Integrating Patient-Centered Exercise in Pain Management

if you're somebody who's, Really struggling to determine what the hell am I doing with exercise? If it's not getting strong, that's getting people better. What is it? Where does exercise fit? God, there's a patient of mine who has no interest in picking up a barbell or doing anything that looks even remotely close to CrossFit or fitness forward type activities, which I'm a huge fan of myself, but so what do we do in those situations? What is going on everybody? Welcome back for another episode of the Modern Pain Podcast. This week I wanted to do something a little different. We've had some great experts, some great patients, some great people who've come on the podcast. Every once in a while I like to drop a little bit of my thoughts on some topics and one topic that has been getting some thoughts of mine as far as really thinking and looking at social media and seeing everybody comment and the wild west that is exercise and social media. I decided I wanted to talk a little bit about exercise this week. So I hope you find some value, enjoy the episode and let me know what you think when you get done listening, love to hear your thoughts, enjoy the episode.

This is the Modern Pain Podcast with Mark Kargela.

Wanted to come on tonight and talk about exercise and modern pain care. It's one of those things that has made a major shift in my practice as far as how I look at it, how I kind of approach it, what I think is going on with it. And we'll, we'll allude to that tonight. We'll kind of talk, we'll start a little bit about, okay, well, where do we start with exercise as far as how we're taught. get into, well, where's the patient at? Because I think sometimes, I don't know, for me, I made assumptions of the situation and applied exercise into maybe a, a non person centered way of putting it. And then we'll speak into graded exposure techniques, which is a huge part of what I do daily. And I think it's a huge part of what you do daily. Whether you know it explicitly or you just kind of are implicitly doing it. And I think we can do it better by being more consciously aware of what you're doing. That we're often bringing people in a feared movements and loads and things they might be concerned or apprehensive about that if we have a more explicit process of recognizing and bringing it into the room and talking through it and doing all these things again, we'll talk about it more graded activity. One of those things. I think Bill Ford ice, one of the true originators of graded activity and practice with some of the pain programs he ran. Um, he wrote a book, and I'm forgetting it, but, um, I know, um, Mike Stewart and others and, uh, Kevin Volz actually referred to Bill Fordyce's book, um, that basically talked about a pain program, multidisciplinary pain program, but it really focused on a graded activity approach, and we'll speak to that. And then at the end, I'll talk maybe some more details of how I apply exercise and I'm gonna open the floor for those of you on the replay, listening to that. Maybe can chime in, in the comments. I'd love to hear kind of some of your thoughts, um, and things like that, but let's get into traditional exercise. Now I'm going to go to my way. I was taught and trained exercise. I was in how I considered it, right? I thought, you know, pain was weakness and that the stronger you get, the less pain you'd have. That was just, you know, kind of an implicit assumption that I thought Yeah, pain is due to weakness, and of course we've seen research around the core and other areas where, hey, you know, the timing or the cross sectional area of the abdominals don't change with core exercise, yet core exercise improves people's pain, so what's that all about? I was trained with the, what has been playfully called the blue whoopee cushion, but if anybody's seen like it's almost like blood pressure cuff bladder where it's got to read out like the blood pressure, um, you know, measuring device, which I can't pronounce nor will I butcher it in front of you all, uh, sphygmomanometer, again, there it goes. So, But anyway, being able to like look at tightening your transverse abdominus and really isolating the contraction of your transverse abdominus and only having it to a certain, within a certain, you know, millimeters of mercury difference as far as pressure that you're, that expertly can control it. Yet we see these programs, do they, can they help some people? Yeah, there's actually research and evidence to show that these programs can help people. Does it have anything to do with the TA timing, transverse abdominus timing that was the birth of all this transverse abdominus work that I think we've, for the most part, moved on. I'm not saying there can't be a time and a place, but I honestly can't tell you the last time I've cued a TA personally. But, um, and again, if you do it, it's not to say, you It's wrong that you're doing it to get anything that gets stronger or can get people engaged, especially if they, you know, feel like something's improving and you have a narrative behind it that, you know, somebody