Episode 10

*AUTO-GENERATED*

Body Logic Physiotherapy, empowering people to achieve better health.

“We’re seeing these similar sort of ideas coming up that people consistently hold, this view that their body is damaged in some way. Pain will always get worse over time. That weight bearing through a joint, for example, that has changes in it, is going to cause more damage to that joint. That exercise isn’t useful, because it can’t restore joint tissues or joint structures and so surgery is going to be an inevitable occurrence down the line, we’re going to need surgery eventually.”

That was Dr Sam Bunzli, and this is the Empowered Beyond Pain podcast proudly brought to you by Body Logic Physiotherapy. Welcome to Episode 10.

Wow, double digits already! This week, Professor Peter Sullivan, Dr JP Caneiro and I were joined by researcher Dr Sam Bunzli online. We discussed a fantastic recent paper all about how beliefs that influence pain, that they co-authored together. In that paper, they used a clinical case to illustrate the critical role that beliefs can have on a person’s journey from acute pain to ongoing pain and then from pain and disability to recovery, which we discuss in this episode. That case was Jamie and he has actually appeared on the podcast before in Episode Four and Five and is a guest in an upcoming episode, discussing how pain flare-ups don’t necessarily mean you’re damaging yourself.

He has a great patient story on the Pain Health website, which I highly recommend you watch. It’s one of the most common resources I find myself sending to patients. You can find the link for that video, as well as the beliefs paper we discussed today, and much more on the show notes page which is www.bodylogic.physio/podcast.

We hope you enjoy this week’s episode and remember to ask, is there more to pain than damage?

[Music]

So welcome everyone, we’re very lucky here to have with us Samantha Bunzli. We’re gonna go straight into rather than me introducing her, i’m gonna let her speak about herself and introduce herself so welcome, Sam.

Thanks Kevin – thanks for inviting me along today, a pleasure to be here.

So about myself, I’m a physiotherapist. So, I did my undergrad physio degree in New Zealand, so in Otago. So I’m a fellow kiwi, like Pete. That was quite a while ago now. So, I worked for around 10 years in musculoskeletal clinical practice, and sort of in New Zealand and in the UK, and I guess the thing that always stood out for me in clinical practice were very much the patient’s stories. That’s a bit of clinical practice that I really enjoyed more than anything else, was listening to people and I think that it became really apparent to me quite early on, that therapeutic value of that of just sitting in space and letting somebody tell you their story and feeling listened to.

So, that was definitely what I was passionate about, sort of. Life circumstances took me around about and I landed in Perth and knocked on Pete’s front door, and we sat down and had a coffee good sort of out of the blue and started talking a little bit about, you know, what I was interested in and I was kind of keen to get into the research space again.

Just always with this focus of the patient’s story and the patient voice, and that was, at that sort of time, was really missing in the literature. There wasn’t an awful lot in the musculoskeletal space that was really prioritizing or valuing that patient perspective. I ended up doing a PhD looking at pain-related fear, from the perspective of of people experiencing chronic low back pain and in that PhD, I really used a qualitative method. So, again that was a relatively new methodology in that field but was something that really became central to to all my research. So since then, I have been applying qualitative methods to prioritize that patient voice in various different musculoskeletal conditions. So where it began – my journey in research began with low back pain, I’ve since moved into the arthritis space and I’m now working as a postdoctoral researcher at the university of Melbourne in the Department of Surgery. And so we mostly do Osteoarthritis research and I use qualitative methods, so interview-based methods, to look at things or explore things like patient beliefs around what osteoarthritis is, how people make decisions about treatment, their experiences of care, how they perceive their treatment outcomes, those sort of things.Yeah, and so that’s sort of taken me to where I am at this point now. A couple of years into my post-doctoral position and that’s probably me.

Yeah, awesome and I think you’re being very modest there, you’ve picked up a fair few accolades along the way. Perhaps, Peter, you can jump in and and talk to some of the awards and the positions that sam has – or sam’s research has – taken her.

Well, I think Sam could do that but I think one of the things that you allude to, Sam, is that when you came to this space, the kind of qualitative research was relatively relatively new in terms of musculoskeletal pain. And, you know, that’s really changed and I think some of your work has gained significant recognition and particularly in the Orthopaedic space recently. I don’t know if you want to talk a bit about that, because that seems like a really wonderful development in an area that’s so biomedically and maybe structurally focused to actually become more person-centered in its orientation.

