Rethinking Structure and Function in Osteopathy: Breaking Free of Outdated Beliefs

[00:01:34] Mark Kargela: Recently, a group of osteopathic clinicians and physical therapists and researchers have been speaking out in osteopathic journals about some of the issues existing in osteopathic practice. Now, don't get me wrong. These issues exist well beyond osteopathic practice. They exist in physical therapy practice.

They exist in chiropractic practice. This week's guest, Diego Hidalgo, is a trained osteopath and physiotherapist, and him and his colleagues have been raising concerns over these dated theories and their lack of scientific proof. Diego and I talk a lot about their paper around I'm Atomical Possibilisms and some of the challenges that brings as far as better helping and understanding those people in pain.

I think you're going to enjoy the episode. There's a lot of great discussion points that Diego brings up and I think you'll get a lot of value out of the episode. This is the Modern Pain Podcast with Mark Kargela.

Welcome to the podcast, Diego.

[00:02:22] Diego Hidalgo: Thank you so much, Mark. Thank you for having me here today.

[00:02:25] Mark Kargela: Awesome to have you. We're going to get right into it today because your paper really caught my eye. I work in an osteopathic college in, uh, [00:02:34] you know, DO training and here in the U S and we'll, we'll probably speak to that. The differences about, you know, osteopathic training here in the U S and maybe what we see in Europe and abroad, but.

Let's get into this discussion and let's talk about the paper you had here because the paper I thought was a great paper it Brought up a lot of concerns. I've had within physiotherapy practice So I'm by no means are we throwing rocks and glass houses here physiotherapy has its own Issues with what we're going to talk about anatomical Hospitalism and I know you're a physiotherapist yourself and you've you're co authored this with some osteopathic practitioners I believe over there in the UK.

Can you speak to a little bit of what's meant by anatomical possibleism when it comes to what you discuss in the paper?

[00:03:14] Diego Hidalgo: Sure. Uh, anatomical impossibilism or possibilism is kind of a framework that has been used for a long time to make sense of the things that we have been seeing on clinical practice. We have a lot of gaps in our reasoning as physical therapies, osteopaths, chiropractors, and we have tried to [00:03:34] fill those gaps.

In the paper, we talk about the God of the gaps. We have tried to fill those gaps with the models that make more sense. And in this case, it was anatomy. Anatomy has been the hard sign that has identified us. And kind of opened the mainstream medical field for us because before we were kind of not, yes, it's something like massage therapies.

So in that sense, I believe that we have used anatomy to create a lot of our reasonings and many of those reasonings have changed. Kind of turn at, turn against us, they have kind of, uh, uh, created a revolution against us. But, uh, in the time that we were promoting anatomy as our cornerstone, it has been key to give us a place within the medical field, the mainstream medical field.

[00:04:29] Mark Kargela: Yeah, yeah. No, I think anatomy has been such a cornerstone. I know in my [00:04:34] physio training it was huge and I think it's been put in perspective and your paper I think nicely brings up A lot of the discussions of why we need to put anatomy in perspective, just because of what science and what our understanding of pain and everything talks about the paper.

For those of you who are watching here on YouTube or listening on the podcast, it's called it's all connected. So it all matters. The fallacy of osteopathic anatomical hospitalism. I, uh, it's a tent tongue tying, uh, title there, but

[00:04:58] Diego Hidalgo: Yes, we did it on purpose.

[00:05:00] Mark Kargela: yeah, exactly. You made it hard for these podcasts guests or hosts here to kind of get through it.

Um, I'm wondering, we had Ian Harris on a few weeks ago and obviously a very prominent Australian, uh, osteopath, uh, orthopedic surgeon who really spoke to some of the issues that he faces in his profession. One of the big things is this, uh, pathologizing of normal or this medicalization of the normal. And in your paper, you all talked about pathologizing imperfect features.

And I remember Coming out of school and even in school, I was trained with osteopathic, uh, principals. I [00:05:34] took some continuing education where it was very osteopathic based. I was, Michigan State University was very close to me, which is a very big osteopathic manipulative medicine hub here in the U. S. Um, so I was very deeply trained in it for an extent, but can you speak to what you all mean when you talk about the pathologizing of the imperfections and, and kind of the issues we have with that?

Within not just the osteopathic practice, I think it exists across different professions.

[00:06:00] Diego Hidalgo: course, so we have chosen osteopathy, but osteopathy is just the, what we believe is the peak of this model of reasoning currently, but it applies also to every other profession in the musculoskeletal field, including also surgeons. So the thing with pathologizing what's normal or what we'd call ugliness is that, uh, when we're studying.

We use textbooks that show us what is considered as the perfect, uh, human. So kind of, uh, uh, similar, for example, uh, uh, [00:06:34] height, um, uh, uh, how do you mean wingspan? Yes. Wingspan. Uh, we talk also about how perfectly should all the vertebrae or the bones look, how the, all the muscles, many, many times, the textbooks, textbooks kind of use like bodybuilders.

