From Batman to Alfred. Redefining our Role in Pain Management

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The Modern Pain Podcast is a proud member of the PT Podcast Network. Make sure you check out pt podcast network.com for other awesome PT related podcasts

Mark Kargela: 0:09

if there's anything we've learned from research and our better understanding of the science around pain it's that we need to change as clinicians. We need to go from traditional biomedical models, where we treat people like cars to a more person centered bio-psychosocial approach. We need to look beyond biomechanics and pathology and work towards understanding unique people and how their unique stories can impact their biology and in turn pain. For me, it's always been a little bit helpful and even probably therapeutic to talk to others, who've navigated that journey well. This week's guest Craig Liebenson is someone who has adapted his practice and teachings a ton as it's become clear that we need to bring the humanity back to healthcare. And this episode, you'll hear Craig's background and philosophy and how his practice has evolved. We discussed the importance of behavior change and how adopting a patient centered model is a must in clinical practice. There are a ton of challenging contexts, clinicians practice in that make it hard for them to practice in a person centered model. You may be surprised what he tells his students who are struggling to provide people with the time and attention they need. Hearing Craig story and perspective. We'll give you a great example to follow and better your own practice. Enjoy the episode.

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This is the Modern Pain Podcast with Mark Kargela.

Mark Kargela: 1:18

Welcome to the podcast, Craig,

Craig Liebenson: 1:20

Mark, it's a pleasure.

Mark Kargela: 1:22

you know, we were talking before this has been a long time coming. I think, you know, you and I have had traded, you know, messages and social media posts, you know, commenting back and forth on each other's stuff, um, like minded individuals. So I said, man, we got to get Craig on. Cause it's, you know, we always have these kinds of somewhat abbreviated discussions. So today we'll have a much more in depth discussion on some of the things I think we share a lot of, uh, Similar viewpoints. So hopefully you'll, you guys will find some value in this stuff, but before we get into the discussion, Craig, I'd love to hear kind of where you're at, what you're up to, and then we'll get into some questioning about your journey. Cause I think yours is somewhat similar. It sounds like to mine, but what are you up to? Where are you at?

Craig Liebenson: 1:58

I'm in Los Angeles. I'm a chiropractor. Um, and, uh, things I'm working on right now are, um, uh, really, uh, transferring, uh, the, uh, Teaching towards, uh, my co faculties, Ryan Chow, Donald Mull, Katie Dabrowski, multidisciplinary team. I'm 63 years old now. So where I'm at, it's time. It's time to kind of, um, pass the torch to the next generation. And, um, I feel really excited about, uh, the community. I feel really excited about where, uh, I feel really excited about where I'm at. Our musculoskeletal space is, is headed, although, uh, I'm charged with, um, I'm charged with the insecurities and the imposter syndrome and the angst about, um, how slow knowledge translation is. And I think that just keeps my passion burning. Um, so, I'm really thrilled at this moment to see that the community is growing. Um, and maybe post Lancet, the expose, the three part expose on back pain, Um, how, uh, people became more comfortable from the researchers on down to using social media in a positive way. So, I don't know why I'm optimistic. There's really no reason for me to be optimistic, but I am.

Mark Kargela: 3:25

You know, it depends on what you read. I've, I've learned to really filter my feeds to make my sanity stay in check and all that stuff because yeah, social media can be the wild West and a lot of good discussions to be had. As long as you can kind of filter out all the. The interesting things that come through the feed, you know, I've, I was peeking at your biography on your website before we, we came on here and I'm like, man, Craig's had interactions with the Vladimir Janda. And I, and so just some of the mindsets and thought processes. I remember when I was going through PT school, upper cross syndrome, lower cross syndrome, and all these good things that, you know, great theories that were coming out around the time, and, you know, Janda being a massive pioneer and things. I would love to hear your journey of kind of and kind of how you've shifted over time with with kind of your, your approach and your thought process. Obviously, signs of a good clinician is one that changes as as research and as obviously our biggest teachers, our patients tell us we need to. I'd love to hear your journey and kind of how it's kind of evolved over time.

