Ep. 28 - Alexis Maxence Léveillé PT, MScA, MDT: MSK Science or Fiction? @NoBullshitPhysio

Welcome back! We're here this week with Alexis Leveille. He's a physical therapist and content creator, known for his handle @nobullshitphysio. His page debunks a lot of the literature floating in the rehabilitation world, helping people understand what's science and what's just...not.  Lets hear the debate with DaPrato and Alexis.

Find Alexis @nobullshitphysio on all platforms. 

Transcript

Alex 0:00

you know, as a, as a physio, I, my role personally you'll have the way I see it is I'm kind of like a travel agent. So it's more, we're there on a, as needed basis. And we're, we're there to make people have a good trip.

Chris 0:22

all right here we are. It's a warriors parade day here in San Francisco, and I have a great guest, Alexis Levier tell us where you're from, tell us where you're at, tell us your pronouns, tell us all those fun things so we get acquainted here.

Alex 0:37

Hi, my name is Alex. I'm a physio up in Montreal. I'm self-employed and I'm a soccer player and I just see patients here and there. And then I have a meme page. Well, it's a science page actually, called no bullshit physio where I review bad science.

Chris 0:51

Yeah. And, and you've grown significantly just in the last, you know, year or two, and I think the traction is the hotly contested debate of what is real science and what isn't? And I think there's, there's pendulum swings going both directions when, as it applies to manual therapy. So let's dive into your page a little bit. It seems like you get a lot of traction. It's no bullshit physio. It's, it's great. You know, grab your attention title. Tell us how you got to wanting to do this platform and where the no bullshit physio came from.

Alex 1:24

I was on move view boards a lot. I dunno if you're familiar with their page.

Chris 1:27

Oh yeah.

Alex 1:27

And in my opinion, they share a lot of misinformation and I was getting really frustrated. So, um, instead. Like basically writing essays in the comments that I decided to start a page to debunk that misinformation and it got the ball rolling.

Chris 1:42

Tell us maybe how you tried to take a different tangent, what your background was to give you a little bit more direction towards the meme way of, I think, you know, informing and influencing people on going out there and finding the answers for themselves. Why, why the memes?

Alex 1:58

Honestly, I don't know. I've always, I think I have an internet brain, if that's the way to say it. Like, I have lists of weird videos and I've been, I'm known amongst my friend as the guy who has like the weird videos and I, you know, I love watching commentary channels, so it's always been a, a way for me to kind of phrase things. I just kind of fell into it and it's cuz the stats classes were so boring and I figured like how can I spice this up? And I, I think memes kind of work. Um, and it's also like sometimes you read a paper and you don't really know what the author's doing and you know, there's this expression, you know, an image is worth thousand words.

Chris 2:33

Absolutely. Well, like you're saying it's powerful and it, it it's able to send a message that is very complex and I find that to be a big issue with physios and chiros and other health professionals all over the place, trying to keep up with current research. So you sound, when I listen to your other podcasts or some of the things you do on your page, a very intelligent human that tries to analyze the pros and cons of each side and then takes a certain stance based on the literature that you've read. And you seem to be able to have this really amazing gift and not many people have it of remembering the author of the year and what the content was of that article. So tell us how, how do you stay up on top of that and how do you categorize that and shelf that in your brain? How do you get to that place?

Alex 3:21

I don't know. I, I think it's just practice. Like a lot of people ask me about things and I try to answer every comments cause I don't wanna fall into an echo chamber.

Chris 3:29

Yeah.

Alex 3:29

Which I think is great to learn stuff. Once you've came back to the same study about five times. It's just storing your brain. In my opinion, there's this, quote by the calf like honey de calf, you said that like memory was like, it's like a road in the forest. It's easy to always take the same road, but if you take a different road at some point, it's gonna be easier and easier cuz the trees are gonna be cleared and stuff. I think memory's kind of that way.

Chris 3:50

Yeah.

Alex 3:51

So I've been to the same road a bunch of times. So I just remember the same studies and at some point the major claim was supported by those, those major studies.

Chris 3:58

Yeah. Yeah. So practice let's let's play some devil's advocate right away. Cuz we, we talked a little bit, you know, I think foundationally you and I are very similar, but we definitely live in different areas of the use of manual therapy, the ideas behind the power of manual therapy and some of the foundations of what is a mechanical effect that may translate downstream into not just short term effects, but maybe long term effects. We just don't necessarily have the means to maybe measure some of these things. I find that a lot of like antagonists on social media in general use these big studies. Like, you know, the it band can't be stretched because it takes 9,000 Newton meters, blah, blah, blah. But they're not actually thinking about what the actual details of that argument is. And they're, they're bringing these things in kind of haphazardly because they've used it in the past. Mm-hmm um, how do you apply? I guess it stepping back. My question is how do you apply some of these great foundational important studies to the subtle details and the finer details of what you are discussing with each, you know, podcast or each Instagram debate or social media kind of blog that you're getting into with some of those things.

Alex 5:07

It is kind of hard. I'd say I'm almost guilty of not doing that a lot of the time. So like for, if you're coming back to the example of like the it band being stretched, like the fascia, that's the, what study is that again? I forgot the Chowdry 2008 study.

