The worst pain is unexplained pain. In this episode of the Hands-On, Hands-Off Podcast, physical therapists Amy McDevitt and Paul Mintkin explore why pain without a clear diagnosis is often the most distressing—and how physical therapists can communicate pain more effectively when imaging, MRI findings, and pathoanatomy don’t provide clear answers.
This conversation dives deep into pain science, musculoskeletal pain, low back pain, and the limitations of medical imaging in explaining symptoms. We discuss how over-reliance on MRI results can increase fear, catastrophizing, and confusion for patients—and how language, context, and functional diagnosis can dramatically change outcomes.
Learn how to reframe pain using the ICF model, why pain does not equal tissue damage, and how PTs can shift from chasing a pain generator to treating the whole person. The episode includes a real-time patient role-play, practical communication strategies, and insights on direct access physical therapy, lifestyle factors (sleep, stress, activity), and the future of PT education.
This episode is essential listening for physical therapists, manual therapists, rehab professionals, and students looking to improve patient communication, reduce fear, and deliver truly person-centered care.
00:00:03 --> 00:00:05 Okay, welcome to the Hands-On,
00:00:05 --> 00:00:08 Hands-Off podcast from the American
00:00:09 --> 00:00:10 Academy of Orthopedic Manual Physical
00:00:10 --> 00:00:11 Therapists.
00:00:12 --> 00:00:13 I'm Amy McDevitt,
00:00:13 --> 00:00:15 and today I decided to bring on my
00:00:15 --> 00:00:17 good friend and colleague, Paul Minkin.
00:00:18 --> 00:00:21 Paul has been a therapist for over thirty
00:00:21 --> 00:00:21 years.
00:00:22 --> 00:00:24 He's been in academics and he's also been
00:00:24 --> 00:00:27 involved in entry-level education,
00:00:27 --> 00:00:29 residency education, fellowship education.
00:00:29 --> 00:00:31 And today I wanted to just have him
00:00:31 --> 00:00:34 chat a little bit about an article called
00:00:34 --> 00:00:36 the worst pain is an unexplained pain.
00:00:36 --> 00:00:39 And that was published in JOSPT just
00:00:39 --> 00:00:41 recently, but we've had some kind of off,
00:00:42 --> 00:00:42 uh,
00:00:42 --> 00:00:44 offscreen conversations about this topic.
00:00:44 --> 00:00:46 And I just wanted to bring Paul on
00:00:46 --> 00:00:47 to talk a little bit more about it.
00:00:47 --> 00:00:48 So, um,
00:00:49 --> 00:00:49 Paul, welcome,
00:00:50 --> 00:00:51 and thank you for agreeing to come on
00:00:51 --> 00:00:52 the podcast today.
00:00:53 --> 00:00:54 Well, thanks for having me, Amy,
00:00:54 --> 00:00:55 and you forgot to mention you're an author
00:00:55 --> 00:00:56 on that paper too, so...
00:00:57 --> 00:00:59 Yeah, yes, that's right.
00:00:59 --> 00:01:00 So I'm an author.
00:01:00 --> 00:01:03 And then we also have Jeremy Lewis as
00:01:03 --> 00:01:04 the senior author on this paper.
00:01:04 --> 00:01:06 And what was kind of fun, Paul,
00:01:06 --> 00:01:08 if you don't mind me telling the story,
00:01:08 --> 00:01:10 is the three of us were chatting at
00:01:10 --> 00:01:13 the AOMT conference last year and just
00:01:13 --> 00:01:15 talking about things that we're passionate
00:01:15 --> 00:01:17 about and work that we're doing and
00:01:17 --> 00:01:18 research and that sort of thing.
00:01:18 --> 00:01:20 And we kind of just made a little
00:01:20 --> 00:01:22 bit of a pact or a decision to
00:01:22 --> 00:01:23 write a couple of passion papers together.
00:01:24 --> 00:01:26 with each of us leading a paper about
00:01:26 --> 00:01:27 something that we were passionate about.
00:01:27 --> 00:01:29 And so it's this is kind of a
00:01:29 --> 00:01:31 fun result of a conversation that started
00:01:31 --> 00:01:32 at a conference.
00:01:33 --> 00:01:33 Paul,
00:01:33 --> 00:01:35 tell us a little bit more about why
00:01:35 --> 00:01:39 this is a passion paper for you.
00:01:39 --> 00:01:40 Well, you know,
00:01:40 --> 00:01:43 I have always respected Jeremy Lewis's
00:01:43 --> 00:01:43 work,
00:01:43 --> 00:01:46 and so he gave a pre-conference course at
00:01:46 --> 00:01:48 last year, which was outstanding,
00:01:48 --> 00:01:49 but he brought up this
00:01:50 --> 00:01:52 quote by Hillary Mantel that the worst
00:01:52 --> 00:01:54 pain is an unexplained pain.
00:01:54 --> 00:01:56 And that just really resonated with me.
00:01:56 --> 00:01:58 And how do we make sense of that
00:01:59 --> 00:02:00 to our patients?
00:02:00 --> 00:02:02 And that's always the challenge, you know,
00:02:02 --> 00:02:04 whether they come in with imaging that
00:02:04 --> 00:02:06 shows this is going on or,
00:02:06 --> 00:02:06 you
00:02:07 --> 00:02:09 know the the really tough one is the
00:02:09 --> 00:02:13 patient who has maybe symptoms and has
00:02:13 --> 00:02:15 x-rays and has an mri and doesn't show
00:02:15 --> 00:02:17 anything right and so like what's going on
00:02:17 --> 00:02:19 now and i see a lot of patients
00:02:19 --> 00:02:20 who have been to
00:02:21 --> 00:02:22 you know,
00:02:22 --> 00:02:24 chiropractors and physical therapists and
00:02:24 --> 00:02:25 physicians.
00:02:25 --> 00:02:26 And the physician tells them, you know,
00:02:26 --> 00:02:27 it's a disc problem.
00:02:27 --> 00:02:28 And the chiropractor tells them they've
00:02:28 --> 00:02:30 got a vertebrae out of place.
00:02:30 --> 00:02:32 And PTs are as guilty as anybody else
00:02:32 --> 00:02:34 of labeling patients.
00:02:34 --> 00:02:34 You know,
00:02:34 --> 00:02:36 your SI is out of place or your
00:02:36 --> 00:02:38 nominant's rotated or things like that.
00:02:39 --> 00:02:41 So they've heard three different stories
00:02:41 --> 00:02:42 from three different providers,
00:02:42 --> 00:02:44 and they don't know where to go with
00:02:44 --> 00:02:44 that.
00:02:45 --> 00:02:47 And just trying to make sense of that
00:02:49 --> 00:02:50 for the patient that's sitting in front of
00:02:50 --> 00:02:52 you can be challenging.
00:02:52 --> 00:02:56 So we'll get into talking about the ICF
00:02:56 --> 00:02:58 model and things like that.
00:02:58 --> 00:02:59 But as physical therapists,
00:02:59 --> 00:03:00 we treat human beings.
00:03:00 --> 00:03:01 We don't treat pathology.
00:03:01 --> 00:03:05 So shifting the focus away from trying to
00:03:06 --> 00:03:09 pinpoint the pain generator is a useless
00:03:09 --> 00:03:11 exercise for most of our patients.
00:03:12 --> 00:03:12 Yeah,
00:03:12 --> 00:03:13 and you said something that resonates with
00:03:13 --> 00:03:14 me too.
00:03:14 --> 00:03:16 It's kind of both sides of this argument.
00:03:16 --> 00:03:17 So it's whether the patient has had
00:03:17 --> 00:03:19 imaging and there's a whole plethora of
00:03:19 --> 00:03:22 things that were read by a radiologist the
00:03:22 --> 00:03:23 patient is reading,
00:03:23 --> 00:03:24 sometimes even before they have an
00:03:24 --> 00:03:26 opportunity to interact with the provider
00:03:27 --> 00:03:28 to get context.
00:03:28 --> 00:03:30 And it's the patient who doesn't have any
00:03:30 --> 00:03:31 findings on imaging
00:03:32 --> 00:03:34 That feels like something has gone
00:03:34 --> 00:03:36 horribly wrong because there's no evidence
00:03:37 --> 00:03:39 of anything that's problematic or
00:03:39 --> 00:03:41 explaining why they have certain symptoms.
00:03:41 --> 00:03:43 So I like that you called that out
00:03:43 --> 00:03:45 because it can happen on kind of both
00:03:45 --> 00:03:46 sides of that argument.
