Ep. 400 Navigating Low Back Pain In Training w/ Dr. Q & Dr. Katie

Location: Austin C4 / Nutrabolt. Time 8-4

https://www.eventbrite.com/e/navigating-low-back-pain-in-training-with-katie-dabrowski-and-q-willey-tickets-1996909407794

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Doc Q IG: Coach_Q_Physio & Doc Katie: Ktdabrowski

Back pain is one of the fastest ways to make a confident lifter feel fragile and it’s also one of the easiest places for bad information to hijack a training plan. We sit down with physical therapists Doc Q and Doc Katie to talk about what actually feels “scary” in both personal training and physical therapy: flare-ups, client anxiety, imposter syndrome, and the pressure to deliver a perfect fix when pain doesn’t behave like a neat checklist. 

We dig into pain science and the biopsychosocial model of pain, including why fear based language and over-medicalization can create nocebos that shrink someone’s life. You’ll hear how they think about progressive overload in rehab, why many posture and biomechanics stories don’t hold up well in research, and how to stop treating every ache as a crisis. A key takeaway is the “trainable menu” for low back pain: keep a list of movements someone can train right now, then build smart entry points back into the positions they fear or avoid. 

We also cover when imaging makes sense, when surgery is truly appropriate, and why population level data often favors conservative care while still leaving room for individual exceptions like progressive neurological symptoms. If you coach clients, treat patients, or manage your own low back pain, you’ll walk away with clearer language, better decision making, and more confidence under the bar. Subscribe, share this with a coach or clinician, and leave a review with the biggest back pain myth you want gone.

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Transcript

Welcome And 400th Episode

SPEAKER_00 0:00

Howdy y'all, welcome back to the show of fitness podcast. Today is a super, super big event. We have two physical therapists on the podcast today. Doc Q, Doc Katie. Thank you for taking the time. How are we doing today?

SPEAKER_01 0:15

Fabulous.

SPEAKER_00 0:16

Love that. The other really cool thing is today marks the 400th episode for the Show of Fitness Podcast. We have uh been doing this for about three years. We love educating trainers and coaches, leveling up their skills. And we're going to talk about the course that they're going to be having in Texas and Austin. But before we do that, we want to ask a question from our followers.

What Feels Scary In Pain Work

SPEAKER_00 0:37

We have our own certifications, and a lot of uh trainers want to get into the horse's mouth per se. And so there's a question from Mr. Carlos, and he's on our platform, and he's asking, what do you feel is the scariest part of the personal training industry, but also the physical therapy industry? And we both can tackle that one. That's a good one. Q, do you want to take it away?

SPEAKER_02 0:58

Sure. Yeah, I can start. Um I scary maybe isn't the word that I typically think of, but I I appreciate the question and I understand where that's coming from. I think you know, when we talk about the word scary, what is scary? And I and I think about uh, okay, what are the barriers or what are the intimidations, what are the imposter syndromes, what are things that maybe people struggle with on, you know, both on the clinical-facing side as well as from the training-facing side. I think for physical therapists, um the you know, scarier portion, or I guess some of the scariness, somebody commented on a post that I recently put out uh as part of another podcast where I was talking about how trainers and these and and people that work as coaches really kind of are this front line of healthcare that you're seeing people more frequently, you have a much better touch point of they're gonna be the ones that tell you they're in pain first, maybe, and even in some cases as a personal trainer, and maybe this is part of the scary part, is that like you're gonna have times where people don't feel good, where you overshot, or they just had you know some aches and pains pop up as part of nor normal training, or even like even a significant flare as they were lifting, they heard a pop and like something really hurt. And I think that's not something that's wildly uncommon, despite people being responsible and trying to do their very best. And I think that on the personal training side, everybody's always so scared of hurting people that sometimes we end up managing people away from loads so much, and you know, I think that it's going to happen. So you have to acknowledge and even like help people acknowledge on the front end that like things are not always going to be optimal and perfect, and that flare-ups, if especially if you've had any kind of you know, uh significant pain injury history, those things are very likely to come back at some time point, and for reasons that have nothing to do with the exercise selection, nothing to do with you progress them too soon while that does happen, and while that can happen, and I'm not throwing that away, it's that there's some things that even if you do all things right, you may still have flare-ups occur. Now that also happens on the physical therapy side, albeit perhaps it can be more expected only because we communicate about it up front, but it can even be more pressurizing because they're coming for you specifically to solve that pain. And now, if you have somebody who has a flare-up, well, are you just a bad provider then? Because your whole goal isn't just to train and to push weights. Now the pressure is upon you to fix, quote unquote, fix the pain. And now you have a flare-up that's almost worse sometimes than being a personal trainer. And so I think on both sides of things, we get so averse and scared of hurting people that um, you know, sometimes we nocebo things or we have a very um negative affirmation kind of talk and language from two sides of things where we say, if you don't work out, all of these bad things could happen in your life. If you don't work out, you may get fat. If you don't work out, and I think that we need to get away from that and have more positive messaging in terms of like, here's all the things there that you could stand to gain from exercising, both socially from a mental health perspective, from prevention of uh non-communicable diseases, from you know, pain, injury prevention, all those kinds of things, like it's all wrapped into all the huge positive messaging of interacting with weights. Now, it doesn't even have to be wildly heavy to start. We we have good evidence that weightlifting and training doesn't necessarily have to be stimulated by lifting only heavy loads. In fact, lifting moderate loads, there's lots of different ways to progressively overload someone. That could be progressive ranges of motion, that could be progressive uh adding a set, that could be adding a few more reps at the same weight. Uh, there's a lot of ways of what progressive overload means that you don't have to necessarily just load, load, load, load, load, hit people heavy. And I think maybe that's where some people get a little bit uh inundated with the, you know, what's on social media and maybe a little bit intimidated and the scary part. My point is that we are trying to promote a public health message that engaging with physical activity is extremely positive for a host of benefits that go beyond just performance benefits, but can even be positive for pain and in the rehab setting as well, and that we shouldn't be scared of when people have flare-ups because that's a normal part of living human life, even if you were very sedentary on the couch and you never lifted weights at all, and then you were doing laundry or doing dishes and you threw out your back or something like that. You know, those are very common experiences, whether or not you're being physically active. So we shouldn't be too scared of that. And um, hopefully that kind of at least covers some of that question. I know I I said a number of things there. What would you say, Katie?

