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FC2O Episode 20 - Diane Lee
49 Plays5 years ago
Discover the importance of nutrition, touch, motor control, preventive medicine, mentoring and issues with some popular research approaches with Diane Lee - one of the most precious treasures in the world of physical therapy.
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Transcript
Physiotherapy and Nutrition: What's Missing?
00:00:00
Speaker
So physiotherapists are typically not trained in nutrition or in gut health. And yet I don't think we can deny the emerging evidence that gut health and the fact that two thirds of our immune system lines the gut and its role in inflammation, that the role that that plays in core control and in the people that we see that are often diagnosed with fibromyalgia or polymyalgia or multiple muscle pain syndromes.
00:00:28
Speaker
a lot of these people come in and they've got a diet coke in their purse and they're chewing sugar-free, they're eating aspartame and they have no clue that what they're feeding themselves may be contributing to their headaches, bladder cystitis, back pain, you know, the complex person with multiple comorbidities that are excluded from all trials because they're too complicated.
00:00:55
Speaker
These these people often I will start with gut health. There's so many reasons why we can't treat the human being like a building or a machine. So I'm excited for our future and I think I think there will
00:01:10
Speaker
There will always be therapists who are better at education and training. There will be therapists who are better at manual methods, and the best people will be the ones that can educate, use their hands, use touch to change the nervous system, use touch to change whatever it is we're changing, and also help people to move better, to train better, to get stronger, to be fitter, to eat well, to do all the things we need to do to keep the home we live in named our body as healthy and as efficient as we age.
Meet Diane Lee: A Trailblazer in Physiotherapy
00:02:09
Speaker
This week I'm excited to tell you that we have the world-renowned physiotherapist Diane Lee on FC2O with us. I've been lucky enough to know of and latterly to get to know Diane for a couple of decades now. She is a whirlwind of knowledge, ideas, insights and passion for all things pertaining to helping optimize the therapeutic landscape. As a thought leader and author of multiple highly prized textbooks and papers, Diane is a real treasure in the field of manual therapy and rehabilitation.
00:02:38
Speaker
Recently, I've had the good fortune to co-author a paper with Diane for the Journal of Body Work and Movement Therapies, which is available for free for just a few weeks, so details of how to access that are in the show notes. Now, before we get going, I want to tell you a quick story about Diane. Three or four years back, I was sat in a coffee shop with a friend of mine who used to run the largest continuing professional development company for manual therapists in the UK.
00:03:04
Speaker
He provided courses with anyone who was anyone on the global stage, from Shirley Salmon to Lorimer Moseley or Douglas Hill to Paul Hodges, and including, of course, Diane Lee. And so I asked him, out of everyone you've seen present across the years, who would you say was the best? Whose course would you recommend the most? He paused for a moment, searching the depths of his mind. Then he turned to me, looked me in the eye and said, Diane.
00:03:32
Speaker
And then he nodded, said, yep, Diane. So you're in for a treat. And I'm confident you'll love hearing the wisdom of a true master over this podcast. So enjoy the show. Here we go.
00:03:55
Speaker
Welcome to another edition of FC2.0 with me, Matt Walden, and my guest today, Diane Lee.
From Gymnast to Physiotherapist: Diane's Journey
00:04:01
Speaker
Diane, welcome to the show. Yeah, thanks for the invitation, Matt.
00:04:05
Speaker
That's a pleasure, that's a pleasure. Now Diane, I've obviously been aware of your work, I think like most people in the manual therapy world, for many many years. I think probably even as an undergraduate I was aware of your books in the library and particularly when I was doing my research into my dissertations and theses, then I had to delve deeper into
00:04:29
Speaker
a whole array of different approaches and your name was one which featured quite prominently whenever I was looking for information relevant to what I was researching. So I've been aware of you since the 1990s but I think your
00:04:46
Speaker
The first book I saw of yours was the Pelvic Godel. Was that the first book you wrote? No, it wasn't actually. The first book that I ever wrote was together with Mary Walsh and that was in 1986 and it was a workbook of manual therapy techniques because we were teaching manual therapy methods at that time and I'm very tired of people
00:05:09
Speaker
slowing the course down by having to write things down. So we thought that if we wrote it down for them and took a few pictures, it would be a good idea. My father-in-law thought it was a terrible idea, but it was good in the end. But that was my first foray into writing. But you're right. From the first published book, it was in 1989 with Elsevier, and that would be The Pelvic Turtle. Yeah.
00:05:30
Speaker
Right. Right. I see. Okay. Okay. Fantastic. So then I think you and I first met around 2003, but let's sort of talk about your career and how you got into physiotherapy or do you call it physical therapy in Canada?
00:05:46
Speaker
Physiotherapy. Yeah. Wow. Okay. So I was a competitive gymnast when I was a teenager and a child and I dislocated my elbow at the age of 16, one of my injuries. And I ended up having physio at the time and I was in grade 11 and it was a time when everyone was thinking about what are you going to do after school? And my father wanted me to be an English teacher because I could write well. And that was the last thing on the planet I wanted to do. I wanted to go for a gap year.
00:06:12
Speaker
And, but that was in backpack Europe. That was the thing to do in the 1970s. So, but that was totally under the question. It wasn't going to happen.
Mentorship in Manual Therapy: Why It Matters
00:06:20
Speaker
And so physio seemed a bit interesting what they were doing with my elbow. So I looked into it at UBC and what I really liked about it was that there was 800 applications per year and only 30 people got in. So I thought, huh, if I apply for this, I'm not going to get in. And then I get to go travel. Guess what? I got, I got in, I got in and not being,
00:06:41
Speaker
talking one to tell my father a lie, I sort of went along with it. But for the most part, I really didn't like it much. I didn't find much use in it. But you got to remember what physiotherapy was like in the 70s. I mean, the best thing about being the old dinosaur now is the evolution and change that I've seen in this profession. Because what we were doing at that time, we had no anatomy of the spine,
00:07:06
Speaker
We learned nothing about manual therapy that belonged to the chiropractor, to somebody else. There was no manual therapy then. This was long before iPhone even existed. We pounded chests, fitted crutches, walked people, mobilized them, gave them exercises. The only hands-on intervention was effleurage, massage, not even specific trigger point stuff.
00:07:28
Speaker
That was my beginning into physiotherapy, but I really, my good fortune was to meet Cliff Fowler and to be able to work in his practice and to be mentored by him, John Oldham, David Lamb and Earl Petman, who are the founding fathers of annual therapy in Canada. Right. Fantastic. 1981. Yeah. Yeah. Yeah. And so where did your journey go from there? So did you actually work in the practice with them or they trained you?
00:07:54
Speaker
I did, I did. I was working at the Workers' Compensation Board. I spent nine months in general practice, in hospital because you couldn't get into private practice. They barely existed in BC at the time. I think there was only two, Cliff's and another fellow in North Vancouver. And everybody had to work in a hospital doing a junior rotation before you could even apply at the only orthopedic place was the Workers' Compensation Board.
00:08:19
Speaker
So after nine months in the hospital and hating it, I actually got a job at workers comp and I didn't really like it much there either. Physios didn't seem to do very much other than hot facts and ultrasound. And I started doing the manual therapy courses, which were very, very new in 1997. And it was at that time that Alan Morgan was looking for somebody to help him in his practice. And he had a split practice with Cliff Fowler.
00:08:49
Speaker
My the day I decided to quit Physiotherapy and go back into medical school was the day my husband phoned and said that he'd got accepted into dentistry So one of us had to keep working And so I took this job way on in the boonies in Surrey. It's like a 45-minute drive from where we were living and
00:09:08
Speaker
And from the day I started, from the day I started, I was like, roll up your sleeves, here we go, you know nothing. And this is, it was just the wildest, the best year of my career. He taught me how to clinically reason before there was even a word for it, taught me how to make sense of findings, taught me to trust my hands, taught me to test the evidence that wasn't very good, that was being published in terms of comparing it to what I felt in clinical practice
00:09:38
Speaker
I really believe in mentorship, that mentorship is the thing that turns a new grad physiotherapist into a quality clinician versus a technician. For me, in 1981, being part of that whole group that helped to develop the curriculum for Canadian manual therapy,
00:09:58
Speaker
was pretty awesome to be part of and and we've grown we've grown a lot since those days as well and some of those we'll chat about is because of the evidence and changes and things and and some of it is just because we didn't follow anyone we
00:10:11
Speaker
kind of like Canada is in general, we integrate it. Yeah. Yeah, yeah. And that's very obvious from your work, you know, looking at all of the different fields that you've drawn into your work. And I remember reading that pelvic girdle book and seeing you had evolutionary anatomy in there and that you had drawn concepts. Well, lately, I think in your maybe third or fourth editions, you were drawing a breathing pattern
00:10:34
Speaker
issues and this kind of thing into your models and I can see that's obviously just the way your your mind works is to is to integrate but so so okay so you know you've gone through your training you've had this mentorship where did you go next.
Building a Clinic: Diane's Entrepreneurial Story
00:10:50
Speaker
So I only worked with Cliff for a year and the fellow whose practice I was taking over, Alan Morgan, he came back to work and basically there wasn't room in his practice for two of us. And I was essentially let go with about two or three days notice that's it because he was coming back.
00:11:10
Speaker
So my father was in construction at the time and Cliff called my dad and said, how would you like to build your daughter a clinic? There's a small space next to the orthopedic surgeon that refers to us. And so that's what happened. My dad came down to North Delta and took this little 500 square feet and converted it into
00:11:30
Speaker
four room clinic, no exercise space, just all manual therapy rooms, one for traction, three for manual therapy, small reception area. I was 26 years old and Cliff said me, you're way too young to be doing this. Keep your head down, do good work and just let your results speak for themselves. And that's what I did. 500 square feet,
00:11:50
Speaker
practice grew from single practitioner to, I think the most of that I've had has been staff of 25, 18 of us, 18 of us now, it's been the clinic has been in 12345 different locations.
00:12:05
Speaker
I've never expanded to more than one clinic I've always wanted to be on site and to mentor within just I wasn't interested in a number of different places I wasn't interested in the big business model. I was interested in education right from the get-go and So I've had a clinical practice of my own since 1981 started teaching in the orthopedic division after I
00:12:30
Speaker
became a fellow of the Canadian Academy of Manual Therapy also in 1981. That was a busy year. Yes. And so I started teaching in the courses that were developed by Cliff and Dave and Earl, the guys that were, and gals that were ahead of me. Yeah.
