Chapters Transcript Video Know Pain, Know Gain Adriaan Louw, P.T., Ph.D. presents at the Johns Hopkins Department of PM&R’s Grand Rounds on November 13, 2017. I there. Uh Thank you for rearranging your, adjusting your clinic schedules. If you bear with me, my voice has been uh cutting in and out all weekend. Uh It's a pleasure to be able to introduce Doctor Lyle to you guys this morning. Uh He's earned his undergraduate and master's degrees in physiotherapy at the University of Stellenbosch in Cape Town, South Africa, excuse me. Uh He's adjunct Clinical Faculty at Saint Ambrose University at uh South College and then also the University of Nevada Las Vegas where he teaches pain science for the past 20 years. He's been lecturing both here in the US as well as internationally uh at both manual therapy conferences, uh Pain Science seminars as well as medical conference. He's a certified spinal manual therapist, certified pain therapist and he is author, co-authored, over 50 peer reviewed articles. He received his phd uh pain Neuroscience education and he's also the uh part of is the director of the Therapeutic Neuro Neuroscience Research Group, which is an independent collaborative uh initiative, studying pain neuroscience. And lastly is the program director and Therapeutic Pain Scientist and Pain Science Fellowship through the through Evidence and Motion without further ado, see you very well. All right, thank you. Good morning. Excellent. Um There's a really cool new study that just came out. It's a double blind study on two blind people that told us for bad voice. The thing that really helps the most is hugging and so I think all the residents as you go through the day, please hug Terry because it helps, it helps the throats a lot. Very excited to be here this morning. And thank you guys for having me. I'm kind of on a long trip on my way home. It's been three months since I got to get home today. So I'm sure there's honey, dude is waiting for me. I got to break the leave. I got to take the trash out. So I'm excited to go home, but I'm not that excited. So anyway, it's nice to stop here this morning. Um I'll try and do this this morning as quick as I can. I'm, I know we don't, we don't have a lot of time, but I'll quickly run through this. First of all, a disclaimer, I publish books on pain. Don't buy them, please. Um I do seminars, please do not attend them. And um I'm actually pretty happy all our resource is self funded. Um When we do speaking engagements, a bunch of our money goes that way. Um We have no interest in any pharmaceutical companies, et cetera. Um This is what you're going to learn today. It's in your hand out. Um I am from South Africa. If you guys head south, you're not going to get there. Um If you drive 19 days, you're gonna get to Brazil, take a left at the big tree and you can come visit me any time you're going to get wet. Um By the way, I have to put this out this morning. Um I do not have Ebola. Uh Most people when they find out I'm from South Africa like, oh, I gotta be careful, don't talk to him during the break. Um There's more South Africa and by the way, there's three, you can fit three United States in Africa before you visit me. And so don't come to me during the break and say I have a cousin in Nairobi. Do you know him? I probably don't know your cousin but maybe I do. Who knows the real privacy of this morning's presentation is we don't have time to cover the cool things in life. Um The deadliest animals of Africa, the deadly snakes. We've got the beautiful scenery. Um, unfortunately, I have to talk about a horrible thing this morning called Pain. So please can visit us any time we lose a couple of Americans, but you don't want them back anyway. So. Alright, so we're gonna start this morning with a patient. We have to always start with the patient because I hope everybody understands this morning. If we lose the patient game over, right. It's about the patient. So all of us can probably sing the same pain song that has been sung all over this world with people with chronic pain. Where do they hurt? What makes him better? What makes him worse? And, and this is no reflection on the patient. Don't get me wrong this morning. But it's a common analogy. All of us know this. So I want to introduce you this morning to one of my patients and you guys see patients like this all the time we call her is Susie this morning. So if your name is Susie, I deeply apologize. Right? So Susie comes and sees us. She's got widespread pain. Currently, she's getting epidural injections or as my patients call it epidurals. She's getting nerve ablation, medial branch of the facet joints that are ablating those nerves and she's getting physical therapy. And in my profession right now, the thing she's getting is core, core, core. And every time we say that your transversus abdominous should fire 0.05 seconds faster. Which is ironic because the Australian spine only has three muscles, transversus mtu and the deep net flex or no other muscles apparently matter. But that's another story. She's seen many providers, 17 physical therapists, 19 chiropractors, three podiatrists, nine doctors everywhere we see these stories, right? They go on these journeys which we know they have to do. The pain is spreading in Suzie's body. There's increasing pain if I went to a physical therapy school this morning, I would ask him which Dermato and I'm sure there will be some students sitting there going well. It's a little bit of one, maybe a two. Obviously, this is way more complicated. The bad news for us today is the Institute of Medicine says there's 116 million people in America right now struggling with chronic pain. As we're sitting here today, we know 94 people in America today are dying from prescription opioids. There is obviously a major problem. So the issue for us is obviously how do we deal with patients like this? At least in my profession, we have to figure out a way. What do we do for them? Well, here she is, you'll notice this is Susie, this is the actual patient and she's blind. Um This is her standing in neutral and we are asking to bend forward and that's as much as she will bend forward. I reach over and I ask her, why are you stopping? What is she saying? It hurts. Which for me is a major problem because she has tied movement to pain. I'm a physical therapist which means I'm now public enemy. Number 10 no, you come as a physical terrorist. He's going to bend me. No, no, no, no. Right. So she's very afraid of me, by the way, if I will run over to her brain and put a stethoscope on her brain and I can listen to her brain. I'm sure we getting things like movement equals pain. By the way, if I avoid moving, I will probably stop hurting. And although we know avoidance helps short term, you sprain your ankle this afternoon, shift your weight away from it makes sense. Totally sense. But long term it serves no purpose. The two smartest behavioral psychologists in the world, Joan and Steve Linton showed us that avoidance leads to this youth, depression and disability which we now know feels more pain. Ok. Fine. Where were you? A few months ago when I asked the lady in the clinic, what brings on your patent? Every breath I take on this God forsaken planet hurts. Well, Suzie, I need you to avoid breathing for a little while and see how that works out for you. Obviously, I failed my ethics course, it doesn't work. Avoidance doesn't work especially long term. The problem is we now know there is growing evidence for chronic pain, no matter what condition we look at that. There is an overwhelming amount of evidence that movement is critical. Actually, for