Normalize Pain Without Minimizing It

SPEAKER_03 5:39

Definitely in agreement. I think that's a huge part of um our uh uh the stuff that you and I are so passionate about of really kind of making people realize like pain, Craig Liebenson. We were speaking of him earlier. He's he talks about this a lot. Pain's gonna do what pain's gonna do. So we kind of have to understand that pain is a really normal part of being a human without being dismissive. That's a hard thing to do. We can normalize it, but we can also make people make unfortunately, sometimes that message can be received as like, okay, well, maybe we don't care. It's definitely not that. Um, but it's it's a part of life. So how can we work on things that improve every other aspect of quality of life? That even with if you are experiencing pain, um, I think of it as making, you know, if your pain is this size, you have to make your life bigger around that pain because sometimes it's going to be a part of our lives that we deal with. So I definitely agree with all of that stuff. I think something else that could be maybe considered scary or at least just quite challenging to navigate is a lot of our jobs kind of end up becoming undoing harmful narratives that people come to us with from what they've been told in the past or the information that they get elsewhere or what somebody else has told them before about their pain, or about these kind of like predetermined limitations that they think they have. And that can be really difficult and kind of scary to navigate because you are trying to help somebody come to a new conclusion who's pretty firmly in a belief that is like the opposite of what yours is about their pain, their function, how resilient they are. And that can be tough to navigate. Like, this is stuff that Q and I talk about a lot. Like, you know, we don't want to um be like bold in a China shop and just be like, you're wrong, everything you've ever been told before was wrong. The person you worked with before sucks and was wrong. Like we can't send that message, but we have to figure out a way how to navigate and maybe help people see pain in a different light. And those conversations, I guess in theory, could be scary. Like it's hard to have those conversations with people, but I think it's a big part of our job too.

SPEAKER_00 7:46

And when I was talking to my students about this question, uh, you know, we talked about the personal training industry. Obviously, the interest standards are pretty low. But you know, last two years I've been to about 30 lifetimes. And it was interesting when I survey, you know, these 700 plus trainers, how many of you have been to a hands-on learning course? I can't tell you how often it was people come up to me and say, This is my first time. It's really just mind-blowing that it's like, you know, we're personal trainers, and so many trainers read it's an outdated textbook. You know, these private equity firms have a lot of money to pump in marketing, and then all of a sudden you think you're qualified, but you don't have hands-on learning. But I just think it's so important for trainers to get in the trenches and learn from people like yourself. And now I'd be interested to hear what your thoughts are on this, not to come off as negative, but from the physical therapy side, I really feel like that halo effect plays a role. I've met with so many physical therapists who, you know, they they treated me very delicately. And they almost started out with a fear-based principle. And then there's therapists I've met with who just didn't look the part of the therapist. And it's like the thing about you two, like I would go to you and be like, whoa, you're badasses. You look apart, you talked apart, you're super educated. And I would just I'd soak up the information. But I feel like on the other side, there's there's some coaches that really just are a little too delicate. And you know, maybe we could practice what we preach a little bit more.

SPEAKER_03 9:02

Definitely. Yeah, I think that is um kind of a common theme in the rehab space. Um, I think in school, we're taught very well how to like manage complex medical cases that do need to be handled with a little bit more um, you know, delicate nature, I guess, or maybe they have some considerations that we have a lot of, again, medical factors to consider. Something that Q and I, I think, get really frustrated with. And I know you could speak on this, um, Q as well.

The Problem With Over-Medicalizing

SPEAKER_03 9:33

The over-medicalization of musculoskeletal rehab and just orthopedic stuff is a big area of frustration for us because um, unless there's pretty specific like neurological red flags that are present or like a specific mechanism of injury or like a traumatic event occurred, um, there's been this extreme like over-medicalization but over-clinicalizing, if we can make that a word, of a lot of just like aches and pains and stuff that people are gonna experience as humans. And not everything needs a specific diagnosis, not everything needs um to be handled really delicately. And I think that is like by and large, if you're an outpatient orthopedic physical therapist, like that's more of what you're gonna see, like somebody whose knee hurts when they go downstairs. It's not a medical emergency. Um, and not to downplay that the pain sucks, it absolutely does. But more often you're gonna be met with cases like that where it's a lot more about improving your overall health and fitness to have downstream effects on your pain outcomes and what your tissues are able to tolerate, um, as well as taking a more active approach that pushes people a little bit harder than probably what they're used to. So that's a big frustration. There's just this kind of low dose, very low level of care that's honestly much lower than any training stimulus. So, how can we expect it to actually make somebody's tissues change that have been injured or that are hurt or that don't tolerate things well? It always just seemed to me this very obvious disconnect. Like, if we need progressive overload to achieve the goals of strength training, why do we not need it to achieve the goals of getting somebody healthier after an injury? Like it seems obvious to uh I think practitioners like us, but it's still not quite the norm, which is frustrating.

