Hypermobility, Pushups Over Quad Sets, and Lat Dominance – Movement Debrief Episode 28

Movement Debrief Episode 28 is in the books. Here is a copy of the video and audio for your listening pleasure.

Here is the set list:

  • How do testing considerations differ for people with joint hypermobility syndromes?
  • What does treatment look like for the hypermobile client?
  • Why I like pushups and other upper body exercises can be effective selections for lower body problems
  • What “pain science” courses do I recommend
  • What’s the deal with overbracing and cueing abdominal coordination?
  • How can you reduce lat overactivity
  • The clinical reasoning model that I am thinking of

If you want to watch these live, add me on Facebook, Instagram, or Youtube. They air every Wednesday at 7:30pm CST.

Enjoy. (sorry about the audio delay, still making some tweaks on my new computer)

Zac Cupples iTunes                

Here were the links I mentioned:

Here is the first way I assess coordinative variability

 

The next test assess coordination, power, and fatigability of joint variability:

Noi Group

Explain Pain Course Notes

Graded Motor Imagery Course Notes

Mobilisation of the Nervous System  Course Notes

Therapeutic Neuroscience Education Course Notes

International Spine and Pain Institute

“All Gain No Pain” by Bill Hartman

Enhancing Life

Method Strength

Andy Mccloy 

Trevor LaSarre

Here’s a signup for my newsletter to get a free acute:chronic workload calculator, basketball conditioning program, podcasts, and weekend learning goodies:

 

Check out the mentor program

Practical Pain Education

I gave a talk on how I approach pain education in the land of China, and yes I finally got around to re-recording it.

Here were some of the topics I discussed in this talk:

  • The history of pain education
  • The difference between the three pain mechanisms
  • What the current research suggests regarding pain and threat
  • The 14 most common maladaptive pain beliefs, and how to squash those thoughts via education

If you want immediate access to the remainder of the 1 hour and 49 minute talk, and a FREE 21 page PDF file of my talk notes, fill out the form below.

Without further adieu, here is the first 20+ minutes of the talk.

Come Hang With Me: Courses At My Clinic

Dear Readership

 We are hosting several courses at my clinic this year, and we would love to have you, the readers, attend.

We...The readership
We…The readers

The three courses that East Valley Spine and Sports will be hosting are all excellent courses. I have taken two of these classes prior, and the third I have taken a prior rendition of. And let me tell you, these courses are boss.

Aside from us bringing some excellent content, you will also have the opportunity to hang out with a good group of people, and imbibe in some good beverages with me.

Class is next, the course is nice, and we can talk neuro all night.
Class is next, the course is nice, and we can talk neuro all night.

Here is what we are bringing.

PRI Pelvis Restoration: March 28th-29th

 I took this course a little over a year ago (read the review here) and I am very excited to be learning from Lori again. She presents this very complex material in a systematic and understandable fashion.

Most importantly, she’s funny!

Thank you, she'll be here two days.
Thank you, she’ll be here two days.

Signup for the course here.

ISPI Therapeutic Neuroscience Education: Educating Patients about Pain: June 6th-7th

Adriaan Louw is one of the best speakers I have heard, and the material is priceless (read my review here).

10% chance Adriaan will wear this outfit at the course. 100% chance the class will be stellar.
10% chance Adriaan will wear this outfit at the course. 100% chance the class will be stellar.

This course gives several practical insights as well as easy-to-learn neuroscience education that will help you become adept and educating patients on pain.

Signup for the course here.

ISPI Neurodynamics: The Bodies Living Alarm: October 17th-18th

 I took a version of this class when Adriaan spoke for the NOI group, and I am excited to see what tweaks have been made since. This time we are bring Louie Puentedura in to teach the class. I am excited to hear his perspective, as I have never seen him talk. Adriaan speaks highly of him, so he’s okay in my book!

And it's not an easy read.
And it’s not an easy read.

Signup for the course here.

 

We look forward to seeing you. Come learn, laugh, and party with us in lovely AZ.

The Post Wonderful Time of the Year: 2014 Edition

And That’s a Wrap

It’s that time of the year that we get to look back and reflect and what posts killed it (and which bombed).

It seems as though my fine fans be on a pain science kick this year, and rightfully so. It’s some of the best stuff on the PT market right now. It’s definitely a topic I hope to write about more in the coming year, and one I will be speaking on at this year’s PRC conference.

