Silvan (00:00)
Hi everyone, welcome back to the Silvates podcast. Today I'm joined by two osteopaths and educators, Lazarus Nono and Krutika Patel, for a conversation about how osteopathy has changed, both in the way that we practice and the way we teach it. So we're going to explore what new graduates are doing well, where some of the gaps in their confidence and clinical reasoning might be, and whether there are areas of the body that as a profession we sometimes overlook.

So in particular we'll get into the foot and ankle and why they sometimes can become an afterthought in clinical practice.

Now Lazarus and Krutika have also developed a CPD day around this area. So later in the episode we'll hear about what led them to create it and what they think clinicians could be doing differently. But before we get into all of that, Lazarus and Krutika, thank you so much for coming on the podcast.

lazarus nono (00:54)
Thank you for advising us.

krutika (00:56)
Thank you for having us. a pleasure.

Silvan (00:59)
Yeah, and I mean I've been taught by both of you and so this is a real treat for me and I've also worked alongside you in clinic. But for those people who might not be as familiar, can you give us a little bit about how you came to to the profession?

krutika (01:19)
Lazarus, I'll let you start.

lazarus nono (01:21)
When I came to the profession, I was a dancer. I injured my knees. That led me to thinking that I'd like to treat dancers. Went to the British School of Osteopathy where I also met Krutika, qualified from there in 98, 97, sorry. And then after a number of years in practice, I joined the British College of Osteopathic Medicine. Been there for 24 years, really enjoying it.

and I did a master's in performing arts medicine in 2014.

krutika (01:55)
I actually stumbled upon osteopathy. I was quite lost in what I wanted to do. So I was doing a degree in applied biology. And my best friend at the time was training to be a physiotherapist. And so I ended up in a lot of anatomy lectures and found it fascinating. towards the end of the year, I decided that

I needed to change and so wasn't too sure exactly whether I wanted to do physiotherapy and another friend of mine was applying for osteopathy so I researched into it and I thought sounds interesting so I applied for it and to be honest I've never looked back.

Silvan (02:47)
That's amazing. And both of you s both studied and graduated together

And you've been in practice for almost thirty years, both in practice and in clinical education. How

krutika (02:59)
Mm-hmm.

Silvan (02:59)
has the profession changed since you graduated?

lazarus nono (03:07)
I think that it's changed quite a lot. Where I think that when Krutika and I graduated, I think that we treated the person a lot more. I think now people drift towards treating bits of the patient and not actually trying to link the individual as a whole. And that's what the philosophy is saying that we must always pay attention to the patient.

and not to the bits and pieces that make up the patient. I think that there's a lot more drift towards that. I think also technique appears to be dominating visually on social media. So people get in the impression that osteopathy is about technique and not its philosophical stance and how it approaches the patient.

Silvan (04:03)
that's really interesting now as you talk about sort of the dominance of social media and how that's really given everyone an insight into what osteopathy is, but what you're saying and what I'm hearing is that it's a very small part of what osteopathy is, actually.

And so Lazus, what do you think we're doing better now than we were maybe doing twenty or thirty years ago?

lazarus nono (04:28)
I think that these students communicate much better. So when Krutika and I trained, our communication was quite different to now. So I think that we did a lot more hands-on work.

but we didn't communicate what we were thinking about so much to the patient, which now I think we may have slightly tilted the pendulum in the opposite direction where the students are really good communicators and they're expressing themselves verbally really well.

that that sometimes is encroaching on their ability to actually use their skills. So the patient is hearing the story, but they're not actually getting the treatment or the time that they deserve or what they're actually paying for. So I think we need to get that balance between our generation who communicated less and got home with the work and this new generation who is communicating really well, but doing less work.

in my opinion.

krutika (05:34)
I also feel that there's a lot of emphasis on consent these days, which I think back in our day, we didn't have that. It is a good thing. I do think that it's needed, but I think we're a little bit too scared now to do a lot of things.

