Jared Powell:
Today's guest is Erik Meira. Erik is a consultant physiotherapist in Portland, Oregon. Erik is known as the science PT and is gifted at exploring and explaining the application of science to physical therapy practice. Erik is also the OG and Pioneer of Physical Therapy Podcasts, and I know I have personally learned a great deal from Erik's public musings over the last decade. This episode is a bit different. Instead of dealing with a mundane clinical issue or condition, we talk about science. We do our best to bring it back to clinical practice, but we do go deep into the realms of philosophy of science, metaphysics, and I make no apology for that. Seriously, though, this was one of my most enjoyable and thought-provoking conversations to date, and I strongly encourage you to give it a listen.
Jared Powell:
Without any further delay, I bring to you my conversation with Erik Meira. Hi everyone. Welcome to another episode of the Shoulder Physio Podcast. Very special guest today, Erik Meira. Erik, how are you, mate? I'm doing great. How are you doing? I'm good, I'm good. Erik, I was just chatting to you a moment ago. You are the og, you are the original podcaster in the physical therapy space. When did you start, Erik? Give us a little bit of the history there because I find it quite fascinating.
Erik Meira:
Yeah, so the, the first show was originally called PT Podcast was actually still exists. It's actually run by Scott Greenberg and Jason Torry now, which was just an interview show that started back in late 2011. Recorded the first episode, I think it's September of 2011. And then PT n Quest, me and my second guest from PT Podcast, which was JW Matheson, upon finishing that podcast were like, Hey, we should do a journal club type thing, because back then you, you bought like a packet of bandwidth basically. And I had way more than I needed for the one podcast. I was like, you know, it's free for me to do a second one. And so we started PT Inquest, I think it was January or February of 2012. So yeah, been a while. Yeah.
Jared Powell:
And it's still going today.
Erik Meira:
Yeah. Yeah. I brought in a couple more, you know, JW kind of back down last year and brought in a couple more voices. So we got Jason Tory and, and Chris Genau. And bringing in Megan Graham has been helping out as well. And so it's great cuz I get to step back a little bit and, and let other people kind of take up that torch some I'm, I'm a big fan of kind of passing things along, letting other people step into spaces.
Jared Powell:
Yeah. Maybe our politicians could learn from that. Erik, it's a nice, it's a nice philosophy. Yeah, I, I do, I do. While, while, while we're on your podcast, I do just want to give you a shout out and speak for a lot of others and say, thanks for doing it. You've, I I've been a physio for 12, 13 years and it sort of coincided around the release of your podcast and I've listened to hundreds of hours. I'm, I'm, I'm embarrassed to say no, but I'm proud to say it's been really helpful for me on my journey. So thank you Erik. It's been really good. Oh,
Erik Meira:
I appreciate that. Yeah, we're coming up on 300 episodes and it's funny because when we started it, we didn't think anybody would even listen to it. It was more just an exercise in having these conversations and we just put it out there and it, it's amazing how much it's grown and how how many people listen to it and, and get value outta it, which was always surprising to us.
Jared Powell:
Has it helped you sort of in your journey as well to figure things out and think deeply about certain topics? Yeah,
Erik Meira:
Absolutely. I'm a big fan of kind of thinking in public, and I, I think that's one of those things that we've become really bad at lately because everybody's afraid of saying something that's gonna be judged later cuz everything's kind of recorded. And so when you are kind of spouting off to an audience that's knowledgeable, you have to really think about what you're saying and think about how it's gonna come back around to you later. And so it's a, it's a nice exercise in really kind of pumping your brakes, trying to consider everything and, and being from, from that perspective. And, and, and again, that's also kind of from how we approached it. There are definitely people out there who just have an agenda and they're gonna push that through no matter what. But ours was always trying to, to be as honest and transparent as possible through that. And that's definitely helped me. There's definitely articles that we reviewed on the podcast that I probably wouldn't have read otherwise, but it was just a matter of, Hey, we gotta, we put something out, let's find an article real quick. And it's like, oh, wow, those are really interesting articles. So, you know, it definitely helped me. And then, and then again, as I said, it, it helped me be kind of a, a little bit of a public thinker, if that makes sense.
Jared Powell:
Yeah. It's quite a vulnerable thing to do, Erik, as I'm starting to find out, you know, you, you, yeah, you, you're sort of on record a number of times with hundreds of hours of, of you talking into a microphone to somebody else. It almost feels like a private conversation, but thousands of people listen to it. So, but I think that gets to the core of today's chat, which is about, which is about science, right? And you kind of, it's okay to be wrong, it's okay to evolve your thoughts and your thinking. And it's o in fact, isn't that, isn't that the crux of science? Like being wrong is a feature, it's not a bug of science. Yeah,
Erik Meira:
Absolutely. Science, you know, this goes back to decart the, the Koji do I think therefore I am, which is the root of what that means is that there's nothing you can know for certain other than that you exist. So meaning that you can never be right, but what you can be is wrong. And so what you can do is do the best you can to be less wrong. That would be, as Isaac Asimov's favorite famous saying, is the effort to be less wrong. And so what you're trying to do is identify where things that you know not to be true and steer yourself away from that. So science is weirdly a very strong embracing of and certainty, which a lot of people see it as the opposite. They see it as being very certain and very kind of strident in, in your beliefs. But the way science works is that you could be strident in your beliefs and certain about things that are not true, but that is a very narrow slice that takes a lot of work and a lot of effort to establish. Yeah.
Jared Powell:
So one of my favorite philosophies is, is Carl Pop. And I mean, that's almost echoes entirely his philosophy in that we can never know the truth. Newton thought he was right. Well, he was right in some respects operationally. Right. But when it comes to gravity, he was proven wrong. Right? So you can never know the actual truth. We can perhaps get closer to something resembling the truth by steering away from things that are obviously false.
Erik Meira:
Yeah. And so Popper was a contemporary Albert Einstein, and that's where that those two kind of come together with Newton is that, you know, Newton's classical mechanics, which is how we describe everything I teach is classical mechanics. I mean, that's Newtonian physics, but it's not, right. It's just, as you said, operationally useful. But when you get into larger structures like planet and things moving close to the speed of light, like light, that's where Einstein's relatively comes in. And that's basically what Carl Popper had looked at, is he kind of stepped back and asked the question, what makes Einstein Scientific, but Freud not mm-hmm. . And so, and it was that idea of falsifiability the idea that, well, what you do is you try to disprove. And so Einstein famously said, no study can prove me. Right. But one study can prove me wrong. So you can have like 20 studies in support, but none of them can prove you. Right. One study by itself if done properly, can refute you. And that's, that's how science works.
Jared Powell:
Yeah. No matter how many white swans you see in a row, it doesn't mean all swans are right as well. Right. That's exactly, exactly right. It's gonna come down under to Australia. But, so before we get into the meat of the chat, Erik, I just wanna catch up with, with where you're at, because I know I really wanna talk about a lot of these things, but I've just gotta intro you a little bit for the three people that haven't heard of you. So what are you doing these days, mate? I know you've you've, have you stepped back from, did you sell your clinic or something and, and what, what are you opt to these days? Yeah,
Erik Meira:
So I sold my clinic back late 2019 with actually the goal of kind of switching to, you know, I tried to sell to a group that would let me kind of shift a little more towards like residency type programs. So, so again, trying to foster more education type things that didn't really pan out. These companies are for profit. They wanted me to be seeing patients at actually a higher volume than what I was doing as an owner. And and then the pandemic hit and that pretty much erased everything. And so then I pretty much went into full-time consultation and education. And so putting on, you know, online courses I immediately started those, you know, with the pandemic still was doing my in-person stuff when, when it could resume. And then doing consulting and mostly with professional athletes and some universities here in the United States.