00:12:51
Speaker
became a chief examiner for the system for 20 years and so was instrumental in developing the Canadian curriculum, which I think in the 80s everywhere in the world was very much based on biomechanics and
00:13:09
Speaker
biomechanical models and not about things being in and out. That was never a philosophy of physiotherapy. What's stopping it from moving and do we have a technique that used our hands that could facilitate that movement? The thing that's really changed Matt has been understanding the mechanisms that underpin what we do with manual therapy. I think the way we touch people has really changed but the fact that we touch them hasn't.
00:13:38
Speaker
Yes, for sure, for sure. Okay, so then did you, when did you write the first, so I think you said, was 89 the first edition of the Pelvic Girdle?
00:13:47
Speaker
So the invitation to write that book came in the early 80s and it came to Cliff. It actually came to Cliff from Gregory Grieve, who some of your listeners will remember from the UK. He was on the board of directors for Churchill Livingston at the time. And it was around about the time that Lance Toomey and Nick Bogduck had submitted their proposals to write their first book on clinical anatomy of the lumbar spine.
00:14:09
Speaker
And the board of directors at Churchill Livingston had said to Lance and Nick, well, what about the pelvis? And Nick had said he refused to write a book that had anything in it for which there was no evidence. And so Greg said, well, wait a minute, I have a friend in Canada who's really into the pelvis. Why don't we invite him to write a book?
00:14:29
Speaker
So Greg called Cliff. There was no email at the time. There was just help online. So he called Cliff and said, want to write a book on the pelvis cliff with all your ideas and things that you've been doing? And he said to him, nope, but Diane will. And I said, who are you talking to? And what's this about? And my husband was in dental school at the time. We didn't have any kids. And I was really practicing in the model that Cliff was using at the time.
00:14:56
Speaker
And I went, sure, why not? So, every Saturday, I would head to the Woodward Library at UBC, where all the references were. It took me four years, Matt, to go up into the stacks where all the articles were. Go through Index Medicus, first of all. Look for the keywords, sacroiliac joint, manual therapy, back pain. I didn't have a term of pelvic girdle pain then.
00:15:19
Speaker
climb up to the stacks, get all these journals, stand in front of the photocopy machine with my bag of nickels, throw a nickel in the machine to photocopy a peach. Yeah. Yeah. And I may get home,
Writing 'The Pelvic Girdle': A Pre-Internet Challenge
00:15:29
Speaker
I may get home after six hours of work with six articles. And you may think that sounds laborious, but it's equally laborious now just to send a search request to the local librarian and all of a sudden within one day you've got like 100 articles to go through. So
00:15:44
Speaker
We're swamped by volume now as opposed to time for them. So after four years, I went all the way back to 1905, which was when Friatt was first writing about sacroiliac joint stuff. So I did a lit review from 1905.
00:16:00
Speaker
to 1980 whatever the year was I was writing and then it took another another three four years to get that book which was state of the art in 1989 and probably should be used as a shoe shim now but yeah that was that that was the process that was the process then. Wow and when did the World Congress on Low Back and Pelvic Pain come into the picture because that must have been around that time was it?
World Congress on Low Back and Pelvic Pain: Opening Doors
00:16:26
Speaker
Here's an interesting story. So I'm at work and I get a page from my receptionist basically who says, there's a guy on the phone and his name is blaming or something. I can't really understand his accent, but he wants to talk to you about, I don't know, but do you want to take the call? And I said, take a message. I put Dr. Andre Fleming on hold.
00:16:53
Speaker
or actually told him I'd call him back. Anyway, when I called him back, this was about 1991, and he was at the time together with Bert Mooney, organizing the very first interdisciplinary World Congress on low back and pelvic pain in La Jolla near San Diego, USA, and it would be in 1992. And somebody had put that very first green edition of the pelvic riddle book on his desk,
00:17:19
Speaker
And Andre had always had this philosophy that the pelvis was going to be important for back pain. And his supervisors had said to him, forget it, Andre, there's no career in the pelvis. Look to the disc, do everything. The lumbar disc is where you're going to make your career. Well, Andre wasn't interested in a career. He was interested in anatomy and connections and function, which is what the little green book was about.
00:17:44
Speaker
And so he gave me a call and he asked me if I'd be interested in presenting on the relationship between the low back, the pelvis, and the hip. He said, sure, how much time do I have? And he said, 15 minutes. Oh my gosh. So I met Andre in 1992 at the World Congress on low back and pelvic pain. And we've just had our 10th Congress in Antwerp just last month.
00:18:09
Speaker
And that experience really opened the door for me to really look at manual methods. At that time, Andre was saying, it's just fiddling, give it up. And so we were at loggerheads right from the beginning in terms of the role of manual therapy and in helping people heal from whatever condition they had.
Evolving Understanding of Manual Therapy
00:18:30
Speaker
We had the opportunity to travel together and to teach in several places in the world in the 90s and be forever grateful for his mentorship and taking my hand in guiding me into different areas that weren't so biomechanical and more about forced closure and form closure and the theories that he developed through his PhD in terms of how
00:18:55
Speaker
how the pelvis functions. And then I was invited to the Gold Coast in Australia in 1995 by Gwen Jell to talk about the pelvis. And I was sitting with a row of speakers and there's this young man sitting next to me 29 years old, very
00:19:10
Speaker
Intent him looking at the paper. He was presenting and he looked at me and he said hi My name is Paul Hodges and I went nice to meet you Paul and he says What are you talking on? So I told him and I said and you and he says tranny I said pardon me tranny I said well, what is tranny transverse of subdominis? Do you know about it? And I went hmm
00:19:34
Speaker
well I know it's an abdominal but that's about all I know and you know where the story goes from 1995 onward and the thousands and thousands this was before he'd even had one paper present uh published oh wow so I followed I followed Paul Hodges work for many many years many decades and he's uh another mentor of mine who's obviously helped me bring some uh of the clinical
00:19:57
Speaker
Information and evidence we have regarding diastasis rectus abdominis to write to publication and Yeah, so that was the world of motor control form closure force closure motor control Integrating it all with biomechanics. So
00:20:12
Speaker
I'm a curious learner as are you and yes very open to New things or new ways of explaining things But what I have never ever ever lost faith in since 1981 is my hands my ability to trust my hands feel I mean I'd understand what I'm feeling but I I do trust them
00:20:35
Speaker
Yeah, I think that's that's lovely that you have that. Because one of the things that you and I have discussed in the past is how sometimes in these kind of more research oriented forums and conferences, you can be there amongst a group of people that really are hands off, they're very focused on experimental research, you know, on lab based information, and they're not actually at
00:20:59
Speaker
the coalface working with the patients. And how do you see that as being reconciled in clinical or for clinicians, let's say, because there's a lot of kind of noise, isn't there, that comes from the world of research, especially with social media these days? Oh, totally, totally. And there's a history and a journey to that as well.
00:21:21
Speaker
In 1995 at the World Congress, Dr. Ben Stearson, who for those of you who know the evidence around the pelvis, will know that in 2002 he did his PhD looking at low transfer tests. And one of the things that he found is that even in people with pelvic girdle pain, the SI joint doesn't really move that much. And so just based on that finding, he made the conclusion that therefore the movement is too small to feel.
00:21:46
Speaker
Meanwhile, at the same time, I was presenting passive mobility testing of the SI joint in the form integrating form and force closure mechanisms and how we can test the articular integrity of the SI joint with form closure tests and how we can test the force closure mechanism with motor control and force closure tests using our hands. And after I presented this, he says, I don't understand what you're talking about. The joint is so small or the joint movement is so small.
00:22:12
Speaker
Tell me show me show me what you're doing and I said well I can't really do that here bent because you have to take your pants off and in the foyer of World Congress It's probably not appropriate. So why don't you come to my room? And after I said that he just looked at me big eyes and I went and let's bring a few other people so I am I I coerced Brett spritz Duga who I knew had a An asymmetric amount of mobility between the left and right sides of her pelvis Let's just put it that way and so Brit joined us and there's a few other people as well
00:22:42
Speaker
So I'm standing on my bed in this hotel room and all these people are laying on the floor and I'm teaching them how to feel the arthrokinematic glide at the SI joint. And Britt is just one of the patients on the floor. And as Bent gets to her pelvis and feels the left and right side, he can clearly feel the difference in amplitude of movement between sides. And he looks up on me and he goes,
00:23:04
Speaker
What am I feeling? I said I don't know but you're feeling something different between the left and right aren't you and he went yes he says you can't teach this in a lecture you can't teach this with a video and I sat back and I went manual therapy is a skill bent you have to train your hands and it can take five to seven years to train
00:23:23
Speaker
The receptors in your hands and your brain and to build the brain maps Although we didn't have that language at that time said it can take time to really do this And if you showed me a video of a hip replacement Do you think that would be enough for me to then go and say I can now do a hip replacement? I don't think so. So we each have a role to play in all of this now
00:23:45
Speaker
That was 1995. In 2001, Barb Hungerford presented her PhD paper, which was looking at the stork test or the single leg sanding test and our ability to feel form and force closure and good motor control patterns in that
00:24:01
Speaker
Again, integrating the evidence that when you stand on one leg, the sacrum should stay mutated or anteriorly or flexed or whatever we're going to call it. The anonymous should be relatively posteriorly rotated and you shouldn't feel any movement between the sacrum and the anonymous when they shift their weight onto one leg and lift the other one. And there's a group of people with pelvic girdle pain for whom that doesn't happen and the anonymous rotates anteriorly.
00:24:24
Speaker
Her methods were using motion analysis and a very rudimentary sort of icon system. It's much more sophisticated now with only 15 measure points. And she showed that, you know, in a lot of people, the inominant would anteriorly rotate, which is relative counter-nutation of the sacrum in this task.
00:24:43
Speaker
But her research wasn't accepted by those in the know at the time because they felt the movement was too small for the human hand to feel. So that was in 2000, 2001 at the Montreal Conference. In Antwerp this year, full circle, full circle.
