Manual Therapy: From Old School to New School. Stories of Practice Transformation

Mark Kargela: 0:00

Hey everyone before this week's content. I have one ask of you. I'm in the process of building out something to really change the game around continuing education. With that said, I need your help to make sure it best meets your needs and solves the problems you're facing day-to-day in the clinic. It would mean the world to me if you could jump on modern pain care.com forward slash community, and let me know what you would like to see built out to best meet your needs. Only take about five minutes and I'd greatly appreciate it. Now onto the content Welcome back to this week's episode of the modern pain podcast. Have you felt a bit lost on where manual therapy fits in pain care. If you look at social media, sometimes it's either it sucks or we should be using it all the time. So where's the nuance in that conversation. I know, I definitely have had moments where I questioned its place in my practice. And even if it had a place at all in some patients. This week, we'll talk with Erson Religioso, or better known as Dr. E. The episode felt a bit like a support group meeting as we shared stories of the traditional old school theories that we had to let go. We also share stories and how our practices have changed over time to put manual therapy in a more person centered position. You're going to leave this episode with a better feel for where manual therapy may fit in your practice and hopefully see a little bit of your own journey in the stories that we're going to share. Onto the episode.

1:07

This is the Modern Pain Podcast with Mark Kargela.

Mark Kargela: 1:12

Erson, welcome to the podcast.

Erson Religioso: 1:14

How's it going?

Mark Kargela: 1:15

Oh, man. Good. Going well, um, I just had another podcast recording before this. Feel like I'm busy as I'll get out chatting with people, but they're great discussions and I'm looking forward to have another good discussion with you. We had, I'd been on your podcast a couple weeks ago, you know, this is, and, and who knows when people are listening. It might be a year or two ago. But, um, and really enjoyed the episode. Obviously, we've, we've shared some similar journeys and we'll touch upon that. Today. Uh, but, uh, for folks that don't know Dr. EI mean, I, I, I'd be, I know most of our audience probably know of you,

Erson Religioso: 1:45

I hope so. But I mean, if they don't, I'm hoping they don't actually,

Mark Kargela: 1:48

this could be an introduction to you and maybe, uh, something that'll generate some interest.'cause it's definitely, uh, you're somebody who I've really enjoyed your perspective on things and I know you teach some good stuff. So, but anyway, let's talk about, uh, kinda your journey, like where, where you're at right now, what you're up to, and maybe, uh, we'll get into some further things about your development over some time.

Erson Religioso: 2:06

Sure. Well, um, I graduated 26 years ago at this point, so it's been, it's been quite a journey and, um, I graduated with a BS MS and there was no even transitional DPT way back in 1998. Um, but I wanted heavily to get into manual therapy. My ortho professor was, uh, he's a manual therapy fellow and also very big in the McKenzie Institute, Dr. Ron Shenk. So he was my ortho professor. He agreed to be my mentor. And, um, I thought I had this roommate who was also really into manual therapy and. He, he said, Hey, let's become chiropractors. And my, my parents as, um, medical doctors had said, you know, we'll, we'll basically disown you if you become a chiropractor. Nothing against chiropractors, but chiros and medical doctors. At least old school chiros and older doctors. I mean, you know, MDs ran like a smear campaign against them and about like the committee on quackery or whatever. We learn all this stuff in like the history of manual therapy in St. Augustine. Right. Mark?

Mark Kargela: 3:09

Yes, we did. Yes, we did.

Erson Religioso: 3:11

Um. Which is why they started calling it adjustment instead of manipulation.'cause they thought manipulation was like literally a, a manipulation of your mind rather than rather than a medical term. It sounded anti medical. So they started calling it adjustment. And um, so my parents did not like that idea. And I remember on my last clinical, I, I, uh, I was speaking to a guy who wasn't my ci but he was the head of the, the rehab department. And I said, you know, I, I really wanna get into manual therapy, but my parents are kind of against. And by manual therapy, I really meant spinal manipulation.'cause to me that was the only thing there was about manual therapy. It was just about more, more kraken, less yaking, more kraken. Right. Um, and he said, Hey, have you ever heard of Stanley Paris? And I was like, who's that? And I remember he put like the, like the PT journal in front of me opened it up to. Whatever. Probably page two or page one or something, you know, like the, I don't even know. Do they still have the, it used to be like a picture of Paris and black and white picture of Paris in the top left corner, two page spread. S one, S two, S three S four E one. You know, surfing MTC, I'm like, oh, what, what's this? You know? So I contact them and that was around, that was around say, December of my final year by the time. And I was really interested. Uh, so I, I, I kept that in mind. And, um, right around the time, like between April and May right, I was about to graduate, they had announced that they started a, um, a manual therapy residency program. ADPT and it was like one of the first DPTs in the nation. Transitional wasn't even a word yet. This is 1998. So I applied the week I was graduating and I got in and I started the program two days after I graduated. Like I graduated on a Friday, took two days off and immediately started working with my mentors, my mentor, uh, my ortho professor. Said, Hey, I'll be your mentor. So he got me a job at the hospital he was working at, at the, at the residency rate. Which meaning at that point, at that time, you know, whatever, I don't know. It was agreed to be like 70% of what a PT makes, but you still work full-time. And, um, so I got all my hours there. Then I flew down to St. Augustine like every other month. I took all the courses, got my MTC, um, just, I loved. All the minutiae you could, you could pile on. You know, like the more minutia, the better. And it was funny because if you remember, I don't know, I took the S, when I took S one, it was five days. I know people were like, oh, it used to be 10 days. And I'm like, man, I thought five days is long. You know? Can you imagine taking 10 days?

