Chronic Pain: When Biomechanics Isn’t the Answer

Samuel Bulten: Once I started looking into the biomechanics and what relation it has with pain, I was quite disappointed, pretty quickly and realized, wow this is not a strong correlation or it doesn't seem to be a big factor at all which was definitely going against my bias.

And it's really nice for clinicians to be able to t hink of that that lens of I'm gonna find these faults that people can't see, and then I'm gonna fix them. And I have and I think that it boosts our egos in some ways. Once I read the research, I was like this doesn't seem to really be a real reason we're helping people. 

Mark Kargela: If you've ever walked outta school feeling confident and then met your first handful of persistent pain cases that didn't respond the way they should, this episode is for you. Today, I'm sitting down with Sam, an exercise physiologist based in rural Western Australia, who's been building a multidisciplinary clinic while also wrestling with the same tension.

So many of us feel we're trained to measure, classify, and solve pain like it's a technical problem, but real people don't behave like tidy systems. In [00:01:00] this conversation, Sam shares is what it's like working in a small community where biomedical narratives still dominate and why that pushed him towards psychologically informed care, acceptance commitment therapy in a more whole person model.

We dig into the identity shift that happens when you stop trying to be the hero who fixes people and start becoming a guide who helps patients build agency. We also get honest about outcome measures and that if you don't measure it, your guessing mindset, what do you do when a patient's life is improving, but the scores don't reflect it?

How do you stay evidence aware without reducing recovery to number? If you're an early career clinician feeling that instability or a seasoned clinician, tired of chasing shiny tools, this episode will help you recalibrate toward what actually moves the needle.

Communication, mentorship, and the courage to sit with uncertainty all while still keeping the love for what we're privileged to do. Let's get into the episode.

Announcer: This is the Modern Pain Podcast with Mark Kargela.

Mark Kargela: Sam, I know a lot about you, but the audience probably doesn't. If you can give yourself, give a little introduction of where you're at and what you're up to.

Samuel Bulten: Yeah, sure. I dunno how far I should go back, but I might [00:02:00] just go to the mid major life points in my life. I'm actually Dutch originally, so I moved to Australia when I was 14. And I've pretty much lived in Western Australia, regional, rural. Besides my study in Perth when I did my degree. And since coming out of uni, I moved to a very remote town Newman, which is in the middle of nowhere.

And then eventually moved to Geraldton, which I lived in before. And my wife is from as well. And that's where I'm based at the moment. So I started as a, exercise physiologists as a sole trader and now slowly build up into a multidisciplinary clinic, which is pretty cool. But it comes with its challenges and yeah, I have a big interest in anything persistent pain, and that's really an area that that yeah, that both fascinates me, but also yeah, I want to see if I can do better.

Mark Kargela: And that's what we're all after for sure, as far as that constant pursuit to, to see if we can improve what we're up to. I'm wondering with a rural setting [00:03:00] having worked in some rural, very small rural settings. You almost become a jack of all trades in there. And I know you're, it's impressive to hear somebody in a rural setting.

'cause I know for me, even sometimes here in Phoenix, which is like the fourth or fifth biggest city here in the us, sometimes it's hard to rally a group of like-minded folks together to really have that multidisciplinary approach. I wonder if you could speak to how that's been getting your multidisciplinary group together as far as in that rural setting and how it's, aiming to serve your community from that whole person approach.

Samuel Bulten: So I do have to be careful with my words 'cause it is a small community. What I did notice is when I was working as a by myself, it's very isolated. I think you have the same problem where you are as well. It's all in silos. At that point I was seeing a lot of people that had already seen physios, chiro been to doctor specialist.

And I have to say that. At the time, and it's still ongoing as well to a degree, is that it's very biomedically driven. The narratives are very much still what we [00:04:00] used to think. And I don't know if that's just rule or if that's just I guess maybe the training in around this town has been about.

And yeah, so at the start I did actually find it was hard to find. Like-minded people. I was lucky enough to work not together with physios, but in the same space with a few physios that actually were up to date with the knowledge. And we do have a local MSK physio who's very much up to date.

I've, Lynn, I'll give him a quick shout out. So he is he's a bit of a leader in the field as well. He is done some, he's got some good papers on his belt. And when I started the multidisciplinary clinic, I was really putting, wording the advertisement for job roles very much in adding those words in the biopsychosocial model to act all these different words that I was hoping we're gonna connect with the right people.

