Evidence Informed Physical Therapy with Dr. Jason Silvernail

[00:00:01] Welcome back to Untold Physio Stories Podcast. I'm your host, Dr. Erson, Minor Manual Therapy and Edge Mobility System. And my guest is Dr. Jason Silvernail. He's been someone I've been wanting to have on the podcast at least, I don't know, three or four times. And this might even be the fourth take. Is this the fourth take?

[00:00:20] I feel like it's only the second, but you know what? Every time I talk to you, brother, it seems like the first time.

[00:00:25] Well, that's great. Yeah, I know because I can't really exactly remember what we talked about because I'm getting old.

[00:00:31] You know, I don't know. I had this very clear memory. I don't know how you feel about this. I had this very clear memory of being like in my mid-20s, maybe around 26.

[00:00:38] And I just remember thinking to myself, I have just got to remember that I cannot remember a damn thing at 26.

[00:00:45] So if I start forgetting things when I'm older, I'll feel better about it. And you know what? That works.

[00:00:50] Yeah. You don't even know what you forgot. I have no idea. It's bliss, right? It's bliss.

[00:00:55] Yes. So I know you usually got to give a disclaimer and everything, but I wanted you to really have to tell your story about how you crossed the chasm and where that term came from and everything.

[00:01:06] Yeah, awesome. Would love to. And thanks for giving me the platform to give my disclaimer on too.

[00:01:11] You know, everything I talk about with you today is my personal opinion and commentary. It does not reflect the official policy or position of the U.S. Army, the Department of Defense, or the United States government.

[00:01:20] And I have to do that because I'm also on active duty in the United States Army, but I'm not appearing as Colonel Silvernail today.

[00:01:26] I'm appearing as Dr. Silvernail. So this is just me and my personal opinion as an experienced healthcare provider and grower of a burgeoning November mustache, which I hope comes through.

[00:01:36] But, you know, it's slow, but don't get there.

[00:01:39] Yeah. By November of next year.

[00:01:41] Yeah. Something like that. I'll keep you.

[00:01:42] Yeah. Yeah. I mean, I wish I could. You know, I'm Asian. So the kind of Asian that can't really grow facial hair.

[00:01:48] Oh, yeah. It comes in pretty thick after a while, but I kind of I end up I end up looking like a police officer from the 70s, I think, you know, I think it's a good look to police officers from the 70s.

[00:01:58] Yeah. Some people think it works on me. I don't know. We'll see.

[00:02:01] Yeah. You're already authoritarian. I mean, why not?

[00:02:03] Why not?

[00:02:04] You know, it is further increase your authority, at least with some people.

[00:02:08] If that helps, man.

[00:02:10] Yeah. Yeah. So, you know, just to preface this story a long time ago, back when I had zero popularity and I was a nobody, which I was probably better off in the PT world anyway.

[00:02:22] I wrote I used to have a blog back when people used to read, you know, the good old days.

[00:02:27] And it was called TheManualTherapist.com.

[00:02:29] And it was solely promoted to I started just to promote my edge mobility tool.

[00:02:34] And, you know, I came at odds, at good odds, though, with with Jason and all the stuff that he and a group called Soma Simple were throwing at me.

[00:02:46] It made me go through some serious cognitive dissonance.

[00:02:49] And I like many people, you know, I basically first became combative.

[00:02:53] And then when when I kind of took a step back after maybe months and months of arguing, I actually started critically looking at the literature like you're supposed to.

[00:03:03] And I realized that maybe I didn't need to change the way I explain things and the way I looked at things and every single thing about the way I practiced and interacted with patients.

[00:03:14] So just just a little little little change like that change.

[00:03:17] It was such a small thing we were asking you to do.

[00:03:20] Yeah, for sure.

[00:03:20] For sure.

[00:03:21] But anyway, I mean, this is not my story.

[00:03:23] It's your story.

[00:03:24] That's just how we met, though.

[00:03:25] It is.

[00:03:26] And it was like it's like so many other meetings that are that are on a digital platform.

[00:03:31] It's they were completely devoid of context.

[00:03:35] They were devoid of the nonverbal communication that humans use to communicate with each other.

[00:03:40] Right.

[00:03:40] So things like, you know, tone and attention like we're completely lost.

[00:03:45] Right.

[00:03:45] And so I think a lot of those things, what happens is, you know, people tend to judge themselves by the words that they say and judge other people by what they think their intentions are.

[00:03:56] And that just tends to spiral things in the wrong direction.

[00:04:00] As each as each side is like, you know, interpreting, you know, what the other person does through a pretty negative lens.

[00:04:07] And I I have not reviewed that conversation.