Mark Kargela: 5:49

Good God. No. No,

Erson Religioso: 5:51

I know, like, right. Even when I teach my two day weekend course, people start to like check out it like the second day after lunch. They're already like, wow, you guys, you were practicing for like 15 minutes and now you're like practicing for two minutes. Right. Everyone's already asking, even at the beginning of the second day, like, hey, you know, if we start early and we cut lunch to 50%, can we get out early? You know, and this is 10 days, right? it was five days and then the next course was like four days. The next course was three days. And, and the funny thing was I didn't like it at the time. I could not appreciate it, but the more advanced the courses got, the less assessments and less techniques there were.'cause in like the first couple courses, S one was like, Hey, here's 500 ways to passively assess someone here's like the same assessments in sidely, prone and supine, and here's the same cervical assessments in side lying and supine and prone, right? Like it's just now, now after those 500 ways to assess someone, here's a thousand ways to manipulate them, right? And, and I was just like, wow, the more the better. And I didn't really realize at the time you that you, you come back on. Not even, I don't even know if you come back on Monday, because I don't even know, was it Monday? I don't even know. Was it like Monday through Friday? So I come, yeah, whatever the next Monday you kind of think, well, now what? Right. And then that's really what it was like. Well, I think I have an idea what to do. I'm just gonna start like, what I call poking and hoping or pressing and guessing, you know? Um, there's not really like a, and even if you really. Affect someone. All these traditional programs had, all it was was just like assessment and treatment. Assessment and treatment. And there's, there's like cursory exercises, right? Maybe like an appendix of exercises that they may suggest.'cause ultimately, I don't know what the modern residency program is like now. I'm, I'm hoping that. At least the majority of them are, are more advanced than this. But back then it was just like, you're gonna fix the patient. Right? You like you are fixing the dysfunction. And the exercises are an aside because for the first 10 years of my career, I would say, well, I'm fixing these. Dysfunctions that I find in you, these physical asymmetries and strength and mobility and the, these exercises are purely to tide you over is. I don't know if I would say that, but that's kind of like the impression I would give. If you do these exercises, the, the improvements you get, maybe you'll keep like 20% of them, but unless you see me X amount of times, we're talking like 20, 30, 40 times. I don't even know how many times people would see me. Right. Back then, I knew every patient's name. Now I'm kinda like, I see patients once every other week, maybe two to three times tops. And they see me like, Hey, remember three years ago you treated my back? I'm like, uh, I don't know. Maybe. I mean, oh yeah, I see you here in my records. You know, but I don't remember them'cause I only saw them like three times over the course of two months. So, yeah, I mean, there was, I finished that. I, I got my DPT, I got um, Eventually I, I got grant grandfathered into Fellowship.'cause it turns out at the time the program was so stringent, it was like more than the requirements for Fellowship. So I got grandfathered into fellowship. Um, incidentally, I also did not pass my manual therapy certification the first time. I don't know, did you, I.

Mark Kargela: 9:12

I, I was lucky that I did. Yes. I, I did, I, I, I sat in front of the man, Stanley Paris, shaking, and, and I, I think I spoke about it in your podcast, but had to recite, I. C0 through C3 biomechanics with rotation to the T And uh, yeah, it was a, it was an intimidating experience. Uh, and, but yeah, got through it thankfully. But yeah, no, I, my, my roommate and my buddy, uh, did not pass this first go round either

Erson Religioso: 9:37

I mean, I got questioned, I believe on three things. And you're really allowed to get questions. Like I didn't, I fail, but I got questioned on three things and I had to fly back like 60 days later just to take those three things over. But I made sure I was ready, you know? Um, and I remember even my mentor said he didn't pass his first time. He said that, you know what you pass eventually, right? You're just either ready or you're not ready. So I, I got my fellowship, uh, I got my MTC, then I decided I want more credentials. I'm gonna just take Mackenzie just for credentials. I mean, on day one, I told my instructor, she's like, why are you, why are you doing this? And I said, I just want more credentials. I'm not even gonna use this. I just want the credentials. I mean, gosh. And she picked on me, rightfully so. She asked me so many questions. I remember there was like a, a drill that she did where, um, everyone had to have like, like a derangement four or anterior derangement or dis like flexion dysfunction. Everyone had it on. You had to like ask what Like, everyone would go round and you would ask questions like, um, so you had to try to figure out what classification you were, and she made me like some obscure classification, like, I don't know if I was a non-responder or something, like, just because I was a jerk, you know, deservingly. So I thought, you know, oh, I'm gonna take Mulligan now, now I'm gonna take the Butler's courses. Now I'm gonna take Institute of Physical Art and learn all about soft tissue work. And every single thing I took, I thought, this is it, man. This is like All my tool Bagg needs. Right. And it's, I think, most people's journey, whether it's manual therapy or not, you just think, well, I'm not getting X amount of my per my patients better, or I'm not good at knees, or I'm not good at whatever, or maybe I need needling or maybe I need to learn more about breathing. You know? And so after I, I took all those courses, I just thought, wow, this is like a really disparate amount of information. You know, like I had taken. And gotten certified in so many different approaches, had all these letters after my name, and, and every single approach is like, unless you do it our way to AT, you're never gonna get our results. And I'm like, well, how can, how can all these people get results if everything is so wildly different? And they're all like bashing each other's approaches, right? Like, everyone's like, oh, Paris is like, Mackenzie doesn't know what he is doing and you gotta be specific. And Mackenzie just causes hyper mobility. And Mackenzie presents actually a bunch of research that basically says like You can't promote hypermobility and you, they present all the palpation based research. It says palpation based assessments are garbage. And they pretty much are, we know that now. Um, and that, that made my head explode. I didn't want to hear that after I just went through fellowship training. You know, I mean, that was quite a bit of cognitive dissonance. So I started to try to try to put all this stuff together and I, I came up with like a, a formula in my head. It's like, well, I'm gonna do. Some soft tissue work and then if that doesn't make'em better, maybe I'll manipulate them if they, if I, they give into the informed consent and otherwise I'll mobilize them. I'll do some neuro mobilizations if, um, they seem to have some kind of chronic tendinopathy or radiculopathy, that doesn't always improve with spinal stuff. And for home program, I'll always give them repeated loading. And if it, if everything is painful, then I'll use Mulligan. Because Mulligan, I used to teach, uh, at the university level, like Mulligan techniques are great, but only if someone is, cannot handle your hands, you know, because mul, one of Mul, the rules of Mulligan is like, it's, it's supposed to be a hundred percent PainFREE. Um, but I just thought, ah, that's only for wimps essentially. Um, and then. So I'm just practicing and, and moving along. I think basically, I think I know everything. I think I'm like the best manual therapist in the world. I'm waiting for. One of my goals I always said is like, just waiting for all these gurus to die off. So, so I could become the next guru. You know? I want be like in