00:03:47 --> 00:03:48 So my first question is,
00:03:48 --> 00:03:50 what are some of your experiences that
00:03:50 --> 00:03:54 kind of shaped your decision to write this
00:03:54 --> 00:03:54 viewpoint?
00:03:56 --> 00:03:57 Well, you know, over the years,
00:03:57 --> 00:03:59 I've had countless patients who come in
00:03:59 --> 00:04:00 with pain,
00:04:00 --> 00:04:03 but there's no clear structural cause
00:04:03 --> 00:04:03 overall.
00:04:03 --> 00:04:05 Maybe their imaging looks normal,
00:04:05 --> 00:04:06 but their suffering is real.
00:04:06 --> 00:04:07 So, you know,
00:04:07 --> 00:04:10 what moved me to write this piece was
00:04:10 --> 00:04:11 talking to Jeremy,
00:04:11 --> 00:04:13 but also reflecting on those patients that
00:04:13 --> 00:04:15 have bounced between providers,
00:04:15 --> 00:04:17 each giving them a different diagnosis
00:04:17 --> 00:04:18 overall,
00:04:18 --> 00:04:20 and it leaves them just confused and not
00:04:20 --> 00:04:23 sure where to go forward, afraid to move,
00:04:23 --> 00:04:24 thinking their back or whatever is going
00:04:24 --> 00:04:25 to explode if they
00:04:26 --> 00:04:27 if they load it.
00:04:27 --> 00:04:29 So in practice,
00:04:29 --> 00:04:31 I see that the worst pain isn't the
00:04:31 --> 00:04:32 one we can see on an MRI.
00:04:32 --> 00:04:35 It's the one that we can't explain to
00:04:35 --> 00:04:39 the patient in terms that they understand.
00:04:39 --> 00:04:39 So really,
00:04:39 --> 00:04:41 my goal is to help patients make sense
00:04:41 --> 00:04:42 of their pain,
00:04:42 --> 00:04:44 even when we can't pinpoint an exact
00:04:45 --> 00:04:47 anatomical diagnosis.
00:04:48 --> 00:04:49 Yeah, yeah, I think that's true.
00:04:50 --> 00:04:51 And I think it's something that I see
00:04:51 --> 00:04:53 in my setting because I treat, you know,
00:04:53 --> 00:04:55 a little bit of a different population
00:04:55 --> 00:04:57 working in a health care system for a
00:04:57 --> 00:05:00 hospital is that, you know,
00:05:00 --> 00:05:02 trying to describe to patients some of
00:05:02 --> 00:05:03 these things are normal age related
00:05:03 --> 00:05:05 changes and they may or may not be
00:05:05 --> 00:05:06 pain provoking.
00:05:06 --> 00:05:08 And so I think that's another kind of
00:05:08 --> 00:05:11 layer to this conversation is we don't we
00:05:11 --> 00:05:13 shouldn't have an expectation that imaging
00:05:13 --> 00:05:15 looks normal in people that are over the
00:05:15 --> 00:05:17 age of fifty or sixty or seventy.
00:05:19 --> 00:05:20 Or even younger individuals, you know,
00:05:20 --> 00:05:22 I treat a lot of college age students.
00:05:22 --> 00:05:23 And, you know,
00:05:23 --> 00:05:25 the research shows that especially with a
00:05:25 --> 00:05:26 condition like back pain,
00:05:26 --> 00:05:29 the individuals who have never had back
00:05:29 --> 00:05:31 pain are going to have findings very
00:05:31 --> 00:05:32 commonly on imaging.
00:05:32 --> 00:05:34 So, you know,
00:05:34 --> 00:05:36 saying that that's the cause of their pain
00:05:36 --> 00:05:36 is not valid.
00:05:36 --> 00:05:37 Yeah, yeah.
00:05:39 --> 00:05:40 And so I love this.
00:05:41 --> 00:05:43 This part of the argument comes early in
00:05:43 --> 00:05:45 the paper and there's a quote here I'm
00:05:45 --> 00:05:45 going to read.
00:05:45 --> 00:05:47 It's receiving a diagnosis carries a
00:05:47 --> 00:05:50 personal significance for patients as it
00:05:50 --> 00:05:51 provides a framework for understanding
00:05:51 --> 00:05:52 their pain,
00:05:52 --> 00:05:54 validates their experience and guides
00:05:54 --> 00:05:55 their recovery.
00:05:56 --> 00:05:58 So yet, you know, the article says,
00:05:58 --> 00:05:58 you know,
00:05:58 --> 00:06:00 the worst pain is an unexplained pain.
00:06:00 --> 00:06:02 So how do you balance the need for
00:06:03 --> 00:06:04 diagnostic clarity and
00:06:05 --> 00:06:07 with the reality that some musculoskeletal
00:06:07 --> 00:06:12 conditions lack a clear structural cause?
00:06:12 --> 00:06:14 Well, that's why I'm honest with patients.
00:06:14 --> 00:06:17 And I do talk about the research that
00:06:17 --> 00:06:19 looks at asymptomatic individuals with
00:06:19 --> 00:06:20 whatever their condition is,
00:06:21 --> 00:06:22 whether it's shoulder pain, back pain,
00:06:22 --> 00:06:23 hip pain,
00:06:23 --> 00:06:24 you know, those kinds of things,
00:06:24 --> 00:06:27 the prevalence of pathoanatomy in
00:06:27 --> 00:06:30 asymptomatic individuals is through the
00:06:30 --> 00:06:30 roof.
00:06:30 --> 00:06:34 So just starting off, you know,
00:06:34 --> 00:06:36 with that and, you know,
00:06:36 --> 00:06:39 I tell them that it's very unlikely that
00:06:39 --> 00:06:42 I'll be able to exactly pinpoint what
00:06:42 --> 00:06:44 structure is causing your pain,
00:06:44 --> 00:06:47 but my job is to kind of listen
00:06:47 --> 00:06:49 to you as a human being and examine
00:06:49 --> 00:06:51 you and come up with all of the,
00:06:51 --> 00:06:54 contributing factors that may be playing a
00:06:54 --> 00:06:56 role in why you have pain,
00:06:56 --> 00:06:58 whether that's limited mobility,
00:06:58 --> 00:07:00 limited flexibility, limited strength,
00:07:00 --> 00:07:03 lack of sleep, poor nutrition,
00:07:03 --> 00:07:05 high stress, those kind of things.
00:07:05 --> 00:07:08 So just reinforcing to the patient that
00:07:08 --> 00:07:11 human beings are complex organisms,
00:07:11 --> 00:07:13 that there are multiple factors that
00:07:13 --> 00:07:14 contribute to a pain experience.
00:07:15 --> 00:07:17 My job is to tease out which ones
00:07:17 --> 00:07:20 can we identify, which ones can we modify,
00:07:20 --> 00:07:21 and moving forward,
00:07:22 --> 00:07:23 from that standpoint.
00:07:23 --> 00:07:24 Yeah.
00:07:25 --> 00:07:27 I don't know if the profession has
00:07:27 --> 00:07:29 evolved, Paul, or if we've evolved,
00:07:29 --> 00:07:32 but I feel like I also see things
00:07:32 --> 00:07:33 in a different lens.
00:07:33 --> 00:07:35 And I used to just think in terms
00:07:35 --> 00:07:35 of, okay,
00:07:35 --> 00:07:39 they have low back pain and this is
00:07:39 --> 00:07:40 the multimodal approach and these are the
00:07:40 --> 00:07:41 interventions.
00:07:41 --> 00:07:41 And
00:07:42 --> 00:07:44 Somehow now there's and maybe it's because
00:07:44 --> 00:07:45 there's been more work in the area,
00:07:45 --> 00:07:47 but I'm thinking and looking at so many
00:07:47 --> 00:07:48 different things,
00:07:48 --> 00:07:50 including what you just spoke to,
00:07:50 --> 00:07:51 which is lifestyle factors,
00:07:51 --> 00:07:53 but also what's going on in their lives
00:07:53 --> 00:07:55 and where they live and how they function
00:07:55 --> 00:07:57 and what kind of transportation they
00:07:57 --> 00:08:00 access and, you know, spirituality.
00:08:00 --> 00:08:02 And there's all these other dynamics that
00:08:02 --> 00:08:03 play in.
00:08:03 --> 00:08:05 that I never really appreciated before.
00:08:05 --> 00:08:07 So I don't know if we've changed or
00:08:07 --> 00:08:09 if the profession has changed and really
00:08:09 --> 00:08:11 decided to put a spotlight on some of
00:08:11 --> 00:08:13 these other more person-centered factors
00:08:13 --> 00:08:14 that really matter.