Erik Meira:
And then the big thing I have coming up is actually coming up this weekend, which may be after this episode comes out is our elite basketball rehab conference, which we're doing with the N B A or not with the N B A, but at the N B A Summer League with a bunch of N B A individuals or people who work in the N B A presenting for it. We have about, we're probably gonna have a total of between 150 and 200 people that actually show up. So it's gonna be a pretty big event. And I'm kind of I'm almost bald because of pulling all my hair out for putting this on, but, but that's kinda my big, big thing right now. I'm really passionate about it because I, what we're trying to do is connect people who want to get involved in that level of sport with the people who are involved with that level of sport and trying to make those connections to help diversify the avenues to get into that level of, of physical therapy.
Jared Powell:
Awesome. And so you, are you a basketball fan, Erik, or is this just a coincidence that it's in basketball? I,
Erik Meira:
I do like basketball. I do enjoy it. It's one of my favorite sports, but I just happen to do a lot of consulting with the b a right now I take care of a couple N B A athletes, and so I just am very, very well connected with it. And then there is this interesting convenience with the N B A is that they have a summer league, which is in Las Vegas. All the teams are there for two weeks. And it's very kind of informal. The games don't matter, it's just this, this interesting little league where they get to kind of test out their new and upcoming players. And so all the staffs are just kind of there with not a ton to do. And so I was like, I'll give you guys something to do if you wanna all come together. And so it, it really comes as a matter of convenience. We're, I'm trying to find ways to expand it to other sports like AmErikan football or potentially soccer or regular football to the rest of the world to do it around some of those. But the difficulty is finding when all the teams are in the same city. That's definitely a challenge.
Jared Powell:
So you're enjoying this sort of next chapter of your career, Erik?
Erik Meira:
I am. Cuz what I'm really passionate about is trying to help others coming up behind me. I found when I was coming up to, to, I came across a lot of difficulty, a lot of roadblocks, and I felt like I was just, just hacking my own way through a jungle to try to get, to reach my own personal goals. And I found it very frustrating and kind of a, a mantra to myself is I wanted to make it that it wouldn't be like that for others. That's the crux of the education I do, is this is like all the things I've learned here. I want to teach you guys that so that you don't have to do all the work I did to figure out like basic physics, something that we should be taught in school. But I'm shocked at how poorly as a profession we understand just, just the basics of physics, which underlies, you know, a lot of what we do.
Jared Powell:
Yeah. Awesome. I, I love it. So what do you do for fun?
Erik Meira:
Currently? I'm trying to finish up my instrument rating for flying. So I'm, I'm a private pilot, so most of my free time is, is rooted in that right now, which is it, it's great. It's kind of meditative. It's, it's cool because, you know, when you're flying a plane you can't think about anything else. you pretty much are very focused on what you're doing. But there's a lot of really fascinating things around it that really kind of fits my personality is that there's like any like, rule that you're following is therefore a very specific reason and they can cite the incident. It's like, the reason we do this is because back, you know, 30 years ago there was a plane that crashed because this cascade of events. And so you're constantly looking for how do these cascades work? And so what's really cool is that causation matters very much in the aviation world.
Erik Meira:
And so it's not a matter of we think this might cause a problem, it's well, does it cause a problem or does it not? And how do we know? And so it's, it's really fascinating to look through the, you know, the, the education of learning how to fly an airplane. You have to learn the history of all aviation developments and why things are the way that they are. And then, you know, if you buy a plane, that plane is gonna have a long history of every incident that's ever happened and why they happened. And so it's really kind of cool from that perspective, from the analytical side. But then on the other side, you have to fly by feel. I mean, you are, you know, you gotta connect yourself to the airplane. The winds are constantly changing in real time and how are you kind of blending with that? So it also has this interesting kind of dance that you're doing well as well, that's very intuitive. So it's a really kind of cool combination of the two.
Jared Powell:
Art and science it sounds it sounds really familiar actually. Yeah. And, and Erik, what's what's your, this is a, this is some odd thing, this is a funny question, but I'm really interested not just in successes, but failures. So what's, what do you reckon has been your biggest failure to, to date? And it, it doesn't have to be like a dramatic failure, but just something that perhaps you've learned from.
Erik Meira:
Well, I will say you know, contrary to what a lot of people think is understanding like, like the business side of things, I've never been great at. I, I just, my attention spans kind of short once, you know I heard somebody mentioning, actually earlier today, I was reading something about driven by curiosity, not by completion of projects, mm-hmm. . And so a lot of my failures kind of re revolve around, you know, taking on something, thinking it would potentially like generate like this is a successful business. And it kind of failing from that perspective, you know, professionally, I would say, you know, especially as a new clinician learning to embrace uncertainty, I have a lot of failures around believing I had answers to things and then recognizing later that no, I don't have any answers to ev anything.
Erik Meira:
And that's why I don't think I've written much about it. I know I've talked about in the lectures I do, in some of the online courses, I kind of fi follow what I call a Socratic method to working with patients, which is the belief that you actually don't have the answers, but you can have the questions. And so you help people through questions, not through answers. And that's, that's something that, thinking I had the answers way back when that was, you know, a big failure on my part with a lot of patients where it's like, I almost had a moment where like I wanted to go through my old patient list and get on the phone and just start calling them and saying, Hey, I'm sorry, . Yeah, I'm look thinking back about your case and oh my gosh, how I was not giving you the information that would've been most helpful for you. You know, we probably had a successful outcome and they probably were very satisfied and they're not aware. But I'm looking back going, man, I, I, I could have helped them in such a better way than I did.
Jared Powell:
Yeah. I've ruminated and meditated on the same thing a long time. I've made, I've made memes about it actually. And I think a lot of people can relate to it because in your first five years of practice, hey, you're just trying to survive and we're doing the best we can, right? And, and with pressures, external pressures, if you're in private practice, there's boss pressures, there's this pressures, there's that pressure. So it's challenging. So I've gotta forgive a lot of physios, but it is good to reflect on it and go, I
Erik Meira:
Could better. Yeah. And that's where I, I, this is almost a life lesson is to, you know, to anybody listening, I'll tell you right now, you are not perfect. You will never be perfect. Do not expect that you are gonna do things perfectly. You will fail, you will mess up. And that is totally fine and acceptable, have the same compassion for others in that regard as well. They are not perfect. They will fail and it is not a failing of them as a person because people are imperfect. And so giving yourself that kind of, okay, it can be really kinda liberating. You know, obviously you don't go through life and like whatever , you know, I, oops, I crashed into somebody in my car. I'm not perfect, you know, you're doing the best you can, but, but understand that doing your be the best you can does not mean you're gonna be successful a hundred percent of the time.
Jared Powell:
Yeah. So this is the idea of, of fallible humans are humans fail. But it's sort of, I think the key thing is here is the response to that. What do you learn from that? Do you evolve? Do you get better? Or you just, you go, well that failure wasn't my fault, that was the patient's fault, they didn't do their exercises, or that was some, some other person's fault. Right? So I think that's a really crucial point. Fall bullism or being wrong is at the heart of learning and progress and, and getting better. So this kind of goes to the next question, Erik, a little bit. So you're the science pt. Where did science, where did this passion for science come from? Was it inherent from a young age? Were you interested in science at school? Did it develop over time? Was there a light bulb moment? Where did an apple hit you on the head when you were walking around and you pondered on the laws of physics? What was it?