Cochrane reviews, it is gold level evidence, motion is lotion, it moves people, it gets so many cool things going, which we'll talk about this morning. So I'm at a crossroads here. She doesn't want to move. I am a movement person. And now what do we do with this patient? The problem is movement will probably drive fear for her. So, what we do next is we start teaching her about her back. Well, Suzie, you have the back of a 90 year old Susie, you have a bulging disc. The biggest one we've ever seen, Susie, your core is weak. The biomedical model that we're following, torn, ripped, rupture, bulge herniate, not only has shown us has a significant limitation. Why? Because we know there are people in this room this morning sitting with a bulging disk and you don't even know about it. We know one in 25 people have a spons whether we have to shift forward. You're not even aware of it. We now know one in three people have a torn rotary cup and guess what? You're not even aware of it. Which is ironic because again, we tell people about the health of their teachers and what does it do? It induces more fear. The famous quote by the late Gordon Waddell who just passed away. And if every therapist in this room would make a plaque in your waiting room. Here it is. The fear of pain is worse than pain itself. Pain Journal. 1993 beautiful statement. But it's true. How many times has somebody said in the clinic with a knee replacement? I haven't even met them yet and I walk out to the waiting room. Hey, Frank. Oh, no, no, no. Here they come. I don't even, I haven't even met you yet, but they're afraid because I'm going to bend their knee. The fear of pain drives pain very powerfully. So our models have to be updated. One of my favorite models is the one by, um Haldeman in Spain a few years ago. This is the model you and I were taught in school. A grade one ankle sprain hurts a little bit at grade two more and a grade three more. Is that true? Yes, it is. Don't become cynical, please. But we know it's not true in everybody. We then come in and do an intervention. We manipulate a joint, we inject something, we medicate it and pain goes away. It works. Still don't give up on us but not for everybody. If this model is true. Then explain to me this morning, a paper cut on the level of tissue injury. Where do paper cuts fit? Zero being no tissue trauma. 10 is severe tissue trauma. Where's paper cuts? Minus one? Right? How much does it hurt? All right. Turn to the person next real quick. One of you guys open your fingers, the other person just give him a quick slice. Right. Then how does that work? It doesn't make sense. Let's flip it the other way around guys. There is a saying in emergency medicine, the worse the pain, sorry, the worse the injury, the less the pain. We know there are people walking into emergency medicine, impaled with a two by four and going, I'm good. I'll just take a seat, get with me when you can, right? How cool is that? There's something obviously wrong. So Haldeman talked about this model here. There are people walking into medicine every day looking for care that have severe pain and disability, but we scan them. We find nothing wrong, we do blood work, nothing wrong. Come on guys, name me some conditions you're currently seeing that have severe pain and disability, but we don't find anything wrong on the test. Fibromyalgia, right? Chronic fatigue syndrome, complex regional pain syndrome, back pain here. Whiplash associate disorder. We can go on and on and on. But before you could get negative this morning and very depressed and I go, I wish we never invited this guy. I want to introduce you to the coolest people I've ever met in my life. People that have disease states, injury, states, but yet experience very little pain and or disability. We have names for them. Iowa farmers, Alaskan commercial fishermen, rodeo, clowns and rodeo, cowboys, demolition derby drivers. It's amazing. There are people out there with the horrible tissues. Come on guys. Last weekend was the New York City marathon. Have you guys ever watched the marathon? You park your lawn chair, you got your cooler today. We're watching the marathon first. The Kenyans. What was that? Right? Then there's that middle. Have you guys seen the back runners of a marathon ever? They run something like this, right? And then they look at their watch. I'm beating my time by nine days. They are disasters mechanically, but they're having the time of their life, which is intriguing because we have to think is this model. Does this model really serve us that? Well? We know in contrast to this today, very well documented, 40% of people in downtown Baltimore today have a bulging disk and life is perfect. Right. We're not negating that bulging disks are an issue. Trust me, if you have a bulging disc and your foot is numb and you cannot pick up your big toe, I will drive you to the or all right, we're not disputing that. But the thing is we have shifted this model bulging disc means pain, which means we're going to intervene. One in three people are walking out of spine surgery with the exact same pain as preop comes at a big cost for us. By the way, we also know they absorb. One of my favorite studies is a Maui study. A few years ago, people showed up at the emergency room urgent care with low back pain and Ridic opathy. They scanned him and found a bulging disc. They then asked him, could he come back every week? They scan him every week. They glowed in the dark by the third week. And what did they show us? They were 50% smaller. Six weeks later, we now have a bunch of research to show us. We scan you nine months later, they get completely reabsorbed or as one of my neurosurgeon colleagues says if they can just stand the pain long enough, it will go away. Right. I'm not talking about neurological deficit, right. We know they look different when you lay on your back. And when you bend over, last time, I checked the vast majority of my patients hurt when they're upright, when they sit, when they bend, when they stand. But yet we find more bulging disc when you lay on your back versus standing upright. So there's this dichotomy between tissue damage and yet a lot of us have these kinds of things, which brings me to one of my favorite slides. LS to me, Nikolai Bo showed us the lumbar spine starts aging in your early twenties if that's news to you. I'm sorry. Welcome to the human race. It happens to all of us. Let's see how smart you are compared to the New Jersey people this weekend. From 20 to 30. Does you back get older or younger? Excellent work, 30 to 40 older, younger, excellent work. You're little behind the Omaha people of 40 to 50. As we trace back pain. You're getting older, right? We call it the wrinkles on the inside. If we scan you, we're gonna find wrinkles on the inside like we find them on the outside. By the way, the wrinkles have names. Stenosis, sclerosis, crack and spurs. We give them names right at what age is back pain. The most prevalent at what age do people seek more care for back pain than anywhere else? Depending where you read 35 40 45 50. So let's have a quick look. This is back pain. Oh Sorry, this is aging of your spine. This is the prevalence of back pain. So what's the correlation between experiencing back pain and seeking care and how old your spine is not as much as you think. Do you know how many Iowa farmers I showed this to? And they say they turn to me and say so just because I'm getting older, doesn't mean I'm gonna hurt. Exactly. Let's move. If you want to look at the research right now, aging isn't correlated to pain. You know why old people hurt is because