The Crackin' Backs Podcast

The Mind-Body Code to Beating Chronic Pain -Dr. Jorge Esteves

• Dr. Terry Weyman and Dr. Spencer Baron

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Is chronic pain really “in the body”… or in the brain’s predictions about the body?
Today on the Crackin’ Backs Podcast, we sit down with Dr. Jorge Esteves, PhD, DO—an osteopath, educator, and researcher whose work reframes low back pain, sciatica, and other MSK issues through the lens of predictive processing, active inference, and interoception. Dr. Esteves explains why pain is more than a physical signal: it’s shaped by mood, memory, context, and environment—and how the right mix of smart touch, simple movement, precise language, and meaning can rewrite faulty predictions and dial down threat in the nervous system.

We explore what he calls “smart touch”—the affective, well-timed, well-paced contact that improves therapeutic alliance, entrains breath and rhythm, and helps the brain feel safe enough to update its story about the spine. We also unpack fresh imaging work suggesting hands-on care can influence connectivity in pain and interoceptive hubs, including the insula—right where body-signal meaning is made. You’ll leave with a 5-minute daily recalibration (breath cue + one gentle movement + one self-touch drill) to keep predictions aligned with reality—especially during a flare.

What You’ll Learn

  • Pain ≠ damage: Why back pain often persists due to over-protective predictions and how to nudge them toward safety.
  • Smart touch, real change: How affective touch, pacing, and breath cues shift interoceptive processing and calm threat.
  • Therapeutic alliance matters: The first 10 minutes that build trust—and the phrases clinicians should avoid because they raise threat.
  • Brains on hands-on care: New imaging insights on how manual therapy may modulate brain connectivity in chronic low back pain.

Learn More / Contact Dr. Esteves

We are two sports chiropractors, seeking knowledge from some of the best resources in the world of health. From our perspective, health is more than just “Crackin Backs” but a deep dive into physical, mental, and nutritional well-being philosophies.

Join us as we talk to some of the greatest minds and discover some of the most incredible gems you can use to maintain a higher level of health. Crackin Backs Podcast

Dr. Spencer Baron:

Welcome to the show. Dr Estevez, great to have you. Thank you. Now, most people think that pain is in the muscles and joints. I mean especially most chiropractors, osteopaths, medical doctors, all healthcare, massage therapists down the line, physical therapist, but Dr George Estevez, you seem to think something very different that's really got some merit to it, and that's how our lives. It the pain is in our predictions, and that the right mix of touch movement, meaning, can rewrite those predictions. So we think of low back pain as being one of the worst conditions in not only this country, but in the world, probably because we're so much more sedentary than ever before, and you know the cost of disability is so high. So could you please explain how the brain and you know how the brain's story provides that

Dr. Terry Weyman:

pain. First off, welcome from Portugal. We're talking to a man from Portugal right now, so that's pretty cool. Thank you.

Dr. Jorge Esteves:

Okay, so let's, let's start this. Yeah, I think starting from, you know, what a lot of chiropractors and osteopaths still sort of think these days in terms of their approach to things such as low back pain, they tend to be very much based on, you know, muscle joints and, and the kind of dysfunctions or subluxations, you know, using chiropractic terminology, or somatic dysfunctions, if we use, you know, an osteopathic terminology and, and I think, you know, there's still, amongst a lot of practitioners, an idea that fixing that dysfunction, fixing the dysfunctional body, is going to be sufficient to, you know, to restore, you know, health, and to restore patients to to the sort of, you know, to where they were before, to a sort of a in a healthy life and and a happy life and so on. And I think you know, that can be true, I guess, in situations where things can be quite simple, quite straightforward, quite linear. You know, someone did, you know, did something kind of twinge a little bit feels a little bit of the pain goes and sees a practitioner. Practitioners reassures, and, you know, Does, does a manual intervention, and the patient feels so much better. And whatever happens, you know, there's a sort of, in a lot of times, a belief that was a cause and effect. You know, I had this, I went to see that practitioner, that practitioner diagnosed me with that particular problem, and and did some sort of intervention. I feel so much better. So therefore there's a sort of a causality there. You know, kind of me with back pain, acute back pain, going to see the practitioner, I get so much better. Surely, that was based on, you know, on the intervention. And that's true in a lot of cases, you know, those kind of straightforward cases, even if you're thinking about, okay, that's the natural history of the condition. Patient will get better anyway, but it is a sort of, you know, something happens. I think the challenge becomes when you know the patient has got persistent pain has been, you know, the pain has been there for quite a while. They have tried, you know, different approaches. They went to see the doctor. The doctor, kind of, you know, might prescribe some kind of medication, you know, got him to do, or her to do some, some diagnostic testing, kind of MRI scan and so on shows, for example, a disc prolapse and and then I think that starts the, you know, the story around the dysfunctional body, something that is not, You know, is not as before, something that needs to be fixed. And I think this is the message that, you know we see clinical practice on a daily basis. You know, the sort of the failed intervention that someone started with the same sort of mechanical, simple back pain. But where is the patient? Number one went to see the practitioner. Got so much better. Patient number two, with exactly the same condition, for whatever baggage that patient brings to the table. You know, history of life, previous experiences of pain, sort of going back to childhood, for example, and so on. You know, all that story sort of builds to something that becomes very personal and very unique to that person and and in some cases, explaining, okay, this is your problem. You've got this kind of this prolapse, but there's nothing to be worried about. For some patients, that's reassuring. Okay, yeah, sure you you know, Doc, you know, I want to see. My neurologist, and he said, nothing to worry about. I'm not a surgical patient. Go and see someone or do some exercises or get better others. Oh, I've got this. I read something on the internet. I spoke to my friends. You know, these days I can even go to chatgpt and ask, what is that about? And I get a lot of input. You know, before we were talking about Dr Google, I guess these days, you can talk about Dr AI in whatever form of AI, yeah, but you know, we're going to ask the questions, and the questions come sometimes a good question, a good answers. Other times, you know, actually bring more anxiety and so on. So that patient, in some cases, starts this journey of trial and error, always with an idea that, you know, I need to fix something that is wrong with my body. Now, of course, you know being a person, being an organism, first, you know. But being a person, you know, the whole concept, what is you know, what is a person? What is personhood? Is a complex construct, because, you know, it's starts by having a body. And having a body is a fundamental part of, you know, of the jigsaw. We use the body for many things, for sort of inputs from the pleasures in life, to use the body as agents to so to interact with the world, to do the things that matter to us, to sources of pleasure, and so on and so forth. So, of course, you know, that's that sort of body is, is a fundamental part of that, you know, what do you call the self? So, of course, when that, and I think it's important to to consider that in a lot of times when everything is functioning, well, that body tends to be invisible, right? We do things, you know, if I go to the gym and I'm sort of, you know, doing I enjoy squatting, or whatever. I'm squatting, I'm not thinking about my body squatting, right? I'm just sort of going with the sensations. You know, I put my weight, I feel great about this. I go for a run, I like this stuff and so on. So I'm not focused on on the inner sensations necessarily. I'm I'm just using my body to do, ultimately, what I want to achieve, which is, you know, I like exercises. I like lifting, I like running. I like doing and then I can. I like playing the piano. I'm not thinking about my fingers on a keyboard. I'm playing. I'm enjoying the music. So the body tends to be invisible in most of the things we're doing in life. Now, what the interesting thing? And I think that's where probably is a good question for practitioners, what happens to the body when the body becomes dysfunctional? Okay, whatever that means. And you know, what does one do with with the body? You know, if, if I've got back pain, then in a lot of times it's very difficult to ignore that back. You know, my lower back. I can't ignore it. I tend to go there. I touch, I press, I squeeze, yes, still here, still sore. I put ice, I put heat, I do something, I rub something with tape, I go and see the chiropractor or the Osteopath or whatever to fix my back. So the thing about, and I think this, this body that is invisible and is in the business of, you know, enabling us to be agents, you know, very much, sort of free to do what we want to do, then we sort of become trapped in that sort of body that became very visible and, and it's, it's kind of there most of the times. And I think, of course, that the natural kind of tendency for someone is to go and see someone that can fix that body, right? So the body is still here, thinking is still important, because that that's ultimately, you know, who we are, is also because we have a body, okay? And you know that body enables us to sort of navigate the world and be who we are ultimately. So I think if we thinking about starting from this perspective, what's what these are, you know, what these ideas bring to the tables? It's the idea of, you know, pain, ultimately, is an experience, okay? And you know, as an experience is attached with, you know, many things in our memories from previous examples, if previous, previous episodes of the same sort of pain, or even worse, kind of, worse type of pain, to the experiences of pain of our family, members of our friends and so on. All that stuff, you know, ultimately contributes so that here, I think it's also important to think about even culture and religion and so on, you know, all those things contribute to the experience of pain and some people being maybe more resilient. And you know, that's okay. Pain is actually part of, you know, it's, part of, you know, it's part of a process anyway, in other societies, no, that's not, you know, it's horrible to have that stuff, and I need to get that fixed So, and this leads to sort of, at times, acceptance of the problem of not or not. So. So I think, you know, it starts from that experience, and that experience, you know, brings those memories, those. Is, you know what in what, in Bayesian terms, are called the priors. You know, something that is in the database. Basically, there's a memory there of something, and I think that's sort of enables the system to predict probably what's going to happen. As a result of that,