Craig Liebenson: 4:19

Wow. So, uh, yeah, when I was, when I was a student in chiropractic school, um, I was more of a mind, uh, that I wasn't becoming a chiropractor because I wanted to do chiropractic adjustments. Um, I wanted to be an alternative medicine practitioner. I felt, uh, That in health care, I already had an idea in health care that we couldn't really trust the status quo. And so that has stuck with me throughout. I always challenged the status quo. And so, um, one thing led to another. Um, I got exposed to. Kim Corr's work on neurobiologic mechanisms of manipulative therapy, an osteopathic researcher, and that opened me up to a broad view of the locomotor system, which eventually led to being exposed to Dr. Carol Leavitt and Professor Yanda's pioneering work. Now, fast forward, fast forward, I always appreciated Gordon Waddell's ideas about the biopsychosocial model, so it wasn't really like, um, a binary thing. Where I was a mechanist, and then I understood the psychosocial or inactive or ecological approach. Um, but, uh, I think that, um, what happened, and I think I'm guilty of this more than, than, than, than Vlad was, um, Professor Yanda. Um, He had an eye. He was able to observe people move like their gait and identify that there was a Some baselines that maybe were contributors He never Ever, and I think he's misunderstood on this. He never really pushed this idea that, uh, we were going to do corrective exercises. I think that that is something that came in more with Gray Cook, and, um, I think that myself, uh, like a lot of people, we were influenced by all of these different planets that were orbiting, uh, in the muscular skeletal space. And so it was very natural to seek these, these kind of recipes or cookie cutters. So, okay, well, the psoas is tight and the glutes are inhibited. Then we should do, um, relaxation, post isometric relaxation, uh, techniques on the, the shortened structures or the overactive hypertonic structures. And we should focus strengthening exercises on the weak links or the inhibited structures. So it became very easy to see like these syndromes and they were comfortable handles. But like anything, it gets out of control and I'm very guilty, uh, of, uh, uh, taking a more mechanical approach, um, over the, over the years. And I think it's, Gordon Waddell, um, uh, knew that we were never given really a good handle for the social. We had the psychological, we knew anxiety, we knew fear, we knew fear avoidance beliefs and abnormal illness behavior, um, um, from Vlyan and other, other great people. researchers. But we didn't understand that that behavior change like Lorimer Mosley says, you know, that's the game that that's the game that we're in is behavior change game and we're not equipped. And the fix it approach winds up sabotaging a lot of people because now we see people. So if we come full, full, you know, full forward, we see people that like, well, I can't, I can't do that exercise because I have this imbalance. And until I release this, my QL, my psoas, my traps, whatever, um, fill in the blank, uh, well, you know, I, even body weight exercise, even, you know, uh, yellow band, theraband exercises, um, people feel fragile. And so I think what we've discovered is that we overemphasize biomechanics and we ignored physiology. And even though we were aware of psychology, because We ignored physiology. We didn't realize that you, if you give people gradual exposures to feared stimuli, the tissues will become not only more resilient and robust through adaptation, but you're, you're concurrently addressing the psychological because you're enhancing, uh, uh, tolerance or intolerance. You're lowering their tolerance while you're increasing their capacity. And now you're marrying the physiology and the psychology. And so these handles, uh, mechanics, physiology, psychology, they're all part and parcel. But by ignoring physiology, we we were pushing the boulder uphill. And I think we're still struggling with the social how to create accountability, how to give support. Um, and you and I could spend the rest of this hour talking about behavior change and what what a challenge it is.

Mark Kargela: 9:11

Yeah, you bring up some good points about, you know, the exposure work. And I think a lot of times we were doing it. Yeah. Implicitly without realizing we were doing it just through a lot of the, you know, graded programming that we did without really having a good record, you know, recognition of, hey, I'm also working on the psychological piece here, which is getting people confident to start engaging their bodies. But, you know, I, I can relate to, you know, some of the things I look in my. Past of, you know, I always turn it like I was putting people in movement jail of like, you know, very hyper analytical biomechanical assessments and stuff to where you got to move a certain way a perfect way that's going to keep you out of pain, which, as we know, and as we've seen, there's been some patients that that can go very much awry, where they really limit life significantly because of these rules that get placed upon them from again, I didn't do we didn't we don't do these things maliciously. I mean, it's part of the learning process as you grow, but I'm sure we all and those you listening can probably relate to some.

Craig Liebenson: 10:06

think it's so hard, Mark, because You know, we want to be scientific and we learn certain things work, but unfortunately we have cognitive dissonance So we see things through these rose colored lenses and we develop this idea about right and wrong and it turns out You know our ability to predict our our our our Need to be accepting of uncertainty. Um, those two things, I think, uh, bring about a humility and, and I really did see a humility in Professor Yonda and Dr. Levitt. Um, uh, Levitt always taught us that we work at the level of acceptable uncertainty. And so, yeah, we have all these techniques and methods, but also, like Dr. Levitt said, don't be a slave of the methods. The methods should serve the goals. So, being person centered has always been. And I think if you're person centered, then, um, you know, like all the self management experts say, like Jan Hertvigensen and Alice Kongstad, um, then it's implicit that we have to give support. So I think the social is something through debriefs and through being there for people. Um, I give my cell number to people. I want text debriefs. I know it's a tough journey. I know resilience doesn't mean I fixed anything like this fix it mindset. We ain't fixing anything. People's pain, like Bronnie Lennox Thompson says, and you just had her. It was a brilliant podcast. I hope everybody watches that. This, this approach from acceptance and commitment therapy that, that, that we have to accept that, that we're not curing, we're not fixing, um, pain. We'll do what pain does, as Bronnie says, and, and to help our clients see and recognize and appreciate, acknowledge and accept that, that We're not really influencing the episodes. The episodes will run a course like colds and flus. Like Deo said years ago, you know, the great evidence based spine expert. Um, we should look at back pain more like diabetes or asthma. We're helping people cope and manage and live their life. And so that's the social. We want to get people back to participation at whatever level that is. You

Mark Kargela: 12:23

to where I just clutched on this model and approach because I don't think I was ready to accept that uncertainty. I mean, there's a little bit private ego thing that's involved. I know for me, I wanted to feel like I was arrived that I was this master clinician who, you know, everybody looked up to clinically and referred me their patients and all these things. So to admit this, I guess I looked at it as like this weakness of like not having the answer like you need to be able to swoop in this room. And like, you know, I've had the beliefs of all sorts of things around manual therapy of like, you know, I can see that dysfunction across the room with. That's a facet of L four or five, whatever. Um, but you know, just the humbling experiences of patient after patient and going through, you know, the highest level of training here and still seeing it, you know, kind of not well fall flat for a lot of patients who have obviously things more complex than that, what was your like transformational, you know, did you have any like specific patients or were there specific things you came across that really kind of smacked you in the head of like, man, I need to kind of change the way I'm looking at things, or has it just been a gradual thing over time for you?