they stop moving, which for me and you should be amazing. The therapist in the room, your loin should be trembling right now. I mean, you should go. This is what we do. You should have serotonin dripping out of your nose, right? Because I sell movement every day. I'm a used car salesman. Come on down to therapy. We got movement. But if you call in the next half an hour, double movement. I'm sorry. You guys invited me. I really apologize. This is what I do for a living anyway. The problem is when people come to us in pain, you need to understand there is a percentage of people that come in that have pain and their tissues are as good as they're gonna be. Tissues have healed. Guys, it's November. We're almost at the end of the year, your department head is going to come to you soon and ask you, hey, guys, our budget is almost done for the year. We have a little bit of money left. We got to spend it before the new budget comes in. Don't buy a new ultra Fix it machine please. Or a new high low table buy a neon sign for your waiting room. Tissues, heal tissues, heal tissues, heel because our patients believe because I hurt my tissues must be bad. Therapists. Do you realize tissues heal without physical therapy at a tailgate? There's a guy spreading his ankle going physical therapy. Bud light, bud light me, I think bud light has made a lot of ankles better, by the way. Anyway, that's another story. So the point is tissues can recover beautifully. And I want you to understand there will be a percentage of people who come to you that hurt and they really hurt. Absolutely hurt. Just for the record. My world is now in neuroscience where we scan brains or whatever, we've never scanned fake pain. Ok. Do you understand that in medicine? As a saying, if you have to prove you're sick, you will never get healthy. You know how many patients walk in every day? They gotta prove they hurt how refreshing when you say I believe you. I may not understand all of it, but I believe you. Right. There are people that don't get the message I'm saying. No, not telling that it's true. They hurt but it's not their tissues. They have a pain problem versus a tissue problem. And now the dynamic has to shift. So the aha moment for us happened in the mid 19 nineties. Um when we were barreling along this world of orthopedics, manual therapy, whatever people would come to us with low back pain and we teach them everything about their back, good dis bad disc, good dis your disc. We run over and grab the spine model. What sits on every spine model in this country at L four, that red pussy bulb, right? And we run over. You got this, you got this biggest one I've seen or is your spine model? So out of shape as you run pieces fall out of it. Yeah. What we have found out is that this don't only not help people, but it actually induces fear. And as I showed you fear drives pain. So a very smart zoologist who became a physical therapist actually came upon the idea. They said, wait a minute, what brings people to therapy pain? So why don't we learn more about pain and then teach people instead about their low back, teach them about pain. Somebody walks in a clinic with shoulder pain, we teach them about pain, not the shoulder because the mechanical knowledge may not be that helpful. So in 1998 at the International Association, a study of pain, the World Body that studies this Louis Gifford presented the first presentation called explaining pain to patients. But as everybody knows what happened in the nineties, evidence based medicine. Do you remember that day, Friday? I'm in the clinic. I'm fixing the world. I am God's gift to medicine. Over the weekend, evidence based medicine came and said everything you did. Friday doesn't work anymore. And I just came Monday in the clinic. I'm it worked Friday. What's going on? So we had to do research, right? So we started doing research, research, research. And so along came a very smart gentleman. We call him sir La Mosley, by the way, and La Mosey came by and studied this idea. People with chronic low back pain came to therapy and one group was taught about the back. This is how you bend, this is how you twist, this is your disc, et cetera. The other group has talked more about pain and lo and behold, it showed the group that was taught more about pain did drastically better on function and on pain measured one year out. So this concept of teaching people more about pain, started growing this idea. Wait a minute, let's teach people more about pain. Long story short as we stand here in 2017, the research now has grown lots of RCTS there are five systematic reviews that says when a patient comes to you Monday morning in the clinic and you teach them about pain and how pain works and they get it in the marrow of their bones. They go, I got it. The pain goes down. Their function improves their catastrophic goes down. Their fear of avoidance goes down. They do more movement even though they hurt. And by the way, they spend less on health care. A very neat concept. If you think about it for those in the room, Mosley showed us the numbers needed to treat for pain. Neuroscience education to improve function is 2 to 1 for pain. It's 3 to 1 for every two people who work in a clinic with chronic low back pain. We teach them how pain works. One in two will statistically significantly shift in function positively. One in three will be pain. The current Holy Grail in chronic pain for medicine is low dose antidepressants and membrane stabilizers, gabapentin and antidepressants like Ssris. These are their nnts. Now, there's a number missing here. Numbers needed to harm. Numbers needed to kill. We know there's a significant risk of suicide with Ssris. Unfortunately, we've never studied it, but I've never heard of a patient that died when we explain pain to them. I've had patients, tell me something about my mother and I've had patients stand up and tell me something about my ancestry, but they haven't died. And in this day and age. When we talk about opioids, opioid addictions, et cetera. The risk benefit ratio is something that has to be considered. So this works. That's all I can tell you this morning. It works. There's growing evidence and we're working on this concept. I need the clinicians this morning to understand this slide for me. This is the holy grail. So when it comes to behavioral medicine, when somebody comes to you in pain, I know we all want to do an intervention and somebody walks out and says, I'm pain free if I could do that. Bill Gates ties my shoes for the rest of my life. Guys, pain is complex. Chronic pain. We're cutting people's limbs off, they still hurt. We're putting them on the most incredible drugs. They still hurt. Pain is not biologically designed to go from 10 to 0. It is designed to go down, down and down. But what happens as pain eases function improves despite the pain. And we have now we just published the first three year RCT of pain neuroscience education and guess what? Pain keeps going down, keeps going down. But it doesn't do this in a week. The mcdonald's approach, right? But as your patient's pain comes down, you notice it has good days and bad days. Football team wins, football team lose, football team wins, football team, wife, happy wife, mad wife, happy wife, mad, right? Pain is very emotional, the ias definition of pain. It's an emotional, there's an emotional component, right? But as patients, we work with patients, this calms down for the clinicians in the room, we give every patient one of these in our clinic, we laminate it, we give it and put it on your refrigerator. That's how it is because what happens? We walk