Dr. Spencer Baron:

you have aroused my curiosity. I mean, here, you know, let me lay the groundwork. I mean, you are an osteopath. You graduated from the International College of Osteopathic Medicine in Malta. You're trained in a certain manner that is traditional to your practice as chiropractors, we are trained in a certain way. How did you come up with this? Because that I imagine that wasn't part of in fact, back in the day, psychosomatic pain was almost an insult to people, you know, they thought, No, it's not in my mind. You know, it's not, you know, I'm not imagining this. So how did that all start for you?

Dr. Jorge Esteves:

I, you know, when I graduated in, in the, in the in the 1990s and and start, you know, of course, the training was, was very mechanical, yeah, like most of us had, you know, either osteos or or chiropractors or even physiotherapists. You know, we had the very mechanically biased type of training, because, you know the idea that he's the body, and you fix the body, and ultimately, you the guy in charge, and you tell the patient what is best for the patient. You're going to have these sort of miracle fingers. You know, your palpation skills are so good that you can diagnose anything that moves or doesn't move, or exists or doesn't exist. You know, jokes aside, but, that's it. So, you know, you go there until you start. I think you know, being stuck on cases where you think, you know, either it for me, was like the observing there tour patients that got so much better. And you think, but what did I do? I know, you know, why did that patient that tells me, you know, oh gosh, you know, I'm 95% better. And, you know, I saw the guy a couple of days ago, and kind of, I think, why, you know, I didn't do anything actually, or maybe the guy was too acute. I suggested, you know, maybe, sort of, you know, put some ice and do this stuff. And I'm going to do just a simple intervention here, just kind of unlock things, you know, whatever that means. And then the guy comes back and says, you know, so much better. And think, okay, that's that's an interesting phenomena here. Clearly, was not just a mechanical thing, okay, down to the guys with persistent pain that you know, whatever you did with the mechanical models, things did not sort of seem to to have changed that much. And, you know, I was in the early in the early days, I was heavily influenced by, you know, what was around, not necessarily, just necessarily in osteopathy, but also, I know, also in chiropractic, you know, think people sort of the work of Vladimir yande, the muscle sort of imbalances, and, you know, all that stuff, you know, sort of remember, you know, consuming a lot of the work of Craig liebensohn, for example. So feminist, so sort of an osteopath looking into chiropractic, kind of textbooks. Was a little bit like, you know, something you know you shouldn't be doing. But, you know, I was very interested, very much in the sort of, you know, learning. I didn't feel like, you know, my profession is just this. I considered, you know, the importance of looking outside and bring to the profession things that can contribute to the development of the profession, rather than being stuck in, you know, in a sort of principles and things that from the late 19th century, and you know, where people said this like this, and has to be like this for the rest of, you know, our lives. No, I started challenging and, and that sort of led me into, you know, research. And, you know, I, you know, I when I did my PhD in cognitive sciences, very much interested in, in the phenomena of palpation, and then try to understand what that was about. And I had the opportunity, and I had great supervisors that were from the field of neuroscience, you know, nothing to do with, with with the profession, because, you know, I remember them saying, Well, you know, you already know about the profession, so, you know, if you want to find them the supervisor within your profession, that's fine, but, you know, but for me now, that's okay. I'm interested in understanding the other side. And how can I bring this to to my field and try to sort of, you know, shape things around this? And that sort of led me to, with our patient interest, to, you know, the effect of touch, and exploring the effect of affective touch. And, you know, we did some research with preterm babies, trying to understand, actually what happens when you touch someone. And the preterm baby was, was a good model, because, you know, arguably, did not have many expectations. You know, a baby. That is 34, weeks old, you know, how much touch does it have? Of Experience? Arguably, some if the mom kind of touched from the outside during pregnancy, if, of course, if they're twins, you know, they touched each other. But otherwise, you know, that was the model. You know, this is a good opportunity to see, actually, what is the effect of touching someone on the physiology. And we observed, you know, interesting findings of, sort of, you know, autonomic arousal as a result of very gentle touch, for example, you know, oxygen saturation going up inside, how come? Or, you know, heart rate variability changing considerably and so on. So it's sort of very interesting things to to to observe, and that's where the the journey started, and through that come comes the whole kind of world of multi sensory integration, Bayesian brain, and then the links to pain and so, so that's why. So the kind of trying to understand what we do from from a different perspective,