[00:04:10] I'm ready to believe I was not on my best behavior at that time either.

[00:04:13] And so I think that I think that it went both ways.

[00:04:17] I do think that it illustrates some important things.

[00:04:20] And I think it is first of all, is your your willingness to reflect on something and to change.

[00:04:26] And, you know, one of the things in our in our previous iteration of this conversation that we tried before with our technology challenges, we talked to I mean, I talked about how I don't think that.

[00:04:37] Any one of us can change someone else's mind.

[00:04:40] I think people only change their own mind.

[00:04:45] So what that what that means practically is that I don't expect when I'm in a conversation with somebody like I was with you about that issue.

[00:04:53] I don't expect for them to say in that conversation, you know what?

[00:04:57] You're right.

[00:04:58] I you know, I think I agree with the way you see it.

[00:05:01] I think I was wrong.

[00:05:02] Nobody ever does that.

[00:05:03] And it's not because they don't have good intentions.

[00:05:06] And it's not because they're not arguing in good faith, because many times they are.

[00:05:10] It's just that it takes time to change your mind.

[00:05:13] And that change comes about with reflection.

[00:05:16] Right.

[00:05:17] Now, when you see and hear other people expressing a difference of opinion and you hear their rationale for why they feel that way, you've got to feel something in that that resonates with you in order for your mind to change.

[00:05:32] And so it is a it is a reflective process that happens between conversations and not within them.

[00:05:40] Yeah, I remember.

[00:05:43] You know, you were saying that, too, last time we recorded and it reminded me of when I was teaching.

[00:05:50] I was actually only shooting a course with Chris Johnson.

[00:05:54] He was teaching the course and every once in a while he would let me teach if he was tired of talking or whatever.

[00:05:58] And I just would quickly show like a hip technique or something.

[00:06:01] And I casually mentioned over the course of like, you know, five to 10 minute module.

[00:06:06] Oh, we can't break a fascia.

[00:06:08] And I think all this band is doing is it just it's changing the perception of stretch and it's modulating pain.

[00:06:15] And, you know, anytime you dramatically increase range of motion, it's some sort of change in perception rather than, you know, a tearing of fascia or something like that.

[00:06:26] And in the meantime, you know, the majority of the class is probably like, why is the cameraman talking now?

[00:06:30] But but there's a guy who actually came on to my podcast who was in the middle of like a Barrel Institute fellowship or something.

[00:06:39] And he just said, yeah, yeah.

[00:06:41] Right.

[00:06:42] I don't know how to say it.

[00:06:42] And he said, you know, you weren't even teaching the class.

[00:06:47] But what you said in five minutes just hit me like a ton of bricks.

[00:06:53] And I just questioned every single thing about what I was learning.

[00:06:57] And he like dropped out of the courses.

[00:07:00] He never even he never even completed.

[00:07:02] And that was never even my intent.

[00:07:04] Well, I mean, it's always my intention to make people think.

[00:07:07] But that's also my next point.

[00:07:09] I remember one time I asked you this is after Therapy Insiders.

[00:07:12] We did an actual interview style podcast.

[00:07:15] And and I said, why do you argue with people online?

[00:07:17] Do you remember what you said?

[00:07:18] I mean, I don't think I do.

[00:07:20] I hope it's clever.

[00:07:22] Yeah.

[00:07:22] Well, you said basically, I don't expect to change.

[00:07:25] I'm not arguing to change the person's mind who I'm arguing with.

[00:07:30] I do it for the lurkers.

[00:07:32] I like that, you know, the people who are lurking and watching the conversation.

[00:07:35] And it's mostly for them.

[00:07:37] And I've always thought about that, too, because like you said, at the at the time,

[00:07:42] you are not changing anyone's mind.

[00:07:45] Right.

[00:07:45] It's like conception.

[00:07:46] Yep.

[00:07:47] I agree.

[00:07:48] Yeah.

[00:07:48] Yeah.

[00:07:49] That's great.

[00:07:49] Yeah.

[00:07:50] I think the best you can do in those conversations, whether you have other people watching or

[00:07:55] not, is do your best to really understand where the other person is coming from.

[00:08:01] And if possible, articulate to them their perspective in a way that they say, you know,

[00:08:08] yes, that's right.

[00:08:08] That's exactly what I believe.

[00:08:10] That's exactly what I think about this clinical issue.

[00:08:13] That is exactly the way I'm approaching it.

[00:08:15] And when I get that kind of verbal confirmation from them, that is a really good sign that they

[00:08:20] feel heard and they feel understood, even if we don't agree on that clinical topic.

[00:08:25] Right.

