Diane Lee Clinician | Educator | Researcher

March 21, 2023 Season 3 Episode 44
Diane Lee Clinician | Educator | Researcher
Show Notes Transcript

By age 16, as a result of her gymnastic pursuits, Diane had an unstable ankle, 'funky' elbow and pelvic floor incontinence and so begin her interface with rehabilitation. Welcome to Physio+10 and our guest Diane Lee.  Diane is a Canadian Physiotherapist, who is known worldwide through her landmark text, The Pelvic Girdle. This book and subsequent iterations parallel our profession's musculoskeletal development. Initially focused on the joint, then incorporating myofascial slings, motor control and most recently, our understanding of emotions, the text reflects our growing understanding of how to manage complex clinical presentations.

Diane explains how;

  • The current focus on RCT, SR and evidence-focused practice is eliminating clinical creativity and sapping professional passion
  • It is important to focus on function, not pain and to test and retest clinical hypotheses, letting the patient's body indicate the validity of treatment
  • Critical it is to develop hands-on skills and why current evidence challenging this skill's importance is flawed - you need validity before you can test reliability
  • It is important for young Physios to be comfortable with discomfort and to surround themselves with their success.

You can watch this conversation on YouTube.

Thanks for listening.

Diane is a University of British Columbia graduate in the field of rehabilitation medicine.  She is a fellow of the Canadian Academy of Manipulative Therapy (CAMT), a certified practitioner of intramuscular stimulation (Gunn IMS) and certified by the Canadian Physiotherapy Association as a clinical specialist in Women’s Health. She was an instructor and chief examiner for CAMT for over 20 years. Diane is also the owner, director, and practising physiotherapist at Diane Lee & Associates, a private multi-disciplinary physiotherapy clinic in South Surrey, BC, Canada. In addition, she is the principal instructor of Learn with Diane Lee (

Diane has been a keynote speaker at many conferences, has contributed chapters to several books and self-published the book The Abdominal Wall & Diastasis Rectus Abdominis (2nd edn).  Her book, The Pelvic Girdle, was first published by Churchill Livingstone in 1989, is now in its 4th edition (2011) and has been translated into multiple languages. The Thorax – An Integrated Approach was released in 2018 by Handspring Publishing. She holds the North American patent for two sacroiliac belts, The Com-Pressor, and The Baby Belly Pelvic Support. With respect to research, she continues to investigate the behaviour of the abdominal wall in women with diastasis rectus abdominis 

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This is your fortnightly installment where I interview a trailblazing physiotherapist that has shaped the profession we're journey, knowledge and insights. You gain the opportunity to plan and guide your own professional journey. My name is Doug Carey and welcome to Physio Plus 10. Welcome back past listeners to Physio plus 10, and you people tuning in for the first time. Thanks for joining us. Our special guest today on the podcast is Di Diane Lee, can you give us a bit of a background into your, um, schooling and where you come from? Yeah. Um, I was born in Vancouver, but uh, at a very young age of 10, we moved to a small town three hours east of here, which is Camloops and, uh, Camelo, bc. And it was there that I got involved in gymnastics and it was there that I experienced my first body injuries. I had a, a very bad sprained ankle. I dislocated my elbow, did a back handspring on a balance beam and landed straddle. And that began my pelvic floor issue. So by the tender age of 1617, I had poor ankle control, a funky elbow rec neck, and was incontinent. And I had no treatment for it other than some ultrasound on my elbow. But <laugh> the, uh, the, the experience with the physiotherapist then and the, uh, whatever, the whole environment of helping people kind of piqued my interest. When after I graduated, I really wanted a gap year to go to Europe. But my father insisted that I had to go to university and I absolutely did not want to be a school teacher. I hadn't a clue what I wanted to do. So I applied for the, one of the most difficult programs to get into. At the time there was 800 applicants and only 30 people got in and gal darn it, if I didn't get in and I had to go, otherwise, I'd admit I had lied to my father. So I ended up in physiotherapy, uh, not knowing what the heck I was getting into because I didn't really wanna go. I didn't wanna go to university that year. So that was my, that was my start of the, the whole thing. And while I love the academics of the program, particularly the neuroanatomy and the neuroscience there, there wasn't very much in 1972 to 1976, which is where my bachelor's degree was at the university, where there was any clinical application of the fascinating anatomy in neuroscience that we learned. So clinical practice of physiotherapy in the seventies was all, you know, fitting crutches and teaching people how, you know, to, to walk and range of motion exercises. And while that is very necessary, it really didn't challenge my brain the way, the way that the, the academics did. So all, all of my learning in terms of orthopedics and manual therapy and everything was all postgraduate. There was, there was nothing in school at, at that time. So, um, and I also, while I really love the neurosciences, I, there was really not much that we were doing at the time with people who had suffered catastrophic neurological injuries, whether it was a stroke or quadriplegic like there is now to really get me excited about going into it. And my, I had, uh, nine months of hospital experience and at the end of it, it was like, get me outta here. I, I don't wanna deal with the risk of someone dying. I really wanna improve quality of life. So there were very few private practices in Vancouver at the time. In fact, there was only three. And I, uh, I felt at that time, overwhelmed, undereducated, useless. I didn't think that anything I did made any difference to anybody's outcome. And, you know, by three or four years into practice, I was ready to quit. And it was right about that time my husband, who was a pharmacist, he hated pharmacy and he wanted something more mentally challenging as well. And he got accepted into dental school. So somebody had to pay the bills and, and uh, uh, and feed us. And it was right at that time that I was introduced to, um, cliff Fowler. And, uh, cliff Fowler is like Australia's Jeff Maitland or Robert El Elvie, as you mentioned earlier. He was one of the founding fathers of manual therapy in Canada. And it was really my good fortune to, in my very, very early years, I think I was only five years out from school that I got to, um, be mentored by him and practiced by him. And it was just a whole other world being with a clinician who thought, who clinically reasoned before the term was even coined, who thought about his thinking. And he got people better and he knew he got people better and he knew what he had done to get people better. And I said, when I grow up, I wanna be like Cliff Fowler. Um, yeah. And that was my early days. Yeah. Well, it's interesting you mentioned Cliff, cuz I had spent some time with Cliff as well when I was there in Canada and, and, and there was that trio wasn't, it was Cliff and Earl Petman, um, and John. Oldham. Yeah, John, I met John as well, but also another guy. Um, David Lamb. David Lamb in, in Calgary. Just outta Calgary. Yeah. And they really were. And all three of them were s sas, well, green Berets is that. I think they were, they were in the Army and they were, uh, so I don't think Earl was, but Cliff and Dave certainly were, they were both trained in the Army in the uk and then em immigrated to Canada, you know, very early with their wives very early and started in Ontario and then migrated to Cliff, came all the way to BC via, um, I think they were in Red Deer in Alberta anyway, they were in Alberta and Dave stayed in Alberta and Cliff came to the wild west. Yeah. And then John was from New Zealand and he came up from New Zealand and I think he met, met these guys in BC So yeah, they were, they were quite the days when, uh, when things were starting. And I was so fortunate to be part of the whole, um, the whole evolution of the orthopedic system in Canada. Yeah. It really was. And I mean, one of my memories of, um, cliff was saying, what are the 12 muscles attached? The clavicle? He just hit me with that when I first walked in the door and I thought, what. We do. We go, this is a different, this is the rollercoaster ride. So, so you, yeah. What, what, what was it about you working with Cliff that was particularly important for your development as a, as a young physio? Oh, teaching me how to think about my thinking. Number one, um, you know, always like he had deductive reasoning before he even knew that he had that it was always the why, what why are you doing this challenge and question sort of everything you do. And then also just the way that he, um, his, his hands were magic. And while he might not be able to explain the, the whys and what that got him to what he was doing things, he was, he, he used listening touch before I even knew, knew what it was and when it, when it would come to, um, uh, something that I was avoiding doing. So I mean, he was helping me, um, become a, um, get my certification in orthopedics in Canada, which in Canada is called your fca. I don't, the fellow of the Canadian Academy of Manipulative Therapy. And you had to pass these rigorous manipulation exams. And I was always afraid of manipulating the AA joint, the, you know, the upper neck. It's