Dr. Spencer Baron:

how do you like? How would you approach a patient now that comes in with even low back pain? I mean, our listeners and viewers, obviously, the majority of them have some sort of low back or neck pain. But what? Makes your management that much different than the way you were trained?

Dr. Jorge Esteves:

I give a lot more attention to to understanding the narrative of the patient. So a much bigger emphasis on the story that the patient brings, rather than going jumping straight into kind of diagnostic questioning, you know, where is the pain? Where makes it worse, and so on. How long did it start? How long ago was that? And so on. You know, of course, that is, you know that, you know, if we put in a kind of using a Socrates model for case history taking, and you ask a patient that has just had an episode of back pain is acute. Of course, that makes perfect sense, because also we need to be safe, and we need to make sure we're not missing, you know, red flags and so on. But I think you know, if you have someone with, you know, a long history of back pain that seems to have seen quite a lot with people, I think you know, fundamental part of that jigsaw is to understand their story. You know, it's sort of what is their story. And I think, you know, in their story, of course, comes the more diagnostic things that we should, you know, still consider, because, you know, we need to be, first and foremost, safe. Ultimately, we operate as primary contact practitioners. And we need to understand, okay, you know, this is something I can do, and this is something needs to be referred to another clinician, to sort of additional diagnostic testing, and so on. So I think an emphasis on the story and sort of understanding the story brings to the table a lot of the a lot of the anxieties, a lot of the frustrations, you know, the bouts of depression, the things that the patients may say they used to be able to and no longer able to do to you know what matters to them? Because the thing again, you know, if you end up sort of prescribing, for example, some form of exercise to the patient, but a patient tells me, You know, I hate exercise, that's not the thing that really matters. And you did not listen to the patient. You're going to sort of, you know, sell them, you know, a few exercises, go home and come back next week. Whereas, if the patient says, what really matters to me is to be able to get back to the bike or to go back to the road or go back to the gym. Yeah. And I think, Okay, fine. If you understand that that you are, you know, you arguably have already an action plan, you have a treatment plan that you started developing together with your patient. So this is sort of when we talking about person centered care. And I think, you know, it's a very sexy thing these days, but a lot of people that arguably say they do person centered care. They end up doing practitioner centered care, because they decide what's good for the patient. And I think a lot of times, you know, the patient are telling you, they are telling you, really, what matters to them, what is the fundamental thing in their lives. You know, if we treat an older an older person, you know, what matters to that person is probably just basic activities of daily living, perhaps right, be able to go out and see friends, go out, you know, shopping and so on and and with that comes the social part of it. Because, again, you know, what we observed is a sort of, for example, the changes in a very mechanical model we had before to a biopsychosocial model became this thing about, you know, we divided things in component, you know, we have compartments. It's bio or psycho or social. And we say, Yeah, we don't do the psychosocial really. But if you understand the patient's story, and really, you. You know, arguably, psychosocial is biological as well. Because, you know, if you not, don't feel well in yourself, and you don't see anybody, and you kind of, you know, you're stuck at home and so on, your biology changes, right? You're depressed, you know, inflammation is up and, you know, and so on and so forth. Your immune system is sort of fighting. So I think understanding the story, understands us to sort of, you know, to see, okay, right? You know, what is the next stage is probably to improve something in terms of, maybe it's the quality of movement, maybe is reducing the symptoms, so the person can start feeling some change and be able to say, well, you know, it's, it's getting better. For example, I, you know, I understand the I understand the process. Because I think, you know, listeners would probably have a lot of experiences, you know, similar to this one, which is the patient comes to see you with with a lot of pain, chronic pain, but he says, you know, out of 10, how much is your pain? Well, you know, it's seven or eight, right? Okay, gosh, it's a lot. Yeah, it's horrible. I'm, you know, I suffer a lot with my pain. And the patient comes back, let's say after two or three sessions down the road, you know, maybe a couple of weeks, and you ask the patient, how do you feel much better? Okay, how's your pain? Well, it's seven. And I think statistically, you didn't change anything, right? It's exactly the same thing. So the question there Nina, what changed, really, that the patient tells you I'm much better. So I think this is clearly not just the sort of physical, mechanical thing that changed, probably that also changed. And that's also important, you know, because I think what is also important not to take away is, I think, if we're going to start saying, well, it's everything is in the brain, which, you know, moves from a body based, kind of mechanical model to a brain based model, which is still body based, right? So nothing changed. It's still biomedical, because it's still focused on one thing. But, you know, it's a sort of understand that actually, through the body is, you know, the body provides us an opportunity to have input to enable some changes to start occurring, right? Because it's part of who we are.

Dr. Spencer Baron:

So interesting, because if we are good listeners, kind of like a psychologist or a therapist, and we utilize that background to guide the patient by, you know, helping them achieve what specifically they want. But we're not psychologists, but we really cater to the thought process. So how do you explain to a patient, because what we do is so physical based on traditional treatment? Oftentimes I tell my interns, I go, man, sometimes we play therapist. In fact, almost every time, but we don't. We're not licensed in that so how do you justify some of that conversation to your colleagues, peers, students?

