Unexplained Pain Is the Worst Pain — Here’s Why

[0:00] Kathy: Yeah. Jason: Pain sucks. Kathy: Yeah. And the worst part is when the patients expect us to solve it like a true crime podcast. Why does it hurt? Who did it? Was it the facet joint in the hallway with the degenerative disc? Jason: Exactly. So, and we deal with it all day long. And it’s not just the pain. It’s the fear which causes more Kathy: pain. Yeah. Jason: Yeah. If you’re listening to this episode and you’ve had pain before, and today we’re going to talk to you about what pain means, why it hurts so bad, and how we can all conquer it.

[0:31] Kathy: Yes. And today we have a special guest. Jason: Very special. She’s one of my favorite people. I can’t wait. So, yada yada yada. This is the PTCH. Hurry up and roll the intro. Raul, Kathy: what happens when a chiropractor and a physical therapist get together to make a health and wellness podcast? Jason: Chiropractors and physical therapists don’t like each other. Oh, think again. Kathy: I’m Dr. Kathy Lynch, physical therapist who likes to help people move and get stronger. Jason: I’m Dr. Jason Young, an evidence-based chiropractor who uses humor just as much as adjustments to help people get

[1:02] better. Kathy: Welcome to the PTCH Podcast. Jason: Remember, there’s no “I” in PTCH. Kathy: All right, we’re live. Jason: Hey, we are back. Kathy: Back again, Jason. Jason: So, Kathy, I’m — I’m doing the intro today. Kathy: Do the intro. Let’s have it. Jason: Here with us today is Dr. Amy McDivet, PT, DPT, and PhD. Kathy: Woo! Jason: Yes, that’s a lot of letters. Kathy: Mm-hmm. She’s an orthopedic manual therapy wizard. I wish I was as good as

[1:32] her. A clinical reasoning ninja and professor extraordinaire. Jason: Okay. Kathy: Okay. So, we’re going to get to you in a second, Amy, but I still got more to gush about you. Well, and if I understand correctly, she made you. Kathy: She did make me. Jason: Okay. All right. This is how you make a physical therapist. Kathy: This is how you make a physical therapist. Jason: Well, tell us more about her. Kathy: Okay. So, not only does she have her master’s in PT, then got her doctorate, then she got her PhD in physiotherapy.

[2:05] Jason: Oh my gosh. Kathy: Yeah. So, she does a lot of research. Mm-hmm. But before all that, she got her fellowship in manual therapy, which is important to talk about because we’re going to talk a little bit more about pain later. But she’s the expert of experts in manual therapy. So a fellowship in physical therapy is like post-graduate — what would — how would you describe it, Amy? It’s a post-graduate certification. It’s like a one to three-year

[2:35] training program where you become an Amy: expert — professional training program where they really kind of hone in on clinical reasoning and other skills. Kathy: Yeah. And on top of that, she’s a co-author of at least 30 peer-reviewed articles Jason: at least. Kathy: At least — at the very least. Jason: You say so cavalier, you know, she’s written like 30 30 peer-reviewed articles. You know, oh my gosh. All right. Kathy: So, she brings the evidence. Jason: She’s like an academic monster. Yeah. Kathy: Okay. Jason: And I’m super excited to have Amy here

[3:05] because whenever people ask me where I went to PT school, you know, I always gush about the University of Colorado and Jason: Buffs. Kathy: Well, we’re actually the — Jason: ‘cause we’re the campus down by Denver. We’re CU Anschutz, which is the medical campus. So, we’re not actually Buffaloes. What are the — Kathy: There’s a whole different mascot. Jason: There is. The medical — be like the reflex hammers or something. Go Hammers. Kathy: Go Hammers. Jason: Yeah. Well, I told you about when I tried to get the chiropractic school to

[3:36] make their mascot, right? The Blazing Joints. I thought that that would be perfect. You know, Kathy: it was in Portland. Jason: Yeah. Kathy: Yeah. So, Jason: that’s right. The Blazers. Yeah. Kathy: So, Jason: yeah. Well, thank you so much, Amy. I’ve been so excited to have this episode. I know Jason says, “I’ve been more prepared for this than I have for any of the other episodes.” Jason: And I’m really excited to have you on and to do this episode just because now Kathy can focus on other things like her

[4:08] family, her work, eating, you know, things like that. Just the basic functions. So, yeah, very glad to have you. Thank you for being on today. Amy: Awesome. I’m so happy to be here. Jason: Yeah. Okay. So, I’ll let you kick it off because we read one of your articles and it kind of correlates with some of the things that we’ve said throughout our 39 episodes so far. So, Kathy: yeah. Now, we’re talking to an expert about it. Jason: So many episodes. We’re literally at

[4:38] dozens of episodes. Dozens. Kathy: Yeah. Jason: Yeah. So, okay. Kathy’s been sending me your articles and so now I’m a big fan, too. Kathy: And your podcast. Jason: And your podcast. Yeah. And she also sent your action figure. Amy: Yes. Mm-hmm. Jason: Do I have a bobblehead though? That’s what I’m in need of. Amy: No comment. So, well, first of all, I really like the title of this article and I heard

[5:08] that you had some naming rights on some of these articles that you’ve written. The one that I want to talk about is “The Worst Pain Is an Unexplained Pain.” That’s an intriguing one. Like, tell us about this article. What does that even mean? An unexplained pain. Why is that the worst? Amy: Yeah, you know, it’s a fair question and to preface before I talk about the article, it’s been a collaborative effort. So, the three authors on this

