Podcast appearances and mentions of sandy hilton

Tim and Bart dive into the challenge of working under time constraints in both public health systems and private practice. They share strategies for setting boundaries, prioritising patient rapport, and delivering high-quality, individualised care despite limited time. The duo discuss the pros and cons of working within a system versus private practice and emphasise the importance of flexibility and challenging the status quo. Packed with practical advice and relatable anecdotes, this episode will help you conquer the clock and thrive in any clinical situation.    Useful Resource A Clinician's Guide to Thriving Under Time Constraints by Le Pub Scientifique & Sandy Hilton. Get your copy now: https://www.lepubscientifique.com/guides   Keywords time constraints, clinical practice, expectations, boundaries, flexibility, individualisation, protocols, efficiency   Takeaways Setting expectations and boundaries is important in managing time constraints in clinical practice. Flexibility and individualization are key in providing effective treatment within limited time. Protocols can be helpful for efficiency, but it is important to adapt them to suit each individual. Doing things well and making the most of the available time is crucial in providing quality care. Sound Bites "Setting out expectations and boundaries is really important." "Therapy starts when the patient leaves the room." "The ability to adapt protocols to suit each individual is a skill." Chapters 00:00 Introduction and Overview 02:22 Whose Problem is Time Constraints? 04:18 Time Constraints in Different Contexts 06:41 Creating a Treatment Plan 09:07 The Challenge of Making a Difference in Limited Time 13:29 The Therapy Continues Outside the Room 15:23 The Importance of Readiness to Change 20:38 Private Practice vs Public Health System 23:23 Flexibility and Choice in Private Practice 25:45 The Value and Limitations of Protocols 28:09 Managing Time Constraints and Asking the Hard Questions 30:09 Doing Things Well in Limited Time Useful Links Le Pub Website: www.lepubscientifique.com  Become a Le Pub member: https://www.lepubscientifique.com/premium-membership  Contact us: lepubscientifique@gmail.com   Follow us: Twitter: @lepubscientifiq Instagram: @lepubscientifique LinkedIn: @LePubScientifique

In this episode Dr Sandy Hilton shares with us how we can approach pelvic pain in a more healthy manner as young clinicians. Including how we can help people without internal assessments and even without internal treatments. She describes it as a spectrum of information gathering.

In this episode, with Dr Sandy Hilton, we talk about the different types of pain, how we can use sensory integration to have productive conversations with the nervous system. Sit back & relax as we explore the difference between nociceptive, neuropathic or nociplastic pain...and why the difference matters. We discuss the concept of how tissues can heal...but the pain can persist. We talk about feeling rude gremlins in the v@gina and golf balls in the rectum, even when there isn't - how thoughts can cascade into painful events, and then when we add the stigma and embarrassment of pelvic pain onto that...and how the pudendal nerve gets blamed for a lot of things it isn't responsible for. Pain is real, it's exceptionally weird and nobody has all the answers - but we have a few great suggestions to help stop the brain being over-protective. We also explore how female pelvic pain is often dismissed and how scary and escalating being gas lit can be... You can find Sandy's books here: https://www.optp.com/Self-Care-for-Pelvic-Pain-A-Sensory-Integration-Toolkit And if you'd like to learn more about Female Pelvic Pain Rehab or understanding the role of hormonal health in helping women live well - here's the link to all of my online courses For all my musings on women's health, especially pelvic pain rehab & oncology rehab, you can find/follow me on Instagram - just click here Until next time, look after yourself and don't forget to...#celebratemuliebrity

A client with chronic pelvic pain has been through the wringer, trying to get a solid diagnosis and effective treatment for what has—for lack of a better option—been diagnosed as levator ani syndrome. Is there anything massage can do for this person? And is there a connection between levator ani syndrome and this client's extreme flexibility? We explore these questions and more on this episode of “I Have a Client Who . . .” Sponsors:     Books of Discovery: www.booksofdiscovery.com     Advanced-Trainings: www.advanced-trainings.com   Host Bio:                    Ruth Werner is a former massage therapist, a writer, and an NCBTMB-approved continuing education provider. She wrote A Massage Therapist's Guide to Pathology, now in its seventh edition, which is used in massage schools worldwide. Werner is also a long-time Massage & Bodywork columnist, most notably of the Pathology Perspectives column. Werner is also ABMP's partner on Pocket Pathology, a web-based app and quick reference program that puts key information for nearly 200 common pathologies at your fingertips. Werner's books are available at www.booksofdiscovery.com. And more information about her is available at www.ruthwerner.com.                                      Recent Articles by Ruth:          “Working with Invisible Pain,” Massage & Bodywork magazine, November/December 2022, page 36, http://www.massageandbodyworkdigital.com/i/1481961-november-december-2022/38   “Unpacking the Long Haul,” Massage & Bodywork magazine, January/February 2022, page 35, www.massageandbodyworkdigital.com/i/1439667-january-february-2022/36. “Chemotherapy-Induced Peripheral Neuropathy and Massage Therapy,” Massage & Bodywork magazine, September/October 2021, page 33, http://www.massageandbodyworkdigital.com/i/1402696-september-october-2021/34.           “Pharmacology Basics for Massage Therapists,” Massage & Bodywork magazine, July/August 2021, page 32, www.massageandbodyworkdigital.com/i/1384577-july-august-2021/34.           Resources:    Pocket Pathology: https://www.abmp.com/abmp-pocket-pathology-app   Chronic Pelvic Pain in Women (no date). Available at: https://www.abmp.com/textonlymags/article.php?article=1550 (Accessed: 2 May 2023).   Gilliam, E., Hoffman, J.D. and Yeh, G. (2020) ‘Urogenital and pelvic complications in the Ehlers-Danlos syndromes and associated hypermobility spectrum disorders: A scoping review', Clinical genetics, 97(1), pp. 168–178. Available at: https://doi.org/10.1111/cge.13624.   https://www.physiotherapyroom.com/Self-Care-for-Pelvic-Pain-A-Sensory-Integration-Toolkit   Knowles, C.H. and Cohen, R.C. (2022) ‘Chronic anal pain: A review of causes, diagnosis, and treatment', Cleveland Clinic Journal of Medicine, 89(6), pp. 336–343. Available at: https://doi.org/10.3949/ccjm.89a.21102.   Levator Ani Syndrome: Symptoms, Causes, and Treatment (2017) Healthline. Available at: https://www.healthline.com/health/levator-ani-syndrome (Accessed: 28 April 2023).   Massage & Bodywork - JULY | AUGUST 2016 (no date). Available at: http://www.massageandbodyworkdigital.com/i/694071-july-august-2016/44? (Accessed: 2 May 2023).   Myofascial Pelvic Pain (no date) Physiopedia. Available at: https://www.physio-pedia.com/Myofascial_Pelvic_Pain (Accessed: 2 May 2023). Self-Care for Pelvic Pain—a Sensory Integration Toolkit by Sandy Hilton, PT, DPT, MS

Mike interviews Physical Therapist Sandy Hilton about Pelvic Floor Pain. Sandy has contributed to multiple book chapters, papers, and co-authored “Why Pelvic Pain Hurts”. She is an international instructor and speaker on treating pelvic pain for professionals and for public education. ~~~~~Sandy's Book~~~~~ 1) Self-Care for Pelvic Pain Book: https://amzn.to/3N4oG9V 2) Self-Care for Pelvic Pain: A Sensory Integration Toolkit: https://amzn.to/3H6vbFn Website: Entropy Physiotherapy: https://entropy.physio/ ~~~~Time Stamps~~~~ 0:00 Intro Song 0:08M Sandy Hilton Introduction 1:00 Brief Book description 1:32 Sandy's Backstory 4:10 Sandy's Website Information 6:10 What is Pelvic Pain? 12:10 How Common is Pelvic Pain? 13:52 What Pelvic Conditions are Common. 20:10 How to determine what is causing your Pelvic Condition? 22:57 Self Care for Pelvic Pain / SIT KIT explanation 26:06 Theory of Sensory Integration 31:20 Can Sensory Integration be used for all kinds of pelvic pain? 32:20 Rules for Using Sensory Integration Tools 37:08 What starts Pelvic Pain? 42:40 Simple tips for Pelvic Pain to feel good each day! 44:22 Last remarks 46:20 Sandy Hilton on social media --- Support this podcast: https://podcasters.spotify.com/pod/show/bobandbrad/support

 I promise we are not a broken record player, our rights are just constantly under attack. We're covering another case of corrupt groups putting not only our lives but others in jeopardy as well. That's right! Targeting uterine healthcare has turned into a problem for those even without a uterus. In an attempt to ban a certain medication used in abortions, this group failed to acknowledge that, like most medications, this drug can be used to treat more than one condition. These sinister groups are becoming bolder and bolder in an attempt to keep proper healthcare from our lives. They'll have to keep on trying! We are keeping our rights and our bodies taken care of. Pain is something uterinekind is definitely familiar with. From periods to chronic conditions, it is so extremely common for us to live with pelvic pain for the majority of our lives, yet our pain constantly gets dismissed.These conditions can heavily impact the way we view ourselves and handle our pains which is why our guest is sharing her incredible knowledge on all things pain. Dr. Sandy Hilton chats with us about what pain is, how we can control it, how pelvic pain works, and what you can do for some relief. Interested in learning more? Check out Why Pelvic Pain Hurts co-written by Dr. Hilton! Lastly, we end on a high note from New Guinea. Sometimes you need to get away from the rest of the world…for 140 years! Thanks for listening, learning, and being you. And join us back here every Tuesday for all things uterus, in service to you, uterinekind.

Lorimer Moseley's Quiz for Clients About Pain Science OT Elevate: The Biopsychosocial Approach to Colorectal ConditionsLindsey's NewsletterTed TalksPredictive Processing as a Theory to Understand Pain with Mick ThackerWhy do we hurt? by Professor Lorimer MoseleyPodcasts One Thing pain podcast with Mick ThackerPain Science and Sensibility with Sandy Hilton & Cory BlickenstaffThe Healing Pain podcast by Dr Joe TattaBooksExplain Pain by David Butler and Lorimer Moseley The Explain Pain Handbook: Protectometer by Lorimer Moseley & David Butler.  Permission to Move by Dave Moen and Farrin FosterOther ResourcesReal Stories of RecoveryThe Neuroscience of Creativity, Perception, and Confirmation Bias with Beau LottoFree course in mindfulness is offered by Monash UniversityZiva Meditation  

There are many, many challenges with pelvic pain that don't happen if you sprain an ankle or have a shoulder injury that you can point to and talk about with your co-workers. With pelvic pain, it may feel hard to show others where it hurts— even a health professional, awkward to talk about it with friends or someone you love, that your morals or faith will be questioned because of religious beliefs, or that the pain will never stop. Dr. Sandy Hilton is a pain and pelvic health physical therapist currently in Chicago at Entropy Physiotherapy.  Sandy works in the clinic and online to help people with pain recover and is an international invited speaker and instructor of other health professionals.  Sandy teaches classes on manual therapy and sensory integration techniques that are purposefully non-painful and help recover tolerance to sitting, bike riding, sexual function and more! Dr. Sandy shares strategies to move through challenges with pelvic pain: Using your imagination to identify what can trigger pain and how to unhook your thoughts from the pain Using graded exposure (from sports psychologists and used in Olympic-level recovery strategies) to start doing something challenging again Gaging your progress in relation to what else is happening in your life— a flareup doesn't mean your progress is slipping away Making it a priority to do something you love every single day I love how Dr. Sandy reminds us that even though the pain can become the center of your life, life is not about dealing with the pain; managing pain is about how you approach living your life beyond the pain and making your happiness a priority. RESOURCES: Free sex and pelvic pain resources https://drsusieg.com/resources-for-pelvic-pain-in-men Online Pelvic Pain Relief Program for Men https://drsusieg.com/pelvic-pain-in-men-online-program Why Pelvic Pain Hurts https://www.amazon.com/Pelvic-Pain-Hurts-Adriaan-Louw/dp/0985718684 Self-Care for Pelvic Pain: A Sensory Integration Toolkit https://www.optp.com/Self-Care-for-Pelvic-Pain-A-Sensory-Integration-Toolkit CONNECT WITH DR. SANDY HILTON Website: entropy.physio Twitter: @SandyHiltonPT Email: sandy@entropy.physio CONNECT WITH ME (DR. SUSIE): Website: https://drsusieg.com/ Instagram: https://www.instagram.com/dr.susieg/ 15-minute call: https://drsusieg.com/pelvic-pain-specialist-15-minute-call VIDEO CHAPTERS 0:00 Intro 4:10 Why pelvic pain is so challenging 9:20 What is graded exposure and how to use it 15:20 Finding the “right” treatment plan for you 16:30 How to stay hopeful that the pain can get better 20:20 We know that pain can change 22:10 Using graded exposure to manage pain after ejaculation 26:30 More repetitions isn't better 28:40 How to talk about graded exposure with physical therapists 33:16 Dr. Sandy's sensory integration toolkit Disclaimer: This information is not intended to substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of a healthcare professional with any questions you may have regarding treatment, medications/supplements, or any medical diagnoses. This information is intended for educational purposes only and is in no way to substitute the advice of a licensed healthcare professional.

In this episode, Founder of Enhanced Recovery After Delivery™, Dr. Rebeca Segraves, Co-Founder of Entropy Physiotherapy, Dr. Sarah Haag, Owner and Founder of Reform Physical Therapy, Dr. Abby Bales, and Co-Owner of Entropy Physiotherapy, Dr. Sandy Hilton, talk about the consequences of overturning Roe v. Wade. Today, they talk about the importance of taking proactive measure in communities, and the legal and ethical obligations of healthcare practitioners. How do physical therapists get the trust of communities who already don't trust healthcare? Hear about red-flagged multipurpose drugs, advocating for young people's education, providing physical therapy care during and after delivery, and get everyone's words of encouragement for healthcare providers and patients, all on today's episode of The Healthy, Wealthy & Smart Podcast.   Key Takeaways “Our insurance-based system is not ready to handle the far-reaching consequences of forced birth at a young age and botched abortions.” “We do need to know abortive procedures so that we can recognize when someone has been through an unsafe situation.” “We really need to take into consideration the ramifications of what this will do.” “This is not good healthcare and we need to do more.” “We're going to have to know our rules, our laws, and what we're willing to do and go through so that we can provide the care that we know our patients deserve.” “We're looking at the criminalization of healthcare. That is not healthcare.” “We know who this criminalization of healthcare is going to affect the most. It's going to affect poor, marginalized people of color.” “We can no longer choose to stay in our lane.” “We need to have a public health physio on the labour and delivery, and on maternity floors.” “We don't get to have an opinion on the right or wrongness of this. We have a problem ahead of us that is happening already as we speak.” “We need to create more innovators in our field, and education is the way to do that.” “This is frustrating and new, and we're not going to abandon you. We're going to figure it out and be there to help.” “Our clinics are still safe. We are still treating you based on what you are dealing with, and we will not be dictated by anybody else.” “If you need help, there is help.” “If we believe in the autonomy of an individual to know all of the information before making a decision, then we still believe in the autonomy of an individual to know all of the information that is best for their body.” “This affects everyone. We're dedicated to advocating for you.”   More about Dr. Rebeca Segraves Rebeca Segraves, PT, DPT, WCS  is a physical therapist and Board-Certified Women's Health Clinical Specialist who has served individuals and families within the hospital and home during pregnancy and immediately postpartum. She has extensive experience with optimizing function during long-term hospitalizations for high-risk pregnancy and following perinatal loss and pregnancy termination. In the hospital and home health settings, she has worked with maternal care teams to maximize early recovery after delivery, including Caesarean section, birth-related injuries, and following obstetric critical care interventions. She is the founder of Enhanced Recovery After Delivery™, an obstetrics clinical pathway that maximizes mental and physical function during pregnancy and immediately postpartum with hospital and in-home occupational and physical therapy before and after birth. Her vision is that every person will have access to an obstetric rehab therapist during pregnancy and within the first 6 weeks after birth, perinatal loss, and pregnancy termination regardless of their location or ability to pay.   More About Dr. Sarah Haag Dr. Sarah Haag, PT, DPT, MS graduated from Marquette University in 2002 with a Master of Physical Therapy. She went on to complete Doctor of Physical Therapy and Master of Science in Women's Health from Rosalind Franklin University in 2008. Sarah has pursued an interest in treating the spine, pelvis with a specialization in women's and men's health, becoming a Board-Certified Women's Health Clinical Specialist in 2009 and Certification in Mechanical Diagnosis Therapy from the McKenzie Institute in 2010. Sarah joined the faculty of Rosalind Franklin in 2019. In her roles at Rosalind Franklin, she is the physical therapy faculty liaison for the Interprofessional Community Clinic and teaching in the College of Health Professions. Sarah cofounded Entropy Physiotherapy and Wellness with Dr. Sandy Hilton, in Chicago, Illinois in 2013. Entropy was designed to be a clinic where people would come for help, but not feel like ‘patients' when addressing persistent health issues.   More About Dr. Abby Bales Dr. Abby Bales, PT, DPT, CSCS is the owner and founder of Reform Physical Therapy in New York City, a practice specializing in women's health and orthopedic physical therapy. Dr. Bales received her doctorate in physical therapy from New York University and has advanced training through the renowned Herman and Wallace Pelvic Rehabilitation Institute, Grey Institute, Barral Institute, and Postural Restoration Institute, among others. She also holds her Certified Strength and Conditioning Specialist certification from the NSCA and guest lectures in the physical therapy departments at both NYU and Columbia University, as well as at conferences around the country. Dr. Bales has a special interest in and works with adult and adolescent athletes with a history of RED-S (formerly known as the Female Athlete Triad) and hypothalamic amenorrhea. A lifelong athlete, marathon runner, and fitness professional, Dr. Bales is passionate about educating athletes, coaches, and physical therapists about the lifespan of the female athlete. Her extensive knowledge of and collaboration with endocrinologists, sports medicine specialists, pediatricians, and Ob/gyns has brought professional athletes, dancers, and weekend warriors alike to seek out her expertise. With an undergraduate degree in both pre-med and musical theatre, a background in sports and dance, 20 years of Pilates experience and training, Dr. Bales has lent her extensive knowledge as a consultant to the top fitness studios in New York City and is a founding advisor and consultant for The Mirror and the Olympya app. She built Reform Physical Therapy to support female athletes of all ages and stages in their lives. Dr. Bales is a mom of two and lives with her husband and family in New York.   More About Dr. Sandy Hilton Sandra (Sandy) Hilton graduated with a Master of Science in Physical Therapy from Pacific University in 1988. She received her Doctor of Physical Therapy degree from Des Moines University in 2013. Sandy has contributed to multiple book chapters, papers, and co-authored “Why Pelvic Pain Hurts”. She is an international instructor and speaker on treating pelvic pain for professionals and for public education. Sandy is a regular contributor on health-related podcasts and is co-host of the Pain Science and Sensibility Podcast with Cory Blickenstaff. Sandy was the Director of Programming for the Section on Women's Health of the American Physical Therapy Association from 2012 - 2017. She is now on the board of the Abdominal and Pelvic Pain special interest group, a part of the International Association for the Study of Pain.   Suggested Keywords Healthy, Wealthy, Smart, Roe v Wade, Abortion, Trauma, Sexual Trauma, Pregnancy, Advocacy, Pelvic Health, Healthcare, Education, Treatment, Empowerment,   To learn more, follow our guests at: Website:          https://enhancedrecoverywellness.com                         https://enhancedrecoveryafterdelivery.com                         https://www.entropy.physio                         https://reformptnyc.com Instagram:       @sandyhiltonpt                         @reformptnyc                         @enhancedrecoveryandwellness Twitter:            @RebecaSegraves                         @SandyHiltonPT                         @Abby_NYC                         @SarahHaagPT LinkedIn:         Sandy Hilton                         Sarah Haag                         Abby Bales                         Rebeca Segraves   Subscribe to Healthy, Wealthy & Smart: Website:                      https://podcast.healthywealthysmart.com Apple Podcasts:          https://podcasts.apple.com/us/podcast/healthy-wealthy-smart/id532717264 Spotify:                        https://open.spotify.com/show/6ELmKwE4mSZXBB8TiQvp73 SoundCloud:               https://soundcloud.com/healthywealthysmart Stitcher:                       https://www.stitcher.com/show/healthy-wealthy-smart iHeart Radio:               https://www.iheart.com/podcast/263-healthy-wealthy-smart-27628927   Read the Full Transcript Here:  00:07 Welcome to the healthy, wealthy and smart podcast. Each week we interview the best and brightest in physical therapy, wellness and entrepreneurship. We give you cutting edge information you need to live your best life healthy, wealthy and smart. The information in this podcast is for entertainment purposes only and should not be used as personalized medical advice. And now, here's your host, Dr. Karen Litzy. Hey everybody,   00:36 welcome back to the podcast. I am your host, Karen Litzy. And on today's episode, I am very fortunate to have for pretty remarkable physical therapists who also happen to be pelvic health specialists. On to discuss the recent Supreme Court ruling in the dobs case that overturned the landmark ruling of Roe vs. Wade. How will this reversal of Roe v Wade affect the patients that we may see on a regular basis in all facets, facets of the physical therapy world. So to help have this discussion, I am very excited to welcome onto the podcast, Dr. Rebecca Seagraves and Dr. Abby bales and to welcome back to the podcast Dr. Sandy Hilton, and Dr. Sarah Hague. So regardless of where you fall on this decision, it is important that the physical therapy world be prepared to care for these patients. So I want to thank all four of these remarkable physical therapists for coming on to the podcast. Once the podcast starts, they will talk a little bit more about themselves, and then we will get right into our discussion. So thank you everyone for tuning in. And thanks to Abby, Rebecca, Sandy, and Sarah.   02:03 I, my name is Rebecca Seagraves, I'm a private practice pelvic health therapist who provides hospital based and home based pelvic health services and I teach occupational and physical therapists to provide their services earlier in the hospital so that women don't have to suffer.   02:20 Perfect Sarah, go ahead.   02:22 I am Sarah Haig. And I'm a physical therapist at entropy physiotherapy in Chicago, and I'm also assistant professor and at a university where I do get to teach a variety of health care providers.   02:35 Perfect, Abby, go ahead. My name is Abby bales. I'm a physical therapist, I specialize in pelvic health for the pregnant and postpartum athlete. I have my practice in New York City called perform physical therapy, and I do in home visits and I have a small clinic location.   02:54 Perfect and Sandy. Go ahead.   02:56 Sandy Hilton. I'm a pelvic health physical therapist. I'm currently in Chicago with Sara entropy. And I'm in Chicago and online. Because we can see people for consultations wherever they are, and we may be needing to do more of that.   03:13 So the first question I have for all of you lovely ladies, is how will the recent Supreme Court ruling in the dobs case, which was overturning Roe v. Wade? How is that going to affect people who give birth that we see in our clinics in the hospital setting in an outpatient setting in a home setting? So let's start with Sara, go ahead. I'll start with you. And then we'll just kind of go around. And and and also feel free to chime in and you know, the conversation as you see fit? Got?   03:58 That's such a big question. And I get to go first. So the question was how, how is this decision going to affect people who give birth? And I would say it just it affects everyone in in kind of different ways. Because I would say what this will undoubtedly do is result in us seeing people who didn't want to give birth. And and I think, you know, the effects of that are going to be far reaching and that we I think maybe we in this little group can have an idea of, of the vastness of this decision, but I think that even we will be surprised at what happens. I think that how it will affect people who give birth. Gosh, I'm kind of speechless because there's so many different ways. But when we're looking at that person in front of us with whatever they need to do For whatever they need assistance with after giving birth, we're going to have to just amplify exponentially our consideration for where they are and how they felt going into the birth, how they got pregnant in the first place. And, and kind of how they see themselves going forward. We talk about treating women in the fourth trimester. And it's, I mean, I'm in that fourth trimester, myself, and I can tell you that it would be harder to ask for help. And I'm really fortunate that I, that I have that I do have support, and that I do have the ability to seek help. I have a million great friends that I can reach out to for help, but I'm just how the how it's gonna affect the women, I'll say, I'm scared, but it's not about me. I'm very concerned for other women who won't be able to access the care that they that they need.   06:05 Yeah, Sandy, go ahead. What do you think? How do you feel this decision will affect people who can give birth, especially as they come to see physical therapist, whether that be during pregnancy? As Sarah just said, the fourth trimester, or perhaps after a procedure, or abortion that maybe didn't go? Well? Because it wasn't safe?   06:30 Yeah, so I work a lot with pain. One of my concerns is, but what is the future gonna hold for some people who did not want to be pregnant not added some sort of convenience or concern for finances, both of which, you know, your spot in life determines whether or not you have the the ability to raise another person at that moment. So there are individual decisions that people should make, in my opinion, but also, there's the if something happens to you, that you did not give permission to happen. And then you are dealing with the consequences. In this instance, pregnancy, and you happen to have back pain or have hip pain, or have a chronic condition, or a pelvic pain history, where you didn't not want to be pregnant. How's that going to affect the pain and the dysfunction that you're, you are already happening? And will it sensitize people to worse outcomes and recovery afterwards, because this is a, you know, there's a perceived injustice scale, I want to pull that back out. I hadn't been using it very often in the clinic just didn't seem to change the course of care. But I think that when I'm working with the people pre post, during pregnancy, I think I'm going to pull my perceived injustice scale back out and see if that might be a nice way to find out. If I need to hook someone up to a counselor, a financial counselor, psychologist, sexual therapist, anyone who might be able to support this person, we already don't have good support systems for pregnancy. I just am astounded at how much what a bad choice it is to add more need to a system that isn't currently handling the demand. I know we're gonna need to get creative because these people will need help. But I am a little awestruck at the possible quantum s we're gonna walk into   08:51 an abbey you had mentioned before we started recording about you know, some of the folks that you see that may have a history of different kinds of trauma, and how that may affect their abilities are to kind of wrap their head around being pregnant and then being forced to give birth because now they don't have any alternative. So how do you feel like that's going to play out in the physical therapy world, if they even get to physical therapy if they even get to a pelvic health therapist?   09:34 Yeah, that's, that's one of the things that I was I was thinking about as everyone was chiming in was, we really are just at the precipice in our niche of our profession, where people who give birth are seeking or even hearing about pelvic health and postpartum care, pregnancy care there. Just barely hearing about it. And my I have, you know, a concern, a very deep concern that these people will go into hiding if they have had an abortion in the past, because are we obligated to report that, and what is the statute of limitations on that, and the shame that they might feel for having had an abortion, or having had give birth and didn't want to, and the trauma that my patients who have, for the most part, not everyone who have wanted pregnancies that either the birth is traumatic, the pregnancy is traumatic, they get to a successful delivery, or they have a loss during the pregnancy, the trauma that they are experiencing, and for the most part, I'm seeing adults, and I cannot comprehend children, because it's this gonna be a lot of children who are forced to give birth, or who are having unsafe abortions, and the trauma that they're going to experience, and how, how much it takes for a person who has sexual trauma or birth trauma to get to my clinic, how these young people how these people who feel that shame, I don't know how they're going to get to me, or any of us, except for a real team based approach with pediatricians, with hospitals, with OB GYN, with your gynecologist with people who might see them first before us. I just don't know how they get to us to be able to treat and help treat that trauma. And like Sandy said, that pelvic pain that might be a result of the trauma if if it's unwanted sexual intercourse, I just don't know how we get to them. And that is something that we struggle with now, with, for the most part, wanted pregnancies. And I don't know how we get there. And I don't think we're prepared as a profession. for that. I think the advocacy for getting ourselves into pediatricians offices into into family medicine offices, is going to be so crucial in getting to these patients. But there aren't enough of us. We are not prepared. And our insurance based system is not ready to handle the far reaching consequences of forced birth at a young age and botched abortions. It is not ready to handle that.   12:52 Rebecca, go ahead. I'm curious to hear your thoughts around this because of your work in acute care systems.   13:00 Absolutely. I believe that I'm beyond the argument of whether this is right, or whether this is wrong. I think that as a profession, we're going to have to quickly change to a mindset of can we be prepared enough to handle what Abby was saying the amount of trauma, the amount of mental health I think, comes to mind when when someone's autonomy is taken away from them in any regard. I was very vocal as to how dangerous it was to force, you know, mandates on people even last year. And now here we are, we're at a point in our profession where we have to now separate our own personal beliefs and be committed to the oath of doing no further harm because this will result in harm, having treated individuals after an unplanned cesarean section or a cesarean hysterectomy, because of severe blood loss. They had no choice in those procedures. And they had no choice in the kind of recovery or rehabilitation they would get. I had to fight an advocate for our services, physical and occupational therapy services to be offered to individuals. So when you're looking someone in the eye who has lost autonomy over their body as last choice has gone through trauma that changes you it changes me really as a profession, even on this a professional or even on this issue. I'm now pivoting as quickly as I can't decide, do I have the skills that's going to be needed to address maybe hemorrhage events from an unsafe abortion that's performed? Maybe the mental health of having to try All across state lines so that you can find a provider that will treat you maybe the, you know, the shame around, you know, even finding Well, you know, is there a safe space for me to be treated for my pelvic health trauma from you know, maybe needing to carry this pregnancy longer than then I would have wanted to, there's, there's so much around this that we really have to start looking at with a clinical eye with a very empathetic or sympathetic eye as pelvic health therapists because of the fact that there's so few of us. And because now we're in a scenario where there will be more people who will be needing services but not knowing who to turn to. So my my biggest hope from this conversation, and many more that we'll have is that there's some how going to be a way to designate ourselves as a safe space for anyone, no matter what choice they've made for their body, period, I'm really done with being on one end of the spectrum with this, I'm a professional that doesn't have that opportunity to just, you know, be extreme on this, I advocate for the person and for their choice over their body period.   16:17 I think we need to, and it's just beautifully, beautifully said, the the getting getting some small systemic procedures in place in the communities we live in, is most likely the first step is reach out to the pediatricians and the chiropractors and the massage therapists and the trainers and the school athletic trainers and whoever you find that can have a connection with people and let them know on an individual basis. So like how do you tell people hey, I'm a trustworthy clinic to come to is not usually by writing it on your website. But if you can make connections in your community and be a trusted provider, that's going to go further, I suspect. I'm assuming there's going to be a fair bit of mistrust. And we have to earn it once it's lost. We've got to earn it back. So yeah, I like the proactiveness of that.   17:22 I, I totally agree on something you said Sandy sparked something that I would love for a health care lawyer to start weighing in on is we want, I am a safe space. I think every patient I have ever met who sees me cries. And I hold I hold that part of what I do. Very close to me, it's it's an honor to be someone that my patients open up to. And I know all of you on this call feel the same way because we we are that place that they they I love hearing birth stories. I love it. Even it just gives me an insight into that person into that experience. I feel like I'm there with them. And I understand better what they have gone through. But what happens when the legal system is going to come for us? Or them through us? What happens to that? How do we continue to be a safe space where they can share their sexual trauma, their birth trauma, their birth history, their pregnancy history, their menstruation, history, their sexual history? All of those really, really intimate things? How do we continue to be that for our patients?   18:56 I think we've had to do this I've had to do this previously, for in some very, in situations of incest in for the most part, we need a trigger warning on this. But, you know, there you have an individual that is a minor, or, or for some reason not independent that is being abused in what is supposed to be their safe space. And then that person, the abuser can be like, Oh, look, I'm helping you get better. And they're actually not safe. So there's some things and if the person you're treating is a minor, that adult has access to their records. And so I've worked in places not I don't know how to do with an EMR but I've worked in places where we have our chart that we write down the official record and sticky notes, which are the things that will not get put in the official record. But we need to have written down so people know it. And we've had to do that in situations where the patient wasn't safe. We all knew the patient wasn't safe. was being worked on to get them safe, but they were not yet safe. And you had to make sure there was nothing in their records that was going to make them more unsafe. I don't know how to do it as an EMR, if someone has a clever way to do that, that'd be great. Or we go back to EMR plus paper charts.   