And I think they have we've got a great team now and we all. Think alike, but we still think differently, which is great 'cause [00:05:00] we, that, that creates a bit of discussion and keeps us all on our toes as well. But yeah it's not easy. I find yeah, there are still people that think very differently in this town.

Mark Kargela: Yeah, and I think you deal with some things that, even in Phoenix, same things where there's, and I think it's a cultural generational thing in health professions just. We're all trained and getting better, but there's still probably a lot of folks out there who are very much reared in a very strict biomedical interpretation of pain.

And therefore those narratives live on probably a lot more strong strongly than we'd like. And then in small towns I remember moving back towards my hometown, there's just a lot of very. Dated narratives around backs and things like that, and I got very frustrated similarly that there's just a lot of kind of disabling narratives out there of, that it, your scans your destiny in a variety of different things. I'm wondering, that obviously brings the challenge of, when you see persistent pain and people who are. Struggling in that model, getting stuck, not, life on hold, all that stuff. What did you, where were the holes you felt like in your practice coming out? 'cause I think we all have 'em, [00:06:00] right?

As I know I did as a physio and we didn't get much of bio-psychosocial. There was a little, psycho disabilities, I think the name was of a class I took, which I saw no connection to what I was gonna do in physio. I thought it was like a, let's check the box so I can get through this. I'm wondering what your journey is to where you've recognized some of the maybe holes in your education, in your practice, and how you've aimed to fix those over time.

Samuel Bulten: . It could be quite a long story, but I'll try and keep it concise. In my degree as an exercise physiologist, really we didn't get taught much about pain at all. I was quite surprised as most of us end up actually working in the space in the MSK and dealing with people with pain.

We did have some training on. MSK, but more on the orthopedics biomechanical sense. But we weren't really introduced to the biopsychosocial model how psychological and social factors could influence pain. And I guess when I first went out into practice, that was. My lens was that vary by me, [00:07:00] medical and biomechanical.

Looking at those issues in the tissues, looking for dysfunctions, muscle imbalances, all those things that we got taught. And I realized pretty early on that it helped some people. But then there were a lot that it wasn't really doing anything for. And, I guess that just made me want to find out why is it not helping these people?

And those were often the people that had been struggling for some time that had seen multiple different people in the past already. And often they were the people that were really struggling and suffering as well. Yeah I found that if I wanted to keep working the space, I felt like a.

I was obligated to find out more and to find out what's going on and yeah. And as I kept reading about it and listening to different podcasts like this one as well and looking at or reading different books and articles. Yeah, pretty quickly stumbled onto the bio psychosocial model.

And yeah, my interest grew into the psychological and [00:08:00] social factors as well. And then when I signed up for my master's in pain management, that's really when I was like, wow, I think there's the psychosocial still where we don't know a lot in that area. And and this. Might be what's missing, but I don't know.

We don't, I feel like we still don't know so much about pain but as I just feel that, especially the social factors there's quite a complex interplay still going on there that I'm still hoping to find out as I'm going along. Learned a lot, but I'm still learning on the journey https://drive.google.com/open?id=1-0blvEZUYQmzrDcd3h_i7CFm8R_uJmiJ&usp=drive_fs .

Mark Kargela: That's the journey, like I said we're all continuing to be on. And you sound so similar to myself and a lot of our guests where you just noticed that there was these group of people where traditional care wasn't cutting, it wasn't getting them to where they needed to be. What's been your view? And I, this isn't to be overly critical of our colleagues and things, but I think there seems to be, it's easy. In my opinion to get stuck on maybe the 80% that are responding. As we would expect, and you could pretty [00:09:00] stay pretty comfortable in your practice. And and then usually it's, you push those 20% off of a, in some sort of patient blaming language.

Have you seen any of that? Have you noticed that in your profession? I know in physio, and this is every profession where it's easy to get fallen into this confirmation bias trap of I have it figured out. I, I don't need any further, this pain sign stuff gets to be threatening to.

Our identity that we're trained in. And sometimes that's hard, I think, for some clinicians to step outside of that because they feel like they're gonna have to surrender all this training and it's gonna, it probably gives us a little bit of some unsteadiness. You have to let go of some narratives and some thoughts.

I wonder if you could speak to maybe what you've, what you see out there as far as maybe, a tendency maybe to sit status quo for some in professions and then how it feels to have to let go of maybe our. A professional training security blanket of how we were trained, and then to get into this chaotic, messy reality that is the clinic.