SPEAKER_02 11:26

Yeah, I I think that, okay, so to separate maybe the fields of like a musculoskeletal healthcare provider versus personal training, it's if somebody's experiencing pain or some kind of an injury, regardless of whether there was you know some kind of trauma associated, and that may up the ante a little bit if there were associated trauma or something more serious. Of course, we want to dig a little bit deeper into what was the mechanism of that particular injury. But to differentiate the field slightly, um, one of the things that you go to school for for earning the doctor of physical therapy thing, the field to become a Cairo or Doctor of Physical Therapy, earning some kind of medical license, is just simply to say with a little bit higher certainty that we have a little bit more clinical testing of what this thing is not. And and that may be what it is not, is a neurological pathology or some kind of an upper motor neuron kind of situation when in the cases of low back pain, or even in the cases of normal um training musculoskeletal aches and pains. Is this a bone stress injury? Is this more of a joint-related pathology of an osteochondral lesion or something more that's more cartilaginous, or is this more soft tissue? And of the soft tissues, is this more muscular or is this more tendinous? Is this ligamentous? Could there be an actual ligament tear here due to like joint play and joint laxity in some of the reports or the mechanism of injury? You know, things like that of ruling out or trying to tailor down a little bit more specifically on what is going on, and and that's fine. And that's where I think we try to create a collaborative process between personal training and physical therapist, where you don't come see a physical therapist and then just get your training derailed and then get inundated with all of these things and pathologizing and over-medicalizing of like, oh, well, you're tight here and you're weak here, and we need to image this, and oh, your fascial lines are off here, and oh, you're lacking this internal rotation because probably all that kind of stuff doesn't matter as much. We we have ideas of like based on what tissue is being you know insulted here, or is the injury uh mechanism per se. But oftentimes I think where Katie and I get so much more frustrated on the clinical side is that that then gets extrapolated into a world of let's loot use a bunch of pseudoscientific sounding phraseologies and make it sound that this thing is this big, scary, mystical thing, and you need to come see me to fix this thing, and that the the modalities, the passive palliative care type stuff, and even the corrective exercises, if you will, are often sold as ways of fixing people and changing biomechanics and biology. And I think that they they really are missing the forest for the trees, in that we are trying to help people navigate and sense make of their pain and why things are occurring the way they are, but we have to also then be good at either working with the individual or with the personal trainers and saying, well, what does the programming look like? And how do we scale this? That we continue to help people be socially active in their physical activity lives and the things that they want to do that engage them with some kind of physical activity. How do we keep training parameters moving in the right direction? I just got off a call for a 90-minute call with Stuart Phillips, who is an excellent researcher and scientist in the field in the protein and musculoskeletal health, who talked a lot about anabolic resistance and metabolic factors. We know that like we're fighting an uphill battle with aging, we're fighting an uphill battle as a population level in society where we are already having a hard time engaging with enough physical activity or resistance training at baseline. That the last thing that we need to do as healthcare providers is over-medicalize or pull people away for from or out of environments where they're becoming physically active and then making them feel like, oh, you're fragile and because you've been lifting this particular way, that's why you hurt. We can't say those things. We actually don't have good data or information as to why certain things start hurting at different time points. Like, even something as simple as like an ACL mechanism of injury has been hotly debated for decades. That we understand that yes, if the knee becomes more valuable and doesn't flex right, and if there's some twisting mechanism, we know that the the shin or the tibia needs to translate forward in order for the ACL to tear or occur. But then when we look at things like a depth drop and you watch patients or clients or subjects jump off of a box and land with dynamic knee valgus or when they squat with dynamic knee valgus, that that has zero correlation with who goes on to go and and tear their ACL. And that's become more and more apparent, apparent over the years now, of more and more research that's come out that like we just can't say with a high degree of certainty that the reason why you hurt is for these reasons. And I think that the our profession does a horrible job at that. And where we try to advocate a lot of is working with personal trainers to say, hey, listen, we can help consult with you and the client on what may be going on and what type of tissue deficit may be happening and potential reasons why, but but at the end of the day, the person still needs to interact with physical activity and engage with these things because we know that this is gonna have the most bearing on long-term health and non-communicable diseases, and may help them overcome their injury sooner. So let's just find the way that we can all work together on this without pulling people out of load and no SIBOing them, meaning that we're gonna inundate them with these uh thoughts or these little gremlins, these little thought demons, that they're gonna get hurt if they keep doing it this way or that it's bad. We we need to get rid of all that negative uh way of communicating. Hopefully that makes sense.

SPEAKER_00 17:12

So, doc, you're you're telling me that lower cross syndrome and just foam rolling your adductors and strengthening your glutes isn't the cure to cancer.

SPEAKER_02 17:19

No, no, no, no, not and not. I mean, yes, we can make funny jokes about like the cure to cancer, but sadly, the things like upper and lower cross syndrome or the you know posterior uh tilt or anterior tilt of the pelvis or the pelvis relation to the the rib cage is blamed and pathologized for all kinds of back pain, shoulder pain, abdominal strains, peck strains. Uh you know, we try to get these over-biomechanical, pathoanatomical ways of viewing the human body, and yet none of them pan out in the in terms of the research. And you can see just as many clients in a in a day, let alone in a year, that will demonstrate all kinds of different movement uh strategies. And some of them have the pains that you may think that they should have based on this one particular model or system that you engage with that you took some three-letter acronym course to learn, and then you'll see just as many who don't have that at all. In fact, they break the rules and may have the opposite thing that you would expect. So we can't say with certainty that any of those things actually cause it are causative, and that just by fixing them that you're gonna fix the person's pain. And that's where a lot of this stuff really just needs to die out and go away.

SPEAKER_00 18:30

I think that's one of the challenging things where I try to critically think and surround myself by great coaches such as yourselves. And you know, when I go and teach a seminar and we you know have some open-ended conversations, you'll have people very definitively say, Well, oh, they they have low back pain because of an anterior pelvic tilt. And we need to, you know, release the psoas and strengthen the glutes. And that's what's worked for me. Therefore, it works. And also, I do have that corrective exercise certification, therefore, I know more than physical therapists, obviously. And it's a difficult conversation to have because you want them to kind of take their blinders off and and look at other aspects of it. And that's why we're so big at it within our courses. You should have a physical therapist on your team and have weekly conversations and talking to them about like, I had a client who came in and they may have had this, but let's talk about you know how I can you know properly train them. But are there any contraindications? Are there things that I can and cannot be doing?

Low Back Pain Course Goals

SPEAKER_00 19:20

And I think that's a perfect little segue into your guys' course on low back pain and really what they're gonna be learning. And you know, one of the topics is talks about being able to know when to refer out those red flags. So, do you want to you know take the floor and just tell us a bit more about the course and then we can dissect uh some of the talking points within that?