Erik Meira:
No, ever since I was a small child I've just always been passionate about science in general. So the natural world and that kind of thing, you know, I would, as a small kid, I would just watch, you know, nature shows and then anything to do with physics I just always found to be very, very cool. It's, it's one of those things that, you know, later in life, I, I it was pointed out to me that I am technically on the autism spectrum, which was very enlightening for me. It, it, it was very freeing for me because there are a lot of things about me personally that I would beat myself up about as to, well, why can't I be better at these social situations and things like that? And then I just realized, oh, that's just not me.
Erik Meira:
I'm literally not wired for that. And so then thinking back about all the things that, that always drove me, and it was always that analytical thinking about, you know, how the world works that, you know, always was kind of a passion for me. And, you know, both my parents my, my mom was a, was a school teacher and my father was an electrical engineer, and they're both Cuban refugees. So it'd come from, you know, totalitarian, you know, environments and things like that. And where a cult of personality basically can drive everything. And so I always had a kind of, you know, instilled in me that you need evidence, don't just go by with how well somebody speaks. You actually have to get down to those what we, what we call those kind of root principles. Where does the concept ground itself, and then how does it grow from there?
Erik Meira:
Has always been kind of a, a passion for me. You know, from a, as a kid I used to do little science experiments as a kid, you know, testing out different detergents on clothes. And I did a whole project on the physics of waves cuz I was kind of into surfing when I was in high school. And so I did a whole project of how waves propagate and, and the difference between a sound wave and a and a a light wave versus a wave on an ocean and how they, they work together and all, all fascinating things that, that made me very boring to people in general.
Jared Powell:
Well, I think it just shows your character and your post. It sounds a lot like Richard Feynman just read his book on, on how he grew up, always tinkering, always trying to explain and figure things out. I think it's either in inherent or it isn't. I mean, maybe to be honest, I, I wasn't, I was more of an active sort of sporting kid and my love for science kind of grew out of that. Later on, actually more after I was interested in injury and, and pain and medicine, then my love for science sort of grew after that. So perhaps you can come into it later, but especially physics, it, it feels like there's an innate curiosity of the natural world, which is sort of there from a young age. Yeah,
Erik Meira:
For sure. And physics is one of those, you know, I teach a lot of what I teach is, is biomechanics and people are like, well, you know, biomechanics don't always matter and they'll talk psychosocial and all that stuff. It's like, no, you're misunderstanding what biomechanics mean. It's literally in the word, it's the interface of biology with the mechanical world. That is what we do as humans now. It is connected to a brain for sure, but it still has to engage with the natural world. So that interface of the natural world that is biomechanics. So the, what I like to point out is cuz people are like, well, where the knee is in space doesn't matter. It's like, well, it, it doesn't, but the forces around it do. And, you know, biomechanics is how we explain how water moves up a stock, how a nerve propagates a signal, you know, that's all still, you know, where biology meets, you know, the, the real world, so to speak, the physical world.
Erik Meira:
And so to me that was always the underlying math of life, basically. It's not just a ball, you know, a ball rolling down a hill or something. It's, it's then how does an organism interact with that in all the fascinating ways that, that that happens. You know, you think of something like weather systems, for example. That's all physics going on there, but it's so complicated of a stew that to unpack it all, I mean, to me it's the coolest thing ever because it's so complicated. But you know, at the end of the day it produces a storm.
Jared Powell:
Yeah, no, it's somewhat predictable. Yeah, you're right. I wanna go back as just a moment sort of backtrack a fraction. You said something really interesting to me how your parents were, were Cuban immigrants to the US and they came from this totalitarian authoritarian regime and that I've just straight away sort of related that to science, right? Which is the opposite. It should be the opposite of it's nelus inver, right? Take no one's word for it, which is what these authoritarian regimes actually are. And so are you reflecting back there and going, well, perhaps that shaped my curiosity of science, sort of going against this authoritarian way of thinking and sort of opening up creativity and, and critical thought, or were you aware of that from a young age?
Erik Meira:
Yeah, so science is, is, there's a lot of different ways science has been described. You talked about the you know, Karl popper's, falsification, falsifiability you know, you could talk about David Hume's induction decart, you know, with the lack of un the the lack of certainty. But one of the things that's highlighted that I really like to go back to is we're known as the mertonian norms of science, also known as the, the kudo norms. And so that's communalism, universalism universalism, I mean disinterest and organized skepticism. And so these kind of things are all rooted in this idea of getting away from groupthink in general, and transparency and the openness of sh you know, sharing and then being skeptical. You know, I think you mentioned Richard Feynman before, and he would talk about that all the time, is it doesn't matter who said it, it matters to you who, how do you support the ideas?
Erik Meira:
What is it based in what is it rooted in? And so, you know, total totalitarian regimes are exactly the opposite. They are trying to close conversations. They're trying to induce certainty. I mean, I, I don't wanna get into left-wing versus right-wing politics, but it's all the same. You know, you'll see people who will say, oh, well don't admit that because that undermines our cause. It's like the truth never undermines a cause. If your cause is undermined by truth, then you have the wrong cause. You need to take a step back and let the, those conversations happen and, and be okay with somebody saying, you know, I'm, I'm skeptical about this idea, let's discuss it. And that's where, you know, being able to lay something out from its, you know, again, its kind of first principles, you know, is really important. And so, yeah, I mean, you know, coming from, you know, being raised by a family that went through all of that that's definitely and I mean, Cuba is what it is.
Erik Meira:
There's plenty of examples around the world, and even in free societies, you have groups that try to, to push these kinds of agendas. So you definitely see them. But it is the antithesis of, of science. You know, you can look at who was it, Chenko from the Soviet Union who was like their, like the director of agriculture or whatever. He basically decided that, you know, there's certain, certain scientific ideas that were anti Marxism, therefore they couldn't be true. And so they ignored them and then it created a massive famine. And it's like, no, it's, you know, you can't argue with reality. That's, you know, no matter how much you want it to be true.
Jared Powell:
I agree wholeheartedly. I I kind of, I'm reminded of a quote here by, by Papa and he says, every idea, every opinion is valid, but every idea and every opinion is open to criticism. And I think that sort of gets to the heart of what you're saying. Would you agree?
Erik Meira:
Yeah, absolutely. And this is something that I think is really important for people to understand. And I teach this very specifically, do not identify with your beliefs. That is the most dangerous thing you can do because the second you identify with your belief, any attack on your belief is an attack on your identity. And that is extremely dangerous because you will not tolerate attack on your identity. And so what I always teach people is when, when they s you know, as you interact with the world, your brain is automatically gonna explain what you're seeing. It's just creating a structure for you to get by with the world. So you see an event happen, you create some sort of causation to it as a way to start thinking about it. The problem you have is that you become committed that that must be the answer and your brain almost never goes to the right spot first.
Erik Meira:
And so what I always recommend people do is just take a quick step back and say, what are all the other ways I could explain how this happened? You don't have to believe any of them, and they can be all nonsense. I mean, just whatever, just make up stuff. What are all the ways? And, and the funny thing is, is a lot of times the most absurd thing, you then take a step back from it, go, Hey, actually wait a minute, let me think that through. And you start to go, okay, well following this line of reasoning we end up over here. And that's a really interesting space to be, let me really think through this. The other thing is, and and I call it like alternative hypothesis generation, meaning you are just coming up with lots of different explanations for what you saw. You get to own all of them because you came up with all of them.
Erik Meira:
So when one of them is attacked, you're not worried because you've got all these other ones as well. And so the more broad you are in your attempts at explaining things in lots of different kind of crazy ways, the more you are able to shift as evidence shifts. Cuz as we talked about, you know, if you have like 20 different hypotheses, what'll start to happen is some are gonna get refuted and you'll easily let go of them because you're not holding them precious. And so as you lose more and more to falsification, you're only left with a handful of possibilities. Again, none of them being a hundred percent accurate, but they all are kind of orbiting around quote unquote the truth which you can never access. And I think that's really important to have that kind of flexibility.
