Welcome back to the Healing Pain Podcast with Ericka Merriwether, PT, DPT, PhD

Weight and race both have direct connections to pain perception, but this aspect is seldom considered by many healthcare professionals. This leads to countless issues that make a person’s pain even worse. Joining Dr. Joe Tatta to discuss how to solve this problem is Ericka Merriwether, PT, DPT, PhD. They dissect how to improve methods towards obesity and racial issues by exploring the intersection of weight, race, and pain. Dr. Ericka also explains how PTs should focus on promoting physical activity as medicine before delving deeper into psychological approaches and taking action on a patient’s mental health.

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Exploring The Intersection Of Weight, Race, And Pain With Ericka Merriwether, PT, DPT, PhD

Joining us is Dr. Ericka Merriwether, a distinguished expert in the field of physical therapy and pain neuroscience. She is an assistant professor of Physical Therapy and Medicine at the prestigious Steinhardt School of Education, Culture, and Human Development, as well as the Grossman School of Medicine at New York University. She earned her PhD in movement science from Washington University in St. Louis and her doctorate degree in Physical Therapy from the renowned Mayo Clinic School of Health Sciences. To further hone her expertise, she completed a Postdoctoral Research Fellowship in Pain Neuroscience at the University of Iowa.

What truly sets Dr. Merriwether apart is her commitment to exploring the intersection of weight, race, and chronic pain. Her research delves into the mechanisms of chronic widespread musculoskeletal pain with racially, ethically, and diverse patient populations. Her goal is to identify culturally appropriate personalized targets for pain management.

In this episode, Dr. Merriwether will shed light on the fascinating connections between weight, race, and pain and offer insights that have the potential to revolutionize how we approach pain management and improve the lives of countless individuals. Whether you’re a healthcare professional, a patient dealing with chronic pain, or simply someone eager to learn more about cutting-edge developments in pain science, this is an episode you won’t want to miss. A big thank you for joining us again, and without further review, let’s dive into its captivating conversation with Dr. Ericka Merriwether.

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Ericka, thanks for joining me on the show.

Thank you for inviting me. It’s great to be here.

The topic of obesity is one that we hear about every day in the media. It’s in our professional education as healthcare professionals. The public is aware and concerned about it. Within the last several years, you’ll catch us up on the research. The topics of obesity, pain, pain perception, health, and wellness promotion have started to show up in the physical therapy literature. I’m excited to speak with you as an assistant professor at the NYU Department of Physical Therapy. You teach there full-time, but you also are a pain researcher. Tell us how you began your career and where your interest lies in pain research.

A lot of my experience was born out of wanting to optimize movement first in athletes and in people who were not athletes. I’ve been in this space since my sophomore year of college or undergrad. My interest in pain was born out of recruitment from my PhD program in Movement Science at Washington University.

I did not have experience with pain beyond what I’d learned in my physical therapist’s education. Once I was involved in a randomized controlled trial of TENS, which many of us use as a pain control mechanism in our practices, I had a better understanding of how to use TENS, pain pathways, potential mediators of pain, and the universality of the experience of pain. I haven’t met a person yet who hasn’t had a pain experience. All of those things solidified my research and personal interest in understanding the pain experience and factors at the individual to the macro level that influenced that experience and to better inform rehab practices.

I know some of your early PhD work. You worked with Kathleen Sluka on some of the TENS projects.

That was in my postdoc. Dr. Sluka was my postdoctoral mentor. My role in her lab was to work on a randomized control trial of TENS for the movement of pain in women with fibromyalgia. I had a role in a basic science project to look at immune system factors that were related to some of the clinical outcomes that we measure as physical therapists. I had a wide range of experiences in Dr. Sluka’s lab.

That’s been a number of years now. How has that changed? What’s the focus of your research now?

I draw on a lot of those principles that I learned in my postdoc, but I’ve used or leveraged that to focus on the pain experiences, particularly of folks who are raised Black or Hispanic/Latino. That was a natural transition based on some of my advocacy at the time for patients and scientists who are underrepresented in a lot of these spaces.

I was quite resistant to making that the focus of my study. We get into that other place at another time. The 2020 pandemic and the events surrounding the murders of George Floyd and Breonna Taylor forced me to reevaluate my values and how to align my research with my values. That is how I’ve developed this independent line of research I’m doing.

It sounds like that experience that we all went through, but it helped you niche down and focus as far as a research area goes. Oftentimes, they tell people, “Do your research?” You focus on a topic that is new, novel, or one that could have an impact on society.