00:08:16 --> 00:08:17 Yeah, I think it's both.
00:08:17 --> 00:08:20 I think hopefully we continue to evolve
00:08:20 --> 00:08:22 and start to realize, again,
00:08:22 --> 00:08:24 that we're treating human beings.
00:08:24 --> 00:08:26 We're not treating pathology,
00:08:26 --> 00:08:27 especially as
00:08:27 --> 00:08:29 as physical therapists and that kind of
00:08:29 --> 00:08:29 thing.
00:08:29 --> 00:08:31 And then one other point I wanted to
00:08:31 --> 00:08:32 comment on, you know,
00:08:32 --> 00:08:34 I also teach in fellowship and I had
00:08:34 --> 00:08:37 a fellow say once, you know,
00:08:37 --> 00:08:39 if a patient comes into me and brings
00:08:39 --> 00:08:40 their MRI, I tell them,
00:08:40 --> 00:08:41 I don't even want to see it.
00:08:43 --> 00:08:44 And, you know, for me,
00:08:45 --> 00:08:46 that is like slapping the patient in the
00:08:47 --> 00:08:47 face.
00:08:47 --> 00:08:48 They've spent this time,
00:08:48 --> 00:08:51 this money to get this image and you
00:08:51 --> 00:08:52 won't even look at it.
00:08:52 --> 00:08:55 Now, we've talked about how, you know,
00:08:55 --> 00:08:57 pathoanatomy is prevalent in asymptomatic
00:08:57 --> 00:08:57 individuals,
00:08:57 --> 00:08:59 but you need to validate that patient's
00:09:00 --> 00:09:01 experience,
00:09:01 --> 00:09:02 what they've been through and that kind of
00:09:02 --> 00:09:02 thing.
00:09:02 --> 00:09:04 So I will take the time to pull
00:09:04 --> 00:09:04 it up.
00:09:04 --> 00:09:06 Let's look at this and go through it.
00:09:06 --> 00:09:09 And then I will look at what they
00:09:09 --> 00:09:10 find on the imaging and I will tell
00:09:10 --> 00:09:12 the patient my job is to see if
00:09:12 --> 00:09:15 what I find in my clinical exam correlates
00:09:15 --> 00:09:16 with what we see on the imaging.
00:09:17 --> 00:09:18 If it does, great, we'll move forward.
00:09:18 --> 00:09:19 If it doesn't,
00:09:19 --> 00:09:23 then there are some other things that we
00:09:23 --> 00:09:23 can treat.
00:09:24 --> 00:09:24 And again,
00:09:24 --> 00:09:26 it is common for individuals to have
00:09:27 --> 00:09:30 pathoanatomy on imaging that does not
00:09:30 --> 00:09:32 correlate to symptoms.
00:09:33 --> 00:09:33 Yeah.
00:09:33 --> 00:09:35 And I find myself having that conversation
00:09:35 --> 00:09:37 actually quite a bit with my patients
00:09:37 --> 00:09:40 because most of them present to PT with
00:09:40 --> 00:09:42 imaging in hand because we're in a
00:09:42 --> 00:09:44 hospital-based system and that's just how
00:09:44 --> 00:09:45 that system works.
00:09:45 --> 00:09:48 So tell us a little bit about how
00:09:48 --> 00:09:51 the ICF model and maybe using language
00:09:51 --> 00:09:52 surrounding a functional diagnosis might
00:09:53 --> 00:09:55 help some of this situation with our
00:09:55 --> 00:09:55 patients.
00:09:58 --> 00:10:00 again we're trying to identify things that
00:10:00 --> 00:10:02 we can treat you know we're not going
00:10:02 --> 00:10:04 to go in and fix somebody's disc or
00:10:04 --> 00:10:06 if they've got a torn labrum in their
00:10:06 --> 00:10:09 shoulder or something like that so you
00:10:09 --> 00:10:11 know i'm going to be identifying uh
00:10:11 --> 00:10:12 impairments to movement you know you look
00:10:12 --> 00:10:15 at the mission statement for uh the apta
00:10:15 --> 00:10:17 you know optimizing human movement and
00:10:17 --> 00:10:19 that type of thing so my exam is
00:10:19 --> 00:10:22 really focused on barriers to the tissue
00:10:22 --> 00:10:24 that whatever tissue it is that they've
00:10:24 --> 00:10:24 injured
00:10:25 --> 00:10:27 uh making a complete recovery so that
00:10:27 --> 00:10:30 includes physical factors like you know
00:10:30 --> 00:10:33 strength flexibility mobility those kind
00:10:33 --> 00:10:35 of things but also those other lifestyle
00:10:35 --> 00:10:38 uh things that we talk about so i
00:10:38 --> 00:10:39 tell my patients at the end of the
00:10:39 --> 00:10:40 exam look
00:10:41 --> 00:10:41 You have back pain.
00:10:41 --> 00:10:43 I don't know exactly what the structure
00:10:43 --> 00:10:43 is,
00:10:43 --> 00:10:46 but these are the key impairments that I
00:10:46 --> 00:10:48 have identified that I think are barriers
00:10:48 --> 00:10:50 to you getting back to doing what you
00:10:50 --> 00:10:50 need to do.
00:10:50 --> 00:10:52 And we're going to focus on treating those
00:10:52 --> 00:10:54 because the research would suggest if we
00:10:54 --> 00:10:55 improve those things,
00:10:56 --> 00:10:58 it's likely that you'll feel better.
00:10:58 --> 00:10:58 Yeah.
00:10:59 --> 00:11:00 And we speak to in the article a
00:11:00 --> 00:11:03 little bit about using words like pain.
00:11:03 --> 00:11:05 things are irritated or sensitive,
00:11:05 --> 00:11:08 or I find myself with patients using,
00:11:08 --> 00:11:09 you know, you're not really,
00:11:10 --> 00:11:12 you're sensitive to load right now.
00:11:12 --> 00:11:15 And those, those resonate with patients.
00:11:16 --> 00:11:17 Like your nerves are irritated,
00:11:17 --> 00:11:19 things like that, instead of using,
00:11:20 --> 00:11:20 you know,
00:11:20 --> 00:11:22 more of that pathoanatomic language that
00:11:22 --> 00:11:22 we know can,
00:11:23 --> 00:11:25 can in some patients be harmful,
00:11:25 --> 00:11:27 but I do feel like patients understand it
00:11:28 --> 00:11:29 when we break it down in that way.
00:11:30 --> 00:11:32 Have you ever had trouble kind of
00:11:32 --> 00:11:34 implementing some of that language and
00:11:34 --> 00:11:36 talking about, you know,
00:11:36 --> 00:11:38 mobility impairments or movement
00:11:38 --> 00:11:39 coordination or things like that with
00:11:39 --> 00:11:40 patients?
00:11:40 --> 00:11:41 Yeah.
00:11:41 --> 00:11:43 I mean, that's, that's always a challenge.
00:11:43 --> 00:11:44 I mean,
00:11:44 --> 00:11:45 a lot of patients come in with the
00:11:45 --> 00:11:47 thought that pain equals harm.
00:11:47 --> 00:11:48 Every time I feel pain,
00:11:48 --> 00:11:51 causing damage to the tissue overall.
00:11:51 --> 00:11:53 And so that's the first thing we need
00:11:53 --> 00:11:54 to kind of straighten out.
00:11:54 --> 00:11:57 And I'm a big advocate of pain science
00:11:57 --> 00:11:58 education,
00:11:58 --> 00:11:59 but I think a lot of it has
00:11:59 --> 00:12:01 gone way overboard that we don't need to
00:12:01 --> 00:12:03 get that detailed with our patients
00:12:03 --> 00:12:04 overall.
00:12:04 --> 00:12:04 Look, there's
00:12:05 --> 00:12:07 these things that are contributing to the
00:12:07 --> 00:12:08 symptoms that you're having.
00:12:08 --> 00:12:09 And like you said,
00:12:09 --> 00:12:11 your tissue just got overloaded.
00:12:11 --> 00:12:14 If you are a sedentary individual and you
00:12:14 --> 00:12:16 help a person move and you expose your
00:12:16 --> 00:12:17 back to loads it hasn't seen in ten
00:12:17 --> 00:12:18 years,
00:12:19 --> 00:12:21 we would expect that you would be a
00:12:21 --> 00:12:22 little bit sore.
00:12:22 --> 00:12:24 And it does all come down to load
00:12:24 --> 00:12:26 and building the tissue's biologic
00:12:26 --> 00:12:28 capacity to tolerate load.