Craig Liebenson: 13:24

know, we see the younger generation today, uh, Talk about facing imposter syndrome, and I don't think that any of us if we're honest can ever say that we could tell like this person would respond to sacred iliac or you know general cavitation or you know Muscle relaxation or advice to meet the PA guidelines So in terms of myself I feel like Uh, what I think my superpower is that I've always known that I didn't know, and that's driven me to be a seeker for knowledge. Um, and I've always felt like an imposter. Um, I'm just trying to be there with people, and I think the transition isn't from thinking I knew to thinking I don't know. Um, but, but I think what it really is, is, is from, uh, Being more explicit and comfortable in that space of acknowledging that uncertainty with people, um, being somebody who's, who's not dismissive. So, you know, if you tell somebody, well, it's going to run a course and you say it in a way where it's just matter of fact, well, that's dismissive. So finding that kind of heart center where we're really, really giving care. and sharing our space with people. So maybe not even not even in a way that is is full on empathy, more compassion. So So yes, we are aware of the land mines. So it's not just, you know, we're understanding where they are, which is empathy. But we also want to provide some leadership from our experience and our knowledge and help them establish a beachhead. And show them a roadmap, like there is a roadmap. I think the biggest roadmap pivot is really the ACT one for me, and what I'm learning from Bronnie. Um, this idea about resilience, about acceptance, and it is, it's gonna, it's gonna occupy me for the next 20 years. to tell people that they're that we don't say it this way, but that in reality that they're gonna have to accept the pain like pain is normal. Your body's built to last is not built to break, but that you can function. That is, I mean, I'm not equipped for that, so I am the biggest imposter. But, but I feel like that's the road. The road forward is people are going to be 70, 80, 90. Can they stay in the game? Can a 75 year old plays golf right now? Who is a, um, you know, I'd say I can think of a, of a picture right now. I have a woman I'm working with, 75, trim. Uh, didn't get the memo about sarcopenia. And so she does Pilates or bar method. Um, does some cardio, plays golf, doing what she loves socially. Uh, but. Now I'm realizing and and and again, it's motivational work that I'm not trained in. I realized well Can I talk to her about would you like to play when you're 85? Okay. Well, here's here's what I think from my experience It's gonna take the science tells us that if we build muscle mass now Biologically your biological age will will get younger. You can blow out fewer candles at your next birthday than your last birthday. It's a biomarker and it's the low hanging fruit for you. So is that a dysfunction that we're correcting? No, but it kind of is. It's a gap and I always want to bridge the gap for me. Jill Cook's model, uh, with podia. This is the needs gap analysis. It is my lifesaver. It's my GPS and having that That was a big pivot for me to see, okay, I'm still looking at floor. I'm just not calling it maybe what I called it before. Now it's, you know, like Rachel's softness, you know. Okay, stress, sleep, um, anxiety, social isolation. You know, these factors are just as important as, um, strength. Just as important as hitting the PEA guidelines, being a non smoker. Et cetera. So there's a limited number of these things. There's probably less than 10 of these, Mark. And that's where I really pivoted away from the mechanical towards these things that can wind up pain and are actually also the same thing that are accelerating age. We're older, younger. And that also is just a gift to all of us in the musculoskeletal space. The silver lining is people see us for pain and we get to talk to them about how to make their health span last their lifespan.

Mark Kargela: 18:26

You bring up some good points around ACT and I love your approach because it's, you know, you're bringing in a lot of lifestyle medicine type, you know, pillars and different things like that with when you want to talk about ACT and I'm with you. I think anybody who hasn't read Bronnie Thompson's blog, you're missing out because she gives like free education. I mean, and she's talking about some high level stuff around ACT. She just

Craig Liebenson: 18:47

They're short, too.

Mark Kargela: 18:48

Yeah, they're definitely well digestible. She writes them in a good way. She's a good writer. And, um, she, she kind of just unpacked the whole hexaflex model of act, which was a brilliant bit of writing to kind of help us navigate it with. Because I share some of the same frustrations, I'm not equipped coming out of school and even in the con ed space, it's kind of limited as far as like, I know act needs to be part of the gig. I see such value in the whole acceptance piece and getting people, you know, pushing towards valued living versus this, you know. You know, walled in the existence that sometimes health care, you know, pants folks into what do you feel like when it comes to like the, the clinic floor and the ability just to just, because for me, I feel like I just got to, I just got to wade into these conversations. Some of them are going to go okay. Some of them may not go okay, but I'm going to definitely put myself out there with these concepts in mind and see. And I think that's been a huge learning opportunity for me. I mean, again, some conversations haven't went as well as I'd hope them to go. But as you start working with some of these kind of psychologically informed principles, it seems like your best teacher. And if you can get some mentor, obviously practice where folks are supervising and maybe giving you a commentary, that's great. But a lot of us don't have that. So what are your thoughts on just kind of putting yourself out there in these conversations and being willing to have these discussions that might go against our comfort zone. I know for me, I was much rather talk about facet joint things or, or, or discogenic things or things that kind of were, you know, are kind of physio wheelhouse as far as more of the tissue based stuff. But obviously we know the value that talking about how this is affecting people's lives and how they can start integrating some of the good things we're doing mechanically, but looking at it versus that tree approach, this more whole forest perspective that you speak of, how's that been for you?