SPEAKER_03 19:37

Yeah, for sure. I think something that Q and I are really passionate about is helping people to understand, like once the very obvious scary stuff is ruled out, people are really safe to exercise. And in fact, there's very few instances when truly being told to not exercise is the right answer. And that's like a big takeaway that we want people to have from this course, especially for low back pain, because it's the scariest usually. It's usually the thing that most rehab providers and trainers feel the least comfortable with because back pain, no matter how minute it actually is, or no matter how relatively like not a big deal it is in terms of what tissues are dealing with it, it's always like big pain. The pain levels are high, the emotion is high, the stakes are high, and it's a very emotional process. And we probably all have experiences in our life where somebody we know close to us has had back pain for a long time and their lives look very different because of it, or somebody was told that they need surgery, or somebody had a disc injury 20 years ago and they're still being told that's the reason for their pain. So we all have, I think, this kind of warped perception of what back pain is. And I think that makes it more emotional than a lot of other types of pain. So a big goal that we have is to really make it clear and streamline the decision-making process of unless these specific neurological things are present or a mechanism of injury or a traumatic event or red flags that point to something systemically going on that's none of our scopes of practice, not PTs either. There's signs of infection if there's signs in history that do make you think of something like cancer. That's none of us. That's that's not what any of us should be dealing with. But the reason we talk about it isn't to scare people, it's more to show you these are rare, they're very obvious. And then in the absence of them, you can have a lot of confidence that exercise is exactly what you're supposed to be doing with this person. And our big goal is like we want people to feel really comfortable with a trainable menu for somebody who has back pain, basically, meaning like, what's the list of all of the things that somebody can do that don't really trigger their symptoms? For me, like I have a history of disc perniation and back pain, and I deal with my flares and I work through that with Q. And for me, like most upper body stuff is pretty fair game. So I can always feel confident knowing. Even if I'm in the midst of a flare, I have a trainable menu that I can pull from. So that's what we want to help coaches feel comfortable with. What's your trainable menu for any client that you're dealing with who's experiencing pain? And then the opposite of that is what's the stuff that currently does not feel like the client has access to it? They might be scared. It might be a position that triggers some emotional stuff about maybe how they think they initially got injured. It might just be a position that physically doesn't feel good right now. So how do we start to build up entry points for those positions too? So we have kind of two concurrent goals. I want to beef up as much as you can do without irritating your symptoms. And then I want to find that entry point for stuff that maybe right now feels a little bit off limits. And if we can do that for everybody, like that is a game changer for how people think about pain. It doesn't necessarily think it doesn't necessarily mean that you can't do anything or your training has to dramatically change. There might be instances when you're a little bit more acutely flared up. And that's also okay when we have to find ways to move that aren't triggering. And it might not only be about a training stimulus all of the time. Like for me, for example, when I had a more acute flare about last year, initially I kind of had to get through the process of like right now, like today, isn't about a training stimulus, and that's okay. It's about moving in a way that my body is getting positive messaging that I am okay, that I'm getting movement in, that I'm, you know, keeping my brain a little busy. And that's okay if it starts that way. But our goal is to then transition how can we make this a training session? And how can we do this in a way that builds up some confidence again?

SPEAKER_02 23:37

Yeah, I think that what Katie started with at the very beginning of talking about what back pain is for most people. It is, I mean, it's scary because people can experience back pain to a degree where they literally can't get up off the floor, they can't move off the couch, they can't sleep, they can't sit. Like it's so excruciatingly painful and debilitating at times that I think the level of anxiety that comes with that is how could something that is so painful and so debilitating not be medically serious? Because anything else that you would experience in life to that degree that shuts your life down that much, you go to the emergency room for because you literally couldn't even go to work that day. And now you have on the other side of this coin, we're saying, Well, my you know, in the absence of these other red flag symptoms, it's actually not serious, and I think that really messes with people's heads because it feels extremely serious, their subjective experience is so serious.

Why Non-Specific Back Pain Exists

SPEAKER_02 24:35

Um, and you know, I think even the the non-specific low back pain talk, I still hear back and forth, I even hear you know, some folks on on larger podcasts that are clinicians of some kind say what a stupid uh diagnosis that is, or what a dumb thing, non-specific low back pain is never a thing. Um, and it's silly to say that because it 100% is a thing, but it's just not a specific diagnosis. And when we say non-specific low back pain, it just means that our ability to identify with any kind of real clinical reliability what is the source or the root cause of this pain, and therefore what should be done to fix it, air quotes, is so poor. We we don't have any kind of reliable imaging related information or databases or studies that reliably show that when something looks aberrant or abnormal on an imaging finding, that it will match the degree of symptoms or the type of symptoms that the people will have. We also know from clinical science and symptoms that we don't have good prognostic value type tests of how long will this pain occur for. I've had people that are just completely in debilitating pain who can't get off the couch, and then two days later they're they're telling me, like, ah, you know what? I'm actually like 80% better today. And two days ago, I was like in tears thinking my like whole training career was over. And I have other people that have these kind of minor flares, you know, it takes them down by 20 or 30 percent in their training, but it just lasts forever, you know, it can just go on and on and on, and it's really challenging and up and down. So my point is that like we just say non-specific low back pain because we don't know with any kind of clinical certainty, no matter what kind of imagery use, no matter what guru out there on some podcast is saying, they're charlatans if they are saying that they have certainty around identifying why back pain occurs and what exactly needs to be done about it. And I think Katie and I, and and Craig Levinson, who we talked about earlier, and you know, there's so many others in our space that are more evidence-based practitioners. What the thing that we're trying to communicate is that we don't have a particular system or model that we're selling, that you don't just watch people move and identify very specific patterns and then say, Oh, yep, you have this pattern and you're rotating this much or flexing or extending this much, therefore you follow our system, our protocol, and boom, you're gonna fix everybody. That's not how this works. It's so much more individualized and nuanced, first of all, and there's no fixing back pain. 80% or more of adults across the world will experience low back pain at some point in their life, irrespective of activity levels, strength, work, labor environments. And sure, there's some predictive models that have shown that certain labor environments, uh, social, uh, socioeconomic demographics may play into who experiences these things more. There's probably some collection data bias on some of those parts. So, my point is that like most adults, most humans who live life will experience some kind of back pain at some point in life. Your risk goes up for experiencing back pain again once you've had it in the past. That's true for any injury. That like once you've experienced the injury before, your risk or potential likelihood of experiencing something similar in a similar area goes up. That's just part of reality. We get that. So the charlatans and people out there saying, Oh, this is how you fix back pain and just follow our system. We're trying to move away from that and say, Hey, let's not try to eradicate this thing that's a very normal part of human experience, the same way that gray hair, that wrinkles, all the other parts of aging occur to everybody, and the the only certainty that we have in life is that we will all die. We know that for sure. I don't mean to be overly morbid, but like you're not going to optimize life so much that you just don't die. We know that. So we need to think about back pain in terms of hey, yes, we're trying to maybe reduce the likelihood or reduce the effects of back pain on people, but we're not trying to eradicate or solve or fix back pain. We're trying to create a model in which people can then, yes, have a trainable menu that they can sense make of this thing. Pain and suffering, I tell this to all my clients, are very different things. That the sensation of pain does not necessarily mean loss of life, loss of identity, loss of function in all cases. It's just a sensation where people experience suffering is all the things that come with that pain: the loss of identity, the loss of function, the loss of social engagement, the loss of what it means for their life now and in the future. That's the suffering piece. So, what we're trying to do is reduce suffering, and we're trying to help people navigate and make sense of their pain. And a really good uh pain researcher and researchers, I should say, in Australia, have used the quote and said, just because people have beliefs, you know, you're not gonna, you don't need to necessarily change belief to change behavior. And as trainers and as physical therapists, we're trying to move the needle as on a societal population level on what are the behaviors that we start falling into more and more, what are the types of behaviors we push towards that keep people moving, that help them contextualize their pain and do more and function better in spite of experiencing something that's completely human and something that will likely happen to just about everybody. And it's sad because you even in like really popular um TV shows, like the two Apple TV shows. I just recently noticed this in Ted Lasso. Uh, new season is out, and and right now, and I know that a lot of people love Ted Lasso, but you know, it's sad that they made the head physio uh who they did and and the type of demographic, and then what physio is and what it's communicated to be, is that it's all just palliative hands-on care. And then another show, um, your friends and neighbors with uh John Hamm, they're all talking about the type of physio that they get. And it's ah, my physio's got magic hands, and I need this physical therapy. And you know, even in the the the show, he experiences a period of time where he like throws out his back and just everything that's surrounding about why you have back pain, of because you were an athlete and you got beat up early in life, and now you're wearing tear and paying the price, and then what you do when you're experiencing pain. My point is that in these two TV shows, it's so evident of where heuristically society still is, from what we see in the entertainment, even as well as like what you see on social media, that it's so poor and so off from a lot of the messaging that Katie and I are trying to communicate, and we're simply trying to help pull society up and level up both trainers and coaches as well as physical therapists and chiropractors to simply do better for people than what the normal heuristic in society is. And and so hopefully I've said enough about that, but um I think that that makes sense. Katie, would you add or take away anything from what I can read?