00:12:28 --> 00:12:31 And if you explain it in those terms
00:12:31 --> 00:12:32 to patients,
00:12:33 --> 00:12:34 it tends to resonate with them.
00:12:35 --> 00:12:35 Yeah.
00:12:36 --> 00:12:37 So do you mind if we go off
00:12:37 --> 00:12:39 script for a minute and I play the
00:12:39 --> 00:12:41 patient with my imaging in hand and you
00:12:41 --> 00:12:43 kind of reframe the conversation?
00:12:46 --> 00:12:46 Sure.
00:12:47 --> 00:12:47 All right.
00:12:47 --> 00:12:49 So I'm going to, for a moment,
00:12:49 --> 00:12:50 pretend that I'm much younger.
00:12:51 --> 00:12:52 I'm a thirty five year old female.
00:12:54 --> 00:12:55 But, Paul,
00:12:55 --> 00:12:56 I've been having all of this pain going
00:12:57 --> 00:12:58 down my right leg and I had an
00:12:58 --> 00:13:00 MRI because my doctor thought that would
00:13:00 --> 00:13:01 be the next step.
00:13:02 --> 00:13:04 And I have disc herniations.
00:13:05 --> 00:13:07 So I have disc herniations that they said
00:13:07 --> 00:13:10 L three and four, L four, five,
00:13:10 --> 00:13:12 both on the right and the left side.
00:13:12 --> 00:13:13 And I've got some disc herniation.
00:13:13 --> 00:13:16 decreased disc height is what the MRI
00:13:16 --> 00:13:17 report had said.
00:13:17 --> 00:13:19 And so, you know,
00:13:19 --> 00:13:20 what are we going to do about this?
00:13:20 --> 00:13:21 I don't know that I think physical therapy
00:13:21 --> 00:13:23 is going to work because we talked about
00:13:23 --> 00:13:23 injections.
00:13:25 --> 00:13:27 Yeah, so first of all,
00:13:27 --> 00:13:29 I want to validate that your pain is
00:13:29 --> 00:13:30 real,
00:13:30 --> 00:13:31 and I apologize that you have to go
00:13:31 --> 00:13:32 through that.
00:13:32 --> 00:13:34 And I understand that may be difficult for
00:13:34 --> 00:13:36 you to be going through that.
00:13:37 --> 00:13:39 Again, with my exam,
00:13:39 --> 00:13:40 I'm going to be trying to correlate what
00:13:40 --> 00:13:42 we see on imaging with some of the
00:13:42 --> 00:13:43 symptoms that you have,
00:13:43 --> 00:13:44 and they may correlate with
00:13:45 --> 00:13:46 what we see on the imaging and they
00:13:46 --> 00:13:47 may not.
00:13:48 --> 00:13:49 But we do have some good treatments that
00:13:49 --> 00:13:52 we know that can decrease the load in
00:13:52 --> 00:13:55 the region here and optimize the mobility
00:13:55 --> 00:13:56 of the tissues around there.
00:13:56 --> 00:13:59 But really our goal is to create the
00:13:59 --> 00:14:01 optimal environment for your back to
00:14:01 --> 00:14:03 recover from whatever is going on in that
00:14:03 --> 00:14:04 region.
00:14:05 --> 00:14:07 There's likely with the imaging findings
00:14:07 --> 00:14:08 that we're seeing some inflammation,
00:14:08 --> 00:14:10 some overload in through that area.
00:14:10 --> 00:14:12 And if we can get that calmed down,
00:14:12 --> 00:14:13 then the tissue can heal.
00:14:13 --> 00:14:14 As soon as that starts to heal,
00:14:14 --> 00:14:16 your symptoms will improve.
00:14:17 --> 00:14:18 There may be flares as we kind of
00:14:18 --> 00:14:19 go through things.
00:14:19 --> 00:14:20 Obviously,
00:14:21 --> 00:14:23 if the imaging is showing all of those
00:14:23 --> 00:14:25 things overall that are going on,
00:14:25 --> 00:14:29 we want to be respectful of that as
00:14:29 --> 00:14:30 we're progressing through.
00:14:30 --> 00:14:31 But the goal is to get you back
00:14:31 --> 00:14:33 to doing the things that you want to
00:14:33 --> 00:14:33 do and
00:14:34 --> 00:14:36 you know not laying around we know that
00:14:37 --> 00:14:40 bed rest and things like that just tend
00:14:40 --> 00:14:42 to make these symptoms worse on on
00:14:42 --> 00:14:44 multiple levels both from a healing level
00:14:44 --> 00:14:46 and a psychological level so you know i
00:14:46 --> 00:14:48 don't want to dismiss what we see on
00:14:48 --> 00:14:50 the imaging but you know there's plenty of
00:14:50 --> 00:14:53 people out there who have really uh
00:14:53 --> 00:14:55 terrible looking backs on on imaging who
00:14:55 --> 00:14:57 have no pain so there's no reason why
00:14:58 --> 00:14:59 you can't get back to doing what you
00:14:59 --> 00:15:00 need to be able to do
00:15:01 --> 00:15:03 Yeah, that was pretty good, Paul.
00:15:03 --> 00:15:05 I'll give it a nine out of ten.
00:15:07 --> 00:15:09 Maybe a ten out of a ten if
00:15:09 --> 00:15:10 you inserted a little teach back in there
00:15:10 --> 00:15:11 or something.
00:15:11 --> 00:15:12 But no, I'm joking.
00:15:12 --> 00:15:13 That was great.
00:15:13 --> 00:15:15 I think you covered so many bases.
00:15:15 --> 00:15:19 You talked about maybe decreasing some
00:15:19 --> 00:15:22 catastrophizing if that's present because
00:15:22 --> 00:15:23 you kind of normalized a little bit of
00:15:23 --> 00:15:24 the imaging.
00:15:24 --> 00:15:25 But then you also talked about
00:15:25 --> 00:15:27 contribution of lifestyle factors and
00:15:27 --> 00:15:29 other things that we'd be doing together
00:15:31 --> 00:15:32 in physical therapy in order to mitigate
00:15:32 --> 00:15:33 some of that pain.
00:15:33 --> 00:15:36 But I think it's great to just give
00:15:36 --> 00:15:37 people an opportunity to hear what a
00:15:38 --> 00:15:39 conversation might be like that you would
00:15:39 --> 00:15:41 have with a patient.
00:15:42 --> 00:15:43 You started to talk a little bit about
00:15:43 --> 00:15:44 lifestyle.
00:15:44 --> 00:15:47 And so the article did cover some and
00:15:47 --> 00:15:49 highlight some of these lifestyle factors
00:15:49 --> 00:15:51 like sleep and stress and nutrition and
00:15:52 --> 00:15:54 How do you kind of integrate those into
00:15:54 --> 00:15:55 your treatment plan?
00:15:56 --> 00:15:58 Or maybe you titrate them in over time
00:15:58 --> 00:16:00 without overwhelming the patient or maybe
00:16:00 --> 00:16:02 stepping out of our scope of practice?
00:16:03 --> 00:16:05 yeah so that's a great question you know
00:16:05 --> 00:16:07 one of the things i'll use especially with
00:16:07 --> 00:16:09 somebody that's had symptoms for a while
00:16:09 --> 00:16:11 going on is i'll have them watch that
00:16:11 --> 00:16:14 youtube video explain pain in five minutes
00:16:14 --> 00:16:15 because it does such a nice job of
00:16:16 --> 00:16:18 going through all of the different
00:16:18 --> 00:16:20 lifestyle things that may be contributing
00:16:21 --> 00:16:24 to symptoms such as sleep and stress and
00:16:24 --> 00:16:26 nutrition and activity levels and
00:16:26 --> 00:16:27 And that type of thing.
00:16:27 --> 00:16:29 So I like to really frame lifestyle as
00:16:29 --> 00:16:30 part of recovery.
00:16:30 --> 00:16:32 It's not an add on.
00:16:32 --> 00:16:34 And I explained to patients that pain is
00:16:35 --> 00:16:36 like a dimmer switch.
00:16:36 --> 00:16:39 So things like movement, sleep, stress,
00:16:39 --> 00:16:40 all have the ability to either turn that
00:16:40 --> 00:16:43 dimmer down or turn it up.
00:16:43 --> 00:16:45 And then I try to pick, you know,
00:16:45 --> 00:16:47 after the patients watch that five minute
00:16:47 --> 00:16:47 video, I say,
00:16:47 --> 00:16:49 did anything resonate with you there on
00:16:49 --> 00:16:50 your sleep and your diet?