believes in and, you know, getting, you know, some improved contraction isn't a bad thing. It's just, is it necessary to get people or is it the secret sauce that surrounds intervention, the context, the non specifics and the other things that might be driving some of these outcomes. So then I, we were all, or I shouldn't say we were all, I was taught, uh, upper cross syndrome, lower cross syndrome, stuff. And again, maybe some things that are still helpful for that. Because I, I do think, you know, some of the thought processes of like, maybe some patterns of weakness that, and maybe patterns of inactivity just for people, um, and postural positioning and stuff. Does it have to do with one side's being tight, one side's being weak, not necessarily. And I think the research has been pretty conclusive that, you know, lower cross syndrome and upper cross syndrome, while brilliant theories at the time, haven't really hashed out in the research and haven't really shown that the body necessarily works that way in this like crossed fashion. But so anyway, that was kind of where I was at. And then if you were going to be, Hoping people with athletics you had to be very detailed with your biomechanical understandings And I think there's still some validity to that like if you're working with professional athletes where like, you know Changing mechanics of their baseball pitch or their golf swing or whatever It may be the skill highly skilled movement that they're performing can make big differences in performance Does it necessary to decrease pain or I don't think we have a ton of research to show that there's really a lot of nitpicky biomechanical things that need to change. You know, Q angle is one of the big things around there. Oh, we gotta stop this dynamic valgus. And, and I know there's some argument. Chris Powers is one of the researchers. I think he's in Stanford, but has really gotten into anterior knee pain, patellofemoral issues, and still I think is very big proponent of, you know, looking at dynamic valgus and stuff. And I do think there's some, you know, dynamic valgus under fatigue for somebody who's not load prepared, especially females who tend to have maybe a little bit more mechanical issues. Disadvantage in that can maybe be more at risk for ACL tears and things like that. Um, that along with the female triad, which I know has been moved on to a different, um, Term which I don't know because I haven't kept up with that side of things in a bit But anyway that that should give you a general night. I'm hoping that if you're listening to this, this is something that yeah Yeah, all these things are similar things that I've heard. I'm 20 plus years out of school So maybe some of the programs that you if you're newer a graduate you've you've seen things move on a little bit So that's where We, I started, and then I think one of the keys that I didn't think about as I was getting into clinic and starting to work with people with exercises, I'd assume like people are coming into clinic and they're going to exercise, they know it. It's their PT, we're PT for physical therapy. We're going to do physical stuff. We're going to exercise. And it was just kind of this, this is about me and my toolbox that I'm going to kind of. I don't know, I guess you could say push upon you or kind of impose upon you where there wasn't this really big consideration that is this patient going to even have any interest in something that looks like exercise. One of my criticisms right now, I think is I, I think the overall push to strength and conditioning and getting people more loaded appropriately and to the loads that their life needs and maybe even picking up a barbell and doing things that, you know, I think traditionally we grossly under loaded and under exercise people. But I also think we have to recognize that, hey, not everybody's an exerciser. And no matter how awesome CrossFit is or how awesome functional fitness is and the life changing thing, I mean, I honestly credit it with literally giving me years back in my life because I was In a hugely unhealthy, pre diabetic, you know, I, I don't kid when I think it's added some significant years to my life and literally probably saved my life. And when I started and how it's really transformed my mental health, physical health and everything in between. But that's not everybody. I'm not everybody. Not everybody's gonna go on and go to CrossFit and do that. Not, and people have lives and, and context and things that exist around them that may not make them become an exerciser. And I honestly think, why do we have to Make it exercise. Why can't we just, I try to lose the word with a lot of people, like, let's just get you doing things that get you looking more like the things you want to do in life. And again, hopefully in our interviews and things with people, we have a good idea of what are their valued activities, what things matter to them, what things are meaningful to them, that if I can structure a narrative around those things that I continuously push in the patient's face, not in a negative way, but showing them that what we're doing, it's