just we had the whole vertebra artery testing thing sort of scared the heck out of me. And it was like, oh God. So Cliff had put up a chart in his office and every day I had to tick off on the chart what I had successfully manipulated that day. And it was very obvious a pattern was arriving. I mean, I had no problem with the thorax or the lumber spine as I joint was a bit of a, ugh, tough go for me cuz he really had to use a bit more force. I don't manipulate them now. Um, and the upper neck was just a blank slate. And so every time he would have somebody that he thought required C 23 aa, joint away manipulation, he'd just come and knock on my door and, and he would just say to the patient, I need her for a minute, grab my hand and take me into the room and go do the left away. Do the right, but do that. No clinical reasoning, no nothing, no, no stability checks, no nothing. Just pure trust. Okay, cliff, if you say so, and I, I, one time I'll never forget, he came in and came and said, you know, I want you to do an extension manipulation or inferior glide manipulation on this fellow C 23. And it was always the hardest ones. Like, now we know you don't have to be so direction specific then we didn't, we thought you had to be, and I'm hitting this poor ass neck and nothing's happening. And then he threw an x-ray up on his X-ray viewer and he says, what do you think of this? And I looked at it and I looked closer and I went, I think that joint's fused Cliff. And he goes, yeah, you weren't listening with your hands, were you? You were just trying to impress me. Get outta here, listen to your hands,<laugh>. So, and I'm sure you had the same experience with him, he'd set you up for some lessons somehow. And he obviously knew the fellow's net could tolerate what I was doing, but it was just like so many times driving home, ripping my steering wheel off, going, oh, he got me again, he got me again. You know, because you should never blind trust anybody. You know, you should always be feeling and listening and going, why am I doing this? Oh, anyway, yeah. So the hand training, the manual training, the thinking training, and just like you had, you know, how many muscles attached to the first rim? I dunno, well I'll go home and look it up. And there was no Google, right? No internet, no Google. It was like, how do I look this up? And you're thumbing through the pages of Grey's Anatomy and running to the library and going into the stacks of the library trying to find articles and things and yeah, it was a different day. Yeah, it was a, it was a different day. But he, um, yeah, he knew he, he had trained with James Siriak, he knew Freddie Colton board, he knew, he knew everybody at the time and they had such high respect for him. And I think one of the things that Dave and John and Cliff decided, and Earl and I were probably the first mentees of these guys. And um, what they decided at the beginning was not to follow anyone, not to become, uh, a we are go, we're going to become a Maitland Canada. We're gonna become a Colton born, this is gonna be a Colton board program. It became integrated right from the very beginning that we're gonna take, take all of it and we're gonna integrate it for, for whom is this model or method appropriate. So integration has always been, you know, Canada's thing. And uh, um, and so we never really had the battles of the wars over, you know, a Mackenzie approach versus a Mc Maitland approach. It was always a Canadian approach, which was, was all of it. And, and for whom, and that requires no recipes or protocols, but just an ability to think. And, uh, and, and they were the ones that started it like that. And it remains that way to this day. Yeah. And that's, I guess unknowingly, that's what I noticed when I was there doing the EV program, was that I suddenly realized this is so eclectic. It's got a lot of mateland in the assessment. It's got a lot of cotton born in the, in celiacs in the, the frictions and the soft tissues, and then some, um, cel shamin and stuff in the muscles. And it really was, it was a appe of all the best things around the world at the time in a manual therapy course. And that made it quite exciting. Yeah, we had very little access to evidence that was really applicable to our practice. Like there weren't very many physiotherapists doing PhDs at the time. There wasn't a PhD program for physiotherapy in Canada. And, and, you know, research was just starting it in in early eighties. And so we didn't, we didn't have any of that to, to fall back on our, our evidence was, was almost 100% based in clinical expertise and clinical experience. And with the evolution and arrival of evidence, I think it's, it's good, but it's also, um, it's also stop, stop some critical thinking. It's also stopped some creativity and people don't feel that they have permission to do things for which there's no evidence. And yet most of the patients that I see, there's no evidence anywhere that duplicates their story, they're excluded from all studies cuz they're too complex, they have too many comorbidities and, um, you know, if you've ever been pregnant, if you've ever had surgery, I don't want you here. You know, and it's like, okay, well that eliminates 90% of my practice. Um, so it is difficult and I I actually don't really recognize my patients anymore in the RCTs that are published. It's some generic person who has pain, right? And it's all seems to be led by pain, which is not the way we've been practicing for 40 years. Our practice has always been led by function. What can't you do that is causing no csection neuropathic pain or neuroplasticity? What, what can't you do? And if we can restore function, then the nervous system hopefully will take care of itself, right. Unless there's a processing error. And at that time we didn't even know anything about central sensitization or noce plasticity. So there's been a lot of really good stuff that obviously has evolved, but we also lost a lot of stuff with clinicians who, who really believe that if you're meant to be evidence-based, that means there has to be a piece of research out there that's gonna tell me what to do for this person. And that's, that's killing us. That's killing us. Yeah. Well that's, that's so true. And I, I remember sitting down with, well, listening and talking with Brian Mulligan about that, and he sort of said, look, my job as a clinician is to treat them and find out how to get 'em better. And then it's up to the researchers to prove it, prove why it's happening,<laugh>. But it certainly wasn't gonna slow down his creativity in developing a program that was effective at the cold phase, which is helping patients improve their function. You know, and there, Doug, there's no, there's nothing better for me than seeing therapists, young therapists who either come through the clinic or come on courses, start to get, um, start to get creative and start to get curious if you like, about their assessments and what they're doing. And to see the passion come back for the profession when they can actually see a path or they can, they can see a way forward for this individual. And if they can motivate them to make these changes, to see the rewards that come back. Right? It's, um, yeah, it's, it's, it's not, it never gets old helping the, the new clinicians organize all their knowledge into a framework or a way. And then for them to be able to recognize what's missing and they can go trundle off and take all of multiple courses that are available and sort of fit them in their closet organizer once they have a structured way or an organized way of de determining who's, who's, who's, what's appropriate for whom. And I think that's what I now call the integrated systems model, or this model, which is a regional interdependent approach looking impairments. So just because your knee is sore doesn't mean I'm gonna treat your knee, especially if it's an insidious onset. We've gotta look at foot control, hip control, pelvic control, all of the things that possibly could be overloading the knee. And very rarely are you treating insidious onset knee pain by treating the knee. Now if you have an acute knee injury, of course the knee is the place that you go. And we could be talking about back pain, neck pain, you, you name it, right? But it's about having a biomechanical framework where we're not judging people. We're not saying, Ooh, your posture's bad, you shouldn't be doing that. We have a, an idea and looking at what one moves and we think maybe that's not such a good idea and offer up a suggestion or a change. So if I gave your pelvis a bit of control, a bit of a hug, some force closure, and now you step forward on that leg, what does it feel like for you? And we let their nervous system be the judge. Better, worse, no change. So if you are applying a, and people don't like this word, but I use it anyway, a correction, which is simply a change. If I change this, um, and it makes your neck get sore, or if you feel that you have to use more effort to move, then I'm not going in the right direction. But if I can align or con control or change something and you go, wow, that feels amazing, I know I'm on the right track, because that person's nervous system has less threat, less pain, less, uh, bracing with it. And so we initially judge, but then we always test. And I think this is where what we started with the three month manual therapy course that you were on in terms of the whole biomechanics sort of number of years ago now, to to, to where we are at now, to a lovely model that allows us to, uh, test our hypotheses and not just have them and say, you shouldn't do that. You should change, you can go, this might be better for you if you sat in a different way or stood in a different way or had an orthotic, or didn't have an orthotic, right? So we're looking at what do all