20:18 Even to to add to your point, Abby, if we're looking now at possible, you know, jurisdiction, you know, lead legal their jurisdiction or subpoena of documentation, you know, after having intervened for someone who may have had to make a choice that their state did not condone? Yeah, no, I, I'm completely, you know, on guard against that now, and that those are things that I'm thinking about now and thinking about, well, what would my profession do? Would we back, you know, you know, efforts on Capitol Hill to advocate for, you know, someone who, who has lost their, their autonomy, or lost their ability to, to at least have a safer procedure, and we've had to intervene in that way. You know, I think about that now, and I, that makes me fearful that this is such a hot topic issue that, you know, we might not as an organization want to choose size, but we as professionals on the ground as pelvic health therapists, I don't think that we have that luxury and turning someone away. And so So yeah, I think more conversations like this need to be had so that we can form a unified front of at least, you know, pelvic health specialists that can really help with the the after effects of this.   21:38 And I think a big barrier to that legal aspect of it is, you know, what is our legal responsibility. And what happens, if we don't do XYZ is because a lot of the laws and a lot of these states, some of these trigger laws and other laws being that are being passed, the rules seem to be a bit murky. They're not clear. And so I agree, I think the APTA or the section on pelvic health needs to come out with clear guidelines as to what we as healthcare professionals, can and should do. But here's the other thing that I don't understand and maybe someone else can. What about HIPAA? Isn't that a thing? Where did the HIPAA laws come in to protect the privacy between the provider and the patient? And I don't know the answer that I'm not a lawyer, but we have protection through hip isn't that the point of a HIPAA HIPAA laws? I don't know what   22:44 you would think so. But unfortunately, one of the justices who shall not be named has decided that abortion does not fall under HIPAA, because it involves the life of another being in so I can only state what has been stated or restate. But yes, the those are the very things that I'm afraid we're up against as professionals.   23:12 Yeah, I think they're going to try to make us mandatory reporters. for it. I think they're gonna try to make all healthcare we are mandatory. For some things, the thing that's good for some things. Yeah, the   23:24 thing that bothers me about that is the where I'm in Illinois right now, Illinois is a designated, look, we're not, we're not going to infringe on people's right to health care. Just great. But some of the laws and I've lost track, I was trying to keep track of how many have are voting on or have already voted on laws that would have civil penalties, penalties of providers from other states, regardless of the Practice Act of that provider, to be able to have a civil lawsuit against that provider. So that's fun. And then we go back to what ABBY You had mentioned before we started recording about medicine, that that is considered an abort efficient, I have a really hard time with that word. But that is also used for other conditions that we see in our clinics for pain for function and things like that. And then where's our role?   24:33 Right, so does someone want to talk about these more specific on what those medications are and what they're for? So that people listening are like, Okay, well, what medications, you know, so do you want to kind of go into maybe what those medications are, what they're for and how they tie back into our profession. Because, you know, a lot of people will say, well, this isn't our lane. So we're trying to do these podcasts. so people understand it's very much within our lane.   25:03 Well, I yeah, it's just from a pharmacology standpoint, the one of the probably most popular well known drugs that's used for abortion is under the generic name of Cytotec misoprostol, and that's a drug that's not only only used for abortion, but if individual suffers a miscarriage is used to help with retained placenta and making sure that the uterus clears. What other people don't know is is also used for induction. So the same drug is used for three or four different purposes. It's also used for postpartum hemorrhage. So measle Postel, or Cytotec is a drug as pelvic health therapists we should be very familiar with. And we should be familiar with it. Not only you know, for, you know, this this topic, but it's also been a drug that's been linked with the uterus going into hyperstimulation. So actually putting someone at risk for bleeding too heavily. And all of this has a lot of implications on someone's mental health, who's suffered a miscarriage who's gone through an abortion that maybe was not safely performed, which I have had very close experience with someone who's been given misoprostol Cytotec, it didn't take well, she continued bleeding through the weekend, because she lived in a state where emergency physicians could opt out of knowing a board of medications. So as professionals, we do need to know, a board of procedures so that we can recognize when someone has been through an unsafe situation it is, it is our oath as metal as medical professionals to know those things, not to necessarily have a stance on those things that will prevent us from providing high quality and safe care.   26:52 Another one of the medications is methotrexate, and it's used to treat inflammatory bowel disease. And as public health specialists, we'd see people who have IBD, Crohn's and Colitis, who have had surgery who are in flareups who are being treated like that treated with that medication. And it is again used in in abortions. And when you're on that medication, you have to take pregnancy tests in order to still be able to get your prescription for that medication. And as a person who I myself have inflammatory bowel disease and have been on that medication before, I can tell you that you don't go on those medications lightly. It is you are counseled when you are of an age where you could possibly get pregnant, and taking those medications. And it's very serious to take them. And you also have to get to a certain stage of very serious disease in order to take that it's not the first line of defense. So if we start removing medications, or they start to be red flagged on EMRs, or org charts, and we become mandatory reporters for seeing that medication, God forbid, on someone's you know, they're when they're telling us what type of medications they're taking, that there would be an inquiry into that for for any reason is just it's it's horrifying. I mean, it's, we treat these patients and they trust us, and we want them to trust us. But as we get farther and farther down this rabbit hole of, of going after providers, pharmacists, people who help give them information to go to a different state, I just it is. Like I said before, the breadth and the depth of this decision, reverberates everywhere. And if if PTS think that they are in orthopedic clinics, that they are somehow immune from it, you're absolutely not. And for those clinics who have taken on or encourage one of their one of their therapists to take on women's health because it's now a buzz issue. It's really cool. You are now going to see that in your clinic. And you know, like Rebecca was saying before, you know any number of us who have really strong and long term relationships with patients who are pregnant who are in postpartum I have intervened and sent patients to the hospital on the phone with them because they have remnants of conception and they have a fever and someone's blowing them off and not letting them into the IDI and sending them home. And we we are seeing those patients, they have an ectopic they're, they're bleeding, is it normal, they're calling me they're not calling their OB they can't get their OB on the phone. They're texting me and saying what should I do? And they have that trust with me and what happens when they don't? And they're bleeding and they're not asking someone that question and they don't know where to go for help. And so I know I took this in a different direction and we talked about pharmacology, but I just thing that I have those patients whose lives I have saved by sending them to the emergency department, because they are sick, they have an infection, they are bleeding, they have an ectopic, it is not normal. And I don't know what happens when they no longer have that trust with us not not because we're not trustworthy, but because they're scared.   30:26 The heavy silence of all of us going   30:31 you know, it's, it's not wrong. And I think the like, it just keeps going through my head. It's just like, so what do we do? I mean, Karen, you mentioned like, it'd be great if somebody came out with a list of, of guidance for us. And I just, that just won't happen. Because there's different laws in different states, different practice acts in different states. And no one, you know, like you even if you talk to a lawyer, they're going to say, this would be the interpretation. But also, as of yet, there's no like case law, to give us any sort of any sort of guidance. So that was a lot of words to say, it's really hard. I can tell you in Illinois, like two or three weeks ago, I'd be like, like, I'm happy, I feel like Illinois is a pretty safe space. We have, we have elections for our governor this year. And I have never been so worried, so motivated to vote. And so motivated to to really make sure to talk to people about it's not just like this, this category or this category, it's like we really need to take into consideration the ramifications of what this will do, I think there was a lot of this probably won't affect me a whole lot. But I think I'm guessing I think a lot of us on this call maybe I think all of us on all of us on this call, have lived our lives with Roe v. Wade. And, as all of this is coming up, and just thinking about how it impacts so many people, and how our healthcare system is already doing not a good job of taking care of so many people, the fact that we would do this with no, no scientific, back ground, no support scientifically. Like I pulled up the ACOG statement, and, and they condemn this devastating decision. And I really, I was like, it gave me gave me goosebumps. And this was referred to in our art Association's statement. And it makes me sad that we didn't condemn it. Hope that's not too political. But I'm really sad that we didn't take a stronger stance to say, this is not good health care. And we need to do more. Again, and that's like, again, so many words, to say we're gonna have to make up our own minds, we're gonna have to know, our rules, our laws and what we're willing to do, and go through, so that we can provide the care that we know our patients deserve. And that's going to be really hard. Because, you know, if I talk to someone, and if I call Rebecca in Washington State, she's going to have something different than if I talk to Abby in New York. And you know, that so it'll be, it'll be really hard even to find that support. That support there's going to be so much support, I think, from this community, but that knowledge and that, that confidence, we have to pull together so we have to pull together with all the other providers, but also we're gonna have to sit down and figure this out to   33:59 the clarity. So it's, I think a practical step forward would be each state to get get, like, every state, come up with a thing. So pelvic health therapists in that state come up with what seems to work for them get a lovely healthcare lawyer to to work with them with it. And then we could have a clearinghouse of sorts of all of the state statements. I don't know that that needs to go through a particular organization. I I know that they're in the field of physical therapy, two thirds of PTS aren't members. And we need this information to be out there for every single person so that they know   34:44 that we'll have to be grassroots there's I don't think that there's going to be widespread Association support from anywhere. But that being said, I think it's a great idea.   34:58 What are we going to do about it? Hang on issues that are too divisive, you're absolutely right, individual entities are going to have to take this on and just put those resources out to therapists who need them need the legal support, need the need to know how and how to circumvent issues in their states. And, you know, like I said before, even how to just provide that emotional support, there's going to be needed for their, their, their patients, so, and that's okay, if the organizations that were part of are not willing to take a heavy stance, you know, even like last year, if you're not willing to take a heavy stance, on an issue where someone feels their autonomy, and their choice is being threatened, then it's okay, well, we'll take it from here. But, you know, that's, that's really where these grassroots efforts come from and abound, because there are a group of individuals who are willing to say, No, this is wrong. And I'm going to do something about this so that our future generations don't have to suffer.   36:02 Yeah, and I think, you know, we're really looking at the criminalization of health care.   36:09 That is not healthcare.   36:12 And we also know who this criminalization of healthcare is going to affect the most. And it's going to affect poor, marginalized people of color, it is not going to affect the wealthy white folks in any state, they'll be fine. So how do we, as physical therapist, deal with that? How do we, how do we get the trust of those communities who already don't trust health care, so now they're going to stay away even more, we already have the highest mortality, maternal mortality rates in the developed world, I can only imagine that will get worse because people, as we've all heard today are going to be afraid to seek health care. So where do we go from here as health care providers? I,   37:10 Karen, you're speaking something that's very near and dear to my heart, I act as if you had to take this on, I am very adamant that we can no longer choose to stay in our lane, we do not have that luxury. And I as a black female, you know, physical therapist, I don't have the luxury to ignore that because of the color of my skin, and not my doctor's degree, not my board certification and women's health, you know, not my faculty position, I when I walk into a hospital, and I either choose to give birth or have a procedure, I will be judged by none other than the color of my skin. That is what the data is telling me is that I am three times likely to have a very severe outcome. If I were to have a pregnancy that did not go as planned or or don't choose a procedure, you know, that affects the rest of my function in my health. And so given the data on this, you're absolutely right there, there is going to be very specific populations that are going to receive the most blowback from this. And as a pelvic health therapist, I had to go into the hospital to find them, because I knew that people of color and of marginalized backgrounds, were not going to find me in my clinic. And we're not going to pay necessarily private pay services to receive that care. But I needed to go where they were most likely to be and that was the hospital setting or in their home. And so, again, as a field of a very dispersed and you know, not very many of us at all, we're going to have to pivot into these areas that we were not necessarily comfortable in being if we're going to address the populations that are going to be most affected by the decisions our lawmakers are making for our bodies.   39:11 You know, there's something that I think about, often when I hear this type of conversation come up in, in sexual health and in in whenever I am speaking with one of my patients and talking about their menstruation history, and, and them not knowing how their body works from such a young age is I just wonder if we should be offering programs for young people like very young pre ministration you know, people with uteruses and their parents, and grandparents and online, online like little anonymous. Yep. nonnamous   39:51 for it's just   39:52 Yes. Yes, it's it's just, you know, Andrew Huberman talks a lot about having data Back to free content that scientific, that's factual. And I think about that a lot. And I think, to my mind, where I go with this, because I do think about the lifespan of a person, is that creating something that someone can access anonymously at any age, and then maybe creating something where it's offered at a school? You know, it's it's ministration health. And it doesn't have to be under the guise of, you know, this happened with Roe v. Wade, but this it could be menstruation, health, what is a person who menstruating what can you expect? What you know, and going through the lifespan with them, but offering them? You know, I think I think about this with my own children, as our pediatrician always asks the question of the visit, who is allowed to see under your clothes who is allowed to touch you? And it's like, you and my, I have a five year old. So it's Mom, when when when I go number two, a mom or dad when I go number two? And that's it. And you know, I think about that, and I think about how we can educate young people on a variety of things within this topic, and kind of include other stuff, too, that's normal, not normal, depending on their age. Absolutely, there   41:22 was what I was excited about in pelvic health. Before this was people like Frank to physician and his PhD students and postdocs are working on a series of research about how if we identify young girls that are starting their period, and having painful periods, treat them and educate them, then that they will not go on to have as much pelvic pain conditions and issues in the future. So we look at the early childhood events kind of thing, but also period pain. And How exciting would it be if we could get education to young girls about just how their bodies work. And to know that just because you all your aunties have horrible periods doesn't mean that you're stuck with this, just like maybe they just didn't know, let's help you out and constipation information and those basic health self care for preventative problems. So I was super excited about all that. And now it's like, oh, now we have to do it. Because in that we can do little pieces of information. So people have knowledge about their body, that's going to be a little bit of armor for them, that they're going to need and free and available in short, and you know, slide it past all the YouTube sensors. This is this is doable, but it's gonna take time money doing, but we can do it. Well, it sounds like, ladies,   42:52 we've got a lot of work to do. One other thing I wanted to touch upon. And we've said this a couple of times, but I think it's worth repeating again and again and again. And that's that expanding out to other providers. So it's expanding out, as Rebecca said, expanding out to our colleagues in acute care, meaning you can see someone right after a procedure right after birth right after a C section. And, and sadly, as we were saying, I think we they may start seeing more women, I'm not even set children under the age of 18. In these positions of force birth on a skeletally immature body. So the only place to reach these children would be maybe in that acute care setting. How what does the profession need to do in order to make that happen? And not not shy away from it, but give them the information that they need. Moving forward?   44:07 I was just gonna say that I've given birth in the hospital twice. Not at any time was I offered a physical therapist, or did a physical therapist come by and I am in New York City. I gave birth in New York City, planned Solarians because of my illnesses. And nobody came by I did get lactation nurses, any manner of people who were seeing me I was on their service. But that has been something that we needed anyway. We mean to have a pelvic health physio on the labor and delivery and on the maternity floors, who is coming by educating as to what they can start with what they can expect. When can they have an exam if they want to have one? Who is a trusted provider for them to have one. And we need to get the hospitals to expand acute care, physical therapy to labor and delivery and, and the maternity floors. As a routine, it's not something you should have to call for, it should be routine clearance for discharge the same way you have to watch the shaking baby video to get discharged.   45:27 I'm happy older than all of you. I don't have it either. But taking baby video is not something that even existed back in the day. But that makes sense. I mean, I once upon a time was a burn therapist, and I was on call at a regional Trauma Center. And you know, it's like you're needed your, your pager goes off, because that's how long ago it was. And you just came in, did your thing, went back home went back to bed. There is no reason other than lack of will, that PTS couldn't be doing that right now.   46:03 I'm now of the opinion where it's unethical to not offer physical or occupational therapy within 24 to 48 hours of someone who had no idea who did not have a planned delivery the way they expected it who has now and a massively long road to recovery. After a major abdominal surgery, I'm now of the opinion that is unethical for our medical systems to not offer that those rehabilitative services. And I've treated individuals who had a cesarean section but suffered a stillbirth. So the very thought of not providing services to someone who has any kind of procedure that's affecting, you know, their their their not only their pelvic health, but their mental function. That to me is now given the you know, these these, this recent decision on overturning Roe v Wade, is now now we're never, you know, either we're going to now pivot again as pelvic health therapists and start training our acute care colleagues, as we did with our orthopedic colleagues, as we've done with, you know, our neurology colleagues, whatever we've had to do as pelvic health therapists to bring attention to half of the population, you know, who are undergoing procedures, and they're not being informed on how to recover, we will have to start educating and kind of really grow beyond just the clinics and beyond what we can do in our community or community. But we are going to have to start educating our other colleagues in these other settings, we don't have a choice, we know too much, but we can't be everywhere. And not all of us can be in the hospital setting, we're going to have to train the individuals who are used to seeing anything that walks through the door and tell them get over to the obstetric unit. Okay, there's someone there waiting for you.   48:06 Yeah, I totally agree. I mean, when I think back I remember as a student working in acute care and how we had someone who's dedicated to the ICU, we had someone dedicated to the medical floor, we had somebody who was dedicated to the ortho floor, and most of the time they had their OCS, their, their, the one for for, for ICU care, the one for NeuroCare, or they have a specialty. And I think it is just remnants of the bygone era of it's natural, your body will heal kind of BS from the past. It's just remnants of that and it's just, we don't need the APTA to give us permission to do this, this is internal, this is I'm going into a hospital, and I'm presenting you with a program. And here is what this what you can build this visit for here's the ICD 10 code for this visit here is here is here are two people who are going to give you know, one seminar to all of your PT OTs, to you know, so that you are aware of what the possible complications and when to refer out and that kind of thing. And then here are two therapists who are acute care therapists who are going to also float to the maternity floor one of them every day, so that we can hit the we can get to these patients at that point, and that is just that's just people who present a program who have an idea, who get it in front of the board that that it is not permission from anybody else to do it. And, you know, it really it fires me up to to create a world in which you know, when you know people who are the heads of departments and chairs and you know on the boards of directors You know, being in big, big cities or small cities, when you know those people, you know, you can, your passion can fire them up. And if you can fire people up, and you can advocate for your patients and you can in that can spread, you can make that happen. And this is, you know, I feel radicalized by this, I mean, I'm burning my bra all over the place with this kind of thing. And I just feel like, if we can, if we can get to young people, and if we can get to day zero, of delivery, day one, post delivery, or post trauma, then then maybe we can make a dent, maybe we can, maybe we can try, maybe we can really make a go of this for these people. Because, like I keep feeling and saying I, we are not prepared for the volume.   50:54 If individuals are going to be forced to carry a pregnancy, that they may not want to turn because it's affecting their health, we're going to have to be prepared for this. Again, this is not an option really, for us as pelvic health therapists, because we know what's down the road, we've seen mothers who have or you know, or individuals who have suffered strokes or preeclampsia or seizures, or, you know, honestly, long term health issues because of what pregnancies have done to their body. And now if they want the choice to say, you know, I'm not ready, they don't have it anymore. So we really don't have a choice. We have to start expanding our services into these other settings, making our neurologic clinical specialists in the hospital, see people before they have a stroke before they have a seizure actually provide services that can help someone monitor their own signs and symptoms after they've had now a procedure or given birth or even had, you know, a stillbirth, unfortunately, because the doctor had to decide, well, yes, now we will perform the abortion because you know, your health is like on the cliff, I mean, we're going to be seeing these and we just have to prepare. And if it's not our organizations that are laying the foundations, we will, we'll take it from here,   52:15 we need to reach out across so many barriers, like athletic trainers, they're gonna see the young girls, they're gonna see their track stars that is not reds, it's pregnancy. And it could be a very short lived traumatic pregnancy, in girls that are just not develop. They're developed enough to get pregnant, they're not developed enough to carry a healthy baby to term. Kind of just makes me like. But Rebecca is right as we don't get to have an opinion on the right or wrongness of this, we have a problem ahead of us now, that that is happening already, as we speak, that people are going to need help. I love that we have more technology than my grandma did when she was fighting this battle. And we have YouTube and we have podcasts and we have ways to get information out. But we need to use every single one of them in our sports colleague or athletic trainer colleagues. They need to know the signs. Because they may be the ones that see it first.   53:21 Yeah. And Sarah as being the most recent new mother here. What kind of care did you get when you were in the hospital?   53:36 I was sitting here thinking about that. And I mean, I will say that the care I had while I was there, that I had an uncomplicated delivery in spite of a very large baby. And I was fortunate enough to leave the hospital without needing additional help. But I wasn't offered physio. Nobody really they're just really curious to make sure you're paying enough. And that's about it if you're the mom and my six week visit was actually telehealth and that was the last time I had contact with a health care professional regarding my own health so it is minimal even if you're a very fortunate white woman in a large metropolitan area and but I'm working now further north and with a pro bono clinic clinic and in an area where we do a lot of work with communities of color and I'm I'm like I honestly don't even know the hospitals up here yet. But I'm gonna I have so many post it notes of things that are gonna start happening and start inquiring because Rebecca like we need to get into the hospitals like if if I can Do that. And honestly, up until now, like my world and entropy was, and pre this decision was it, there's so many people out there who need help with pelvic issues in general, like we can do this forever. And we set our clinic up so that people who weren't doing well in the traditional health care system could find us and afford us. At least some people could, I realized that it wasn't in companies, encompassing everybody who could possibly need help, but we were doing trying to figure out another way. And so again, like, like, again, the offer of assistance I got was minimal. But also I didn't need much. And I was in a position where also, I knew I could, I could ask for it if I wanted it. And I could probably get it if I needed it. And I'm just thinking about, again, some of the communities I'm interacting with now, in some of my other roles and responsibilities, and I cannot wait to take a look and see, how can we get in there? How can we be on that floor? How can we? What What can we make, make happen like, because it needs to happen, these are these, this is the place where I'm scared to start seeing the stats,   56:21 wouldn't it be amazing if you can get the student clinic part of that somehow somehow and get, you know, young beyond that bias, but younger, most younger but but like the physicians the the in training the PTs and training the PAs the you know, and get like Rebecca had said, let's get let's get the team up to speed here, because there aren't enough pelvic health therapists already. And they're heavens, we need, we need to get everybody caught up.   56:58 And there's so much I was telling you that being around student health care, providing your future health care providers is really energizing and also really interesting. I mean, the ideas that come up with in the in the connections they make and and the proposals they make are just amazing. But two things that I've noticed that I think probably we run into in the real world, real world, outside school world as well, is one. The that's being able to have enough people and enough support to keep it sustainable. So you have this idea, you have the proposal, you made the proposal, how are we going to keep it going and finding the funding or the energy or the volunteers to keep it going. Things ebb and flow, you get a great proposal, you're like yes. And then I literally today was like, I wonder what's up with that one, because it was an idea for a clinic to help was basically for trans people to our tree transitioning and might not have the support that they need. And also I was reached, they come up here for women's health clinic. And I'm going to reach out to them now. Because this again, this decision changes that because it is a pro bono clinic that they would like to set this up in and before it was going to be much more more wellness. And now it could turn out to be essential health care. So that's one thing. But then the other thing is still the education, that in school, we're not taught about what everyone else can do. And I think again, figuring out a way to make sure that future physicians really know what physical therapists have to offer, especially in this space. Most people know that if their their shoulder, their rotator cuff repair, they should send them to pt. But really, we need to get in with OB GYN news, we need to get in with the pediatricians. And I don't want to say unfortunately, but in this regard, unfortunately, we're going to have to really make sure that they know what we're doing. And again, I'm already kind of trying to think like how can we make this just part of how we do health care.   59:20 So I think I'm following in your footsteps by going into education and by by being a part of our doctor of physical therapy programs. You know, I especially chose the program in Washington state not because you know, of just the the the opportunity to teach doctors or incoming doctors but it was also an opportunity to teach doctors of osteopathic medicine and occupational therapy therapists. It was you know, very intimate program and opportunity to make pelvic health or women's health or reproductive health apart of cardiopulmonary content, a part of neurology content, a part of our foundations a part of musculoskeletal and not a special elective course that we get two days of training on, I had the opportunity to literally insert our care, our specialized and unique care and every aspect of the curriculum, as it should be, because we are dealing with, you know, more or less issues that every therapist generalists or specialists should be equipped to handle. So in the wake of Roe v Wade, to me, this is an opportunity unlike any other for pelvic health therapists to really get into these educational spaces where incoming doctors are, you know, MDS or PA programs, or NP programs are our therapy practices, and start where students are most riled up and having those ideas so that they can go out and become each one of us, you know, go into hospitals and say no, to obstetric units being ignored, go into hospitals and give and services to physicians. You know, we need to create more innovators in our field and education is the way to do that.   1:01:12 I just wrote down check Indiana and Ohio, and then I wrote border clinics, because Because Illinois is a it's like a not a prohibition state. Having so many flashbacks, because Illinois, is, is currently dedicated to maintaining health care access for everyone. We have cities that are on the border. And I was thought of that when you were talking, Sarah, because you're up next to Wisconsin now. But we have we have the southern part of the state and the western part of the state. And those those border towns are going to have a higher influx than I will see in Chicago, maybe. But I would anticipate that they would,   1:01:56 you know, and again, this is where laws are murky. Every state is different. It's I mean, it's a shitshow. For lack of better way of putting it I don't think there's any other way to put it at this point. Because that's kind of what what we're dealing with because no one's prepared, period. So as we wrap things up, I'll go around to each of you. And just kind of what do you want the listeners to take away? Go ahead, Sandy,   1:02:33 this is this is frustrating and new, and we're not going to abandon you. We're gonna figure it out and be there to help.   1:02:41 I would say that our clinics are still safe, it is still a safe place for you to open up and tell us what you wouldn't tell anybody else. It's still safe with us. And we still have you as an entire person with all of your history. We are still treating you based on what you are dealing with and not. We will not be dictated by anybody else. Our care won't be mandated or dictated by anybody. Sarah, go ahead.   1:03:22 What I would say is I would echo your safe. If you need help, there is help. And I'm sorry, that that this just made it harder than it already was. And I would say to healthcare providers, please let remember, let us remember why we're doing what we're doing. And, you know, we do need to stand up, we do need to continue to provide the best care for our patients. Because to be honest, I've been thinking like, I think it's a legal question. It's a professional question. But ultimately, if we can't give the best care possible, I'm not sure I should do this.   1:04:01 Ahead, Rebecca,   1:04:02 for our health care providers, in the wake of Roe v. Wade, being overturned, wherever we are, you know, as an organization or on our stance, if we believed in the autonomy of an individual to know all of the information before making a decision, then we still believe in the autonomy of an individual to know all of the information that is best for their body. And that is the oath that's the that's the that's the promise that we've made as professionals to people that we're serving, and to the people that we're serving to those who are there listening to this. You have safe spaces with providers that you trust and we're going to continue to educate one another, our field and also you we're going to put together resources that really bring During this education to your families so that you don't have to feel like you're in the dark and you're alone. This is not something that is per individual or per person. This affects everyone. And we're dedicated to advocating for you.   1:05:18 Perfect, and on that we will wrap things up. Thank you ladies so much for a really candid and robust discussion. I feel like there are lots to do. I think we've got some, some great ideas here. And perhaps with some help and some grassroots movements, we can turn them into a reality. So thank you to Rebecca to Sarah to Abby and to Sandy, for taking the time out of your schedules because I know we're all busy to talk about this very important topic. So thank you all so so much, and everyone thanks so much for listening, have a great couple of days and stay healthy, wealthy and smart.   1:06:03 Thank you for listening and please subscribe to the podcast at podcast dot healthy, wealthy smart.com And don't forget to follow us on social media    