in the clinic. How are you doing? I heard. How are you doing? I heard. How are you doing? I heard But in the meantime, there are we risk shifting. Their fear of sorry, their neck disability is shifting. Focus on function. Or as I tell my patients Suzie, a month from now, I'm going to see the grocery store. I'm going to ask you this. How are you doing? And you're going to say this. I heard and I'm going to say this. I know two months from now. How are you doing? I hurt. I know three months from now. How are you doing? I hurt. I know but there'll come a time and day. I'm gonna catch you at the store. How are you doing? You're gonna say this. I'm doing great. I'm getting ready to run the breast cancer fund run. I am soccer mom of the month. I'm cleaning my house and I'm gonna ask you, how's the pain? Oh I still hurt. See the difference. It's that shift and it takes a lot of work guys. We are spending trillions of dollars on this stuff right now. But the point is pain free is not the solution. It's the, despite the pain, we're moving patients and we have a plethora of research to back this idea. But the problem is patients obviously expect to be pain free today. Right. I wish it was that simple. I really wish it was. It's a little bit more tricky than that. So, who does this approach? Well, to date it is mainly done by physical therapists. It doesn't mean we are the only ones who can do it. We just got done with a massive trial in the V in Minneapolis where we trained physicians, psychiatrists, well, physician, psychiatrists, psychologists, clergy, so workers, PTOT, et cetera, everybody can do this. All right. So this is not, we just happen to be doing the current research. Um, how long do we take time to spend with people in a therapeutic environment? We spend about 10 to 15 minutes for therapists. It's got to be above eight. So we can bill for it. Um, but we cannot spend five hours with a patient with a cognitive intervention because we have to see 20 people a day or whatever it may be. Um, typically one to twice a week and they typically are stand alone with all other treatments. We often combine them with the physical treatments. One on one is by far the best education is one on one is by far the best, especially for pain. Why? Because pain is an individual experience, we did a huge study where I went to big cities in this country and I stood on the stage and we invited people with chronic pain for free. Come listen to this thing about pain and they love it and they laugh and deadliest animals of Africa slides or whatever. And they come to me afterward and said that was fantastic. But let me ask you about my pain. This pain is individualized, right? The future, however, will have to be groups because we're running out of money. Dr Richard Deo calculated by 2050 we're going to spend every penny of our gross domestic product on health care. As we're all staring down this thing called healthcare reform and bundled payments, which it seems to be happening. Um We may have to look at more group interventions um for especially for educational models. What do we teach patients? All these beautiful words. You remember these synapses, action, potential inhibition, facilitation, by the way, I've never used any of these words as a patient. But guess what we do, we take this advanced neuroscience and we put it in a story. How do we learn in life about stories? How do how does society learn stories? Right? OK. How many of you guys can remember the story that taught us in the hair hands up? Yeah. How many of you guys can remember what you taught about history in second grade? No, we learned through stories. What we've just really done is we've taken the most advanced neuroscience, put it into a story, tell the patient, the story and guess what a large percentage goes. I got it. Thank you. And that is the idea behind the educational models. So we use prepared pictures, metaphors and hand drawings and I'll show you one in a minute. By the way, we have 46 stories we've designed and research for the last 10 years that we use for a variety of different conditions. We had headaches, chronic fatigue syndrome, whatever it may be we're studying but it's stories and metaphors we're using. So this is Bill for, he's the father of behavioral medicine and I love his quote education to behavior changes. Like throwing wet spaghetti at a brick. Can they print any larger on cigarette packages that smoking kills? We are spending $2.1 trillion telling people smoking causes cancer and people are smoking. Anybody know what the smoke cessation success rate is. It's about one in five. They even changed the message recently. Mhm. I mean, you know, there's a guy that said I, I'll do cancer but, 00, no, no, no. Right. They're trying to change the messages, et cetera. So the issue is education as an intervention by itself is not that powerful. We gotta add it with something else. What we recently found out is when you do pain neuroscience education, teach people how pain works and you combine it with something physical that combination is far superior and especially something that's movement based, preferably active versus passive because we know we need to have the patient take control and help themselves in the review we just got done published last year, we looked at all the different systematic review, sorry, randomized clinical trials using P and E high quality trials that showed when you combined pain, neuroscience plus movement in all. But one study there was a statistical significant reduction in pain and that's why I tell physical therapists always pi neuroscience education isn't psychology? All right. I'm not a psychologist. I work with psychologists. I highly, I highly regard them and every time I meet a psychologist, I just have the urge to tell them. I love my mother. Sorry, I just, the psychologist one day told me of course, he said Adrian, I will seize psychology if you in one sentence. Yes, sir. He said you either love your mother or you hate your mother. That's psychology right there. Now, I'm sorry. I don't mean to say so I just feel compelled. But so I'm not a psychologist, I'm a physical therapist that does a cognitive intervention, but a combined movement with it. That combination seems to be quite powerful. So let's go back to our patient, Suzie right here. She is. In the old days. I would go sit with her and tell her how bad her back is. It's the worst back. I've seen the last back. I saw like this, that patient is dead now. Right. We'll tell her the horrible stuff and what would happen is it would definitely flare up. Oh, by the way, if I did my old manual therapy approach and work on her and she came back and she flared up, it was her fault. How dare you flare up me, Mr Super manual therapist. You probably did something wrong at home. Stupid patient. Right. That's what we did. We blamed the patient. What do we do? Now? We take somebody with chronic pain, especially somebody with central sensitization and we realize they need more of a cognitive reappraisal of what's happening to them. So for Suzie, why did we do this? Because she has all the hallmark signs and symptoms associated with central sensitization. We now know that central sensitization is one of the categories that really respond well to pain, neuroscience education. There are three people in our research. We have figured out that does really good with this type of cognitive restructuring, high fear, avoidance, high pain, catastrophes, catastrophic. You see the cup is half empty. That's it. Life's over. Bury me. Now, I have a bulging disk. I'll never walk again. How did you get your frank? I walked