The Perception Of Pain with Dr. E

February 1, 2024

Join us for a wonderful discussion with Dr. E who joins us to demystify pain perception and share transformative physical therapy techniques. Dive into a world where comfort meets science.

Summary:

Back pain and physical therapy with Dr. E. 0:00
Physical therapy background and career. 1:57
Manual therapy, product development, and marketing. 2:51
Manual therapy and the limitations of human touch. 8:29
Pain science and manual therapy. 13:14
Perception of pain and threat. 17:49
Pain perception and the brain. 19:50
Posture, exercise, and pain management. 25:27
Low back pain treatment and desensitization strategies. 30:35
Modern manual therapy and its mechanisms. 35:50
Pain science and nervous system function. 39:37

Transcript:
Natalie 00:00
Hi, I’m Natalie garland and I’m here with Derek Berkey. This morning, how are you, Derek?

Derek 00:03
Doing great, great.

Natalie 00:05
Good. I’m excited for this podcast today. And for our guests, Dr. Erson religioso, who’s a doctor of physical therapy, manual therapy fellow and a mentor to physical therapists all over the world, and specializes in a lot of like back pain. And I’m really excited because my back is really been hurting.

Natalie 00:23
Yeah, primarily just from like, carrying the weight of this podcast. Wow. Okay, sorry. But I’m really excited for our listeners to hear this conversation with Dr. E. He has so much knowledge and passion surrounding this subject. And to hear Dr. E talk about what’s actually happening in the body when people are experiencing pain because a lot of people, it was like, 80% of people experience back pain, especially lower back pain.

Derek 00:36
Has it?

Derek 00:53
Yeah.I mean, yeah, I think that back pain is a something that a lot of people struggle with. And just like pain in general, you know, like, I think that the chronic stress that people feel, and that experience on a day to day basis, all feeds into the kind of like this. It feeds into pain. And so I think that we’ve gotten, we’re gonna get some really cool and really good tools to be able to utilize on a day to day basis. So.

Natalie 01:15
Yeah I’m excited for people to hear Dr. E talk about what’s happening in the body when they’re experiencing pain and hopefully come out of it feeling like they’re going to be better able to attack whatever’s going on in their body and find some relief and some healing. Dr. E. Welcome to Invigor medical podcast.

Dr. E 01:31
Yeah, thanks for having me.

Natalie 01:33
Yeah, we’re really excited to have you on today. We typically do kind of a free flowing podcast, but with questions to go back to so I’m excited that today you were like, no, no, let’s just go for it and get into the questions and have a conversation. Yeah.

Dr. E 01:48
Yeah let’s, I don’t even know what that means.

Natalie 01:51
You did make a joke earlier that you’re just a walking soundbite. So I’m excited to see that live in action as we’re recording today.

Dr. E 01:57
Alright, yeah, hopefully. Well, I hope I didn’t hope hype myself up too much.

Natalie 02:00
Right. Set the bar a little too high for yourself. Maybe No, I think you’re gonna do fantastic. Why don’t we start with a little bit about you and your background and how you got here sitting in this chair and you know, your passion for physical therapy?

Dr. E 02:14
Yeah, well, actually, I’m not even sitting on a chair.

Derek 02:15
Of course. Physical therapist fashion sitting on a stablility ball.

Dr. E 02:20
I don’t have a chair, ya know? Why would I be static. I’m gonna keep I just got to keep on moving.

Derek 02:26
Maybe we need to get those for the studio in here.

Natalie 02:29
You’d just see me constantly bouncing?

Dr. E 02:33
Yeah, I know. I have to control myself to prevent myself from bouncing, or it wouldn’t be good for the camera. Yeah. So yeah, I’ve been a physical therapist for 26 years. I originally graduated with a BS and MS. From diva College in Buffalo, New York. And that’s where my practices. And right around that time I wanted to become a I was really interested in manual therapy, and particularly spinal manipulation. I thought the end all be all that would make me the best physical therapist in the world, was if I was able to learn spinal manipulation. My parents are medical doctors. And at the time, they were really against like traditional chiropractic. That goes back to way back in the 60s when like medical doctors tried to smear chiropractors and renders like this committee or quackery, and they were interesting, you know, that’s why chiropractors started calling, manipulation adjustment because manipulation sounds like literally trying to manipulate your mind. So adjustment saw that, you know, much more gentle, but they said, hey, you know what, we’re basically going to disown you professionally and potentially, from the family if you become a chiropractor. So I learned, I learned that there was this route of manual therapy fellowship, where I could study in this new Doctor of Physical Therapy program in St. Augustine. It was probably one of the first doctor physical therapy programs in the United States in 1997-98. So I, I literally applied to this program, two days after I graduated, and I got in and I just started going right back to school, like I had one, one weekend off, and I started going right back to school.

Dr. E 04:03
I did ended up doing a manual therapy, fellowship and residency with my mentor, Dr. Ron Shank, who was also my orthopedics professor. He was the reason where I got so interested in manual therapy. And I learned that there’s a whole lot of things other than just spinal manipulation or soft tissue work and nerve flossing and a whole other host of things. And I wasn’t satisfied there. I tried, I learned I learned that there was like all these gurus like every profession, I don’t know, maybe physical therapy more than most. We have all these gurus, you know, like like Maitland and McKenzie and David Butler and all these guys who kind of like just made a name for themselves. They have a whole series of seminars and you can get certified in their approach. So that was my next goal. I’m gonna get certified and get as many credentials after my name as possible. I don’t know if you if you’ve seen my bio, I have like lots and lots of letters after my name. And at first that was my goal to be more credentialed than anyone else. And also, I’m going to I’m going to learn from all these gurus, because there could be only one. And I know these guys are all going to die off one day and I thought I’m gonna replace them, like, just so arrogantly, I just thought I’m gonna be like the next big thing. I want to teach all these seminars.

