Welcome back to the Healing Pain Podcast with Matt Erb, PT
We have a brand new topic. We’re discussing how you can use mind-body medicine to treat chronic pain. Mind-body medicine refers to the interaction between the mind the body and the spirit. Specifically, the ways in which physical, emotional, social and spiritual factors together can directly affect health. With the advent of modern medicine and pharmacology, mind-body medicine had been downplayed in the Western world when researchers and practitioners start to see the benefits of combining approaches. We have substantial evidence to support mind-body practices, which focus on the interaction of the mind, the body and behavior to improve both physical as well as mental health.
My expert guest is Matt Erb. He is a Physical Therapist, originally trained at the University of Iowa and based out of Tucson, Arizona. He’s a Senior Faculty Member and Clinical Supervisor for The Center for Mind-Body Medicine in Washington, D.C. His clinical practice focuses on mind-body integrative care. He’s the Founder of Embody Your Mind specializing in high-quality teaching, consulting and integrative and mind-body medicine topics. I want to thank Matt for joining us. We cover lots of ground with regards to mind-body medicine and the biopsychosocial model pain. You’re going to learn a lot about mind-body medicine and how you can implement it into your practice.
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How To Use Mind-Body Medicine To Treat Pain With Matt Erb, PT
Matt, welcome to the show. It’s great to have you here.
Thank you. I’m excited to join you and talk a little bit about my experiences, including a relationship to your own. We’ve got some shared paths going here.
It’s one of the reasons why I wanted to have you on because mind-body medicine has been an interest of mine for a long time both for personal, as well as for professional reasons. You’re a licensed physical therapist. Tell us when you first became interested in mind-body medicine and how that started to become infused into your practice.
Right out of the gates, I had an intuitive sense that while I appreciated my training much, it was much lacking and understanding human behavior. I had the fortune of taking my first position in Minneapolis right out of my last clinical at a clinic in the Metro area there. My desk mate sat next to me, Molly Lahn, she’s a physical therapist at the Minneapolis VA works in the chronic pain program. She has since gone on to get a PhD in mind-body medicine with an emphasis on organizational and systems development, which is quite interesting. Back then, we started talking about psychological factors and patient care. We both had an interest in involvement in personal yoga practice at the time.
She had shared with me that in her undergraduate work, she’d done a thesis or honors project on mind-body concepts. She shared with me some of those early writings. Some of the stuff back in the ‘80s and ‘90s. Some of the early pioneers in that area. That launched the interest. I tell this story often when I’m teaching, but I remember early in my clinical practice, having walked into a treatment room and I had an inappropriate gesture, “You must be in a lot of pain.” This person looked at me and said, “I don’t have any pain.” I said, “What are you here for?” She says, “I’m falling and I’d like to work on my balance.”
The backstory to this is I worked in a medical clinic alongside the family practice in internal medicine doctors and they had radiology. We were all in the same flow. I had seen some imaging that she’d had demonstrating multiple compression fractures in the thoracic spine. She was experiencing rheumatoid arthritis, severe scoliosis, and kyphosis. She was stiff with little movement. I was like, “There goes much of what I learned.” This is a hot topic and understanding the complexity of pain. I remember something shifting in me about, “There’s a lot more happening here in health experience than meets the eye.” That’s what launched me into it. I could fast forward to the whole center for mind-body medicine, but I’ll see where this goes and see if that’s appropriate.
As you’re having that experience with that patient and she’s in many ways, opening your mind to, “There are other factors that are influencing what’s happening here?” Did you then pick up books or look for training? What was your path toward more mind-body medicine and practice?
At that point, it was largely through experiential learning in the clinic and also the Yogic model or framework of whole-person well-being. At that time, I was not at all clear into how to break out of the mold that I had been trained in looking at the human body as biomechanical and my job was to identify the problem and fix it. I wasn’t sure but early on, it was experimenting and somewhere along the way, a friend of Molly had suggested that she attend training, Center for Mind-Body Medicine, which she did. She came back she said, “This is what we’ve been talking about.” The next time, I went to the training and went through the series. That opened up a lot more avenues for me to see how to begin to co-create a more whole person way of working with people that respected the professional scope, for example. That was the biggest pivotal turning point and shifting the entire trajectory of my career. It was having attended those training with the Center for Mind-Body Medicine.