Dr. Jorge Esteves:

I think that's well, first is one of the anxieties in in the professions, I don't think is just mine, when we start talking about these models, and people say, Well, you know, I don't, I'm not a clinical psychologist, and I don't want to be one, okay, so I think that's the first that's the first point. We're not clinical psychologists. We don't need to be clinical psychologists, but I think, you know, we need to have some of the skills that clinical psychologists have. And this is, you know, it's a debate that's going on in in, in the musculoskeletal world website. Because, you know, can put here the kind of, you know, Kairos osteos and physios together. But it's clearly a debate going on about, you know, communication being kind of soft skills, or fundamental skills, for example. And I think, you know, they are fundamental skills, because, you know, if we want to provide good person centered care, then we need to be good listeners, we need to be empathic, and we need to sort of, really, at times, help deconstructing some of the kind of, you know, some of the rigid belief systems that the patient have, but not in the same way a psychologist would do because, you know, we're not licensed to do that, but with techniques that you know using a lot of times is, you know, is using the body, for example, or using words, if you so wish, but the body provides, I think you know the beauty of this, and actually, if we don't lose the body, because, you know, the danger is, you know, a few years ago, when pain science became quite important, there was a lot of shift towards pain neuroscience education, and a lot of practitioners just kind of teaching the patient a lot about, you know, this is your brain. This is how your brain works. You know, no brain, no pain, all that stuff to. To the sort of the point that sometimes, you know, people would sort after 10 minutes of explaining to a patient what is a brain, what is the nervous system, and so on, that you we felt like we have just lost a patient hasn't got a clue what I'm talking about, because the patient does not have a degree in neuroscience, and it's just too much. It's just, you know, it's a bridge too far. You know, doesn't change. It didn't change anything. Was like people then, sort of, in a nutshell, then was okay, what did you learn? You telling me that the problem is in my head, right, isn't it? So that was the shift from the problem is not in your body to the problem be in your head. So I think that was a danger. And then the sort of, you know, again, one thing that tends to worry a lot of practitioners, at least in my profession, is that this idea that we're going to become just hands off, you know, we don't touch the patients anymore. It's just talking therapy. But the patients go to see someone for, you know, the physical, manipulative work as well. Okay? And of course, you know, you may decide on, you know at times that you know there's less, there's less hands on and more hands off, and other times, there's not a lot of talk and a lot of action, let's say. But I think the body provides that important anchor for for the change. And I think that's, that's what I think it's important to emphasize, you know, out of all these sort of predictive system that the nervous system is the body is arguably the, you know, the sensory landscape. And if you want to use an analogy, we become landscape gardeners, you know, where with sort of, really the inputs and the things we do can be through, yeah, can be through very specific type of manipulative work, but can be through very generic type of work, which is more akin to graded exposure therapy. You know, if someone is very, you know, is frightened of moving forward, because the low back pain is horrible, and forward flexion is what they really hate. If you somehow, through movement and some, you know, touch base things, and you know, you start changing the model. Because, you know, they start thinking, Oh, okay, actually, I can, yeah, it feels better. I can touch my toes and so on, you are changing the model. You're changing the kind of depth, what is called the generative model. So I think that is, you know, so the techniques still make sense, but I think that, I think, you know, there's an opportunity to refocus the lens and not just thinking about the technique as something that fixes a particular dysfunction, to think about the technique as a tool to get into that system, and the possibility of, you know, leading to sort of bigger changes. So that's the way I see it, not just, you know, not just a sort of the manipulation does that thing mechanically, because, you know, the evidence actually doesn't show that the mechanical part is really, what really makes the

Dr. Terry Weyman:

difference. So, you know, on that, on that topic, Doc, you you're starting to touch on a little bit. We aren't clinical psychologists. You know, we do touch people, and you argue about a well timed touch is very important. And what does a Smart Touch look like to you in your practice?

Dr. Jorge Esteves:

Hmm, that's an interesting question. What is the Smart Touch look to me? I think, for example, you know, when we touch someone in a sort of, you know, from a therapeutic perspective, and we are, you know, this, there's a, sort, of course, a conversation going on when we, let's say, deliver some form of technique, and we get some kind of outcome, right? So, you know, I tend to, you know, I tend to teach my students, sort of, okay, when you, when you delivering the technique, you are constantly assessing what the technique is doing, right, what ultimate, ultimately, the tissues are telling you, you know, I think you know what the tissues are telling you. I don't think is just necessarily at the tissue level, but sometimes at a higher level, you know, you know, the person, you know when you're delivering the technique, and the person, sort of, you feel like, yeah, there is, there is a, sort of a, something starts changing, and starts changing radically, in a sense of, Well, this is kind of fascinating kind of thing, you know, it's, it seems to be, it seems to have eased off a lot of this tension. For example, here the patient is telling you, at times you know, again, the patient may be telling you that you know what that hurts but feels so good, okay. Again, there's an anticipation of relief on of part of that. So so that is, that is giving you the opportunity. To really, okay, let's, let's stay here for a little bit. And staying there, you can also then synchronize with other without the senses and other things in that body. So for example, you may feel like the patient is too anxious about what's going on. Seems like the tissue level, something is happening. But you might sort of think, okay, you know, if I change the conversation here, okay? And if I start talking about football, for example, and you know, it's the, you know, you you the sort of support the same team and so on, and they kind of suddenly everything changes, because the focus is no longer on what you do, but the conversation that gives you an opportunity I carry on working whilst I'm chatting to my patient about football, for example. Or you think, okay, the patient is super anxious about what's going on there. And you think, okay, let's use some, you know, mindfulness based techniques by simply for example. Let's think about for example, in either use breathing, for example, or you could even do some visualization. Imagine you close your eyes. Imagine you're in sort of the place you love going on holidays, and you see, you can observe what happens to the tissues, because sometimes the tension goes away the patient, what what felt really tight was also because there was a sort of a huge anxiety about what's what's happening. What are you doing? You know, is this going to happen? Help or not? On the contrary, there are times where I think, you know, we palpate, we feel something. And that is a sort of a straight away, an acute response, you know, a super protective response about what's happening there. And I think that is a question again, you can modulate with things, okay, why is this what's going on? But also, and I think this is also an important part of, you know, who we are as practitioners, because we're hands on practitioners, you know, sometimes that is potentially opening a Pandora box about, you know, previous histories in the life of that patient about, you know, abuse and so on and so forth. So the touch is a form of language is, of course, an intervention is super powerful part of our therapy, but also a form of communication at times where you feel like, you know, here, I'm not a psychologist, but I can use some techniques would potentially enable me to potentiate the effect of that technique, for example, making something that felt really uncomfortable to something Yeah, you know what? I Yes, go ahead and do that, or other way around, where we have the ability to perceive things where either there's an anxiety about the symptoms, a sort of a fear of movement, for example. And you know, when you touch the patient and go and before you touch, they already sort of say that's hurting kind of thing. So maybe, you know, maybe there's a sort of sensitization going on, and you have to be careful about that and so on. But I think that is, you know, that's where touch plays an important role that hands on care, and sometimes the words alone do not give you that, because the patient may say, Well, yeah, it hurts over there, but, but kind of you know, having that experience, that dialog with the patient is, is a fundamental part of the jigsaw. In my opinion,

