WEBVTT 00:00:02.572 --> 00:00:06.092 all right welcome to hands on hands off 00:00:06.253 --> 00:00:09.593 i'm your host today moya tillery um and 00:00:09.634 --> 00:00:12.535 for this episode i am joined by someone 00:00:12.914 --> 00:00:15.455 i respect deeply um and i've had the 00:00:15.494 --> 00:00:17.835 pleasure of working with for a couple of 00:00:17.876 --> 00:00:20.797 years now dr ron shank ron is a 00:00:20.836 --> 00:00:23.157 professor he's a mentor a thought leader 00:00:23.176 --> 00:00:26.057 in ompd and mechanical diagnosis 00:00:27.559 --> 00:00:30.160 Today we're talking about bridging the gap 00:00:30.440 --> 00:00:33.521 between the evolution of OMPT and 00:00:33.561 --> 00:00:34.743 directional preference. 00:00:34.843 --> 00:00:36.283 And if you followed Ron's work, 00:00:36.804 --> 00:00:39.365 you know that he's been involved in both 00:00:39.426 --> 00:00:40.847 worlds, so to speak, 00:00:41.027 --> 00:00:43.307 or are they the same worlds? 00:00:44.289 --> 00:00:45.850 That's for us to get into today. 00:00:45.890 --> 00:00:46.509 Welcome, Ron. 00:00:46.549 --> 00:00:48.531 Please tell us a little bit about yourself 00:00:48.612 --> 00:00:50.472 and we'll get the conversation going. 00:00:51.033 --> 00:00:52.173 Well, thanks, Mo. 00:00:52.192 --> 00:00:52.853 Thanks for having me. 00:00:54.134 --> 00:00:55.853 I'm a graduate of Ithaca College Physical 00:00:55.895 --> 00:00:56.655 Therapy Program, 00:00:57.195 --> 00:00:58.655 and then I went on to do a 00:00:58.734 --> 00:00:59.856 residency in Gulfport, 00:00:59.875 --> 00:01:01.375 Mississippi with Mike Rogers, 00:01:01.415 --> 00:01:03.116 who's one of the founding members of AOMT. 00:01:04.016 --> 00:01:04.436 Later on, 00:01:04.496 --> 00:01:07.617 I became McKenzie certified and earned my 00:01:07.677 --> 00:01:11.319 PhD and became a fellow in AAOMPT. 00:01:11.998 --> 00:01:13.920 And from the mid-nineties on, 00:01:14.019 --> 00:01:16.900 I've tried to bridge the two schools of 00:01:16.960 --> 00:01:17.281 thought 00:01:17.881 --> 00:01:19.504 And I really do think there's a place 00:01:19.543 --> 00:01:24.472 for directional preference in the schema 00:01:24.492 --> 00:01:26.536 that we use for examination intervention 00:01:26.575 --> 00:01:28.400 for people with musculoskeletal disorders. 00:01:29.417 --> 00:01:30.617 Yeah, no, that's great, Ron. 00:01:31.278 --> 00:01:31.638 Thank you. 00:01:31.697 --> 00:01:33.058 It's such a pleasure to have you. 00:01:33.138 --> 00:01:36.120 I'm glad we get this time to chat 00:01:36.161 --> 00:01:38.081 about something that I think has been on, 00:01:38.543 --> 00:01:38.783 you know, 00:01:38.802 --> 00:01:41.043 maybe certain people's minds as far as 00:01:41.103 --> 00:01:44.325 bridging this gap in these two very 00:01:44.506 --> 00:01:47.408 clinically applicable and appropriate, 00:01:47.507 --> 00:01:47.808 right? 00:01:47.927 --> 00:01:49.149 Once you figure out which patient is 00:01:49.168 --> 00:01:50.930 appropriate for what technique or mix of 00:01:50.950 --> 00:01:51.530 techniques. 00:01:52.911 --> 00:01:53.831 I want to know a little bit. 00:01:53.891 --> 00:01:56.093 I think we can take it back, Ron, 00:01:56.153 --> 00:01:57.254 if you're okay with that. 00:01:58.536 --> 00:02:00.578 Let's start with maybe your personal 00:02:00.617 --> 00:02:01.117 journey. 00:02:01.177 --> 00:02:04.200 You've mentioned OMPT giants like Mike 00:02:04.219 --> 00:02:06.542 Rogers and the late Dick Earhart in your 00:02:06.701 --> 00:02:07.382 own training. 00:02:08.302 --> 00:02:10.425 You've also had numerous publications on 00:02:10.485 --> 00:02:11.526 directional preference. 00:02:11.945 --> 00:02:14.247 Can you walk us through maybe how you 00:02:14.288 --> 00:02:16.288 first encountered directional preference 00:02:16.449 --> 00:02:20.352 and perhaps how your understanding of 00:02:20.592 --> 00:02:22.253 directional preference has evolved? 00:02:23.870 --> 00:02:24.090 Sure. 00:02:24.670 --> 00:02:26.711 So back when I was at Ithaca, 00:02:26.991 --> 00:02:29.372 one of our musculoskeletal professors was 00:02:29.451 --> 00:02:30.252 Robert Sprague. 00:02:30.872 --> 00:02:34.493 And Bob Sprague is well known to people 00:02:34.533 --> 00:02:36.634 in AAMT. 00:02:37.294 --> 00:02:40.257 Bob is a founding member of MAPS, 00:02:40.896 --> 00:02:41.736 Maitland Seminars. 00:02:41.796 --> 00:02:46.038 But he also taught with Robin McKenzie 00:02:46.058 --> 00:02:48.639 himself early on when Robin McKenzie first 00:02:48.659 --> 00:02:51.640 came upon his directional preference 00:02:51.661 --> 00:02:52.100 approach. 00:02:52.991 --> 00:02:54.992 And so Bob kind of integrated the two 00:02:55.734 --> 00:02:58.314 back when I was an undergrad in physical 00:02:58.375 --> 00:02:58.735 therapy. 00:02:59.515 --> 00:03:01.917 And it was probably a little too much 00:03:01.997 --> 00:03:04.399 to handle for someone who's not seen 00:03:04.459 --> 00:03:05.158 patients yet. 00:03:05.739 --> 00:03:07.539 And it didn't begin to make sense until 00:03:07.621 --> 00:03:08.001 I took, 00:03:09.020 --> 00:03:10.641 I started working at a hospital in 00:03:10.681 --> 00:03:11.042 Buffalo, 00:03:11.082 --> 00:03:14.343 New York and seeing outpatients and began 00:03:14.544 --> 00:03:15.965 to apply some of that. 00:03:16.044 --> 00:03:19.586 But to further that thinking in that area, 00:03:19.646 --> 00:03:21.068 I took a McKenzie A course, 00:03:21.127 --> 00:03:22.008 a lumbar course. 00:03:23.431 --> 00:03:24.413 And around that time, 00:03:24.432 --> 00:03:25.674 I was a clinical instructor, 00:03:25.734 --> 00:03:31.016 and one of our students came into the 00:03:31.056 --> 00:03:32.078 clinic and said, you know, 00:03:32.098 --> 00:03:34.419 you ought to think about this residency 00:03:34.460 --> 00:03:35.400 program they have. 00:03:35.419 --> 00:03:37.322 I had just spent six weeks there, 00:03:37.961 --> 00:03:40.002 and it's down in Gulfport, Mississippi. 00:03:40.043 --> 00:03:41.364 And I said, wow, really? 00:03:41.865 --> 00:03:42.305 He said, yeah, 00:03:42.365 --> 00:03:44.485 he worked there for a year for this 00:03:44.526 --> 00:03:45.526 guy named Mike Rogers. 00:03:45.887 --> 00:03:48.008 And what he does is he integrates all 00:03:48.049 --> 00:03:49.229 different schools of thought. 00:03:49.949 --> 00:03:52.371 So I really do think Mike was a 00:03:52.471 --> 00:03:54.772 forerunner in combining schools of thought 00:03:54.812 --> 00:03:57.133 and utilizing what's best for the patient 00:03:57.574 --> 00:03:59.074 and not necessarily trying to get the 00:03:59.115 --> 00:04:01.556 patient to fit into your school of thought 00:04:01.616 --> 00:04:02.516 or your way of thinking. 00:04:02.937 --> 00:04:04.717 So we were exposed to osteopathic, 00:04:04.798 --> 00:04:06.459 Maitland, McKenzie, 00:04:07.399 --> 00:04:09.881 many different approaches for management 00:04:09.901 --> 00:04:11.600 of people with musculoskeletal disorders. 00:04:12.442 --> 00:04:14.043 And it wasn't until I returned back to 00:04:14.103 --> 00:04:15.143 Buffalo and 00:04:17.286 --> 00:04:19.528 continue to see patients that I thought I 00:04:19.569 --> 00:04:22.190 maybe wanted to explore that directional 00:04:22.230 --> 00:04:23.851 preference approach or the McKenzie 00:04:23.872 --> 00:04:24.672 approach a bit more. 00:04:24.773 --> 00:04:29.336 So I pursued certification in that while 00:04:29.656 --> 00:04:32.437 still studying and practicing manual 00:04:32.458 --> 00:04:33.139 physical therapy. 00:04:33.178 --> 00:04:35.420 And I thought right from the beginning, 00:04:35.459 --> 00:04:36.860 like Mike had told us, 00:04:37.762 --> 00:04:39.963 if you have an understanding of many 00:04:40.004 --> 00:04:40.903 different schools of thought, 00:04:40.963 --> 00:04:42.766 you can apply them to a fairly high 00:04:42.826 --> 00:04:43.026 level. 00:04:43.564 --> 00:04:45.605 You can help more patients because we know 00:04:45.665 --> 00:04:49.387 not every patient's going to respond to 00:04:49.487 --> 00:04:50.187 one approach. 00:04:50.509 --> 00:04:53.250 And although we may be biased towards a 00:04:53.370 --> 00:04:54.690 particular system or approach, 00:04:54.711 --> 00:04:55.252 and that's good, 00:04:55.791 --> 00:04:58.574 we know that the reliability of these 00:04:58.613 --> 00:05:00.514 different systems we have for examination 00:05:00.535 --> 00:05:01.055 and treatment, 00:05:01.536 --> 00:05:04.257 not one stands out as being more reliable 00:05:04.858 --> 00:05:05.379 than another. 00:05:05.738 --> 00:05:06.860 But what we do know is when you 00:05:06.879 --> 00:05:09.221 have a system and you have a way 00:05:09.281 --> 00:05:11.403 of approaching a patient in a systematic 00:05:11.442 --> 00:05:11.762 manner, 00:05:12.401 --> 00:05:14.201 that you tend to have better outcomes than 00:05:14.721 --> 00:05:18.802 people who just kind of do things without 00:05:18.882 --> 00:05:22.682 a treatment-based classification type of 00:05:22.723 --> 00:05:23.184 approach. 00:05:23.264 --> 00:05:24.524 And interestingly, 00:05:24.983 --> 00:05:27.184 when we were down in Mississippi, Dr. 00:05:27.223 --> 00:05:27.824 Dick Earhart, 00:05:27.944 --> 00:05:29.805 also a founding member of AOM, 00:05:30.045 --> 00:05:31.846 he'd come down to the residency every year 00:05:32.466 --> 00:05:33.446 and do some teaching. 00:05:34.321 --> 00:05:37.802 And he was, of course, 00:05:37.841 --> 00:05:39.002 a proponent of the treatment-based 00:05:39.021 --> 00:05:40.142 classification system. 00:05:40.202 --> 00:05:41.983 So matching that impairment and those 00:05:42.002 --> 00:05:44.043 functional limitations to a particular 00:05:44.064 --> 00:05:44.903 classification. 