these changes do to other places in the body? And it takes away, takes away a lot of the, the hard work because it's the person themselves, it determines whether it works for them or not. Mm-hmm. <affirmative>, yeah. Hard to, to research this method because there's, there's so many balls in the air and so many pieces, but in reality it's very simple. Yeah. You're taking the complex and making it simple, but you're, there's a lot of, I guess, background, it's like the tip of the iceberg, you know, you are seeing the tip, but there's actually a lot behind Absolutely. That sort concept. And I guess that can be a bit, uh, confronting to new grads because they, you're all, you are asking the body, but you're also applying a lot of clinical reasoning behind that. Like, why might I be doing that? Um, yeah, I thought so too. And, and we never had, we didn't have new grads in the clinic for years. And then last year, um, there was a, a young gal who was treated in this regional interdependent manner, or when she was a teenager and, and had injuries playing soccer or football. And then she went into physio school because of her experience and all the time through school, she kept saying to her physiotherapist, when do I get to learn the why behind the what, why, and when do I treat this knee? And not just what do I do with it? And Sean Campbell was her physio and he said to her, oh, you're not gonna learn that at school. You're gonna have to go and train with, uh, with Diane and you're gonna have to go do the integrated systems model series after that, that's when it's come together. So when she graduated, she approached me and Sean had said, you know, I'd love you to meet this gal. And I go, I don't hire new grads, Sean. I mean our co caseload's so complex. Let her go get confused somewhere and then, and then we'll put it all together for her. But within an hour of meeting her, I thought, this gal knows exactly what she wants. She's known what she's wanted since she was 16. Let's see where we can go with it. And my senior team just looked at me like, dear and headlights, we're doing what? How's this gonna work? So she did the six month mentorship program and also was mentored by two of us for two hours a week in the clinic. And she has done amazingly well. And because she had nothing to not unlearn, but she had nothing, she had no other models to integrate. She had no other, um, she just knew how this is how I would treat her back. This is how I would treat a hamstring, but not why it, it was so simple for her to just take the whole approach and learn it. And everybody on the course was quite envious that she was beginning her career with a, uh, with a method like this. And now she's going off and doing her manual therapy courses, wants to get her dry needling cuz she knows where it all fits into it. Right. She knows where, where it all fits. So yeah, we can train new grad, new grads. Wait, you just have to be careful the caseload that you give them, right? Yeah. So you can't give them somebody that's really, really complicated, that's got multiple impairments and yeah. And a and a phenotype of pain. That's, that's more no castic than nociceptive than, than that gets more difficult. When you, he, after working with Cliff and receiving your mentorship and getting direction, like you obviously then stepped out into your own private practice. Was that solo or in partnership with someone like this? This is after your husband? Yeah, solo got his dental degree too, I guess. So, so Cliff had a, um, it was an interesting arrangement. He had his practice almost like a duplex with Alan Morgan, who was another, uh, fairly senior clinician and instructor from the, from Ontario who moved to BC and they had their own businesses, but they shared a reception area and then they had their own treatment area on either side. And Alan needed somebody to cover his practice form because he had sudden difficulties with his heart. He had multiple sclerosis that had a flare up. And he, and, and he had just had a number of health issues that, that, that happened. And I was supposed to go and work with John Oldham. I had taken a job with John, but you know, this is the whole network. And John and Cliff talked and basically they decided that Diane was gonna run Al and Morgan's practice for him. And, uh, while he was off, and I, I mean I was coming from the worker's compensation board where we had like an hour just to put a hot pack, an ential on someone and then sit and pick your nose. So I go into practice and we have 15 minute appointments and I'm supposed to assess and treat someone and 15 minutes. And the first afternoon I had three hours and I was, they saw 19 people. I, I'll never forget it. And at one point I, I just didn't know what to, to do with this person. I went and knocked on Cliff's door and he had his feet up on the desk and he's reading something and he go, I said, can you help me with this? And he said, sure. And he did some quick little thing and said do L five and they'll be better. And, and the patient said to me, what are you gonna do to my L five? And I went, hell of I know. And I ran out and I said, don't you ever do that to me again. This is not the way you teach. Just I need more than that. I really need, I need more than that. So I settled into a rhythm of, of working Alan's practice for him and being mentored by Cliff. That's how it started. And in the beginning, I would sit with my pile of charts at lunch and he'd say, tell me the stories. Tell me who you saw this morning. And I hadn't a clue what I was doing with anybody. But slowly over, um, the period of the year, it started getting, the clinical reasoning started to come and then Allan got better and he wanted to come back to his practice. So he told me, he was meeting with me on the Friday and I told Cliff, oh, he's gonna let me go. And Cliff goes, no way. He'd be nuts to let you go. He's gonna hire you. I said, I don't think so. He's gonna let me go. And so on the Friday, that's exactly what he did. He said, thank you very much for the year. I'm coming back to work on Monday. See ya. Like no notice, no nothing. And meanwhile, my husband's in dental school and I don't wanna go back to the hospitals. I don't wanna do that. There's, you know, three private practices in BC at the time, John Oldham, um, uh, Jim McGregor and Cliff, that's it. And they didn't have a spot for me. So Cliff knew my dad was in constructions in Camelo. So he phoned my dad and I said, and said, what are you doing for the next six weeks? My dad said, yeah, no much me phone George Akins, who's an orthopedic surgeon, and said, Hey George, is that little space still open next to you? And, and George goes, yeah, why we're gonna bill Diana clinic. So <laugh>, he had my dad come down and I had zero money to do this. Um, and so my first clinic cost me $20,000 and that's what I owed the government and taxes. So I used the tax money to, to, to buy this clinic. And I was 27 and he said to me, do not go meet a doctor. Do not show your face. You look like you're 20 years old, not 27. We're gonna send you some patients, just do good work and your practice will grow. And that's exactly what happened. I just sat there and did what he taught me to do and sent out a lot of progress notes and nobody knew how old I was, how young I was. And here I was in business by myself. And uh, yeah, that's how, that's how the practice started. And it went from 500 square feet to 6,500 square feet in North Delta. And then in 2000 I sold that one cuz I, uh, I wanted to move onto that where I was and move to a different town within the lower mainland. But yeah, that's how I got into private practice. Yeah. Wow. The bank didn't lend me any money because they said that my chances of being successful in private practice were the same as if I was to open a shoe repair shop on the top of a mountain. Yeah. So that's, that's how much, how much they wanted to give young married women in, uh, 1981. Yeah. Yeah. Thank goodness for mentors. I mean, that, that would have to be the most, uh, extensive mentoring I've ever come, come across.<Laugh>. Oh, it was just, yeah, phenomenal, phenomenal. He was, yeah. He was a mentor all my life. Yeah. Yeah. Um, next big step, I guess, and this is with, I'm thinking about the young physios that are listening to this podcast, was that you wrote your book when you first booked The Pelvic Girl in 1989 mm-hmm. Which says a lot for your interest in pelvis or all things to do with pelvis, the younger physios that are listening. Do you have any advice on writing and publishing a book? Sure. The story around this one involves Cliff as well, because the invitation for that book came from, uh, Gregory Grieve in the uk. So it was right around the time when Nick Boda and Lance Tomy had submitted their proposal for writing the book, clinical Anatomy of the Lu Spine. Um, and at the time the pelvis was becoming very trendy in physiotherapy circles. And so Churchill Livingston, as it was known at the time, which became Elsevier Churchill Livingston, really wanted Nick and Lance to include the pelvis in their book. And Bo Duck refused because he said, there's no evidence that the Sacc joint moves, and this is quackery. There's no way we're gonna put anything about the SI joint in, in, in this book. And so the board at Churchill Livingston asked Gregory Greeve if he knew anybody who was skilled enough to write a book on the pelvis. And he said, yeah, my good friend Cliff Fowler in Canada. And they said, well, can you reach out to him to write a book? Well, if they'd known Cliff well enough, like his, his writing skills and his, his verbal skills weren't, uh, weren't his best, and he would, he would admit that. So when Greg grieve called Cliff about this book and what he wanted to write it, he says, no, I'm not gonna write it, but Diane, well.