I'm wondering if you could speak to that a little bit.

Samuel Bulten: So I think it, once I started looking [00:10:00] into the biomechanics and what relation it has with pain, I was quite disappointed, pretty quickly and realized, wow this is not a strong correlation or it doesn't seem to be a big factor at all which was definitely going against my bias.

And it's really nice for clinicians to be able to. t hink of that that lens of I'm gonna find these faults that people can't see, and then I'm gonna fix them. And I have and I think that it boosts our egos in some ways. But yeah, it did. Once I read the research, I was like this doesn't seem to really be a real reason we're helping people.

And I think it was. A little bit of the drive of just to, to figure out what is actually going on, then be staying critical. I think I've always been quite critical and have that imposter syndrome, which can be helpful in some ways, really unhelpful. But I have, yeah, over time I've just tried to.

Hold onto things very loosely. So I'm not really holding onto anything too strongly. 'cause I've noticed [00:11:00] that sometimes when I do that's new evidence comes along or new opinions come along and they change my mind, I think. And. A recent example is probably, I've been a big fan of everything the no group does and explain pain, and that was probably the first kind of eye opener for me that, oh wow, this is a different view and it makes sense.

And it was presented in a really nice, neat way. And also acquired an entertaining way to books are really awesome to read. But yet recently, and I think we've spoken about it as well that our staff had a little bit of criticism there and then I realized, oh, there's actually a few more bits of criticism and actually thought there was quite a lot in it in that criticism.

Not saying that I think everything is bad, I think there's still amazing stuff in what they do, Tono a group and explain pain. But it did resonate with me a little bit when I did take on that, explain pain and try to. Pain splain to people and thinking that will get 'em better. And yeah, failed [00:12:00] miserably.

It, yeah, it resonated with me. 

Mark Kargela: I and I, again, there's no I agree with you. I don't think there's any, thing wrong with no groups and stuff, and, Adrian Lowe's group and others who I think, pioneered a lot of thoughts and regard out there, but they're also humans, right? They're also gonna have their biases and their views on things, and that's okay.

I think as long as being a critically thinking human being to recognize that. Maybe I don't need to read these books and then go out and buy a polo and suspend any critical thought towards these folks because we're so enamored by some amazing work. Don't get me wrong. I think we, that they've, LMER and David Butler and Tasha and all those folks over there have done some amazing work that we should be thankful for and still do it.

They're still pumping out some good stuff. I agree. Asaf has poked some holes in some of the nociceptive theories and, pain in the brain and things, which I think even the Noif folks I think have moved off of, that maybe way of speaking about pain as much because it's so much more complex than the brain.

It's in, it's embedded in a world and unique [00:13:00] humans experience and all that good stuff. But yeah it's interesting to see our ebbs and flows as we drive in and out of different groups and their thought processes. But I think you're a great example of how I recommend I try to live as a clinician is holding things loosely, trying to keep the person I'm serving and as the priority, not my ego or my, bias belief systems, owning the biases I bring into the treatment room to, to recognize that these are how I think and what I, my tendencies to think, but I need to hold them loosely 'cause that may not align with the person in front of me.

Have you found. An ability to have that kind of way to maybe not have to be the expert who's just dictating all this is the way it is, this is how you're gonna do it. This is because I say so, to maybe having a little bit more of that co-constructed, like equal expertise in the room. Do you feel like that's been a journey for you?

Samuel Bulten: I think communication is probably the most powerful skill we have and the skill I'm still trying to get better at constantly and I don't think, I don't know if anyone can truly master it. But early on I actually did do the communicate [00:14:00] course with, nick Hannah, and he had he explained that the dreaded triangle where we are seen as the hero and that's what we go into the profession. And then we got the patient who's burdened and then we're gonna fix them. And he I can't remember exactly the, the opposite. He had a different kind of theory where we are more on par and we're to coach.

And they're very capable of finding their own recovery and living their own life. And we're. Just coaching them helping them. And that was quite early on in my career and that really stood out to me and that was a bit of a moment as well. Again, Bruce, the ego initially, ' cause you go into the healthcare thinking that, oh, I'm gonna fix some people and have this knowledge and I'm gonna just give it to people and they're gonna be doing amazing.

And realize it wasn't the case. And yeah, people are just far more complex and we really aren't the experts in the room. And people have very complex lives and there's a lot of social factors going on, psychological that [00:15:00] we don't know and we will never know. And we only play a very small part in their journey as well.

