembered, and honestly, the more we pile, we make it more and more complex. It becomes more and more difficult for the patient to
00:20:11
Speaker
understand what's wrong and how to manage it. It just add layers and layers of complexity, something that can be followed. Okay. Okay. So yeah, let's go back to the plaster cast. I'm not saying that it's wrong to look at diet, but it might not be necessary. Yeah. Okay. Okay. That's fine. That's fine. So yeah, so let's go back to the plaster cast discussion. So the person has just had their cast off. Obviously they're now more into the
00:20:39
Speaker
the adaptation phase. That's right. It's a remodeling phase of repair. The latter phases are more to do with reconstructing the tissue. That reconstruction of tissue, recovery of range of movement, and recovery of motor control are highly specific. So you want to be very, very close to the activity that you're trying to recover.
00:21:07
Speaker
rather than far away from it. So if it's, say, walking, you're trying to recover. Remember, our patients have different goals than us. We quite often think of, we need to improve plant deflection and dorsiflexion. All the patients want us to be able to walk up and down stairs. So they have a very clear goal, which is different from our goal. So now what it means is that, additionally,
00:21:36
Speaker
would get them onto a machine that does some kind of plantar dorsiflexion. You can take that element out of the functional task and practice it outside the functional task. Now, the problem with that is that it doesn't transfer back. All that happens is that the
00:21:56
Speaker
Our body is a very obedient servant in some way. It will do what we ask it to do. So we'll get very good at doing a plant of dorsiflexion on a wonderful, shiny machine in the context of, say, a G. But it doesn't necessarily transfer to, say, something like walking or walking up and down stairs. I mean, even simple things like balance. I'm just reading around balance and specificity of balance. It's something that I've looked into the past, but there's a lot more research now.
00:22:26
Speaker
It's totally non-transferable. It cannot be. And you can't even measure people's balance by asking them to stand on a single leg because it doesn't represent the balance of walking or going up and down stairs. So each one is a unique balance program, and you have to practice the thing. If you practice something away from that, which is dissimilar to the goal activity,
00:22:52
Speaker
it just doesn't happen. Let's say if it does happen, it's not the most effective way of working. Sure, sure. Okay, okay. I have something else I can say about adaptation, but this is just a slip my mind at the moment, but yeah, so, you know, if you're going to elaborate further on the sort of adaptation process or how you facilitate that.
00:23:20
Speaker
Basically, it's about exposure. You need to expose the person to the activity often. That's why we have to engage them in that activity. That's exposure, repetition. The other thing is specificity. It has to be specific to the goal. It has to be very, very similar to the real activity. The principle is you can only learn
00:23:48
Speaker
what you've practiced, you can't learn what you've never practiced. So if you are doing some exercise on a machine...
00:23:57
Speaker
We get really good at doing that, but we don't necessarily get good at walking, which is the goal activity. Yeah, yeah. I remember what it was I was going to say. I actually supervised a thesis quite a while ago now, probably 15 years or so back. But the guy was, what he was assessing was MET, so contract relax stretch to the soleus, to see how that would improve, obviously, range of motion, range of dorsiflexion at the ankle joint.
00:24:26
Speaker
And then he was comparing that with a group that just did squats. And what he found was that they both improved, but there was no statistical difference between the two. So in other words, because you were demanding the range of motion through doing the squat-based activity, Celeste was adapting to that, but there was no statistical difference between the two.
00:24:50
Speaker
the treatment group and the guys that are doing squats. So in other words, you're as well to do the activity, which is exactly what you're saying there. Yeah, yeah. Because it works on exposure and repetition, the whole adaptation process is driven by the fact that we do it often. Yes. If you think that if you come, if a patient comes to our clinic, and let's say your treatment is half an hour, the MIT part is let's say three to five minutes out of that. If that. Yeah.
00:25:20
Speaker
Now they're 168 hours in a week. And you've stimulated for five or 10 minutes out of the 168, whatever. It's a very, very ineffective way of working. The difficulty is it's very difficult to then teach the patient to do it correctly in any way so that they can't do a meeting on themself, but they can. But it's really difficult for a person to learn to do that correctly if you want.