<Laugh>. So that's how that started in, in 1989. And that was 80, that was 81 and it, it took eight years to get that book to press because I want it to be as evidence-based as it could. But that meant going to the University of British Columbia every weekend, going into the stacks, walking downstairs with stacks and stacks of journals after going through Index Medicus and trying to find articles. And then you'd have a handful of nickels stand in line at a photocopy machine, throw them in the machine page by page by page to get your articles. So four hours of work might get you three or four articles. Now that may sound laborious, but it's almost as overwhelming now to just do a, a search and send to your librarian, can you do a search for me on whatever topic and then get inundated with pages and pages of references? Right. So to, to, I I wanted to go back to the 19 hundreds. I wanted to see whatever was written on, uh, sacred Elliot joints since 1900 and, and integrate it and go and go from there. So it was, it was, it was a really good experience to just, cuz I was writing really from my experience, uh, for the year in terms of working in training with Cliff, who was really, really interested in the SACC joint and its, its relationship to low back pain, groin pain, hip pain. And the model we were using at the time was very osteopathic. So Ed Styles had come to Canada and had introduced the osteopathic approach to the pelvis, which was more of, um, Mitchell Moran mi uh, Fred Mitchells and, and his father's kind of way, muscle energy kinds of things. Um, Ford and backward torsions, anterior rotated enormous, a very positional approach, right? And, and so that first book was really just documenting what we were doing at that time. Then in 1990 Fi 92, I, um, was working at the clinic and this little green book, the 1989 book had landed on the desk of Andre Fleming. And, uh, Andre Flemming, as hopefully most of you know, has been the, the chairman of the World Congress in low back and pelvic pain since its inception in 1992. And he had just finished his PhD and he was really passionate about the pillars. His supervisor had said to them, don't do your PhD on the sacc joint of the pelvis. Everything is about the disc. Have a, let's figure out the, the low back pain in the disc. And he said, no, no, no, no. Like, look at these fascial connections that are going from the slings that are going from Dorsey through the glutes and crossing through the back. I wanna study the pelvis. And so when my book landed on his desk, he was interested in it, wanted to hear more about it. And so he called the clinic and he had a very, um, he has a very, uh, strong Dutch accent, right? So he's from Belgium. His first language is Dutch. And, um, my receptionist could barely understand him. He says, there's a guy on the phone and I think his name is leaning or blaming, do you know him? And I went, eh, take a message. <laugh> take a message. Oh my gosh, I can't believe I did that. Anyway, I called him back and the bit later and he invited me to come to the very first Congress, world Congress will low back and pelvic pain in La Jolla in San Diego in 1992. And I would have 15 minutes to discuss the relationship between the low back lap pelvis and the hip<laugh> in, in 15 minutes <laugh>. So I got there and ev there was only men presenting duck only men. And I had this lovely navy blue suit that I'd bought to present in and everybody else was presenting in a navy blue suit. So I thought, I can't wear this. So I went shopping and I found this jacket, I won't forget it, it was like Joseph's coat of many colors. I've had all these crazy different colors on it and I don't know what made me do that. But anyway, I wore that and talked about the relationship with low minutes. And what transpired from that was I got to travel with Andre from 1992 till probably 2010. I mean, we're, we still are really good friends. And I've been, I've been all over the place with, with with Andre teaching courses and spending many, many hours talking about manual therapy. And he'd be saying, it's fiddling, give it up. You know, it's all about training slings. It's all about exercise and emotions. It's the emotions that really get people going. And I'm going, you know, we can do things with our hands anyway. I can talk for hours about this lovely guy. Um, and it was through, um, the, his exposure internationally that I was introduced to Paul Hodges in 1995. And I was sitting next to Paul at a conference on the Gold Coast and we were both presenting, and he asked me if I knew anything about tranny Anyway, tranny didn't wanna be stupid, I don't think so transverses a dominance and I went that skinny little flank steak in our body, <laugh>. He had not had one article published at that time. And, um, and after hearing sort of his work on Transverses in the motor control and listening to, to Andre and the rest of it, I knew that we had to move beyond the joint. That manual therapy had to go far beyond biomechanics. We had to start looking at mild fascial slings. We had to start looking at motor control. And yes, of course emotions were important with it. So it led to the whole integrated model of function that Andre and I developed in 1998 looking at form closure, force closure, motor control, uh, and each edition of the pelvic girdle book has told the story of who has mentored me over my career. So the second edition in 1999 was a lot of the, the, the integrated model of function and work with, um, and then the third edition layered on all the contributions from the UQ group with Julie Hydes and, and Paul Hodges and looking at motor control and its relationship to, um, topel the girdle function. And then the fourth edition in, in 2010 is where the integrated model, integrated systems model sort of came where we started looking at drivers and looking at remote system impairments in its relationship with, with pelvic control. And that's when I was working very closely with Linda Joy Lee. And, um, so there's been, it, the, the books have been a journey of mentorship. So for the young, for, for and for the young therapists out there, um, I wouldn't say that I, my experience in career has been that much different than many, many people I know. But what I've done along the way is documented and whether the books that I've written have been self-published, such as the first edition of the Thorax book. Second one now is with Handspring Publishing the two abdominal wall and d r a guides that are both self-published, um, or whether you, you are commissioned by, by a publisher, what writing things down and putting things out there do is creates our history. It creates it a document that actually really shows the journey of physiotherapy over time, over time. And so it's important, it's important to write those things down and not to be afraid that we may not have the evidence for everything that we're doing. Right. Hmm. Well when you, when you sort of detail that the pelvic girdle does almost parallel the development of our profession, starting off on a manual osteopathic and then moving into a bit of a, a myofascial and then moving into bio psychosocial model, it's really starting to integrate all those components and they're all important in every patient as well. Yeah. And I hate it when people hold me back to 1999 and say, oh, we know what she does, you know, instead Yeah. She looks at the P S I S going up and then does this cuz it won't go down. And it's like, oh, no, no, no. Come on <laugh>. I, I have learned a few things since 1999 <laugh>. I think. And, and that's, and that's, you know, put that out there. Cause I know talking to Peter Sullivan, he, you know, the one thing that he always says he laments is titling his PhD, the instability of the lu spine in regards to, you know, his stuff. He said, you know, now we'd never say that, but the reality is, at that time, at that point of our development and understanding that's what it was. But it doesn't mean that it's not true to its time. It's like history, isn't it? You've gotta look at a piece of, you know, something, something happened in the context of what was happening around it. And that's the important side of it as well. Oh, so true. So true. And it, and, and it was how we were using the word instability, you know, the word stability and instability itself became like the six blind men in the elephant. It, it meant different things to different people and therefore the word itself became useless to us. Cuz we didn't, unless you defined what you meant by using the word you didn't, communication became, you know, difficult. Um, and, uh, and, and I'm hope that doesn't happen with the word control now. Like we're kind of substituted stability control, knowing that control, we have to control our joints, um, in some way. And, and it doesn't seem to get as much abuse as the, as the word stability, but yeah, for sure. <laugh>. Yeah. As part of your journey, you know, you've traveled and taught, as you said, a lot around the world. How has this experience for you sort of influenced your understanding in clinical practice? Oh, it's just really made me realize the more years, years I practice, and the more I learn, the less I know. Um, you meet so many, I've just had been so fortunate to meet so many incredible people and clinicians, um, through my travels and to be, you know, when you have an open mindset and you watch people work and you watch sort of how they work and the results that they get, which can be totally different from how what you would've done, it makes you very humble and respectful of the human form and the human body. And that there isn't one, just one way to help someone get better. And that every clinician needs to develop what works best for them. How are they best able to influence and to change behavior in, in the person that