Yeah sure, so certainly that’s right, I mean i work with orthopedic surgeons and it’s really quite unusual that they have embraced qualitative our image of an orthopedic surgeon perhaps not being very generous to orthopedic surgeons but was this very much the idea of a biomedical viewpoint and that and the sort of biopsychosocial and viewpoint of understanding the patient voice and that being important was was something that was relatively new in this field um but all the sort of hurdles that i’ve had along the way to publish some of this work is now getting that recognition and i have just recently been appointed as an associate editor on clinical orthopedics and related research um so they are really keen to profile the patient voice more in in this journal and um that’s a really exciting opportunity for us i think so really keen to hear more of the patient voice and how that using qualitative methods or interview-based research can advance the field in ways that otherwise wouldn’t be possible so this idea that’s starting to recognize that not everything that that is important can be countable so not everything that counts as countable um and that we need to to to explore other methods to be able to tap into some of these more social processes that can’t be quantified that can’t be measured can’t be counted and that that’s important as well so so that’s a really exciting opportunity um that has has recently come to fruition and i have had um some some success with with grants as well and i think that that’s starting to also recognize um within the system the importance of of qualitative methods of the patient’s voice so things are starting to turn a little bit um but certainly it has been relatively slow moving to get acceptance with some of these alternative methods that aren’t um typically what we think about research and and and in a very biomedical field such as musculoskeletal research yeah absolutely and sam could you just quickly um i suppose define or contrast qualitative research compared to quantitative research just for the listeners sure so i think comes back to that idea that you know some things can be counted and it’s important that we we measure things and that we count things and that’s an important part of research but there are some things that can’t be accessed through these countable methods so when we’re thinking about someone’s um how someone decides on what treatment they’re going to undergo how how surgeons make decisions about who they’re going to operate on it’s the idea that we can take evidence-based practice but how do we apply that in practice and understanding some of those those social processes because they are social processes they involve a variety of contextual sort of factors it’s those are the sort of um research questions that are that we can use with qualitative methods so that involves us interviewing typically interviewing people that have a carefully selected group of people who can give us rich insights into their experience so it’s not that we’re going out and trying to sample a random selection of of the population that we can then generalize these findings to but we’re really trying to select people that can can give us that rich deep understanding and really try to delve into their experiences um in order for us to to understand these experiences better and really adopting their perspective here so we’re not trying to put our pre-existing ideas on what they’re saying it’s not a survey where we think um okay beliefs are important um do you believe this yes or no or rank this on a scale from zero to ten that would be coming from from our viewpoint and asking the patients what we think they’re thinking but and we’re flipping it on its head and we’re asking the patients well tell us what’s important tell us what you’re thinking and then really just um flipping things on its head i guess and and profiling their voice in what we publish yeah exactly giving giving the patient the voice right and trying to hear that those stories um so we’re very lucky to have uh three of the auth or the three authors of a recent paper that was published in the brazilian um physical therapy journal um jp canero peter o’sullivan and sam bunsley here the paper was a master class titled beliefs about the body and pain the critical role of musculoskeletal pain management um and what i kind of wanted to do was sort of talk about the reasons behind the paper and then kind of i guess digest it and make it digestible for our listeners so um can we start perhaps sort of just looking at the or answering the question of what are beliefs and and how are they formed maybe i i can jump in there so i beliefs can be defined in various ways but we can be we can think of them as sort of a fundamental truths or deeply held opinions and they help us make sense of a situation and help us decide what to do in a given situation um so some of you might have heard me talk about the common sense model before and this is something i developed in my phd and we found this a really useful framework to to understand the beliefs of people experiencing musculoskeletal pain um so the model tells us that when we experience a symptom of pain we we try to make sense of that symptom by drawing on a set of beliefs about it so this set of beliefs comprises of our beliefs about the identity of the symptoms so what we think the symptom is our beliefs about the cause of the symptom our beliefs about the consequences that the symptom could have what we think we can do about the symptom and how long we think it’s going to last um so these beliefs are formed by our previous experiences of that symptom by observing others with it and what we might have heard about it so maybe from the media or from clinicians or other sources so based on this set of beliefs we then make a decision about what we’re going to do about that symptom and so this is called what we call problem solving behavior so let’s say we think we have a slip disc um that’s caused by lifting um we believe that that slip disc can push on the spinal cord and that could leave us paralyzed so based on that set of beliefs what would be a common sense response to what is quite a threatening set of beliefs would be to avoid lifting to avoid something that we think is going to make that disc bulge worse so at the same time that this set of beliefs can give rise to an emotional response so symptoms which we think are will have severe consequences and for example end up in a wheelchair or that we think we have little control over they’ll typically elicit a fear response and so in some cases our behavior then can be driven by this emotional response or and typically fear avoidance behavior rather than problem-solving behavior in some cases and this can be particularly the case when our problem-solving work is problem-solving behavior is no longer working so sometimes we get stuck in in a cycle there where say we’ve been avoiding lifting now for six weeks or maybe we’ve been doing core strengthening exercises for three months and we still think we’ve got a a weak core we’re still experiencing the symptom all the symptoms are getting worse um and so this can can create then also this this this uncertainty there’s lack of um of of controllability over our symptom and we can we can then elicit that fear response um there as well i don’t know if it’s helpful maybe to to illustrate this with it with an example i know in our paper we draw an example of jamie um pete do you want to yeah so um jamie was a chap who you can actually see his story on the pain health website there are two jamies he’s jamie e um and uh jamie tells his story as someone who who hurt his back lifting a bit like what you’re saying sam develop back pain his pain didn’t go away he ended up having a scan told he had a disc prolapse um had a variety of treatments was off work uh became very fearful guarded um kind of engaged in protective you know habits like sitting really straight which he was advised to do working on his core when that didn’t happen when that didn’t work he ended up having um a discectomy so spinal surgery which didn’t help and in fact um he described that as pain kind of deteriorated after that and he was um at a point where he was um i had really lost control uh his sense of control over his pain in his life so um the things he really valued was physical activity which he described as being very important for his mental health and his physical health well-being um and he was told he would never run again never left again he had um told he had degenerate discs um and uh and that he should it was dangerous for him to lift he’d become very very fearful and he said you know terrified of bending um and his spinal structures became very sensitive and he guarded his back the whole time and he was at a point essentially where he believed the only thing that was left for him the only option for him was to have a spinal fusion um to fix his problem so from the perspective of what you just described sam he was someone who’d been told he was damaged and that he his belief was that was that the only thing that could fix him was to have his spine fused to have those damaged structures fixed together and his strategies are controlling his pain was to avoid movement activity loading exercise work uh he spent his day lying down he was very doing very little and he became very frightened and depressed and stressed that was not sleeping so he got stuck in this horrible cocktail of um that was linked to a belief but also these actions that just weren’t working for him so he