So I think there's a lot of fear behind what we do and how we do it.

lazarus nono (06:06)
Yes,

the consent is, as you say, a critique, extremely important, but if you're asking consent for every move that you make, I think from a patient's point of view, it's quite alarming. And also they can't relax because you're constantly asking them if you can do this, if you can do that. And I think in all walks of life, you you expect people who are professionals.

to do their work, you know,

So if a builder came around to your house and he was laying tiles for you and every second he said, you know, is it okay if I take the tiles out? You said, yeah, I'll take them up because we're going to replace them. And then once he took them up, he said, is it okay if I scrape all the old tile and stuff off the floor? said, yeah, of course you got to lay the tiles. And then before he started the job, said, is it okay if I now use the grouting that I want to use to stick them down on the ground? You would be, you know, you'd be very confused.

that you've employed this person to do a job, you have a conversation with them, and there comes a point you've got to trust the person that they're going to do the job. So it's the practitioner's duty, I think, is to ensure that the patient understands clearly what to expect. But there comes a point where you have to feel confident that the patient is going to trust you in what you're going to do because you have their best in your heart and in your mind and not constantly

them about everything that you do may I touch this may I push you in this direction may I look at this I mean it's just a little bit too much I think

Silvan (07:43)
I suppose what you're both saying is there is obviously a need for consent and that's

lazarus nono (07:46)
Hmm.

Silvan (07:46)
a valid thing, but I suppose there is a issue of asking to perform a certain technique once you've already gained consent for that sort of treatment.

lazarus nono (07:56)
Exactly.

Silvan (07:58)
And I suppose what I'm wondering is are new graduates then leaving university better better prepared than maybe previous generations that you've seen whilst teaching?

krutika (08:12)
think as far as putting everything together is concerned, sort of looking at short-term management, long-term management, I think they are looking at osteopathy a bit more holistically than we used to. From that perspective, yes. Are they academically...

efficient enough when they leave? Yes, I do think so. There does seem to be a little bit of a gap where mentoring is concerned because I feel that a lot of students sort of graduate, get out there, but then get a little scared to sort of go into practice. And if they set up

private

practice straight away, then they are sole practitioners. And if they go into practice with other osteopaths, often they're left to their own devices on their own. And again, it's similar to being a sole practitioner. So from that perspective, I do feel that there is a gap in the market where mentoring is concerned.

There's nobody to sort of go back to to ask questions. At college, we were the safety nets. They could always come to us and talk ideas through. Apart from their peers, it's difficult to go to somebody with more experience and talk through a case or what to do.

Silvan (09:59)
I think

lazarus nono (09:59)
I would agree

with that. think that mentoring is a good idea because the student graduates and as Krutika was saying, they've got a lot of support and then they're dropped into the big world on their own.

And I believe that there's quite a large statistical dropout of osteopaths when they qualify. I don't exactly know why, but I would most probably guess one of it is because of the insecurity of being on your own and getting lost with nobody to respond to and get some feedback from. So yes, I think that those who in the Institute work very hard.

I think they stay in the business longer and those who weren't quite sure of what osteopathy really was going to be and they sort of drifted through not working as hard as they could have worked and then when they're then allowed to practice, I think that's when they realize how difficult it is when they're on their own.

there's nobody to help them, just them and the patient who is demanding silently. think that's the most striking thing about the business is the subtle demand from the individual of what they want from you. And if you can't give it to them because you don't feel you have the skills, then that can be really quite crushing and destroys your confidence quite quickly, I think.

Silvan (11:27)
I think that's really interesting because certainly when I graduated I went straight into NHS practice and I remember Grathica calling you up because I wasn't sure about a particular diagnosis or a treatment plan. And you were so readily available to talk me through things. And it interestingly and accurately got me through that first year of NHS practice because I was a little lost and I think I would have

you know, done well with some mentoring, which indirectly I suppose you provided with my weekly phone calls. but Lazarus, I think what you talk about, and we could do a whole other episode if you wanted to, about sort of why graduates don't continue in the profession when they leave. I have a lot of hypotheses, and I think to summarize, I think the profession is at fault, but also teaching institutions to a certain extent, there is an expectation or a promise that is made.

that isn't necessarily delivered when you're out in practice. And it is hard. It is hard when you start out. But I'm interested in hearing what other people listening to us might think because I think that's a really healthy discussion to have. And I think there's yeah, there's a whole other podcast in there, I think. But

lazarus nono (12:42)
I would

agree. I think the progression as you highlight in career is not obvious to the graduate. And so they've only got one possibility is when they graduate, they could go into practice. And if they're brave enough, they could go into teaching, but that's it. There's nothing else for them.

in the National Health Service, there's so much more. There's so many other avenues you could go down if

krutika (13:10)
Yeah.

lazarus nono (13:10)
you wanted to. So I think the profession definitely needs a better progression if they're going to survive. And without that progression, I don't think they will survive for the next, I mean, it's been in this country for over 100 years, but I doubt that it will survive if it doesn't have a progression for the next generation to see its potential.

and where it can go to, I would agree, yeah.