Jared Powell:
Yeah, a hundred percent. And that's really well said. We, I've, I've been in, I've been through stages when I sort of have held beliefs a little bit too close, and I've had to really think, and it's got uncomfortable when evidence comes out, especially in the last five years with this mechanism or mediation analysis research, which has come out that has refuted a lot of our explanations by how our treatments work. And I've had to take a step back and go, right, how do I explain this to a patient? You know, like if I'm prescribing exercise, how does it work? We actually don't know. So I've now got several hypotheses of how exercise may help and how, how about this, right? The hypothesis, the hypothesis I will invoke will be different perhaps for each person based on their clinical presentation. Do you have anything to add to that?
Erik Meira:
Oh yeah, absolutely. That's, and, and you know, I find it funny a lot of times come at, people come at me with what they think I believe and they're, they're attacking it. And I was just like, I don't, right. You know, I've got 12 hypotheses to . Yeah, well, you know, people say you believe quad strengthening is, is is the most important thing for for a c l rehab. And I'm like, no, I believe that monitoring the quad and assessing when it has come back online fully is a key part. Hence I say it's the quads until it's not the quads. But that's what I'm saying is that's your indicator. Now, I'm not saying you can actually willfully change it now. Yeah. I would do a program that pokes at it and it's loading it, but I'm not saying that if you do three sets of 10, oh no, wait, God forbid, three sets of 10.
Erik Meira:
If you do, let me see, four sets of eight because strengthening conditioning principles here, Erik, come on. Yeah. I mean, what am I doing ? So if you do four sets of eight for sure, you know, not three sets of seven that'll kill you. But if you do four sets of eight for however long at this dose is whatever that you're gonna will your way past that quad deficit. It's like, no, no, that's absurd. And I I don't believe that, but people will say, I do. And and again, you'll you'll notice what I actually will, the statements I actually make end up being very vague in kind of, this is what we are pretty certain about. That there is something about when that quad comes back online that is an indicator that this person has moved into a phase, that their return to sport is gonna be a lot safer.
Erik Meira:
And I can explain all the reasons. Having a quad deficit can drive problems if they try to force themselves back. But that does not tell me how that intervention is going to work, just how we're tracking it. And so it's very specific to, and, and, you know, I talk about this a lot of being very, very clean in your, in your interpretation of evidence, don't over interpret, really think about, okay, what exactly is this study saying? So I don't add conclusions to what I'm seeing that aren't actually there. There's a, a philosopher Fitton who was he has a very funny comment where somebody was talking about the fact that the earth goes around the sun. And he, you know, this other person's comment was that, oh, well they, you know, we believed that the sun revolved around the earth because look at all the evidence when you look outside.
Erik Meira:
And Dickinson's reply was, well, what's the evidence look like if the earth is going around the sun? Exactly what we see. So it's just your interpretation that's flawed. It's not your evidence necessarily. So interpretation is your most dangerous thing, and that's where it's you, you gotta really dial back. And, you know, I talk about that in my foundations course where I give examples of, okay, here's, here's a study now what exactly does that study actually say? And then I give all the examples of how people, what they think it means as far as how they interpret it and how they implement it. It's like, no, it doesn't mean those things at all. It means this very narrow thing right here. And then what are you gonna do with, with that? And the reality? And this is what you're getting at when you talk about like exercise for, I don't know, like OA or something like that.
Erik Meira:
There's this huge cascade of forks of possibilities that come out of that. And what's probably the reality is that the reason it works for one individual, maybe a completely different avenue than the reason it works for another inter individual. And so this is where I'm a big fan of just spit balling with the, with the patient and be like, Hey, here's all the things that it might do and might not do. I'm also not saying because, you know, I I'll say, you know, spending time with your family, their quality time is probably gonna make your osteoarthritis feel better. You could do that. You know, it, it is just, you know, managing your stress better and, and exercise may be a way that people are managing stress. And that's the effect. That's what's actually the exercise is doing. It has nothing to do with strength, it has nothing to do with blood flow. It has nothing to do with getting fluid exchange or whatever all these other explanations we have for it, that we have very little evidence that it, that it's causal. And so just pitching it to them of, Hey, you know what, exercise seems to work for a lot of people. Here's the potential mechanisms. Play with them as you see. If it seems to be working for you're great and if not, let's explore some other options that might be most effective for you.
Jared Powell:
Oh, perfect. That's exactly how I practice. You, you reviewed one of my papers, Erik, on your show and you did a great job. Oh, sorry. And we found we found there were over 30 different causal explanations or mechanisms for the effective exercise for rotator cuff tendinopathy. Over 30 different mechanisms in clinical research, which have been profited or proposed by clinical researchers. None of them proven, none of them actually really tested. There's only one mediation analysis ever been conducted in shoulder pain for exercise, which is criminal. And yet we have all these theories about it. It's fas So the overinterpretation thing is also hilarious. We see this on Twitter every day. We see a paper gets released a fascinating clinical trial or systematic review gets released and there'll be 58 different interpretations of the same data. And that just vindicates precisely what you're saying, this interpretation based on your bias and based on what you see. It's really quite hard to watch sometimes when we see these debates going on and on on social media. And you can just, if you take a step back, you can see it's bias against bias. Yeah. What do, what do you think when you watch these debates?
Erik Meira:
Yeah, so, you know, first off, it, it's the most frustrating thing is one of the reasons why, you know, I, I started bringing more people into ptn quest because, you know, you do it for 10 plus years, you really start getting frustrated with the body of literature that you keep seeing these studies. Like, like you're pointing out is where they, they did exercise for tendinopathy and outcome is positive, therefore, my mechanism that I'm using to explain it must be true. It's like, that is not how this works at all. And it's, what's frustrating is it's the same study over and over and over again. Can we just get the understanding that you need to go back to the mechanism and test the mechanism? Because if you claim exercise does a thing, first off, you have to show like, so let's look at like infectious disease.
Erik Meira:
Let's make it very black and white here. So somebody comes in with a fever, you know, all these symptoms, this is what they're complaining about, this is the thing that they're upset about. You then establish that there is a very high rate of a certain microbe in this individual. So you're, you're making a correlation between those two, then you're going to do an intervention of an antibiotic or something like that, that you're gonna give them that antibiotic results in a decrease in the microbe or, or the bacterium or bacteria in this respect. Which then coincides with their change in symptoms. So you have this kind of network of things. You don't just like throw 'em in an ice bath and say their temperature went down, therefore the ice bath cured them of whatever was causing their symptoms. It's like, no, you just treated the symptoms and that doesn't have anything to do with causation.
Erik Meira:
You know, it just has to do with the symptoms change. Now it's possible that ice somehow kills the bacteria and so you inadvertently did treat the cause, but you have no understanding of that mechanism and it keeps you from actually being more direct and intentional about what you are addressing. And so we see this all the time with our literature where it's like, can we just, and this is something I've been pushing the profession for years to do. Can we have some sort of an agenda here collectively where we say, here's the question we need to answer first. Then once we answer that question, then that creates these three questions. Now those three questions need to get answered. And then the answers to those three questions creates 16 different questions. And you see how it kind of builds our knowledge base. This is the problem.