Dr. Spencer Baron:

I agree. Dr Terry and I have been practicing for a long time. I'm going on my 40th year, and I have seen phenomenal things that didn't used to make sense. But then when you start explaining it to your your interns or new associate doctors, you start to catch yourself talking about listening skills, you know, and and being being socially adept in a manner that most doctors of that generation are just all about writing a prescription, You know. And so many times when you look back, you see patients that defy all the laws of healing, but you did something different. You listen to them, you you put your hands on them a certain way. You know it becomes, you know, you I think you referred to it like as a therapeutic alliance. And how does somebody create that, that therapeutic alliance with a patient? And then, how does somebody, you know, unknowingly, you know, create, you know, a miscommunication or, well, you can see it in a patient, if you're perceptive enough that they're having it, they're not having a good experience with you in the beginning. But do you have any suggestions that would help with that therapeutic alliance?

Dr. Jorge Esteves:

So the therapeutic alliance. Is something that is kind of, these days, very much accepted across a number of professions as being essential for for good, you know, so to effective care. And there's, you know, there is good research demonstrates that, you know, good therapeutic alliance leads to better outcomes. I think straight away, one thing it's important to, you know, to understand that, you know, we it's, it's highly unlikely that we going to develop, you know, robust therapeutic alliance with every single patient comes through the door, because that's just kind of the human nature and communication and and so on and so forth. Okay, how? Practitioners develop a good therapeutic alliance? I think it starts with, starts with that capacity to really listen and to sort of provide an environment that is welcoming, that where they feel safe where you have addressed, you know, their expectations, for example, I think that's an important part of the you know, that needs to be pretty much discussed at the beginning. You know, for a patient that comes to see you for the first time, and you know, you have one particular type of practice, one particular approach, and the patient expects something completely different. But if you did not ask, okay, you don't know, right? When you know. So I think that is important when part of you know, okay, tell me your story, but also tell me what's what's, you know. What do you what do you expect out of this? You know, interaction, and this, you know, process. And I think you know, if they understand, if we then sort of start aligning our expectations with their expectations and and, you know, we understand what really matters to them, and we understand what we can or not do. So I think, you know, we start sort of creating a in the beginning of a relationship that is trustworthy, so the patient knows that there's not just coming every week because you just want to, you know, cash in, basically, but, but they understand there is a process there. I think again, that that is important part to consider. You know when I you know when you explain to your patient after, let's say, your your initial evaluation, what you found, and what you think the plan of care is, and so on. It should be a sort of a frank discussion about, you know, okay, this is the plan, what you think, negotiate that plan with the patient. You know, not something that is, you know, is a sort of put on them because, you know, it's sort of, you know, you think this is the right way of treating you, and therefore, you know, they need to obey. Now, it's the other way around, right? So they are kind of, you know, they're experts in their body. They know what. Can also afford. They they either, you know, the whole thing makes sense to them or does not make any sense. So all those things are part of developing that important alliance. You know, how can people develop those skills? And, you know, develop robust Alliance, as I said, communication. But communication here is not just sort of verbal communication. Non verbal communication is a critical part of it. You know, just good listening skills, you know, just knowing what, not to say anything, and just listening to them, you know, as a sort of not to interrupt all the time when you're asking the same question 10 times and and they're fed up because they already answer you that stuff, okay, when you you know again, expectations are, you know, if someone go, you know, if a guy comes to See you, you know, the sort of, you know, in our age group, let's put it this way, and comes to see you with with a sort of simple ankle sprain, and you suddenly, you're talking about the prostate and so on. Does not make any sense, does it? But if you explain to the patient that the role of the practitioner is actually also to assess health and make sure that he's safe and there's no other stuff going on and so on. Sure, when you ask questions about, how's this and that, yeah, sure, I understand why I'm answering the questions. But if I just sprained my ankle and he did not explain, and I think that, you know, Cairo or an ostio does that stuff, you know, I don't think I need to answer the question. I think you know, what is that coming from? So I think is a sort of explanation of the process. If people don't understand the process, it starts outside the clinical practice, you know, starts with, you know, the website starts with the forms of communication, starts with the presence out in the Wilder world, right? It then sort of includes the people that work in your practice, you know, who answers the phone, who, kind of, you know, welcomes the patient, and so on, because you could be the best practitioner in the world, but they come to see you, and they just had a fight with the with the receptionist. They're not a good place, right? You can provide, you know, you can think you can be the best. Best guy in the world, but, you know, it's not going to align anything. You know, they are, they are in a sort of Super Fight or flight or I kill you sort of state, and they're not going to sort of respond to the treatment. And so, yeah, getting the team together, I think this is because each one of us will have a role to play in that team. I think

Dr. Spencer Baron:

what you're saying is so exquisitely important that they don't teach this in school. And when I realized over the years with interns, I often say that the examination starts before the exam. Sure, and the days when, in fact, I was just mentioning this yesterday to my new intern back in the day when, when people would hand write and fill in their their their their forms. I'm not a handwriting analyst, but depending on how thorough they were or how scant they were, that's how you may start to move into your your your consultation and history and exam. If they're, you know, certain handwriting, if it's nice and big and flowing, usually they're very loving and compassionate and they Yeah, I know it's, it sounds odd, but that, you know the even the first phone call to your front desk, I'll ask them, I go, what was the patient like? How did they How would, oh, they were really friendly. Or they were very short, Curt, you know, not very they must be in pain. Or, you know, it was actually fascinating when you when you look into their history before you actually take their history.