Mark Kargela: 13:32

throne

Erson Religioso: 13:33

yeah, absolutely. I mean, there could only be one, you know, not like I have to cut their heads off like Highlander, but, uh, I, I just thought these guys aren't gonna last forever. I mean, someone's gonna take their place. It's gonna be me. You know, um, so I developed a, I remember one on one, so one time, um, I ended up treating a chiropractor son. He saw that I was using like these crude wooden tools like that the Institute of Physical Art used to, used to promote like these Like knuckle shaped things, you know, you could hold it a certain way and it's supposed to like, kind of replicate a knuckle.'cause they said, you either dig in like this or you use this wooden tool. So I used to call'em wooden knuckles, and I had a couple of patients who were woodworkers, so they were very crude. I used to say they were like snowflakes because literally every single one was different. You know, they, they were not like, and they didn't roll off a machine, so they said, Hey, have you ever heard of Graton? And I'm like, well, what's that? You know? And, and so he brings in these tools and he unwraps them and, and you know, it's like a, the way he unwraps them is kind of like. You expect it to glow, you know, like the, like the box in Pulp Fiction, you don't even know what it is. Every time they open it up, it's just like, where it's like amazed and it's glowing. It's, I don't know if it's supposed to be some sort of metaphor or something, but, um, he's just, I was like, wow, these are great. And he's like, oh, look at this. You can, you can, you can feel the fascial adhesion. So. That, that let, I was like, well, how much are they? And he's like, they're$3,000. And I'm like, what? So I, again, I had another tool who's a, a metal worker. He is like, I'll make you something simple. I designed my all-in-one edge tool. I used to call it the oscillator.'cause as a joke. Uh, I would say that's, um, it, it's coming back from the future to destroy your fascial adhesions. Uh, and, and I started blogging about that. You know, I started blogging about that because I thought I'm gonna start selling this online. And that's how I started. Um. I made the manual therapist.com. I got, I got that domain. It, it's, I, I used to ask people like, uh, there was like Mike Reinold, Charlie, we grf all these like OGs of, of the PT world. And, um, I'm like, Hey, can you share my stuff? And they're like, I don't know you bro. You know, like they vetted me. I'm, I'm just like, come outta nowhere, ask me to share my stuff. So I thought, well, I'm gonna, I'm just gonna start making so much content that. People will share my stuff. Like I, I didn't earn a share, you know? Um, so I started doing all the Edge tool stuff and, um, I sold thousands of those things at, at quite a markup. Um, it eventually be called, eventually became the Call the Edge tool because Tim Flynn contacted me. He's like, Hey, we wanna to use these in EIM courses, but we don't like the name fasci later. Like, you need to come up with a more professional sounding name. So on Facebook I'm like, Hey, you know, could someone come up with a better name? And someone said, the edge tool goes along with Dr. E, you know, and the eclectic approach. I'm like, oh, okay. Everything's gonna be e based. Um, so that's where the Edge tool came. Um, and then I ended up starting like a e-commerce store edge mobility system with a bunch of like white labeled different products. And my whole model was to To, you know, see what's really expensive and bring it to the market at a more reasonable, practical price. So my, my blog really exploded in popularity for like the first year, and I got lots of shares and lots of likes and everything. And then, then I got invaded by Soma Simple. And I don't even know if they were around. Um, a lot, a lot, a lot of, like, their founders and their biggest voices are still around. And I think that, you know, um, I. Oh gosh. Who might think of Jason Silverdale, who you've had on your podcast a couple times, and I'm gonna have on my podcast, uh, for the first time, um, in a couple days, he basically was one of the people who's just like, Hey, you know, you're holding, you're, you're holding back the profession. And they presented me with all this research. And when you have research, obviously that contradicts everything you believe and everything you've, you've been teaching. Um. You can make two decisions. You can basically say, this is BSS and never look at it again. Which I did for a while. And I argued. And I argued and argued and I mean, I was like staying up past midnight, like just fighting with these people on my keyboard. And my wife's like, man, are you still like arguing with these like from this form? And I'm like, yeah. You know, they're like. Insulting me and I, I'd say a lot of them probably had good comments that I didn't want to hear. But I mean, a lot of it was kind of vitriol and a lot of ad hominem attacks, you know, I mean like you don't need to lead with, you are a dinosaur holding back the profession you can lead with, maybe you should look at this research, you know, I mean, there is. What you're saying and, and, and they did say this, like one of the things they would often say, which is I often say my courses too, like, all this stuff works, but it's not for the reason why you think it works, that that's a better thing to lead with rather than your dinosaur holding back the profession. And this is why. But I mean, there, there was one night where I did critically start to look at this research and I'm like, oh, I think I am rock. I think I do need to change. And so I started. Going lighter and lighter with my soft tissue work, with my mobilizations, with my manipulations. Um, you know, I, I'd stop teaching the stress strain curve. I mean, St. Augustine is every, everything, you gotta get into the plastic range of the stress strain curve because otherwise you're pretty much doing the patient a disservice. You know, you, if you don't, you're not deforming tissue. Why even putting your hands on people, right? Um, so yeah, I mean, I just started, I still use the Edge tool, but I use it more of like. As a barrier rather than like if, maybe if I don't wanna touch someone, you know, and I still sell them, but not obviously not nearly as much. I feel like that that is kind of like the peak is was around when I got really popular for the next several years and now there's a very big anti-man therapy sentiment. And I think that's also very unfortunate because I think a lot of like manual therapy as the way it's viewed now is like the way that maybe you or I viewed physical agents right, because we were thought like, oh, manual therapy is this specialty and it's the end all be all. And everyone in all, everyone who our, our PT forefathers did, uh, all ultrasound and eim and, and that was all just like passive garbage that a monkey could do. And now they're like, well, monkey, any monkey could do manual therapy and get results. And, and that's probably true too. Although I think the monkey doesn't have as much placebo, probably doesn't have quite as much authority. You know, maybe if the monkey was in a lab coat and where a stethoscope. And the monkey had a degree, maybe he would have some placebo about it. But, um, I think, I think there's, it will, it will probably come back around, but I think there's just a disservice. And you and I talked about this on my podcast too, when people are very anti-man therapy, you know, and I think, I don't, I don't know what it, I know why they're doing, and I know, I know that exercise should be the goal and an active approach should be the goal. But there are just people who are in pain. Are not gonna respond to like deadlifts and kettlebell swings and whatever else you're doing, like Turkish gett, ups, all that stuff is great if you can tolerate it. You know, even loading a tendinopathy, research shows it's okay to load a pen tendinopathy, even if it's painful. Yeah. But it still requires compliance, you know? And if you can make it less painful. They're more likely to be compliant or adherent. I mean, I don't know what the current word is. The meat's all the same. If they do it, if they dose high enough, they dose often enough, they'll get better. But if it hurts too much, they won't. If they wait, if they wait till your till, your visit, they're never gonna get better.