This episode is about something that is relevant to all helping professionals—avoiding burnout. Join me as I talk with Sandy Hilton, a veteran clinician who has been practicing full-time for over 30 years.   Join Sandy and me as we talk about how she's managed to not only avoid burnout, but to stay open, curious, and excited about clinical practice all this time.   To join the Be A Better PT Facebook Group, visit: www.Facebook.com/groups/BetterPT   If you enjoy this episode, share the love! When you share this episode with your friends, throw me a tag so we can connect! I'm ALWAYS looking for fellow PTs to nerd out with. You can connect with me via: My Website: www.AndrewHammondPT.com Instagram: www.Instagram.com/AndrewHammondPT Twitter: www.Twitter.com/AndrewHammondPT Facebook: www.Facebook.com/AndrewHammondPT

Episode Summary In this episode, Co-Founder of Aivo Health, Melissa Farmer, talks about the mind-body approach to treating chronic pain. Today, Melissa talks about the mind-body approach, getting patients to be more receptive to the mind-body approach, and how practitioners can recommend psychological care for chronic pain. How can psychology work to treat people with chronic pain? Hear about the gaps in chronic pain measurements, the psychology behind farming pain out, the Aivo Health App, and get Melissa's advice to her younger self, all on today's episode of The Healthy, Wealthy & Smart Podcast.   Key Takeaways “The body and mind aren't separate. They work together, they interact, and that impacts the experience of someone who lives with chronic pain.” “Just because we can't measure it with an existing tool, doesn't mean it doesn't exist.” “A patient saying that they're in pain is all the proof that you ever need to believe that they're in pain.” “We all have a collective responsibility to empower people who have been living with chronic pain.” “One of the most powerful tools for pain relief is between peoples' ears.” “Your identity is not your accomplishments.”   More about Melissa Farmer Melissa Farmer is a veteran chronic pain researcher-turned-entrepreneur. During her graduate studies at McGill University, she trained with a world-class multidisciplinary team at the chronic pain center founded by pain research legend, Ronald Melzack. She earned a doctorate in clinical psychology and neuroscience. Dr. Farmer went on to pursue postdoctoral training with neuroimaging pioneer Vania Apkarian at Northwestern University, where she specialized in brain imaging of hard-to-treat chronic musculoskeletal and pelvic pain.   In 2018, she left academia to co-found Aivo Health, a startup with Vania Apkarian and a chronic pain patient/entrepreneur. Their mission is to bring insights from the top tiers of pain science directly to people living with chronic pain.   On twitter, Dr. Farmer has an international following of influencer physiotherapists who appreciate her ability to translate basic pain science research into understandable language.   Suggested Keywords Healthy, Wealthy, Smart, Healthcare, Physiotherapy, Chronic Pain, Psychology, Treatment, Mindfulness, Meditation, Therapy, Trauma, Pain Relief, Mind-Body,   To learn more, follow Melissa at: Email:              melissa@aivohealth.com Website:          https://aivohealth.com LinkedIn:         Melissa Farmer Twitter:            @Farmer_MindBody   Subscribe to Healthy, Wealthy & Smart: Website:                      https://podcast.healthywealthysmart.com Apple Podcasts:          https://podcasts.apple.com/us/podcast/healthy-wealthy-smart/id532717264 Spotify:                        https://open.spotify.com/show/6ELmKwE4mSZXBB8TiQvp73 SoundCloud:               https://soundcloud.com/healthywealthysmart Stitcher:                       https://www.stitcher.com/show/healthy-wealthy-smart iHeart Radio:               https://www.iheart.com/podcast/263-healthy-wealthy-smart-27628927   Read the Full Transcript Here:  00:02 Hey, Melissa, welcome to the podcast. I am so happy to have you on I have heard raving reviews from Sandy Hilton and Sarah Haig about you. So it's great to have you here.   00:15 Thank you so much, it is a pleasure to be here with you. And today we're going to talk about treating patients living with chronic pain from a mind body approach. So before we get into the meat of the interview, can you define what a mind body approach to the treatment of chronic pain is? Sure, a mind body approach to the treatment of chronic pain acknowledges that we are embodied in these, you know, this skin, muscle bone, that we feel emotions in our bodies, that sensations have emotions that are attached to them. And it also acknowledges that all of these conscious experiences like pain and chronic pain arise from the brain. So they're conscious perceptions that are shaped by our thoughts and emotions and feelings and past experiences. So it's an acknowledgement that the body and mind are separate, that they work together they interact. And that impacts the the experience of someone who lives with chronic pain. And now here's here's the hard part as clinicians, what can we do to help our patients be more receptive to this approach when it comes to pain management, because chronic pain, any clinician will tell you is not an people living with chronic pain, excuse me, it's not a it's not an easy road. So what can we do to allow our patients to be more receptive to this? Because oftentimes people will say, so you're saying it's all in my head? And that's not hopefully not what we're saying. So got it? Oh, not at all. So one of the most powerful things I think, that we as clinicians can start with is a simple statement, I believe you, which is something that many people with pain don't ever hear. And it can be such a powerful statement, because then instead of coming to an appointment with, you know, evidence that they've prepared to prove that their pain is real, you know, tests, scan results, etc. You push all that off the table, you say, I believe that you're in pain right now, and I'm ready to help you. That's, that is, I think, one of the first pieces of resistance that we can remove, just by validating their experience.   02:53 And I think especially whenever people have lived with chronic pain, and have seen many, many, many, many doctors, they get used to this feeling that they need to   03:08 convince the person in front of them that their suffering is real. And if we just if we   03:19 if we get up that out of the way, just by acknowledging that common humanity, I think there's there's one level of resistance that's removed quite quickly. And what about providers, or medical professionals who our education, whether it be formal education school, our clinical rotations, has sort of trained us to look at scans and say, Oh, this is it. This is what's causing it. So what can we do as providers to? To break us out of that, if it's in the scan, then that's, that must be what it is. Do you know what I mean? Mm hmm. I think getting in touch with some humility. So crepe is a great way to start. Because one of the issues with scans and test results is that these are things that   04:14 scientists and the medical professional has decided these are measurable, objectively accessible, indices that we've all sort of mutually agreed, indicate that something you know, there's some sort of structural abnormality or whatnot. In other words, we're testing to look for what we know might exist. Another way of saying that is that we're only testing for the things that we've thought about before, and that we know how to measure and there's a lot of things that we don't know about and we don't know how to measure. And just because we can't measure it with an existing tool, doesn't mean it doesn't exist. And, you know, from a basic science perspective, right   05:00 My background is in basic science of chronic pain, we do not know a lot about chronic pain mechanisms. And so having sort of the humility to recognize that   05:18 the nervous system is incredibly complex, the brain is incredibly complex, there are many things we don't know how to measure, and it doesn't mean that they aren't there,   05:30 we tend to cling to tests that reflect our particular training. And from a patient perspective, what that means is that they get different types of snapshots. For instance, if someone has   05:45 lower back pain, they may get MRI scan to one, you know, from one doctor, if there's comorbid, visceral pain, which could be referred, for example, they might get a colonoscopy from another doctor, each of every every, you know, we've talked about silos before, you know, in the general field.   06:06 Each of these silos have their preferences for these different tools, and they all provide small snapshots. And it's sort of like the, you know, the blind men feeling on different parts of the elephant, you know, that really handy metaphor, just because you're a trunk expert, or you're a, you know, a, an, an elephant foot expert doesn't mean that you're able to see the entire picture. So Humility is a great attribute. Yeah. And where do you think this kind of false dichotomy between the body and mind originates from? Is it that, you know, Decart Deyan? Theory, you know, that happened centuries ago that we continue to accept? Or is it that we put more weight to the objective and less weight to the subjective? Or is it both? Or is it all the above and more,   07:06 all of the above, for sure, especially in the pain field, Decart has, he said, really strong influence, and he suggested that the body is like a machine. And you can sort of causally identify almost like a, you know, knocking down a line of dominoes. A cause effect, cause effect cause effect. And that's how you understand a more complex organism. But   07:34 what he, he sort of, it's interesting, he, he essentially said that, you know, like the body, the material, it works on different rules than consciousness. And he sort of made this blanket statement that we all accepted. So in a sense, relying on the words of a philosopher 400 years ago, is the basis for our logic today is a little a little surprising. But it's something that many people haven't questioned. And, unfortunately, in the, in standard medical training,   08:09 I'm sure you're familiar that like, especially in Northern America, in medical school, they receive anywhere between four and 11 hours of pain education,   08:21 there isn't enough time to go into the depth, the proper depth that this subject deserves. So I think that it's a, unfortunately, a reflection of these overly simplistic heuristics that medical professionals and other practitioners receive.   08:40 That that just doesn't do justice, to pain at all. Yeah, and like you said, because pain is so complex, because pain is an emotional and   08:54 physical state   08:57 that I think people are always looking for the answer. I know, patients are always looking for that one doctor, that one test that one scan that will say, Oh, this is it. This is the problem because people like logical things, right? People like well, point A, here's the problem. I can do B and I will end up with C feeling better. But when it comes to chronic pain, we can't look at the body and mind as separate. And I think a lot of people do and that does really is a recipe for some really ineffective treatments for pain. So what what can we do if a patient comes to us and they have sort of accepted that their mind body and mind are totally separate? And their kindness I must have done something I've got I've had this pain. I you know as a practice, I'm sure you've heard it. I hear it all the   10:00 Time, I'm sure I did something again, or I must have done something to flare it up. So how can we respond to that in a way that's accurate and helpful.   10:12 One of my beliefs, and this may not be a popular belief is that   10:19 the body has done nothing wrong, whenever it creates chronic pain, the body and mind it that chronic pain isn't a mistake.   10:29 And I say that from a scientific perspective, because whenever I've studied the mechanisms from the nerve ending on the skin, you know, whenever pain signals or nociceptive signals are transmitted from the surface of the skin, to the spinal cord to the brain, the body is naturally designed in a way that amplifies pain signals. So amplifying pain is how nature works. And it works that way. Because pain is a really important thing to notice. Pain is a primary reinforcer. And that means, by definition, it's aversive, you don't need to condition or to pair it with anything for an animal or for a person to try to avoid something, it's painful. And that's why it's always sensory and always emotional. It's always aversive.   11:23 And whenever, you know, as I've studied chronic pain populations over the years, and I've looked and really considered and reflected on the biological changes that I see all of these, these mechanisms that sort of turn up the volume of pain, whether it's at the nerve and the surface of the skin, or in the spinal cord, or in the brain, they're all there for a reason. And it's because the signal is incredibly evolutionarily important to respond to.   11:55 And the division happens in the brain where once it gets to the brain, and creates a emotional memory, or a fear memory. That's whenever the brain adapts and changes in response to that incoming signal. So in a sense, that's the point where the brain begins to adapt to accommodate the pain in someone's life, rather than just being passively responding to the environment. And that's one of the   12:31 one of the main features of chronic pain, where it's no longer just a, you know, whenever you see a patient to   12:42 has pain that still increases and decreases in response to external stimuli. That's a great sign because it means that the nervous system is still really closely linked with the environment. Once pain fluctuations start to vary independent of the environment, that means that it's become   13:01 more hard coded into the nervous system.   13:05 So that whenever I see patients who you know, who do have pain that's responsive to seeing the environment, I congratulate them.   13:15 But again, the idea that   13:19 it's adaptive to remember what causes pain means that it's also adaptive to create pain memories. It's also adaptive to change how you move in relation to pain. And it's adaptive, to feel depressed, and to feel anxious. Those are all completely normal, understandable responses to pain. And the   13:44 thing that isn't as natural and healthy is the inability to go back to baseline after you've hit that new state. And one of the reasons is that whenever you have chronic pain, so many experiences during your daily life, reinforce that cycle that you don't have many opportunities to learn what the lack of pain is like.   14:07 And something this is something I call relief learning. So it's natural for us to pay attention to periods of escalating pain. It's something it's a skill that can be learned to pay attention to periods of pain relief. And that's something that a lot of patients don't naturally do. And it's something that   14:31 if you don't come at it from a brain perspective, you might not see the importance of it. But anytime pain is decreasing, or it's lower than it normally is. That's the time that you should be focusing on positive emotions, relaxing the body, learning new skills, that's optimal learning time. So of that, one of the reasons I bring that up is that the the brain even though it's responsible for creating this chronic state   15:00 It's also the key to changing it and shifting back and reversing to the pain free state. The plasticity of the brain is is just a never ending thing of beauty. Absolutely. Absolutely. Well, now let's talk about, because it sounds like, and I love what you just said, it sounds like we're really focusing on sort of psychological care, which is part of care for chronic pain. And I love something that you wrote in that if mind based treatment helped my pain, then my pain must not be real. Hmm. Right is maybe something that might be in the back of someone's mind someone living with chronic pain are in the forefront. So how, how can   15:45 psychological care? Whether that be CBT, or mindfulness, or you know, there's a million different kinds of, I'm sure scientists, psychological care. So   15:58 how can people use psychological care, but not D legitimize their pain experience, not make them feel like, well, if, if this helped, then   16:10 my pain wasn't real, because if it were real, then that injection would have taken it away, or that movement or that stretch, etc, etc.   16:20 One of the things about trading   16:25 one of the things about psychology is   16:30 that sort of inherent in this illusion that the mind and body are separate   16:37 is that   16:40 whenever you have a new experience, there are measurable neuronal changes in the brain, there is a physical change that occurs, there is a measurable change that occur that occurs, even if you know we don't have the tools right away to measure it.   16:58 psychological changes are biological changes. And there's what 4050 years of science that reinforces that. So just because a psychological treatment can help doesn't mean that it isn't biological, it just reinforces that this source of the biological change is different from what you expected it to be. So I know that a lot of people with pain   17:27 you know, if for instance, their lower back hurts, or if a certain limb hurts, they assume that the source of the pain must be in that body part.   17:38 And although this is getting a little high up,   17:44 in terms of mechanisms, one of the reasons why we can even tell where our body parts are, is that there are maps in the brain. For instance, you know, one of the examples of this is the homunculus. But there are actually four different maps in different parts of the brain, that help us understand where our body is in space, and where our hand is where our lower back is. So you don't know where your lower back is, unless your brain helps you decipher where in the body map it is. So, you know, in multiple levels, this this idea of separation is really artificial, it really doesn't serve the experiences of people with pain.   18:25 I understand that.   18:28 Also, that one of the reasons why patients may adopt this kind of thinking is because they're   18:37 trying to work with the perspective of the provider who's treating them. If the provider has these assumptions, patients naturally, just to adapt, they have to play the same bowl game they have to in you know, they might do this through Google searches, or educating themselves on the web, or looking into pain, neuroscience education.   19:03 In order to be heard, I need to study the way that this is described online and in the literature, I need to be able to talk to my doctor in a way that they can understand.   19:16 And even that   19:19 even even that point where it's like I need to interpret my internal experience into something else so that someone else will believe me, I feel is sacrificing their internal experience of pain. No doctor   19:35 I almost think that like   19:38 a patient saying that they're in pain is all the proof that you ever need   19:45 to believe that they're in pain. You don't need a test. I really believe this. And so much the point that you know, I've I've I worked with Dr. Vani up caring for many years. The reason why his research   20:00 has been replicated so many times and has been published in such higher to high tier papers is because he looked at the patient's perception of pain and mapped brain signals to that perception.   20:17 He listened to the patients from the very beginning, he didn't say, Well, you have to finish the standardized questionnaire. And that'll tell me, that'll be the way that I measure whether your pain is there or not. He had a moment by moment, measure of pain intensity that he used to extract the signals from the brain during these brain scans. And that's how he found his fantastic findings that have been replicated again, and again, by different by different groups. And those are the findings that reinforced that as pain becomes more chronic, the brain regions that are correlated with the perception of pain change from sensory related regions early on, to emotional related regions within a year. In other words, after a year of living with pain, emotional brain regions are correlated with the sensory perception of pain.   21:15 Another way of saying that is that the sensation becomes emotional.   21:21 And that isn't saying that it's not real that saying that it's so real, you can measure it on a brain scan, you can see the pictures, you can replicate it across studies. It's that real?   21:34 So I feel like I've sort of No, no, gone in a few directions to answer your question. But   21:44 all all patients,   21:47 all we need to do is take patients word for their pain, we don't need any extra evidence that it exists, we just need to take them seriously. And to reinforce that, it's not your fault that you have this pain, you did not cause your illness, your body was doing exactly what it was designed to do exactly what we would expect a healthy person's body to do. It's not your fault. So let's, let's work together and find   22:19 your own path to pain relief learning. Right. And obviously, everyone's path is different and individualized. And I think we can all agree on that. There was something that you had said,   22:31 as you were speaking, that popped something that caused me to think that sometimes I don't know if you've seen this, but is it easier for patients to sort of farm their pain out to sort of third person their pain, versus first person their pain, meaning they may describe it, or they may listen to the way the doctors describe it, and not think of it as their first person pain, but think of it more as third person. And I'll give you an example of what I mean by that. So I have a long history of chronic neck pain   23:07 during my 30s, like, literally, the decade of my 30s For the most part. And I had I was giving a keynote talk a couple of years ago. And so I joined a speaker salon, or speaking group to help with this talk. And it was about they wanted me to talk about my experience with pain. So I went out there and I started it like imagine a patient walked in and had all these symptoms, right. And the woman who is not a clinician, a health care practitioner in any way. She is a writer, director and speaking coach, her name is Tricia Brooke. She said, Well, hold on a second. I'm gonna I'm gonna stop you for a second. I said, yeah, yeah. What is it? She's like, Is this about you? And I said, Yes, it is. And she's like, Well, why are you talking about it in the third person?   23:57 I said, Oh, well, because at the end is the big reveal that it was me and she's like, people know, it's you. You're up there talking about it. Like so why don't we change it to the patient and change it to me. And I started and within five minutes, I was crying so much I couldn't continue.   24:15 And I was like, This is why it's not first person because it was so hard. For me it was a lot easier to sort of third person it out or farm it out. And then going through this for eight weeks, I was finally able to get through the whole talk and someone came up to like, you know, I really liked those parts when we were first doing it when you were crying a little bit. I'm like, that wasn't part of the bit. That wasn't a bit that was me not being able to talk about my experience with pain, because it's emotional and sensory. So the although at this point now I had not had pain in years. To the extent I had it when I was speaking about it right, but to your point   25:00 The emotional attachment was still there.   25:04 So what do we do with that?   25:10 That's such a great   25:13 question.   25:18 I think it's self protective. Initially, whenever just just as you described, it's self protective and that you live with the pain every day.   25:30 It's a way to distance yourself from the suffering.   25:36 So on one hand, I understand 100% Why people do that. And in a lot of the patients that I've seen, over the years have done that too.   25:50 I think that   25:58 something that comes up for me right now, is that the words that one person uses for their own pain are the most therapeutic words that they could   26:10 use.   26:12 In that, engaging in the pain memory, from a psychological perspective, is one of the things that allows you to change that memory.   26:23 And I kind of wasn't planning on going here. But it's, it's an opportunity.   26:29 One of the reasons why psychological approaches to   26:34 chronic pain care have the potential to be so effective is that if pain is an emotional memory,   26:45 we know from 20 years of basic science, neuroscience, that emotional memories can be fundamentally change. There are rules, there are very clear rules.   26:59 The rules are you revoke the memory, on purpose as fully as possible.   27:07 You ideally introduce some type of contradictory experience something surprising, because that really makes the   27:20 the brain state more salient, it makes the brain pay more attention to what's happening. And then within three hours, you induce relief, psychological relief, deep breathing, I've worked with patients where we administered propranolol under the guidance of their you know, their doctors, but deep breathing is enough. And that if you are able to induce in sort of controlled conditions, these experiences where you fully experience pain, how it is for you, using your words, the emotions that come up in your body. That is how you fundamentally changed the memory structure of chronic pain.   28:06 Fascinating, you can do that in little bits across time.   28:12 Under more controlled conditions, you can do it in one big whammy exposure session.   28:17 Interesting, I think I did it in little bits over an eight week period in front of an audience   28:23 in front of a very safe audience of 14 amazing women. And you were also in a sense, potentially reshaping your pain narrative, as you're going through this, too. So you know, per Gillette Abelton.   28:38 You know, working with the pain narrative, and changing the meaning of the pain story over time is one of the another way that   28:48 that your pain story itself can be really therapeutic. Yeah, yeah, it was. It was wild. But it's it's a good example, I think of how even though I had not had pain for years, but the emotional attachment to it was so strong that I couldn't even get through a paragraph of this talk without crying. I was like, I think I need to come off the stage. And then each time it got, you know, it took more and more time, I guess before I would have like a really emotional response. But I have to say since then it was like,   29:28 like a weight off my shoulder. You know, and this is years after not years, maybe like six years after I really had more consistent chronic pain. So it was years and it was it was years after the pain had the chronic pain had subsided.   29:45 That's interesting too, because it suggests that there's a larger memory structure underneath there that even if the sensory aspects have been remodeled, the emotional attachment can still remain. And so in a sense, perhaps   30:00 that experience helped to heal the entire memory structure in a way that it you know, it wasn't quite complete just with the sensory pain being gone. Yeah, yeah, maybe it closed the circuit a little bit, so to speak. But anyway, it was it was highly, that's fantastically effective. But it just goes to show and again, I wasn't working with a professional perhaps if I were maybe I would have closed that circuit a little earlier. Or maybe not. Maybe this was the time, we don't know, too many questions to answer. So it's just right, you didn't just write for us at the right time. So, you know, just goes to show that when we're when we are treating chronic pain, we need to target the brain. Right? I think you need to have psychological care. So what do treatments look like? Obviously, reminding the audience that everyone is different, and everyone is individualized. But what are some examples of how psychology can work with people with chronic pain?   30:57 Well, so there are a number of evidence based approaches.   31:01 So cognitive behavioral therapy is one that everyone knows about Acceptance and Commitment Therapy, Mindfulness Based Stress Reduction, even pain, neuroscience education for some people. And whenever I think about these things that I typically look at the biases of the person in front of me, is the person in front of me a highly logical, rational type of person, I'll direct them to cognitive behavioral therapy, are they more embodied emotional person, they might be more open to mindfulness meditation approaches, or Acceptance and Commitment Therapy.   31:38 I think, especially people who have been in the healthcare system, go around for years and years and have some trauma related to being a chronic pain, patient benefit from pain, neuroscience education, just because it helps them get a better understanding of what they've been working with. So in a sense, you know, we have sort of a number of different tools that we know of in the literature, and adjusting each tool based on the the worldview of the patient is the best way to go. I think that's such a great way to look at it. And what advice do you have for let's say, physical therapists, occupational therapists who are working with patients with chronic pain? What is your advice to us to recommend psychological care? How, how can that conversation initiate?   32:36 And what is the best way for us to refer out?   32:46 I think that one of the best ways to initiate the conversation is by expressing empathy, and compassion, it looks like you're really having a tough time with this.   33:01 And from what you've described, it seems to impact many areas of your life, I see that you feel anxiety, I see that you've experienced some depression, I see that this stresses you out,   33:16 have you thought about support some sort of psychological support? To help you through this, that's, I think one of the most open ways that that this can, this can happen and a lot of physical therapists that I'm that I've interacted with, have taken it upon themselves to learn some of the psychological purchase, because it's almost   33:41 because they've sort of found themselves in the position of being the psychologist whether they liked it or not, or whether they had the training or not. And I've really admired a lot of the physical therapists that I've interacted with, because they've gone extra steps to learn what it is that they might need to know in order to provide better psychological care, as you know, as a physical therapist.   34:09 However, there are lots of times whenever the degree of distress or the degree of suffering, it is beyond training, you know, the training that you might have as a, as a physical therapist. So that's whenever it's time to bring in a professional   34:29 in terms of identifying   34:32 the optimal type of treatment or making referrals. That's very tricky of because there aren't a lot of pain psychologists in North America.   34:47 Even if I were to come up with a list of them, a lot of them that I know of are in academia and the people that   34:55 are in sort of the private sector. They have that specialization just   35:00 because they have lots of experience there. So it's, I kind of, I don't have, I don't have many suggestions. In this case, I do have a suggestion of a tool that I've helped to develop, that could supplement that in a way.   35:19 But in terms of finding the optimal,   35:25 as per the optimal psychologist, I think it would come down to therapeutic alliance. And that's something that each person has to feel out for themselves. And that, okay, you have a person who's highly rational, logical CBT might be the thing for them, have them talk to three different suggests they talk to three different people who feels right.   35:45 Because I'm a firm believer of therapeutic alliance, in the larger sense. And the the foundation of therapeutic alliance was best articulated by drum Frank, in his book, persuasion in healing. And one of the things he described is the healer suffer relationship. And one of the core tenants of the healer separ relationship, the healer believes that they can heal, the suffer, believes that the healer can help them. And they come together and interact with a number of rituals together, that are intended to relieve the suffering. So if you have someone who's on your side, even if they don't have the right training, but you trust them, you feel like they get you, that's more therapeutic than their training proper.   36:35 And that's, it's it's tricky. But for instance, even just talking on the phone for 15 minutes, to three different practitioners is enough to be able to get that feeling. Yeah, that's great advice. Thank you for that. And now, as we wrap things up here, what would you like the listeners to take away from this conversation? If you could wrap it up in a bow? What would that what would that present look like?   37:06 I think   37:08 we all have a collective responsibility to empower people who have been living with chronic pain.   37:20 And I think that,   37:22 you know, based on our conversation, one of the most powerful tools for pain relief is between people's ears. And I really think that that's the most empowering approach as well. And that I, at my core, I don't believe that we, that people need to rely on   37:40 doctors or medications or even approaches nearly as much as their own brains.   37:48 I, I know that it's difficult to get access to tools and psychological approaches that enable that. One of the things I'm doing,   38:00 you know, just from a, from an entrepreneurial background, is working on tools that will help people with that. But the key to long term pain relief, is teaching people to attend to patterns of pain relief, and what really feels like even if it's just a few moments every day. So my overall bold statement would be the key to your pain relief is paying attention to whenever the pain is less whenever you have time, to enjoy things in life to engage in positive emotional learning. Those are the keys to pain relief, because the more you focus on those moments during the day, and the more we encourage our patients to focus on those moments, the better they'll get, and the more quickly they'll get better.   38:50 I love that. And now where can people find you? What do you have going on? What's coming up? Let us know. Yes. So one of the things that I've done in the past few years after leaving academia, thank goodness, is I co founded a startup with Vanya, up Korean and a chronic pain patient, make Mika Michalak. So he's an entrepreneur, finished entrepreneur who has had chronic pain himself. And we   39:18 created a tool that is essentially insights from Bonniers research in an app form.   39:29 And it contains Mindfulness Based CBT exercises and tools that I wrote, and pain neuroscience education that I wrote. So in a sense, it is a expert created tool that is designed to give all of these insights directly to a patient without them having to rely on doctors or any formal care.   39:56 Because one of the apps Oh, the app is   40:00 Ava health app.   40:02 So if you go to www dot Evo health.com, you can learn more about it. And one of the one of the things that I it's a real conviction of mine, the science that's needed to heal chronic pain exists today.   40:21 You know, this is work that Vanya has been doing for years. And the time that it takes to sort of for that knowledge to trickle down to clinicians and to, you know, clinical guidelines, is 10 to 15 years. And one of the reasons why we decided to do this was because if it exists today, patients deserve to have it today.   40:42 So it's, it's a labor of love.   40:46 And I invite anyone listening to this podcast, to recommend to check it out yourself, to recommend it to your patients. And to contact me directly at Melissa at Ava health.com. If you'd like some more information about how to use it to help your patients. I'm very open to that. I love it. And we'll have the link to that in the show notes at podcast dot healthy, wealthy, smart, calm. And again, that website is www dot A i V as in Victor Oh health.com Just so people have the spelling of that.   41:27 And now one last question that I asked everyone and knowing where you are now in your life and in your career, what advice would you give to your younger self, let's say a fresh face out of grad school or maybe undergrad wherever you want, wherever you want to take that starting point.   41:45 I would say Melissa,   41:49 you're either identity is not your accomplishments.   41:55 Think about what   41:58 drives you what creates the most passion in you. It's to help people get better. And to support people while they're healing.   42:08 instead of chasing after the shiny ego cries that other people applaud you for take a step back and focus instead on what makes people feel better now make choices to help people heal.   42:32 Now, don't worry about long term research because long term research won't help people now.   42:39 I love that advice. Thank you so much. This was a wonderful conversation. I always learn such I always learned something new. And this was a lot of new so I want to thank you for coming on. Thank you so much for having me. And I really appreciate it was wonderful and everyone thank you so much for tuning in. Again. If you have any questions for Melissa you can reach her at a vo help calm and have a great couple of days and stay healthy, wealthy and smart.

Join Sandy Hilton as they discuss the one thing they want people challenged by pain to know about.Sandra (Sandy) Hilton graduated with a Master of Science in Physical Therapy from Pacific University in 1988. She received her Doctor of Physical Therapy degree from Des Moines University in 2013. Sandy has contributed to multiple book chapters, papers, and co-authored “Why Pelvic Pain Hurts”. She is an international instructor and speaker on treating pelvic pain for professionals and for public education.Season Two of One Thing is powered by the Australian Pain Society. For more information on One Thing check out onething.painsci.org or search for @OneThing_Pain on Twitter and Instagram. Our GDPR privacy policy was updated on August 8, 2022. Visit acast.com/privacy for more information.