But without further ado, here are the top 10 posts of 2014.

10. Treatment at the Hruska Clinic: PRI Dentistry and Vision

Lift scores 6/5 with the Bane mask on. #alternatingandreciprocalwarrior
Lift scores 6/5 with the Bane mask on. #alternatingandreciprocalwarrior

Going through the treatment process as a patient has really upped my game in terms of knowing when to integrate with my patients. It has also been a life-changing experience for my health and well-being. Learn how they did it for me.

9. Course Notes: THE Jen Poulin’s Myokinematic Restoration

She's a myokinematic beast!
She’s a myokinematic beast!

So much fine tuning occured the second time around. I love how Jen acknowledged the primitive reflex origin of the patterns, as well as fine tuning both lift tests. She’s an excellent instructor (and fun to party with)!

8. Treatment at the Hruska Clinic: Initial Evaluation

Producing so much saliva
Producing so much saliva

The start of my alternating and reciprocal saga. Made for one of the most fascinating evaluations I have ever experienced. Ron Hruska is otherworldly.

7. Course Notes: PRI Postural Respiration

Chiari malformation waiting to happen.
Chiari malformation waiting to happen.

I love a good foundational course taught by the Ronimal. You always get a few easter eggs that allude to higher level courses and concepts. A must-take course.

6. Course Notes: PRI Craniocervical Mandibular Restoration

Ron looks even better in person with the meat suit.
Ron looks even better in person with the meat suit.

One of the most powerful and humbling courses I have ever been to. Ron goes all out on this course, as it is his baby. What dental integration can do to a system under threat is a concept that I hope is further explored in medicine. We can’t do it alone folks.

5. The End of Pain

Still verklempt by the overwhelmingly positive response.
Still verklempt by the overwhelmingly positive response.

This post marked a shift in my thought process and a realization of the possibilities that an integrated health system can accomplish. I have high hopes for our profession, and feel excited that an original post had so many views.

4. Course Notes: PRI Pelvis Restoration

A good group to learn from and with.
A good group to learn from and with.

It seems that with each PRI course you take you go another layer down the rabbit hole. Pelvis is a great course to link up Myokin and Respiration; especially with Lori and Jesse at the helm.

3. Course Notes: Dermoneuromodulation

Diane is bullseye with her neuroscience.
Diane is bullseye with her neuroscience.

Couple the best manual therapy explanation I have come across and a gentle technique and you get a rock solid course. The only downside is that now Diane has tarnished any other manual therapy course for me, as I can’t rationalize any other explanatory model given.

Fine by me.

2. Course Notes: Therapeutic Neuroscience Education

Stayed hungry to learn ever since this course.
Stayed hungry to learn ever since this course.

I love Adriaan’s practical application of pain education to patients, and he is one of the best speakers in the biz. There’s a reason why I am hosting him again next year.

1. Course Notes: Explain Pain

A legend
A legend

A great neuroscience course, a great practical course, and getting to learn from a PT legend? Sign me up.

Game Over!

And that marks the last post of 2014. Which were your favorites? Which are you hatin’ on? Comment below and let’s hope to even better content in 2015!

496d30611f94277eee71b80e3cd0f24cb9

Course Notes: Therapeutic Neuroscience Education

How’s Your Pain How’s Your Pain How’s Your Pain How’s Your Pain?

To purge onward with developing some semblance of chronic pain mastery (ha), my employer had the pleasure of hosting a mentor and good friend Adriaan Louw.

I first heard Adriaan speak in 2010 when I was in PT school. I was amazed at his speaking prowess and the subject matter. Unfortunately, my class could only stay for a little while in his course, and onward life went.

I went on with my career focusing on structure and biomechanics and forgetting about pain. It wasn’t until I ran into Adriaan again two years later. He was teaching me Explain Pain (EP), and forever changed how I approached patient care.

It’s funny how things have come full circle.  Here we are, Adriaan teaching Therapeutic Neuroscience Education (TNE) through The International Spine and Pain Institute (ISPI), and me promoting his work to my colleagues.

A lot has changed in two years. EP and TNE are quite different courses, and I learned so much this weekend that I continue to become more engrossed with what I do.

So thank you, Adriaan, for playing a huge role shaping me into who I am today.  I have now become very much more interested in what ISPI has to offer, and I think you should too. And no worries Adriaan, I will stay hungry 🙂

Inside joke...So can't believe I forgot to take a pic with this guy.
Inside joke…So can’t believe I forgot to take a pic with this guy.