right. But they see life is, that's it. And yeah, hey guys, next week's Thanksgiving, isn't it? We all have one of those family members that, that says that you, you don't want to invite them, right? That Debbie downer like, oh, we got to invite cousin Eddie again and he's always so down. He's such a downer. Well, some people, unfortunately what happens during their medical process, visits and visits and visits, what happened? They become very down and we can measure with pain catastrophes, scales. But they actually do really well when you teach them how pain works. So, moving on, there are many stories. As I said, there's 46 stories we designed for different research projects. We did that. What I'm going to show you real quick is the highest ranked story by all patients in all the trials we've done. You're going to look at it right now and you're going to say this is silly. I get it. I apologize. You're gonna look at it and go, I cannot believe they gave the guy a PD for this nonsense. It works. I'm sorry. So what we do is we take the nervous system and we, we metaphorically compare it to an alarm system. So I would tell a patient, Susie, great new research out of Tokyo Sydney, London and Iowa Iowa Department of Tourism asked me to say that by the way, actually there isn't a department. His name is Frank. Anyway, our body has a living breathing alarm system called the nervous system. There are 45 miles of nerve running through the human body, wiggle your big toe to notice the back of your neck, move, move your head up and down the. Notice. Your low back move. How many miles notice? Recall now, Suzie, our nervous system works like an alarm system. When life is good. It's just buzzing along. Life is pretty good. If you step in a nail, you hurt your back. I punch you in the arm. What happens? Your alarm system ramps up and goes ding, ding and fires a message. The message will fire us safe. If you step in a nail from your foot to the spinal cord to the brain, it says dinging ding, there's a nail in the foot that punch in the arm. Dinging. Adrian is a jerk, right? What should happen is we take care of it. So what do we do? We pull the nail out and our alarm corms down. How many of you guys have stepped in a nail by the way? Or a thumb tack when you pull it out of the pain, just go away. It lingers, doesn't it? So what happens? Our alarm system will slowly calm down and you get on with your life. We hurt our back. We can get some help and it calms down, right? Fair enough. Adrian punches you in the arm. Adrian is a jerk call the lawyer take care of the problem and it calms down. Well, Susie, we now know in one in four people in this world, the alarm system gets activated through an injury, an accident, emotion surgery. And what happens you take care of it. You go see the doctor, you go to the emergency room, but the system never calms down. Now, your alarm system is running at a much higher level than before the injury before the accident. And what this does, it completely changes your life before you develop pain. You could walk five miles, drive five hours in the car to grandma's house. You could deal with stress of the husband and the kids. Now, 20 minutes of walking, ding, ding, ding, the alarm goes off. Five minutes in the car, ding, ding, ding, the alarm goes off. Now, I know you're looking at this right now. And is it kind of silly? It works. This is a metaphor for central sensitization, aloia hyperalgesia. These fancy things were taught this slide is the highest ranked single picture by patients in all our clinical trials where they go, I got it. Now they ask us questions at this point. What do you guys think? They ask us? How do I tone it down? That's the number one question. And when I do that, I want you to do this. Why? Because they're not focused on their disk, they're gonna go. How do I turn? That's the right question. Now, don't kid yourself. What does a real patient say? What does this have to do with my bulging disk and say, OK, Frank, let's talk about bulging disk today. I believe why we cry in therapy every day is because we peel onions layers, right? And if you can get quicker down to the core, this, yeah, this sounds great. But what about my to rotary cup? Right? And say, OK, well, let's talk about rotary cup today. OK, fair enough. So what we now talk about are the nonpharmacological ways of calming the nervous system down in rehabilitation. There are 20 different things we have measured with scanning that can calm the brain down. That is non pharmacological. You guys do understand the most powerful Walgreens in the world since eras, our brain produces opioids, 50 times more powerful than what you can get into the emergency department this afternoon. It has to because as I'm lecturing right now, there's a farmer in Iowa today putting up a fence, the old girl grabs his shirt by accident and pulls the arm and cuts his arm right off. What does his brain do? It turns on and Keflin Endorphin. Serotonin shuts it down. He feels nothing. It puts a tourniquet on his arm, it picks up his arm, he walks a mile to his truck, right. Gets in the truck and he drives 20 miles to the, er, some sort of coffee then goes to the, er, right. Yeah, our brain can do it. Now, there's things in therapy we can actually do to turn the system beautifully on. So, come on, guys in a perfect world. What do we do? Sally walks in chronic pain, we teach her how this works, we build a nonpharmacological therapeutic program and as this thing gets better and better, my physicians come in and we take the drugs and we slowly taper down. I'm very happy to report that. What we're doing here is now part of the anti initiative in the va big shift in trying to get people obviously towards the opioids motion is lotion. I don't have to prove to you guys that that movement is important. This slide is amazing. A six mile run produces 10 mg of morphine in the brain. So any runner in the room, you're a drug addict, shame on you, right? But exercise. This is just one example of there's many of these out there. So there's the thresholds that we use in exercise for people is the Hoffman study. As an example, 50% of your vo two max for 10 minutes produces the happy chemicals. By the way, this part of your slide is called the runners high watch this this afternoon you put on your running shoes, you walk out of the front door, you start running two minutes and you think to yourself. Oh my gosh, running sucks. Why am I running? I hate running two minutes later. Like, you know, this feels a little bit better and then a few minutes say, oh, this is really good. You know, I should run a marathon. I'm probably half Kenyan. I can win. The whole thing. What happens is you start producing the happy juices. Right. So the idea would be now in therapy and Sally walks in with triple fibromyalgia, right? I cannot start her with 10 minutes, but we start with three minutes, two minutes somewhere. And we add a minute every other day. The falter study, they took people with chronic fatigue syndrome, fibromyalgia started with three minutes of walking, minute and a half turn around. Come back. You're done every other day. They added a minute, every other day, they added a minute to these thresholds, right? So this is just one example of this stuff. We can do therapeutically to calm the nervous system down. So here is Susie Blind is a vet and I ask her now after teaching her how pain works, I'm a manual therapist. I didn't mobilize, I didn't manipulate her or anything. We just explained to her how pain works. I asked her, can you just bend forward to me? This is her inflection and extension. So there is an