00:25:49
Speaker
So it's kind of doomed to failure. Yeah, it's something that I remember reading a paper on, I can't remember the authors, but it was 1998. And it was the first time I'd read the idea that, you know, muscles may be tight for a reason. And essentially, essentially what it was saying that, you know,
00:26:10
Speaker
when you have, and again, they were looking at soleus in runners, and they were making exactly the point you're making, you know, if you stretch for even five minutes, which most people would not stretch for that long, but then you go out for an hour's run, where the stimulus on the body, is it going to be more towards tightening the soleus because you're running for an hour? Or is it towards stretching the soleus because you stretch it for five minutes? And you know, there's the kind of counterbalance there is quite obvious that it's not sufficient, but also
00:26:38
Speaker
It's basically a competition in adaptation. Exactly, and then they point out that the tension there optimises stability at the joints, it optimises recoil, the recoil happens sooner, so therefore you end up with a more efficient gait pattern. They listed all these things and it was a bit of a moment where you look at it and you think this is interesting because for so long the idea was that if you're going to do a sport, you can do something active, you must stretch beforehand.
00:27:07
Speaker
that really doesn't have any real, it doesn't make any sense from an evolutionary perspective either, does it? It makes no sense. If you're in the middle of a safana and there's a tiger coming at you, you don't stop and do your five minutes of yoga stretches to make sure that you are warmed up and you are now agile enough to run. That's it. We are really involved to
00:27:37
Speaker
to function maximally within milliseconds because it's such a survivalist essential. You can't afford to warm up, which also asks, for example, the big question, what is the human warm up? How are we, stupid humans, the only animal on the planet to do a warm up? Why are we doing that? Does it have any value? Is it psychological? Is it physiological? Does it really do anything?
00:28:06
Speaker
interesting questions. Yeah, they are very interesting.
Integration in Movement Learning and Pain Management
00:28:09
Speaker
They cover me a lot for this kind of question. Yes, exactly. So one of the areas where I think a lot of the guys that obviously listen to the podcast are from the Czech training that I've been involved in and practice for many years now. And, you know, one of the things that we talk about is this idea of isolation to integration. I know you don't subscribe to that. Are you able to explain
00:28:36
Speaker
You've already touched on it, but you're able to explain a little bit more why that doesn't make sense from your understanding. Okay, so when we learn... Okay, so when you learn a task, say to reach for a cup, there are two components to it. The goal of the task, to reach the cup.
00:29:04
Speaker
and the movement that you use for reaching the cup. Now, so from very early age, we associate, it's integrating basically, the task and the movement that we use for it. We don't have to think about it. So if I ask you to reach for a cup now on the table, you just switch what you wouldn't even know that you're doing it almost. It will be something in the back of your mind. So the movement and the goal are fully integrated.
00:29:33
Speaker
Now, when we start asking people to focus on their body, we are doing a strange thing. We are disassociating, we are disintegrating the task and the movement or the movement from the task. So when you disintegrate the movement from the task, you actually degrade rather than enhance the movement or the task.
00:30:04
Speaker
So the classical one which they did is they asked two groups to lift a damper to a certain height. And one group is given an external focus of attention, i.e. just focus on the goal. And the other group is given an internal focus of attention, focus on your arm, what it's doing while you're lifting. So that's an internal focus. They're focusing on the movement also, not just the task, the goal. So they're disintegrating it.
00:30:34
Speaker
And what they find is that people who use an external focus of attention, their EMG activity is less. They are doing the same activity a lot more efficiently. And it also has consequences for transfer and learning and so on. And this has been shown quite consistently for the last probably 10 or 15 years. It's a very well-established thing.
00:30:57
Speaker
So we know that actually if you do know that movement is organized as a whole, the whole body is organized in one goal. Even bits that are not moving are inhibited in some way. So it's an active brain process, the whole map is drawn for that movement. Now, what we then do is we disintegrated the movement.