Dr. Terry Weyman:

So, you know, was this back in the day, I actually still do that because of those reasons. I still have everybody fill out their stuff. I still do all the handwriting stuff. I still do. I'll do anything electronic, because I think when you go electronic, you lose stuff, yeah. And so I, you know, back in the day, I'm still in that day because the information is too valuable to throw it away, go electronic.

Dr. Jorge Esteves:

Sure. No, I agree with that. And I think, you know, with that was much more of, ultimately, your writing, but you thinking, you know, your clinical reasoning continues. You know, you you kind of okay, all right, so I'm just gonna ask you this, this question next, yeah, and I think sometimes the typing, kind of, you know, you there, and sort of, I know this from experience when, when I lived in the UK, a lot of, a lot of patients complain about the, you know, the family doctors. You call it the general practitioner, because, you know, goes to the, you know, the the guy sitting in front of a computer, and the patient is sitting kind of, you know, at the 90 degree angle, and he's looking at the computer. Doesn't, never look at the patient and try the patient says, you know, never looked at me, never palpated. That's No, no, I was there for three minutes, came in, got out, oh, okay, didn't, didn't watch anything. Didn't realize that I was in pain or was fed up or whatever. I didn't, didn't see my body language,

Dr. Terry Weyman:

yeah, even. And as a as a practitioner, and then when I go in as a patient, and I have two nurses there, and they're the ones writing the notes, and they're the ones doing stuff and and the doctor is talking about something else, I'm like, All right, where's this disconnect? That it's just such a disconnect we do. I went back. We only did electronics for a little bit. I went back. Everything's handwritten now. Everything's back to how it was when I first started. I got rid of all my electronics. I got rid of all my iPads, I got rid of all that. And people will say, Oh, you're not high tech. And I go, you're right. I'm I actually want to make you better. I don't. I don't care about the high tech. And I went back to all that, and I get rid of the person in there, and I ask the questions now. And so it's interesting. On a fun note, I do want to ask you something, because you listening. You talked about safety, you talked about Google, you talked about Dr, Google, Dr chat, BGT. And millions of people look up sciatica, look up low back pain, and they already come in with a preconceived idea what's wrong with them, right, and, and, but most practitioners chase the pain and and in your thought process, you know the brain, our brain has already made predictions what's wrong with us, where do you see that brain being wrong? And how do you see the way where the brain is getting it wrong? And how do you make this prediction and change this prediction into a different thought process when they walk into your door?

Dr. Jorge Esteves:

Well, I would go beyond just the brain, but, you know, think about the whole, you know, the whole nervous system, because, you know, we can think about also the whole interoceptive system, because, you know, a lot of things are before they go up to, you know, to to the black box, the kind of process that, you know, in the periphery. In the viscera and so on. And and start sending the messages that anticipate the consequences of actions. And, you know, and some kind, you know, a lot of times they already start a cascade of events that could be protection, or could be, oh gosh, this is great, or whatever. And, of course, you know what they bring, you know, all the information that have been consuming, you know, out out there quite a you know, some of it with, with some good validity, others very questionable, because, you know, it's, you know, we know, if you go to Google, used to be the worst case scenario, you know, if you put back pain, you know, you would be like, you know, the differential diagnosis started with cancer to kind of probably going to die tomorrow anyway. And so, so and people, you know, humans, tends, you know, they're pretty good at sort of avoiding uncertainty, and they tend to catastrophize very easily, right? So if you kind of tell someone, oh yeah, it could be that. And and your friends, and the friend of a friend, and so on, all had that stuff, and really had the, you know, the worst kind of case scenario they you tend to sort of think that that's probably what's, what's happening with you. So it's, it's normal that you know, in that context, in that context of uncertainty, that people tend to sort of get stuck in something that is protective. And I think you know, with this thing about predictions, and you know, there's some complex kind of stuff that we talk about in our work, you know, like the free energy principles and so on. But, you know, basically, if we thinking from from simple terms into, you know, thinking that at all times, organisms tend to, you know, prevent entropy, right? And entropy is disordered, so, so we prevent entropy, and we tend to prevent entropy by very much limiting ourselves to a number of states that prevent that entropy, right? So, if this is bad for me, I avoid that stuff. You know, this is something that I don't need to think about consciously my system. Does it okay? So, you know, if I, if I had an experience with something that experience wasn't very, very good. Next time I I'm, you know, I have the same experience, I will get stuck in that, even though I anticipate what, what happened last time, and kind of, Oh, don't move. So I think that is just a normal thing. And this can happen with pain, of course, you know. So if we thinking, last time, I kind of had the long car journey, and I kind of got out and I was, I went on holiday, and kind of did, you know, let's say 1000 kilometer journey got to the end. I, you know, I unloaded my car to the hotel, I got stuck. And, you know, my holidays were horrible because I had terrible back pain. Next time, you know, I'm kind of think about driving, do a long car journey, probably, my system already predicts that it's probably not going to be very good for me anyway. Okay, so, you know, the likelihood of me potentially develop back pain when I sit for long periods of time, it's probably going to be higher than, you know, would normally be for another person's kind of just an example, the same way, if you're thinking about, you know, we mentioned before, back pain and bending forward, which tends to be one of the things people are quite scared about. Why? Because they see the picture of the disc, and you bend forward and the disc bulges, and you're going to touch the nerve root and all that stuff. So someone with a history of chronic low back pain, if you tell you know your patient in front of you, okay, I'm just going to assess you. Let's do a few movements. Would you mind? Would you bend forward, touch your toes? What you observe in a lot of times you observe them either moving really slowly or, you know, going to extension, locking up the back, and then kind of try to go down. Okay? I said, No, no, it's not like that, you know. It's just kind of what you mean, you know, you you kind of, you're telling me to go that. So the system knows that that is equal to danger. And if I'm preventing disorder entropy, sure I prevent that. And kind of the system is not stupid. And with that anticipation of that, the system could even create so much tension that actually what happens you start moving forward and you put so much tension that actually feels uncomfortable, is a signal that is enough to sort of, yeah, okay, validates my model, and you are stuck in that. Okay, so this is, this is a nutshell, you know, fear avoidance expressed through this prediction thing. Okay? Uh, and you observe this in your with your patients, you know, for example, in physiotherapy, the work of people like Peter, Peter Sullivan in Australia, with cognitive functional therapy, they talk a lot about this stuff. And, you know, they they even ask the patients, you know, to do some exercises, some experiments with the patients. For that which one of them is okay? Imagine you. Well, you know you you want to move forward, and this is your fist, okay, so make a fist and try to bend. And how does that feel? I think it feels horrible, right? Because I can't I'm tightening up at the same time. I'm kind of trying to move now, try to move freely, relax completely, and try to bend forward, and the hand goes, and the sensations in the bodies are, wow. That's different. And that's a lot of times what happens with patients that tighten up everything, either because people told them contract the core before you bend or whatever, and they tighten up everything because they they know that the they anticipate the outcome, the outcome is fine, and they lock themselves up okay. So in a sense, the difference here between what is the prior, the experience, and the actual experience now was the prior dominated over the experience. I already anticipated bending forward was going to be bad. I started bending forward. I got a little bit of a twinge, ouch. Lock, don't move. And they tell you, yeah, that hurts a lot. So we didn't move that much, did you now that hurts a lot. Okay, so how do you deconstruct that, or how do you change that? So one way is to, of course, surprise the system, right? It's, of course, very easy to say, but lots of times quite hard to do, right? So if you somehow violate their expectations by introducing something that's actually created a sensation that was one of they were not expecting. Let's, let's continue with the back pain. Now let's imagine, for example, actually, let's imagine they are kind of not sure they they're acute back pine or, you know, sort of the back is very stuck, if you want to put it that way. And you decide, okay, I'm going to do, yeah, I'm actually going to do spinal manipulation on the lumbar spine. But, you know, I do something very minimal leverage, not a sort of huge levers, just something minimal that ultimately what I want to achieve is a bit of a shock to the system. Okay, so that sort of, you know, thrust that, you know, you get that sort of almost rebound and suddenly clicked or didn't click, but kind of suddenly the muscles switched off, kind of, wow. There is that period of Oh, and then you imagine, okay, let's, let's see. Let's, let's have a look. Let's see how it feels. And the patient may tell you, I actually feel it's painful, but feels better, right? And then they sort of okay when I will leave it like that. Today, we're going to observe how things progress and so on. And they start moving, you know, they sort of gonna start getting dressed, and they say, actually, I could, I managed to put my shoes on, right? So from this perspective, what you what you have introduced. You introduced something violated the expectation that whatever movement was going to be painful, and with that surprise, because you surprised the system, you introduced something that provided you with an opportunity for resetting the whole thing. Because ultimately, they're the ones doing the reset right? They're the ones that's through the movement. So I say, actually, oh, actually, I feel okay. Actually, it's a little bit better. And they go home and say, yeah, it's still hurts, but I can walk, yeah, yes. Versus the other guy that you know, you did all your testing and he finished and say, okay, still hurts. And yeah. Yeah. And they lock into they continue, they continue like this. What it basically you want? Okay? Then you can play with advice, and you can be your psychologist by sort of reassuring them that actually, you know what happened is a protective mechanism. Is a sort of a non specific back pain. There's a twinge there, there's a muscle spasm, and the muscle spasm is there in the business of protecting. And you know, when CIS starts getting away, the system knows that it does not need to be fire all the time to protect, because it's no longer an issue to protect. I think you know with this predictive model, of course, we have a system, either the nervous system, but. Is arguably the neuro immune system. You know, working together, they are in the business of protection, and they protect, protect, protect, right? So, of course, if you have, you know, if you fighting a virus or a bacterial infection or something, yeah, you expect the system to be pretty, pretty efficient at sending the troops to the right places to fight that. Okay, the problem, then is when, when the problem is no longer there, but the system continues protecting and and you are in the protective mode all the time, which is what you tend to find at times with chronic back pain and so on, which is, there's no longer tissue damage. Everything is fine. The X rays, the MRI show, everything is fine. Why is the person still stuck? I think that's where my kind of being a little bit more creative with the approach, in my opinion, can can give us an opportunity, a window of opportunity, to sort of change using the body because, you know, we haven't left the body alone.

Dr. Spencer Baron:

You know, it's fascinating. You not only what you're describing is so impactful and that practitioners should make efforts at doing this more often, but it took a course in mild traumatic brain injury years ago, and it was, I was the only they're all functional neurologists that were chiropractors that were studying this level of nervous system, and one of the comments or one of the teacher showed us was something about phantom limb pain, for those listeners and viewers that don't know what phantom limb pain that is the extreme amount of pain and discomfort that someone has after they've had an arm or leg amputated or they've lost it, and maybe in the military or an accident of some sort. And one of the solutions that they use, one of the treatments, was so fascinating. It would be to take a like a portable mirror, like a wall mirror, or even, like, if your closet is mirrored, your closet door. You could use your closet door and bring the mirror so you only see the side where you have the limb is still intact, so you don't see the one that's amputated or lost. And you do movements and exercise, and you actually create it looks like you have a isomer, like a perfect image of the opposite limb in the mirror. So you're tricking your brain into believing you have the limb and it and it actually creates a cessation of the pain and discomfort that you were having a few practices of it. So what you're saying that's like, I the epitome of what you're describing here, and how you change the thought or the brain, yeah,

Dr. Jorge Esteves:

and ultimately, the phantom limb pain is again on that business of protection. So you know, the brain still has a representation of that limb, because, you know, that doesn't disappear straight away. You know, can, you know, through neuroplasticity, can remap and become shorter, and so on. But for a while, is still there, is there's still a part of, you know, the representation. So it's still protection. And of course, you can treat the brain, because, you know, by using, you know, are the senses, and this is the creating that which is, you know, for those of you that may have seen the fun, the rubber hand illusion is works in exactly the same way. You know, you trick the brain because you know the vision takes over, for example, touch and proprioception, and you think that happens. But with that, with a mirror. Actually, one suggestion for some of the listeners that we want to try is again, with your chronic back pain individual, because this actually can work with mirrors quite nicely. If you've got two mirrors, one in front of a patient and one behind the patient, and imagine the patient has got problems in side, bending to the right. If you ask the patient to side, bend to the left whilst looking at the mirror in front of them, which they see their back, their brain sees them side bending to the right, right. So this is the thing you know. You can you can sort of remap. You can sort of change things by playing with the senses and, and this is about tricking the brain. Yes, it is. And, you know, touch plays a role there. But, you know, we, I think sometimes you have to be clever and introduce other things in the practice where, you know, we sort of play with a nice plasticity of systems, you know, in the thing. Is that interaction, the interaction at the end of the day, and as a kind of yesterday, was chatting with it, with a colleague that actually happens to to work in in a College of Chiropractic in the US in the UK, and and we were talking about, you know, because we working together in the research, that what we should be talking about here that is quite important, is the whole therapeutic encounter is not just a technique, is not just what I do, but is the encounter itself that it's got so much, you know, communication. Sometimes there's no much you know. There's no much talk. You know, there are patients sometimes, you know, you don't talk that much, right? And you kind of do your stuff and they get back, and so, how do you feel? And so on. I had that experience when, when I, when I lived and worked in Saudi Arabia, and for a while I did not have an interpreter in My Arabic is pretty bad. And in those cases, I kind of, you know, survived with the basic communication, but, you know, things that were very much through language. It's through, you know, body language, through the hands on care and, you know, at the end, asking someone translate and so on. So it can be done as well. So it's not just, do I need to talk, talk, talk, but it's create that, what I call in in some of our papers, the therapeutic ecological niche, where you've got, you know, within that niche two people, or sometimes three or more. You know, if you're treating, you know family, you know, if you think pediatrics or Geriatric Care sometimes, or you know, husband, wife, or whatever. And then you have to communicate also with the other one, because, you know, that's how you emphasize the importance of something else. But you know, within that niche, that communication that is leading to changes. And I don't think, you know, we need to be sometimes too precious about, you know, is the technique is doing the trick. And you know, if I don't do the do the technique, I lose my identity as a practitioner. No patients come to see a Chiro because they like chiropractic or to see an osteopath because they prefer that. Okay, it's not the technique itself, in my opinion, is the package, is the approach. And maybe some guys are kind of straightforward and get to the point, and other guys like talking a lot, because we end up attracting the patients we kind of feel comfortable with and they feel comfortable with us, and that's fine. It's quite pluralistic here, you know, it sort of doesn't have to be, you know, black or white kind of thing. You know, that's a lot of shade of gray, shades of gray in clinical practice most of the times, right?

Dr. Spencer Baron:

So, so Dr Estevez, we're, we're nearing the end of the show, but we have a fun part that. Well, the whole thing is fun, but there's what we call rapid fire questions. There are five, excuse me, five, five questions that I ask you. Yeah, four or five, five questions that require a quick and brief answer, and that's how we end our show. Some of it has nothing to do with what you what we've talked about. Some of it's all, you know, personal and I mean, open to the public. If you're ready, I'll ask you the first of five questions. You're ready, it's fine. Okay, name one narrative reframe for maybe like a desk worker, something that is good for anyone who has a desk job,

Dr. Jorge Esteves:

anything that's good for a desk job,

Dr. Spencer Baron:

which is probably everybody, most people on the planet right now,

Dr. Jorge Esteves:

that's a Tough one. Set up some, you know, actually use facilities of, you know, smart watch, for example, to remind you to get up.

Dr. Spencer Baron:

So move good. You know, it's something that they would tell themselves, like, your spine is adaptable. It's not fragile. You know, things like that that they would show up, repeat, right? Yep. Question number two, what is one environmental tweak, something that you know an hourly like you had mentioned that you feel everyone should

Dr. Jorge Esteves:

do, get up and move. Yeah, have the excuse of going to the toilet, for example, but get up, get out and get up and move. I think that's, that's the fundamental thing.

Dr. Spencer Baron:

Yeah, very good. Or get up and grab something to eat in the refrigerator. Absolutely. Question number three, build us a kind of a nervous system mix tape or, you know, one song that would boost vagal tone, or one that would help the brain up, you know, that would update these predictions during movement. And you know, something for, you know, maybe a postseason integration. Is there? Is there a music, or anything that you would suggest?

Dr. Jorge Esteves:

Yeah. Um, actually, I mentioned my my experience in Saudi Arabia when I didn't have interpreted, I used a lot of classic music and a particular opera, and there was a good way of sort of really tuning into the, into the autonomics, into the into the parasympathetic Absolutely,

Dr. Spencer Baron:

actually, that is gaining a lot more attention. They there is been some research on the Mozart effect on the body the what is it? The two pianos in D minor, the Sonata that it seems to be where the research was done. It's fascinating. That'll be good for another conversation. So you once highlighted f1 world champion Lewis Hamilton for giving osteopathy a shout out if you were on an f1 grid with 60 seconds before the lights out, what's your your no table, no tools, pit stop routine to kind of downshift someone's arousal for maybe a driver or a weekend warrior before that big moment,

Dr. Jorge Esteves:

just a quick Upper Cervical kind of gentle release.

Dr. Spencer Baron:

Very nice. He's good at these

Unknown:

rapid fire.

Dr. Spencer Baron:

Yeah, you're Portuguese, shaped by UK academia, so now leading in Malta. What's one?

Dr. Jorge Esteves:

Well, now, now I moved, I moved to Portugal. You moved back to Okay, yeah, moved to port after 26 years. Yes.

Dr. Spencer Baron:

What's one tiny daily, micro habit that you've borrowed from each culture that improves body awareness or lowers stress.

Dr. Jorge Esteves:

Oh, gosh, from from the from the Middle East, a sort of more laid back approach, kind of not worrying too much. And, you know, let things happen. Sometimes can be bad, but all frustrating, because in a particular when you were in the UK based system, sort of very much more intensive, more intense, more things have to be done, kind of routines to so one the more laid back, sort of, you know, breathing from Portugal, things, eating, eating can be no Well, you know, my routines are I, for me, fundamental is exercise. So regular exercise on a daily basis. So that's the kind of what I got from, you know? What I can still what I still continue doing. So stay

Dr. Spencer Baron:

always a golden approach. Exercise is probably one of the most solid forms of therapy, there is well. Dr George Estevez, thank you so much for all your information. It's been fantastic. And all the way from Portugal, this has been a great show.

Unknown:

Thank you.

Dr. Jorge Esteves:

Thank you for your invitation. And was really nice chatting to you guys. Thank you.

Unknown:

You're great. Thank you. Thank you for listening to today's episode of The Kraken backs podcast. We hope you enjoyed it. Make sure you follow us on Instagram at Kraken backs podcast. Catch new episodes every Monday. See you next time you.