SPEAKER_03 31:31

No, it's perfect. And I I think like our big goal for this course is to help more, I think just people in our uh movement professionals, an umbrella term. I put I put trainers, coaches, rehab providers all in that because I think the the more we can do together, the better we can help people at large instead of being feeling like we're separate, which I really don't think we are, um, and increasing confidence with navigating things that otherwise can be scary. So the patterns in people's pain history that they tell us, the program design variables that we talk through with clients to help understand what's like their body used to doing versus maybe what they're asking it to do, um, what's their training history, all of those things tell us a lot more about somebody's um experience of pain than a specific diagnosis. So we're trying to like level the playing field. If low back pain is something that impacts 80% of people, every person who's a trainer is going to experience a client who has back pain. So the more that we can help everybody in our industry kind of realize like, okay, this is something that inevitably we're all gonna run into. How can we best manage it? How can we not scare people? How can we rule out the stuff that we need to rule out? And then otherwise, how can we help people become more confident in understanding like you're gonna encounter this stuff as a coach, where we got your back? It doesn't, it can sound scary, but here's a few principles that we base our decision making off of that can help you also make decisions that can help people stay active.

SPEAKER_00 33:03

I think that biopsychosocial model of pain is really important because like you know, piggyback off what you guys were saying is so many practitioners start out with fear-based. And I remember when I was benching back in the day and try to hit that 315, arched a little too much, hit a little pop on my back, and exactly everything that Q was talking about that pain. I mean, I I was hopeless. And I go to a doc and I get an MRI, and oh, guess what? You have a disc protrusion. I'm like, what the hell's that? I thought uh I thought a herniation was bad, but now I have a protrusion. Let's bring you over here to this little model on the table. And oh, this is a slip disc and your back is screwed. And by the way, you should never run, jump, squat, deadlift again. And we also want to cauterize the nerve because that's gonna be your best bet. And I'm just like, wow, no hope whatsoever. And then when I met with Doc Craig and when I went to him, it was great just because just uh the humility and it was just normal conversations. He didn't treat me like, oh, Chris, you have a little back pain, give me a hug. It's just like, how's it going? You know, what's your background? Oh, you can easy all just cool. We're talking about people we know, and oh, I know Waterberry and cool, and did a couple tests. He's like, Okay, you know, once you do this over here, get up 10 times. I was like, I can't do that. He's like, I'll be back, you'll be fine. And I was just like, there's something in his tone and just his, you know, I'm just like, you know, there is some, there's some hope here. And when I started going through it, a lot of it just because of his disposition, it gave me hope. And I feel that there's a lot of people out there, they get this, you know, prognosis and they're they're diagnosed, and there's just no hope. And so, you know, when you go to courses like this, you're gonna now have hope because you're learning from people who know what they're talking about and you've also experienced it. And you know, that's what we're talking about a little bit earlier is about, you know, you know, low back pain can be really traumatizing. And it's just unfortunate that people will try to simplify it by saying, oh, the reason you have low back pain is because you have knee valgus, and therefore, then we're scaring you. And it's like, oh, don't deadlift anymore, don't squat anymore because that's bad. And let's play around with some bands and a bowsuit bowl.