tried so hard to work on his core and his posture and do all the things have been taught and it didn’t work he felt like he was getting worse and so his his story is kind of like the worst case scenario of where that common sense model just falls apart with someone with pain where the belief drives unhelpful behaviours and emotions that leaves a person sort of stuck and maybe we can come back to jamie’s story later around the kind of positive influence that you might have around those beliefs because jamie didn’t go for the surgery he still has discs that don’t look perfect on a scan he still has degenerate discs but he’s back living again and engaging in movement and activity and work and loading and sport and weights and playing with its kids and as emotional responses are very different yep absolutely one of the things that strikes me with jamie’s story is that he develops quite biomedical beliefs or what we would label as biomedical beliefs and how these can often perpetuate the the care and the advice that we’re given and that people go under so i was hopeful that maybe we could talk about comparing sort of or biomedical beliefs or how biomedical beliefs may result down that path and perhaps what other more helpful beliefs might be appropriate to substitute in in that case so sam maybe you can stop sure yeah i wonder if it maybe it it might help to have a little background to these biomedical beliefs perhaps so we can have a little discussion about that yeah absolutely um it’s a little history lesson there but but i think what we’re finding for our research is that um all throughout western cultures the predominant framework of the way we think about our health and our bodies um and pain is through a very biomedical lens so through this biomedical lens pain is the result of bodily damage and the pain experience it directly relates to the amount of of bodily damage so we think of the the hand on the hot plate the longer we leave it on the hot plate the more damage and hence the thinking goes the more pain and this model has been around for over 400 years so it dates right back to the time of descartes in the 1600s um who who first described this idea of dualism so the separation of the person into two parts the body and and the mind the mental and the physical um and and way back then this dualism model was useful because it allowed the doctors to to sort of dominate or own or manage the body while the church could still retain control over over the soul um what this model then created was it was the idea that the body is a machine then comprised of of different parts so we might have our musculoskeletal system we’ve got our cardiovascular system for example and each part can can break down over time or can give rise to separate disease entities or health conditions so we might think of cardiovascular disease of osteoarthritis for example and each of these diseases then requires specialist medical intervention or mechanics to then fix them so an orthopedic surgeon or a cardiologist and and so the the doctor or the clinician becomes this expert that can see inside the body and is charged with identifying that disease process and then fixing that disease process um so so really that that idea that we have an objective sign of a disease then means that um it can be fixed but if we can’t find that sign of medical disease of objective disease then that person becomes sort of morally weak in some way and this model this dualism model means that suffering i mean suffering is invisible but it’s subjective and it’s not really within the scope of of medical profession of clinicians to to fix um so this has been around for as i said around 400 years it’s still the predominant model that exists in our worldview we learn it from a very very young age with our hand on the hotplate but it does cause tension for people experiencing something like for example non-specific low back pain um and we first sort of described this this tension or as a group when we first started looking at this we did a systematic review where we we pulled together um we looked at the literature and we pulled together all the studies that had explored uh the experience of non-specific low back pain and from the perspective of individuals so qualitative studies um and from the perspective of the patients we showed that most of the participants in those included studies really had that the predominant view was this biomedical view but the problem was when they weren’t receiving but they were all experiencing non-specific low back pain so there was really not that patho anatomical explanation for the pain that they were really searching for and that created problems for people because they felt like the absence of that that diagnostic label meant that their the legitimacy of their pain was being questioned by others or was being doubted by others and certainly since some of the qualitative work we’ve also done within this group and other groups has shown that that that that is probably a justifiable perspective that in that clinicians have also described in interview studies um some stigmatization of patients that lack that biomedical explanation for their pain so but beyond sort of problems with with stigmatization the difficulty is is that when you don’t have a biomedical explanation it’s really difficult to then enter the diagnosis treatment cure pathway um so that creates real problems for people if they can’t get that diagnosis they become very stuck trying to either search for that diagnosis or just waiting until maybe that diagnosis will suddenly appear um it’ll become big enough or bad enough to be able to be to be observed um and in the meantime their lives can really we described lives on hold they can just put everything on pause until they get that that diagnosis um so what we’re seeing is moving on from sort of low back pain as is the work we’ve done in arthritis of people with knee osteoarthritis and with hip pain we’re seeing these similar sort of ideas coming up that people consistently hold this view that their that their body is damaged in some way um that um that pain will always get worse over time that weight bearing through a joint for example that that has changes in it is going to cause more damage to that joint and that exercise isn’t useful because it can’t restore um joint tissues or joint structures and so surgery is going to be an inevitable occurrence down the line we’re going to need surgery eventually so this is something that we’re repeatedly seeing in in these different musculoskeletal populations so yeah i could just pop my thought in here because what you’re highlighting there sam is really interesting and just for the listeners non-specific low back pain it’s a kind of label that researchers and some clinicians might consider for someone who presents with a back pain problem who has a scan and the scan doesn’t demonstrate something on it that explains their pain experience so it’s kind of a default label which leaves people in a bit of a vacuum whereas something like arthritis you have a demonstratable um something on a scan that may have an association with that and jp i’m i’m interested in your perspective on that because you also have did your phd in back pain but have now moved into the arthritis space and you’ve got these two kind of difficulties where there’s someone who is looking for um evidence of damage but can’t find it on one space which is the back pain example you give sam and then you’ve got an example of someone who’s got a diagnostic label of damage which has other consequences um around how someone might respond to um that label and i’m interested in probably both of your experiences but maybe jp you would like to talk to that yeah it’s a great um it’s a great point for discussion and probably something that as a clinician and researcher i noticed the difference uh the stimuli but also the difference in the in the patient’s perspective uh so with with back pain when they when they don’t have this like you said you know they’re searching for a reason for their pain and their scans don’t match it uh they may be um they may be presented with comments such as uh when i look at your scans you shouldn’t be feeling the pain that you have or the scans don’t explain the pain that you have and that plays with the lack of validation that sam was talking about before and that really leaves people uh wondering about their condition um and on the other hand you get patients with osteoarthritis they put a plain x-ray and the demons they show to the patient and say look you can clearly see that there’s no space here in this side of the joint so it becomes very evident and very apparent that you don’t have pain i’m sorry you have pain because your structure is not um it’s not good enough so on one hand you have a patient that you know the skin is telling them that there’s you know we don’t know why you have pain and therefore there’s not much you can do about it and on the other hand you have someone that we know why we you have pain and there’s not much you can do about this unless you fix the structure um and and it’s a very interesting um and difficult path for clinicians of course for the patients it’s very difficult to to navigate through that uh but for clinicians as well and with back pain we can see that um we see patients changing how they they understand their problem and they can see that sometimes or in various times that pain is related to several factors and multiple domains in their life so they can change the narrative to understand pain as a broader experience