magic afterwards.
Adrian, welcome to the AM podcast.
Thanks for coming on.
Thanks for having me, Jimmy.
I appreciate being here.
This is the teaser.
This is the thing before the thing,
because the AOMT conference
is coming up in just a couple of months.
You guys are doing this, uh, St.
Louis, Missouri in October,
which is a great time to be in St.
Louis.
AOMT.org is where people can
find more information.
You're speaking there this year.
What do you,
what do you think about that conference?
How does that feel?
What do you, what do you,
what do you look forward to
in an event like that?
Yeah, the AOMT conference is, um, you know,
it's really interesting.
I'm actually a manual therapist,
so this is a background.
that is actually my stomping
grounds and then you move
heavy into the pain world
and it's always good to go
back to your roots I have
always loved it I like
learning from them I like
learning at these events
but then also now bringing
the pain stuff with us and
coming hey guys annual
therapist moving into the
pain world um you know this
is maybe how we should look
at things so I i love it um
I think I'm going to be
honest sometimes I have a
love-hate relationship because um
Sometimes we're stuck in
this old manual model,
and I think people know
what I'm talking about.
And on the flip side,
we got this painting that is cool.
It's altruistic, but you got to apply it,
which I think this is the
perfect venue for it.
where they combine both of
those two worlds.
So, yeah.
Okay.
Well, it sounds a little revolutionary,
and that's my first question.
You use this phrase, pain revolution.
Help describe that and help
people understand it so
they can either make their
own sign and march with you
on this pain revolution and
its significance really in
orthopedic physical therapy.
How and why should people
join in on this revolution?
Well, it's happening,
regardless if people join or not.
That's the easy part.
In the early 1990s,
when I got into this whole
world of pain science, people kept saying,
there's a pain revolution,
pain revolution.
I kept looking, well, where is this?
And it was four guys doing something cool.
But what's happened now is, Jimmy,
this stuff has now reached
a scale that is, the tide is coming.
There's nothing you can do about it.
It's in PT schools.
It's in OT schools.
It's in medical schools.
There's textbooks.
It's at every presentation.
The joke of AOND is actually,
The tweet that went out a
few years ago and said,
I showed up at the AONT
conference only to have a
pain conference breakout.
It is now so embedded in
everything that it doesn't matter.
It's going to happen anyway.
So the revolution is really
to take what you were taught, your basics,
your foundations,
which I still think is phenomenal,
but then pushing the
envelope and taking on the
new concepts of pain
science is really what it is.
It's happening.
So in this case, what's the easiest way?
Come to AONT, come take the conference.
Take these sessions that are
a little bit on the fringe
of pain science versus just orthopedics,
right?
And then I think that is how
people start getting into it.
All right,
this next one goes more specific.
We throw this term around,
nociplastic pain.
How do you explain it to
someone who wants to learn more?
Maybe someone who showed up
to the AOMS conference at a
pain conference broke out.
How do you describe it and
why is it clinically challenging?
Maybe that's why people
avoid it or don't understand it.
Yeah.
Well, the first thing we do in medicine,
if we don't understand something,
we change the name.
So this phenomenon has been
called central
sensitization for the
longest time I've been around.
And in the last few years, the scientists,
the academics have changed
it to nociplastic pain.
Long story short,
it's where the central
nervous system actually
starts driving your pain experience.
So we have normal,
healthy information coming
into the central nervous
system that then amplifies this.
So now things like light
touch becomes uncomfortable,
which we call allodynia.
We get hyperalgesia.
And for the manual therapist,
it becomes tricky because I
was taught way back dozens
and dozens of years ago
that when I palpate and
poke in areas and people say, ooh,
it's painful there, the problem is there.
But in these patients, unfortunately,
no matter where you poke,
it's sensitive because the
system amplifies it.
So your tests that you use,
your treatments that you
use becomes a little bit less reliable.
In the old days,
if I would poke at an area
and it was a joint,
then that's the problem.
But now those tests are not that reliable.
So we had to change the way we test you.
We've got to change the way
we treat you and approach
you accordingly.
So it is challenging.
And it's about one in five patients,
what the data tells us,
walk into private practice
or outpatient therapy has
central sensitization or
nociplastic pain.
And they are just challenging.
The easy thing is, Jimmy,
I'll just say this.
Every therapist I've ever
talked to can sing this song.
Where do they hurt?
Everywhere.
What makes them better?
Nothing.
What makes them worse?
Everything.
I'm not trying to be funny about it.
I don't make fun of it.
I spend my life dedicating.