To show what should and to me look like and that's like, that's the 1 percent of people that we see in clinical practice. So, uh, when we talk about pathologizing ugliness, we mean that we have seen over and over and over again that during many MRIs or during many, Uh, let's say physical explorations, we have found things that didn't look like those textbooks.

And because there was a friction between what we are talking is the perfect thing. And what we are seeing in clinical practice, we are thinking, okay, then that's the cause of the issue. If we apply this to, for example, uh, surgeons. We can see how this works because if we go [00:07:34] to place A, because place A is in pain right now, and we find something that doesn't look like the textbook that we have been shown. Of course, we will say, if the issue is here, it's because of this structure and I need to change the structure. to change the pain. So we have inherited this model or with this way of thinking and we have done exactly the same in osteopathy or physical therapy. The thing is that, uh, we have also, and that's the possibility isn't part.

We have tried to establish connections that sometimes were quite absurd because you know, I can understand that you have a patient that has, let's say, a bone that doesn't look like it should, and we say, okay, you should have this checked out or maybe have an x ray to see if there's something weird going on, like a luxation or something like that, but we have tried to say, okay, You have pain in your wrist, for example, because there's a structure [00:08:34] B that is located on the contralateral shoulder that doesn't look like it should, or it's not acting like it should.

For example, uh, osteopaths have these kind of tenets, and one of those tenets is that the structure governs function. So the way your structure looks will lead to a better or worse function and many or most of the. treatments that I learned because I'm a physical therapist, but I also have a formal education, college education as an osteopath.

Uh, they will say you need to change the structure to change the function. So if pain is the issue, there's an structure that is not working or doesn't look like it should. We are talking here about, uh, for example, uh, a misaligned back or, uh, that doesn't look as perfect as it should, or, or for example, a shoulder that is slightly higher than the contralateral one.

So yes, when we are [00:09:34] pathologizing ugliness, sometimes, many times we are pathologizing human Human existence, because all humans are imperfect. Asymmetry is the norm in humans. And we try to perpetuate this bias. We are trying to, we don't do it on purpose, but we are making a lot of patients feel like they have something wrong with them in the terms of structure that they need to have a surgery done, for example, to correct some things, or that they need to go to a chiropractor two or three times per week for the next.

Years, 10 years, 20 years. So it's a, there are perverse incentives. That, um, in part, they are intellectual and in part, they are, uh, about of course about money, but I believe that we can do much better and we can do it not due to common sense, but due to not necessarily due to common sense, but we have the data.

We have a lot of clear data showing us that look, things don't need to look up. As perfect that [00:10:34] they look in a textbook to work perfectly fine. And we are seeing, for example, how people with, uh, I think that it was last year here in Spain, there was a cerebral palsy patient that finished a marathon. And that was kind of a change of paradigm for many, because they said it's impossible that something with a cerebral palsy can finish a marathon because.

Their structures are completely, uh, let's say destroyed from a cognitive or from a neurological perspective. And even, even with those barriers, he finished that showing us again, because we see this every time showing us again, how resilient the human being is, how many things we can do, even if we don't look perfect, how many variability there is within us, within, you Many really common and mundane movements like working.

We are seeing this every time again, and we are trying to convince people that they are breathing wrong, that they are walking wrong, that they are [00:11:34] eating wrong, that they should sleep only using 35 pillows, all placed in a very specific order to correct. Any kind of imbalance and, and many times what we are doing, path, path pathologizing data is pathologizing the, the reality of most humans because nobody lives in the way that these people want us to live.

[00:11:58] Mark Kargela: Yeah, you, you bring up some good points. I think it's that whole osteopathic and it definitely, I remember it very clearly in physical therapy school. This, you know, structure equals function and that was. where our theory on pain really still lied. I mean, I remember in, in PT school and physio school where we'd get a little bit of the gate theory, but it still was very much derolved around the periphery.

Right. And there's so much human error and bias that goes into, if you conceptualize that everything exists in the tissues, when you go looking in the tissues, you're going to find things and. You nicely bring up some of the normal asymmetries and [00:12:34] anatomical anomalies, like we learned this perfect, um, you know, human structure that's got all this asymmetry and things.

I remember, and I've talked to numerous anatomical colleagues and they kind of chuckle at it, like, Do you remember when you're, you did, we had a dissection or your cadaver lab in anatomy where we saw real, and there was, you know, asymmetry was the rule, it wasn't, you know, something where, uh, these folks were perfectly symmetrical yet we still have a lot of these theories that have us stuck in the tissues.

And as I've said, it's, it's osteopathic, uh, practice is kind of the example here, but it exists still chiropractic physio still has, has some big issues. in moving through that. When we think of the modern understandings of pain, obviously it's gotten us past structure. Doesn't make us throw out structure, because that's usually the big argument that gets thrown back.

Well, you're just saying we just talk to people and we don't move. I think it de emphasizes the necessity of perfect structure, and you brought some great examples up. I'm just wondering, Where [00:13:34] you see the kind of current definitions of pain and current practice patterns out there and maybe obviously in your paper, osteopathic professions been identified, but in physio, it's similar physical therapy, same issues.