00:25:01
Speaker
I walk into the surgical session where Ben Stearson is moderating the session and I got there a little bit late and he's talking about diagnostics and the diagnosis for who needs surgery and who doesn't for pelvic girdle pain and up on the slide he has a list of tests and one of them is the one-legged standing test, stork test, julรฉe test, whatever you're going to call it and the fellow who's palpating is feeling on the weight-marrying side and I didn't interrupt his presentation. I didn't want to be
00:25:29
Speaker
controversial but I did approach him at the gala that night and I said man are you using the the low transfer test in standing he said I
Challenges in Manual Therapy Research
00:25:37
Speaker
am and I said can you feel the movement now and he goes no but my physios can and I can test my physios so he does he does interarticular injection techniques he feels this he sees the strategy change though he's tested it at the same conference this year Joe Abbott who is a biomechanist from the UK
00:25:57
Speaker
and she has totally changed the trajectory of her PhD since doing the ISM series with me and has gone into investigating integrating robotics research, manual therapy, she's done an incredible amount of study looking at why do we have such difficulty with inter and intratester reliability and it comes down to a number of different things
00:26:20
Speaker
But basically using the Vicon system and several markers all over her body and all over her hands and she developed some gloves, but now she's tossed the gloves. She is reliable to within 0.0056 degrees of transverse plane rotation of the pelvis. And the test is in the moment, in the moment. It is not testing over time because we know pelvic position changes over time.
00:26:48
Speaker
And all her studies are really showing is, can we feel the things we say we can feel with the hand? So there's some huge breakthroughs that are going to start going through in the next five years that help to explain why the methods for studying what we do as manual therapists have failed.
00:27:08
Speaker
manual therapists. So her paper was titled the evidence based methodology has failed the evidence based understanding for inter tester reliability. There's so many reasons why we can't treat the human being like a building or a machine. So I'm excited for our future. And I think
00:27:25
Speaker
I think there will there will always be therapists who are better at education and training There will be therapists who are better at manual methods and the best people will be the ones that can Educate use their hands use touch to change the nervous system use touch to change whatever it is We're changing and also help people to move better to train better to get stronger to be fitter to eat well to do all the things we need to do to to keep
00:27:53
Speaker
the home we live in named our body as healthy and as efficient as we age. Yeah, yeah, for sure, for sure. Now I know you know Serge Grakovetsky very well as well and for a little period of time he was flying over to the UK fairly regularly to do events with me as well and of course he brought his spinoscope with him which again was a kind of early iteration of the Vicon system but specifically for the spine.
00:28:19
Speaker
And I remember reading a book which he actually called The Spinal Engine 2, which I don't think he ever published. But within that, he had talked about how, and of course, he was trying to justify the spinoscope methodology of having these markers, these reflective markers on the skin. And he was saying that even though the markers don't exactly reflect the underlying joint motion,
00:28:42
Speaker
what they do reflect is a composite of the joint motion, the deep fascia, the musculature, the superficial fascia and the skin, which actually is a kind of more real world integrated understanding of what's going on in the spine than just trying to assess an isolated joints. And I think that was quite an interesting point because that obviously relates very closely to what we're palpating with our hands. We're not just palpating joints, are we?
00:29:04
Speaker
Absolutely. He was so far ahead of his time. I remember taking weeks to read through the article, the optimum spine, that big thick article that was sort of a Coles notes version of the spinal, the spinal engine. And yes, it's one of the hardest things I have in teaching now to convince students to do is to back off with their hands like they reach so hard for the bone that they prevent
00:29:34
Speaker
the natural movement from occurring and I think Jean-Claude Guillermo's work from France in looking at functional living fascia has really really helped me be able to teach people that when the bone moves because it is connected to everything all the way through to the surface of the skin it will create this tsunami effect through the tissue that you will feel with your hands
00:30:00
Speaker
But not if you not if you press real hard. So the lighter we are with our touch, the more we actually feel. You don't actually have to be on a bone to feel it move. And I think one of the things that Barb Hungerford showed in her studies in 2004 were that even though measuring movement on the surface of the skin isn't a direct reflection of the amount of movement of joints, it's a reflection of the pattern of movement.
00:30:26
Speaker
So you actually have to have pins in bones and things and eliminate all the other tissue in order to actually quantify what the joint movement is. But that is so clinically irrelevant. That's the surgeon's realm. We're never ever going to be using that in clinical practice. So it doesn't translate to clinical practice to even do research like that.
00:30:48
Speaker
the tool we have is our hands and knowing and understanding more about how to use our hands, how to surface landmark, whether the thumb should be in the vertical plane, whether the thumb should be in the horizontal plane, what's the best way to place your hand in order to set it up to be able to feel the relative motions. So there's lots of things coming soon that will make that sentence be much more clear. Okay, okay, good, good.
00:31:17
Speaker
Now, earlier you mentioned when you're talking about Andre Bleeming, you were you alluded to the fact that he didn't think that the path you were going down was the right path.
Changing Perspectives: Manual Therapy's Role
00:31:27
Speaker
And could you elaborate on that a little bit?
00:31:31
Speaker
sure we were um the first uh somewhere oh the cobwebs matt hang on this is back in the late 80s early 90s it'll be the early 90s 92 to 95 we are traveling together and he really felt that that manual therapy his words were to me were manual therapy is fiddling
00:31:49
Speaker
Give it up. Monohar Punjabi had just published his paper with, you know, the balls in the bowl, the two balls in the bowl, one sort of showing stiff joints, one showing sort of a loose joint. So you've got an open flat bowl and the ball and it can roll further. And this was all talking about zones of motion. So the neutral zone, if you take two people and you're assessing the same joint, so it's not a different joint, but say two thumbs, two metacarpophalangeal joints.
00:32:17
Speaker
and you move one thumb, you glide it dorsally and ventrally, that there can be two very different feelings in terms of the amplitude of the neutral zone. How big is the amount of slide or glide you can move the proximal phalanx relative to the metacarpal before you hit resistance. R1 in Maitland's terms or your beginning feel in Syriac's terms, whatever you're going to call it. This whole neutral zone, elastic zone thing,
00:32:45
Speaker
And so we were, I was trying to explain to Andre, we were in Billund, Denmark at the time about to present at a conference and we'd gotten there a couple of days early. Both of us had gotten our dates wrong. So we had a couple of days to kill. And the only thing I could think of was to use Punjabi's model of balls in the bowl to describe to Andre
00:33:08
Speaker
what i feel in my hands when a joint is compressed by muscles that may be overactive i don't know if that's the right term to use but muscles that are driven by the nervous system where they're being told to contract too much by the nervous system that situation that feel in my hand is very different
00:33:26
Speaker
than a joint that has been sprained and perhaps has more thickening around the capsule or tissue that's not as hydrated and in the old days we would have called that a stiff fibrotic joint. So those two joint fields are very different versus a joint which has lost the ligamentous integrity like an ACL injury, a complete evolution of the ACL and what that would feel like. So we started drawing all these different shapes of balls and bowls to explain what
00:33:56
Speaker
What the hands were feeling and as part of this Congress we we had a there's 250 people there and we had a short Practical session at the very at the very end and there was only 40 people in the practical session but this is where I actually taught the passive mobility test for the sacroiliac joint and and I
00:34:17
Speaker
There must have been an uneven number because Andre became a patient for some reason and somebody did it on him and he could actually feel it because our Interception in our body if we bring our awareness to it. He's an extremely aware guy Is is good and he could actually feel the difference when I was saying okay now contract your pelvic floor See what that feels like arch your back see what that feels like I was going through the form of force closure mechanisms showing how different Strategies could compress and therefore stabilize the SI joint sure
00:34:46
Speaker
And he actually and he actually got it He actually could feel it in his own body and then he wanted to learn it in his hands And now he's been sort of teaching it for 30 years And doesn't he doesn't understand it. I don't think any of us do completely understand how manual methods work But those of us who use our hands in practice as well as everything else are fairly certain they do yes, don't know how to explain it and help develop good research studies that that that
00:35:16
Speaker
That actually duplicate or replicate what it is that we do do in the clinic because you know I'm sure you've had this experience as well You can be on a course and you can have two different practitioners doing so-called the same technique on your shoulder and one of them you want to say oh keep going that feels lovely you can feel things soften and open up and somebody else who is doing Technically exactly the same things, but it hurts you're bracing you're getting defensive and you just want to tell them to take a hike and
00:35:45
Speaker
So it's the way we touch. It's the amount of force. It's the softness. It's who you are in your interaction with the person. I mean, I think Bialoski and his whole model of
00:36:00
Speaker
the different components in terms of touch is so relevant to what we do in terms of manual intervention. It's not just about the technique, right? It's not just about the technique. Yeah, absolutely.
00:36:17
Speaker
Absolutely, yeah. One of our wise old owls at the Osteopathic College always used to say, this is a guy called Mr. Kylie, I don't know if you've ever met Dennis Kylie, but he I think was the Dean of the British College of Osteopathic Medicine for many years and he used to say
00:36:32
Speaker
you have to love the body. And he would show perhaps a mobilization technique of the thoracic spine, but he'd just get in really close and make the person feel supported. And he was soft in his touch, but he was strong. And he was an amazing technician, but had that kind of connection, which is what he was trying to convey by saying you have to love the body. So I think you're absolutely right. The touch and the way you interact is so important.
00:37:02
Speaker
Two words you said there that I so resonate with, soft but strong. So the patient always is in control. Now, this is different than a manipulation technique, but for like a high velocity, low amplitude thrust, but which has its place as well. But I don't use those techniques as much as I used to. But the soft but strong, this is where we're going. I think we have the biggest opportunity to change pain, change sensory input into the brain.
00:37:31
Speaker
change our somato perceptions so that you can start to reorganize the mental body map if you like it to be able to demiscriminate between safe movements and threatening movements to provide the safe stimuli and to be able to have the person move while you're Facilitating movement kind of like a mulligan thing like Mobilization with movement that sort of stuff where you can if you change the person's experience of their body and the sensory input
00:38:01
Speaker
From an area that normally hurts and you provide a different sensory input from an area of the body that normally hurts For me that that is that is so changing so empowering for the person to then absolutely start to take back control and to start to want to have those experiences with their body when they move in that way again, and I can do this I can explain this much better with my hands than I can with with my left brain and language and
00:38:31
Speaker
Yes, yes. And I guess it's also one of the things that I find very interesting when you see these kinds of debates emerging around what's the right thing to do and what's the right technique or the right approach for a given situation.