00:16:52 --> 00:16:55 your exercise levels, your stress levels,
00:16:55 --> 00:16:56 things like that.
00:16:56 --> 00:16:59 Did anything resonate with you on that
00:16:59 --> 00:16:59 front?
00:16:59 --> 00:17:01 And they'll always come up with one.
00:17:01 --> 00:17:01 Yeah,
00:17:01 --> 00:17:03 I should get some more sleep or I
00:17:03 --> 00:17:06 should drink more water or things like
00:17:06 --> 00:17:06 that.
00:17:07 --> 00:17:09 And then I'll pick one small achievable
00:17:10 --> 00:17:11 change at a time.
00:17:11 --> 00:17:14 So maybe let's increase your activity.
00:17:14 --> 00:17:15 Let's try and have you go for a
00:17:16 --> 00:17:17 every day.
00:17:17 --> 00:17:19 Or let's come up with a consistent
00:17:19 --> 00:17:19 bedtime.
00:17:19 --> 00:17:20 Why don't you start going to bed at
00:17:20 --> 00:17:22 the same time every night so you get
00:17:22 --> 00:17:25 a consistent amount of sleep so your
00:17:25 --> 00:17:26 tissues can heal?
00:17:26 --> 00:17:29 So I try not to become a nutritionist
00:17:29 --> 00:17:30 or a psychologist.
00:17:30 --> 00:17:32 I just try to help them see how
00:17:32 --> 00:17:35 these habits can influence healing and
00:17:35 --> 00:17:37 collaborate with them on coming up with
00:17:37 --> 00:17:40 some strategies that may help them.
00:17:40 --> 00:17:41 Yeah.
00:17:41 --> 00:17:43 And I think based on my experience,
00:17:43 --> 00:17:45 even incremental change has changed.
00:17:45 --> 00:17:47 So even if we can help them implement
00:17:48 --> 00:17:49 a little bit of extra sleep or a
00:17:50 --> 00:17:50 fifteen minute walk,
00:17:50 --> 00:17:52 and I usually say to patients outside
00:17:52 --> 00:17:53 always, you know,
00:17:54 --> 00:17:57 unless it's it's not safe or the weather
00:17:57 --> 00:17:57 is not in favor,
00:17:57 --> 00:17:59 it's so good for you to do that.
00:17:59 --> 00:18:00 But, you know,
00:18:01 --> 00:18:02 there is a lot of power in it
00:18:02 --> 00:18:03 being incremental.
00:18:03 --> 00:18:04 And I don't think we're necessarily
00:18:04 --> 00:18:06 outside of our scope and making those
00:18:06 --> 00:18:07 recommendations.
00:18:08 --> 00:18:08 Yeah,
00:18:08 --> 00:18:10 and it can be overwhelming for patients if
00:18:10 --> 00:18:11 you throw it all at them at once.
00:18:11 --> 00:18:13 I need you to eat better,
00:18:13 --> 00:18:14 and I need you to sleep better,
00:18:14 --> 00:18:15 and I need you to drink more water,
00:18:16 --> 00:18:17 and I need you to decrease your stress
00:18:17 --> 00:18:17 levels,
00:18:18 --> 00:18:19 and I want you to do some mindfulness
00:18:19 --> 00:18:19 kind of things.
00:18:20 --> 00:18:22 The patients are like, whoa, whoa, whoa.
00:18:22 --> 00:18:23 This is physical therapy, isn't it?
00:18:23 --> 00:18:24 Yeah, yeah.
00:18:27 --> 00:18:30 You talked about the importance in the
00:18:30 --> 00:18:31 article of language,
00:18:31 --> 00:18:33 and we did talk about this already a
00:18:33 --> 00:18:34 bit,
00:18:34 --> 00:18:37 but what are some common phrases or
00:18:37 --> 00:18:40 metaphors that you have found helpful or
00:18:40 --> 00:18:42 maybe even harmful in communicating things
00:18:42 --> 00:18:44 to patients?
00:18:45 --> 00:18:47 Well, we've all heard these,
00:18:47 --> 00:18:49 but I see college-age students who are
00:18:49 --> 00:18:50 told by their healthcare provider,
00:18:50 --> 00:18:51 you have the spine of a
00:18:54 --> 00:18:56 It's out of alignment or you need to
00:18:56 --> 00:18:57 be careful.
00:18:57 --> 00:18:59 You could make this worse, you know,
00:18:59 --> 00:19:00 those kinds of things.
00:19:00 --> 00:19:01 You know,
00:19:01 --> 00:19:03 really educating the patients that really,
00:19:03 --> 00:19:04 if we're talking about back pain,
00:19:04 --> 00:19:06 your back is strong and it can tolerate
00:19:06 --> 00:19:07 a lot of load.
00:19:07 --> 00:19:09 It's not going to explode if you bend
00:19:09 --> 00:19:10 forward,
00:19:10 --> 00:19:12 which a lot of patients truly believe
00:19:12 --> 00:19:12 that,
00:19:12 --> 00:19:14 that if they bend forward and try and
00:19:14 --> 00:19:14 touch their toes,
00:19:14 --> 00:19:17 something terrible is going to happen.
00:19:18 --> 00:19:19 And then also, you know,
00:19:19 --> 00:19:20 the pain science stuff,
00:19:20 --> 00:19:21 pain does not equal harm.
00:19:22 --> 00:19:22 You know, if we can...
00:19:23 --> 00:19:25 get that into patient's head.
00:19:25 --> 00:19:26 Yeah.
00:19:26 --> 00:19:27 You,
00:19:27 --> 00:19:29 you helped somebody move last weekend and
00:19:29 --> 00:19:31 your back is really sore and it's probably
00:19:31 --> 00:19:33 going to be sore for, you know,
00:19:33 --> 00:19:34 a period of time overall,
00:19:34 --> 00:19:36 but pain does not mean you're causing any
00:19:37 --> 00:19:38 damage to the tissues overall.
00:19:39 --> 00:19:41 And then really getting the patients to
00:19:41 --> 00:19:43 think about their body is a complex system
00:19:44 --> 00:19:45 that requires, you know,
00:19:45 --> 00:19:47 not just strength and mobility,
00:19:47 --> 00:19:49 but all those other lifestyle factors,
00:19:49 --> 00:19:51 appropriate sleep and decreased stress
00:19:51 --> 00:19:52 levels and those kinds of things.
00:19:53 --> 00:19:54 Yeah.
00:19:54 --> 00:19:56 And I have another kind of separate
00:19:56 --> 00:19:56 question.
00:19:57 --> 00:19:58 I remember we talked about this with
00:19:58 --> 00:19:59 Jeremy when the three of us were just
00:19:59 --> 00:20:02 kind of having a conversation about some
00:20:02 --> 00:20:02 of this.
00:20:02 --> 00:20:06 But at least where I'm working in
00:20:06 --> 00:20:07 outpatient and hospital system,
00:20:08 --> 00:20:10 imaging is a huge barrier.
00:20:11 --> 00:20:13 And I spend a lot of time undoing
00:20:13 --> 00:20:13 it.
00:20:14 --> 00:20:14 You know,
00:20:14 --> 00:20:16 I have a patient that comes with imaging
00:20:16 --> 00:20:17 and then we have to talk about,
00:20:18 --> 00:20:18 you know,
00:20:18 --> 00:20:20 thinking about the imaging in a slightly
00:20:20 --> 00:20:20 different way.
00:20:20 --> 00:20:23 And it's not catastrophic and your body is
00:20:23 --> 00:20:23 strong.
00:20:24 --> 00:20:25 And to your point, you know,
00:20:25 --> 00:20:28 your lumbar spine is well supported
00:20:29 --> 00:20:30 ligamentously and by all these muscles.
00:20:30 --> 00:20:32 And maybe you're just reacting,
00:20:33 --> 00:20:34 the tissues are reacting to some load.
00:20:34 --> 00:20:37 But Jeremy was describing he didn't quite
00:20:37 --> 00:20:39 have the same problem because they don't
00:20:39 --> 00:20:42 utilize imaging as readily or as often as
00:20:42 --> 00:20:43 we do in the United States.
00:20:44 --> 00:20:45 what, where do you see the,
00:20:46 --> 00:20:47 how are we ever going to kind of
00:20:47 --> 00:20:49 get around this culture?
00:20:49 --> 00:20:51 And maybe it's too big of a question
00:20:51 --> 00:20:52 for, for, you know,
00:20:52 --> 00:20:53 us to even think about,
00:20:53 --> 00:20:56 but it's really a barrier in my opinion
00:20:56 --> 00:20:56 to recovery.