Natalie 05:11
Lofty goals. I love it.

Dr. E 05:13
Right? Yeah. I mean, I even told some instructors, so arrogantly, “Look hey,” they’re like, “Why are you taking this course?” I’m like, I only want the credentials. I’m not even gonna use your approach.”

Derek 05:22
Oh wow.

Dr. E 05:23
I know, I know, I was the worst right?. And then I started, I started blogging in about 2010-2011. I had one of the first like, main PT blogs, I was one of the first kind of PT influencers before PT became, uh, influencer was a word. I had this really popular blog at the time when back when people read, you know, on the internet instead of listen to and watch like, a minute and a half vertical video. Yeah. So yeah, that really blew up. It was called the manual therapist.com That’s still in existence today, but mostly for like a kind of ever-growing content. So that kind of got put me on the map. And I started like teaching trying to promote, like this particular product that I sold like a handheld tool, let me go get that.

Derek 06:10
Is this a graston?

Dr. E 06:11
It was this thing, for like, mobility.

Dr. E 06:14
Oh, the Graston tool.

Dr. E 06:14
Yeah, it’s not really Graston though, the whole point was that Graston tools are $3,000. And I was able to sell this for like, $120, I literally sold 1000s and 1000s them.

Natalie 06:25
Is that like a torture device? Like on of those torture devices, like dig in to your muscles?

Derek 06:28
Basicly.

Derek 06:29
Can I just take a moment to highlight how incredible that is? Like, I don’t know, I’m coming from this from working in a physical therapist, clinic as an aide. And like seeing all the physical therapists like setting the Graston tools up on like this podium, sit, you know, it’s like a shrine of Graston and like, if you took one of these tools and dropped it, yeah, they would get so mad.

Dr. E 06:29
Yes, that is part that is part of my journey. Because when I when I initially developed it, I was a rock climber. And I said, you know, like, I need to save my hands for rock climbing. So I was beating up and bruising patients so much, that I thought I need to use a tool to make it better. And I thought these Graston tools are too impractical to, even though I’m a successful physical therapist, I thought something can be done to like bring this to the masses, right? So I started selling that on Amazon and then eventually got an E-commerce store eligibility system, I started branding like, a bunch of different products, white labeling them, but making them much more accessible to not only the public, but also to clinicians who don’t necessarily have like 1000s and 1000s of dollars extra to spend on their practice.

Dr. E 07:30
Yeah, right. Like, like the whole clinic just is quiet because it’s like, oh, man, just scratched like the, did he scratch the $500 tool or the $700 tool, you know?

Derek 07:39
Yeah and I never understood it because I’m just like, these are just like, like just pieces of metal with this bevel, like, how could this cost so much?

Dr. E 07:47
There’s a big markup on those things?

Derek 07:49
Yeah, so I think it’s incredible.

Dr. E 07:50
They’re also like wrapped up they’re wrapped up into cloth right? And I just said this on a podcast two days ago, like you’ve been wrapped in cloth, you expect it like, light to come out.

Derek 07:59
Yeah.

Natalie 07:59
Angels of heaven singing.

Derek 08:00
Yeah its a piece of steel, right?

Derek 08:00
Like, a box from Pulp Fiction, you know, the bulk, the box from Pulp Fiction that like everyone opens and like, it’s like, glowing, everyone’s looking at it. It’s just like a mystery, right? Like, like, these things are so special. And not to say that my tool isn’t special. I just say if you drop it, not the biggest deal in the world. If it gets a couple scuffs, not the biggest deal in the world.

Dr. E 08:17
Yeah, yes, it’s steel. It’s nothing, nothing more special about I mean, I do say it’s covered with pixie dust too, you know, my particular version?

Natalie 08:27
Oh, yeah, of course. Absolutely.

Dr. E 08:28
Right. Yeah. Yeah. So I tried to start promoting that. And I realized that there’s no reason to go back to hammer.com, right, like you buy one of these things, you buy a hammer, you never go back to hammer.com. And so you essentially know how to use it. So I thought, well, I’m going to start showing videos of me using it. And then people got interested not only in that, but but my particular background of having like, kind of amalgamated all these different approaches from all these gurus I listened to. So that’s where my brand Modern Manual Therapy and what I call the eclectic approach, because it kind of fits in with my whole E-brand, like Dr. E, with my first name Erson. And that tool is called the edge tool, so everything, kind of went around the E as a logo. And I actually ended up getting teaching gigs all over the world because people were so interested in my YouTube videos. And that ended up being a lot less about the tool and more about how I eventually kind of combined like a McKenzie approach which standard modern manual therapy and what’s called pain science education, which we’ll get into later with about the back pain, to kind of like empower the patient because I went from I have these, you know, magic hands that are going to fix you and my X ray eyes can tell exactly where the points that need to be like elbowed out or you know like I need to just like work on these things until you feel better I need to bruise you because I’m breaking up scar tissue, to now I use this tool was like the force of a cat or dog licking you and I’m so gentle and I think that every every single technique can be and should be pain free. Like no one should ever be sore from physical therapy unless it’s like delayed onset muscle soreness from exercise. So that’s my transition of, you know, initially wanting to sell a tool and my first videos and like the first year that are still available on YouTube where I was showing people like before and after you’ve got to bruise people to actually get this done to now, use the force of a cat or dog licking you because it’s impossible to break up scar tissue.