00:38:48
Speaker
Quite frequently, it doesn't seem like there's the kind of clinical experience behind the arguments. And what I mean by that is that some of the techniques that I learned from you in the early 2000s, so for example, form closure, essentially mimicking the transverse abdominis function with the active straight leg raise test, that assessment. I remember having a basketballer come in, and this is one of those situations where I'd organized a meeting
00:39:18
Speaker
and had said to these, they were mainly check trained professionals, but I said to them, you know, if you've got any clients that you want to bring in and we can do a sort of live case study, then we'll do that. And so you're on the spot, you're there at the front, and I know you do this as a living, so you're used to this. This was quite novel for me at the time. And this guy brought in this elite basketball, he was in the England basketball team. I suppose that doesn't necessarily make him elite.
00:39:46
Speaker
you know what we like at basketball in England. But anyway, he's national or international level. And he had this recurrent hamstring strain. And so it must have been after 2003, because I've read Barbara Hungerford's paper, who you mentioned earlier, about how the biceps femoris will increase its tone when there's sacrilegic joint pain and the transverse subdominis seems to decrease its tone or decrease its firing.
00:40:12
Speaker
yeah, delay as firing. And so I was aware of that and I remember looking at his low back and his low back had striations and you're kind of looking thinking that that looks like what we might call a multifidus inhibition or some kind of segmental instability. I don't know if that's still politically correct or accurate but nevertheless there's these indicators there that maybe there's something going on in that
00:40:38
Speaker
deep multifilist area in the lumbar sacral region on the same side as his hamstring injury. So I did the active straight leg raise with the reinforcement of transverse abdominis and he got his leg up to about 45 degrees and he's holding his hamstring going, oh, that's it. I can feel the strain in my hamstring.
00:40:56
Speaker
I thought, okay, that's, you know, it was quite, it was quite acute. And obviously quite a low level of hip flexion. He's only, like I say, 40, 45 degrees and he's feeling the pain in his hamstring. So then I reinforce the multifidus. And
00:41:12
Speaker
suddenly he could lift his leg right the way up to you know nearly 90 degrees and his pain had gone and he just looked at me like i was some kind of magician as if to say like what have you just done it like his pain had magically gone away almost like a you've you've magically unstrained his hamstring yeah yeah not a hamstring that's it that's it you just found a pelvic driver
00:41:37
Speaker
There you go, there you go. But so but then you have people, of course, I've seen it a lot on the forums just recently who say, you know, well, I mean, there's a paper even called the myth of course, stability, which which, you know, okay, it maybe isn't quite driving it motor control approaches in the way that you practice them. But nevertheless, there are people that are very dismissive of this kind of approach. But when you're working with clients and seeing those kinds of
00:42:02
Speaker
things happening the whole time then even if the theory behind it is wrong there's obviously clearly clinical value to it. Well that's what I keep hanging my hat on and and you know I've been interested in in the thorax for decades and it's a very difficult region to research because we don't have yet, Joe Abbott's working on it, we don't yet have a machine on the planet
00:42:27
Speaker
that can measure movement between like a sixth and seventh rib, so between two rings. So if we consider one thoracic ring, so two vertebrae and its ribs and all its attachments all the way around, you essentially have 10 pelvises stacked on top of one another, right?
00:42:44
Speaker
And we don't have a machine that yet can measure what's happening between the two now, or let alone within a ring. Now, there's those who will say, well, why do you have to? That's too biomechanical. But in 1996, when I published a paper in a journal on
00:43:02
Speaker
I like what I called at the time a lateral shift lesion all bad language now I know that was 96 forgive me but I picked up that in it that there's there is people who had trauma to their thorax a seatbelt injury or a direct blow who couldn't rotate
00:43:18
Speaker
very far at all. And it seemed to me that there was this one ring, one segment, that was held in a rotated position with a contralateral translation. When I would do a high-velocity, low-antitude, manip technique on that, their rotation was restored completely. And that was in 96.
00:43:36
Speaker
And then in 2003, so Linda Joy Lee joined me in 1999 at the clinic and she started to assist on some courses, became very clear very early on that very, very bright clinician, bright gal, lots of innovative ideas. And in 2003, she actually showed me something that she figured out, which is this thing called a thoracic ring of correction that you could actually do something with your hands that changed
00:44:03
Speaker
The movement pattern changed the ability of this person to move immediately and I mean it blew me away when she showed me that in 2003 and we've gone on went on to develop this whole thing called the integrated systems model which isn't just about the just about thorax but it's the power of it is that and the touch is really light that you can touch somebody that lightly and now I call it working in the nervous system
00:44:27
Speaker
And evoke a change in with that sensory input evoke a change in the motor output To the point where you can increase three someone's range of motion 40 50 degrees. Now. This is just a test. It's not treatment It's diagnostic, but it's certainly just like your active rate straight leg raise test rules out that the joint is stuck Stiff or that there's anything biomechanical
00:44:50
Speaker
about that if we define biomechanics as only being joints. For me, biomechanics is about everything. Biomechanics is about posture, movement, motor control. It's the one word that describes it all. But the thorax, if in that same guy that had hamstring pain, posterior thigh pain, poor pelvic control, if you had supported his pelvis, so did a compression of his pelvis, like the act of straight abrease, there's a subgroup of people where that wouldn't have improved.
00:45:20
Speaker
Now, would you have then gone on and treated his hamstring? No. Because you could have exactly the same thing happen by taking the twists out of his thorax. You could take the twists out of his thorax, and that can change the motor control strategy to the pelvis, stabilize the platform indirectly, and his leg would have popped up. So we started with Jan Men's test on the act of straight leg raise in 1995.
00:45:45
Speaker
And I remember Andre calling me and saying, we've got the gold standard test now for, and we were calling it pelvic stability at the time. We don't know about, we call it control, but in the time it was called pelvic stability. And it was the ALSR test and just generically compress the pelvis. And if the leg flies up, then the pelvis is in stable, train them.
00:46:06
Speaker
And I said, oh, leave it with me for a while. It seemed that seems too simple because when you when you treat complex patients like you and I do, we know that nothing is ever as simple as what they have to reduce it down to to study it and research. So I started playing around with locations of compression, compress the pelvis in the front, compress it in the back, compress one side in the front, one side in the back. And this is what led to the development of the compressor belt. And now the more modern the baby daily pelvic support.
00:46:36
Speaker
where the straps, you can vary the location of compression. Now, it doesn't mean that if you bring the straps to the front, that transversus is weak, or if you bring it to the back, that multifidus weak, because it's about force vectors, and you just have to assess the motor control to understand what the deficits are. But the patients- Just to explain the strap a bit better to the listeners. Well, you describe it, because I know roughly how it looks, but you have a better
00:47:05
Speaker
So it's a belt that's quite different from the Sirola. In the Sirola belt, the straps are attached over the back of the sacrum, and then you pull from there and attach to the sides of the inominate. On the compressor belt or the baby belly belt, the straps, the compressing straps, so you have this elastic belt that wraps around you, number one, just a very general compressive strap. And then a second set of straps that are sewed in the mid-exiliary line. So they're sewn just in the plane or the line of the greater trochanter.
00:47:34
Speaker
And then you can take these straps and either attach them to the front of your pelvis for more anterior compression. You can attach them to the back over the sacrum for posterior compression. And we used to think at the time that it would do what multifidus should do, do what transversus should do, but clinically it didn't pan out. It wasn't like that. Because you could have too much
00:47:58
Speaker
um well it's all about force vectors is basically what it's about but there's also a group of people with pelvic girdle pain that when you compress their pelvis it hurts more and their their task whatever it is whether it's an active straight raise or squat or single leg standing test gets worse
00:48:14
Speaker
That tells you that further treatment of the pelvis in terms of training or motor control training is not going to work. You're not working on the place in the body where you're going to get your biggest change. So in the integrated systems model, we call it finding the driver, which is basically the region of the body, which is the best place to start to intervene, at least with manual methods anyway.
00:48:39
Speaker
And do you, I know this is probably the material of the courses that you run, but do you have any kind of model as to how to prioritise assessment of the
Finding the 'Driver' of Pain: A Clinical Approach
00:48:51
Speaker
body? Or is it a case of going through each kind of key area one by one?
00:48:57
Speaker
So if we were to take the hamstring example. Yeah, it is. So let's say you have an elite level athlete, basketball player, football player, whatever, eight level athlete who has chronic recurrent hamstring pain. First thing that comes to my mind is exactly Barb Hungerford's research.
00:49:14
Speaker
they're overusing their biceps femoris, or their medial hamstring, whichever one that is the problem. Then the next question becomes why? So for me, I follow Andre's philosophy of that the pelvis is a platform to which attaches three levers, and I would always start at the center of the body. Do they have pelvic control? Can they control the joints of the pelvis? Yes, no.
00:49:35
Speaker
And then if they have loss of pelvic control over activation of biceps, I want to know why. Is it the old ankle sprain that is causing excessive internal internal rotation of the hip to which is mucking up the motor control strategy, at which point you would, you're looking up and down the body the whole time for the task. So you would pick a task. So you'd ask the guy, so when does your hamstring hurt?
00:49:58
Speaker
Well, when I go to do a jump, a single leg, don't show me how you jump. And so you watch them jump and often they'll take off on one or two legs. And then you assess the entire body visually to look for where does it look like there's suboptimal alignment, biomechanics or control for this task.
00:50:17
Speaker
And we actually divide the body into functional units. So the first functional unit is the trunk. So we're looking at about rings up to about the third ring. So just around the axilla area down to the hips. We look for things that are suboptimal in that area.
00:50:32
Speaker
And I know some of your listeners are going to think this language is dangerous. It really isn't when you watch us work like this. We're looking for really significant things that are fairly obvious, not little tiny things. And then just because the person has a finding, it doesn't mean that it's relevant. You then have to test it.
