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Pain science and integrative and lifestyle medicine can effectively fill in the gaps of manual therapy and exercise prescription for your physical therapy patients. Isn’t it frustrating how your manual therapy skills and exercise prescription work great for one patient…and barely move the needle for your next one?
This feeling of hopelessness was also familiar to each of these three leaders in the field of Physical Therapy, Dr. Adriaan Louw, Dr. Brett Neilson, and Dr. Jessie Podolak. Some of them were even considering leaving the field entirely until they learned about pain science.
Over time this understanding of pain science led to a deepening interest and research in to how lifestyle factors influence a person’s experience of pain.
While lifestyle choices, relationship with stress, personal relationships, sleep quality, nutrition, and more can all impact a person’s pain – they can also directly affect everyone’s quality of life. And even a few small, deliberate changes can help you thrive after years of fatigue, pain, or chronic stress.
Dr. Ginger Garner recently sat down with these 3 experts for an interview. During this talk they shared insight into how pain science and integrative and lifestyle medicine are critical for addressing pain in physical therapy.
Dr. Louw, Dr. Beilson, and Dr. Podolak all contributed to the book, Integrative and Lifestyle Medicine in Physical Therapy. Their chapter is simply called, “Pain”, which gets to the heart of managing complicated and chronic pain cases using integrative and lifestyle medicine along with pain science.
Do you wonder what is within your professional scope to help your patients navigate their chronic pain without drugs or surgery?
That’s what their chapter in this book is all about.
This interview/podcast takes on a serious topic with plenty of laughter. We can’t wait for you to listen.
For those of you that prefer video, watch this discussion around pain science and integrative and lifestyle medicine. You can also listen to it on our podcast, Living Well.
You can check out their chapter, “Pain” in the book, Integrative and Lifestyle Medicine in Physical Therapy.
Adriaan Louw earned his undergraduate, master’s degree and PhD in physiotherapy from the University of Stellenbosch in Cape Town, South Africa. He is an adjunct faculty member at St. Ambrose University and the University of Nevada Las Vegas, teaching pain science. Adriaan has taught throughout the US and internationally for 25 years at numerous national and international manual therapy, pain science and medical conferences. He has authored and co-authored over 100 peer-reviewed articles related to spinal disorders and pain science. Adriaan completed his Ph.D. on pain neuroscience education and is the Director of the Therapeutic Neuroscience Research Group – an independent collaborative initiative studying pain neuroscience. Adriaan is a senior faculty, pain science director and vice-president of faculty experience for Evidence in Motion.
Brett D. Neilson is a physical therapist who holds a Doctorate of Physical Therapy (DPT) and a Doctorate of Science in Physical Therapy (DSc) and is both board certified in orthopaedics (OCS) and is fellowship trained in orthopaedic manual physical therapy (FAAOMPT). He is the Admissions Director and Assistant Professor of Hawaii Pacific University’s Doctor of Physical Therapy Program. Dr. Neilson has published several peer reviewed articles and presented at both state and national conferences. His current research agenda focuses on the relationship between sleep and pain. He continues to practice in clinical care in the state of Washington for an in-home, outpatient physical therapy company.
Jessie Podolak received her MPT degree from the College of St. Catherine, Minneapolis, in 1998, followed by her transitional Doctorate from Regis University, Denver, in 2011. She has been teaching pain neuroscience education and manual therapy techniques at continuing education courses since 2013 and has served as the Program Director for Evidence in Motion’s Pain Science Fellowship. She has participated in and lead research exploring the attitudes, beliefs and behaviors of middle school students related to pain, emphasizing healthy options to address pain when it inevitably occurs. Jessie owns and operates her community’s first direct-pay physical therapy practice, seeing a variety of patients with acute and chronic pain conditions. She has special interests in complex and chronic pain, manual therapy, Pilates, spine and running injuries.
00:03 Dr. Ginger Garner : Hello everyone and welcome. I am here with my esteemed colleagues today and we are here to talk about integrative and lifestyle medicine in physical therapy. I am very excited to welcome not one, not two, but three authors that have contributed to the text, Integrative and Lifestyle Medicine in Physical Therapy. And I wanna jump right in and introduce them so we can get started with our conversation.