Mark Kargela: 20:59

I love the Yeah. I'm, I'm in the background here kind of now, I'll probably have edited out my chuckles just because I don't like to override the, the discussion going on, but just the. Yeah. One, I get a little flashbacks of my St. Augustine training and I, again, I also echo that I, hopefully things have progressed in advanced. It's been a, a quite a while since I've been through that training. So I, I, I would just hope, um, that, that things have moved past the, the, immaculate hands and, and things, and, um, it's interesting

Erson Religioso: 21:27

I always ask though, I don't mean to interrupt you, but at what point, what step of our like 21 step evaluation?'cause it's like some kind of crazy 21 step, 25 step evaluation. Every time I meet a St. Augustine grad who I'm teaching, I'm like, hey. Are they still teaching? Like the 21 step evaluation or like Yeah, and I mean as, as recent as like three or four years ago, they were still teaching this, that I'm aware of, but what step do you, did we learn or when did we finally put our hands on people? Do you remember?

Mark Kargela: 21:56

Uh, I don't remember when exactly it is, but it, I, it, it, I do remember the 21 steps now that you say that it's

Erson Religioso: 22:02

Yeah. it was also like, it wasn't even like step two or three, it was literally like. 12 or 13 like, and I don't even remember what the other steps were before that, but that is a lot of steps to do before a physical assessment. That is a lot of minutae

Mark Kargela: 22:18

Yeah, I still remember some of the just like outlandish techniques. I remember E2, there was all sorts of things where you're, you're doing all sorts of like interesting things. But again, I, I can't speak for where that's at right now, but hopefully, you know, as with us, all things have progressed a little bit. I, I, I I remember so much simple. I was around. So much simple when you were having those discussions and I was at that point

Erson Religioso: 22:40

you in it?

Mark Kargela: 22:41

You know, I think I might've chimed in once or twice, hopefully in a respectful way. I don't even remember. Um, but, uh, I I just remember, like, I was always afraid to, to comment.'cause you know, there were some pretty, you know, pretty loud opinions in there. And, uh, some, you know, I was kind of fearful to, I, I had sensed, you know, it was kind of, I was in a similar boat as you were as far as like. Initially getting really pushed in front of me, these views of like, uh, what you think, you know, you don't know, and what you think you're doing is really not what's happening. And that was just, yeah, that was too much to hear at first. And the old cognitive dissonance. Clutch to your beliefs, that backfire effect that happens when somebody gets confronted with things that, that oppose their current belief system. And then same thing, I think I just came around to it like, you know, you can't, you the, this, the, the evidence was way too strong that, that there's definitely manual therapies not as I don't wanna say magical, but is is capable of things that we thought it was the segmental specificity and things you've already alluded to. We've had a discussion online. I don't think you've been a part of it, but there's been a discussion. I put a, a post up on, uh, Facebook and on x and I'll, I'll link it in the show notes here so folks can see the discussion, but about what it means to have good hands.'cause that that has been something that has been, uh, you know, something that I has very much evolved over time. I used to think good hands man. I need to be able to palpate that penny through like a New York City phone book. I need to be able to do all these things with my fingertips that are just gonna be the, the, the reason this complexity that I was seeing in clinic wasn't getting fixed by me is just because I hadn't honed these amazing sensory apparatus that were my hands. That were gonna detect these, like you said, these dysfunctions and fix'em and get people where they need to be. And that's, that was like a good 10 years of my career, just voraciously pursuing the next

Erson Religioso: 24:25

You gotta get those 10,000 hours in right.

Mark Kargela: 24:27

Exactly. I mean, I was like, I wanna get to those 10,000 as quick as possible. So that was what hands mean meant to me. I'm, I'm, I'd love to hear your, your thoughts on what good hands meant to you earlier in your career and maybe where you think it kind of falls now. I.