00:50:49
Speaker
So if they've got a loss of pelvic control when they stand on one leg Then i'm going to give them pelvic control So i'm literally going to compress the pelvis and then ask better worse. No change. Oh, no, my hamstring still killing me Meanwhile, they've collapsed on their foot their heel has gone into eversion their foot's flattened and you go All right. So let's see what's happening with the foot. So you go down to the foot You stack the hind foot you hold it there. You palpate the SI joint with your other hands you have them shift their weight onto that side and they go
00:51:19
Speaker
My hamstring doesn't hurt as much and you go oh and guess what when you have your foot right under your body your SI joint doesn't unlock or doesn't give way and We can spend hours debating the mechanism of that
00:51:31
Speaker
But to be honest with you, Matt, that's for research. I don't care. I just know that if I fix this foot and if I get this foot functioning better, I'm going to change the strategy that he's using to stabilize his pelvis. That would be called a foot driver and so on and so on. So you go to the different regions or areas of the body quickly. So within 10 minutes, I want to know, can I change pelvic control?
00:51:54
Speaker
by changing somewhere else. Where do I have to go to change the motor control strategy for pelvic control? And if no correction anywhere changes the pelvic control, then I have to go to the pelvis. I have to go to the pelvis. If the pelvis isn't able to transfer load, you can't sit, you can't stand, it's difficult to sleep, it mucks up everything.
00:52:21
Speaker
Yeah, yeah, yeah, for sure, for sure. Okay, so now, I know we've talked a bit about motor control, but and also a little bit about, you mentioned manipulation earlier, and I remember a conversation that you and I had quite early in the 2000s and
00:52:38
Speaker
I think I was asking you about motor control and made some kind of comment. There was a little bit negative, perhaps, about spinal manipulation, saying, you know, perhaps spinal manipulation isn't the answer to all low back pain or something like that. And you wrote back to say, well, actually, you know, it does something, and we don't know what it does yet. And I just thought it was fascinating. And you've done some training with Laurie Hartman, I believe, at various points. And yeah, yeah.
00:53:05
Speaker
So now where does, because obviously quite a few of my listeners are osteopaths, as in British osteopaths and you know sort of more manual therapy oriented osteopaths. So where would you see manipulation and or other mobilisation techniques fitting into? I think the
00:53:28
Speaker
I'm not sure if you've seen the article by giles gyer jimmy michael james inklebarger the spinal manipulation therapy is it all about the brain it's a current review of the neurophysiological effects of manipulations what i was reading this morning getting ready for just waiting for your podcast um and it's uh it really is a good article that kind of summarize again historically that what we thought in terms of the man the neck mechanisms of spinal manipulation so
00:53:58
Speaker
We used to have in days gone by these theories that biomechanically what manipulation could do, it could release traps and ovial folds or meniscoids, it could restore so-called buckled movement segments, could reduce adhesions, or it could have a reflex effect of normalizing overactive muscles. And this was sort of kind of the four basic sort of premises in terms of how spinal manipulation works.
00:54:27
Speaker
And I think for the spine, I think that the main mechanism theory that's getting explored a lot is the neurophysiological one. The effects that high velocity, low amplitude impulse to the skin, to the fascia, to the joints, to the fat, to whatever receptor is going to receive this impulse.
00:54:47
Speaker
the influence that this has in the nervous system. I think this is the mechanism or the explanation that's really getting investigated a lot.
00:55:02
Speaker
Every time I think that spinal manipulation is and I don't want to minimize this and say merely neurophysiological because it's a pretty powerful neurophysiological tool and opens up the nervous system for different ways to move allows the body to move differently. So when we couple that release technique with movement and motor control and movement training and you put the two together, it's pretty powerful.
00:55:25
Speaker
somebody will come into the clinic that week with an entrapped meniscoid. Like if you've ever seen one, there is just no denying that there's something in a very arthritic back that has lots of degenerative changes in the zygapophyseal joint. This is going to be really bad language, but I have no other way to explain it. Something gets stuck and you can do all the general
00:55:52
Speaker
Chicago million dollar roll techniques that you want with that person. But unless you are precise, specific, and you can distract and gap that joint, nothing will change. But if you can, and you can gap that joint, and there's a horrendous clunk that's way different than a cavitation of a healthy joint. It's just a way different sound. They stand up, their shift is gone, they're straight, they're sore, and now they need their multifidus trained often, because it's been inhibited by this pain.
00:56:20
Speaker
But you don't see these people in the research because I see like about one of them a year and they're just not around to be able to take a group of 40 or 50 people with locked backs or necks or whatever we want to call them.
00:56:36
Speaker
but talk to any clinician that's been in practice for 40 years and they'll tell you that that once in a while they run into something in their practice where man it sure looks like something stuck but it's certain that's not the most common thing you see but I want to throw that out there because I really do think the condition exists it's just not common and more commonly what we see is the the motor patterns like the committed motor patterns that we can use high velocity techniques to
00:57:06
Speaker
Reset to change to create a relaxation response to create a change a change in the in the motor output and it will only be temporary often it's only temporary if If the person continues to go back and use their body as they normally have so unless we bring awareness to
00:57:26
Speaker
possible reasons why or how this is happening repeatedly for them and have them strengthen and train or train in a different way. Often it becomes recurrent. I think we all still have those people in our practice that have been manipulated repeatedly
00:57:44
Speaker
And we're all guilty of doing this at some point. They come back and they just, you know, I just want you to crack my back. My back is out. I want you to crack it. And the hard thing to crack is the belief that, you know what? We don't do that anymore. We don't. Yes. Some of it's about patient expectation and they get better, but you're feeding into it. And I'm always in this dilemma when it happens. Yeah. I'll do anything but manipulate that back to try and make a change just to treat their cognitive belief and
00:58:13
Speaker
that's it. Yeah, for sure. They're hard, they're hard, especially when you've been, when you've been guilty over 30 years of feeding into it.
Preventive Roles in Therapy: A New Perspective
00:58:22
Speaker
And anyway, anyone who says they haven't isn't telling you the truth because we all grow, we all learn and
00:58:28
Speaker
been there done that i could remember in the 1980s early 80s after treating somebody probably with a manipulation technique this person saying are there any exercises that i could do for this and honestly saying for them none that i could think of and now and now you could give them a list as long as your arm right that's it yeah for sure for sure well you know leading on from that
00:58:53
Speaker
The preventative side of physical therapy I think is something that's a little bit understated and perhaps, or let's say historically, of course, the reason a patient comes to see us is generally because they're in pain or they're
00:59:10
Speaker
dysfunction for want of a better term, you know, for perhaps something's clicking, something doesn't feel right to them, however they want to express it. And it's because that thing has become persistent and hasn't gone of its own accord that they tend to seek out someone like like you or me. But do you think we have a role
00:59:30
Speaker
more so in prevention that you know it's a kind of it feels to me like it could be more of a fertile field than just reactive stuff. Absolutely and the problem is how do we language it and not create practitioner dependency so
00:59:45
Speaker
So we have, I think that the dentists have created a fantastic model. The chiropractors have tried to, but then they've been accused of just having people come back and creating practitioner dependency. So there's the extremes there. How come it works for dentistry, but it hasn't worked so well for chiropractic. And in physiotherapy, we tend to say, you know, when the patient says to you, should I come back in three or four months? You know, we'll see how it goes. See how it goes. And if you're having any trouble, come see me.
01:00:14
Speaker
So again, we're relying on pain and dysfunction as the indicator as to when you should come back, which is not right. Like if we want to help people who are really active stay well in their body, the question is, can we pick up relevant impairments before there is a danger signal? And I think we can.
01:00:38
Speaker
Um, but in order to do this you we we have to rely on some understanding Of how we think that person should be moving and I know that this is fraught on social media and in the research with people saying well It doesn't matter how you move doesn't matter how you sit just sit just move just do anything And and it's about determining the relevance and that's that's the tricky bit so if you bring somebody back and you three four months after you've seen them for back pain or whatever and
01:01:06
Speaker
and you look at them and you go, how are you doing? And you're saying, oh, no, things are going well. I'm doing everything. And there's no meaningful task. There's nothing that you task that you can evaluate because they're not having difficulty with anything. Now we're becoming judgers. Now we're starting to look at someone's posture, how they're moving, and we're judging that this may not be ideal for them. And
01:01:31
Speaker
sometimes unless it's really obviously bad like you're bending your finger backwards and sitting on it nobody would ever think that that's a good thing to do um yes like it's an extreme because we can't just talk about anterior pelvic sway or s postures anymore because there's people who are highly functioning that have that kind of posture um yeah we have to
01:01:53
Speaker
It's an area I would love to get into, but it's an area that's going to be fraught with, well, how relevant is this finding? Like when I teach, one of the biggest things I really try to instill in the students is just because you have six or seven things that you find doesn't mean that any of them are relevant. You have to test the relevance of that finding.
01:02:10
Speaker
to the task and the patient's experience in that task. You have to change the nervous system, you have to change how they're perceiving their body, and it has to be related to that task if the finding is going to be relevant. Otherwise, we're just, we're making decisions that are, you're just catastrophizing the whole situation. So in prevention, I think there's some things I think that are an absolute must.
01:02:33
Speaker
You must have pelvic control, if you don't have good pelvic control during your task, it just makes sense to me that that something's, something's going to go awry. So, be one of the one of the tests that I would that I would look for.
01:02:48
Speaker
We have gotten involved with the Manchester Football Club a number of years ago, LJNI, when they got some funding to do some screening of their players every six weeks. So they adopted the integrated systems model and did some screening for their players. And whether it was coincident or not, who knows? But they won the Premier League that year and they had the lowest number of players lost to injury in the season. So they were at the top of the Eakes Grand Store or whatever that thing called.
01:03:16
Speaker
They did really, really well. They did really well. And that was when the therapist introduced whole body screening. So I think it's done in the Cirque for sure. I know that. So Cirque du Soleil is in town and I'm doing some consults with him coming up. And for some of them, it's prevention. So for dance companies, sports teams, they're certainly on it, but it hasn't extended to the general public.
01:03:45
Speaker
and part of it because we don't have a good way of knowing what's healthy movement, what's healthy sitting, what's optimal, what should we be doing. I think it's a good idea. I'd love to be involved with it. I have people coming back in the clinic and I just
01:04:01
Speaker
cross my fingers and my toes and sort of hope that things that I'm finding are relevant and that they stay healthy and that I'm not wasting their time and money by doing it. But I'm cognizant of the conversation in the back that says posture doesn't matter. So for me, I really think it does. But there's there's extreme, right? There's there's subtle ones that don't.
01:04:20
Speaker
Yeah, well, one of the things that I've experienced having been involved in the check system as I have, it kind of straddles those two worlds of clinical work and rehabilitation, but also the kind of strength conditioning, personal training worlds.