they're working with. So not every method is going to be, um, appropriate for everyone. And I've seen, I I, I've seen so many different clinicians work in different models and yet, and, and, and get great results. So it, it just makes you humble. It makes you humble and makes you realize that there's, there's still lots to learn. And that's, that's the beauty of this profession. If, if you're bored in it, if you don't like what you're doing, that's your fault, go change it. Go find something different. Because you can, you can be creative, you can, um, develop and create products if you want. You can, you can travel. Um, and if you find that you're, you are, you're burning out of seeing too many patients, then there are so many other things that, that you can do that will, will really open up, open up the world to you if you just care to take the risk and try. So I'm not, I'm not a risk taker. I'm not sure that that I chose to do that. It was one of those things where like, Andre called me, do you wanna come to California to do this? And I went, okay. Um, and I didn't say no to it. Right. Let's see, let's see what this is like, and, and the book itself, um, like how much money do you make when someone else publishes your book? Peanuts? Peanuts, you, you don't, but you make more than money. You ha you create opportunities. People, people reach out to you and go, Hey, I'm really interested in what you wrote here. Can we chat? Can we talk? Um, and I, and I'm, I have such a worldwide network of friends now that I, I could travel forever and not teach and just go visit people and, and uh, play and explore. And there's just been so many gifts from, from being able to, uh, have the honor of, you know, dropping into their curriculums or dropping into their and taking them and taking them on, on a journey. But my company is called Learn with Diane, not learn from. And I really, I really, really treasure that word with, because I learn as much from teaching as I give. So it's a two, two-way street. So the highest form of learning is to teach you, you really, really understand your topic well or don't you know where the weaknesses are and when you care to listen to the others who are are listening to you. It can just be a gold mine of, of ideas and of, um, think you in other sorts of different directions. So very inspiring to meet people all over the world who, who have the same mission as I do. And that's just to help people live a better quality of life. Right? Yeah. If you could change a decision or experience that you have had, what would it be and why? Um, if I could change, um, I think the only thing that I would've done, I was reflecting on this question, is that I would've bought a building in my forties. My husband really wanted us to stop leasing and to buy a building and put the dental practice in one half of the building in the physiotherapy clinic in the other, but it was gonna cost 2 million. And when I was 42, I didn't, that that was a big number, it'd be like six or 8 million now. And, uh, and we didn't do it. Um, and I, that is the of, of, of all of the things that I've done, I thought about this question when you sent it to me. What, what do I have any regrets of anything that I've done or what wouldn't have done? Yeah, I probably wouldn't have continued to, in my building. Yeah. That's it. And it has nothing to do. I have nothing to do with, with clinical practice, nothing to do with, um, yeah, with that I, uh, I would've bought a building. And the, and the question, I mean, I, I won't say the answer, but the question is why would you have wished you b bought it? I think I know why, but just so you clarify it. Why, why did I reach that. Decision? No, no. Why do you want you, why do you wish you had bought it? Um, well there would've been, there would've been more equity in it in the sense that, um, uh, yeah, probably just more financial than anything else. And being able to, to design it and not be limited by the design of the building already built to be able to create and have your dream space. Um, you have, I would've had more money, um, per month to, to be able to invest in equipment I wanted without, you know, that thousands of dollars going out every month to just to pay the least. Um, but you would've had a mortgage of course, but the mortgage where you would basically have been paying, paying yourself. Um, yeah, I dunno that that's, that's probably the main. Reason. Yeah. That, that's, and that's good because that's a blend of both, you know, cuz people, you know, physios is a, is a profession, but then you have to become a business. So there's just as important to understand, you know? Absolutely, yes, you're gonna have a mortgage, but you will have the flexibility as long as you know, you can make the payments, you can create and design your own space. Um, and you have inequity, which is rising with time, hopefully as appreciation occurs. So, you know, you're moving with the tide as so to speak, financially if you can maintain those commitments. But I like the idea that you've got, it's yours, you can do with it as you want creativity wise. And I think that also reflects our profession. You know, we're going from a manual therapy to an exercise model, to a Pilate studio, to functional rehabilitation. So we need to have those almost bigger spaces to enable us to run lab classes or osteoporosis classes or all that sort of stuff. Mm-hmm. <affirmative>, it's, it's a moving model and having your own space means you can do that sort of stuff. It is, it is. Yeah. And I think, you know, I mean since 1981 I've been a clinic owner and, um, and, and exactly as you say, it gives you the flexibility and a little bit more control and return on return on your investment over time. Yeah. Yeah. What's your hardest lesson that you've learned? Die being a physio. Um, that you can't fix everybody that to, to step back and recognize when you either don't have the skills or the person is in the wrong place and you sort of, you keep them coming for too long or you keep them coming to the point where you, you feel, you feel ineffective or whatever. Um, and, and it took me a long time to feel less than to feel, oh, if, if Cliff saw this person, they'd get, he'd get them better, better. If Earl saw this person, he'd get them better to feel comfortable knowing that I've done my best and whether it is that I just don't have the skills for this person or not when it was, when is the right time to really refer them elsewhere or to tell them, you know, I just don't know. I don't have any more tools in my toolbox for, for you for this. And, uh, that's hard, that's hard to say. Sorry, I, I couldn't make a difference. And to be okay with that at the end of the day and not ruminate over it and feel less than, or, you know, we all, we all start off with the imposter syndrome, you know, we sort of kind of feel not good enough. And then you get to a point where you start to feel capable in some areas and then you branch out into something else and the imposter syndrome comes back. But, um, I mean I always, I, there's always, always gonna be patient that that comes through your door where you, you don't figure it out. You can't, you can't make a change. Things don't change. And, and you have to come to that, that point where you kind of go, this is it in their best interest. It's in their best interest not to see me anymore. Um, not because, um, often because I just don't know what else to do or what else to offer them from all the tool, the tools that you have. So that's, that's probably, um, and, and to know that I will never be a fixer, that I can only be a coach and if somebody is not yet ready to take the journey that I think they need to take in order to, um, feel better if, if they're not ready to work on function and they are still looking for, where's the pain coming from? I need another m r I can you, you gotta find out where my pain's coming from. And if they can't let that go and they can't start getting stronger and start working on, um, whether it's motor controlled or whether it's mobility, whatever it is they need to do to, to realize that sometimes it's time to say goodbye for a while and yet you've still planted the seeds in their brain and it, it's not uncommon for them to go back in a year or two and they say, okay, I get it. I'm ready. Right. Um, and it's also hard, I think the, the lessons are when the psychosocial barriers are actually the driver, when they are the barriers to the recovery or their beliefs and their social relationships or their work relationships that are just so toxic that you're just creating this, um, upregulated sympathetic nervous system. They're always in a state of threat and it doesn't have anything to do with their biomechanics. It has everything to do with the relationships that they have themselves in. And I don't feel confident enough to say, you should get out of this relationship, but I can hold up a mirror and I can say, you know, have you thought about how you feel when this person walks in the door or how, when you're working with this and, and when you get into these situations, how does your body respond to that? You know, oh, Bessel Vander cooks your body keeps the score kind of thing. Um, and when they don't get it and they go, no, no, no, no, it's my SI joint and it's out. You just need to put it in. And you know, oh, probably beyond that. Um, yeah, so those are, those are probably the, uh, the hardest ones to know when is it time to stop? When do you stop? And also the other hard lesson is not paying attention to when those, uh, spikes go up in the back of your neck when you first meet someone and you really go, I don't like you. And it doesn't happen very often. It doesn't happen very often that you, you meet someone and you're just going, I don't even wanna be in the room with you, let