00:31:23
Speaker
And then what we do is we then fragment the movement into smaller beats. So it's kind of two levels of separating what you're doing from the goal. First of all, you took the movement away from the goal, practice the movement on its own, and then you are taking the movement and saying, now we're going to look at individual muscles. So it was further kind of lower
00:31:54
Speaker
dismantling the whole thing. And the brain just hates it. So what is happening in the reality is, let's say you give someone a dumber and you show them how to do bicep curls. Remember, the body is a very obedient servant. So yes, you're activating that muscle, but the rest of your body is also doing something. It's only in our mind that we have separated it in that way.
00:32:21
Speaker
Yes. But what is happening is, again, you're getting this problem of specificity. You're just learning to do biceps curls really, really good, really well. But it doesn't necessarily mean that if you have a frozen shoulder, it will help you to scratch your head. Yes, exactly. Yeah. Yeah. Okay. It wouldn't transfer. Yeah. Yeah. So it has problems with transfer. It actually degrades movement when we do all this fragmentation. Yes. Yeah.
00:32:49
Speaker
Okay, so maybe going on. My count is saying.
00:32:53
Speaker
kind of stop line is integrate in order to coordinate. Okay, I was gonna say I remember going on a course with Shirley some and the physiotherapist and she was explaining similar to what you're saying that, you know, when you have a shoulder, a shoulder course, and she was explaining that, of course, you know, you get winging of the scapula is quite a common movement, which she would call a movement impairments syndrome.
00:33:19
Speaker
And of course we know that when the serous anterior is inhibited or paralyzed that we get this winging of the scapula a week. And so she was making the point that there was a research study that she referenced which was showing that if you do what's called a push-up with a plus and so it's a standard push-up but you just go a little bit further and that activates
00:33:40
Speaker
the the psoriasis anterior so it conditions the psoriasis anterior and she was making the point that you know you can do as many push-ups with a plus as you want but it's not going to change the movement pattern of the scapula when let's say you reach for a cup in the in the cupboard like you just were giving as an example because it's a completely different pattern and um yeah so but what's interesting is uh i have had a look at her book for example yes yeah
00:34:04
Speaker
how exercise is anything but functional. And you see that a lot actually in movement rehabilitation. Everybody knows the science, but when it comes to the practice, it remains very traditional, what I would call extra-functional movement.
00:34:24
Speaker
exercise or activities that the person has never been exposed to. And that's not only just this book. If you go to any library and you look at the rehabilitation books, it's all invented exercise. And the more outlandish the exercise is, for some reason we give it higher value. That's just the human condition, isn't it?
00:34:52
Speaker
When you talk about modulation of symptoms, the third in the process approach, you can have a pathology but not feel it. If we scan any of our bodies, we'll find multiple pathologies, which we are not aware of.
00:35:11
Speaker
But that doesn't mean that we are so functionally we are all white. So let's take that as an example. A patient comes to you and they've got a chronic lower back pain. They had it for a year or two years or 10 years, doesn't matter. If you do your treatment, whether it's active, whether it's passive, and they get better within a month. You scandal back before, you scandal back after, would you see any differences?
Balancing Independence in Recovery
00:35:38
Speaker
Probably not, no. The answer is probably not.
00:35:41
Speaker
So the question is how, how can we recover from such a deep pathologies, cover functionality. And that's the third, the third mechanism that the body does is that it can modulate what we experience as pain, very, very effective. And that can happen reflexively, like the pain gate mechanism, spinal processes, upper kind of spinal and then kind of higher centers processes. So it's very, very complex. Yeah.
00:36:11
Speaker
But the body can't do that very effectively. And so when you start looking at pain, this is what I said. It's like a game of thrones. Anything works. It's all fantasy land. And, you know, so you can do manual therapy and it works. You can do cranial and a cranial person tell you it works for me really well. And spinal manipulation works really well. And you do costability training and it works really well, as equal as walking. So of course, but in that dimension,
00:36:40
Speaker
And we are not working with certainties as we do for say, if we know that someone can't walk, we know that we need to get them up and walking, you know, it's quite clear the physiology and what we need to do. But when we talk about modulation of symptoms, this is what I was talking about that the next decade for me is understanding
00:37:10
Speaker
how people experience pain and the belief systems and how we can work with those systems to switch off pain. But it's nothing to do with motor control.