So I think. I did realize that quite early on, then shifted that mindset. Still trying to, 'cause there's still occasions where I start going into the driver's seat. I'm like, oh no, don't do that.

Mark Kargela: I think that's something too that we all battle and there's a time and a place, right? Sometimes patients need some guidance and are asking for it, and it's appropriate for the context and the situation in front of us. There's a criticism out there that some physios and I'm guessing exercise physiologists, chiros and other health professionals have of taking this approach somehow, like surrenders your expertise that you're just throwing away all this advanced training and you're becoming some sort of just coach. I don't see it that way. I still see that we have our expertise to sprinkle in contextually appropriately, not just force fed like we said.

I'm wondering if you could speak to that as where you feel like we, we sit with taking this coaching guide role that it's still a way to embrace our professional skills, but in a more patient. Centered way. I'm wondering what [00:16:00] your thoughts are on that.

Samuel Bulten: That's still a skill I'm trying to hone in on. I think there's a analogy in Indi Act model about the two, climbing the two mountains and you are climbing one and the patient is climbing another and we're looking at at them from our mountain. And we may be able. Guide their path going forward and pick up on factors that may be influencing pain or recovery that they may not be seen because they are potentially stuck.

And I guess that's the lens I take now is to find maybe, yeah, be that bird's eye view, but not necessarily dictating what that's gonna be, but more suggesting options and giving options.

Mark Kargela: Yeah, that's a great way to approach it where you kinda, take that, offering a menu of choices that the patient can then decide. Knowing their context, knowing their resources, and obviously then we can really skillfully help navigate their, what's going on in their world and maybe problem solve with them, not for them type thing.

Which I think is the difference I've found in my practice, which I. It's [00:17:00] what's invigorated to my practice personally is like everybody's got a unique life and a complex existence and trying to, obviously we're privileged to get invited in to see if we can move somebody in a positive direction.

With that said, there's a tension. You and I've had this discussion, we've had it in the community and I thought, man, we gotta talk about this on the podcast. 'cause it's just a common one I've had with folks who are ment mentoring in the programs and things like that. This tension of how we're trained to, to measure our effectiveness with somebody where we have this very linear, black and white, very objectifying.

I'm gonna put your pain on a zero to 10 scale. Your back's gonna be put on in a sweaty scale. And all these different scales, which again, I'm not here to say those aren't useful, so don't get in the comment section yet, people, but it doesn't, when you try to take such a complex experience.

'cause a lot of these. Tools, although a lot of the ones, the promise and the others are really showing some promise to pun intended, maybe, of, being able to encapsulate more the complexity and the wide breadth of what influences somebody's wellbeing and pursuit and things. I'm [00:18:00] wondering if you could speak to the attention you've noticed where you were trained to if you don't measure, you're guessing whether things are improving, which you've mentioned in our community, which I definitely was trained very similarly, like yet.

It's sometimes hard to put our finger perfectly on, some objective number to encapsulate a very complex experience. I'm wondering if you could speak to the struggles and challenges you've had. 'cause I know it's a challenge that I've had and a lot of the people listening here have had as well.

Samuel Bulten: Yeah, I think yeah, ex exactly what you've mentioned is some of those struggles I've been having, i've gone through a lot of different phases where I guess yeah, we're trained to use objective measures or to use measures that have been tested and validated, reliable. And in both uni courses that I did that postgrad and undergrad, that was very much the case and I guess.

That's one thing I still believe in to a degree. I think I think this narratives and measures that I hear a lot of people tell me about muscles not firing and [00:19:00] postures and and they're not being tested by reliable measures and they've just been, they're just guessing. And. I guess that did, does rub me the wrong way.

'cause I'm going, how are these people just telling you that's the reason for your pain. But they've not tested it in any reliable way. And that's why I guess. Yeah, that's why I have been looking for these objective measures that I can test and that I can retest in the future as well for one of those being the reasons why as well as the training.

But I think especially with the ACT model it's potentially also maybe more self-serving. I've noticed the measures, it's more. It's about me feeling good that I'm making a difference. And it's, yeah, I guess it, it's to stroke my own ego and going, oh, am I doing a good job? Am I helping?

It's still good to know, as, as well, but I have noticed maybe I'm doing that a little bit more for myself more than anything else. And yeah. But especially with act, it's, I don't think it's possible to truly measure [00:20:00] if you are making a difference in someone living a meaningful life or a life, a full life.