Personal Training and Wellness in Physiotherapy
01:04:37
Speaker
Of course, a lot of what the personal training world is doing is preventative and it's building people's health, it's building their strength and it's building their resilience and so on. And at the higher ends of that world, I think there's a lot of potential carryover with what we're doing and almost preventative side is
01:04:57
Speaker
partly built into that already. And I was going to link it in a bit with, you know, your model, the integrated systems model, you have respiration within that model, don't you? Absolutely. Yeah. And I don't know, because I haven't looked at it recently. But did you ever I know, I've heard you talk about nutrition as well. But
01:05:18
Speaker
obviously, again, you know, linking back to the personal trainers, that that's part of their world is, is the sort of its wellness, you know, its health, sleep, its hydration, its nutrition and its movement. And so these are a lot of things that are, we assume, and some of the research suggests are preventative in musculoskeletal pain. So more than that, they're restorative, Matt, sorry to cut you off, keep going. Yeah. Well, no, no, that's fine.
01:05:46
Speaker
We've got a bit of delay. Yeah, exactly. So physiotherapists are typically not trained in nutrition or in gut health.
Nutrition's Impact on Musculoskeletal Health
01:05:54
Speaker
And yet I don't think we can deny the emerging evidence that gut health and the fact that two thirds of our immune system lines the gut and its role in inflammation
01:06:06
Speaker
that the role that that plays in core control so if you ever see someone who has irritable bowel or just even gut sensitivities one of the things that they'll say is I'm bloated well the bloating is in part sure swelling of the organs but it's the inhibition of the abdominal wall as well because
01:06:25
Speaker
it hurts to use it. So there's a direct relationship there between visceral health and visceral health of all sorts, whether we're talking endometriosis or cystitis or chronic kidney pain, kidney stones, stomach ulcers, pancreatitis, all of those things. Visceral health is intimately related to musculoskeletal health, not only anatomically, because the fact the organs hang off our skeleton,
01:06:49
Speaker
but the visceral somatic and somatovisceral reflexes through the nervous system and also just because of pain responses. And in the people that we see that are often diagnosed with fibromyalgia or polymyalgia or multiple muscle pain syndromes,
01:07:08
Speaker
A lot of these people come in and they've got a diet coke in their purse and they're chewing sugar-free. They're eating aspartame and they have no clue that what they're feeding themselves may be contributing to their headaches, bladder cystitis, back pain. The complex person with multiple comorbidities that are excluded from all trials because they're too complicated.
01:07:34
Speaker
These people often, I will start with gut health, but I'm not the person to supervise that. I share with them a lecture I have from the Anti-Aging Conference in Las Vegas, which is called Food and Pain, and it's a series of speakers talking on the relationship between food and pain. It's a 45-minute lecture.
01:07:57
Speaker
And I say, if this resonates for you, then here's a number of people that you can go see that will really help to get your gut health in better order. And then let's see what the relationship is between some of your MSK symptoms and how you're able to move and your gut health. I think it's a huge player and part of it. And something that physiotherapists are not
01:08:19
Speaker
adequately trained in terms of their formal training if they have training in it like Jessica Drummond she's amazing in the United States on on all things gut but she's got that training after her graduation so it's been a special interest of hers yeah yeah yeah one of the one of the papers that I've been aware of um is uh that there was a paper that I I quoted in um in one of my editorials which was a a guy called Aspero
01:08:46
Speaker
and I think his co-worker was Malagalada or something like that and it was a paper from 2005-2006 and it was on IBS and what they had done was they had taken x-rays of the gas surface area in IBS patients.
01:09:03
Speaker
with the assumption that of course you know if your waistband increases by you know in some cases as much as 100% I mean you can get a big you can go from you know 24 inch waist to 45 inch waist like it properly blows it huge sort of expansion of the abdominal wall and what they found was that the gas surface area across I forget how big the group was that they assessed but across the the experimental group they found
01:09:30
Speaker
gas only accounted for 18% of that enlargement. So the other 82% is essentially inhibition of the abdominal wall. So that's the only other thing really that can explain it.
01:09:46
Speaker
So yes, it does make sense that these conditions would potentially have a direct effect on the motor control because one of the things that I've understood from Paul Hodges' work, and I'd love to ask him more about this, and perhaps you would have further insights as well, is that pain seems to inhibit more the tonic drives as opposed to the phasic drives and tonic motor neurons.
01:10:15
Speaker
Of course, when we're talking about pain, we're normally referring to somatic pain, pain from a joint, pain from a muscle tear, that kind of thing. But visceral pain can do the same, it would seem, through this example of the irritable bowel syndrome and the inhibition to the abdominal wall musculature.
01:10:38
Speaker
Absolutely. And of course, it's the tonic system that's... I don't think it's been studied. I really don't... I don't know for sure. But at the last IPPS meeting, International Pelvic Pain Society meeting, which is more about cystitis and vulvodynia and pelvic organ sort of pain as opposed to pelvic girdle pain. It's a multidisciplinary conference as well, an excellent one.
01:11:02
Speaker
The common feeling was that a lot of these conditions are not about the organ itself. It's about that the representation in the brain. The brain is misinterpreting the signal as being from the organ when in fact the underlying mechanism between all of this is inflammation and that the main source of inflammation that's coming from is the gut.
01:11:25
Speaker
And the way forward is to restore the gut health. So it's certainly a big player. It's all integrated, right? It's all integrated and interesting. And we can't have the tools to fix every single thing that comes in our office, but we have to be able to recognize the things that we have tools for and the things where we need to refer out.
01:11:47
Speaker
Yeah. And when you take that evolutionary view of human function, then if you go back into kind of deep time, as it were, then you see that the earliest organisms were essentially a gut tube surrounded by musculature. So we talk about the worms and even anemones and things like this. There's different body plans. So you've got anemone, the anemone body plan, which is
01:12:14
Speaker
sort of earliest of the body plans and you move into the flatworms and then the roundworms and then essentially our body plan which is the same body plan as fish but they all have the same feature that the gut tube has a muscular wall and then we just have an extra layer of musculature around that but it kind of makes sense that if the gut wall is inflamed that it's going to affect the
01:12:39
Speaker
the musculature of the body wall as well because you don't want to compress something that's inflamed, right? Exactly, exactly, exactly, exactly. So I don't know how an RCT is ever going to be able to investigate or test the
01:12:57
Speaker
all of the mechanisms at play that we have to consider clinically when looking at the complex patient with persistent pain. So until we actually see a different way, and I think it's going to be a mixed methods research, sort of you having both, you know, qualitative and quantitative methods of some sort.
01:13:15
Speaker
Yes. Or I would love to see us get back to the N of 1, the single case report and discussions of the single case report. Yes. Man, I miss those so much. I don't recognize my patients in the RCT, but I certainly recognize them in the 90s and the 80s when single case reports were being published.
01:13:34
Speaker
Yes. Because it's what we're treating. We're treating an individual. We're not treating a group and maybe a suitable model for pharmaceuticals, but I think it really has failed moving evidence-based practice for treatment forward. We can bench research for individual things that we see in response to pain. And the other thing, Matt, why are we still starting the inclusion criteria for anything with pain?
01:14:01
Speaker
If we look at the pain research, we know that persistent pain, I'm not talking acute conditions now, but persistent pain is an output. It's an impression of the brain. Then why are we trying to find a functional or an intervention that relates to movement, posture, whatever, and seeing if it's going to change pain? That'll never work.
01:14:22
Speaker
to heck with the pain in terms of the inclusion criteria, but let's let's go. Let's go to assess function. The reason it's been stopped is because we've had difficulty getting intertest reliability for the tests that we use to determine function. This is the ground point where things have to change this. And we're just starting. So I've been working with Joe Abbott for the last few years in terms of testing, testing ways of all the things that I see when I teach as to why people are not reliable.
01:14:52
Speaker
And and moving forward if we can start to get more tests that are reliable Sensitive and specific then we can start to develop some research trials around function regardless of location of pain Regardless of the hate the behavior of pain because you know, all of that is merely is merely an output but start to look at if we improve function if we can improve how well somebody moves how strong they are how and
01:15:19
Speaker
Efficient they are with their movements. Will this change the pain pattern? So we're close. We're close. We are but close in research means like 10 years, but that's that's
01:15:32
Speaker
That's where we're at. It's exciting. It's an exciting time to be a manual therapist. I'm not, I'm not depressed about where we are at all. I think that it's where it's good to have to be criticized. It's good to reflect and to be challenged. Not in a personal way is where some of these social media trolls do. I mean, some of the bad language they use and some of the rest of it isn't helpful at all, but to really be critically challenged and to look at what you're doing, it doesn't mean that what you're doing is wrong.
01:16:00
Speaker
but perhaps how you're explaining it.
01:16:03
Speaker
can be a bit different. And I think, I think that that things have changed over 40 years, for sure, in terms of we are not just a single modal anymore, we're not just training or doing exercise, or we are not just doing thermal modulation, you know, with machines, we are not just doing manual therapists, manual therapy, things are definitely integrated. Yeah, which is fantastic. Yeah. But
01:16:31
Speaker
our mechanisms into understanding how and why these things work has what has really changed over time. Yes. Yeah. And that's like you say, that's that's great, isn't it? Because it's opening up so many new fields and new paradigms even to explore. It's I think it's very exciting. And now you mentioned because obviously you've just come back from was Antwerp the the World Congress. Yeah. And you were saying that
01:16:58
Speaker
There there was discussion of targeted interventions for individualized care, which is obviously what you're just alluding to there. But this is something that's being actively pursued now.
01:17:09
Speaker
Not enough, not enough. So a lot of the keynotes, so Paul Hodges, Linda Van Dillon, Carla Stecko, a lot of these guys are really talking about targeted interventions that, you know, and same with the McKenzie group, they've been doing it for a while. And I think the reasons why the McKenzie group has got such solid research backing their approach is that right from the get go,
01:17:31
Speaker
It wasn't based on, okay, you've got back pain, let's extend you. It was always a directional preference, right? There was always a functional thing that they tested. So they've been subgrouping and classifying people ever since they started. So the Mackenzie method has always been subgrouping and classifying things right from the get-go.