In this episode, Pain Scientist, Clinician, and Distinguished Professor at the University of South Australia, Lorimer Moseley, talks about pain and research. Today, Lorimer talks about his many streams of research, assessing cognitive flexibility, and his MasterSessions. What is cognitive flexibility and how does it affect pain? Hear about the social determinants of pain, COVID's impact on Pain Revolution, the complexity of chronic pain, and the responsibility that comes with doing pain research, all on today's episode of The Healthy, Wealthy & Smart Podcast.   Key Takeaways “One of the biggest determinants of your health in the US is your zip code.” “[Cognitive flexibility is] the ability of your system to change its behaviour when the task requirements or conditions change.” “If you're going to label something, it should be what it says it's doing.” “[chronic pain] is one of the most burdensome health conditions in the world.” “There's genuine, realistic, scientifically-based reason to hope things will keep improving for people with chronic pain.” “Love and be love.”   More about Lorimer Moseley Lorimer is Bradley Distinguished Professor at the University of South Australia. He is a pain scientist, clinician and educator. He has made seminal contributions to how we understand pain and why it sometimes persists and has developed treatments that are now considered front line interventions in clinical guidelines internationally. He has authored 370 research articles and seven books. His contributions have been recognised by government or professional societies in 13 countries. In 2020, he was made an Officer of the Order of Australia for distinguished contributions to humanity at large in the fields of pain science and pain medicine, science communication, pain education and physiotherapy. He lives and works on Kaurna Country in Adelaide, Australia.   Suggested Keywords Healthy, Wealthy, Smart, Physiotherapy, Pain, Research, Cognitive Flexibility, Chronic Pain, Perception, Responsibility, Recovery,   Notable Mentions Caitlin Howlett. Dan Harvie. Pain and Perception, by Dan Harvie and Lorimer Moseley. Epiphaknee, by Lorimer Moseley, David Butler, and Tasha Stanton. Participate in research (it takes just 20 minutes). MasterSessions.   To learn more, follow Lorimer at: Website:          https://www.tamethebeast.org                         https://www.painrevolution.org                         https://people.unisa.edu.au/Lorimer.Moseley   Subscribe to Healthy, Wealthy & Smart: Website:                      https://podcast.healthywealthysmart.com Apple Podcasts:          https://podcasts.apple.com/us/podcast/healthy-wealthy-smart/id532717264 Spotify:                        https://open.spotify.com/show/6ELmKwE4mSZXBB8TiQvp73 SoundCloud:               https://soundcloud.com/healthywealthysmart Stitcher:                       https://www.stitcher.com/show/healthy-wealthy-smart iHeart Radio:               https://www.iheart.com/podcast/263-healthy-wealthy-smart-27628927 Read The Full Transcript Here:  00:03 Hi, Lorimer, welcome back to the podcast. I'm so excited to have you back on.   00:08 Good. Thanks for having me.   00:10 And so today we've got a lot to cover, because we are going to be talking about some of your current projects, new developments that maybe happened since 2021, where you had well over 30 publications. So you had a very, very busy year, I would say. But as we go, as we kind of go through and talk about some of the things that you're working on, I just want you to let me know if there's anything that you're like, Whoa, hey, I can't talk about that. Or if there is reason to be a little vague, because things might be ongoing trials and things like that. So we'll definitely keep that in mind. Now, let's say you've had a lot of publications over the last year, what are some current projects, or discoveries or developments that really stuck out for you in your most recent research?   01:08 Ah, nice question. Um, one of the things about being a scientist in a clinical field is that here, it's not often that you get a revolutionary discovery, it's quite unusual. So what I think the things that I'm most excited about are not, not so so much particular papers, although there, there are some really tiny phones, there's one that's not published yet, but will will be out in the next couple of months that I'm particularly excited about. And I can allude to that. But I think sort of like these, these streams of research in which I'm involved that are turning me on a bit, the moment and one of those is a continuation of the whole explain pain thing. But over the last sort of four or five years, we have discovered, we've looked really closely at but at the the outcomes of clinical practice in where people are delivering great educative interactions and, and I've had a fair degree of, of influence over them. So I feel really confident that I did, they're supposedly doing well. And those data from a big cohort of people suggests that, in about half of the people with chronic pain, they see they have this shift in understanding of the problem, but a real flip. And it's in a predictable way, you know, shifting towards really deep in your belly can conceptualizing pain as a protective feeling that's being produced for a reason. And we need to work out what that reason is, and it will almost well, it will certainly not be a single reason, there'll be all these little contributors. So real flipping, understanding. And, and I guess, understanding that as pain persists, the system becomes over protective, and, and really embracing that as a reality. And that's a really hard thing to do. But those those half of the people who do it has great outcomes a year later. That's a for me, that's a really exciting discovery. The half of the people who don't don't have great apples. So for me, again, it's a really exciting discovery. The problem is that we're only winning in half the people. You know, we're only nailing it in half the people and the interventions good across seems to be good across everyone. So clearly, our markers are what's good intervention, they're not accurate. So my gut feeling about that was not accurate. So we've been looking deeply at how, how can we expand that group from half to bigger and, and unexpectedly for me, doubling down on the on the criticality of learning. So I've been learning a lot about learning. And that's been infiltrating our research and infiltrating the whole way we go about helping people with chronic pain or at risk of chronic pain. And so I'm really excited about that. And we're seeing its scientists talk about seeing a signal amongst the noise. And in chronic pain, there's just so much noise, right? Because chronic pain is this truly, in my view, truly bio psycho biggest and it's more or less social thing. And if we can intervene and see a signal in that group, that's a really exciting development. And   05:03 I, I'm more excited than I was maybe seven or eight years ago about the potential power of of new and better ways to get people to give people understand. And I started banging on about this in conferences and stuff maybe three or four years ago. And I have this slide that that is intentionally slightly provocative, particularly to the physical therapy world. And that sort of pain science education world, I think in in the US the brand name as popular as paid in neuroscience, education, p and E. These are all brand names, right? PMA expired pain is a brand name. So I like to avoid the brand name. So I call it sort of pain science education or modern pain education. So this slide is meant to be slightly provocative, in say, has education become the objective, instead of learning being the objective, and I think for me, education became the objective. And that was a mistake that, that I made. And I think my research made that mistake, and my clinical practice probably made that mistake. And my own outcomes over the last 10 years, and I get I keep really tight audit data, I can see the benefit of my own development as a, as a clinician, educator, and probably as a human on outcomes. So I'm excited about that, for sure. And I can give a little, a little teaser to the paper that we expect to come out the next couple of months in a big journal near you, which looks at a clinical trial of chronic back pain, where we have done two things that I think are really unusual for our field. One is we've tested, I think, a new complex intervention. And it's made up of less new interventions, but they're all sort of put together into a package if you like. And the other thing that was different that we did that, that are Yeah, I think I'm really proud of the team led by James McCauley is the senior author on it. And Ben once and I were important in sort of formulating the treatment, but Ben's been really critical. But we were all very keen to make the control group the best placebo intervention, we could. So we put a lot of effort into credible brain targeted treatments, matching the educative component. And testing whether people had different expectations or perceived credibility or beliefs about whether they are in treatment or not. So from my perspective, it's a very tight trial. And James and I were fully expecting that we would not see a signal in this. But we would be interested in secondary analyses which tell us mediating effects like what, even though there wasn't an overall effect, where what worked, what what might have been helpful. So that's what we were expecting, but in fact, we saw a clinically important signal. And that's very unusual in back pain trials. It's if you have a control group where you've got a waiting list or usual care, or you've gotten there's been a couple of trials published slightly, or you've got open labeled saline injections, you know, these treatments that will have some sort of effect, but they're no match. Right? So you're not really asking, are the particulars throughout this treatment? Important? All of those treatments will show a signal they all they always do they show exactly the same signal. I've done those randomized control trials. So that's one thing, you can design a trial in a way that you'll show signal. But it's a bit meaningless to us as real world clinicians. Or you can design a trial that we would call an explanatory trial that says, Okay, we've kept all of these things the same in the two groups and the things that we kept the same were as much of that nonspecific therapeutic alliance engagement, credibility expectation, which, which I think is a big part of the whole pain science education thing. So I do think we have to monitor that. You might hear my dog the other   09:38 room. Right. All right. We're pet friendly around here. What's exciting   09:42 about that is that it means there's some sort of delivery bandwidth to be won, I think it might be this new piano that I discovered even better. Yeah. So anyway, so that will be coming out. I can't say anything more about that, but, but it's a really exciting development. And we've got we've got a few trials that are testing versions of these sorts of things for for different conditionals. But uh, going at the moment and the way we're constructing the education component and integrating it with the movement and loading and anti inflammatory component. So that is three pronged approach. Really exciting for me, as I, you know, I've been doing this for quite a while that feels like, I still feel like a kid. But, you know, I have been researching for a while. And this is a really exciting time, I reckon, in the chronic pain world, because I think we're starting to chug forward again, I feel like the field was stalled a bit. But jumping forward. That's one thing. And then then on the other other side research streams, one of our team called Dr. Emma Karen is doing really difficult and really important, work really well investigating the influence of social determinants of health on chronic pain outcomes. First focusing on low back pain. She's published a couple of systematic reviews, and mixed method study on that, that is pretty intimidating. For those of us trying to move the the outcomes in a positive direction, because as we were talking about before, caring that the social determinants of health are very powerful, and they're powerful in back in back pain and pain outcomes. They're really hard to shift, you know, they're very hard to do much about so. At our field, the pain, field musculoskeletal, the the sort of arthritis field has or has engaged with, it's way better than then the non Arthritis, Musculoskeletal pain, pelvic pain, Fibro fields, we, you know, it's remarkable how little attention, it gets the biggest social and when we talk about the biopsychosocial model, we nearly always conceptualize that as a smallest session and the people around you social, which is important. But we haven't really integrated the biggest social Yeah, the world in which you live in your access to health care, illiteracy. Poverty.   12:29 Yeah, that sort of stuff. Absolutely. And I think you kind of hit the nail on the head as clinicians, oftentimes when we talk about the bio psychosocial, we think of the socials, what's your support system at home? You know, do you have, you know, can you get to, can you get to therapy? Do you have access to therapy? But what we're not asking is, do you have access to other medical care? If you need it? Do you have access to fresh foods and vegetables, which we know can play a part in, let's say inflammatory responses in the body? Do you have access to a pharmacy? Do you have access? I mean, all of these things make a huge difference, you know, or do you? Is your social part of that bio, psychosocial? Are you working three jobs and raising children and not having time to fit some of this stuff in? Right? So social part becomes a really big S for a lot of people. Certainly in the United States, like I said before, one of the biggest determinants of health of your health in the United States is your zip code.   13:37 Yeah, it's remarkable.   13:40 So social determinants of health is is high priority. And I think maybe people shy away from it, because it's can be so overwhelming. So I don't know what you guys are finding research wise, if there are way and how you can address that?   13:56 Oh, it's it's overwhelming, for sure. And I totally understand why there is a reluctance to go there. And there are also I think there's very complex ethical considerations about going there. We've we've been planning a study in the northern suburbs of Adelaide where I live, which is an area that's really different to the say, the inner suburbs of Adelaide with respect to all that sort of predictable social determinants. But one question that we've had to look in the mirror about is if if we develop this so we're working on developing a screening tool. If we start to identify people that have significant unmet social needs, and we can't do anything about it, is that is that a ethically defensible position? Yeah, we were able to say to people, okay, we know what the problem is, you know, this, you can't have because we got no mechanism Have of meeting that need. So it's quite a challenging area to move into. Because if you if you imagine that the understanding and overcoming persisting pain is a very slow step by step journey. And now we really have to imagine that instead of going in a straight line, we're almost going in a circle, and we're making slow step by steps of the entire circumference of the circle, you know, and you move a little bit, then you have to stop and move a little bit more somewhere else. Otherwise, you're going to break. And the people who suffer when you break will be the same people, you know, the, the more vulnerable people. So it's a really challenging field. And yeah, I can't, I'm excited to be getting dragged along by Mr. and her colleagues on on this. But I'm also so impressed with how, how robust the approaches to it. So yeah, there's a couple of her papers out already and more, more coming. And I think there'll be really influential in the field. Because no one there are people there. There are people who are engaging in this, but very few people are thinking to themselves, I'll take on that challenge. Yeah,   16:28 yeah. Very, very difficult.   16:31 It's relevant to it's really relevant, or I guess my interest in it was sparked by our work with pain revolution, which is an outreach project program for rural areas. And it sounds like it's similar in the US. But there's there's areas in Australia not far from big cities, what we would call a big city of Adelaide a million people. There's areas two hour's drive from Adelaide that cannot get a GP or a physio, or a psychologist or an occupational therapist, to worth it. And they've got, you know, wanting four of them have a persisting pain problem that affects their lives. There's no, what do we do? What do we do about that. And so pain revolution is, is really trying to ultimately build workforce capacity. In giving people health professionals have some description, when I care what description, in fact, we were, were looking for money to try our non healthcare professional, being coached and becoming a rural coach. But the idea of that is that if people we know I think from other areas of the pain field that if if a healthcare professional of any persuasion, understands deeply contemporary pain, Science and Management, and takes a defendable, scientific, and now evidence based approach, then outcomes can be better for sure. And outcomes will be promoted by engaging in in care locally, the moment the only model we've got is a fly in fly out model, which is where, you know, the health professionals go from the city and spend a day in the country and come back a month later, in my view, of very limited benefit. Or we've got a full five model where the patients, that consumers come down to the city. And in many cases, that's a 810 12 hour drive. Get an assessment? Yeah, there's no there's no way of training those people or providing effective care for these people. So yeah, yeah.   18:55 And I, you know, yeah, no, no, you know, it this, this conversation about this kind of rural outreach and, and maybe training someone who's not in the medical field, reminded me of a documentary that I saw, Oh, gosh, I can't remember the name of it, if I can ever And i'll put it in the show notes. I can't remember it right now. But it was on it was more psychology based around loss and trauma. And there was a woman in Africa, who was not, not a psychologist, she was not trained. But she, she, I think she was trained in some basic coaching skills, but she lived in the community. And people there were more likely to go to her because she understood the community. She was part of the community and they had really good outcomes. So I'm wondering even if training someone who is not a medical professional, but if it's possible to train them even in you know, you don't have to be there in person, but would that person because they're part of this rural community, maybe have better results and someone just flying in for the month and flying out where you have someone who knows the community understands the struggles, and maybe has known some of these people their whole lives. You know, we talked about therapeutic alliances and trust and beliefs. So with people they're more likely believe someone who's part of their community than someone who's doing a fly in fly out. I don't know, it just reminded me of that documentary.   20:24 Yeah, I totally get that. And I guess we were really embracing that in, in one aspect with pain revolution, because we're training rurally based healthcare. And that was the impetus you know, they're connected to their communities and their communities are really well connected more so than certainly in Australia, in the cities. You know, you're the physio, if there is a physio will be on the sideline at the Netball day or the football game, way with the consumer, you know, these, these people's normal lives and accessibility and those things that I think reduce the power differentials that that contaminate a lot of healthcare interactions. Was it a part of our drive to drive pain revolution rurally, to tap into this already, and you know, the vision that we state, the pain revolution is that all Australians and I think we're going to change that to all people will have the skills, the knowledge and access to local resources to prevent and overcome persistent pain. And that's the real emphasis that we embed the knowledge and skills locally. And, you know, that's, you know, I've been talking to 1010 years about recovered consumers being coaches, not the healthcare person, but recovered consumers, because they have all this knowledge and expertise that no one else can have. Right.   21:56 They're very deep understanding of pain.   21:59 Absolutely, yeah. And pain, and not not only the lived experience of pain, but the lived experience of recovery. And I think that's a untapped massive resource. But there are significant regulatory medico legal barriers to us just pushing forward on that, that we're still negotiating. So that's yeah, that's been at least a decade. My perspective. But paint ray of is is so exciting. It's, it's really cool. Like, we are doing it on a shoestring. And I think we now at the end of this year, we will have, I think we'll have about 35 Local pain collective. So these are networks of healthcare professionals around geographical regions that get together, learn more about how pain works, and the best ways of treating it collectively problem solve pain, rave feeds them. curricula, but really, it's a collective problem solving facilitated group. And yeah, I think the panorama was responsible for delivering around about around about 400 community outreach sessions, amazing Australia, in the middle of COVID.   23:17 I was gonna I was gonna ask, How has COVID affected? What pain revolution has been able to do, let's say last year, as opposed to previous years?   23:29 Yeah, it's, well, it's had its impacts, for sure. And depends where you live in Australia. So two of our states have had a longer period of of living in a COVID world I guess. And in those places, there's there's been no face to face. stuff. They are 2021 outreach tour that we do. So we run this circus that gets a lot of attention raises a fair bit of money on our level of what a fair bit of money is, it's got in the commercial sector be like someone's bonus for the week. But in our sector, it keeps us alive. And we go from town to town, and we run these public outreach and health professional outreach events. We're all dressed up in library, we ride our bikes, and it's all this cool thing. And that's part of a wider program with two other projects that dovetail into that dedicated to the region. And we didn't run that in 2021. And we won't run that in 2022. And that's a big hit for us because it's our main fundraising Avenue. So that's that's a real challenge. Some states in Australia have had basically no COVID And one state still basically there's no COVID Western Australia they They pay us closed to the rest of Australia in the world. And I think they're aiming to reopen in February. Tasmania has recently reopened and they're starting to get cases. But now we're where I live. We are, we're at the beginning of our wall of Omicron. And we really don't know what this year looks like. So we don't have the experience that a lot of places do. And we're very grateful for that. But we also clearly like deer in the headlights at the moment. Federal governments are going everything. Rules are changing all the time, we and you know, we're not as prepared as you would expect us to be having had a month's notice. So that will impact pain revolution for sure. The we're a really small outfit we have I think we have 1.5 full time equivalent staff delivering hundreds of programs, or events, and we're very resilient. And yeah, well, yeah,   26:11 we'll you'll get this done. And And if people want more information, they can go to pain. revolution.org, correct. Correct? Yes. All right. So pain revolution.org, if you want more information about what pain revolution is doing, and maybe how you can help or contribute, if you so if you see if it if it aligns with what you believe in, then I suggest go for it because it is a very worthy cause for sure. And now, it's kind of switching gears a little bit something that we were speaking about sort of before we hit the record button here. And it's a concept that I had to kind of look up a little bit before our talking here. And it's that concept of cognitive flexibility. I think it's interesting. I think it's worth talking about. So I will hand the mic over to you to sort of talk a little bit more about what that is, and how does cognitive flexibility fit in with people living with pain and maybe with practitioners treating those living with pain?   27:21 Yeah, well, thanks. And again, yeah, I feel like I don't actually actually do much of the good work, it feels a little bit like because this work is has been done by Caitlin halat, who's a PhD student about to finish and has a background in psychology. We embarked on a new direction probably three years ago, with with a really sensible prediction, I think that possible contributed to not recovering after an acute episode of pain based on if people familiar with Bayesian or other predictive processing models, based on the idea that the outputs that we generate predictions and the system is influencing itself according to predictions, then we need to update the internal models of the models in order to resolve so if I was to cover that really quickly, if we, if we said, when you bend over and you don't have pain, that what what could be happening there is that your brain predicts that this will be safe, your brain produces a feeling that's consistent with that mn let's say you tweak the annulus of a intervertebral disc or something, you get no sensitive data that are that are within the sensory load. And I like to say within the Tampa symphony of Dallas, extraordinarily complex, beautifully evolved system of of information about what's happening in the tissues, we get data that says this is not what I predicted. The evaluator for this is not what I predicted. So we update the internal model to say the back is vulnerable in some way, let's say. And then the new prediction is, well, let's make pain. And let's influence the system differently. And then if we go in the other direction, and every time we've been able to get this nociceptive data within the symphony, and then one day you don't I know you've been over and and you don't get that. And now the theory is the system detects that error says Hang on. That's not what I predicted. So it updates the internal model to say the back is less vulnerable. And now your brain doesn't produce as much pain or produces no pay, and then you've recovered fantastic. So one potential barrier to recovery according to that theory is failure to update yourself. Title model. And and that should happen. If, excuse me, that shouldn't happen if you if you don't detect the error. So if for some reason you don't, your system doesn't detect that the predicted data, the predicted data, which was not receptive, in part hasn't been hasn't eventuated. And therefore you don't update your internal models. So on the basis of that, we became quite interested in this broad field of flexibility, cognitive flexibility, which has been defined in many ways. But I guess the way that we were thinking about it was the ability of your system to change its behavior are when the task requirements or conditions change. So in the language of have that sort of Bayesian idea, and to your ability to update your internal model of things. So we started digging around in this field, or Kaitlyn really started digging around in this field. And often in a PhD, you'll start with a systematic review of the literature on a question that's most most aligned with what our hypothesis will be driving. So. So Caitlin took on what we thought would be a reasonably straightforward job to review the literature in cognitive, mental and psychological flexibility. So the barrel phrases that are used, often interchangeably, particularly cognitive and mental flexibility. And with the question that would help us determine which is the best way to assess it's what's the best way to assess flexibility. And there's two broad approaches to assessment. One is self report, questionnaires. And they have they were developed out of a line of research, starting with personality tests in the 1960s. And that's this sort of this long line of stuff. And someone I can't remember who but in the, I think in the 60s or 70s.   32:18 proposed that I think it was empirically based but propose that good communicators perform the answer these sub questions in a certain way. And that research would describe them as positive and flexible people and are good communicators. And then that infiltrated the field. And we eventually got to this situation, we've got cognitive, cognitive flexibility scales, things like that. The CFS or, and there's a few of those, completely independently from that was the development of behavioral tests. The most famous and most common is a thing called the Wisconsin card sorting test. In that, in that test, you you sort cars according to one of three criteria, shape, shape, or number, I think, sorry, shape, color, or number. And the rules for sorting change, and you only realize that change when you make an error. Yeah, that so you put a card in a certain pile, and the tester or the machine goes about anything, what should work, and you have to work out what the next set of rules. And the people doing these studies somewhere in the 80s. Or maybe it was a bit later than that, call this cognitive flexibility. So we've got two independent lines, joining a company flexibility, and then that's then all the whole field just went nuts cross contaminating and all that. So Caitlin has now published and once just been accepted last week, to systematic reviews that are massive. And she had to contact authors for nearly every single one of these studies to get data, asking the question How well do those two approaches to testing 100 Flexibility correlate? Because if the system the same thing that should correlate quite well, one of those systematic reviews is in Healthy People. And one is in people with a diagnosis clinical groups. And in both of those studies, there is absolutely no relationship between those two approaches.   34:39 So you have two different tracks on how to assess cognitive flexibility, and there is no correlation between them.   34:47 Not at all. And actually a lot of the tests, there's no reliability data for them. Now, there are some cognitive psychologists who won't be surprised at that finding. And they're the informed one Who, who have been working in this field? I guess. But for people like Caitlin and I and the rest of the team on this project, where clinically, it's such an attractive hypothesis, right? Like if if people can't change their, that if people don't easily change their beliefs, explicit beliefs, their implicit beliefs about the vulnerability of their body, what pain means that the targets of pain, science education, then we know those people who don't, don't change some of those targets of pain science education, don't do as well, when we know that. So it's such an attractive hypothesis that they might be less cognitively flexible. But the barrier with hit is so how do we find out? Because we don't actually know what any of these tests are actually.   35:56 What are they actually test   35:57 measuring? Yeah, yeah. So so the direction for that, and I've asked for money haven't got it yet to do that is to devise a a new way of assessing the ability to change your decisions when there is some sort of risk evaluation involved, because I think for, for pain, I think we talked about the meaning of things being important for painting. And I think one way to distill the meaning is about just a risk profile, that every nanosecond, our system is evaluating risk, and its risk, that determines our feelings. And I would categorize pain as a feeling bad. So my anxiety, fear, fatigue, lead to the toilet, lead to a thirst, all these things, in my view, feelings generated on the appraisal of risk. And, and if we don't have any risk, in an evaluation of our ability to change your behavior, under changing circumstances, and I'm even, I'm nervous to use the phrase cognitive flexibility now, because I know that whoever he is that there are three or four main ways that you understand that. And some of those would be totally different from otherwise. So I would prefer to say, if we keep assessing the ability to change your behavior, according to changed demand or environment. without risk, then I think we might not capture what we need to capture for understanding a potential contribution to the development of chronic pain or recovering from initial pain. So so that, you know, that was one of those, one of those PhDs where it's such an important discovery, actually, and and Caitlin's contribution to the field is very important. But it won't get the citation impacts and the Roth IRA. Because what the country contribution says is, hang on everyone. Why, you know, there are a whole journals dedicated to this. But what is it? What is it, we almost have to go back and start again and say, Okay, let's get really clear on what we're talking about. Let's use these phrases. Anyway, so but that's relevant to the very first question, what are you most excited about? I guess I'm, you're tired to be excited about, clearly, deflationary discoveries like that, but they're so important. They're really important, and they're harder to publish. But they shouldn't publish, in my view, they should publish top journal. In your face. Journal. Yeah. Well,   38:49 it's, it's like, yes, it's sort of this deflated response, if you will, to, to the systematic review, but it is important because it's important to use the right words, and to if you're going to label something should be what it says it's doing. Otherwise, why are you doing these tests? And why are you you know, labeling someone as very highly flex cognitive flexibility or low cognitive flexibility when you don't really know. And then exactly, so how do you then so then your treatment, I look at it from a clinician standpoint, how do you formulate a treatment plan around something that's, that's not accurate or unknown? So I think it makes it really difficult but it's it just underlines the importance of this kind of research.   39:41 And oh, go ahead. No, I was just gonna say I think that um, it Kayla's research doesn't doesn't tell us that these tests are uninformative. But what it does tell us is that we don't We don't know exactly what they what they mean. So that speaks to your point exactly Karen, that that. So what do we do about it? That's a difficult thing, because we don't actually understand them well enough, I think. But can I put in a plug for? Yes, a research project of Caitlin. So final project for a PhD that we desperately need participants form? Yeah. Because it's an online study. Okay. And it's, it's to do with this kind of flexibility. And we need people without pain, as well as people with pain. Well, that's a lot of types of it. But basically, everyone, anyone who has 20 minutes spare. It would be great if they just went and did Caitlin's experiment online. And maybe I could send you the link.   40:48 Yes. Yeah, you send me the link, I'll put it in the show notes. And also put it out on social media. So that girl can can take this online study. So if it's people with or without pain that takes in quite a lot of people, like you said, like, one? Yeah, so I'm assuming she wants a robust number.   41:11 We need lots. Yeah. Because we think the signal will be small amongst the noise. Yeah, but yeah, if we did it, and then ask one of their family members or mate, yeah, that'd be fantastic.   41:25 Yeah, I'd be happy to send you the way about that. Yeah, definitely do. And as I was, you know, as you were talking about this cognitive flexibility, or the ability of to adapt your behavior, and let's say cognitive strategies in response to a changing task, or to a threat or something like that, it, it always reminds me of this experience that I had. So most people who listen to this note that I had a very long history of chronic pain, I think you're well aware of that as well, about 10 years or so of neck pain, chronic neck pain. And it was this was a couple of years after I could say I was recovered, you know, of course, those times when you have flare ups and things like that, but largely recovered. And I was I was at Disneyland with Sandy Hilton and Sarah Hague. And we had waited in this long line, like an hour to go on what I thought was like a jungle cruise. You know, this very, like, get on a boat and cruise around the water kind of thing. Yeah. And we get up there. And all everywhere. Once we get inside, plastered everywhere was date, big danger signs, you know, the yellow dangerous sign, the red X, if you have neck or back pain, you know, this guy. And I was like, you know, so talk about a threat, right? So my normal behavior, and like, my hands were sweating, my heart rate was up, my eyes were dilated. My normal response, I guess, would maybe show my inflexibility would have been to find the nearest exit and leave. Yeah, yeah, get out as fast as possible. Right. And so I think, Sarah, and luckily, I was with two very incredible women who are very well versed in pain science, and I think I am as well, but when it's you, you're you're like, a big, you know, mashed potato, you know. And Sandy and Sarah just looked at each other and looked at me, and I was like, almost shaking. And Sandy's like, Okay, listen, it only tilts about 12 degrees, and it stops and goes, you're in taxi cabs, they stop and go, you're fine. It's this much of a tilt, you'll be fine. And then Sarah's like, yeah, and the person in front of us like six, you know, there's nothing over your shoulders. It's not that dangerous. And they kept playing down the danger. And so I did end up getting on it very, very nervous. And then I got off and I was fine. They were right. Then it allowed me to be flexible enough to then go on another ride after that. Whereas if I went with my original strategy, which would have been to leave, then I wouldn't have done anything else for the rest of the day. Yeah, so that threat, if left to my own devices would have gotten the, I don't want to say gotten the better of me, but I would have reverted back to the behaviors I had during the that sort of 10 years of living with pain.   44:24 Yeah. And, you know, I respect I respect both of those approaches where it makes sense for an organism when you see credible evidence that this is a dangerous situation to take a variety of action. Yeah, makes total sense. And I guess the, I think about the flexibility thing was evident, as Sandy and Sarah are problem solving with you gathering more data. And, and then your choice changed. That's the stuff that seems consistent with in quotation marks flexibility, you know that right? In the face of new data. So the new data, it could work both both ways. And I think there are some people with persisting pain problems where they behave the same way, even in the presence of significant danger cues. And that works against them because they the danger, for example, right, right. Yeah, can work both ways. Yeah, I think I think there's a rich there's there's a rich stream of, of understanding in there somewhere for us to, to uncover. But it does feel a little bit like that's going to require the the archaeologist among us to get out. This is a metaphor, obviously, to get out our brushes and blowers and slowly reveal what that stream of gold is, as distinct from the earth blasters obviously just want to revolutionize in a in a rapid way. And I fit more into the second category. You know, I lose steam on the very slow, the finite, made tool discovery thing. I'm very pleased to be around researchers who are excellent at that. Yeah, it's not so much.   46:25 And I always always think about that. What did I think David Butler said they were what did he call them? Oh, I don't know why I'm blanking. I have the book right here. Super. Ah, I'll think of it. It'll come up. It'll come up later. It's from explain pain supercharged, you know, the graph and everything leads. So if you have more, yeah. Dangerous safety Sims. He called them Super Dungeon Sims. Yeah. Jensen says, so he was like, Oh, I think Sara and Sandy were your super Sims at that moment, which is maybe what you needed? Maybe? I don't know. But like you said, it would have been just as valid as if I was like, I can't do this. It's too stressful. You know? Yeah, it's too dangerous. Too dangerous. Yeah. Because those   47:14 were the cues that you were, you're getting? Yeah, yeah. And just take it off. I always say it's important in a situation like this to take a moment to reflect on the contrast between the resources available to you in that moment. Right. Which, okay, Sandy and Sarah? Unique, exceptional, exceptional resources. Like, yeah, scrub exceptional. Yeah. But even without them, take your own resources. You know, you're informed, you're, you're resourced with intellectual and other capacities and understand how things work and biomechanics, you've got incredible resources, and then just take a moment to reflect on the contrast when you and most people? Yeah. And is it? Is it any? Is it any wonder at all that people face those situations? And yeah, there'd be a lot of people with chronic neck pain, even if they're on a recovery journey, who would get into that situation and their neck pain would flare up, they wouldn't even do the rod, that's right, leave and they kind of flare up and, and the rest.   48:24 And everything that comes after that, go back   48:27 to the doctor, get a new script, you know, and we do we attempt to, or they I think there's a tendency in our field to, to look, look down on that approach in some way. But, you know, as they are, that's substantive people. But it's totally predictable. And an excellent, excellent biological organism doing that. And we have to overcome, we just always have to remember the resource differential.   48:58 Yeah. Oh, that's, I never even thought about that. But that is so true. And, you know, it just goes to show you why people living with chronic pain, why the burden of disease is the high one of the highest in burden. It's the most one of the most burdensome health conditions and diseases in the world. In most countries. I mean, just low back pain alone, the burden of disease in the United States, I think is third, that's just low back pain. We're not talking about oh, a and other knee or neck pain, other chronic conditions. It's third Well, I mean, things might be different now with COVID. I don't know. But um,   49:38 you know, it's usually with disability. And they usually for disability metric for iPads way out in front. Yeah. Yeah. Yeah. I mean, on other metrics to use last year's lost, which includes mortality, then it drops down, right, just a bit.   49:56 Right, right. But you know, it just goes to show all of the things that you that you've been working on in 2021 and that you're excited about coming up, let's say in 2022 and all the incredible researchers and PhD candidates that you get to work with it just shows how complex and complicated chronic pain is. And that one or two sessions of pain science education in clinic cut it for most. No, absolutely. And it just shows the complexity of it and how difficult it is from a research standpoint, a clinician standpoint it is a tackle these problems on an individual basis and society as a whole. So I mean, keep keep doing that. Keep fighting the good fight, as they say.   50:40 That's scary. Because yeah, gobsmacked, nice weeks that I get to do this for a job and I get paid for it.   50:52 Yeah, speaking. And speaking of helping people around the world, you've got master sessions coming up. So you did this in 2021. So now you're doing it again in 2022. It's going to be May 13. To the 16th. Depends on where you live in the in the world. But you want to talk a little bit more about the master sessions, who's involved and what it's all about.   51:13 Well, yeah, that I mean, that was that was really cool. We sewing in 2021. No one's traveling, obviously. And noi group UK put, to me this idea of doing something a bit different. And it was really different like I was so that it it, we had two broadcasts, and they were timed friend friendly time zones for Europe or for the Americas. And then Australia and Asia sort of could go to one or the other with not quite as friendly. So for one broadcast, I was starting, I think at 6am. For another broadcast, I was finishing at about 11pm, something like that my time, but it was really well planned really well resource like they are, I'm in a studio basically, I was in that it was in the NOI group offices in Adelaide, but set up like a studio with a producer and sound people and a couple of cameras and Tim Cox working as emcee does a beautiful job on that. And we had a team of people downstairs ferreting around for the papers I was mentioning and all that sort of stuff. And it we were we didn't know how it would go because it was it's not like it's not like a zoom conference. Or, or cause it's really quite different from that there's a fair bit of interaction and it went, it went really well was really good fun, really well received. And the feedback has been overwhelmingly positive. I, I was joined by two people for 2021. social pressure Tasha Stanton came to speak. And she so she did a about a 30 minute talk. And then she and I chatted for about 45 minutes and and then we open it up to q&a and and that conversation between Tasha and I and then the other person who contributed that our two people were Mark Hutchinson, who's professor of everything. Adelaide University, one of the one of the exceptional communicators on neuro immunology, related to pain and defense, personal defense. And so same sort of format with him. And then with David Butler, who everyone knows, if you don't know, David, you, you're missing a key part of life you should have. So it was amazing. It was yeah, it was a really well, it's lots of comments like, I never thought online education could be like this and that sort of stuff. So that was really positive. So in 2022 in, and I think the dates you mentioned are probably the Americas day, so that we're doing to broadcast again, where we got feedback that we're responding to, so the schedule is changing slightly. Mark Hutchinson and Tasha are both coming back to do longer stints. And then we're also having in people with really interesting research and great clinical engagement. So for example, Dr. Jane charmers who's done some excellent work in pelvic pain. So she'll come and she'll do a talk and then we'll, I sort of interview them. So it's the massive sessions are a massive amount of work for me because I need to have my head around everyone else's stuff as well. So I can ask meaningful questions, but the, the feedback is is about how useful those conversations are as well. So yeah, so this Jen channels there's Haley leak, Haley leak has has started working with investigate what people who are recovering from paying value in learning about to publish one paper on that in pain, a beautiful paper, I think that I think should shift research direction of a few groups. Haley also has the probably unique among pain scientists brag point of winning the Australian survivor 2021. So she, she survived. And part of the reason for her survival, I think was her deep understanding of how pain works. And there was some great episodes where she there was one where she I think she was standing on like Pogi point things, Poles, they were all doing this with a with another thing coming slider down lower and lower for six hours.   56:08 And lead athletes x s as people have already fallen out and and so she's she's actually done an incredible job in disseminating modern understanding of pain to the wider community because they've all said, How did you do that. And she's able to talk about her understanding of pain. And pain does not mean damage pain is because it was a thing. So no wonder the host is making these comments like that they're trying to rev up my payment system. So incredible impact and she's got a high profile among the people who watch on Survivor on telly. So she's able to integrate that experience with her research. And she's very interesting person. So she's she's coming Sarah wall works doing really interesting work with younger kids. Looking at how how we can engage with young kids on everyday paints in a way that will help them be resilient later. So really fascinating work that she's doing. And then I'm on there as well. So I think I'll cover about half of the time. And it's great fun. Yeah. And you know, people go look at the reviews and all that sort of stuff. But yeah. Love people to to get involved in that. That's in that's in May. Yeah.   57:30 And is there? You may not know this, but is there like a cutoff date for signups? Or can you sign up like the day before? If you wanted to?   57:39 I think there's a right shift. Okay. I think there's an early bird, right. I think I actually don't know much about that sort of stuff. But they they do have to. I mean, the earlier they get a feel for numbers that they they're able to judge sure how to do it, because it takes a lot of bandwidth and all that sort of stuff.   57:59 Right? Yeah. All that behind all the behind the scenes production stuff. You're the On Air talent, you don't have to worry   58:05 Exactly. Worry about any of that. But But noi group, if they get annoyed by it, they'll learn everything   58:12 about it. Yeah, yeah. And again, I'll put the links in the show notes here. And we'll put it out on social media as well. So that if people are interested, then I highly suggest signing up because it what a great, what a great lineup. And it's not until May. So you have plenty of time to shift your schedule and try and figure out, you know, kind of block the time off so you can be part of it. And one other thing, I believe this is true, you can correct me if I'm wrong. But if you if you're in the Americas, and you you paid for it, you live in New York City, let's say I pay for I live in New York City, I can also watch the other, also get the recordings of the other broadcast.   58:55 That's correct. So you get both and you you don't have to be there live watching it in bed. But if you're not you, you're not engaging in the q&a and all that sort of stuff. Yeah, but you get access to both broadcast and you get access to the thing called the Padlet, which is it was an amazing resource from the first time because this is all of the stuff that the team downstairs is getting while the master sessions around. So let's say Professor Mark Hudson mentions this are really exciting new study from so and so which show this then someone downstairs will get that study put the paper on the Padlet. So it's some incredible resource as well. And they have access to that. I don't know for how long afterwards   59:40 Yeah, yeah, but you but you have it Well, it sounds amazing. And I think it's so great that this is probably something if not for COVID Maybe you would not have done and it's made a big impact, right so   59:54 and and when COVID no longer what it is I'd prefer to do it this way.   1:00:02 Yeah, yeah, amazing. Amazing. And now, I don't want to monopolize any more of your time. But is there anything that we didn't cover that you were like, Oh, I really want the listeners to know this or, or is there a big takeaway?   1:00:18 Ah, I think the takeaway is, it's really consistent over years, actually. Whenever I have an opportunity like this to chat, with such an informed and, and clever interviewer, like you, I'm always struck by how, how important people like you are for our community, because I see my role sort of knowledge generation and, and dissemination in sort of conventional ways, you know, books and articles and things like that. But we need people like you, to spread it, to play the critical role and getting it out to the, to the world in a way that's accurate and engaging and, and it's people like you who put in so much so much effort for your community. And whenever I think about takeaway, I just am reminded of of the potential benefit we can still bring to humanity by doing this chronic pain thing better. And we have made progress, know that we made progress. But it feels to me like were climbing up a really, really tall mountain. And now when we look back, we can see we've actually come quite a long way. But when you look ahead, there's still still a bloody big mountain. So all of these things would have hope. I think there's genuine, realistic, scientifically based reason to hope things will keep improving for people with chronic pain, that will people will have better outcomes. So that's my take home. But can I give a plug to a book that I'm an author on? Yeah, it's a self plug. But I'm not the main author. So Dan Harvey, a truly innovative scientist. And I don't say that lightly. There's not many innovators out there. But Dan Harvey is an innovator. And he's the first author on a book called pain and perception. And the Americans can get that through IPTp. Elsewhere, you can get through no group. And it's a I think it's a beautiful book. It's all about understanding through illusions, and sensorial experiences, more about how pain works, sort of like a coffee table, book waiting area book. The feedback has been fantastic. So yeah, I'm really excited to be involved with that with Dan. And I'll just mention another book that's available in in North America, but not in Australia. And it's called Epiphany. And test Stanton has joined Dave Butler and I to, to write a consumer focused book around the osteoarthritis.   1:03:17 And I will say, I, when I first saw this epiphany, it's not how you would normally spell epiphany. It's, it's, it's an what do they call it? It's an acronym an acronym? Yes. So it's explaining pain to increase physical activity in knee osteoarthritis.   1:03:39 Correct. It's spelled AP IPH a knee,   1:03:45 right? Yeah, very clever. Cuz I was like, epiphany. What did I say? Episode? I don't even know. What's epiphanies? And you're like epiphany. I'm like, oh, yeah, that definitely makes more sense. That definitely makes more sense. But yes. And we'll have we'll have links to all of this stuff, again, in the show notes. And, you know, one last question and talking about, you know, all of the work that you do that isn't in very important work, and it can impact not one or two people but millions of people living with chronic pain. So do you as a researcher, how do you deal with maybe feelings of overwhelm with the responsibility that that place is on your shoulders? Or do you think about that at all? Or am I just projecting what I would feel if I were in your position?   1:04:36 I think you're projecting. I don't, I don't feel overwhelmed in the slightest. I don't feel any sense of responsibility to humanity. That's, that's changed because of what I do. I feel I feel that I have a responsibility. I don't know if I feel I have responsibility. I want to use my resources and my knowledge and my skills, and my connections and my relationships to, to be the best Lorimar I can be if that makes any sense and, and the values by which I judge that are not at all on chronic pain outcomes. I'm a very sort of process driven person, I want to make sure that today I did the best thing I could do. And I don't have any illusion that I, I could use outcomes as a marker of, of how well I've lived my life. Because I just think there's too much noise for, for me to have a measurable signal in the world. So I want to make sure that in this moment, I'm being authentic and true and real. And today, I'm doing my very best, I do my very best. But I do that, because I like myself more when I'm doing my very best. But I feel any burden to humanity. That's different from the burden that I think anyone who grew up in my in my world and life with my skill set, and my influences would have.   1:06:24 Yeah. And I think that's great, universal advice for for anyone. And, you know, normally when we finish the show, I always ask people, What advice would you give to your younger self? So I don't know if any piece of what you said would be maybe part of that advice. But is there anything else that maybe you would give to a young a young Larmour? fresh out of university for first time University, not? Subsequent?   1:06:48 Yeah. I think that I would, I think there would be advice, I don't think it would be remotely relevant to my work, I think it would be love a beloved, look for that, and express and, and value that with the entire depth and breadth of your being. And for me, that includes being a neuroscientist and paying dude with a extraordinary fortune of being able to do the things I enjoy doing for work and resonate with my values and all that sort of stuff. And ultimately, I think we're such a sophisticated organism that, that we may want to one one day discover that it's all just to love and be loved. And I don't know, great advice.   1:07:43 Great advice. Thank you. I'm sorry, not a sage. But no, no, it's amazing advice. I appreciate it. Thank you so much for taking the time out to come on and talk about all the stuff you have going on. And is there a place where people can find you? If I don't know they have questions, websites, something like that.   1:08:07 Yeah, so finding and I've got a homepage at the University of South Australia they can find out about personal pain revolution is doing some good stuff on Annabelle, what we're doing that I I get a lot of emails and I just can't possibly respond to them.   1:08:26 We're not here to give out your your emails, or your personal phone number or anything but I think pain revolution, Oregon and the University of South Australia are great ways for people to find out a little bit more about you because as we said, before we get on the air you are not on social media. So there is no Twitter handles or Instagram or tic TOCs none of that stuff. None of that. So people can find you again, pain revolution.org or University of South Australia's website or you can just do a Google go to ResearchGate read all your papers. There's plenty of ways to find out more about your research and and what you have coming up. So plenty of ways to do that. So again, thank you so much for coming on. I appreciate it.   1:09:12 Oh, thanks so much for having me. You're a legend. Keep it up.   1:09:17 Thank you. Thank you so much and everyone. Have a great couple of days and stay healthy, wealthy and smart.

Welcome to this international party episode of The Pelvic Health Podcast.  Movers & Mentors is a new book by physiotherapists Tim Reynolds and Bryan Guzski featuring the thoughts and advice from leaders in physiotherapy and movement science - a book in which I was asked to contribute to along with absolutely brilliant names, including both Julie Wiebe and Sandy Hilton.  Tim Reynolds asked to interview me about some of my answers to very cool questions in this book and I thought it would be more fun to have Julie and Sandy join, and decided to make it even more international and exciting by inviting another brilliant physio - Biljana Kennaway. I hope you all enjoy!!!! Find the book HERE Bios via link on the names above :) Bios: Bryan Guzski PT, DPT, OCS, MBA, CSCS (couldn't party with us for this episode) is an outpatient orthopaedic physical therapist practicing in Rochester, NY working primarily with patients with spine related issues and persistent pain. Bryan earned his Doctor of Physical Therapy degree from Ithaca College in 2014, completed an orthopaedic residency program through Cayuga Medical Center in 2015 and received his Orthopaedic Clinical Specialist certification, and earned a Master of Business Administration degree from Simon Business School at the University of Rochester in 2021.    Tim Reynolds PT, DPT, OCS, CSCS is a Clinical Assistant Professor of Anatomy & Physiology at Ithaca College and a part-time physical therapist practicing at Cayuga Medical Center in Ithaca, NY where he predominately treats patients with spine or lower extremity impairments. Tim earned his Doctor of Physical Therapy degree from Ithaca College in 2014 and completed both his orthopaedic residency and spine fellowship through Cayuga Medical Center, and currently helps mentor and teach in both of these programs as well.     

On this episode we have Sandy Hilton she is a Physical Therapist out of Chicago who is the co-owner of Entropy Physiotherapy & Wellness. She is also an international instructor and speaker on treating pelvic pain for professionals. She is a regular contributor to physionetwork and is the co-host of the pain and sensibility podcast. We were pumped to have Sandy on the podcast to talk about all things pain. We dive into the BPS model, how we implement it, and if there is more we should be considering beyond the BPS model. This conversation was insightful and is a topic we are always looking to learn more about. You can listen to the episode on Spotify and Apple Podcasts. If you enjoy this episode could you please help us out by subscribing, dropping a review on iTunes, and sharing this episode with one other person. Your feedback and support mean the world to us! Sandy Hilton Twitter: https://twitter.com/SandyHiltonPT Website: https://entropy.physio/ Podcast: https://open.spotify.com/show/4cJ0NzTtDuETxKL0nBhavh?si=fWEcvQOrQESIZe8EdtJF1A&dl_branch=1 Physio Network *** To start your 7 day free trial click the link below*** https://www.physio-network.com/research-reviews/#a_aid=tmpts&a_bid=0942bcda Follow us! @themvmtpts Website: https://www.themovementphysio.ca/ Instagram: https://www.instagram.com/themvmtpts/ PTCOFFEECAST Join The Coffee Club: https://www.patreon.com/ptcoffeecast?fan_landing=true Instagram: https://www.instagram.com/ptcoffeecast/ Email : themovementpts@gmail.com Coffee Club Members Joe Rinaldi- Cafe Club

Sandy Hilton of Entropy Physiotherapy and Wellness in Chicago, IL joins the show today. In addition to treating patients and offering continuing ed courses at Entropy, she is also an international instructor and speaker on treating pelvic pain, and co-host of the Pain Science and Sensibility Podcast. Sandy was the Director of Programming for the Section on Women’s Health of the American Physical Therapy Association from 2012 - 2017. She is now on the board of the Abdominal and Pelvic Pain special interest group, a part of the International Association for the Study of Pain. In this episode she drops some gems on the pros and cons of running a cash practice, the importance of having a talented team around you, and some unique views on what "telehealth" appointments can look like. (**This interview was recorded in 2019 but was dug out of the archives after we realized we never shared this great information with our listeners!**) Sandy's Links: Follow Sandy on Twitter @SandyHiltonPT Website: Entropy.physioBook: Why Pelvic Pain Hurts

In this episode, Tim talks with the amazing Sandy Hilton about overcoming a pain in the butt, or the pelvic floor, or the low back. This is an educational Pelvic Pain episode full of information to help you walk away from pain and restore your health. To learn more about Sandy, or to consult with her, check her out here: Entropy Physio To learn from Sandy and attend her courses, check her out here: https://www.physio-network.com/masterclass/pelvic-pain-a-clinical-course-from-pain-to-pleasure/ Pelvic Health Solutions: https://pelvichealthsolutions.ca/about-us/our-team/sandy-hilton-instructor/ --- Support this podcast: https://anchor.fm/original-strength/support