[5:39] article are Paul Min, who was my mentor, Jeremy Lewis, who’s an amazing, well-published author and educator who’s in the UK, and the three of us actually were just kind of shooting the breeze after hours at a conference. And we talked about developing a couple of passion papers about — it’s kind of like medical narrative, like what do you care about? What blows your hair back? And what do you want people to know? Because sometimes, you know, it gets — not boring,

[6:10] but it’s a little less inspiring to to write up an RCT, you know, and and get to the results. It’s not necessarily a compelling story all the time. And so, we decided to write some narratives. And this is one of three narratives. And the reason why we decided to talk about this is we’re we’re really, I think, as a profession, both in chiropractic and in physical therapy, moving into a space of highlighting person-centered care and what that really means. And so “the worst pain is an unexplained pain” is really meant to kind of touch on the fact that sometimes the hardest

[6:40] things for our patients is to not have an answer. But we know that not having an answer is probably the answer. Kathy: Yeah. And sometimes it’s normal. Jason: Well, and and it takes a while to get used to that, right? Like it’s really hard. Kathy: Yeah. I remember as a student, you know, and and I’ve mentored a few students becoming, you know, practitioners and it’s it’s very uncomfortable to not know exactly what’s going on sometimes. Jason: Yes. Yes. And it’s even worse for the

[7:10] patient if they think people don’t know what’s going on with them. Kathy: Nobody knows what’s going on with me. Jason: Yes. Yeah. I mean, then they’re distraught because they’re sitting — Kathy: I’m just busted. Jason: Yeah. I’m broken. Kathy: I’m a medical mystery. Jason: Yeah. Yeah. But then at the same time, when we’re so specific about what we think is going on, they attach to that too, which can also be quite harmful, which is something else we described in this article. Kathy: Yeah. You talked about — in the article you talked about patients feeling stuck

[7:41] when pain feels mysterious. So, can you talk more about that? Yeah, I think — and it’s — I don’t think this is just related to musculoskeletal pain. I think it’s nonspecific abdominal pain or headaches, things like that, right? But I think “stuck” — the word “stuck” kind of reflects this emotional toll of uncertainty and what that means to people. And I think many patients without some kind of an explanation, they move into this space of catastrophizing and thinking that

[8:12] something is seriously wrong. So sometimes without an answer, when they’re told they have non-specific back pain or they have non-specific belly pain, something could be really wrong. And this leads to, you know, not just catastrophizing on the part of the patient but unnecessary imaging and sometimes invasive procedures and a lot of frustration, I think, on the part of the provider and the patient. And so that’s what we meant by feeling stuck. I mean, when pain is mysterious it feels ominous and it creates fear and

[8:42] fear creates catastrophizing, and then patients get into a very different space that is sometimes — I think you’d both agree as providers — can be hard to get them out of. Kathy: Yeah. Really. Jason: Well, I I think first of all, props on being able to say “catastrophizing” so well and easy. It just rolls off your tongue. It’s even harder to spell, and it’s such a great word. But it’s it’s dangerous. You know, there are people that they take extreme measures whenever they think that something is extremely wrong

[9:13] with them. And it’s amazing sometimes how quickly people get better just by knowing what’s not wrong with them. You don’t even have to find the exact thing. Right. Yeah. Right. Right. Agreed. Jason: Well, “this doesn’t look like cancer, diabetes, or you’ve been abducted by aliens.” And so, you know, the only thing that’s left is non-specific low back pain or mechanical pain, which I think we’re gonna talk about a bit later. Right. Kathy: Yeah. And that’s a really good point. I got to tell a kind of a funny family story. It’s a little

[9:44] tangent on this. My grandma was, I don’t know, 88, 89, and she was having really bad back pain. And so somehow she got into the ER or got in to see her doctor and they did an X-ray. They might have done a CT scan of her chest, and the doctor comes out like, “Okay, yeah, actually you have what’s called a thoracic aneurysm, and it just keeps getting bigger and we can’t really do surgery, it’s not really

[10:14] going to help — like, this is what you have.” And she’s like, “Oh, thank God!” “Thank God!” And the doctor’s like, “No, ma’am, Mrs. Cullen, this is life-threatening. Like, you’re probably going to die from this.” She’s like, “Oh, yeah, but I thought you were going to tell me I had cancer or something.” But just like you said, right? Jason: You told me what it’s not. Oh, thank God it’s not cancer. Kathy: Well, and she felt better. Jason: And that’s such an interesting thing, too, because all this stuff means different things to different people. And so, there are some people that might

[10:45] be like, “Oh, I’ve got cancer. Cool.” Right? And there are some people for whom cancer took a parent. And so it’s like, that’s the worst possible thing that you could say. And Amy, you mentioned a patient-centered approach, which I think that’s what makes all this so tricky, is because not all the words mean all the things to all the people. Right. Exactly. Right. Yeah. I I think that’s tricky and and some of the the projects I’m working on right now are are surrounding contextual factors. And so when we talk

[11:15] about contextual factors, to your point, it’s all these other things that are potentially influencing either how a patient feels or what their expectations are for their provider. Like your story, Kathy, totally resonates, right? Because it’s like, wait a minute, you actually might not live as long because you have this other thing, and and her personal connection to cancer and what that could have meant for her was so much stronger than something that’s probably more realistically life-threatening, right? And we can’t ever anticipate what

[11:46] all those layers are. But it’s our responsibility if we’re truly person-centered to peel back some of these layers, because that’s how we’re ultimately going to help the patient get the most optimal outcomes by really understanding what’s under the hood. Kathy: Yeah. And Jason and I have talked about this on several episodes, too, is — and and you allude to it in this article — is that as healthcare providers, we’re kind of doing a lot of harm, right, with our words. Yep. Yep.