But there's this commonality
in the clinic we see.
These patients are challenging.
We don't know what to do with them.
We're not trained well to work with them.
And that is why it's
important for us to take it
to that next level.
Do you see the people that
attend a conference like
the AOMT conference,
they're searching for
answers to things like this
because they're so
frustrated by not being
able to help those patients
when they come across them
in their clinics?
Yeah, I'd probably say some of them.
I mean, that is how I got there.
People always ask me,
how did you get into pain science?
Well, I failed.
The tools I had,
and I was trained by some
of the best people on this
planet with the biggest
names that people would hang on to.
And I couldn't help them.
And so we went to this payment side,
which made it filled in a
lot of the gaps.
So I would argue that at AOMT,
we're going to get people
that have maybe tried their tools,
they trade, and they've got to a limit.
I don't know what to do now.
That's good for you.
AOMT is also very progressive.
These people that attend
AOMT are the tip of the spear.
They're the best of the best.
They are people that read.
They read our articles.
Trust me, they show up and they'll ask me,
hey, you remember that paper on line 27,
paragraph three?
I'm like, whoa, dude, I wrote the paper.
I don't even remember.
So I think it's a little bit of both.
I think there is the,
I don't know what to do.
Adrian, please help me.
But there's also the, hey,
I'm really into this.
This makes sense.
And I want to take this to the next level.
So it's a little bit of both.
Yeah,
I think it's one of those two
directions why people would
do this specifically here.
Yeah.
Let's talk about a different
phrase that I'm not even
sure I came across when I
was in PT school.
Help me understand the
concept of high impact
chronic pain and how it's
emerged really in clinical practice.
What is this when this term comes up?
Or is this another word
that's just been given a new term?
No,
this is actually a subset of chronic
pain.
So, you know,
it's not as if chronic pain
is bad enough.
There's a subgroup within
chronic pain that's even worse.
It
And again, I'm not making fun of it.
They just if you read the research,
it just says there's a group of people.
If you look at one in four
people in this world suffer
from persistent pain on
some regular basis.
And within that subset,
there is a smaller subset
that this is really impacting them.
And there's criteria in
terms of how it impacts
their function and their
ability to literally get
along in their life.
And so we need to do even more for them.
And so if you go search for
high impact chronic pain on the internet,
you're gonna find it in
complex conditions like
chronic low back pain and
fibromyalgia and knee osteoarthritis.
And so it's just people that
are really affected even more so.
I don't particularly care for it.
I'll be honest with people.
I think, you know, I'm a clinician.
I've always been a clinician.
I think of the clinical idea.
And I just hate the idea of
going to a patient and saying, you know,
it's not bad enough that
you have chronic pain.
You have the worst chronic
pain we've got called
high-impact chronic pain.
Now, I'm not making fun of it.
The scientists that do the work,
I know who they are.
I know that they do amazing things.
I think the world of them.
I read their stuff.
We have not even got chronic pain right.
And now we're saying, hey,
you guys are not getting this right,
but you've got to do even more for this.
I think it's a little, it's tricky,
but I understand why they're doing it.
There's a subgroup of people
that need even more.
And that is why they're
identified according.
And I may be missing the whole point,
but I've read as much as I can in it.
I'm just a little concerned
because in the clinic side,
a patient will walk in and say, no,
I don't have chronic pain.
I have high impact chronic pain.
And that's just another setup.
It's like I got a very rare
case of frozen shoulder.
You know, it's unfortunately,
I think for the patient side,
it's a cry for more help.
Hey, you guys aren't listening.
I need help.
So I'm just I'm always
worried about these labels
we add on to it.
But that was going to be my
follow up was do you think
throwing an additional
label on that helps or harms?
I think it harms.
I don't think it doesn't
change one bit for a
clinician in this country.
If a patient walk in the clinic,
Jimmy walks in the clinic.
Hey, Jimmy, what brings you here?
I get chronic pain.
I know what I can and cannot do with you.
An hour later, Jenny walks in.
Hey, Jenny, what brings you here?
I've got high-impact chronic pain.
Nothing's changed for me,
except for the fact that
I'm probably thinking like, oh, crap,
this is even worse.
It's going to be even a
worse day in the clinic.
It doesn't change.
I still have the tools that
I have in front of me.
On a national scale, at a higher scale,
you can talk about multidisciplinary,
interdisciplinary,
but we're not even there yet.
So I apologize to the people
that are listening that's
probably involved in the
gathering or whatever,
but I'm a little concerned
where we go with labeling, unfortunately.
It can get counterproductive
in certain situations.