So without further ado, here is what I learned.

The Power of Words

 It’s getting worse. One person out of 3.5 has chronic pain.  Many of these people have tried many treatments, heard many explanations, and lost all hope.

And here they are, in your office. The patient thinks you are going to be another statistic.  Another failure. Another person who can’t help them.

So what do you do?

The answer: Apologize, and tell them they are going to be okay.

These are some of the most powerful words in medicine, and likely words that these people with chronic pain have never heard. Most importantly, they satisfy the ultimate goal of TNE:

Reduce the perception of threat

That, my friends, is what all physical therapy interventions do. Exercise, manual therapy, and education all reduce threat perception.  These simple words can often jump start the process.

Changing Cognition

Fear and catastrophization are often the big components that we have to battle with the above patients.  When these beliefs regarding pain are present, a cycle of avoidance and disuse occurs.  These factors can continually perpetuate the pain cycle.

When experiencing pain, we can go one of two routes.

I was inspired by the class to detail this artwork with blue arrows, contrasting to Adriaan's black. I feel the blue juxtaposes quite nicely against the white backdrop
I was inspired by the class to detail this artwork with blue arrows, contrasting to Adriaan’s black. I feel the blue juxtaposes quite nicely against the white backdrop

We can see how understanding pain can have profound impacts regarding recovery, yet the converse can lead to a debilitating cycle. Our goal is to steer people towards confronting their experience as quickly as possible. Knowledge can be powerful at reducing chronic pain.

Realize that there are many other factors that go into which path one will travel. These factors may include pain beliefs, sleep, behaviors, family, social circle, job, etc. These examples are a few of many variables that make pain as complex as it is.

The best that can be done is to manage the threats you are able to influence and educate the patient on understanding other possible factors.

Psychologist Wannabe

Now some of you psychology fans might be thinking that this strategy may be stepping into areas outside of our scope. But think of how we treat impairments that may be impacting one’s movement:

  • Stiff joints – manual therapy
  • Altered muscle recruitment – motor control
  • Muscle stiffness –manual therapy

What if the impairment impacting one’s movement is one’s thoughts and beliefs? What intervention would you utilize to address this area?

Clockwise ultrasound of course.

The brand I use. Combo only baby!
The brand I use. Combo only baby!

The logical choice of course, would be educating the patient that these thoughts and beliefs do not relate to the pain experience. Successful education may affect the impairment shackling that person.

Educate

Why is it that when patients come to us in pain we teach them anatomy? This was a question Adriaan posed to the class that summed up my frustration with much of traditional orthopedics in a way I never could.

There are a few studies (here and here) that have demonstrated that educating patients on anatomy and biomechanics has limited efficacy and may increase fear.  Moreover, using degenerative terms are associated with poorer prognosis (here).

The problem with this strategy is that it does not adequately address what the patient is seeing you for–pain.  Fortunately, the evidence for TNE is becoming quite compelling (check it).

It’s All in the Delivery

So TNE sounds all well and good, but the question must be posited: how? There are several ways to skin this cat (as long as the cat gets skinned):

  • Research demonstrates only performed by PTs currently.
  • Sessions can last from 30 minutes to 4 hours, but Adriaan suggested 10-minute increments.
  • 1on1 is best, but groups of 8-10 people are also good.
  • Use props – pictures, drawings, metaphors, etc.

The research also demonstrates that certain content must be covered:

  • Pain neurophysiology.
  • No reference to anatomical or patho-anatomical models.
  • No discussion of emotional or behavioral aspects to pain.
  • Nociception and nociceptive pathways.
  • Neurons.
  • Synapses.
  • Action potentials.
  • Spinal inhibition/facilitation.
  • Peripheral sensitization.
  • Central sensitization.
  • Plasticity of the nervous system.

One phenomenal way to gauge if patients understand your education is by having them fill out the Pain Neurophysiology Questionnaire (PNQ). This tool covers a large portion of TNE, and can give you talking points on where your education ought to be targeted.

I have been having patients fill this out for a few weeks now, and it is amazing how many people have pain misconceptions even after I perform TNE. Most of the learning that was occurring was superficial. This tool gives you reason to reinforce your education, as well as a way to have evidence of learning.