is moving towards those things you told me that matter to you. Um, and you know, I don't, does it need to be an exercise or can it just be a movement that looks like the things you told me you want to do? And maybe it looks like an exercise and I don't get too caught up in dosing and different things like that. We'll talk about, you know, great exposure, great activity, great loading, we'll probably talk a little bit about as well. But why, why we make this assumption everybody's going to be an exerciser in their physical therapy. And then if they're not, of course, what do we do? I know historically, well, the patient's noncompliant patients, you know, just not into it. They're not bought in. I would argue that's an us issue. That's an, you're not meeting your patient where they're at. You are trying to pull the patient where you're at and they're not there and you need to be better at scaling your expectations back. In some instances, I don't think we should completely say, well, nobody's going to want to exercise. That's ridiculous. We should give people the opportunity if they want to become a CrossFitter. Maybe you talk to them and they're really, you light a fire and ignite a passion and give them an opportunity and they jump on it and they just make a 180. I've had patients where they made a massive change in their health trajectory by deciding exercising things, but to, to push that upon everybody. And I don't think most of us do that, but I think there is, I have seen some with the zest of like CrossFit and functional fitness and all these things. And I'm a huge fan of Jeff Moore's group, Ice Physio. I just think some people have taken it to where not everybody is that ideal client for an Ice Physio thing. And not everybody is an ideal client for me either. That's nothing wrong with that. I just think you just have to recognize where's the person in front of you at and can you tailor yourself to them and not vice versa. So that's one of the big things with exercise. The other thing I think we don't recognize with exercise is that we're doing graded exposure every day in clinic. I would argue if you're doing exercise with people you're doing graded exposure whether you know you are or not. And by that as you're getting people engaging in movements and activities that they're a little apprehensive, anxious, scared even, over performing because they're fearful that it's gonna crumble their disc or whatever. We all have heard the narratives of frailty that come in our doors with people that feel like I am a broken, you know, frail, fragile individual that I have to, I've just, and you'll hear the stories of avoidance where I just don't do that with my back, I just never do that with my knee, I just don't do that with my shoulder. And we get them doing those things and ideally in a way that starts building them up. So in a nice explicit graded exposure thing is you recognize and you just start incorporating your dialogue about what do you think about us doing that? What do you think about us stepping up a step or working up that flight of stairs that's right over there in the corner of our clinic? Or what do you think about us starting to work on some squatting with your knee? Just so you can get enough feel for. What's their beliefs and thoughts and fears around doing things that they're not doing you I think sometimes we think well That's just a weakness or that's a dynamic valgus. That's hitting their knee. That's why they don't squat maybe it's because they're freaked out and they've been avoiding it and the common thing and you've probably heard me if you've been in this community for a significant period of time is Things I'll tell patients is like, you know, do you think you're gonna get back to walking up steps by avoiding them? Is that, is that important to you? Would it be, would life be better for you if you were able to get up and down steps? And of course, if they say yes, then what's your current approach or that? It sounds like you're avoiding steps. And do you think that's a ticket to getting you to the ability to get back to them? And ideally, no. And then, well, would you be willing to try some things with me? Because I think, you know, our skin will never get tolerant to the sun by living in a cave. You know, we're not, it's just not going to happen. And I joke and say, yeah, of course, not skin. It's not great to get too used to the sun because we know skin cancer, blah, blah, blah. Um, but yeah, but if, and I'll use that analogy, like if you do start getting back out in the sun, well, how would you approach it? What would be a smart way to do it? So you don't like get sunburn, right? And they'll say, well, I'll start very slowly, you know, get out in short doses of time. And I was like, that's exactly what we would do with exercise and loading your knee. and, or you know, or loading your shoulder. But then you've also got to have these discussions of what they think is going on. And again, maybe have a narrative where, or understand if their narrative is like, I got a torn rotator cup that's, you know, at risk to fray and tear more, or they think their