Craig Liebenson: 20:34

don't know. I don't know. I don't know where to start or what to say. You know, you started off talking about the clinic. And I'm reminded of something Daniel Lord said to me. So he was one of my hosts, a chiropractor in the San Francisco area. And he went on to, um, Head up Crossover Health where they provide health care for self insured Fortune 500 companies starting with Facebook who he worked with and He wrote this very interesting thing where he talked about the tyranny of the visit and I like to think of it more as the tyranny of the clinic and and this is This is a real frustration for people that I'm mentoring Um, they're in a space. So a they come from a culture where they've come from physio or Cairo school or even the training space. It crosses over. Um, um, and they've learned to fix it approach because it's comfortable, right? It's a nice level one stuff. And I even know educators who think, well, it's okay to give people cookie cutters and protocols because that's their on ramp. And I feel like, no, I'd rather we give them principles from the get go. I think they're gonna eventually hit a wall. Um, and I don't think we need to give them cookie cutters. But I think that you have the culture of the fix it and overly bio. Um, and they're not learning A. C. T. They're not learning motivational interviewing, nothing about Catching the story and being passionately curious about the story like Joletta Belton and, and Peter O'Sullivan talk about, um, so they're at disadvantage from the start. The history ain't sexy. There's no seminars that are, that are popular, uh, on the history and motivational interviewing hasn't gotten out there. really in, in, in muscular skeletal care. And, and so we then get into the gym or clinic environment. And now you have the client expectations. So you have your culture from your education. Now you have the client expectations. And probably since the 60s or 70s, you know, patients of physiotherapists and chiro, chiros, they want the ultrasound, they want the stem, they want the laser, they want the dry needling, they want the, the rub, you know, um, and, and so you now have the client expectations, you know, and then you have the person you work for, which in Cairo, you know, maybe, you know, somebody who's, You know, the brought you in as an associate or in physio. It's like more corporate even, you know, or maybe you're in the hospital, you know, and so, you know, we talk about, um, the social and vested interests. So there's the cognitive dissonance and the status quo situation of what we learn, and it's hard to de implement what we learned and implement new stuff and therefore to translate knowledge. And then we have the social, the vested interests where you may have an employer or you're working in a place where you got a. be transactional. And so profit gets ahead of people. It can't be person centered. These are these are, um, things which lead to burnout. and are a ball and chain. And so we tell all our mentees that they have to leave. They have to become independent, that they will not be able to succeed in those environments. That ecology is, is going to make them feel like imposters. If they're young, it's going to burn them out. If they're seasoned, um, they need to strike out on their own. And so there is like a line in the sand, Mark, uh, and we've only realized that because the transactional model is, is, um, a dead end. And so when we're truly person centered, it's all, to use the word you just, you just mentioned, it's gotta be value based. So what is value? So, you know, we have, we had, um, uh, Lisa Ann. wrote, did a beautiful podcast recently. I forget her last name. Um, on value and what people value. And that's what we're trying to ascertain. Ascertaining value is a big part of this, this brilliant podcast. And I'll, I'll give you the link later. Um, but, uh, ascertaining value, finding out what matters to people, determining what matters, measuring it, if we can measure it, and then creating a plan to bridge the gap from what they have to what they need and guiding them through the process. These are principles. It's not about protocols, not a cookie cutter. And and principles will will make it easier. So it's not that it's harder. If you're principle based, it will make it will free you.

Mark Kargela: 25:15

I know. And it's such a, it's a, it's an uncomfortable jump because it's almost like people are mooring themselves away from the heart, unmooring themselves to this harbor of safety, um, that these like very rigid cookie cutter thought processes are, uh, and you gotta, you just got to navigate the seas. But if you have principles, it puts you in a very, you know, seaworthy boat, I guess you could say that will help you navigate that where, when you're experiencing turbulence and all the things that, you know, day to day clinical practice has, you have, Some principles, because that's where cookie cutters fall short on the complexity of human beings. We're rolling through our clinics. There are just cookie cutters that there is no cookie cutter for unique people. It's just you got to be able to kind of adapt what you said. Principles of things, and it's just a hard jump. And I love I love the fact that you're engaging your mentees and helping them because I have to walk a delicate line because I'm in the university and we have relationships. I With some clinics, because we're always trying to help our students gain clinical exposure and their clinical placements and stuff. So, but I see some of these places where how do you even have a conversation with a person in these situations? And then like the workload and productivity and things, and it's just, it's a tough one. And I've had to kind of politically, you know, let, it's

Craig Liebenson: 26:25

why is it? Why else? Why else? Wouldn't it be mark that that that we only get what 14 percent of evidence in practice over three decades?

Mark Kargela: 26:34

yeah, yeah, that, that whole, yeah. And it's, I mean, we're not producing environments where that evidence is easily emerging when we got people just trying to survive with. You know, just relying on the cookie cutter because that's the quick and easy and kind of

Craig Liebenson: 26:48

Well, look at Twitter. Look at the arguments. Look at how things degenerate.

Mark Kargela: 26:52

Yeah.