Erson Religioso: 24:42

Yeah, I mean, honestly, when I was in labs, just early labs, early manual therapy labs, even in ortho labs, I was never one for palpation. I always felt like I. I don't really know if I'm palpating these things that I'm supposed to be palpating. Um, I'm very much a visual learner. Um, not so much a tactile learner. So for me to feel like, and, and I don't know why I never looked at my textbooks, and it was a reason why I never quite got as good as grades as I, as I should have, because a lot of my professors specifically had questions that were only in the books, and all they ever did was, was. Study off my notes. Like literally I would sell back my textbooks at the end of the, to, to the bookstore and I would crack'em open and receipt would fall like they would crack open because I never opened my textbooks Um, so yeah, I mean, what I thought were good hands were for me to be able to feel mostly the asymmetries in segmental motion. The gapping, the approximation, um, certainly to feel fossil adhesions, whatever I'm feeling, you know, I don't even know what I'm feeling at the time, like. In, in my courses now. That's why I asked like, are you feeling tone or bone? You know, um, I used to say bone or tone all the time, but there was one particular juvenile class that I had where I was saying, I said boner so many times because I kept on saying bone or tone. Bone or tone. Everyone's like, keeps on saying boner. Um, so now I say, is it tone or bone? You know? And, and because when you change things rapidly, if you really shifted bone, like more than a millimeter, I don't even know if we can shift bone a millimeter. If you shifted it like. Centimeters. Like you think you would actually be rupturing something, you know, and then like what, what would be the difference between from a, a, like getting hit with a baseball bat and what you just did with your hands? Why do they feel good? Your placebo isn't that strong. know, may thi maybe it is, but I, I doubt it because it would, physical trauma is physical trauma, right? So yeah, back, back then I thought if I can feel these things, plus if I could Cavitate any joint I want in the spine within like two or three tries because I, I, my, my buddy who eventually he went through all of St. Augustine training with me, then he went to four years of chiropractic school. He was, he became awesome, awesome. At manipulation. And I feel like I was only, I. Okay at it. And then he just gave me a couple tips, like just practice on your speed, don't practice your force. Practice with the med ball and just like work on your speed, work on the, the crisp. Especially with cervical, it's mostly with cervical'cause I was pretty good at thoracic and lumbar, so I, those are, those are my definitions. You know, feeling segmental, mobility, hyper hypermobility, hypermobility feeling for fossil adhesions, not so much trigger points. I never really appreciated trigger points. Um, I mean, yeah, I used to be able to tell people. Like, do you, do you know, um, that movie, uh, what was that movie with, uh, Russell Crowe where he was, he would just like look around and he would see all like these relationships between like DA Beautiful Mind.

Mark Kargela: 27:49

mind. Yeah.

Erson Religioso: 27:50

Right. I would say, Hey, you know,'cause people, I would just palpate people in their first rib, like, whoa, man, that's right where it is. Or, you know, find their C five down glide grade two restriction. They're like, whoa, that's right where I needed it. And I'm like, yeah. You know, it's like that movie A Beautiful Mind where Russell Crowe would just look around. He could see all these relationships. I like, I could look at you and I could see where the, this function is. And one patient's like, you know, he was crazy, right? I'm like, well, I'm, I'm that, but not crazy. But I guess I was crazy to believe that.

Mark Kargela: 28:19

Hey, I, I honestly, to talking to you, I feel like I'm at an AA meeting where like, Hey, my name is Mark. I'm a recovering, I'm a recovering old school manual therapist. And, you know, and we're, we're just like rehashing. I did it on your podcast. You're doing it on mine, but, uh, yeah, no, I, I it, so let's go into good hands'cause I think you've, you've done

Erson Religioso: 28:37

Yeah. I think the, I think there's still a good hands.

Mark Kargela: 28:40

I agree. Tell us what your thoughts are on it.

Erson Religioso: 28:43

Right. And I think there's still like the lost art of manual therapy would be. that you even place your hands on people. I remember, um, one of the differences between Butler and Mosley, um, was that, and people don't realize this, I think'cause they think that, oh, they're just both big pain science guys, is that Mosley's background is like in motor control and whatever exercise. But he was never really a manual therapist versus Butler was a classically trained manual therapist like you and I. So I remember. Well after sensitive nervous system came out and David Butler started teaching, explain Pain all around the world. He had that, he used to have that blog. Was it NOI Jam or something? It was great, right? That a man, I used to love that. And he just posted this really simple case where he said that, you know, in the middle of like a, I don't know, explain pain residency or something, wherever. He had a bunch of People mentoring at his facility or his hospital, wherever they were in Australia, um, said that everyone was trying to talk this woman's pain outs and of course, do all this education, use metaphors and all this stuff we're supposed to do. And he came in and just said something like, you know, put his hand on her shoulder, like, everything will be okay. Or, and she's like, oh, you know, no one ever touched me before and you finally touched me. And I thought my body was so fragile, it didn't matter what all you guys were saying it, I just thought I was so fragile based on my scans. And that's where he's, he said like, you know, there's still such a power to touch, you know, if someone is that fear avoidant and they feel like they're that fragile, there is something to even this, like the comfort of touch. So I think that is like the beginning of the art and, and, and, um, the guy who actually told me about Stanley Paris, who was like my The hospital supervisor at one point, he eventually became my fellowship mentee because I got fellowship before him and then he, he formed his own practice and, and, um, I always like a practice within his practice. And this guy is the nicest, like most charismatic guy you'll ever meet, not so much into pain science and doesn't really like all that kind of like non path anatomical thing. But since he was just so nice, like he just had, I just call him like the PT concierge, like if that was his brand. Someone would be like, oh, in the waiting room, he would just go see people and often he was like 20 minutes late. He was just like always chatting and whatever. So he, you know, someone who's like high fear avoidance. I just remember seeing him do this. She, she didn't wanna be touched. He was like walking her back to the avav room. She's like, oh, you know, I have a, I have a really bad disc herniation, and. I just, uh, I'm so afraid to forward Ben and he is like, oh, here, you know, I made you hot chocolate in, in the Keurig. And he put his arm around her. He's like, I got just a thing for that. He just let her into the val room and that was it. You know, and just a thing for that I think is like just a little white lie that a lot of people need to hear, because I, I know that this was a podcast, this was like, someone asked this on, on Twitter, I think it might've been Andrew Rothchild, like my podcast. So he said like, how do you feel about people who Who need to hear a path, anatomical explanation. I'm like, I have no trouble telling them a little white lie. You know? If they're like, Hey, I have a really bad disc herniation. I'm like, these exercises are really good for that disc herniation. Even though in my head, I think by really good, I mean, just desensitizing your system opposed to whatever, putting the jelly back into donut, you know? So I think like part two of good hands is. Knowing when to put hands on people and, and when not to put hands on people. And, and how do you do it? Like the skill is using in a way to de desensitize the system. Um, but also explaining that this is not fixing you. This is going to temporarily reduce the sensitivity of your, your loading strategy, your activity, your position. You know, we're changing that neuro tag temporarily, and I'm gonna give you something to capitalize on that. To keep that desensitization going. Right? I'm not fixing you. So part, I think that's, that's the, that's the skill. And also again, just not causing pain. There's some things that maybe have to be painful, like a shift correction. Um,'cause I think if someone's laterally shifted lumbar lateral shift, you, you need to do that shift correction. Um, but, uh, I think, yeah, not causing pain, not thinking you have to be specific, but also knowing when to do hands-on and when not to do hands-on. Yeah.