immediate effect. But now by the way, this is a simple case study, right? Not simple. She's a real patient of mine. But the point is we have now RCT systematic reviews. All the resources show it really affects people's movement positively. What we now have been working on lately is that can we maybe prevent disability? Can we do this for acute pain? Because we know it works in chronic pain. We have all the evidence to prove it. I want you to understand this morning, we're not trying to prevent pain. Iii I shudder when I sit at a conference and somebody talks about let's prevent pain. Guys, pain is normal without pain. You'd be dead. Mendelian disorder. Congenital insensitivity to pain is very, very tragic. People die very young. What can we prevent chronic chronicity? We can prevent disability, right? Pain is a normal human experience, allergy. You'd be dead. So, what we have said is, can we make people so smart that when they get pain, they choose to go this way? Not that way. Ok. Physical therapist real quick. Sorry for the others. How many of you guys, by the way in this room have had back pain hands up. If you're a healthcare provider, you've never had back pain. You're dead to me, you're just useless. Ok? How many of you guys have had back pain, treating somebody with back pain? How many of you guys have back pain, treating so much back pain, knowing your pain is more than theirs, right? The therapist you lean over the patient. You're stupid patient. I'm gonna go, I'm gonna go get the hot back. I'm coming. Hold on. Right. We just published a paper on that. We went to the PC conference. Do you know that? 96% of the P attending the conference have had back pain? 90% reported having a back pain, treating somebody with back pain and 60% percent were convinced that they had more pain than the person on the table. What percentage of the therapists took a day off from work? Zero. Zip Nada. Because if you hurt your back today as a therapist and I run over and put a stethoscope on your brain and I listen, you know what your brain says, does back pain. Everybody's got it. Nothing I could do for it anyway. Might as well keep working. I mean, think about it. Right. How cool is that? I know this is not Kosher this morning, but low back pain is the common cold of the musculoskeletal system. We all get. It usually goes away by itself. Give a little bit of time, lay low for a day or two, a little bit of stretching and it goes away. There's a small group of people that develop bronchitis that need to go to the doctor. Well, guess what back pain can do the same thing. Now, the question is this morning, do you think Pfizer will sponsor that billboard for us or the American College of Surgery? No, it's, it's, there's something here. So, what we want people to do is when they hurt become PTS. Buy the t-shirt, no fear and move on. Right. So, we've been testing this in the last couple of years, right. So, real quick. Um, we spent about five years and a ton of research to figure out and we build a preoperative pain neuroscience course. We wanted to teach people before surgery, we wanted to teach them about pain. The idea is, can we teach you more about pain? So they do better on the other side. So we chose spinal surgery just because so many people walk out of surgery with the same kind of pain and disability. By the way, we did a whole bunch of testing and there's a whole bunch of studies we did. This is a single case design. This is a lady with an L five S one, her dis she's laying in a scanner, nice and relaxed. She's watching a movie. If you want to know it was, it was Finding Nemo. There's no brain activity when you watch Finding Nemo. And after five minutes, we asked her to do an anti pelvic tilt which really hurts by the way. And we now know that the pain neuro matrix work from meals, the brain just lights up, basically just lights up all this incredible pain experience. We pulled her out of the scanner, we took her back to the room, we sat her for 20 minutes and just explained to her, this is how pain works. And basically this is sort of doing the same thing as that. But after learning about pain and that is a 20 minute intervention, we have other scans that when we do it for about two hours, the brain completely calms down. By the way, this translates to straight leg rates going up for reflection improves pressure, pain al Gomery, there are physical changes in the system as well. Apart from fear goes down catastrophes. So we did a, a multi center randomized clinical trial patients getting ready for spine surgery. One group saw the surgeon before the operation for education and then they went through surgery. The other group saw the surgeon and then were sent to therapy for one visit. 30 minutes. This is how pain works. There's a $3 booklet, have surgery. We didn't try and talk him out of surgery, by the way. So very excited about the program. We took pay patients through it and lo and behold it failed. I was very devastated because what we showed is one year later, people that learned about pain was no better for function, leg pain, back pain or whatever. And as I was looking at this data, I was thinking to myself, oh, this is really horrible. I hate phd work. And then my mentor, David Butler emailed me back and he said, you idiot, you found the Holy grail. I said, what do you mean? Watch this guys? Remember? Pain free isn't the, we didn't expect people to walk out of surgery. Pain free. Pain is normal, right? Pain says what? Don't run the New York City Marathon day one post laminectomy. It teaches us slow down a little bit. Right. Fair enough. Here's the interesting thing. If you look at the behavioral aspect, even though our patients had the same amount of back pain, leg pain and disability. They rated their surgery for superior on about every category. We ask patients questions, right. We ask them things like knowing what I know. Now I would do this again in our group. Yep. The other group, no surgery met my expectations. Now, this may not seem that important. But guess what Blue Cross is all over this data because they like patient satisfaction. The surgeons that I present at conference are like, yeah, but guess what many of my physician colleagues, their pay is tied to patient satisfaction. Here's the important thing. Our patients spent 45% less on health care in the one year post surgery. And that's the behavioral shift even though I heard I'm not going to go to therapy even though I heard I don't need an MRI because pain is normal. We we we saved over $2000 per patient. By the way, three years later, the same savings was still intact. So we three years later, we tracked them out. The interesting thing is we saved over $2000 per patient. There were 600,000 dys in America last year. If every patient followed this protocol, going to therapy for one visit, 30 minutes, $3 book, we would have saved $1.2 billion. And I'm mentioning this because for any therapist in this room that wants to do research for the love of God. Measure money, all right. I sat with the CEO of Blue Cross and he told me, he said, Adrian, I don't give a rip about patent function. I care about money. And I said, thank you for being honest with me. At least I need to, I'm not making fun of. This is serious stuff. Guys, there are people dying from prescription opioids today. This is a serious topic, but we need to start measuring things that really matter. Um Obviously, and I'm not saying it doesn't matter because guess what the patients were way far better off with this. When this got done, we designed a knee replacement one. We just submitted this two weeks ago for publication, we