If I was a patient,
I'd be catastrophizing.
It's not bad enough that I
get chronic pain.
I get worse than when there is, right?
It's like, wait a minute, it's not that.
I mean,
it's a lot bigger than three years.
So you said a second ago, hey,
if Jimmy walks in with
chronic pain or high impact chronic pain,
you still have the same
tools available to you to
treat that person.
So let's go to let's go to
tools and tools or skills and techniques.
So you said at the outset of
this conversation,
you're a manual therapist to, you know,
found this this study of pain.
What specific pain science
skills and techniques?
Do you think manual
therapists should develop
to better manage complex
cases like some of them
we're talking about?
How much time we got, Jimmy?
Yeah, that's a good question.
I think a good start would
be to understand pain,
to really understand the biology of pain.
The biggest thing,
the hardest thing in pain
science right now is pain phenotyping.
The fact that there are
different kinds of pain.
You already mentioned nociplastic pain.
When patients come in, pain isn't pain.
There is pain that's driven
by nociceptive input,
which is nociceptive-driven pain,
which is kind of our bread and butter.
It's sprains, strains, and stuff.
Man, we're good at this.
We are so stinking good at this.
Peripheral neuropathic pain,
which is your radiculopathies,
carpal tunnel, whatever.
If you understand neurodynamics,
nerve movement and stuff,
you'll be okay with that one.
And then we get nociplastic.
So for a manual therapist to understand,
there are really three
buckets that people show up.
And for this bucket, we do this.
For this bucket, we do that.
In terms of examination and treatment,
we've done a lot of this
actually at AONT before.
This will continue on.
It's a lot of this stuff
being put out there.
But we have to match the examinations,
the vigor, the intensity,
the duration of our
examinations based on which
bucket they sit in.
The treatments must shift
from nociceptive is going
to be very traditionally
orthopedic-based.
Jimmy, lay down, crack your back,
you sit up and go, oh, jeez, thanks,
Aidan, I'm good.
I'm going to go home, right?
Whereas that technique does
not work in the last
patient group with nociplastic.
You manipulate them and they
flare and it takes a week
to calm that system down.
Or they say, oh, that was good.
Can you do my neck now?
And they become addicted to your hand.
So we have to match the treatments,
especially in manual therapy,
because we can often flare them.
We can make them addicted to our hands.
So it's a beautiful balance,
but you must know what kind
of pain you're dealing with.
Yeah.
Talking about balance,
we're talking about pain.
on a podcast about a
conference from AOMT with manual therapy.
So should it be pain
neuroscience education and
manual therapy education,
or should these things be combined?
Should you not be able to separate them?
I think they go hand in hand,
and that is exactly one of
the sessions we're doing,
blending the two.
You know,
I was in another podcast a little
while back,
and somebody asked me a question,
and I don't know why, but it slipped out.
Somebody asked me,
how come you're so good at pain?
And I don't think I'm that good at pain,
by the way, Jimmy,
but it just slipped out, I said,
because I'm a good manual therapist.
And the host said, well, wait a minute,
what does that mean?
I said,
because manual therapy gave me my
basic skill set of reasoning,
thorough evaluation,
building a connection with my patient,
all necessary things I need.
And then the pain science
takes me to that next level
to take the complex patient.
Here's the reality.
If you only do one of these two,
you're limited.
Because if you only do manual therapy,
you don't care about pain science,
what people think, their fear,
their catastrophization,
you're not gonna make it better.
And I would go the other side because,
Jimmy,
I live in the other world where I
go to pain conferences where people don't,
you don't touch people
because if you touch them,
they become addicted, whatever.
Some of the most incredible
Changes we see in human
beings that come to
rehabilitation is with our hands.
They want pain relief.
Manipulation,
if you look at the effect
sizes with manipulation,
high velocity thrust to reduce pain,
that's actually quite significant.
I'm a physical therapist, and you know,
last time I checked,
we don't have a ton of
tools to take your pain
from a nine to a seven in one visit.
Manipulation does, dry needling does.
There are techniques that can do it.
And so if you walk into my
clinic and you're really hurting,
I need you to do something
to get you from here to here.
And then you go, oh, man,
that feels better.
Now you're more open to listening to,
let's talk about exercise
and sleep and nutrition and this stuff.
So I think they go hand in hand.
On the one side,
I need to reduce your pain.
And manual therapy gives me that part.
But also it gives me the basic skill set.
I've said this for the longest time.
You have no business
teaching somebody about
pain unless you've made
sure they're safe and you
do your due diligence.