I don’t think I strive for novelty. It happens because people aren’t asking the types of questions I’m asking. A lot of those questions are informed by people with lived experiences with this intersection of having a racialized identity and having an obesity identity, as outlined by the World Health Organization. I recognize my positionality as a person who lives in a Black woman’s body, but I don’t necessarily live in a fab Black woman’s body or a Hispanic woman’s body. It’s important for me to acknowledge that positionality because it helps me center the voices of those who do and what types of questions are impactful to them, which we want in the physical therapist space and other healthcare spaces.

I appreciate how you start to mold and shape your career around this awareness of social determinants and how your research can have an impact on social justice. Where did the obesity part come into that?

That started in my postdoc when we were doing the TENS study. A lot of the participants, 60% of them, would be classified as obese by the World Health Organization. This was around 2014 and 2015. We were asking questions about this overrepresentation of folks with BMI and obesity range. We were looking at our data and looking at the literature that was fairly sparse at the time on why this comorbidity existed. That part started before the intersections of race and gender in many ways happened that I’m doing.

There are a lot of components here that we’ve already started to mention. All these things are starting to intersect. It’s intersecting in your research, the clinic, and people’s experience of pain. I want to start to dig down into some of the details and share with us what you know about the foundational place for us to start. Since this show centers around pain, let’s start here. How does weight impact someone’s pain perception?

That question was less loaded than it is now. There are a lot of layers that I’m still learning about at the base of that pyramid. Are there intra-individual factors like biological factors, which I see a proliferation of work around inflammatory biomarkers of both conditions, psychosocial comorbidities associated with both conditions?

Researchers, myself included, are trying to look at some of those intra-individual factors. Their interpersonal factors to consider are the relationship that the patient has with their social support system, if they have one, and the interaction that patients have with their providers. That’s relevant for physical therapists because it speaks to the shared decision-making process. There are these macro-level factors. These are barriers to access to pain management, forms of weight management, stigmas, and discrimination that folks encounter either in the healthcare system or in society in general, not having access to fashion.

We live in New York. We all want to look fashionable at some point anyway, but having access to cute fashions or not having a lot of space to sit on public transportation or planes. There are all of these things that converge to make a pain experience for a person in a bigger body. That augments that or makes it worse in many ways. I’m trying to better understand at these different levels how that’s happening.

Living in a different body or a bigger body than society is prepared for, educated about, or learned to destigmatize can have an impact on someone’s pain experience. The idea of the adequate size seat, which you hear about nowadays on the news, things like planes and trains, is interesting in and of itself because people don’t think that one social factor could have an impact on someone’s pain experience. Tweeze apart that a little bit. How does the size of the seat potentially affect someone’s pain?

It’s not obvious, but I was at the San Diego Pain Summit in February 2023. Shout out to Dr. Mescouto, who said this. When you go to a healthcare provider’s office, how it looks sets the tone. If you are in a bigger body and the seats are small, and there’s no opportunity to have seating that accommodates your body, that sends an unintended message that the person’s not welcome there. If everything is built for people with smaller bodies, folks don’t want to be there. You have them in mind when you’re trying to come up with a shared plan to intervene in whatever it is they’re there for.

The types of paintings or art that you have, if you even have art in there, do they depict people that look like the range of bodies that we have in society? Are they skinny, rich, White folks? Little things like that could make a huge difference in terms of developing and maintaining trust with our patients who have these experiences.

The so-called centers of healing that we have in our society haven’t necessarily considered different body shapes and sizes.

I can’t speak to it since I haven’t been there. If the seating is not appropriate and not just for folks in bigger bodies but folks with disabilities, consideration for all types who could potentially become patients or participants in that healing institute is important.

As practitioners reading this, it’s a consideration that when you look at your office and clinic, whether it’s physical therapy or other clinics, have you taken into consideration that the environment is set up for different types of lived experiences?

Even the treatment tables or plinths, are they adjustable? Can they accommodate folks in bigger bodies? Do they have a weight limit of 200 pounds? I consider them small changes, but these are changes that could make the space more welcoming and inviting to prospective patients.

A lot of these fall under the social context, the context that someone’s moving in and out of. A lot of these have to do with social factors and determinants of health. What does the research say regarding the depth of the impact of social determinants of health on obesity versus biological factors like metabolism or psychological factors like depression?

I don’t know if we have enough time to go into all of the stuff since there has been a rapid proliferation of the conversation of social determinants of health in the pain space and the physical therapy and rehab space. There are some smart people that I know in the pain space and the rehab space who talk about how these social determinants affect the physiology of pain and whatever other health conditions we are treating directly or indirectly.

The determinants of health are economic stability, education access and quality, healthcare access and quality, the neighborhood and built environment, and social community context. These are the things that impact the pain and rehab response to interventions or assessment and how we view and how people view their pain experience.