Um, I'm just wondering where you see some of the disconnect with current understandings of pain, modern pain theory and what you're seeing out there in clinical practice.

[00:13:56] Diego Hidalgo: Of course. So for example, in the I-S-P-A-I-S-I-A-S-P, uh, definition of pain, they, they talk about potential. A potential threat that may be producing that producing that nociception that then leads to pain. So there's a class because We never take for granted the potential part for us. Always there's something going wrong.

There's a structure that needs to be fixed in some way. We may not take into account many of the [00:14:34] psychosocial issues. And many times when we are trying to deal with these, these pains, yes, these pains, we are kind of, Forgetting about many times the pain, what's pain, what's what really pain is. And we are trying to constantly throw everything at pain.

The, I think that the, the expression that you use is throwing the kitchen, uh, like all the tools you want more tool, because you have seen that this pain is not the healing. So you need to buy new courses, uh, try new techniques. Uh, you need to always. Keep doing things to people instead of doing things with people trying to, uh, let the pain subside in some ways.

We are seeing how many of the conditions that afflict the musculoskeletal field are self limiting in, in nature. So natural history and regression to the mean are important allies, sometimes enemies in the case of, yes, certain conditions, but no, not [00:15:34] most of them. Most of them have a favorable prognosis and we are trying to make.

Find, find the, find a guilty, find someone that's guilty and make no prisoners. Then, uh, like we are trying to destroy the things that we believe that are wrong. And of course there's a, there's a contradiction between the models between how the biopsychosocial model or the definition of pain is, is defined.

Yes. Uh, how pain is defined and how we are practicing in the, in our clinical reality, because we are always Yes. Trying to make this passive care. That doesn't take into account much of the individual. The individual is thrown at a treatment table. We start throwing them things to see what happens.

Nothing happens. The patient starts to feel powerless. We keep saying that there's something wrong, that we need to fix it. We don't fix it. Uh, we will send them maybe to the surgeon or to a colleague. And of course, sometimes we will, uh, kind of justify our approach because we will see those quote [00:16:34] unquote, uh, miracles.

So then after treatment number 35, the patient will feel much better. But maybe what we are doing is, uh, fooling ourselves because we are saying, yes, uh, after a year, the condition has improved a lot due to all the treatments that we have performed. But the reality is that maybe it was natural history.

The patient has spent a lot of money just to, you know, Experiment on the things that we can offer and many times self management is a key option that we may not propose enough, especially because, uh, and I think that this also varies depending on the culture. There are certain cultures in the world that are more individualistic or collective.

So I will expect for someone that is quite individualistic to say, okay, Tell me what I need to do because I don't want to be coming here every day and it's a bit of pain and I'm fine with that. It's kind of related to self efficacy, but there are other, uh, [00:17:34] persons, maybe depending on the demographics too.

Maybe it's people that are older adults, for example, that say, no, no, I want you to fix this because I don't feel comfortable dealing with this alone, or I don't feel even comfortable dealing with this. I want you to, to help me or to heal me like the doctor has been doing forever. Heh heh. Heh heh.

[00:17:54] Mark Kargela: You bring up the thoughts of regression to the mean and natural history of conditions. And that's, I remember personally, that was a tough thing. Cause you, you know, I, I think there's a sunken cost. We all have as professionals where we're, we're trained in, uh, you know, very, and I went down the manual therapy.

Those of you who listen, know my journey with manual therapy that I would, you know, more letters, more letters, I got to have this. And I really self identified with it to the point where When I heard some of these narratives coming of, well, maybe it's just natural history and you're just hanging out with a natural course of the condition or, Hey, yeah, when people come to see you, their, their pains usually at an up, uh, you know, at the peak of it's, uh, you know, [00:18:34] nastiness, I guess you could say, and it's got usually one way to go.

It's going to improve. And that just was too hard for me to consider early on in my career to where, well, it's got to be me. I mean, I want to feel worthy. I want to feel like I belong. I want to feel like I'm making a difference. And I still think we can write, but it needs to be. under some, you know, solid scientific theories and then maybe again, putting patients more in the driver's seat.

Cause this brings me to the one concern I have, and I'd love to hear your thoughts on it as well as. medically unexplained symptoms. And anybody who works with, you know, pain, we'll get patients where they've been through all the testing, all the ologists out there. I used to work at the Mayo Clinic, which is one of the world's most preeminent medical facilities out there.

And I'd see people go through all the ologists and, you know, just, you know, just note after note of all these folks and well meaning folks trying to see, okay, is there something I can identify within my little categorical understanding of the human body and pain. And see if I can help this person.

Oftentimes that might cause a person to get 15 different diagnoses. Um, [00:19:34] sometimes they'd still have medically unexplained symptoms where there just wasn't that thing. And again, when we look at pain, it's kind of makes sense as more as now we understand that there's just so much that goes into it. To expect to put one little like nice, neat, tidy label and, and things on this.