Craig Liebenson: 26:53

you know, I see Greg Lehman and Chad Cook going at loggerheads, and I'm, I'm watching this and I'm like, I want to say, why, why? I have utmost respect for both people. It doesn't make sense to me, but, but, but I guess, you know, talking to you, um, we take a step back, give a little, you know, Use objectivity. Well, we kind of, kind of can see why, you know, it's the nature of the beast on these platforms and then depending upon what people's agendas are, they can get, uh, they go into these little, these little vortexes. Um, uh, you know, I think Louis Pasteur said it. There's a lot you can learn by observation. I think if people sit back and they observe, you know, it's like with, with clients, you know, like, I could be blind, like you can, if you listen, if you observe with, with just hearing, there's a lot you can learn. You know, when we do motivational interviewing, just sitting back and listening. Peter says it, you know, tell me your story, and then you just, you pause. You're, you're receiving. You're taking it. But do we know where we're headed? No, I spent 45 minutes. Peter said Peter spends an hour on this whole thing, including his behavioral experiment. And after the history, I'm not as good at taking a history as Peter. I got to spend 45 minutes on just listening to their story. Then I do the behavioral experiment for 45 minutes. Then I run out of time because now I want to connect the dots and create sense making and do a teach back. Um. Give them videos of what their, what their movement snacks are. Like an hour and a half isn't enough time on the first visit.

Mark Kargela: 28:39

Yeah. No, I agree with you on that. It's you. I feel like man, I could have like a three hour evaluation for some folks, especially when you're seeing just a lot of like Complex. I mean, everybody's got complex stories, but when you're like, wow, there's a lot of things I need to start, you know, piecing together for this person and creating a, a context in your clinic to help them start challenging some of their beliefs. How has it been for you? I know for me it was a major struggle to allow silence to exist in my treatment room. I always had to fill it with my knowledge and my expertise and, um, to me it just snuffed out the other expertise that sits in the room, which we know is our patients. Probably the biggest expert, obviously the expert in their, their life and their experience and what pain is to them. How's that been for you? Like, do you find that that's been something you've had to hone over time or is that something that allowing that silence to exist so patients can kind of process emotions and, and having that kind of discomfort as a clinician where you're kind of maybe squirming a little bit on the inside of like, these are some tough, you know, emotions coming out. What's been your experience with that silence?

Craig Liebenson: 29:39

Well, you're making me uncomfortable now. so I, I'm, I think I'm schizophrenic. Um, my, my family tells me that that like, I don't, I don't listen well. And, and, and in, in the clinic space, working with people. Um, trying to find out what's meaningful, what matters to them, what they value. I feel like I've trained myself, like, like, I've conditioned myself in, so it's not the tyranny of, of my office, the room where I, where I get the story. Um, I feel like I've conditioned myself in that room. Um, To sit back and to create a space, to give space to the person that's coming in and in the end of the session, I feel comfortable about, um, uh, sealing that by saying, listen, what you're paying for is, is concierge and what concierge is in this situation is debriefing later. I want to hear from you later. We're not fixing anything right now. This is an ongoing thing. And so things are going to crop up. You're going to have questions later. Um, you're going to have flares. Um, and, um. I want you to reach out to me good, bad or ugly. So the encouraging them about what the process is. I mean, there, there is a playbook. There's no cookie cutters, but there's a playbook. Like, I have a zillion things to train a hinge and a zillion things to train, you know, trunk vertical, knee dominant squats. And I've got push and pull and, and I got a playbook for the lifestyle stuff. Um, so we're able to generate game plans. But we know, we know that whatever we start with is plan A. And we know that planning is necessary, but plans are useless, like Dwight Eisenhower said. So, we are going to plan. It'll be shared decision making, co created. Um, but the biggest thing, going back to Gordon Waddell, who for me is as much a mentor as Levitt and Yonda was, Um, he baked in from Engel the social, and maybe that's why Peter Stilwell and others don't like biopsychosocial because they recognize there was the tripartite approach, there was bio and psycho and social, and maybe they realize it because, well, where's the social? You know, social wasn't just the work comp system. Um, but I think that, that concierge medicine, providing supportive self management, um, if we get into what it really means, the playbook is, if we unpack it, it means that, that there's a communication tool for people whereby they can debrief with us. And I think that's the meaning of concierge. So when somebody pays me for the first visit, they're paying me for support. It's not a separate charge. Um, and I want to hear from them, good, bad or ugly. The worst thing for me, you talk about pivots. I'll see people I haven't seen in 10 or 15 years and they'll come in. The first thing they say is, Oh, I've been great. I'm still doing those exercises. You gave me their God send blah, blah, blah. And then I'm like, Oh no, you're still doing the pelvic tilt. You're still doing abdominal hollowing or you're still bracing. I'm like, ah, what did I do? I feel like shit.

Mark Kargela: 33:12

Hey, we've all been there. I've had my, I definitely have had my repeated patients from like, Ooh, man, that was Mark pre, uh, you know, pre, you know, updating some thinking processes and things like that. Let's, let's bring it to research a little bit. Cause you, you mentioned some of the frustrations of, you know, how that gets in the practice and different things. One of my thoughts and, you know, I talk to people like I feel like sometimes research isn't telling us anything super new. I mean, I think we have a lot of information out there and I mean, and then maybe it's because I think sometimes we keep beating the same horse of. You know, pet one intervention versus another with people who are very biased towards one intervention and lo and behold that interventions better than the other one. But, um, where do you think we need to move in research? And I know it's the eternal question of how do we shorten that gap and you know, how long it takes to get the research into practice and then the limited amount that even enters practice. Um, what are your thought processes and where do you feel we need to go in that front?