Erik Meira:
And Newton even talked about this, of, of this intention to answer all the questions in one generation. It's like, no, you need to find the questions you can answer well and answer those and let the next generation take it from there. Understanding you are not gonna have the finance answer. Well, we keep trying to do is do a study that answers the final question of quote unquote, what do we do? And we don't move ahead in any way. Not sure there's value to those things, but we don't need 2000 studies of it. , we got the gist of it. You you rub on something, it feels better. Okay, good. Established. Honestly, I don't need a study to tell me that I can do that to a patient and they go, I feel better. That was all I needed. I don't need research to be telling me that. So stop doing those studies, you know, and, and kind of go, let's establish some things better at our kind of base level. It just seems more important. Yeah,
Jared Powell:
We've put the cart before the horse, haven't we? We've, we've gone to effective all these effectiveness studies which have come out comparing things and they're all kind of the same. There's over a hundred, there's like 150 clinical trials in the shoulder pain, which shoulder pain would say, yeah, it all kind of works, like one point out of 10 reduction in in pain or this and that and Right. We have no idea on the causal mechanisms, mechanisms underpinning the treatment. And if we did have an idea, perhaps we could be more targeted in our treatment, which might actually change the effect size. Well how about we just try that anyway and figure it out first, right? And and instead of just conjecturing and hypothesizing, which is fine. So clinical, we're not, we're not sort of denigrating clinical trials here. No. The whole point of a clinical trial is to show the average effect of an intervention compared to another group. Right. It's sort of comparative effectiveness. You do this, this group had this result, this group had that result. Let's compare. We're not tr the clinical trial is great from that respect, but it's not designed to elucidate or manifest causal mechanisms. We need a different design there and that's fine.
Erik Meira:
Yeah. And this is where, this is where, you know, trying to get people to understand, you know there are like studies that, that are putting people into groups and then there are studies that are moving people from one group to another and differentiating between those two. So an example would be you have a study that says people who can do 15 single leg squats three months after, or say six months after an A C L reconstruction have a much lower incidence of second injury. And so our conclusion from that as a profession is that we need to get our patients to be able to do 15 single x squats by six months is no, that study that was described is just putting people into groups and saying at six months. And, you know, I go into much more detail on these kind of things of, of how you would actually even make the statement that I'm gonna make, which is a lot more than just this one study.
Erik Meira:
But that one study is basically saying at six months you can categorize people into likely to have a second injury, not likely to have a second injury by making somebody be able to do 15 single leg squats by six months. That does not move them from one group to the other. You think it's moving them from people who are gonna get a second injury to people who aren't. But you're not necessarily doing that, that that's, at least that study is not saying that you'll do that. That gets more into an intervention study. And we saw this with hop testing, you know, hop tests where the, you know, there are studies that came out that showed you 'em at six months if their hop tests look bad, their likelihood of a second injury is gonna go way up. So we started working really hard at hop testing or at hopping, got everybody better at hopping, but we didn't solve the underlying thing that was the root problem for the original cohort, which is that they can't decelerate using the anterior knee.
Erik Meira:
And so we basically taught a bunch of people how to, how to hop, but it didn't actually translate to any sort of injury prevention for them for that second injury because it didn't sort the original problem. And so, you know, again, this gets back to being very disciplined in your interpretation of a study study does not say getting them to do the 15 squats is gonna change them to another group. The study is just saying, Hey, you know, if you have two peop two groups of people that are, if you have a big group of people who are six months out from ACL reconstruction, you can do this quick dirty test and make some predictions, but it doesn't say you can do any it doesn't describe your intervention.
Jared Powell:
Yeah, no, we can bang on about this for hours. I love Oh, sure. I'm not gonna get through all my questions. Erik, I wanna ask you, in fact, this is the first question that I had written down. So what, what role, Erik, and this is gonna be obvious, but I want you to just go through it from your perspective, if you don't mind. What, what role should science play in physical therapy? Like, should it be the cornerstone or should it be a backwater, peripheral fringe kind of concept that we apply? And then I wanted, I take you to take that a step further and I want you to think about can the standards of robust science, you know, that we see in physics and chemistry and maybe to a lesser extent biology be applied to things that are murky, like pain and psychology and sociology. So start with where should science be in pt and then how adequate do you think the scientific method is in physical therapy and explaining complexities of like pain, for example?
Erik Meira:
Yeah, I mean, what I would like to see is, would be studies that give us better understanding of our basic science, of what underpins what we're doing and, and how we're doing it. You know, simple things like, you know, if, and, and maybe, and I mean we do have some, it it, what's funny is it seems like we've all kind of gone this weird circuitous way to it, like our understanding that manual therapy probably isn't changing some's tissue. But that could have been a very easy study done very quickly or a handful of studies to establish that if that was an intentional thing. But what we did instead is we kept looking at the effects of manual therapy a as far as like the effects on pain, the effects on the patient. And we, it was from all the conflicting evidence with that, that we started to go, Hey, wait a minute.
Erik Meira:
You know, what would underpin all of this if there were that, if there weren't the specific effects we thought if they were all non-specific, but we could have g been a whole lot more direct with that. And that's where I think physical therapy science should be, you know, driving itself in that way. The other thing would be to get us to be understanding probabilities better. And so patients are not all the same, we understand that, but we can use probabilities to start kind of categorizing them to at least be more predictive. And we could even be predictive as how they respond to an intervention, even if we don't know the interventions mechanisms. But you can see if you understand the mechanisms, you can be testing for the mechanisms in somebody. You know, back to the example with an antibiotic. You give a doses of antibiotic to a patient and you test their, their blood and the bacteria has not changed.
Erik Meira:
Well, this is a different kind of bug you know, a different kind of bacteria or this person has such a raging case that the amount of antibiotics that you're throwing at it is not effective for this person. So being able to understand that, but that's, that's a very mechanism way to go about that. And, and this is where, you know, someone breaks their leg, for example. Well there's some very much, there's some very real there, quote unquote nociception going on there from that fracture. But there's also an experience of pain that that person is going through as well. And so you can, if we had a better understanding, we could understand on an individual case by case basis of how that interface is happening and how we're kind of working through that. This is where, you know, we have this kind of one size fits all type thing of, you know, even within the pain science world is, oh, we just need to quote unquote pain science our way through this.
Erik Meira:
It's like, well, but there's a lot of complexity to that that's based on the individual. You know, people would also say, well, pain science understands that. It's like, yeah, but that's why it becomes so difficult to research is because it's not a one size fits all type thing and it's very hard to control for it. It's very hard to set up a study for it. And so unless we can start categorizing patients better and and organizing things to go about it, you know, we're gonna have a hard time kind of understanding the, the roots of that. And, and that's where, you know, I do teach a lot about, you know, psychological inter interventions in general. Cause a lot of what we do ends up being from that perspective. And my former co-host from PT Inquests, JW Mathson would say, you know, you like to talk about the dodo effect.
Erik Meira:
The Dodo is the character from Alice in Wonderland that ran around and said, everybody wins. And everybody gets PR gets prizes. And in psychology what you'll find is any intervention works because what a patient needs from a psychological perspective is just somebody to listen to them and have compassion. Your intervention doesn't necessarily do that much after that. It's just trying to give somebody a mirror to allow them to kinda work their way through their process. But that process is unique to the individual. And until you watch them go through the process, you don't know what the actual answer is for them.
Jared Powell:
So just, just on that, I've, I've got a paper coming out in Ptj in a week or so, and it, it's exactly what you said, which is, which is crazy. The universe is , you're listening to the universe, the we're all connected quantum consciousness, blah, blah, blah. Where I basically asked patients with shoulder pain what their experience was with exercise, right? And we found that most people have had a positive experience with exercise under certain conditions and with certain caveats. And it was basically, did they get along with their clinician was number one. And so I had patients see multiple different clinicians given almost the exact same exercises, but their response to the exact same exercise was different based on their relationship with their clinician. So if they trusted their clinician there was therapeutic alliance, blah, blah, all these buzzwords that we like to use, then they had a good result with exercise and they probably would've had a good result with manual therapy, dry needling, acupuncture, yep. Surgery, whatever you wanna say, right? So, so these interpersonal relational factors are super important.