00:05:45.423 --> 00:05:46.444 And that fit very well. 00:05:47.324 --> 00:05:49.245 It was very compatible with MDT, 00:05:49.305 --> 00:05:49.704 I thought, 00:05:50.245 --> 00:05:51.425 and also 00:05:53.507 --> 00:05:54.747 the treatment-based classification 00:05:54.767 --> 00:05:57.410 approach has a specific exercise category, 00:05:57.889 --> 00:05:59.711 which is based on centralization. 00:05:59.771 --> 00:06:01.733 So if patients with peripheral symptoms 00:06:01.773 --> 00:06:03.634 were found to centralize with extension, 00:06:04.134 --> 00:06:06.596 they'd be placed in that specific exercise 00:06:06.617 --> 00:06:07.156 category. 00:06:07.216 --> 00:06:10.620 So Dick Earhart too taught with Rob 00:06:10.639 --> 00:06:14.362 McKenzie early on and appreciated some of 00:06:14.463 --> 00:06:15.684 what he had to offer. 00:06:16.084 --> 00:06:18.446 But being a chiropractor and a 00:06:19.288 --> 00:06:20.470 manual physical therapist, 00:06:20.490 --> 00:06:22.029 a physical therapist, Dick Earhart, 00:06:22.790 --> 00:06:24.711 used a combination of schools of thought 00:06:24.732 --> 00:06:25.112 as well. 00:06:25.732 --> 00:06:28.113 So I had a lot of respect and 00:06:28.153 --> 00:06:31.194 was influenced greatly by that. 00:06:31.274 --> 00:06:34.036 And the fellowships and residencies that 00:06:34.096 --> 00:06:38.218 we developed were based on that concept of 00:06:38.358 --> 00:06:39.338 integrating approaches, 00:06:39.439 --> 00:06:41.821 using the best features of different 00:06:41.841 --> 00:06:43.862 approaches to find out what's going to be 00:06:43.901 --> 00:06:45.942 best for that person sitting in front of 00:06:45.983 --> 00:06:46.083 you. 00:06:48.701 --> 00:06:50.281 And our ordainment program required 00:06:50.322 --> 00:06:53.663 McKenzie A and B courses. 00:06:54.423 --> 00:06:56.884 The McKenzie Fellowship, 00:06:57.586 --> 00:06:58.745 which was post-diploma, 00:06:58.786 --> 00:07:00.107 so these were people that reached the 00:07:00.146 --> 00:07:02.747 highest level of training at MDT, 00:07:03.208 --> 00:07:04.728 were then exposed to other schools of 00:07:04.769 --> 00:07:06.028 thought as part of their fellowship 00:07:06.569 --> 00:07:06.850 training. 00:07:07.470 --> 00:07:09.951 So we utilized the same clinical 00:07:09.971 --> 00:07:11.612 instructors and mentors. 00:07:11.872 --> 00:07:15.353 And we think that that combination of 00:07:15.392 --> 00:07:16.574 approaches still 00:07:17.343 --> 00:07:21.528 giving respect to that person's bias and 00:07:21.788 --> 00:07:23.750 understanding what's their go-to, 00:07:24.310 --> 00:07:25.632 but still being open-minded. 00:07:26.233 --> 00:07:29.295 And I see in our schema of examination, 00:07:29.315 --> 00:07:31.538 which was developed by Ciriacs, active, 00:07:31.577 --> 00:07:32.098 passive, 00:07:34.214 --> 00:07:35.175 resistive movements, 00:07:35.255 --> 00:07:37.317 we can put it after the active movements 00:07:37.357 --> 00:07:38.197 testing end range. 00:07:39.399 --> 00:07:41.459 Prior to testing passive intervertebral 00:07:41.519 --> 00:07:43.721 motion or single segmental mobility 00:07:43.762 --> 00:07:44.242 testing, 00:07:44.723 --> 00:07:47.485 why not explore the potential for a person 00:07:47.524 --> 00:07:50.225 to find a directional preference through 00:07:50.245 --> 00:07:51.887 their own volition? 00:07:51.987 --> 00:07:54.509 So before we would test end range, 00:07:54.550 --> 00:07:56.151 we test the person's ability to go to 00:07:56.230 --> 00:07:56.870 end range. 00:07:57.230 --> 00:07:57.812 People can do it. 00:07:58.151 --> 00:07:59.673 Some people need assistance in that. 00:08:00.394 --> 00:08:00.634 And 00:08:02.079 --> 00:08:05.300 Whereas extension may be in thought of as, 00:08:05.680 --> 00:08:08.560 or neck retraction in the upper quarter 00:08:08.901 --> 00:08:11.521 thought to be a movement that may produce 00:08:11.541 --> 00:08:12.942 a centralization of symptoms, 00:08:13.242 --> 00:08:15.122 there's actually many different loading 00:08:15.163 --> 00:08:17.163 strategies and directions that may be 00:08:17.223 --> 00:08:19.985 explored in order to find if that person 00:08:20.004 --> 00:08:22.245 may centralize or exhibit a directional 00:08:22.285 --> 00:08:22.805 preference. 00:08:24.625 --> 00:08:26.326 And, you know, 00:08:26.387 --> 00:08:29.327 I think it may be gaining some traction 00:08:29.747 --> 00:08:30.427 when we look at 00:08:31.843 --> 00:08:32.743 Patient empowerment, 00:08:33.062 --> 00:08:35.144 people may be able to treat themselves and 00:08:35.183 --> 00:08:37.745 not necessarily be dependent to as great 00:08:37.764 --> 00:08:38.684 an extent on us. 00:08:39.065 --> 00:08:39.365 However, 00:08:39.404 --> 00:08:41.206 people do need hands-on and those 00:08:41.985 --> 00:08:45.126 approaches that foster hands-on training 00:08:45.167 --> 00:08:46.947 and cycles motor skill development, 00:08:47.326 --> 00:08:50.408 when they treat the patients and they 00:08:50.427 --> 00:08:51.347 encounter that patient, 00:08:51.368 --> 00:08:52.528 they put their hands on, 00:08:54.308 --> 00:08:56.029 regardless of the algorithm they follow to 00:08:56.090 --> 00:08:56.549 determine 00:08:57.754 --> 00:09:00.676 that intervention they're doing so in an 00:09:00.735 --> 00:09:03.037 extremely competent and confident manner 00:09:03.057 --> 00:09:05.638 which is then conveyed and the patient 00:09:05.677 --> 00:09:09.178 thinks well this person is skilled and 00:09:09.619 --> 00:09:12.159 knowledgeable and you're already halfway 00:09:12.200 --> 00:09:14.240 there then you know the right alliance 00:09:15.139 --> 00:09:17.241 And the trust, yeah, the trust is there. 00:09:18.062 --> 00:09:19.942 Ron, there's so much in what you said, 00:09:19.962 --> 00:09:23.025 and I think that this is part of, 00:09:23.086 --> 00:09:24.105 you and I talked about this, 00:09:24.125 --> 00:09:26.408 this is kind of why I immediately thought 00:09:26.427 --> 00:09:28.509 about you in talking about something that 00:09:29.529 --> 00:09:31.912 is foundational to OMPT. 00:09:32.712 --> 00:09:34.994 You've kind of seen the evolution of how 00:09:35.033 --> 00:09:38.356 we've gotten here and have spoken to that. 00:09:38.576 --> 00:09:40.758 And what I'm pulling from a lot of 00:09:40.798 --> 00:09:42.580 what you said just now too is, 00:09:43.279 --> 00:09:43.480 you know, 00:09:43.500 --> 00:09:45.221 those are the things that we're teaching 00:09:45.561 --> 00:09:47.042 for those of us in academia. 00:09:47.582 --> 00:09:48.182 And, you know, 00:09:48.263 --> 00:09:51.144 even clinical teaching is it's still got 00:09:51.164 --> 00:09:52.405 to be about the patient, right? 00:09:52.466 --> 00:09:54.567 Like it still has to be patient focused 00:09:54.606 --> 00:09:55.288 and the patient, 00:09:55.347 --> 00:09:56.808 if you treat the impairments, 00:09:56.908 --> 00:09:58.889 it almost doesn't matter, you know, 00:09:58.970 --> 00:10:00.571 maybe what path or what, 00:10:00.770 --> 00:10:03.432 what siloed thinking you choose because 00:10:03.452 --> 00:10:04.212 you're tailoring it, 00:10:04.332 --> 00:10:05.813 tailoring it to the patient. 00:10:06.534 --> 00:10:07.695 And that's really important. 00:10:07.735 --> 00:10:09.636 A lot of evidence now we know through 00:10:09.657 --> 00:10:11.138 like the CPGs is that, 00:10:11.839 --> 00:10:15.933 a multimodal approach to intervening for 00:10:16.134 --> 00:10:17.339 our patients and I think 00:10:18.630 --> 00:10:21.273 I've been guilty of it too, 00:10:21.312 --> 00:10:22.754 especially when I first became a fellow. 00:10:22.813 --> 00:10:23.115 I was like, 00:10:23.195 --> 00:10:24.735 I want to do all these techniques on 00:10:24.875 --> 00:10:25.336 everyone. 00:10:25.416 --> 00:10:27.418 I want to practice, get my skills well. 00:10:27.457 --> 00:10:29.639 But you may go a year and never 00:10:29.679 --> 00:10:31.860 have to manipulate a talocrural joint 00:10:31.941 --> 00:10:33.682 because you just don't have a patient that 00:10:33.722 --> 00:10:34.263 needs that. 00:10:34.302 --> 00:10:37.585 So I really have a deep appreciation for 00:10:37.725 --> 00:10:41.148 the way that you have illustrated kind of 00:10:41.168 --> 00:10:41.808 where we were 00:10:42.950 --> 00:10:44.711 how you lived where we were and how 00:10:44.750 --> 00:10:46.331 you are now living where we are. 00:10:48.333 --> 00:10:50.235 I do want to shift a little bit. 00:10:50.275 --> 00:10:51.657 You started to go into this a little 00:10:51.677 --> 00:10:52.096 bit, Ron. 00:10:52.116 --> 00:10:54.019 Let's shift to OMPT practice, 00:10:54.879 --> 00:10:57.020 specifically where you've seen it evolve 00:10:57.081 --> 00:10:59.123 from really hands-on, 00:10:59.562 --> 00:11:00.985 heavily hands-on approach, 00:11:01.544 --> 00:11:03.567 maybe clinician-focused approach, 00:11:04.466 --> 00:11:05.729 to periodically, 00:11:06.349 --> 00:11:08.110 what I would say now of somewhat of 00:11:08.130 --> 00:11:09.412 a more hands-off approach, 00:11:09.951 --> 00:11:11.971 while acknowledging the expertise of the 00:11:12.011 --> 00:11:13.852 manual therapist who needs to put their 00:11:13.893 --> 00:11:18.494 hands on. 00:11:18.634 --> 00:11:20.573 Where does directional preference fit in 00:11:21.073 --> 00:11:24.475 now as we're sort of bridging these two 00:11:24.534 --> 00:11:26.475 paradigms where we're occasionally 00:11:26.514 --> 00:11:28.456 hands-on, occasionally hands-off? 00:11:28.635 --> 00:11:30.056 Where's directional preference? 00:11:30.096 --> 00:11:30.875 What are your thoughts? 00:11:31.176 --> 00:11:31.615 Yeah, well, 00:11:31.676 --> 00:11:34.677 you said something I think that's pretty 00:11:34.736 --> 00:11:35.576 profound in that 00:11:36.243 --> 00:11:38.004 We have to have an examination that's 00:11:38.065 --> 00:11:41.268 inclusive enough to appreciate a potential 00:11:41.327 --> 00:11:41.908 impairment. 