alone help you. You're not going to, if you can't establish rapport and you can't, you can't at least like this person to take them somewhere, it's not gonna work. And then as a clinic owner, I have to decide, is there somebody with a, a different personality than me that's better suited to work with this person in the clinic that I can be justified in saying, I'm gonna put you on this person's caseload. I think you'll do better. You'll you'll do better than them with me. And I usually say, I'm not available enough for what you need. That's kind of how I do it. But really it's that I don't want to, and I think someone else is better, but I think if somebody is, is not appropriate for the clinic at all, then I don't let them stay. And, and those are hard. That's hard. And, and that's gonna lessen because when I have, and I've sort of paned them off onto another therapist cuz I don't wanna see him, I, I hear about it and have to deal with the problems anyway as the clinic owner, right. I, I have to deal with either their complaints or the admin's complaints. Um, yeah. Doesn't happen very often. Those are the, those are, those are the hard things. And also hard to let someone go when you make a bad hire. So when you hire someone that isn't a fit for your team or isn't a fit for the model that you guys practice in the clinic and, and the patients are falling off, like they see them once or twice and then they go, they're not coming back cuz they're not getting the same kind of care that they get from other people. And it doesn't mean that what this person is doing is not good, it's just not what's expected from either the patient or it's not the expectation of the clinic. And then having that hard conversation that is about, yeah, I screwed up, made a bad hire, it's not about you. There's gonna be a place where you fit, but it's not here. It's time to say goodbye and, and not honoring those, those feelings. So that's the tough stuff about being the boss, right? Yeah. We've gone from being a clinician to the highest low fire, fast business philosophy of um, being a clinic owner or <laugh>. It's the hats we wear, right? I mean the. Hats, yeah. Multiple hats. Yeah, totally. Mm-hmm.<Affirmative> getting into something nice and simple for 200 bucks or less, what's your best app or tool or investment that you've made in yourself to assist in your clinical development? A great anatomy text. Yeah. I mean you probably. Anatomy, text, digital, it all comes back to anatomy, right? Yeah. Yeah. And you know, for me it's not an app. It's uh, I love my real anatomy books, you know, McMinn and I can't remember the name of the other authors. They're over there. So Gray's Anatomy probably would be the, the one that my go-to. And uh, there's Rohan Rohe or something. Yeah. I love the real anatomy dissection books where you're actually looking, looking at things For me. Anatomy book. You, I know you did the, I think it's the changan cuz I think you mentioned intermuscular stimulation of your course. But the thing I found with the dry nailing I found really interesting is diving into the radiology textbooks. We know that the, the serial sections where you can sort of look at the depth anatomy, that's something that we don't tend to get as much. And the topographical stuff. I'd love that. Ooh, yeah, that sounds like that sounds great.<laugh> Well the apps do that too, right? And they're layers great. Someone's drawing of it. And I don't trust it. I don't trust that it's real. I need to see the real <laugh>. Well, and even going back one step further now, I mean, when you start to go back to the cadavers and you're still look in the anatomy labs, you realize anatomy is not literally cut and dried. It's very variable and there's lots of inno you know, variations that we've gotta realize a person in front of us might be that 12% variation that doesn't have this or has an extra one of that. And you know, it's, it's, it's good for minor selves that drawings are register a drawing as an interpretation. It's not always reality too. So is solar prepared cadavers? So in, in 2010 when the fascial conference was in, uh, Amsterdam and Yap Vanderwal just said a brilliant presentation showing that there's no such thing as a ligament, that the connective tissue in the body is just all thickenings and changings and everything else. And the only time we see a ligament is when some anatomist tends to cut, cut the cadaver in a way that makes us see this thing more, you know? Yeah, yeah. Uh, ilio, tibial tract is just part of the alata of the entire thigh. Um, like yeah, he really blew my mind with that presentation thinking, you know, and guillon barretto's work, right? Everything connected with loose to connective tissue that the skin isn't separate from the bone and there's fives and connections all the way down. Anatomy, anatomy, anatomy. Yeah. Yeah. So I think like you sort of said, we've gone from the mechanical to the myo mechanical to the bio psychosocial. I think the last, well, who knows, it's gonna be the last thing, but we're gonna, we've gotta throw the fascia in there as well now because Oh yeah. Actually it's, it's linking it all together. Absolutely. Okay. So what would you say is your most out on the limb decision that you've made in regards to your career and what was the outcome of that decision? So I would have to say, in thinking about this, was when I made the decision to resign as Chief examiner of the Canadian Orthopedic Manipulative Therapy Association. So I was examining, um, fairly experienced therapists for 20 years, and it is in, in Canada as far as physiotherapy goes, a pretty prestigious position to have, right. But what I really felt that was happening and still do with the orthopedic division, is that it was standing in the way of orthopedic manual therapy becoming a master's degree program and universities. So it was all sort of outside of and not affiliated with, uh, the university. Um, and I really felt that, that we were standing in the way. Um, and, and I think that if many of us had stopped that it might have encouraged the movement of the whole program into university based. So now we have two, um, university programs now, one in Western Ontario and one in at UBC here. But they took a long, long time, long time to come. Letting go of that group was feeling like I was amputating a hand because it was letting go of all the senior manual therapists in Canada, you know, Carol Kennedy and, and Elaine Matthew and Lori McLaughlin and all these people are working so hard to further the education of, uh, young therapists that were coming up. And I left for a couple of reasons because I really felt that it, the program should be in a, in a university. And that as long as the program was successful and kept going, it wouldn't go there. But I wasn't so egotistical enough to think that just me living would make leaving would make that happen. It was also because the program was staying too much in the joint. By 1999, I had learned more from Andre and Paul Hodges and the UQ group about the role of motor control. Laura Mosley's work was just starting then in terms of like looking at, at pain neuroscience. And none of it was getting in incorporated into our program. Now I'm sure it is now. Um, yeah, I'm not sure. I'm not sure exactly what's in it to be honest with you, but at the time we were still, you know, if the joint won't go up, you gotta find a technique to make it glide superiorly. If if it won't go down, you gotta GLD inferiorly. And that wasn't my clinical experience. My clinical experience was that joint manipulation techniques have more of a neurophysiological effect and can change things than they do biomechanical. Now that doesn't mean if you have a stiff joint but has a restricted superior glide that you can manipulate it any way you want. In fact, I don't manipulate stiff joints, I mobilize them. But a joint that's held compressed by overactivation of multifidus rotor thinking in the thorax that's gonna respond to a needle dry needle, it, it's gonna respond to a, a specific distraction manipulation. It's gonna respond to, yeah, reset. Um, and, and we'll make a change. And I have a left right dyslexia. So sometimes when I turn people prone, I forget which side I'm on, what left and right is or the other way. And there was many times that I'd figured out, okay, I need to make this joint glide superiorly, and I would make it glide superiorly and realize, oh shoot, I'm standing on the wrong side of the patient. I did the wrong joint and sit them up, but the range of motion was restored. And he kind of go, how do I reconcile this biomechanical model thing in terms of what I, what I need to do? And so it was hard for me to examine and mark somebody as being right or wrong because they had done something that matched my clinical experience, but was marked wrong for this exam because it was supposed to be a different glide. So I was, I was too much the devil's advocate, and it was just time to leave and, and, uh, create something of my own that was a little more, more, more integrated. But from 99 to now, it it's been, it's been a lonely journey. I've missed, uh, I've missed a lot of those people for, for, for a while not being part of the collective of, of, of great minds. And, uh, and that's, that's probably and out of the limb decision, the outcome of which is that I've lost touch with the bees. Bees and the who's who in, in the orthopedic division in Canada. But I gained connection and community with like-minded individuals, researchers, and clinicians alike worldwide. So my network of of people now are, you know, in Japan and Finland and Denmark and Australia, um, United States, they're not in Ontario and uh, uh, and Quebec where most of the ortho stuff in BC here, uh, is being led. I've, I've retained contact with a couple of people in BC