Dive into Diagnostic Precision with Dr. Michael Maxwell

In this powerful conversation, Dr. Beau Beard sits down with Dr. Michael Maxwell to unpack what separates average clinicians from exceptional ones. This episode goes beyond technique — diving into personal journeys, clinical evolution, and shared obsession with diagnostic precision, manual therapy, and evidence-informed rehab.

Dr. Maxwell shares how his personal back injury catalyzed a career focused on clinical precision, and together they challenge many modern assumptions in pain science, manual therapy, and musculoskeletal diagnosis.

If you’re a chiro, physio, or movement professional who believes that diagnostic clarity and clinical integration are the holy grail, this one’s for you. It’s a masterclass in how curiosity, experience, and critical thinking mold a practitioner.

Takeaways

Technical difficulties are common in podcasting.

Chiropractic education can be a mix of practical and theoretical learning.

Clinical reasoning is crucial for effective patient care.

Understanding pain mechanisms is essential for treatment.

General exercise has specific physiological effects.

Experience in rehabilitation helps contextualize basic sciences.

Specificity in treatment can lead to better patient outcomes.

The biopsychosocial model is often misunderstood in practice.

Manual therapy has known mechanisms that can be applied to treatment.

Continuous education is vital for professional development. Tailored interventions are crucial for effective patient care.

Core competencies extend beyond clinical skills to include soft skills.

Observation and awareness are key to understanding patient needs.

Curiosity drives continuous learning and improvement in practice.

Understanding patient mechanisms is essential for effective treatment.

Building a team of experts enhances clinical outcomes.

Diverse perspectives contribute to better patient care.

Shifts in clinical thinking can lead to improved practices.

Systemic factors play a significant role in pain mechanisms.

Empathy is a vital component of successful treatment.

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Beau Beard (00:01.026)

So sometimes I'll look or you'll look like you're low bit rate. Don't worry about it. That's kind of part of it because it kind of reduces the upload quality. And then later it kind of increases the bandwidth and everything will be crystal clear. So don't worry if it looks bad right now.

Michael Maxwell (00:11.032)

Yeah.

Michael Maxwell (00:17.722)

And I should be using, I had this all set up, but it doesn't sound like this is using my actual mic right now.

Beau Beard (00:23.693)

Mike.

Is that an option down in your mic settings too, down at bottom there?

Michael Maxwell (00:31.276)

gives me on and off again, which is weird.

Beau Beard (00:33.09)

Huh. Yeah. I I hover over mine and it gives me like five different.

Let me see, I might be able to do it on my end.

Michael Maxwell (00:40.876)

and I'm really good.

Michael Maxwell (00:44.866)

I should have, mean, hold on. Let me just go back to my preferences.

If I go in here, check, check, check, check. I mean.

Michael Maxwell (01:00.776)

Okay, let's just see.

Beau Beard (01:03.79)

It might be a permissions thing too, because I can see your settings in mine.

Michael Maxwell (01:05.56)

change this back.

Michael Maxwell (01:12.811)

Right, just give me one second here. Redact audio source. Okay, so somehow it switched. weird.

Hold on, something's funkier. Maybe when I moved it.

Michael Maxwell (01:34.581)

Audio source. What the That goes nowhere.

Michael Maxwell (01:58.201)

says cannot use accessory because it uses too much power. That's so weird. I literally just had this all. I literally just had this all set up and then went.

Beau Beard (02:04.347)

so you're.

Yeah, it's only done that one time before with like a USB mic, but that sure mic is a XLR or USB.

Michael Maxwell (02:16.008)

No, it's a yeah, I'm connected to my iPhone you using the USB, which is going into a volt like amplifier basically. So it's like, yeah, I had this all set up system and now it's not even recognizing it at all. Just give me a second. If I can start this, I do have a backup option. So I do have a lapel night.

Beau Beard (02:40.504)

And to be honest with you, the mic right now sounds 90%. Yeah, like it's not echo-y, it's not tinny.

Michael Maxwell (02:44.235)

You said, yeah.

Michael Maxwell (02:49.718)

Yeah, yeah, I can just use the lapel mic. This the second time in row I've bought this Shure mic to get super good audio quality. Alright, I'm gonna go to lapel mic here.

Michael Maxwell (03:10.476)

Yeah, something happened. Yeah, something happened when I when I because I was just I just tested this all and it was working totally fine. But as soon as I connected to Riverside, it went weird on me. something about it said maybe there's a power draw that I don't know.

Beau Beard (03:10.594)

Yeah, it's a nice microphone. Sucks.

Beau Beard (03:28.526)

Power drop, because like I said, it'll downplay it, but I wonder if it's a permissions thing instead of power. I wonder. I don't know.

Michael Maxwell (03:33.527)

Right. Yeah, it made sense. Let's start that out another day.

Michael Maxwell (03:49.622)

Okay.

Yeah.

Michael Maxwell (04:00.407)

I went back and listened to a couple of your podcasts. I don't even remember. just kind of listened to a few of them just to kind of get a feel for what you were driving towards. like the first one, I think it was the first one or two, you had some like technical difficulties. I like, was kind of laughing to myself because I was like, yeah, I've been there.

Beau Beard (04:04.13)

Which ones?

Beau Beard (04:21.996)

Yeah, that's, yeah, we've pretty much ironed that out. That's Riverside also, like you could literally, I mean, some people, you you'll get hisses and stuff, which sucks, but even that now with their AI editing, I mean, it's like, you could literally be in a subway and we could probably get it to sound pretty damn good. it's.

Michael Maxwell (04:40.353)

Yeah, and even this isn't letting me, Like it's just saying the same thing. It's telling me that it's not even giving me the option. So I don't know if it sounds all right to you, then we'll just roll. Yeah.

Beau Beard (04:51.778)

Yeah, and what I can also do is, like I said, this goes through Riverside edit and then I have an editor so I can literally just, they'll like quality control the whole thing. Yeah. Yeah.

Michael Maxwell (05:02.647)

Sure. Yeah. Cool. Alright. How close do we want me here since I don't need my mic anymore?

Beau Beard (05:10.53)

Yeah, you're good there.

And we're recording already. I don't like to do and I'll do a formal intro that I'll give to them after I just like to get into it. So we're not like, Hey, let's start the podcast. But I've actually never met you in person. mean, I've known of you for a long time. Yeah.

Michael Maxwell (05:21.898)

Yeah, totally.

Yeah, sorry, just give me a second. I feel like I'm washed out a little bit with my lighting there. All right, whatever. Okay, buddy. Yeah, I know we've I know of you. I kind of got wind you were. Did you did you do your preceptorship with Brad? Or you just knew? Yeah, okay. Yeah.

Beau Beard (05:48.322)

Yeah, so it was when Brett was in his old Moscow Mills office and it was right when Hilgefort left. like I was in this weird scenario because that's what all my interns will ask me like, what were the big things that you learned during your internship? I go, I was basically free labor because Brett just got overwhelmed when his only other partner left and that was this small office. So I was like, I didn't know what I was doing in terms of DNS or anything early. And he was just like, do this, do this, do this.

kind of a terrible learning experience because he had no feedback loops. He didn't know the, you know, the concepts. But at same time, it was almost like a year or two into practice for me. was like, like all these little light bulbs are like, that's what I was doing there. That's what I was doing there. So it was kind of like reverse engineered learning, I guess. Yeah.

Michael Maxwell (06:23.21)

Yeah.

Michael Maxwell (06:31.029)

Right.

Michael Maxwell (06:34.613)

Trial by fire. Yeah.

Beau Beard (06:35.84)

Yeah, for sure. Well, it is every day anyways. Yeah. So what on did you go to CMCC? Or where'd you go to school?

Michael Maxwell (06:39.221)

Yeah, there we go. Yeah.

Michael Maxwell (06:44.469)

UWS back in the day WSCC but yeah Western states

Beau Beard (06:45.912)

Okay.

Beau Beard (06:51.714)

And then where are you practicing where you're from originally or where are you from?

Michael Maxwell (06:56.373)

I am from Victoria, BC. So it's on Vancouver Island, just off the west coast of Canada. So just just west of Vancouver, basically. Yeah, born and raised here, spent my whole life here, except for when I went to UBC in Vancouver, and then Portland for for UWS.

Beau Beard (07:15.79)

Do you have any, do you have like a typical chiropractor origin story or how'd you get into the field or why?

Michael Maxwell (07:20.373)

Yeah, I don't know if it's typical I probably is somewhat typical so I I hernaded a desk and That would have been I would have been 19 just like probably 19 to 20 years old in that range and It was pretty acute man, like I couldn't even wait bear on my left side had like electrical pain down my leg Had pretty significant calf wasting within like six to eight weeks

And I had seen a few different people and a kinesiologist who I had mentored with in my high school co-op, he suggested that I actually see a physio and the physio was from New Zealand and he actually kind of practiced more like a Cairo. He lays down some pretty good adjustments and he just fucking dropped on me, man. I mean, it wasn't a painful adjustment at all. In fact,

I at that point had been about eight weeks out and still unable to weight bear on my left leg without like shooting pain going down my leg. And he did like, it would have been a right side of lumbar roll and a pretty like hard, like traction adjustment, like just yanking on my leg pretty much. And I walked out of there, you know, with, without that shooting pain. And that was a huge turning point for me in terms of that kind of like acute phase recovery.

And he addressed me probably two or three times and then transitioned into rehab. And I really didn't get that much better with the rehab that I was doing with them. So then I ended up going to see, you know, a couple different people over the years. Mike Murray, who was like an active release chiropractor at Victoria BC, kind of one of the first guys in Canada doing active release technique. And then one of his associates who was, I would say just younger, keener, more thorough.

did a pretty good job with me. And again, I was probably at like 80%, and I was just like pretty impressed with the clinical reasoning process that that one chiropractor kind of employed with me. Like he was, his diagnostic reasoning, how comprehensive and thorough he was, was impressive to me. And then I kind of plateaued at like 85, 90%. Like pre-injury, like I was, know, front squatting, 300, back squatting, 350 kind of thing. Like I was reasonably strong.

Michael Maxwell (09:44.276)

And I was kind of like most of the time pain-free but still really unable to load And I ended up seeing a guy in Vancouver when I was in school there a couple Kyros actually as well who he didn't really make a big difference for me but a guy who eventually taught for Tom Myers through anatomy trains So good friend today actually Just had dinner with him actually a few weeks ago

So yeah, it's kind of multiple different practitioners who worked with me, but those that impressed me the most were kind of those with the clinical reasoning set of a chiropractor, but they were all helpful in different ways. And so when I was pretty young, I kind of thought to myself, you know, like, it doesn't make sense to me that I need to go see three different people to get the reasoning and the skill set to get me better. Like it seemed like

each person provided one plug, you know, where I kind of felt like why couldn't I have gotten that with one person and just, you know, ultimately gotten better in a much quicker timeframe? Of course, you know, I don't, you know, N equals one, you know, you don't know what my natural history would have been or how those interactions ultimately influenced it. But my experience was that I got a tremendous amount of benefit from the adjustment in acute phase, ironically, like Lombard.

discogenic, radiculopathy, et cetera. And then I got some benefit with like active release techniques, soft tissue skills that took me from like probably like 50, 60 % to like 85%. And then I got, I just was not getting any gains on that last 15 % with active release, the adjustments, mobilizations, et cetera. And then when I saw this like structural integration based body worker, he was able to kind of take me to being, you know, mostly resolved.

I still can't load my squats the way I did back in the day, but it's not really a priority for me either, so it's not like I'm trying to push it. Anyways, so this is long story, but then I go to school. I was actually in school when I saw the body worker, and I knew that I was going in the direction I thought at that point, physiotherapy. And then I was kind of trending towards Cairo as a result of my experiences with my back injury.

Beau Beard (11:47.662)

Mm-hmm.

Michael Maxwell (12:06.695)

but it still was undecided. And honestly, it just came down to evaluating the curriculum in detail. So I just like had the curriculum of like physiotherapy, had the curriculum of chiropractic, looked at like sports medicine, physiatry. I knew I wanted to be an MSK specialist. I just didn't really know exactly what domain. But you know, the physiatry and sports medicine was like interesting from a diagnostic perspective, but I wanted to be the like boots on the ground hands on. Like those professionals typically...

they diagnose, then it's kind of like, we'll see you later. You know what I mean? Then they're referring out to other people who actually put the work in. And I really was quite intrigued by manual therapy and the influence that it can have over human movement. So that left me with physio and Cairo. And when you look at the curriculum, Cairo is just so much more comprehensive in terms of differential diagnosis. So I was swayed in that direction. So that's why I ultimately went to Cairo School.