[12:17] Jason: Catastrophizing. Kathy: We are. Jason: Well, sometimes the patient doesn’t even have to be the one catastrophizing. See, I can say too. And you know, it’s the doctor — the doctor tells them that something is torn Kathy: or cracked or crushed or broken or degenerated. And I think — so those words apply sometimes, because can you tear something? Sure. Jason: Yeah. Kathy: And can it be crushed? Absolutely. But I

[12:48] think that there’s some skill to what’s going to be the best way to communicate with this particular patient. Jason: Yeah. And don’t forget the word “fissure,” because — Kathy: Oh, you know, isn’t that what happens? Like, isn’t that what precedes an earthquake, right? Jason: I have — I have not in my word. Kathy: We’re in a disaster film now. Jason: Talk about harmful words. Kathy: Oh, yeah. Jason: Yeah. I feel like they love to look at X-rays with their patients, and I don’t — I’m not

[13:20] — they like to look at the X-rays with their patients like, “Yeah. See this fissure right here? This is where your bone is cracked.” And meanwhile the patient has already fainted over here. Kathy: Oh, look at all that arthritis. You whip out the A word on somebody and they will age by 10 or 15 years right in front of your eyes. Jason: Yeah. Kathy: Yeah. But I think we’ve become part of the problem. I would never blame medicine, because I think even in our training — in our respective training — Jason: we kind of teach to pathoanatomy, because

[13:51] we’re trying to figure out what are the most evidence-based outcomes that might align with a pathoanatomic term. Kathy: You’re going to have to define that for people, because we have some folks that, you know, they don’t do 13-letter words. So what is pathoanatomical? What are you talking about there? Jason: So — that’s a good point. So when I’m talking about a pathoanatomic term, I’m talking about naming the problem, or the pathology, or maybe the root cause. And so an example of that would be, you know, one of the terms that you used

[14:22] already, Jason, which is like a degenerative disc — like, you know, a degenerative disc is something that actually is a normal age-related change in a lot of people, Jason: but it’s villainized and used as something that’s considered abnormal. And it maybe is in some individuals, but it’s all about the context — meaning the age of the individual who maybe is, you know, having imaging or an X-ray or something where this finding comes up. But I guess my point is that we

[14:54] oftentimes are part of the problem, because we have learned to describe this pathoanatomy, or the changes that we see, Jason: but it’s not always helpful, and we’re not always accurate, and we’re not always correct in naming those. And so I think what becomes difficult is people don’t recognize the difference between maybe a true abnormality and maybe just a normal age-related change that we’re going to see in a lot of tissues. Just like the gray hair on our heads — you know, after

[15:25] a certain age, no one’s squawking about that too much. Kathy: But when we see something that’s degenerative in some other part of our body, we start freaking out. And as patients, I mean, you know — and so we’ve perpetuated a language problem that actually is more harmful Jason: and has led patients to believe that something is broken and it needs to be fixed, Kathy: right? Well, maybe we need to normalize “degenerative” and just start calling it degenerative hair Jason: instead of gray hair.

[15:55] Kathy: You’ve got pigmentation degeneration. Jason: Hey Amy, can I ask you a question about something? Because, so I’m a chiropractor and I know that in my profession Kathy: some of these catastrophizing words are used for marketing Jason: by some people that maybe aren’t so scrupulous. And I don’t know how it is for physical therapists, but sometimes we like putting up that X-ray or

[16:27] throwing out that word because it’s like, hey, compliance — that’s what we want. And that’s one of the reasons we do scans and MRIs and stuff like that: we’re trying to buy compliance by showing these things. So where do you think the trade-off is between having these discussions for the sake of compliance and helping people understand how serious something might be, and Kathy: using the language to help them recover? Jason: Yeah, I think that’s a great point, and

[16:58] I’ll try to kind of give you two scenarios. One scenario is there’s some kind of a diagnosis that’s going to require medical intervention. So let’s say someone that has — kind of for the layman — it’s like a fracture in a part of the — um, here I am, I can’t even talk outside of — Jason: you talking about spondylosis? Kathy: I’m talking about a spondylo — Jason: oh, spondylolisthesis! We talked about that last episode or two ago,

[17:29] yeah. Kathy: We’re just getting all the long words. Yeah — fracturing part of the spinal structure. It’s a defect and it might require, in some cases, intervention. And so there’s that need to talk about something specifically. But I think if we’re talking about Jason: — let’s use the example of an onset of pain that doesn’t have a trauma associated with it, where, you know, it’s a lot of the patients that we see who have like a slow onset of back pain or shoulder pain or fill in the blank, whatever you want that to be. We don’t

[18:00] actually know with certainty — even if they have imaging, an MRI, X-ray — that the report actually is reflecting what’s wrong with them. But yet we say, “Look at here — here’s your facet arthropathy and your degenerative disc.” So instead of using that language, we’re proposing that you talk about: there’s a lot of tissues in your spine. You’ve got facets, which are the joints. They have a little what’s called a synovium in there. There’s a capsule, which is part of the joint. There’s muscles and tendons and other things in there. All of those tissues are

[18:30] susceptible to load. And so you could potentially have a load problem, you know, where we have a balance that we’re trying to get to, or some kind of a homeostasis. And when tissues can’t take more load, they become exhausted, and sometimes we have pain — that’s what’s manifested out of that scenario. And so I think there’s a lot of ways to describe this to a patient without really reinforcing that we believe with 100% certainty that it’s a degenerative disc or that it’s a nerve.