When we know there's just such a whole complex. Mass chaos, biopsychosocial entity that emerges from a person. Um, and their unique pain experience, almost like the unique fingerprint that we all carry. Yet we want to put it in this unique bucket. Bringing this to this thought of anatomical possible ism.

Um, I just worry that those folks with, when desperate for, A diagnosis and, and desperate for an answer that there is not any, and it seems like it, they are easily able to grab onto something where there's a very. you know, elaborate story of, you know, things that don't have much scientific basis of cranial bones and, and SI joints doing a bunch of different things and, and [00:20:34] things that against, not me, not personally, but science is telling us that this isn't the way the human body works.

Do you worry, or do you have concerns that there are patients that when they have these complex cases that they can easily fall into and not just with osteopathic, cause I know physio physical therapy and other. There's no shortage of stories that can be thrown at people, um, to, to get them believing that I found the thing.

And I see people with chronic pain who've been through all the The latest things with chiropractors, osteopaths, physical therapists, and things, I just, do you, can you see the issues that would kind of coincide with this anatomical possible ISM and maybe the, the ability to give some people that may just need a more self management.

I need to take ownership and not try to find some new fix for this thing. I need to start working back into life and doing things where when they get pulled into this anatomical possibilism type approach, where we can make elaborate stories of elaborate ties of anatomical structure, uh, you know, devoid of a lot [00:21:34] of scientific backing that these folks can get stuck in that.

[00:21:36] Diego Hidalgo: Yes, of course. So there are two papers from the same group. I think that it's Tammy Hoffman, uh, they published two papers about the expectations of both, uh, physicians and patients about what the benefit and the effect sizes of the treatment they were receiving. What do they think? What did they think about it?

So I call this the dictatorship of good intentions because clinicians want to help, they want Patients as much as possible and patients want, want, want to be helped as much as possible too. So because it's a reciprocal, uh, connection, we are seeing how this clash between the both, both sides is kind of showing up on, on the, on the clinical base, on the clinical reality on a daily basis.

Um, Uh, it's of course, I understand the need, the needs that both sides have, because [00:22:34] they, for example, for chronic pain patients, pain patients, they want to believe that there's a cure, that there's something that they haven't tried yet that will heal them and take them out of the misery, miserable times that they are experiencing.

And clinicians want to feel appreciated and want to feel, uh, kind of, let's say valued. By society, they want to feel that the role that all the society impose on them, and they may try to reach those connections. They may try to find a those, let's say that those anatomical possibilities. Impossibilities and they will try to, to try things hoping that some of them work.

So, of course, for chronic pain patients, what we are seeing is that most of them are not recovering quickly. Many times because, because maybe we are not asking the right questions. Maybe we are not [00:23:34] seeing the red flags and we should maybe ask a rheumatologist, for example, to give them a check. Maybe that's a rheumatological condition.

Maybe that there's a fracture or, uh, yes, uh, I s I stress fracture too. So we need to clear those red flags. And after that, we may be dealing with things that escape our abilities. Maybe, uh, Currently, pain is still a mystery, and it's not easy to deal with it, especially when the symptoms are quite vague, when I say vague, and I'm not saying that in a punitive term, but what I'm saying is that, of course, if the only symptom that you have is pain, it's quite hard to With our test to be able to diagnose and specify what this path of anatomical structure is involved with it, then we send them maybe for a major test.

We see how everything comes clear. And the thing is that. patients want to be, to have something [00:24:34] wrong with them because the uncertainty of dealing with something that is seems totally fine is quite a, it's a horrible experience for both, for both sides, of course, for the patient that have, have pain, but, uh, feels that, that there's nothing wrong with them or that people may not believe them because there's nothing wrong.

Because of course, if you, if you broke your arm, people is going to be. quite, uh, they're going to understand a lot because why you have pain. But if you're, uh, if you have chronic pain, many chronic pain patients talk about this, about not feeling part of the society or their social circles, because they are constantly being accused by society as a whole, that they are faking or pretending, and that leads to a lot of frustration.

Powerlessness, um, depression, of course, and many psychosocial issues that are both modulating, modulating the symptoms and on the intensity. [00:25:34] So yes, I believe that anatomical possibilism in part has been conceived to deal with many of those strange cases. And from, let's say from a thousand anatomical possibilism reasonings, if one of those reasonings can of click.

And the patient starts experiencing much better for reasons that may not have to do with the treatment itself. That person is going to, both the patient and the clinician are going to spread that. As a, as a rumor, because, uh, people want to believe that there's a fix for them too. So if one has a fix, the, the rest may have a fix too.

Um, we may see in those, in those ways, the, the birth of a new guru, for example.

[00:26:26] Mark Kargela: Yeah, you bring up some, some great points. There's society, especially, um, societal challenges that a lot of patients [00:26:34] face with. You know, not signaling to society that they're in pain because, you know, chronic pain can be one of those invisible diagnoses as far as it doesn't often show on the surface. You might see it in people's movements and their facial expressions and things, but again, they're not in a wheelchair.