00:11:42.369 --> 00:11:44.451 So if we go in and our only 00:11:44.490 --> 00:11:46.592 tool is to test repeated end range 00:11:46.653 --> 00:11:47.134 movements, 00:11:47.153 --> 00:11:49.316 then we're kind of left with that in 00:11:49.355 --> 00:11:51.197 terms of how we may manage the patient. 00:11:51.738 --> 00:11:55.261 If we omit testing muscle balance, 00:11:56.643 --> 00:12:00.206 we then lose the opportunity to encourage 00:12:00.245 --> 00:12:05.309 people to stabilize or utilize exercises 00:12:05.350 --> 00:12:07.230 that may address their chief impairment. 00:12:07.711 --> 00:12:09.953 So when we have a thorough examination 00:12:09.994 --> 00:12:12.134 that may be inclusive of testing repeated 00:12:12.195 --> 00:12:12.576 end range, 00:12:12.615 --> 00:12:14.317 I would certainly recommend that. 00:12:14.576 --> 00:12:16.859 We could put an asterisk toward or at 00:12:16.899 --> 00:12:20.261 that impairment and that tends to stand 00:12:20.402 --> 00:12:22.903 out that we appreciate maybe the thing 00:12:22.923 --> 00:12:24.785 that we go after initially. 00:12:25.702 --> 00:12:28.183 And if we don't have a thorough exam, 00:12:28.224 --> 00:12:29.583 then we're missing out. 00:12:29.604 --> 00:12:31.345 We're really not doing that patient 00:12:31.384 --> 00:12:31.845 justice. 00:12:31.904 --> 00:12:33.066 And it could be done in an efficient 00:12:33.086 --> 00:12:35.466 manner provided you have exposure and 00:12:35.505 --> 00:12:37.726 training in these different approaches. 00:12:37.807 --> 00:12:39.847 So we're finding that some people are 00:12:39.908 --> 00:12:43.948 interested in pursuing further training in 00:12:44.788 --> 00:12:45.230 MDT. 00:12:45.330 --> 00:12:48.671 And we also find that our MDT fellows, 00:12:48.971 --> 00:12:50.772 McKenzie fellows that are now part of the 00:12:50.812 --> 00:12:54.133 Academy are learning more from our other 00:12:54.232 --> 00:12:54.932 colleagues who 00:12:55.611 --> 00:12:55.812 you know, 00:12:55.831 --> 00:12:57.052 are approaching patients a bit 00:12:57.072 --> 00:12:57.493 differently. 00:12:57.533 --> 00:12:59.413 And that was really the vision of the 00:12:59.433 --> 00:13:00.714 founding members of AOM. 00:13:00.754 --> 00:13:05.495 They all had their very invested 00:13:05.735 --> 00:13:07.856 approaches to treating patients, 00:13:07.917 --> 00:13:10.359 but they had the vision to understand that 00:13:11.399 --> 00:13:12.759 it wasn't the answer for everyone. 00:13:13.460 --> 00:13:15.041 And it's the difference between an 00:13:15.100 --> 00:13:17.701 institute and an academy. 00:13:18.022 --> 00:13:18.942 So, you know, 00:13:18.961 --> 00:13:20.543 the academy is comprised of a lot of 00:13:20.582 --> 00:13:23.024 different institutes and schools of 00:13:23.104 --> 00:13:23.504 thought. 00:13:24.345 --> 00:13:25.065 And really, it's 00:13:25.525 --> 00:13:28.206 It's very rewarding and exciting to go and 00:13:28.246 --> 00:13:31.508 learn something new when we go to these 00:13:33.009 --> 00:13:36.169 conferences and hear research and see 00:13:38.171 --> 00:13:39.890 techniques taught in these breakout 00:13:39.931 --> 00:13:42.532 sessions that maybe we wouldn't be able to 00:13:42.572 --> 00:13:44.393 offer our patients without that exposure. 00:13:44.432 --> 00:13:46.114 So you can pretty much say if you 00:13:46.153 --> 00:13:48.674 go to a McKenzie conference, 00:13:48.695 --> 00:13:50.235 you're going to hear about McKenzie. 00:13:50.254 --> 00:13:51.336 If you go to a Maitland conference, 00:13:51.355 --> 00:13:52.015 you're going to learn about 00:13:52.784 --> 00:13:54.245 Maitland or Maitland seminar, 00:13:54.265 --> 00:13:56.008 you're going to learn about Maitland. 00:13:56.207 --> 00:13:56.788 That's fine. 00:13:56.807 --> 00:13:58.809 And when you learn something to a very 00:13:58.850 --> 00:14:00.571 high level and you're able to distinguish 00:14:00.610 --> 00:14:02.251 signs and symptoms and come up with a 00:14:02.292 --> 00:14:04.354 classification or diagnosis, 00:14:04.693 --> 00:14:05.995 patients are probably going to do very 00:14:06.034 --> 00:14:06.294 well. 00:14:06.895 --> 00:14:08.998 And we had some McKenzie fellows go out 00:14:09.038 --> 00:14:11.600 for mentorship from a Paris fellow and 00:14:11.659 --> 00:14:12.900 both learned from one another. 00:14:13.541 --> 00:14:18.585 And I've been a mentor for people from 00:14:18.705 --> 00:14:19.905 James Dunning's program, 00:14:21.043 --> 00:14:22.224 and other programs as well. 00:14:22.244 --> 00:14:23.725 And I've learned and then adopted 00:14:23.785 --> 00:14:24.947 techniques based on that. 00:14:24.986 --> 00:14:28.149 So that's really a compliment to those, 00:14:29.091 --> 00:14:32.053 Stanley Paris and Dick Earhart and Mike 00:14:32.073 --> 00:14:34.296 Rogers and others, Bjorn Svensson, 00:14:34.336 --> 00:14:37.719 who had that vision way back when that, 00:14:37.859 --> 00:14:39.860 and they didn't always agree. 00:14:41.282 --> 00:14:42.363 I understand that it was, 00:14:42.743 --> 00:14:43.683 and I was a member of the board 00:14:43.744 --> 00:14:45.306 at AOMT at that time, you know, 00:14:45.346 --> 00:14:45.525 that 00:14:46.038 --> 00:14:47.178 You know, there's, you know, 00:14:47.239 --> 00:14:48.859 sometimes some very... 00:14:49.740 --> 00:14:51.100 Some heated discussions. 00:14:51.120 --> 00:14:51.841 Heated discussions. 00:14:51.860 --> 00:14:52.341 Thank you, Ma. 00:14:52.980 --> 00:14:55.442 Heated discussions in regards to how 00:14:55.481 --> 00:14:56.602 things were being approached. 00:14:56.663 --> 00:14:57.543 But still, 00:14:57.582 --> 00:14:59.083 they were able to let that go. 00:14:59.183 --> 00:15:01.284 And it's really for the betterment of the 00:15:01.325 --> 00:15:01.764 patient. 00:15:02.365 --> 00:15:02.625 Yes. 00:15:03.751 --> 00:15:04.634 Yeah, I love that, Ron. 00:15:04.833 --> 00:15:05.975 And I, you know, 00:15:06.196 --> 00:15:09.422 you know that I went through MTI and 00:15:09.701 --> 00:15:12.567 Tim and Krzyzewski and Peter Kroon 00:15:12.746 --> 00:15:15.572 developed that program and similarly. 00:15:15.753 --> 00:15:17.355 They were right after me, so. 00:15:18.163 --> 00:15:18.842 So, you know, 00:15:19.023 --> 00:15:20.884 you basically know what I learned and what 00:15:20.923 --> 00:15:21.563 they taught. 00:15:22.384 --> 00:15:23.144 Exactly. 00:15:23.384 --> 00:15:24.565 And a whole lot more. 00:15:25.264 --> 00:15:27.445 But that's part of what I really 00:15:27.465 --> 00:15:30.505 appreciate about our community of practice 00:15:30.566 --> 00:15:32.787 after going through MTI, which, 00:15:32.846 --> 00:15:34.147 like you said, is an institute. 00:15:34.167 --> 00:15:35.706 That's an important distinction that I 00:15:35.746 --> 00:15:36.527 never thought about. 00:15:36.667 --> 00:15:39.868 Institute versus academy is getting this 00:15:40.067 --> 00:15:42.129 mix of techniques and schools of thoughts 00:15:42.188 --> 00:15:42.288 and 00:15:43.328 --> 00:15:45.070 It really deepened my appreciation, 00:15:45.169 --> 00:15:45.630 I think, 00:15:45.791 --> 00:15:47.831 to the homage that you paid to the 00:15:47.871 --> 00:15:49.033 founders of AOMT, 00:15:49.052 --> 00:15:54.056 which is that our outcomes are that much 00:15:54.096 --> 00:15:56.278 better when we do kind of infuse these 00:15:56.317 --> 00:15:59.639 different techniques versus walking in our 00:15:59.700 --> 00:16:00.841 single silos. 00:16:00.900 --> 00:16:01.721 And, you know, 00:16:02.042 --> 00:16:04.903 one size fits all treatment has obviously 00:16:04.964 --> 00:16:07.985 been disproven to be effective in managing 00:16:08.046 --> 00:16:08.385 patients. 00:16:08.426 --> 00:16:10.027 I love this community practice for that 00:16:10.067 --> 00:16:10.386 reason. 00:16:10.746 --> 00:16:11.707 So now I have to put you on 00:16:11.727 --> 00:16:12.248 the spot. 00:16:13.028 --> 00:16:13.130 Thank you. 00:16:13.836 --> 00:16:15.557 before I go into mentorship, 00:16:15.597 --> 00:16:17.980 because you talked about mentoring, uh, 00:16:18.000 --> 00:16:19.741 different people from different programs. 00:16:19.782 --> 00:16:20.982 We're going to end on that Ron, 00:16:21.023 --> 00:16:21.802 because selfishly, 00:16:21.842 --> 00:16:23.083 I really want to spend a little bit 00:16:23.104 --> 00:16:25.306 of time there, but do you, 00:16:25.346 --> 00:16:27.927 do you think Ron that at where we 00:16:27.967 --> 00:16:30.230 are right now and what you've seen, 00:16:30.269 --> 00:16:31.029 what you're seeing, 00:16:31.090 --> 00:16:33.831 do you think that OMPT and MDT are 00:16:34.393 --> 00:16:37.835 like finally coming together or do we 00:16:37.855 --> 00:16:38.836 still have some work to do? 00:16:38.875 --> 00:16:39.736 What does that look like? 00:16:39.777 --> 00:16:40.496 What are your thoughts? 00:16:40.778 --> 00:16:42.719 Well, it's moving in that direction. 00:16:43.179 --> 00:16:43.580 And, uh, 00:16:45.009 --> 00:16:46.850 You know, directional preference, I think, 00:16:46.909 --> 00:16:50.452 is kind of a hard concept to argue 00:16:50.472 --> 00:16:53.154 about in regards to asking people to move 00:16:53.195 --> 00:16:55.196 in directions to end range and see if 00:16:55.236 --> 00:16:58.379 that direction produces a lasting change 00:16:59.239 --> 00:17:00.259 in their signs and symptoms. 00:17:00.299 --> 00:17:03.643 So it isn't just a person moves in 00:17:03.663 --> 00:17:04.303 a certain direction, 00:17:04.323 --> 00:17:05.923 they feel a decrease in their symptoms. 00:17:06.003 --> 00:17:07.786 It should be decreased and better or a 00:17:07.885 --> 00:17:10.207 lasting improvement for it truly to be a 00:17:10.248 --> 00:17:11.147 directional preference. 