but, um, it was too difficult to watch after, after a while. And even now when Kate's going and doing the, the, the level courses, um, here to get her manual therapy stuff. And I said to her, you're going all the way. You're gonna go all the way and get your F camp and uh, we're gonna mentor you through it. And when it comes to the clinical reasoning stuff, let's chat. Because a lot of it is not what she has learned in the last few years from a regional interdependent approach. And so, yeah. Anyway, that's, uh, that was probably the most, uh, um, out on the limb decision that I made, was to quit a program or to quit the division that I actually created the curriculum for. I, back in 83, I actually set up the OSCI exams from a, used to be Cliff, Dave and John sitting there grabbing a question out of their head, no prep, no nothing. And so I created thir 13 or 14 different exams that were randomized. So, and John had to ask the question that was in front of him, right? He could. And he, and it couldn't be just what he thought the answer was. We had an agreement as to what would be accepted as the answer. So we started to standardize the exam. And I had developed all of that in the, in the early eighties and brought some structure to, um, to the whole orthopedic diviv and then walked away, walked away. What three things stand out for you professionally so far in your career? They're not things, they're people. So that, I couldn't find three things that, that sort of stood out, but three. Highlights. They can be in highlights, they can be human or not human <laugh>. Yeah. So the, the three highlights for me, number one would be the power of mentorship. So Cliff, Andre, and Paul, they, uh, um, they just, the journey that they took me on that, that whole thing, that the, that the, the mentorship, they challenge me, my beliefs, my experiences. And they've absolutely been responsible for a lot of my growth as a clinician and also as a human being. Um, these guys, the other thing is, has probably been the privilege and honor of helping someone get better. The, that, that someone trusts you enough to allow you into their life, to touch their body, to they trust you enough to, to prescribe for them what it is that they sh should do. And uh, and at the end of it, if there is a success story, just at the end of it, just that feeling of the privilege we have to work with other human beings to get better. So again, it's not one single thing. It is, it's just that experience again and again that just keeps, will never let me give up clinical practice. So there's many, many clinical nurse that don't touch patients anymore. They only do admin in Canada. They just do admin and they manage. Um, there's a lot of educators in Canada who don't treat patients anymore. And I don't know how you can do that because if you're not getting fueled by the practice itself, um, yeah, I don't know how you can be the best educator that you can cuz the stories come from the clinic. The examples come from the clinic. If I hadn't been working through Covid, I wouldn't have realized how important it was to get into trauma-informed care, to dive into POEs polyvagal theory and understand what the stress and, and trauma of the fear of getting sick with covid and infecting our grandparents or our parents and the kids not, you know, being safe going to school and what that was doing to our moms. You wouldn't, I wouldn't have felt it. I wouldn't have seen it. And there was times in 2020 when we opened back up again when our care was so psychological, people just wanted to come in and talk to another human being that wasn't their family and, and be held, be touched without being gloved. We didn't glove, we hand sanitized, but it was, it, it was incredible being part of the working through that pandemic and being in the trenches with the team and knowing what they were going through. Yeah. So those are probably two things. The last thing that stands out for me is the opportunity that opportunities in this profession are profound. And um, but they, they, they don't always come to you that you have to, you have to seek them out. But you can, as I mentioned earlier, you can do so many things in this, um, profession and um, just go get it. Just go get it. So how much we can do, how much we can do and diversify that we can do with this. And, and, and people say, oh, you're all, you're still so passionate about what you, what you do, how, how come you're not gonna retire? I mean I'm 69 this summer, why aren't you going to retire? And I went, what would I do? This isn't work. This is, this is life. This is life. Yeah. Yeah. If you could step back some way through time and have a chat to your younger self, are there any bits of advice that you'd like to share knowing what you now know? Yeah, you know, when you're, when you're old, you wanna be young. When you're young you wanna be older and wiser. And it seems like we always wanna be where we're not. And I think what I'd say to my younger self is then and younger people is you are right where you are meant to be. And so stay in the discomfort, work hard and the rewards both personal and professional will come. So, and just keep learning. Keep learning. Never thinks you know one else. Cuz you never do, you never do. I know a, uh, a therapist I worked with at the workers' comp, she didn't like me much. Um, I don't know why, but she didn't. I got the energy feel from her. She didn't like me much. And she'd say to me once, I've forgotten more than you'll ever know, young lady. And I also think of Pat now and I sort of think, gosh, I feel exactly the same.<laugh>, <laugh>, I've forgotten more than people will ever know. But that's probably not true. But it is uncomfortable in the early stages. It is difficult. It's, uh, and it's supposed to be, it's not supposed to be easy, but uh, just sit worth it. Sit with it. And uh, as long as you have one experience today where you kind of go, that's a great story or this was fun, then you're on your way. You're on your way. Cliff used to say, surround yourself with your successes. And if you, if you can do that and you have your su successes around you, then it won't feel like work. You won't feel like work. Yeah. I like the idea of being comfortable in discomfort and it's, um, I, it sort of seemed, I was just talking with a, another lady, um, a a little while ago, Linda Kong, who's a Singaporean Australian who's done lots of things in the area of lymphedema, which is a, is a tough gig, um, at the best of times. And she has that same philosophy that, you know, you've gotta step out of your comfort zone and be discomforted cuz that's where the growth is. There's no growth in comfort and I really like that really resonated with the things that, you know, I've done and you've just, you know, expressed that same thing in a different way. So I think that, you know, in today, today's society, we may be getting a little bit too comfortable and in that way we limit our growth. So it's good to hear from different people that have gone on and done a lot of things that part of the, the ability that they achieve what they have achieved is by being comfortable and stepping outside and being discomfort in in that, in that process. Yeah. Well said Doug. Yeah, I would, I would agree. I would agree with that. Yeah. Looking forward where you see, or where would you like to see our profession of physiotherapy heading in the next few years? I would like to see less specialization and more of, um, an integrated approach to return where, where instead of, you know, I hear so many therapists say, you know, oh, I'm an expert in the knee, I'm an expert in the back, or I'm an expert in, in the neck, but who's the expert in the person, right? There's so much to know about the whole body and it's just impossible to know it all. But we have to have a framework where we're looking at everything in everything in in relationship. I don't think we have to choose between hands on or hands off. I think the better question is when to use our hands and when to use our voice. And most often we need to use both, right? There's a place for, for manual therapy, there's a place for exercise, there's a place for education, and it's knowing when to use, when to use what. I know I couldn't work without the training that I have had in my hands. And we were speaking before we started about, um, the Somalia, the, the, the person who is trained to know, to understand the region, the age, the, I'm not a big wine drinker, but all of the things that a Somalia can do. And apparently they can identify 400 different taste sensations in, in their mouth. A Jean Pi Bural says that we can develop the hand to be as sensitive. And I don't know if, if that's true, but we can certainly develop the, the hand for from for being much better, uh, if we use it. And I think the, the research from music is clear on this. If you look at the brain maps of, of a violinist, um, versus the brain maps of the piano player. So in a piano player, both sides of the brain, both the left and right hands are, uh, the brain maps are very large because they use both hands. But the violinist who, who uses the left hand in a very fine tuned independent finger way versus the bow has a very different brain map for the left hand and the right hand. So it develops, it develops with use. And I think it's exactly the same with, um, with manual therapy. And so often the people who don't believe in some of the things we find, so if we take a thoracic ring for example, Punjabi has shown us in 1976 when when the thoracic ring rotates, it translates contra laterally one millimeter. And people have said, you can't feel one millimeter of translation. We do the same thing in the SI joint. It moves between four to six degrees. How do you feel reliably four, four to six degrees of movement. And the people who