00:37:21
Speaker
goals. Okay, okay. Yeah, I know, but it is to do it. I mean, again, we touched on this last time you spoke and I'd like to bring it up again is that it's it is very much to do with the patient taking the reins and being more active and and actually giving them tools to get themselves better, isn't it? That's that's that's got to be part of the process rather than it being a dependency on an extrinsic device or individual or whatever. Yeah, interesting thought, isn't it?
00:37:51
Speaker
So from the research, we are told that these patients should be kind of independent of us and they should be dealing it with themselves. It's fantasy land. It doesn't happen. People need other people to help them to get better. Quite often, what I see in clinic and pushing them away to self-care can work for some people.
00:38:21
Speaker
but not everybody. They need us to contain their fears, to assure them, to create a structure for them to recover. And that's what a lot of the research doesn't see. So I'm having doubts with that, let's say, this whole model. So some patients absolutely need to be there for them. Yes, yeah. So more like a coaching model.
00:38:52
Speaker
with maybe some treatment thrown in, or I suppose it's going to be very from person to person, but... That's our idea. We have to be careful with that idea that everybody can self-care and just give them a sheet of exercise and they'll do it at home and everything will be fine. Yeah, yeah. Sure. Good, good. Of course it's a quote. Yes, yes. I don't know how it goes across stability training, but basically,
00:39:21
Speaker
three basic processes, repair adaptation, modulation of symptoms. If you can identify the process by which your patient is getting better, we have very clear guidelines what can be done to provide a supportive environment. And it's actually quite straightforward. We've overcomplicated something, which is we do naturally anyway, basically all these processes pre-exist us
00:39:51
Speaker
So people do adapt, people do repair, people do modulate their own symptoms. They are there to just kind of amplify these effects, these processes, support them.
Accessing Resources and Concluding Thoughts
00:40:01
Speaker
And what level do you go to in this? Because I know I'm just looking at the sort of outline of the model. So we've talked about recovery processes, talked a bit about behavior, psychological factors, not so much. But do you work on those, again, within the treatment session? Or do you refer out to other specialists to help you with the psychology side of working with? No, I do the kind of the psychological interventions more about the reassurance.
00:40:31
Speaker
It's more simple things. It's not deep psychotherapy. So some cognitive tools, not too many of them. But I'm attentive to the patient's emotional and psychological state and respond accordingly. No more than that. I don't know. I don't refer very rarely. My wife is a psychotherapist.
00:41:00
Speaker
refer between us is close to zero. Very, very rare. But I do learn a lot from her about the psychology and management of patients. She's an expert on that. Yeah, yeah, yeah. Excellent. Excellent. And so if people want to learn more about how to apply the process approach, or indeed any of your other approaches and courses that you have, where's best to go to? Yeah, the best is to go to our website,
00:41:31
Speaker
CPDO.net, if you can have it also on the website. Yeah, I'll pop that up. Yeah, no problem. Excellent. Yeah. Books, they can find on Amazon or on our website, but all information is there on that website.
00:41:44
Speaker
Fantastic. Fantastic. That's great. All right. Well, thank you very much for that today. I hope it wasn't too combative. I wasn't trying to be too combative, but I was trying to reconcile my understanding with where you are at as well. And I think, you know, I think we've got some interesting headway there. I still will take you up on that offer. I have to come on to one of your courses and see if I can
00:42:05
Speaker
be fully convinced of some of these finer points in motor control and so on. But yeah, that's great. Thank you for sharing your time and your experience. Thank you for the invitation. Look forward to our past crossing down the line. Yeah, all right. Great stuff. Bye bye. Thanks. Take care. Bye bye.
00:42:26
Speaker
So there you go, short but sweet. As you all have gathered, I have a lot of respect for ale, for his work, for his willingness and courage to swim against the tide, and because he's a great guy.
00:42:36
Speaker
We have some differences of opinion and understanding in certain areas relating to posture, motor control and so on, which we will hopefully get back to further down the line. But overall, I find this process model of working with patients a great concept and a beautiful example of someone who's found simplicity on the other side of complexity and helps move us from chaos to order. Thanks for joining us on FC2O. See you on the next show.