[19:01] I love “nerve encroachment.” That’s amazing. That always makes people feel good. Right. Well, and one of the things I’ve tried doing lately is — because as part of like the required conversation when you’re having these — you know, doing your PARQ — one of the things I’ve really tried to lean into lately is helping people to understand, if you do nothing about this, what’s going to happen? Just having a candid conversation with them about that, because there’s a lot of things that if you do nothing, it’s probably just going

[19:31] to get better. And I think that that helps some people. And so it’s like, do we want to work on getting this better quicker, or letting it get better and hopefully preventing the next time that it happens — but not the time after that, because I have kids who are in college and I need you. No, I’m just — I know where you’re going with that. So, but you know, I think helping people to understand that natural history — like, this is how this is going to play out — that even kind of softens it

[20:01] so that, like — I mean, because people are afraid of cancer because one of the natural outcomes they’re thinking with cancer is death. Yeah. Right. Yeah. And if there were like nine or 10 different types of cancer that, hey, it’s probably just going to go away on its own, then nobody would be afraid of it. Right. But I think that with a lot of these things, if we just help people to understand, hey, this is probably what’s going to happen — let’s see if we could just speed up your recovery or give you a better recovery. You know, I think what you said is really important, which is actually being

[20:32] Kathy: authentic in our conversations with patients and disclosing the natural history of a condition, which means neck pain happens in, you know, this percentage of people and it’s a recurring condition. So this is likely going to happen to you again, but we’re going to arm you with all of the things that you need to know in order to help mitigate, you know, symptoms — and what we would call modulate your own pain — when this happens again. But I really agree with you that it’s important to talk about, you know, that most of these conditions are going

[21:03] to improve naturally without any intervention, but we’re speeding it up. And it’s not just maybe what we’re doing — it’s actually making some important lifestyle-modifying factors occur too, like better sleep and nutrition and mobility and walking and aerobic activity. I think sometimes we forget to tell patients that all of those factors are actually part of what’s driving outcomes, not just our hands-on care or the exercises that we prescribe. Yeah. I don’t think — especially in our profession — I feel like Jason’s

[21:34] Jason: profession kind of has embraced that a little bit more. We got it all figured out. No. Yeah, we can help — this. No, no, but I feel like with PTs, we’re like, well, that’s not in my scope of practice to talk about nutrition, or to talk about, you know, therapy or things like that. And I think that we’re losing that opportunity to be able to speak with patients about those kinds of things — like lifestyle factors, like you were saying. I mean, are you guys teaching different things like that

[22:05] in PT school now? Yeah, we are. And there’s really been an important shift, I think, to talk more about populations, communities, lifestyle factors —

[22:05] Kathy: lifestyle factors — all of those things that we know influence, you know, patient outcomes, because the care that we provide as physios and as chiropractors, you know, only gets us about 20 to 30% of the way there — is what some of the metrics are showing us. And so if we don’t talk about some of

[22:36] those other factors that are going to influence outcomes, we would definitely be remiss, and we’re not practicing patient-centered care. We’re practicing knee-centered care or shoulder-centered care. So all those things matter, and you know, sometimes what we’re doing is just planting seeds. Yeah. Right. Just actually just asking them questions about, “Oh, what do you like for exercise?” and they’re like, “Well, nothing.” And you know — And you know, I don’t judge. I say, “Okay, you know,

[23:06] I watch cooking shows.” Yeah. But that plants the seed. That’s how I exercise. Exactly. That — that plants the seed, like, “Oh, she asked me about that.” But I don’t, you know, I try not to judge about it. Yeah. No, but then it opens up that opportunity for you to say, “Do you mind if I share some information with you about exercise and low back pain? There’s a lot of research that’s been done about this.” They never say, “No, don’t share information with me.” That’s a really good point. Yeah. I have found people that actually do — like, “I don’t want to know.” Yeah.

[23:36] “Don’t tell me why that’s bad for me.” Yeah. Like, I had a patient who actually wrote on their intake paperwork — they’re like, “Don’t talk to me about soda.” Yeah. That’s — it’s a hot button. It’s a hot button. Like, I’m drinking my soda. Don’t — don’t tell me. All right. Guess what we’re not talking about? We’re not talking about soda. Tell me why we can’t talk about soda. Yeah. And it’s like, I kind of wanted to go and get through the whole thing and be like, “Well, so that’s what you have going on. Now let’s talk about

[24:07] what to do about it. And that’s all the time we have for today.” Wait, what? We’re not going to talk about it? Well, there was only one thing that could have helped you. We just needed you to drink more soda. More soda? Well, you said not to talk about soda. I was going to suggest you drink more, but you didn’t want to talk about it. So I guess you should just drink less. So, no. My patients hate me. Okay, that’s not true. Can I ask you a question real

[24:37] quick? So, how did you get into this? Like, why did this even occur to you to be something important to research and learn about and everything? Yeah. For me — well, a couple things, I guess. I educate physical therapist students. So I think we’re always trying to push the envelope and telling them what’s important. And it’s not all just about examination and intervention — it’s about the humans in front of them that they have to talk to and connect with and establish a rapport with. But I think actually more

[25:08] Kathy: importantly is the practice that I work in. It’s a hospital-based outpatient practice. And I rarely see anyone that hasn’t already had imaging before they come to see me. Jason: Wow. Kathy: And so the damage that has in some cases been done, right? Because they had to go and get their imaging first, then they can come to PT for treatment of whatever it is. Let’s say it’s low back pain. They’ve already looked at all their imaging results. They poked around in the EMR Jason: and they’ve really started getting