Erik Meira:
Yeah. So that's known as congruence from a Rogerian psychotherapy perspective. And that's what I teach. And again, I mentioned Socrates being kind of that root thing and, and Carl Rogers, who was the founder of Rogerian Psychotherapy is also how you get cognitive behavioral therapy acceptance and commitment therapy. All these things are kind of rooted in Gerian psychotherapy. And it's this idea of you don't have the answers, it's just how do you reflect them back to the patient and allow the patient to be the driver of their, their of their cure, so to speak, or their, their process. And, and this gets into, if I can divert just a little bit here to talk about Socrates, cuz this is one of those things, we all know this Socratic method of, you know, you asking questions in order to teach. And, and I love asking people, well, why do you, why do you think Socrates thought that worked?
Erik Meira:
And they're like, oh, well, because you're, you're telling you're allowing them to find the answer for themselves and that's more useful to learn. It's like, nope, he didn't believe that. What he believed is that the knowledge acquired by another person is unique to them and it is a different knowledge than yours. And so you cannot transfer your knowledge to the other person. You can only give them a process for them to find their knowledge, which is gonna be unique to them. So even the idea of two plus two equal four, you understand that differently than I do just because we are different people. And that's what, what Socrates was believing. And so therefore he also did not believe he needed to know the answer in order to teach somebody the answer. He just needed to have the ability to ask the questions, to help guide them through the process, their own process to get that.
Erik Meira:
And that's what that ary psychotherapy is, is that you are still kind of just reflecting back to the person and letting them be like a third party viewer of their own problem and kind of advise themselves through that. And so I do the same thing for human movement. I don't believe that I can tell somebody the right way for their body to move, but I can try to create some some inputs to the system, some information, some feedback intuitively and let the organism start to find its best way to organize its movement. But I have no idea how that person sitting in front of me is supposed to be moving.
Jared Powell:
So this sounds a bit like epistemological relativism, where different people come to know different things in different ways, which is different from an objective knowledge or that we, that we might have. So I want, do you, are you, is your ontology realism, do you think there's a real world out there that we can come to know things about? So would you say you're a realist and a subjectivist when it comes to epistemology or relativist? When it comes to epistemology? How would you de describe yourself if I'm not getting too left field?
Erik Meira:
No, I, I definitely, so, you know, you get into like, postmodernism and some of this, and so the, the idea here is this gets into the difference string of objective knowledge and subjective knowledge. And so, like subjective knowledge would be, you know, your reality is different than my reality because of your, your, you know, you're from a different country. You were brought up differently than I was skin color being different you know, differences in gender, et cetera, et cetera. That makes these different realities for people. But we can all have a process to come at whether or not the sun goes around the earth or the earth goes around the sun. That's not, I can just believe whatever I want. I have to, there is a process for that. So that's that ob objective knowledge. So there my belief structure is that there very much is a real world because the second you, you argue against that, you really start to lose a lot of ability to have anything really to work with there.
Erik Meira:
And so I don't go to full relativism in that respect, but what I'm really getting at is more of that kind of psycho biopsychosocial philosophy of there's always a human being inside of the patient in front of you that has to have that engagement and, and that interface with the real natural world. And so what I can do is I can manipulate the real natural world and then watch how that organism organizes around that world and help giving them environments for them to find their own truths, so to speak, from within their perspective of reality. So it's this weird kind of dualistic kind of view for that. You know, it'd be different if you're dealing with an animal that's not a human that you can't communicate with the subjective experience. There is gonna be, you know, blunted so to speak, compared to a, you know, a more cognitive being like a human. And so then you can be a little more just, you know, don't worry about the dog's experience, so to speak. You know, I, I think there are probably a bunch of dog trainers out there who would say, well, hold on a second. You have to get into the personality of that individual animal, and that's the way that you engage with them. And, and I would just say it's probably not quite as diverse as, as well, your engagement won't be as diverse because of the difficulty of communication. So, yeah. Yeah.
Jared Powell:
No, I love it. So I, I think I'm the same. I think there's a real world out there. I think if a tree falls down, it probably makes a sound, even if there's nobody there to hear it. Yep. But from a, from a knowledge perspective, especially when we're dealing with pain and injury and suffering and all of this stuff, I think that people will experience that differently. And it's up to us as a clinician to kind of work with that and not just assume, okay, you have back pain, your back pain's like the next 100 people. I'll see therefore, therefore I'll do this treatment just like everyone else. Well,
Erik Meira:
I mean, and so this is where you can see, you know so here you know, 10 kilograms of force makes this person say, ouch. But it doesn't make this person say, ouch. So what's the difference here? Now, there could be a structural thing that's, that's something is broken or torn or whatever, but it could also just be a calibration issue. So this organism, sensors, so to speak, are not calibrated quote appropriately. So they're going off when they shouldn't be. So they perceive danger when there isn't. And it's like, you know, like an alarm, you know, a motion sensor in your front yard and that motion sensor, you want it to catch the burglar and go off, but you don't want it to catch, you know, go off when the fly goes by. And so you gotta kind of calibrate that sensitivity there. And so, you know, a lot of times the patient's coming in and their alarm system's going off because of a fly, well, it doesn't mean that you need to stop all the flies, . You need to make it not be so sensitive to flies and make it be sensitive to things it's supposed to be sensitive to. And so, again, this is where, you know, two people, it's a perception thing. It's a, it's a sensitivity thing. And that's more than quote in your head. That's an entire organism, you know, from the nervous system through the physi all the way into its interface with the physical world and those biomechanics.
Jared Powell:
And I reckon it's an influence like generational too, right? With genetics and all this stuff as well. Oh yeah.
Erik Meira:
Oh yeah. Absolutely. So yeah, from a genetics perspective, and then also the, your cultural, you know, this is where the word meme interestingly, we, we think of it as, as a certain thing, but meme is actually a term that was coined by Richard Dawkins. And it, it's a, it, it's a play on the word genes. So you have your genes, which is your d n a, that is kind of your, it's inherited in your d n a from your ancestors. But a meme is the same type of inherited or, or heritage that's inherited, that's cultural, that is becomes woven into your being the same way your d a is. And so it's these things that are handed down culturally as well that influence you know, what you're, you know, this is where, you know, certain cultures are afraid of certain animals and other cultures aren't , you know, where they're totally fine with, with that. And it's just a matter of culturally how it's been instilled in them. They don't have the same physiological response as somebody else to the same stimulus, but it has nothing to do with their quote genetics. But it is, they're, you know, handed down through them, through their ancestry still.
Jared Powell:
Yeah. And both tricky and sticky and hard to change. You know, me, mathematics and genetics, like equally will, will sort of influence a person's perspective on the world. And it's so fascinating to think that, and when we deal with science, right, there's this whole western wealthy science that we study people and we sort of neglect the rest of the 90% of the world and we just go, ah, you just must be like western white people, right?