01:17:52
Speaker
So now we're starting to see the leading researchers in the world in motor control and back pain starting to talk about how important it is to target interventions, et cetera, et cetera. So what we still heard a lot of at Antwerp was non-targeted research. And it drove me crazy. Because at the end of the day, the non-targeted research comes out with no statistical difference. So I'll give you one example. One person presented a paper
01:18:20
Speaker
People who had lumbopelvic pain, inclusion criteria were lumbopelvic pain, a slow timed up and go, and difficulty standing on one leg. The 60 people were allocated to three different groups. That was all the assessment was, three different groups. One was given training for transversus and multivitus.
01:18:40
Speaker
And that was called the core stability group. Second group were given just general exercises, like plank and sit ups and those sorts of things. And the other group was just given general advice, be active, go do whatever it is that you want to do. No statistical difference in any of these groups at the end of the day measured on OSWIS-free and quality of life scales at some pertinent time.
01:19:03
Speaker
And therefore, the conclusion is that core stability exercises don't work for lumbar pelvic pain. I mean, how ridiculous? I went running down to the mic and basically said, look, all week we've heard about targeted interventions where in the inclusion criteria in terms of differentiating the groups of people were put in, did you even identify that there was a deficit of transversus or multifidus in the people who were given that training? Because if there's no deficit, there's going to be no difference whether you train them or not.
01:19:30
Speaker
we are so much further ahead than some of the research that was presented. So a lot of it was really good, a lot of it was interesting, it was good, but the clinical piece is really lacking for me, not being able to see clinicians work.
01:19:48
Speaker
It reminds me a little bit of, there was a paper, I was in one of these discussions talking about posture and how it's, you know, seemingly irrelevant in some circles. And I said, well, can you provide some papers? And someone provided this meta-analysis. In fact, several people pointed this one meta-analysis. And it, I find it cool that they'd gone from about 10,000 papers looking at sacral spinal curves and the relation to low back pain.
01:20:16
Speaker
they whistled it down to the best highest quality 52 papers. And then, you know, the conclusion when you read the abstract or the conclusion of the paper was that essentially there was no statistical significance or association with posture and low back pain. And you're looking at it, but they're saying, you know, they're just using low back pain as a heterogeneous
01:20:43
Speaker
you know, it's a heterogeneous issue, but they're labeling it as a homogeneous problem. And of course, you know, when you actually dig down into the papers that they analyzed, then when there were two papers in there that related specifically to disk injured patients.
01:21:00
Speaker
And of course, we do know that disc injured patients will vary depending on where the disc bulges and all kinds of other factors. But both of those, they found that those groups have had flatter lumbar spines, right? Which is kind of what you might expect for a disc pain group. And then the others were essentially, you know, just low back pain. But
01:21:22
Speaker
To conclude at the end of that that therefore low back pain is not can't be correlated with posture was a very sort of to me it seemed a very.
01:21:34
Speaker
kind of amateurish finding. And it might be me misunderstanding it, but it didn't really instill confidence in me that this was kind of the key paper that was being pointed to. And it just strikes me that that kind of broad brushstrokes approach, as you say, and the meta analysis kind of approach has many, many issues associated with it. And if we put too much value into that and ignore our clinical experiences and other
01:21:59
Speaker
biomechanical and physics-based rationale, then we could come a little bit unstuck.
01:22:06
Speaker
Couldn't agree more, couldn't agree more. And I don't think SAKIC ever, ever intended that evidence-based practice be solely based on research. There's always three components to the model. Your evidence informed, pay attention to the evidence, how does it relate to your clinical experience, and how does that match the patient's values and goals was always what it was about.
01:22:30
Speaker
Yeah, a lot of hand. But the pendulum is swinging back. The pendulum is swinging back. And I think that while there's several things we can grump about or starting to see more clinicians be able to work with researchers and instead of sitting in isolation and complaining about researchers doing and researchers complaining what clinicians are doing and saying,
01:22:51
Speaker
But you know the time has come to sort of facilitate the the the working together and I think that's I I've so enjoyed working with Paul Hodges I so enjoyed working becoming the opportunity to work with with Joe Abbott and to see the challenges that they have in research It's easy for us to sit in clinicians and and say well, why don't you just do this and it's harder It's harder than we as clinicians imagine sort of setting up good good good trials, but
01:23:20
Speaker
I agree with you that the way we are investigating the kind of complex work that you and I are doing with complex patients with persistent pain, it's certainly not serving us well. And I think they know it as well.
01:23:39
Speaker
And I'm optimistic that in time it will change. And really we only have, when we talk about social media and the people that are on it, you just have the extremes. The mainstream of our professions are really not as locked into one end of the spectrum or the other. Most of us are
01:23:58
Speaker
looking for how can we best apply what tool we have in our toolbox for the person that's sitting in front of us. I don't often run into the people in courses who are very adamant that it be hands off or hands on. Most most people are it's I want to know when to use my hands. I want to know when not to. And and that's that's the healthy question to ask is when when do I do this and show me how show me how to be better at what I do.
01:24:28
Speaker
We're all we're all seeking to strive that yeah be better at what we do because at the end of the day all of this is really just to reduce the number of musculoskeletal conditions there are worldwide that are leading to opioid addictions and Really really poor quality of life. I mean if we can stop that trend that that really is our our role, right?
01:24:52
Speaker
Yeah, for sure. For sure. Yeah. Now, one thing I wanted to just go over briefly with you is is that that may be an impossibility. It's your clinical puzzle and that you've got a clinical puzzle image, which I've picked up from. Now, which paper was that? It's from one that you published in the Journal of Body Work. Yeah. It's the Bency Continents and Breathing Role of Fascia Following Pregnancy. And so the diagram, which I'll put in the show notes so people can see it, if that's OK with you.
01:25:23
Speaker
you've got within that you've got so well first of all the title I think is very important because you've got strategies for function of performance and I think that positive spin on things as opposed to strategies to avoid back pain let's say you know which would be more of a negative I think that's quite an important thing that you know you've you've titled it that but then within the puzzle you've got in the outer ring you've got
01:25:44
Speaker
the neural components, the myofascial components, the articular components. So that's kind of a little bit Punjabi's model type inclusion there. But you've also got the viscera in there. So those are the four outer units that encase the middle component. And within the middle component, you've got
01:26:04
Speaker
the virtual body, the story, the emotions, the meaning and the goals. And I just think that's a great model. It really fits with a lot of what I've come to understand of the important aspects of what a patient is coming in to see us with and what they're searching for. But do you want to explain briefly how you put that together and why it's important?
Reflection Tools for Physio Students
01:26:27
Speaker
So this was a graphic that Linda Joy Lee and I developed together and it was published in 2007 and for a number of years it was a reflection tool or a way for students to look at the whole person and not just a joint or a muscle or the organ with the whole goal being and the accomplishing ring around it being
01:26:49
Speaker
to remember that what we are trying to change is function and a performance and by changing how they are moving or performing or sitting or what they are doing will often lead to better outcome.
Listening to Patients: Beyond Words
01:27:04
Speaker
So that's what the graphic was to represent that when you are going through your examination these are key components of your assessment. So it begins with hearing the story of the person in the middle
01:27:16
Speaker
And from the story, what you're trying to gain is, is there any cognitive dissonance? Is there any beliefs or myths in the story that you're going to need to need to address? Are there any medical conditions? Is there any, any emotional impact on this? So we are trying to get the three dimensions of the person's experience, the sensorial dimension. In other words, where do you hurt? What makes it better? What makes it worse?
01:27:41
Speaker
What do you believe is going on in your cognitive beliefs around it? And how has this affected you emotionally and then from that and the whole person in the middle?
Personalized Motor Control Strategies
01:27:49
Speaker
You're gonna get the task that you want to work on because strategies are tasks specific The evidence is clear that motor control and strategies are unique to the individual and they are tasks specific and
01:28:00
Speaker
So we can't just look at, if you have back pain, we can't just look at forward bending, because if you get back pain with walking, nobody bends forward when they, well, some people bend forward when they walk, but they shouldn't be. So anyway, you pick your meaningful task from that. And then on the outer circle,
01:28:17
Speaker
is where the tasks go. So you may look at a standing starting position screen and then look at one-legged standing and thoracic rotation two screening tasks that would be useful for walking if walking was the task that they wanted to work on or to improve their function of.
The Clinical Puzzle Model in Practice
01:28:32
Speaker
So in the outer wheel of that clinical puzzle is where you write your findings in the sense of
01:28:37
Speaker
your alignment biomechanics and control and finding drivers so that kind of gets charted in the outer wheel of that circle. The inner pieces are what your further assessment of that body region. So let's take our hamstring guy again and let's say that we decided that that his pelvis was really the motor control in his pelvis was the problem. You compress the pelvises like popped up you went right I need more information about this pelvis. Then your further tests of active and passive mobility
01:29:07
Speaker
active and passive control for sort of your four main tests, headings of tests that you need to have in your toolbox, will then differentiate for you whether or not there was a problem in the reticular system. Can the joint move? Is it well controlled? The neural system, which is huge. It's where all the motor control stuff and neurodynamics and virtual bodies all live. Do you have a problem in the myofascial system? So the myofascial system speaks more to the structure. Is there been a fascial tear at the insertion point of the hamstring?
01:29:37
Speaker
Is there a bleed in the muscle?
Evolution of Clinical Models in Physiotherapy
01:29:39
Speaker
I mean, you ruled that out with your test and your act of straight leg raise, but that'd be the myofascial. And then the visceral, is there a visceral component contributing to the motor control strategy you're seeing? So IBS, cystitis, endometriosis, or any of the Boral stuff, which is looking at poor mobility or movement of the visceral relative to one another as you move from whatever it is that have
01:30:00
Speaker
cause them not to not to move well. Now there are more we started with this in 2007. So that model is quite old now. But they were the main ones that were appropriate to physiotherapy. So you notice there's not a lot of gut health on there, although I suppose it could go in the visceral component.
01:30:16
Speaker
But you could start to expand and develop more and more and more systems.
Thoracic Ring Function and Movement Efficiency
01:30:21
Speaker
But it was a starting point or a way for us to start to organize information that was really relevant to the scope of practice of physiotherapy anyway. And you could probably have a clinical puzzle that was a little bit broader or different for osteopathy.