Arpita 5:22

The Chowdry study that they mention is titled the three dimensional mathematical model for the deformation of human fascia in manual therapy. The study applies a strictly mathematical model that used established theories of elasticity to explore the relationship between mechanical forces that were applied to fascia. And then the changes that resulted in those tissue. Also in this next section, Chris and Alex discuss I a S T M, which is instrument assisted soft tissue mobilization, which is the use of any tools. So for example, Guha to help with soft tissue treatment.

Chris 6:01

Yeah.

Alex 6:02

You know, that study, a lot of people will cite it and just be like, Hey, so therefore, yeah. Is IASTM doesn't work or foam rolling doesn't work? I, that's not my opinion. I'll usually look at the data on effectiveness after. Yes. So, and my claims usually, like, it probably works the same as other things, but, the evidence is not great. So for form ruling, I think the evidence is not that great. And then, I C TM, if you look at the evidence right now, I don't think we can say that it works. I think it's pretty bad. I it's against my bias. Like I don't, I don't think I a C TM works really well, but, and know my experience. Like I tried it for a bunch, bunch of times and it, it seems to pan out for me, but

Chris 6:39

as a general, let's unpack that a little bit as a general tool for which pathology or which region of the body or Is that an overall theme? Yeah. If you collect all the studies put together as a systematic review, most systematic reviews end up being inconclusive anyways. Right. And there's not great recommendations and it's always. More studies needed bigger, more powerful, you know, higher number of subjects, blah, blah, blah. Yeah. But as it relates to what, in your experience, or in your review of the literature, what does is SDM seem to not work the least with?

Alex 7:15

Um, so I think the first things they attacked was in asymptomatic people then symptomatic people. They did two studies back to back was about, um, whether it changes muscle activation patterns mm-hmm, doesn't seem to, and then they compared to, uh, increasing range of motion. I think they did that at the ankle. Um, yeah, it didn't seem to pan on that. Well, uh, and then if you look at pain, I think it's the same as just manual therapy, which makes sense. Cuz to me it is not any different using your hands. Right? Um, yeah. Yeah. I mean it, some of it like, you know, it's quite similar. Yeah. Um, and then, you know, I think. The sub classification. So people think of it in terms of biomechanics. You know, like using a manipulation versus a mobilization or using that versus a massage. I think it makes sense at that regard. Right. If you have, cuz I think we don't have like specific data on this, but you know, sometimes you see like particular pain and this one's like more clearly muscular pain. Yeah. More mild, right? Yep. So we probably use what we call traditional manual therapies. So mobilizations and manipulation on these patients. But then if I'm looking at someone who has like more muscular pain, I'd probably go for a massage, but the reason might be different. So for me it's more about the expectations yeah. Of the patient. It just makes more sense. Right? Absolutely. And if it makes more sense, biomechanically, why not? Right. Cause there's no difference to me as a clinician for using either one. Yeah. Um, Yeah, so it's hard. So I think to go back to your question, I think a lot of the sub classification should be looking at patient expectation, cuz it definitely seems to be bigger, the most powerful predictor, like Klu did a study on this in 2004 for acupuncture. Like if they believe that it works, it's probably gonna work if they don't, it probably won't work. Bishop did a study on this in 2016 for spinal manipulation. Mm-hmm I think it's like 60% more likely to work. If the patient strongly thinks that the spinal manipulation's gonna work. So, and the massage was included in there and they had like similar outcomes regarding beliefs and effectiveness. So yeah, I think that's the main value that a lot of very, and I don't think you're among them cuz again, you read a lot and you're very, obviously you're smart. Right? Right. So I think a lot of manual therapy and I don't wanna use the term disparagingly, but you know, gurus, so people are very heavy into it. The ones that are just like traditional manual therapy guys, they'll, they'll focus on like biomechanics and like small prediction rules, which don't seem to pan out that well. Yeah. Rather than stuff that's more impactful against like patient beliefs and you know, if it's an acute or chronic stuff like that. Yeah.

Chris 9:40

If I had to summarize, you could pick a needle, you could pick a scrapy tool, you could pick your hands, you could pick a cup. You could pick any of these things and they kind of have a similar outcome and the outcome is going to be more highly predicted by what the patient came in expecting to get in that treatment session more than anything as it relates to manual therapy. Right? Yeah.

Alex 10:03

Yeah. I do think other things matter. I just think that's the strongest variable and it's the more actionable, I I'm pretty sure. Some other variables matter, like we've talked about online, we've talked about fascial sliding before. We don't know if that matters yet. We just know that some stuff like K tape or, um, you know, is C TM can change the fascial sliding or gliding. Sorry, but we have no idea what that science, if that remains long term, first of all, or if it matters clinically, right?

Chris 10:28

Yeah. How do we measure the exactly quantity entity of hyaluronic acid in there? So that, that's one of my favorite things to like discuss and debate is like, okay. Yes. We finally figured out that. You're not gonna overstretch and create change by pulling origin to insertion. You're not gonna create a lot of long term change with any of those manual techniques. What you're creating is moderate changes in the short and possibly middle term amount of time of lubrication of the tissues around that area. And you can use whatever tool you want or whatever hands you want, or whatever self kind of mobilization aspects that you want. But there are no studies yet that say, this one produces this much highor acid content versus this one produces this much. We just, we finally got to a place where we found that, oh, Ha is actually very sticky in these areas of densification on chronic issues with people so let's actually investigate that, but that's where we're at, right? That's the, the naivety, I think of some people's idea and approach to manual therapy is they think, oh, this is the, this is the key. This is the like golden Chaus of it all, but we haven't measured, which produces which type of changes and especially in the short versus long term of it all. Yeah.