00:20:57 --> 00:20:58 What do you think the answer is at
00:20:58 --> 00:21:00 least in the United States and in our
00:21:00 --> 00:21:02 health system in terms of our utilization
00:21:02 --> 00:21:04 of imaging or over-utilization,
00:21:04 --> 00:21:04 I should say?
00:21:06 --> 00:21:06 Yeah, well,
00:21:06 --> 00:21:10 it's got to be a systemic change overall.
00:21:10 --> 00:21:11 And if we just followed the guidelines,
00:21:12 --> 00:21:13 I mean, the guidelines are very clear.
00:21:13 --> 00:21:14 If you have a new onset of back
00:21:14 --> 00:21:15 pain with no red flags,
00:21:15 --> 00:21:17 imaging is not indicated.
00:21:17 --> 00:21:19 Don't even go there.
00:21:19 --> 00:21:20 But unfortunately, like you said,
00:21:21 --> 00:21:23 when you were talking about Jason,
00:21:23 --> 00:21:23 you know,
00:21:24 --> 00:21:26 He feels like he has to order the
00:21:26 --> 00:21:27 imaging or whatever.
00:21:27 --> 00:21:29 It's kind of part of the script that
00:21:29 --> 00:21:30 you go through.
00:21:30 --> 00:21:32 But, you know, really changing that,
00:21:32 --> 00:21:33 if you read the guidelines,
00:21:33 --> 00:21:34 they are very clear.
00:21:34 --> 00:21:36 And if we just followed that, you know,
00:21:36 --> 00:21:38 on the radiology front, it's interesting,
00:21:38 --> 00:21:40 you know, where I practice up in Boulder,
00:21:40 --> 00:21:42 a lot of the radiologists are starting to
00:21:42 --> 00:21:43 put little blurbs at the
00:21:47 --> 00:21:50 Patients who are from thirty to forty,
00:21:50 --> 00:21:52 it's common to see this or that,
00:21:52 --> 00:21:53 just to put that in on the bottom
00:21:53 --> 00:21:55 so that the patients can see that some
00:21:55 --> 00:21:57 of these findings are normal in people who
00:21:57 --> 00:22:00 don't have symptoms overall.
00:22:00 --> 00:22:04 The setting I work in,
00:22:05 --> 00:22:06 about seventy percent of the patients we
00:22:06 --> 00:22:07 see are direct access,
00:22:07 --> 00:22:09 so they come in and see us first.
00:22:10 --> 00:22:10 Man,
00:22:10 --> 00:22:12 seeing somebody with two days of back pain
00:22:12 --> 00:22:14 who has not seen another provider is,
00:22:14 --> 00:22:14 you know,
00:22:15 --> 00:22:17 life-changing as a physical therapist
00:22:17 --> 00:22:18 compared to the patient who has seen ten
00:22:18 --> 00:22:21 providers and had pain for five years and
00:22:21 --> 00:22:23 had all the imaging and things like that.
00:22:23 --> 00:22:23 You know,
00:22:23 --> 00:22:27 those are so much harder patients to treat
00:22:27 --> 00:22:29 overall because they've got all of this
00:22:29 --> 00:22:31 information in their head that is just,
00:22:32 --> 00:22:32 you know,
00:22:32 --> 00:22:34 we've done a lot on expectations.
00:22:34 --> 00:22:36 Their expectation is rude, right?
00:22:36 --> 00:22:38 Their back is broken.
00:22:38 --> 00:22:39 Yeah.
00:22:39 --> 00:22:39 Yeah.
00:22:41 --> 00:22:42 I envy you, Paul.
00:22:43 --> 00:22:45 I haven't seen a patient with acute low
00:22:45 --> 00:22:47 back pain in over ten years.
00:22:49 --> 00:22:49 Unfortunately,
00:22:49 --> 00:22:51 we don't have direct access in our
00:22:51 --> 00:22:52 hospital system,
00:22:52 --> 00:22:53 which is unfortunate because we're in a
00:22:54 --> 00:22:55 state that allows direct access.
00:22:55 --> 00:22:58 But I'm not going to stir up that
00:22:58 --> 00:23:00 hornet's nest at the moment.
00:23:00 --> 00:23:03 But it's unfortunate because I believe,
00:23:03 --> 00:23:04 and you know this too,
00:23:04 --> 00:23:06 the trajectory can be so different
00:23:07 --> 00:23:07 um,
00:23:07 --> 00:23:08 when you see someone just a couple of
00:23:08 --> 00:23:11 days out of an injury or a new
00:23:11 --> 00:23:13 onset of pain versus someone that I
00:23:13 --> 00:23:15 usually can't see for eight to ten weeks.
00:23:15 --> 00:23:17 And by then they've already had imaging
00:23:17 --> 00:23:19 and a whole plethora of other things have
00:23:19 --> 00:23:21 happened, um, you know, in that,
00:23:21 --> 00:23:23 in that time, which is just, um, again,
00:23:23 --> 00:23:24 it's just unfortunate.
00:23:24 --> 00:23:24 Yeah.
00:23:24 --> 00:23:27 You know, I had to, uh,
00:23:27 --> 00:23:30 taught a course this weekend and had a
00:23:30 --> 00:23:32 great discussion with some of the people
00:23:32 --> 00:23:35 there and, um, the, uh,
00:23:37 --> 00:23:38 uh, we, we kind of talked about,
00:23:39 --> 00:23:39 you know,
00:23:39 --> 00:23:41 primary care physicians role in treating
00:23:41 --> 00:23:43 conditions like back pain.
00:23:43 --> 00:23:44 And, you know, in my opinion,
00:23:44 --> 00:23:46 and you've taught the medical students at
00:23:46 --> 00:23:47 the university of Colorado as well,
00:23:47 --> 00:23:49 they get very limited training in
00:23:49 --> 00:23:51 musculoskeletal conditions.
00:23:51 --> 00:23:53 So for a primary care physician to see
00:23:53 --> 00:23:56 a patient with back pain to me is
00:23:56 --> 00:23:58 out of their scope of practice overall.
00:23:58 --> 00:23:59 I mean, they can handle the, the, the,
00:24:01 --> 00:24:01 you know,
00:24:01 --> 00:24:03 major conditions and things like that.
00:24:03 --> 00:24:04 But that would be like us trying to
00:24:04 --> 00:24:06 treat somebody with a complex, you know,
00:24:06 --> 00:24:09 endocrine problem or something like that.
00:24:09 --> 00:24:11 You know, the physical therapist,
00:24:11 --> 00:24:13 the providers who should be the front door
00:24:13 --> 00:24:15 to the management of musculoskeletal
00:24:15 --> 00:24:17 conditions and not that we can diagnose
00:24:17 --> 00:24:19 cancer or some of these other
00:24:20 --> 00:24:22 But we know the patients that belong in
00:24:22 --> 00:24:23 our clinic today and those that don't,
00:24:23 --> 00:24:25 and we refer appropriately.
00:24:25 --> 00:24:25 I mean,
00:24:25 --> 00:24:29 we've published a report on over sixteen
00:24:29 --> 00:24:31 thousand patients seen direct access.
00:24:31 --> 00:24:33 We didn't miss a single fracture or tumor
00:24:33 --> 00:24:34 or that type of thing.
00:24:34 --> 00:24:36 So, again,
00:24:36 --> 00:24:37 we should be the ones seeing them.
00:24:38 --> 00:24:39 And if we do,
00:24:39 --> 00:24:41 the trajectory is completely different.
00:24:41 --> 00:24:42 Yeah.
00:24:42 --> 00:24:43 Yeah, I agree with that.
00:24:43 --> 00:24:44 I was just yesterday I was talking to
00:24:44 --> 00:24:45 Stephen Spoonmore,
00:24:46 --> 00:24:48 who we both did research with many moons
00:24:48 --> 00:24:49 ago,
00:24:49 --> 00:24:50 and he has worked for a number of
00:24:50 --> 00:24:53 years up in Alaska with some of the
00:24:53 --> 00:24:54 indigenous populations.
00:24:54 --> 00:24:56 And we were talking about this really cool
00:24:56 --> 00:24:56 idea.
00:24:56 --> 00:24:57 you know,
00:24:57 --> 00:24:59 primary care model that they were trying
00:24:59 --> 00:25:00 to get off the ground where, you know,
00:25:00 --> 00:25:03 patients are being triaged by this team,
00:25:03 --> 00:25:05 including primary care and sometimes
00:25:05 --> 00:25:08 behavioral health and PT as a part of
00:25:08 --> 00:25:10 that in order to kind of have this
00:25:10 --> 00:25:12 team-based approach to determining,
00:25:12 --> 00:25:14 you know, the best path for the patients.
