Welcome back to the Healing Pain Podcast with Dr. Jarod Hall
Every doctor considers every patient as a case study in and of itself, and that every patient has a different way of defining the pain they are feeling. Dr. Jarod Hall explains how group discussions among patients transform into a healing environment where a physical therapy session isn’t just another day of exercising. Learn why doctors need to create constant dialogues with patients to lessen the fear of the pain they are feeling.
Pain is multi-factorial. Addressing the complex nature of chronic pain by a skilled clinician is vitally important. The best research indicates that physical therapy informed from a biopsychosocial model of care is most effective. Within that framework, there are many treatments to choose from. The current challenge lies not only in predicting who will best respond to one approach over another, but in understanding the process that explain how or why specific therapies work.
Joining us is Dr. Jarod Hall, who is a licensed Doctor of Physical Therapy. His clinical focus is in orthopedics with an emphasis on therapeutic neuroscience education and the purposeful implementation of foundational principles of exercise in the management of both chronic pain and athletic injuries. He’s an adjunct Faculty Professor at the University of North Texas Health Science Center in their Doctorate of Physical Therapy program. He assesses and treats orthopedic injuries, pain science and manual therapy and educates on that at the university there. Additionally, he’s a blogger whose work has focused on how to succeed in the clinical environment as a new graduate physical therapist, debunking common exercise and rehab myths, manual therapy and pain science education.
Create A Healing Environment Through Group Discussions with Dr. Jarod Hall
Dr. Hall, welcome to the Healing Pain Podcast.
Thanks for having me on, Dr. Tatta. I really appreciate the invite. It’s an honor to be on here with you.
Jarod and I were chatting beforehand that I love to talk to all the most popular “pain science gurus.” I love to talk to the PhD people on the lab who are toying with mouse models of pain and things like that. I also love to talk just to the everyday clinician who is a good clinician, who has great credentials and is doing awesome things out there in the world. It’s great to have you on.
I want to start out, as a DPT, as a physical therapist, you’re working in the clinic everyday with patients and you’re seeing a lot of the same common pain syndromes that a lot of us are seeing in clinic. We have a great message that’s really starting to build in the physical therapy world. My question for you to start out is, as you see patients in your clinic and you start to talk to them, what is the message that you feel is not reaching the average patient who you’re seeing?
I just feel like the average patient really has a poor understanding of what pain is and how pain is produced in the body or what that sensation actually means. I feel like most people function under the premise that pain is directly associated with tissue damage and the worst pain that they’re experiencing, the worst tissue damage they probably have in their body. This is reinforced with the plethora of imaging studies that we have out here. It’s reinforced with the surgery community and some of the excessive surgeries that the data is showing that we have today. It’s reinforced with family members, friends, it’s reinforced on TV; pretty much from every aspect in a patient’s life. They’re getting the message that tissue damage equals pain and that the worse tissue damage they have, the worse their imaging is, the worst their pain should be or the more unlikely to get out of pain they’ll be.
It can be a confusing topic for someone to hear something like this. If you’re a practitioner, this may be new information for you if you’re not up on the latest science around the concepts of chronic pain. If you’re a patient, especially, it can be confusing because this is a message that permeates our healthcare system but it’s also a message that people just pick up when they’re younger, from family and friends or the environment around them that you don’t have to have tissue damage to have pain. Let’s say someone has an autoimmune disease in which there’s an active disease process happening. Because there is tissue damage with that, how might that be different than someone who has an MRI for a herniated disc and they’ve had pain for ten years? How are those two patients different in the way you approach them?
I think that’s a great question and I want to preface what I say by emphasizing the fact that every single patient is different. Roger Kerry and his group have a big push that N equals one, that every patient is a case study in and of their self. As far as autoimmune condition goes, we know that the immune system is involved here and the immune system is a large mediator of inflammation within the body. Anytime you have an active inflammatory process, you usually do have a nociceptive component or danger messages ascending up all the spinal tracts into the brain.