And the only way you can do
it is by being a good manual therapist.
Go through all my reflexes, my strength.
sensation to make sure Jimmy is safe,
he should be, and not see the doctor.
You have no business.
So you have to have both.
And it's unbelievable that people go,
this one or that one.
I don't see how we cannot
have these two cohabitate.
We talked about communication,
or you brought it up in
several different ways.
And I'm a person who loves
communication and where it comes in,
especially in a patient interaction.
How can or how should
therapists effectively
communicate pain science
concepts to their patients
to help improve treatment outcomes.
We talked earlier about maybe there's a,
there's a line where it's
too much or maybe putting
too many words on it.
So, you know, when someone asks,
how do I communicate this?
How, how much, when, where all those W's.
the answer is yes I mean you
know christmas we're
talking about there's 80
million americans in
chronic pain and we need 80
million different ways to
do it because they're all
individual beings right um
in the most basic way to
teach people about pain
there's two ways jimmy one
is a technique I literally
say jimmy listen you're
doing great I'm so proud of
you we're making good
progress but today I need
to teach you something very
important so I sit you down
and we're having a very
deliberate conversation I
need to explain to you why
When it's cold, you feel your neck.
Nobody's ever done it,
so let me do that today.
That's one type.
And we call that often pain
neuroscience education.
I sit down, it's almost like a technique.
I'm doing this thing,
and we have data to prove
that your fear goes down,
your catastrophization goes down.
So it works.
I mean, I can actually bill you for it.
The other way of doing it,
which I find very intriguing,
and this is kind of where
the research is going,
is called pain neuroscience
communication.
And that is people that we train,
and we've been tracking the
data in our research,
that if we train people in pain science,
They change the way they talk to people.
They're softer spoken, less provocative.
They stay away from words that harm.
They use more calming,
relaxing reassurance kind of.
It's almost like you take a
shaker and you shake it
through the clinic a little bit.
It's like you sprinkle this
little bit of things.
So we call that pain
neuroscience communication.
And we're tracking some data
in some of our research there.
So I think it's both.
I have heard people say, you know, Adrian,
I've learned this pain stuff from you.
And I find myself, I'm softer spoken.
I slow myself down and make
sure there's reassurance.
There's all the things that we care about.
So it's a little bit of both.
But I think at its basic core, Jimmy,
it is reducing words at harm.
Therapy has the most harmful
words known to man.
Torn, ripped, ruptured, bulged, herniated.
Take them out of our vocabulary.
use softer spoken words that
still explain.
I know this is gonna be a
little blasphemy at AON,
but they have shown us that
words like sprain and strain,
as benign as they are,
they're actually benign.
The top of the top manual
therapists will say, well,
that doesn't really tell people,
but the patient study show
us that if I tell you a
sprain or a strain,
it doesn't evoke fear and
you understand what's happening.
So we can soften, explain, calm down,
reassure,
That's why I love being a therapist.
99% of what I deal with is
not life-threatening.
99.99999%.
So for me to walk up to Jimmy and say,
Jimmy, you're going to be okay.
I know you're at your ACL, dude,
but guess what?
I've seen a hundred people
like you just last year.
Are you going to be okay?
See the guy on the bike there?
It was just like you a month ago.
Now look at him.
What am I doing?
I'm calming,
taking away your fear or anxiety.
So it's a little bit of those.
It's reducing the words at harm.
giving information that is
understandable and reducing
fear and catastrophization.
And it's not necessarily deliberate.
It is just, we change the way we practice.
You said that people that
study pain neuroscience communication,
they begin speaking softer.
Why do you think that is?
I want to take a guess and
you tell me if I'm right or wrong.
Do you think now that they sort of,
because now you're studying
people and not a condition,
do you think there's increased empathy?
And now that they understand a little more,
they're a little softer?
Yeah, we have shown it.
We have tested health care providers,
measured their empathy and compassion,
and then we teach them.
And afterwards,
the compassion and empathy
changes drastically.
We just completed a study on
medical residents and did
the same thing to show they
turn extremely empathetic
compassion towards people in pain,
which isn't that just the coolest thing?
So, yes,
we're focusing on the human being
versus the condition, right?
But yeah,
it's just to understand what
they're going through.
These poor people are struggling.
They've been everywhere.
Nobody can help them.
You know, the thing about chronic pain,
though, Jimmy, is the bar is so low.
The good news is the bar is so low.
Meaning what?
Meaning that they had been so underserved.
Nobody's done anything for them.
But that's the good news, too.
And I tell residents all the time,
if you don't know what to
do with a patient, just be there.