Alex 11:45

And I I'd go further and say that we haven't had like a mediation analysis where we see that these changes that we can like measure with.

Arpita 11:54

A mediation analysis, quantifies cause and effect. So basically it's a way to explain the relationship between two variables.

Alex 12:03

I guess you use like a blood test or something. And we haven't seen whether that like correlates with people getting better. If you look at the structure of the tendon, right. It doesn't change that much with exercise. Whereas all our exercise was aim as you know, doing ecentric to modify the tendon. But we see that it's not, I mediaing variable. If you look the cook and work, um, that's one of the things they changed on it that it's like people get better. Despite the tendon structure, not changing in the scar tissue part. So it'd be great if, you know, ha is like a definite factor that helps for manual therapy. I think that would be great for manual therapy and physical therapists and orthopedic. It would be great for everyone, for everyone. Yeah. Cause we can even like, you know, we can, if we can inject it, we can remove it too. You know? Um, it's just, we don't know yet. And that's kind of my stands for everything that I'm kind of agnostic. I want to be honest and be like, I don't know. So if I don't know, I'll just be very conservative. That's just kinda my personality.

Chris 12:53

Yeah. No, that, that totally makes sense with it all. Um, let's dive into the shift. I think just in the last year or two of biomechanics, meaning less and less powerful predictors of pain or of, improving biomechanics actually preventing injury. What is your, stance on where the biomechanics lie in, in a level of importance in your practice or in which you think the research says currently

Alex 13:24

I'd say if we look at movement quality and that's one of my big things, I don't think we can predict injuries using it for most things. Uh, I think we can predict where the injury will happen. Us to a point, right? We can't say, oh, you're gonna get injured on may, may, May 10th, right? Yeah. But we can, um, you know, statistically say you're more likely to get injured at the ankle or the foot, if you are anterior foot striker. Yeah. And you're more likely to get injured the hip or the knee if you're rear foot striker. But if you look at total risk of injury, it's pretty much the same. I'd take BNO, did a study on this, like the systematic from 2020 said that. And then the Macy study said the same thing. Yeah. So it's more like if you're using Azo more, you're more likely to injury it cuz there's more opportunity to injure it the same way that if you, you know, play soccer more often, you're more likely to spray your ankle than someone who never plays soccer. But your, you know, injuries are just a part of participating in life. So I think. That's the shift where it's like, we know biomechanics matter, but not necessarily in the, the amount of injury. Yeah. More in, as a measure of load management. Right. It's like a micro version of something.

Chris 14:30

Yeah. Yeah. So to unpack that real quickly, you are going to see possibly compensation methods or less efficient motion that will hopefully guide you into a place of understanding that, oh, this person keeps on, you know, injuring their right knee because they're doing these particular quality of movements more often. Yeah. But you can't say that you're going to prevent an injury. Like one of my favorite things to debunk is the whole Bulletproof, your whatever, right? Bulletproof your back, Bulletproof, your ass Bulletproof, your, your dad bod like all these Bulletproof, your things from the prehab guys or other groups that are trying to sell you on preventative medicine or. I mean, that's, that's kind of a load of shit, right. At this point in terms of preventing the injury.

Alex 15:21

Like I think I know what people mean when they say you can't prevent injuries, we can reduce the rates, but you know what I mean? It's just odd for me, but I know what people are saying. And I, I think again, I think it's people for some stuff like manual therapy, the pendulums like left or right, right. Neurophysiological and then biomedical, right. It's going one way or the other for, biomechanics. I think it's swinging in different directions for different things. So for strength, I think for injuries it's way, way better than before. Right. For example, the best example is ACLS, where we know that strength is very predictive of injury. We can even quantify it, right. Each percent you're missing in quad strength is a 3% increase in, uh, ACL re-injury risk,

Chris 16:01

which is huge shift from where we used to live 10 years ago of hamstring quad ratios. Right. And like, oh, the ratios off then you're, you're kind of fucked.

Alex 16:09

So that grim study from 2016 is just, you know, it's something that's very actionable. And I think that's one of the biggest things that we got from physio. Like I think physios are the biggest impact I think is for ACL. Yeah. And that's cuz we have quantitative data that we can use and that can be actionable. I don't think moving quality is there now. So if there's some that comes in the future, I'm fine. For, for me, my stance is just that we're bad at measuring biomechanics. It doesn't seem to predict injuries, but it, and if we quantify a load management, that's just, that's another thing.

Arpita 16:39

Load management is the reduction of physiological stressors in order to improve function and facilitate recovery. So reducing training to improve performance in the long term.

Alex 16:51

So Paquette came out last year. He just wrote what load management was. There was no Delphy consensus or whatever. It was just people doing all the research and in S area did the paper last year where he was, were 2020. And he said, you know, basically we can't use little management principles to reduce injuries cuz we can't measure it well.

Chris 17:08

We don't even know what it is yet.

Alex 17:09

So I think that will come in the future where the acute or chronic ratio will be usable in a certain way, but it'll just have to be a more encompassing definition that probably includes stress and sleep and stuff like that. It's probably way far in the future, but for now it doesn't seem like, you know, whatever the MBA is doing, it's guesswork, which I think is useful. Right. If you feel terrible, you should probably rest if you're a high level athlete. Yeah. I think that's as much as we can say from the load management thing, as far as much as people are like nailing into it, um, you know, listen to your body, that's pretty much the advice we've gotten for all, all these papers.