Silvan (13:36)
Yeah. I want to come back to the teaching in a way. is there anything that you still teach now or maybe stop teaching than you did when you first started?

krutika (13:53)
I think we integrated things a little bit better. We had a subject called neuromuscular skeletal system and that was very integrated. So I found when I first came back to teaching that things were quite separate. Each subject was quite separate. And then when you came into clinic, students had to put it together and they found it quite difficult to

assemble

everything. It was like a giant jigsaw puzzle and assembling everything together. And I think I remember doing tutorials in my lunchtime and piecing things together for the students because I knew that we were better equipped that way. And there was definitely a gap in teaching.

where that was concerned. I was lucky that Gemma, who was the clinic tutor at the time, figured this out. And she sort of, I remember her coming up to me and saying to me, what's going on in your lunchtimes? Cause you're never here. And I said, I'm just too busy doing tutorials and the students kept asking for it. So she integrated that into the pre-clinic sessions.

where the second years go into third year, and we started incorporating a lot of those ideas into it. But recently I found that Marianne, who's the head of clinic now, has started doing the clinical integration, which I think is fantastic because that is where year one and year two students are taught case-based.

and we're moving more towards case-based and integrating things a little bit better. So we're starting to get there, but then we have this problem of students leaving the profession because they're not feeling supported enough. And then we have the drop in numbers.

and then at the same time we have the institutes closing like BCOM for example so I mean just when we're figuring things out and knowing how to do things better we're fighting another battle I guess

Silvan (16:29)
Yeah,

and I suppose Lazarus, has the way you taught changed over the years or ha do students maybe learn differently today than they did before?

lazarus nono (16:41)
I think students definitely learn differently and I think that as Krutika said, the student arrives at the institute and they're open to learning osteopathy and then along their journey they find out that what they thought they were paying for is not exactly what they're getting and therefore then they become disheartened and then they don't respond in an enthusiastic way that they started so

I think it's a recent, it's quite a recent thing. been sort of escalating where each year the students are not really getting what they thought they were getting. So therefore they don't work the way we hope they should work.

and then there's a bit of a tug of war because they're not happy that they're not getting what they thought they were going to get and we're not happy because they're not doing what they should be doing. So for example your year was very enthusiastic, worked really hard towards achieving

krutika (17:38)
Mm-hmm.

lazarus nono (17:39)
the goal because I think that your year was clearer on what you were trying to achieve. Now it's not so clear and I think that's what we've got to change if we're to survive that when the student comes in as

said it needs to be joined up where if you're learning about the upper limb

You learn all the techniques about the upper limb. You learn about all the pathology of the upper limb, all at the same time, so you can make those links. So it's not you learnt about the upper limb at beginning of the first semester. You learnt some pathology halfway through the first semester. And then at the end of the semester, you learnt some techniques. That just doesn't allow the student to see the links. And so the frustration then is the tutors don't understand why the students

students are not progressing the way they should be progressing.

And the students are irritated that they're expected to know things, but they've forgotten it. And the reason why they've forgotten it, because they can't associate with it. You know, it's too packaged as package one, package two, package three. And the time they finished package one, they've forgotten it because they're now focusing on package two instead of one big package that you can really get your head around. And then you can start seeing the pattern and actually starting to use

those skills. So I think that's what we need to also think about changing.

Silvan (19:07)
So

what I'm hearing there is there's a difference in expectation but also curriculum. Now, Krutika for you, if you were to sort of, you know, start from scratch and redesign the whole curriculum, what would you definitely be including?

krutika (19:22)
Well,

From the syllabus that we had at BCom, I would definitely include nutrition because I thought that was a very important part of it. I can understand naturopathy needing a little bit of updating, but definitely nutrition. I agree with Lazarus that I do feel that all the subjects need to run together.

coordinated with a certain part of the body and that would make learning a little bit easier. was still, don't get me wrong, it was still a little bit disjointed when we were students, it was never perfect, but things like neuromuscular skeletal system, that really integrated things a little bit more than we had the functional anatomy, regional anatomy, again it put things together. So

It wasn't as disjointed. So they were still running somewhat parallel with each other so we could integrate things. Yes, we had to fit the technique in, but it wasn't as difficult to do so.