Just be there.
Say, you know, how are you doing today?
Now, what can I do in this 30,
40 minutes I got with you
to make your day better today?
And now...
hear me correct,
and specifically for Aiont,
you've got to be good at what you do.
It annoys the life out of a therapist.
So Adrian's just saying we
just need to be happy and whatever.
No, be good.
Otherwise, you're useless.
Your skills must match what you're doing,
not only the cognitive side,
but the physical side.
I mean, seriously, you have to be good.
Patients know when you're good.
And that's why I love Aiont.
I love manual therapists
because you've got this side covered.
You're excellent at what you
do with your hands.
But now bringing the soft skill set,
that is what's really, really good.
A few years ago at Aon in Reno,
Bill Boysenold,
who was formed at UW Madison,
made this beautiful statement, Jimmy,
where he said,
these things like compassion, empathy,
respect, listening,
they're not soft skills,
they're essential skills.
I like that better.
Yes, me too.
And it was an instant, I was like, dang,
that is really, really good.
They're essential,
especially for this population.
Bill said it way better.
I did a presentation on the
importance of soft skills,
my background in journalism
and communications before
becoming a physical therapist.
And the title was,
why are these soft skills so damn hard?
Yes.
Because some people will say, well,
why are they so difficult to do?
And you want to talk about
words by calling them soft skills.
Do you decrease or increase the value?
Some people say, well,
I decrease the value and it
should be simple.
So why?
So I've done it.
Right.
The goal of communications
is just to have communicated.
No, no, no, no, no, no.
The goal of communication is
to achieve understanding.
Right.
So the fastest lesson that
I've ever learned is
children and puppies.
If you're not communicating
right to children and puppies,
you will get no result.
But you'll say,
I just yelled louder and I
said it more and they didn't do it.
They didn't understand.
Right.
Because your soft skills
were not on there.
We're not working because
the goal was to achieve
understanding not to have communicated.
Correct.
Oh, beautiful.
Yeah.
I have to remember that one.
What should someone look forward to?
You have a couple of presentations,
one's virtual,
one's in person at your presentations.
Essentially, Adrian,
I'm giving you first dibs
to put butts in seats for
your presentation.
What are people going to
look forward to in St.
Louis?
Yeah, so we have these two parts.
We have two sessions.
One is on blaming pain
science and manual therapy,
which we just talked about.
What we, myself and Dr. Louie Punta Dura,
my buddy Louie,
and I are going to do
together is basically show the two sides,
why it's important to do
manual therapy and why it's
important to pain science,
but then more important how
these two work beautifully together.
We believe they're not mutually exclusive.
And we're going to share
that data to show how you can basically,
for lack of a better term,
take one patient and start
the manual way and end up
in pain science.
The other patient,
you start with pain science
and end up with manual therapy.
They're not exclusive.
And you can use them
interchangeably for different reasons.
We can talk about the words we use.
I think one of my favorite
quotes my buddy Louie
always talks about is,
I still do the same manual
techniques I've always done,
but I explain them different.
We don't fix things.
Things don't go out of place.
We don't put things back in place.
We're just getting some nice movement.
We're getting things to move a little bit,
get some blood flow,
oxygen to calm the system.
So we change the words,
but it's the same stuff.
The other one we're doing is
on whiplash injuries.
There's just...
Of all the musculoskeletal conditions,
that's the one that goes
the most into chronic pain,
about 40% of people.
And some of the amazing
research from Michelle
Sterling's work in
Australia has looked at
therapists doing early intervention,
psychologically informed care,
like reassurance,
all those things in the
emergency room early on
that actually calms the
system beautifully,
then allows them to move
and be treated with hands-on.
So those are the two
sessions we're doing at AONT.
Perfect.
All right.
Last thing we do on the podcast,
let's wow them.
What's words of wisdom?
What's the last thing you'd
want to leave with the audience?
Is there any idea, sentiment, quote,
mic drop moment?
What do you got?
Yeah,
I should have thought about that one.
I think what it's becoming
very favorite in the pain
world for me is the fact
that pain that is
understood is not to be feared.
The more we teach our
patients what's happening to them,
the more they calm down and
fear drives pain powerfully.
So if they understand their pain,
they're not afraid of it.
they will move and in this
conference be touched and
go I'm okay I'm not being
hurt I'm just sensitive and
I think that's a critical
element well said uh
looking forward to st louis
looking forward to your
talks and appreciate the
time giving us a little
tease ahead to am's event
thanks jimmy appreciate it
that's it that's all we need