Mark Kargela: 33:10

You know, just that communication with the hands-on has like the confidence, you know, it hopefully in general, the trust, the, the relationship building like your, uh, colleague had demonstrated there with a hot chocolate and armor on the shoulder. I'm not saying we all need to do that, that may not be our, you know, personalities for any, all of us, but. I do think hands-on just, you know, again, it doesn't need to be this hyper analy, you know, paralysis by analysis. I am identifying like a faulty car or things in alignment. But I do think there is some benefit of one being able to, like I. Lay your hands on to respect the sensitivity of somebody.'cause you're not like a bull in a China shop just blasting through it. Um, you're not awkward with how you're explaining it, where the person, like, this dude's creepy. Um, where you explain it in a way that engenders trust and confidence and you apply it in a way that responds to the unique sensitivity and response to that system underneath your hands. And you. And again, I don't think it needs to be all that magical, but I, I do think there's an art. I mean, somebody on, uh, my Facebook thread had talked about you, you've all had a, we've all had like a bad massage therapist where, you know, a good one man. It's like, they, like, they're playing your body like a, like an amazingly well-crafted instrument. And some folks are like, you know, the first person who's first getting on the piano and just like pounding the keys, like where it's just uncomfortable. So there is. Art of it. I mean, I don't think we've obviously fully even understand all that, but the, the, the physical communication of your hands to hopefully engender a sense of trust and hopefully build a movement confidence when you're starting to passively move a body part that you want the patient eventually, like you said, to take over and actively move it. And if you can desensitize it passively in a way that, hey, no, actively, I'm able to move it and explain it in a way that doesn't make them think that only way. This thing is gonna feel better as if Dr. E lays me on that table and nudges on my back for a good 15 minutes. And I, I, I think we've all been there in manual therapy jail with people where it's been like, you know, 24 visits and we're still doing the same the same soft tissue

Erson Religioso: 35:03

for sure.

Mark Kargela: 35:03

the same nudge on the back. And, and they keep coming back happy as it could clam, you know, nothing changing outside of the treatment room. But man, they love it inside the treatment room. But yeah.

Erson Religioso: 35:12

I always say that every clinic has their lifers, but not, you don't want 80% of your business to be your lifers. You know, every clinic has like the patient that's been there so long, they can show the other patients how to do their exercises.

Mark Kargela: 35:23

Yeah. And I've, I've, I've worked with folks where man, they're working on the same people that they've worked on for years and years. Maybe they take a month or two or a year break, but it's that, it's the same thing, you know, that's, it's interesting where, you know, we can build these practices and I know I did for myself, where you just build this like sea of confirmation bias, Ronnie.'cause all, you gotta be folks that just, you know,

Erson Religioso: 35:43

Right. Every, everyone just says, you're great. You got magic hands mark. Magic hands.

Mark Kargela: 35:48

Yep. Yep. You have a gift in

Erson Religioso: 35:50

Oh, right man. I used to love magic hands and now I hate magic hands. You know, every, I used to love it, man. It wouldn't, what a. Great ego booster that is, it's for someone to tell you you have magic hands. You know? And now when someone says that, I'm just like, oh, cringe. You know, like, oh,

Mark Kargela: 36:04

Yeah.

Erson Religioso: 36:05

did you not hear what I was saying?

Mark Kargela: 36:09

You, you bring up something that I think's worth talking about.'cause I, I, we talked, touched upon this a little bit in the podcast, uh, from my perspective, I know you touched upon it in your experience as well, but the whole ego shift that happens as you kind of have grown and recognized. One, our limitations with. You know, our skillset and like, again, you've, the, the analogy and things, everybody that we like to throw out there is, you know, we wanted to be Batman earlier in our career careers where we're freaking swooping in and saving the day. Throw up the bat signal of pain and we're gonna go and like knock it out. And then. Realizing that our role is probably more the Alfred. I know you had alluded to, like, you feel like sometimes you're more of a coach than you are like a clinician at times, um, to help people out of their situations. But I'm wondering where your ego had to go. I know for mine I had to go away from this like need of like being important and equation and the hero of the story to that supporting Rob. I'm curious what your experience was with that.

Erson Religioso: 37:01

Yeah. I would've to say that was a, that was one of the biggest shifts because I. I thought I had like these super gifted hands. And even though I still think, um, I'm, I'm good at manipulation because when I teach manipulation, I realize, and I'm sure if you've ever taught me the completion, you, you've seen and people like you might never be able to do this. you know, especially cervical. That's what I'll say. Like cervical is like the great equalizer. You can, you can be like. Like a super small ectomorphic 90 pound girl, or like a 300 pound guy, but you're not gonna be able to muscle your way through a great cervical manipulation. You know, like you, you may, you need finesse with this, but anyone can muscle their way through, like thoracic and lumbar, you know? Um, so, oh gosh, I just derailed myself. What did you just ask me again?