Beau Beard (13:04.813)

you've I mean the main reason I wanted to have you on besides just having a conversation with somebody I haven't formally met which hopefully we get to meet in person at some point besides virtual was um you know from what you portray online and what I've heard about you and you know some of the things I've read like we I can tell obviously how detailed and how I don't want to say mechanistic because that can sound bad but like kind of in the weeds you're willing to go in a good way but that leads to this like diagonal

Gnostic Accuracy piece, which is kind of at the heart of what I preach within our office walls and teach a little bit. And you mentioned that multiple times already. So as you went through school, obviously already had this diverse palette of what you'd experienced as a patient. And I agree the irony behind the biggest hammer as a chiropractor got you the furthest home after this. And then it was kind of all the other pieces that kind of stacked on top of it.

But as you went through school, what was the, did your mindset change at all? Or did you kind of say, okay, I'm going Cairo and I want to be boots on the ground and diagnostic accuracy is at the heart of it. And you already knew what you were doing. Or did some of this stuff get formulated along the way? And how did that play into like when you got introduced to things like, know, DNS and NDS and how did that start to change your, your personal palette as a practitioner?

Michael Maxwell (14:19.363)

Yeah, okay.

Michael Maxwell (14:24.518)

Yeah, I I guess the other part of the origin story is that I was personal training when I was 17 years old. I took like a medical exercise specialist certification when I was 18. You know, I went through the personal training certification twice because I didn't feel like I learned it quite well. Like I was really passionate about exercise, working out and training at a pretty young age. And, and, you know, just as I knew I was going in the direction of at that time, I thought physiotherapy. So I had done a lot of mentorship with kinesiologists. So I was very exercise based from day one.

and then I also kind of saw the potential for manual therapy, especially with my individual interactions with different practitioners and the eclectic balance of different manual therapies and how they could influence different, presentations. so, I kind of went into school thinking that the pillars of rehabilitation were, exercise, in

all of its forms, manual therapy, and manual therapy divided into like joint specific mobilizations, manipulations and soft tissue techniques. So that was kind of like my foundation before I even went into school. That was my opinion. That's what I thought was essential in the ideal management of patients.

you know, before I even went to my undergraduate studies, I was mentoring underneath that chiropractor that had treated me. So I ended up, you know, after I got my medical exercise specialist, I actually was like assisting him as like an ART assistant. So I was, you know, putting modalities on, putting hot packs on, helping him move limbs for active release techniques, doing exercises with his patients as he would recommend, witnessing his differential diagnostic and clinical reasoning skills.

So I kind of went into my undergrad already with somewhat of a foundation, I thought at least, for what were the key parameters for managing patients. So when I went into chiropractic school, none of that really changed. I just knew that all of it was relevant. So I don't know if you had this experience, but...

Michael Maxwell (16:43.921)

A lot of people, especially in that first year of chiropractic school, first six quarters when it's very basic science-based, they were like, oh, why do I need to know all this physiology? Why do I need to know the biochemistry? You know what I mean? Histology, et cetera. And I knew from day one how essential those things were to completing the picture in differential diagnosis. So.

I felt like chiropractic was a really, really good education in the basic and clinical sciences to form the foundation for clinical practice. So it didn't really change, but it certainly provided, I think, the best foundation I could have gotten out of a degree to move forward.

Beau Beard (17:31.096)

Yeah, to say that, so I teach a course called art of the assessment and this is when people say first principles approach, some people kind of want to almost scoff at that now because of how it's used and maybe how poorly it's represented. But the first principles within any medical practice, it doesn't matter if conservative MSK or oncology, whatever, it is the core sciences. And I agree that for some reason in particular,

physical therapy, chiropractic, it seems to get glossed over, not in terms of how we're taught. I feel like I had wonderful professors and it's what you put into it, but it's almost like we're, for two reasons, and I'd love to hear your comment on this, is we breeze over because we see these big manual skills, patient interaction, we're gonna have to go do these things. But then also, we're having to go through, and I say have to, continuing education outside seminars from.

Michael Maxwell (18:01.008)

Thank you.

Beau Beard (18:21.87)

day one, MPI, and, you know, DNS, we can do all those things. We don't see how important those core sciences are in terms of the understanding of all of these concepts. We just kind of see, I'm learning this stuff and then I'm going to learn how to do the things that I go that are actually important. And it's kind of, then we get into practice and you're like, you read a research article, you go to a seminar, and now you have no filter to screen these things through because you didn't, you know, understand physiology 101 as good as you could or histology or.

um, neuroanatomy and all of a sudden you're like, Oh, I have to go back and research or what I kind of find in our profession. And you're much more involved in the continuing education game is people rely on what they're told via a method or a technique rather than trying to kind of, I don't want to say pick it apart, but basically apply a filter and say, what does this make sense? Right? Yeah, it may get a result, but why is that occurring? And can I better myself as a clinician by applying that filter? Um, so

Again, I would say it's rare that you have this template. I'd say it's very rare that you're like, I had these pillars going into chiropractic school, right? A lot of us have some experience and you're like, God, I did a lot better and I'm gonna go do this thing, because I'm involved in sports or I like medicine or whatever it is. So I think that's rare. Be as you went through school, besides just kind of really honing in on those core sciences.

What was the thought process behind, obviously you're not reading or you search at this point, you're not trying to understand like concepts you're gonna use in future practice. How are you like propping this up in your mind of like, I know this to be the most important thing. Because I'm assuming you're a kinesiology undergrad, so you were kind of experiencing, know, vast swath. But like when you dove into physiology and all the other systems, you know, or systems of systems, how are you starting to frame in your mind of like, man, this is gonna be important, I'm gonna use this later.

I mean, how much are you having to revisit that, you know, all of that now?

Michael Maxwell (20:19.252)

Yeah, I mean, I think a big part of that, which I feel like is super helpful for anyone who has actual experience working with people in the context of rehabilitation before they go into school, it helps you contextualize the basic science based off of clinical presentations of patients that you've seen in the past.

You know, like I said, I started personal training when I was 17. I did my medical exercise certification when I was 18. I was working in the chiropractic multidisciplinary office when I was 19. I had seen a lot of different clinical presentations and I'm trying to make sense of it as I'm going through, obviously not having the rich background in basic sciences yet, but even going into my undergraduate degree and continuing to personal train, practice as a strength conditioning specialist.

I was always trying to apply the basic sciences into the people that I was working with, whether that's a rehab case or whether that's just personal training. So I think that is a huge difference is that we go into Carpetic education, many of us go into Carpetic education with no experiential background. And you spend like two years only learning the theory before you even start to think about

how you would interact and work with patients. And I feel like it's way easier to learn the theory when you have a practical foundation because you then start to interpret the basic physiology, biochemistry, histology through the lens of the patient presentations that you've seen in the past as you start to make sense of it all, if that makes sense. So I felt like I could contextualize physiology when I was going to school based off of

people that I had seen or I'm currently seeing because I was still working as a personal trainer. To me that made mastering the theory so much easier. Like to me the basic sciences were really, really easy. Not because I'm super smart, but because I had all this experiential background to apply my knowledge to. And then you're not remembering like individual pieces of facts. You're creating stories that fit within physiology and patient presentations. So that I think that's a big

Michael Maxwell (22:40.097)

difference, you know, and I feel like we probably need to do a better job of getting people into that kind of clinical reasoning mindset from day one, so that when they're going through biochemistry, histology and physiology, they're starting to put those pieces into the puzzle of a patient's presentation. In the end of the day, like diagnosis, you know, is it comes down to what is driving the physiology

that results in the expression of the patient's symptoms. know, it's like, Shacklock has the saying is, physiology is the gateway that underpins or translates the biomechanics into symptomatology, right? In other words, like it all comes down to physiology. Like a person doesn't have pain unless the biomechanics has an influence over the physiology. So there's some weird mix of,

biochemical compounds that are activating a nociceptor or a secondary wide dynamic neuron or something of that nature that's creating the patient's symptoms. So that's kind of a cool thing to think about if you think about it. So like let's say you've got a patient and they have a supraspinatus tendonopathy and you decide that you're gonna do, I don't know, let's pick something abstract. Exercise is obvious. Let's say you decide to do active release technique on them.

and you've changed that patient's symptoms, not in the temporary, but they report to you that six weeks after, they still continue to experience symptom relief. Well, you could make a story up about adhesion this and adhesion that. The reality is you're not putting a fucking adhesion on the supraspinatus with your hands underneath the coracoacromial arch. But obviously in that N equals one presentation, the patient reports and you've observed a change in their symptomatology. You could say it's placebo.

Sure. But I would argue that it comes down to the physiological mechanism and something shifted in their physiology. Could be the placebo, could be the manual contact, could be the movement associated with the manual contact and the treatment. It could be the fact that the patient felt temporarily better and then they walked out of their office and they used their shoulder more and loaded their tendon.

Michael Maxwell (25:03.83)

But the bottom line is all of those mechanisms converge onto a change in the biochemical compounds that result in the expression of nociception.

Beau Beard (25:13.998)

When I saw a post you put up that, or maybe it was a blog about this whole idea that pain is just basically an experience and that we're missing the mechanistic components that underpin it, which you and I would, we'd sit around and drink glass of wine, we'd just kind of be saying the same thing over and over to each other and kind of probably smile and be like, yeah, yeah, yeah. So don't want to be an echo chamber, but I do want to dig in on this stuff. So I 100 % agree with you when we,

even if we say, oh, it's a placebo effect, like you said, well, you had an effect and that effect is a catalyst, right? It's almost like shirting your cat, but there's a million opportunities for physiology to change. we probably, this is what drives me nuts in practice, you never really know, right? You have a narrative that we create and hopefully that's based on core principles of science. But at the end of the day, you'll never be able to fully

basically rope in exactly what changed. Even if you had a deep needle biopsy or all these things going, like immediately you'd just be like, you don't know because you don't know what the catalyst was. So let's back up for a second and dig in because there's so much stuff there. So it's almost like things were revealed to you in a clear fashion because of your experience going before you went into chiropractic school and now you own a continuing education company. You teach,

Michael Maxwell (26:33.867)

Thank

Beau Beard (26:41.87)

all the time, you say that we need more clinical reasoning paired with the core sciences so it kind of does more of this revelatory teaching rather than just kind of like get in this core block stuff and then get into patient treatment. How would you do that? Do you have any ideas of how we could do this better in chiro school or outside of school?

Michael Maxwell (27:03.465)

I mean, man, it's such a complex question.

Beau Beard (27:10.232)

And I know some schools are trying to do this, right? Like earlier trimesters, they will have a clinical reasoning class, but they'll have different phases. So at Logan, you now have clinical reasoning instead of just try six, I think they have three phases of it, right? So they're trying.

Michael Maxwell (27:12.629)

Yeah.

Michael Maxwell (27:25.203)

think the strength of medical school is that they're literally in clinical rounds from day one. They're running through exams within the first few months of school. I had a patient who is just, he's kind of on the tail end of school now, but he's probably year four or five now, but I've been seeing him off and on for years, even before he was going into school.

And I remember chatting with him about, how's your school going? Like, what are you doing? And just kind of, you know, inquiring about the program and where their emphasis is. And he literally was examining patients within like four months. And man, that's a huge strength of medical school because they're already forced by the virtue of having hands on a patient and doing an exam to think about, well, what the heck is going on in this patient?

Beau Beard (28:04.654)

Mm-hmm.

Michael Maxwell (28:22.27)

You know, I would say like the patient imposes clinical reasoning on you. You know what I mean? So the second you have a person in front of you, you have to start thinking about, okay, what is going on with this patient? And it's those questions that take you through the rabbit hole. You know what I mean? And that's really what we need is we need the rabbit hole. We need to continue walking down that rabbit hole with every single patient.

to kind of funnel our way down into something that makes sense. So, in present day, I think we have a couple ways to do this. I think that the phenotyping of a patient's presentation and a patient's physiology is super important. So, we've got Annie O'Connor's...

book who you know she wrote on nociceptive inflammatory ischemic nociplastic mechanisms and then she had cognitive affective social. think she has social in there right? Just did she have social as a separate? Yeah, right and then you got neuropathic. Alright, so in Walton and do you know Dave Walton and James Elliott? Yeah, so in their book.

Beau Beard (29:31.544)

Social is part of the fact of, yeah.

Michael Maxwell (29:45.889)

I kind of like the way that they've, so by the way, I love Annie. I think she's amazing. I think her book was revolutionary in our profession in terms of getting people thinking about the phenotyping of patient presentations and how that shifts, how we interact with them. However, I do think that there was a mistake made in the terminology used in that they're not actually pain mechanisms.

There's no such thing as an affective pain mechanism. There's no such thing as a cognitive pain mechanism. That's not a mechanism that's a potential driver, that's a potential influencing factor over the patient's pain presentation. It is not a pain mechanism. There's ultimately, yeah.

Beau Beard (30:32.014)

Wouldn't you, so can I pause you for a second? Wouldn't you agree though that the way that Annie explains effective, right, is that you have one of the preceding three, right, ischemic or, and then you have an overlying emotional or social factor that then brings it to effective. So the mechanism is kind of cooked in. Am I wrong on that?