meniscus is going to shred if you squat on it or whatever, maybe, and you got to address that too, right? You got to show them they're safe to do that or say, Hey, I completely validate their fear and their concern and empathize with it. And then say, You know what? We had a lot of folks who are in that same boat fearful when you hear that, but actually sometimes movement, the very things that you're avoiding, um, and you want to get back to are the very things we need to start working back into to get you to start tolerating it. We need to get you back. We didn't get you out of the cave and start nudging into it. Would you be willing to kind of nudge into some of that sensitivity if it meant it got you back to walking up to the second floor where your grandkids play and you can play with your grandkids again? Yeah. Or whatever it may be for that patient. But, and then as you get into these fear activities, you just think about, you know, be creative, right? We'd be creative with how degree, like, you know, again, I'm always trying to get a mental read. I'm like, what do you think about us doing this? What do you think? You'll hear me. What are your thoughts about? What are your thoughts about? What do you think about us doing this? Hey, I'm thinking we might do something a little bit different today. I'm gonna think we're gonna go up this flight of stairs. What do you think about us doing that? And just get an idea, like if they're like, Oh my God, you know, and they start hyperventilating and the anxiety in there, you know, you can just see, okay, let's, let's, and then maybe we break it down and we back it up. Maybe we just step up a little small box. That's like half a step's height or whatever it may be. I don't think we're, we're all listening to this can probably get creative of ways to kind of, if they're not ready to do the full flight of stairs, Maybe it's a step up to a normal step. Maybe it's a step up to a half step. Maybe it's, um, you know, a leg, single leg press on a, um, you know, with a little step on there. So they have to kind of press on the step and bring the other leg too. I mean, there's a variety of things you can do, um, with it. But I think being explicitly aware of the patient's mindset around exercise and what they're doing and what you're asking them to do. Um, it's huge because then again, you can identify some blocks and barriers to them engaging in movement and, or exercise again, or valued movements. And if there's some narratives that pain neuroscience education, or would you be willing to, would it be okay if I talked to you about what we know about arthritis and what we know about exercise? Because understandably, a lot of people hear that, man, I got bone on bone and I'm going to go to this Mark guy and he's going to exercise me. It makes no sense, right? And then most, again, most of us, yeah, it doesn't make frigging sense. Like why would I exercise something that's. degenerating, um, our good degenerative joint disease, all that, and I'm sure we all could have a support group of some of the CRUD narratives that medicine gives to people. But anyway, another lecture that'll be. So again, graded exposure, I should say. Is, um, one of those things that I think having some skills and we'll maybe have a little bit of a see if I can bring some speakers in on graded exposure, um, and help. And I don't, again, I don't think you need to be a psychologist or some master, uh, PhD to do it. This is simply taking things people are fearful of and exposing it, stem to it in a dose without a narrative of that where they can. Without giving them a narrative of frailty, fragile, or you as a therapist looking fearful because I, I had students sometimes I'm like, you're going to have them do what? And I can just see like, like, I'm gonna have them bend their back. And I remember, and I've been this student, I've been this clinician where like, you know, flexing in the back. I used to believe that that was dangerous for periods of time. And clinician, what do you think you're going to portray to a patient when you're trying to do exposure work and the therapist looks more freaked out than the patient about doing things? So. Again, that's probably, hopefully, an extreme, but again, our mindset and our narratives that we're operating under, we need to be willing to challenge those. Um, let's move into graded activity. Graded activity, I think, gets misunderstood with graded loading. Graded activity is just a, um, oh, what's the, quota based, and it's very much activity contingent programming, where we're not rewarding, um, We're not rewarding pain contingencies where everything is based on what the number is pain. I get medicine when my pain is a certain level. I do rest when my pain is a certain level. This is activities, ideally something that are meaningful or valuable or at least represents a movement of some of the concerning area where they are to slowly increase their activity level. on a dependent on what, how they work with their program or their, their programmer, where it is just a stepwise, slow increase. And then sometimes you got to scale your, your