00:17:11.729 --> 00:17:14.289 And originally, Robin McKenzie, 00:17:15.211 --> 00:17:17.192 described it in terms of centralization. 00:17:17.211 --> 00:17:19.192 So if symptoms were found to move from 00:17:19.211 --> 00:17:21.853 a more distal to more central location, 00:17:22.432 --> 00:17:25.094 then that would be directional preference. 00:17:25.134 --> 00:17:26.374 But that's just one example. 00:17:26.433 --> 00:17:29.414 It could also be localized pain that 00:17:29.474 --> 00:17:31.255 decreases or remains decreased, 00:17:31.714 --> 00:17:33.695 or maybe a baseline that improves. 00:17:33.736 --> 00:17:35.796 It may be range of motion or maybe 00:17:35.836 --> 00:17:38.797 a neural sign that changes and remains 00:17:38.916 --> 00:17:41.298 improved as a result of moving in a 00:17:41.377 --> 00:17:42.458 particular direction. 00:17:43.157 --> 00:17:45.219 So there's been over fifty articles 00:17:45.278 --> 00:17:47.099 published on centralization. 00:17:48.060 --> 00:17:50.182 MDT is among the most researched 00:17:50.221 --> 00:17:54.003 approaches in musculoskeletal practice. 00:17:54.484 --> 00:17:56.006 And I think part of the reasons, 00:17:56.865 --> 00:17:59.508 one of the reasons it's so researched so 00:17:59.567 --> 00:18:02.689 extensively is that it seems so simple, 00:18:02.729 --> 00:18:05.691 but it's not that simple, actually. 00:18:05.770 --> 00:18:08.093 And in a scoping review that was recently 00:18:08.133 --> 00:18:09.313 published in the Journal of Physical 00:18:09.353 --> 00:18:09.732 Therapy, 00:18:09.973 --> 00:18:11.094 there's found to be one hundred and 00:18:11.114 --> 00:18:12.414 eleven, you know, 00:18:13.103 --> 00:18:15.703 different definitions in the ten thousand 00:18:15.763 --> 00:18:17.584 articles that were described, 00:18:17.644 --> 00:18:19.223 not a hundred eleven different 00:18:19.984 --> 00:18:20.765 definitions, but. 00:18:21.785 --> 00:18:22.224 You know, 00:18:22.384 --> 00:18:24.285 there is a quite a bit of discrepancy 00:18:24.325 --> 00:18:25.486 in how it's defined, 00:18:26.086 --> 00:18:28.806 so operationally defined as a lasting 00:18:28.846 --> 00:18:32.166 improvement in a baseline as a result of 00:18:32.207 --> 00:18:35.827 moving repeatedly or sustaining an end 00:18:35.867 --> 00:18:36.288 movement. 00:18:36.387 --> 00:18:39.148 So the evidence is emerging. 00:18:39.169 --> 00:18:40.449 You know, it's not 00:18:42.875 --> 00:18:43.636 You know, 00:18:43.656 --> 00:18:46.117 in a systematic review published by 00:18:46.198 --> 00:18:48.779 Halliday in Journal of Orthopedics and 00:18:48.799 --> 00:18:49.859 Sports Physical Therapy, 00:18:50.099 --> 00:18:53.961 they found when MDT or McKenzie was 00:18:54.041 --> 00:18:56.243 operationally defined in the clinicians 00:18:57.084 --> 00:18:59.945 operated according to that, you know, 00:18:59.986 --> 00:19:02.826 those definitions that MDT did have a 00:19:03.067 --> 00:19:04.127 greater treatment effect size. 00:19:05.201 --> 00:19:08.203 when we looked at credentialed therapists 00:19:08.243 --> 00:19:10.506 or people who've learned this approach in 00:19:10.586 --> 00:19:12.988 a article published in twenty twenty five 00:19:13.428 --> 00:19:14.568 by Hanneman and colleagues, 00:19:14.588 --> 00:19:17.332 they found that those that were trained 00:19:18.092 --> 00:19:20.733 had more favorable outcomes in comparison 00:19:20.773 --> 00:19:21.835 to other approaches. 00:19:21.855 --> 00:19:22.315 Yeah. 00:19:22.895 --> 00:19:23.135 You know, 00:19:23.155 --> 00:19:24.696 if they had that training in it. 00:19:24.737 --> 00:19:27.819 So it's about exposure and 00:19:29.400 --> 00:19:31.221 paying respect to the evidence in the 00:19:31.260 --> 00:19:31.641 literature. 00:19:31.921 --> 00:19:32.080 You know, 00:19:32.101 --> 00:19:33.961 we have systematic reviews and 00:19:34.001 --> 00:19:36.123 meta-analyses and randomized controlled 00:19:36.163 --> 00:19:38.844 trials that might show the efficacy of a 00:19:38.903 --> 00:19:39.845 particular approach, 00:19:39.884 --> 00:19:42.026 but ultimately it boils down to the 00:19:42.066 --> 00:19:43.165 evidence of the patient. 00:19:43.205 --> 00:19:43.766 And like you said, 00:19:43.786 --> 00:19:47.008 you're able to identify, you know, 00:19:47.067 --> 00:19:48.388 functional limitations, 00:19:48.548 --> 00:19:50.169 patient's perception of pain, 00:19:51.089 --> 00:19:52.529 contextual factors, 00:19:52.549 --> 00:19:53.631 and put it all together. 00:19:54.090 --> 00:19:56.112 and determine what's best for that patient 00:19:56.592 --> 00:19:57.392 right there, 00:19:57.451 --> 00:20:00.452 because that can't be captured, you know, 00:20:00.573 --> 00:20:02.953 in these, when we look at the, 00:20:03.213 --> 00:20:03.375 you know, 00:20:03.414 --> 00:20:05.335 the evidence synthesis from a systematic 00:20:05.375 --> 00:20:07.576 review or meta-analysis or even a 00:20:07.615 --> 00:20:08.916 randomized controlled trial. 00:20:08.957 --> 00:20:10.436 So, you know, it's a balance. 00:20:10.497 --> 00:20:12.258 It's a balance of the evidence literature 00:20:12.718 --> 00:20:13.958 and the evidence of the patient. 00:20:14.479 --> 00:20:14.699 You know, 00:20:14.719 --> 00:20:16.858 we respect to the evidence that's there, 00:20:17.319 --> 00:20:19.039 but we also have to pay respect to 00:20:19.519 --> 00:20:20.820 the fact that sometimes, 00:20:22.471 --> 00:20:25.094 evidence emerges over time. 00:20:25.114 --> 00:20:26.974 Back when Dick Earhart taught us a 00:20:27.035 --> 00:20:28.497 sacroiliac joint course during our 00:20:28.537 --> 00:20:29.217 residency, 00:20:29.717 --> 00:20:31.739 he did a gapping technique for the 00:20:31.798 --> 00:20:34.441 sacroiliac joint and described it as being 00:20:34.480 --> 00:20:37.002 effective for treating many different 00:20:37.583 --> 00:20:39.585 diagnoses related to the SI. 00:20:40.545 --> 00:20:42.547 And he showed us this one technique that 00:20:42.606 --> 00:20:43.247 was a gap. 00:20:44.028 --> 00:20:46.329 Some people wanted to learn, you know, 00:20:46.430 --> 00:20:48.151 a number of SI techniques. 00:20:48.171 --> 00:20:49.231 That's one that's good. 00:20:49.795 --> 00:20:51.958 I'm good about that if we have one 00:20:51.998 --> 00:20:52.499 go-to. 00:20:53.038 --> 00:20:54.181 And you said it's more important that we 00:20:54.201 --> 00:20:55.722 get a joint to move. 00:20:55.742 --> 00:20:56.144 Correct. 00:20:57.065 --> 00:21:00.409 And actually, years later, 00:21:01.230 --> 00:21:03.834 that same technique, 00:21:03.993 --> 00:21:05.496 which was described as a gap for the 00:21:05.536 --> 00:21:06.417 sacroiliac joint, 00:21:07.070 --> 00:21:09.571 became the technique lumbopelvic thrust 00:21:09.592 --> 00:21:12.292 that was in Flynn's study of clinical 00:21:12.333 --> 00:21:15.134 prediction rule for lumbar manipulation. 00:21:15.213 --> 00:21:18.375 So the technique he was demonstrating back 00:21:18.414 --> 00:21:20.635 in the eighties and nineties and teaching 00:21:20.895 --> 00:21:23.917 ended up being part of our- Implemented in 00:21:23.958 --> 00:21:24.498 practice. 00:21:24.917 --> 00:21:25.637 Yeah. 00:21:25.657 --> 00:21:27.179 Involvement of a clinical prediction rule. 00:21:28.884 --> 00:21:29.065 You know, 00:21:29.085 --> 00:21:30.467 we can't be dismissive of things, 00:21:30.527 --> 00:21:31.907 especially when they come from expert 00:21:31.968 --> 00:21:34.250 clinicians who've seen thousands of 00:21:34.951 --> 00:21:36.491 patients over many years. 00:21:37.579 --> 00:21:38.141 it works. 00:21:38.540 --> 00:21:39.801 But then when they disseminated 00:21:39.842 --> 00:21:41.563 information to people like Julie Fritz, 00:21:41.583 --> 00:21:43.223 who was at the University of Pittsburgh, 00:21:44.384 --> 00:21:46.567 Dick Earhart was there, you know, 00:21:46.586 --> 00:21:49.568 and Julie Fritz helped influence the 00:21:49.609 --> 00:21:51.030 development of that clinical prediction 00:21:51.050 --> 00:21:53.152 rule, you know, 00:21:53.172 --> 00:21:56.095 then we give respect to those that were 00:21:56.134 --> 00:21:58.997 really providing evidence of those 00:21:59.057 --> 00:22:00.258 patients they were seeing. 00:22:01.057 --> 00:22:02.259 Yeah, I love that, Ron. 00:22:02.799 --> 00:22:04.141 I think it's really important. 00:22:04.622 --> 00:22:07.064 I'm glad you talked about that scoping 00:22:07.104 --> 00:22:09.605 review because I had a couple thoughts and 00:22:09.726 --> 00:22:10.747 questions and things. 00:22:10.847 --> 00:22:12.189 But well, 00:22:12.209 --> 00:22:14.351 I think it's important to go back to 00:22:14.891 --> 00:22:18.615 what you said about variability and not 00:22:18.674 --> 00:22:20.997 having that common taxonomy and shared 00:22:21.157 --> 00:22:21.917 understanding. 00:22:22.898 --> 00:22:24.920 It may seem like a silly parallel, 00:22:24.980 --> 00:22:26.819 but it's like being in a relationship, 00:22:26.880 --> 00:22:27.039 right? 00:22:27.099 --> 00:22:29.101 If you're not speaking the same language, 00:22:29.240 --> 00:22:30.801 your understanding of what the other 00:22:30.842 --> 00:22:32.402 person is saying to you is going to 00:22:32.422 --> 00:22:32.922 vary. 00:22:33.521 --> 00:22:35.442 And not to mention the impact that could 00:22:35.502 --> 00:22:37.824 have clinically on our patients who are 00:22:37.884 --> 00:22:39.523 hearing, you know, 00:22:39.564 --> 00:22:41.045 something completely different from a 00:22:41.125 --> 00:22:43.244 provider who maybe shares the credentials. 00:22:43.285 --> 00:22:44.605 Like, it can be... 00:22:45.566 --> 00:22:45.746 You know, 00:22:45.766 --> 00:22:47.707 and I think this applies not just to 00:22:47.767 --> 00:22:49.166 directional preference, obviously, 00:22:49.207 --> 00:22:51.147 and the variability in defining it, 00:22:51.748 --> 00:22:54.348 but to manual therapy itself and OMPT, 00:22:54.368 --> 00:22:56.690 which has lacked that common taxonomy. 