Michael Maxwell (30:53.153)

yeah, I feel like seeing Annie talk in person and reading her book, I don't think that's clear enough. I think, I think, I think, I think it should have, the terminal, she just should shift entirely away from a pain mechanism. Because to me, when I read that book, and to me, when I hear Annie talk, is that she's describing these things as mechanisms, but they're actually drivers.

Beau Beard (31:17.314)

Yeah, so you're saying it's the not necessarily the semantics with the categorical breakdown that if you broke them into effective that now we could somehow, know, if maybe we're not being super aware of like the whole picture, just say, it's effective and then bypass the mechanism that got them there that could still exist or maybe doesn't at this point.

Michael Maxwell (31:36.987)

Yeah. Yeah, I think, well, you know, I posted on Facebook the other week that I feel like one of the most damaging phrases that's come out of the pain science world, which I think it's probably damaging to even call it pain science. It was a statement made to the effect of, and you can correct me if I'm wrong here and we can probably Google to make sure I don't get this wrong. But I believe the statement is no deception is neither sufficient nor necessary.

to cause pain. And I think that is factually inaccurate. And I think it's incredibly damaging to the psyche of a clinical practitioner and the way that they engage clinical reasoning. And it creates this, you know, essentially this out, you know, like, well, you know, if nociception is neither necessary nor sufficient, then I don't really need to worry so much about nociception because it's probably just, you know,

something in the psychosocial realm, right? Even when that might be a very apparent influencing factor over this patient's presentation and very apparent that you need to work through their emotions and their cognitions, the feelings and thoughts that they have about their current situation and potentially social factors as well that might be influencing it too.

you still have to make sense of how those things are influencing the nociceptor apator apparatus. And I think what probably is more likely than not is that you have a nociceptive driver that has an overlay of, you know, three, four or 20 other things that make the nociceptive driver persist.

And no see plastic pain is probably a little bit of a different bucket. And I think we're living on a big continuum where if you have anyone with chronic pain, regardless of the degree of no see plastic mechanisms, there is going to be adaptation of the nervous system that's going to likely amplify the sensitivity and the presentation of that patient's pain.

Beau Beard (33:54.734)

Well, even the phenotype of the person coming into the scenario of the mechanism, right, which we know, I mean, all the way from collagen distribution to psychological phenomenon. Like, but I think at the heart of this is, you know, correct me if I don't want to put words in your mouth. We can't categorize a person. We're a complex organism. And again, we can't put somebody into one of the six categories of pain because they're never one of the six. It's always a combination or percentage that, oh, it's 10 % ischemic or it started there and now it's

Michael Maxwell (33:58.664)

Exactly. Yes.

Beau Beard (34:24.494)

30 % effective and look, there's a little motor autonomic, but it's not, you know, textbook. Like I, what I tend to see in particular with like new grads and interns, this isn't a knock, but I think it was popularized as you said, as like an out of, it's almost like we would treat people in a mechanism or mechanistic fashion, right? Pathway anatomical, when that failed, it became, which is such a terrible use of the terminology of biopsychosocial case now. And it's like, but that's,

you're, what are we talking about? Like it's always biopsychosocial and it's not that we go from treating, you know, the physiology of the person realizing, it's a nonphysiologic, this is a psycho, no, no, no. In my opinion, I just think that got like overplayed and it's not moving into that realm. You're treating an organism, which is a conglomerate of all these things. And that's, to be honest, why your job's kind of tough. It's much cleaner to say,

They're in this category, we're treating this specific thing and then we have this cookbook play. I mean, you know as well as I do, I that's the whole reason that we say in a one, like that doesn't exist.

Michael Maxwell (35:31.882)

Yeah, well, I mean, and the other wrench that can be thrown into it is that sometimes maybe none of it really matters because the person has a biological predisposition for, you know, a nociceptive system that goes awry. You know, like so and we don't I don't think we have like direct mechanisms to treat

that specific dysfunction yet. I think the answers will probably lie within the pharmaceutical industry and the biological sciences that underpin the specific biochemistry that drives that system. And there are some things that are coming out now that are making some changes in that realm. But I think that the reality is a lot of times our interventions are indirect.

Well, not a lot of times. They're always indirect mechanisms into a complex physiology that manifests itself as pain. So you're right that yes, there is always, you know, an element of all of it. I don't know, neuropathic would be a good example of that, however. So listen, if a person has pain, there's activation of the nociceptive apparatus. That's clear, you know? So if they have pain,

there's activation of the nociceptor apparatus. It might not be a neuropathic mechanism. Neuropathic specifically meaning that something that's affecting axons and dendrites and cell bodies. And sometimes it's neuropathic nociceptive whereby it's the nociceptor within the nerve that's causing the pain presentation, which then gives you this weird category where they have a nociceptive pain presentation, but it's a nociceptor within a nerve.

i.e. the nerve inner voron. So it's in Walton and Elliott's book, I personally feel like they said neuropathic has a nociceptive mechanism, but you would treat it as if it's neuropathic. And I disagree with that. I think you treat nociceptive pain that is within a nerve like it's nociceptive mechanism, which means, you know, try to address the nociceptive driving mechanism, right? What is compressing, irritating and flaming or sensitizing this nerve?

Michael Maxwell (37:46.214)

And that doesn't need to involve pins, needles, tingling, know, radiating pain, electrical pain, et cetera. It could be just a classic deep dull ache that is a, you know, very similar to something that would be quote unquote plantar fasciitis, but it is not. It is the nociceptors within the nerve, i.e. the medial calcaneal nerve that cause that deep dull ache that results in pain when they load their plantar fascia first thing in the morning. But then as they move around, the shifting of physiology and the biochemical compounds

components of that tissue is spread through and you get better molecules coming in and they don't have pain anymore, right? So, and then you have, you know, central nociplastic again, like I said, you probably always have an element of sensitization in chronic pain patients, but perhaps not necessarily the acute pain presentation that's maybe irrelevant. But then you have cognitive, emotional, socio-environmental and sensory motor disintegration, right?

What I would say is that yes, everyone has a social factor, everyone has an emotional factor, everyone has a cognitive factor, but they might be completely irrelevant to the resolution of their pain. So you need to see those things, you need to observe those things, you need to make sure that you're screening for the potential risk factors that might be at play, but they might be totally irrelevant to the resolutes in that patient's pain. You know, like I'm sure you've seen it, where a patient comes to you,

Beau Beard (39:06.766)

Thank

Michael Maxwell (39:13.381)

They've been to eight different practitioners, including a pain specialist. They've been thrown in the biopsychosocial bucket, which really means the psychosocial bucket. They're basically telling them that, listen, this is, you know, it's not really a problem with your, I don't know, your back. It's just this, you know, nociceptive apparatus gone awry. And now you have what's called nocoplastic pain. And we feel like you need to manage your emotions better. We think that if you think about your pain a little bit better,

and you maybe help address your relationships and social environments, maybe you can walk your way through this situation to a better outcome, which still means you have chronic pain. And in those patients, I've identified very clear nociceptive drivers, addressed those drivers and the patient's pain resolves. After years, like six, seven, eight years of chronic persistent pain and literally doing nothing, not talking to them, not...

Beau Beard (40:11.662)

Mm-hmm.

Michael Maxwell (40:12.12)

changing their thinking, not changing their emotions, not changing their social environment, just changing some specific mechanism that's, you know, for example, loading the nerve at the interface of piriformis. Something as simple as that, right?

Beau Beard (40:24.75)

Well, there's so many freaking veins we could go down. I wanted to point this out. and this is no knock on Benjamin. So your counterpart was somatic senses. So when I did an interview with him, I went, we were kind of going down this rabbit hole, right? We were talking about, know, peripheral nerve, know, cutaneous nerve sensitization possibly leading to trigger points. And then like, you know, kind of thinking about these like mechanisms and

what that does to change your treatment, but then also of how that curiosity of, what's, you know, like what started this? What's actually happening? You know, what, like you said, like there's a mechanism that may have preceded this that still is occurring, that's now absent and we've kind of shifted, you know, departments, but Ben kind of came back at one point, he goes, it really doesn't matter. He goes, what we want to do is, you know, when we get people out of pain, we want to get, you know, positive moving experience, get a move in, that's the goal. And I was like,

Michael Maxwell (41:14.66)

Thank

Beau Beard (41:22.414)

But then that leaves a giant gap of like the betterment of you as a clinician and the betterment of the profession, my opinion, right? Because if we don't ask those questions, mean, what do we, you what's a researcher doing? Where's the theory come from? What do we explore? But what you're also saying is you're also, it's not being left on the table for research, it's being left on the people that are basically the left out, right? Six to eight years of being told that this is, you know, non-mechanistic or it's outside of the realm of typical, you know, conservative musculoskeletal, you know, like,

Maybe not, maybe we just kind of missed these, maybe poorly understood, poorly observed, probably a little bit of both. So this gets at the heart of again, why I wanted to bring you on here of, it seems like you talk a lot and your articles and what you teach is about diagnostic accuracy, which gets down to these core sciences, understanding the principles that then prop up all of the methods and techniques and everything that we're doing from a hands-on approach.

When we're looking at this, for students that are in school or new grads or docs, because that's probably the most people that are listening to this, let's say they are, obviously we all know about this. We learn core sciences, we've graduated, it's being talked about. But let's say people are kind of just skipping along through practice. They're applying methods, they're applying techniques, they're going through an exam, but it's kind of, maybe it's not the flying seven, but it's kind of the same thing.

or we're not questioning, how do we kind of put a break on and then say, well, this is what I need to start paying more attention to or looking at, or is there some sort of gross process? So we talked about this clinical reasoning in school or early on in the profession, but if we're already in practice, how do we kind of say,

I have to start paying attention and what do I pay attention to? Because it sounds like we're just opening up Pandora's box. I've got everything that's possible can and will happen. And some of the things you're learning are probably not right. And the things that we're doing, we don't even understand what's happening. So you can understand the daunting like, ugh, for a student or somebody that's in practice.

Michael Maxwell (43:32.909)

But I think the thing is that we do have.

Science has elucidated mechanisms of many things, just not all things. Where it can't help you is defining the mechanism of an individual patient. But we do know with, I think, reasonable accuracy the mechanisms of manual therapy. Will we learn more in the future? Yes, we will. But I think we have a reasonable understanding of the mechanisms that underpin the effects of manual therapy.

I still think by the way, there is one group that still says that the mechanisms of manual therapy are global in nature, contextual in nature. But if you look at Stechow's work, I think there's also, and Bowe's work, I think there's also clear indications that you have changes within the local tissue as an outcome of manual therapy as well. So I think we have known mechanisms for manual therapy.

Listen, we have like thousands and thousands and thousands of studies on exercise and not just like, you know, specific mechanisms of loading, but also, you know, just cardiovascular physiology, et cetera. So we, kind of understand how exercise works, which is obviously complex and comprehensive, but we have a pretty good idea of how that works. And we have a pretty good idea for.

the set of assessments and mechanisms that can contribute to a patient's pain presentation. So it just comes down to something as simple as how does this movement load all of the tissues in area X, Y, and Z? So, give you an example. If we go into multi-segmental flexion and we bend down, we touch our toes. What are all of the mechanisms at play when we do that thing? Well, you have...

Michael Maxwell (45:26.625)

sensory motor control or motor control mechanisms that influence the lumbopelvic hip rhythm. You have the control mechanisms that influence the coordination of diaphragm, pelvic floor, abdominal wall, i.e. interabdominal pressure mechanisms and how that pulls them through a flexion mechanism. You have the eccentric activity of the paraspinal muscles that goes EMG silent at the end range of motion. Note that's

superficial erector spinae, not the deep rotatory multifidus. You have the elongation of the nervous system. So the entire nervous system from the spinal cord and the brain all the way down to the toes is elongating. And while it's elongating, it's also sliding. And the sliding mechanisms change depending on the range of motion. So the first movement, if you do a true multisigmental flexion,

If I look down and I curl through my spine, what's the first movement of the spinal cord? It goes up, right? But as I transfer that movement down into my lumbar pelvic hip mechanism, it pulls it back down and eventually it doesn't really move that much because you're tensioning in both directions. Right, so you go from a cephalad slider to a caudad slider or proximal and distal slider relative to the lumbar spine into a tensioning mechanism. And that tension is transferred through the entire system.

That makes sense. You have opening of the facet joints. You have elongation and tensioning of supraspinous ligament, interspinous ligament, ligament of flavum. You have opening of the posterior disc and elongation of the fibrocardial adhesives fibers of the posterior annulus. You have compression of the anterior annulus. You have a posterior migration of the nucleus, which by the way is normal and healthy in this situation.

And you have compressive mechanisms which load the disk, load the nucleus into the posterior annulus. All of which is normal. Yeah.