Sometimes they're not in, um, you know, have a cast or a neck brace on that, that signals to society. That, Hey, this person's in pain. And unfortunately that, that does equal a lot of horrible experiences and a lot of invalidation that some of our chronic pain patients deal with when they're trying to navigate a very massively difficult situation and then a society that they're trying to exist in.

That's not very validating. That's invalidating. That often can be downright rude and nasty. Um, so folks that are trying to, you know, do as best they can in the circumstances when it comes to our. Understandings of psychosocial trajectory, you know, this is the thing too, when we see studies, there's always a Jarvik study and I'll link it in the show notes that I [00:27:34] think it was a seven year, 10 year study where it looked at MRIs on the baseline of a big, pretty solid group of people.

And then I think it was either seven years or 10 years out, the people that had pain, they went back and looked at MRI studies in hopes of seeing, okay, well, what are the imaging findings that. would predict these people that develop pain in this time span. There were some mild, you know, associations with MRI findings, yet the biggest association was depression.

So these psychosocial components being massively predictive. I'm wondering what your thoughts are as far as when we get people so tied in with anatomy and I can definitely reflect upon this in my own practice I, I discuss my, my position as a reformed movement jailer, as far as I used to get people in this movement jail where you can only move a certain way.

And when we get people in this mindset of just very frail anatomical structures that are in and out of place, um, to me, and I see it on a regular basis, where these people [00:28:34] have zero locus of control over their symptoms. When this mythical out thing happens, They have zero control because it's not till somebody can put it back in that they have control.

And I know a lot of our osteopathic and chiropractic colleagues in physical therapy are as frustrated as anybody that that exists, but there are still a lot of issues when we, when we use these theories that kind of are formed on anatomical possibilism and things. Where do you see this influencing people when it, when we're looking at psychosocial behavior, like how people think?

And behave around pain when they're engaging in care that's formed on some of these less than ideal theories.

[00:29:14] Diego Hidalgo: Yes. So of course, humans are embedded within a environment and that environment goes far beyond their own body. Because they are constantly interacting with, uh, many humans, including their family, their friends, their, uh, peers, their bosses, uh, [00:29:34] society as a whole. Apart from that, of course, they have some interesting or some things that can modulate and that go beyond the biological, because they may be, you know, In an environment that may be a social, uh, lower socioeconomical, uh, socioeconomic class.

For example, we see, we see a lot how patients that has that background tend to do worse than those who came from, um, or let's say, uh, high class, uh, high class standard. Yes. Uh, and the thing with anatomy is that it's, it's something that is physical that you can palpate that you can see, that you can approach in ways that seem very, very logical.

They seem very logical because you can touch the structure. There are certain things, for example, you cannot interact with the mind. You can interact with the brain, but not, not with the mind, for example, from, from a clinician perspective. And of course, anatomy seems to be the [00:30:34] bridge. That connects both the desires of the patient and the certainties of the clinician because the, the clinician is very, very much into anatomy.

It's his bread and butter and patients, all of them are completely open to believe in that. What is causing them their pain is something that is completely physical that you can, uh, pinpoint. perfectly that you can say, okay, the cause of your pain is here, or, uh, it's maybe not in, in a given muscle or bone.

Maybe it's the way in which you use that anatomy. Then we are entering into biomechanics, but maybe the issue is not that you have, uh, an ugly looking bone. Maybe the issue is that you are walking in a way that is red, changing, The load patterns that you should be experiencing, um, because you are changing those loads that should be the standard way.

Now that's causing your pain [00:31:34] because you are, you are overloading certain areas. Of course. That's, that's, uh, an explanation that can be logical because it's, we see, for example, in ACL patients, how there are some interleaved and interleaved compensations during the post operative process, and we see how certain areas may be under load because others are taking control.

of the staff, for example, with the arthrogenic muscle inhibition. But in the case of, let's say, the average orthopedic patient that has been working the same way for 50 years, how much of the blame is to be put on, on the way he's walking. Sometimes I have runners that may, may say, look, I've been running for 30 years and maybe there's something wrong with my, with my cadence.

Maybe there's something wrong with my stride. And I think. And then I, sometimes I ask them this question that why do you think that the way you run is wrong [00:32:34] after 30 years that you haven't have any issue related to this before? And they would say no, because I've been checking some YouTube videos and they are always constantly blaming this structure.

And now, before I was trying to deal with the pain in my own way. Like ignoring the pain, but because the pain hasn't settled yet, I've started to seek for help and that health has become, I've seen so many, let's say famous YouTube channels that are telling me, uh, from people that seems to know their stuff, uh, they are telling me that I'm running wrong, that I should change out of things.

And look, they offer some new shoes. Or they often sort some treatment or some biomechanical analysis that I believe that it can fix me, but they live too far from my, from my place. So I believe I would like to try that. Let's say, eh, be a mechanical, be an anatomical staff to see if it works. Uh, many of those times we can deal [00:33:34] with that with self management because many times the issue is not, um, the way you are doing things.