00:22:56.730 --> 00:22:56.930 You know, 00:22:57.009 --> 00:22:59.630 Chad talked about this in the article a 00:22:59.671 --> 00:23:00.250 couple of years ago, 00:23:00.290 --> 00:23:01.230 I think it was twenty one, 00:23:01.270 --> 00:23:02.932 where manual therapy has just been 00:23:02.991 --> 00:23:05.332 demonized and and just, you know, 00:23:05.392 --> 00:23:07.053 sort of tossed to the wayside. 00:23:07.093 --> 00:23:09.173 And he's kind of advocating that we define 00:23:09.213 --> 00:23:09.753 it by 00:23:10.894 --> 00:23:14.076 it's evidence based function versus that 00:23:14.237 --> 00:23:15.337 one technique, you know, 00:23:15.377 --> 00:23:17.440 like the Chicago roll or whatever the case 00:23:17.480 --> 00:23:17.941 may be. 00:23:19.182 --> 00:23:20.083 This is the, 00:23:20.242 --> 00:23:23.405 the definition has to encompass all of the 00:23:23.445 --> 00:23:24.906 things, not just the techniques, 00:23:24.946 --> 00:23:26.628 but also the clinical effects and the 00:23:26.709 --> 00:23:27.269 outcomes. 00:23:27.750 --> 00:23:29.230 So, I mean, 00:23:29.270 --> 00:23:30.172 what are your thoughts around like, 00:23:30.271 --> 00:23:34.415 why is directional preference so hard to 00:23:34.476 --> 00:23:35.457 define? 00:23:35.477 --> 00:23:35.576 Yeah. 00:23:36.214 --> 00:23:36.454 Yeah, 00:23:36.535 --> 00:23:39.897 I think I touched on a little bit 00:23:39.938 --> 00:23:42.660 earlier in that it's not understood to be 00:23:43.240 --> 00:23:44.520 a lasting change. 00:23:44.560 --> 00:23:48.804 And it's sometimes thought of as someone 00:23:48.824 --> 00:23:50.945 that's got low back pain and peripheral 00:23:50.986 --> 00:23:51.486 symptoms. 00:23:51.506 --> 00:23:53.647 They do extension and lying or standing 00:23:53.688 --> 00:23:54.588 lumbar extension. 00:23:55.628 --> 00:23:57.170 and it centralizes or it doesn't 00:23:57.230 --> 00:23:57.990 centralize. 00:23:58.589 --> 00:24:00.250 Then we move on to something else. 00:24:00.951 --> 00:24:04.472 So looking at weight-bearing versus 00:24:04.532 --> 00:24:05.913 non-weight-bearing movements, 00:24:05.973 --> 00:24:07.233 not just in the sagittal plane, 00:24:07.273 --> 00:24:09.634 but the transverse plane and a combination 00:24:09.654 --> 00:24:11.496 of transverse and so forth. 00:24:11.556 --> 00:24:15.458 And you also mentioned kind of the 00:24:15.498 --> 00:24:17.298 language issues we have. 00:24:17.939 --> 00:24:20.319 When I was in our manual therapy 00:24:20.359 --> 00:24:21.000 residency, 00:24:21.039 --> 00:24:22.921 we were taught a posterior to anterior 00:24:22.980 --> 00:24:24.061 central vertebral pressure. 00:24:24.813 --> 00:24:26.654 thought to be having an effect on the 00:24:26.714 --> 00:24:28.376 zygopal seal joints potentially. 00:24:29.077 --> 00:24:32.340 And then later on in MDT training, 00:24:32.441 --> 00:24:34.363 we were taught a lumbar extension 00:24:34.403 --> 00:24:35.124 mobilization, 00:24:35.243 --> 00:24:38.587 the identical hand placement, location, 00:24:38.968 --> 00:24:39.769 and we're moving 00:24:40.289 --> 00:24:41.030 At that time, 00:24:41.090 --> 00:24:42.832 it was thought to be moving the discs. 00:24:42.912 --> 00:24:45.653 So we're moving away from pathoanatomical 00:24:45.692 --> 00:24:47.294 diagnoses, which I think are good. 00:24:47.314 --> 00:24:49.935 We're moving more towards classifications 00:24:49.955 --> 00:24:51.717 based on movements and responses to 00:24:51.777 --> 00:24:52.178 movement. 00:24:52.438 --> 00:24:54.219 I think MDT fits in well with that. 00:24:54.719 --> 00:24:55.960 We, though, 00:24:56.000 --> 00:24:57.161 shouldn't lose sight of those 00:24:57.221 --> 00:25:01.983 pathoanatomical diagnoses because they may 00:25:02.023 --> 00:25:03.805 be very helpful in us establishing 00:25:03.845 --> 00:25:04.424 parameters. 00:25:04.464 --> 00:25:05.405 So we wouldn't treat 00:25:06.347 --> 00:25:07.509 disc pathology, 00:25:07.548 --> 00:25:09.730 if we hypothesize it to be disc generated, 00:25:10.051 --> 00:25:11.432 the same way we would treat a muscle 00:25:12.213 --> 00:25:14.195 that's weak or a power deficit. 00:25:15.156 --> 00:25:16.238 So there's a balance, too, 00:25:16.278 --> 00:25:20.442 between the pathoanatomical diagnoses and 00:25:20.521 --> 00:25:23.404 the movement-based diagnoses. 00:25:23.484 --> 00:25:25.066 And like, unfortunately, 00:25:25.105 --> 00:25:26.126 many times in our profession, 00:25:26.146 --> 00:25:27.147 it's got to be one or the other, 00:25:27.448 --> 00:25:28.128 right? 00:25:28.169 --> 00:25:28.890 It's got to be one. 00:25:29.602 --> 00:25:30.301 oh, 00:25:30.321 --> 00:25:31.722 I'm pathway anatomical or I'm 00:25:31.762 --> 00:25:32.383 movement-based, 00:25:32.663 --> 00:25:35.005 you need really to understand both. 00:25:35.105 --> 00:25:36.445 And understanding, though, 00:25:36.486 --> 00:25:38.406 that we don't always know the pain 00:25:38.446 --> 00:25:38.967 generator. 00:25:39.787 --> 00:25:41.647 But if we have an appreciation of how 00:25:41.667 --> 00:25:42.749 that person moves, 00:25:42.769 --> 00:25:46.471 then we may establish a parameter that's 00:25:46.510 --> 00:25:47.070 quite different. 00:25:47.111 --> 00:25:47.971 If it's ligamentous, 00:25:48.010 --> 00:25:50.053 it may be a thousand reps. 00:25:50.113 --> 00:25:51.573 If it's muscle, 00:25:51.913 --> 00:25:54.214 it may be three sets of ten every 00:25:54.255 --> 00:25:54.654 other day. 00:25:55.316 --> 00:25:56.576 And when I got out of school, 00:25:57.237 --> 00:25:58.498 everyone got three sets of tests 00:25:58.778 --> 00:26:00.719 regardless of the diagnosis. 00:26:00.759 --> 00:26:04.740 So we have some challenges with language 00:26:04.760 --> 00:26:06.181 as you touched on. 00:26:06.340 --> 00:26:10.042 And we need to work towards more 00:26:10.103 --> 00:26:12.904 commonalities rather than pointing out 00:26:13.565 --> 00:26:15.445 differences and discrepancies. 00:26:15.486 --> 00:26:17.406 And that's a job. 00:26:17.866 --> 00:26:19.188 That's not easy. 00:26:19.897 --> 00:26:20.657 Well, it's a big job, 00:26:20.678 --> 00:26:22.618 and I think the scoping review is really 00:26:22.659 --> 00:26:24.920 starting to probe that a bit. 00:26:27.560 --> 00:26:31.123 There seems to be this conflation of the 00:26:31.163 --> 00:26:31.762 two terms, 00:26:31.803 --> 00:26:33.884 centralization and directional preference, 00:26:33.943 --> 00:26:35.003 which you're highlighting. 00:26:37.545 --> 00:26:41.208 not just what the scoping review found, 00:26:41.268 --> 00:26:44.090 but a lot of other studies use them 00:26:44.191 --> 00:26:47.712 interchangeably. 00:26:47.792 --> 00:26:51.455 I think because of my training with Tim 00:26:51.476 --> 00:26:52.096 and Peter, 00:26:53.438 --> 00:26:54.979 it's clear that there's a difference. 00:26:55.519 --> 00:26:57.740 I think if you think about the fact 00:26:57.780 --> 00:26:59.321 that there are those of us who were 00:27:00.462 --> 00:27:03.244 in fellowship training programs and 00:27:03.645 --> 00:27:04.626 treating patients, 00:27:06.354 --> 00:27:08.855 We need clarification of those two terms 00:27:09.016 --> 00:27:12.159 because the impact that this could have on 00:27:12.199 --> 00:27:13.579 those of us as clinicians, 00:27:13.619 --> 00:27:15.020 but also in our patients. 00:27:16.221 --> 00:27:17.603 I think you already kind of touched on 00:27:17.643 --> 00:27:19.304 the difference between the two, 00:27:19.924 --> 00:27:22.047 but I just want to highlight that we 00:27:22.086 --> 00:27:24.248 talk about taxonomy and common taxonomy. 00:27:24.288 --> 00:27:26.490 It's not just words on paper or in 00:27:26.569 --> 00:27:27.151 research. 00:27:27.810 --> 00:27:29.573 The clinical application of these 00:27:29.673 --> 00:27:33.375 mechanisms, both powerful but distinct, 00:27:34.056 --> 00:27:36.239 It has a direct impact on clinicians who 00:27:36.278 --> 00:27:37.059 are trying to learn, 00:27:37.140 --> 00:27:38.182 clinicians who are 00:27:38.621 --> 00:27:40.221 now in academia trying to teach, 00:27:40.260 --> 00:27:41.842 but then of course the patient at the 00:27:41.882 --> 00:27:42.741 center of all of it. 00:27:42.781 --> 00:27:45.603 So I just want to underscore how important 00:27:45.643 --> 00:27:49.044 what you're saying is and to also maybe 00:27:49.104 --> 00:27:50.844 invite the listener to understand that 00:27:51.444 --> 00:27:53.125 we're talking about directional preference 00:27:53.144 --> 00:27:54.605 and OMPT and centralization, 00:27:54.625 --> 00:27:58.165 but this applies to many things in 00:27:58.205 --> 00:27:59.047 physical therapy. 00:27:59.106 --> 00:28:00.946 So I just really appreciate that 00:28:01.207 --> 00:28:02.968 conversation, Ron. 00:28:04.067 --> 00:28:05.409 What are your thoughts on the scoping 00:28:05.449 --> 00:28:05.808 review? 00:28:07.189 --> 00:28:08.150 There's a lot in there. 00:28:08.230 --> 00:28:11.030 Where are you going with this next, Ron? 00:28:11.730 --> 00:28:11.891 Yeah, 00:28:11.932 --> 00:28:15.093 so I think as was done by Halliday, 00:28:16.292 --> 00:28:18.114 we need to look at those that 00:28:18.574 --> 00:28:19.714 operationally define 00:28:20.474 --> 00:28:23.856 directional preference and those that 00:28:24.156 --> 00:28:26.518 didn't give a very clear definition of 00:28:26.557 --> 00:28:27.858 directional preference and look at the 00:28:27.898 --> 00:28:30.840 difference in outcomes in those studies. 