00:25:14 --> 00:25:14 And I think that's,
00:25:15 --> 00:25:16 I think it's really cool.
00:25:16 --> 00:25:18 And I think it's kind of the ideal.
00:25:18 --> 00:25:18 So, you know,
00:25:18 --> 00:25:20 hopefully we can continue to work towards
00:25:20 --> 00:25:21 those, those models.
00:25:21 --> 00:25:22 Yeah.
00:25:23 --> 00:25:24 Yeah.
00:25:24 --> 00:25:26 Rebecca Griffith in the emergency room
00:25:26 --> 00:25:28 getting physical therapy in the emergency
00:25:28 --> 00:25:28 department.
00:25:28 --> 00:25:31 That is life-changing overall for
00:25:31 --> 00:25:32 everybody involved,
00:25:32 --> 00:25:33 even the healthcare providers.
00:25:33 --> 00:25:36 Yeah, absolutely.
00:25:36 --> 00:25:38 And she's done some great work, I believe,
00:25:38 --> 00:25:41 in really messaging that and how important
00:25:41 --> 00:25:43 that is at both a national and
00:25:43 --> 00:25:44 international level,
00:25:44 --> 00:25:47 which hopefully is another kind of agent
00:25:47 --> 00:25:48 for change.
00:25:48 --> 00:25:50 So in terms of education, I mean,
00:25:50 --> 00:25:52 we're both entry-level educators,
00:25:52 --> 00:25:53 but on top of it,
00:25:53 --> 00:25:55 you educate in some residency and
00:25:55 --> 00:25:56 fellowship.
00:25:57 --> 00:25:58 From that lens,
00:25:58 --> 00:26:00 what do you think needs to change in
00:26:00 --> 00:26:04 terms of how we educate students or
00:26:04 --> 00:26:05 learners, I should say,
00:26:05 --> 00:26:05 to better
00:26:06 --> 00:26:08 be prepared to kind of have this
00:26:08 --> 00:26:09 person-centered,
00:26:09 --> 00:26:11 non-pathoanatomical approach?
00:26:11 --> 00:26:14 And how do you still talk about
00:26:14 --> 00:26:18 pathoanatomy without it translating to the
00:26:18 --> 00:26:20 speak that we use with the patients?
00:26:20 --> 00:26:22 Because we're advocating in this article,
00:26:22 --> 00:26:23 in this viewpoint,
00:26:23 --> 00:26:25 to really talk about more of a functional
00:26:25 --> 00:26:26 diagnosis.
00:26:26 --> 00:26:29 Yeah, I mean...
00:26:30 --> 00:26:32 It's kind of the nature of the beast
00:26:32 --> 00:26:33 that we need to teach our students how
00:26:33 --> 00:26:35 to do all these exam things.
00:26:35 --> 00:26:36 And we have all these special tests that
00:26:37 --> 00:26:40 purportedly identify structural pathology
00:26:40 --> 00:26:41 and things like that.
00:26:41 --> 00:26:43 But I'm really trying to move my students
00:26:43 --> 00:26:44 away from that.
00:26:44 --> 00:26:45 I'll teach them those tests,
00:26:45 --> 00:26:48 but I also teach them how to interpret
00:26:48 --> 00:26:49 the findings,
00:26:49 --> 00:26:51 meaning that you can't rule in most
00:26:52 --> 00:26:54 conditions that we're seeing and really
00:26:54 --> 00:26:55 emphasizing that
00:26:57 --> 00:26:59 teaching them how to connect with people
00:26:59 --> 00:27:01 and how to improve the therapeutic
00:27:01 --> 00:27:04 alliance and treat the human being that's
00:27:04 --> 00:27:04 sitting in front of you.
00:27:05 --> 00:27:06 This is not a knee.
00:27:06 --> 00:27:07 This is not a shoulder.
00:27:08 --> 00:27:09 This is not a back.
00:27:09 --> 00:27:12 This is a human being that has complex
00:27:13 --> 00:27:13 things going on.
00:27:13 --> 00:27:16 So part of it is just
00:27:17 --> 00:27:17 It's habit.
00:27:17 --> 00:27:19 It's what's been done before and that kind
00:27:19 --> 00:27:20 of thing.
00:27:20 --> 00:27:22 So we really need to shift the educational
00:27:22 --> 00:27:26 model from teaching our patients to look
00:27:26 --> 00:27:28 for something that's broken or something
00:27:28 --> 00:27:32 to fix and steering more towards that ICF
00:27:32 --> 00:27:33 model to think in terms of
00:27:34 --> 00:27:36 function and how impairments affect a
00:27:36 --> 00:27:38 human being's daily life,
00:27:38 --> 00:27:41 not just what structures are involved.
00:27:41 --> 00:27:42 So, you know,
00:27:42 --> 00:27:44 I try to present a balanced approach with
00:27:45 --> 00:27:45 it.
00:27:45 --> 00:27:45 But unfortunately,
00:27:46 --> 00:27:48 they need to learn some of these special
00:27:48 --> 00:27:49 tests for the board exams and things like
00:27:49 --> 00:27:50 that.
00:27:50 --> 00:27:51 Right.
00:27:51 --> 00:27:51 But
00:27:52 --> 00:27:52 You know,
00:27:52 --> 00:27:56 I really do look at individuals now from
00:27:56 --> 00:27:57 that ICF model.
00:27:57 --> 00:27:58 They have low back pain width.
00:27:58 --> 00:28:00 What's the underlying impairment that's
00:28:00 --> 00:28:02 most likely to give us the biggest bang
00:28:02 --> 00:28:04 for our buck from the intervention
00:28:05 --> 00:28:06 standpoint?
00:28:06 --> 00:28:08 And then really teaching them about the
00:28:08 --> 00:28:11 therapeutic alliance and taking time to
00:28:11 --> 00:28:12 get to know the individual.
00:28:12 --> 00:28:12 You know,
00:28:12 --> 00:28:15 I've said over and over again to my
00:28:15 --> 00:28:16 students, you know,
00:28:16 --> 00:28:17 your interaction may outweigh your
00:28:17 --> 00:28:18 intervention.
00:28:19 --> 00:28:20 Yeah, yeah.
00:28:20 --> 00:28:23 It is tricky because we have to kind
00:28:23 --> 00:28:24 of teach both things and then at the
00:28:25 --> 00:28:27 same time somehow cohesively deliver a
00:28:27 --> 00:28:29 message that we don't want to be
00:28:30 --> 00:28:33 over-emphasizing pathoanatomic terms with
00:28:33 --> 00:28:33 patients.
00:28:34 --> 00:28:35 I was just teaching in our hybrid
00:28:36 --> 00:28:38 immersion at University of Colorado
00:28:38 --> 00:28:39 yesterday,
00:28:39 --> 00:28:39 and I
00:28:39 --> 00:28:42 we were working on teaching shoulder
00:28:42 --> 00:28:43 content.
00:28:43 --> 00:28:45 And one of the ways I felt like
00:28:45 --> 00:28:47 I could kind of try to couch this
00:28:47 --> 00:28:51 together is we were talking about shoulder
00:28:51 --> 00:28:53 pain with movement coordination deficits.
00:28:53 --> 00:28:54 But then we were talking about what
00:28:54 --> 00:28:57 pathologies might kind of nest underneath
00:28:57 --> 00:28:57 that.
00:28:58 --> 00:28:58 But still,
00:28:59 --> 00:29:00 because we don't have confidence,
00:29:00 --> 00:29:02 we know for sure that someone has
00:29:03 --> 00:29:04 multi-directional instability or that they
00:29:04 --> 00:29:06 have a laboral issue.
00:29:07 --> 00:29:09 It's still just a hypothesis under this
00:29:09 --> 00:29:12 broader category of movement coordination.
00:29:12 --> 00:29:14 And so I was trying to figure out
00:29:14 --> 00:29:16 a way to kind of house pathoanatomy under
00:29:16 --> 00:29:17 each of these,
00:29:17 --> 00:29:19 but being very explicit with the students
00:29:19 --> 00:29:22 that we don't have confirmation all the
00:29:22 --> 00:29:25 time that this is exactly what we're
00:29:25 --> 00:29:26 dealing with and it can be harmful.
00:29:27 --> 00:29:29 to describe pathoanatomy to the patient in
00:29:29 --> 00:29:30 the absence of clarity.