But yes, I would agree with Lazarus on that. I would personally do that as a foundation when you're learning your anatomy, physiology, neurology, all of that. Try and sync the technique in with that as well.

but then at the same time have the clinical integration, which I think is really good. And that would make the whole syllabus work a lot more synchronized harmoniously.

Silvan (21:14)
Mm.

lazarus nono (21:15)
I would agree as well, think that what Kriteka highlights is the college got into a bit of a habit of scrapping things instead of modernizing things. So they

krutika (21:24)
Mm.

lazarus nono (21:25)
scrapped naturopathy. Now, Jonathan Shaw had so much to offer, but if they brought somebody in to help him to modernize, then they could have really changed naturopathy and...

complimented his knowledge with new ideas, but instead they scrapped that and brought in functional medicine. They brought in functional medicine, then functional medicine died. Similar to hands-on skills, there's a misunderstanding that students need time to learn things, to then start to understand, and then to start to own the things.

Scrapping half of the technique means that the students get one opportunity, two opportunities to do the technique and then it disappears instead of constantly reintroducing it. So eventually the penny drops and you've got to feel comfortable. I think that's what the Institute has sadly forgotten. You've got to feel comfortable with the technique. So first of all, you're shown something and it's a mystery. What am I

trying to do here and then you get a second attempt at it and it feels a little easier and then you do it a third time and then you start for yes I understand and then the fourth time you actually start thinking about your literature that you have and what you're trying to do with that technique and not just I taught you how to examine the shoulder once that's it and now you've got a

figure it out and work with it. I don't think that works myself.

krutika (23:04)
I was just going to add to that because as you know, we merged, said the European School and British College of Osteopathic Medicine. We merged together a few years back. And initially I thought it was a very good idea. Well, I say a very good idea. I thought it was a good idea. I thought we would bring the best of both together and incorporate that into a really good course.

And yeah, that was what I was expecting. But unfortunately, what happened was that we lost a lot of natural, what we completely lost natural, the nutrition, which was a great shame because I thought that was integral part of us as BCOM. And then

I

thought there would be a little bit more of visceral osteopathy and the cranial would be there, but I was hoping a bit more of visceral osteopathy, which I would have welcomed as well. But in essence, what we got was the fact that all of European schools techniques came to us.

And when it came to us, we started teaching things like general osteopathic treatment and BLT, balanced ligamentous tension, and visceral came along, cranial came along. All of this came too early. So we started a lot of this in year one. But if you think about palpation skills,

When you come to year one, you're literally just learning how to, your body positioning, hand holds, learning the technique, routines, all those sorts of things. Just getting introduced to patients and how to treat or just assess even. And then all of a sudden there you are doing general osteopathic treatment.

which is more like harmonic assessment kind of thing. And then balanced ligamentous tension, which needs a lot of tissue palpation and learning different tensions and running through the body. These are skills that a year one student really does not have. They need the foundation of techniques, structural techniques. That's what osteopathy is initially.

is building a foundation in structural techniques, building a foundation of knowledge, anatomy, physiology, nutrition would be fantastic, all of these sort of things. And then moving on to as the years progress, starting to introduce these other techniques.

Silvan (26:11)
So I suppose what you're talking about there is the blind spots in the curriculum itself, things that we're no longer doing or no longer emphasizing a lot. I'm thinking about the profession as a whole. Are there any areas or even areas of the body that we are unintentionally overlooking?

lazarus nono (26:30)
To answer that question, think yes, I think that it comes back to what Kritega was saying, that it's about palpation. So previously in your year, in the second year, you had lots of different soft tissue techniques taught you, which helps you to hone your skills from that point of view. Now, because of the new curriculum and they don't have a lot of time,

to revisit things.

The feet are one of those areas where students, feel, don't feel confident enough to analyze the feet and think about what role the feet may be having on, for example, the simplest thing. If you've got stiff feet and you've got a raging lower back.

Well, when you're walking, if your feet are stiff, what shock absorption does that provide for your back? Are you even considering it? Or are you only treating the back? Although you can see the feet are very dysfunctional. And if you weren't very good at feet in college because you only did them twice, then you're not going to have the skill set to be able to manage that area of the anatomy.