Maybe it's the intensity in which you are, you are doing those things that, that, uh, quote of, uh, sometimes the issues that you are doing too much too soon, maybe it's that you are overloading me, uh, we are ecological beings, we are interacting constantly with things and our capacity is constantly changing.

It's normal that some days we feel better or worse physically or mentally, uh, than others, and we need to deal with that. We need to understand. Why those things happen, what things are within our control, but also admit that many times, we live in a world that is constantly interacting with, with our body and there will be emerging elements, elements that will emerge and that are going to, escape our reasoning, escape our control, we are not, we are not going to be able to diagnose them or detect them because many times we don't really know what's happening, [00:34:34] but maybe many times what we're seeing is that those things stay for a while and then they leave.

How many times we wake up with pain in our neck? And the next day we are totally fine. And we haven't have any kind of trauma, any kind of issue that could justify that pain, but if we ignore it, uh, we are, we are seeing that the prognosis is quite favorable, but we are also seeing that if we obsess over that issue and we start trying everything, we may, uh, develop a lot of anxiety.

In the way we lose our autonomy, because we will, we will be told that we need to experience that we need to become passive subjects and go to a clinic, pay a certain amount of money, and then experience those treatments. And we will, if we have success again, we will say, okay, that was because of the treatment, because if it was, if it was If it was not for the treatment, there was no reason, reason to justify that because people don't know about natural history.

They don't know about regression to the mean or other [00:35:34] statistical phenomenons that may be affecting their, their pathology.

[00:35:39] Mark Kargela: Yeah, the, you bring up great points around it. I think there's just a, there's a cascade of events that can happen when people get some of these labels and, and some of these things that, that convince them, especially in the presence of. To me, when we think about the misdirected problem solving model that a lot of our psychology colleagues, um, talk about and where, when we get people that oftentimes the research supports, it's more of the dysregulation in their life that surrounded this pain, this depression that's emerged because their life's been shrunk, their lost their identity, all these things that our patients tell us in their stories when we actually give them time to talk and listen to them.

That it's probably those things driving it yet. What we do as a healthcare system, because we don't honor that psychosocial piece, um, and you, you spoke to it very well that all of a sudden now, instead of us pointing the problem of like, Hey, let's get your life around these [00:36:34] symptoms better and of course, do things that can help physically movement, things, all the things you mentioned as far as maybe some of the loading, you know, adapt adaptations and things to help people a little bit more adaptively move and engage in things.

So when we fail to, to kind of, you know, identify or help people make sense that it's probably more than just the alignment of your pelvis and static, you know, standing position or how, how, how big the part of the PSI drops in a stork test or whatever it may be. That, that we, you know, tended to do in the past that we get people trying to solve a faulty anatomy problem for a faulty life and coping and, you know, a faulty ability to continue to pursuit of valued activities in our world.

I just think it's. It gets to be frustrating. And I'm with that frustration we have with, you know, and again, I've been these, uh, the clinician I speak of the person who used to put, you know, the, the movement issue or the anatomical things of these are why you're, you're not getting [00:37:34] back to it and not even given their, their narrative or their story of stage.

And like, cause I had no idea how it tied into things when I was just focusing on the structures, dictating all the function. And that was my sole pursuit. That's a tough switch for a lot of therapists to make and to, and you've mentioned some of the things already, as far as like our identity, our value to society.

Um, you know, our justification of all the horrible events and stressful things that we go through in university when we're trying to accomplish, you know, becoming an osteopath or, or a physio or a chiropractor or things like that with that challenge to make that switch often comes reactions that aren't always the most pleasant from folks that are not ready to make that switch.

I've probably been that person when people were questioning my traditional beliefs on manual therapy, as far as. Um, you know, that it wasn't all about me, Jedi hand skills and development of all these amazing skills. I'm not saying again that there's not some value in being good with your hands, but obviously we've overemphasized it.

With that [00:38:34] said, the reactions that you've received, I've, I've read some of the responses to this article and others, your, your coauthor, Oliver Thompson's kind of coauthored some other papers around, um, some of the challenges and I think constructive criticisms on maybe where osteopathic profession in particular needs to kind of move forward.

What has been your experience maybe within the, your professional circles, be it via journal responses and things like that, but also just. In general on social media and things, when you start discussing some of these papers and things, what, what's been the reaction you've received and any of it surprised you at all?

[00:39:07] Diego Hidalgo: Well, I think that I need to, to divide the responses that they have received because I believe that because I'm embedded within this echo chamber of people that are evidence based and there has, there have been a lot of great responses. I will say that the majority of the responses have been very, very positive.

They have told me how much this was needed, uh, how much we should [00:39:34] took. talk about these issues and the lack of papers that are kind of examining these, these issues from a critical perspective. Some others, a few, just, but just a few, say that we are trying to destroy the profession or the value that we provide to society, or that we are trying to get revenge because we don't like what we do.