First, I want to introduce Dr. Brett Nielsen. He is a PT and super nerd with two doctorates, a DPT and his DSc. And he’s also board certified in orthopedics and fellowship trained in orthopedic manual therapy. He’s admissions director and assistant professor of Hawaii Pacific University’s Doctor of PT program. He has published, he has peer reviewed articles, he has presented at state and national conferences. He’s very focused on research that attends to the intersection between sleep and pain. And he continues, also because he has spare time, to practice in clinical care in the state of Washington for in-home outpatient PT.
So, not busy at all.
Moving on, we have Dr. Jessie Podolak who received her MPT and DPT degrees. She’s been teaching pain neuroscience education and manual therapy in continuing ed for a decade and has served as the program director for Evidence in Motion’s Pain Science Fellowship. She’s participated in and led research exploring the attitudes, beliefs, and behaviors of middle school students related to pain, emphasizing healthy options to address pain when it inevitably occurs. She owns and operates her community’s first direct pay PT practice, seeing a variety of patients, acute, chronic care, kind of across the spectrum, and she has special interests in complex and chronic pain, manual therapy, Pilates, spine, and running injuries.
And finally, we have Dr. Adrian Lowe who has his undergrad, master’s, and PhD in physiotherapy from the University of Stellenbosch in Cape Town, South Africa, one of my favorite places in the whole entire world. He is adjunct faculty at St. Ambrose University and the University of Nevada in Las Vegas teaching pain science. He has taught everywhere. That’s pretty much his amazing bio for 25 years at numerous conferences in pain science, on manual therapy, and has co-authored and authored over 100 peer-reviewed articles related to spinal disorders and pain science. He completed his PhD on pain neuroscience education and is the director of the Therapeutic Neuroscience Research Group, which is an independent collaborative initiative studying pain neuroscience. He is also senior faculty because he has spare time too, pain science director and vice president of faculty experience for Evidence in Motion. Thank you.
And now we can all exhale. Thank you guys for being here. Thank you for contributing the pain chapter in our text. We’re really excited to have included this chapter. And I want to talk to you about that and just numerous other things in our time together today. So I have a question because this is a question I often get and it’s one I’m really curious about and that is what made you choose PT to begin with?
And just jump in, feel free to jump in.
03:56 Dr. Jessie Podolak: I blame my mom (laughter).
She thought that I would be good at it. She worked in a clinic and I heard the word therapy and I didn’t, in my high school brain, I thought that just meant people laying on couches, talking to psychologists. I’m like, I don’t want to do that. And so she said, no physical therapy. And she dragged me to work with her one day. And I watched the PT, Frank, helping a post-stroke patient in the parallel bars. And I was there for five minutes and I’m like, yep, that’s what I want to do.
Dr. Ginger Garner : Wow, how old were you?
Dr. Jessie Podolak:I was a sophomore in college and I was considering pharmacology at the time. And so I knew I wanted to do something in health. I liked science. So yeah.
04:39 Dr. Ginger Garner : Was your mom a PT?
04:40 Dr. Jessie Podolak: Nope, she was an aide. She was support staff. She worked her butt off. So yeah, she’s a great mom.
04:48 Dr. Ginger Garner : Oh wow, and yeah, the unsung heroes, right? Yes, yeah. Oh my gosh, what a great story.
04:51Dr. Jessie Podolak: Yes. She’s a farmer too.
04:57Dr. Ginger Garner : Oh, wonderful. My people.
05:03 Dr. Adriaan Louw: Brett, are you next?
05:05 Dr. Brett Neilson: Sure. Let’s see. I come, my mom’s a nurse, my aunt’s an OT, and then I have two cousins that are OTs, and one of them is my aunt’s daughter. And so I think, you know, therapy and healthcare was always something that, you know, I thought I might want to do. I quickly learned that engineering wasn’t quite the right fit for me. I wanted something more active. I didn’t want to sit at a desk all day. I thought about becoming a physician, but I was like, that’s just far too much schooling. So physical therapy sounds like the right balance and fit. And I think what’s really funny is that I’m a lifelong learner, and I don’t think that I’ve really stopped going to school since I’ve been a physical therapist. And so my rationale for not becoming a physician was, while probably a great choice, was a really poor rationale because I’ve done just as much schooling. So here we are today.
06:06 Dr. Ginger Garner : (Laughter) Oh my gosh, wow, all these family members in health care.