00:28:31.381 --> 00:28:34.142 So that's the next step with that. 00:28:34.182 --> 00:28:38.664 And also one of our fellows in training 00:28:38.825 --> 00:28:39.684 recently graduated, 00:28:39.724 --> 00:28:41.987 I think he'll be recognized this October 00:28:42.727 --> 00:28:44.468 or in November at AIOP. 00:28:45.252 --> 00:28:46.453 is going to look at, 00:28:47.094 --> 00:28:48.433 and Chad Cook's his advisor, 00:28:48.534 --> 00:28:50.154 one of his advisors, 00:28:50.515 --> 00:28:52.455 look at the mechanisms behind why 00:28:52.496 --> 00:28:54.616 directional preference may work. 00:28:55.376 --> 00:28:57.458 So we have these theories, 00:28:57.518 --> 00:29:00.138 and Rob McKenzie originally had this DISC 00:29:00.259 --> 00:29:03.000 theory, but he, right from the get-go, 00:29:03.019 --> 00:29:04.421 said this is a theoretical model. 00:29:04.941 --> 00:29:06.582 You know, it may apply, 00:29:06.622 --> 00:29:07.643 but it may not apply. 00:29:08.324 --> 00:29:10.085 I heard him say before his passing at 00:29:10.105 --> 00:29:10.704 a conference, 00:29:11.425 --> 00:29:13.747 I wish I had named this approach. 00:29:13.767 --> 00:29:14.667 We're going to move people in the 00:29:14.708 --> 00:29:16.269 directions that make them feel better and 00:29:16.328 --> 00:29:17.869 avoid those that make them feel worse, 00:29:17.950 --> 00:29:18.730 at least initially. 00:29:18.990 --> 00:29:20.872 But that had been too long of a 00:29:20.892 --> 00:29:21.932 name. 00:29:22.432 --> 00:29:25.415 But he thought of it as being an 00:29:26.776 --> 00:29:27.477 evolving approach. 00:29:28.426 --> 00:29:29.067 definitions. 00:29:29.268 --> 00:29:31.348 He originally described it as movement of 00:29:31.409 --> 00:29:33.550 symptoms from a more distal to more 00:29:33.611 --> 00:29:34.711 central location. 00:29:35.673 --> 00:29:38.914 When we proposed development of a McKenzie 00:29:38.974 --> 00:29:39.516 fellowship, 00:29:39.556 --> 00:29:42.438 he was very supportive of that because he 00:29:43.318 --> 00:29:46.080 originally was a manipulative 00:29:46.300 --> 00:29:49.344 physiotherapist and thought that 00:29:50.321 --> 00:29:50.481 you know, 00:29:50.501 --> 00:29:52.284 maybe too many people have moved away from 00:29:52.344 --> 00:29:53.085 putting hands on. 00:29:53.526 --> 00:29:55.728 Putting hands on is going to be necessary 00:29:55.768 --> 00:29:58.030 and it's part of the MDT approach. 00:29:58.070 --> 00:30:01.694 So I think what we need to do 00:30:01.714 --> 00:30:03.876 next is see when, you know, 00:30:04.397 --> 00:30:07.761 these studies follow the operational 00:30:07.801 --> 00:30:08.481 definition. 00:30:08.541 --> 00:30:11.285 Does it make a difference in outcomes? 00:30:11.346 --> 00:30:11.665 Yeah. 00:30:12.002 --> 00:30:14.304 NMA, NMA, now we'll see, 00:30:14.344 --> 00:30:16.503 but that's the purpose of exploring that 00:30:16.864 --> 00:30:18.744 and looking at the mechanisms of why it 00:30:18.765 --> 00:30:19.085 works. 00:30:19.184 --> 00:30:22.766 So in our programs, 00:30:22.826 --> 00:30:24.125 our fellowship programs, 00:30:24.205 --> 00:30:29.047 we have the clinicians, 00:30:29.527 --> 00:30:32.367 the fellows in training thoroughly 00:30:32.567 --> 00:30:35.068 understand when we bring a joint to end 00:30:35.108 --> 00:30:36.588 range, what tissues are affected. 00:30:37.644 --> 00:30:38.806 So it's just not the disc, 00:30:39.425 --> 00:30:41.727 it is ligament, it's cartilage, 00:30:41.807 --> 00:30:43.067 it's muscle. 00:30:43.768 --> 00:30:45.288 And when a person goes to end range, 00:30:45.328 --> 00:30:48.069 things may change dramatically in terms of 00:30:48.089 --> 00:30:48.830 a baseline. 00:30:49.391 --> 00:30:50.991 And we know that with manipulation and 00:30:51.031 --> 00:30:51.731 mobilization, 00:30:51.771 --> 00:30:53.093 when we bring a joint to end range, 00:30:53.153 --> 00:30:55.294 people may demonstrate improvement. 00:30:55.473 --> 00:30:56.713 When a patient moves to end range, 00:30:56.753 --> 00:30:58.375 if they can move to end range, 00:30:58.414 --> 00:30:59.516 truly move to end range, 00:31:00.455 --> 00:31:01.696 and are they a good candidate for end 00:31:01.737 --> 00:31:03.877 range testing is another question that 00:31:04.038 --> 00:31:05.159 hopefully is appreciated 00:31:06.106 --> 00:31:07.627 by the clinician in terms of safety. 00:31:07.708 --> 00:31:10.288 But there's tissues that are going to be 00:31:10.348 --> 00:31:10.789 stressed. 00:31:10.890 --> 00:31:13.351 And in our Damon Fellowship, 00:31:13.411 --> 00:31:16.232 we had three people who were in the 00:31:16.272 --> 00:31:17.353 program at the same time. 00:31:17.393 --> 00:31:20.595 Megan Donaldson was one of our fellows in 00:31:20.654 --> 00:31:21.055 training. 00:31:21.335 --> 00:31:22.115 Corey Simon, 00:31:22.435 --> 00:31:24.596 who is going to be a keynote at 00:31:24.636 --> 00:31:26.357 the upcoming conference. 00:31:26.978 --> 00:31:29.299 And Eric Miller, they studied together. 00:31:29.599 --> 00:31:32.622 But Corey put together a joint manual, 00:31:32.882 --> 00:31:33.162 which 00:31:34.550 --> 00:31:36.092 you know, looked at, you know, 00:31:36.132 --> 00:31:38.093 the biomechanics, arthrokinematics, 00:31:38.252 --> 00:31:40.115 osteokinematics of all the joints from 00:31:41.154 --> 00:31:43.916 cranial to caudal and what tissues are 00:31:43.936 --> 00:31:45.838 brought to end range when we bring a 00:31:45.858 --> 00:31:46.959 joint to end range. 00:31:47.420 --> 00:31:49.441 And that became our study manual for both 00:31:49.520 --> 00:31:50.000 programs, 00:31:50.040 --> 00:31:52.442 both the McKenzie program and the Damon 00:31:52.462 --> 00:31:52.782 program. 00:31:53.022 --> 00:31:53.983 And it still is today. 00:31:54.084 --> 00:31:55.505 So we thank him for that. 00:31:55.545 --> 00:31:57.165 He used that as a study guide. 00:31:57.425 --> 00:32:01.028 I asked him, you know, if, you know, 00:32:01.068 --> 00:32:03.089 we could use it ongoing in the program. 00:32:03.109 --> 00:32:04.290 He said, of course. 00:32:06.770 --> 00:32:06.951 you know, 00:32:06.990 --> 00:32:10.892 and we have a number of fellows in 00:32:10.951 --> 00:32:12.971 training who, you know, 00:32:13.011 --> 00:32:14.512 have to put in a considerable amount of 00:32:14.593 --> 00:32:17.353 study time just learning that. 00:32:17.614 --> 00:32:21.934 And as do most manual OMPT programs. 00:32:21.994 --> 00:32:22.275 So, 00:32:23.134 --> 00:32:26.236 but we want that to be integral so 00:32:26.276 --> 00:32:26.455 that 00:32:27.849 --> 00:32:32.133 We appreciate when we bring a joint to 00:32:32.173 --> 00:32:33.534 end range or a person goes to end 00:32:33.554 --> 00:32:35.015 range, what's happening? 00:32:35.736 --> 00:32:37.877 And we can hypothesize. 00:32:38.837 --> 00:32:40.640 And McKenzie had an original hypothesis, 00:32:40.680 --> 00:32:42.760 which he later expanded to extremity 00:32:42.800 --> 00:32:43.501 joints as well. 00:32:43.821 --> 00:32:44.382 So obviously, 00:32:44.402 --> 00:32:46.144 the DISC model wouldn't work in the 00:32:46.163 --> 00:32:46.683 extremities. 00:32:46.723 --> 00:32:49.125 But we're seeing emerging evidence for 00:32:49.726 --> 00:32:51.468 testing end range with extremity 00:32:51.708 --> 00:32:52.288 conditions. 00:32:53.169 --> 00:32:56.230 And that is very interesting. 00:32:57.983 --> 00:32:59.845 in terms of what, why, 00:33:00.066 --> 00:33:02.047 and how does that person improve. 00:33:02.467 --> 00:33:04.248 But it's all about baselines, you know, 00:33:04.288 --> 00:33:06.789 rechecking a baseline to see if there's a 00:33:06.890 --> 00:33:07.990 lasting improvement. 00:33:08.090 --> 00:33:09.811 And we can't just go by symptoms. 00:33:09.852 --> 00:33:14.476 So I think it's sometimes the MDT approach 00:33:14.516 --> 00:33:15.656 is misconstrued to be, 00:33:16.037 --> 00:33:17.557 it's only about symptoms. 00:33:17.617 --> 00:33:21.560 And it could be a change in mechanics, 00:33:22.181 --> 00:33:23.122 a myotome, 00:33:24.366 --> 00:33:25.667 But it's got to be a lasting change, 00:33:26.268 --> 00:33:29.351 a neural tension sign. 00:33:29.530 --> 00:33:30.791 Ron, yeah, 00:33:31.452 --> 00:33:34.576 I think you're really – we talked about 00:33:34.615 --> 00:33:35.376 bridging the gap. 00:33:35.477 --> 00:33:37.999 Everything you're saying sort of brings 00:33:38.078 --> 00:33:41.781 those two schools together. 00:33:41.843 --> 00:33:42.742 When we were talking, 00:33:42.803 --> 00:33:44.825 we talked about how – 00:33:44.704 --> 00:33:47.066 OMPT is also end range, right? 00:33:47.105 --> 00:33:49.767 Like joint manipulations are at end range. 00:33:49.846 --> 00:33:51.886 And I don't know if it's just something 00:33:51.926 --> 00:33:53.968 about repeated movements that people 00:33:54.028 --> 00:33:56.669 forget that it is we're talking primarily 00:33:56.709 --> 00:33:57.489 about end range. 00:33:57.528 --> 00:33:58.588 But, you know, 00:33:58.608 --> 00:34:00.089 I think that's an important thing that 00:34:00.630 --> 00:34:03.230 comment and phrase that sort of bridges 00:34:03.250 --> 00:34:03.711 the gap. 00:34:03.871 --> 00:34:05.211 And similarly, right, 00:34:05.250 --> 00:34:07.791 like even with OMPT and kind of your 00:34:09.512 --> 00:34:10.833 manual manipulative 00:34:11.592 --> 00:34:14.713 approach it's it's we're also looking for 00:34:14.773 --> 00:34:16.695 lasting change right you don't you don't 00:34:17.074 --> 00:34:18.956 look for a cavitation and go yay as 00:34:19.016 --> 00:34:21.077 many of you know and many of us 00:34:21.117 --> 00:34:24.719 know it's it's about the test retest it's 00:34:25.737 --> 00:34:27.157 Establish a baseline, 00:34:27.599 --> 00:34:30.061 apply your technique or techniques, 00:34:30.221 --> 00:34:31.222 and then retest. 00:34:31.362 --> 00:34:32.443 And, you know, 00:34:32.463 --> 00:34:33.945 when you phrase it like that, 00:34:33.985 --> 00:34:35.467 which is why I really wanted to have 00:34:35.487 --> 00:34:36.367 this conversation, 00:34:36.407 --> 00:34:38.989 because I knew that you, again, 00:34:39.090 --> 00:34:41.853 have bridged both worlds and still do and 00:34:41.913 --> 00:34:44.996 can kind of help make sense of maybe 00:34:45.076 --> 00:34:45.496 where... 