There’s no doubt that any time there’s active inflammation, the brain is supposed to perceive some damage and possibly create an output of pain. As far as the person with a disc herniation, we know that it appears that disc herniations happen pretty much throughout our entire lifespan, as early as the 20’s, as late as the 80’s. They’re cyclical in nature. It appears that they heal. In fact, the research shows that worse the disc herniation is, the higher the likelihood of healing. I think that a disc sequestration, which is considered to be the worst type of disc herniation, has approximately a 96% healing rate judged by some studies.
You can have a disc herniation without having an active inflammatory process anymore. You could be imaging a disc herniation six or eight or ten months after its initial onset, there’s no active inflammatory process, there’s no true nociception going to the brain at this point or the brain has deemed the nociception coming up non-dangerous at this point. You can have that there with absolutely no pain at all and no impairment to function.
You kept using a specific word that my ears perked up. You kept saying that these are concepts that are reinforced to patients, that tissue damage equals pain. As a physical therapist in practice, how much of your time do you spend actually educating a patient or working with a patient on how to unwind that reinforcement that they’ve received?
Honestly, I try to do it from the second the patient walks in the door to the second that they leave. A lot of people think that you need to dichotomize and spread out your treatment into just education or just manual therapy or just exercise. Every time I have a patient walk through the door, it’s a constant dialogue back and forth. I’m trying to create an environment that dissipates those ideas or decreases fear surrounding those ideas. I might get multiple patients involved. If there are a lot of patients in the clinic at the same time with some of my fellow therapists, we might get a group discussion going amongst patients about different injuries and different stories that convey the message that this person had tissue damage and no pain, “Look at this research study that shows all of this disc degeneration and no pain. Did you know that 40% of people have a meniscus tear and they don’t know it?” All these type of things that lead to a group discussion especially where everybody can be heard and feel as comfortable talking to convey that message and really help patients wrap their mind around some of this literature that we read.
The group dynamic is so important especially when you talk about the social aspect of pain. Pain can often be isolating for people. Putting people in a small group, whether it’s three to ten people, where you have a skilled clinician like yourself that’s moderating the group and guiding them on their path toward wellness can be important. In that group setting, I think it’s important to talk about a lot of PTs have yet to really grasp the group setting. In fact, when I first started practicing way back in 1996, we actually did a lot more group therapy. Insurance companies did away with certain codes and certain reimbursements, which really shifted our practice. I predict that we’re going to rapidly move back toward a group because I think it’s really efficient. In the small groups that you’ve had, how has the group, in a way, started to heal itself without you guiding them? I wonder if you can talk about that because oftentimes, we think when we lead a group that we have to always be on and be providing information, but oftentimes the people in the group start to contribute to each other’s needs.
I think without even us facilitating anything, humans are very social creatures. There are some pretty good psychology research out there that shows that isolation is one of the worst things that we can experience. If you look at the prison research, you’ll see repeatedly that prisoners report that solitary confinement is far worse than any other form of punishment that they receive in prison. If you, as a clinician, steer the topic of discussion and then allow people to hash it out between themselves, and every now and then step in to redirect the topic or give another little bit of information, you’ll see patients usually start to build a bond with each other. All of a sudden, your clinic becomes a healing environment where they enjoy being there. It’s not just a place that they come to do exercises. It’s a place where they come to socialize, to get interpersonal interaction, to learn more about themselves, to learn more about pain, to feel better when they leave because they have exercised and they have bonded.
Without a doubt, if you have four patients in the clinic, one of them will have had a radiculopathy of some sort or a lumbar or cervical disc herniation and they’re like, “I had that ten years ago and it totally went away after a little bit of physical therapy.” You can ask the question, “Why do you think that went away? Did your disc herniation go away? Did we calm down your nervous system? This is why that might have gotten better. This is why maybe even if you still have a disc herniation on imaging, it’s not a big deal at all.” You just really try to ameliorate the fear avoidance and the anxiety surrounding some of these common buzzwords that we hear in the medical community.