Understanding that a lot of what we’re dealing with as physical therapists doesn’t happen in a vacuum is important. There’s an increasing recognition of that in the literature. What I hope is happening that is playing out in one-on-one or group interactions with patients on the ground. I hope I answered that question adequately.

You make a good point because the word bio-psychosocial is everywhere. To a certain extent, our profession has, instead of clinging to the social, decided to cling to the psychological first. It fits with our history as a profession. We like to identify, label, resolve, cure, and fix fill in the blank, where it’s a greater challenge to necessarily do that with the social determinants of health.

Keeping these into consideration in your evaluation, treatment, psychologically informed care, and trauma-informed care can have a profound, although sometimes maybe not as easy to measure impact. Do you think that’s all fair assessments with regard to people who have pain and/or weight challenges?

You said a lot there that I agree with. I never thought about it that way until now. Thank you. I did think about psychologically informed care and why there was such a rapid uptake of that compared with the social determinants of health and our proclivities to want to fix and cure because that’s still within the medical model of health and wellness.

We’ve been talking about social determinants of health, but we haven’t even talked about the political determinants of health, which is an emerging model. It’s like the social determinants of health, but it talks about the social drivers at the legislative levels that impact the social determinants of health and all of the other things we’ve been talking about. It seems intractable.

How do you deal with racism? How am I supposed to deal with racism as a clinician? I’m not going to cure racism. How do I intervene in stuff like that? It also forces a question like, “Where do I sit in my awareness and acceptance of all of this stuff?” A lot of this is new knowledge for physical therapists and other clinicians and not so much for others.

Thinking about this in terms of patients, particularly patients with lived experiences with pain, obesity, and a host of other comorbidities, it’s relevant to at least ask about social support and access to things because that impacts the intervention plan. Not addressing that and not thinking about your own biases or blind spots because we all have them is doing our patients a disservice. Having safe or brave spaces to have these conversations among ourselves and with patient advocates and policymakers opens up a discussion as to how we can embed these things into our physical therapist practice and update our practice guidelines to include this stuff.

As a professor, what do you see the role of a physical therapist with regard to the care and management of obesity, knowing that it oftentimes does intersect with weight management?

I’m fairly new to the weight management space in terms of seeing how healthcare does that particularly primary care or bariatric surgery, which is what the space that I’m in now. I see a tremendous opportunity for physical therapists to understand what the weight management options even are and how eligibility is determined for said weight management options.

We’re seeing a lot of discussion around medications such as Wegovy for weight loss. That has come out in the mainstream. We should educate ourselves on what these medications are because people are increasingly seeking them out or being prescribed based on whatever the criteria are. Bariatric surgery, lifestyle, weight management, who goes in the pipelines for these things?

That’s a lot to put on physical therapists to do that themselves. Maybe in the future, there will be some additional education or specialty as we do with neurology and orthopedics, something that focuses on how weight management happens because it’s much more complex than I thought. Who goes into this weight loss or weight management pipeline versus this one? What goes into those decisions is beyond the physiology of it. Can your insurance cover it? Do you have access to the tools for remote support nutritionists? Physical therapists would be valued in these spaces because we’re not in these spaces now.

Look at the number of people who have obesity and the comorbid disability and physical impairments that may be occurring in those spaces.

These are not well addressed in weight management spaces.

I’m imagining that at some point, they’re receiving advice on exercise and physical activity. We all know it can be very difficult to engage in exercise and physical activity when not only do you have extra weight on you, but also that weight itself is potentially causing an impairment that is impeding your ability to begin an exercise program of some sort.

This is me walking around New York and in the spaces that I’m in, talking with people. For people with lived experiences with being in a bigger body, particularly if you are Black or indigenous, the messaging around wellness is much better received than the messaging around imminent death if you don’t do this. Having a say in how that discussion even goes, is pain a problem? If so, how? Do we want to talk about the role your weight plays? Do we assume that if you’re in this weight management space, you and your doctor got it? We can talk about the movement and function because that’s what we can offer to you as physical therapists.

Starting there is important because before we launch into, “Your BMI is high. That’s a risk factor for that.” Losing weight is not something that happens quickly. What can we do now to maximize my function? Engage in physical activity, which a lot of people want to do. There’s this assumption that goes with the stigma of laziness, even though obesity’s been medicalized.

As physical therapists, we’ve been grappling with this as a profession for a while now. What is our role in the wellness space, particularly in promoting physical activity as medicine? There’s a ton of opportunity for us in these spaces that I’m occupying and in our practices as they exist now, injecting these types of changes in how we converse with folks who live in bigger bodies that have pain.

I appreciate the shift or helping all of us shift from what’s wrong and what’s the pathology to wellness. We’re talking more about a term that I’m bringing up called Salutogenesis, which is the movement toward health and wellness. That message is one that people are more ready to receive. How do I become well again?