[25:38] fearful Kathy: and they’ve started catastrophizing and worrying before anyone has level set what’s actually happening. That’s why I’m so passionate about this because I’ve learned that the imaging and the patho-anatomical terminology that patients are constantly being bombarded with, and the medicalization — meaning thinking that there’s always something that needs to be fixed — is really hard to undo. Jason: You know, when we could have just talked about you have low back pain with what

[26:09] we call mobility deficits, which means we need to get things moving a little bit better. And sometimes your back, you know, sustains loads from excessive activities or maybe sedentary posture. And we need to kind of just work on decreasing some of this load in some of the tissues in your spine, but your spine is strong. It’s made to move. That’s how it’s actually designed. And some of those things that we saw in imaging are normal age-related changes. You just happen to have some pain in some of the tissues. Kathy: If I could just get that out,

[26:40] Jason: you know, eight weeks before, Kathy: Yeah. Then sometimes we can prevent some of these other psychosocial factors and fear Jason: that ends up kind of overlaying what’s happening, when it may have been a simple couple of visits to work on some mobility and some exercise and strength and a little education, and then it becomes something very different. Kathy: That’s where this came from. Jason: Yeah. And I think with that imaging piece too, I think one thing that I’m

[27:11] seeing more and more is practitioners who are ordering imaging, and then you have a radiologist who is interpreting the imaging, and it might be that the only thing they’re going over with them is that summary at the end where it’s like no significant findings or something like that. Or it might say Kathy: age-related degeneration or something. And so then the physician just says, “Oh, okay. That’s what this is.”

[27:42] But patients, like you said, they can read those reports. It’s in their MyChart or whatever. And they look at that, and whenever somebody brings in some imaging, I say, “Did your doctor go over this with you?” And they’re like, “Well, they told me that everything was fine.” I was like, “Yeah, but did they tell you what this stuff means?” And they’re like, “No.” “Would you like to know?” “Oh, yeah. Okay.” Because there are so many big words, and we’ve used so many of them today, right? And it’s scary to read some of these big words

[28:12] and it’s like I don’t know if this actually means what he’s saying it means. And so Kathy: I find that even just sitting down and saying okay, that’s what this is, and pulling out a spine model and being like, this is that part, this is that part, and this is what they’re seeing, and this is why they think it’s normal. And so yeah, nobody’s lying to you when it says this is normal. It actually is normal. And I find that that makes people feel a lot better. At least they don’t come back. Maybe maybe that’s — and I’m just guessing — they don’t come back because they’re all

[28:42] better. Jason: Let’s go with that. The story you tell yourself. Okay. Kathy: But I agree with you. Sometimes there’s like two or three impression points at the very end. Jason: That’s what I was looking for. Impression Kathy: after three pages of all the other things. Jason: It’s like, how do you give me three pages and yeah, that’s nothing. And the reality behind it is the radiologists are just — they have to name everything that they see. And so what these reports are void of is the

[29:13] clinical correlate. Kathy: There’s no opportunity to say, well, do you have right-side leg pain? Do you have right-side symptoms? And so it’s literally just them reading everything they see. And that’s the requirement. That’s all they’re expected to do. But many of those things and many of those findings aren’t necessarily correlated with anything that’s happening. Or they could be, Jason: but that’s the problem — that clinical piece is missing from a typical imaging report. Kathy: Well, and sometimes the radiologist’s hands are kind of tied because they’re not getting enough information with the

[29:44] request. Like I found that when I give the radiologists more information, I actually get way better reports back. And so if I’m like — Kathy: totally — Jason: I want you to take a neck x-ray and these are the views that I want, I’m going to get back a very vanilla report. If I say I want you to take a neck x-ray, this is somebody who started having pain two weeks ago after a fall, Kathy: I get much better information because sometimes the radiologist doesn’t even have the context for what’s going on.

[30:15] Jason: So it’s hard to get the information that you want. Kathy: Totally. My husband works in the ED at one of the hospitals in Denver, and he always prefers to be able to get on the phone with the radiologist who’s in the hospital reading the imaging, and they talk back and forth about symptoms and clinical Jason: presentation. But a lot of times in some cases the radiologists are ten time zones away in a different country, potentially just, you know, again interpreting what they see. Again, those

[30:46] are two very different scenarios and unfortunately the patient gets caught up in some of that at times. And is privy to a lot of what’s in the report nowadays Jason: without having someone like you, Jason, to be like, “Hey, this is actually what this means. Let’s look at the spine and let me show you some of this is normal for someone in your age cohort.” Jason: Yeah. And then they Google it, right? Kathy: Of course. Jason: Yeah. Yeah. They’ll Google it, which I do it. Kathy: Yeah. How do you think I’m making these diagnoses?

[37:58] probably not exercising hard enough, right? And what’s important is your recovery from it. You shouldn’t be in pain all the time. It shouldn’t be altering your ability to be happy and fruitful and go to work and all those kinds of things. But man, we need to stop telling people that if you have pain, well, then there’s definitely something wrong with you, right?

Kathy: Yeah. Case in point, women have babies.

Jason: Right?

Kathy: Yes.

Jason: Like, I’m sorry, I’ve had three. It hurts.

[38:28] And it doesn’t stop after the delivery. We don’t think the best about it, catastrophize about it because it’s a normal thing. And somehow we’ve like lost the ability to normalize things like back pain and foot pain and things crack and crunch once in a while and our bodies change and they do age, just like the hair on our head looks different than when we were young. But you’re right, we have to do a better job of

[38:58] normalizing it and telling people that it’s going to come back, because often it does.