did a pre-op knee replacement program. And again, basically, what we showed is people had a drastic shift in some of their beliefs, going heading into knee replacement. And the interesting thing is the knee that's getting the knee replacement on pre-op when we teach them, the knee calms down 20%. We use pressure Al Gomery, we can press 20% harder before they. Yeah, that's it. And so the nervous system actually dampens before the knee replacement. Um Also they are way more satisfied. We now are tracking these patients two years out. Um Actually, if I head back today, we're going to get the data this afternoon, um, they actually do way better than the other group for knee replacement. And then finally, the study that's getting me most excited is this one. We went to the middle schools in Wisconsin and we trained 5th, 6th, 7th and 8th grade, middle school kids on the neuroscience of pain. So we sat with kids. We taught them a 30 minute lecture like today about how pain works and lo and behold their knowledge jumped higher than any health care provider. We ever measured fifth graders, outscored 6th, 7th and 8th graders and sorry, I apologize if it offends you. But when 1/5 grade boy can sit in a classroom, scratch his rear end, dig in his nose go, I got it. Then there's no reason people cannot got it. Youngest patient we've ever done this on is four years old. Oldest is 104. So your span is right there. And by the way, if your patients have, the brain has been affected, mild traumatic brain injuries, whatever we are now trialing a program in the VA for PTSD and mild traumatic brain injuries for our soldiers. So it can be done. I know you're looking at this going well, this is too complex. My patients won't get it. Yeah, they can. They're smarter than you think. Trust me, you just need to get it down to their level. Anyway, we showed that the knowledge shifted drastically. A lot of positive beliefs shifted in the kids. We repeated in Kentucky where kids knowledge went up and as the knowledge went up, the fear of physical activity reduced, we're right now, busy with a multi center trial where kids in middle school are getting either a paint science lecture or they're getting a sprain lecture, the sports medicine model. And now we're tracking these kids through school and we're counting how many of them missed time from pe school visits, hospital visits, doctor's visits, et cetera, et cetera. Right. Which is kind of ironic who teaches us about pain? Our parents. Right. It should be. What were you taught about pain? How many? Hello, Kitty Band Aids. Did you get? How many Sponge Bob Band Aids? How many kisses on the knee or were you privileged? Like me to live in Africa on a farm? My dad said, beautiful loving saying like, suck it up. I'll give you a reason to cry. Hold up the fence. The animals are coming and don't bleed on that new freaking shirt, right? But now almost we have to get in and you do understand Big Pharma is raising our kids now. Pavlov, right? When you hurt kids, Tylenol kids, Ibuprofen FDA just cleared HYDROcodone for kids eight years and above. So the point is we're training generations. There's a massive shift in how we're teaching people how pain works. So how does this work when I teach you about pain? Your threat level goes down and it has a massive activation of the opioid and Cannavo system. Beautiful resources shows when people understand what's going on with them. The paint system actually engages back again and your and your naturally occurring, opioids, cannavo, et cetera. Start kicking in. I'll finish with the final slide. Louis Gifford, the guy that started this, he trained Butler Moseley myself, et cetera. He said when a patient walks in the clinic on Monday, there's only four things they want to know from you. Number one, what is wrong with me? What is wrong with me now, this is where I get some therapists say, well, we don't really diagnose. Yeah, we can go to the physical therapy diagnosis, working hypothesis. The bottom line is if you don't tell a human being what's wrong with them, they'll go somewhere else. Dr Google, Professor of Wikipedia, right? They go seek the answer. You know what's a really cool research? It says you don't even have to be correct. There was a study in England where they had general practitioners literally tell patients. Listen, I'm not 100% sure what's going on with you, however, based on everything and then they explain to them what's going on. They even prefaced it and if it made sense, they said I'm good. How cool is that? You don't have to be correct. Number two, how long will it take? Have you guys noticed the hardest thing in medicine is prognosis. Have you guys ever had a patient walk in easy and like, 02 visits you'll be out of here and then one year later, 87 visits later are you doing Frank? Much worse, by the way. Have you ever had a patient walk in with chronic pain, you think? Oh, this is going to be a tough 10, this is going to be a long, I'm gonna have to move jobs here to get away from this one. And then you say something at the second visit and they click and they go, I got it. Why if you focus on pain you're in trouble. If you focus on function, that's that shift behavioral stuff, right. Number three, what can I do for it? The future of health care is to help people help themselves. We're running out of money guys. The model has to shift. And number four, what can I do for you? For the therapist in the room this morning? Our roles have to shift from fix it to management, to empowering to coaching, especially for chronic pain. Nothing wrong. If somebody wakes up in the clinic, sorry, wakes up at home and the neck is, hey, hey, how's it going? American Idol neck syndrome, right? Manipulate them up. You're good. All right. Go back to work. That's different. For chronic pain. We have to more empower. This is the locus of control. We have to empower active treatments, teaching patients, empowering patients, etcetera, etcetera. All right. The only thing for people with pain, what is wrong with me? They want to know, why do I hurt? How long will it take? What do they want to know. Is there any hope guys, neuroplasticity gives us hope your brain is 125,000 miles of wiring it will be replaced in three weeks. It's plastic. How freaking cool is this the world of neuroplasticity? All this cool stuff we're learning about the brain, the nervous system tells us it can shift, it can move. How cool is it? You know what it means for someone in pain? There's hope there's hope these things can change. And that's what's so cool about embracing neuroplasticity and neuroscience into practice, right? Any questions, comments concerns hateful remarks. Thank you. Any questions? I think we have a couple of minutes there. Yes, ma'am. The chronic pain. Um Every time we have to ask them, what is your pain, pain, pain, pain, pain, pain. Yeah. And I'm very happy to Yeah. So I'm very happy to report joint commissions dropping pain ratings because it means nothing. I'm a neuroscientist. I do not own a painter. What you paying? Seven out of 10, it's five. You're lying, son of a gun, right? Ron Mezak showed us when if you ask people pain ratings three times in a row, what's your pain? What your pain, pain, you increase pain because of pain, neuro matrix. But we're still in the system. And by the way, joint commission will take a while to get through the system. So I tell my students, you have two options. A patients in the room, they had a knee replacement. You have two options. You can jump in the room with a hockey mask and a chainsaw and ask them what's your pain? Or you can walk in and say hi, Sally. How are