Beau Beard (47:27.982)

Can I stop you for a second? So I'm assuming, this is I want clarification for those listening, being aware of all these mechanisms that are occurring, right? Let's just pick like a few, like the cephaloids sliding of the spinal cord in the first portion of multisigmental flexion. I'm assuming it's important to you because if somebody's going through this gross motor movement, right, that is probably not a great audit if we're trying to be specific, but...

if people present with movement aberration or pain in these parts of the movements, you can already have suppositions, right? And divergent thinking is this mind explosion of like, that's kind of interesting that the pain gets better as they go further in the movement or it gets worse. Am I right or wrong on that? Is all of these things are occurring in your mind from a mechanistic standpoint still that you're like, I can have hypotheses that now I have to crush while I kind of stack testing and by the time I'm done with my exam,

based on my understanding of anatomy and physiology and all these things, you're like, yeah, this seems like the most likely. I bring that up because, I mean, I'm not trying to be mean to the profession. 90 % of the profession is not thinking at that high of a level of the mechanisms of like a gross motor movement.

Michael Maxwell (48:24.032)

Thank

Michael Maxwell (48:41.396)

Well, yeah, but so let me, I'm gonna take this further. just bear with me. So you also have changes in position of the dura. You have changes in position of the nerve root. The dura and the spinal cord are moving anteriorly. The nerve roots are moving anteriorly. If they slide upwards, they're gonna be moving up into the pedicle. If they slide downwards, they're moving down into the inferior pedicle. You have obviously length and tension relationships through all of the muscles.

The point is that you need to see all of this. And that's just fucking gross anatomy. And then there are also underlying physiological mechanisms. So when you elongate a nerve, for example, so let's say you start with proximal sliding, which means you're kind of early in the toe region, you haven't drawn tension to the system yet, meaning you're kind of lower on the stress strain curve.

So you're sliding proximally, but you haven't tension yet, then you draw it back down and you start to draw tension to the system. Well, the tension in the nerve changes physiology in the nerve, does it not? Changes physiology in muscle too. If you stretch a muscle and you put it on length, it changes blood flow, right? It also changes sensation, right? So, you're activating muscle spindles and glutathenin organs, there's a perception that occurs in...

in this whole process where you feel length and changes in length through the entire system, including nerves, legaments, muscles, tendons, et cetera. So we need to be able to kind of go all the way from the superficial levels, layer in all the way down to the physiological mechanisms associated with that movement. And then we need to make sense of it. So how would you make sense of it? You'd break it down. So if a person has pain with that movement,

You would layer that into individual components of sensory motor control, trunk stability, IAP. How is that regulated? How does that influence the patient's pain presentation? You would evaluate very specifically the nervous system, how proximal sliding, distal sliding, and tension influence the patient's pain presentation. You would segmentally evaluate how length and tension through the paraspinal muscles, through the posterior ligamentus adbratus, through the disc.

Michael Maxwell (51:03.615)

through the hamstring, you know what mean, all of it. You just break it out, i.e. SFMA, right? So once we observe everything, then we're funneling into what is the most probable mechanism that underpins this patient's presentation? And that's the fundamental question. What is the most fundamental mechanism that underpins this patient's presentation?

Beau Beard (51:28.238)

And we're and again, that's a component because that's meat suit component, right? And then we have the mind behind, you know, the physiologic brain. what what's the right?

Michael Maxwell (51:38.046)

But that's part of it. That's part of it. know, that's part of it, right? So that might be, you know, when I say a fundamental mechanism and talk about the most primary mechanism, and then you might have a secondary, a tertiary, you know what mean? You might have other drivers open at the station.

Beau Beard (51:50.488)

Well, I don't even think secondary or tertiary because they're coexistent. mean, it's almost like quantum mechanics is play. They're all existing at the same time. And we do have to prioritize. So maybe you do have to kind of give a numerical order to them because of treatment. You can't treat all at once with all interventions, but that's no different than you have to also create an A-B experiment to have a clinical audit process where you're like, am I actually doing anything? And that's where you...

Michael Maxwell (52:07.006)

Yeah.

Michael Maxwell (52:17.622)

Yeah. Yeah, and I guess I guess that's what I mean by primary and secondary is that is the point of emphasis that needs to be placed on this driver over here, which you think is the most fundamental mechanism now. Now here's here's the next layer, right? Is every intervention is an evaluation. Right, so so if you've created a clinical hypothesis based off of patients presentation, the next layer in your evaluation is to do an intervention.

that is as specific as possible to the biological mechanisms that underpin that specific driver of the patient's presentation. And if you are on par, you will either make it better or worse. Hopefully better, but you'll change it.

Beau Beard (52:56.494)

Even when we, yeah. And again, and when we say it, know, pain and audits, I'm assuming again, not to put words in your mouth. Yeah. So I have to ask this question. So there are for sure people listening, but then also just in our profession in general, which we have one of the most contentious, you know, maybe professions that exist. What do you say to those people that say, well, this doesn't matter, right? Why are we going so in the wood or in the weeds with the details of this stuff?

Michael Maxwell (53:05.169)

Yes. Yeah.

Beau Beard (53:25.762)

when we see this generalized approach that's become popularized of like, are, the resiliency is low, they need to be load managed first, yeah, we have to protect them, so we have to be aware of injury mechanisms, but outside of this, why is this guy, Michael Maxwell, telling me I have to understand these anatomical things on top of the physiology, on top of the organismal systems of systems?

Michael Maxwell (53:47.573)

Because it's simple because if you don't understand the mechanisms that are underpinned a patient's presentation, you lack specificity of intervention, which means you lack specificity of outcome. It's as simple as that. And moreover, you can injure them. You can harm them. I had a patient that I've been seeing over the last, I guess it's been about nine months now. She was pain free. She just has diabetes and

and type 1 diabetes and wanted to make sure that she was optimizing her health, hasn't done a lot of exercise in her life and wanted to get proactive in being healthier. She made a very wise choice. Instead of going to see a personal trainer, she said, you know what, I'm going to go see a physiotherapist to design my exercise program because I assume that their knowledge level is higher and they're going to be better at designing a program for me. Very wise decision.

Probably not right, but very wise. So she sees this physiotherapist. The physiotherapist within a person who has incredibly limited mobility and very poor movement has her within a couple months doing like loaded squats, cleans, deadlifts, like a variety of movements that she had no business doing. So she ends up hurting her back.

sees this guy for another few weeks but loses trust. So she goes back to her doctor, talks to her doctor about it. Doctor gives her a referral to see another physiotherapist. That other physiotherapist does a better job in giving her regressions, so not doing like loaded deadlifts and squats, but still totally misses the boat in the specificity of the intervention required to get her better. She had minus 20 degrees of hip extension. I am not joking you. Like I had to like...

push hard on her thigh in a Thomas test to get her to 10 degrees. She had zero degrees of dorsiflexion. Zero. She had no dorsiflexion. And she was doing goblet squats.

Michael Maxwell (56:01.04)

You know, so listen, it literally took two weeks of just doing basic stretching of the tight stuff to 90 % knock out her pain. And then over the following...

Beau Beard (56:14.21)

That doesn't even seem that complex, right? That seems like how'd you miss it, right?

Michael Maxwell (56:16.965)

It is the most my God, like an incredibly average personal trainer would have would have recognized this in like five seconds, like unbelievable. But the reason why these other two physiotherapists did this is because they believe that the general is what matters. That the specificity doesn't matter and therefore we're just going to exercise.

We're just gonna do some back bridges. We're gonna get stronger. You we're gonna do some squats, you know. We're just gonna generally exercise, because it doesn't, the specificity doesn't matter. Bullshit, it doesn't matter. Like if you, if you're, it doesn't make any sense, man. Like load matters. Load matters. And if a patient's pain is provoked by a loaded mechanism, i.e. she reports that when she brushes her teeth, washes the dishes, cooks her vacuums, she has pain.

but she doesn't have pain otherwise. It's only during those activities. So why? You have to ask yourself why. So her supine three months position.

Literally couldn't do it. Call it minus five seconds that she can hold this position. She literally cannot even hold her legs up. Without, yeah. She literally cannot hold her legs up. So if you cannot gain basic competency in human movement, why are we training squats? And if you don't see those things, what are we doing? Like, what are we doing? It doesn't make any sense. So,

Beau Beard (57:26.85)

Yeah, and she's doing a squat.

Michael Maxwell (57:48.772)

Here's the thing, if you don't see it, how can you make a comment or a statement that is not relevant?

What I disagree with is that people are making the decision to not see things. They're saying because pronation is normal and the foot pronates and there's different degrees of pronation and everyone is blah blah blah blah movement variability blah blah blah blah blah. I'm just not even gonna fucking look at it.

Beau Beard (58:19.222)

Yeah, ignorance is not knowing stupidity is not acting on the information you have. So yeah.

Michael Maxwell (58:23.106)

Yeah. So like, you know, I was given a colleague of mine a hard time the other week, not because I didn't think he was seeing these things, but because he wasn't notating it. I'm just like, hey man, I've noticed like a couple of patients that we've, you know, co-treated. When I look back at your chart notes, like I'm seeing a lot of things in their movement that I think highly relevant or possibly relevant, and I'm not seeing you're notating those findings. Are you not seeing that or are you just not notating it?

And then we would talk through the case and be like, no, I was seeing that. I'm just like, well, if you see it, you should notate it. Because you can't draw a correlative statement if you don't make the observation. And in clinical practice, like we don't have any possibility to draw, as you mentioned earlier, firm causal conclusion. We just can't do it because there's too many overlapping mechanisms that could potentially be at play, right?

but we can make a series of correlative statements that if we funnel that down through the mechanisms of the individual patient, we can draw down to the most likely correlation that underpins the mechanisms of that patient's presentation.

Beau Beard (59:37.838)

Yeah, we're much more like a lawyer than we are a scientist. I mean, we have to have a scientific frame of mind, but like in terms of coming to a diagnosis prognosis and then an intervention or trial of care, yeah, it's more of, I'm gonna present the case first to yourself. So this is what I tell interns all the time, your lack of confidence is largely coming from your lack of your ability to walk down the narrative that actually makes sense, right? You jump to a conclusion, you miss some piece of information.

And now in your own subconscious mind, maybe not even in your frontal cortex, you're like, this doesn't even make sense to me. it's not, you can't, I don't want to say sell it to the patient, but you can't deliver that narrative to them to get the rapport and the reassurance that they need to stick with you for that trial of care. But again, it plays back to, and again, we could just keep parroting and echoing this, that the core sciences.

prop up everything else you do in practice. But one thing I wanted to touch on in terms of the core sciences that you had mentioned was when talking about mechanisms of, know, soft tissue mechanisms and the understanding of exercise science, you're like, well, we understand these pretty well. We understand these pretty well. Why do you think it's such a contentious debate within our professions of these mechanisms still, even though I would agree with you that we do largely understand that these things occur in terms of

Michael Maxwell (01:00:44.698)

Thank

Beau Beard (01:00:58.926)

what StECO's put out and how the cardiovascular system is being approached and tendinopathies. But everything, and I'm not saying it's not up for debate, obviously it is because nothing's law, there's very few physical laws. But why do you think that you have an approach where you're like, well, we kind of understand these and we can weaponize them versus some people like, we don't understand them, so that's why they do take that general approach.

Michael Maxwell (01:01:22.651)

Yeah, I think it's because they're stuck up on the ability to make causal conclusions. So you need a large randomized double blind control trial, blah, blah, blah, blah, blah, blah, all of that stuff in order to draw a conclusion on causality. I think that not because we don't understand, listen, we have enough science

on the basic biological mechanisms of manual therapy to have a pretty reasonable interpretation of how it might work. But that's different than saying, you know how it is working in this individual patient. Right? And listen, some patients I'm adjusting not because I believe that they have some specific segmental dysfunction, but because I'm trying to access some kind of an analgesic mechanism. Right? In other patients, I'm adjusting them because

I'm trying to tap into movement and emotion segment that isn't otherwise happening. And in some patients I'm not doing either because I don't think that the mechanism is relevant to their clinical presentation. You know what I mean? I think the reason why people are so laissez faire, it just doesn't matter is because they're stuck up on the scientist's version of this and the scientist's version

of trying to bring us towards some law of causality is probably not going to bring us to any firm conclusions on individual patient in about a thousand years. You know what mean? Like, because every patient is so distinctly unique in their physiology and their biomechanics and their anatomy and their, you know, emotions, just like it's way too complex. Yeah. So all we have is a bunch of data points.

Beau Beard (01:03:12.75)

Yeah, you can't test it. Yeah.

Michael Maxwell (01:03:19.34)

that we collect from an individual patient in which we can create a narrative that draws us towards the most likely causal mechanisms. But that doesn't mean we're concluding that, I'm directly intervening this therapy onto this causal mechanism, and this is exactly why it's working. No, it's just like one cluster of fuck of physiology that is influenced by a variety of different things, right? So it's like you made a statement earlier.

Like people say, general exercise, general exercise, general exercise is all that's required. But they're making a statement that general exercise has general mechanisms and it does not. General exercise has very specific biological mechanisms. Right?

Beau Beard (01:04:07.064)

Yeah, otherwise I get huge biceps from going on a walk. Yeah.