I like the terminology you use, “Advancing whole-person care.” It’s interesting. I haven’t heard that too often. Most of the time, people are throwing out the more technical biopsychosocial model. Tell us in your words and experience, what whole-person care looks and what that involves in your practice.
This is a hot topic because biopsychosocial does have this tendency to compartmentalize those three things. Even though I don’t think that was the original intent behind the idea. I’m going to preface what I’m going to say by suggesting that my hope is at some point in the evolution and are co-creating and mutual learning around improving health care that labels will not be needed. I have chosen and this can be loaded as well and I’m sure you know the word integrative, which is a derivative of the word integral. When I look at the idea of biopsychosocial if we can see that as one as a whole and potentially also acknowledge that there are spiritual facets to people’s lives, which could be added in the psychological compartments, for example. Also, the cultural aspects of people’s health experience, which could be technically put into social. I believe it’s my personal preference that integral or integrative is more encompassing. In this regard, we can look at the construct of the body, mind, and environment. I know you’ve had more Marlysa Sullivan on here.
In her paper on the explanatory framework for yoga therapy, she introduced that abbreviation BMV. Seeing that body, mind, and environment are inseparably embedded into a living system and they can’t be removed from each other. The idea of using integrative is to look at biopsychosocial but adding in other levels as well as certain constructs. I’ll give you an example of a construct both, so we tend to get it easily into either-or thinking. I commented on this on a Facebook post and looked at this debate over pain. Is it a sensation? Is it a perception? A lot of these challenges if we adopt non-dual thinking, can help us navigate these territories in a way that serves the person in front of us. It’s both body and mind. It’s both a sensation and there’s a perceptual component when it arises into consciousness, for example. For me, it’s going beyond biopsychosocial or at least looking at it from this lens that there’s an interdependence in the living system as a whole. I’m not sure if I’m losing people in this talk but that’s the start of my answer.
We’re keeping up with you and I enjoy some of this talk around the alphabet soup that we’ve created with not only regard to pain but probably all health models. As physical therapists talk about it as physical therapists first, where are we finding success with a holistic biopsychosocial model and where we still tripping over ourselves and making mistakes that we probably should have buried a long time ago?
The probably the biggest mistake and all credit tone of my friends and colleagues and who’s a key mentor in my growth professionally is Matthew Taylor. He first introduced me to the idea of seeing that we’re set up in a fixie fixer dynamic. That implies the fixer of the broken. Right out of the gates, we’ve failed to acknowledge that a person is already whole and that it’s perhaps more our job to see that people are in process at any point in time around any aspect of their experience. If we rush into rescue or to try to necessarily fix, we may lose the point of seeing that bigger picture of complexity. This is a paradigmatic, blind spot that we’re implicitly unconsciously led to believe that it’s our role to know an absolute why and to be able to fix the problem in front of us.
The paradox of this is that we all in human nature, myself included, have a tendency to want to be fixed. We hope for that something that suffering and pain can be necessarily taken away from us. We have this setup of coming in as a patient and hoping that there’s an answer, an absolute why and that there’s some quick fix. There’s we have this culture of quick fixes, so that’s the biggest blind spot. One other thing I would add to this question is it was Rebecca Craig, who was the former editor of PT Journal, had an editorial in that issue years ago on Psychologically Integrated practice.
She said, “We’ve long been giving lip service to biopsychosocial. It’s time to yell about this.” In my observation, that transition occurs slowly. I still think we’re largely giving lip service. Unfortunately, and fortunately, the pain neuroscience education movement has become the way that many therapists are attempting to address the psychosocial landscape of people’s lives. It becomes more of talking at and not moving beyond the lip service or the education into relational and international ways of supporting the person across those levels to the extent that it’s possible.