Now I have been talking a lot about education, and the common misconception is that all you do is talk to your patients. This thought is far from true. Most of the study designs in Adriaan’s systematic review had other interventions along with education. So it is only one piece of the puzzle. You do not have to completely change how you treat patients, you must only change the framework at which you educate and think.

Pain Neuroscience…Learn It!!

If you are going to explain pain to patients, you have to know more about it then they do. To enhance our knowledge base, we can discuss the PNQ in detail. So fill it out before reading on.

Go ahead, I’ll wait.

Did you fill it out yet?

Fill it out. It's right there!!! Do it now!!!!!!
Fill it out. It’s right there!!! Do it now!!!!!!

Okay, here we go:

Pain receptors convey the pain message to your brain: FALSE

Why – Tissues only send danger messages. Compare suffering an ankle sprain on a sidewalk versus a busy street. The latter would not necessarily hurt.

Fun fact – There are no unmyelinated nerves in the body. Every axon wears a coat; it just depends on what degree

Pain only occurs when you are injured: FALSE

Why – Injury and pain are not synonymous. Think about when you get a bruise and are not aware of it.

Fun fact – Tissues heal in 3-6 months. This includes your bulging discs.

The timing and intensity of pain matches the timing and number of signals in danger messages: FALSE

Why –  This statement predominately deals with descending modulation and interneurons.  In acute pains that end quickly, danger messages make their way up to the spinal cord and then the brain, but the brain sends endogenous opioids down the system to turn the dial down on danger messages.

There are many other fibers that that send messages to the brain, one example being A-betas. These sensors carry information regarding light touch for example.  If you occasionally feel that you are wearing pants (unless you are not), you can thank these fibers.

Stopped wearing pants ever since this course.
Stopped wearing pants ever since this course.

However, you don’t have to constantly be reminded that you are wearing pants, so an interneuron in the spinal cord will prevent this information from reaching the brain. The interneuron is like a club bouncer; only the VIPs pass.

However, if danger messages (via A-delta and C-fibers) continue firing to the spinal cord, the interneuron could potentially die from amino acid overload. When this change occurs, the club called your spinal cord has no bouncer, thus all information from the periphery will make it to the brain. This input barrage can significantly impact your body’s ability to modulate danger messages, and eventually pain.

Fortunately, interneuronal death takes months to years in most cases except when someone gets struck by lightning, electrically shocked, or in whiplash. But the message is clear; we must do what we can to modulate nociception and pain so this change does not occur.

The best way to treat chronic pain is to prevent it.

Nerves have to connect to a body part in order for that part to be in pain: FALSE

Why – Phantom limb pain, duh! The somatosensory homunculus is what allows for this phenomenon to occur.

He runs the show.
He runs the show.

When areas are used less, such as in pain states, the area of that body part becomes less clear. These changes can occur as fast as 30 minutes. The research shows the more “smudging” of these areas you have, the more pain you have.

So in phantom limb pain, the body part is gone, but the brain representation of that area remains.

In chronic pain, the central nervous system becomes more sensitive to danger messages from tissues: TRUE

Why – Interneuron death plays a role, but also descending influences from the brain contribute.  Because more danger messages are occurring, the brain is less likely to utilize endogenous opioids to calm the system down.

From a survival standpoint this makes sense. In chronic pain, the future becomes less certain, and your top priority is to stay alive. If I can make you more sensitive to your environment, I can better protect you.

The body tells the brain when it is in pain: FALSE

Why – The brain is what produces pain. The body can only produce danger.  The brain activates many areas in the pain experience, making pain multi-sensory.  And the more this pain map is run, the more efficient your brain becomes at producing it.

Fun fact: The amygdala’s role in pain could be why females have more chronic pain than males.

The brain can send danger messages down your spinal cord that can increase the danger messages going up the spinal cord: TRUE

Why – If there are enough danger signals reaching the brain, the brain will want to know more; thus impacting the periphery.

Nerves can adapt by increasing their resting level of excitement: TRUE

Why – Action potential are key. Every nerve has a resting amount of activity, and a certain amount of stimulus is necessary before this action potential occurs.

When someone is extra sensitive, the nerves increase their resting excitement level so action potentials more readily occur. Adding more ion channels to less myelinated areas can further compound this sensitivity.

Fun fact – Ion channels change every 48 hours, and therapy can positively influence the change.

Chronic pain means an injury hasn’t healed properly: FALSE

Why – Read, like, everything I have ever written ever. Pain and injury are not the same thing.  Tissues heal, tissues heal, tissues heal.