And yeah, I think I just need to be comfortable with that and just try and play the role that to the best of ability. Yeah.

Mark Kargela: And again, it's a tension I've navigated as well because you're trained to, to put these things on it, and especially when you're trying to justify it with. Third party payers and different things like that where. You have to show that you're making some progress. And I wouldn't say, we suspend all, measurements and I know you're not saying that either.

There can be some value in that. But you, and I've spoken to where I've had patients where they are happy, they are like, ecstatic with their outcome, feeling good. We measure their off sweat street and it's actually worse than when they started, which you used to be like, oh my God, this makes no sense.

And from a, again, from. Support from a payer, but then again, we have to get more into the humanity parts of measurement, in my opinion, to where we're measuring. Are people pursuing what matters to them? Are they engaging back in maybe vocational activities and work? Are they engaging back into things that are meaningful and valuable to [00:21:00] them in life?

And I, there's some values based things you can do with that and we're gonna share more in our community that you'll see Sam and what, we'll share some here in the show notes as well. But yeah it is challenging and I don't think it's necessarily. Because I get where your motivation comes from, right?

'cause you can say the sacrum is malaligned if and my repositioning did it. Yet we know the reliability of that whole thing. And the mode of measurement is faulty from the get go. And it becomes pal palpatory palia as Diane Jacobs is nicely coined, but it, yeah, it's, it is a challenge, right?

But I think when we dictate the measurements for patients versus. Them dictating what measures of meaningful successful life. I think we do need to come up with some better measures that encapsulate all of it, right? We can still do some objective things. Things that come to mind for me is if you did a little clinical QST testing, quantitative sensory testing, you could do alomet can, although it's a little bit of a, painful test where you're pushing and seeing measurement of like peripheral sensitivity, right?

To see [00:22:00] how sensitive tissues are, which can give us a little bit of a measure of systems. I envision, and I'm wondering your thoughts too, on the future of maybe. Lifestyle factors and things that measure like heart rate variability gives us, somewhat of a metric on autonomic function if people are riding towards, sympathetically driven thing, which we often see with some of our people struggling with pain.

I wonder what your thoughts are, and maybe if you've considered any use of like lifestyle measures and more kind of physiologic me metrics. I know in exercise physiology are experts at really kinda looking at some of those metrics. I'm wondering where you're, where you sit with that.

Samuel Bulten: Yeah, definitely. I think I have used QST more of a brief version of it and not with all the fancy equipment that they normally do it with, and, I have used, actually, I've got one of those pressure pain threshold devices as well. And I did use it for some time. I don't use it anymore actually.

I think it's still useful to find out how sensitive areas are in, in some ways I [00:23:00] think it can be useful, but there's so much to go over with people and there's so much to dig into and so much information to to get from people and a lot of, so I think. Some of these measures they do take a bit of time to get an accurate measure.

Takes a lot of time. And I go, how meaningful is this actually to the person? How sensitive they are to pressure and by 0.5, is that really gonna make a difference in their life? So I guess that's where I've moved away from it a little bit more. I have definitely looked at. Things like by feedback and heart rate variability.

For me so far and like I'm definitely not an expert and haven't read all the papers, just from what I've read. I wasn't convinced yet that is something I need to really incorporate 'cause that was gonna move the needle. I've def you always intrigued by these things and I do often. Go, oh, wow.

Shiny tool. And this is gonna be a good measure and I could show people but I have to hold back and just read [00:24:00] a little bit more about it to make sure that it's actually gonna make a difference. And then I find I'm not overly convinced by a lot of these objective measures. It seems to be the subjective that trumps it all.

Mark Kargela: I totally agree with you on that. It's, I think it's hard as a, as a. Scientific profession, I guess when it's, when some of the real scientific rigor, which I get, I'm not saying we don't need to be unci, that we need to be unscientific, but we have to recognize, especially way science was basically constructed and delivered to people where we create average and is averages and means across populations of humans, and the people we see in clinic often escape those normalized populations that are underst study.

So it's hard. To take these like rigid, objective ranges of what is success and not that is constructed. And maybe I don't, I, again, I'm not here to say you shouldn't do RCTs and that stuff. Of course you do, but you have to recognize the limitations. When we take that mode of gathering knowledge and try to ascribe it to the knowledge we're trying to figure out [00:25:00] with a unique person in front of us in the room, it doesn't always translate well.