We’ve talked a little bit about the message that’s not reaching a patient regarding pain. What do you feel is the message that has yet to reach clinicians and really land on them in a way that’s impactful?
Interestingly, I think it’s the same message that hasn’t reached patients yet. It’s definitely getting better. We’re really rallying as a physical therapy community to understand that pain is multi-factorial and pain is more than just tissues, pain has a psychological component, pain has a sociological component, pain has a nutrition, a sleep. It’s so multi-factorial. If I could just implant one thing into every person’s brain across the entire world, it’s that pain is just an opinion of the perceived danger that their central nervous system has. That can be based on just a myriad of factors. It could be inflammation but it also could be fear. It could be lack of movement. It could be an altered brain map. It could be lack of sleep. It could be so many different things.
The immune system really has my attention right now since we’ve recently found out that there’s an immune cell in pretty much every synapse in the human body and it mediates how much and what neurotransmitters get to the other side of the synapse and is transmitted to the brain. If your immune system is not functioning appropriately, the likelihood that you’re going to have pain dramatically increases. That could be mediated by an autoimmune condition or even just lack of sleep and poor exercise and poor diet.
I think the fact that about 70% of your immune system actually lives in your gut because your gut is oftentimes the one barrier that is fighting off or fending off the most potential invaders, so to speak, is often a really important place to talk about when we talk about the immune system and health and pain. Do you talk about nutrition with your clients at all?
As much as I possibly can without stepping over my bounds and out of my avenue in my practice act with what I can do. I try not to prescribe specific nutrition but I give general recommendations because I feel like that’s safe and within my scope. I have lots of open discussions about nutrition. I talk daily about the microbiome because I think that while the research is still pretty early on this, there are some really interesting stuff coming out as far as the alterations in the microbiome that we see with people that have impaired blood glucose levels and insulin sensitivity. The fact that there are some studies that using probiotic supplementation might decrease depression and anxiety and some different things like that.
It’s just such an interesting area of research. I try to talk with everybody that I can about it. In general, I give the basic general nutrition recommendations about fruits and vegetables, avoiding excessive alcohol consumption, trying to stay away from excessive refined sugars and that sort of thing. Just eating a more balanced diet is really going to take a lot of people a long way.
Recently, we’ve had a scope of practice change in the world of physical therapy that I had the privilege of working with APTA to get that in place where nutrition is now within our scope. It’s important to have people at least screen for it, start to talk about it and later, as your personal scope develops and if you want to go further in that one topic, then you can take it further and you can work with a specific diet or getting more specific. It’s not just the general eat more fruits and vegetables and stop eating added sugar or adding sugar to your diet that can help dramatically, especially when you’re working with someone who has a chronic inflammatory disease like obesity, prediabetes or diabetes.
Included in your credentials is an orthopedic certified specialist, an OCS, as well as a CSCS, which is a Strength and Conditioning Specialist. I really love the CSCS because when I first started working with interns and training new physical therapists that work with me in the clinic, it was amazing to me really the vast array of competencies that physical therapists have around exercise. Why is strength and conditioning something that a physical therapist really should learn to incorporate heavily into their practice?
My background was in strength and conditioning prior to physical therapy school. It’s what I did in undergrad. I loved to run speed camps and develop programs for individuals. I do think that is just helping me tremendously as it relates to prescribing exercise for patients. If we look at the APTA’s Choosing Wisely Campaign, we know that one of the five factors that we met a definitive stance on was underloading patients, especially the geriatric population.
We have a consistent problem with underloading and we know that strength and function is somewhat dose-dependent. If we’re not applying a dose that’s sufficient enough, we’re not going to get a response that’s adequate. It’s just like medication or it’s just like a poison. The dose makes the poison or the dose makes the medication. If we’re underdosing, we’re not going to get maximum benefit at all. If we’re overdosing, we’re probably going to get some negative side effects and some patients have excessive pain after a session. Really honing in the ability to develop and track volume of exercise, understand what your goals are and what the patient’s goals are as far as strength development or power development or endurance, tissue loading and the tissue homeostasis model. It’s not new information but it was re-proposed by Scott Dye in 2008 about maintaining a proper amount of overload to progress tissues without going outside of the homeostatic zone. I think that those are foundational and every physical therapist should know at least somewhat how to do those things.