Receptors on nerves work by opening ion channels in the wall of the nerve: TRUE

Why – See above.

The brain decides when you will experience pain: TRUE

Why – Pain is a brain construct. Tissues can only send danger messages.

Fun fact – Laughing at a joke requires 5 different areas to be active in the brain.

And not a single of these areas have been active during this blog.
And not a single of these areas have been active during this blog.

Worse injuries result in worse pain: FALSE

Why – See video below

When you are injured, the environment that you are in will not have an effect on the amount of pain that you experience: FALSE

Why – Injuries and pain occur in an environment, not a vacuum. An ankle sprain may hurt on a sidewalk, but likely won’t if a bus is about the hit you.

Fun facts – Injuries in high stress environments are 7-8 times more likely to produce chronic pain. Also, kids who play contact sports early in life have less chance of developing chronic pain.

It is possible to have pain and not know about it: FALSE

Why – Pain is a conscious decision by the brain.  No brain, no pain.

Nerves can adapt by making more ion channels: TRUE

Why – I already answered it duuuuude.

Second order messenger nerves post-synaptic membrane potential is dependent on descending modulation: TRUE

What did I just say? – I don’t know.

Why – The brain has the abilty to inhibit information coming up from the periphery via endogenous mechanisms.  This is how placebo works.

Nerves adapt by making ion channels stay open longer: TRUE

Why – Because I said so…directly above. The brain will also make g protein ion channels, which can stay open for several minutes. This type allows for more danger messages to fire.

When you are injured, chemicals in your tissue can make nerves more sensitive: TRUE

Why – Much was previously mentioned, but the stress response plays a huge role here.  When you go into a more sympathetic state, adrenaline, cytokines, and cortisol pump throughout the body. This change increases sensitivity of nerves throughout the body systems, and those in chronic pain are more geared toward this state.

Put it all together, and what do you got???

So with all the above information, we can see there are many misconceptions regarding pain. So it becomes very important to define what pain is. Here is a great definition:

“Pain is a multiple system output activated by an individual’s specific pain neural signature. The neural signature is activated whenever the brain concludes that body tissues are in danger and action is required.”

whoa

So Let’s Do Something about It

While we do need to know all the nitty-gritty regarding pain physiology, your patients and clients will not know what the heck you are talking about. Thus, you have to teach this information in a patient-friendly manner. Here were some of my favorite ways Adriaan used for TNE.

You can also mention to patients in chronic pain that one in three people keep their nerves elevated past normal healing times.

With this example, there are usually three questions that arise:

  1. How do you know this?
  2. Why did my nerves stay/become so sensitive?
  3. What can be done to calm them down?

Number one can be answered by the following points:

  • You told me – it takes less activity for pain to arise.
  • Your tests told me – physical exam and neurodynamic tests.
  • Your doctor told – any anti-depressants or drugs like Cymbalta or Lyrica can calm the nervous system down.

We can answer number two by having them think about the many factors that could enhance sensitivity. These factors could be failed treatments, hearing different explanations, pain chronicity, life worries; basically anything that could make you feel threatened.

Number three is easily answered by explaining the powers of education, exercise, and medication.

The Old Speeding Bus Trick

Say you sprain your ankle. Would it hurt? How about if a bus was about to run you over? This tactic demonstrates that the brain makes a conscious decision as to whether or not pain should be experienced; and the greater threat always wins.

I Hate Having Neighbors

Here is a great way to explain spreading pain to patients.

Say your alarm goes off and you begin to feel pain. If your alarm stays on long enough, the noise may wake up your neighbors.  If the neighbors stay awake because your alarm keeps going, eventually they will get agitated. It wouldn’t be surprising to see neighbors even farther away waking up if the alarm stays on too long.

And there are many ways your neighbors can be agitated.
And there are many ways your neighbors can be agitated.

You can also tie in the immune system in to this example. Immune molecules are like little police men that check out everyone and make sure the situation is okay. Nearby neighborhoods might also be checked out just to be safe.

The police watch the area until the problem is taken care of. But as is customary, a few months later the police may check-in to make sure everything is okay. This analogy can explain why pains you once had can reoccur.

The Road Often Traveled By

This analogy is a great way to show how chronic pain allows for neural pathways to turn on more efficiently.