Natalie 10:21
Impossible to break up scar tissue.

Dr. E 10:24
It’s impossible.

Natalie 10:24
And so yeah, all these people are going through all of this pain and these bruising

Dr. E 10:28
For no reason.

Natalie 10:28
And getting literally beat up and there’s no reason for it.

Dr. E 10:31
Yeah, so let me ask you this question. How much force do you think it takes to stretch out Fascia? Which is like, you know, everyone else is working on fascia. Fascia is kind of like, when you peel back the skin of a chicken, it’s like the white stuff in between the skin…

Natalie 10:48
Right, like that little layer you peel off.

Derek 10:50
Connective Tissue

Dr. E 10:51
Yeah, it’s like literal layer of connective tissue. It’s like, kind of like, it’s really thin. So, to form fascia 1% it takes 1000s of pounds of force. 1000s of pounds. And it’s not to say that I shouldn’t say it’s impossible, I would say it is very impractical to think that you’re doing it with your hands.

Natalie 11:12
Okay.

Dr. E 11:12
Also that other studies where they removed. Like, say, for the sacroiliac joint, everyone else says like, I should say this too, oh, your hips are rotated they’re outof place, right? Like, oh, you bent forward, you heard a click, maybe didn’t hear click, but Well, let me let me palpate you with my magic hands. And oh, your hips are rotated and they’re out of place. But they did, they’ve done studies where they remove all the skin, the glutes, all the tissues, everything that like comprises the whole pelvis on like a fresh cadaver. And the only thing that’s left are the ligaments that are around like the sacrum, which is the triangular bone of one of the bones that are feeling out of place and the two iliac crest bones. And someone in one of my classes actually said this and they said this is like an experiment for PTs learning how to be manual therapists in a particular program in Australia, and they said, “Okay, now that we removed all the supporting structures that the average like living person has, the only thing that’s left is these ligaments, and these three bones. Now try to take them apart.” And they said it took it took them over an hour with a hammer and chisel was only when they were able to take apart and both these girls to the CrossFit there were like huge, really jacked really fit. They said they were like sweating by the time they were done.

Derek 12:26
Holy cow.

Dr. E 12:27
And that’s after you remove the glutes and the tissues and everything else that supports it. Another really good example is I’ve heard a surgeon on a podcast just laughing at you know, PTs or chiropractors and massage therapists making the claim that the pelvis is out of place because he said that, so he’s like an ER, ER doctor, he says in a head on collision typically, and people maybe slamming on the brakes, something like that. So see, you’re slamming on the brakes, and you get hit again, 1000s of pounds of force. This the femur, right, like the largest bone in the body, the femur actually fractures before the pelvis goes out of place. Like that’s how strong…

Natalie 13:03
Wow.

Derek 13:03
Holy cow.

Dr. E 13:04
…our bodies are. So again, if it takes 1000s of pounds of force to break up tissues, plus, it may takes even more for like the pelvis to rotate out of place. It’s not to say that manual therapy doesn’t work, because manual therapy definitely works to improve mobility, and to decrease pain. But it does not work for mechanical reasons. There’s not like a simple fix of like, I’m just going to do this. And now you’re going to be put back into place. Because if you can get put back into place that easily either like your therapist is Superman, or the Incredible Hulk or you know, like superhumanly strong, or they’re not really they’re not doing that. And another question I also asked my courses too is if if we could break up tissues, like what would be the difference between me using a tool or my hands or an elbow or something like that, or the ground what’s called the ground reaction force of a fall, like if you fall and you sprain your ankle. The difference with that is it probably is like maybe a couple 100 pounds of force, but it’s also really quick. So when it’s quick, you need less force to rupture something. When something ruptures, like when a muscle ruptures or tendon ruptures or a ligament ruptures or tears, it’s actually acute trauma. So then there’s bleeding, and there’s inflammation, and then the body makes that area sensitive and it hurts to touch, it hurts to move. So what would be the difference between like the ground reaction force of an acute trauma and our hands? Like if I was breaking up scar tissue, it would actually be an acute trauma and you wouldn’t feel better, you would feel worse because you’d be bleeding internally.

Derek 14:38
At that point, you just be creating new scar tissue.

Dr. E 14:40
And then well you don’t even, you can’t even really create new scar tissue because new scar tissue, I mean, yes, if you actually created an acute inflammatory process, it would eventually scar tissue would be laid down,

Dr. E 14:52
And then you’ll just increase and increase, yeah.

Dr. E 14:52
But scar tissue isn’t necessarily a bad thing. I mean, we’re not lizards is the thing, right? Because lizards regenerate Right perfectly, you know, we’re not lizards or Wolverine who has like a healing factor and like, exactly heal back whatever, or the Incredible Hulk and like he cut off his arm, you can actually regrow an arm. We’re not like that. We actually, everywhere we’ve ever been injured, we just lay down scar tissue and scar tissue is not a bad thing. It’s just a result of the healing process. Can potentially it be weaker or tighter? Sure, but I mean, most people just continue to move and scar tissue along with a lot of other things and I alluded to this earlier, which is what we call now Modern Pain Science, or it’s not even really modern anymore, it’s like over 20 years old. Modern Pain Science has identified so many things about are essentially myths about what causes pain, it’s not like disc herniations, or degeneration or osteoarthritis, or inflammation, or scar tissue or something being in or out of place. All that has pretty much been disproven to cause pain, can it potentially sensitize the system to make it more sensitive so that certain movements hurt? Yeah, but I mean, it turns out that a lot of these findings like disk, disk issues, or arthritis, moderate to severe arthritis, all of those have been found in completely asymptomatic people, when they started like over 20 years ago, scanning people and looking at MRIs, and CAT scans and X rays of completely asymptomatic people. And turns out that they have a lot of these same issues, that people who are in pain have. So it’s really hard to say that disc issues caused pain or arthritis causes pain when asymptomatic people also have these things on scans.