SPEAKER_03 34:52

No, you bring up there's like two points that I want to make quickly on what you said. The first one being of just mentioning when you were experiencing your session with Craig Levinson, like his disposition and how he just spoke to you. Um, that's a big thing that Q and I are really passionate about as well. And I think something that makes somebody a really excellent provider, and again, umbrella term, trainer, coach, rehab provider, somebody, something that makes them excellent is also just how they interact with the person in front of them, not the laundry list of certifications or the numbers and the letters after their name and all of these special fancy exercises. It's can you make somebody feel safe without maybe like overdoing that and being a little bit too accommodating because you still have to provide a plan and be, you know, confident. Um, can you make somebody feel like, oh, he's not acting like I'm so fragile that I'm about to explode the second I do this? Maybe I can calm down too. And it's not being dismissive to your experience, but it's also taking a step back and being a little bit more relaxed with how we handle pain. I think that goes a long way. So that's a big part of this course, too, is how do you actually communicate in a way that um shows that you have the confidence to navigate what this person is scared of, but you're not dismissive, that you have the empathy, but also the understanding of like, if I'm not super tense about this, it's gonna make the person less tense. I think that's very, very important. Um and so I'm glad you brought that up because I think that is probably more important than any magic exercise than anybody thinks they could learn about navigating pain. It's like, can you talk to the person? Can you understand what this pain is taking from them? What part of their identity that they don't really feel connected to anymore? And like, how can you make them feel connected to themselves again? That's within all of our job descriptions. Like, that's exactly what we all do, and it's not just reserved for rehab providers. So I think that's a really important part of it too. Um, and I got so excited about the first point that I forgot my second point. So that's you know, we'll just pivot from there.

SPEAKER_02 36:54

Yeah. No, it's good that I think, yeah. And now maybe this is the second point, but like the two things that comes to my mind would be yes, on one side, we're trying to instill confidence in people who are interacting with other folks that are experiencing low back pain, because they should know, hey, here's all the potential things that we do need to be concerned about. Here's all the potential things that we're ruling out that this is not. Once you've ruled out these things, and then talking, Katie and I talking about what certain things to look for, pattern, signs, symptoms, whatever it might be with low back pain, just helping people contextualize and understand what this thing is that they're looking at makes it so much less scary that you can have that type of demeanor, you can have that type of interaction because Craig, for example, in that interaction, he's seen hundreds and hundreds and hundreds of folks with low back pain. He knows what's serious, he knows what's not, he knows what he's looking for. It's no longer the scary monster under his bed because the monster is hanging out in the room all the time. It's it's a friend now, like it's not scary anymore. And so I think on one side of things, we we want to help people see that that portion, but then on the other side, saying, Hey, here's all the potential things that should be liberating and freeing all the potential things that you can do with it, given certain signs and symptoms. And it's not this very regimented protocol that you have to memorize, and it's only if you see this, then you you know have to do this. We're trying to help people see, yes, this isn't that scary for all these reasons. Here's what it is, but then also here's all the things you can do from a programming and exercise selection standpoint, and here's some strategies that we use with our clients or with other people with certain whether they're you know a catastrophizer or they're freaking out about their pain and they're really, really worried, or they're more of a confronter and they're looking to push through things. You know, that's something we talk about. But there's there's two a two-sided uh coin here or a double-edged sword where we're trying to say, Hey, this is not scary, and then here's all the options you have to deal with it that helps trainers and providers on the medical side face this thing with such a level of comfortability that that will inevitably rub off on all the patients and clients they see. Where now, if I'm not freaked out about it, they're not gonna freak out about it. We've got options, I can talk about it very clearly, and hopefully, what people walk away with from the clinic or the seminar, the course with us is those types of tools that they can now go in and they're not worried about flare-ups because they're gonna happen anyway. And when they do, here's how we talk about it. And you got a host of things in your in your tool bag, if you will, that you can just use and and sift through and and uh navigate it with people and all the ways that people do it uniquely um with their relationships, and and hopefully that uh that covers.

SPEAKER_00 39:35

I read a book I think called Crooked back in the day, and and Craig was mentioned in there. And one of the things that they said is they interviewed, I think, a hundred or low back orthopedic surgeons and they asked them if they'd ever get low back surgery, and all hundred said no. But you know, I'm sure that there are some times, but not to knock Western medicine, but a lot of times when you go to, you know, if you're a hammer, you're gonna find the nail. And if you go to a lot of these docs, they're gonna say, well, you know, let's get surgery. In your experience, are there times when there are, you know, surgery is required?

When Imaging Or Surgery Fits

SPEAKER_00 40:09

I mean, obviously, besides like tumors and stuff like that, but are there times when you know that has come up and you're like, okay, that's actually a good idea?

SPEAKER_03 40:16

Yeah, absolutely. And that's what I think it's important that we talk about this too, because um I've also had patients referred to me where, you know, working with previous providers. And again, I think all of our goal is to try to think keep things as conservatively managed as possible. But there's absolutely instances where it's appropriate to get another opinion or where seeking out less conservative measures is the absolute right call for this person's safety. When things are unstable, when you have risk of bigger deal issues happening, if you don't get something um surgically um intervened upon, like that's important. If you've tried things for a very, very long time and there hasn't been a noticeable change that you that would be reasonable and logical to expect with the measures that you've put forward, we might need another opinion. Um, there is, it's not always the thing that is bad. Like, surgery is not the all this like negative beast that we're saying is never appropriate. And I think that can get lost in translation sometimes because by and large, unfortunately, we are over-imaged and we are overcut. Like that is of absolute reality of our medical system. Even like talking with people about truly what the clinical practice guidelines are for when low back pain should be imaged versus not, we are over-imaging by like exponential amounts versus actually what is truly based on literature and on clinical practice guideline recommendations that practitioners are supposed to follow. Most people getting imaging for their back pain don't have any of those things actually being met. So that is a very real thing. However, there's absolutely instances when it's the right call to have surgery. When we have neurological symptoms that are progressively worsening, when we have loss of strength that is neurologically mediated and it is not improving with training the area, that is absolutely when surgery is something that we probably need to look more into, but also still get opinions. It's more of like it's a way for us to acknowledge the fact that there are absolutely times when a more medical route is necessary. It's very similar with people utilizing diet and exercise to help with lifestyle things like blood pressure and other things that can be medically managed. There also are things where if you're making all of the behavior changes and things are still not moving in the direction that we would want them to, maybe medicine is appropriate for you and keep doing the stuff that is the positive behavior change, but maybe it's appropriate for you. And so that's okay too. There's absolutely instances when I meet with somebody and I say, Hey, I think we need another opinion. Or we try things for a very long time and I say, Hey, I think it's time that we look at another opinion. So we have to be able to know when that is appropriate, but it not be our knee-jerk reaction when somebody has pain.