There are certainly social determinants to health that we can advocate for policy change but we don’t have an influence on. I see that as a second area we want to help physical therapists and other rehab professions move out of approaching something PNE, Pain Neuroscience Education. This is another tool that we’re throwing at people to fix the problem. It’s not approached from that intersubjective process of mutual learning that we’re here to explore together. I don’t know the answer but let’s see what can come of this.
Pain Neuroscience Education explains the pain. It has wonderful research around it. Lots of physical therapists and more people are excited about it than use it in practice. You should be a fly on the wall and see what people are doing. It’s been a nice model for PTs to latch on to and say, “Yes, I do some form of psychological informed care.” You’re going on a deeper level and saying, “It’s still keeping both the practitioner and the patient caught up in that struggle to fix something that there’s something wrong and someone is damaged and broken.” Even though that whole model is around not being damaged and broken.
It can for sure. It doesn’t have to. Therapeutic education and the existing research tell us there’s something important that happens there but we can’t assume that self-translation is occurring when we offer that information. An example of something I teach is, if I’m going to offer some education about the state of pain science, I want to immediately turn it around and say, “What did you hear me say?” To hear how they’ve translated it because there are gaps between the sender and the receiver. There are filters in place there and the oftentimes people will be shocked at what you intended to convey is nowhere near what was heard when you presented the education. Self-explanation has to occur and we have to go a step farther into offering effective experiential learning that allows people to have a new experience that makes that part of their lived experience. It becomes embodied in real to the person.
To check-in with someone and see how much of that learning has been absorbed, we need to revisit that and focus on more learning and to be aware of that. Oftentimes there’s a partial reconceptualization that if we don’t check in with someone, we’re not aware of that necessarily. How does all that start to influence self-care? Are we talking about self-care and enough in practice as physical therapists and looking at mind-body medicine?
I would start by acknowledging that I do believe, constructs of self-care, self-regulation, self-awareness, self-expression, the self-part is supporting each person’s capacity to come to know and discover things for themselves. To know their truth, experience, and answer. There’s also a little bit of a risk and this has been a little bit of one of my own personal learning because I’m learning it, it’s a little bit of a soapbox. We also have to take self-care and context itself because the construct of self-care arises from an individualistic view of culture in society. We’ve failed to miss the collectivist view that we’re all together in community, whether it’s a family, social, community or a culture unit.
There’s a risk for the self-care construct to be co-opted by this individualistic nature where we end up shouting personal responsibility of people when community-based care is what’s needed. We need those larger shifts in how we relate and exist as a society. That’s a preface to the question and having said that, the research is good. That personal responsibility and a sense of autonomy cultivating the sense of empowerment around one’s health experience is vital. The question becomes, how do we do that not in supporting the other person and in a way that’s not preaching at the person.
We have to take this self-care and context from the acknowledgment that it does play a role, but we have to acknowledge some of the larger determinants and not lead people to believe. If you think positively or if you do the right self-care, you won’t be having this experience. It can, in a way, set up or reinforce that fixer dynamic as well as aversion or avoidance of the experience. It’s important that we lead people into self-expression, self-regulation, mitigating allostatic load, for example, when you look at stress research. The context and the place from which we do that has to be formed and acknowledge as to why am I suggesting or supporting this person self-care.
It’s beginning to take it out of the sterile clinic room and helping someone integrate that into their life and having whole communities do that, which starts to talk more about the social aspects of the biopsychosocial model. It’s not It’s not something that I don’t think practitioners ever probably talk about or include in a plan of care for patients.
That may be large because the question is, how do we effectively support someone’s social environment and how do we affect at that level? The starting point is understanding that your interaction with the other is social interaction so the nature of the relationship that I am in with this person. It’s a starting point for supporting their social landscape and to some degree, at least basic education that if we think of body and mind being placed in an environment, I at least want to be curious about what this person’s social environment looks like. I asked people, “How supportive do you feel at a social level?” I start to get a little bit of a sense of home life and living environment.
If you look at the research on epigenetics, you can see that there are changes picking someone up and removing them from their current environment and placing them into an entirely new environment can introduce dramatic, physiological changes. That’s independent of having suggested that you need to do self-care. I know that we can’t change some of that, but we at least have to acknowledge it and that acknowledgment of it itself can be therapeutic. It’s validating that this person isn’t taking on an excessive burden of self-responsibility for you and that’s what sets up blame and shame dynamics that, “I’m at fault here,” so we run into a tricky dilemma.