Craig Liebenson: 34:10

Don't get me started. You just, this is like a whole nother pod.

Mark Kargela: 34:14

Can of worms?

Craig Liebenson: 34:16

first of all, as we kind of spoke about, there's the culture of the schools. And it may be, it, it may be worse in Cairo school, but, but there's a lot of things that are a lot better in Cairo school. But one of the things maybe that's worse in Cairo school is, you know, we don't have endowed faculty, you know, the schools are now universities, but That's a newer thing culturally, um, but what is being taught in schools is not up to date. The Lancet is now how many years old, Mark? And, and who's aware, who's aware of that, that are, that are teaching in schools? At least in Cairo schools. I, I, it's, it's, it's, um, it's an abomination. Um, so. You know, that's number one, but, um, Peter O'Sullivan, if we skip ahead and don't talk about the schools, um, Peter in his recent publication about cognitive functional training showed the beginnings of what it takes. So he's with people that didn't know CFT. and it's a three month process for them to become minimally competent. They're doing videos of them interacting with people so they can show them their, uh, uh, their body language, their tone of voice. It's like PNF, like tone of voice matters. Inflection matters. It's not just what you say. It's how you say it is how you act. Um, and then how you can see the responses in people when, Somebody has a fixed mindset. The client has a fixed mindset. The patient has a fixed mindset. How, um, the physio handles that. If the person is expecting a quick fix, is super anxious, has a lot of fear, or they're more of a know it all, you know, um, This, this is, uh, so complex and so for, for cognitive functional training, which would apply to other, other approaches like ACT, um, three month journey to minimal competence, a lot of debriefs along the way with the clinicians as they're sharing struggles, They're sharing videos of interactions. They're getting feedback from Peter and his team. And after the end of three months, they now have some competency. Well, that doesn't mean they're anywhere close to mastery. Um, it's an ongoing process. Not easy. So, how do we bridge the gap? How do we get more, um, implementation of high value approaches? Um, follow Peter's model to, to a great degree. I, I think that we're starting to see the signs. Um, I think the Lancet researchers realized that they needed to use, use media. They needed to get, um, New York Times, Wall Street Journal, etc. Um, on board. Uh, they needed to make their power points more sexy. They needed to do a Twitter storm, not leave social media to knuckleheads. Um, and, um, I don't know. I have no reason to be optimistic, but I am. I'm going to seize on these things as sources of optimism. But, but ultimately, I think as a, as a physio and a Cairo, you and I, um, we can't let our 000 We can't let our our unis and colleges off the hook. We have to keep our foot on their throat. It's not acceptable It's never been acceptable Never never and I think the Greg Lehman Chad cook discussion I think that illuminates issues between social media and academia So Greg is very much a social media Person Um, extremely smart. I'm not saying it to disparage. Um, I learned a ton from him and Chad is on social media, but he's very much an academic person and, um, why there has to be a dichotomization there. Uh, I think it highlights maybe something that, uh, you and I, um. Can use to shed light on your question. I don't know the answer But I kind of feel like there's something in there, you know, Chad saying well, we make mistakes we move forward and We with humility Reconceptualize is that enough

Mark Kargela: 39:21

yeah, the challenge to I see, and I'd be curious to see your thoughts on this is, uh, you know, we have like, and we'll just go with the US physio culture because it's, you know, this yearly CSM combined sections, meaning it's like our, you know, Yearly big event. And it's I just see it. So when I went last year, I did go. Um, and I've been most of the last few years and I just see this like it's the stage for academics who are pushing the publish or perish. They got to get something out. They put this thing together and it just seems like It's, it's a researcher's, you know, zone of like, but where's the real stuff that clinicians can grab onto and get value in and use in the clinic on Monday I just see there's this disconnect to me of like this whole research culture that gets created through academia and then what's happening on the front lines of clinical practice and I get it because there's not very many, although I greatly appreciate folks like Peter O'Sullivan you've mentioned who are navigating both worlds who he's in the clinic working with patients. I would. You know, I think that's huge. I also recognize it's not always, you know, an option for some of the folks who are, you know, busy with academia. I also, you know, being part of academia, I think there is just so much fluffy, ridiculously procedural stuff that has zero to do with how well we're delivering a good product to the students and keeping things. But it's just, I don't know, I could go, we could probably go on for an hour about the issues with academia. Um, I'm trying to think what even my question is right now. I, I'm just, I guess my frustration is and I'd be curious what yours is on this disconnect between the academic world. And I know you've, you've kind of alluded to it with Greg and, and, and, and Chad, as far as this, you know, gruffing they had back and forth with each other. Where do you think we can do as clinicians who are struggling to find some value? I mean, I like, I mean, I mean, to me is like, we need to have folks attending folks, your, your courses working with your faculty because they're folks that are seeing patients that are learning day to day and are navigating the same struggles and battles. Um, we try to teach the same stuff when we do some of our coursework. Uh, what do you think needs to happen to kind of help that, you know, divide of the academic and the clinician?