06:11 Dr. Adriaan Louw: Well, the good news is I don’t have anybody in healthcare. That’s good. So I should have listened to them probably. Um, you know, Ginger, people have asked me that for so many years. Um, I’m just going to be blunt. Uh, the reason I got into PT school was I was too dumb for medical school. Um, I applied, couldn’t get in. And, um, you know, the funny thing is I had no idea what PT’s were doing. Um, I knew about medicine. I knew about sports, both of those. So they go hand in hand. Right. And, um, I remember going to PT school and within the first semester, I was like, I don’t understand any of this stuff. I don’t know what it is. But it’s pretty cool. And so I actually fell in love with PT while in PT school. So I, there was no, this is the higher calling. This is no, I’m going to change the world, make the world a better place. It was just more of a, as I went through the process, I was like, wow, this is cool. I just got a patient out of bed and, oh, this is cool. Like somebody can raise their arm better when they left here. And it wasn’t me, it was my instructors and that, that got my attention. So, um, yeah, it was pretty simple. And here we are, what many, many years later. Yeah.
07:11 Dr. Ginger Garner : What a way to land into your passion, you know?
07:15 Dr. Ginger Garner : I thought I was actually going to go to law school.
07:18 Dr. Adriaan Louw: Not too late.
07:21 Dr. Ginger Garner : I know. If it wasn’t so expensive in the United States, it would be a good combination because, and we’ll get to this later, but I know you guys are big believers in advocacy as well. And I think that’s where it came from. So like the passion never left. I wanna help people get better, but there’s also this policy side that kind of plagues us and that we always need to be involved in, but we’ll get to that in a minute.
What do you think that…and this is kind of up to your interpretation on this question. It can be where your passion is in physical therapy. Obviously, pain neuroscience is a big deal. But it also can be a particular favorite thing or story about physical therapy for those who are listening who may be interested in PT or maybe just want to get to know more about your origin story and how you ended up where you did.
08:16 Dr. Adriaan Louw: How long is this webinar? How much time do we have?
Yeah, I have no problem going first. If you would have told me 30 years ago, I was gonna sit and talk to people about chronic pain, I would have said, you’re out of your mind. There’s no way, anyway. I had a big love for acute care therapy, worked in intensive care units, ICU, emergency departments, loved the whole acute care thing for that matter. And again, a twist of fate in South Africa, our training is different. So if you don’t pass your PT degree, you gotta spend another six months in training. And I did not, I did not pass my final exam. And which at that point was a terrible disaster in my life. Only to sit here 30 years later going, it was the best thing that ever happened to me because in the six months that I got retrained, more training because I wasn’t smart enough, I had an instructor that took me under her wing. And that’s where I fell in love with spinal manual therapy, clinical reasoning, all this stuff, including some pain, early, early pain stuff. And then once I started practicing, I was very orthopedically trained and I again failed. I mean, this sounds like one failure story, but I couldn’t help people with chronic pain. So I remember going to South Africa on a trip, telling my instructors how utterly useless they are because I don’t know what to do with these people that are complex. And they shoved a few papers in my face. I read it, I came back and like, this is pretty cool stuff. And the rest is history. So again, it’s not a failure. It’s a, you know, we often hit a roadblock and then we think it’s a terrible thing, but it takes us another direction. And I’m utterly excited about what I’m doing. Just, you know, Jess and Brett is here. I work with him a lot and, you know, the things we’re doing is amazing, but I would never have ended up here at Ginger, not even close. I would have been just a good old ortho therapist going in Monday to Friday, doing my thing. And no, nothing more than a joint, a muscle, a tendon and a ligament. And there’s nothing wrong knowing those, but there’s so much more out there than that. So yeah, it’s probably a quick and easy way.
10:13 Dr. Ginger Garner : Yeah. I can’t remember who said experience is the name we give to our mistakes or our failures. And I’ve always remembered that because I don’t consider failures to be failures, just like, you know, in your experience. So I come back to that quote quite often. And it’s also really inspiring to hear your stories to other other kids out there who are interested in PT or thinking that they’re experiencing failures when really it’s just it’s experience. We all move forward based on experience.