influenced by several aspects of their life whereas with osteoarthritis that’s a much more difficult narrative to change because they are constantly dwelling on the fact that my scan shows the generation and you can see the damage in my joint and and perhaps well one of the things that we need to do is to is to understand that from a different perspective we keep talking about joint damage and tissue damage but having a health perspective on the joint is is a is a perspective that gives patients um more capacity to change and if we think of the biology of the body we’re extremely organic and plastic and modifiable and we adapt to most the majority of things that we expose ourselves to as long as we give enough time and we do that in a graduated manner so with a patient with back pain that doesn’t have that clear structure it may be uh you may have a stronger argument to say look we don’t need to worry so much about the structure because it’s sensitized but we can target the modifiable factors with a patient with knee away that they have a very clear change in their skin trying to shift that narrative it may actually create a barrier between you and patient and perhaps the change that we need to do is to tell the patient do you understand what creates health within the joint that you have so the structure that you have hasn’t stopped adapting you know the structure that you have is actually amenable to change you can as sam said we can create more tissue we can build more cartilage in there but the remaining of the structure that you have can become healthier and how do we do that we do that through movement through loading through building confidence in that leg through strengthening your muscles and to understanding that you know you can live a a life to the full despite having changes in your structure and that that is a broad comment you know some people uh may try all those uh um what is recommended uh by the literature may still find barriers and and may need to have surgery which in some cases it’s extremely appropriate uh and life-changing for some of these patients so there is a a change in in the patient’s perspective of how much of a threat uh it is that structure or that label to to their life and their ability to achieve their goals and also on the clinician to understand how they can convey that message in a way that doesn’t create so much of a barrier we kind of got three different examples here i think and one is say in the in the backspace where there’s no diagnosis which can create a lot of distress and and this kind of stigma that maybe it’s in my head that that my pain isn’t real it’s not believable like there’s a whole lot of distress around the absence of a label um but then in jamie’s situation he’d been told his diss were damaged um they were degenerate narrow you know they weren’t trustworthy and that created a lot of distress um and avoidance and guiding of that body part and i think what you’re touching on there jp is that to for for any tissue be it back or knee i never so the idea of saying to jamie no you don’t have degenerate that’s that’s not true because he did you can see it on his hand and he had edema around the bone which we know is associated with pain that’s like inflammation around those structures but if you take the analogy if you’ve got a sore wrist and you clench your fist all day and you don’t move it it puts load and stress and it makes those structures unhealthy so the having a different way of of understanding your label and understanding that actually movement and loading and strength is what makes those tissues healthier which is what jp’s alluding to gives a whole different dimension around the emotional response so that means it’s safe to engage with work it’s safe to move it’s safe to play with my kids i can go back to boxing i can gradually build the capacity to to bend and lift and twist my back and lift weights again and that’s the journey that um jamie took but if you asked jamie if he had still had a degenerate discs he would say yeah of course i do but i don’t fear those degenerate this more i just know that to keep my back healthy i need to care for my general health and the health of my back through good sleep regular physical activity a routine of movement and strength and mobility that allows them to do what he wants to do and so that kind of triad around belief but those things that both jp and sam allude to around the meaning of that label is the key um because that could be a meaning that enables people to become much healthier in their life and it can have positive spin-off to their cardiovascular health their mental health is social health because they care for themselves in a broader sense um and and often that’s a positive journey that you can see but for others it’s a much harder journey where they’re stuck with that view that i’m damaged and they find it really hard to get past that that’s right and stuck with the idea that there’s nothing they can do to control that it’s changing those beliefs around controllability and and and and beliefs about the future and how how they’re likely to track into their future and i think where it really becomes so tough uh and you know we could talk a bit about that is when they’ve then gone and had the fix and you know i can think of numerous cases i’ve seen a lady who’s had two knee replacement a knee replacement and then a revision of a knee replacement and she feels like her knee is she can’t trust a knee it’s a it’s a need that she hates she literally says i hate my knee i don’t trust it i’m worse now than before i had this and why has this happened to me because i’ve been fixed i look good on scan but it feels terrible and and that’s really hard for people who we who have had the fix and it hasn’t fixed them uh and and i know you know you’ve been involved in um some work around that kind of that pathway that people can go down sam who might have had a joint replacement as effects and and it’s not worked well for them that’s right and so and and and sort of the other scale of that when you were giving that example i also recall talking to somebody who who sort of explained that they had been to a doctor for for other reasons and for whatever reason ended up mentioning that they had some niggles in their knee and got a knee scan as well or an x-ray of their knee and showed that they had quite advanced osteoarthritis in that knee and i will refer you to the orthopedic surgeon and suddenly they find themselves going through surgery without really any understanding that that was necessary and suddenly then get themselves stuck in a pain pattern after surgery when really that pain wasn’t necessarily you know something that was at the forefront of their mind pre-surgery but it it developed this this real sense of threat and this is a serious problem that i have here and really adjusted behavior and really avoided any loading through that knee and um and got themselves really stuck after surgery and the difficulty often is that from the surgeon’s perspective that you know this this this joint looks great and the the the replacement perhaps was done you know was a success we’ve got objective signs of this on x-ray but this person is still experiencing pain becomes really difficult when we’ve only got that biomedical model to draw on we’ve fixed the damage so what now that becomes a really hard hard concept and then i suppose the patient becomes re-stigmatized right yeah exactly one specific pain because they should be fixed and that’s not fixed and it reminds me of that paper that um i think it’s called looks good feels bad yeah around the lived experience and people have had a joint replacement and they’ve been told your knee’s good and they go but it feels terrible um so that’s kind of like that revolving door of like i’ve got a label i fix it now it’s not fixed what’s my label yeah and people often i think in that sort of situation some of the literature shows just give up on care because they feel like they reach the end of the road there they’ve gone to surgery that was their last resort so there’s nothing left for them now so just sort of somehow learn to put up with this which is which is you know really obviously detrimental when they’re sitting at home they’re not they’re not engaging in physical activity they’re not living their life yeah and and that’s really really problematic and very sad yeah and if we look at the at the start of that pathway of you know seeking care to manage your your near white this misperception or misconception that if you load the joint will make it worse so there’s no point in trying it kind of basically puts a barrier at the beginning of a journey the the literature actually tells us is the is the journey to get started on so you know if you believe that you can’t use that joint and it doesn’t feel safe and it hurts when you do it so why would you do it so you and there’s and that’s where we hear lots of stories of patients that are just doing time while they they can get to an age where they should get a knee replacement and that’s the tricky thing in in society because the narrative of a knee replacement is very strong because it’s quite a successful surgery if you look in the in the in the spinal surgery space there are not many surgical procedures that are successful for for back pain and and you know if you look at back and leg pain a different story but for for fixing the back there are not many surgeries that are very successful but for the knee you know there’s many stories there that are life-changing so it’s a very uh