Silvan (27:42)
And why do you think it is that the foot receives, you know, s less attention than say like the spine or the pelvis when we practice?

lazarus nono (27:52)
think it's just time, as I previously said, I think that also as Krutika said, that the syllabus is given tasters, so you do technique, you do a little bit of cranial, you do a little bit of balance, ligamentous tension, you do a little bit of general.

body treatment is all too much instead of focusing. So when they come out, they really feel confident that they can assess every area of the body and they can treat every area of the body. And then there's the opportunity to go and learn more skills. But instead they've had all these tasters, but all the tasters haven't necessarily grounded their foundation to actually feel confident. So then they go into practice and

they can't manage certain areas.

Silvan (28:44)
what's a misconception that clinicians might have about sort of the foot or even foot biomechanics?

lazarus nono (28:55)
Well, if you're not thinking about the feet, then you're not going to assess them. And if you don't assess them, then you don't have an opinion on whether or not you should treat them. And now, as you remember, Sylvan, as a student, I would always say to you, if you're not...

assessing it, not thinking about it, then you cannot develop an opinion. You don't have to do anything about it, but you've got to first of all be confident enough to assess and think about it and then make a decision whether you as the practitioner feels this area isn't relevant to your treatment and not you've excluded it because it's something you're not interested in or you don't have the skill set. So I think that's the issue.

Silvan (29:43)
Will say, Lazarus, your voice has stayed in my head far beyond graduating. The if you're not assessing, you're guessing is still there. But Krutika,

lazarus nono (29:51)
Exactly. Yes.

krutika (29:52)
yes.

Silvan (29:54)
I was I was thinking, have you had any sort of patients who have really had breakthrough moments in in in their treatment when you started addressing foot biomechanics or treating the foot?

krutika (30:06)
I I started that a long time ago. So when I first graduated, I did find I lacked a lot of confidence. There were calls to Lazarus in panic and what do I do with this patient or how would I treat this? And over time, as I always say to students, it takes you a couple of years before you start getting confident enough and start practicing.

your style of osteopathy as you develop it. So initially, I used to focus in on the problem. So where the site of pain was, you treat that, and then you think, well, what do I do next? And I didn't know what to do next. So I would sort of just hope that that was it. And then patients go off. And then after a while, I started realizing that actually, you know,

if I worked on a certain area and how the body was connected and through muscles and muscle chains and fascia and all of that and how everything linked together. I mean, we learnt it, but I didn't put it into practice or because the tutors were there, I didn't sort of, they did the job of putting it together for me. So all of a sudden there I was on my own and I'm thinking,

What do I do with this patient who's got an issue with their foot, for example, and then a low back pain? I can treat the low back pain. What am I doing with the foot? And then over time I thought, well, what am I seeing here? And as I started doing the exploring side of it, or let me just have a look and see what's going on over here, I eventually found that, Subtailor.

Sub-Taylor, if that's restricted, that's going to cause a problem with the superative fib. And then I thought, actually, Taylor Crorall does that as well. And then I started finding my way through and it was the patterns that I saw that developed in patients. And that's what really excelled my sort of exploration and starting to see things. And

Yeah, I think that's what sort of triggered off the whole sort of exploring areas and treating different areas. And then I actually started getting really good results. And that sort of just sort of snowballed really from there. And here you are. And I guess that happens with a lot of people as well. know, as further they go into their career, they start finding things.

on their own and then putting things together, which is what tutors do when they come to clinic.

Silvan (33:07)
And I suppose you you know, Krutika, you're talking about how practitioners sort of

develop a sense of what they need and and look for sort of they look for it in it outside of their practice to get more confidence. I want to talk a little bit about the CPD that you both created.

krutika (33:27)
Mm-hmm.

Silvan (33:28)
can you tell me why you decided to start with the foot?

lazarus nono (33:33)
We decided to start with the foot because at the end of the day, all the techniques are basic techniques. And what one must realize is basic techniques, you're trying to get under your fingertips to allow you to then express yourself and to feel comfortable.