SPEAKER_02 43:06

Yeah, I think that it does get into this category, especially with some of the um speaking to the converted here of people that are already kind of more in the category of like, I know exercise is you know necessary, I know that movement is good. And then sometimes if somebody gets surgery or is leaning towards the need for surgery, they see it as just a total, utter failure, you know, and they just see it as such a uh bad, you know, bad connotation that, oh my gosh, you know, you need surgery, you've really you've really messed up, and your life is forever going to be changed. Well, we all we know that like that that side of the coin is probably too far on that end of the spectrum, that people do benefit from surgery. What we can say is that on population levels over hundreds of thousands of participants, that for chronic pain, things like surgery does a very, very poor job at solving things like low back pain. That surgery for low back pain is very Poor in terms of its ability to change pain relative to if they just pursued more of a conservative management type strategy. But that's population level data that doesn't account for all the very nuanced one end of one or individual situations, like what Katie was saying, where you have, you know, progressive loss in neurological mediated uh, you know, pain or loss of function, loss of sensation. Even people who, you know, you've come at this problem for a long time, you know, years of all kinds of different strategies of how to manage this thing, and it just continues to be so debilitating and it's progressively taking more and more away from them in life. Yes, perhaps surgery could be an option, and that should be seen as like, hey, guess what? It's not that you failed and you've reached the end of your line, it's more of, hey, here's another potential route that you still have on the table. We're just trying to keep that option on the table as long as possible, that we don't have to cash that check as early in this process because we know that 95% or more of people will not need the surgery, let alone that you know, of those five percent who get surgery, they maybe a very small percentage of people will actually benefit far and a way greater than had they not. And so, yes, while we have on one side of the coin that this uh thing of surgery and overimaging has been far overdone, um, you know, and that when you go and see a cutter, a physician, that the thing that they're gonna do is to cut. That's what they do. And and their triage in their clinic of somebody who does orthopedic spinal surgery, is they need to decide on that day in that visit with you, am I cutting or am I not cutting? Because if I'm not cutting you, like I don't have a need for you in my office, and you don't need to be here either. This is like time is money, and you're not this isn't the place for you. So I need to decide triage-wise, like, am I doing surgery or not? And unfortunately, because of the system and the way it works, if there's something that I could cut on and I could surgically fixate, oh well, I have to tell you that, like, yes, I can do surgery, and I think that heuristically, from a societal norm, they hear or patients hear, oh, surgery could be done. Oh my god, I need surgery then. Because how is anything that could be potentially fixed with surgery ever gonna change if I just do physical therapy? That doesn't make sense. So I think there's a lot lost in the communication there, and that's why we err on this side the same way that in the the nutrition space or the fitness side of things. Yes, is protein important? Yes, protein is important. However, if you're not resistance training, you're gonna be anabolic re anabolically resistant to that protein. That like uh a quote that Stu Phillips used earlier, he said, you know, uh resistance training bakes the cake, and that protein is really just kind of the icing on the cake. But like, I think what we're saying is that surgery is not useless, that it's not this horrible thing that every uh things should be avoided at all costs. But just like the icing on the cake, it's a part of some people's medical management, it's just so overly pushed and overly done so often that yes, we're gonna push against that, but we're not trying to say, and maybe what gets lost in translation that surgery is completely useless. And I hope that this conversation, people are gathering that that, like, yes, in 90% plus of these cases, surgery is not the answer. That does not mean that if you get surgery or that if surgery may be indicated in certain cases that you failed and it's the worst thing ever, and you're just debilitated for life because you can also have good outcomes with that. I hope that's clear.

SPEAKER_00 47:25

Absolutely. And and I think that's the the great thing about pain science, it's so fascinating. And I know there's a lot of trainers like me when I first started learning more about it. I wanted to learn more. And I, you know, I went to lunch with the pre-ab guys, Dr. Waterberry, and I'm like, hey, you know, what are some resources you guys can give me? And they gave me one of their USC textbooks, and it took me about 19 years to read four pages, but you know, a little too esoteric for my my dumb trainer mind. Are there some resources that you know you found that, you know, not necessarily dummy it down in a bad way, but you know, I love Dr. uh Lorimere Mosley because I think he has a great character in the way that he just presents it. It's funny and it just it's easy to understand. Are there some good similar or you know additional resources that you suggest for the pain sciences?

SPEAKER_03 48:06

Yeah,

Best Pain Science Resources

SPEAKER_03 48:07

it can definitely become a little bit more like esoteric and philosophical, which if you like that stuff, it's awesome. But if you want a little bit more, I think on the practical side too. I think, I mean, Instagram is a great resource for people who practice in this way and talk about it a lot. Um, Ryan Chow from Reload, when he goes in his zone and writes on his stories some of the things that he's thinking about, it's always very simple, but like heavy-hitting concepts. Like he's a great person to follow to just kind of go through his brain and how he navigates things. Um, I like the person that you mentioned as well too. Tame pain is another good resource online, too. Um, there's a few uh um Hannah moves on Instagram. So Nick Hanna is a great resource for kind of the psychological and social implications of pain, but he explains them in a really like beautiful way. Like the all of his posts are very artistic and just like it's very um, I think the way that he explains pain is awesome. And a little bit less, I think esoteric, um, that's a great resource too. Those are some of my favorites.