[00:08:25] For sure.

[00:08:26] And I think that I'm always trying to explain in the best method possible why I believe what I do

[00:08:35] about clinical practice in a way that I hope will resonate with others and create that reflection

[00:08:41] and mind change down the road.

[00:08:43] Yeah.

[00:08:45] I can't remember what I was going to say, but so this is something that I also asked you about last time.

[00:08:54] And I really liked what you said, and hopefully you will actually be able to replicate it.

[00:08:59] Brush your zone.

[00:09:00] Yeah, for sure.

[00:09:01] But what do you make of the trend toward, you know, I only do strength training and manual therapy is all passive.

[00:09:12] Therefore, it's useless.

[00:09:13] I mean, I understand that we should be moving away from passive strategies, but I don't understand the it's completely useless standpoint because I just feel my question to them as well.

[00:09:24] If someone comes in with, say, neuroscience and a lumbar lateral shift, you can't just give them kettlebells and have them, you know, do farmers' carries to straighten up.

[00:09:34] I mean, if that works, great.

[00:09:36] But for me, I say there's a time and a place.

[00:09:39] But what do you think about that?

[00:09:41] Yeah, well, I think I'm probably going to commit a cardinal sin in an interview and say I actually don't accept the premise of the question.

[00:09:50] And so let me explain to you a little bit about what I mean.

[00:09:52] So I think that the issues that we're talking about are not clear cut.

[00:09:56] All the all the easy things that there are in medical practice and in clinical practice and PT, all the easy stuff has been settled.

[00:10:04] We really are now at a place where the only problems that really remain are the difficult, thorny, challenging ones.

[00:10:11] And they don't have clear answers.

[00:10:12] And one of the reliable tells that I use for someone who lacks content knowledge in a topic is that they have a strident or black and white opinion about something.

[00:10:25] Now, that doesn't mean that there are no differences between issues and that everything is 50-50 equal forever the end.

[00:10:32] That's not what that position means.

[00:10:34] That position just means that people who are representing complicated things in simplistic terms reliably usually lack that contextual knowledge.

[00:10:44] And so I would start with that.

[00:10:46] And I would follow up with I don't really accept the passive versus active dichotomy.

[00:10:50] I don't understand really where that comes from.

[00:10:53] I don't think it's I don't think it has a strong scientific backing.

[00:10:57] I think that with respect to treatments that some people would call passive, there's actually some pretty good evidence for them.

[00:11:02] I think with some with respect to some treatments people would call active, there's actually not very strong evidence for.

[00:11:08] And I would think that instead of active versus passive, I think we need to articulate evidence informed versus not evidence informed.

[00:11:17] And when we say evidence informed, what do we mean?

[00:11:20] Well, we mean randomized trials, systematic reviews, and clinical practice guidelines.

[00:11:23] And is manual therapy represented well in recommendations in clinical practice guidelines?

[00:11:30] Yes, it is.

[00:11:31] Are there randomized trials of patients with common problems treated with manual therapy as part of their physical therapy regimen who experience improvement, improvement on the basis of how you and I understand it, Dr. E, a definite difference in a validated outcome measure?

[00:11:49] Yes, there are.

[00:11:50] Right.

[00:11:51] And so actually, I'm an author on this recent paper, Redefining Orthopedic Manual Physical Therapy.

[00:11:56] You know, it's called Orthopedic Manual Physical Therapy, a Modern Definition and Description.

[00:12:00] I highly encourage you to look it up.

[00:12:02] It's available there.

[00:12:03] And I think that in that project, we essentially took a remit from the American Academy of Orthopedic Manual Physical Therapy to redefine OMPT as distinct from manual therapy, as distinct from any other system, and say, here's what orthopedic manual therapy is.

[00:12:22] Here's how you can recognize it in the clinic.

[00:12:25] And here's a clinical case where we show you how you can recognize it in the clinic or in a randomized trial.

[00:12:31] And I think I'm hopeful that that provides a level of clarity on some of these issues that I think, you know, has maybe here before been a little lacking.

[00:12:38] Yeah.

[00:12:40] Yeah.

[00:13:08] I just got to put it simple.

[00:13:10] I heard once somebody say, you can't go wrong getting strong, but a lot of patients come to me because they went wrong getting strong.

[00:13:16] And they need my help to improve their mobility and function so that they can return to getting strong without pain.

[00:13:23] Yeah.

[00:13:23] I mean, the strong only is like mobility only.

[00:13:27] Yes.

[00:13:28] Right.

[00:13:28] Or pain science only.

[00:13:29] Yes.

[00:13:29] Or the manual therapy only.