Chris 17:44

It's a great segue into, okay. I get in these debates, you know, people that don't like manual therapy and are much more, I guess, aggressive about anti-man therapy than you are. It's the people. I think that I have false narratives that I think everybody should be fighting anyways, like cuz. Even, I fight that. But when we think about the arguments of anti-man therapy individuals, it generally comes back to their idea of load management and you just need to pick the right load to start with, and then progressively increase that. But like you're saying, there's no precision yet with it. And when you can't define what that, you know, descriptor of what true load capacity is and what true load management looks like, how can you say that your program is any better than the next person's. How do you define that? You are providing an expertise that someone can't just go and, read a couple things on the internet and pick it for themselves,

Alex 18:37

Hard to say I mean, it's hard it's to say it's, it's, it's very open ended question. Yeah. I think sometimes people can, it's just not everyone. And I, I think that's when we come in. I almost feel guilty seeing patients sometimes if that makes sense. Yeah. I'm like, yeah, maybe you don't need me that much. So I try to treat as little as possible. So if people want manual therapy, I'm like, Hey, go see that guy. That's that's all he does. He's very good at it. Yeah. Yeah. Yeah. And they're very good. I know I'm not like that. Yeah. I'm the annoying science nerd. So I know that they'll probably get a better time and a better outcome in manual therapy with these people, whatever the reason. Um, so that's one of the reasons why I don't use manual therapy that much. If I were working completely alone, I probably use it more. Right.

Chris 19:13

That makes sense. That's that's such a good, important detail. I think because to have options for your clients is, is at the end of the day, it's about the client. It's not about you and your ego and your. Research based bias it it's about the client, you know, it's like figure it out for that, but that makes so much sense that you have those options for people within your, you know, workspace, which is cool.

Alex 19:35

Yeah. And what I was gonna say is that, um, you know, as a, as a physio, I, my role personally you'll have the way I see it is I'm kind of like a travel agent. So it's more, we're there on a, as needed basis. And we're, we're there to make people have a good trip. If the injury is a trip or we're like, oh, we're gonna guide you through it. And then there's these options. If you need me, when you're there and something doesn't work, just call me and we can provide options. Right? Yeah. And we tell them the price we tell'em this option, this, that option. I'm like this exercise is gonna take that long, probably for you to get better. If we use exercise manual therapy, you can, it'll just might be a bit more expensive if you wanted to marriage, just home exercise. It's just, they're completely informed about how manual therapy works and then it's in their hands.

Chris 20:13

That totally makes sense. Before we leave load management, one of the interesting things, like I deal with a lot with the endurance runner population as well. Yeah. Both at the NCAA level with our cross country teams, but also just triathlon humans here and, and, uh, distance runners in San Francisco. And, and one of the interesting things that I've seen, you know, that was debated a lot more, I think five years ago is all right, there's this idea of, okay, each week you're coming off an injury, you don't wanna increase your mileage by X percent of your previous mileage. And generally that consensus was like a 10% rule 10 years ago.

Arpita 20:50

Just to quickly clarify that point. The 10% rule says that you should never increase your weekly running mileage by more than 10% over the previous week to prevent injury and promote recovery. This is highly debated. And as Chris alluded to, it's generally less accepted today.

Chris 21:07

And then papers came out saying, well, 10% rule doesn't actually change the injury rates whatsoever. And so that was debunked. And, where do you see us being at now in terms of recommendations for load increases in a progressive nature? What does that look like? Either for resistance training or for, you know, return to run type.

Alex 21:26

So that paper, it didn't work the 10% rule, but the problem is none of the people in the study complied, there was like a 1%, there was a 1% compliance. And if you look at all the papers, there was a metaanalysis on this. I think the average compliance in, running program is something like 30%.

Chris 21:42

Yeah. It's terrible.

Alex 21:43

We know in practice, it probably doesn't work because no one does them. Yeah. But we dunno if it's purely because the problem would not work if people would apply it.

Chris 21:51

I think the people that did better in that, in that study, I think if my mind remembers it correctly, is the people that did 20% increases actually had the best outcomes, more so than people that went slower, like a 5% increase rate, but it's because those individuals probably had other variables that prevented it. Right. Maybe they're more intelligent, chose, better other, um, necessary recovery strategies, sleep, nutrition, hydration, all the other things. That maybe led to them being less likely to be injured. It is very interesting that there's so many variables to these things. So I, I think that's one of the challenging parts for if I took manual therapy out of my practice. Yeah. And I had my education, I had my strength and conditioning background that was like my foundation anyways, going through PT school. And I had, you know, common sense to try to talk to people, listen to people and try to give them sound advice. What are some of your sound principles when it comes to delivering a more precise progression for your client?

Alex 22:51

I think that's one thing that physios are missing a lot is being aware of like what the prognosis is for each condition. So I think one of the main things, if you look at what patients want is they wanna know how long it's gonna take.

Chris 23:02

Yeah.