So one should never be afraid of revisiting basic ideas because the more you revisit it's a bit like a book. When you first read something it's just too much. Your second read it feels more comfortable. Your third read you start to remember sections of it. Your fourth read you're already skipping bits of it because you know it and you're starting to put things together and you're starting to understand it and that

strange chapter on complex pathology suddenly becomes demystified because you've read it a number of times and you're no more afraid. And I think technique is like that as well. The more you revisit your basics, the more you start to feel your expression because you build structure over and over again, you build that structure. So then you start to feel confident to handle the feet on a day to day basis and not leave

them alone. And remember that we are supposed to be treating the patient and sadly we've been focusing on pain too much and as you're aware Sylvan pain is very complex so if one is focusing on pain only then you could say if you're trying to remedy the pain then just go to the pharmacist and they will give you medication that will get rid of the pain and it will remedy the problem. But as an osteopath

we're supposed to be addressing the patient's health. So when the agitator still said that how nature put us together will determine how we move.

and how we use our body over a long period of time will determine how we will use that anatomy. And over time, we change our anatomy because of how we use ourselves. And it's the osteopath's job to try to nudge the body back to some normality. Now, depending on how young or old the individual is, your nudge may not be as successful as you'd like. So if I meet somebody

are young, then the possibility of nudging them back to what we say normality is, is much greater. But if I meet somebody who's quite senior, then the possibility of nudging them back to normality isn't there. But what I should be thinking about is addressing their functionality, allowing them to fulfill their dreams on a day to day basis. And that means looking outside the box. So when an elderly person comes to you and says,

I've got balance problems, you need to think about the feet because your balance starts with how you put your feet on the ground.

and how you propel yourself through the environment. And if your feet are stiff, painful and dysfunctional, then that's going to be difficult. But the patient may have come to you with lower back pain, but you're looking at the lower back and you're thinking, yes, but look at your feet. They don't function well. So no wonder why you're falling over. And every time you fall over, your lower back gets worse. So instead of just treating your lower back, I need to be able to within the session address you. And that means

treat your lower back, treat your balance and treat your feet as well and treat you as a person and not you as a bit of pain that I should treat.

Silvan (37:20)
And I was thinking, Krathika, who is the CPD designed for then?

krutika (37:26)
Actually, this EPD is actually designed for anybody who's interested in the biomechanics of the foot. you revisit techniques, diagnosis, learning about how they work together

Because the foot is such a big subject. It's difficult to cover all aspects of the foot and you have to break it down. Otherwise, we'd probably be doing it for sort of a week straight. So initially, we've broken it down into just the arches and how they function and what happens if the arches

dysfunction, how to test for it and how would you treat it and the techniques that are associated with it. So I think it just puts together a small piece of the puzzle for the foot itself. Ideally we want to move forward and then look at gait mechanics for example and then certain dysfunctions but for now

just looking at the arches was a point that we thought we would start with. And then as far as who the audience would be, well, it's open to any manual therapists that can be sort of physiotherapists, osteopaths, new graduates or, know, osteopaths that have been out in practice.

and feel that they just would love to gain a little bit more insight into it or revisit it. It's same with the physiotherapists, chiropractors if they want to go into a little bit more into the way osteopaths view the foot for example. But those are the people that we are targeting at the moment and opening it up for in the future,

lazarus nono (39:40)
And the course is designed for people who hold a professional degree. And those would be podiatrists, physiotherapists, osteopaths, and chiropractors.

Silvan (39:53)
And I suppose when I've done some of these C P D sort of courses, there can be a lot of content, of course, and that's kind of what you want and what you're paying for. But I suppose with your CPD C P D specifically, you know, what will somebody be able to do differently or think about differently on the Monday after the course ends?

lazarus nono (40:16)
I would hope that after the course ends on the Monday, that the first thing they'll do is they look at the feet and think about the feet. And if we're lucky, they will actually assess the feet and maybe incorporate them into their treatment plan. So to answer that question, then I'd be very happy if on the Monday, the individual that attends our course actually

assesses somebody's feet and incorporates it into their lower back treatment and actually stands back and thinks that made sense to me. I've been treating this person's back and I've been doing some great work, but I mean, I've really now thought about the stresses coming up through the biomechanics and working on the feet. I feel has really helped me and I think when that patient comes back, I'm going to be really interested and see how they feel. I'd be really happy if they did that.

krutika (41:16)
Yeah, similarly, I think I feel the same way as well. So, you know, it's building the confidence in the individual. So as osteopaths, we're taught how to treat more holistically. But from a podiatrist's point of view, it'd be great for a podiatrist to say that, yes, I know that there's a dysfunction over here. And if it's an MSK podiatrist, then obviously they'd be looking at the knee, the hip, the back.