Mark Kargela: 37:50

I was just saying like how the ego shift

Erson Religioso: 37:52

Oh, right, yeah. So. I mean, going back to that cognitive dissonance, I had to just realize that I wasn't doing all these things and I really went back and took a big look at. Most of my McKenzie training. And then I started mentoring in fellowship, a couple, that was when the McKen around the McKenzie time, like two years after I started blogging. And I started having these slowly shifting. Obviously this was, this wasn't overnight. Um, the McKen McKenzie Institute through my mentor said, well, we wanna be part of the A-O-M-P-T. So we want route, we want route to fellowship for our diplomats. So I started mentoring some of these McKenzie diplomats and um, You know, they, a bunch of them were in my practice on and off and I'm just doing all this mobilization and patients are like getting better and not better and they're like, oh, hey, lemme just try this. And I remember a couple times there's like a, a shoulder patient or a knee patient that I'm just struggling with and they're like, oh, lemme just try this. And it's like repeated knee extension, open chain or repeated shoulder extension, like passively. I remember saying like in my head like, well, that's the dumbest thing I ever saw. And a patient like both patients were so much better, so grateful to this Mackenzie Diplomat and, and the guy who I was training is like, I'm gonna give up manual therapy after seeing that. I'm like, you don't give up manual therapy. But I mean that, after I saw it so many times, I just thought there's really Hey, there is something to this MDT, you know, and that became that start. I started shifting more and more to, this is gonna be primarily my home program as opposed to use this and stabilization and whatever else I was showing at the time. I don't even know what to analysis can become the majority of my treatment and I only put my hands on to get them to be able to do MDT repeated like repeated loading type strategies. Um. So, yeah, that was really hard. I mean, it was hard to, to give up that, that confidence. Um, and in the more research I read, the more I realized that all these things work. We still don't really have a great idea why they work. I know Chad Cook recently has, um, presented some research that I still have yet tore, read about maybe there's more chemical mediators rather than, um, just pure changes in, um, In perception. Uh, but if that were true, I still think like, why does it change so fast? You know, like even even when I have a headache or something and I take an ibuprofen, like I try all those retractions, I try all kinds of natural, you know, like movement to base things. And I'm like, I'm just gonna take, finally break down, take an ibuprofen. Now I take turmeric, but I used to take ibuprofen. I would feel better like almost within a minute of swallowing it. And I'm like. I know it's not better. Like why? I'm skeptical. I, it's not like I just bel believe in it so much. Like why does it work that fast? I don't know. And I actually, I meant to ask you this too,'cause I've been meaning to ask someone this. What do you think the mechanism is when someone gets like one treatment for severe pain and they're better and they never did their exercises?

Mark Kargela: 41:08

Yeah, I, I think it's a shift, you know, top down personally. Like it was just enough of a, of, uh, something that built their You know, be it implicit, like be below the consciousness or whatever that, that little hindrance or apprehension or kind of fear avoidant kind of behavior around that spot that it was just enough to say, I, I can shove this thing in the background.'cause I know I'm confident that I'm safe to move. And, um, I mean that's probably, I know some people are gonna, oh my God, that's not, uh, but um,

Erson Religioso: 41:37

Well, I mean, what else could it be?

Mark Kargela: 41:39

I mean, there's obviously, we know mechanical changes aren't behind that and, and different things, but you'll hear those like, and we've probably all had'em in practice. Like these,

Erson Religioso: 41:46

Yeah. Like one adjustment

Mark Kargela: 41:48

Yeah.

Erson Religioso: 41:48

or one cortisone injection or one whatever, and they're a hundred percent better forever. And Oh yeah, I didn't even bother do any exercises.

Mark Kargela: 41:54

I've had some folks come in on their second visit, like, you know, they got cookies and tow and they're like, oh my God, it's, I've never, I've been pain-free for the last, you know, week and a half. I can't. Thank you. And I'm like, I'm just looking at my notes. I'm like, what did I do to this person? Because I'm like, there must've been something I'm forgetting that I did. And it was nothing outta the ordinary. It was, whether it be a basic mob or miss, sometimes it's like a, a Mackenzie, you know, repeated load thing. Um, and like boom, like again, just like massive, massive, like 180 in life type changes. But yeah, I, I, I definitely think there's more to it than obviously the mechanical. We know that it's definitely more than that and even You know, placebo and all those things. I think we're, we're still figuring that all out, but I, you know, it's fascinating stuff to think about what is behind those changes. For sure.

Erson Religioso: 42:38

Yeah, I don't know. I think I, I just look at it as like the right explanation at the right time. You know, all these, like, all these planets align such that there's literal, you just eliminated. They went from a hundred percent threat to, to zero threat.

Mark Kargela: 42:57

no, that makes, that makes sense. That makes sense. I mean, uh, it, you know, I remember back in the day, I would've tell Yeah, man, that that was,

Erson Religioso: 43:05

Oh

Mark Kargela: 43:05

it was that mo man. I did the, I, you, I perfectly locked out that C two and man, that thing popped and cavitated like it's never popped before.

Erson Religioso: 43:11

And then no more positional fault. Positional fault back in place. Everything all aligned, now.

Mark Kargela: 43:17

Sacral torsion is eradicated

Erson Religioso: 43:18

Oh man, that's the worst there.

Mark Kargela: 43:21

Yeah, The the SI joint

Erson Religioso: 43:23

is the worst.

Mark Kargela: 43:23

the, yeah, that gives me the most headaches of my p prior manual therapy training. It gives me like shivers and I still work with close by in proximity. A lot of o traditional OMM practitioners and I'm, I still get like PTSD when I see some of the, the notes that come through and some of the narratives. But, you know, you know, some professions are struggling to move forward other than others. We have our own issues obviously in, in physio as well, but man, we

Erson Religioso: 43:47

problem is that they, they're successful, right? There's a problem with any manual therapist, I mean, the confirmation bias is strong, right? more successful you are, the less you need to think that you need to change. I was successful,

Mark Kargela: 44:00

yeah. And that's

Erson Religioso: 44:01

know, I got people better. I.