Alex 23:02

So using that and then kind of basing the return to play on that is probably one of the best things we can do. But if we're looking at someone with persistent pain, like low back bend and stuff, we know they're not probably not gonna get injured. Right. Yeah. Yeah. So we can use that to accelerate recovery quicker. So I'm, I tend to be aggressive with my return to play. Especially if the patient values it a lot. Cause I know it's good for mental health and they're gonna like physio more. Compared to if I just tell them not to do anything. So I think. Knowing that pain is not, does not equal. Damage is very useful. And then, the other point was prognosis, but the third one would definitely be just if you wanna reduce injuries, strength is probably your best friend. That's the one time where strength is very important. And, um, I think the research on this is very useful. There's good research on groins. There's good research on ACLS. There's good research on future patella pain like Popeyes from 2015, like knee strength is the main predictor of, uh, basically a new episode of knee pain. It's not that great, but it does seem to, there does seem to be a small effect where if you're strong somewhere, you're less likely to have pain in the future. So, yeah, that's what I tell people. It's like, I don't need to get you stronger to get you out of pain, but once we're done, we're gonna try to make you stronger. So you're less likely to come back here is so people, yeah,

Chris 24:17

It's empowering, right. It's setting the bar higher than they came in with, hopefully, which hopefully gets them, you know, in a better place of self-efficacy or whatever. And I think some of the better clinics are doing that now, even on the private practice level, like private practices generally get such a shit wrap because they wanted to see the patient three times a week for so many weeks because it's a business model. Right? And I think the better private practices now, again, are starting to shift towards let's get you stronger than you've ever been, so that you're more resilient than you've ever been for not only getting out of this injury episode, but preventing your future injury episode for your knee or your ankle or your whatever. Yeah. Which is really interesting and I'm in a hospital based setting. And I think what you are saying. Your practice approach really resonates with me because I don't wanna see someone any longer than I need to. Our ability to get access for our patients is so poor that we have 500 evaluations at any one day waiting to come into our clinic. And so for people to take a step back and say, I don't need to see this patient so many times and that they are probably gonna, if they come in, if you give'em a good prognosis and it matches what their expectations are, you give,'em a good strengthening program. You help'em along with decreasing their anxiety with this little bit of manual therapy stuff they're gonna do quite well with just three sessions, maybe four sessions. You don't need to see someone 12 times every time, you know?

Alex 25:42

That's a good point that you're bringing cuz I was talking to Chad cook and listening to his debate with meins the other day. And one thing that he mentions is that, people will get a quick pain reduction, do much better, long term.

Arpita 25:56

Chad cook is a physical therapist and researcher at duke university. He has published numerous papers, including those on manual therapy. Adam meins is also a physical therapist known for some of his controversial opinions, including being opposed to manual therapy. The.

Alex 26:12

If we do reduce that pain early on, does it reduce the, the risk of chronic pain? We don't know.

Chris 26:17

Well, it definitely reduces their anxiety, right. Oh, for sure. That's important. Creates a fear. Yeah. And their fear placed is like, oh wow. I don't have to sit there. Forever. That's not gonna be there long term. You may me feel better already. Maybe I can go back to lifting weights. Maybe I can go back to playing a little soccer.

Alex 26:35

The reason I think it's interesting is cuz it crosses a lot of fields. So, you know, for medical management, right? One of the arguments, I think some doctors say you need to get the morphine right after the surgery. Otherwise you're gonna get, if you get a lot of pain early on, it's gonna translate to chronic pain after I think the data is mixed right now. But I think that's a big question. We need to answer with pain science and just manual therapy. And I think that can affect decisions for public healthcare, right. Like how aggressive do you wanna be early on? I think that's a big question that is gonna be useful clinically.

Chris 27:04

Yeah, for sure. The problem, I think. Though is physios are guilty of this a lot, but probably most other professions as well, whether you're athletic trainer or an acupuncturist or a chiro, is we like algorithms and, and protocols, right? We like very specific, like if this equals this, then we can do this and this equals this. Then we can do this. Let's say you had a student with you and they're in their final rotation. How do you teach someone to step away from such a linear approach to PT the way traditionally we are taught? And, and how would you teach that student to, to think critically and be, but still efficient?

Alex 27:41

I made read the T afar study 2021 mm-hmm classification based approach provides small, but clinically meaningless, differences in treatment effectiveness. So the paper shows that it really doesn't make a difference if you're using those specific classification things, it's a hard pill to swallow. And I think I'll do a cop out. I think my answer would be you let'em use those approaches and then see their shortcomings. Let'em falter Yeah. The way it happened for me is I was very into MDT. I think I got certified in like less than a year. And then. You know, it didn't work the way they show in the courses. So I try to, I just went a few months to try to prove myself wrong. I'm like, oh, I'll just do the opposite. Yeah. I didn't see a big difference.

Chris 28:22

Yeah. No, same with me. I did a bunch of manual therapy stuff and I was like, I forgot the technique. I didn't look at the book cuz I didn't wanna look stupid in front of the patient. Yeah. I just did it. And I looked back at the book. I was like, damnit, that was the opposite of what they said, but it still worked.

Alex 28:35

So it was kind of like an, I learned it through experience, but then I, I went through the whole manual, the Mackenzie reference list and they have some good studies, but then I realized the claims were overblown cuz yeah. They're not all great studies. It's hard to say, cuz I I'd say I almost use like an algorithm. I, I use it like little wood model, but it's not a model. It's just, I read all like most of his studies and it's very simple barebone, like get the patient confident, educate him and then tell'em to exercise. yeah. In a way that's like a little bit, it provokes a little bit of pain and then it takes away the anxiety regarding the pain. But I I'd say you expose him to a lot and then you'll see that there's contradictions between the systems.