sort of moving up the chain and recognising how important it is to understand the foot biomechanics and how it influences different areas of the body. And if it's not within their realm, for example, then to refer them on to a practitioner that would be able to deal with it. Similarly with physiotherapists, whereas, you know, rather than being sort of treating

a foot, they're thinking more of the kinetic chain and the biomechanics of it and how it would influence other areas of the body. Not that we're going to be talking a lot about that in the CPT itself, but just identifying the functions of the foot rather than the anatomy, the physiology, the myology of it.

lazarus nono (42:43)
Well, I think that what we're trying to do, what our goal is, Krutika and myself, is we want to really move away from what social media is selling and that's technique. We want to try to encourage osteopaths to talk about their intellect. You know, we've got a lot of young graduates out there that have worked extremely hard.

and very bright and at college they did really well and what we want the general public to know is that intellectual part of them and not osteopathy is about when I come to see you you crack something you push something no I want people to

understand that an osteopath is a good clinician first. We use our clinical knowledge and that's all in the background, all that time that is spent reading, thinking about all the stuff that the patient doesn't realise that we address. That's what we are first of all and the tools that we use with our hands are something that allows us to express our intellect.

it's not the other way around and sadly it's become the other way around. People think who Ostechars are is what we do with our hands and not our intellect and

I know that Critico feels is that we start with our intellect and we express our intellect through our hands and not the other way. don't do things with our hands and we've got a little bit of intellect that sometimes we use. No, we use 90 % of intellect and 10 % of expression of our hands. Yes, it looks like that it's 90 % of hands, but it's what's in

the background, that's what's important and that's what I'd like to try to change on social media that we start and say to the general public when you see a manual therapist, when you see an osteopath, what you must realize is it's their thought process is what you're coming to see them for and not whether they're going to

manipulate your joints or do things like that. No it's not technique at all, it is their intellect.

krutika (45:07)
I completely agree with what Lazarus is saying over there. Having that confidence in also, yes it is, and it projects itself in our intellect is projected in the techniques that we do and how we treat the body and how we educate our patients. But it's the confidence that you have in the handhold when you're doing these

techniques as well is just as important in reassuring the patients itself. bringing us back to the CPD itself is empowering the professionals out there to regain their confidence so to speak of through the knowledge that they have forgotten for example or just need a helping hand in

just a gentle reminder of the techniques that they had learned when they were studying. And over time, you're never going to remember all of them, but this will just...

remind you again, I guess.

Silvan (46:25)
That's really interesting. And I suppose what you're saying there is being able to demonstrate how you work as an osteopath isn't just through your hands, but it's the intention, it's the purpose, it's the confidence behind that. That's really what a lot of people are doing and might not necessarily see overtly from a patient perspective or from a perspective of social media.

I wanted to ask you both a few short questions. So, Lazarus, what is the best piece of advice you've ever received as an osteopath?

lazarus nono (46:57)
Study your basics. Keep revisiting your basics and the questions you ask yourself will be answered.

Silvan (47:06)
Yeah.

and so Krutika, what's a clinical mistake that has taught you the most in practice?

krutika (47:17)
to keep revisiting your working diagnosis. So I find that the working diagnosis changes as you move along with treatment. So keep testing, keep revisiting and keep testing other areas as well to see.

if there's a dysfunction somewhere else that's simply reflecting on the original problem itself.

Silvan (47:49)
Okay. And Nazus, what is one book that every osteopath should read?

lazarus nono (47:57)
Every osteopath should read. That's quite a... Well, I want to say an osteopathic book that I suppose really what one should read all the time is anatomy. I know that sounds...

bit of a cliche, but I've got to come back to what still says and that is know your anatomy. If you understand the body, then you're no more guessing and you're no more trying to remember, you are actually understanding. So you move from guessing to reading the structures and you can only read the structures by understanding your anatomy. So in actual fact, I started out by apologizing, but I'm going to say no, definitely the book you should always have by your bedside is your

NASBI book and constantly read it and yeah.

krutika (48:51)
Can you see I nodded through all of that? Because I do think it's anatomy, anatomy, anatomy and physiology. But the two together, yeah.

Silvan (49:02)
I might not necessarily have the anatomy book on my bedside table, but

krutika (49:04)
What?

Silvan (49:06)
I'm hearing the message. I suppose, Grothica, what is one thing every sh student should practice more of?

krutika (49:20)
would be biased if I said technique because that's what we teach. But I do think palpation is the key. So knowing your techniques and then being able to get a routine will therefore...

take the emphasis away from doing the technique and you start to get feedback through palpation. that's where you, for me, that is one of the most important. So routines build palpation.