Derek 14:54
Yeah, you know that uh, oh sorry…

Natalie 15:05
No, you go.

Derek 15:10
I was just gonna say it sounds like we’ve kind of gotten ourselves to a good point to talk about back pain, because we’re talking about pain in general. But I also I don’t know…

Natalie 15:58
Yeah, well, I’m just curious because the, this whole line of talking started with you talking about using this tool, and it’s like, as gentle as a dog or a cat licking you then you’re like, also, you literally all this force can’t move these things. And so I’m like, well, then how does this other tool work then? That’s what’s going through my head.

Dr. E 16:55
Well yeah, I mean, you know what, I probably still the majority that I sell, they all work the same way. So it turns out that whether you’re getting scrapes, or if you get like acupuncture or dry needle or you get like an adjustment or what we call manipulation, physical therapy, we don’t call it adjustments. Or if you get an injection or anything that works works rapidly. So pain is purely a result of your central nervous system or your brain detecting threat. And this is a subconscious detection. It’s not necessarily a conscious detection. So this is this is like the basis of pain science. Pain science, again, from like, 2002 when it’s when these sort of two physical therapists in Australia started pioneering this movement. Again, looking at like the scans of completely normal people, they realize that pain is purely a result of when your nervous system detects threat. If there’s a-and the example is this guy, this physio Lorimer Moseley-He’s one of the most charismatic physical therapists you’d ever get on podcast. It would be great, but …

Derek 18:00
What was his name again?

Natalie 18:01
Yeah, we’ll make a note of that.

Dr. E 18:03
Lorimer Moseley. He even has like this, this video where he’s telling the story. It’ss on a TED talk, actually. He, he said he’s like hiking in the outback. And he thinks he stubbs his toe. So his toe hurts, but he finishes the hike, and then I guess when he takes his boot off, I guess his foot may be like, really swollen? He’s like, well, that’s really weird. Like, why? Why does my foot look like this? He goes to the ER or I don’t know what they call the ER the ED in Australia these days. And they said, Well, hey, you know, it’s really good thing that you came here because you got bit by like the most venomous rattlesnake in all of the Outback. And you’d be dead if you wouldn’t have come here, you know, next time, he’s like, Oh, my gosh, like, I can’t believe I narrowly survived, right? The next time he’s hiking. And so he barely had any pain. He just like, oh, I stubbed my toe. I can finish the hike. Right? But now the next time he’s hiking, he stubbed his toe. He experiences severe pain, right? Because he’s really living the whole experience of oh my gosh, did I just get bit? Am I going to die? So it’s all about the perception of threat. Right? Another great example of this is I’m probably older than you guys but I don’t know if you know who Kerri Strug is. Do you guys know who Kerri Strug is? The Olympic gymnast.

Natalie 19:17
Yeah!

Derek 19:18
I don’t.

Natalie 19:18
I totally know that. Like it’s from way back. It’s like early 90s. Right. She was like big, right?

Dr. E 19:23
Early 90s. Yes. Yeah. She thought she sprained her ankle. She had to like she did one vault. She landed wrong. She thought she sprained her ankle. And she basically has to have like this perfect vault to be, whatever to get the gold. She ends up like landing perfectly and then she like hobbles off and she’s like, she’s carried off by her coach. She only thought she sprained her ankle, but it was really fractured.

Derek 19:46
Holy cow.

Natalie 19:47
That’s right, I do remember that story.

Dr. E 19:48
So if she had known it was fractured., if she had gotten the results of the X ray, chances are she would have been a lot more pain and she wouldn’t be able to do that. But I mean, again, it’s all about the perception of threats and you know, again, there are a couple other researchers who were like, if you had an ankle sprain, and you’re hot, you’re hobbling across the street, but a bus was coming for you, like the bigger threat kind of takes precedence, don’t necessarily feel pain, right? So it’s not to say that again, a fracture doesn’t cause pain, or inflammation doesn’t cause pain, but it’s purely about how much threat does the nervous system detect because it the nervous system is purely trying to protect you. So again, when people were like, oh, you know, my MRI says that I have severe degeneration, and I have like this L four or five disc herniation. It’s pinching on a nerve, like all these things are what I call thought viruses, right? They’re like, like, degeneration. It’s severe. You know, another thought virus is, your surgeon might say, like, oh, well, you needed surgery yesterday, like these terrible messages. Like running is bad for your knees or deadlifts are bad for your back and turns out again, all these things have been totally disproven running is good for your knees. Deadlifts are actually good for your back. And, you know, I’ll say things like, well, you know, there’s actually a good amount of research that shows that if you take 1000, pain-free people off the street, and you MRI, all of them, anywhere between 50, and 70% of them may actually have disc herniation. And they don’t have pain. You know, it’s one of my questions to any low back pain patient, a neck pain, patient or patient with any kind of pain, who’s received the bad news of a thought virus on their skin? Like look? Even if you’re if your pain might be 10 out of 10 at worst, but is it come and go? They might think it’s constant. But usually, you know, my it’s my definition of constant is, from the moment you wake up to the moment you go to bed, constant to me means you always feel something like as soon as you’re conscious, you feel it, you can’t get busy and ignor it. It’s the same in every single position are like oh, no, you know, it’s really just kind of worse in the morning and better as the day goes on. And again, it’s worse than when I get home. I’m like, Well, do you think of a x ray or MRI in the morning, and then like, when it feels worse, and you get the same x ray again, in the afternoon, you get the same x ray and evening. But you have bad news and an x ray. It’s bad no matter what. But if there are times when it’s come and go, that, that means that it’s not possible to be only related to however your skin looks like.