00:29:30 --> 00:29:32 Because to your point earlier,
00:29:32 --> 00:29:33 even with imaging,
00:29:34 --> 00:29:35 we don't have a hundred percent clarity
00:29:35 --> 00:29:38 that that's the pathoanatomy that's kind
00:29:38 --> 00:29:40 of driving the symptoms.
00:29:41 --> 00:29:41 So.
00:29:43 --> 00:29:43 Yeah.
00:29:43 --> 00:29:44 And I, you know,
00:29:44 --> 00:29:46 I've used that engineering that, that, uh,
00:29:46 --> 00:29:46 uh,
00:29:49 --> 00:29:51 meme or whatever the engineering flow
00:29:51 --> 00:29:54 chart where does it move yes should it
00:29:54 --> 00:29:56 no then you know then what are we
00:29:56 --> 00:29:57 going to do we're going to stabilize it
00:29:57 --> 00:29:59 we're going to put some duct tape on
00:29:59 --> 00:29:59 it or that kind of thing right try
00:30:00 --> 00:30:01 and uh
00:30:01 --> 00:30:02 You know,
00:30:02 --> 00:30:03 hold it down a little bit or keep
00:30:03 --> 00:30:04 it from moving too much.
00:30:04 --> 00:30:05 Or does it move?
00:30:06 --> 00:30:06 No.
00:30:06 --> 00:30:07 Should it?
00:30:07 --> 00:30:07 Yes.
00:30:07 --> 00:30:09 Then that's WD-Forty.
00:30:09 --> 00:30:11 Squirt some WD-Forty on it so it moves
00:30:11 --> 00:30:12 a little bit better.
00:30:12 --> 00:30:13 So applying some manual therapy.
00:30:13 --> 00:30:16 So when I use those same kind of
00:30:16 --> 00:30:17 descriptions to patients,
00:30:17 --> 00:30:18 you're a little stiff through here.
00:30:18 --> 00:30:20 You're not moving like you should be.
00:30:20 --> 00:30:22 And if we can improve the mobility here,
00:30:22 --> 00:30:25 then it's likely that it will decrease the
00:30:25 --> 00:30:27 amount of compensation you need to do at
00:30:27 --> 00:30:28 the level above.
00:30:28 --> 00:30:29 Or if you're moving too much,
00:30:30 --> 00:30:32 we need to just improve your body's
00:30:32 --> 00:30:36 ability to stabilize that level and keep
00:30:36 --> 00:30:39 it from getting irritated by moving beyond
00:30:39 --> 00:30:41 its normal physiologic motion.
00:30:41 --> 00:30:41 Yeah.
00:30:42 --> 00:30:42 And I agree.
00:30:42 --> 00:30:44 And I think that actually makes sense to
00:30:44 --> 00:30:44 people.
00:30:44 --> 00:30:46 Somehow we just get tempted to kind of
00:30:46 --> 00:30:48 fall in the trap of pathoanatomy,
00:30:48 --> 00:30:51 but that's not always the most productive
00:30:51 --> 00:30:52 place to go.
00:30:52 --> 00:30:53 But I agree.
00:30:53 --> 00:30:55 I think that language makes a ton of
00:30:55 --> 00:30:55 sense to people.
00:30:56 --> 00:30:58 Um, so as we kind of close up,
00:30:58 --> 00:31:00 what are some things that you're currently
00:31:00 --> 00:31:01 working on or what, what,
00:31:01 --> 00:31:03 what other passion projects do you have?
00:31:03 --> 00:31:05 Are you working on any research right now?
00:31:05 --> 00:31:06 What, what's, uh,
00:31:06 --> 00:31:07 what's blowing your hair back at the
00:31:07 --> 00:31:08 moment, Paul?
00:31:08 --> 00:31:09 Well, I guess you don't have that much,
00:31:09 --> 00:31:09 so.
00:31:14 --> 00:31:19 I'm really moving into looking at burnout
00:31:20 --> 00:31:22 and mindfulness and things like that.
00:31:22 --> 00:31:24 We're working on a project where we're
00:31:24 --> 00:31:25 looking at dry needling.
00:31:25 --> 00:31:27 We just published a case report on a
00:31:27 --> 00:31:29 patient that I caused pneumothorax on,
00:31:29 --> 00:31:30 which I think as a profession,
00:31:30 --> 00:31:32 we need to be honest and say these
00:31:32 --> 00:31:35 things do happen and the prevalence is
00:31:35 --> 00:31:36 probably much higher than we think it is
00:31:36 --> 00:31:37 overall.
00:31:38 --> 00:31:38 You know,
00:31:38 --> 00:31:39 we're going to explore that and kind of
00:31:40 --> 00:31:42 survey emergency room physicians and kind
00:31:42 --> 00:31:44 of see how often do they see patients
00:31:44 --> 00:31:48 who have developed a pneumothorax due to
00:31:48 --> 00:31:50 potentially needling or those kind of
00:31:50 --> 00:31:51 things.
00:31:52 --> 00:31:53 But we're also, you know,
00:31:53 --> 00:31:55 Josh Cleland and Megan Donaldson and I are
00:31:55 --> 00:31:57 working on looking at burnout in academic
00:31:57 --> 00:31:58 faculty.
00:31:59 --> 00:32:02 There's a lot of evidence in medical
00:32:02 --> 00:32:04 literature, but as far as allied health,
00:32:04 --> 00:32:06 physical therapy, speech,
00:32:06 --> 00:32:07 occupational therapy,
00:32:07 --> 00:32:09 we don't really have a good handle on
00:32:09 --> 00:32:12 the level of burnout in academia overall
00:32:12 --> 00:32:13 because I've been through it.
00:32:14 --> 00:32:16 Josh, my best friend, has been through it.
00:32:17 --> 00:32:19 And it's definitely challenging.
00:32:19 --> 00:32:21 So number one,
00:32:21 --> 00:32:23 what's the prevalence of burnout in
00:32:23 --> 00:32:24 academic faculty?
00:32:24 --> 00:32:26 And then ultimately,
00:32:26 --> 00:32:28 how can we improve that or decrease the
00:32:28 --> 00:32:30 likelihood of that happening?
00:32:30 --> 00:32:31 So those are a couple of the big
00:32:31 --> 00:32:32 things that I'm working on.
00:32:32 --> 00:32:34 But I have my finger in a lot
00:32:34 --> 00:32:34 of different things,
00:32:35 --> 00:32:37 educational competencies and things like
00:32:37 --> 00:32:37 that.
00:32:37 --> 00:32:40 But plenty to keep me busy.
00:32:40 --> 00:32:41 Yeah, great.
00:32:41 --> 00:32:44 Well, I look forward to, you know,
00:32:44 --> 00:32:45 catching up at the conference,
00:32:45 --> 00:32:46 which is coming up in a couple weeks,
00:32:46 --> 00:32:48 and then also seeing the fruits of your
00:32:48 --> 00:32:50 labor in terms of some of this burnout
00:32:50 --> 00:32:51 work, which, you know,
00:32:51 --> 00:32:54 is very different from, I think, medicine.
00:32:54 --> 00:32:56 And so I love that you're calling that
00:32:56 --> 00:32:57 out and doing a little bit more work
00:32:57 --> 00:32:58 to explore maybe what some of the
00:32:58 --> 00:33:00 differences are and how we can mitigate
00:33:01 --> 00:33:01 it.
00:33:01 --> 00:33:03 Because it's hard work being in academia,
00:33:04 --> 00:33:06 lots of high expectations.
00:33:06 --> 00:33:08 And so I look forward to hearing a
00:33:08 --> 00:33:09 little bit more about that.
00:33:10 --> 00:33:11 Yeah, one more quote from Julie Whitman.
00:33:11 --> 00:33:12 I remember she told me, you know,
00:33:13 --> 00:33:13 in academia,
00:33:13 --> 00:33:14 once you get on the treadmill,
00:33:15 --> 00:33:16 you can never stop running.
00:33:16 --> 00:33:20 So that's how it works sometimes.
00:33:20 --> 00:33:21 That resonates.
00:33:22 --> 00:33:23 All right, Paul.
00:33:23 --> 00:33:25 Well, it was a great conversation.
00:33:25 --> 00:33:27 And thanks so much for the conversation
00:33:27 --> 00:33:29 about some of the work that you're putting
00:33:29 --> 00:33:29 out there.
00:33:30 --> 00:33:33 And we shall see you again when another
00:33:33 --> 00:33:34 brilliant paper comes out.
00:33:34 --> 00:33:37 We'll bring you on and unpack it together.
00:33:38 --> 00:33:39 All right, thanks so much, Amy.
00:33:39 --> 00:33:39 All right, thanks.