increases back sometimes, but it is, it is regardless of what symptom behavior is, you are going to make this stepwise progression because you're trying to break people out of this. My activity level is based on my pain level. It's my activity level is a steady activity level that does not, change regardless of where my pain is that day. That is a massive shift for patient, right? Especially if you're now also engaging this patient in symptom modification procedures And that's one of the things hard with like a graded activity program if you're also on the part of this session is like trying to make their symptoms Decrease and then escape their symptoms it now you're also telling them to forget that pain number and let's now get an exercise and it doesn't So great activity is probably for the person where, hey, this is more of a persistent pain, nociplastic dominant situation where it's not an, obviously you're not going to graded activity and acute ankle sprain where, hey, you probably best to not move and engage that ankle for a little bit, just not too long. Obviously then we step in, make sure it's appropriate healing times and we start reloading and getting them confident and loading again. So of course there's a time and place not to, to do graded activity and to work on pain contingencies because when things are an acute injury. and healing stages than pain, I guess is often a better guide, um, in those situations. Um, but it shouldn't be, again, sometimes can be too much of a guide. So we don't want to put it at the driver's seat, but, um, so that's graded activity. And again, it doesn't, it's not super complex. It's, I mean, it's hard for the switch of like, you can't be, I need to decrease symptoms and now, Oh, on the flip side, like I said, I also need to get you in this program that doesn't worry about your symptoms because you're You're sending conflicting messages with the patients when you're taking those approaches with people. Um, so that exercise for me, honestly, I have a blast with it. One, it's taken much more. I would say early in my career, I was probably about a 50, if not 60 percent manual therapy, 40%, um, you know, therapeutic exercise, maybe even greater. Because I, those of you who know me know that my first parts of my career were very much focused on you know, the Jedi hand skills and feel like I needed to identify all motivated. And I wanted to help people, but I thought the only way I was going to help this complexity with people is by identifying the tissue faults or dysfunctions and fixing them with my hands or doing, you know, manual therapy techniques and then complimenting them with very specific exercises that targeted these very specific dysfunctions and now exercises. To me fun. I like seeing challenging people mainly to say, Hey, what's meaningful for you? And this is where I think act is an awesome strategy because you can start using some strategies to find out what are their valued goals, what are their things that would get them to start and start to point them to that, and then steer your narrative around everything you're doing to those things, you know? Right. And then as the, you see that. Cognitive fusion around beliefs of what's going to happen to their knee or their shoulder or their back come in you start teaching them some skills you start teaching them Some present moment skills you start teaching them some mindfulness skills to where they can start not anchoring or get latching on or getting hooked by You know these thoughts and ruminations of pain and starting to get hooked and thinking about being present and engaging and valued things where I always tell patients like neurologically, we want your nervous system to start paying attention to life and doing things that mean bring value to you. So it's not your pain, your pain, your pain, my knee, my knee, my knee, my knee is with me, but I'm getting to life. And the more our nervous system and those nervous system pathways are engaged in life and all the things that life has, then maybe those nervous system pathways that are engaged with you and your pain sensation, Can decrease but also I don't it might happen to me not but again I would you be willing to and have the pain here and maybe not a huge amount different But man, you're playing with your grandkids. You're doing the things that you told me are meaningful. Would you be willing to? Experience some of this if it meant that you were back to the things again reflecting back what they told you Hopefully the showing the patient that man I he knows exactly what makes me tick what exactly bring and some people aren't able to bring it out and that's where obviously You you might need to do some values clarification with people to see, you know what, and there's some exercises and things that Bronnie shared in her work that can help us understand what people's values are. But if you can point things towards values and to me, let's get creative. Like, you know, I got a patient right now, she's a, she's looking to retire. She's owns horses, two horses, and that's her big, you know, one of her big issues is that's what, you know, hugely