Dr. E 20:04
But there’s something else, you know, that story kind of reminded me of, a kind of a story on the flip side, where somebody who was like a construction worker stepped on a nail. And the nail Yes, it’s perfectly completely through the shoe. And he’s like, Oh, is it the most pain he has ever been in his life. He goes to the ER, they take the boot off and the nail went between his toes. He was never, he was never punctured. So it was like it was all perception.

Dr. E 22:37
Yes, that is actually that is actually told in our in like some pain science classes. And there’s another one actually, I thought you’re gonna say this one because that’s that’s a classic. There’s another one where a construction worker or some guy, he dropped his nail gun. It goes off and he’s like, like, it goes off, like upward. He’s like, Whoa, I mean, like, I’m just so lucky that nothing happened, right? So months go by this guy eventually developed headaches. He eventually gets like some sort of a head scan or something. And then it turns out that this nail went up his nose into his brain. But he didn’t even know it. All he could think of was that I really lucked out. So that’s almost like a similar kind of story. But it’s in a different direction. So another another flip side.

Derek 23:22
Well, yeah, and then the other one that came into my mind is you see these these thought experiments where someone puts their hands on the table, and then they put a mirror…

Dr. E 23:31
Oh, yeah, the mirror or rubber hand experiment.

Derek 23:33
But they put like, they put a wall and it’s a fake hand. And there.

Dr. E 23:39
It’s, that’s called the rubber hand illusion. Yeah,

Derek 23:41
Yeah, maybe you can explain it. I’m sure you can explain it way better than I could.

Dr. E 23:46
Oh, essentially. So imagine, like they say, to put your hands in this box, and the box is covered by a curtain. And then I think you could like, See, you’re supposed to be able to see your hands. But really, the hand is like a rubber hand. So the hand that you see, it doesn’t even have to it turns out to be like a perfect replica. Like for me, I’m darker skinned. It could be like this totally white looking rubber hand like that even look like my hand. And yeah, and when I smash it with a hammer, the person usually recoil some pain. Yeah, that’s called the rubber hit. That’s called the rubber hand illusion. And it’s the reason why tools like the mirror box exists to mirror boxes, like also something for rehab. You know, it’s like if there is a if you imagine like a box with a hole in it, there’s a mirror on one side. So if I put my hand in this box, the mirrors on here, so if this hand is in severe pain, or can’t move or have a stroke or something, any of my good hand is actually reflecting where you’re supposed to look at is like you see a reflection of your good head. And then you could you could like do stuff like this or stuff like this, and maybe things you couldn’t do if you had a stroke. Or you can just purely move and it looks like like the illusion is that the left hand is moving without any pain or that the left hand is moving perfectly without any these kinds of like motor or neurological deficits that you may have as a result of, again, whatever happened, like a stroke, or something wild.

Natalie 25:05
That’s crazy. That’s really wild.

Derek 25:08
So So then leading back to this question about lower back pain, we talked a little bit before the show started about, like how prevalent back pain is, when I worked at a physical therapy clinic for a little bit, it was the majority of the people that came in, I used to, you know, I’d look at the prognosis there, and it’s like, lower back pain, and then all the exercises are listed. I’m sure that’s similar with your experience as well.

Dr. E 25:31
Well, I mean, the exercises are usually just, they should be like, unique to the patient, and not I mean, there’s certain exercises that are better and certain exercises that are bad. But just like, I mean, one of the myths I want to dispel is like, there’s no good or bad postures, like there’s no good or bad exercises, but there is certain things that may be bad for you at a time. You know what I mean? Like how, if you sprained your ankle, there may be certain things you can’t do for a while, but it doesn’t mean that you should never be able to, like twist your ankle and again, or, or do the things that hurt your ankle. So I think that some some things like posture are, like demonized, because they’re like, Oh, this is such a bad posture. And I mean, physically and like, visually, you may not look great, because they’ve done studies that show that people who sit like this, like, look less cognitive than people who sit like this are less attractive. But that doesn’t mean that it’s good, or even predictive of low back pain. Because the thing with this is that if everyone sits like this, this just kind of compounds upon the too much kind of syndrome, if the average person forward bends their head and neck and they’re low back two to 3000 times a day, right? So we might do the same thing with our elbows. But like the elbows are my favorite example. Yeah, if you take your if you treat your elbows, like we treat our spines and their necks and our low backs, what if we bend them two to 3000 times a day? We probably do. But the difference is, we only go forward with our necks and our low backs. And we very rarely go back right? Even though that’s literally built in by God that like you can actually extend your neck and extend your back. But we walk around with our elbows and our knees and our hips and everything they go, all their other joints go through a full range, right? But imagine, so if you treat your elbows like your back, if you just walked around like this all day, and you never fully extended your elbows, you’re like, Hey, what’s up,

Dr. E 27:20
You’d get in a lot of fights.