Certain things or we are bad with our hands when it comes to hands on treatments or because we want to impose our paradigm paradigm of exercise or because we want to I don't remember who said that because that's it was something like Yes, of course, because, because a lot of people like you, uh, are trying to build their telehealth practices.

It's, uh, you need to support the idea that manual therapy is not a special, and that those that are currently doing manual therapy are doing something that is giving [00:40:34] patients superb results compared to exercise. And the thing is, What I would like people to understand is that, of course, the body is really complex, but because it's really complex, it's not that easy to, let's say, solve.

We are not like a puzzle that is trying, lacks the last piece. Our body is great at regulating things. Uh, if we have issues with our anatomy, for example, we will be able to deal perfectly with them most of the time we are seeing them, for example, with a scoliosis, uh, but the, the responses have been usually the same, uh, things, the same themes that have been reoccurring time, time and time again, because when you read the, when you read the criticism that have been made, And they don't evolve, they, they don't evolve with time.

They are always the same things that have been said. And the sad [00:41:34] thing is that we need a critical majority to change the field. And the changes that we will need to undertake within the field to change things and to adapt to the current times are going to ask us to make a lot of sacrifices and to rethink.

The way in which we approach the clinical encounter because the clinical encounter is changing and it's changing quite fast. If we're not open to to change the way in which we are responding. We will not be able to deal with the question because the questions have changed. For example, I was thinking that osteopathy was founded on 1874 and we are trying to use many times the same reasonings, philosophical principles, let's say, that Taylor still proposed.

The same can be said, for example, for chiropractic and David Palmer. philosophies, both of them are quite related. the same can be said, of course, from [00:42:34] physical therapies. I believe that physical therapists are a bit more advanced in this reasoning currently, not much, but they are, let's say a step ahead in this discussion.

But I believe that many within these three, these three professions are still working within these, this paradigm that needs to be needs to be changed.

[00:42:59] Mark Kargela: Yeah, I think, uh, I would agree. I think, you know, and I'm, of course, biased of my opinion that physios are a little bit ahead of the curve. I mean, there's still examples of very dated, uh, ways of kind of thinking and you, you bring up some great points of, of, we're still working with theories that were back in the 1800s to, and I, It's not to say that theory can't, I mean, there's been theories that have proven true.

I mean, some, uh, maybe not to the 1800s, but you know, it's a lot of Einstein's work and a lot of really smart people's theories carry on today. It's not to say that we're just disregarding their work, but when science is kind of staring at square in the eye and saying, we need to double think that it just, [00:43:34] it seems like, you know, and it probably comes a little bit of a clinical comfort zone.

And it's a very destabilizing experience. You mentioned how their clinical encounters changing. We need to change with it and understand. I mean, I think it's the same things that we're dealing with, but our, our conceptions and our ability to kind of pull pieces together beyond the tissues. I've one thing I've always appreciated about osteopathic theory is this thought of interconnectedness, right?

This thought of whole holism of being able to like, look at the whole picture. The problem is, is the whole picture. Isn't just putting connecting dots within different anatomical structures. We need to be able to put in the whole of the person's psychosocial existence. You know, society around them, social determinants of health, all these various things that we know have great impact on their trajectory when they're encountering a pain experience.

Well, I want to maybe wrap up the podcast with one last question. You spoke to it a bit, but where do you think, um, we need to go to help people? Clinicians because [00:44:34] it's you're never going to change anybody right and say you're doing it wrong You need to do it this way because that that that never never works I'm wondering what you think would be ways to maybe Help because social media becomes this like again this very dichotomous, you know oftentimes can be nasty where people are, you know getting you know, very Polarizing opposite end discussions and there's rarely a middle ground that gets discussed of like, okay Well, what can we pull from some of these?

You Dated theories. Cause there's, you know, maybe some, some pieces that, that make sense. There may be some that don't of course, but, um, I'm wondering where you think we can go to kind of help in a, this exists again within physiotherapy and osteopathic and chiropractic, but how do we help as a profession?

And this is, I wish if we had the answer to this man, we'd probably be running for president of our world associations around these things, but where do you think we need to go to help our. Prof respected professions start moving past these dated theories and start embracing, you know, this more person centered, psychologically informed, [00:45:34] still respecting the biological components of a pain condition.

Where do you think that needs to head?

[00:45:39] Diego Hidalgo: Uh, I believe that we need to be more empathic with each other. Um, I believe that many times we believe people because we trust them. We are, our judgments are usually supported by what we think about that person. And in the sense of, for example, my osteopath, uh, lecturers were great people. And, uh, even when I disagree with them in a lot of things, They were top tier persons.

And that's one of the things that I believe goes in favor of many osteopaths, that they are great people, that they are many times, they are people that are really trying to help as much as they can. So we need to. Let's say destroy all the ideological walls that we may have built during this, this decades look each other in the [00:46:34] eyes and, and let's open an honest discussion, but I believe that for that honest discussion to have an impact, the impact that I think we should have, there's, there needs to be some, uh, Love between each other.