People know there’s something wrong. They know that this is hurting and this is not right. They know they have some extra weight on their body. How do I move toward living a vital well life? That health and wellness promotion sits squarely in our scope of practice. We are talking about physical activity, sleep promotion, and avoidance of risky substances. All of these have a stress management and an impact on potential mechanisms in someone’s pain perception. That may be contributing to the experience they’re having around obesity and/or pain.

That’s not to say that we have to take ourselves out of the tertiary care space because we’re still needed there, but we are primed to even be in the referral space. Some of these wellness things that we’ve been talking about are becoming more mainstream, particularly in popular culture. We can capitalize on that as physical therapists and be in the health promotion and wellness space with these social and political determinants and identity-related issues in mind. We’re giving the best advice that’s tailored to what our patients need and meeting them where they are.

How is a good socially informed physical therapist who understands the intersection between pain, obesity, and one’s experience who’s a person of color? How is that good for someone’s mental health in their healthcare? A physical therapist who understands the intersection, the interrelatedness between pain, weight, and someone’s skin color. How does that improve? Where’s the potential there to improve someone’s mental wellbeing?

Acknowledging that that intersection exists is a great start because everybody who has a BMI in the obesity range is not experiencing pain, the healthcare system, or the context in which they’re operating the same. Acknowledging and not necessarily asking, “Did you experience racism now?” People might not be comfortable asking that question. Understanding that these experiences differ based on a lot of these identity intersections and how multiple systems of oppression can converge to make that pain experience worse, and thus, mental health is important.

Understanding that a lot of these psychological comorbidities like anxiety and depression underlie both conditions. If you’re addressing the pain, which is comfortably in our wheelhouse, you may be affecting these other comorbidities without necessarily directly measuring the improvement in those comorbidities or tracking those improvements you may be affecting. Those are a couple of ways that clinicians can think about how to impact and create a positive experience that could help mitigate the effects of a pain experience. I hope that answered your question.

It speaks to the work you do. I know you have a couple of grants and projects that are in the works. We’re all interested to see what the outcome is and what new information will be delivered to not only people with health conditions but also those of us who treat them, i.e., physical therapists, especially because you’re going to embed this into the program and your research will help inform what we do as physical therapists, both in the DPT curricula as well as the clinic.

We’re in the early phases of understanding the mechanisms of pain and how they respond to weight loss. We’re using bariatric surgery as our weight loss model, particularly in those who are raised not Hispanic, Black, or Hispanic Latinx. For this study, we’re interested in understanding how we’re looking at chronic widespread pain. Some of the features that we associate with chronic widespread pain, which of those features are active before and if they change after surgery? It’s about understanding the role of weight.

If you can manipulate weight in this dramatic way, what is it that we can focus on in terms of pain management at these different stages of weight loss or weight regain? That’s what we’re interested in to set the stage for thinking about how to support folks with their pain management no matter what their weight is or where they are in the weight management phase. I feel like I need to understand better what’s active when, how weight influences pain physiology, and how the context in which this is happening plays a role in that.

I’m excited. It’s daunting because we’re getting started. I’m always nervous. It’s like, “Are you able to recruit and keep them in?” I hope that what informs physical therapy is what is the actual role of weight. Should we intervene and support with weight management and when versus pain management? That is the most important potential contribution of this particular project.

Let our followers know how they can learn more about you and stay abreast of your work.

I am on X, formerly known as Twitter at @emerriwether. I’m also on LinkedIn. I also have a profile on the NYU Steinhardt website. Those are three ways in which you can find me.

I want to make sure to point all of you to those resources. I want to thank Dr. Merriwhether for being here to talk about the intersection of pain, obesity, and social determinants of health. Make sure to follow her on her LinkedIn. You can find her at NYU, which is New York University at the Doctor of Physical Therapy program. Make sure to share this episode with your friends and family on your favorite social media channel. I thank you for being here, and we’ll see you in the next episode.

Important Links

• Dr. Ericka Merriwether – LinkedIn
• @emerriwether – X
• NYU Steinhardt – Ericka N. Merriwether

About Ericka Merriwether

Dr. Merriwether is an Assistant Professor of Physical Therapy and Medicine at the Steinhardt School of Education, Culture, and Human Development and at the Grossman School of Medicine at New York University (NYU). Dr. Merriwether earned her PhD in Movement Science from Washington University in St. Louis, and her Doctor of Physical Therapy degree from the Mayo Clinic School of Health Sciences. She also completed a postdoctoral research fellowship in Pain Neuroscience at the University of Iowa. Dr. Merriwether’s research broadly examines mechanisms of chronic widespread musculoskeletal pain in racially and ethnically diverse patient populations to identify culturally appropriate, personalized targets for pain intervention.