01:30:34
Speaker
but a way of helping to develop a closet organizer, if you like, or a structure, a way of organizing the information that you get from your assessment. And it's a reflection tool. It's a tool that, if you're struggling with somebody, you can sit down with a puzzle and fill in the blanks and kind of go, oh, I missed this. I missed that. I should have asked this question or that question to sort of bring some clarity to somebody's whole story and perhaps help to illuminate what the pathway is to change.
01:31:02
Speaker
Yes, yeah, that's fantastic. Really good, really good. So and of course, it ties in a little bit with the paper that we've just co-written for the Journal of Body Work and Movement Therapies. So the paper is called Thoracic Ring Function, Movement Efficiency and Injury Prevention. And, you know, what
Muscle Activation and Thoracic Mobility
01:31:20
Speaker
I'm tasked with doing for the Journal of Body Work is to pick out a couple of papers that we want to include in the rehabilitation section and then to write an editorial
01:31:31
Speaker
on those papers. So I asked you, Diane, to help to co-write this paper. So we picked out in particular a paper by Morley and Traum and essentially they were looking at how restriction
01:31:48
Speaker
of a sort of artificial restriction of the trunk using some kind of brace affected gate patterns. So do you want to talk a little bit about what you wrote there? Because it was quite an interesting... Sure. So I kind of drew from the motor control research that was summarized by Hodges and Smeets in 2015.
01:32:11
Speaker
which notes that multiple studies have shown that motor control changes in the trunk in response to pain are highly variable, number one. And the consistent finding is there is this redistribution of muscle activity with the deep muscles becoming inhibited and the superficial ones augmented.
01:32:29
Speaker
And the redistribution of muscle activity clinically, what we find is that it leads to rigidity. So while the superficial muscles can stabilize us, they prevent us from moving well. And that essentially is like casting the thorax.
01:32:45
Speaker
and so what what we found clinically for years now and LJ started this work years ago is that the this redistribution of activation can affect like one fascicle of the external oblique or one fascicle of iliocustalis and that can impact the mobility of one rib which will then impact an entire ring so all of a sudden you've got one ring in the thorax that's rotated to the right and if that muscle
01:33:14
Speaker
Won't eccentrically lengthen or relax and allow the rib to move as it needs to move for left rotation Then that ring will stay in right rotation When you turn to the left and it if you've got multiple like that if you've got several Rings that have been hijacked by various different muscles What you see in the spine is a person who turns and instead of having a beautiful long concave curve in their spine they've got multiple kinks in the curve and
01:33:42
Speaker
multiple things going left and right left and right left and right and this is essentially a Casted trunk. It's just the rings are not dancing or moving in the same direction as they as as that they need to So that's how it that's how we then applied that clinically and then went say okay So which one is which one's the relevant one? Which one which one should we start to change and this is this whole thing about? finding finding the relevant ring because some of those are going to be compensating for
01:34:12
Speaker
the relevant one and when you change them are not necessarily going to change the clinical presentation. So just like your active straight leg raise guy again, if the pelvis wasn't the driver, compressing or controlling the pelvis wouldn't have changed his pain experience, wouldn't have changed his functional ability to lift the leg. So here in thorax, if we're looking at thoracic rotation, which is an essential component for a runner, it's really how we get our drive and force for running.
01:34:37
Speaker
So if you can't rotate your thorax incongruent to the pelvis, that's really relevant. So this was me trying to draw an analogy between how casting the trunk in an experiment is actually seen in clinical practice and using the motor control evidence to support what I see clinically or we see clinically within
Rotation Loss and Load Shifts: Consequences
01:35:00
Speaker
the thorax.
01:35:00
Speaker
Yeah, yeah. And essentially what Morley and Trauma were suggesting and what they measured was that, of course, this then leads to fatigue sooner because they're actually measuring oxygen uptake. And then, of course, you know, fatigue may lead to compensations elsewhere in the kinematic chain and or, you know, increased risk of injury or certainly lower performance. So, you know, just a fascinating sort of insight
01:35:29
Speaker
as to how you can artificially create that bracing, but then the body can equally cast itself in some instances, and that's obviously going to have a knock-on effect. Which it seems you've managed to effectively counteract at Manchester City, which is fantastic. Yes, exactly, exactly.
01:35:50
Speaker
Great. And then there was another study within that paper which was looking at motor control, as they say, core muscle activation exercises versus conventional treatment. And that was looking at it in respect of patients with knee OA.
01:36:07
Speaker
Now I don't know if you want to expand on that aspect of it as well but I think essentially it ties in with the same discussion that when there's altered motor control at the core or altered force transfer at the trunk then that can potentially have an impact into the lower limb as well and therefore create asymmetric loading and stresses through the lower limb.
01:36:32
Speaker
And over time, the hypothesis is that this can wear the joint out. So the knee is particularly vulnerable to areas of the body that lose their rotational ability. So subtalar joint, hip and thorax. So in these those three areas when something mucks up your subtalar joint and it can't rotate well or your hip or your thorax, then the lumbar spine and the knee really have to take on more responsibility for rotation. And neither the low back nor the knee are designed to rotate.
01:37:01
Speaker
So that can be a reason why they start to get grumpy or start to even get a thritic, but even just changes of center mass over base of support. So if the thorax is now not sitting stacked on top of the pelvis, but is
01:37:17
Speaker
Lateral translation couples with rotation.
Advice for New Graduates: Mentorship Over Business
01:37:19
Speaker
So when the thorax rotates it translates to the contralateral side. That's Punjabi's work from 1976 as well And so you get a displacement of the center of mass off the center and so that's going to load one compartment of of the knee More on one side than the other right? So yeah, yeah medial if it is shipped us to the left it's going to be more medial compartment loading of the right knee lateral compartment loading of the left knee and
01:37:43
Speaker
Which again sort of sets you up for potentially having some having some wear and tear down the road if it's not if it's not addressed. So We do see we do see the victims being the neck the back of the knee and the perpetrators often being the foot the pelvis of thorax and the cranium Yeah, yeah how we tend to see the patterns for sure Yeah
01:38:06
Speaker
So well that paper is going to be available, it's already available online but the issue I believe is coming out in the next couple of weeks and so you'll be able to see that there online. We'll also be sharing what's called a share link which I think for 60 days means we can actually share this
01:38:24
Speaker
paper for free and if you're on any of Diane's courses or anything with me then we're allowed to also hand them out to us to our students which is which is great so but I'm sure so if you if you contact us directly we'd be happy to share the paper as well but Diane I was just thinking we could finish off perhaps with
01:38:47
Speaker
a little bit of wisdom from you in terms of when people are coming up through physiotherapy school or osteopathic school and of course we're all exposed to the online world and the social media world now and so I think it would be quite confusing if I was back at college now because
01:39:06
Speaker
There's so many disparate ideas and opinions. And this is why I call the podcast From Chaos to Order, because what we're trying to do is to find some order amongst the chaos. And I think that's where someone with your level of experience and having seen the trends come and go can give a little bit of wisdom to those that are just making their way on the early phase of their journey.
01:39:30
Speaker
We're starting to see, at least in Canada and British Columbia here, a lot of new grad physios opening practices as soon as they graduate and get into business. And I think that's the wrong step. I think the first five years after practice is you've just been given a license to learn. You have some tools, but you don't have any zero clinical experience yet. Find yourself a mentor. Find yourself somebody that you really resonate with that works the way you look at it and you go,
01:39:59
Speaker
I want to be like that person when I grow up. I want to be able to do that. And then spend some time with them if you can. Take some time and put yourself back into the seat of the student. You've graduated, you've got a closet with a few tools in it, but not a lot. And I like to see therapists who take my courses after they've got about five or six years where they've
01:40:24
Speaker
They've gained some clinical experience and their closet is really messy. They've taken tons of different courses and all the stuff is all on the floor and they just don't know when to do what to help organize things. But you need a mentor. We need mentors in our lives and we can't be running businesses and looking after staff and human resources and worrying about beliefs and the rest of that.
01:40:46
Speaker
if we really want to develop good clinical skills. So take the time, give yourself the gift of time, find yourself some mentors and keep following the evidence, but build your clinical tools and don't forget those hands. Those hands are a powerful, powerful tool. That would be my biggest recommendation.
01:41:05
Speaker
Excellent.
Learning with Diane Lee: Online Courses
01:41:06
Speaker
Fantastic. Well, Diane, thank you so much for your time today and for all of your work. I mean, we barely touched on most of it, but yeah, it's been a huge inspiration to me to be able to both read your books, come on your courses and to do this paper together and the podcast together. So thanks so much for all of that. Yeah, thanks for mine as well, Matt. Thank you.
01:41:30
Speaker
So Diane, before we wrap up, could you just let the listeners know where they could find out more about your own work? Yeah. So if any of you are interested in any of the online courses or material that Matt's been referring to, I encourage you to check my online education workshop, which is Learn with Diane Lee. Come and play with us. Fantastic. Yeah. And I can highly recommend it. OK. Thanks, Diane. Take care. Thank you, Matt. Bye bye. Bye.
01:42:00
Speaker
Well, I hope you enjoyed that chat with Diane as much as I did. Diane is such an insightful and innovative practitioner, and this shines through in her books, presentations, and courses, which are well ahead of the curve, as I'm sure you've sensed, as we chatted through Diane's highly decorated career. What appealed to me most about Diane's approach is her open-mindedness and her ability to integrate cutting-edge conceptual information with highbrow leading research science to create one of the most innovative and effective rehabilitation programs on the planet.
01:42:28
Speaker
If you enjoyed hearing Diane just touch on the importance of the patient's story and their meaningful tasks, then you will love both the recent podcasts I did with Brony Lennox-Thompson, episode 16, and the upcoming podcast I have with Dr. Nick Penny, who did his doctorate in the biopsychosocial approach to working with people, and in particular, the application of mindfulness practices to helping those experiencing persistent pain.
01:42:52
Speaker
Both Nick and Bronnie are based in New Zealand, where I'm headed in March 2020 for a two-day seminar called 2020 Vision, putting persistent pain behind us in the next decade, which aims to provide working clinical models to help the health or fitness professional effectively apply what is most current in the scientific literature within their working environment. Further details can be found on the show notes or at mattwarden.com. Just search 2020 Vision.
01:43:18
Speaker
Looking forward to seeing you, perhaps with your 2020 vision already secured, at the next show.