Jason: Yeah. Well, and I think it’s a greater metaphor for life, too, because there’s physical pain and sometimes it feels very out of reach for people to be able to do anything about it. But then there’s also other types of pain, too. There’s pain that just exists in our head. There’s emotional pain. Like, I was talking to somebody yesterday who’s just going through a really hard time and they said, you know, I’m a resilient person and I’ve gotten through so much stuff and I’ve been through so

[39:28] many things, and they were like, but this feels like too much. And just listening to that, you know, let them unload, and then we just talked about, look at all the stuff that you have gone through, all the stuff that you’ve overcome — like, where were you at point A and look at you now. And one of the things about being resilient is that before you’re resilient, everything has to suck. It has to hurt. It has to be bad. Otherwise, you’re not

[39:59] being resilient. You’re just being normal, right? And so, if you’re a resilient person, you got to go through some stuff, right?

Kathy: And I think that we can help people do that physically and it kind of pours over into other aspects of their life. And that is what I love about being a healthcare provider — it isn’t that it’s like, oh, your back pain went away, yay. It’s like you could see a better, more whole, more complete person walk out. Like, that gets me going.

Jason: Yeah. Yeah.

Kathy: That — and all the money.

[40:29] Jason: All the money we made.

Kathy: All the money. Oh my gosh. Look how rich we are.

Jason: So much money.

Kathy: That’s what hurts my back is carrying around all these bags of money all the time. Like, I got backpacks full of it. It’s like, ah, my back. I need to go see Kathy Lynch.

Jason: You know, and Paul Mani, the primary author on the paper here, something he always has said is pain reminds us that we’re alive.

Kathy: Yes.

Jason: You know, and I kind of love that. It’s like, I’m living in this body and it,

[40:59] occasionally things hurt, but hurt doesn’t equate to harm.

Kathy: No. And that’s the other story that we have to tell patients — hurt doesn’t always equate to harm.

Jason: Yeah.

Kathy: Yeah. But pain makes us feel — it’s like you know you’re alive, and I think that’s amazing.

Jason: Mhm.

Kathy: Now, we shouldn’t glorify it at the same time, because

Jason: don’t run around —

Kathy: Yeah, I know, people are like, screw these people. They think I should just be hurting all the time or else I’m not having a good time.

Jason: Yeah, I am not going to endorse

[41:29] physical therapy or

Kathy: — a body of health. Yeah,

Jason: sounds like they want me in pain.

Kathy: Oh my goodness.

Jason: Oh, what about this question? Should we ask that question? All right. So, can you give us — let’s say that you got to reach into everybody’s practice. What is one phrase that, if you could, you could just reach into every clinician’s vocabulary and just remove it permanently? It would just disappear forever. Something they could never say

[42:00] again.

Kathy: I guess I would say, you know, and some of it comes from us and some of it maybe comes from more the medical community, but — you have the spine of a 90-year-old — kind of a thing.

Jason: Gosh, that’s why I like her. Oh my gosh, you’re the best. Amy.

Kathy: I told you.

Jason: And then the bone on bone thing.

Kathy: Oh, bone on bone.

Jason: Say more.

Kathy: You know, we’re guilty of it too — bone on bone, everybody.

Jason: Yeah. Well, it’s not

[42:30] just us in the room. Like, gosh, primary care doctors say that all the time — bone on bone. How do you recover? How do you help a patient recover emotionally from bone on bone?

Kathy: Oh, well, I think — I think that’s actually part of the strategy. So, I think a primary care doctor, when they see something — oh, they do an X-ray and it’s like, oh, you’re bone on bone — it’s almost like, yes, I get to punt.

Jason: What?

Kathy: Right. Because what’s your primary care doctor going to do about —

Jason: Oh, he gets to — yeah. Yeah. What are they

[43:01] going to do about a bone on bone problem? Nothing I can do.

Kathy: They’re not going to do anything, right? Oh, I got to send you to the surgeon or I got to send you to the physical therapist. And what they don’t understand is that when they send somebody to that next level, they’ve handicapped them already. And I’m not talking about the patient — they’ve handicapped the provider, because it’s like, now I have to un-bone-on-bone you.

Jason: Yeah. And the patient can’t unhear what they heard.

Kathy: Yes. Yeah. And they don’t believe us.

Jason: They don’t have the symptom that correlates. Yeah.

Kathy: With whatever, you know,

[43:31] and they don’t believe us because of cultural authority. So, it’s like somebody shows up and they’re like, well, my MD said that I’m bone on bone. And it’s like, well, okay, let’s talk about what that really means, and everything, and I disagree with this. And they’re like, well, they’re a medical doctor, so —

Jason: it’s like, okay,

Kathy: he told me, so I’m gonna believe.

Jason: Yeah. It’s like, well, go back to him and ask him to do something about it then.

Kathy: You guys are spicy.

Jason: We’re very spicy.

[44:01] Kathy: I know. I think it’s that last episode we did, Kathy. I think you just kind of liberated us with — yeah — that conversation. So, but yeah, it’s not — it’s not fair and it’s not helpful — but I think it’s also not their fault because it’s like — Jason: yeah — Kathy: you’re trying to clear patients. You’re trying to get them to the next step. I don’t think they’re doing it with ill intention, but that’s that’s the — Jason: Yep. Yep. Kathy: And it’s important to recognize that not every patient should push through and try to persevere through something that’s changing their lifestyle and

[44:33] really robbing them of their joy and activities that they love. I mean, there are always a subset of patients where surgery is probably the best option, and I talk about that a lot with people. But we’re talking more about maybe insidious onset of a musculoskeletal thing. And they may have mild disability and mild pain, but the story that they’re hearing from either us or other providers is that it’s very grave indeed. You know, that’s kind of what I’m