10:49 Dr. Jessie Podolak: Yeah, I can go next on that because it’s a similar thread is I had been practicing for about a decade and had a lot of extensive training in manual therapy and Pilates. And so I thought if only we’ve had the perfect structure and alignment and the greatest core strength, these patients should be getting better. And it was good training. And I was starting to get confident in my hands. I was helping a lot of people, but there was this segment of the patient population that I just kept falling flat on my face with no matter how hard I tried. And I just, I wanted to help them, but I just was hitting this roadblock. And I started thinking, I think I must really stink at this. Maybe it’s time to hang it up. You know, I had paid off my student loans. This was back in the day when school wasn’t so expensive. It took me a decade to get those things paid off. I’m like, okay, well, maybe I’ll go work at Subway and be a sandwich artist now because it was really bothering me. I thought I was not doing well. And about that time, the transitional DPT was coming around. And so I was getting students who were having, you know, degrees that were exceeding mine. I thought, well, I’m either going to level up and get with the program, or I’m going to kind of go work at Subway. And someone mentioned Regis University. One of my competitors down the street had gone for her TDPT through Regis and Tim Flynn. And so she started kind of poking at me. And that’s the program that I went with and during that course, Management of the Lumbar Spine, this was like 15 plus years ago, Tim talked about, he had a whole week on the biopsychosocial approach. And I was like, oh my gosh, this is it. This is that subset. And somebody said, has anybody, have you ever, Jess, you seem really interested. This was hybrid learning back in the early days. Jess, you seem really interested in this pain, this biopsychosocial stuff. Have you ever gone to a pain neuroscience education class? And I said, no. And so I looked up and lo and behold, Adriaan was teaching in Minneapolis down the street from me, for 90 miles away. And it was like the next weekend. So I quick signed up for Minnesota APTA, went to PNE class, TNE, that he was teaching and Explain Pain. And it was like, oh, the heavens opened up and the doves flitted down. And I was like, this is it. So between Tim’s take on manual therapy and the biopsychosocial and then hearing PNE, it was like, okay, I’m not going to be a sandwich artist, I can do this. But it’s a lot more complex than I ever give it credit for. And then Adriaan got me turned on to those couple articles by Aisle Liederman, the fall of the structural model and the myth of core stability. And I was like, Oh, my gosh, this is a big paradigm shift. But it was really good. It was. It was really good both and versus either or thinking so it was a good paradigm shift. And I was ready for it. But it took a decade of failures. So…
13:49 Dr. Adriaan Louw: Sorry Jess.
13:51 Dr. Brett Neilson: Gosh, my story is elements of both of what’s been shared by Adrian and Jess. And I think, you know, I got out of PT school and I suffered from new grad physical therapy syndrome which is, I felt like manual therapy could cure anybody. I received a really heavy dose of manual therapy training in my undergraduate, thankfully. And I thought that was the end all be all. And, you know, I found out really, really quickly that you can’t just walk in and treat a knee or treat a spine, right? That these body parts are connected to a whole person. And it was a big wake up call when I had some patients that, wow, they did so well with, you know, manual therapy and exercise and they got better really quick and easy and it was a lot of fun. And then on the flip side, I’d have a very similar patient who, you know, should be responding in the exact same way and they were not. And at that point in time, I was missing, right? I was missing this whole person approach. And so I think through, you know, training and, you know, connections with other, you know, leaders and physical therapists in our profession, I started realizing, you know, my limitations and how complex pain was and how individualized it was. And it was, you know, meeting people like Tim Flynn and others, and then, you know, Adriaan, I think, really kind of put the pieces together when I met him, I think back in 2015-ish, just kind of put the pieces together, like, oh my gosh, like I felt kind of like on an island, like I’m the only one who’s kind of seeing these things and I quickly very, you know, realized that, no, this is, you know, everybody and it’s only those who are being inquisitive in really looking at their outcomes and looking at and asking those questions of why isn’t this person doing well when they should be? You know, I think that’s kind of what kind of steered my trajectory away from, you know, a very manual therapy heavy focus into more of a holistic treatment approach for my patients and, you know, kind of fed into other avenues of my career so far, so.