SPEAKER_02 49:14

Yeah, I'm trying to think. Um, in addition to that, uh the modern pain podcast, uh um Cargula, I'm trying to pronounce his last name. I can't remember his Instagram handle. Um, I think he does a good job. I mean, there's people in our space that that are kind of the the folks that a lot of people may um be familiar with or or look towards. Um Eric Maida. Um, then you have like Ben Cormac and Greg Lehman that talk a lot about being skeptical in this in this pain world and and how it's not as as clear or straightforward as as some people make it sound. You know, those are pretty good resources to start dipping your toes in. And I think Barbell Medicine Group and E3 Rehab do great jobs in in this space, both with what they put out on blog posts as well as um from their podcasting and and YouTube videos that they create. Um, we're obviously gonna miss a lot of folks here, you know, in listing of all the people that we look to or listen to that do a good job in this space, but um, I think that instead of maybe instead of like saying these specific people listen to them, I think from zooming out even more. If you're listening to content that is very certain, where they say, if this, then this, I would be skeptical. I would just be skeptical. And I tend to listen to people who have a lot more nuance or a lot more zooming out and saying we don't know a handful of things. Here's some things that we kind of generally land on. How that looks for your individual, you know, patient in front of you may be different. I like Nick Hannah, for example, because he uses a lot of just general analogies that would be true if there's something that could be applied to the physical therapy spaces that would also be true for things like mental health space or that have the ability to transcend the world of just physical therapy from more of a philosophical or the way that we look at how we interpret some of these um findings in the research. I think those are generally going to be very good people to listen to because it's full of something that we experience as humans across all different domains of our lives. That when we look at physical therapy and pain, some people want to get very pathoanatomical and say, ah, you have pain because of this slit disc that's now pushing on this specific nerve root that's causing this very specific type of pain. And if you rotate to the left by 30 degrees, then that will fix your pain, or if you just do these repeated extension exercises, or you need to strengthen your core and stabilize it because the spine needs stability, or you know, never do these types of exercises, it starts becoming further and further away from what could be applied at broad to a lot of other things. And I think that um, from a general concepts perspective of the people that you're listening to, I would be very skeptical of people who want to get very in the weeds of pathoanatomical type nature of findings and biomechanical nature of things because it's just not that reductionist. It'd be great if it was. I personally selfishly, I would love if it was important. Yeah, I mean, it would just make our jobs so much easier if they're like, oh yeah, every time you see this, you just do this. And it's unfortunate because people that believe that or that sell that type of stuff, yes, it does work, it just doesn't work for the reasons why they think it works. It's that anything could work, especially when you're dealing with people with chronic pain. Any number of things could potentially flare them up, and any number of things could also be really positive for them. Anything that's just simply different could be positive. Your, as a clinician, your confidence in your treatment as well as their confidence in the clinician's treatment is one of the biggest players in people's actual real perception of pain experience and quality of life improvement, as anything has ever been shown in terms of the specific exercise selection or program. So, like, there's just so many contextual things that are baked into this, and that doesn't mean that we should just say, like, oh, placebo is useless and don't, you know, don't uh play up the confidence in what you're delivering. But I do think that there's a lot of folks who feel very confident about the systems and the protocols that they've put in place because they quote unquote work for their clients, but then you have other so many people who do the exact opposite or a very different strategy of things, and it somehow magically all works for their clients too. And so I think just helping to zoom out and say, hey, maybe it's not as very, very intricate and specific as we would like it to be, which is the illusion of modernity, is that we have all this technology, and so therefore we should be that specific in healthcare by this point, and frankly, it's just not, and I don't think it ever will because of all of the nuanced complexities of what goes into what causes pain and why at different time points it's a moving target. So if you can just zoom out and think from bigger, higher level picture, I think that also takes down this imposter syndrome of people thinking, oh, if I just get enough certifications and if I just know enough, I could finally treat people with low back pain in the perfect way. And it's like, no, we're trying to give you the like tools that will be the gift for the next 20, 30 years of your life of working with anybody in any kind of pain, in any kind of situation, both from training frustrations of performance side of things, I'm not making the gains or losing the weight that I want, as well as I'm not making the gains or losing the pain that I want over here in the clinical side.

SPEAKER_00 54:25

One of the difficulties that I have as a teacher of trainers is I get a lot of people who are really enthusiastic about learning more. And I don't necessarily want to crush their enthusiasm or you know, be sitting over here on my high horse, but they'll be saying things like, Oh, I'm really excited to get my corrective exercise certification. And I'm like, my mind goes, well, that's stupid, it's not gonna do much. But you know, or I'm gonna do this PRI course. I just got this Anatomy Trains book. I'm really excited and supple up or and oh, I love following Milo and you know, squat you. And I just kind of let it, you know, okay, that's cool. But I try to, you know, steer them towards more, oh, check out this podcast over here and listen to this. And I don't want to make them feel bad because you know, especially with trainers, you know, the education is just really easy. You you take an ask some, you know, 120 questions and all of a sudden you're certified. And then you you learn about you know PRI and you're okay, I want to learn more about that. And then it makes sense. You it's like, oh shit, I never heard about this angle. That's pretty cool. It must be, I gotta go blow up a fucking balloon for the next three days. And then they get some buy-in, but it's like, I don't want to discourage it. So, you know, how would you coach me to you know better whether it's navigate these enthusiastic minds? Because yeah, it's great to learn, but do they need to make the mistakes that a lot of other trainers have done where it's like, yeah, I didn't need to do that course or that course or that course or that book?

SPEAKER_03 55:40

It's a great point. And I think, I think it's easy to be on the other side of things and now say, like, oh, that stuff isn't important. Um, I think there's a little bit of I think a very common thing when somebody enters a new career field or um is trying to level up in some way is to get excited about it and find everything possible that they can do in a way that they think it's gonna make them excel. And I don't think that's a bad thing. I think going through that process and learning how to for yourself determine information that aligns with your the way you want to practice, that aligns with evidence, that aligns with your thought processes, or that goes against them. Like I think all of that is valuable and important. I think where it gets messy is when we basically hold ourselves, be like we become beholden to a system that we now think we need to do everything based on what the system says and put every human being that we work with in a box to fit what it says. So that's where I think what Q is saying is helpful as well. Like, I don't necessarily think there's something wrong with seeking out this information and doing a bunch of courses, especially as you're newer or especially like you're getting excited about things, but have antennas up. Are people speaking in absolutist claims? Are people saying that everything else out there doesn't work and is stupid and this is the only way? Um, do people have actual things that are like biologically plausible? Like we talk about this a lot with um critiquing literature, like is or just any sort of claim that is being made? Like, is it plausible that this like physiologically, biologically does something? Um, I think we have to be better at discerning what type of information is that we're getting information from. But I I don't I don't want to say like, don't go and take these courses, but actually think about the information that you're consuming. And I would venture to say, if anybody out there 100% of the time believes that their system is the answer and the only answer, I would say look elsewhere. And I think we could probably agree about that on every aspect of life. Like we could get into any topic of discussion. And if somebody only looks at one answer for one thing over and over and over again for every single