[00:13:32] Like, I understand why when it's only one thing.

[00:13:35] But again, that's just the same thing like you said.

[00:13:37] Anyone who is basically all in or 100% with a complex topic using simple ideas, it's kind of like what I would say is a red flag.

[00:13:48] Like one of my colleagues says, anyone, it's a red flag to me when someone says, I'm 100% certain exactly what is wrong with you.

[00:13:58] Or I know exactly what to do with you.

[00:14:01] 100%.

[00:14:02] That 100% certainty only sit, deal, and absolutes is what I say in my courses.

[00:14:06] I mean, there's definitely a level of confidence that we can reasonably defend scientifically and with evidence and or defend with a rationale.

[00:14:17] Like, for example, in the diagnostic world, right?

[00:14:20] There definitely are those things.

[00:14:22] But let's just think about it.

[00:14:23] Just think about it outside the terms of the clinic for a moment.

[00:14:29] Who is applying the black and white frame most often to issues?

[00:14:36] All or nothing issues, right?

[00:14:38] Well, that's reliably how young people and children position things, right?

[00:14:45] No, Bobby, you can't have that candy.

[00:14:47] That means you must hate me, right?

[00:14:49] And so we have to realize that as you develop your ability to think and as you develop your critical thinking skills, your use of that all or nothing frame naturally drops away, right?

[00:15:01] And that means that you're able to describe differences between two things and make distinctions with a level of fidelity to what the content actually is according to an objective standard.

[00:15:15] And it's not all this or all that or none this or none that.

[00:15:19] Right.

[00:15:20] There's all the shades of gray, right?

[00:15:22] I like that.

[00:15:23] It's not always young people, though, I would say.

[00:15:26] No, I know.

[00:15:26] But I mean, that's a reliable indicator, right?

[00:15:28] It is.

[00:15:29] I think you see it more often in children than you do in adults.

[00:15:33] But I think one marker of our ability collectively to reason well and reason reliably well on complicated issues is our ability to leave some of those things behind, right?

[00:15:47] Yeah.

[00:15:47] And I think that in order to hang on to that frame, people will respond and say, well, that doesn't mean you're just saying there are no distinctions between things.

[00:15:57] And we just have to be ready to respond to that part of it.

[00:16:02] I mean, one way to look at it is like this.

[00:16:04] You know, I think that when we make distinctions if something's true or not, we basically have sort of three levels of certainty.

[00:16:11] We have majority, which is like, you know, 51% certain that something is true.

[00:16:16] We have most, which is like the classic 80-20.

[00:16:19] And then we have most all, which is 90% plus.

[00:16:22] So when I have a judgment I make about something in the clinic, I try to think to myself, what is my level of confidence in this judgment?

[00:16:30] Am I just barely over 50% for thinking this is true for this patient?

[00:16:34] Am I fairly certain that it's most likely like 80-20?

[00:16:39] Or am I very confident that most all of the issue is this thing that I'm thinking about and that's the 90% plus?

[00:16:47] And that's a quick sort of rule of thumb that you can use in determining how certain should I be?

[00:16:53] And how much confidence should I relay to someone else about this judgment that I'm making?

[00:17:01] Think about those three levels.

[00:17:03] Yeah, that's great.

[00:17:04] I would say I'm kind of stuck at the 80-20.

[00:17:06] You know, I was 95 and above pretty much when we were arguing way back when.

[00:17:15] But I've never quite gotten that.

[00:17:18] I always say, like, sometimes I wish I could bottle a little bit of that overconfidence I had because sometimes I'm so uncertain.

[00:17:25] And I don't want it to reflect or adversely affect my outcomes.

[00:17:30] Because if this uncertainty, I'm not in the way, not in the uncertainty in the way that I would say a real McKenzie trained clinician, like a diplomat, the way they interact with patients, I feel like it's kind of like a charming kind of uncertainty.

[00:17:46] But I don't have that.

[00:17:48] I don't have their scripts and everything.

[00:17:50] And I notice many of the best MDT instructors have this kind of programmed uncertainty.

[00:17:56] They're like, well, let's just see what happens.

[00:17:57] I don't ever want to present it that way.

[00:18:00] I want to just say, like, well, I think this is going to happen when we do this.

[00:18:03] So let's try this.

[00:18:05] If you are compliant with the recovery plan I give you, then I'm 80% certain you're going to get better.

[00:18:10] But I always say, like, well, even if it's a simple ankle sprain, it just can't give you 100% guarantee.

[00:18:15] Yes.

[00:18:15] Yeah, I think that's a good way to put it.