When I say love, I say that we appreciate others, because, for example, Greg Lehmann is great at this. Greg Lehmann has that ability to debate about a given topic. You can disagree with him, but you are At least that happened for me. I was like, dude, I disagree a lot with, with, I disagree a lot with the things that he's saying, but I don't have anything against him.

Um, I respect him because he shares many of the beliefs that I have. So I'm going to try to be more open to that, this idea. I'm going to read more stuff about this idea. And it's, I believe that if you can control the emotions. If you [00:47:34] can control the emotional side, you can control the ideological or the epistemological side if we are open to, uh, reach each other and have an honest discussion, uh, maybe having some beers.

Uh, so, uh, trying to be good persons helping good persons, because I, I doubt that. Most people doing this job is here with bad intentions. We are, most of the time we are maybe fooling ourselves. Uh, we are, uh, kind of trying to perpetuate the things that we recognize as, as ours, because it's, we are, it's part of our identity.

What we do, if we have been doing the same things for decades, it's normal that we don't want to change. There are many on the fence. That are open or maybe they are more open to change their stuff, but they want to see really clear, uh, evidence about why things are a way or are not a certain way from people that [00:48:34] they respect.

So if we were able to, uh, let's say choose or convince the most prominent osteopath from the, let's say, uh, anatomical possibilities site and tell them, Hey, I tell him, Hey, could you talk with the rest of your people or the rest of osteopath that, you know, that have this similar model of reasoning, uh, and tell them that you have changed and all these things, I'm sure that many people will follow him.

The sad thing is that. The people that is in power, because it's at the end, everything is about power dynamics. The people that is in power, they don't want to lose the things that put them in those places. I think that it was Max Planck who said that many times science advanced one funeral at a time.

Some people may need, unfortunately, some people may need to die to change the paradigms because they won't be able to admit. or to advance. But I believe that if we want to change things, we want to do it [00:49:34] from a place of respect when we, a place where we respect each other. Um, I believe that the question is not about, I believe the question is not about what's the, the truth, but how can we introduce that idea that may be more accurate.

In the head, in the mind, uh, of people that has a lot of things going against them accepting that, uh, fact or that, uh, yeah, that point of view.

[00:50:06] Mark Kargela: Yeah, good, good points and agree. It's, it's, it's tough. You know, I think we've all probably had points in our careers where certain things that we really held tightly to are really fond of, of as far as interventions and way of looking at things were challenged. I spoke numerous times to some people challenging my view, some people I highly respect.

And I think, Being able to be empathetic towards each other, we're all in this for the right things. The people I know that are practicing under these, like you [00:50:34] mentioned, with your osteopathic professors in university, they're great people. I have nothing personally against that. I think we do owe it to our patients to update our understandings, especially when we see sometimes the negative consequences of getting people anchored, overly anchored in their anatomy and not anchored into their life.

And sometimes, you know, stuck in a, you know, modifying structure when it's something beyond the physical structure that needs to be modified. Um, so I wanted to thank you so much for your time. Thank you for your efforts on this paper. I really, uh, greatly enjoyed reading it. We'll link it in the show notes for you.

So those who are watching and listening. So you can maybe give it a good read for yourself. There's also some good responses from some folks. And it's just interesting to me. It's a good social experience. You can see some folks that reacted in a professionally critical way of the paper. And I, you know, I think you, you all have kind of done a good job responding to that in an equally professional manner.

So again, thank you so much for your time and thank you for your work on this.

[00:51:28] Diego Hidalgo: Thank you, Mark, because, uh, Anatomical Possibilism or this piece, uh, [00:51:34] has been in part thanks to you. Thanks to Gerard Hall, thanks to Greg Lehmann, Eric Mira and all that people. But in part it has been thanks to you because when I was a student and I have these kind of issues, I remember listening to many of your podcast episodes and I experienced the struggles that you were talking about and you helped me tremendously when it comes to being a lighthouse for my way of reasoning.

And in this case, because it's about manual therapy, I wholeheartedly thank you. Because you have been key for my development in this area, and I can say without a doubt that the this paper wouldn't be the same if it was not thanks to you to showing the things that you that you think for putting your work out there and allowing us to pick your mind for a while.

[00:52:27] Mark Kargela: Well, I greatly appreciate that. Those are very kind words. And the whole reason I do this, right. Is to try to help people [00:52:34] think. And if it's, as long as it's in the spirit of trying to better understand and help people in pain, which is kind of the whole mission of what we do, then, then I'm all in on it.

So again, thank you so much for those words and thank you all for who are listening or watching on YouTube. If you're listening to this, make sure you subscribe via your podcast listening service. And if you could leave a review there, that would greatly help the podcast. So we can get more of this information out and same thing on YouTube, leave a comment.

Or maybe at least subscribe or pass it on to a colleague who might be struggling with some of the difficulties, uh, as far as navigating some of these topics we spoke today in practice, we'll leave it there this week. Thank you all for listening. And we'll talk to you all next week.