Chris 29:16

Um, so, so on that note, how do we get better studies conducted in the manual therapy world? When let's say in my case, if I do a really well designed double blind randomized control trial, and I get a sample size that has enough power of analysis to really make some good statistical inferences on it. Yep. I come out with it. People are still gonna point a finger and say, I have bias, and they're gonna dismiss this study. How do we get quality studies from intelligent people that have some background in things? When I have no motivation to do that because I'm still gonna get pissed on because people are gonna say there's bias behind it. So I've stuck specifically to just pure imaging. Anybody else can come around and measure exactly what I'm measuring and say, does it have a mechanical effect or not? That's all I'm doing because if I go towards that randomized control study, I'm gonna get so much flack on the bias component of it. Where are those good studies coming from and how do, how do we get those more of them done?

Alex 30:19

Um, I think you, I think you're being pessimistic, right? And I'll, I'll say that it's the, the reason manual therapy gets so much flack is that often they're not well designed. Yeah, I agree. Right. But, um, I have a big bias and overall where I think the way we should make research better is to be way more selective. If we pre we force everyone to pre-trial register. Where they can't back out or change the protocol after, and we make them big studies. Yeah. And they're approved in advanced, then I think we will get fewer, but better studies.

Chris 30:53

But to play devil's advocate, you're also creating a bigger barrier for people to go through more hoops, the IRB process, as it is, is already very daunting. Right? Yeah. And so to create another barrier, another step of like this peer reviewed of, like registering this study so that you have it stamped as like, this is your protocol, this is what you're gonna do. This is what's you you're gonna stick with this. That's great. I think it is a great idea, but it's also creating more hoops to jump through, you know?

Alex 31:20

Yeah. And I mean, it's, that's what I said. It's gonna suck for people in universities, but it's gonna be great for everyone else. The quality, but yeah, the quality, but I also think you could, all, you could cut down on this by doing, uh, secondary papers. Right. Like if every R C T at a mediation analysis, if you have a very large RCT, you can do a lot of things. As long as you declare the hypotheses in advance, you can have multiple primary outcome measures.

Chris 31:44

To get one variable only is almost kind of impossible in the human system as it relates to musculal health. I think that's, that's super true. Let's go back. Into, as it relates to research, one of my big I, I think, you know, Hills that I try to fight on still is the idea of the, the fascial, I think variety throughout the body. And people love to cite the it band, but is the fasc at theta band, same at the, the fascia that's around your sternocleidomastoid. Is that fascia the same as the fascia that integrates your, you know, lateral RET AUM and, um, Pika around your knee? These are all different fascial tissues that have different ratios of different, biochemical. Yep. I guess substrates. And because of that, I think a lot of people that like to Dison manual therapy say, well, fascia is this empty bag that people are throwing, the causation on. Yeah. And I think often manual theists also get into this idea of fascia being a root source of issues when they haven't studied the, the pain science kind of paradigm. But like, you know, the idea that fascia cannot change ha has very little biomechanical, I think, truth to it. There, there are small micro changes that are changing all the time. The idea that satellite cells come in and heal a hamstring tear. It does come back down to connective tissue, right? And some of the physiology of what we learned that happens with that is still fascia. And so it's not that fascia, isn't powerful. It's just what we can change and what we have the ability to change with our hands or with our tools. But when you talk about the, it ban, tell me, in your words, somebody comes into your clinic with an it band syndrome and they have a compression issue right what do you do for them other than send them to the manual therapist down the hall? That's really good at what he does.

Arpita 33:42

I'm pretty sure most people listening to this podcast are familiar with it band syndrome, but if you're new to this world, welcome it. Band syndrome is when the thick fascia from your hip to your knee causes friction and then eventually pain because this fascia is so dense it's treatment. It's often debated.

Alex 34:00

Honestly, I pretty much treat it just like patella femoral pain. And then usually they come in, if they say I have it Ben syndrome, and they'll say like, Hey, I've been rolling it and it helps. And I'll just go keep doing that. Cool. They tell me, I hate it. It doesn't do much. They'll say, well, you don't have to do it. If you wanna do it, you can do it, but that's not a priority. Yeah. Um, yeah, I usually do it that simple cuz again, if it is compression, patella, femoral pain is also part of it is like compression, right? And I haven't seen like data that we can change that compression with or interventions. Actually, if you look at most interventions at work, people get better, but the compression stress of the knee didn't change. Yeah. And when they, they lost weight. But then when we look at strengthening, a similar thing happens where, the people got stronger, but the compressions increased at the knee a little bit. So people are getting better regardless. So I don't the compression definitely. Well actually, probably is the cause of the pain, but we don't necessarily get better because the compression stopped. It's probably more relationship. Yeah. It might just be that we got used to it.

Chris 35:01

Just taking a step back, it just makes so much sense to simplify things. And I think people love to make it so much more complex than they need to because it makes'em sound smart. And I think it's part of our ego checks, you know? Yeah.

Alex 35:13

I just like people to be conservative and be honest with were saying, um, and we're talking about different fashion.

Chris 35:19

We had a bunch of, uh, people chime in on Instagram, you know, I said, what do you wanna ask him? What do you wanna debunk? Some of the bullshit and people were like, let's debunk the idea of face cupping.

Alex 35:31

My question would be like, why would we doing this for like aesthetic purpose?