And our discussion here, hopefully, is shown that it's a tension that we all deal with. But I think if we put the person, and I agree with you, the sub, the subjective, and I, brownie doesn't like subjective 'cause it's, and I'm with her on it as far as it almost makes it seem like it's less than the important data of the objective data.

It's I would argue the persons, and you've already made that argument that the person's experience and where they're at in life and how they're moving towards the right things that maybe get labeled as subjective. Is much more powerful than what an I'll take somebody back to life and happy over their a SW street score, being worse.

Okay. It's weird. I don't get it 'cause, but to me it's good evidence that the way we try to quantify a very complex experience misses the mark for some people. And we just gotta find some ways to, and it sounds like you've made that kind of jump to where, hey, I still have those things and I still use them, judiciously and professionally, but.

There's a whole lot more out there than just the, that objectification [00:26:00] of a very complex experience. Is that kind of where you sit?

Samuel Bulten: I do still use some of these tools and I like using sometimes the manual muscle testing, just even just to show them that. There's maybe not so much of a difference or even to when they do improve over some sessions, they go, oh, look, you're getting a lot stronger and look how robust as this now.

And so I do still use objective measures where appropriate. I think also some of the questionnaires they have similar issues as well. 'cause they're just a point in time when they fill it out. And for example, the brief pain infantry, it's the last 24 hours and we know persistent pain just it's not linear.

It doesn't just go in one straight line. And people can have flareups. So if you measure at one point and you measure it again in the. Flare up and maybe they were doing really well. And then you're gonna see you're not really gonna see an accurate measure there either. I think probably one of my favorites is probably the patient specific functional scale because it is a little bit, allows a bit more freedom.

It's not a zero to 10. Often [00:27:00] find people that zero to 10, they just really struggle with it. How do you put a number to mood or how do you put a number to quality of life, all these different things, people just really struggle. So yeah, I don't know really how use, I still use them, but they definitely have limitations.

They only tell you so much. 

Mark Kargela: I'm wondering. If you can put yourself in the shoes of a, and I know you trained some folks that are in university. We had men you had mentioned you're in the process of doing, I think right now. How do you approach that struggle that and let's put ourselves in the shoes of that university student, or maybe it's that early career cl career clinician who's feeling lost and unstable because the way the black and white version of healthcare and pain that they were taught.

Is anything but what they're seeing in the clinic. I'm wondering what advice you'd have to somebody who's navigating that struggle.

Samuel Bulten: Ooh, that's a really good one because I don't know how, if I've got. A whole lot more confident over the years, but I think I'm more comfortable with with uncertainty at this stage and being more comfortable not having all the answers and [00:28:00] not being the expert in the room. So I think that's probably the main one is to go you are.

Gonna fix everyone and actually probably not gonna fix many people. But you can be a really helpful guide along the way and you can still make a big difference in people's lives. I think getting mentoring earlier would've been really good. I tried to do it all myself and try to do all the research myself.

And you do get into some. Interesting spaces. So I think getting some mentorship early is probably all surrounding yourself by people that are also learning. I think the main thing is to stay curious, to stay passionate about what you do and keep learning. I think once you finish uni, that's really when.

When it gets real. And we've gotta keep learning at that stage which is annoying 'cause we all wanna go, oh, that's ticked off the list. I have all these skills now and I'm good to go. But I think if we really want to be good, we just gotta keep studying, keep learning.

Mark Kargela: Do you think there's a misdirected problem solving model issue? We have as a [00:29:00] early career clinician or as somebody coming outta university where you try to, you go out and you try to solve the wrong problem, where it's a technical skill issue I'm trying to solve. I just need more tools and things in my belt.

Versus what you had spoke to earlier, like communication. It's the soft skills that I would argue are the ones that if we could focus on earlier on,

Samuel Bulten: Yeah.

Mark Kargela: we did a pretty good on I'm guessing it's similar with exercise physiology, where you come out with a pretty solid skillset, but. To apply to a complex human is where the struggle lies.

I'm wondering if you, what your thoughts are on that. Do you feel like sometimes we come out and we're focusing on the wrong problem and we probably could shortcut a lot of the frustrations if we just solved the right problem early on.