00:34:46.536 --> 00:34:47.998 they seem so separate, 00:34:48.157 --> 00:34:51.300 but they're actually quite similar in the 00:34:51.340 --> 00:34:53.041 clinical application and the things we're 00:34:53.061 --> 00:34:54.681 looking for as far as the effect on 00:34:55.581 --> 00:34:56.302 the patient. 00:34:56.342 --> 00:34:58.344 So I really appreciate that, Ron. 00:34:58.603 --> 00:34:58.903 Thank you. 00:34:58.983 --> 00:34:59.344 And you know, 00:34:59.364 --> 00:35:01.985 there's mechanical effects that we propose 00:35:02.445 --> 00:35:04.987 with manipulation and a person moving to 00:35:05.068 --> 00:35:06.509 end range, 00:35:06.628 --> 00:35:06.748 but 00:35:07.382 --> 00:35:07.623 you know, 00:35:07.663 --> 00:35:09.344 we're seeing more and more evidence of the 00:35:09.804 --> 00:35:12.568 neurophysiological potential effect and 00:35:12.628 --> 00:35:14.148 even the placebo effect. 00:35:14.188 --> 00:35:17.711 And that's if the person moves better and 00:35:17.871 --> 00:35:21.335 continues to move better and it turns out 00:35:21.376 --> 00:35:22.797 it's placebo, that's not a bad thing. 00:35:24.538 --> 00:35:27.721 But how that person is being approached is 00:35:27.780 --> 00:35:29.702 the difference maker in terms of whether 00:35:29.742 --> 00:35:33.867 that placebo may be achieved or occur 00:35:34.465 --> 00:35:36.005 And that's that they're confident in their 00:35:36.085 --> 00:35:36.666 clinician. 00:35:36.686 --> 00:35:38.568 They have a good working relationship. 00:35:39.409 --> 00:35:42.231 They have shared goals in terms of the 00:35:42.291 --> 00:35:43.251 patient's outcome. 00:35:44.092 --> 00:35:47.795 And then when that clinician puts hands on 00:35:48.556 --> 00:35:49.918 in a confident and skilled manner, 00:35:49.938 --> 00:35:51.418 they're there, right? 00:35:51.438 --> 00:35:53.141 They're there. 00:35:53.420 --> 00:35:55.442 And then if they see a within session 00:35:55.862 --> 00:35:57.103 change in a baseline, 00:35:59.036 --> 00:36:03.396 they're really going to be there and buy 00:36:03.456 --> 00:36:06.418 in, so to speak. 00:36:06.458 --> 00:36:07.199 The question is, 00:36:07.259 --> 00:36:08.998 can they treat themselves? 00:36:10.119 --> 00:36:13.161 Do they require us to put hands on? 00:36:13.820 --> 00:36:14.340 Many do. 00:36:14.800 --> 00:36:16.362 Maybe we can move them along more quickly 00:36:16.461 --> 00:36:17.061 if we do. 00:36:17.081 --> 00:36:19.422 It can be a combination of the two. 00:36:19.862 --> 00:36:20.603 But ultimately, 00:36:20.643 --> 00:36:22.443 we want people to be able to be 00:36:22.483 --> 00:36:25.105 empowered and self-treat because 00:36:26.293 --> 00:36:28.355 we spend billions and billions of dollars 00:36:28.414 --> 00:36:30.456 on musculoskeletal healthcare and we just 00:36:30.516 --> 00:36:31.697 can't afford it anymore. 00:36:32.257 --> 00:36:34.300 So we don't have enough evidence of this 00:36:34.340 --> 00:36:34.559 yet, 00:36:34.579 --> 00:36:37.282 but if the patients can become empowered 00:36:37.322 --> 00:36:37.981 to self-treat, 00:36:38.021 --> 00:36:40.244 maybe we can reduce recidivism and they 00:36:40.264 --> 00:36:41.264 don't need to come back. 00:36:41.724 --> 00:36:43.905 But if we don't give them that opportunity 00:36:44.507 --> 00:36:47.088 to become empowered or take a role in 00:36:47.108 --> 00:36:49.730 their own outcome, 00:36:51.871 --> 00:36:53.293 then they're gonna be dependent on us 00:36:54.400 --> 00:36:54.639 You know, 00:36:54.659 --> 00:36:56.260 and I've made that mistake in my career, 00:36:56.320 --> 00:36:58.563 putting hands on too soon or in a 00:36:58.603 --> 00:37:00.804 patient who may have an external locus of 00:37:00.844 --> 00:37:04.547 control and then becomes very difficult. 00:37:04.567 --> 00:37:06.168 Even if we have a good working 00:37:06.208 --> 00:37:07.969 relationship, you know, 00:37:09.295 --> 00:37:10.835 they become dependent on us. 00:37:10.916 --> 00:37:13.219 So I'd rather educate that patient on how 00:37:13.259 --> 00:37:15.260 they could self-treat than me be the 00:37:15.300 --> 00:37:17.742 person that is supposedly making them 00:37:17.822 --> 00:37:18.063 better. 00:37:18.123 --> 00:37:20.005 We want them to make themselves better. 00:37:20.485 --> 00:37:26.230 And that's why I believe so strongly in 00:37:26.289 --> 00:37:31.014 that testing of sustained and repeated 00:37:31.074 --> 00:37:33.416 movements to see if that patient can use 00:37:33.456 --> 00:37:35.398 that as part of their management. 00:37:36.121 --> 00:37:37.782 But then if we just test that and 00:37:37.822 --> 00:37:39.443 we don't test muscle balance, 00:37:39.463 --> 00:37:42.045 we don't test activation of deep spinal 00:37:42.085 --> 00:37:42.527 muscles, 00:37:42.586 --> 00:37:44.527 if we don't check for yellow flags, 00:37:44.568 --> 00:37:47.911 then we're going to miss out on something 00:37:48.070 --> 00:37:49.472 else that person needs. 00:37:49.793 --> 00:37:53.635 So it's just not about that. 00:37:53.695 --> 00:37:53.775 Yeah. 00:37:53.795 --> 00:37:53.896 Yeah. 00:37:53.916 --> 00:37:54.317 Rated movement. 00:37:55.103 --> 00:37:56.965 Yeah, it's got to be comprehensive, Ron. 00:37:57.045 --> 00:37:57.525 I love that. 00:37:57.545 --> 00:37:59.626 And I think both approaches certainly take 00:37:59.666 --> 00:38:00.228 that on. 00:38:00.447 --> 00:38:02.750 And as we're chatting, 00:38:02.789 --> 00:38:04.632 you just kind of keep adding to this 00:38:04.731 --> 00:38:07.594 bucket of this proverbial bucket that I 00:38:07.614 --> 00:38:08.914 have in my head that says, 00:38:09.556 --> 00:38:11.338 let's put all these things together that 00:38:11.378 --> 00:38:13.539 tie these approaches together. 00:38:13.760 --> 00:38:15.041 And obviously, 00:38:15.101 --> 00:38:16.963 self-efficacy is one of those. 00:38:18.204 --> 00:38:18.523 That's a... 00:38:19.744 --> 00:38:20.965 That's the end goal, right? 00:38:21.085 --> 00:38:22.626 It's you start with a therapeutic 00:38:22.646 --> 00:38:23.226 alliance. 00:38:23.646 --> 00:38:25.447 The name of the podcast is Hands On, 00:38:25.507 --> 00:38:27.588 Hands Off for a reason. 00:38:27.688 --> 00:38:28.768 So, you know, 00:38:28.789 --> 00:38:30.489 I think you're speaking to a lot of 00:38:31.110 --> 00:38:35.431 the similarities and commonalities in even 00:38:35.472 --> 00:38:36.592 the approach, right? 00:38:36.612 --> 00:38:38.333 The execution may look different, 00:38:38.353 --> 00:38:42.576 but the approach and the foundation is 00:38:42.615 --> 00:38:44.896 very similar as well as what we're trying 00:38:44.916 --> 00:38:46.197 to achieve with our patients. 00:38:46.237 --> 00:38:47.177 But the self-efficacy 00:38:47.617 --> 00:38:50.980 self-efficacy piece is one that I just 00:38:51.000 --> 00:38:52.900 want to underscore that you brought back 00:38:53.041 --> 00:38:54.862 into this conversation appropriately. 00:38:57.003 --> 00:38:58.023 Ron, I know you and I, 00:38:58.083 --> 00:38:59.623 we could probably go on and on and 00:38:59.744 --> 00:39:00.364 on and on, 00:39:00.465 --> 00:39:05.086 but I told you that I am interested 00:39:05.246 --> 00:39:05.387 in, 00:39:05.447 --> 00:39:07.867 because you've done a lot as a clinician, 00:39:07.927 --> 00:39:09.208 as a faculty member, 00:39:09.309 --> 00:39:12.831 in higher education leadership and just 00:39:14.260 --> 00:39:16.382 fellowship and residency and all the 00:39:16.422 --> 00:39:16.681 things. 00:39:16.702 --> 00:39:17.963 You've done all the things, Ron. 00:39:18.222 --> 00:39:20.844 And one of the things that selfishly I 00:39:20.885 --> 00:39:23.706 want to highlight is your mentorship of 00:39:23.826 --> 00:39:26.547 some really incredible clinicians, 00:39:26.608 --> 00:39:28.648 researchers, thought leaders, innovators, 00:39:28.688 --> 00:39:31.829 Corey Simon, Megan Donaldson, Eric Miller, 00:39:31.871 --> 00:39:35.092 who taught my last two students in the 00:39:35.112 --> 00:39:36.373 clinic at D'Youville. 00:39:36.512 --> 00:39:39.675 And so I feel like we're kind of 00:39:39.715 --> 00:39:41.496 coming full circle where 00:39:42.155 --> 00:39:43.695 a lot of the folks that you've poured 00:39:43.755 --> 00:39:44.536 into, Ron, 00:39:44.637 --> 00:39:47.856 are pouring into our profession and OMPT 00:39:48.838 --> 00:39:51.318 in even more variable ways. 00:39:51.617 --> 00:39:52.699 What is the secret? 00:39:52.838 --> 00:39:54.759 What is your philosophy on mentorship? 00:39:54.998 --> 00:39:55.358 Why? 00:39:55.458 --> 00:39:56.119 You're humble, 00:39:56.199 --> 00:39:58.940 so you will not appreciate me saying this 00:39:58.980 --> 00:39:59.400 this way, 00:39:59.440 --> 00:40:01.481 but why are you such a great mentor, 00:40:01.541 --> 00:40:02.181 Ron Shank? 00:40:03.166 --> 00:40:05.007 So I've had a lot of good mentors, 00:40:05.108 --> 00:40:07.871 great mentors, and great leaders. 00:40:08.432 --> 00:40:10.295 Interestingly, the other day, 00:40:10.474 --> 00:40:13.099 Megan Donaldson, who's our Aon president, 00:40:13.139 --> 00:40:15.822 as well as our program director at the 00:40:15.862 --> 00:40:17.463 Medical University of South Carolina, 00:40:17.523 --> 00:40:20.228 where I am now, put out a... 00:40:22.614 --> 00:40:24.474 something for us to read is faculty on 00:40:24.514 --> 00:40:25.394 teaching and leadership. 00:40:25.434 --> 00:40:27.996 And I've always believed that effective 00:40:28.036 --> 00:40:29.878 teaching or mentorship is really about 00:40:29.998 --> 00:40:30.938 leadership. 