strong uh carrot in front of patients where they go you know you can try whatever you want but at the end of the day you’re going to come back and knock on my door to get that knee properly fixed and some people might just you know if you have if you if you have confidence in yourself and you have good coaching you might not own that advice and you might you know pursue a new way of dealing with that problem and if you find a way of reconceptualizing and understanding it differently then go hang on a second actually if i load my joint it makes it healthier it makes it better and again talking about you know we keep talking about joint health but if we think about making someone healthier you know we go back to the joint and we go you know it’s all about the structure but how about how we are living our lives you know are we sleeping enough are we uh are we coping with the stress that we have in our in our lives uh are we um socializing enough you know our is our biology in a in a context that is healthy you know are you eating healthy is your weight are you in a healthy weight so it’s like a healthy approach to your um a healthy lifestyle to get better health in your in your joint as well so it’s like creating an anti-inflammatory context to be able to rehab that knee and that involves your diet your sleep your stress your physical activity levels uh your mood so it’s a much broader approach to me to modify the biology of your body and that’s perhaps a a part of the story that not many people have access to yeah i think that’s so interesting jp and and you know we have looked at for example people on the waiting list for surgery that haven’t engaged in any exercise or weight loss intervention or they’ve really got to this end of the line before they have um they have attempted any of these self-management or you know non-surgical interventions um and and it’s really disturbing as you say when people think well i’ll just i’ll just wait until it gets bad enough until i’m old enough but in the meantime you know 10 15 years can sometimes pass and that person has really not been engaging in a lot of activity and all the health you know consequences of of that are just smiling spiraling you know out of control um but i do i really like the idea of of knee health as being the vehicle for living and and by getting people you know to to to exercise with their knee they are starting to live again um and that participatory way of looking at this rather than an impairment or disability way of looking at this and and changing some of our language around that i think health um participation what we can do not what we can’t do is really really important there so the other thing i’d love you to draw on sam is um part of your phd track people over time and so you took a group of people who are very disabled with back pain and who are very fearful and you found that some people significantly improved over time and you kind of mapped some changes around some of their beliefs but also some of those responses to pain that were associated with that improvement um would you like to speak a bit about that yeah so so this was yes i did a prospective study and there was no particular intervention involved but it was just following people across time and it was interesting to see to see some people and and quite confronting to see some people that that went down a really um a really challenging path of of quite interventionist treatments and and quite um quite extreme surgical interventions and and in some cases um you know being quite physically a lot more disabled by the end of that journey but but some of them at that point when perhaps they had it was only a three-month follow-up um so in some cases i’d interviewed people that that had undergone recently undergone surgery and really were hopeful that they had been fixed and were feeling like they were seeing early signs of being better after having you know quite a significant back fusion for example or sacroiliac fusion we had a couple of people that had quite extreme combinations of surgeries um and quite confronting to see that that hope that they had now been fixed and that once they had got past that acute um postoperative period that they would start to feel better um so that that was interesting to see people that had taken that journey um and for others that had taken more of a um of a cognitive behavioral approach and i know that some people had had undergone cognitive functional therapy as well some people that were able to to make sense of their pain in a different way and that was really interesting to look at as well so the people that did feel that they had could get control over their their their behavior control over their emotional responses to their situation and what was really key in those people that seemed to improve was really this idea of of behavioral experimentation um and so um really having the opportunity to to experience another way of of thinking about their pain sometimes that seem to occur and i know jp you will you have done a lot more weakness of the case series um sort of more in-depth individual level but certainly from people’s descriptions of what was important from a very sort of broad patient perspective was this idea that they had experienced a new way of making sense of their pain that that really did seem to be more helpful to them um and that seemed to be a real key for the ones that three months down the track had made quite significant improvements in their life participation and their in their situation um just in that short period of time really but jp maybe you want to talk a little bit more about yeah and and it kind of springs to mind the case that i’ve seen recently of uh um he’s about 64 years old uh has been playing tennis for over 30 years and just before kovya he always played twice a week and once kobe had hit he significantly reduced his physical activity you know he was stuck at home once he was allowed to play again he was really eager and went back on the on the court three times a week so he came back to the court with a higher frequency and deconditioned and then his knee got sore and he’s got a history of five arthroscopies on that knee and he didn’t have a good strength and his knee became sore and he had a skin and he was highly implanted and so he came to see me because he wanted to do some prehab before he went for surgery and when i look at when i listened to his story it became very apparent that there was a significant changing load in his story and that had sensitized a knee structure and when you look at the uh at the habits that he had adopted because of that and because of the fact that he was going for surgery and he needed to protect and preserve that joint um he he was putting a lot of extra load in that leg he was co-contracting his muscles he was avoiding the leg as much as he could he was resting more he became even less active and when i asked him to write his overall health he rated himself as being you know as unhealthy he had been and he said look i feel like i aged 20 years in the last couple of months uh you know i’m walking slower i don’t recognize myself my mood is low so for this guy that was catching up with his mates twice a week and playing singles at the age of 60. um he was doing you know he was living life to the full he was getting on his bike and doing a bunch of things and all of a sudden you can see the impact on his overall health and mood and and his emotional response to that and when i asked him to demonstrate to me how he would you know get up from a chair how he would walk he had adopted really unhealthy and unhelpful responses that became quite clear through experimentation that they were not helpful and actually when he was asked to engage his leg more and to put weight on that leg and engage his uh his whole body he actually realized that he was moving faster and he was feeling good and a clear example was getting him from a chair you know he was literally getting up as a 75 year old man when he was only 64 and not putting any weight and grunting and grinding and when i asked him to use both legs and to engage his body and relax the more he did it the faster he was moving within the session and after he’s done about 20 of those he sat down and he’s going how come can this happen how can i have a knee that is sore that i can see on the skin that i don’t have any space and i’m booked for surgery and i can actually do this feeling younger faster and in an easier way and so to him that experience was really powerful because that made him challenge his beliefs and challenged the narrative that he had been presented so far and i said look we there’s there’s a journey to to um for us to go through here but this is quite positive it’s telling us that your body likes that he likes movement as long as it’s done in a graduated manner and then we look at some of the things that he could do and getting him to engage on the bike and getting him to be active again you know a couple of weeks later he was way less sensitized and he was feeling better and i’m not saying that this guy is gonna go and never have a surgery in his name but he is looking back at becoming active and get back at being physically active twice a week as he was before uh despite the fact that he had changes in his name now the changes in his knee did not appear during the period of two months of of uh isolation of coffee they’ve been there for a period of time especially with a history of five arthroscopies in that knee but they became highly sensitized because of the fact that he