Craig Liebenson: 41:33

I think without a doubt Anybody who's in the muscular skeletal space? should be Well versed in the evidence to do research and not know the evidence. That is going to lead to further polarization and a longer knowledge translation gap. So if somebody's in a bubble in an ivory tower and they're doing research on something in a very isolated way, but they're not aware of things like the guidelines on back pain or the unifying principles about how any region of the body, whether it's shoulder or knee, are still adhering to the same principles that have been. you know, exposed to be kind of our bedrock for low back pain, you know, things like reassurance and reactivation. Um, you know, this idea that, um, that, oh God, I don't even know where to start mark. And you said you kind of lose your train on like, what am I really asking? It's such a big thing. But, but at the end of the day, I honestly believe that we have to stay anchored to the real world of the patient of the client. And that takes us to value the value equation. And when we're in the ivory tower, I could give a damn. It has to relate to what people in the trenches, your graduates are going to face in the real world. So they're dealing with a transactional expectation from their employer and their client. They're having to navigate the fact that there is no quick fix. It gets back to all the stuff that, that, that, that drew me to you in the first place, Batman and Alfred, you know, we're not going to be able to satisfy our ego and be, you know, the magic isn't in our techniques. It's not in the. the encounter. It's in the empowerment. It's in, as you said earlier, when we started today, it's the self efficacy we give people the feeling that they're resilient. So if we reassure people, we were activate them if we make them feel resilient so that they can spring back from the ashes when flares occur, which will occur. Then, uh, then we build in them kind of the anti fragility that will help them handle novel things. Uh, that we can't anticipate. That's the uncertainty. And so, as people in academia, they have to be anchored to the real world. So, maybe it's an impossibility. Maybe most of them are there because they're not successful in the real world or they made a choice. I don't care. But for the young physios and the young chiros and the coaches out there, we all have to realize that yeah, there's some value in research. But But who's going to help me in the trenches game plan? Who's going to give me a playbook for providing inestimable value to people? Well, it's going to be people like you, and it's going to be people like Katie Dabrowski who has two clinics where she's giving jobs to young physios, uh, where they're working on a gym floor, empowering people about how to set them up for, set themselves up for success so that their health span will last their lifespan. So I think it's really buyer beware. And I don't want to worry too much about academia. I, I think we just got to move forward. It's important. Um, but we have to focus on. We know so much now. How can we make it more practical mark? And when you get when you talked about, um, this Batman and Alfred thing, and I think it was, um, what's the person's name? It's

Mark Kargela: 45:31

Rod Henderson.

Craig Liebenson: 45:33

Yeah, you know, the, the icon of that and every young Cairo wants to be a Batman. Every young physio wants to be a Batman. Um, it feels good and they're entitled to that early on, but if they also can at least accept another role as Alfred and then over time they'll figure out where they're comfortable. I'm comfortable 100 percent as Alfred. You know, I think that's the greatest thing at all. It's like, can you help a person feel empowered and have self efficacy to the point where they become intrinsically motivated to address all the lifestyle things that are the perpetuators and the predisposing factors of, of more disabling musculoskeletal problems in the future. None of which are related to fix it. None of which. If we're talking about smoking and opiates and alcohol and weight and you know, process food and not doing strength training and not doing aerobic training and sleep hygiene and stress and social isolation. You know, it's it's at most 10 things. And are those not as important as your piso ass? As Joe Rogan says, give me a F and break. So lifestyle is sexy and there is research. It may not be in physio in Cairo school. But there's research on all the social factors. There's, there's research on sleep science. There's, there's research in the physical activity space on the relationship of physical and inactivity to cardiovascular disease and cancer and, and, and metabolic disease. Um, just as there's research on smoking, so there is research. It just isn't in physiotherapy school.

Mark Kargela: 47:30

Yeah, and that's the problem and

Craig Liebenson: 47:31

So I'm, I'm passionate about this mark

Mark Kargela: 47:35

Hey, and I admire it and I love it. I think, you know, that's part of the reason I think, you know, we jive with so well on social media and things as we share a lot of the same frustrations and have some of the same kind of motivations to change it a little bit. Cause I do agree. There's, I see academics, one, I see folks who are pushing the research and again, it's just this, it loses sight of the real, you know, that. What's it in for the patient type thing? It's like, it's just, to me, there's just, you know, motivations that don't always again, land well with who's the person who's struggling right in front of us to get back in their life where life is shrunk and they're not doing it. Yeah, we're, we're just at conferences, you know, hobnobbing with each other of, Oh, look at this P value yet there's chronic pain still sucks and people, people are statistically, it's not moving in the right direction. Um, and again, I just think it's a, another comfort zone we can hang into is like the, be the academic. Uh, and again, I am somewhat, I'm a

Craig Liebenson: 48:29

I, Mark, I think this, I think the sexiest thing is to empower people, and it's what Mosley said. The hardest thing is behavior change. Can we empower people? Can we empower changes? When I was a Cairo student, to your point, what was I told? I was told, don't worry about diet and exercise. People aren't going to comply. And I studied motivation, adherence, and compliance until I finally realized compliance is an effing prison term. So why are we still talking about compliance? But let's talk about adherence. Well, we have a body of scientific literature about shared decision making and about therapeutic alliance. Okay, tell me more how we build therapeutic alliance. Well, we create sense making. Like, this stuff is all science. It is being researched. So, let's put it front and center. Connecting the dots. Shared decision making, therapeutic alliance, um, these are the languages of value from the client centered perspective. Well, let's dig into all the other aspects. If ACT and cognitive functional training and motivational interviewing aren't being taught in the schools, how can we expect, uh, the faculty's research to be on point? Or are we back to the biopsychosocial trichotomization, which isn't the real world? Well, we need to put it all together. Who's putting it together? The people that are practicing in the trenches have no choice but to put it together. So they are our teachers. So then we need to reverse engineer back to the schools pressure about, well, here are the struggles. Here's why they feel imposter syndrome. Here's why they feel burnout. because they are having trouble translating the knowledge into practice, de implementing, de implementing evidence, discord, and care, which is a super wicked crisis.