00:40:30.978 --> 00:40:31.858 So, you know, 00:40:31.878 --> 00:40:33.619 and if you think about somebody that was 00:40:33.980 --> 00:40:36.501 an effective leader or a coach that you've 00:40:36.541 --> 00:40:36.880 had, 00:40:37.362 --> 00:40:40.603 it's someone who you have a trust in 00:40:40.643 --> 00:40:42.523 each other, a trusting relationship. 00:40:43.224 --> 00:40:45.565 They have a belief that they're going to, 00:40:45.585 --> 00:40:47.726 we can be led or learned 00:40:48.402 --> 00:40:50.923 take you on a learning journal that you 00:40:50.963 --> 00:40:53.626 have respect and appreciation for what 00:40:53.666 --> 00:40:58.427 that student has done up to this point 00:40:58.467 --> 00:41:00.349 and that they're willing to learn more. 00:41:01.208 --> 00:41:02.269 Um, you know, 00:41:02.389 --> 00:41:04.371 and I was always amazed of these McKenzie 00:41:04.391 --> 00:41:07.032 diplomats who come in and, you know, 00:41:07.532 --> 00:41:08.672 now they've learned something to the 00:41:08.713 --> 00:41:09.172 highest level. 00:41:09.193 --> 00:41:10.054 They want to learn more. 00:41:10.213 --> 00:41:11.054 I mean, that's, 00:41:11.313 --> 00:41:13.614 that's quite a impressive compliment, 00:41:13.655 --> 00:41:15.076 but it's, um, 00:41:16.996 --> 00:41:17.177 you know, 00:41:17.217 --> 00:41:19.059 when you have that type of relationship 00:41:19.079 --> 00:41:20.079 with your students, 00:41:20.320 --> 00:41:23.402 or those who you're mentoring, you know, 00:41:23.461 --> 00:41:25.903 you end up supporting one another, 00:41:26.264 --> 00:41:27.945 and then just kind of guiding each other 00:41:28.085 --> 00:41:31.409 along the next step in their journey or, 00:41:32.128 --> 00:41:34.771 you know, in the mentors journey. 00:41:34.851 --> 00:41:37.673 So I think really, 00:41:38.614 --> 00:41:41.836 leadership is into effective teaching. 00:41:41.896 --> 00:41:42.737 And when 00:41:45.099 --> 00:41:47.340 When you can establish that rate, 00:41:47.581 --> 00:41:48.902 it's kind of like patient care. 00:41:48.942 --> 00:41:51.583 When there's a belief that you're going to 00:41:51.603 --> 00:41:53.045 be led in the right direction, 00:41:54.346 --> 00:41:59.088 then it just becomes a matter of keeping 00:41:59.128 --> 00:42:01.010 our minds open and learning from one 00:42:01.050 --> 00:42:01.429 another. 00:42:01.510 --> 00:42:06.313 So I think that those people who are 00:42:06.353 --> 00:42:11.775 good mentors or teachers tend to be good 00:42:11.815 --> 00:42:12.516 leaders as well. 00:42:13.226 --> 00:42:14.786 Yeah, I love that, Ron. 00:42:15.708 --> 00:42:16.528 I love that so much. 00:42:17.068 --> 00:42:18.949 The first thing you said was that you 00:42:18.969 --> 00:42:19.931 had great mentors. 00:42:19.971 --> 00:42:21.532 So, you know, 00:42:21.572 --> 00:42:25.675 great mentors breed great mentors who 00:42:25.735 --> 00:42:26.936 breed great mentors. 00:42:26.996 --> 00:42:29.117 And I think in, obviously, 00:42:29.257 --> 00:42:31.460 in the leadership of Megan, Corey, Eric, 00:42:31.500 --> 00:42:33.280 and others that you have mentored, 00:42:34.521 --> 00:42:37.364 there have been more leaders and this sort 00:42:37.405 --> 00:42:38.605 of generation of leaders, 00:42:38.644 --> 00:42:39.726 not just within AOMT, 00:42:39.786 --> 00:42:41.266 but in the profession. 00:42:41.367 --> 00:42:41.487 And 00:42:42.108 --> 00:42:43.648 I love the parallel to patient care. 00:42:43.688 --> 00:42:44.708 I think it is about trust. 00:42:44.789 --> 00:42:46.369 And something that you said that I really 00:42:46.409 --> 00:42:49.590 appreciate is that with your expertise and 00:42:49.630 --> 00:42:50.552 wealth of experience, 00:42:50.592 --> 00:42:53.672 you're still willing to learn from your 00:42:53.713 --> 00:42:54.353 mentees. 00:42:54.393 --> 00:42:55.554 And I love that. 00:42:55.574 --> 00:42:56.693 When I was in the clinic and I 00:42:56.713 --> 00:42:58.474 was taking students, it was selfish. 00:42:58.574 --> 00:42:59.695 I wanted to learn from them. 00:42:59.795 --> 00:43:01.356 I knew they were getting the latest and 00:43:01.376 --> 00:43:01.956 the greatest 00:43:02.556 --> 00:43:04.297 from whatever program they were coming to 00:43:04.317 --> 00:43:04.697 me from. 00:43:04.757 --> 00:43:06.137 And I wanted that knowledge. 00:43:06.177 --> 00:43:07.617 And so it was a little bit selfish, 00:43:08.418 --> 00:43:09.679 my approach to mentorship, 00:43:09.699 --> 00:43:11.818 but I love that you, you know, 00:43:11.978 --> 00:43:14.800 it's great to see the outcome of dedicated 00:43:14.860 --> 00:43:16.500 mentorship, not just clinical, 00:43:16.539 --> 00:43:18.221 but also professional development, 00:43:18.840 --> 00:43:20.740 and to see where all these great thought 00:43:20.780 --> 00:43:22.501 leaders are, thanks to, you know, 00:43:22.561 --> 00:43:24.041 some influence from you, Ron. 00:43:24.101 --> 00:43:25.862 So, and I know it goes both ways. 00:43:25.882 --> 00:43:26.762 Oh, thanks. 00:43:27.505 --> 00:43:28.148 Yeah, so Ron, 00:43:28.188 --> 00:43:29.610 what's next for you in this space? 00:43:29.690 --> 00:43:32.356 Maybe in mentorship or in leadership, 00:43:32.797 --> 00:43:34.061 if I could put you on the spot, 00:43:34.521 --> 00:43:35.505 what are you working on? 00:43:36.847 --> 00:43:37.509 Tell us more. 00:43:37.987 --> 00:43:38.186 Yep. 00:43:38.246 --> 00:43:40.568 So, you know, a few things. 00:43:40.628 --> 00:43:43.650 So we have a research task force that 00:43:43.710 --> 00:43:47.434 explores studies on directional 00:43:47.474 --> 00:43:47.994 preference. 00:43:48.293 --> 00:43:50.195 And, you know, 00:43:50.295 --> 00:43:53.458 we have quite a large and emerging or 00:43:53.478 --> 00:43:55.858 growing group that's looking at that. 00:43:56.139 --> 00:43:58.940 And some are McKenzie trained, 00:43:59.021 --> 00:44:00.643 some aren't necessarily. 00:44:00.742 --> 00:44:01.742 So, you know, 00:44:01.782 --> 00:44:03.925 we're open to people that are interested 00:44:03.985 --> 00:44:05.226 in kind of 00:44:05.786 --> 00:44:07.815 putting out ideas as we do, 00:44:07.976 --> 00:44:09.722 and then we go into breakout rooms. 00:44:10.914 --> 00:44:12.094 on particular projects. 00:44:12.114 --> 00:44:14.096 And so we meet quarterly. 00:44:14.135 --> 00:44:16.737 And that's been very fruitful, I think. 00:44:19.980 --> 00:44:22.661 And MUSC is very supportive of us doing 00:44:22.702 --> 00:44:23.702 clinical research. 00:44:24.003 --> 00:44:28.505 And having the ability and the freedom to 00:44:28.606 --> 00:44:31.168 balance both teaching and clinical work 00:44:31.407 --> 00:44:34.670 and clinical research is really critical, 00:44:34.710 --> 00:44:35.530 because if you take 00:44:36.601 --> 00:44:39.644 one element out, it's tough. 00:44:40.065 --> 00:44:41.847 It's tough. 00:44:41.867 --> 00:44:43.367 I think they all complement each other. 00:44:43.387 --> 00:44:45.670 And I was very fortunate to have worked 00:44:45.690 --> 00:44:47.210 for institutions that were always 00:44:47.791 --> 00:44:48.632 supportive of that. 00:44:48.713 --> 00:44:51.755 So continuing to do research, 00:44:51.956 --> 00:44:52.795 clinical research, 00:44:53.297 --> 00:44:53.717 once we 00:44:55.018 --> 00:44:57.820 complete our build out of this new 00:44:57.880 --> 00:44:58.541 program. 00:44:59.362 --> 00:44:59.541 You know, 00:44:59.561 --> 00:45:01.503 I have an office here that I see 00:45:01.543 --> 00:45:02.003 patients, 00:45:02.043 --> 00:45:04.005 so I want to get back into doing 00:45:04.485 --> 00:45:05.025 more of that. 00:45:06.126 --> 00:45:07.789 And of course, you know, 00:45:08.409 --> 00:45:09.349 work with our students. 00:45:09.389 --> 00:45:10.371 So, you know, Mo, 00:45:10.391 --> 00:45:13.652 how fun and exciting that is to see 00:45:13.693 --> 00:45:14.994 them, you know, 00:45:15.034 --> 00:45:17.356 begin to learn and begin that process. 00:45:19.318 --> 00:45:21.119 have them understand that this is just the 00:45:21.139 --> 00:45:21.719 starting point. 00:45:21.739 --> 00:45:24.961 DPP is just the starting point, 00:45:25.021 --> 00:45:27.204 and it's kind of what you do after 00:45:27.224 --> 00:45:29.826 you leave that makes the difference. 00:45:29.846 --> 00:45:33.407 What greater compliment to an instructor 00:45:33.447 --> 00:45:35.550 than to see the people you've taught do 00:45:35.590 --> 00:45:36.070 very well? 00:45:36.650 --> 00:45:39.512 And that makes it all really worthwhile. 00:45:40.494 --> 00:45:41.695 A thousand percent, Ron. 00:45:42.155 --> 00:45:42.876 Very well said. 00:45:42.936 --> 00:45:45.659 I have nothing to add and I will 00:45:46.239 --> 00:45:48.442 continue to be inspired by your work and 00:45:48.461 --> 00:45:50.443 your leadership and hopefully be, 00:45:51.885 --> 00:45:52.184 you know, 00:45:52.626 --> 00:45:55.568 a force of some good in this OMPT 00:45:55.608 --> 00:45:58.650 world and sort of bridging gaps where gaps 00:45:58.710 --> 00:46:01.213 exist and for the good of the profession 00:46:01.413 --> 00:46:02.753 and our academy. 00:46:02.813 --> 00:46:03.355 So it's really 00:46:03.735 --> 00:46:05.434 This has been such a rich conversation, 00:46:05.494 --> 00:46:05.715 Ron. 00:46:05.795 --> 00:46:07.675 I've never had one that wasn't with you. 00:46:07.735 --> 00:46:09.976 So thank you for sharing your insights, 00:46:10.036 --> 00:46:12.177 your history, your journey, 00:46:12.197 --> 00:46:13.416 your experience. 00:46:13.737 --> 00:46:15.858 And for those listening, 00:46:15.918 --> 00:46:18.159 please hit the subscribe button, 00:46:18.278 --> 00:46:20.918 stay tuned, share with your friends, 00:46:20.938 --> 00:46:22.340 your students, your colleagues, 00:46:22.579 --> 00:46:24.760 and we will see you next time. 00:46:25.019 --> 00:46:25.780 Thanks again, Ron. 00:46:26.360 --> 00:46:26.760 Thank you, Ma. 00:46:26.780 --> 00:46:27.760 Take care.