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Dr. Sarah Haag to talk about exercise and urinary incontinence. This interview was part of the JOSPT Asks interview series. Sarah is the co-owner of Entropy Physiotherapy and Wellness in Chicago. Sarah was awarded the Certificate of Achievement in Pelvic Physical Therapy (CAPP) from the Section on Women’s Health. She went on to get her Doctorate of Physical Therapy and Masters of Science in Women’s Health from Rosalind Franklin University in 2008. In 2009 she was awarded a Board Certification as a specialist in women’s health (WCS). Sarah also completed a Certification in Mechanical Diagnosis Therapy from the Mckenzie Institute in 2010. In this episode, we discuss: The prevalence of urinary incontinence Is urinary incontinence normal Pelvic floor exercises Pelvic floor exam for the non-pelvic health PT Sports specific pelvic health dysfunction And much more Resources:  Entropy Physiotherapy and Wellness JOSPT Facebook Page JOSPT Journal Page  More Information about Dr. Haag:  Sarah graduated from Marquette University in 2002 with a Master’s of Physical Therapy. Sarah has pursued an interest in treating the spine, pelvis with a specialization in women’s and men’s health. Over the years, Sarah has seized every opportunity available to her in order to further her understanding of the human body, and the various ways it can seem to fall apart in order to sympathetically and efficiently facilitate a return to optimal function. Sarah was awarded the Certificate of Achievement in Pelvic Physical Therapy (CAPP) from the Section on Women’s Health. She went on to get her Doctorate of Physical Therapy and Masters of Science in Women’s Health from Rosalind Franklin University in 2008. In 2009 she was awarded a Board Certification as a specialist in women’s health (WCS). Sarah also completed a Certification in Mechanical Diagnosis Therapy from the Mckenzie Institute in 2010.  Sarah has completed a 200 hour Yoga Instructor Training Program, and is now a  Registered Yoga Teacher. Sarah looks at education, and a better understanding of the latest evidence in the field of physical therapy, as the best way to help people learn about their conditions, and to help people learn to take care of themselves throughout the life span. Read the full transcript below:  Read the Full Transcript below:  Speaker 1 (00:06:25): So, and hopefully it doesn't want to lose what we're doing here. We'll see. Okay. Going live now. Okay. Welcome everyone to JLS. PT asks hello and welcome to the listeners. This is Joe SPT asks the weekly chat where you, the audience get your questions answered. My name is Claire Arden. I'm the editor in chief of Joe SPT. And it's really great to be chatting with you this week, before we get to our guest. I'd like to say a big thanks for the terrific feedback that we've had since launching [inaudible] a week ago. We really appreciate your feedback. So please let us know if there's a guest that you'd like to hear from, or if you have some ideas for the show today, we're in for a very special treat because not only are we joined by dr. Sarah hake from entropy physio, but guest hosting [inaudible] asks today is dr. Karen Litzy who you might know from the healthy, wealthy and smart podcast. Dr. Lexi is also a new Yorker. And I think I can speak for many of us when I say that New York has been front of mind recently with the coronavirus pandemic. And I'd like to extend our very best wishes to everyone in New York where we're thinking of you. So I'm going to throw to Karen now. We're, I'm really looking forward to chat today on pelvic floor incontinence and exercise over to you, Karen. Speaker 1 (00:08:25): Hi everyone, Claire. Thank you so much. I really appreciate your giving me the opportunity to be part of J O S P T asks live stream. So I'm very excited about this and I'm also very excited to talk with dr. Sarah Hagar. Sarah is an educator, a clinician, and an author. She is also co-owner of entropy wellness and our physiotherapy and wellness in Chicago, Illinois, and is also a good Speaker 2 (00:08:56): Friend of mine. So it's really a an honor for me to be on here. So Sarah, welcome. Thank you so much. I was really excited that all this came together so beautifully. Yes. And, and again like Claire had mentioned, we're all experiencing some pretty unprecedented times at the moment. And the hope of these J O S P T asks live streams is to continue to create that sense of community among all of us, even though we can't be with each other in person, but we can at least do this virtually. And as Claire said, last week, we want to acknowledge our frontline healthcare workers and colleagues across the world for their dedication and care to those in need. And again, like Claire said before, a special shout out to my New York city colleagues, we are they are really working like no other. Speaker 2 (00:09:52): And I also want to acknowledge not just our healthcare colleagues and workers, but the scientists, the grocery store workers, the truck drivers the pharmacist, police, firefighter paramedics, they're all working at full capacity to keep the wheels turning around the world. So I just want to acknowledge them as well and thank them for all of their hard work during this time. Okay. So, like Claire said today, we're going to be talking about the pelvic floor, which is something Sarah loves to talk about because what I also, I also failed to mention is she is a certified pelvic health practitioner. So through the American physical therapy association. So she is perfectly positioned to take us through. And as a lot of, you know, we had, you had the opportunity to go onto Slido to ask questions. You can still do that. Even throughout this talk, just use the code pelvic that's P E L V I C, and ask some questions. Speaker 2 (00:10:57): So we do have a lot of questions. I don't know if we're going to get to all of them. So if we don't then certainly post them in the Facebook chat and maybe Sarah can find those questions in the chat below. And we'll try and get to those questions after the recording has finished. All right, Sarah. So like I said, lots of questions and the way the questions were, were written out, kind of corresponds quite well with maybe how you would see a patient in the clinic. So let's start with the patient comes into your clinic. They sit down in front of you. Let's talk about the words we would use in that initial evaluation. So I'll throw it over to you. Okay. So being a pelvic health therapist, obviously most people when they're coming to females, Things that happen in the pelvis, I like to acknowledge it, that there's a lot of things happening in the past. So I have Speaker 1 (00:11:54): Them tell me kind of what are the things that have been bothering them or what are the things that have been happening that indicate something might be going on? Like if something's hurting, if they're experiencing incontinence, any bowel issues, any sexual dysfunction. And, and I kind of go from there. So if the talk that's the title of the talk today includes incontinence. Continence is a super common issue that let's see in general might pop in. And if you would bother to ask there's actually, I think it's like one out of two people over 60 are experiencing incontinence of some kind. The answer is going to be yes, some, so you can start asking more questions. But starting out with what, what is bothering them is really what I like to start with. Then the next thing we need to know is after we vet that issue or that priority list of things that are bothering them in the pelvis, and it's not uncommon actually to have. Speaker 1 (00:13:00): So let's say they start with a discussion of incontinence. I still actually ask about sexual function, any pain issues, any bowel issues, just based on the innervation of the various, the anatomical arrangement of everything. It's not uncommon to have more than one issue, but those other issues might not be bothersome enough to mention. So it's kind of nice to get that full picture. Then the next thing we really want art. So there are times I've met women who come in and they're like, Oh yeah, you know, I have incontinence. And you're like, okay. So when did it start now? Like 25 years ago. Okay. Do you remember what happened then? Typically it was a baby, but sometimes these women will notice that their incontinence didn't happen to like four or five years after the baby. Hmm. So that's information, that's very help if they say my baby that was born six weeks ago, our interventions and expectations are going to be very different than someone who's been having incontinence for 25 years. Speaker 1 (00:14:05): So again, knowing how it started and when it happens, when the issues are happening, I just kind of let them, it's like a free text box on a form. Like just, they can tell me so much more excuse me. And when we are talking about things, we, I do talk anatomy. So when it comes to incontinence, I talk about the bladder and the detrusor, the smooth muscle around the bladder, the basically the hose that takes the urine from the bladder to the outside world. I do talk about the vagina and the vulva and the difference between the two. And then actually we do talk about like the anus and the anal sphincters and how all of that is is all there together and supported by the pelvic floor. Speaker 1 (00:14:54): Cause that's in physical therapy, it's going to be something with that pelvic floor or something. Drought, does it need to be more, more pelvic floor focused or does it need to be behaviorally focused, which is the case sometimes, or is it that kind of finding that perfect Venn diagram of both for those issues that the person's having? And let's say you're in a part of the world. One of the questions was what if you're I think this question came from Asia and they said, what if you're in part of the world where you have to be a little bit, maybe more sensitive around even the words that you use. I know we had gotten a question a couple of years ago about a woman in the Southern part of the United States that was from very conservative area. And do we even use these words with these patients? Speaker 1 (00:15:48): So what is your response to that? My response is that as healthcare providers, we are responsible, I think for educating people and using appropriate words and making sure people understand the anatomy like where things are and what they're supposed to be doing. However, definitely when I'm having this conversation with someone I want them to feel at ease. So like I will use the Ana vagina anus, anal sphincters Volvo, not, it's not a vagina, it's a Volvo it's on the outside. But then if they use different terms to refer to the anatomy, we're discussing, I'm happy to code, switch over to what they're most comfortable with because they need to be comfortable. But I think as, as again, healthcare practitioners, if we're not comfortable with the area, we're not going to make them feel very comfortable about discussing those issues. Right. Speaker 1 (00:16:43): And that makes a lot of sense. Thank you for that. So now let's say you, the person kind of told you what's going on and let's, let's talk about when you're taking the history for women with incontinence, especially after pregnancy, are there key questions you like to ask? Yes. So my, my gals that I'm seeing, especially when they're relatively relatively early in the postpartum period, are the things I'm interested in is did they experience this incontinence during their pregnancy? And did they have issues before pregnancy? And then also if this is not their first, tell me about the first birth or the, or the first two birth. So the first three birth to really get an idea of is this a new issue or is this kind of an ongoing marked by so kind of getting a bigger picture of it. Speaker 1 (00:17:49): And then also that most recent birth we want to know, was it vaginal? Was it C-section with vaginal birth? If there's instrumentation use, so if they needed to use forceps or a vacuum that increases the likelihood that the pelvic floor went over, went under a bit of trauma and possibly that resulted in a larger lab. And even if there isn't muscles, it's understandable that things might work well, if it's really small and if it's still healing you know, different, different things like that. So understanding the, kind of like the recent birth story, as well as their bladder story going back. So you've met first baby or before that first baby so that we know where, where we're starting from. And the, the reason why I do that is because again, if it's a longterm issue, we have to acknowledge the most recent event and also understand there was something else happening that, that we need to kind of look at. Speaker 1 (00:18:58): So would I expect it all to magically go away? No, I wouldn't. There's probably something else we need to figure out, but if it's like, Nope, this onset happened birth of my baby three months ago, it's been happening since then three months is, seems like forever and is also no time whatsoever. It took 10 months to make the baby. So it's you know, if you tear your hamstring, we're expecting you to start feeling better in three months, but you're probably not back to your peak performance. So where are we in that? And sometimes time will cure things. Things will continue to heal, but also that would be a time like how good are things working? Is there something else going on that maybe we could facilitate or have them reach continence a bit sooner. Okay, great. And do you also ask questions around if there was any trauma to the area? Speaker 1 (00:19:56): So if this birth was for example, the product of, of a rape or of some other type of trauma, is that a question that you ask or do you, is that something that you hope they bring up? It's, that's honestly for me and my practice, something, I try to leave all of the doors wide open for them to, to share that in my experience you know, I've worked places where it is on it's on the questionnaire that they fill out from the front desk and they'll circle no to, to any sort of trauma in the past. Speaker 1 (00:20:34): Yeah. They just, they don't want to circle yes. On that form. So and also I kind of treat everybody like they might have something in their past, right. So very nonjudgmental, very safe place, always making them as comfortable in a safe as possible. And I will say that there's anything I can do to make you feel more comfortable and more safe. We can do that. And if you don't feel safe and comfortable, we're not doing this w we're going to do something else. Cause you're right. That it's always one of those lingering things. And the statistics on abuse and, and rape are horrifying to the point where, again, in my practice, I kind of assume that everybody has the possibility of having something in their past. Okay, great. Thank you. And now another question that's shifting gears. Another question that came up that I think is definitely worthy of an answer is what outcome measures or tools might you use with with your incontinence patients? So with incontinence, honestly, my favorite is like an oldie buddy, but a goodie, like just, it's an IC, it's the international continents questionnaire where it's, I think it's five or six questions. Just simple. Like how often does this happen? When does it happen? Speaker 1 (00:21:58): There's a couple of other outcome measures that do cover, like your bladder is not empty. Are you having feelings of pressure in your lower abdomen? It gets into some bowel and more genital function. Can you repeat that? Cause it kind of froze up for a second. So could you repeat the name of that outcome tool as it relates to the bladder and output? Oh, sorry. I see. IQ is one and then, but like I see IQ vs which renal symptoms, right? So there are, there's a lot of different forms out there. Another one that will gather up information about a whole bunch of things in the pelvis is the pelvic floor distress bins questions about bowel function, bladder function, sexual function discomfort from pressure or pain. So that can give you a bigger picture. I'll be honest. Sometimes my, the people in my clinic they're coming in, and even though I will ask the questions about those things, when they get the, the questionnaire with all of these things that they're like, this doesn't apply to me. I'm like, well, that's great that it doesn't apply to you, but they don't love filling, filling it out. So sometimes what I will go with is actually just the pale. Speaker 1 (00:23:24): Can you say that again? Please help me. Oh yeah. Oh, so sorry. The patient's specific functional scale where, where the patient says, this is what I want to have happen. And we kind of figured out where they are talk about what would need to happen to get them there, but it's them telling what better. Right. Cause I've had people actually score perfect on some of these outcome measures, but they're still in my office. So it's like, Oh, I'm so patient specific is one of my one of my kind of go tos. And then there's actually a couple of, most of these pelvic questionnaires finding one that you like is really helpful because, because there's so many and they really all or discomfort. So if you have a really good ability to take a really good history, some of the questions on that outcome measure end up being a bit redundant. Speaker 1 (00:24:26): So I like, and you know the questions on there, make sure people are filling them out. You look at them before you ask them all the questions that they just filled out on the form for you. Yes. Good. Very good advice. So then the patient doesn't feel like they're just being piled on with question after question and cause that can make people feel uncomfortable when maybe they're already a little uncomfortable coming to see someone for, for whatever their problem or dysfunction is. So that's a really good point. And now here's a question that came up a couple of times, you know, we're talking about incontinence, we're talking about women, we're talking about pregnancy. What about men? So is this pelvic floor dysfunction? Is this incontinence a women only problem? Or can it be an everybody problem? So it very much can be an everybody problem. Incontinence in particular for men, the rates for that are much lower. And typically the men are either much older or they are they've undergone frustrate removal for prostate cancer. Speaker 1 (00:25:33): Fleur plays a role in getting them to be dry or at least dryer. And then it's like the pelvic floor is not working right. That can result in pain. It can result in constipation. It can result in sexual dysfunction. It can result in bladder issues. So it's, so yes, men can have all of those things. In fact, last night we had a great talk in our mentorship group at entropy about hard flacid syndrome. So this is a syndrome with men where everything is normal when they go get, get tested, no no infections, no cancers, no tumors, no trauma that they can recall. And, but the penis is not able to become functional and direct. And with a lot of these men, we're finding that it's more of a pelvic floor dysfunction issue, or at least they respond to pelvic floor interventions. Speaker 1 (00:26:30): So having a pelvic floor that does what it's supposed to, which is contract and relax and help you do the things you want to do. If, if we can help people make sure that they're doing that can resolve a lot of issues and because men have pelvic floors, they can sometimes have pelvic floor dysfunction. Okay, great. Yeah. That was a very popular question. Is this a woman only thing? So thank you for clearing up that mystery for everyone. Okay. So in going through your evaluation, you've, you've asked all your questions, you're getting ready for your objective exam. What do you do if you're a clinician who does not do internal work, is there a way to test these pelvic floor muscles and to do things without having to do internal work? My answer for that question is yes, there are things that you can do because even though I do do internal exams, I have people who come to see me who are like, no, we're not doing that. Speaker 1 (00:27:31): So, so where can we start? And so the first one is pants on and me not even touching you pelvic floor, I wouldn't really call it an assessment or self report. So even just sitting here, if you, if you were to call me up and and this actually goes into, I think another question that was on Slido about pelvic floor cues. So there is actually then it seems more research on how to get a mail to contract this pelvic floor then actually females. But I would ask you like like this is one that my friend Julie, we would use. So like if you're sitting there and you just sit up nice and tall, if you pretend you're trying to pick up a Ruby with your PA with your vagina is not on the outside, but imagine like there's just a Ruby on the chair and you'd like to pick it up with no hands, breathe in and breathe out and let it go. So then I would go, did you feel anything and you should have felt something happen or not. So if, if you did it, would you mind telling me what you built? You're asking me, Oh my goodness. Oh yes. I did feel something. So I did feel like I could pick the Ruby up and hold it and drop it. Speaker 1 (00:29:04): Excellent. And that's, and that, that drop is key. Excellent. So what I would say is this is like like a plus, like a, I can't confirm or deny you that you did it correctly, but I like, I would have watched you hold your, like she holding my breath. Is she getting taller? Cause she's using her glutes. Did she just do a crunch? When she tried to do this, I can see external things happening that would indicate you're might be working too hard or you might be doing something completely wrong. So then we'll get into, I mean, you said, yes. I felt like I pick up the Ruby, but if it's like, Hmm, I felt stuffed, but I'm not really sure we would use our words because they've already said no to hands to figure that out. But again, I can't confirm it. People are they're okay with that. Speaker 1 (00:29:48): And I'm like, and if what we're doing based on the information you gave me, isn't changing, we might go to step two. If you can send in step two is actually something, any orthopedic therapist honestly, should not feel too crazy doing. So if anyone has ever palpated the origin of the hamstring, so where is the origin of the hamstring facial tuberosity? If you go just medial to that along the inside part get, don't go square in the middle. That's where everyone gets a little nervous and a little tense, but if you just Pell paid around that issue, tuberosity it's pretty awesome. If you have a, a friend or a colleague who's willing to let this happen is you ask them to do a poll of our different cues with that in a little bit. You say that again, ask them to do what to contract the pelvic floor. Speaker 1 (00:30:44): Okay. And again, figuring out the right words so that they know what you're talking about. We can talk about that in a minute, but if they do a pelvic floor contraction, you're going to feel kind of like the bulging tension build, right there may be pushing your fingers. You should feel it kind of gather under your fingers. It shouldn't like push your fingers away, but then you can be like, well, you could test their hamstring and see that you're not on the hamstring and you can have them squeeze your glutes and you can kind of feel the differences. The pelvic floor is just there at the bottom of the pelvis. So you can palpate externally, even through BlueJeans is a bit of a challenge, but if they're in you know, like their workout shorts for yoga pants, it's actually very, very simple. And, and honestly, as long as you explained to them what you're doing and what you're checking for, it's no different than palpating the issue of tuberosity for any other reason. Speaker 1 (00:31:36): And with that, I tell them that I can, it's more like a plus minus, so I can tell that you contracted and that you let go. That's all I can tell. So I can't tell you how strong you are, how good your relaxation Wells, how long you could hold it for any of those things. And then I tell them with an internal exam, we would get a lot of information we could, we can test left to, right? We can, I could give you more of like a muscle grade. So like that zero to five scale be use for other muscles. We can use that for the pelvic floor. I can get a much better sense of your relaxation and see how was that going and I can even offer some assistance. So so we have two really good options for no touching. Speaker 1 (00:32:19): And then just as long as we understand the information we might gain from an internal exam, we can, we can, the information we gathered from the first two ways, isn't sufficient to make a change for them. And then as let's say, the non pelvic health therapist, which there might be several who are gonna watch this, when do we say, you know, something? I think it's time that we refer you to a pelvic health therapist, because I do think given what you've said to me and you know, maybe we did step one and two here of your exams. I think that you need a little bit more. So when do, when is that decision made to reach the point of, they have a bother that I don't know how to address so we can actually go to like the pelvic organ prolapse. So pelvic organ prolapse is, is when the support for either the bladder, the uterus, or even the rectum starts to be less supportive and things can kind of start to fall into the vaginal wall and can give a feeling of like pressure in with activity the sensation can get. Speaker 1 (00:33:39): So then we have two options, which is more support from below with perhaps a stronger meatier pelvic floor by like working it out to hypertrophy. So like if, if I had someone who had that feeling when they were running and we tried a couple are lifting weights, let's go lifting weights. No, like I feel it once I get to like a 200 pound deadlift. Okay, well, let's see how you're lifting when you're doing 150 and let's take a look at what you're doing at 200 in fresh with your mechanics or what's happening. And if there's something that is in your wheelhouse where you're like, well, can you try this breath? Or can you try it this way and see if that feeling goes away? I'm good with that. And if the, that the person who's having issue is good with that. Awesome. But if you're trying stuff or the incontinence is not changing, send them to a pelvic floor therapist, because what we love to do is we can check it out. Speaker 1 (00:34:41): We're going to check it out. We're going to give some suggestions. And then my, the end of every one of those visits that I get from my, from my orthopedic or sports colleagues is I'm like, excellent. So you're going to work on this, keep doing what you're doing. Cause another really common thing is like, is I don't really believe that they can make a lot of these things worse doing the things that they're doing. And by that, I mean, they can become more simple MADEC, but in many cases you're not actually making the situation worse. So if the symptoms seem to be not getting better or even getting worse, doing the things they're doing, they go come back to the pelvic floor therapist. And then that pelvic floor therapist also has a responsibility that the things I'm asking them to do, isn't helping them get there. Speaker 1 (00:35:29): You can try something a little more intense, still not helping. Then that's when I actually would refer for females, especially with like pelvic pressure. So Euro gynecologist for an assessment in that regard. Yeah. So I think I heard a couple of really important things there. And that's one, if you are the sports therapist or the orthopedic physiotherapist, and you have someone that needs pelvic health support, you can refer them to the pelvic health therapist and you can continue seeing them doing the things you're doing. So just because they're having incontinence or they're having some pressure, let's say it's a pelvis, pelvic organ prolapse. It doesn't mean stop doing everything you're doing. Speaker 3 (00:36:12): Okay. Speaker 1 (00:36:15): Correct. Okay. Yeah. It may mean modify what you're doing. Stop some of what you're doing, listen to the pelvic floor therapist. And I'm also seeing, well now we're, aren't we this great cause we're creating great team around this, around this person to help support them in their goals. So one doesn't negate the other. Absolutely correct. And I, and I think too often even, even within the PT world is people start to get kind of territorial. But it's not about what each one of us is doing. It's that person. Right. so telling them to stop doing something, especially if it's something they love it seems like a bad start. It's like, okay, let's take a look at this. Tell me what you are doing. Tell me what you want to be doing. Tell me what's happening when you do that. And let's see if we can change it. Speaker 1 (00:37:02): Cause like I said, like the, the other, that being something they're going to make worse and worse and worse is if symptoms get worse and worse and worse, but they're not causing damage, they're not causing, I mean, what they're doing and say leaking a bit. Got it. And now I'm going to take a slight detour here because you had mentioned pelvic organ prolapse. You had mentioned, there comes a time when, if that pressure is not relieving, you've tried a lot of different things. You would refer them to a urogynecologist now several years ago. They're so you're, you're a gynecologist. One of their treatments might be surgery. So there was pelvic mesh sweats. It's hard to say pelvic mesh surgery that years ago made some people better and made some people far, far worse with, with some very serious ramifications. So can you talk about that pelvic mesh mesh surgery and where we are now? Speaker 1 (00:38:04): Oh, the last bit cut out a little bit. So the pelvic mess, mess surgery and, and Oh, the most important part and kind of where we are now versus maybe where we were, let's say a decade ago or so. Awesome. Yeah. So, so the pelvic mesh situation certainly here, I think it's not a universal problem. I think it's a United States problem is if you're at home during the day, like most of us are now you will see law commercials, lawyers looking for your business to discuss the mesh situation on what's happening is there was there were, it was mesh erosion and the resulting fact that that was a lot of pain because they couldn't just take it all out. And it was several women suffered and are still sad. Speaker 3 (00:38:55): Mmm. Speaker 1 (00:38:55): But that was from a particular type of surgery with a particular type of surgical kit, which thankfully has, was removed completely from the market and isn't being used anymore and mesh surgeries, I would say at least for the last five to 10 years, haven't haven't been using that and mesh surgeries are being done with great success in resolving symptoms. So I think it's important that if a woman isn't responding Speaker 3 (00:39:27): Yeah. Speaker 1 (00:39:30): Well changing their breath or making a pelvic floor or changing how they're doing things is to have that discussion with the Euro gynecologist because they do have nonsurgical options for super mild prolapse. There are some even like over the counter options you can buy like poise has one where it's just a little bit of support that helps you. Actually not leak because if you're having too much movement of the urethra, it can cause stress or it can be contributing to stress incontinence. But so there's some over the counter things or there's something called a pessary, which I think about it. Like I'm like a tent pole, but it's not a pole. It's a circle don't worry or a square or a donut. There's so many different shapes, but it's basically something you put in the vagina and that you can take out of the vagina that just kind of holds everything back up where it belongs, so it can work better. Speaker 1 (00:40:21): And that it's not awesome. But there are also people who are like due to hand dexterity, or just due to a general discomfort with the idea of putting things in their vagina and living them there that they're like, no, I'd rather just have this be fixed. So, so there are, it's not just surgery is not your only option. There are lots of options and it just depends on where you want to go. But with the surgery, if that's what's being recommended for a woman, I really do. Some women aren't worried at all. They've heard about the mash, but they're sure it won't happen to them, but there are when we're still avoiding surgery, even with significant syndromes, because they're worried about the mesh situation. And I would still encourage those women to at least discuss us, to see if that surgeon can, can educate them and give them enough confidence before they move forward with the surgery. Speaker 1 (00:41:18): Because the worst thing I think is when I had one patient actually put it off for years. Not, not just because of the mesh because of a lot of issues, but the first time the doctor recommended it, she had a grade four prolapse. Like that means when things come all the way out. And she it was so bad. Like she couldn't use the pastory okay, so she needed it, but she avoided it until she was ready and had the answers that made her feel confident in that having the surgery was the right thing to do. So it might take some time and the doctor, the surgeon really should, and most of them that I've met are more than happy to make sure that the patient has all the information they need and understand the risk factors, the potential benefits before they move forward. Speaker 2 (00:42:03): Excellent. Thank you so much for that indulging that slight detour. Okay. Let's get into intervention. So there are lots of questions on Slido about it, about different kinds of interventions. And so let's start with lot of, lot of questions about transverse abdominis activation. So there is one question here from Shan. Tall said studies in patients with specific low back pain do not recommend adding transverse abdominis activation because of protective muscle spasm. What about urinary incontinence in combination? What do you do? So there is a lot on transfer subdominant as you saw in Slido. So I'll throw it over to you and, and you can give us all your share your knowledge. Speaker 1 (00:42:55): Okay, well, let's all do this together. So I don't know how many people are watching, but if we just sit up nice and tall and I'm going to give a different cue for the pelvic floor. So what I want you to squeeze, like you don't want to urinate, like you want to stop the stream of urine. Okay. So as we're pulling that in anything else other than the underneath contract, what did you feel Karen? Speaker 2 (00:43:24): Well, I did feel my TA contract. I felt that lower abdominal muscle wall started to pull in. Speaker 1 (00:43:32): Yes. So, so the, the way I explain it is that the pelvic floor and the trans versus are the best is to friends. And this makes sense when you think about when you remember the fact that the pelvic floor, isn't just there regarding like bowel bladder and sexual function. It's one of our posture muscles. So if we're totally like, like slacked out and our abs are off and all of that, our pelvic floor is pretty turned off as well. And then if I get a little bit taller and like, so I'm not really clenching anything. Right. But this is like stuff working like it should, my pelvic floor is a little more on, but not, I'm not acting. It's just but then I could like, right, if I'm gonna, if I'm expecting to hit, or if I'm going to push into something, I can tend to set up more and handle more force into the system. Speaker 1 (00:44:21): So I like to think about it in those in those three ways, because the pelvic floor, isn't just hanging out, down there and complete isolation it's, it's part of a system. And so in my personal, like emotional approach to interventions is I don't want them to be too complicated. So if I can get someone to contract their pelvic floor, continue to breathe and let go of that pelvic floor, then we start thinking about what else are you feeling? Cause I don't know that there's any evidence that says if I just work my transverses all the time, my pelvic floor will automatically come along for the ride. So a great quote. I heard Karrie both speak once at a combined sections meeting and she goes, your biceps turn on. When you take a walk, it's not a good bicep exercise. So just the fact we're getting activity in the pelvic floor when we're working other muscles, what's supposed to work. And also if you want to strengthen that muscle, you're going to need to work out that muscle. Speaker 1 (00:45:26): And that makes a lot of sense and something that people had a lot of questions around where we're kind of queuing for these different exercises. And I really love the can. You've made it several times comparisons to other muscles in the body. So can you talk about maybe what kind of queuing you might use to have someone on? I can't believe I'm going to say this turn on and I use that in quotes because that's what you see in, in a lot of like mainstream publications for, for layman. So it might be something that our patients may see when they come in. So how do you cue that? To, to turn on the pelvic floor? So honestly I will usually start with floor and I do if I'm able to do a public floor exam, that's usually, again, a lot more information for me, but I'm like, okay, so do that now. Speaker 1 (00:46:27): And I watched them do it or I feel them do it and I'd be like, Oh, okay. What did you, what did you feel move? And I start there. And then I always say it's a little bit, like I get dropped into a country and I'm not sure what language people are speaking. So sometimes excuse me, one of the first cues that I learned was like, so squeeze, like you don't want to pass gas. Okay. So everybody let's try that. So sitting squeeze, like you don't care and you got taller. So I think you did some glutes. Speaker 1 (00:47:00): It's like, OK. So like lift, lift your anal sphincter up and in, but activating mostly the back part. So if you're having fecal issues, maybe that's a good place to start, but most people are having issues a little further front. So then we moved to the, can you pick a upper with your, with your Lavia? I had a, I learned the best things for my patients. One woman said it's like, I'm shutting the church doors. So if you imagine the Lavia being churched doors, we're going to close them up. And that, that gives a slightly different feeling. Them then squeezing the anal sphincter. Now, if you get up to squeeze, like you don't want to like pee your pants, like you want to stop the stream of urine. That will activate more in the front of the pelvis. Look, men who are like if it gets stopped the flow of urine, I wouldn't be here. Speaker 1 (00:47:57): So what else do you get? What's really cool is in the male literature. So this is a study done by Paul Hodges is he found that what activated the anterior part and the urinary sphincter, this rioted urinary speaker, sphincter the most for men. What a penis or pull your penis in to your body now for women. So when I was at a chorus and it's like, so let's, let's think of like other cues and other words, but even if, so, I don't have a penis this fall that probably don't have a penis. Even if you don't have a penis, I want you to do that in your brain, shorten the penis and pull it in. Speaker 1 (00:48:42): And did you feel anything happen? Cause we do have things that are now analogous to the male penis, if you are are a female. So I'll sometimes use that. Like I know it sounds stupid, but pretend to draw on your penis and it works and it does feel more anterior for a lot of people. So I'll kind of just, I'll kind of see what's, like I said, sometimes it's like the 42nd way of doing it that I've asked them to do where they're like, Oh, that, and you're like yeah. So then also just another, it's a little bit of like a little bit of a tangent, but so as you're sitting, so if you're, if you're sitting I want you to pick the cue that speaks most to your pelvic floor, and I want you to slouch really, really slouch, and actually to give yourself that cue and just pay attention to what you're feeling. So when you squeeze, give yourself that cue, breathe in and breath out and then let go, we should have felt a contraction, a little hole and a let go. Now, the reason why I say breathe in and breathe out is if you breathe in and out, that's about five seconds and also you were breathing. Cause another thing people love to do when they're trying to contract their pelvic floors, just basically suck it in. Speaker 1 (00:50:10): And so that's, that's not great, but we want to feel the contraction and we want to feel it, let go. And that's super important. I think that was another question on the Slido is that yes. For any muscle we're working, you should be able to contract it and let it go. There's not a muscle in our body where I just keep it contracted. It's going to do much. It might look great. Eventually, but like I couldn't get my coat on, like getting a drink of water would be a little weird. It's not very functional muscles have to relax so that they can contract. So that's a big, yes, it's just as important that the contraction pelvic floor that cue and we felt where it happened, not tall, like, like you're sitting out at a restaurant and you just saw someone looking at you and you're like, Oh, what are they looking at? And then you're going to do the exact same cue and you're gonna breathe in and breathe out and let it go. Speaker 1 (00:51:07): And then did it feel different than menu or slouch that it did it change position? I feel like Karen's Miami. It feels different. Now what I want you to do is if you can, depending on how you're sitting really give me like an anterior pelvic tilt, really happy puppy and then do the exact same thing and then let it go. And so again, some more EMG work from, from Paul Hodges is that when you're in a posterior pelvic tilt, you tend to activate the posterior portion more, which is fine. And if you're not having problems in the front, if you're having problems activating and maintaining continence in the front, actually increasing that lordosis can favor the front a bit. So this is, that's really awesome when people can feel that difference. Because I want you to think about, if you start to leak on your fourth mile of a half marathon, there's no way, no matter how awesome you are, but you're going to be able to squeeze your pelvic floor for the rest of that race. Speaker 1 (00:52:15): Like there's just, there's no way. But sometimes if, because remember your pelvic floor is still doing its thing while you're running is if you're like, well, hold on, when you're at your fourth mile, are you starting to get tired or hopefully not if it's a half marathon, but you know, like is something changing and how you're using your body. And can you, when you get to that point, remember to stay tall or lift your tail a little bit, or is there a cue or something they can change that will help them favor the front instead of going about four steps with the contracted pelvic floor and then losing it anyway. So there's, there's a lot of different ways you can actually make that your intervention for the issue you're having and then let's just get it functional. Perfect. And since you brought up running a question that's been, got, gotten a couple of likes on Slido is how would you approach return to running after pregnancy? Speaker 1 (00:53:15): Do you have any tips on criteria for progress, timeframe and a recreational runner versus a full time athlete? Because I would think the majority of physiotherapists around the world are seeing the recreational runner versus the professional or full time athlete. So first, how would you approach return to running any tips for progress? So that's going to be after pregnancy, sorry. After pregnancy. Yeah. So this is where I was really excited. So just last year I'm going to say her name wrong, but Tom goom Gran Donnely and Emma Brockwell published returned to running postnatal guidelines for health professionals managing this population. And the reason why I was super excited is because even though it was just published last year, it's the first one. There was definitely a lot of emotion and feelings about, about women getting back into sport after having a baby, but to be perfectly Frank, there's very few actual solid guidelines for recreational or others. Speaker 1 (00:54:30): So I have not personally had a child, but I will tell you of all the women I've seen over the years, basically doctors are like, it's been six weeks ease back into it, see how it goes. I'm not really even mentioning if you have a problem come back so we can figure it out. It's just kind of like good luck with that. And as a result, what happens is a lot of women don't get back into exercise or they get back into exercise and and kind of freak themselves out because stuff feels different. So to get back to the question of what do I do, actually this this guide from Tom and team really, really helpful. I think, and, and it's just basically it's it does have a series of exercises that I've actually started to use with my postpartum moms to go like, look, if you can do these things without feeling heaviness, you're good. Speaker 1 (00:55:30): You're good to start easing back into your running program, but get up, get walking because I'm going to post Sandy Hilton and like, you can't rest this better, like just waiting, isn't going to make it all go away. But it can also be deceiving because again, with polo, you don't feel that heaviness and you don't leak. And so I'm just going to stay right here where everything is fine. So that's obviously not a good option longterm option for a lot of reasons. So, so what do I do? I do look at the patient's goals, their previous running history, and if they're having any options I recently had a patient who she was runner exercise or sr after baby number two for a bit, some feeling of happiness that got completely better, baby number three came along. So I saw her a bit while she was pregnant because she got, I think two thirds of the way through pregnancy before she started to feel that heaviness. Again, she was still running, Speaker 1 (00:56:38): Tried to see if we could change that feeling while she was running. And she could until about the, when did she start? I think she didn't stop running to her 35th week, which is pretty impressive. But then she wanted to do a half marathon. I think it was just three months postpartum. Right. So this is like going from having baby to running 13. You think that a lot of people would probably feel that was too soon, too much too fast, but she was able to do it completely symptom-free. So as she was training and she was really fast, she was timing it so that she could get back in time to breastfeed. Like I was like, Oh my gosh, like I, that would disqualify me. Like, there's no way I could run fast enough to make that happen. But she was able to, to work it out where she could perform at her level without symptoms. And I was really happy that I was able to support her in that she did all the hard work. For general people recreational, where you a runner before, or is this completely new and are you having any symptoms and is there any thing you're worried about? Again, a lot of women are worried about giving. Speaker 1 (00:57:53): It's actually really hard to perhaps to give yourself one baby babies are a great way to do it. But that's like the risk factors I look up for something else a couple of years ago, I haven't looked recently, but like you really have any prolonged lifting. So not like your CrossFit three days a week, but like your, your physical labor for eight, eight hours, 10 hours a day every day could eventually do it also having babies. So like once you get to every baby increases your risk of pelvic organ prolapse, which makes good sense. And that, and that is what it is. So kind of looking at what are their risk factors, are there any, and letting them know that if they feel it more, it doesn't mean they made it worse. They just made it more symptomatic. Got it. Great. Speaker 1 (00:58:40): All right. So we have time for maybe one or two more questions, and then I'm going to throw back to Claire. Cause we're coming up onto an hour here, maybe time for one more it's so w what am I going to ask? I think I'm going to go with the gymnasts I work with all believe it's normal to leak a little urine during training or competition. And this is something we talk about a lot. It might be common, but is it normal? You already gave me the answer. What is it, Karen? No, no, no. And so, yeah, so the, the short answer for that is no. Or I agree with the question where it is very, very, very common, and it is still, I would say, not to leak urine. Unfortunately, so there's any researchers out there who want to get together. Speaker 1 (00:59:26): Let me know. We haven't, we have information on athletes and incontinence, but mostly it's prevalent that it happens a lot and gymnastics and dancing and volleyball. There's, there's even some swimmers who have it, right? So there's, there's incontinence across the spectrum, which basically tells me, yep. People have incontinence. Some of the some of the sports are more likely to have urgent continents. A lot of them though, we're looking at stress incontinence, however, for none of the athletes, have, we really had a great study that says, this is what we're finding. We're thinking, this is the cause of this incontinence. And we certainly haven't gotten to the point where it's like, and this is what we should be doing for these women in particular. So I'm, I'm pretty curious as to what we would have to do as, as a profession, as, as a team with researchers to figure out what do we need to look at in these athletes, especially the female athletes, because most of these are also they've never had babies, right? So a lot of these athletes are the liberos. And so we can't, we can't blame them. There's something with how things are working. That seemed to be the situation it's not necessarily trauma or anything like that. So what do we need to look at? What do we think is happening? Can we measure it and assess it? And then can we get an intervention? Speaker 1 (01:00:56): My brain, obviously, something isn't working as well as it could. So could something like that improve their performance, even I don't, I don't know. I'd like to think so. Yeah. That would be distinct study. Yeah. But we ultimately don't know. So if anyone has any ideas for studies or doing studies, let me know, because I can't wait to read them. But I think maybe the first step is to let coaches and parents and young gymnast know very common. Don't be ashamed. Don't let it stop you from doing what you want to do. But also don't just ignore it. Maybe we can figure this out. Speaker 2 (01:01:30): All right. One more question with a short answer, if you can. So, and I'm going to ask this question because I feel like the person who posted this I think posted this in earnest. So that's why I'm asking, this is the last question. So a female patient age, 20 years still bedwetting from her childhood, otherwise she is normal, no incontinence. So other than this, just while sleeping, she tends to urinate any thoughts on this or any place you can direct this. Speaker 1 (01:02:04): Yeah. So I did, I was like, Oh, great question. And I did actually do a little research for this specific question. There's a lot of reasons why nocturnal enuresis, which is what bedwetting is called in the literature happens. And I think it's really important. So I don't know what kind of tests or studies this person has had done or what other issues they may be having. So things like sleep apnea is is something that could be related if there's any medications, any sort of diuretics, any kind of sleeping medications. Again, the fact it's kind of carried on since childhood, I, I would really wonder about how, how is the bladder functioning? The fact that it's working fine throughout the day makes me wonder what's changing at night. And I did find a study where it talked about when they look compared adolescents or adults who were bedwetting to people who weren't, they did have like detrusor overactivity. So like basically like an overactive bladder that they could see on the testing. So I would, I would really encourage this person to find a urologist that they trust if they haven't already and really to maybe investigate some of those other, other factors that could be contributing so that they can get some better sleep and not have that problem anymore. Speaker 2 (01:03:28): Excellent. Excellent. Oh, okay. Claire says we can go for one more question. So I'm going to listen to the boss here. Speaker 1 (01:03:36): And, Oh boy, are you ready? Because this is a question that did kind of get a lot of thumbs up. Okay. So we spoke about Speaker 2 (01:03:44): Briefly before we started. Speaker 1 (01:03:47): So let's see treatment of nonspecific, pelvic girdle pain, not related to pregnancy, which strategy with no susceptive pain mechanisms and which strategy with non nociceptive pain mechanisms would you incorporate with this patient? Okay. So I would say in the clinic, it's, it can be pretty hard. Like, I don't know how I would distinguish being nociceptive and non nociceptive or what even like non nociceptive might be if we're talking more central issues or stuff like that. I don't, I don't know. But honestly I would just look at, so in Kathleen's Luca has a great book about looking at the different types of pain or the different categories of pain and the most effective medications for it. Right. So we're really good in pharmacology. Like if you had this inflammatory process and, and inflammatory and anti-inflammatory should help, if you're having neuropathic pain, you want a drug that addresses that when we get into like physical therapy interventions, what's really cool is exercise is in all the categories. Speaker 1 (01:04:59): And it's one of the things we have the best evidence for. So regardless of pelvic girdle pain in pregnancy or not pregnancy, and regardless of how it may have been labeled by somebody else is I would, I would mostly want to know when did the pain start? Is there anything that makes it better? Anything that makes it worse and see if I could find a movement or change something for that person. Or that made me sound like I was going to do a whole lot of work. If I could find something for that person to change for themselves to have that hurt less and have the I tend, I would tend to keep it simple, mostly cause in the clinic again, we could do a lot of special tests that might say, Oh, Nope, they definitely hurt there, but it's still, if we're looking at what's going to be an effective intervention, that that patient is going to tell me what that is. Speaker 1 (01:05:54): Sorry. It would help a fire mute myself. So looks like we have time for one more. And I, I really, Claire was not clarity did not pop up yet. So we've got time for one more and then we're going to work. We're wrapping it up. I promise stroke patients, dementia patient. We just got the no go. Yes, no, it's a super short answer if you want Claire super short answer. Okay. So stroke dementia patients with urinary incontinence, any useful ideas for the rehab program? Yes, but not get an idea of their bladder habits, their bowel habits, their fluid intake. Because a lot of that's going to end up being outside caregiver help with the, with the stroke, it's much different. It depends on the severity and where it is and all of that. But for people with dementia is if you just get that, like if you can prompt them or take them to the toilet, a lot of the times that will take care of the incontinence. Speaker 1 (01:06:48): It's not a matter of like Cagle exercises. It's more management. All right, Sarah, thank you so much. I'm going to throw it back over to Claire to wrap things up. Thank you both for a wonderful and insightful discussion. Sarah and Karen. So many practical tips and pointers for the clinician, especially I was loving learning about all of the things that I could take to the clinic. So I hope our audience find those practical tips really helpful as always the link to this live chat will stay up on our Facebook page and we'll share it across our other social media channels. Don't forget. You can also follow us on Twitter. We're at Dow SPT. You can also follow us here on Facebook. Please share this chat with your friends, with family colleagues, anyone who you think might find it helpful. And if you like JSP T asks, please be sure to tell people about it at that what we're doing so they can find this here, please join us. Speaker 1 (01:07:46): Next week when we host our special guest professor Laurie from the university of Southern California, Larry is going to be answering questions on managing shoulder pain. We'll be here, live on Wednesday next week. So Wednesday, April the eighth at 9:00 AM Pacific. So that's noon. If you're on the East coast of the U S it's 5:00 PM. If you're in the UK and at 6:00 PM, if you're in Europe, before we sign off for the evening, there's also really important campaign that I'd like to draw your attention to. And it's one that we at Joe SPT supporting and it's get us PPE. So we're supporting this organization in their quest to buy as much a, to buy much needed personal protective equipment for frontline health workers who are helping us all in the fight against the coronavirus pandemic. So if you'd like to support, get us PPE, please visit their website, www dot, get us ppe.org, G E T U S P p.org as always. Thanks so much for joining us on this stale SPT asks live chat, and we'll speak to you next week. Bye. Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram  and facebook to stay updated on all of the latest!  Show your support for the show by leaving a rating and review on Apple Podcasts!