you doing? What's on TV? How was the food did your family get? Oh, hey, by the way, I got to get a pain rating from you. It's not just asking about how we ask it. Unfortunately, our system is we're busy. We're all very busy. We borg into rooms, we've got another patient. So we, so it's also the way we ask it. Right? Fair enough. Now, my mentor, Jeff Maitland, I was trained by an iconic manual therapist. He told us when a patient comes and say I got a deep burning ache in my arm. We're not allowed to ask him, how's your pain? How's your deep burning ache? And so I will often ask him, can you rate your deep burning ache, which I would say is a softer word. Now, I'll get the same number that I need for my paperwork. And, and so it's a little more complicated, but I think there's a way to ask it. We have to ask it. It's the system I work in the system you work in the system is changing though. So I'm very excited about that part. Any other questions? Oh, you already asked, you cannot ask again. Yes, ma'am. Yes, I'm not allowed to say that. This is, this. Yeah. There, there are many of those out there but I'm not here to promote those whatever. But we can just, if you just go, type in, pay in education, there's a lot of other groups out there as well. We just the, one of the a African animals. Sorry, I've not just that. Yes, ma'am. Yeah. I, I, first of all, my, our intention has never been for a physician to do it because they're too busy. So when we go to medical schools, when we talk at physician assistant schools, when we talk at medical conferences, I, I'm trying to get physicians aware of what we're doing so that the physician can sit with the patient in their limited little window and say, hey, listen, this is what's going on. I want you to go to therapy and they're gonna explain this to you. Um, now would I love a physician to maybe change their language a little bit? Get away from torn rip rupture bols herniate and talk about, hey, your nerves a little bit sensitive. But hey, go see Terry and he will explain it to you and go see him for a little while. Come back and talk to me again. Um, my psychologist, I apologize again. We have a significant shortage of psychologists in this country, period. Um II I get inundated with people asking me where do we find pain psychologists? They don't exist? I meet this pain psychologist every week I just met one at clinic and I woke up and I said, where do we find you? And they said we don't exist. They were very rare. So everybody in this room knows there's a problem with mental health services anyway. So I do not negate psychologists. Um So when I work with psychologists, so I tell them I will take care of the, the basic ones. But when it gets very complicated, there's all these layers, depression, et cetera, then I, then we we very close. So I again, I do not expect my psychologist to do a lot of pain in education. They may deal with the deeper relationship stuff, the deeper stuff, it doesn't mean they cannot do it. We have trained psychologists, we've trained doctors, we've trained nurses, we've trained everybody. So by no means actually, if I wish the whole system would do it. Um So yeah, there was a question in the back. So that kind of into that question. So I was wondering with the intervention, obviously pay education is very important. But I was wondering if you thought that the even the socialization and like that extra sort of empowerment of um getting together with their best or even like with a bunch of Asians who experience the same thing. Does that contribute to that? Absolutely. We've done studies with one on one. We've done group sessions, groups are powerful. There's some research we've done in the department of defense that shows groups are actually more powerful because people can actually discuss it, especially when there's other people that have had successes. So in Springfield, Missouri, we're doing a study where people do group sessions, but we bring in a patient that's gone through the groups of success and they come in and they basically fuel the group. There's a lot about social interaction stuff. Clinical journalist paid in 2011 showed us that social interaction is one of the most powerful things to boost the human being's immune system. So there's a lot of other factors we built into this model too. Yes. But in most of our group sessions, it will be a therapist. Plus a psychologist, a rheumatologist. Remember, pain is complex and it will never be one profession. It's got to be multidisciplinary. It's got to be interdisciplinary. So we do embrace all of that. Absolutely. Yes, sir. Yes, because we are visual creatures. We are visual creatures. So yes, we, we do this and you know, Terry, we got 60 seconds, right? This is what I teach PT students, right? You can draw it. You don't have to buy anything. I just tell students this in PT school every day. Our body is an alarm system, right? This is your nervous system buzzing along this call. Let's call this your right arm nerve, right? Buzzing along life is good. I punch you in the arm here. Your alarm system ramps up. There's a threshold here it fires a message to your brain saying Adrian equals jerk call lawyer, right? What should happen is you call the lawyer, sue me and the nervous system calms down and life is good again, right? But what happened in you, Suzie? You hurt your back, you went to the, er, you went to the doctor got an injection, you went to therapy, your back nerves were buzzing along, enjoying life, it ramped up and said, go to the er, and instead of coming down, they came here, this is what you could do before. This is what you can do now. Oh, by the way, I got homework for you tonight. Go home tonight. Shut the TV. Off. Get something cold to drink, preferably a light Chardonnay from South Africa and write down all the things you could do before you had pain and what you can do. Now there's always homework, there's got to be written homework. Then we start saying, ok, while you're home, I want you to think what things in your life do you think has kept it up and then they come back and they start peeling layers. I haven't told you this but I'm going through a divorce. I haven't. So these are those slow layers we develop. Yeah, but you can do it visually and these things are literally in the clinic we write in the clinic, we'll take a picture of it, print it out, send it home with them visual. They're very visual creatures. Yes. Ok. Yes, sir. That just made me think real quick. I know we're in the title on time. Uh But with so many people going to the emergency room and kind of getting triaged and going back medicines and more scans. Do you see a role of physio? We're doing it in Minneapolis right now. We are doing it for motor vehicle collisions. There is, there's some research, if you look at J OS PT or whatever, there are papers out there, therapists role in the emergency room, I think, especially when people have been cleared for the medical stuff. Then there is this need to give them early education. The virus study is one of my favorites in spine where people get taught in the emergency room about pain, etcetera and they get drastically different than the other groups. They got standard care. I think in any scenario where we can only intervene, it's way better. No doubt about it. But remember again, we got a screen early on. I don't want you to go and explain to somebody something. Meanwhile, there's some serious. Yeah, so we got a screen. Absolutely, no doubt about it. All right. Thanks for coming. Good morning, sir. Thank you, sir. Pediatric. Created by
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