meaningful thing to her. That's like joy, passion, and owning the horses, caring for the horses. Being able to ride them and do things. Obviously this time she doesn't ride a lot because it's 110 degrees out right now, but, um, She wants to be able to do it and she still rides a little bit, but she's struggling to, but we were doing all the things like, You know, stepping over a, I got things set up where she's pushing over her leg to like she's, you know, getting on top of the horse and coming off the horse. She has a hard time with hip flexion and a few things. We're boxing, we're doing fun stuff, we're doing all the things that just make her feel like, Man, I can do. Uh, you know, things my body maybe isn't as broken as it is. I think exercise and, or valued movement maybe is a better word is, is awesome. It can look like exercise, but I think, um, and some people value the feeling of, man, I just fricking picked heavy stuff off the floor. I pushed weights overhead. Some people don't, you ask Bronnie about exercise and every time I've heard her talk about exercise, it is not her jam, nor will it probably ever be. And that's fine. That's a lot of our patients and that's fine. What is her jam? Getting in and doing work with her jewelry. Getting out, I think, in the garden and doing some work in, um, with that. I, I, I don't know all of her hobbies, but I would key into those. What are the things that would be meaningful in your life that would make you feel like you're checking off things in life that matters, that makes you get out of bed feeling like you're experiencing joy and happiness and fulfillment in your life. Um, and then structure our exercise program around those things. But if you can find that in your patience. world, man, I think that's the, that's the secret sauce is if you can show patients, I think the compliance rate goes up when they hear you, you know, talk about this is you getting back to your paneling with your grandkids. This is you getting back on that horse. This is you when you're starting to talk about these exercises where one, you're showing that I know what makes you tick. I know what's meaningful for you. I listen, I care. I want you back to those things. And then let's get you doing things that get you back to those things. Would you be willing to Obviously, it might take some act work and some different things to get them to say, to put the struggle with pain aside and say, it sounds like these things are meaningful to you. It sounds like you've been doing, and then again, there's goes to learn helplessness thing where we say, hey, maybe in the 15th pain doc, the, you know, 100th procedure, the next, you know, surgical procedure, the next, uh, you know, specialist, or massage, or your manipulative treatment. Maybe that's what, you've tried all those things and it isn't working. But. You know, or I wouldn't say it isn't working. How do you, how's that getting you, is it getting you closer to the things you just told me that are meaningful to you, meaningful to you. And then again, you can go into the short term, longterm, you know, gains and costs with it. And hopefully people can come to the conclusion that, shoot, I got to take a different route instead of like face on and tug playing a tug or this pain, maybe I need to put it on the side and lock arms with this guy and start working, walking towards meaningful things in my life and stop putting those things on hold. the way medicine does, because medicine puts people in this stupid battle with the 0 to 10 and ask them about it constantly. And Medicare wants you to ask about it, JCO wants you to ask about it, and all these, you know, accrediting bodies here in the U. S. I don't know how it is overseas, but I'm sure, um, there's some dated ways of looking at pain ratings and NRPS scales and how continuously putting that stupid number in front of somebody's face to where their success in this world is based on what that stupid number is. You know, as again, that's numbers that's so invalidating and so reductionist on such a massively complex and unique person by person experience. So I'm off of my soapbox. Hopefully this brought you some value. I'd love if you could comment in the comments, how has your approach with exercise changed? What are you doing differently? Excuse me with, with exercise, how were you taught and how does it look then? And how does it look now? And with our understanding of pain signs, what is exercise looking like for you? Um, how does that change things? I'd just love to hear it in the comments. So, again, I hope this was valuable for you. Thank you for watching. And I hope to see you online soon.

This has been another episode of the Modern Pain Podcast with Dr. Mark Kargela. Join us next time as we continue our journey to help change the story around pain. For more information on the show, visit modernpaincare. com. This podcast is for educational and informational purposes only. It is not a substitute for medical advice or treatment. Please consult a licensed professional for your specific medical needs. Changing the story around pain. This is the Modern Pain Podcast.