You’re talking about underloading and dosing, which if you’re an exercise physiologist or you’re a PT, you probably know what those things mean. Sometimes there are people looking for pain relief that listen to this podcast. Can you explain what underloading means in simpler terms to both the practitioner as well as the patient?
In the absolute simplest way that I could explain it, if you can lift 100 pounds off the ground and that’s 100% of your maximum load, that’s the most you can do, underloading somebody might be having them only lift 10% or 15% of their maximum load. Maybe they’re only lifting ten or fifteen pounds off the ground and doing a set of ten of this or a set of fifteen repetitions of this is not going to be enough to stimulate any muscle growth because it doesn’t tax the system. It doesn’t tell the muscles, it doesn’t tell the brain, it doesn’t tell the nervous system that, “I need to get stronger. I need to get better because I’m being asked to do more stuff. I’m being asked to do more exercise. I’m being asked to be a bigger, stronger, more robust system.” Usually, if you ask your body nicely, which is the appropriate amount of load, you’ll have a really positive response and you’ll get a little bit stronger steadily over time.
That’s a really good hermetic response, weight training in so many ways. With the dosing, when you’re working with someone with chronic pain, if someone comes in and they have fibromyalgia, maybe they have a diagnosis of osteoarthritis also, how do you start describing to them how much exercise they should be incorporating into their life? Oftentimes, they’re fearful or oftentimes they’ve been “hurt” by someone because they’d been given too much exercise or overdosed.
With conditions like that, if we just look at loading, we’re selling ourselves short. If we just go to the traditional operator mindset of applying exercise to a patient, we’re going to be selling ourselves short without addressing some of the other factors that might be going on. It’s all about meeting a patient where they are and giving them as much as they can tolerate without going too far over that. Usually on the first day, I’ll underload a patient purposefully or at least what I think will be underloading them to see what their response is. If they come back the second day and they’re like, “That was no problem, I felt great, or maybe I got minimally sore.” I’m like, “This is perfect. We know where your loading zone is.” I explain to them that we have to work at the ceiling of your loading zone to slowly push the ceiling up over time.
I have lots of graphics in my clinic, lots of pictures that show the effects of progressive overload and the Toblerone effect. If you think about the Toblerone candy, you lay it on its side diagonally and it has a positive angle up and then a little bit of a drop down. Maybe that’s a regression or maybe that’s an exacerbation of their condition but it’s okay because it’s going to spike right back and we’re going to go up further over time.
I know one of the things you like to blog about are some of the myths around pain. We talked earlier about you don’t have to have tissue damage necessarily to have pain or there’s not a correlation between tissue damage and the symptoms of pain that someone is experiencing. What are maybe the top three myths that you find are still pervasive in healthcare today either in the patient side or the practitioner side?
That’s a big question as well. I would say one of the biggest myths that I still run into on a daily basis is that your vertebral alignment very easily gets out of place, that people with just everyday activities or sleeping wrong or lifting a grocery bag could somehow have their L5 slip out of place or maybe their cervical vertebrae shift and move out of place. Usually it’s referred to as a subluxation generally because they might have heard it from one practitioner or another. I certainly don’t want to put the emphasis on any certain profession at all because we’re all guilty 100%. The idea that the body system is not strong and not robust and it can just easily be shaken out of place is one of the biggest myths that I come into contact with almost every day.
How do you start to talk about those concepts? I think sometimes it’s been ingrained in people that, “My L5 is out of place or my occiput is off my C1,” you hear all sorts of things that come from some well-trained practitioners who’ve been around for a long time, who really help people in a lot of ways. How do you start to have that conversation? Why is it important to have a conversation with a patient that their body doesn’t fall out of alignment just by picking up a water bottle off the floor?