[45:03] talking about. Jason: And I think the harm that gets done too is when they’re — they’re told these things on the X-rays, they stop doing things. Kathy: Yeah. You know, like, oh, this is just going to make it worse in the moment. Jason: Yes. Kathy: I’ve reached that point in my life. Jason: Yep. Kathy: I guess I gotta give up pickleball. No, pickleball is what you do when you’re old. Jason: Yes. Okay. So, let’s flip that question then. Kathy: Okay. Jason: What phrase

[45:33] should clinicians start using tomorrow? Kathy: Like what would be a way? Jason: Yeah. I think like if we’re talking about someone with low back pain, you say — Kathy: you know what, your back is strong and it’s adaptable and it’s designed — I say this all the time — it’s designed for movement. And it’s designed to absorb force and shock, and we can help it move better. Jason: Yeah. I think this helps to reframe pain as — we have to kind of reframe

[46:05] pain as a solvable problem, not like a defect or something that needs to be fixed. But reminding people how strong they are and, you know, they have the ability to adapt. I think people don’t recognize that. Kathy: Yeah. Yeah. Well, and I think that that’s so good too, just because — I don’t know — sometimes it’s just like, so you got this problem, like what are you going to do about it? What are we going to do? Like,

[46:37] you can eat a bunch of pills, or — do you really think you’re just going to be weak for the rest of your life? Is it just time for the crossword? Is that what you’re going to do? You’re going to be the crossword guy now? Kathy: I think that some people do. Jason: Yeah. Kathy: Yeah. Some people do. And that — I think that’s where I feel like a lot of the harm comes in. Jason: Yeah. Kathy: Is they just stop doing, and they’re not aware of the fact that like when you start thinking like that when you’re 45 years old, guess what? You have maybe half of your life ahead of you still. So you’re going to do 40

[47:07] not-fun years. Jason: Yeah. Yeah. Kathy: Yeah. Jason: That’s where we come in though. Kathy: Yes. Jason: We reintroduce the fun. Kathy: Yeah. I think that’s really important. You got to ask everybody like, what do you love to do? Jason: Yeah. Kathy: Like what do you love to do? Like what’s your favorite way to exercise? Like what do you like to do for fun? What do you like to play? Because I think that that’s a good thing to focus on — getting people back to that — and everything else in their life gets better. Jason: And sometimes they’ve self-prescribed that they shouldn’t do it anymore out of fear. Kathy: Yes. Jason: And a lot of times they just need us to

[47:38] validate that and give them permission to play pickleball. Kathy: Yes. Jason: You know, they’ve just decided they’re not going to do it because they’re afraid that they might cause more harm. But there are few studies that show that there are certain things that are going to make things a whole lot worse. Kathy: Yeah. Amy, so — are you giving people listening who are experiencing some pain, are you giving them permission to go out and just like, try something? Amy: Yes. Jason: I think that’s where we’re at. I think I am. I mean, even people are afraid to walk. And I’ll tell my

[48:08] patients with spine pain, hey, the first 5 to 10 minutes are not going to be great. I guarantee you it’s not going to be great. Keep going and see what happens at 5 to 10 minutes. And I bet you things are going to feel better, and then I want you to keep going. And most of the time it’s going to be okay. And if it isn’t, let’s find a way to fix it. Jason: Yeah. Amy: Right. Jason: Right. Most of the time it’s going to feel pretty good. Kathy: Totally. I think I need to go for a

[48:39] walk. Amy just gave me permission to go for a walk. Amy: Please go for a walk. Kathy: You know what I think we should do? Jason: I think it’s game time. Kathy: It’s game time. Jason: It’s game time. Kathy: Yes. Jason: What does that mean? Amy: Oh, I don’t know if she’s seen the PTCH Podcast. We play a game every single episode and it’s really fun. Jason: Yeah. This is how we finish it, and they’re all like — they’re darn near impossible to win. I think that Kathy actually made this game. Kathy: I made this one, and she cranked it up to a level — expert,

[49:11] level PhD game here. So — Jason: yeah — Kathy: it’s not to spell catastrophizing backwards, is it? Jason: Yeah, it’s to spell it at all. Right. I get to see. That’s it. Yeah, I’m tapping out. Yeah. So, it’s more fun. It’s more fun than anything. We will not be counting wins and losses with this one. So, the title is “Pain Science: Would You Rather?” where absolutely no one makes good

[49:42] choices but everyone learns something. Kathy: Yeah. Jason: So these are impossible choices that clinicians face every day, except we’ve managed to make them weirder. Kathy: Okay. Jason: So I’m going to ask you, would you rather — I’ll give you two choices. You can’t say both. You can’t say neither. Just pick the one that you like. Kathy: Yeah, that’s easy, right? There’s no points even. You’re gonna win. Okay. Jason: You’re gonna win. There’s no — okay. Would

[50:12] Jason: Would you rather spend an entire day trying to explain to patients why degeneration isn’t a death sentence, or explain to 15 different people that the leg length discrepancy is not actually 2 inches?

Kathy: These are all like inside jokes. I love it.

Jason: It is.

[50:43] That’s brutal. Which one would you rather?

Kathy: I would rather do the first one.

Jason: Okay.

Kathy: Okay.

Jason: Yeah, I would.

Kathy: You seem really good at it. Seems like you’re experienced at explaining what degeneration is and what it isn’t.

Kathy: Yes.

Jason: Okay. I think I’d rather do that one. Yeah.

Kathy: Okay.

Jason: Final answer.

Kathy: Hey, you got a point. Good.

Jason: Yeah.