Dr. E 27:23
Maybe, yeah, I did martial arts. Yeah. But the time you finally extend your elbows, by the at the end of the day be like, Whoa, that’s really stiff, right. So that’s why it’s so many people-Its not that sitting is bad for you. But it’s a lack of a change of position that’s bad for you. And again, same, same thing with running, it’s not that running is bad for your knees. But running is very repetitive. So things just add up faster, the more repetitive your activity is, if we just extended our necks like this, or like extended our backs like this, and you want if you just got up and changed position, like every 20 minutes, you sat on their Swiss ball, or physio ball or whatever. And if you move regularly, if everyone moved regularly and move their necks and backs and low back, or necks and low backs through a full range, there probably be a lot less low back pain. Because its not necessarily that this is bad, it’s just that not getting out of that position is bad. Like I can sit up like this all day and something else will just bother me because it’s the lack of variability that causes things to add up rather than it being good or bad position. Does that make sense?

Natalie 28:32
Mm hmm.

Derek 28:32
So just out of curiosity, what is the mechanism behind that? Is it like a like a? Oh, I want to say, you know, synovial fluid moving around? Or is it like your lymphatic system that needs to be kind of pumped manually by you by your movement? Like what is the actual mechanism?

Dr. E 28:48
It’s hard to say because again, synovial fluid, like joints are definitely healthier when you move around. So synovial fluid will, like joints will break down faster. If you actually stop moving just like our skin breaks down, just like lying on a hospital bed, right? But it’s not purely just synovial fluid. Because again, a lot of the findings like that you see on scans that where it looks like someone has moderate to severe degeneration and potentially less synovial fluid. They’re seeing a completely asymptomatic people right going back to even say like a they took a bunch of people with like older individuals with, you know, moderate to severe osteoarthritis on an x ray and they only had like left sided knee pain, but they X ray the right knee that doesn’t hurt at all. And guess what, it looks just as bad in some cases worse, because its not like the one knee is older than the other unless they literally had just like a total knee replacement. The knees are the same age yet why does the one knee hurt? It’s not purely due to a lack of synovial fluid or arthritis or you know, wear and tear. Those things are what we call pain signs called like gray hairs on the inside or skin wrinkles on the inside. You know it’s not like I mean, if I didn’t find and shave my head, I’m pretty old now I’d have like lots of gray hair. But that’s not a reason for like my head to hurt, right? I have a like all these like, Dad, I bags and everything. If this was on an x ray or CAT scan, it’d be like, well, you have moderate severe skin degeneration, but it’s not enough for my skin to hurt, right? That’s why I like using jet-more gentle terms that have these thought viruses, like gray hairs in the inside, you know, what I would tell people who are just like, so worried about me looking at their skins like, hey, you know what, if that doesn’t show a fracture, or cancer, I don’t care, because we can’t change what that says. But we can change things that you’re essentially doing potentially one thing or many things that kind of fill up your cup or sensitize the system and I just have to find out what desensitizes your system. So if you do like, that’s in everything I do is called like a recovery plan. So we avoid the things that kind of trigger your complaints and makes your system more sensitive, regardless of what your back or your neck or your shoulder. And we do a high dosage of particular movements that desensitize your thing or your system or empty your cup. And maybe other things to like, get better sleep, maybe put tumeric and smoothie too, for anti inflammatory stuff like I do way more than just like your kind of standard PT because I tried to look at like, the whole ecosystem, rather than, you know, do these 10 stretches in this back book.

Derek 31:22
Right.

Natalie 31:23
Could you walk us through that then a little bit like if I were a patient that was coming in with the low back pain, and you you just you just said, you know, let’s figure out what sensitizing the system and what we need to do to desensitize the system? I mean, obviously, as you’ve expressed, like, it can be very unique. And it’s not necessarily this is a one size fits all treatment. But can we just maybe walk us through some examples of I’m coming in with low back pain? What is it that you’re doing to determine what we need to stop doing and what we need to start doing?

Dr. E 31:49
Yeah, well, a lot of times it comes back to really detailed history, you know, like, I might spend 20-30 minutes on a history. Has this ever happened in the past? How has it been in the past month or so? Is it getting better, worse, or not changing because alot of times it’s getting worse. And you have like neurological signs or something I may need to refer you out. But if it’s getting better, or even if it’s like, come and go, if it’s like I always say, I’d rather see a 10 out of 10 intermittent pain, because 10 out of 10 intermittent pain, to me is easier to treat than two out of 10 True constant like unrelenting pain never ever changes, despite any treatment or anything that’s there may be a nervous system that is actually unresetable. But 10 out of 10 intermittent pain means there are times when your nervous system is safe. So to me that’s like you fit into what I would call a rapid responder category. There’s probably something today that I’ll be able to find-a movement, a position or stretch that you can dose over and over and over again, to eventually convince your nervous system that it’s safe. So I go also, like, ask you simple questions like well, what makes it better? What makes it worse? And we kind of run from there if you say like sitting and driving and bending and squatting and dead lifting make it worse, we may need to avoid or modify those things temporarily. Again, but not forever. Because I think a lot of things with the back is like, oh, we should just never deadlift again. Or he just stopped heavy squats, which was like the worst advice ever because everyone should literally be working out more instead of working out less right? And again, they’ve done research that shows that people who do deadlifts have less pain and people who don’t do so it’s really hard to say that deadlifts are bad for your back.

Derek 33:25
I feel like you, I feel like you-I’ve only heard one other physical therapists say that deadlifts are good for your back. So…

Dr. E 33:32
You’re not listening to the right PTs.

Derek 33:33
I’m not listening to the right PTs.