I like to use research here. I like to let them know that idea has been explored thoroughly in lots and lots of research studies and it’s never been proven. In fact, it’s been quite disproven. I like to use cracking my own knuckles as an example. I say, “If that pop in your back is your vertebrae going back into place, do you really think that your fingers are out of alignment right now? Look at them. Do they look straight? Do they look normal?” I crack my fingers like so and I say, “Do you think that just random cracking with no thought applied to it really put my fingers back into place?” I pose questions to them that will make them think about, “Does this really make sense?” I want to lead them to come to their own conclusions instead of just forcing my opinion or my thoughts down their throat.
I imagine using some motivational interviewing techniques is really important to having that discussion because oftentimes, people believe in these things wholeheartedly.
If you just immediately go against everything that they think, you’re probably going to have a bit of a backfire effect. It has to be done skillfully. It has to be done politically correct. It has to be done eloquently. You can’t just automatically shoot down everything that a patient thinks because they’ll take that as a personal attack and you’ve lost that patient at that point and you’re not going to make any positive strides with them.
As practitioners embrace some of this information, it can be really inspiring to them and they can feel really empowered by it. One of the challenges that I see is people then take this information and they want to firehose at people either doing one clinical session or they hop into a Facebook group and they’re firehosing people in a Facebook group with all this information. The truth is that practitioners, in a lot of ways, are no different than patients. Over time, when you see that with a little bit of information is how you’re going to learn and actually it’s probably the best way to learn and the best way to promote behavior change in patients.
I love to jump on Facebook and see the guy that learned something new yesterday calling everybody else stupid for what they don’t know today.
What’s interesting about that is you have to be careful because in about three to five or maybe ten years, what you posted could be debunked or changed. In many ways, probably what happens is it’s evolved. It’s really what happens. Most information evolves to a higher level but it’s no longer the way you exactly saw it.
Jarod, it’s been great talking to you. I know you do a lot of blogging and a lot of work on your blog. Can you tell the listeners of the Healing Pain Podcast how they can access some of your awesome information on your blog?
It’s a long URL but it’s going to be DrJarodHallDpt.blogspot.com. That’s where you’ll be able to find my blog page. On Facebook, I have a professional page that again is Dr. Jarod Hall, PT, DPT. On Instagram, you’ll find me @DrJarodHallDpt and the same with Twitter as well.
I want to thank Dr. Hall for being on the Healing Pain Podcast. Of course, the best place to visit him is on his blog, DrJarodHallDpt.blogspot.com. You can find out great information there on exercise, manual therapy and, of course, some latest information on pain science. I want to thank him for being on the podcast this week.
With every podcast, make sure you hop in to iTunes and give us a five-star review. Make sure you hit the like button or more importantly, make sure you hit the share button on Facebook, LinkedIn or on Twitter so you can share this information out with your friends and family. Thanks for being with me. We’ll see you next week.
About Dr. Jarod Hall
Dr. Jarod Hall, PT, DPT, OCS, CSCS is a physical therapist in Fort Worth, TX. His clinical focus is orthopedics with an emphasis on therapeutic neuroscience education and purposeful implementation of foundational principles of exercise in the management of both chronic pain and athletic injuries. Jarod has shown clinical excellence in securing designation as an Orthopedic Clinical Specialist (OCS) and Certified Strength and Conditioning Specialist (CSCS). He is also adjunct assistant faculty at the UNTHSC DPT program, instructing in the assessment and treatment of orthopedic injuries, pain sciences, and manual therapy. Dr. Hall regularly presents continuing education at the state and national level for practicing physical therapists. Additionally, Dr. Hall is an internationally recognized blogger, whose work has focused on how to succeed in the clinical environment as a new grad, debunking common exercise and rehab myths, manual therapy, and pain science.
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