Samuel Bulten: I think we're all drawn to the shiny tools that have all the promises behind it. And I've been carried, I've got carried away on those sometimes as well. I've. Seen something where I'm like, Ooh, that's really exciting, and this might finally be the answer to all those people that I'm struggling to help.

And then realizing later on that it was one of those things again that didn't really get the results I wanted. And I think the [00:30:00] research for pain, for in the way in, I interpret it anyway, it's the, it doesn't seem to, the interventions don't. Seem to matter. Maybe they, they're all on par in terms of the outcomes that we get from them.

And yeah, some are a little bit better than others, but I think it's really, I think the communication is what makes it more effective. We know that therapeutic alliance and contextual factors are some of the biggest game changers in, in, in what the results that we see with people. I think I realized that quite early on.

And yeah, and that's I guess the main reason I've started to focus in on that and communication as a skill. And the more I read into it, the more I think it's something I'm gonna have to keep working on. It is a bit frustrating ' cause it is a bit of a soft skill and it. You think, oh, how much has it move the needle?

But I think you can have all the knowledge in the world and all the tools in the world, but if you don't know how to communicate, really not gonna get very far with someone. And I [00:31:00] guess that's the kind of what I believe in a little bit.

Mark Kargela: That echoes the experience I had. I spent 10 to 12 years of just chasing more manual therapy expertise, thinking that eventually I was gonna hit this. Skill level where it was gonna all start making sense. And then, that's what almost drove me to quit the profession early or a few times.

Because I felt like I just wasn't figuring it out. I just, maybe I'm not cut out for this. So totally agree with your thoughts on that as far as recognizing that it's, there's not this destination, i, because every time humans are gonna be complex and there's gonna be situations that you've never faced before that enter your clinic on a regular basis, that you're gonna have to have a reasoning and thinking process.

To navigate that uncertainty. And you've mentioned how you're much more comfortable now to sit with that uncertainty and to find a way with a patient, with a struggling human being to navigate the way out of that in a way that works for that unique person. You've also spoken about mentorship, which I agree with you.

That's the whole reason we do what we do, is 'cause we recognize that was the piece that really helps [00:32:00] people. Take all this confusing myriad of data 'cause there are no shortage of people peddling technical courses that this is a missing piece to you figure figuring it out. And I chase those courses for quite some time.

And I'm not saying some of 'em can't be helpful 'cause there's, as you mentioned, some helpful interventions that can move, but you also. Pointed out that in what we agree with and what the research would agree with that, especially the R two study around chronic low back pain, that a lot of these interventions probably are pretty similar in their effectiveness and the ones that are probably better are the ones that the clinician is most biased in and are more popular culturally versus some specific special mechanism that exists in this treatment.

But that's a hard pill for. For a lot of clinicians to solve. But with that said, the mentorship piece, I'm wondering what, how would you approach or recommend somebody with getting mentorship early on as far as how's that helped you and how do you think mentorship fits within, a journey as a clinician trying to navigate this uncertainty?

Samuel Bulten: I think it would if I was to go back in time. Listening to different [00:33:00] views, I would say is a good idea. So looking at opposing people with opposing views even, and to I guess to figure out then what aligns with you as a person and also that what you're seeing in the clinic.

And for me, that's why. Over time, I did get drawn into act. I found that aligns the most with, and I'm not an expert in act, but that seems to very much align with the journey I've gone through. And obviously for me, being a big fan of your podcast and now being on it, Woohoo that was a it felt like a bit of a natural fit when you did have that mentorship program when you started that out.

So that yeah, that drew me in pretty quickly. But I think for people it is to to find someone that aligns with what you're experiencing and then, I guess you can always test the orders, so I think you try it out and see if it, and if it changes, then you can always go elsewhere and look for someone else.

It doesn't, you don't have to stay stuck with one [00:34:00] person, even though you might have invested money and time into it. But yeah, you can always change. I think finding someone with. I guess more experience than you is always good. 'Cause really a lot of people have already walked where you are about to walk and to get a bit of guidance in those really difficult moments where you do have people break down in front of you and crying and maybe even telling you life's not worth living.

That, that can be really challenging when you're a young clinician. We don't really get taught. How to deal with that in uni. And I always say my tissue box in my room gets used a lot and I didn't think it would ever would 'cause exercise physiologists, what are you why are you gonna use the tissue box?

But it gets used a lot in my room. So I think and it can be, especially if you are maybe a bit more empathetic, it can take a toll on you as well. And you don't really wanna. You don't wanna do it by yourself. It's it's, yeah. You're gonna come [00:35:00] across some really tough moments that I think you need support with at some capacity.