Erik Meira:
Yeah. Yeah. Well that, that's the thing, you know, in, in getting into, cuz sometimes people will like vilify like, like quote unquote western science. It's like, well, the scientific process, yeah. It does come from, you know, originally from Aristotle up from the Greeks and, and through like that. But it's, it's a non cultural process. And this is where, you know, post-modernists would particularly disagreed with me. It's like, well no, it's, as you were just talking, it's it's part of the meme, it's part of this, this, and it's like, well, but the point of it is to get away from all subjectivism and get strictly into an objective type thing. So I like to point out is that, you know, I mentioned, you know, whether or not the earth goes around the sun, that's a question that can be answered in a scientific way. Whether or not I love my wife is not a question that could be answered through a scientific method, but that doesn't make my love for my wife any less real than whether or not the earth goes around the sun.
Erik Meira:
And so it's just a matter of trying not to conflate these things or trying to apply a scientific method to a thing. Cuz you could talk about like, the belief structures of an indigenous population. Is that not real? It's like, well, you know, any sort of story has, its, you know, its utility in the culture, which is a very real thing. And it's a way of interpreting. I mean, sometimes I'll even tell somebody we'll do like a, a hip hip flexion activity like post-surgical and a and a arthroscopic hip procedure where I have them do like a coddle glide with one hand as they pull the, the knee up into flex and they find they go way further. And I go, I want you to imagine that you're pushing the head of that femur out of the socket as you're pulling it up.
Erik Meira:
And they're like, oh yeah, yeah, I totally feel that. So, okay, that's not happening at all. But you believing that happens is what you're doing is what is driving the actual push that's making this interface do the thing that it's doing for whatever reason that it's doing it. And so you know, science can't tell me why that perception does what it does. You know, there that, that gets into psychology, which, you know, is arguable of how scientific you can be with that process. But science can tell me whether or not that joint is moving. Okay. And so that's where the pulling those things apart, it's, it's, it's not trying to be a cultural thing, it's just trying to get at and, and I think that's where the, the conflict be comes in is where a quote unquote scientist says, stop acting like you're moving that joint because it's not moving. It's like, well, no, you can still act like it. You can still imagine it, you know, you know, sometimes you'll tell somebody to kick a ball and you want it to have the arc have it fly like a rainbow does. Well they're not gonna make it actually fly like a rainbow. But the idea of an arcing thing, it's just the storytelling that helps communicate between humans that doesn't have to necessarily have that quote scientific method through it. I'm not sure that I'm making any sense that
Jared Powell:
No, there's a, there's a, so we're, we're both gonna say a lot of quotes here and there's a quote that comes directly to mind. It's a theory or a belief system doesn't have to be completely right for it to be helpful.
Erik Meira:
Right, exactly. Yeah. The, the same idea of you know, all models are wrong, but some models are useful Yep. To, for another quote. But yeah, that, that's exactly it, is that we, we can't be perfect in our understanding of anything. So every way that we understand something is a model, you're trying to be as accurate as you can, but you just understand that it's still a model. What I'm, what I'm doing, what I'm saying. I have these conversations with patients all the time with the athletes in particular. It's like, I'm trying to put a load to this area here. Here's five different ways to do that. To me, they're all the same. But for whatever reason, for you, exercise number three seems to really load it the right way for you. But on this other person, exercise number two was the one.
Erik Meira:
And so I still have to wait for you to give me the interface to, to gimme the answer as to what's the exercise we're gonna do. And that's why I always teach exercises from a biomechanical perspective of think of the load profile you're trying, trying to get, and how many different ways you can get it. And then you play with it and let the patient tell you, cuz you're like, I need to get a load profile in this way. Here are all the different avenues to do that, but I have to have the athlete tell me which is the one they're gonna select. And you could say, well, that's pure, their perceptions like, well, but do you really know the anatomy of this individual? Maybe the fibers of their muscle, where their tendon issue is happens to line up to slightly different between these two exercises. That's more nuanced than your understanding. And you actually found the right exercise from a biomechanical perspective, not just from the interface with that individual. And who are you to say, which is the better one the patient has to tell you.
Jared Powell:
Yeah. And Erik, another thing you've just reminded me of again, is one of these famous studies, these twin studies here in Australia where they take literal identical twins, they give them exercises to do, and these genetically exact same human beings, literal clones respond differently to different ex to the same exercise. Isn't that just mind boggling? And then Yep. And then we expect athletes to respond the same. Right? It's just silly when you actually look at it from a deep perspective.
Erik Meira:
Oh, I mean, I don't want to get into, you know the identity of a person because you get into, you know, like multiverse type ideas where, you know, there's a, there's a universe where you made a different decision in your life, and so now you're this different direction. And so is that they're,
Jared Powell:
They're already in quantum mechanics. I love it. Let's go there. Yeah,
Erik Meira:
Yeah. Well, there, there's a really cool thought experiment where you, you go to the future and they have a teleporter. And the way the teleporter works is you step into the teleporter and it makes a perfect copy of you down to the molecule and builds it. Like, so you're, you're in Australia, it builds it in London and adds the same time. It builds it in London and you appear in London and your memories, everything are still intact. You're, you're teleported to London, it destroys what the thing that was there in Australia. So then the question is, if there's a malfunction and the machine doesn't destroy you in Australia and they're like, oh, sorry, it was a malfunction, but you're in London we're gonna go ahead and kill you here in Australia, who's the real you, the, the, the one that ended up in London. And, and so this gets into what makes us even who we are. And that's where those twin studies, because essentially they are clones upon birth, but the second they're born, they identities diverge because identity comes from experience. And so, yeah, I, you know, I don't wanna get too metaphysical, but
Jared Powell:
Totally. No, totally. And so, and we, and if we extrapolate that to just generally seeing unique patients, we have to expect there's gonna be some variance perhaps in how we should treat people. This is kind of basic, but I think it's important to say. Yeah.
Erik Meira:
Well, and that's where, you know, as I teach, it's like be very hesitant as how you're interacting with your patients. It very much is a, a little bit of a poke, poke. How do they, how do they respond to that? Poke, poke? How do they respond to that? Okay, here we go, here we go. Here's a little more. And, and you know, as you get more experience, you start to get a sense of pretty much everybody responds this way to this. It's not until I get to my second visit that I start to see them diverge. And so that's where you're, you're kind of moving through that, that process. And, and, and to me, I think that's what experience gets you if you're honest with yourself.
Jared Powell:
Yeah. No, I, I'm agree. Let's I'm gonna ask you one or two more questions. All right. Then I'll let you go and have some drinks for the 4th of July over there in the us For sure. So for clinicians, let's try and let's try and bring this back to clinical practice. Always important, rather than just talking about metaphysics and philosophy of science ,
Erik Meira:
Whether your identity is real . That's right.
Jared Powell:
I had another example which we could use, but we'll save that. I want to, how do clinicians use, or how should they use science in their practice? And this can be broad sciences, can be like behavioral experiments, or it can be like, how do they use evidence in practice? How should they use and engage with science in clinical practice?
Erik Meira:
I think the biggest thing is to challenge your certainty and give you that exercise in alternative explanations of things and using science to kind of explore through that. So for example, when I read an article, what I do is, you know, people get into are you looking at the are are you looking at the, you know, the, the statistics, what kind of analysis they did? Is that p value really accurate? You know, what about those confidence interval? It's like, no, no, no, no, just read what they did, read what they're concluding, and then take a step back and ask yourself what are all the other ways that could have explained what, what just happened in this study? That you should immediately be able to write a list down of all the different ways that you could have explained it, then read the actual paper.
Erik Meira:
I mean, you can get that from the abstract right off the bat, then read the actual paper and see did they actually answer these things? Because if they did, then oh wow, that conclusion, it has some, a little more weight to it. But if they absolutely ignored all these confounders that you popped, that popped in your head, well keep holding onto those confounders. And so this is, as I was talking about before, that, that idea of generating all these alternative hypotheses, that's where you then go to the literature where you're trying to clean that up, that list up and just be like, you know what, these couple studies here really showed us that it's, you know, for example, you did a manual therapy intervention. You said, oh, I, I moved this person's rib. That's one of your alternative hypothesis. You have these other ones of, it's just the interface with me.