Mark Kargela: 44:03

And, and that's a struggle I see with like osteopath. I never see any osteopathic folks drifting out. They're very, a tight-knit group in their o their OMM like conferences and stuff. They get no reason to challenge their beliefs'cause they're surrounding themselves by like a massive dose of confirmation bias. And, and, um,

Erson Religioso: 44:19

Are still all in that type one and two lesion and FRS ERS and

Mark Kargela: 44:24

and uh, you know, yeah, leg length discrepancies. Everybody's got pelvic asymmetry and all these different things. And, uh, and again, you're right, these people get better. And the problem is, is we don't look zoom out and say, well, what's behind that? And then I remember John Child sharing a story about how he like, challenge this OMM background or his osteopathics. He was trained a bit in like MET and went and purposely. Treated the opposite of what the positional faults would say. So if this person was ERS left, he further jammed it in the ERS left with a technique that was aimed in that direction. And lo and behold, test treat, retest, people are still having positive changes. So it kind of, um, was, you know, his thing. And I started playing with that in my clinic. I'm like, dang it, he's right.'cause these people are still like, if I, if I go with the positional fault supposedly, that my magical hands are identifying or I go against it, I still make positive change. So yeah, it's, it's, it's interesting, um, with

Erson Religioso: 45:16

Yeah, not too many people were brave enough to do that, you know? Um,

Mark Kargela: 45:20

I, you know, I remember hearing like, um, yeah, gosh, Amy Eicher is a, a PTA good friend, um, who's, uh, who's gone through a hell of a journey getting si fusions and stuff. She was very much, she had her PT come to join her on a surgery to fuse it so that she made sure she went into surgery, you know, aligned. So the doc, the

Erson Religioso: 45:41

Oh, she had to be a line first.

Mark Kargela: 45:42

Yeah, before the surgery. Yeah, this was, she was like, and then she's reformed from that thought process, but she tells a story of a osteopath who you know is assessing her pelvis and back. She's got back pain and she said, you know. Pathologizes her SI joint and she's like, well, it's fused, it's not moving. And the opa, instead of saying, oh, maybe I'm wrong, maybe I, my hands aren't, you need to go to the emergency department right now'cause your, your fusion has failed. And like, it was just interesting like how gripped onto our, our belief systems

Erson Religioso: 46:15

Oh, well, I mean, at least she, she thought of something, you know.

Mark Kargela: 46:17

Yeah. Yeah.

Erson Religioso: 46:18

I mean, I, I have two, I have two stories about this actually. Um, my, my, my podcast host Andrew Rothschild, before he was a pt, I dunno if he was doing personal training or whatever. I know he has a background kettlebells. He had some s pretty severe low back pain. He ended up with a fusion. Um, lots of hardware, multi-level fusion. I, I think at least like two levels. Three, or maybe, I mean by two levels. I mean oh 4, 5 0 5 S one, I think, um. And went all the way through PT school, all, all the, I mean, his, his pain was better. He got back into Kettlebells. Got, um, he's very, very fit and he just decides, like after learning about pain science and everything, and also being exposed to my blog and eventually like, come in contact with me, um, he's like, well, I'm just gonna outta curiosity. I'm just gonna see. What does my back look like on a scan? And he posts this in all his courses now too, because he teaches like my, my pain science, um, version, uh, like under my branding, eclectic mine in patient education. All his hardware is all busted up. It's like all broken. He has like floating screws and everything and he has no pain. He's like no longer fu I don't know if it's like a natural fusion, but I mean his hardware is just like, just all jacked up.

Mark Kargela: 47:31

Yeah. And, and I mean that if that isn't like the example of treating the human like a machine with a fusion of, I mean, again, there's maybe a time and a place. Of course we, but that surgery often obviously has run, run away from the evidence horse a little bit. Um, man, we could talk forever on this stuff. I appreciate, I know you're, you're busy, you got family today. This is your day off. I appreciate you spending some of your time with us today. Um, I know I benefited from the discussion. I'm sure folks out there, um, if you, if you feel like this episode was like a, uh, you know, an AA meeting of recovering manual therapist and maybe you feel like a recovering manual therapist. And again, hopefully you don't hear that. Manual therapy is a terrible, horrible thing. It's just hopefully you've reconceptualized what it means with hands-on and what it's capable of, but maybe especially if patients value it, that there's still some value involved in putting your hands on somebody and helping them gain confidence to start moving, especially independently in their life once. If that's the gateway to it, then I have no issues doing that. But anyway, let's, we will wrap it up with that today. Uh, Ersin, thank you again for your time.

Erson Religioso: 48:30

Yeah. Hey, wait a minute. At Modern Manual Therapy on Facebook, Instagram, and YouTube.

Mark Kargela: 48:34

Yes. We will link this all up on the show notes so you can check out, uh, Dr. E and all his on all his awesome courses and things on that. Make sure you check out the PT podcast Network as well.'cause that's where our podcasts are all hosted.

Erson Religioso: 48:45

Part of the PT podcast network.

Mark Kargela: 48:47

Yeah, we're trying to push this, push each other up and, and spread the, the love on the podcast and the PT realm.'cause there's just a lot of people that need to hear some of this stuff. And maybe some people, you know, are recovering manual therapists who need to have a, a vent session that they listen to and, and like, been there, done that. I know the feeling. Uh, so share it with them. We'd love to, to hear their comments and different things on that. But we'll leave it there this week. Hope you guys enjoyed the episode. We'll talk to you next week.

49:11

This has been another episode of the Modern Pain Podcast with Dr. Mark Kargela. 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.