 Yeah.

Mark Kargela: I think getting with people who have had a lot of reps and have navigated some of the situations you've can, you've, you're currently struggling with or are having a hard time managing can be so huge. I remember, it's felt I've, it's taken me this amount of time to feel like I have enough reps under my belt to, offer, mentoring and different type of things, but totally agree with you.

That's been the, a big unlock for me is just to, to have people's perspectives and get some guidance and. Bring my unique struggles to the equation. You've been a amazing, as far as bringing your thought process and just putting it all out there. Here's where I'm struggling, here's where I'm having difficulties and letting folks peak in your practice.

One, I think it's opened up other folks in our community who've had similar struggles and it's been interesting just to see the conversations. I learn a lot from them 'cause that helps us design what content we're gonna create within the community in our courses, but also what we're gonna talk about here on the podcast.

And I think today's conversation is a good example because I know. If you're listening to [00:36:00] this, that you've probably navigated some of the similar waters that Sam and I have spoke about today. So hopefully it's been a value to you. Sam, if people want to follow up with you or chat with you further, where can they find you?

Samuel Bulten: Oh, that's a good question. I'm almost anonymous still, but I'm working on it. So have started doing a little bit on LinkedIn, so you can definitely find me on there. Still in the early stages, i'm still on the fence about social media. I'm really keen, but I'm probably too, oh, I just struggle with the inner critic.

I just, every time I think I'm gonna post something it doesn't happen 'cause I just go, oh, but yeah, I just question myself too much. So maybe one day on the socials. Not right now, but probably LinkedIn and yeah, email is probably the best way, I would say, is the best way to contact me if you do wanna contact me.

Mark Kargela: We will put some things in the show notes. If you wanna reach out to Sam give him a follow on LinkedIn. Just start building it up. And he's put, you've put some. Posts out there. I definitely remember the inner critic of gosh, what if I say something or people are gonna hate what I say and all these different things of that.

But I think you have a [00:37:00] great perspective as evidenced by our conversation today that you need to share. 'cause there's so much crap stuff you shared out there and I know you're aware of it too. And I think we got folks like Adam Mackins and others who are fighting an amazing fight that I'm greatly appreciative.

I'm not ready to go at it as, as aggressively as Adam is.

I would have heartburn and, dealing with all the vitriol that comes back when you're trying to, criticize the narratives out there that are fair,

Samuel Bulten: But we need people like him, I think. Um.

Mark Kargela: Percent.

Samuel Bulten: No, I'm really, he's probably a big inspiration and a big influence on me and the way I do things. And yeah, he's, he just says it how it is and some people are definitely not gonna like him for it. But yeah, I think, yeah, he's I, I think we need more people like him.

Mark Kargela: Yeah, and you just gotta learn how to build a, a thick skin to recognize,

Samuel Bulten: Yeah. I couldn't do it. 

Mark Kargela: Are and where you got what, what you're doing and what, what's really meaningful. And when some of the, the comments, and not we get 'em a bit here too, is that not everybody, I, you're not gonna be for everybody. And I totally had to that [00:38:00] realization and be okay with it.

And that's okay. We're all unique humans, but as long as I can live to my values as far as what I push out there on social and feel good about it then, I'll be okay with the people that, doesn't, don't resonate with it and move on. But yeah. Anyway, Sam, thank you so much for your time today.

I really appreciate you being part of our community and jumping on the podcast today to share your experience. I know it's been helpful for folks that have been listening.

Samuel Bulten: No, thank you so much, mark. Like I said, I've been a massive fan of this podcast and so it's, yeah, it's been awesome having this as my first recording, so that's beautiful. Yeah. Thank you.

Mark Kargela: You're welcome, and I'm sure one of more to come as, as you get yourself out there and you do your thing and you're leading the way and you're small community there in Australia and it's it's great to see.

Samuel Bulten: . Fantastic. Thank you.

Mark Kargela: For those of you listening, if you could just jump on and subscribe, that would be huge. If you know somebody who's navigating the same struggles that Sam and I spoke about that him and I both have dealt with in our career send us episode to them so they can see that their struggle, they're not alone in that struggle, and that there are ways to navigate to your way out of it.

If you're watching on YouTube, subscribe there. We are [00:39:00] gonna leave it there this week. We will talk to you all next week.