Think of a neural pathway that would lead to a pain experience as a dirt road. If  you get a lot of traffic along that pathway, eventually the road is going to have to get bigger to accommodate. So perhaps the road is widened.  Maybe the next step is the road getting paved, then making the roads 2-laned, etc.

The more that pain pathways run, the more fluidly they do so.  The pain experience is created faster and faster with the more traffic encountered.

Just the thought sends my amygdala crazy.
The analogy alone makes my amygdala go crazy

The Top 5 Reasons Why a Bulging Disc Ain’t a Big Deal

 You are inevitably going to run into someone who thinks having a bulging disc is a death sentence. Here are the 5 facts (in order) that you should mention to them:

  1. 6 weeks after a scan is performed bulging discs become smaller.
  2. You can get completely different results depending on the time of day the MRI was taken; early am is more likely to show disc bulges.
  3. Position MRI was taken in affects results.
  4. Levels that swell don’t move much; thus laying still or moving can impact results.
  5. 40% of asymptomatic individuals have bulging discs.

Two Lions Walk into a Bar…

This analogy is a great way to explain the stress response. Imagine you are watching television minding your business when a big African lion walks in the room. What happens to your body systems?

  • Adrenaline pumps through the bloodstream, increasing heart rate, breathing, alertness, etc.
  • Big strong muscles turn on; smaller muscles turn off.
  • Raise voice and speak short and sharp.
  • Shallow and fast breathing.
  • Digrestion slows.
  • Memory fogs.
  • Reproductive systems stop (unless you dig lions)
  • Many other things.

When the lion leaves the room, the body returns to its previous resting state.  Chronic pain states is akin to having this lion following you at all times.  This state, which can be perpetuated by many factors, can keep the above changes going relentlessly.  Our goal with therapy, is to make that lion less threatening.

Stratergize

While we have been exposed to great science and metaphor, the practical component was what did it for me. Adriaan had so many wonderful suggestions for implementation that I had to list some of my favorites:

  • Train the entire staff on TNE; including front office.
  • Designate particular days as TNE days.
  • Can teach in 10 minute increments.
  • Carefully use the word pain. Asking patients pain rating repeatedly may increase pain ratings.
  • Have a strict cancel/no show policy: Adriaan likes one cancel; >10 minutes late leads to a reschedule.
  • No more than 5 exercises for HEP.
  • Aerobic exercise is huge for chronic pain. Perform at >50% VO2 max and >10 minutes.

A big one for me regards coping skills. Before a patients calls in on a bad day to see a therapist, 5 strategies should be performed first:

  1. Problem solve – find a cause/relationship.
  2. Ice/heat/TENS.
  3. Perform your exercises.
  4. Get away – walk for a little bit, then relax and take a cleansing breath.
  5. Do not cancel all activities. Do as much as you can.

Quotes from Adriaan

  • “Light a candle, watch Oprah.”
  • “The holy grail to chronic pain is prevention.”
  • Take that patient. Own that patient. Fight for that patient.”
  • “Your challenge is to be so good a these [chronic pain] patients that the other stuff will become mundane.”
  • “If you are a PT and have not had back pain you are dead to me.”
  • “Aerobic exercise is gold standard for chronic pain.”
  • “Parenting sets up pain later on.”
  • “The biggest boost for the immune system is social interaction.”
  • “Low back pain is the common cold of the musculoskeletal system.”
  • “Your job is to make your patient so smart that pain decreases.”
  • “30% of pain is insidious onset”
  • “You are not treating evidence, you are treating a patient.”
  • “The best clinical question you can ask is ‘what do you think is going on with your x.’”
  • “Pain protects.”
  • “Make patients responsible for their own care.”
  • “The bigger threat wins.”
  • “The biggest predictor of chronic pain is acute pain.”
  • “pain spreading is an expansion of receptor fields.”
  • “When pain is involved motor control becomes 2nd.”
  • “Pain is a unique human experience.”
  • “If you live your pain, you become very good at living your pain.”
  • “Don’t forget the human being.”
  • “You are a walking placebo pill.”
  • “Lyme disease is the new fibromyalgia.”
  • “A brain that doesn’t know is the most dangerous thing on the planet. Make the unknowns known.”
  • “Pain is what I think.”
  • “You own your pain.”
  • “If you teach about pain and they feel worse, you got them.”
  • “Chronic pain patients are not weak, they are deconditioned.”
Any social interaction is better than nothing.
Any social interaction is better than nothing.