Kathy: Yeah. You’re going to get a point on all of them. Actually, this next one’s worth four

[51:13] points, so good luck. Okay, here we go. Would you rather have every patient walk in saying, “I saw something terrifying on my MRI report,” or have every patient begin with, “I Googled it and I’m pretty sure my spine is collapsing” — for four points.

Kathy: I feel more hopeful with option number one.

Jason: Yes.

Kathy: Okay.

Jason: Well, she got it right. She’s two for two. That puts you at five points. Very good.

Kathy: No, because I think we can — I can change four lives instead of just one

[51:43] right there. So I’m going for four lives.

Jason: There we go. I like it. I like it. True.

Kathy: All right.

Jason: Okay. Oh, this is almost an easy one because she’d probably do this. Would you rather teach a full semester of PT students about the biopsychosocial model without using any slides,

Kathy: or convince a room full of clinicians to stop using the phrase, “Your disc is out of place?” Oh, good heavens.

Kathy: Oh, definitely. Definitely number two, because that’s going to have

Jason: immediate impact even though number one

[52:14] is in my wheelhouse.

Kathy: Yeah, totally.

Jason: I’m going for impact factor and that’s number two.

Kathy: Okay.

Jason: Yes.

Kathy: I love it. Okay.

Jason: You don’t have to give me any points. I thought I was going to pick something else.

Kathy: I think you’ve already maxed out. I think the scoreboard shuts off at five. So you got it. You already won.

Jason: All right. Question number four. Would you rather have to explain central sensitization to a very literal engineer, or convince an elite athlete that resting for 48 hours won’t destroy

[52:45] their career?

Kathy: I mean, number one sounds way easier.

Jason: It does.

Kathy: It does. It does.

Jason: You’ve worked with elite athletes.

Kathy: My dad’s an engineer and my brother’s an engineer, so I know how to handle that crowd. So I’m definitely going to go with number one.

Jason: Okay. Nice. All right, I think — oh, this is the last one. Okay. Would you rather do a full day of evaluations where every patient asks, “But what’s the real cause of my pain?”

[53:15] Or do a full day where every patient says, “I don’t care about the cause. Just fix me.”

Kathy: Oh,

Jason: yeah. That one’s like a knife.

Kathy: That one’s rough.

Jason: This one’s getting personal.

Kathy: That’s a Sophie’s choice.

Jason: Yeah. I like my odds on number one better.

Kathy: Yeah, I would agree with that.

Jason: But 25 years ago, I would have said number two. Yeah. Because I was like, “Yeah, I fix people.

Kathy: Fix it.”

Jason: And can we acknowledge one of the most nauseating things in healthcare is how many of us are talking about the root

[53:46] cause.

Kathy: Oh yeah. Yeah. They’re not treating the root cause.

Jason: You didn’t get to the root cause.

Kathy: Trust me, I know the root cause, guys.

Jason: It’s the rotator cuff.

Kathy: It’s the rotator cuff. Yeah. Your rotisserie cuff is —

Jason: Yes.

Kathy: Don’t forget about the piriformis.

Jason: Has somebody said that to you? The piriformis.

[54:17] Yeah, the piriformis.

Kathy: Oh my gosh.

Jason: Oh man, that really hurts my SI joint. I know.

Kathy: Oh jeez.

Jason: Yeah, got a lot of educating to do out there.

Kathy: We do. We do. And we’re one step ahead now with this episode. So let’s hope it goes viral.

Jason: Well, Kathy, take homes.

Kathy: Take homes. Let’s normalize pain. I probably just stole yours, but it’s

[54:47] amazing.

Jason: Yeah.

Kathy: Yeah. Oh, now it’s my turn.

Jason: Oh, yeah. Sorry, I stole yours.

Kathy: You didn’t? And then I was like, now I forgot mine. No. I think — I don’t know what I’m talking about. Well, I think what I’m bringing back to my clinic is I’m leaning more into what do people love that they want to get back to.

Jason: And really, that should be the focus of every visit, because that’s why people really show up — is they want more of the

[55:17] stuff that they love. And the pain or the dysfunction, whatever they’re coming in with, that’s just an obstacle, something that’s in the way of their passion. Let’s get them back to those things. So,

Kathy: well, Amy, wow. Okay, Kathy, I get it. She’s wonderful. Thank you. Thank you so very much for being here on the show and bringing all your wisdom, smarts, and knowledge with you. If somebody wants to get in touch with you, can they?

Jason: Yes. Okay, I’m open to it.

[55:47] What’s a good way for people to get a hold of you?

Kathy: I’m on Twitter. I’m on LinkedIn. I can’t remember my Twitter handle. It’s something AW McDevitt.

And then Amy McDevitt on LinkedIn. Okay. Yep. And then you can Google me at CU. And there’s other contact information that way. And I want to thank both of you for having me come today, because it’s really just about being the best providers we can all be in order to better serve our patients, because they deserve that. And so I’m

[56:18] really passionate about trying to just remember that we need to be intellectually curious, but also exercise intellectual humility and put the human in front of us at the front of all of this, whether it means we change language or we learn about better rapport or better ways to do things. That’s really what it’s about. So thank the two of you for caring to talk about this topic, because it’s something that I’m personally passionate about.

Jason: Yeah, I love it. Thanks again. Thank you so much. And thanks again to our

[56:50] Sponsors. We got to mention sponsors every time. So, Encore Physical Therapy — PT so good, you’re going to want more — and Body of Health Chiropractic and Wellness Center. And oh, and then there’s one other important thing that we have to cover, and that’s that there’s no “I” in PTCH.

[57:28] The music — — I can’t hear you. We’ll stop in a minute.