Mark Kargela: 50:23

yeah. No, I think

Craig Liebenson: 50:25

it's just this fucking world. There I go again.

Mark Kargela: 50:29

No, it's all right.

Craig Liebenson: 50:30

a swirling vortex.

Mark Kargela: 50:32

No, I agree. I think the ivory tower needs a better serve the front line. I think sometimes the ivory tower is just serving the ivory tower and publisher Paris mindsets and environments. I know there's a lot of nuance to that for academics. We're ready to scream

Craig Liebenson: 50:45

I have, I have respect, but I'm not going to worry about that.

Mark Kargela: 50:48

no,

Craig Liebenson: 50:49

to worry about, I'm going to worry about the people of the world, the fact that over 80 percent of people are inactive and that physios and chiros and trainers should have a relationship that's for life. It's not transactional. It's not for six weeks. That whole six week transactional thing, you know, you're a better clinician because your PVA, your patient visit average is low. Supported self management. As Alice Kong said, and Jan Harkinsen said, is an ongoing thing. So we need to learn from trainers. Being a positive health coach is for clinicians. The idea that trainers are beneath us. No, we need to, ethically speaking, we all need to be this Alfred figure that empowers people about the lifestyle approach. 82 percent of people do not meet the PA guidelines and we're worried about PRI and DNS and, and subtle biomechanics and kinesiopathology. to recommend to people the safety and efficacy of general physical activity advice and use the musculoskeletal pain episode as a, for its silver lining. Hey, your pain is going to do what it's going to do. Let's nourish the tissues. The motion is the lotion. This is an exciting time,

Mark Kargela: 52:16

Yeah,

Craig Liebenson: 52:17

not if we're a hostage of all the entrepreneurial seminars or, uh, or limited by just what we learned in school.

Mark Kargela: 52:26

agree. I think there's there's a lot to be excited about. And sometimes I get too curmudgeony and bitter over some of the

Craig Liebenson: 52:32

No, you don't. You, you're not.

Mark Kargela: 52:35

think, like you said, if we can make Alfred sexy, I think that would make a big dent in it. And I think we just still have this culture and physio. I know for sure where dry needling is the current craze. And again, I'm not completely against it. I don't think it's anything new. That's going to be some amazing Transcribed Change in the statistics that continue to trend the way they do, but that's just us searching for some sort of security of, well, I'm gonna latch onto this and clutch it as the, because you'll never have a short supply of people that will get excited over whatever you're confidently peddling as a clinician. But if we realize it's probably that confidence in the context versus the specialness of the intervention, but that's a whole nother. Episode. I want to respect your time today. You're busy. You got many things going on. Um, I we maybe we have to have an episode episode 2 down the road and have some further discussions on some things. Um, but for those folks who are. Interested in kind of learn a little bit more about you and your, your teachings and your practice.

Craig Liebenson: 53:29

Um, people can contact me on social media at Craig Liebenson. C R A I G L I E B E N S O N, so they can DM me, uh, Twitter or Instagram. Uh, they can go to First Principles of Movement, the website, and there's a lot of, uh, uh, free content there. Uh, we did a high value webinar series on, um, Uh, telehealth and really the Batman versus Alfred approach, where I brought in guests like Lorimer, uh, Matt Lowe and other people, Peter Stilwell dropped in. We had an amazing, amazing group of people. So everybody was a very captive audience and a hostage and we have almost 30 hours of content that's free, uh, that they can get access to through, through the website. So, um, I'm out there.

Mark Kargela: 54:15

Yeah, we'll link, we'll link all of Craig's contact information, his website and all that stuff is something you should all check out. I think Craig's doing some great stuff and we were greatly appreciative of all the things you're doing and keep it up, Craig.

Craig Liebenson: 54:27

Thank you, Mark. It's been, it's been a privilege. Thanks for tossing me a vine.

Mark Kargela: 54:32

Absolutely happily do it and we'll do it again sometime for those of you who are listening. We'd love to have you subscribe to whatever you're listening on whether it be a podcast or on YouTube. Um, and if you can spread this episode to maybe somebody else who's in the front lines of the clinic, struggling, burning out and all these things and see that there's maybe a silver lining and an alternative way of getting about it. We'd greatly appreciate that, but we'll leave it at that this week. We'll talk to you all next week.

54:55

This has been another episode of the Modern Pain Podcast with Dr. Mark Cargilla. Join us next time as we continue our journey to help change the story around pain. For more information on the show, visit modernpaincare. com. This podcast is for educational and informational purposes only. It is not a substitute for medical advice or treatment. Please consult a licensed professional for your specific medical needs. Changing the story around pain. This is the Modern Pain Podcast.