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Sandy Hilton, David Butler and Bronnie Thompson on the show to discuss persistent pain during COVID-19.  In this episode, we discuss: -Shifting current healthcare curriculum to better educate clinicians on persistent pain -Can passive modalities empower people to pursue more active treatment options? -How to create more SIMS during the COVID-19 pandemic -Can telehealth appointments adequately address persistent pain? -And so much more!   Resources: International Association for the Study of Pain Website Factfulness Book David Butler Twitter Sandy Hilton Twitter Bronnie Thompson Twitter   A big thank you to Net Health for sponsoring this episode!  Learn more about Four Ways That Outpatient Therapy Providers Can Increase Patient Engagement in 2020!                                                                      For more information Bronnie: I trained as an occupational therapist, and graduated in 1984. Since then I’ve continued study at postgraduate level and my papers have included business skills, ergonomics, mental health therapies, and psychology. I completed by Masters in Psychology in 1999, and started my PhD in 2007. I’ve now finished my thesis (yay!) and can call myself Dr, or as my kids call me, Dr Mum.   I have a passion to help people experiencing chronic health problems achieve their potential. I have worked in the field of chronic pain management, helping people develop ‘self management’ skills for 20 years. Many of the skills are directly applicable to people with other health conditions.   My way of working: collaboratively – all people have limitations and vulnerabilities – as well as strengths and potential. I use a cognitive and behavioural approach – therapy isn’t helpful unless there are visible changes! I don’t use this approach exclusively, because it is necessary to ‘borrow’ at times from other approaches, but I encourage ongoing evaluation of everything that is put forward as ‘therapy’. I’m especially drawn to what’s known as third wave CBT, things like mindfulness, ACT (Acceptance and Commitment Therapy) and occupation.   I’m also an educator. I take this role very seriously – it is as important to health care as research and clinical skill. I offer an active knowledge of the latest research, integrated with current clinical practice, and communicated to clinicians working directly with people experiencing chronic ill health. I’m a Senior Lecturer in the Department of Orthopaedic surgery & Musculoskeletal Medicine at the University of Otago Christchurch Health Sciences.   I also offer courses, training and supervision for therapists working with people experiencing chronic ill health.   For more information Sandy: Sandy graduated from Pacific University (Oregon) in 1988 with a Master of Science in Physical Therapy and a Doctor of Physical Therapy degree from Des Moines University in December 2013. She has worked in multiple settings across the US with neurologic and orthopaedic emphasis combining these with a focus in pelvic rehabilitation for pain and dysfunction since 1995. Sandy teaches Health Professionals and Community Education classes on returning to function following back and pelvic pain, has assisted with Myofascial Release education, and co-teaches Advanced Level Male Pelvic Floor Evaluation and Treatment. Sandy’s clinical interest is chronic pain with a particular interest in complex pelvic pain disorders for men and women. Sandy is the co-host of Pain Science and Sensibility, a podcast on the application of research into the clinic.   For more information on David: Understanding and Explaining Pain are David’s passions, and he has a reputation for being able to talk about pain sciences in a way that everyone can understand. David is a physiotherapist, an educationalist, researcher and clinician. He pioneered the establishment of NOI in the early 1990’s. David is an Adjunct Associate Professor at the University of South Australia and an honoured lifetime member of the Australian Physiotherapy Association.   Among many publications, his texts include Mobilisation of the Nervous System 1991 The Sensitive Nervous System (2000), and with Lorimer Moseley –  Explain Pain (2003, 2013), The Graded Motor Imagery Handbook (2012), The Explain Pain Handbook: Protectometer (2015) and in 2017, Explain Pain Supercharged. His doctoral studies and current focus are around adult conceptual change, the linguistics of pain and pain story telling. Food, wine and fishing are also research interests.   Read the full transcript below: Karen Litzy (00:00:23): Hello everyone. And thank you for joining us today for this webinar. For those of you who are here live, you got to hear a little bit of pre-conversation which is great. And of course in that pre-conversation we were talking about all the things happening in the world today, specifically here in the United States with a lot of unrest and protests for very, very good reasons, in my opinion. And so we just want to acknowledge that and that we see it and that we are trying to learn, and we are doing our best to be allies to our fellow healthcare workers and citizens across the country and across the world for all of the other countries who have been showing solidarity. So I'm Karen Litzy, I'm going to be sort of moderating this panel of minds and I'm going to now go round and just have each of them say a little bit about themselves. So Sandy I’ll start with you.   Sandy Hilton: Okay. Hi, I'm Sandy Hilton. I'm a physiotherapist here in Chicago, Illinois with Sarah Haag. We have entropy physiotherapy and our clinic is predominantly working with pain. It's like a hundred percent of my case load is people in pain and about 80% of that is pelvic pain in particular. But I still see, you know, the rest of humans. David Butler (00:01:49): Hi, I'm David Butler from Adelaide Australia. I'm a physio, although I'm completely a professional and I believe everybody has the exact same role in treating pain. I'm trying to hire, but I can't retire. And then in world, our changing knowledge and our changing potential just keeps me, keeps me on track. So yeah, any sort of pain I'm happy to talk about. Bronnie Thompson (00:02:16): I’m Bronnie Thompson, I'm an occupational therapist by original training with some psychology thrown in, and I'm an educator and clinician as well, but a teeny tiny bit of research, but not much. And I'm a painiac and quite proud of it actually.   Karen Litzy: Excellent. So again, everyone, like I said, if you have questions as we go along, please feel free to put them in the Q and a part. And I will be looking at that as we're going through now, like I said, we've got some questions ahead of time, but before we get to some of the questions that some of the listeners and viewers have wanted to ask, I also want to just quickly acknowledge that we've got a bit of a mixed audience, so we've got healthcare practitioners and clinicians and we've also got people living with pain. Karen Litzy (00:03:11): And so as a clinician for me, it's a great opportunity. I think to address people in pain who maybe don't have the access or the ability to kind of get this information that's in their town or where they're living. So I am really, I'm really looking forward to this discussion, especially for those people that are watching that are living with persistent pain. So the first question I'm going to ask is and I'll ask this of all of you. If you were to give a piece of advice to a new professional or a healthcare professional that is sort of newly working with people with persistent pain, what would that piece of advice be? Sandy Hilton (00:04:11): I'm in Chicago. I'm just going to take it. I really like to stress, especially to students that, you know, we get this concept that the longer you've been in the field, the better you are at it. And, I think that maybe we make different mistakes, but everyone is learning this. And there's so much about pain that we're learning. And so if you're just starting in, I don't know that you might have an easier time because you have less bad habits to get rid of and can start with some of the better newer research and avoid some of the mistakes we made. Bronnie Thompson (00:04:50): So she's doing the popcorn approach. She looks at me. And so I think my advice would be, listen, listen very carefully to what people tell you and trust that they're telling you your experience. Don't try and read stuff into it, just listen and reflect, show that you're listening by reflecting what you've heard. So you can give that you've understood one another, because it's really easy to come out of school with all of this knowledge packed up and your brain thinking, Oh, I've got to do an info dump just like that. And it's not that great for the person, stop and listen. David Butler (00:05:37): They are lovely comments. I'd add. I would welcome anybody to the most new and exciting area of health. And there is a true pain revolution out there. And I would say to anybody, when you come in to just lift your expectation of outcome or what, might've been five or 10 years ago, because the clinical trials and our knowledge of the potential for humans to change is just increasing so dramatically. And I say, now we can say think treatment, not necessarily management because for many people recovery or some form of recovery is on the cards and what's leading the charge is the talking and the movement therapies. It's not the drug therapies for chronic pain. And, I just like to reflect as an older therapist now, patients who maybe 10, 15 years ago with maybe complex post pain surgery or Phantom limbs or complex regional pain syndrome would have thought, and I can't really help here. Now we welcome them through the door and you can get such pleasure, pleasure from treating these people no matter how long they've had the problem. Karen Litzy (00:06:48): Great. And, I would echo what Bronnie said is, you know, really listen and also believe, you know, they're giving you their experience. So try and take your bias out of it and believe what they're telling you and try not to talk them out of it because you see this quite a bit of, Oh, I have pain with this. And well, do you really have pain with that? Or is your pain really that much? And as the patient, it's very frustrating to have someone try and tell you what your pain is. So I'm looking at it from the person who has lived with the really chronic and at times debilitating neck pain is just listen, which is good. Believe them, and try not to talk people out of their experiences because it's very frustrating and it's very sort of dehumanizing for the patient, you know? Karen Litzy (00:07:54): And when I look back at when I first met David and went up to him at an APTA event and said, would you like to be on my podcast? And he said, yeah, sure, but I'm going to New York. I said, Oh, well, that's great. Cause that's where I live. And so then he met me at my, where I was working at the time and spent two hours with me. And I just, after that felt like, Whoa, like this is the first time that someone really listened and didn't interrupt and believed what I was saying and really set me on a path that just changed my life. Like, I don't know where I would be, had I not had that encounter with David. I think it was like 2011 or 2012. And so I always reflect on that and try and be that person, because I know what it felt like. Karen Litzy (00:08:45): And then when someone does come in and, and gives you their full attention and their time and their understanding, and then says, well, challenges your beliefs in a positive way, it was something for me that, you know, and I've talked about it many times that just completely changed my pain and my life. And so, you know, try and be that person is what I would say to people.   Bronnie Thompson: It's like, we've got to remember that people with pain and I live with fibromyalgia, those of you that don't know that's my reality, it's our experience and what it's like to live without pain. You know, what it feels like to know the things that sit at off things that settle it down and our relationship to it, to that pain and conditions. We come in with a whole lot of knowledge about other people and what we've seen. So we are experts and a whole lot of stuff, but what we're not experiencing as this person's life, their experience via what they're wanting from us even, what's important to them. And that's where when we meet and we can kind of share the hidden paradigms things that we don't know about each other, then we've got a chance to make a huge change and that as we know, I just feel so good about what I do. I just love it. I'm such a pain geek. Sandy Hilton (00:10:09): And I think the pain science or the science of pain really gives as a clinician, a lot of comfort to the listen to them, believe them, you don't have to prove it. You don't have to go. And like they say, I hurt here. You don't have to go poke it to reproduce the symptoms to believe it. And that's how I was taught of you have to reproduce the symptoms so that you can document that it's true. And it was like, that's a giant piece of unnecessary that we don't even have to do anymore, which really saves us a lot of time, not to mention establishing that trust and not being one more person. That's poked them in the sore spot. But, that's the thing that I was taught in school. Bronnie Thompson (00:10:58): So the question is, do you think that all chronic pain patients were not treated particularly when they were having the first or second episodes of their acute pain or are they in any way destined to become chronic pain patients? Well, my story is I hurt my back. I was what, 21, 22, doing a tango with the patient and a doorway patient was bigger than me. I landed on the floor on my back and I had all the best evidence based treatment at the time, maybe not, maybe not all the ultrasound, but you know, they didn't lie. They're really and relax a bit. Bronnie Thompson (00:11:48): But I didn't recover. I was then seeing the Auckland regional pain Center with amazing dr. Mike Butler, who is a rheumatologist and founded, and basically was one of the first in this initiations of bringing the international association for the study of pain to New Zealand, good friend of Patrick Wall knew her stuff very well. Gave me the book the challenge of pain to read. So essentially an explain pain paradigm back in the eighties, I know pain pretty well. My pain has not gone away. So there are some people who will not have a complete recovery of all of their pain, but because none of our treatments provide a hundred percent abolition of pain and actually I'm comfortable with it. I live with the pain and it gives me some stuff that some other people don't have access to. I know what it's like to have every bit of my body feeling really rotten. Bronnie Thompson (00:12:53): At the same time. I'm not limited by my pain. And I think sometimes we look at pain removal is that end goal. But I think our end goal is to help people live full, productive, satisfying, joyful and enriched lives. And some people will bring the pain along with them and many people won’t have to and that's amazing. Let's let the person make that decision about what is the most important outcome. But yeah, sometimes we can do all the right things, but if you have a spinal cord injury and you've got a smashed up spine, probability is that at the moment, our technology doesn't give us a solution. We can help, but we can't always take it all away.   Karen Litzy: David, what are your thoughts on that, that sort of movement from acute pain to chronic pain? You know, what are your feelings on that is, is like you said, are you destined to have it are I know, cause I get this question a lot from people like, well, you know, it started out with like an ankle sprain or it started out with a knee sprain and now it's turned into this. So did I do something wrong or was something not done? David Butler (00:14:12): I think you’re not destined to have it, but I think our treatment or therapies and the politics of treating acute pain probably gets in the way. And I also think if someone's hurt their back or any part of their body bad enough to see a health professional, the data is that 50 or 60 or 70% will have a recurrence in the following year. Now most health professionals think a recurrence is a reinjury, but if they really explored what happened, that reoccurance probably happened at a time when they would look at down and flat the immune system's a bit out of balance and they might've just done something simple, lifted up and picked something we would now from pain science, reconceptualize that as well, that's quite good. It's your body testing yourself out like a fire alarm with all the stuff you've been through in the past. It's no wonder your brain. Wouldn't want to play it again to check out how your systems are working, but that just simple piece of knowledge and usually should check to make sure nothing serious has gone on because you check and you can normally say, well, that should ease in a couple of days. That's an example of a little bit of knowledge dampening down. They don't have to go through the old acute process again of more, x-rays more tests, more power. David Butler (00:15:31): I think if that's correct, that observation was seen for many years, it could save governments Billions. Bronnie Thompson (00:15:37): Oh, absolutely. We've got a great thing. The language we use don't we, is it an injury or is it just a cranky body? David Butler (00:15:46): That whole linguistics? And for me and my treatment, you're now a physio by trade. I feel it says important to help someone change the story, to have a story, to take their experience out into society and let it go. That to me is as important as having healthy movement, although they obviously like go together. Sandy Hilton (00:16:07): I was gonna say that the saving of money for systems, for sure, but also the saving of time for people and the saving in our healthcare system. Every test you go do is going to cost you a lot of money. And, that time that it takes to get it in a time away from work and family and the concern of what the test results will be. If we can divert them wisely to not do that when it's not really indicated, that's just so good.   Bronnie Thompson: Yeah. And then I also for, you know, I've had a test now I'm going to wait for the results and now I'm going to wait for what are they going to do as a result of those results? And then, Oh, it's the same. And it just feels very demoralizing to people. And I think that's something we need to think about with make the decision about when and we to stop doing investigations often. That's the sense of the clinician worrying that something, are they going to sue me? It’s not a good way to practice.   Karen Litzy: Yeah. here's another, we'll do this from Louise. She says, picking up on something David had said earlier, how do we move towards being more, a professional? How do we move the pain industry toward this goal? Excellent question Louise. David Butler (00:17:51): There's a lot of answers to it, but a couple would be, I think you just got a quite badly out there would know sports trainers who could deliver an equally good management strategy to some physios, to some doctors, et cetera, right? This pain thing is across all spectrums, which is why the national pain society meetings are so good. And why everybody there is usually humbled and talks to all the other professionals because they realize the thing we're dealing with is quite hard. And we need all the help that that's a weekend get, but it ultimately comes back to provision of pain education throughout all the professions and that pain education should be similar amongst all the professions it's not happening yet. We've tried pushing it, but it's not out there. And it's incredible considering the cost of pain is to the world is higher than cancer and lung diseases together. Karen Litzy (00:18:51): Yeah. The burden of care is trillions of dollars across the world. And, you know, even in the United States, I think the burden of care of back pain is third behind heart disease, diabetes. And then it was like all cancers put together, which, you know, and then it was back pain. So, and, and even I was in Sri Lanka a couple of years ago and I did a talk on pain and I wanted to know what the burden of disease of back pain was in Sri Lanka. And it was number two. So it's not like this is unusual even across different, completely different cultural and socioeconomic countries. And, you know, David kind of what you said, picks up on a question that we got from Pete Moore. And he said, why isn't it mandatory that pain self management and coaching skills isn't taught in medical schools? Is it because there isn't expertise to teach it? Well, I mean, David's right here. He's semi retired. David Butler (00:19:58): Why isn’t that mandatory? That's a big, big question. I would say that the change is happening. Change is happening. I would say that at least half of the lectures or talks I give now are to medical professionals and out of my own profession or even more than half. So yeah, change is happening, but it's incredibly slow. It needs a bloody revolution, quite frankly. A complete reframing of the problem and awareness that this problem that we can do something about it and awareness that there's so much research about it let's just get out and do it now. Sandy Hilton (00:20:40): The international association for the study of pains curriculum and interdisciplinary curriculum would be a nice place to start. And I know some schools here in the States are using it in different disciplines to try and get at least a baseline.   Bronnie Thompson: The way we do it as the core for the post grad program, that I am the academic coordinator for it. Doesn't that sound like a tiny, tiny faculty. But anyway the other thing that we know is that looking at the number of hours of pain, education, Elizabeth, Shipton, who's just about completed. If she hasn't already completed her PhD, looking at medical education and the amount, the number of hours of pain, it's something like 20 over an entire education for six to six or more years. In fact, veterinarians get more time learning about pain then we do then doctors medical practitioners do, which suggests something kind of weird going on there. Bronnie Thompson (00:21:50): So I think that's one of the reasons that it's seen as a not a sexy thing to know about and pain is seen as a sign of, or a symptom of something else. So if we treat that something else in pain will just disappear, but people carry the meaning and interpretation in their understanding with them forever. We don't unlearn that stuff. So it makes it very difficult, I think for clinicians to know what to do. Because they're also thinking of pain is the sign of something else not is a problem in its own, right? Persistent pain is a really a problem in its own right. Karen Litzy (00:22:29): Yeah. And wouldn't it be nice if we were all on the same page or in the same book? I wouldn't even say the same chapter, but maybe in the same book, across different healthcare practitioners, whether that be the nurse, the nurse practitioner, the clinical nurse specialist, the physician, the psychologist, the therapist, physical therapist, it would be so nice if we were all at least in the same book, because then when your patient goes to all these people and they hear a million different things, it's really confusing. I think it's very, very difficult for them to get a good grasp on their pain. If they're told by one practitioner, Oh, see, on this MRI, it's that little part of your disc. And that's what it is. So we just have to take that disc out or put it back in or give a shot to this. Karen Litzy (00:23:25): And, and then you go to someone else and they say, well, you know, you've had this pain for a couple of years, so, you know, it may not be what's on your scan. And then the patient's like, who am I supposed to believe? What am I going to do? And, and you don't blame the patient for that. I mean, that's, you'd feel this that's the way I, you know, I had herniated discs and I say, you just get a couple of epidurals and the pain goes away and then it didn't. And I was like, Oh, okay, now there's so my head, I was thinking, well, now there's really something wrong.   Sandy Hilton: That's the problem. Because yeah, if you think it's the thing you did that helped you or didn't help you, then you lose that internal control. Karen Litzy (00:24:13): Yeah, yeah. Yeah. So I think, I think it's a great question and, and hopefully that's a big shift, but maybe it'll start to turn with the help of like the international association for the study of pain and some curriculum that can maybe be slowly entered or David can just go teach it virtually from different medical schools, just throwing it out. There is no pressure, no pressure. Okay. Speaking of modalities, we had a question. This is from someone with pain and it's what can be the appropriate regimen for usefulness of tens, for acute and chronic cervical and lumbar pain of nerve origin. So Bronnie, I know that you had said you had a little bit of input on this area, so why don't we start with you? And then we'll kind of go around the horn, if you will. Bronnie Thompson (00:25:24): I think of it in a similar way to any, any treatment, really, you need to try it and see whether it fits in your life. So if you are happy and tens feels good and you can carry it with you and you can tuck it in your pocket and you can do what you want to do. Why not just is, I would say the same about a drug. If you try a drug and it helps you and it feels good and you can cut the side effects, there's nothing wrong with it. Cause we're not the person living life. It's more to think about it in a population. How effective does this? And my experience with tens is that for some people it does help and it gives a bit of medium, like a couple of hours relief, but often it doesn't give long sustained relief and you have to carry this thing around. That's prone to breaking down and running out of batteries, right when you need it. So to me, it's agency, but then I put the person who's got the pain and the driving seat at all times to say, how would this fit in your life? Do you think you want to try this one out? It's noninvasive it's side effects. Some people don't like the experience and sometimes the sticky pads are a bit yuck on your skin, but you know, that's more bad. So yeah, that's my, my take on it. David Butler (00:26:44): I haven't used it for 40 years after the second world war. When you start to stop, when they, I was friendly with the guy who invented it and I'm thinking it'd be happy pet we'll would be happy to, with these comments that I agree with what Bonnie said. Absolutely. I would also say that, hi, wow, you have got something there which can change your pain by scrambling some of the impulses coming in. You can change it, let's add some other things which can change the impulses coming in or going out as well. So let's use that. Let's get you building something, maybe something repetitive or something contextual or something as well. So you you've shown change you're on the track. So I would use it as a big positive to push them on keep using it, but on the biggest things. Sandy Hilton (00:27:32): Yeah, the advantage is it's. So it's gotten so inexpensive. So for something that has minimal to no side effects and has the potential of helping them to move again, which I think is always the thing that we're aiming for. It's not very expensive. But now like several hundred dollars, right? You can order it online. Now you don't even need a prescription or approval or anything like that. Karen Litzy (00:27:59): Yeah. Yeah. That's true. And something that I think is also important is, you know, you'll have people say, Oh, those passive modalities, that's passive. You know, I had a conversation with Laura Rathbone Muirs. Is that how you say the last name? I think that's right. Laura. And we were talking about this sort of passive versus active therapies and, you know, her take on, it was more from that if they're doing these passive modalities, they're giving away their control. And, she said something that really struck and, kind of what the three of you have just reinforced is that no, they still have that locus of control. Cause they're making that conscious effort, that conscious choice to try this, even though it's a passive modality, they still made the choice to use it. Karen Litzy (00:29:03): And I think that coupled with what David said, Hey, this made a difference. Maybe there's some other things that can make a difference that I think that I don't think they're losing that locus of control, or I don't think that they're losing they're reliant on passivity, right.   Sandy Hilton: When they have their own unit and they're not coming into the clinic to have it put on you. And you lie there on the bed while you do it.   Bronnie Thompson: It's something that you have out in the world. It's not different to sticking a cold compress on your forehead when you're feeling a bit sick, you know, we did it. That's just another thing that we can do. So I see it as a really not a bad thing. And it is in the context, you know, if you can do stuff while you've got it on, then it's the hold up problem, as long as you like.   Karen Litzy: Great, great. Yeah. As long as you like it. Exactly. Yep. Okay. so we've got another question that we got ahead of time and then there's some questions in the queue. So one of the questions that we got ahead of time was how do we explain pain responses like McKenzie central sensitization phenomenon in modern pain science understanding. David Butler (00:30:35): I'd answer that broadly by saying that the definition that we've used and shared with the public in the clinical sense is that we humans hurt when our brains weigh the world. And judge consciously subconsciously that there's more danger out there than safety. We hurt equally. We don't hurt when there's more safety out there, then danger. So somebody who's in a clinic and is bending in any way and it eases pain. There will never be one reason for it. So it might just be, that might just be the clinic. It might be the receptionist. It might be all adding up. It might be the movement. They might've done one movement. And so, Oh, I can do that. And then all safety away, we go again, the next movement helps within that mix. There may be something structural. You've done to tissues in the back and elsewhere that might have eased the nociceptors that barrage up. But by answer will always be that when pain changes, it's multiple things are coming together, contributing to them. And they'll never never just be related to nociception. Sandy Hilton (00:31:49): I have to say this to say, I am not McKenzie certified. So this is my interpretation of that. I like the concept of you can do a movement. That's going to help you feel better. And we're going to teach you how to do that throughout the day. Maybe as a little buffer to give you more room, to challenge yourself a little more knowing that you'll have a recovery. And I just pick that part and use that.   Bronnie Thompson: I heard the story of how it all came about and it, and it's you know, it's an observation that sometimes movement in one direction bigger than another. And that's cool. It's like, you're all saying, let's make this little envelope a little bigger and play with those movements because we're beasts of movement. Bronnie Thompson (00:32:50): We just forget that sometimes we think we've got to do it one way. And you know, I can't tell my plumbers who crawl under houses. Look, you've got to carry things the way, you know, the proper safe handling thing. And I wasn't, I was the same safe handling advisors like me. But you know, there's so many ways that we can do movements and why can't we celebrate that? And the explanation, sometimes we come up with really interesting hypotheses that don't stand the test of time. And I suspect it might be some of the things that have happened with the McKenzie approach. It's same time. What McKenzie did that very few people were doing at the time was saying, you can do something for yourself that as we are the gold ones, that's what changed. David Butler (00:33:40): Bronnie, what's really helped us to start the shift away from poking the sore bit, come on, do it yourself. And, and I always give great credit to Robin McKenzie for that shift in life. Sandy Hilton (00:33:53): Yeah. And an expectation that it's going to get better. Right. David Butler (00:34:00): You think that’s showing something in the clinic that helps. Wow. Let's ride let's rock. Karen Litzy (00:34:07): Yeah. And oftentimes I think patients are surprised. Do you ever notice that Sandy, like, or David, or, you know, when you're working with patients, they're like, Oh, Oh, that does feel better. And they're just sort of taken aback by, Oh, wait a second. That does feel better and it's okay. I can do it. Yeah. And then you give them the permission to do so. And like you said, is it's certainly not one single thing that makes the change. But I think everything that you guys just said are probably the tip of the iceberg of all of the events surrounding that day, that time, that movement, that can make a change in that person. And I think that's really important to remember. That's what I sort of picked up from the three of you.   Bronnie Thompson: But the stories like that kind of convenient ways of, for us to think that we know what we're doing, but actually within what this person by what this person feels and how they experience it. And the context we provide us safety, security. And I'm going to look after you, that's, you know, changes, motivations about how important something is and how confident you are that you can do it. We can provide the rationale important part. The person ultimately drives that. So we can also provide that sense of safety and that I'm here. I'm going to hang around while you do this stuff. Let's play with it. Let's experiment. And if we can take that experiment, sort of notion of playing with different movements in, we've got a lot more opportunity for people in the real world to take that with them. We can't do that. Or forgive people are prescribed. You will do this movement. And this way perfectly I salute, but the old back schools, Oh, I know scary, And they did get people seeing the other people were moving. And that's a good thing that we can take from it. It's always good and not so good about every approach. Karen Litzy (00:35:11): Now I have a question for David and then out to the group, but you know, we've been talking about Sims and dims and safeties and dangers. And so for people who maybe have no idea what we're talking about, when we're talking about Sims and dims, can you give a quick overview of what the Sims and dims, what that is so that people understand that jargon that we're using? David Butler (00:36:40): Okay, it's a model we use. There's lots of other similar models out there. So basically based on neuro tag theory, the notion of a network that there's danger danger in me networks out there, and there's safety in me networks, rather simple, structured thinking here, and we've looked at these this has emerged due to the awareness, the pain science that we have a network in our brain. But me as an old therapist, when the brain mapping world came in and we realized, hang on pain, isn't just a little nest up there. There could be thousands of areas of the brain ignited indeed the whole body ignited in a pain experience. And one of the most liberating bits of information for me and my whole professional career, because what it meant was that many things influence a pain experience and a stress experience, move experience lab experience, and many things can be brought in to actually try and change it. David Butler (00:37:39): And all of a sudden means that everything matters. So this is where dims danger in me, safety sims in me, it was just a way to collect them. So an example of a dim with categorize them could be things you hear, see, smell, taste, and touch. So for one person, it could be the smell of something burning or looking at something or hearing something noise. The things you do could be a dim. It could be just doing nothing, but then there's Sims, gradually exercising, gradual exposure seems in things you hear, see, smell, taste, and touch could be going out. One of my most common exercises I now give somebody is to go down to our local market and find four different smells, four different things to taste, four different things to touch. And then they'll say, why should I do that? Because you can sculpt new safety pathways in your brain, which will flatten out some of them, some of the pathways they're linked to pain and it comes to of the things you say important. David Butler (00:38:37): You know, I can't, I'm stuffed, I'm finished. I got mom's knees. We try and change that language too. I can, I will. I've got new flight plans. I can see the future, the people you meet, the places you're with. So it's a way of categorizing all those things in life into either danger or safety, we try for therapy, we try and remove the dangerous. It is often via education. What does that mean? And we try and help them find safety and health professionals out there are good at finding danger, but we're not used to getting out there and finding those liberating safety things. And of course the DIMS SIMS thing. It's also closely linked in, we believe to immune balance. So the more dims you have, the more inflammatory broad immune system, the more sims you have, you move more towards the analgesics or the safety. And so it's the way to collect them. It's a way to collect as we try and unpack and unpack a patient's story listing to it within to unpack it and then to re-pack it again with them in a different way. Did that make sense? Karen Litzy (00:39:49): Absolutely. Yes. I think that made very good sense. And I believe you, there is a question on it, but I believe you answered it in that explanation. It says, have you had patients that cannot find Sims or it's difficult to identify and if so, how can you teach them what a SIM is? But I think you just answered that question in that explanation. David Butler (00:40:11): Once they get it. They're on their way. And we send people on SIM hunting homework. So for example, the same might be places you go, okay, if you can get out, just walk in the park or walk somewhere, then power up the SIM by feeling the grass, touching the box, spelling something. And we pair it up by letting them know that if you do that, your immune system gets such a healthy blast, that it can also help dampen down some of the pain response. Bronnie Thompson (00:40:39): And with regard to our current situation, sort of around the world COVID-19 and all the subsequent stuff. And also the situations in the U S at the moment, is it any wonder that lots of people are feeling quite sore because we’re eating this barrage of messages to us. And so I would argue that at the moment it might be worthwhile if you're a bit vulnerable to getting fired up with the stuff said, it's a good idea to ration, how much time you're spend looking at the stuff, not to remain ignorant, but to balance it with those other things that feel good, that make you feel treasured and loved and committed. And for me, it's often spending some time in my studio, walking the dog, going outside, doing something in nature. And there is some really good research showing that if you're out in the green world nature, that there is something that our body's really relish, kind of makes sense to me. Sandy Hilton (00:41:42): So taking that concept into what's going on right now, there's been a challenge clinically of the things that helped people balance that out, got taken away from them. Yeah. So it was a complicated it still is. It was a complicated thing where it wasn't your choice to stop going to the swimming pool because it made you happy and it gave you exercise and balance this out. Someone closed the pool and told you, you couldn't go. And so there's all different layers of loss in that and lost expectations and loss of empowerment and all of these things. So we have had to help people rediscover things that they could access that could be those positives. And that's been hard and really working my muscles of how to help people find joy or pleasure or happiness or safety in an unsafe environment to really get that on a micro level when you've lost the things that used to be there. And, it's been like a lot, but you can do it. It just takes concentration. David Butler (00:42:57): An important thing. That's so important. I think a question for therapists health professionals should be a sane question should be, you know, what's your worldview at the moment. And I would ask that, and it's usually not good, but I chat and have a chat. And actually I'd like to take people through some graphs that the world is not as bad as it really is. And if you look at I've been reading a book by Hans Rosling called factfulness. And really over time, our world is getting better. There's less childhood diseases, a whole range of things, getting better, bad, and bad things, getting better. This is a hiccup. This, for example, I had a musician recently and I had a graph I could show her that say that there's now 22,000 playable guitars to a million people in the world. But 12 years ago, there was only 5,000. All right, this is just one little thing. All right, cool. There's a lot of stats that show that our world is improving, you know, children dying, amount of science, a whole range of things. And this hiccup we have that I'm hopeful humanity can get, can get through, but just a little message I pass on is therapy. Bronnie Thompson (00:44:13): Even though we can't do stuff, we can't access places. What can't be taken away as our memory of being there. So it's really easy to take a moment to back a memory that feels good to say, actually, you can't take that one away from me. I might not be physically getting there, but I can remember it, feel those same feelings. And then being mindful.   Sandy Hilton: This is funny because if you look at Bronnie's background, that's one of the memories I've been using. When I lost the lakefront, I was like, okay, I'm just going to sit there and pretend that I'm not at that beach by that pier. So it's, it's fabulous. And even pictures or recordings of things that you've done before is like, okay, now there is still good stuff. I might not have it right here, but they're still good stuff. So that's really funny. As soon as I saw the picture, I'm like, yeah. And gratitude and just, yeah. Bronnie Thompson (00:45:05): The other thing as well, we've always got something that we can be grateful for all that. It might feel trite, you know, I'm living in winter, but I've got a roof over my head. I can have a damn fine cup of coffee and probably a nice craft. I'll at the end of the day, these are things that I can do and can have any way. So we can create the sense of safety insecurity inside ourselves without necessarily having to experience it. David Butler (00:45:38): Right. Just a quick comment. I would share that with patients who can't get out are saying the things you do when you're still can be as important as the things you do when you move. Right? So let's explore. If you can't do things, you can still really work you yourself with the things you do. And you're still calm. The introspection reading, thinking, contemplation memory enhancement, go through the photo album, et cetera. And I'd also like to always say to someone to link that in that is a very, very healthy thing to do to your neuro immune complex. Karen Litzy (00:46:13): And that sort of brings, I think we answered this question. This was from a woman who is living with chronic pain and at high risk with COVID-19. So how do we get past the fear of going out where people are crowding areas to get the exercise we need to maintain our fitness and muscle tone to reduce our pain. She said, even though I'm doing exercises and stretching, I've lost the ability to walk unaided on uneven grounds through weeks of lockdown. And the hydrotherapy pool is closed. She said, she knows, I need to get out and walk more, but shopping centers, which are the best place to find level floors are out. And a lot of places that she used to go are now very crowded because people are, don't have the access to gyms and things like that. Are health professionals able to suggest options when she lives in a hilly area with only a few but all uneven footpaths or sidewalks. And she has a small house. Sandy Hilton (00:47:18): That's the kind of thing that we've been doing since it's like, okay, let's problem solve this out. Because yeah, you have your carefully set way to get through this and then it's disrupted.   Bronnie Thompson: Yeah, boy, I like having lots of options for movement opportunities. So we don't think of my exercise, but we think of how can I have some movement today and bring that sense of, we are alike to be like, if I can imagine I'm walking along the beach while I'm standing and doing something and, you know, doing the dishes or watching TV or something that still can bring some of those same neuro tags it's same illusion, imaginary stuff activating in my brain. And that is a really, really important thing because we can't always the weather can be horrible, especially if you're in Christchurch and you can't go out for a walk. Bronnie Thompson (00:48:27): Yeah. But you know, we can think novelty is really good. So maybe this is a really neat opportunity to try some play. And I've been watching some of the stuff that our two chiropractor friends do with you put, let's put, at least try some obstacle courses and the house so that it's not we're not thinking of it as exercise. And I've got, do three sets of 10, please physios change that. Let's do something that feels like a bit of fun. There's some very cool inside activities that are supposed to be for kids. I haven't grown up yet. I'm still a baby. Sandy Hilton (00:49:16): Yeah. A lot of balance and things like that you inside that would help when you have your paths back outside. Yeah, yeah.   Karen Litzy: Yeah. Great. And then sticking with since we're talking about this time of COVID where some places are still in lockdown, some places are opening up. Bronnie and David are in an area of the world where they have very, very few cases, very, very few cases, Sandy and I are in a part of the world where we have a lot more than one. So what a lot of practitioners have had to do is we've had to move to tele-health. And so one of the questions David Pulter, I believe, as I hope I'm saying his name correctly is do we perceive that our ability to be empathetic and offer effective pain education is somehow diminished by a tele-health consult. So are we missing that? Not being in person.   Sandy Hilton: I have found it equally possible in person or telehealth cause you're still making that connection. We do miss stuff. We can't read the microexpressions in people as easily. So we as therapists have to work harder, but for the person on the other end, think about what the alternative is. Sandy Hilton (00:50:46): And it's been really cool for the people with pelvic pain, that every single time they've gone to a physio it's been painful. And on tele-health it's the first time she has been able to talk to someone about all of her bits and pieces without being afraid that it's going to hurt because there was no way to see somebody inside somebody's home.   Bronnie Thompson: You get to know something more about me. I've met more pets than ever thought. It was wonderful. This is a privilege that occupational therapists have had for a long time. And I'm so pleased that other other clinicians are getting that same opportunity, because we know so much more about a person when we can see the environment that they live with. That's just fantastic, but it's harder. David Butler (00:51:39): I find I've come back into clinical practice. I thought I was going to retire because I wanted to go, but also doing it. I was hopeless at first, but I'm really enjoying it. And I actually believe, I actually believe for the kind of therapies we're doing it's equal or better than face to face. Ideally, I think I'd like to have one face to face or maybe two but then to continue on with the tele health, particularly for people are in rural areas and it's almost no this kind of therapy was coming anyway, but the COVID has hastened it. So I found myself getting anecdotally here a much more emotional, closer, quicker link to patients by the screen. They were in a safe place. They're in their house. That's number one. They're not in a clinic you're there. And you can actually look at that face in the screen, as we're doing now, I'm looking at your faces, maybe one or two feet away, and I'm just keep looking at you. David Butler (00:52:46): And there's this connection, which is there. And there's also these other elements it brings in like, you start at 10 o'clock and you finish at 10:45. So there's open and closure, which isn't really there in some of the, in some of the clinics, the difficulty I'm having with it though is I was never in face-to-face practice a very good note taker. I used to make notes at the end. I was talking too much, but what you have to do here, my suggestion with face to face is you really need to plan and make your notes straight after. What did I tell that one on the screen, last clinical context, to sort of remind you of all the little juicy bits that we've got in the interaction. So it's really, for me, it's coming back to curriculum and mind you, I'm glad I'm not doing dry needling or just manipulating it with the talking therapy, but my suggestion is to have the habit curriculum. David Butler (00:53:44): So I've got my key target concepts. I know that I've addressed them in that particular session in the next session. I know I've gone back and I've done teach them the self reflection as well. Then to come back to see if I can get it all, or if I've translated my knowledge into something functional or some change. So I'm really, I'm really loving it. And I think there's something rather new and special with this, with this interaction. But maybe that's just me as a physio who sort of used to the more physical stuff. Maybe this is something more natural to the psychologist, its perhaps, but I'm with it. Bronnie Thompson (00:54:22): I’ve been doing the group stuff. And I found that has been, I've seen, I like it because they don't have to go and travel someplace. It does mean that we can offer it to people who otherwise can't get here. You know, they can't seek people, especially rural parts of New Zealand, low broadband is not that great in many parts as well. So it gets that it's an opportunity. I'd like to see the availability of it as an option. So we can use like we do with our therapies, we pick and choose the right approach or the right piece at the right time and the right place that doesn't have to be one or the other, like you said, you could see him a couple of times in person and then a couple tele-health and then maybe they come back again and then you do mix and match.   Karen Litzy: We have time for one more question here, maybe two. So David, this was one you might be able to answer it really quickly. As a practitioner, what is the utility of straight leg raise slump and prone knee bend test and the assessment of chronic back pain. Is it still relevant? David Butler (00:55:38): Oh gosh. Oh gosh. I'm going to dodge that question and would say it, it would depend on the client who comes in so I think those neurodynamic tests, which I still do. I think the main principle from them is you're testing movement. You're not testing a damaged tissue and anytime you're doing a physical examination, the deeper thing is the patient is testing you. You're not testing them. So what that patient, what that patient offers back in terms of movement or pain responses or whatever, depends on so many things. I might however, have a client and they are out there who do have maybe a specific stickiness or something or something catchy, whatever that may well, the scar around it might well be polarized by action, where I might spend a little bit more time taking a closer look at it. Now that might be relevant. Someone might have, for example, someone might come out of hospital and have had a needle next to the IV drip, next to their musculocutaneous or radial sensory nerve there where it's really worthwhile. Let's explore all the tissues here and see that that nerve can move or slide or glide. But in the second case, I'd made a clinical decision that we probably have issues out in the tissues, which are with a closer evaluation. That's a really broad answer. Karen Litzy (00:57:11): I think it's a tough question to answer because it, sorry, got a cat behind me. I felt my chair moving and I was like, what's going on? Just a large cat. So last question. So how to manage tele-health when the patients may be kind of embarrassed of their house or context or spaces or family it's very common in low socioeconomic patients. So they may not want to turn on their camera.   Sandy Hilton: Yeah. I've had that shaking well, and I've had people in their car or very clearly like I'm kind of angled cause there's a lot going on in my house and I don't have a green screen. So where it's like, and there's just a wall behind me and it's one of the reasons like I'll talk to him ahead of time of if I'm in the clinic, it's clearly the clinic, but I'll tell them I'm at my house. Sandy Hilton (00:58:12): Cause of COVID. So, you know, no judgment, you're going to see a wall and probably a cat and just kind of be up front in the beginning of this as a thing, I've had people that start with the phone on or turn it off or whatever, you just, you roll with it. But I have those conversations ahead of time, before we even do the call.   Bronnie Thompson: It's about creating a safe space for people. You know, if somebody feels, you know, was not having the video, it won't be that long before. I hope we've got some rapport and it feels better. I'm just, I'm doing a bit of a chuckle because the reason I've got my green screen behind me as my silversmith studio, which has an absolute shambles because it's a creative space. So I'm just disguising it because it's works. David Butler (00:59:07): There is something about delivering a story of some talking in the patient's room and there's cupboard doors open and you're looking in their cupboard at the same time. And you know, looking at that, then I just look at that thing. We’re safe here. Karen Litzy (00:59:26): Well, listen, this has been an hour. Thank you so much. I just want to ask one more question or not even a question, more like a statement from all of you that, what would you like the people who are listening and they're, like I said, there were clinicians, there were non-clinicians on here. And I think from the comments that we're seeing in the chat is very valuable and very helpful. So what do you want to leave people with?   Sandy Hilton: I'm gonna echo how I started. We're learning more every single week. I'd say, day but I'm not reading that often. So even if you've gone or you've treated someone and you couldn't quite figure out a way to help them, don't give up because there's more information and more understanding and more ways to get to this all the time. And I don't think you're stuck if you hurt. David Butler (01:00:26): I'd like to mirror those comments, explore the power of tele health, lift your expectations of outcome for those patients, people who are suffering and in pain, who are listening for those who are getting into pain treatment there's a science revolution and a real power in that revolution behind what you do. So just go for it. Bronnie Thompson (01:00:52): I think don't be hung up on with the pain changes or not, be hung up on does this person connect with me. We create trust. Am I listening? Can I be a witness? Can I be there for you? Because out of that will come this other stuff. There are some people whose pain doesn't get better. It doesn't go away. And that's a reality, but it doesn't mean that you have to be imprisoned or trapped by your pain. That means you develop a different relationship with your pain. And I think that's a lot of what we are doing is creating this chance to have some wiggle room, to begin to live life. That's what I'm looking for. Karen Litzy (01:01:53): Beautiful. Well, you guys thank you so much. And for everyone that is here listening, I just want to say thank you so much for giving up an hour of your time. I know that time is valuable, so I just want to thank you all and to Bronnie and to David and to Sandy. Thank you. Thank you. Thank you. And kind of on the fly. So I just want to thank you so much and to everyone. I guess the thing that I would leave people with is, if you're a clinician or if you are a patient, the best thing that you can do, if you are in pain is reach out to someone who might be able to help you, find a mentor, find a clinician, ask around Google, do whatever you can try and find someone who like Bronnie and David and Sandy I'll echo everything. You said that number one first and foremost, you connect with and that you feel safe with. You want them to be your super SIM, you know, like Sandy's my super SIM. Karen Litzy (01:02:48): So you want them to be your super SIM. And, if you can find that person, that clinician just know that that there can be help, you know, whether you're struggling as the clinician to understand your patients or your the patient struggling to find the clinician, I think help is out there. You just have to make sure that you be proactive and search for it. Cause usually they're not going to come knock on your door. So everybody thank you so much for showing up. Thank you, everyone who is on the call and to everyone who is watching this on the playback I hope you enjoyed it. If you have any questions, you can find us we're on social media and various websites and things like that. So we're not hard to find. Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram  and facebook to stay updated on all of the latest!  Show your support for the show by leaving a rating and review on Apple Podcasts