Dr. E 33:36
Those PTs also probably don’t deadlift. I mean, anyone who says that is one not up with the research and to just plain ignorant I mean, it’s just like saying, again, I’ve heard PTs say running is bad for your knees. But it’s like it’s not that’s like saying lunging and jumping especially it’s jumping bad for your knees. And yeah, in fact, they’ve done studies that show that running is not running is worse reduces people who don’t run at all tend to have more arthritis than people who do run.

Derek 34:00
Right? That’s crazy. Anyways, I just thought that was very interesting. But yeah, I appreciate that, that the, that the, the field is moving more towards these types of modalities, because it’s like, you know, I guess the reason why I bring that up as the the physical therapists that I hear is like, these are dangerous compound movements, you know, it’s very, you know, you’re working with very high loads, and it could result in very severe injuries. When really, it’s like, it’s working out good.

Derek 34:28
It could, yeah, in worst case scenario, and if your form isn’t good, you know, all these things can like build up but like, really, I totally agreement with you of like, you know, if you’re, if you want to strengthen your back, you’ve you’ve got to do it by strengthening your back. You can’t like work around that. You’ve…

Dr. E 34:28
They could.

Natalie 34:44
Do bicep curls forever and get a stronger back.

Derek 34:45
Exactly, exactly.

Dr. E 34:47
Right. And the other thing is like, you know, thanks to Paul Hodges, he’s like one of the physical therapists who first did like the they’re all the research on low back pain and how that affected like core-everyone, like he kicked off the whole kind of like core stabilization movements. And everyone’s like, Oh, you got to work on your core for low back pain and also just to make you a better human being, like literally became the answer to every every problem known demand, and is that the paid signs came along with our debts? It’s like, that doesn’t relate the low back pain at all. I mean, is it good? And people are like, What about core exercises then like, hey, look, you know, actually like Olympic lifters with the strongest quarters in the world, and they still have pain. Then I’ve treated little old ladies with like, couldn’t plank for, you know, negative five seconds, and they have no pain whatsoever. And it’s really hard to say that, like, that’s, I’m not saying its not good for you that like it’s good for maybe performance and sport. But does it prevent low back pain? No, it doesn’t prevent low back pain because the strongest athletes in the world with amazing cores can still get low back pain.

Natalie 35:50
It’s so interesting. And cause so forgive me if I’m going to try to dumb this down a little bit, because I’m trying to keep up with what you’re saying. But like when I heard you saying like figuring out exercises to I don’t know if he said the word trick, but this is how I remember-it tricking the nervous system into relaxing. So the suggestion that the nervous system is doing something and creating pain, or it’s like there may not necessarily be this huge injury or issue that needs like really intense care. It’s like you’re trying to reset the nervous system so that you can get rid of the pain.

Dr. E 36:19
Yeah I said reset.

Natalie 36:20
Reset, okay.

Dr. E 36:21
Essentially like, and going back to how do things work, whether again, whether it’s like a manipulation or adjustment or scraping or acupuncture, needling, all those things are really just inputs, like they they’re like, you know, going up the nerves and your nervous system has to make a judgement, Is this safe? Or is this dangerous and and often, the more novel or different, and the more, the more novel and non threatening the input is, they can reset that area. And now all of a sudden pain and movement thresholds. Like before, there’s kind of like what I call a CNS or central nervous system lockdown or a n neurological lockdown, where the muscles are all tighten, it’s trying to guard the spine or trying to guard the hip or something that was that may or may not have been injured. But anytime the treatment works rapidly, it’s not because something was put back into place. It’s because the perception of threat is now reset, like an alarm has temporarily gone off. So now movement and pain thresholds are improved. But previously, it would have been like, oh, we just fixed you because we were put back into place. But since all that research is coming out that you’re not doing anything mechanical, to put something back into place, you’re not like realigning something that we know that it has to be some sort of change in perception. at the central level, that changes movement because you’re not rupturing anything.

Natalie 37:41
Right. This has just kind of clicking something for me.

Dr. E 37:43
So that’s part of my brand.

Natalie 37:44
Oh, go ahead.

Dr. E 37:47
Yeah, it’s part it’s part of my brand of modern manual therapy is that every treatment works the same, because I’ve studied a lot of different kinds of treatments. And it’s easy to say like, oh, soft tissue work is the best or adjustment is the best or dry needling or acupuncture is the best. But they all work on the same mechanism of just changing perception. Certain things may work better on others, because maybe, maybe you can sell it better as a clinician, or maybe your therapist has like better hands or they have more training

Derek 38:12
Or there’s better codes to charge insurance.

Dr. E 38:14
For whatever reason. People also have like, yeah, people have preferences too, right? I say that, like treatments are kind of like preferences. Like you might you might like chicken, steak, and sushi, but you know, the therapist doesn’t have chicken, steak or sushi on the menu, and they only have like, these particular treatments, maybe you won’t respond as well.

Natalie 38:33
Yeah.

Dr. E 38:34
You know. So it’s not just-because there’s a big movement toward, in physical therapy toward let’s promote active things instead of passive. Passive being traditional manual therapy, where I’m going to fix you or needling or, you know, where you just go and go and go, let’s try to give the patients an empowering way to fix themselves. That’s why I call them recovery plans. Like I tried to see that a little as possible be whatever it is, see people like two to four times versus was 25 years ago, I’ve seen people two to three times a week for like 30 to 60 visits, you know, or until they break up with you. That’s what they say like, oh, you know, you need to break up with your physical like every physical therapist, chiropractor, massage therapists, whatever, give them six tries. If you haven’t gotten any relief in six tries, it’s very unlikely in their stats to back this up. It’s very unlikely they’re going to do anything for you. And they can be trying their hardest. Oh, yeah, they could be trying their hardest, but if they don’t, if you don’t respond, it’s not like we’re gonna they’re saving their magical homerun super technique for the seventh visit.