became deconditioned and then he went back at doing an activity that demands were way higher than his capacity and so then you know that just kind of highlights the story of that he came in with a really strong uh narrative and a mindset and he was taken through an experience that challenged that and they actually made him feel um healthier and better within that session and there was a a way in to get him changing his uh reconceptualizing the way that he understood his problem yeah so it sounds like he’s like he’s experiencing that sort of experiential learning was really really important for him and if i was to sort of kind of summarize i suppose if we were talking about beliefs today perhaps it sounds like those um beliefs that his pain was due to those changes on his scan resulted in those behaviors of avoiding the leg and then the leg getting more sensitive and more deconditioned um and and um maybe we can talk a little bit about how those like i’m just thinking from the perspective of the listeners like okay maybe some of the beliefs that i have about my pain my knee pain or my back pain might not be that helpful um how do people go through that process of of going from the stage where okay i recognize these beliefs might not be that helpful what can i do about it and then how can i get to get there so i’ll put my hand up for that one and i think one of the really difficult things um to navigate as a health consumer which i have been uh but also as a healthcare practitioner is to how to interpret a diagnostic label and and that’s a really tough space so you know we know for example that um stuff on the scan some things are associated with pain and other things hold a less important associated association with pain so it’s it’s not kind of black and white so there are some things like a fracture we know are strongly associated with pain we know that if you’ve got a disc prolapse with acute disc prolapse and radiculopathy linked to it with um uh changes in neurology then that that those structural findings are strongly yes correlated with pain at that time but if you look at people three or six months later what you see on the scan is not so well correlated with pain so what can be really structurally a structural label that is associated with your pain can can change into something else down the track so nothing static in the body and that makes it really hard to navigate as a health consumer but also as a healthcare practitioner our responsibility is to say you know which of these things are associated with your problem and which of the things warrant you to go for further investigation and may be an indication for surgery and then which of the things that are actually modifiable like the examples that you gave jp um we’re an actual fact and i think the patient story matched to the presentation so important with that um you know so if you have had a trauma there is an indication to make sure you haven’t got a fracture um uh you know if you have got a neurological deficits there is an indication that a progressive to seem to go for a scan to you know to identify whether there are um significant findings but if you’ve got a history like you you describe jp where there is no trauma it’s just a period of lockdown where you’ve had inactivity and it’s been a stressful time and and maybe sleep has been disrupted and you’ve not been engaged in the same way and you develop pain and you get a diagnosis then that’s a whole different meaning and that’s the key thing i think that’s hard for um for health consumers to navigate because they get a label which comes with a whole lot you touched on that earlier sam the whole belief system that goes to that label that doesn’t kind of fit with its just about damage it’s other factors that become important and i always go back to the patient’s story as showing us the kind of pearls that are critical to understand that the relationship between structure and pain and the other factors that play with it so what is what is what is threatening what is real threat and what is what are we what are we perceiving as being threatening exactly when when they’re perhaps not and changing that that meaning of threat is something that that we can do that is modifiable yeah and also going back to what you said kev you know about unhelpful beliefs and and shaping behaviors that people can take it’s also really important to to highlight that a lot of these behaviors they are triggered by a pain experience so pain makes you want to protect a body part pain makes you you know tense up your muscles and maybe take the weight off a leg or avoid bending and they may be initially helpful and your beliefs and how you understand your condition will make you continue or not with those behaviors you know as sam pointed out before it’s a it’s a problem-solving um behavior pretty much so if i think that i will cause more damage to my knee if i put weight on it it just makes sense that i’ll continue to keep my weight off and if i continue the weight off and i’m still sore and i’m doing less you know there’s no reason why i would challenge that and try more similar to what with jamie you know he’s following all the rules of the of how you should care for your back you know or the rules that we think are right you know keeping a straight posture resting you know getting a strong core and he was actually getting worse so if you’re following the rules and you’re not only not getting better you’re actually getting worse you you know it doesn’t make a lot of sense but you feel too frightened to go and challenge that unless you get good coaching and coaching that actually provides you with an experience that allows you to challenge that behavior that you’re taking because the the behavior experiments that the sam was talking about before they they are a hypothesis that we create based on the patient story and we test them to see if the behavior is actually helpful or unhelpful and that’s really important maybe it’s also maybe interesting to touch on the role of behavioral experimentation as well in in our um during the interview process as well jp so so the idea that you know we have some beliefs we you know it is important as clinicians that we really sit down and we understand the patient’s story that we are um you know listening and or directly asking about what their beliefs around around what they think is causing their pain and what they think some of their responses and things so we need that very very careful history um taking but sometimes some beliefs are explicit and you get that response from the patient but in other cases we hold implicit beliefs as well that aren’t easily um elicited on asking so and and jp you’ve done a lot of work in that space um yeah they’re two very good points and if i think on on the passion that i just described during his story he told me that you know after he got the diagnosis and he had been resting for a couple of weeks he was just desperate to do some exercise and he said i just want to hop on the bike and i just went for a bit of a bike ride and doesn’t matter i’m gonna have surgery in my knee so i’m just gonna go for it and he actually felt better after it and but he didn’t realize that until he was yeah he was asked to reflect on it you know so i said you went for this bike ride and how did you feel afterwards well it felt good so what do you think that tells you well i don’t know maybe actually using the knee is not so bad or maybe the bike is a good good thing to do so it it’s kind of that experimentation you’re talking about during the interview with sam which you are kind of highlighting some of the pearls that the patient brings up in the story to pose that and ask them to reflect on that and say does that really make sense with the behavior that you or the action that you’re taking um so that’s what one of the the aspects the other aspect is about we can ask people about what they believe in and we can ask people why they do and why they take certain behaviors or they adopt certain behaviors but we can only express what we want to but also we can only express what we are aware of and some of these implicit beliefs they you know they’re really deep-seated and we cognitively may not know the reason why they’re there um or for instance you may ask a patient are you do you avoid bending and they might tell you they don’t or are you fearful of bending and they say they’re not but when you ask them to pick something up and you may be a pen and they’re okay to do it but it may be a 10 kilo weight which mimics a box that they have to lift at work they may not behave the same and they may say look i i don’t want to do that or that gives me you know the thought of doing that gives me anxiety or they behave in a different way when they do it they might still do the task but they guide themselves they hold their breath or they brace themselves to to be able to do it so some of those behaviors may only be elicited when they are faced with a task that is either feared or it’s provocative and it’s usually a task that it’s something that they have to do so it’s related to work or it’s a value task such as lifting a child or or going for a run or or exercising so it’s really important to not only ask patients about what they think and a great example of that is questionnaires you can give a questionnaire to a patient like we do in the practice every patient that comes in the door they get a short questionnaire that gives us an idea of their of their profile and sometimes we get the questionnaire that doesn’t look bad at all but when you