16:09 Dr. Ginger Garner : Oh, you guys are like speaking my story. I was an athletic trainer first. Actually, personal trainer. Knowing I was going to PT school, athletic training was like, yeah, this looks kind of similar. I’m going to do this on the way, you know, to PT school. So, athletic training was next and very manual therapy. So, you know, it’s all ortho, sports, covering swimming, baseball, all of it, football. And I was launched into, as a baby PT in 1998, and I didn’t know it at the time, but it was the number three county for the opioid epidemic or would become that over the next 15 years, as I lived there 21 years. And so I quickly realized, holy crap, the stuff that I learned in PT school is, it’s not enough. It’s not working
And I was very overwhelmed. Jessie, it reminds me of your story. Like I thought, I am doing the wrong thing here. You know, I don’t feel effective at what I’m doing. I feel burned out, frankly, you know, probably depressed too. Anyway, long story short, that’s kind of you know, my trajectory into what we’re talking about today, integrative and lifestyle medicine. So it’s a pretty good segue to go into the next piece of that taking your stories, we have really similar backgrounds of coming from somewhere else and then being faced with realities in the system of epidemic chronic pain and chronic disease and figuring out, whoa, this isn’t polio of the 20th century, you know, in acute care physical therapy, we’ve got a whole different population to deal with now. So I’m wondering, um, what really piqued your interest?
You know you’ve all had amazing stories of coming out of what we know as the regular physical therapy kind of biomedical model into a biopsychosocial model into a PNE informed model but then what flipped, you know, what tripped your trigger, you know, what sent you over into the integrative lifestyle medicine realm in addition to.
18:37 Dr. Brett Neilson: I guess I’ll jump in. I think I started, you know, I’m reflecting and I think I’ve kind of found this route more for my own personal health. I mean, as you know, we’re all aging and you go for your annual physicals and you know, your doctor saying, oh, your blood pressure’s looking pretty high and maybe it’s time to put you on some blood pressure medications, my family history, et cetera. And I just, you know, felt like, gosh, there’s gotta be a better way. There’s gotta be another way than just taking a pill, right? As a PT, I know that, you know, pills have a lot of shortcomings and there’s a lot more benefit to movement and exercise. You know, movement is medicine. So I felt like, gosh, there’s gotta be something. And I don’t remember how I stumbled across it, but really my first introduction was the book by Dr. Michael Greger, How Not to Die. And a fantastic book on nutrition and the value and just loaded with evidence. So he’s like, speaking my language. And so I kind of figured out, you know, who is this author and found out that he’s tied into the lifestyle medicine group. And I just kind of started following that. And so that kind of then kind of spurred into other areas of reading, you know, the obesity code and other books that really kind of started to shape my understanding of the whole person, right? And if I really, you know, started thinking about it, I’m like, gosh, in order to be a healthy, well-functioning human being, you need to be, you know, getting movement and exercise, right? You can’t be, you’ve gotta be, you know, physically in shape. You’ve gotta be, you know, getting decent sleep, how important that is.
You’ve got to be eating pretty well. And then you’ve got to have some good social support around you, whether it’s a job, something that gets you driven and wakes you up, or gives you motivation to get out of bed in the morning. And then I started reflecting, how many of my patients are struggling with those things, and am I asking about those things, and am I being inquisitive enough? I’m asking them a lot about their movement, but am I really considering, are they sleeping well, are they eating well? And then putting two and two together, I’m going, gosh, maybe these are some of the recipes for why some of my patients are doing well and getting better with just standard physical therapy, manual therapy, exercise, etc., and others really aren’t. And then lastly, having kids. Having kids really makes you experience some of these things, right? Sleep deprivation and how looking at how I function as a human being when I’m sleep deprived, not getting good sleep, getting multiple wake-ups, and I am not my best version of myself. And, gosh, yeah, it would make sense that I’m not creating an environment for, you know, say recovery in this stance. So maybe there’s other things we need to be addressing with our patients before we get straight to the movement component. So that’s kind of my bit of a journey.
21:49Dr. Jessie Podolak: So I can share next. I would say a lot of my interest and passion in integrative lifestyle medicine comes out of pain science. We teach PNE Plus, it’s not just understanding why we hurt, it’s what are the things that are gonna take that understanding, make movement safe and make the rest of the pieces come together. And we talk about pillars, sleep being one of them, goal setting, knowledge, movement. So there’s certainly overlap. And being an instructor, our patients need to know the top of the iceberg, we need to know the bottom of the iceberg. So that lifelong learning, that inquisitiveness, what’s the big deal? Why is Adriaan so worked up about this sleep stuff and what’s these things? And so just reading more on sleep, one of the probably most impactful books for me was Matthew Walker’s, Why We Sleep.