Natalie 39:37
Right. This is just making me think it’s like kind of clicking some things into place for me. Just this past summer like an August or something I kind of had like a pinch in my on my shoulder on my left scapula had been bugging me for a couple days and I was like stretching and trying to figure it out and I woke up one morning and felt real stiff again like my neck was heavy and did this stretch and arch my back and I felt like a pop on my scapula, and like, in the most pain I’ve ever been in ended up like literally passing out on the floor from hyperventilating from pain and going to the ER, it was crazy. I’ve never had an experience like it. And I ended up I was like, Okay, well, you know, chiropractic, physical therapy, I’m going to do one or both. And I went to a chiropractor first.

Derek 39:37
Right

Dr. E 40:17
Right, because its the easier way.

Natalie 40:20
Its the easier way. I just met this chiropractor at some networking event the week before. And I was like, you know, it’s quick and easy to get in. Let’s just go let’s just try this first. Something. And it was interesting, because he did this very long examination did all of these kinds of different testings for movement and holding and strength. And it was the longest time a chiropractor ever spent with me doing this kind of tests. And he eventually was like, “I am almost…”

Natalie 40:41
Yeah, I just kind of what I was thinking is like, eventually, it was like, I’m almost positive before he’d ever done any kind of adjustment or anything. He’s like that you have some kind of nerve bundling, that’s actually up at the base of your neck and it’s caused this issue. And it’s been it, you said something earlier, which is pretty much what he said, which I’m going to bet, but essentially, it was in protection mode, thinking that there was all these issues, and it was causing things to tighten up in order to protect and that’s why I ended up kind of having an injury actually separate from where the nerve bundles were. And that wasn’t even actually the issue at all. And he just did the little manual, like the gun adjustment, you know, and it was literally four visits, maybe. And I was experiencing no, no more pain at all, and found some other issues simultaneously fixed. And I was just kind of like, well, that’s some cool magic. But now that I’m listening to you explain this, it’s like lightbulb and coming together for me that there were these other issues that I was experiencing that were actually related to my nervous system. And so could you kind of like unpack that in just a little bit more detail about what is happening in that cirumstance?

Dr. E 40:42
Sounds like a PT.

Dr. E 41:46
Yeah, real quick. I mean, like, they’ve done studies where they look at pain pressure thresholds, like they feel-see how hard can they push using, like some sort of dynamometer or measuring device? Like how hard can they push on someone, before they feel pain, so that’s measuring their pain pressure threshold. And then if they’re in if they have low back pain, maybe they have like less pain pressure threshold at their back. And maybe if they’re rating sciatic, or they also have a certain threshold in their leg that’s like, that’s also you know, better in the leg that doesn’t hurt, then they do something like a spinal manipulation. Like a, you know, an adjustment or something. Then they’ll look at the pain breath or pressure thresholds. And all that is an improvement is fine, but it also improves on like the shoulder. Because, again, David Butler, who’s one of the therapists that founded pain science, he calls it the drug cabinet of brain, it’s very similar to, like, if you get a cortisone injection in your shoulder, because your shoulder hurts, but you also happen, to have hip pain you didn’t tell the doctor about, the hip pain feels better because it’s a systemic effect. So when the brain is under threat, certainly, it’s kind of like being protective and vigilant about areas that it feels that needs to be protected. But anything else, because there is literally an entire systemic effect of improving pain pressure thresholds everywhere where you might have pressure, it’s, it’s again, that tells us that it’s more central and not like a pure mechanical thing that happened with any treatment. But uh…

Natalie 43:18
That’s, that’s wild to me, just to kind of think about how it’s all connected. And I do remember him talking to like asking about, like, any other ankle injuries or any other place that I have pain that’s kind of like persistent or comes back and, and like me, telling him all of these things is how he got to that point, he’s like, yep, before I’ve even touched you, I’m pretty sure this is what’s going on, because you can just like, connect all of the dots. And it just, it just kind of blew my mind. I hadn’t really thought about it in the terms until you started describing that. It sounds like there’s like a lot of different directions, we could go with this. And we’ve barely skimmed the surface. We haven’t even talked about mobility much and we you know, touched on back then I feel like there’s so much more you have to say you bring a lot of passion and knowledge. So I will just say we’d love to have you back so that we can do a part two to this episode. And just thank you so much for taking the time to sit with us. Is there anything that you want to leave our listeners with before we sign off here?

Dr. E 44:04
Yeah, sure. If you ever get bad news, and you tell someone about a scan, or someone tells you you shouldn’t do a particular exercise or activity that you love, why don’t you email me or reach out on social media? I’m @ModernManualTherapy on Facebook, Instagram, and YouTube. And I always get back to people who ask me questions. I don’t do you know, I do online virtual consults as well. And many times I can get you better, better enforced or even more so um…

Derek 44:34
I love it.

Natalie 44:35
That’s awesome. Well, thank you so much for taking the time to chat with us today.

Natalie 44:37
Thank you so much for joining us.

Natalie 44:38
We look forward to having you on again.

Dr. E 44:39
Okay. Thanks you guys. Have a great holiday.

Podcast Guests

Dr. Erson Religioso III
DPT

Podcast Guests

Natalie Garland
Host
Derek Berkey
Host
3180 W Clearwater Ave G, Kennewick, WA 99336
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