Chris 35:35

Some people think about it as, avoiding the Botox, avoiding some of the other facial lift surgery things and, you know, promoting better blood flow to areas that would, maybe turn over some of the collagen remodeling that happens in the area, which, you know, it, it's not as long as you're not paying a lot of money for doing it. And you're, you know, buying a little Silicon cup that costs eight bucks who the hell cares go put marks on your face. I don't care.

Alex 36:03

Yeah.

Chris 36:03

But it's also one of those things that like, you know, I think the claims that people end up going into is like, well, if you do this, you are going to affect your spleen because this is part of that channel. I'm a scientist at this point of linear correlations. And I love seeing what correlates and what is causation. And I definitely think, you know, there's some ideas that get a little bit tangential when you talk about those things, you know?

Alex 36:26

And it's the same thing in pain science. The whole movement, reliability thing. That movement reliability decreasing is a risk factor for pain. And then the idea that manual therapy can create dependence. I think that, okay, so I'm kind of in between, so I don't think I agree. There's no data on it, but there's just for a fact, people get treated for life by the chiro and they're like, you need to come back every week. Yeah. Or you need to get a massage to reduce injuries. Like I don't, I think that. Patently kind of a dependence if you, if you know what I mean. Yeah. I think people also order estimate how big of an impact we have on like people's dependence. Like we can make them a little bit more active, but it's extremely hard. So I definitely think that someone who's using manual therapy with a good narrative of like. Hey, you know, it's probably short term pain reduction, maybe some stuff, the media term, we don't know. I'm completely fine with.

Chris 37:16

And I, I think, you know, the rest of the realm is the unknown. Like we just don't have all the answers for some of the other things, but, you know, I think if you use common sense, unfortunately there, there are still very strong voiced humans in the anti-man therapy world that say manual therapy in all forms and fashions are, is shit. And unfortunately they don't, they don't sit back. And actually there was that great, uh, podcast with Chad cook and Adam meins on physio network, you know, and I felt, unfortunately I felt that Adam meins. A totally different route than his general stance. And he softened himself up because he didn't wanna look like an ass, you know?

Alex 37:55

Uh, yeah, no, I agree with you. Um, I think Adam's starting extremely aggressive. I've been following for so long. Like, yeah. I mean the beginning of my career. And um, if, if I listened to his podcast all the time, I think his stance, what it is, but it's, it's been evolving. Yeah. And I just think he has yes. Online. He has a very aggressive yeah. Stance. And for him where he was coming from, he was like the only voice I was saying that at the time. True. Yeah. Right. So I think he was necessary, but now it's kind of harder for him. It almost seems like hypocritical when he is more nuanced. If you're a new grad and you see that, you'll see it as like, oh, and I used to be that guy. I saw Adam and I was like, oh, every form of manual therapy sucks. I never touched my patients, which is, I was like that for a while,

Chris 38:35

which very, very hard to have that much influence on these soft minds, these new grads that are coming out. And then they piss on everything that does have some foundation still, you know? Yeah. Because, because people are so black and white in the way they wanna approach things and the way they wanna take their path until you have that experiential knowledge to see that, well, it doesn't work the way that I got taught this, but it also doesn't work this other way. And unfortunately I think he, he polarizes a lot of the issues, which is what I wanna give you credit for is like, I think you definitely draw attention to the bullshit out there as your, you know, handle so appropriately is named, but it also, you come about it with a little bit more, I guess, appreciation for the things we do not know, and I think that that's an important, humble component to, to retain that.

Alex 39:23

The, the way I see it, it's kind of like a clinician, right. I don't think I'm the clinician for everyone. Yeah. The same way I don't think you are, or Adam is. And I think it's the same way for, uh, debunkers so people respond very poorly to it. So people get really offended. And I sometimes I don't understand why I'm like, I'm not even critiquing what you're doing. Some people are gonna respond well to Adam and I think I'm one of them where it just made me actually more nuanced. Cuz I went from one extreme to the other and then I just fell in the middle.

Chris 39:49

Is there anything else that you wanted to dive into as it relates to some of the, uh, the things we were talking about before?

Alex 39:54

I think I'm curious just about, and honestly, I haven't read a lot about the cupping. I'm just curious about your stance. Uh, I dunno if you know, they're trying to make cupping illegal in Spain and it's I heard about this. Yeah. I think, uh, who's that guy that's trying to do that, uh, he's like the skeptical science guy.

Chris 40:10

So in France and in Spain, it comes back to a religious yes. Principled aspect. Yeah. And unfortunately this is not a science debate. It is a, I think a chasm and a split between nationalism and religious freedoms and religious, expression because a lot of the Muslim population in France and a lot of the Muslim population in Spain use this as a prophetic medicine. So in those cultures, wet cupping or hi JMA or whatever type of hi language they wanna use with it is used because it's part of the Quran.

Arpita 40:51

Okay. So wet cupping is where a cup is placed in the skin and the skin is punctured and then blood or other fluids are drawn out in the process. Dry cupping is what we usually use in physical therapy settings, where suction is applied to the skin to move fascial mobility.

Chris 41:09

And part of that religious expression is not something that you're going to be able to take away from people based on science, based on efficacy, because honestly I've read up and down the literature on wet cupping and it's just, there's zero. Good, well designed methodology studies in terms of like what the total effects are, whether you're actually taking heavy metals out, what type of actual measurable outcomes you can get from something that is, you know, putting a cup on squeezing out the blood, because you've Lance the skin and having some type of change that is measurable. Um, so it's not a science debate in Spain or in France, it's a religious debate and a sectarian kind of differential between those things.