[00:18:17] I think that, you know, in the Maitland concept, which is the manual therapy framework that I learned in fellowship training, like we talk very similarly with patients the way that MDT folks do.

[00:18:27] Is that, you know, I'm reasonably confident that this is what's going on and here's why I think that.

[00:18:32] And if you do this and you experience this result, that will increase our confidence in this pathway forward.

[00:18:40] I think we do, we can't let our uncertainty bleed through to the point where it's kind of nihilistic about caring for patients.

[00:18:49] Because I do think most patients with pain and movement problems have issues that are generally speaking amenable to what we do in physical therapy.

[00:18:58] And that should have, that should experience some level of relief.

[00:19:01] And I would think that the evidence supports that position.

[00:19:05] Well, we run out of time because I only set aside half an hour, but I mean, I could just talk to you for hours because it's knowledge.

[00:19:11] Every single, every single little breakout you do is a huge knowledge bomb.

[00:19:15] So where can people find you?

[00:19:18] Yeah.

[00:19:18] Well, I'm very easy to find on social media.

[00:19:21] Almost all of my places are at Jason Silvernail, whether that's, you know, Facebook or X, or I can have a TikTok account.

[00:19:27] You can also find me at JasonSilvernail.com.

[00:19:30] All right.

[00:19:30] Hey, thanks for coming on.

[00:19:31] And I'm pretty sure this episode is going to air in its entirety and the audio and video will be great.

[00:19:37] I love to see it.

[00:19:38] Please tag me and we'll see you there.

[00:19:40] All right.

[00:19:40] Hey, thanks for coming on.

[00:19:42] You bet.

[00:19:42] Hey, if you haven't rated and told physio stories yet, please give us five stars wherever you listen to podcasts, especially Apple and Spotify.

[00:19:49] That helps our discoverability.

[00:19:50] And make sure to reach out to Jason if you have any questions or comments about this podcast.

[00:19:56] And as always, you guys have a great day.

[00:20:00] All right.

[00:20:01] I just wanted a quick clip, a knowledge bomb from Dr. Jason Silvernail.

[00:20:05] So basically, what is your take?

[00:20:07] What is your hot take on whether imaging should be used or shouldn't be used in physical therapy?

[00:20:14] Have we demonized it or what?

[00:20:17] Yeah.

[00:20:17] Yeah.

[00:20:17] Well, first of all, I think it's really important if we're going to be first contact providers, which I think all of us need to be as DPTs.

[00:20:23] Uh, I'm super excited about the potential for real-time ultrasound because I think that's an imaging modality that aligns with our practice very well.

[00:20:30] I would say in general, especially some of the advanced imaging modalities we have now, such as MRI and CT, they can provide a very detailed assessment of the health of the tissues that does not reliably translate to how people feel.

[00:20:49] And so we have a situation in which most of our patients are getting too much imaging and imaging that is not going to help them manage their condition.

[00:21:00] And it's not going to help the health care providers involved in their care providing good care.

[00:21:04] So that's one problem.

[00:21:05] That's an overuse.

[00:21:06] And there are some people in physical therapy who say that we have gone too far in the, in criticizing imaging and that there are a lot of patients who need imaging that don't get it.

[00:21:16] And I think they're right also.

[00:21:17] I think that there's a small number of people who don't get the right imaging at the right time to get a good differential diagnosis for their problem.

[00:21:25] I can certainly think of examples of that in my own, in my own, uh, practice.

[00:21:29] And I bet others have as well.

[00:21:31] So I think it's okay for us to admit that while many patients get too much imaging, a small number don't get enough and we should be working on both problems.

[00:21:39] Yeah, for sure.

[00:21:40] I think, uh, when an interesting takes I heard from Lance Mabry was that, you know, all the pain science type research basically shows that it's all nocebo, but that's only because the people who are explaining it are full of nocebic messages.

[00:21:54] He said that absolutely, you know, imaging is just imaging and it's all depends on how, how, how it's, how it's explained.

[00:22:00] So if someone like you or I or Lance saw the, saw the image and said, Hey, you know what?

[00:22:06] This is no problem.

[00:22:07] Or, you know, this is, this is totally common.

[00:22:10] It's, it's all of a sudden could potentially become placebo and not nocebo.

[00:22:13] So yeah, I think Lance has got some great points.

[00:22:16] Yeah.

[00:22:17] Yeah.

[00:22:17] All right.

[00:22:18] Hey, thanks for that quick take.

[00:22:19] You bet.

[00:22:20] Have a good day.

[00:22:22] Thanks.

[00:22:23] Yeah.

[00:22:23] What do you think?

[00:22:23] Cool.

[00:22:24] Yeah.

[00:22:24] Great.