talk to the person and some you allow them to tell their story or you expose them to some of the tasks that they are frightened of you can see that there’s a mismatch between what’s actually happening and what they portrayed on their questionnaire and that’s not to say that people are just they don’t want to tell you is that sometimes they’re not aware of some of those behaviors and they’re quite implicit as you said so we’ve got lots of sorry are you going to say something about jackpot yeah i was going to say that one of the studies that we did we also looked at some of the beliefs not only of the patients but we look at implicit beliefs of clinicians uh and that and that is a a an interesting story in itself because similar to you know we are part of this society and with as sam said we’ve been uh um offered the biomedical model as the mainstream of our education and our training is really focused on the body and how the body works so when we ask some of these clinicians about their beliefs about situations such as bending forward uh you know keeping your back straight or rounding your back in a more relaxed manner the majority of these clinicians said it’s safe to to bend and lift with a round back and but when you actually put them through a test that requires them to or doesn’t allow them to to think much about their response so it’s like a reaction time task their response is different and it demonstrates that they have an implicit belief that actually bending and lifting that with a round back is dangerous so that demonstrates that um we can hold these implicit beliefs as well and they can be related to our training can be related to the experiences that we have and that may play a role in how we behave in the clinic yeah every advice that we provide yeah sorry david i was gonna say i’m also interested in the idea too that that we have sometimes um i think these these set examples that we use on metaphors that we often draw on and and sometimes i think we we use the analogy of the body as a machine a lot for example as a clinician and so i think that in talking about nuts and bolts and and squeaky joints and i think we can be saying and and perhaps we we want to be conveying a different message but we’re using a language that really perpetuates some of those pre-existing beliefs around the body as a machine and around the biomedical you know damage and and i think that that’s something that perhaps we need to to think about very carefully as clinicians too what message the patient is receiving when we’re using some of that language yeah and and and some of these um let’s call it mixed messages that we’re giving so we may tell the patient one story but we may present ourselves differently you know our body reactions might be different or we might say you know it’s okay to safe and load and uh we just got to make sure that cartilage is okay so we don’t you know we don’t create a new injury uh so we just like leave these you know little bits of message that undermine this message that the key message we’re trying to convey and similarly to patients some clinicians may not be aware that they’re doing that and that’s one of the things that we really wanted to bring up on this paper there’s some suggestions for clinicians to to perform self-reflection you know and one of the ways of doing that is you know getting your colleague to sit in and watch you with a patient or film yourself where you can actually then look back and and you know you will you experience that clinical encounter and then you look at the video and you see the things that you how your body reacted the things that you said and some of these analogies they are saying wow i can’t believe i said that because that goes against the key message that i’m trying to give to this patient or someone told me uh you know i booked for surgery and i might not have said anything i might just look at the patient and go and make a a non-verbal cue that gives my explicit um belief about that attitude that the patient has taken so these things are really important for us to to reflect on and see if we actually practicing according to what um what we believe in yeah absolutely is is there an alignment there with what we’re what we’re saying and what we’re doing and what the what the evidence suggests as well yeah i just wanted to talk finally a little bit about some of the barriers to implementing these changes obviously we know how important beliefs are um in in potentially perpetuating ongoing pain and persistent pain and a big part of of this podcast is to try and empower people to to create change and empower clinicians to create change but i wanted to sam quickly if you could talk a little bit about some of the barriers that are that are around for that well i think some of them we’ve touched on so some of these pre-existing models that we we you know automatic models we draw on as the both the patient perspective but also from the clinicians um i know that we talk a little bit in paper around sort of funding models and and more um multidisciplinary care models uh jp maybe a better place to discuss i guess one of the um you know we have beliefs on both sides we have the beliefs of the patients and we have the beliefs of the clinicians themselves and these can be barriers on itself but one of the key things that can become a barrier is uh where patients receive mixed messages so they might come into a clinical encounter where they had a positive experience they’ve been given a new way of conceptualizing their problem maybe it’s a broader perspective you know we’re talking about their lifestyle their diet you know their weight and they come home and they tell their partner or they tell their family members and they say well but then you look at your skin did you actually see the degeneration in your knee you know you know that’s all well and good but you you’re still going to need that knee replacement so you can get them mixed message or the counter belief within your your family group of uh partners and friends and uh or you may come out of the session and get a really positive um new way of thinking and you go back to see your doctor or you go back to see your surgeon and you get a mixed message again you say well you know at the end of the day you do have degeneration and what we know is that this is a disease that will keep progressing and that can be a massive barrier for patients because they are they feel quite vulnerable they’re going from you know the physio the gp the surgeon the exercise physiologists and they are getting different types of information and that can be really tricky for patients uh and and they can really impact on their on their ability to to move forward uh and you know what sam touched on around funding uh it’s difficult sometimes for patients to to have a a team that cares for them uh and and even when they do have that uh and they have access to it the communication within that team has to be quite unified to deliver the same message because otherwise the patient just feels pulls pulled apart and they don’t know who to believe and then they start doing their own research which might end up in something different again so these are some of the the things that consumers are uh are dealing with and and that’s why it’s so important for them to have places where they can go and they can get credible information that considers the evidence and translates it in a in a digestible uh way so they can understand and they can question that and we talk about having a um like a societal change in how we understand pain and sam alluded to this before we are fighting with 400 years of of looking at uh at this single view of a problem but the more we spread the message the more patients will feel empowered and they may come to a visit and they will question if the care they’re receiving is actually based on evidence you know is that really what suits my my story so these are some of the things we we bring in the uh in the in the paper to to discuss i don’t know if you want to add anything page um you know i think you’ve covered a number of them the fact is that jp and i’m um you know i kind of look at my clinical experience and certainly what we know from research and we know that um some people are more vulnerable than others and that vulnerability often lies with people who’ve had significant social disadvantage people who don’t have good social support people who don’t have a lot of confidence in their ability to make good decisions or make decisions for their health they want to be fixed so it’s too hard and often i think the health system promises they give them simple um and not evidence based diagnostic labels which come with the promise of effects and so often you know the fix is not it’s it doesn’t happen for many people uh and and that’s the trap i think is that what what you highlighted sam was that understanding of pain it’s way more complex than just you know pain equals damage and in many cases it’s not related to damage at all related to tissue being sensitive for a whole lot of reasons and that’s the hard part of navigating that process and i think having like you said a trusted clinician who is evidence informed who puts you as a patient in control it educates you and puts you in control of your health journey and gives you honest um uh information so you can make good choices that are informed and that are evidence informed about that pathway and takes you on a journey to put you in control is the key um but so often that doesn’t happen in a health environment that is um based on you