Alex 41:54

That's what I see. There is quite antisemitic there.

Chris 41:57

Absolutely. Yeah. And so unfortunately, like they're using it as this gauge of, you know, trying to interject government control over something that I think doesn't have a really good answer on the science anyways. And they're getting in there mostly because of religious reasons and it's kind of yucky to see. Yeah. You know, to be honest. Yeah.

Alex 42:16

I think I'd be okay with just like banning wet cupping until we have like good studies justifying its use for, except for research. But cupping, I don't think we have a great argument to ban it.

Chris 42:25

There, there isn't. Um,

Alex 42:27

because there's worse things out there, way worse you I have with

Chris 42:30

what cupping a lot of times is these Hema practitioners are doing weekend seminars to certify someone. That doesn't have a medical degree. Like you, you're not a physio, you're not a medical doctor. And you go to a weekend course or two, and then you're certified because you can use it as a, you know, again, a religious expression. Oh shit. So that's, that's where the danger lies to the public. I think that needs to have some education on what is safe, what isn't, because some of these things are being offered that aren't necessarily, truly, I think, med, medically educated humans, um, ready to provide a service like that.

Alex 43:07

Yeah, that sucks. Cause yeah, the, the there's a study on this, that, um, cancer, if you have cancer, you're risk of survival decrease. If you use alternative medicine. wow. Yeah.

Chris 43:16

Well at least give people the options right here are the statistics on this. Here's the St. Statistics on this. You are in charge of your own body, do what you need to do, but at least present the actual factual information, you know? And I think that's what someone that comes in with a religious background and they're like this SMA wet cupping will cure your illnesses and no, well actually there's no data for. And you're going to lead someone astray that would've ne you know, maybe gotten more appropriate care for whatever disease pathology that they have, you know? Yeah. More first line. Yeah. I'd say exactly. Yeah. Which is one of the challenging things. But, you know, for me, I think it, it's kind of also, I think you're being naive as a anti-man therapy person to see that when you put something like a cup on and you're causing some type of microtrauma, it it's the same as a dentist taking his metal instruments and picking at your gums. Cuz you have gun disease. You're trying to stir up. It's like the surgeon that's hooking a few holes in the car is to try to do some type of microfracture. You're trying to do things that encourage a natural response of healing into a tissue area without having to stick a needle through the body. So you're trying to do things that are going to stimulate. Natural healing processes and growth processes of these tissues. So that that's what stirred my mind is. Like, let's take it back to natural physiology when it comes to cupping. It hasn't gone away in a long time because it does something to these tissues. And for me, I just figured out that, well, some of these things, when you can add that part in with movement, you know, adaptability and variability, as well as loading principles, it seems to get people even, you know, a little bit more bang for the buck and it doesn't cost anything I can have.'em do their deadlifts while a cup's on. There's no change in time. There's no change in their value. I'm not charging him anymore. You know, I just throw a cup on their hamstring while they're doing their dead lists. And boom,

Alex 45:14

I think you are an exception though. That's one of the reasons why I like that you're so one of the persons teaching it, cuz a lot of people will be like, oh you just come for cupping and you come three times a week.

Chris 45:23

That is turned into a lot of what my page has kind of done in a similar fashion to yours is let's call out the that's my, what the cup Wednesdays, what the cup Wednesdays is all about. What's this portion. I love that series.

Alex 45:33

If you have an influence on that, can you make sure the literature is better than the dry kneeling of literature?

Chris 45:38

Yeah. That's the problem. Yeah. And I I've swung my pendulum in the dry kneeling world because I used to think that points matter and know I'm starting to come to a conclusion that doesn't matter necessarily where you put it. It's the. You know, I think neurophysiologic effect of having that thing done to it, you know? It's all apples to oranges in most of the mucosal literature across the board, whether you're talking about cups or dry kneeling or spinal manipulation, you know, it's, it's, that's the hard part of where we're at right now.

Alex 46:09

Yeah. Yeah. The peer review needs to be better too. That's something where we're talking about stuff.

Chris 46:14

Yeah, this is, these are good comment. And like I said, for the listeners listening to this, you have this personality, that's a big personality on Instagram, no bullshit physio, a and he calls out a lot of things that I think in my mind are also kind of like fishy. And, and I think we need personalities. Like you, Alexis, thank you. And there are things that, you know, you're gonna rub people the wrong way at times, but if they takes a step back from their ego and have, can have a, I think a respectful conversation like we're having right now, people will understand each other from both sides a little bit more clearly, and what the intentions are. I think this is a, a fun discussion to get into some of the nuance. But I really look forward to your page growing more. You've definitely got a flare and then you guys should all go check out his stuff. Tell us where to find you on all the things, the YouTube and other things.

Alex 47:06

First of all, thank you. I'm, at noble should physio on YouTube, Instagram, and Twitter. So Twitter, if you just want to hear me discuss papers and then Instagram for the memes and deep dives, and then YouTube for the very long videos, I have more coming. I have one on functional patterns coming recently, and then one on the carnivore MD.

Chris 47:23

It was, it was great to have this discussion and you guys go check him out. So, we hope to hear more from you in the next few months and years, man. All right. Take care.

Arpita 47:45

Thanks for listening. This episode was produced by me, R P OPA and Christ proto. Follow us on Instagram for updates and please like subscribe and rate the podcast to keep more great episodes coming to follow Alex and its adventures. Find him at no bullshit physio.