It’s probably a great segue into some of the work you’ve done around ACE and trauma. I know you were part of a paper that was published in 2019 in Archives of Rehabilitation Research and Clinical Translation. Can you say a little bit about your paper on ACE, trauma-informed care and rehab?
I’ve been interested in this topic for many years and it finally led to the desire to try to encourage more awareness within the rehabilitation process about the topic. Some people consider it probably in the top five, I’m choosing that number myself, public health topics of our time. The question again becomes, how do we convey the message that our history may have translated into biology into physiological patterns of regulation, for example, and to do so in a safe way. That was the effort behind the paper. We tried to design it approaching the topic from a phenomenological heuristic that’s invitational. This may be an ingredient. I don’t know for sure. When I introduce it, I give a little education about the original study that we know that the more stressors we’re exposed to and the developmental stages of our brains and bodies, it impacts how we relate to stress and the environment around us later in life.
It is linked to health challenges. I say, “Look back but don’t stare.” If it’s affecting you, we discover that by what’s happening with you and your life. We worked with the present moment. I also don’t make any assumptions because our health is a recipe for soup and having a high ACE score, maybe one ingredient there. We also know that there are significant mitigating factors if we were exposed to high levels of stress growing up, that are protective, and may reverse those effects. I want to acknowledge the presence of this but without making assumptions and focusing on what your needs are in the present and how we can best help support getting those needs met because that’s the context.
There’s some resiliency baked into ACE for some people as well.
The ACE movement is inseparable to examining and studying the whole concept and topic of resilience, including the biological underpinnings. I co-authored a chapter in a proposed book. It’s designed for medical education, physician education and reducing burnout. The rate of burnout and healthcare professionals across all disciplines is skyrocketing, particularly in medical education. We were asked to write a chapter on the biological underpinnings of resilience and the science of ACE and the mechanisms by which prior adversity may have translated into physiological impact as part of that question. You can’t separate that.
As a physical therapist, how can we begin to approach and talk about ACE? Should we be targeting and trying to maybe do something to treat someone with a history of trauma as a child? A lot of physical therapists, when they hear things like that, they start to say, “This should be a patient is referred on to a mental health provider.” “This is outside of my scope of practice.” Where does that sit with you because I know you’ve done a lot of work in this area?
This brings up another important topic. If we rush to assume that this person needs psychotherapeutic or mental health care around that topic, we may have added harm because it’s prologuizing the experience. In having worked with Dr. Felitti, indirectly and directly in some of my work, he provided me some data which is published in our paper. In a cohort of over 100,000 people, when they ask people these questions validated, “I’m sorry, that happened to you,” but did not rush to suggest they needed psychotherapeutic resources. It led to an approximate 35% reduction in subsequent doctor’s office visits over the following year. Whereas when you look at a standard biomedical evaluation, which doesn’t dig into psychosocial content at all. That on average, leads to a reduction in future health care visits by 10%. That’s significant from a public health perspective.
There may be cases but it needs to be self-selected. If I elect to and in the course of working with someone, educate about this topic, certainly gauge the response. It always comes back to, “If you felt you ever wanted or needed further resources around those past experiences, around this specific content, please let me know we’re happy to support you and that there are options.” The good news is learning some foundational self-care skills, this is where the healthy approach to self-care comes in and mind-body medicine, that there are tools that can enhance your well-being in the present that have been shown to positively impact the physiological substrates. I’m not going to get into unnecessarily all the science but we’re talking vagal nerve biology, heart rate variability, the balance of autonomic activity or the HPA Axis, and the neuroendocrine involvement in that. We could keep going down the list of what those biological underpinnings are that are influenced by the inclusion of mind-body skills training within the therapy model itself.
In your practice, you’ve been on a long journey of mind-body medicine and you mentioned yoga. Are there other types of interventions that you’ve started to weave into that tapestry?