know getting its income from you know quick fixes sadly yeah and certainly it’s a it can be cheaper for the patient to go on and have surgery if they have private health if they go through the public system other than going and getting evidence-based care of exercise education weight loss uh and that’s that’s tricky on itself uh and perhaps i think that it’s important to to to make clear here is that we are not always advocating against surgery that’s not the uh that’s not the point the point is to is to advocate that people get uh what is recommended based on evidence and that people get a chance to try that and try that for enough time before they go on to have surgery so i have a case of a patient who was really unhealthy and you know she had several comorbidities she was overweight she wasn’t sleeping well uh and she had significant knee pain and she was told that she needed surgery but she was scared of going for the surgery because she heard about what in the consult she was told about all the risk factors and all the potential adverse effects that could happen with the surgery and she said look with my health and where i’m where i am at the moment that may be me and i’m scared of that so that created an opportunity for her to look at her overall health and go through a program where she strengthened herself she got healthier she was sleeping better uh so she ticked a lot of the boxes and at the end of that journey uh actually a knee replacement was it was was a good thing for her but she went into that knee replacement with uh without the unhelpful habits that she had she went with with way less weight and much more confident in herself and the outcome of the surgery she had the surgery and she did really well and she went become she became active but a lot of that lifestyle was installed before the surgery and then she just picked up after the surgery because she put herself in a really good condition and so these are really important things that we are not here to to tell people that they shouldn’t have it we’re trying to identify you know when should you have it and and who should have it and that’s that’s a tough question to to answer uh and that’s where the the this this partnership in the in the clinical encounter is really important uh between clinician and the patient and the rest of the team that’s right we just the best way we can keep people moving and how can we do that as clinicians yeah exactly that’s awesome um guys i kind of want to start wrapping it up now or um we’ve we’ve talked a lot about how how these beliefs and lots of like broad topics around societal changes and things like that so i think that’s really valuable for us to start um thinking deeply about this sort of stuff um sam well all of you you three you that paper is is fantastic in the british uh sorry the brazilian journal of physical therapy um and the the research that you guys are doing is contributing heaps to um us advancing our knowledge and and as part of this obviously podcast it’s about trying to translate that um sam you’ve done a lot of work in hearing the stories of patients going through this sort of tough journey and done a lot of research working with a variety of different professions and obviously pain for body areas people with pain in different areas i kind of wanted to see if you could leave the listeners with a couple of take-home tips um in terms of sort of encompassing um what what the common pitfalls are when it comes to um these these traps or cycles that people can get in that aren’t that helpful but like i think at a very certainly based on some of the work i’ve done i think it’s really important that we we do learn to obviously listen to our patients that we listen to those stories that and i think the common sense model is a nice framework for us to maybe start doing that it helps i think as clinicians to have a road map of of how can i be listening to the story what should i be listening for and i think really listening to to asking about those those key belief dimensions what do you think is causing your problem you know what do you think is your problem what what label have you what diagnosis have you been given what does that mean to you um you know what what do you think caused that what do you think the consequences of that are going to be what can we do about it what are you doing about it and how long do we think this is going to last i think listening asking those questions listening for any um maybe unhelpful beliefs that they’re telling you listening for any gaps in their understanding the things that aren’t making sense for them it’s maybe a good place to start for clinicians not feeling very comfortable about you know we do read about all these different beliefs in the literature it can be difficult to understand what are the key things that i need to be listening out for so i think that that’s a helpful start for for many people um to begin with yeah absolutely i think i’ll add a couple of things there and say that for for patients to feel comfortable questioning the their clinicians you know when you go to whoever you’re seeing i think you gotta think before what are the things that i want to be able to do that i can’t do because of this what are my goals where where where do i want to be and what do i see as the barriers and what is my understanding of this problem and when you go to that session you question those things and make sure that you leave with a with something that it’s it’s clear to you of what your problem is and if it’s not clear and or the clinician doesn’t have time uh maybe ask for a place where you can read about it that that clinician thinks provides you with credible evidence um and in that session if you don’t feel like things are making sense to you question that and ask why because some some patients come into the clinic and they may feel that they just need to take the information and what we’re saying is the absolute truth and and we learn a lot from listening to the patients we learn a lot from being questioned and challenged and when they question us or we realize that we haven’t made things as clear or we could make things clearer and that’s really helpful in both ways so it’s like feeling able to do that i think would be my my tip yeah absolutely anything else you guys want to talk about peter do you have another tip finally on that um i think i think it’s really hard for people to navigate the internet you know people will often go to the internet when they are feeling like what’s going on here and um and there are some credible places to go to like the pain health website is a really great website that is designed for consumers um that’s written to for their voice and that captures the stories of people like jamie who give a broader understanding of pain that you know sam said that pain does not and may equal damage but in so many times cases it doesn’t and when and damage heals and often pain doesn’t go away once you’re healed it’s a different kind of pain it’s got a different kind of meaning and that idea of if it hurts it and it is if you’re broken then there may be a period that you need to rest but if it’s not broken don’t rest it you know it is safe to engage with mood and activity and build your confidence to do the things in life that are important for you and those are the things that are really important that we don’t kind of hold a label that traps us into prison um and that limits our ability to engage with life um i i that’s where we often see the the real harm done around some of those belief labels um is the consequences and the distress that can can lead people in yeah awesome thanks very much for your time sam especially it’s on us late over there in queensland um awesome to chat to you all uh fantastic work with all the research that you’re doing and um yeah look forward to keeping in touch thanks kid thanks man thanks sam so there you have it another episode of the empowered beyond pain podcast my take homes were the beliefs we have about our body heavily influence how we use it and how we feel about it so if our beliefs are misguided or inaccurate our actions and emotions will follow suits potentially resulting in a negative spiral of more pain and functional loss the common beliefs about pain and i’m talking particularly about persistent pain here are a little well a lot outdated sam talked about a 400 year old model of pain that is still widespread in the community something we’re trying to change and with acute trauma tissue damage is likely to be the key driver of pain but the longer that pain goes on the more that our behaviors contribute to driving the pain and what drives those behaviors well it’s usually our beliefs next week we start our in-depth discussion of the 10 back pain facts discussed in episode 4 and 5 and let me tell you we have some spectacular guests lined up including patient voices and world leading researchers show notes as always are available at www.bodylogic.physio forward slash podcast and if you like the content and want to show your support the best way is to leave a review or share the podcast until next time though remember to ask is there more to pain than damage please note what you heard on this episode of empowered beyond pain is strictly for information purposes only and does not substitute individualized care from a trusted and licensed health professional if you would like individualized high value care for your pain sports or pelvic health problem head to the bodylogic website and make an appointment theme music generously provided by ferven and cash.