In honor of the recent DPT and PTA graduates across the country we had some very special guests send us their ultimate message that they wanted to share with all PT/PTA graduates as they start their careers for a special commencement episode featuring: Ben Fung, Sandy Hilton, Sarah Haag, Zak Gabor, Stephanie Allen, Justin Moore, Greg Todd, Barbara Sanders, & Jeff Moore. Thanks to the Knowbodies podcast for creating this creative idea for an episode in the past!   The Knowbodies 2016 DPT Commencement Speech Episode            The PT Hustle Website Schedule an Appointment with Kyle Rice HET LITE Tool Anywhere Healthcare (code: HET)      

Sandy Hilton and I discuss our top tips on how to effectively search for that journal article you are looking for. It takes time, can be confusing at times, can lead you down rabbit holes but there are ways to work it out...you just need to be persistent. Hope you enjoy. Check out my Instagram @pelvicwod for the Infographic summarising these tips, as well as www.loriforner.com   

On this episode of the Healthy Wealthy and Smart Podcast, I welcome Dr. Jason Falvey on the show to discuss healthcare fake news.  Dr. Jason Falvey is a physical therapist working as a post-doctoral research fellow at Yale University in New Haven, CT.  Jason’s research interests focus on improving post-acute care quality and outcomes for older adults recovering from major medical events, such as surgery or critical illness. In this episode, we discuss: -The definition of fake news as it relates to healthcare and medical disinformation -What Jason recommends you do when you encounter articles with a high comment to retweet ratio -How you can avoid falling trap to your biases by crowdsourcing to interpretate literature -The importance of seeking information not affirmation -And so much more!   Resources: NY Times Fight Fake News Why Healthcare Professionals Should Speak Out Against False Beliefs Jason Falvey Twitter Jason Falvey Yale Email: jason.falvey@yale.edu  The Outcomes Summit, use the discount code: LITZY For more information on Jason: Dr. Jason Falvey is a physical therapist working as a post-doctoral research fellow at Yale University in New Haven, CT. He holds a bachelors degree in English, and a doctor of physical therapy degree from Husson University in Bangor, Maine and a PhD in Rehabilitation Science from the University of Colorado, Anschutz Medical Campus.  He is also a board-certified geriatric clinical specialist. Jason’s research interests focus on improving post-acute care quality and outcomes for older adults recovering from major medical events, such as surgery or critical illness. To date, Jason has authored or co-authored 18 peer reviewed papers in widely read rehabilitation journals.   Read the full transcript below: Karen Litzy:                   00:01                Hey Jason, welcome back to the podcast. I'm happy to have you back on even though we're not talking about what we usually talk about when you're on these podcasts and we have our specials with Sandy Hilton and Sarah Haag but I think this is still a really great topic and I'm happy to have you on to dive into it. Jason Falvey:                 00:24                It’s great to be back and I have been excited to present this topic for a couple of months. While it’s no sex podcast part five I think we can definitely got come up with some interesting points for the audience. Karen Litzy:                   00:37                Yeah, I think so too. And so everyone today we are talking about fake news as it relates to health care. Because I know a lot of you that are listening are in the healthcare world and if you're not, this is also a great way for you to kind of understand that everything that you read on social media isn't true gasp, right. So, Jason, let's talk about first, what in your opinion, is the definition of fake news as it relates to healthcare and let's say medical disinformation? Jason Falvey:                 01:19                Yeah, I like the term medical disinformation because fakes news is not nearly as common in medicine, you know, as far as the falsified information. But medical disinformation is much more common than people may realize. The context is most of the hundred shared articles of last year, over 50% of them are of poor evidence quality when experts have actually rated that. So when I talk about fake news and medical disinformation, I'm really kind of breaking it down to a handful of categories. So there's fake news that's rare, but it does happen that's false or completely inflammatory, you know, that is completely falsified data, or completely false claims that are created to either scare somebody into making different health care decisions or drive them towards a curative product that may be your marketing. So that’s not common, but that definitely is out there. I think the more common pieces of fake news and medical disinformation are hyperbolic and intentional. Jason Falvey:                 02:34                So the splashy headline that says Bacon Causes Cancer, you know, where people are putting that headline so it’s clicked on and read when the real story behind a lot of that evidence is substantially more nuanced. And then there's also hyperbolic and unintentional where a well meaning university employee publishes a press release on investigators article and misstates or over-interprets the conclusions to be much broader, more sweeping than they are suggesting that a drug cures cancer or Alzheimer when really it was affective in early stage studies for one particular protein in a mouse model. So those are the three definitions I tend to stick with, but really it's medical information that's not fully accurate, that’s shared widely and may influence healthcare decision making. Karen Litzy:                   03:32                When we talk about these flashy headlines and this medical disinformation whether intentional or unintentional, as healthcare professionals, sometimes we're responsible for sharing that. It's not just the lay public. Right. So when you look at these headlines and you read through let's say a press release, is that where it ends? Do you say to yourself, yeah, this sounds good. I'm going to share it. Jason Falvey:                 04:05                I think that should be the focus of what we talk about today and that is how do we as health care providers recognize fake news? How do we kind of avoid unintentionally sharing it and how do we avoid intentionally sharing it? So I think my guiding principle for all of these things, for any healthcare professional, it's Hippocratic oath, it's do no harm. And then health care beyond what we do with patients and beyond the hands on care that we provide sharing misinformation, whether intentionally or unintentionally has the potential to cause harm. Patients for going standard of care treatment and in lieu of an alternative medicine or unproven other therapy that may actually cause their health to decline, you know, or causing them to participate in a treatment that is unlikely to benefit them and causes harm both financially or time and potentially health care harm. So I think Hippocratic oath above all else should really drive our decision making and the impetus for why we should care about this. And the other guideline I use is I really want patients and providers both to be looking at social media and healthcare information that they're sharing and really make sure that they're seeking information, not affirmation. So they're seeking to broaden or challenge their pre held assumptions and not just share things, read things and kind of propagates a worldview that just affirms that are already firmly held biases to harm a patient. Karen Litzy:                   05:58                Okay. Yeah, but so you mean we can't cherry pick things to confirm our own biases to make ourselves look better? Is that what you're trying to say here? Jason Falvey:                 06:16                Yeah, that sounds like a terrible polarizing thing to say, but I'm really going to stand by that I think and just say I really don't think we should be cherry picking evidence and just sharing evidence that is fully supporting our world view. We may have a brand to keep, you know, I don't think I would widely share studies that I think are well done that maybe say physical therapy isn't as helpful as other things, but I certainly would acknowledge that they exist. I don't think I would market them heavily, but I certainly wouldn't ignore them or basically say that they're not accurate either. But I think we have to be really careful, especially when we're talking about vulnerable patient populations, thinking about patients with dementia or patients with cancer who are really hanging on hope that there's something medically that can be done that's outside of what's already been offered to them and kind of have a cure. And I think it's really important that we choose our language and we choose what we share, how we share, and the quality of what we share very carefully. Karen Litzy:                   07:29                Well, and you know, that goes back to do no harm. And I think goes back to being an ethical person because when you look at these vulnerable populations, like you said, the elderly people with possibly terminal diseases, people with chronic pain, these are people who are looking for things that they feel they have not gotten that will fix them. Right? And so that's where snake oil salesmen come in. That's where people sort of touting that they have this great flashy thing that isn't supported with evidence, but it sounds really, really good. And so how do we as healthcare professionals combat that without looking combative and turning off those people that we actually want to help? Jason Falvey:                 08:22                Yeah. How do we combat that information without unintentionally propagating it either. I think when we evaluate information, I think one of the things I really encourage is time, take time to think about the information, take time to research the primary source of that information. Take time to recognize if there is potentially both sides of an issue. So outside of things like, you know, vaccinations causing autism, which is a clearly manufactured result. If you follow back the evidence or if you go ahead and follow back evidence about infant chiropractic work. But I guess generally falsified or highly, highly, highly biased to the point where there really isn't a pro side, but a lot of medical things have a potential pro and con side. So I think it's important to recognize the nuance and carefully layout reasons one why you disagree with something and two the rationale methodologically, not just your opinion of kind of how you came to that conclusion. Jason Falvey:                 09:42                But I think you have to do that without validating what you think is a very poor quality or highly biased or dangerous source to share. If, for example, you saw a tweet about the harms of vaccination and it may be, it was for your older adult population getting the chicken pox vaccine and it caused them Alzheimer's, you know, caused them to get dementia. Let's say you just saw a story like that. Which is not true. How do you, you know, how do you combat that? Some people would just retweet it with a really dismissive comment, like this is garbage. Don't listen to them. Well then doing that, and I'm guilty of this in the past as well, we've actually unintentionally propagated that information. Right now I have not very many followers, so 2000 followers all of a sudden see that and potentially one more retweets it and then another 2000 people. So I unintentionally exposed 4,000 people. Even if I'm dismissing that information, I've lent it credibility by sharing yet. Jason Falvey:                 10:51                I think what I have to do is write something about the study, not actually link or validate in some way and not unintentionally spread fake news. And there's not an easy way to do that. So I think you really have to toe the line between not sharing the primary sources, potentially providing that provider of fake news, financial revenue from clicks, which is a lot of times what they want. Or providing a really misguided researcher, a clinician validation that their technique is not loved by the general medical population because they're jealous of his success, you know, something that they can take it the other way to spin it as a positive for their business. Karen Litzy:                   11:39                Right. And because if you're re tweeting this and clicking on it and retweeting it, you're giving it life, which is what they want. That's what we don't want to do. Jason Falvey:                 11:52                Right. And I think that's one of the ways that propaganda is designed right from the early days of using propaganda as a war tool. It was shared not just for people that believed in it heavily. It was shared in outrage and passed along and whispered about which served the exact same purpose. So really it's hard to discipline ourselves in a really, like we see something, we feel like we immediately have to react on social media and immediately have to comment on it. And I've been guilty of sharing articles that are either satire and actually taking them seriously, which has happened once in a fatigue non-caffeinated state. And also information or studies, which I think in hindsight probably weren't high quality or perhaps overstated its conclusions. My own articles have had overstated conclusions written and press releases that weren't by me or interpretation of written press releases that are perhaps more definitive than I would have wanted, you know, not fake news, but certainly unintentionally declarative about the quality and strength of the evidence versus, you know, the hypothesis generating evidence that it was. Karen Litzy:                   13:16                Yeah, absolutely. You sort of alluded to one way as healthcare providers that we can combat the fake news or the medical disinformation and that's taking time to read the source if it's a press release, to read the article, to maybe look at the methodology and to see how would rate this study? So that's one way we can combat it, which takes time. And like you said, on social media, people often react quickly because it's emotional. So maybe we need to take a deep breath and then take a moment and think about what we want to do. Do we want to share this misinformation or do we want to read it and come up with maybe another way to share more positive information? What else can we do as healthcare providers to get around this fake news? Jason Falvey:                 14:14                When we encounter something that we think is fake news or unintentionally or intentionally hyperbolic to the point where we think it's harmful to patients. And I think that's the line I draw. If I think that potentially sharing or engaging with this information in any way which propagate information that's harmful to patients. I generally take a little extra caution. And one of the things I look at, you know, I see in politically or in health care news, if I see a that goes out that has a really high comments or retweet ratio. So there's this term ratioed and it's not scientific and it's not peer reviewed. But I find that the good starting point when you see a tweet from a government official or a healthcare provider, healthcare related source, and there's more than double the amount of comments, then there is retweets and the likes. Jason Falvey:                 15:18                It makes me go and do a little bit more investigation. You know, sometimes those comments are positive and way to go. And sometimes there's a lot of skepticism or criticism of the findings or people really, you know, offering some real insight into some of the problems in methodologically or otherwise. And often a well done methodological study can be completely blown out of the water on Twitter by a very poorly written headlines. Right. We should care about storylines, not just headlines. And one of the ways we do that, looking at comments, retweets, and the likes, looking at that ratio and look at the source, right? Who's retweeting? And so I pay attention to that because most fake news on the Internet is actually propagated by bots. So there's a very high percentage of fake news that was propagated by automated accounts that are automatically set up to capture certain hashtags or certain language and amplify it. Jason Falvey:                 16:23                You know, if you're a political audience would know that that's how the Russians basically designed the misinformation campaign to influence the 2016 election using bots to amplify certain messages. Well, that happens to a lesser extent in health care. There are certain pockets, you know, of health care professionals, and there may be some in our profession that provide certain treatments. There may be some in other alternative medicine professions, there may be some in mainstream medical professions that are physicians or nurses who use their medical expertise and propagate information about medical techniques like abortion or vaccines in a way that makes them seem more credible. So I look at who's retweeting what the population of people are retweeting is, who the person the primary sources coming from. Right. You said if it's a summary of an article from a press release or somebody's blog, like I want to go and find that primary source and then also look at the bias of the person who may be interpreting that information for me if they're a credible source. Karen Litzy:                   17:40                Yeah. And I think you also want to keep in mind those hot button issues may have more misinformation about them. Like you said, vaccines, abortions, these are hot button issues, right? So you have to I think take a more examining eye to some of these hot button issues then with others. That's not to say that other issues in health care do not have as much misinformation surrounding them. But when you're talking about things that are really emotional for people, I think that's when you have to also take a good editing eye to some of this information being put out there. Jason Falvey:                 18:26                Looking at the source of information is one thing you can see. Cleveland clinic has accidentally posted fake news before where they put in like a really positive result from an innovative experimental therapy for cancer. And they put it in a brain scan and said this person had a miraculous results forgetting to mention that they also were receiving the standard care and this additional therapy would, they didn't know if that was the cause or if it was just a normal reaction to the normal care. But then all of a sudden you created a demand for something that is at best maybe ineffective and at worse, we don't know if it's harmful. By having a high visibility site, your responsibility for news is even higher. So I think that's an important piece. Like know who's tweeting it, but then go back and make sure you have the whole story. If it sounds too good to be true. Jason Falvey:                 19:38                This is the humanities education that a lot of PT students have complained that they've had to take history and literature and policy courses throughout their undergraduate degrees and some have suggested streamlining education to really eliminate those things. My counter argument is those skills you learned from critical thinking and critical reading and analysis and understanding of historical context and how to read hyperbole, how to read marketing and different kinds of language really with a critical eye, you tend to develop a radar for when you're suspicious of information and when you want to go and look a little deeper, even if it's from what you view as a pretty credible source. Karen Litzy:                   20:27                Yeah, absolutely. So we've got taking your time really looking at not only the source of the article but who's re tweeting it and that retweet to comment ratio. Is there anything else that we should be doing as healthcare professionals to make sure that we're not propagating this misinformation? Jason Falvey:                 20:54                Another thing I think would be really helpful is crowd sourcing, right? So most of us are networked on social media with a lot of other really knowledgeable professionals. You know, I know that on my Twitter feed alone, half the people are probably smarter than me. Karen Litzy:                   21:10                Oh, I don’t know about that. Jason Falvey:                 21:14                But that's intentional, right? Like I want to be in a community of really intelligent people who think about issues critically, who may have different opinions than me. And I could say, I just read a study about Xyz and the conclusion seems flawed. Who would want to, you know, and maybe I don't name the article, maybe I don't put a link to it. I just put the tweet and throw out a few names and say, Hey, I would love if some of my community would like to take a look at this and tell me what they think. Right. If I'm on the borderline of whether or not I think this is legitimate or I asked somebody in the profession, you know, lean on them to really make sure that I'm taking that extra step to not share information that is influencing medical decisions in a negative way. Jason Falvey:                 22:03                And I teach my patients these same strategies, right when I'm talking to patients and caregivers who are googling information, WebMDing, looking at blogs, and I've had patients with significant neurological illnesses that are terminal. And one of the places I've practiced, and I won't name that place if it's a relatively rare disease, but this person searched the literature and she was very well educated person, searched the literature high and low for a cure for her neurodegenerative disease and found one that was highly controversial. Probably harmful. And she invested thousands of dollars and hundreds of hours of travel over three months for something that was not beneficial while she was askewing typical medical care. So you know, that kind of taught me how to teach patients, not just how to look for information, right? That's part of the problem. But how to evaluate information, how to triangulate information to make sure that the reference that they found is supported by expert opinion and maybe other articles and making sure that there's a critical mass of support for this particular treatment before they really make a major alteration to their course. Jason Falvey:                 23:21                A single article about a vitamin supplement that might help that has little harm. You know, that may be something that I don't intervene on, but somebody who's thinking about making massive changes to their medical routine, whether it has directly to do with Rehab or not. I encourage people to look at the literature critically and I use the word triangulation and I draw it out. I'm just like, you should be able to verify this information should be similar between these three things. Right? And if they tell me that they've done that and they found those three things, I'm more comfortable, even if I disagree, at least I've done my diligence to make sure they looked at the issue in a robust way and not fallen victim to something that was purely a single tweet or Facebook post of medical disinformation. Karen Litzy:                   24:15                That's a shame. And I think it's important that you brought up that as healthcare professionals, we should be talking to our patients about this and we should be teaching them stuff. Glad that you went through that. Yes, we should be teaching them what to look for. If we can have a more educated patient base and a more educated base of health care professionals that high in the sky view. Of course the amount of misinformation may be less. Jason Falvey:                 24:45                Yeah. And I think there are certain countries that have done a lot of work. Norway for example, has done a lot of work from a country perspective on educating citizenry on medical and you know, general disinformation, both political and medical and teaching, how to recognize it. Giving a lot of the same strategies we've talked about of really time and a little bit of additional resource and that solves so many of the problems. If you don't change some of these decision making process and they still are firm believers in the medical information at that point then you go to some of the other strategies, you know, more targeted intervention. But I think as a general population strategy, those are great places to start and really just, I tell patients all the time, I am going to be telling you seek information, not affirmation. Jason Falvey:                 25:45                If you have a friend who told you about this treatment, you need to remember that everybody responds individually, the medications and treatments and you know, cause I think we've all had patients that say my friend got this therapy and their knee got better, really inappropriate for that patient. But it's really hard to walk that back, you know, from just your professional opinion. So teaching them how to look for information and letting them look for it on their own instead of providing it to them I have found is sometimes a helpful strategy because it feels like I'm not forcing my view on them. At the end of the day you can rest knowing that you put tools in people's hands, you know, health care providers or patients teach them how to do these things. I mean, but it does take some effort on their part too. Jason Falvey:                 26:37                You definitely have to want to read these things carefully and you have to have the mindset that you don't want to just look for information that validates what you already believe. And I've seen this, you know, I don't like to pick on dry needling, but I definitely have seen people who are very strong believers in dry needling, just cherry pick evidence that supports their worldview, without recognizing that there's a lot more nuance to that discussion. And I'm not anti or pro dry needling. I'm pro information. Looking carefully and realizing that there are patients who do benefit from it, but it is certainly not a blanket treatment that everybody should be using and it's a tool in your bag, like everything. So, I think it's really important to just have that seek information, not affirmation. If I can say something a few times on this podcast that will be what it is. Karen Litzy:                   27:40                Well, and then my next question would be, after having this great conversation, is there anything we missed and is there anything that you really want people to stick in people's minds, which I think you just said it, but I'll ask the question anyway. Jason Falvey:                 27:55                Yeah. And I think the other thing is like, when you are a healthcare professional, I think investing money in like high quality sources or whatever source. For me, I tend to read a newspaper in New York Times or Washington Post. I have a subscription to it. I try to support that kind of, you know, to provide financial resources to a place that I trust to provide good information because that is positive reinforcement, right? I try not to provide positive financial rewards to places that are providing this information. And you do that by clicking on their articles, right? You read a headline and it's like vaccines cause autism study says, and I clicked on that headline, I’ve unintentionally propagated and supported financially that fake news provider who now is incentivized to create more fake news. So I think it takes a lot of discipline to not fall victim to our need to read everything. Jason Falvey:                 29:02                And you know, sometimes we have to think about the greater good is not clicking on that article. Shutting it down, blocking that news source or whatever, if you really feel like it's egregious enough and not engaging with it. Creating polarization. Polarization is what creates ratings on television. Polarization is what creates ratings on radio, polarization is what gets people to download podcasts and things that are highly controversial. Polarization, you know, sells books, right? The top selling books on New York Times bestseller lists are generally, there's political books that exist, sometimes multiple political books that are on that list from different points of view. So I think it's really important that we don't support agregious, you know, fake news providers or fake healthcare news providers and don't engage with them on Twitter because that's giving them a form of a positive attention. Even if you're criticizing their work, that they can go ahead and leverage to share more. Karen Litzy:                   30:13                Yeah, I thank you for all that great information. And hopefully the listeners can really take this in and understand that what we do on social media has ramifications one to our profession and two to the people we serve. So before we leave, I have a last question and normally I ask people, what advice would you give to yourself as a new Grad? But I'm going to ask you, what advice would you give to yourself as a new Grad physical therapist in light of fake news? Jason Falvey:                 30:50                Oh, that's a great question. Beyond the sentence I said of seek information not affirmation, which I think is helpful for research and beyond, I think one of the things I would tell myself as a new Grad physical therapist in this era is I would be incredibly thankful for my English education, my bachelor's degree in English, all of the humanities and critical thinking classes that I took and all of the writing that I did because trust me, I wrote enough papers as an undergraduate that probably could have qualified this fake news cause I didn't really read the books very carefully and really had some made up opinions about what I thought was happening. So I think I can recognize the difference in that writing now. And I would tell myself, be appreciative of the education in humanities and the historical context that you've gained and use those skills. Don't forget about them. They are valuable parts of your tool bag. They are not direct patient care skills, but there among the most critical soft skills you can obtain to really do a good service to your patients and teaching them how to use those skills and taking healthcare into their own hands. Karen Litzy:                   32:13                Awesome. Well, thank you so much. This was a great discussion. I'm glad we finally got to do this. Where can people find you if they want more info or to ask you questions? Jason Falvey:                 32:26                Yeah, so I am listed on the Yale site, I am not officially representing Yale now just to put that out there, but my email address is on the Yale division of geriatrics site. I'm also on Twitter at @JRayFalvey and I'm sure you'll put that in your show notes. Those are the two things. And hold me accountable. Do you see me sharing something that you think is not a great source of information? Tell me about it. Right. And I think holding each other accountable is part of this process and doing that in a professional way is all the better. Karen Litzy:                   33:07                Thanks again for coming on. And everyone, thanks so much for listening. Have a great couple of days and stay healthy, wealthy and smart.   Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram  and facebook to stay updated on all of the latest!  Show your support for the show by leaving a rating and review on iTunes!

Sandy and Bronnie join the podcast today to discuss graded exposure for musculoskeletal issues, including (of course) sexual pain. We discuss what it is, why it is useful and how we can go about implementing it in a variety of pain conditions.

F. Scott Feil sits down with Sandy Hilton, Sarah Haag, & Karen Litzy while they are all at CSM 2018 in New Orleans to talk about international conferences. They talk about the benefits of going to international conferences, how to navigate international conferences, how to navigate which conference is best for you to attend, differences between conferences in the U.S and conferences outside of the U.S, the guests pitch their favorite conferences, and much more!   Join Karen and others at the Women in PT Summit!! The Early Bird rate expires on August 1st so be sure to grab a ticket at the discounted rate! Women in PT Summit: http://womeninpt.com/   Karen Litzy's Website: https://karenlitzy.com/  The Healthy, Wealthy & Smart Podcast Website: http://podcast.healthywealthysmart.com/  The Healthy, Wealthy & Smart Podcast on Itunes: https://itunes.apple.com/us/podcast/healthy-wealthy-smart/id532717264?mt=2  Karen's Interview on Therapy Insiders on "Why Aren't There More Women Leaders?" : https://itunes.apple.com/us/podcast/why-arent-there-more-women-leaders-special-episode/id609009250?i=1000384711690&mt=2  Karen's Facebook Page: https://www.facebook.com/karen.litzy  Karen's Twitter Page: https://twitter.com/karenlitzyNYC  Karen's Instagram Page: https://www.instagram.com/karenlitzy/  Entropy Physio Website: http://entropy-physio.com/  Pain Science & Sensibility Podcast: https://itunes.apple.com/us/podcast/pain-science-and-sensibility/id1003630972?mt=2  San Diego Pain Summit Website: https://www.sandiegopainsummit.com/  Sandy's Facebook Page: https://www.facebook.com/sandy.hilton.73  Sarah's Facebook Page: https://www.facebook.com/sarah.haag.129  Sandy's Twitter Page: https://twitter.com/SandyHiltonPT  Sarah's Twitter Page: https://twitter.com/SarahHaagPT  Sandy's Instagram Page: https://www.instagram.com/sandyhiltonpt/  Sarah's Instagram Page: https://www.instagram.com/ssarahjopt/  The PT Hustle Website: https://www.thepthustle.com/  Schedule with Kyle Rice : www.passtheptboards.com    HET L.I.T.E Tool: www.pteducator.com/het  Biographies: Sandy Hilton graduated from Pacific University (Oregon) in 1988 with a Master of Science in Physical Therapy and a Doctor of Physical Therapy degree from Des Moines University in December 2013. She has worked in multiple settings across the US with neurologic and orthopaedic emphasis combining these with a focus in pelvic rehabilitation for pain and dysfunction since 1995. Sandy teaches  Health Professionals and Community Education classes on returning to function following back and pelvic pain, has assisted with Myofascial Release education, and co-teaches Advanced Level Male Pelvic Floor Evaluation and Treatment. Sandy's clinical interest is chronic pain with a particular interest in complex pelvic pain disorders for men and women.  Sandy is the co-host of Pain Science and Sensibility, a podcast on the application of research into the clinic.    Sarah Haag graduated from Marquette University in 2002 with a Master's of Physical Therapy. Sarah has pursued an interest in treating the spine, pelvis with a specialization in women's and men's health.  She went on to get her Doctorate of Physical Therapy and Masters of Science in Women's Health from Rosalind Franklin University in 2008. In 2009 she was awarded a Board Certification as a specialist in women's health (WCS). Sarah also completed a Certification in Mechanical Diagnosis Therapy from the Mckenzie Institute in 2010.  Most recently, Sarah completed a 200 hour Yoga Instructor Training Program, and is now a  Registered Yoga Instructor. Sarah plans to integrate yoga into her rehabilitation programs, as well as teach small, personalized classes.  Sarah looks at education, and a better understanding of the latest evidence in the field of physical therapy, as the best way to help people learn about their conditions, and to help people learn to take care of themselves throughout the life span.   Karen Litzy started her physical therapy career in an inpatient hospital in Scranton, Pa. Moving to New York a few years later she had the opportunity to work for the New York public school system, Broadway musicals and orthopedic outpatient clinics. While the work was rewarding, she always felt like she could do more to serve her clients.  As she was searching for ways to provide a more comprehensive approach to practicing physical therapy she became overwhelmed with requests from clients to be seen in their home or office. This was an opportunity to provide not just convenience, but a different kind of practice. By adopting a “concierge” model, she could dedicate a full hour of one-on-one treatment to each and every client. Now she had ample time to evaluate, treat and re-evaluate. The concierge model allowed me the time to provide vital client education. Her clients would now benefit from a comprehensive home education program.  As part of her commitment to her clients and her career, She is constantly engaging in continuing education. She has been lucky enough to learn directly from some of the best in the profession. She has received certificates from Dr. David Butler, Dr. Lorimer Moseley, Dr. Adriaan Louw, Dr. Paul Hodges, The Institute of Physical Art, The American Physical Therapy Association, Hospital for Special Surgery, and many more. She graduated from Misericordia University with her masters degree in Physical Therapy in 1997 and then graduated from the same university in 2014 with a Doctorate of Physical Therapy.  She is the host of the podcast, Healthy, Wealthy, and Smart. The podcast provides up to date clinical information combined with business strategies from the best and brightest thought leaders in physical therapy, wellness and entrepreneurship. The show promotes the profession and provides a channel to get the most accurate information out there for both practicing physical therapists and everyday people.  She is a proud member of the American Physical Therapy Association (APTA), the Orthopedic Section of the APTA, the Section on Women's health, the Home Health Section and the Private Practice Section of the APTA. She is also an official spokesperson for the APTA as a member of their media corps.  Physical therapy is an ever evolving practice and for her, a personal journey. That's why she's committed to staying at the forefront of the industry. Through continuing education and her practice, she works to enrich myself so she can impart to others the true value of physical therapy. Her mission is to show people how physical therapy can improve their lives. This is what drives her to help her clients attain their own goals and for herself to build upon the work of those who have helped lead the way

F. Scott Feil interviews Sandy Hilton & Sarah Haag (Founders of Entropy Physio in Chicago, IL) while live at CSM 2018 in New Orleans with Brandon joining via computer. Sandy & Sarah discuss their development and path to where they are now, the most common conditions they see related to female and male pelvic health, most effective education tactics for teaching patients with pelvic health conditions, advice for the newer clinician looking to develop more into pelvic health, and much more! Entropy Physio Website: http://entropy-physio.com/  Pain Science & Sensibility Podcast: https://itunes.apple.com/us/podcast/pain-science-and-sensibility/id1003630972?mt=2  "Why Pelvic Pain Hurts" book: https://www.amazon.com/Pelvic-Pain-Hurts-Adriaan-Louw/dp/0985718684/ref=sr_1_1?ie=UTF8&qid=1529551059&sr=8-1&keywords=why+pelvic+pain+hurts  International Pelvic Pain Society: https://www.pelvicpain.org/  International Continence Society: https://www.ics.org/  APTA Clinical Practice Guidelines: http://www.apta.org/EvidenceResearch/EBPTools/CPGs/  Sandy's Facebook Page: https://www.facebook.com/sandy.hilton.73  Sarah's Facebook Page: https://www.facebook.com/sarah.haag.129  Sandy's Twitter Page: https://twitter.com/SandyHiltonPT  Sarah's Twitter Page: https://twitter.com/SarahHaagPT  Sandy's Instagram Page: https://www.instagram.com/sandyhiltonpt/  Sarah's Instagram Page: https://www.instagram.com/ssarahjopt/  HET L.I.T.E Tool: www.pteducator.com/het  Biographies: Sandy Hilton graduated from Pacific University (Oregon) in 1988 with a Master of Science in Physical Therapy and a Doctor of Physical Therapy degree from Des Moines University in December 2013. She has worked in multiple settings across the US with neurologic and orthopaedic emphasis combining these with a focus in pelvic rehabilitation for pain and dysfunction since 1995. Sandy teaches  Health Professionals and Community Education classes on returning to function following back and pelvic pain, has assisted with Myofascial Release education, and co-teaches Advanced Level Male Pelvic Floor Evaluation and Treatment. Sandy's clinical interest is chronic pain with a particular interest in complex pelvic pain disorders for men and women.  Sandy is the co-host of Pain Science and Sensibility, a podcast on the application of research into the clinic.    Sarah Haag graduated from Marquette University in 2002 with a Master's of Physical Therapy. Sarah has pursued an interest in treating the spine, pelvis with a specialization in women's and men's health.  She went on to get her Doctorate of Physical Therapy and Masters of Science in Women's Health from Rosalind Franklin University in 2008. In 2009 she was awarded a Board Certification as a specialist in women's health (WCS). Sarah also completed a Certification in Mechanical Diagnosis Therapy from the Mckenzie Institute in 2010.  Most recently, Sarah completed a 200 hour Yoga Instructor Training Program, and is now a  Registered Yoga Instructor. Sarah plans to integrate yoga into her rehabilitation programs, as well as teach small, personalized classes.  Sarah looks at education, and a better understanding of the latest evidence in the field of physical therapy, as the best way to help people learn about their conditions, and to help people learn to take care of themselves throughout the life span.