Michael Maxwell (01:04:11.114)

Exactly. So there's no such thing as general exercise in the realm of physiology. There's no such thing. We call it general because it's things that people generally do, I guess. Like, I guess walking is a general exercise. guess, you know, hiking is general exercise. But all of these things have very specific physiological mechanisms. And so the question in an individual patient is, are the specific mechanisms that I'm looking towards going to be most

succinctly gained by a general exercise approach or do I need a specific intervention or a specific exercise to get that specific mechanism?

Beau Beard (01:04:51.49)

And if we wanted to take, being honest, if we want to take off our pleasantries, and I know that you're Canadian, that has nothing to do with it, but people are lazy. Clinicians sometimes are just lazy, right? And the bandwidth that you're putting into each patient visit, each minute, it sounds like, is very high. So the throttle's down. and that's why, but I think that some people are like, I'm gonna make some money and I'm gonna see 50, 60 people a day, which my...

Michael Maxwell (01:05:11.241)

It's really tiring.

Beau Beard (01:05:19.818)

Retort to that is like how could you it's the impossibility of both time and bandwidth there is like I don't get it and maybe that's just my lack or you know my limitations But if you know if we kind of wrap this up because we keep coming back to this like you have to kind of have a filter to Apply this stuff which gets into the evidence, you know that we're basing things on you still have to interpret that as a clinician, right? you cannot take you know the conclusion or

you know, the methods and say, well, that's what we apply because that's not how it works, right? It may work in one out of 100 that they're the textbook. Man, I went through, you know, Keith Barr's Tendonopathy Protocol verbatim and it was just like, boop, you know, perfect. Like that's a rare, that is a rarity even if it does exist. So I wanna put kind of a bow on that because I know we're just keep, you know, beating it down and I couldn't agree with you more on this stuff too, but I wanna kind of open it up to more general because,

Michael Maxwell (01:06:05.559)

Yeah.

Beau Beard (01:06:15.822)

Again, like I mentioned, you own Somatic Senses or Kona, I believe, still with Ben. And you've been in the continuing education realm forever, which it's even funny that we call it continuing education, that like that's part of our job. So to think that like you're doing more than other people is, I wouldn't say laughable, but it's like, hopefully we'd all be motivated to learn as much as we can to help people as much as we can. And it's not hopefully just a selfish endeavor. But if we're going to be educating ourselves and educating clinicians, what

Michael Maxwell (01:06:37.279)

and to both.

Beau Beard (01:06:45.738)

Outside of what we learn in school, core sciences, generalized methods, adjusting soft tissue, things like that, are there core competencies of a clinician that you think need to be present outside of the clinical skills to actually be good at this job? And maybe, you know, if you want to get to that world class, like they have to be present.

Beau Beard (01:07:05.526)

I mean that could be anything from soft skills to creativity. There's all sorts of things that play into the job that you and I do.

Michael Maxwell (01:07:16.009)

Yeah, mean, so we're specifically excluding, you know, or taking for granted that we already have a basic education and physiology, etc, etc. Right. So.

Beau Beard (01:07:27.288)

Yeah, because the tough thing with this question again is we learn certain things in school and we know that we don't learn all of the things in school that you and I use in practice every day, right? So let's take that at face value that there's all of these other, I would say concepts. I hate to even say methods and techniques. Like there's concepts that have been applied using, you know, science, you know, IE, neurodynamics, DNS. It's people understanding the core sciences, looking at it through a different lens and applying it over and over and, you know, maybe eventually testing it or, you know,

methodizing it. But is there anything else that you're like, God, if you can't creatively think, if you can't have an imagination, if you can't store house information and, you know, critically think within a visit, like, it's just not gonna happen, like, it's gonna be impossible.

Michael Maxwell (01:08:04.278)

you

Michael Maxwell (01:08:10.601)

Yeah, man, this is such a layered question. I think being keenly present in every single moment that you have with a patient and being astutely aware of all of it is probably the most imperative first principle. With the second, which comes very close next to it, is asking the question why. So, you know, I remember

observing a, he was a neuropsychologist a few years ago and seeing him work with patients and him commenting afterwards, like, hey, did you see this? He was seeing like, know, pupillary dilation and constriction and he was seeing like, you know, soft brows and raised, you know, know, nostrils, you know, he was seeing stuff to the to a level of, you know, acuity that I just wasn't seeing.

And so it just requires an incredible presence and awareness and observation of the patient to be able to see the things that you need to see to dial in to, you know, the most probable mechanisms that need to be addressed on that patient. I think, you know, listen, like DNS is, you know, learning from Pavel and the Prague school. It's a, it's it's a little bit like a shortcut.

in the sense that it probably would have taken me, you know, 40 years to figure the shit out that I learned from them in a couple of years, right? And now that I have that lens, now my future learning is catapulting off of that new foundation. So that's really where I think continuing education comes in. It is that, okay, if you were present in every single moment for every single patient and you had enough time with them,

to make appropriate observations and ask the question why, you might get to where Pavel is, was, know, 40 years from now. But, you know, when you go to continuing education events and you see how other people are thinking, and you hear how they're processing, and you see what they're seeing, it gives you like another layer up to see new things that you hadn't seen before. But I think it all comes down to just like this inherent curiosity of trying to understand

Michael Maxwell (01:10:35.475)

what is going on with this patient and why are they experiencing pain? And that means that you have to kind of go down rabbit holes. And something that I don't think we do enough of, and this maybe is a...

That might be a totally unfair statement actually, because I don't know that people are not doing this. My impression is that people are not doing this. But I don't think people are taking their chart notes at the end of the day or at end of their week and going through those two or three patients where they're not 100 % sure and reading through it and dissecting it and reasoning it and then asking that patient be like, hey, you know what? I don't think I got this quite figured out. Can you book a re-exam next time so I have more time with you?

because I wanna take another deep dive on this, because I'm not a half percent sure I've defined this with the clarity that I need to move forward. And I think that needs to happen a little bit more. And that's why I challenged my colleague to make those notations. hey, if you're seeing it, write it down, because when you go back and look at that patient's chart, you can start to make sense, based of all of the data that you have and the interventions that you.

you performed and the progress of that patient of what were the most likely mechanisms at play. And then over a career, you start to recognize those patterns a little bit quicker. So again, present moment and curiosity. think those are the first principles that I would say are most imperative. And, you know, sometimes the answers are going to come at, you know, I don't know shit about this. I got to go.

on PubMed and do a deep dive into some research and learn more. Because, man, like, I still feel like a total fucking infant. You know, like, when I take a moment and pause and I read through the literature, there is so much to learn. It's ridiculous. You know, I had a patient come in the other week, has this weird, you know, neurological condition that I had never even heard of before.

Michael Maxwell (01:12:43.668)

Turns out it's a biomechanical mechanism that influences physiology specifically of the spinal cord whereby the dura in the spinal cord essentially shifts excessively anteriorly often associated with a kyphosis of the cervical spine like a loss of lordosis and it creates an ischemic and inflammatory mechanism in the spinal cord and it almost presents almost like ALS but it's very focal.

and, it tends to have like a short clinical course that reaches termination, but you don't recover from because essentially the nerves die. so it's like, shit, I've never heard of that before, but once I, I took a deep dive and I'm just like, man, there's another differential diagnosis for a slump test. You know,

Beau Beard (01:13:31.33)

Yep. Yeah. Well, the crazy thing is it's literally like you're teaching my course right now. All the, and the only reason I have a course is because you say the same things over and over with new grads or interns or when people ask you questions and you're like, you know, I teach a whole section on observation and people think it's kind of silly because you weren't, not just talking clinical observation. You build observation skills by being more aware in your general life, right? There's so like we were at a course in Texas.

and the guy that owns the clinic drives into this clinic every day. There's trees outside his clinic. And this is kind of a proven thing that for every plant that you actually know, like the name of and then the scientific name, right, you have a further understanding of the ecosystem. And then if you understand what animals would live in that tree and all this, and we kind of played this game, like everybody go outside. Everybody that's at this seminar was from Texas, not me. And I go, can anybody name any tree by just name, plain name?

not one person. Which again, if you're like, well, I'm not an arborist, my parents didn't spend time, whatever, but you drive by this stuff all the day, you can't even name it, which then paints your reality. So all I was trying to point or draw the picture of was, hey, your observation and your awareness is going to be determined by your conscious level activity. That's no different than you being in the room. And you said being aware of how they respond to a word or a statement that you say.

on how your posture affects their posture, do you need to use your position, posture, or stance to then facilitate something in them? like, the more aware you are of these things, just the easier job gets, which is already hard, right? To have this kind of diagnostic, mechanistic, interventional approach, but then you're like, okay, I have to make my job easier by understanding all of it. And then like I said, curiosity is at the heart of it, and you're just always asking why, or how could I get better? Why did that actually happen, right?

you have some whiz bang effect and you're like, well, I thought it was this, but man, that like got better a lot faster, changed much quicker than I thought it could or didn't change at all. So if we have those core competencies, if we reviewed of kind of curiosity, observation or awareness, if we want to say that in the room, if you're building a team of doctors around you,

Michael Maxwell (01:15:37.778)

Thank

Beau Beard (01:15:55.798)

Right? And let's keep it within our profession. If you're like, I wanted to work around the top five physicians, clinicians, whatever you want to call it in our realm, conservative musculoskeletal care, as of right now, we'll just call it the Avengers of musculoskeletal care. Who would it be? And then why would you pick each one?

Michael Maxwell (01:15:57.234)

Yes.

Michael Maxwell (01:16:18.44)

man, so many options.

Beau Beard (01:16:22.082)

And again, there's people you want to hang out with and then there's people you want to learn from. it's not under. No, no. Yeah, let's go. You can go dead presidents with it.

Michael Maxwell (01:16:27.089)

Do they have to be alive?

No.

Michael Maxwell (01:16:37.169)

I mean, I think Pavel would be a clear one.

I'd probably-

Beau Beard (01:16:46.348)

and why him specifically? can assume, but just give me a quick why him specifically.

Michael Maxwell (01:16:54.257)

Pavel approaches his work with a level of curiosity and there's just this incredible depth to his knowledge and breadth to his knowledge that he then applies with this very persistent sense of asking why and trying to figure it out that I find is incredibly inspiring. He's probably one of the most knowledgeable clinicians in our world.

and he just has a tremendous sense of humility and how he evaluates patients because he just continues to ask the question of why. and, he, he's just incredibly thorough and comprehensive. He also has, I think he, didn't get a lot of credit for this probably because of, English not being, you know, his primary language, but he has a way in how he interacts with people that, almost like invites you in.

his, his emotional intelligence, I think is incredibly high. So, you know, it's a tough question for me, because I, to be honest, like, I would rather put myself in a room of people where I don't think or feel like I've mastered those skills. So I would almost like want to be in a room with like, I don't know, like, say Michael Gervais, or something like someone like that, to to so part of being a

Beau Beard (01:18:18.318)

Yeah.

Michael Maxwell (01:18:24.11)

you know, a growing practitioner is understanding who you are as a person, what your strengths and limitations are. And my strengths are definitely in the realm of observing people and collecting data and reasoning through the data to come to reasonable hypotheses on a patient's presentation. I think that's my strength. My weakness is very clearly like social

interaction intelligence, like I'm, I'm, I'm fairly like, my affect is fairly serious in my demeanor. A lot of my patients, you know, feel like I'm really serious. And it's not because I'm, you know, I'm certainly not mad or angry. I'm just like, that's how I concentrate. I'm very quiet in the clinical room. Like I don't talk a lot. Like it's when I teach courses, you know, I'll make the comment of like,

Beau Beard (01:19:11.992)

bandwidth is high.

Michael Maxwell (01:19:19.333)

I actually don't like communicating that much. I would much rather be silent in the treatment room and not talk at all because I want to be acutely aware of the patient and me and our interaction in a non-verbal respect. So for me, communication with other people is my limitation. So why would I want to stick myself in a room with someone like Michael Gervais or someone in that realm is because I feel like they're

They're just wizards at communicating with people in an emotional and social context. And that's a limitation that I have that I would like to continue to get better at. And I continue to work on that weakness as I go through my career, because I think my strengths are way the hell up here. My weaknesses are down here. And I know that I'm never going to bring my weaknesses up to my strengths, but I want everything to shift up throughout my career. So I'd say someone along the realms of like Michael Gervais, Pavel Kolaj.

I would love to be, you know, in the room with someone in the realm. Like I could, like Feldenkrais, for example. Like I'd probably say Feldenkrais would be one. I might, you know, I never met Ida Rolfe, but I might say Ida Rolfe. And a close second might be my colleague Mark Finch, who has taught for me in the past, but I just feel he's like incredibly talented with his hands and...

His observational abilities are incredibly refined. And I think a final one would probably be someone in the medical world. And I don't even really have like top names off the top of my head, but it would be, know, someone from the sports medicine or surgical realm that has mastered the ability to evaluate a patient.