I have a little bit of bias of preference for the inclusion of biofeedback. It’s an evidence-based modality so I am doing heart rate variability assessments on all of my patients and teachings, tools and skills that have been demonstrated to improve heart rate variability. It’s important because heart rate variability is strongly correlated. It’s like a clinical predictor of numerous health care challenges up to and including mortality. Low heart rate variability predicts mortality. It’s vital that we consider how to positively impact that as reflecting the larger state of health in the organism and the person. Biofeedback, I do body temperature distribution, EMG, multi molder, I do neurofeedback, so EEG guided neurofeedback, which has a growing evidence base.
The use of processes of mental imagery and guided imagery, sometimes it’s as simple as steering people towards part of their home program, if they’re interested, is listening to pre-scripted free guided imagery recordings. The evidence is quite good for impact. That’s where we get into some of these submodalities. We have to still approach them from, “I’m not throwing this up to you to fix the problem or to convey that mindfulness, for example, is going to fix everything, but it may enhance your well-being and it becomes a form of mature coping to utilize these tools.”
As a physical therapist, all the modalities you mentioned are well within our scope of practice. However, in school, we’re still teaching things like hot packs, ultrasound, and electrical stimulation, which may or may not have their place but some of the ones you mentioned are quite advanced modalities that leverage the latest technology and how the neuroendocrine-immune system is functioning. Can you talk a little bit more about neurofeedback? It will be a new topic to a lot of physical therapists that are reading this. When you say biofeedback, many people understand that but neurofeedback is something that was quite different.
I’m going to start with classical conditioning and that in some of the biofeedback that I teach. We’re specific about which tool or tools conscious breath, awareness and the regulation of one’s breath quality and parameters directly and immediately impact heart rate variability. In neurofeedback, the state of brainwaves is fed back to the person via sound or imagery and it’s a reward operant conditioning that it’s desirable. For example, one image I use a lot is it’s called The Space Flower. It’s like a galaxy and when the flower opens, the state of the brainwaves is moving towards the desired state.
I was at the ACRM, an annual conference. A person presented on this large scale nationally funded study on Alpha-Theta Brainwave Training for ADHD at the CC, which is a point on the top of the head over the sensory-motor strip. The early data is suggesting that there is a definite therapeutic effect. They’re not entirely sure how it comes about, which is where contextual learning how much of it is the balance of the relationship with the person offering the biofeedback and how much of it is the actual feedback? They designed the study to try to look at the data in a way that allows them to examine the complexity and determine how much of it is from shifting that locale towards an Alpha Theta Balanced brainwave state, but the research is good that it improves focusing concentration and other parameters in ADHD. You’re training off of the brainwave data.
That overlaps with mindfulness, which you may be able to implement if you’re doing neurofeedback with patients.
I raised that question and in his presentation at the ACRM conference that by nature sitting with someone recording you, and another person sitting with you naturally evokes present moment attention. How is it supporting the self-referential processes or at least the correlates of self-referential processes in the brain? I’m trying to not be too Eurocentric and get yelled at but you get what I’m saying. You’re right the context of awareness itself and presence of attention, maybe the therapeutic effect and dependent of the feedback.
There’s some good observer perspective that happens within some of those neurofeedback exercises. I had a chance to see a psychologist do it and as I’m watching, my brain is going crazy. I’m like, “We need this in physical therapy.” It’s nice to learn about ultrasound, but I saw what was the potential of that and this is an advanced modality that all of us should be using in our practice if you’re working with all the various types of chronic and comorbid conditions that we see as physical therapists. Speaking about chronic unquote comorbid conditions, of course, obesity, poor nutrition is all linked to poor health as well as chronic pain. Have you ventured into that area of treatment at all?