challenge that are the people who can't find the finding because they haven't trained their hands. And you can't interpret a finding, you can't find, so the loudest voices are the ones who, who, who aren't very good because they haven't put the time in to, uh, to train their hands. That's, that's, that's one of the reasons for it. The other reasons for the inter tester reliability, the poor inter tester reliability we have is that the human body is dynamic in, its in the way that it moves. And every time we move or do something, so take the mobility test for the sacroiliac joint, which has 12, um, more than this now, but at 2010 when I presented they said IED in Montreal, at that time there were 12 inter tester reliability studies that showed we couldn't agree on, on whether the P S I S goes down relative to S two on mobility testing. When Barb Hungerford was analyzing her research on this stork test in 2004, we were sitting on a beach in White Rock together looking at her data and she had 409 84 data points for every time the person stood on one leg and lift the other one. And what was interesting is that the degrees of motion for anterior posterior rotation at abduction, internal external rotation of the anonymous we're different every time the person lifts the leg. Now we know that diverse motor control str uh, strategies are healthy. The more we do things differently, the better it is. So now bring all that evidence to an inter tester reliability study. How do we know that the person who's lifting their leg is doing the same thing every time? So unless we have a machine that can measure at the same time as the tester is testing it, you have no idea if the same thing happened between tests and between days. And in fact, Joe Abbott, who is a biomechanist in the UK has just finished an eight year PhD looking at this part of this inter intestinal reliability. And she actually built some, um, gloves that had motion sensors on the, in the hands. Okay. She built these and used the bilon system and sh the test that she used was just transfers plane rotation of the pelvis. So is one side of the pelvis more forward than the other. And at the moment that she said, now, um, a marker was put on the, on the, on the vicom system. Sorry, I'm not explaining this well. And the data was compared at both point, at both of those points, right? So Joe would've said the pelvis is rotated to the left and the, and the system would calculate whatever it did and said the pelvis is rotated to the whatever it was. She was right 99.9% of the time. And her margin of error was if the was was 1.6 degrees. So if the pelvis was only rotated 1.6 degrees, she couldn't pick it up with her hands. We can be that good with our hands and she's, and we have this kind of reliability, but looking at inter tester reliability and in truck tester reliability, we'll never show reliability if we are looking at it with the human form. Cuz they do different things every time they move. And Doug, the most consistent thing about a motor control deficit is its inconsistency. People do different things every time they move, they use different strategies. Sometimes it moves and sometimes it doesn't. And so how do we reconcile that? But we should, we should go on for 12 hours <laugh> talking about reliability, but there are a lot of problems with the evidence around it. And that body of evidence is one of the main reasons manual therapy's getting thrown out because the first thing they look for in any test is reliability. And Joe's point is that if the hand's going to be used as a measuring tool, it has to show validity before reliability. You wouldn't use a thermometer to measure distance. So in a lot of the studies is can the hand is the hand the most useful thing to measure what it is trying to measure? It's gotta be the first question before we go for reliability. So we're gonna see some work with some publications come out from Joe Abbott over the next three, four years and it's called Hoda, a hands-on data acquisition and analysis. How do we acquire data using our hands and how do we an an analyze it and how, how do we get agreement and why don't we get agreement is what her thesis and her PhD has been all about. And it's what one of the things that keeps me going cuz I think the pendulum's gonna come back and we are gonna see people scrambling hands again. Fingers crossed. <laugh>. Well, I, I wanna pick, I wanna pick out two things there. I thought particularly, I mean there's a lot interesting. One is the development of the skill through the, the practice, you know, and we take the violin as a great example, particularly when you compare it to the piano player. And secondly, we use the hands for two things. One we use to assess and one we use to treat. Yeah, and I think that's an important point too. The focus has been on the hands as a treatment tool and I think people are forgetting that the hands actually are primarily, you've gotta have them assessment tool, which is what Joe's stuff is starting to show us now. But I I think it's important to point out that you can't develop your, your hands on skills without the utilization and them. It's true. And the. Real, the brain, the brain brain map is, is real estate. And if you don't, you know, if you don't occupy it with the uses of say testing and calibrating with finger touch, then something else takes over it. It's just, it's competitive real estate in there. Yeah, absolutely. Yep, absolutely. All right. And then the big question, what is Di Li going to do over the next few years? You said you're 69, you're an honest lady, you like to, you know, that's. I'm, I'm 60 <laugh>. I would've said only 57, but if you gotta say 69 <laugh>.<Laugh>. Yeah, no, I'm 68, 69 next summer. Yeah, well, and so by that, you know, most would think that I'm in the autumn of my career, but I don't really feel that I, that I am. And I, I hope to really continue to learn and then share what I learned. I was in Australia at the end of November taking a course with some colleagues, and one of the things that we learned was what happens to the cranium for newborns delivered by a forceps. And I've been seeing a number of newborns born with, uh, lots of pain when they lay on their back, lots of fussiness, they cry a lot and they, and this one child I'm thinking of in particular, a lot of difficulty turning his head to the left. Um, and you know, the oxy putts in four pieces in the newborn. And, and I'm learning that, uh, with we're using our hands, we, we can change that. And in one session I had this child being able to lay on his tummy, turning his head to the left, nursing from his mom's right breast. Um, his whole sphenoid and frontal area started to expand out. Do you see the changes in the oxy putt that I would like? But I am, I'm very curious and interested with the newborn cranium at the moment. And, um, so I will always have a small clinical practice and, and people are always asking me, when are you retiring? I live in Squamish now, which is halfway from Vancouver to Whistler. It is a beautiful, uh, see to sky highway, but it's a difficult highway to drive in the dark of the rain. It's scary. It's when they race all these cars on. And so I've always said, as long as I can drive that highway, I'll, uh, I I will be in the practice and the only thing that's gonna stop me would be a stroke or dementia. Um, and, uh, you know, I I, uh, I, yeah, I'm just gonna keep going. And I, what I've realized in the last year is that I love, love, love new grads. I love new grads. They are so passionate and exciting and, and, and they're just little sponges and ready to go and, uh, um, I love working with them. So I'll continue doing that as well. So I am bringing the i s m series course to Sydney, Australia this year. So for any of you're out there listening and you wanna come join me in a, in a six month mentorship, Kathy and I are coming to, to, to Sydney. So it's, it's on the website. Love to meet, uh, meet some of you there. Um, um, and, uh, yeah, so I'll still have, uh, I don't know what I'm gonna do with the clinic, Doug. I think, uh, I think over the next I've got a succession plan kind team, within the clinic itself. Um, so that it, it's, I want it to stay intact. I want it to stay exactly as it is. I sold one in 2000 and I sold it to a big corporation, um, made a lot of money, but I hated what I left behind, you know, in the sense that people were in this corporate thing now. And Bill Lyons, who's from Tasmania, took it over for me and he just did an amazing job sort of keeping every, everybody integrated and, and ran a, ran a great, great team until he died this summer. Um, and uh, yeah, and I want to, I, I really wanna leave the legacy of that place and people in place where there's always mentorship where, and it, where people feel safe to come and be vulnerable and learn and know that there's no such thing as a stupid question and there's no competition and people are collaborating and, and sharing. So yeah, I'm not done yet. I'm not done yet. <laugh>. Diana, thank you so much for staying up late and joining us on Physio plus 10 and sharing an absolute rainbow of our ideas and thoughts and, you know, experiences and journeys. And I'm sure there's gonna be a lot of people looking forward to catching up with you in Sydney if they can get to there. And he is not, um, look forward to seeing you when you next arrive in the Australian shore. So thanks. Thank you very much for joining us on Physio plus 10. Thanks for having. Me. Thanks so much for listening to this episode of Physio plus 10 in which I trust you. Again, some valuable insights. It'd be awesome if you could leave your 2 cents worth as a review or rating of this podcast. And I look forward to sharing the story of another trailblazing physiotherapist with you in two weeks time. Stay safe. Bye for.