And from their unique perspective, which I don't think we always share. it kind of goes back to like my clinician back when I was at UWS, Dallap used to always kind of hammer on us about having a comprehensive list of differential diagnoses. And we never, we would never really like reach his standards because he would always ask us. What's another one? Like, what's another one? And I feel like chiropractors, because we, have this like fairly contained environment where we don't see all the stuff that like goes into a hospital, for example, or to a neurologist.

Michael Maxwell (01:21:46.22)

or a neurosurgeon, et cetera, I feel like sometimes our differential diagnostic list is too short. And I feel like that's a limitation created by our environment. So the other person I would want in the room is someone like a neurologist, a neurosurgeon, or a sports medicine doctor who is in that world and sees things from a slightly different lens.

Beau Beard (01:22:07.018)

On that note, so I bring up this book called The Six Thinking Hats by Edward De Bono, who basically came as a physician, but then kind of get into the finance world based on this book. So the six thinking hats are these six different colored hats that basically walk you through the process of thinking. Black hats is like the things that could go wrong, right? Red hat is intuition. The green hat is divergent thinking, which is differential diagnosis, right? It's the explosion of all the possibilities. The convergent thinking is the pruning of the possibilities.

down to some sort of something that makes sense, but also the black hat like, I gotta be aware of this. So have the yellow hat that's kind of that convergent process. And then we just kind of, and then the white hat, sorry, is your like objective data. So it's the data that you put into this. And I always bring that up because you'll fall to the level of your systems, right? So if you lack clinical awareness, you could create, know, that's what the whole SFMA is. Hey, if you're not gonna look global, we're gonna force you to, right? And then we're gonna,

hone it back in and break things down based on what the findings were globally. So I love that you're like, yeah, I need somebody that would look at it in a different light because I agree that we look obviously musculoskeletal, but then we need to look at the other systems that can affect the musculoskeletal, but then also, you know, the, I've never even heard of this thing. Now it's in my purview because I'm aware of it. And now I'm always aware of it because of that. But you had to be aware of the possibility of the thing in the first place, right? Not shut it down to,

Michael Maxwell (01:23:19.244)

Thank

Michael Maxwell (01:23:31.71)

you

Beau Beard (01:23:33.774)

No, that makes sense. Yeah, I love that. So the six thinking hats, Edward de Bono, and then the physician that I would pick from the medical world, if I was in, ask the same question, if you're like, I want somebody that's world class of basically thinking outside the box of the possibilities from just medical.

Michael Maxwell (01:23:40.398)

It was the name of that book again.

Beau Beard (01:23:59.022)

What's going on with this person that's not allowing them to be healthy or out of pain or whatever? Arturo Kostetovol is the head of molecular biology for John Hopkins. He's kind of the head of their, I guess, at the head of using AI as the diagnostic agent once you put in all the data that you still have to be aware of. The physician still has to pump the data in or prompt it to then say,

Michael Maxwell (01:24:23.342)

Yeah.

Beau Beard (01:24:25.816)

well, God, I can't look at 15 million studies all at once and all the case studies and reports. So his take on medical training, which gets at the heart of what we kind of started this conversation is we need less didactic training and we need more clinical reasoning right from the get go is literally at the heart of everything that he teaches. goes, the didactic is necessary, but he goes, if we have this massive.

Michael Maxwell (01:24:45.74)

Yeah.

Beau Beard (01:24:50.196)

AI computer learning system that's going to be able to store all information, then your job is you have to basically learn how to like, you know, look at the patient, observe, deduce, and then prompt appropriately. And that might change over time, but like that's still the, know, we've been in that role for the past, you know, millennia and we're still in that role right now currently. All right, let's keep rolling through these. what, what is something again, in the medical world,

Michael Maxwell (01:25:03.433)

Mm-hmm.

Beau Beard (01:25:19.118)

We'll just leave it to that so it's not just outside of that. What's something in the recent future or in the recent past, sorry, that you have changed your mind on? Something that you held true for a long time that you're like, ooh, based on information, based on clinical experience, could be either or. You're like, yeah, I really about faced on this thing. Does anything come to mind?

Michael Maxwell (01:25:41.133)

Yeah, I mean, this is not a recent discovery, but I would say that diving into Shacklock's work, Bowe's work, and yeah, I mean, when I went through chiropractic school, I wasn't so into the philosophy, philosophy, philosophy.

of Chiropractic, but, and I'm still not, but the original tenet that, you know, the terminology probably needs to be changed, but the original idea that clinical symptoms of a patient are created by compression of a nerve, or a pinched nerve, as they would describe back in the day, man, I'm seriously still mulling that over a lot now, because like, it's like, you know, if you have symptoms in a muscle,

outside of a tear, like, you for example, like my right TFL feels tight right now. You know, I can stretch it, it doesn't get better, you know? And a lot of patients are presenting with the experience of tightness. And it's not because the muscle is tight. And in the end of the day, you know, of course we know that there can be a protective pattern.

But I think a lot of patients are presenting with like low grade irritation or activation of the nociceptor within the nerve and nerve realm that's creating a clinical pain presentation of tightness that's driven from the nerve out. And even if you think about like, when you stretch a muscle, what are you actually stretching? Or how do I say this differently? When you stretch a muscle, what is the reason why you feel a stretching sensation?

Beau Beard (01:27:27.566)

First yeah

Michael Maxwell (01:27:35.776)

The only reason why you feel a stretching sensation is because you're pulling on a nerve. And you're pulling on the nerve, you know, obviously through its, through its terminal, I either receptor, but in the end of the day, you're still tugging on the nerve. So it's almost like, you know, everything actually interacts through the nervous system. And even something as simple as a tight muscle ultimately comes down to

Why is it tight and is it because the nerve is irritated or compressed? And, you know, I don't think it's as simple as, you know, it's always the spine, of course, you have many different peripheral entrapment neuropathies. But I think a lot of the experiential learning that we go through in clinical practice is trying to funnel down, like, what is the balance of factors that leads into this patient presentation and what I've

of being shifting towards is that often it's just an irritated nerve.

Beau Beard (01:28:41.07)

Well, and what I'm constantly curious about is when you, again, you keep, I like the word irritate because we use sensitize and all these things that maybe are misnomers, but it's like, why are these things getting irritated? Because it's not always compression, right? It's not always a mechanical irritation. It's not maybe, you know, we've had all these, you know, the Cinderella hypothesis, all these things, that's kind of the thing. know, I, again, you're being curious, right? Is it.

systemic irritants, systemic inflammation, environmental issues, whatever it is that is this why we're seeing the musculoskeletal burden? Is that solely tied to sedentaryism? All these things come to mind of what is creating this maybe peripheral irritation that then can almost in sequence cause central changes. Obviously, it doesn't take much to have some sort of cortical change.

Michael Maxwell (01:29:14.909)

after.

Beau Beard (01:29:35.362)

But yeah, that's something I'm curious about now is like, okay, why is this occurring? Because it's not always mechanical. mean, that's, you know, obviously we know that, but we don't know why.

Michael Maxwell (01:29:44.683)

Yeah, well, I mean, if you go, let's say you've got, you know, a superior clonial neuropathy that's not, you know, derived from a spine related complaint. So let's say you have an, you know, inflammation and an observed thickening of the superior clonial nerve and the fascia that exists between the erector spinae and the QL as it passes down the flank space and ultimately over

over top of the ilium, the question is what caused that thickening of the nerve? What caused the inflammation of the nerve that resulted in that? And what I think we are pointing to there is that like the global physiology is a potential input into the health of the tissues, the health of the nervous system, the expression of inflammation. And if you didn't layer on those other factors,

of systemic physiological inflammatory mechanisms, maybe it wouldn't have ever evolved into a clinical condition. Maybe the system would have been able to navigate through the present challenge of compression or tension or whatever you want to call it and just come out of it just totally fine. It's not necessarily the load on the system that causes the problem, but the response to the load on the system. It's like...

Beau Beard (01:31:03.128)

Perfect storm.

Michael Maxwell (01:31:09.278)

the difference between like, was it sheer? think it was. Tendonopathy study out of the UK where they looked at patients with history of tendinopathy and patients without a history of tendinopathy and they both had them go through a loading protocol and they observed via ultrasound the response within the tendon. I think they did, man, I think they might've evaluated blood flow as well, but.

Anyways, Cliff Notes version is that those who had tendinopathy and those who did not have tendinopathy both had a thickening of the tendon in response to heavy loading. But the ones who had a history of tendinopathy, that thickening and the swelling essentially of the tendon persisted for like, you know, four or five, six days, whereas the ones who had a healthy tendon, it abated within like 24 hours. So, you know, same load, different physiology. And we know now that

there's an epigenetic shift within these tendons in which that tendon is now primed to express inflammation. So same load, different response. And that's not necessarily because the collagen is different or the collagen can withstand a different load. Although it might be, but it could be both, but it might just be the cellular response to load that's aberrant or abnormal.

Beau Beard (01:32:23.95)

Yeah, I think it can be both.

Michael Maxwell (01:32:32.403)

which then goes back to the rabbit hole of asking why, and maybe part of the why, based off of what we know about risk factors for degenerative tendinopathies and arthritis is that systemic physiology has a massive influence over that. So maybe that's a big part of the priming of the system or the inadequate response to load, or even.

a load that induces a cycle of inflammation, the ability to recover from that versus end up in this cycle of persistent inflammatory mechanisms that results in the degenerative cascade. So.

Beau Beard (01:33:09.614)

Well, that's where you can be a sneaky clinician because you can know the physical, phenotypical presentations of different genetic snips. I know people are like, do you, I mean, you can, mean, there's all sorts of things. We know the big ones, right? Fair skin, redhead, collagen, distribution. But like all of these things come about where, again, are you gonna pull a genetic panel on every patient that has, no, that's...

But there's likelihoods, right? And the likelihoods play into, I have these diff dyes, right? I'm still going through this pruning process. And now that I have these likelihoods present with the history that this person's telling me with their previous treatments, with whatever's going on, and you're like, yeah, like what I would do with somebody else I can't do with this person, right? Even though they may have the same pathway anatomical diagnosis, which is what that study is basically saying. Yeah, I think that's beautiful because that's what...

Michael Maxwell (01:33:42.121)

Thank

Beau Beard (01:34:00.482)

That's again a curiosity thing of God. If they had the Fox2 gene and they have a double allele of the IL-6 gene, they made, this is gonna be a terrible scenario for somebody that I take through like ballistic loading, you know, when they're feeling good. Like it's just gonna be way too soon, right?

Michael Maxwell (01:34:13.019)

Yeah. Yeah, yeah. Is that is that drives you know, that I can't remember the author of the study that Tom Myers wrote about, sorry, not Tom Myers, Tom Ashad wrote about recently where those who are essentially hypermobile, yeah, versus someone who is not. Yeah. Yeah. So the response to load is dramatically different depending on

Beau Beard (01:34:31.444)

That's Keith Barr's work, yeah, out of UC Davis, yeah.

Michael Maxwell (01:34:39.176)

the inherent connected tissue makeup of their tendons, essentially. So yeah, those factors, that would be another, I think, pivotal shift. And actually, I learned that from Pavel first, actually, was the focus and attention to connective tissue quality, just general connective tissue quality, which I think you can get a pretty good feel for just with your hands.

the compliance or elasticity of the skin, the fascia that underlies it, the muscles, all of it kind of gives you a phenotype of the patient's connected tissue quality. And then maybe that can give you some information on how you would proceed into a loading protocol. I wanna go back for a second because you mentioned something about Ben and how he said, it doesn't really matter because you just end up, my hunch is that what he's saying is in the end of the day, you just end up.

loading the system in a way that their system tolerates and you just progress them through some kind of a loading protocol and the specificity doesn't necessarily matter as much. But the thing is like, Ben is a fucking outstanding clinician. You know what I mean? Like his reasoning's, you know, I didn't think it was, I didn't think it was. Yeah, because I just know like, I've seen Ben work and I've seen Ben think, more importantly, I've seen Ben think and work through thoughts and work through, well, we've talked through cases together and

Beau Beard (01:35:44.622)

Yeah, and that was no knock on him. It was just, yeah, he was...