Erik Meira:
It was just my, my I'm coming across as being very skilled and being very compassionate. You know, just making physical contact with the human has a, an effect on them, et cetera, et cetera. These are all these explanations you could have if you go to the literature and it shows that you absolutely are not moving that rib or, or moving it to a new space, well, you can then clean that off your list and say, well, and, and then if a patient says to you, I need you to put that rib in this spot here, you can say, with all honesty, and this gets into a Rogerian approach to interacting with a patient, is you try to find some sort of congruence where you would say, you know, I used to think that that makes a ton of sense. Here's why I would think that the rib is moving because I put all this force and you know, and it feels like it's kind of out and this that, but there was a study where they actually looked at this and it turns out that rib didn't move.
Erik Meira:
This is the patient interaction. This is what's coming from the science, is that you're able to communicate the science to the patient. But you notice how I didn't finish the thought. I didn't say, therefore I just said that study showed it didn't move. What do they do with that? Oh, but I still like it. Well, well, so why does it make me feel better? I don't know. Here's some ideas. I've been wrestling with myself. What do you think? And the patient says, well, I think it's because God comes in through the, you know, whatever. It could be something that's totally out of your belief cycle. It doesn't matter. You can just go, well, we can try it and see how it feels for you and for whatever reason, you know, there you go. But I can tell you categorically it's not a rib, you know, moving in this way.
Erik Meira:
And the patient might go, I don't care. I think it's the rib, it's fine. And you know, you handed it to them and they came to their own conclusions. But that's, that's kind of that handoff. And so to me that's what research is. Really how it's really applied in the clinic is allowing you to have a deeper knowledge. And so that example I just gave there, you know, this is when people say, well, patients don't wanna come in and have you say, I don't know, you're supposed to be the expert. You can't say, I don't know, things are uncertain. It's like, explain why you don't know. Explain the journey. Explain. I used to think this, but this study over here showed that and then this other study over here said this, this. And then some, sometimes the patients are like, wow, I'm really confused. So what should I do?
Erik Meira:
And I say, well, here are some options. Here are the kind of, here are the types of explanations patients have given me in the past as to why they chose this option. Here are the explanations I've heard in the past for choosing this option over here. Does any of those sound like it? It's in line with what you feel and let them make that decision from there. You know, some people like to do exercise cuz a lot of times patient walks into a physical therapist's office, they're there for exercise, that's why they walked in that door. The people who don't want exercise didn't walk in the door . And so yeah, you can offer exercise, they're here for it. That doesn't mean that everybody out there in the street with the same diagnosis needs exercise. It just means that that, that there's a selection bias as to what walked in perfectly fine to say, yeah, you can do some exercise for it. It's not gonna hurt anything. Let's see if you feel better by doing some exercise. And just the, the belief of them doing something can be what's helping them. This is why, you know, a patient, a patient will then go get crystals. They believe that the crystals are doing something. So the act of going to do get the crystals, that is what is making them feel better. Just that they feel like they are in control and autonomous as opposed, and that could be what exercise does. It's just be nice to know . Well,
Jared Powell:
Yeah, let's find out. That's, and just, just on that, the, did you see that mediation analysis which came out this week on that sensory motor training program? It basically found that back beliefs almost mediated the entire treatment effect of exercise and education.
Erik Meira:
So not surprised at all. Yeah, not surprised at all. And so that's where, you know, you know, a patient goes to a chiropractor and says that, that felt better. Well, yeah, you a hundred percent believe that that was gonna make you feel better. There were studies done at a Harvard where they basically put signs up and they're like to recruit people to an acupuncture study. And the, the, the advertisement says, would you like to, to prove the ways that acupuncture works? Well, that's automatically gonna select a bunch of people who believe acupuncture works. And so then they shammed it and did sham acupuncture versus real acupuncture and show that it was extremely effective in both regards. It's like, well, yeah, you have a population that strongly believes it's going to work. If you put up the same thing of want to disprove acupuncture and think it's a bunch of garbage you'll find that there's no effect from sham or real acupuncture.
Erik Meira:
And so yeah, I mean, patient beliefs that is much bigger when the patient's belief and the therapist's beliefs align, then that non-specific effect is gonna be huge. Yeah, yeah. Yeah. And, and as I always say, there's nothing wrong with a non-specific effect, but that's not where we're intentional our specific effects are or intentional. So if it is a non-specific effect, I wanna know that and I wanna lay that to the patient and just go, yeah, you can absolutely exercise, exercise may be a path for you to achieve what you're trying to achieve, but there's lots of different paths for you to do that. And so if you commit to that path and stay committed to it, evidence shows that people tend to feel better. But of course, people who are not doing very well tend to not be committed to the path because it's, they don't think it's working . And so that doesn't mean if they would've been, say, committed that they would have had a good outcome, they probably was just mis been miserable doing their exercises. Yeah.
Jared Powell:
And just back to what you were saying a moment ago, Erik, about uncertainty in clinical practice, there's a, there's a belief I think from clinicians that if you show uncertainty that the patient will mistrust you or go to another clinician or something like that. And I think that's, that's wrong. There's my colleague, Natalia Costa, who's a great qualitative research here in Australia, has shown that people, the clinicians who actually say they're uncertain about something, but then as you said, say why they're uncertain and offer alternative hypotheses, as you said again, and this is all the list of reasons why this intervention may work or may not work based on you as an individual, blah, blah, blah, blah, blah. Then the patient actually feels like that clinician is authentic, they're honest, they're telling the truth, and they're not just trying to be some authoritarian dictator.
Erik Meira:
Yep. Yep. So think of buying a used car. You go to buy the used car. Yeah. If the person that's selling you the car is extremely certain about how amazing this car is and how, you know, it handles perfectly and it's never had an issue and it's, you know, this, this, that it turns Oh, and you ask the question, well, how does, how does it corner Oh, better than any car that's ever, you know, gone around a a track in any way immediately, you're gonna stop trusting that person. But if their response was, you know, I, I don't know, let's jump in and see that you're gonna trust that person so much more if they're having the conversation with you. And when they don't know something, they're happy to explain how they don't know, why they don't know. And all and ways for the two of you together to answer the questions for the, the person who is the client trying to have a, their problem solved.
Jared Powell:
Bingo. Beautiful. I think that's a a really neat wrap up to today's conversation. Erik, you've been the voice of a generation my friend. I, I really want to thank you for all your hard work, continue to do the hard work. We all want to hear what you have to say, and I've, I've really enjoyed today's conversation, so thank you so much.
Erik Meira:
Yeah, I appreciate that. Thanks for having me on. It's a big fan of what you're doing nowadays and keep up the good work.
Jared Powell:
Thank you, mate. Cheers. Thank you for listening to this episode of The Shoulder Physio podcast with Erik Meira. If you want more information about today's episode, check out our show [email protected]. If you liked what you heard today, don't forget to follow and subscribe on your podcast player of choice and leave a rating or review. It really helps the show reach more people. Thanks for listening. I'll chat to you soon. The Shoulder Physio Podcast would like to acknowledge that this episode was recorded from the lands of the Ang people. I also acknowledge the traditional custodians of the lands on which each of you are living, learning, and working from every day. I pay my respects to elders past, present, and emerging, and celebrate the diversity of Aboriginal and Torres Strait Islander peoples and their ongoing cultures and connections to the lands and waters of Australia.