Silvan (50:04)
Mm-hmm.

lazarus nono (50:05)
Just adding

to Kritika's point, it's coming back to what I was previously saying and what Krutika was saying. For example, if you're mobilizing somebody, you're palpating. And so your tempo of mobilization is based on your palpation. So I would agree with Krutika. It's about palpating every time. So whatever you're doing, you are palpating.

and you need to be engaging that palpation and not just pushing the body but palpating all the time and thinking what is the body telling me, what is the feedback I'm receiving.

Silvan (50:44)
and this is a question for both of you really. What is something that you're still learning about?

krutika (50:51)
Do we ever stop learning?

I mean, you keep refining, revisiting and just recreating, to be honest. So I don't think you ever stop, to be honest. I don't know, Lazarus, how do you feel?

lazarus nono (51:12)
I agree with you 100%. I've just finished reading a book on the thoracics and as I was reading it, I was thinking, did I know this stuff? Did I forget it? And at the end of the book, I learned so much. So I think, yeah, it's just, you're always learning and you stop learning about osteopathy when you stop practicing it, when you decide that I don't want to think about this topic anymore.

But as long as you're an osteopath, then every day is a learning opportunity which you must seize and work. So if you're in practice and you're not reading and you're not thinking about what's happening, then you're not growing. And if you're in practice and you're saying to yourself, and I don't mean to be rude.

But if you're saying to yourself, know this, I've seen this pattern before. I know this patient. I'm afraid you've fallen asleep because the body is a wonder to explore and you explore it as critiquing said with your hands, but you must explore it with your intellect. And that only comes with reading research papers, reading textbooks, watching videos. You know, we've been gifted now with the internet. You you go onto YouTube and you

explore a topic and you can see it from so many different angles that your

krutika (52:36)
Yeah.

lazarus nono (52:36)
knowledge can blossom within seconds which before when Krutika and I were learning it was only textbooks that's what it was now you want to know about let's say you want to know about plantar fasciitis you could spend 15 minutes on YouTube and learn so many different things so yeah learn learn more

Silvan (52:59)
Yeah, it's really beautiful actually. And so if anybody listening or watching could take one message away from today's conversation, what would you hope it would be?

lazarus nono (53:13)
I would hope that they take away from this discussion with Krutika and myself is to be inquisitive every day, to question everything, to revise and...

Enjoy the opportunity and again this may sound like a cliche but I hope it's not. To enjoy the opportunity that you have in front of you and that is to interact with somebody else, to influence their life, to make them feel better because at the end of your working day the things that you can cherish is the impact you've had on

other people's lives and that is enhanced by being constantly inquisitive about that individual in all areas of their life.

Silvan (54:04)
What about from you, Krutika?

krutika (54:07)
I think not to self doubt, to be confident. And the only way you're going to do that is to, as we said, read, learn. And that's what we're doing with the CPD, where we're trying to integrate things like the latest research to technique.

to assessment. And when you're things like that, you're building your confidence. So you go out there and you're a better practitioner, which builds your confidence and then your self esteem overall.

Silvan (54:51)
Yeah. And if anybody wants to continue learning from you, where can they find out more about the CPD?

lazarus nono (55:01)
They can go to our webpage, CoreMT, which stands for Core Manual Techniques, and see what we've posted and see whether there's anything they're interested in coming and trying and see what they get out of it.

Silvan (55:19)
And I'll post all those links in the description box below so people can find

lazarus nono (55:22)
Thank you.

Silvan (55:23)
the websites and your socials and things. I really enjoyed speaking to you both. It's been such a pleasure and it takes me back to when I was under your tutelage and I feel like in some ways I still am always learning from you both.

lazarus nono (55:41)
Well thank you for inviting us again and

krutika (55:41)
Thank you. Yes.

lazarus nono (55:43)
it's always a pleasure to have this opportunity to discuss with you.

krutika (55:52)
Thank you for having us as well. And hopefully we could do this again.

Silvan (55:57)
I'd like that

And I'm certainly invested and interested in what you're going to be doing next in the future. But thank you so much for coming. And if you liked

lazarus nono (56:07)
Yeah.

Silvan (56:08)
what you heard today about our conversation today, please like, share, subscribe, send the video to your friends or family and just keep engaged in the conversation. Thank you.

lazarus nono (56:20)
Thank you.

krutika (56:20)
Thank you

for having us.