Michael Maxwell (01:36:01.786)

he comes at movement and loading in a different way than I do, but we kind of are still pointing towards the same underlying mechanism just in a different way. You know, he uses what I really appreciate about Ben is that he uses a very creative space to come out and come into loading protocols to change or influence loading parameters within an individual patient based off of their pain provocation mechanisms and their pain relieving mechanisms. And so, you know,

he might do that with a single arm front rack reverse lunge, but he loads a single arm front rack on the left side because he's trying to unload the left. You know what I mean? So he's coming at it from a way that's incredibly specific at the same time, very general. And that's like the ability to kind of zoom in and zoom out of like what's general and what's specific and understanding there's nothing really that is general. It's all specific just with different mechanisms I think is really important. Because Dimitri, when I was chatting with him,

a couple weeks ago, me and Dimitri probably about on average, you know, once every couple months, we'll hop on a call and we'll end up chatting for like one to two hours about this stuff. He kind of, you know, we had an in-depth conversation about phenotyping of patient pain mechanisms and patient presentations. And he kind of said the same thing as in the end of the day, I'm not sure it really matters because we end up doing all the same things, which is exercise, manual therapy.

observation of social, emotional, and cognitive factors and addressing those as we need to. And we kind of do that with every patient, you know, which is true, right? So, you know, we do all of those things with all patients. And in the end of the day, even if we have a very specific mechanism for a patient's pain presentation, is our goal not to make our patients generally healthier? So am I aiming towards getting my patients engaged in exercise or activity that would be consistent with the international guidelines for exercise and activity? Well, yes, I am.

and that ultimately funnels back down to being generally healthy, right? So whether I start specific and move general or go general and focus on the specific if I need to doesn't really matter.

Beau Beard (01:38:04.11)

When all it comes down to, honestly, if that's how we distill it, if it's two funnels that are connecting in the middle, then it's just effectiveness and efficiency, right? Because you could still get the same thing done in more time or less time or more frustration or less frustration, both for you and the patient.

Michael Maxwell (01:38:13.242)

That's the thing.

Michael Maxwell (01:38:18.596)

Yeah, yeah, yeah. Or the most important part is buy-in because the patient has to feel better for you to show back up, right? So sometimes you need to make sure that your specific intervention initially gives them some relief so that they know that if they continue to move forward with you, they will get to their important outcome markers.

Beau Beard (01:38:22.924)

Yeah, 100%. Yeah. We gotta show back up. Yeah.

Beau Beard (01:38:43.608)

Right. Yep. Yeah.

Michael Maxwell (01:38:44.388)

which is just feeling better and doing what they would normally do in life without having pain, right? So.

Beau Beard (01:38:49.026)

Yeah. And that even gets to your point of, you you mentioned earlier using, you know, an adjustment or mobilization for specific reasons, but then also using a pain alleviating or symptom reducing intervention when you don't think as a clinician, that is the biggest piece of the clinical puzzle. But you're like, I need this to die down. And I mean, I'll tell most people that, right? I'm sure I don't know if you're, I mean, I'm like, Hey, I'm doing this because I want you to feel better. I don't know how much is going to change these audits I'm looking at.

Michael Maxwell (01:39:11.268)

Yeah.

Beau Beard (01:39:16.984)

But like when you, and then we always kind of have the combo of like, yeah, pain alters movement. And so we want to kind of eliminate that anyways, but like, yeah, you have to get rapport reassurance and get them to show back up. And that's how you create your AB experiment. So you have the clinical trial to go through. Yeah, so again, you and I agree on everything. mean, I'm sure in the clinical realm, there's very few things we disagree on. You're just such a bright mind in terms of the.

the details, right? The diagnostic accuracy, the mechanisms behind these things, always asking why. That's why I like to just kind of explore your mind and be like, well, you know, how, why, why did you arrive at why these things are so important, right? Why do you approach your, you know, clinical process in this manner? And I think that's where students and docs and, you know, even lay people are like, God, there's somebody out there that's doing it like this. I either want to, you know, mirror that or I want to push myself.

Michael Maxwell (01:40:06.821)

I mean it just comes down to really just yeah I mean honestly it comes down to just really caring about your patients and caring about their outcomes you know like it bothers me when I can't help people it really bothers me when I don't even if I have like if I have one interaction in a day where I'm just like I just didn't

I didn't nail that one. That was not a therapeutic intervention in the sense that it didn't help that patient on that day in the way that I thought it could have. That bothers me. And I'll think about that for, well, my last one was two weeks ago. So I'm still mulling over that interaction two weeks later on how I could have been better, right? And that, in a...

Beau Beard (01:40:54.062)

I have one coming in today.

Michael Maxwell (01:41:04.237)

you know, maybe part of that's ego. I don't like being wrong. I don't like being ineffective. I like being good at what I do. And part of that's driven by just fundamentally caring about the people that you're working with. And if you care, it's them that's gonna drive your motivation to look deeper and move forward into that process of clinical reasoning, right? That's like, you know, sometimes I'll tell my patients, like I often work like afternoons and evenings because

Mornings for me is a very creative space. That's where my brain is like most effective and most active. So I like to have mornings alone for my creative time and writing and reading and all those things, because I'm way more effective in that time of the day for those things. Because I know that the second that I get a patient in front of me, they're gonna drive that. You know what mean? Because the motivation is so high to do a good job for that patient that it just...

brights your, you know, lights your mind right up. You know what I mean? So.

Beau Beard (01:42:01.422)

when I'm assuming you and I being in the field and kind of practicing similarly, when I get done with a day two, it's like I have five more, six more things I have to look up, think about. So it's like, that's where you have to, and this is why I call this the distillation process, which you kind of talked about earlier with your clinical notes, which I preach too. You already have to do your notes, right? Legally, you're bound to do notes. Now to what level you're going to do your notes, yeah, you have to pass an audit and all that stuff if you're insurance bound.

But if you're already doing them, why wouldn't you take the time and effort to have something that you can review? But reviewing your notes is also different than a creative ruminative process where you're actually now trying to distill ideas into something that's not necessarily conceptually different, but that you're like, I could have approached this case like this. I've never thought about it like that. I've seen this pattern occur. That's clinical leaps and bounds. That's not just sharpening your sword. That's literally getting a different sword, right?

Michael Maxwell (01:42:36.602)

See you.

Beau Beard (01:43:00.342)

I wish more clinicians. I know we're busy. I know we have families. I get it. Like 30 minutes a day, right? An hour a week, whatever it is to do what you're doing.

Michael Maxwell (01:43:09.508)

Yeah, well, we don't, you have to schedule it in though, right? And I think that's, you just pointed you, I think, you know, I mean, I've always been a little bit obsessed with this stuff and I acknowledge that I'm different and not everyone is going to do, you know, 30 or 40 continuing education courses a year. Like that's not normal. Um, so I do have to accept the reality that that's not a typical, you know, thing for people to obsess about these things to the degree that I would.

But I think in the end of the day, even practitioners who have full families and busy home life and full clinical practices, they just need to schedule the time. And I know that a lot of clinicians that I've met over the years, they just schedule half an hour in the morning where they'll read an article or they'll read their chart notes and they do that every day. One of the senior chiropractors, he's retired now, he practiced for 38 years full-time.

41 years before he hung up the hat fully and stopped doing like preceptor ships for us. His dad was a chiropractor, his brother was a chiropractor, so like, you know, through and through just a chiropractor at heart. he was passionate to the day he, you know, stopped practicing and still to this day actually comes in and talks with us and still speaks with passion about the work that he did and continues to do and volunteer work. But my point is that he would come in early to work every single day.

He would go through all of the patients that he had in that day and he would have a system of labeling each patient in what he wanted to work with them within each visit based off of what he had seen the last time he saw them, et cetera. And so just that process of like reflective reasoning is I think super important to continue the evolution of your practice. Yeah, I mean, I get a man like I don't have kids, so I'm not.

When I go home, outside of spending time with my dogs and my wife, I've got time to read scientific journals and write articles and things like that. I know people don't always have that time and I have some empathy and understanding for that. So it just means that in those scenarios, we just need to book the time into our day. You can't just go treat patients nine hours a day and then clock out and then go back and treat patients for nine hours a day and then clock out.

Michael Maxwell (01:45:35.075)

you need to clock in at a different time to continue to learn and evolve as a clinical practitioner. Because there truly is like no end to learning. Like I don't feel like I'm any nearer to the conclusion of my learning process than I did 20 years ago.

Beau Beard (01:45:52.93)

call it competent confusion. You realize, I mean, this is in every field in the world overall, right? Yeah, the more you know, the more you realize how little you know in the whole body of like your field in particular, and then in general. And that can be a little defeating. But what I kind of came to was all the people that I looked up to, or still currently look up to, are very competent, extremely competent. But they're as confused as all of us because they're like, Jesus, we don't understand.

99 % of the stuff that we're looking at to the level that we can be absolute, right? And absolute doesn't exist in our world, right? So you have to be okay with gray, but then that's that. I'm highly competent. I'm still confused. I have to fuel the confusion with curiosity to keep learning. I think that's what you're, I mean, world-class at. I mean, we need people like you. I mean, I'm not saying people that are, you know, know kids and have all the time in the world, but we need somebody that's going to distill this very

highly intentional clinical practice into education for other people because some people might not have the time that you do. Some people may not have the motivation that you do. And, you know, some people might just be a little bit lazy. So I hate to say it, if there's a Michael Maxwell out there that they can learn from or utilize to read articles, go to classes, I mean, that's maybe, you know, what you're here for is like, you can be that conduit of like,

Hey man, I kind of got your backs. Yeah, the oneness is still on you to take this information, make it your own, but like I'm going to try to help distill this thing. Do you ever feel a burden of that or is that just a fun motivation or is that even in your purview of like, that's why I'm doing this stuff.

Michael Maxwell (01:47:27.506)

Yeah, man, mean, it obviously, you know, it for me, it's driven out of just like a pursuit of knowledge. And I'm just a curious person. And I get bored really, really, really easily. Like if I don't either teach a course or attend a course, like every, would say, like, eight weeks is like my, my, my ideal limit. I just start to feel stagnant.

I feel like there's a plateau and that stagnance and plateau kind of is almost like there's nothing that's pushing me further. You know what mean? Like I'm in my own head, I'm in my clinical practice, but it's when I get out and talk to my colleagues, whether I'm teaching and receiving questions and having to think about the questions that people are asking me, which promotes learning, fosters new questions in my mind, which then I go research, whether I'm learning and going into a clinical environment where

where someone else is talking through their clinical process, to me that helps kind of like, keeps me driving forward. So I don't think we're immune to that plateau and I don't think anyone is. And I think we all just need to get out there and talk to other people to learn more, to kind of in the pursuit of curiosity. Cause like, I know that we're on the same page with a lot of things, but you're still a different brain and you think of things a little bit differently. And I know that if I talked to you enough, I would learn a lot from you and probably vice versa.

And you know what? The reality is if I sit down and talk with my colleague in the office who's got a full-time family and isn't a total continuing education nerd like me, but still a passionate chiropractor who cares about her patients, I know I can also learn a lot from her because she's a social wizard. You know what I mean? Like the way that she interacts with people, the way that she communicates with people, how she cares for people, or more specifically, how people feel cared for in her presence.

Is something that that that I can learn from so we all are fitting roles within this community I'm just fitting a very specific role based off of my specific strengths and passions and other people are filling very different roles and Not like I'm not the best carpets for every patient It you know flat out there's there's people who are gonna come into my office and be like well you'd be much better served with you know doctor so-and-so down the road because

Michael Maxwell (01:49:39.787)

from a personality perspective and for what you're seeking and what you're looking for, I think you would be better served seeing that person because their strengths fit with what you're looking for and what I think you need. And our personality types aren't necessarily going to jive based off of my strong, firm, quiet demeanor. And what you need is something that's a little bit more warm and fuzzy. And that's just not me. You know what mean? So.

Beau Beard (01:50:05.538)

That's self, that's being aware just in a different way. It's self-awareness. You're turning the awareness back on yourself instead of, you know, the clinic, the treatment room and the patient. So, and that can be harder to do and then heart maybe even harder to act on. You might know you're, you know, I'm not saying you, but like, if somebody's like, man, I kind of a little condescending sometimes in the treatment room. If you know that you still got to act on it. You got to some sort of like intervention with yourself of like, okay, what am I going to do about this now?

Michael Maxwell (01:50:14.399)

Yeah.

Michael Maxwell (01:50:33.216)

Yeah, and you know what? The thing is like, no one's gonna be perfect all the time. And it just comes down to being like, you know what, I apologize. You know what mean? That wasn't the best interaction with you the other day, and I apologize for that. And then having a conversation with the patient to make sure that they're good with moving forward and that they feel you're still the right person for them. And if they don't feel like that's the case, then you need to move that patient along to someone who you feel would be. So.

Yeah, I mean, I don't think like, you know, there was a movement against gurus in the last 10 years. I think it's gone too far because I think there legitimately are gurus who are ridiculously good at what we do and Pavel is one of them. But I also know for a fact, not because I've been in Pavel's practice, but I know for a fact Pavel doesn't get everyone better.

Beau Beard (01:51:26.2)

Yeah, it's a possibility, yeah.