When we think of pelvic pain, we easily associate that with women disorders which they even call women’s health therapy or women’s health section. There aren’t enough specialized care provided for men who are experiencing pelvic pain, even more so for the LGBT community. Dr. Sandy Hilton is a Doctor of Physical Therapy and one of the world's leading pelvic health experts and the founder of Entropy Physiotherapy which is a practice that specializes in the treatment of complex chronic pelvic pain conditions. She sheds light about women's pelvic pain, men's pelvic pain, the challenges of the LGBT community with regard to finding adequate pelvic health services, how the tragic events surrounding gymnastics doctor Larry Nassar and the #MeToo Movement affected the public's perception of pelvic care, and the role of prevention and education plays in being a pelvic health physical therapist. Sign up for the latest episode at www.drjoetatta.com/podcasts.   Love the show? Subscribe, rate, review, and share! Here’s How » Join the Healing Pain Podcast Community today: drjoetatta.com Healing Pain Podcast Facebook Healing Pain Podcast Twitter Healing Pain Podcast YouTube Healing Pain Podcast LinkedIn

Tyler & Jared were super excited to have an opportunity to chat with Dr. Sandy Hilton of Entropy Physiotherapy & Wellness and from the Pain Science & Sensibility Podcast! Dr. Sandy has been a huge force in elevating pelvic health physiotherapy, persistent pain treatment, and pain science education. Also Dr. Sandy is just an all-around badass. We picked her brain about: nerdy physical therapy jokes, how to measure the strength of literature, manual therapy, finding the magic, is it wrong to make people feel good, dopamine, self-efficacy, words, orgasms, the Gemelli Brothers, incontinence, loading, how long should we be peeing, kegels, how to lift our testicles, clinical practice guidelines, trigger points, and Richard Pryor. Thanks for listening! --- This episode is sponsored by · Anchor: The easiest way to make a podcast. https://anchor.fm/app --- Send in a voice message: https://anchor.fm/duck-legs/message Support this podcast: https://anchor.fm/duck-legs/support

Sometimes, there are pain areas that people aren’t always comfortable discussing. Even further, it’s easy for us to compare, for example, our hands to others around us. But some areas… well, let’s just say, we’re not going around comparing those! So we need a safe environment for patients to feel comfortable and confident getting the treatment they deserve. We welcome back Dr. Sandy Hilton to Pain Reframed! Sandy joined us way back on episode 7! Sandy and her business partner, Sarah Haag, of Entropy Physiotherapy, have made a community out of their clinic due to the forward-thinking environment they have created there, helping to ensure the patients feel welcome and comfortable. We will continue the discussion on how to handle sensitive pain topics and best treat our patients. Don’t forget!! It’s almost here!! June 8-10, 2018 in Denver, Colorado, the Align Conference will be taking place, focusing on neuropathic (nerve) pain.  All of the various concepts of calming the nerves down will be covered at this conference. LINKS: http://entropy-physio.com/ @sandyhiltonpt sandy@entropy-physio.com The Pain Science and Sensibility Podcast http://ispinstitute.com http://www.alignconference.com/ http://evidenceinmotion.com @eimteam

LIVE from the Combined Sections Meeting in New Orleans, Lousiana, Matthew Villegas organized a Q & A with Dr. Karen Litzy and Dr. Sandy Hilton about pain science. Dr. Litzy is currently the owner of Karen Litzy Physical Therapy, PLLC, a concierge physical therapy practice in New York City, where she sees clients in their home, gym or office and she is the host of the Healthy Wealthy and Smart Podcast. Dr. Sandy Hilton is a physical therapist and her clinical interest is chronic pain with a particular interest in complex pelvic pain disorders for men and women. Sandy is the co-host of Pain Science and Sensibility, a podcast on the application of research into the clinic. In this episode, we discuss: -How does psychology and culture impact someone’s pain experience -Managing expectations and celebrating small wins with patients with CRPS -Self care tips to prevent empathy burnout in physical therapy -Interprofessional collaboration to best manage persistent pain patients -And so much more!   Explaining pain needs to be part of a graded education program just like any exercise program as Sandy reminds, “Everyone learns differently and pain is a uniquely individual experience.”   Every small success should be celebrated and Sandy encourages patients to, “Claim those victories because when you can start doing that¸ you can start building on them.”   Patients with persistent pain would benefit from assurance and motivation as Karen stresses, “If you can be the person for that patient to listen to them, to offer good solid advice, help them take control over their life versus the pain controlling their life, and being able to really get them to understand that they are not fragile and they’re not broken and they’re not damaged goods, that’ll go a long way of getting them better without putting your hands on them or loading a tissue.”   Sandy believes the role of the physical therapist is, “Un-scaring someone and giving them a path to follow and sign marks along the way to be able to recognize that they are getting better and being there to walk it through with them.”   For more information on Karen: Dr. Litzy is currently the owner of Karen Litzy Physical Therapy, PLLC, a concierge physical therapy practice in New York City, where she sees clients in their home, gym or office. Aside from physical therapy clients she also sees clients for wellness training, surgical packages and golf fitness evaluations. She is on the board of directors for the non-profit Physical Therapy Business Alliance and part of the PT Day of Service team. Dr. Litzy consults with physical therapy colleagues on how to start and maintain a successful out of network physical therapy practice. http://karenlitzy.com/   For more information on Sandy: Sandy graduated from Pacific University (Oregon) in 1988 with a Master of Science in Physical Therapy and a Doctor of Physical Therapy degree from Des Moines University in December 2013. She has worked in multiple settings across the US with neurologic and orthopaedic emphasis combining these with a focus in pelvic rehabilitation for pain and dysfunction since 1995. Sandy teaches Health Professionals and Community Education classes on returning to function following back and pelvic pain, has assisted with Myofascial Release education, and co-teaches Advanced Level Male Pelvic Floor Evaluation and Treatment. Sandy’s clinical interest is chronic pain with a particular interest in complex pelvic pain disorders for men and women. Sandy is the co-host of Pain Science and Sensibility, a podcast on the application of research into the clinic.   For more information on Matthew: My name is Matthew Villegas. I host Capable Body Podcast (available on iTunes, Google Play, and Stitcher), which aims to bridge the gap between healthcare providers and real people with real stories. Also, the podcast features an active Facebook community that is a safe space where I share more means to connect with my guests as well as some behind-the-scenes extras.   Resources discussed on this show: Matthew Villegas Website Matthew Villegas Twitter Sandy Hilton Twitter Karen Litzy Twitter World Congress on Pain   Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram and facebook to stay updated on all of the latest! Show your support for the show by leaving a rating and review on iTunes!   Have a great week and stay Healthy Wealthy and Smart!   Xo Karen    

LIVE from the Combined Sections Meeting in New Orleans, Louisiana, it is my pleasure to welcome Dr. Sarah Haag, Dr. Sandy Hilton and Dr. Jason Falvey back for Part 4 all about sex. Check out Part 1, Part 2 and Part 3 and enjoy another installment!   In this episode, we discuss: -Biomechanical considerations for different sex positions -How to support your partner following child birth -Why sexual dysfunction may be an important predictor of future cardiovascular problems -Sexual health for the LGBTQI+ population -And so much more!   Pelvic health interventions follow the same treatment principles as any other orthopedic conditions. Sandy stresses, “Strength and conditioning principles really do apply to pelvic health it’s just the movement is a centimeter, it’s very small but the scale is proportionally the same so if you’re having problems with loading and frequency and dosage of your program, just adapt it. You don’t have to stop.” Sarah reaffirms this and recommends that patients, “Do what you do and should you run into issues, again graded exposure and practice I think is the best answer.”   When treating sexual dysfunction, it’s important to consider what could be affecting patients beyond purely biomechanical ailments. For example Sarah explains that, “When someone does become ill, if you’re not typically the caregiver and now there’s that role shift, that’s a psychosocial issue.” Jason stresses the importance this can play with older adults as, “It’s a very hard transition for people to transition from caregiver to lover.”   All physical therapists should be able to break past the stigma surrounding pelvic health issues, even if it is not their specialty. It’s important to inform patients that help exists as Sarah has found that, “When it comes to sexual dysfunction and bowel and bladder dysfunction, a lot of people don’t know what’s normal and even when people aren’t happy with the function which is really the key that they need to get help, they don’t know that there is help.”   For more information on the guests: SARAH HAAG PT, DPT, MS, WCS CERT. MDT, RYT: Sarah graduated from Marquette University in 2002 with a Master’s of Physical Therapy. Sarah has pursued an interest in treating the spine, pelvis with a specialization in women’s and men’s health. Over the years, Sarah has seized every opportunity available to her in order to further her understanding of the human body, and the various ways it can seem to fall apart in order to sympathetically and efficiently facilitate a return to optimal function. Sarah was awarded the Certificate of Achievement in Pelvic Physical Therapy (CAPP) from the Section on Women’s Health. She went on to get her Doctorate of Physical Therapy and Masters of Science in Women’s Health from Rosalind Franklin University in 2008. In 2009 she was awarded a Board Certification as a specialist in women’s health (WCS). Sarah also completed a Certification in Mechanical Diagnosis Therapy from the Mckenzie Institute in 2010. Most recently, Sarah completed a 200 hour Yoga Instructor Training Program, and is now a Registered Yoga Instructor. Sarah plans to integrate yoga into her rehabilitation programs, as well as teach small, personalized classes.   Sarah looks at education, and a better understanding of the latest evidence in the field of physical therapy, as the best way to help people learn about their conditions, and to help people learn to take care of themselves throughout the life span.   SANDY HILTON PT, DPT, MS: Sandy graduated from Pacific University (Oregon) in 1988 with a Master of Science in Physical Therapy and a Doctor of Physical Therapy degree from Des Moines University in December 2013. She has worked in multiple settings across the US with neurologic and orthopaedic emphasis combining these with a focus in pelvic rehabilitation for pain and dysfunction since 1995. Sandy teaches Health Professionals and Community Education classes on returning to function following back and pelvic pain, has assisted with Myofascial Release education, and co-teaches Advanced Level Male Pelvic Floor Evaluation and Treatment. Sandy’s clinical interest is chronic pain with a particular interest in complex pelvic pain disorders for men and women. Sandy is the co-host of Pain Science and Sensibility, a podcast on the application of research into the clinic.   JASON FALVEY PT, DPT, GCS, CEEAA: Jason is a board certified geriatric physical therapist with a strong interest in improving outcomes for both frail older adults and older adults with hospital-associated deconditioning. He has current funding from the Foundation for Physical Therapy (PODS 1 Award, 2015) and the Academy of Geriatric Physical Therapy to support his participation in ongoing research the use of a novel Progressive High Intensity Therapy (PHIT) training program on medically complex older adults after acute hospitalization. He also has funding from both the American Physical Therapy Association Health Policy and Administration Section and the Home Health Section to evaluate how physical therapists can reduce avoidable hospital readmissions. Lastly, Jason is collaborating with local long-term care providers to determine how physical functioning can be assessed and best managed to reduce rates of falls, ER visits, and hospitalization.   Resources discussed on this show: Jason Falvey Twitter Sarah Haag Twitter Sandy Hilton Twitter Uchenna Ossai Twitter Meryl Alappattu Twitter Rena McDaniel Twitter A THERAPY TOOLKIT FOR TREATMENT OF URINARY INCONTINENCE   Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram and facebook to stay updated on all of the latest! Show your support for the show by leaving a rating and review on iTunes!   Have a great week and stay Healthy Wealthy and Smart!   Xo Karen    

Well this was an interesting episode!  Listen in as Sandy Hilton discusses the importance of kegals for men, how to do them and WHY they are so important.  She also shares with us some key signs to be aware of that could indicate your pelvic health is taking a turn for the worse! If you recognize some of these signs, have no fear!  A pelvic health specialist can help you!  Sandy has over 30 years of experience as a physical therapist,  working directly with men, women and transgender individuals to maximize their pelvic health including bladder, bowel and sexual function.  Entropy Website Find a Pelvic Health PT near me! www.menshealth.com/sex-women/kegels-for-men-benefits Sponsored by www.ptuclinic.com Follow the Health and Fitness Connector on Facebook and Instagram!

This week, on Pain Reframed, Dr. Tim Flynn and Dr. Jeff Moore share some of the most powerful and discussed conversations that have occurred here on Pain Reframed throughout 2017. We’re sharing clips from episodes with Sandy Hilton, Dr. Anna Lembke, Dr. Adam Ryan, Dr. Melissa Cady, Dr. Cheryl Keller Capone, Dr. David Hanscom, Dr. Ben Bobrow, Dr. Adriaan Louw, Dr. Beth Darnall, and Dr. Peter O’Sullivan. Thank you very much for listening to Pain Reframed this year and joining in on the amazing discussions! We couldn’t have done this without you and appreciate everything you’ve done for us in 2017. We will talk to you next week to kick 2018 off with some exceptional content! Happy New Year!! Don’t forget to save the date: June 8-10, 2018 in Denver, Colorado, the Align Conference will be taking place, focusing on neuropathic (nerve) pain.  All of the various concepts of calming the nerves down will be covered at this conference. LINKS: http://ispinstitute.com http://www.alignconference.com/ http://evidenceinmotion.com @eimteam

Dr. Melissa Farmer, a clinical psychologist and neuroscientist, joins Dr. Sandy Hilton and myself to discuss what is considered normal in intimacy, pain mechanisms involved when sex becomes painful and pain as an emotional memory.

Dr. Sandy Hilton discusses the basics of how to read a research paper, what is good and bad and where to find it. This is a must for any evidence-based professional in the health field.

Welcome back to Pain Reframed!  Today, we have the second Reframed Recap!  Dr. Tim Flynn and Dr. Jeff Moore look back at previous episodes and interviews to dig deeper and add more commentary and insights learned from these interviews and discussions! This week, we’ll be looking back at the conversations and awesome content shared in the episodes and interviews with Sandy Hilton, The Real Brian, and Dr. Anna Lembke. LINKS: http://ispinstitute.com http://evidenceinmotion.com @eimteam

Welcome back to Pain Reframed!  This week, we welcome Sandy Hilton of Entropy Physiotherapy to the show!  Sandy and her business partner, Sarah Haag, have done some incredible things at Entropy Physiotherapy.  They have made a community out of their clinic due to the amazing environment they have created there, helping to ensure the patients feel welcome and comfortable.  Sandy is instrumental in the areas of pain management as well and will be discussing her thoughts and expertise on this topic. Sandy, Tim, and Jeff discuss pain sciences, how much we actually know about it, what we can do to continually learn and grow and treat the patient as a whole, and the idea of turning pain science into the “air we breathe and not the thing we do.” LINKS: http://entropy-physio.com/ @sandyhiltonpt The Pain Science and Sensibility Podcast http://ispinstitute.com http://evidenceinmotion.com @eimteam

At the Voice of the Patient, we are dedicated to enhancing our ability as health care providers to truly listen to others and to establish a therapeutic alliance. In some cases, we can benefit from listening to the experience and mindset of other providers, such as Dr. Mark Bishop, PT, PhD. Dr. Bishop is an Associate Professor in the Department of Physical Therapy. Dr. Bishop received his entry-level training in Australia and has extensive experience working as a physical therapist. His research interests are in the management of musculoskeletal conditions, particularly pain, by orthopedic physical therapy. He also researches nonspecific effects in physical therapy, including the role of the expectations of providers and patients in therapeutic outcomes. We discuss many aspects of the therapeutic alliance, including therapist expectations, patient expectations, and placebo. We talk about research from Dr. Bishop and other scientists that have tested the role of expectancy in treatment, and Dr. Bishop shares advice for providers to maximize outcomes in an evidence-based manner.  Further reading: Journal articles on expectations: Individual Expectation: An Overlooked, but Pertinent, Factor in the Treatment of Individuals Experiencing Musculoskeletal Pain. Bialosky, Bishop, and Cleland, 2010. The influence of expectation on spinal manipulation induced hypoalgesia: An experimental study in normal subjects. By Bialosky, Bishop, et al. 2008. Patient expectations of benefit from common interventions for low back pain and effects on outcome: secondary analysis of a clinical trial of manual therapy interventions. By Bishop et al., 2011. Journal articles on placebo: Placebo response to manual therapy: something out of nothing? By Bialosky, Bishop, et al. 2011 Placebo, Nocebo, and Expectations: Leveraging Positive Outcomes. By Benz and Flynn, 2013.  Placebo and the new physiology of the doctor-patient relationship. Benedetti, 2013.  Understanding placebo and nocebo responses for pain management. Colloca and Grillon, 2014.  Journal articles on equipoise: Review of clinical equipoise and personal equipoise. By Chad Cook and Charles Sheets.  Early use of thrust manipulation versus non-thrust: RCT. Cook et al., Man Ther, 2013. Objective measures of expectations Development of the Stanford Expectations of Treatment Scale. Patient-defined desired outcome, success criteria, and expectation in outpatient physical therapy: a longitudinal assessment. Zeppieri & George, 2017. #NeedleorNot Oxford Style Debate on Dry Needling at CSM 2017. Thanks to Kenny Venere, Kyle Ridgeway, Kali Aucoin, Mark Milligan, moderator Scot Morrison, and coordinator Sandy Hilton. Blog posts and podcasts: Expectations versus reality, by Kenny Venere Customer Service, by Jerry Durham. Don't Beat Patients with the Science Stick, by Dave Reed. Psychology in Physical Therapy, by the Evidence in Motion Practice Leadership Podcast PT Inquest: The Costs of Low Value Healthcare You can find Dr. Bishop on Twitter @physiobish. You can email him at bish@phhp.ufl.edu.  If you have a story to tell as a patient, provider, or both, then contact Zach Stearns on Twitter @zachrstearns or Dave Reed @DReedPT. Please note that nothing in this episode or any episode of the Voice of the Patient podcast should be considered medical advice. ---------- *Find more helpful podcasts & blog posts at http://TheVoiceOfThePatient.org *Check out the other podcasts in the Senior Rehab Project at http://SeniorRehabProject.com

Jared Updike shares his story about his experience with pain in this episode. He received diagnoses of psychogenic pain, central sensitization, myofascial pain syndrome, and fibromyalgia. Jared wrote a terrific blog post ("Doctor Masseuse"), which I discovered via Paul Ingraham's post on PainScience.com.  Jared Updike is Los Angeles-based software developer who learned about chronic pain and fatigue at the school of hard knocks. He hopes other sufferers can become their own health advocates, learning to manage their issues through patient education and their own informed, considered experimentation. He dishes out life advice and writes about technology, photography and his programming projects at his blog, Jareditorial, at jared.updike.org. You can follow him on Twitter @JaredUpdike. Jared shares his experiences -- including successes and struggles -- and we discuss some of the interesting science about pain. Jared shares his thoughts for health care providers and for patients struggling with pain. I also found out that Jared has been to 56 of the 59 National Parks! We discuss many resources about the science of pain. For more information, consider the following: Dr. Lorimer Moseley's post on Body In Mind: "Resconceptualising Pain According to Modern Pain Science" Dr. Karen Litzy's Healthy, Wealthy, and Smart Podcast with Dr. David Butler about Explain Pain Supercharged The Pain Science & Sensibility Podcast with Dr. Sandy Hilton and Cory Blickenstaff. Dr. Bronnie Thompson's post: "Is Central Sensitization Really A Thing?" Dr. Thompson's blog Health Skills blog contains many other helpful articles about pain. Tedx Talk in Adelaide from Lorimer Moseley - Why Things Hurt. The Message Pod with Dr. Lorimer Moseley: The Revolution in Managing Chronic Pain. MyCuppaJo.com - A blog from Joletta Belton about her experiences with (and without) pain. If you have a story to tell as a patient, provider, or both, then contact Zach Stearns on Twitter @zachrstearns or Dave Reed @DReedPT. Please note that nothing in this episode or any episode of the Voice of the Patient podcast should be considered medical advice. ---------- *Find more helpful podcasts & blog posts at http://TheVoiceOfThePatient.org *Check out the other podcasts in the Senior Rehab Project at http://SeniorRehabProject.com

On this episode of the Healthy Wealthy and Smart Podcast, Dr. Sandy Hilton and I went into the crowd at the San Diego Pain Summit on the last day to get the attendee's views on the Pain Summit this year.  In this episode, we learn: - The common theme running through the San Diego Pain Summit - Which talks resonated with a lot of the attendees of the summit - The reasons why you should attend the summit - What is in store for the San Diego Pain Summit 2018 - Lots of great behind the scenes conversations happy after hours - And much more!   "You know you are in the right room when you are definitely not the smartest person in the room" - Ben Cormack "There is nothing I don't like about the San Diego Pain Summit" - Eric Purves "It is a gathering of all of the clinicians I admire most in the world. Great to be able to to talk with them and pick their brains" - Laura Dunkley "Wonderful conversation about clinical and scientific problems to learn and share together" - Jonathan Fass "We are all a work in progress and you have to be a student first." - Nick Tumminello "The emphasis on making things real for patients. We do things that matter for people" - Bronnie Thompson   Resources: The San Diego Pain Summit   Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram and facebook to stay updated on all of the latest! Show your support for the show by leaving a rating and review on iTunes!   Have a great week and stay Healthy Wealthy and Smart!   Xo Karen   P.S. Do you want to be a stand out podcast guest? Make sure to grab the tools from the FREE eBook on the home page! Check out my blog post on the Top 10 Podcast Episodes of 2016!  

On this episode of the Healthy Wealthy and Smart Podcast, I welcome Dr. Sarah Haag, Dr. Sandy Hilton and Dr. Jason Falvey for another installment all about sex. The was recorded live at CSM and we covered a wide range of topics including 50 Shades of Grey. Two of the four of us read the books…guess which two! Make sure to catch up on Part 1 and Part 2 and enjoy the show! In this episode, we discuss: -What’s normal female anatomy? -Graded exposure for women’s sexual health -Can interventions for sex be researched? -Sex education for people with low back pain -What you should and shouldn’t be inserting into the vagina -And so much more!   For a lot of people in today’s society, there is almost no body part which escapes insecurity. Sandy believes the variety of human forms should be celebrated and genitalia is no different. Sandy reminds us that, “The normal human variability is as variable as noses.”   Patients may question whether they should continue sexual activity that is accompanied by chronic pain. Both Sandy and Sarah emphatically agree, “sex should never be painful,” adding, “if it doesn’t feel good, don’t do it.”   Many chronic pelvic pain patients may have adverse experiences with sex. Sarah finds that a graded exposure treatment plan which is sensitive to psychological associations and fears will lead to better outcomes. Sarah finds, “It’s really important to have something that the person doesn’t feel the need to protect against.”   For more information on the panel: SARAH HAAG PT, DPT, MS, WCS CERT. MDT, RYT: Sarah graduated from Marquette University in 2002 with a Master’s of Physical Therapy. Sarah has pursued an interest in treating the spine, pelvis with a specialization in women’s and men’s health. Over the past 8 years, Sarah has seized every opportunity available to her in order to further her understanding of the human body, and the various ways it can seem to fall apart in order to sympathetically and efficiently facilitate a return to optimal function. Sarah was awarded the Certificate of Achievement in Pelvic Physical Therapy (CAPP) from the Section on Women’s Health. She went on to get her Doctorate of Physical Therapy and Masters of Science in Women’s Health from Rosalind Franklin University in 2008. In 2009 she was awarded a Board Certification as a specialist in women’s health (WCS). Sarah also completed a Certification in Mechanical Diagnosis Therapy from the Mckenzie Institute in 2010. Most recently, Sarah completed a 200 hour Yoga Instructor Training Program, and is now a Registered Yoga Instructor. Sarah plans to integrate yoga into her rehabilitation programs, as well as teach small, personalized classes. Sarah looks at education, and a better understanding of the latest evidence in the field of physical therapy, as the best way to help people learn about their conditions, and to help people learn to take care of themselves throughout the life span.   SANDY HILTON PT, DPT, MS: Sandy graduated from Pacific University (Oregon) in 1988 with a Master of Science in Physical Therapy and a Doctor of Physical Therapy degree from Des Moines University in December 2013. She has worked in multiple settings across the US with neurologic and orthopaedic emphasis combining these with a focus in pelvic rehabilitation for pain and dysfunction since 1995. Sandy has teaches Health Professionals and Community Education classes on returning to function following back and pelvic pain, assisted with Myofascial Release education, and co-teaches Advanced Level Male Pelvic Floor Evaluation and Treatment. Sandy’s clinical interest is chronic pain with a particular interest in complex pelvic pain disorders for men and women. Sandy is also pursuing opportunities for collaboration in research into the clinical treatment of pelvic pain conditions. Sandy brings science and common sense together beautifully to help people learn to help themselves.   JASON FALVEY PT, DPT, GCS, CEEAA: Jason is a board certified geriatric physical therapist with a strong interest in improving outcomes for both frail older adults and older adults with hospital-associated deconditioning. He has current funding from the Foundation for Physical Therapy (PODS 1 Award, 2015) and the Academy of Geriatric Physical Therapy to support his participation in ongoing research the use of a novel Progressive High Intensity Therapy (PHIT) training program on medically complex older adults after acute hospitalization. He also has funding from both the American Physical Therapy Association Health Policy and Administration Section and the Home Health Section to evaluate how physical therapists can reduce avoidable hospital readmissions. Lastly, Jason is collaborating with local long-term care providers to determine how physical functioning can be assessed and best managed to reduce rates of falls, ER visits, and hospitalization.   Resources discussed on this show: Jason Falvey Twitter Sarah Haag Twitter Sandy Hilton Twitter Pain Catastrophizing Scale Orebro Scale   Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram and facebook to stay updated on all of the latest! Show your support for the show by leaving a rating and review on iTunes!   Have a great week and stay Healthy Wealthy and Smart!   Xo Karen   P.S. Do you want to be a stand out podcast guest? Make sure to grab the tools from the FREE eBook on the home page! Check out my blog post on the Top 10 Podcast Episodes of 2016!  

Thanks for tuning in to the Healthy Wealthy and Smart Podcast! Coming to you from Chicago, Drs. Sarah Haag, Sandy Hilton, and Jason Falvey join me for Part 2 on our discussion all about sex! You can check out Part 1 from CSM in Anaheim, California here in case you missed out!   In this episode, we discuss: -Broaching the subject of sex with your patients -Recalibrating sex after surgery and childbirth -Rising rates of sexually transmitted diseases in the older adult population -How a bladder diary can help those with persistent UTI -And much, much more!   Sex has multiple health benefits outside what is commonly perceived and can be utilized as exercise. “There is so much that sex is good for cardiovascularly, musculoskeletally. It’s just awesome for so many reasons mentally. When we talk about population health and things that keep people moving and happy—that’s a good one.”   Sex is an important activity of daily living and can be a tool for clinicians to implement into their home exercise program. “Pleasurable movement is one of the things that help you get back to normal movement. So if you can make this make sense and feel good, it’s probably going to be one of the first and well motivated things you’re going to do in an exercise program.”   After patients have undergone surgery, surgical restrictions are not you’re only guiding tool for sex. “Always let pain be your guide, if it hurts, don’t do it. Sex is never supposed to hurt—it’s supposed to be amazing.”   We tend to forget about the vital functions our pelvic organs perform every day. “Peeing and pooping and sex, they are all very basic bodily functions and we can start to forget about it. If I ask any of you how often you peed today, you would have to think really hard and I betcha 10 bucks you’d be wrong with whatever you guessed. You can go pee mindlessly.” Today's guests: Sandy Hilton PT, DPT, MS: Sandy graduated from Pacific University (Oregon) in 1988 with a Master of Science in Physical Therapy and a Doctor of Physical Therapy degree from Des Moines University in December 2013. She has worked in multiple settings across the US with neurologic and orthopaedic emphasis combining these with a focus in pelvic rehabilitation for pain and dysfunction since 1995. Sandy has teaches Health Professionals and Community Education classes on returning to function following back and pelvic pain, assisted with Myofascial Release education, and co-teaches Advanced Level Male Pelvic Floor Evaluation and Treatment. Sandy’s clinical interest is chronic pain with a particular interest in complex pelvic pain disorders for men and women. Sandy is also pursuing opportunities for collaboration in research into the clinical treatment of pelvic pain conditions. Sandy brings science and common sense together beautifully to help people learn to help themselves.   Sarah Haag PT, DPT, MS, WCS Cert. MDT, RYT: Sarah graduated from Marquette University in 2002 with a Master’s of Physical Therapy. Sarah has pursued an interest in treating the spine, pelvis with a specialization in women’s and men’s health. Over the past 8 years, Sarah has seized every opportunity available to her in order to further her understanding of the human body, and the various ways it can seem to fall apart in order to sympathetically and efficiently facilitate a return to optimal function. Sarah was awarded the Certificate of Achievement in Pelvic Physical Therapy (CAPP) from the Section on Women’s Health. She went on to get her Doctorate of Physical Therapy and Masters of Science in Women’s Health from Rosalind Franklin University in 2008. In 2009 she was awarded a Board Certification as a specialist in women’s health (WCS). Sarah also completed a Certification in Mechanical Diagnosis Therapy from the Mckenzie Institute in 2010. Most recently, Sarah completed a 200 hour Yoga Instructor Training Program, and is now a Registered Yoga Instructor. Sarah plans to integrate yoga into her rehabilitation programs, as well as teach small, personalized classes. Sarah looks at education, and a better understanding of the latest evidence in the field of physical therapy, as the best way to help people learn about their conditions, and to help people learn to take care of themselves throughout the life span.   Jason Falvey PT, DPT, GCS: PhD Student Jason Falvey was awarded a Kendall Scholarship from the Foundation for Physical Therapy in 2014 and a Fellowship for Geriatric Research through the Academy of Geriatric Physical Therapy in 2015 to support his research examining the role of home physical therapy in enhancing function and reducing re-hospitalizations for medically complex older adults. He is also the primary investigator on a research grant from the American Physical Therapy Association, Section of Health Policy and Administration looking at the role of physical therapists in models of transitional care for older adults after acute hospitalization.   Resources discussed in this show: Oswestry Disability Index Finding a pelvic health PT Holly Herman     Make sure to give Jason Falvey , Sarah Haag , and Sandy Hilton a follow on twitter!   Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter to stay updated on all of the latest! Show your support for the show by leaving a rating and review on iTunes!   Have a great week and as always stay Healthy Wealthy and Smart!   Xo Karen   P.S. Do you want to be a stand out podcast guest? Make sure to grab the tools from the FREE eBook on the home page! Check out my latest blog post on Managing Expectations: It Shouldn't be That Difficult!

On this week's episode of the Healthy Wealthy and Smart podcast, Dr. Sarah Haag and Dr. Sandy Hilton join me outside the Disneyland Hotel post CSM to take the taboo out of discussing sex. They are both physical therapists who work with anyone needing to get back to doing what they love and who they love and are making the discussion around sex a little more comfortable and approachable. In this show, we discuss: -What every PT should be asking their patients -Why you shouldn't make assumptions about your patients' sex lives -How to differentiate UTI from DOMS of the pelvic floor -How you can approach your partner who has pain with sex -Guiding principles for pelvic health rehabilitation -How to navigate sex in the nursing home system -And a lot more! Sex is part of normal human function and no other species makes it this complicated. If you are experiencing pain with sex and you want to live a happier and more fulfilled life, there is something you can do about it by seeking help from a pelvic health physical therapist. You can find more on twitter from Sandy (@SandyHiltonPT), Sarah (@SarahHaagPT), and myself (@karenlitzyNYC)!   Thank you for following along and listening to the podcast!   Xo Karen  

On Win's Women of Wisdom today, Best-Selling Author, Win Kelly Charles welcomes Dr. Sarah Haag. Sarah graduated from Marquette University in 2002 with a Master’s of Physical Therapy. Sarah has pursued an interest in treating the spine, pelvis with a specialization in women’s and men’s health. Over the past 10 years, Sarah has seized every opportunity available to her in order to further her understanding of the human body, and the various ways it can seem to fall apart in order to sympathetically and efficiently facilitate a return to optimal function. Sarah was awarded the Certificate of Achievement in Pelvic Physical Therapy (CAPP) from the Section on Women’s Health. She went on to get her Doctorate of Physical Therapy and Masters of Science in Women’s Health from Rosalind Franklin University in 2008. In 2009 she was awarded a Board Certification as a specialist in women’s health (WCS). Sarah also completed a Certification in Mechanical Diagnosis Therapy from the Mckenzie Institute in 2010.  Most recently, Sarah completed a 200 hour Yoga Instructor Training Program, and is now a Registered Yoga Instructor. Sarah is co-owner of Entropy Physiotherapy & Wellness in Chicago, IL with Dr. Sandy Hilton.  Entropy Physiotherapy has been created to provide physical therapy in a comfortable setting, using the best evidence available to help people overcome their pain and meet their goals.  Entropy has also committed to providing innovative continuing education courses for healthcare and fitness professionals from taught by experts from all over the world. Sarah is an active member of the American Physical Therapy Association, as well as a member of the Sections on Women’s Health, Orthopedics, and Private Practice.  Sarah currently serves as the Director of Financial Development for the Section on Women’s Health. Sarah looks at education, and a better understanding of the latest evidence in the field of physical therapy, as the best way to help people learn about their conditions, and to help people learn to take care of themselves throughout the life span. To learn more about Sarah visit http://www.entropy-physio.com/. To learn more about your host visit https://wincharles.wix.com/win-charles. To learn more about the show visit http://winswomenofwisdom.weebly.com. To be on the show please fill out the intake at http://bit.ly/1MLJSLG. Be sure to FOLLOW this program https://itunes.apple.com/us/podcast/wins-women-of-wisdom/id1060801905

In Episode 19 we chatted with one of the hosts of The Pain Science and Sensibility Podcast, Sandy Hilton. Here on Episode 21, we talk to the other host Cory Blickenstaff. Cory works in a private practice in Vancouver, WA. He has presented nationally on topics related to treating pain as well as work site industrial care delivery models. He authored the monograph on work injury prevention and management in the APTA home study course “The Injured Worker.” Cory is also active on social media discussing and debating current practice issues and applications and occasionally writes on the Leaps and Bounds blog.

A few weeks ago I attended the PPS (Private Practice Section) annual conference in Orlando, FL. I was lucky enough to team up with Dr. Sandy Hilton during the conference to ask attendees what they thought of the keynote speeches from Gary Vaynerchuk and Daniel Pink, the break out sessions and the overall vibe of the conference.  In this episode you will hear from many attendees and get real opinions and thoughts from the conference.  What you will hear: * The big takeaways from Gary Vaynerchuk's keynote speech from the first night of the conference. * The big takeaways from Daniel Pink's keynote speech from day two of the conference * How people will take what they learned at the conference and apply it immediately to their practices. * Thoughts on some of the break out sessions throughout the conference. This was my first time attending the PPS annual conference and I think it was well worth the price of admission. Not only were the session and speeches very good, the "behind the scenes" conversation with other attendees was stellar.  It is great to connect with your fellow PTs doing such great and inspiring work! Thank you for listening to this podcast and if you were at the PPS conference and want to add more about your experience find me on Twitter @KarenLitzyNYC have a great week and stay Healthy Wealthy & Smart! Karen

Episode 19 is with one of the hosts of Pain Science and Sensibility, Sandy Hilton. To be fair, Erik conducted the interview with Sandy back in March of 2015, before the idea of Pain Science and Sensibility was even conceived. Like Erik, Sandy is a Combines Sections Meeting program chair, he for Sports Section, she for the Section on Women’s Health, and they both happened to be in Washington, DC for the annual meeting for section program chairs. While they were there, they spent about an hour talking about her upbringing and path to get where she is today. Sandy is a practice owner that specializes in chronic pain and pelvic health in Chicago, Illinois. Her practice, Entropy Physio, is also known for bringing internationally recognized experts into their clinic to provide continuing education for physical therapists. I highly recommend you check out their website to see the amazing lineup they produce each year. The courses are affordable and open to any healthcare providers who want to attend. More information is available on their website.

In this episode Adam talks about pelvic health issues with Sandy Hilton and Sarah Haag, two specialists from Chicago, IL in the US of A. We discuss pelvic pain and incontinence, as well as discussing why there are no male pelvic health physios. Sarah and Sandy also discuss how to overcome the embarrassment of discussing personal and intimate things with patients, and Adam tries his hardest to offend everyone with coming up with as many different terms for male and female genitalia.

In this episode Dr. Sandy Hilton talks about her start in the field of pelvic health and how her treatments have changed over the years as she has grown as a practitioner. Sandy also gives us a preview of her upcoming lecture at the International Spine and Pain Institute’s Clinical Conference: Every Joint has a […]

In this very special episode Dr. Sandy Hilton interviews me! I am on the other side of the mic this week talking about my concierge’s style physical therapy practice in New York City. We also talk about how podcasts have emerged in the physical therapy and have been an integral part of the education of […]