I have both in my academic writing as well as in political practice. I’d start by saying that the topic of comorbidity underscores both our earlier discussion of social determinants of health because there’s a strong link to ACE and obesity, socioeconomic status. Obesity is only two examples, also, the topic of mind-body splitting. In my practice, most of the referrals of people that I’m working with are coming from psychiatrists. They’re referring people who have physical and mental health comorbidity. I know comorbidity can be used in terms of multiple somatic health diagnoses, so that’s another layer of use of the word. We’re writing about this. We’re developing the first of its kind textbook on translating the constructs of integral or integrative care in integrative medicine into rehabilitation practice. In the chapter on defining the need, I’ve got a whole section looking at data on comorbidity, including obesity. What we arrive at is what is the shared physiological underpinnings? How is that set up? That’s what we were talking about in some of the science of psychoneuroimmunology and mind-body medicine points us in the direction of seeing how that happens.
Nutrition-wise, it’s been linked to your yoga practice from my understanding.
I had a chapter in Neil, Shelley and Marlysa’s book on exploring food and nutrition from the yoga cleans, which I see is consistent with the phenomenological heuristic. It must be approached from the concept of relationship. I use this a lot in my work as well. What is one’s relationship to their body or their experience, any part of their experience to the whole to the diagnosis to the pain? In this case, what is one’s relationship with food? A lot of my work there came from the Center for Mind-body Medicine Model. We do a simplified and highly accessible way of working with this, so we explore mindful eating, but we also have people draw your relationship with food.
Take five minutes’ crams draw your relationship with food. It’s quite fascinating to see what can emerge and that language of drawing and that becomes the springboard for that person to explore. It’s not me telling you shouldn’t eat sugar. Which, of course, at a public health level, we can all agree there is an epidemic there in context to high caloric intake, processed foods, sugar, inflammation and how that’s all woven together. We have to look at that social determinants and we have to keep it at, where is this person at? That’s where I know you are like myself interested in the act. If you want to make a change here, and if so, what’s the small step? Are you at 90% reasonably confident that you might want to do this and could do it in the next x timeframe that it comes from that place? Information alone and talking to people is not a sufficient motivator for change.
That’s a great point, especially as practitioners we have so much information that at times we try to impart on patients and it can be a certain effect or the curtain comes down and people gloss over. We live in an information age. We’re sharing so much on social media, you and I have shared a whole bunch here. Take those concepts and break them down into a framework that people can implement into their life and their family and out into the community is important. That’s probably the secret sauce we haven’t created yet. It’s to move all that. Move all that forward. I know you’re at the forefront of all this and people are going to want to continue to follow your research and the books you’re working on. Also, to discover more about your practice, can you share with everyone how they can learn more about you?
If you’re interested both in mind-body medicine, but also community-based health care, which is a small group model. It’s another area that’s woefully missing in the rehab model. Partly because of the payer structure. There’s a lot of people who’d have well-reimbursed groups and group models but the Center for Mind-body Medicine CMBM.org. I’m on faculty with them and clinical supervisors as well for our programs. My website is EmbodyYourMind.com as well as IntegrativeRehabPractice.com. You could look at either of those to access me. I have a fun little teaching page on Facebook. Embody Your Mind is what you’d look up.
I want to thank Matt for being on the show. He’s an excellent physical therapist at the forefront of mind-body medicine. You can learn more about him by visiting him on his website at www.EmbodyYourMind.com at the end of every episode, I encourage you to take this link and share with your friends and family across all social media. We’ll see you next time.
Thank you so much. Bye.
- The Center for Mind-Body Medicine
- Embody Your Mind
- Matt Erb
- Molly Lahn
- Marlysa Sullivan – Previous episode
- Matthew Taylor
- Rebecca Craig – LinkedIn
- Paper – Adverse Childhood Experiences and Trauma-Informed Care in Rehabilitation Clinical Practice
- Dr. Felitti
- Book – Yoga and Science in Pain Care
- Embody Your Mind – Facebook group
About Matt Erb, PT
Matt Erb is a physical therapist, originally trained at the University of Iowa, and currently based out of Tucson. He is a Senior Faculty member and clinical supervisor for The Center for Mind-Body Medicine, Washington D.C. He has a clinical practice that focuses on mind-body integrated care and is Founder of Embody Your Mind, specializing in high-quality teaching and consulting in integrative and mind-body medicine topics.
Matt regularly teaches for the University of Arizona and Banner University physician training programs in Tucson. He is motivated to find and promote better ways of delivering whole-person healthcare.
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