Michael Maxwell (01:51:28.159)

Like there's no guru who is the best practitioner for every single patient. And sometimes they just need an average practitioner who's going to hold their hand through a troubled time and give them some basic skills and tools to move forward with some basic treatments, interventions that they're looking for to get them through this. know what I mean? And sometimes that's just what it is. Sometimes it's just you have a patient who's going through an incredibly difficult time.

they're holding tension in their body, that tension is manifesting as pain. And until they move out of that period, they're probably not gonna find resolution and maybe you just need to hold their hand through there and support them through that process. You do need to obviously seek some degree of understanding within the patient that listen, there's social factors at play here. That's okay. I know you're going through something and I'm gonna help you through it. And you know, that's not.

treating a nociceptive mechanism, that's treating the social and emotional mechanism to make sure that patient feels cared for. And we mentioned or alluded to it a little bit ago, but sometimes the most analgesic thing that you can do for a patient is the thing that they think would help them most. And you know.

Beau Beard (01:52:38.488)

Yeah, well yeah, we always say if they told you, if somebody's like, went to an ART practitioner for something in the past and I had wonderful experience, 100 % resolution or whatever, and you don't take that into account, and I'm not saying you always just do some mimicked action, but you don't take that into account and think that like, ooh, that could be a very strong pain alleviating or a poor building mechanism that I utilize in some form or fashion, I think you're A, being an idiot because you're just.

bypassing like they just literally told you what I like and that is such a big part of that clinical, you know, therapeutic partnership. So yeah, I couldn't agree more.

Michael Maxwell (01:53:14.653)

Yeah. What's really hard though for me is that when you know that that is not going to help them. You know, like, like I find that super challenging. Like I've had patients who have come to me and they clearly have like a micro instability of their lumbar spine that's being perpetuated by activity XYZ. They've seen a chiropractor, they get temporary relief at last two to three days, but it keeps on coming back. They've been going through the cycle for two fucking years, but all they want is an adjustment.

Beau Beard (01:53:22.04)

Yeah, yeah, that's...

Beau Beard (01:53:41.294)

Yeah. You're like, it's the last thing you need.

Michael Maxwell (01:53:42.963)

And I'm like, you know, that's hard for me to just be like, have the humility to step out like, okay, I guess we're doing this, you know what mean? I guess we're gonna do an adjustment today, even though it's like, in a way even potentially contraindicated for your clinical presentation, but we're gonna, you know, if I don't do that on that patient, maybe they're not gonna come back, you know? And so if I want them to come back to get to what I think is really gonna help them, maybe I just do what they want me to, as long as I know that it's not gonna harm them, you know what I mean? As long as it's safe.

Beau Beard (01:54:09.902)

safe. Yeah. And that's, that's tough, especially I mean, I know when I was new in practice, how I tackled those scenarios is also wildly different than how I tackle them now, because I'm still going to broach the the subject, right? I'm not going to just walk away from it, adjust them and be like, you know, but at some point to get the buy in and what we actually need to do, right, the best, you know, clinical intervention for them, you have to kind of at some point without saying it like, hey, that's not the right thing, right? That's not the best thing. But we actually

Michael Maxwell (01:54:12.841)

So.

Beau Beard (01:54:38.786)

in a team meeting just last Thursday talked about internal and external rapport. So like, if somebody is referred in here from somebody, right, like a trainer, and you think that what they're doing with that trainer is hurting them, but maybe that trainer is their best friend, you have no clue, right? You have no clue, it's just on their paper. And then you go about your business and maybe even in a nice way, saying what they're doing is wrong or hurting them, you are literally dissolving trust as you're trying to build.

Michael Maxwell (01:54:54.75)

.

Beau Beard (01:55:07.47)

clinical report, right? You're giving them clinical data and they're like, yeah, yeah, yeah, but this is like, this is my homeboy, this is my family member, whatever. That it gets back to that like highly aware, highly observable work through, they're a person first, right? They're a person with an ailment, not an ailment, you know, with a person attached to it. like tackle like that and you're always going to be better, right? Whether they're telling you what was previously done or, you know, what they don't want done, which could, you know, play the opposite side. Yeah, that's, that's just being a clinician.

You're not just a hammer going in there, but you could still have every clinical skill in the world and be the worst practitioner in the world. Because you don't know how to apply them. You don't know how to pick up social cues. You have no empathy, bedside manner. Yeah, so you got to have it all to what level.

Michael Maxwell (01:55:42.974)

.

Thank

Michael Maxwell (01:55:54.053)

Yeah, then you should probably just be a surgeon.

Beau Beard (01:55:58.178)

Well, and you said earlier about you'd want to be with, you know, a highly somebody in the medical field that's just like world class of diagnosis. So I still remember we listened to Dave King, who's I would say in the top five hip surgeon in the world, in particular with osteotomies and labrum repair at a DNSC course at Bretts, Bret Winchester's place. And somebody asked me like, why do you think you're so like, why are you so good?

And he goes, I'm a messy, what'd say? I'm a messy carpenter in terms of my surgical prowess. It's my diagnostic capabilities. So it's basically who I put in the surgery suite determines my outcomes. And then he went through and I was like, yeah, that's like, everybody hear that? Like, let's hone in on what he just said. Like he's still a really good surgeon, I'm sure, but he doesn't think he's world-class surgeon. He's world-class diagnostician, which makes him therefore a world-class surgeon. So yeah.

Michael Maxwell (01:56:29.56)

Thank

Michael Maxwell (01:56:40.413)

Yeah.

Michael Maxwell (01:56:49.957)

In terms of outcomes, exactly. Yeah. Yeah. To me, it all comes down to diagnosis. To go back to the basics, think that like what a lot of people are missing today is specificity in diagnosis. And a lot of that comes from the positive of pain science is that we're now paying attention to the psychosocial factors with great detail.

the unfortunate consequence is that at the same time they were emphasizing this is that they were intentionally de-emphasizing biology. And that didn't need to happen. It's a little bit like I was watching a podcast of the day from Trigonometry. I don't know if you know them, but not in our realm at all, not trigger points at all, like like triggered. But they were referring to

Basically, I just totally lost my thought. I should have eaten before this. I'm going hypoglycemic here. Where was I going with this? Help me out.

Beau Beard (01:57:56.672)

I don't know, something on the realm of we're talking about being a good surgeon based on your diagnostic prowess, all goes back to diagnosis.

Michael Maxwell (01:58:06.246)

yeah, general and specific, general and specific. I think I just totally lost it. The point I was trying to make was that if we don't see it, we can't possibly determine that there's no usefulness in implementing that potential intervention that addresses that parameter in a patient's outcome. And so we just need to make sure that we're paying attention to things. So, identity politics. That's where I was going with this. They were talking about identity.

Beau Beard (01:58:12.334)

You're good.

Beau Beard (01:58:32.896)

I know it's.

Michael Maxwell (01:58:35.162)

They were talking about identity politics and the one guy's point was that the problem with identity politics is that the more you emphasize one specific group or people that have a certain identity, you actually are de-emphasizing all these other people over here and you alienate them. And by virtue of alienating them, then you create opposition. Instead of just saying, for example, the example that he's giving is that everyone should just have equal rights and privileges.

everyone should be treated equally. Instead of saying these, yeah, these people should have more. And the other person was not on that boat, but that's fine. My point is that we shouldn't have identity politics in our biopsychosocial interventions. We should just be looking at the whole system and not de-emphasizing biology or the biological mechanisms or the no-sysystem mechanisms or the biomechanics or the posture or the, none of it.

Beau Beard (01:59:08.055)

subgroup. Yeah.

Michael Maxwell (01:59:32.742)

We shouldn't be de-emphasizing this bucket just because we're paying attention to the psychosocial realm. We need, yeah, like this is where what we do is so fascinating and amazing. It's the reason why we can learn throughout our whole careers because we actually need to be good at all of it. You know, we actually need to be good at addressing, you know, function, basic human function. And we also need to be really good at understanding the psychological and the social influences of a person's...

Beau Beard (01:59:37.912)

Yeah, how to do.

Michael Maxwell (02:00:02.469)

you know, presentation on their pain presentation, you know, so.

Beau Beard (02:00:07.281)

Infinite game for sure, Well, A, I can't thank you enough for doing this. B, I do hope we get to meet in person sometime in the near future. And maybe I'll take course from here or, you we'll have you come down and teach in Nashville or something. Yeah, any last words? I mean, we've hit on some really good, like we've been repetitive in a good fashion, right? We've hit on notes that we keep coming back to. And anytime that happens, I mean, that's the important pillars of, I would say, how you practice, but then,

Hopefully what we see a little more proliferated within our profession. But any last words before we jump off here,

Beau Beard (02:00:48.47)

Oh, 100%. I know they will. the best thing is you can go to any of the courses that you're an instructor for or that exists in our realm and learn specifics. I think what we actually need at this point in time is better generalized frameworks for how to become a good clinician. You can have all these tools. You still have to create a workable heuristic and...

I think that's what you hit the nail on the head of today is like, what are the bigger pieces that I can go back to, right? Some sort of review process, being aware, being, you know, caring about the patient, reviewing my notes. I mean, these are just core things. is like clinician 101, well, don't go to 102 until you've hit the 101. mean, that's, know, now my editor is probably gonna call this that, but yeah.

Michael Maxwell (02:01:25.402)

Thank

Thank you.

Michael Maxwell (02:01:35.736)

Yeah, I mean, there's, can you think of a continuing education course that you could go to and come out of it after two days and be an expert on that topic or that skill set?

Beau Beard (02:01:47.606)

You know, funny, no, I don't, but in every state for some reason, it seems like you could have dry needling the way they have every state approach it in the US, which is kind of interesting. Right.

Michael Maxwell (02:01:58.724)

Sure, but that's not reality. That's what they're, you what my point is is that you don't, you go to a course to pick up a skillset and get really rudimentary competence in that skillset or, you know, knowledge set, whatever you're focusing on in that course. You need to have that time in your week to review and practice and study and work on it, you know, like.

It took me, this is super fortunate of my background and hosting courses, but you know, I would go to courses 10 times. And, and I still would be like on the seventh time through feel like I'm learning a lot.

Beau Beard (02:02:46.306)

Mm-hmm.

Michael Maxwell (02:02:47.884)

And a lot of people will go to one DNS course and be like, yeah, I got it. You know, they'll go to one neurodynamics course and be like, yeah, I got it. But if you actually like quiz them, you actually ask them to show you like, hey, show me supine three months or hey, show me this, or you ask them some, kind of a more complex clinical reasoning question based off of that content you just taught them. They can't put it together. You know, they can't demonstrate high level competency in that clinical skill. So we need to have a routine in our daily life.

where we're reviewing and practicing and growing the skill set. So if you go to a course, you come out of that course with reviewing it. I actually think that's a huge strength of the new way that we're teaching neurodynamics with the hybrid model is that you do all of the theory for two months before the in-person course. The in-person course is going through all of the clinical skills along with some clinical dialogue. I can't help myself in bringing up clinical cases when I go through that.

And then you have access to that content for, think, sorry, it's one month before the course and two months afterwards, I think, or vice versa, but you have three months total access. And a lot of people will talk about, you know, what it was really helpful to have access to the videos of the skills after the course, because that, cause listen, yeah, like how often do you perform a fibular neurodynamic test? You know, maybe once a week. Right.

Beau Beard (02:04:03.715)

you

Beau Beard (02:04:11.744)

If I mean, yeah, depending on your case, yeah, population bias.

Michael Maxwell (02:04:15.064)

Yeah, like depending on your, you know, practice, you know, like if you, if you have, you don't have like a very like spine or neuro-focused practice, you're probably not performing some of the more specialized neurodynamic tests every day or multiple times a day. So you, kind of need to review that skill. And I still like, I still will go in to some patient reactions. It's just like a busy week and I'll be like, okay, I'm gonna do the fibula neurodynamic tests.

Beau Beard (02:04:17.442)

runners, yeah.

Michael Maxwell (02:04:42.519)

But the point is that we need to be constantly reviewing even the basic skills. Even that like, you know, have you ever seen? Yeah, have you ever seen Dave Traster do a neuro exam?

Beau Beard (02:05:15.8)

Yeah, maybe, yeah. Well, you could be reviewing basic sciences too. mean, that's,

Michael Maxwell (02:05:27.479)

If you watch him do a neurological exam, you're like, I don't know how to do this at all. Yeah. Like I mean, yeah.

Beau Beard (02:05:30.616)

I'm the worst in the world. But you need you need that in all realms, right? Not just clinical, like life in general. I mean, like we went, we worked a triathlon this weekend. And then you think you're kind of like, I'm pretty good something you watch somebody world class, like, yeah, like, yeah, that's, that's what that is. Like, yeah, humility. Yeah. Yeah.

Michael Maxwell (02:05:50.071)

Yeah, it's like watching Pavel do an elbow exam and you're like, yeah, yeah, I'm not getting that kind of information from from that. Yeah.

Beau Beard (02:05:56.142)

Well, cool man. Well, I have to go see patients and put all of the stuff we just talked about into practice. But again, thank you so much for taking the time. yeah, if you're not familiar with Michael Maxwell and what he does, we'll have links to continuing education and on the articles that he writes, which are just a trove of knowledge in general. So thanks again, Michael. I appreciate it, man.

Michael Maxwell (02:06:21.271)

Thanks guys, take care.