Actually it was my kid who got me turned on to that. Said, mom, I think you’d like this guy. So he was in the middle school study pilot group. So he knows that I’m interested. So I think the curiosity, that lifelong learner. Nutrition has always been, I think for many people, just a lifelong journey of experimenting, watching one documentary and going a year being a vegan, and then watching another one and swing the pendulum to a paleo, and then watching another one. And so the curiosity has always been there, but pain science has really pulled it together. And when you think about what helps a person kind of work their way slowly, methodically out of the deep pit of chronic pain is also those very same things that take a person with maybe average health and then help them thrive, right? So it’s the same stuff, it’s just the starting point is a little bit different. So the more we understand the pillars, the stuff, I think the better we can have our own health and those of the patients that we’re treating and helping.
Yeah, So, and Adrian will pick on me, but right, Adrian, I do not send emails at 11 p.m.
24:10Dr. Adriaan Louw: Yeah, but you used to
24:13Dr. Ginger Garner : Oh, zing!
24:15Dr. Jessie Podolak: Matthew Walker scared the heck out of me with that. It was better.
24:15Dr. Adriaan Louw: Yeah. So first, Brett, I don’t understand this whole not sleeping when you have kids thing. I slept really good during our kids growing up. You may want to talk to my wife about that. Yeah. I mean, Ginger, I think I feel now like the whole table has been inverted. I’m the newbie. So yeah, my world is pain science. Adriaan knows a little bit more about pain than most other things, but for me, that’s the exact opposite. I, so, you know, you talk about South Africa. In South Africa, we don’t do a lot of pills, surgery, drugs, whatever. That’s not a common thing. So I always grew up with the idea that there’s healthier ways to do what we do, not because, you know, people are healthy. It just, we don’t do the other side. You don’t inject, you don’t drug, you don’t cut and all those things. And so when I came here, I put it this way. It’s always been in the back of my mind that there’s got to be a better way, but I’ve never overtly believed or did anything about it.
And then, you know, you start teaching pain science long enough and you start attracting all these weird people to the classes, right? And Jesse and Brett and all these, and they started hammering away at things like sleep and nutrition and all this stuff, you know, you know, what is mindfulness based stress reduction? It’s just, it’s a very long word for something. It’s simple, right? You got to be mindful. And so for me, the world was the other way around. It was like, well, there’s this weird stuff on the side that all these weird people do. And then truth be told, as this group would attest to that, the science behind it has just exploded. I mean, I may be many things or whatever, but I love good research. And when I start seeing the data coming out with mindfulness based stress reduction, with sleep, nutrition and stuff, you’re like, you’d be an idiot. There’s probably not the right word in a webinar or whatever. You’d be a total idiot to sit there and go, well, that’s not that powerful. If we see what sleep does and nutrition, all these things, whatever. So the cool thing is my students became my educators because people show up at a class, I teach them about pain. And during the break, we sit and chat and they talk about mindfulness based stress reduction. Like, well, tell me more. And then before you know it, go read this paper. So I was the exact opposite. And if anybody, since they threw out a book, I might as well say that, I mean, way back, I mean, Robert Sapolsky’s book, Why Zebras Don’t Get Ulcers for me was a very cool read because A: it’s from Africa. So I’m from Africa. But it was really cool to understand stress biology as a manual therapist to understand that, wait a minute, stress and what it does to a human being and all that kind of cool stuff. So I would argue today, you’re interviewing probably two lifestyle medicine people and a very green, young lifestyle medicine person that’s very intrigued by it. And I’m so well on my theory to understand all the nuances and details of it. So yeah.
26:50Dr. Ginger Garner : Oh gosh, I love your stories because there’s one thread through them all and that’s the kids are the best teachers. I know my kids are and they continue to, they continue to push my buttons in the ways that I know that I need to either improve on myself, right, or apply what I know in various ways. Sleep is the easiest because kids tend to steal the most of that. There’s no more lingering on a Saturday morning with your cup of coffee.
It’s more like finding the cup of coffee at noon and going, wait, what happened? You know, I need an afternoon nap. But we do learn so much from the kids. I think they teach us more than we teach them. And I think there’s two things that I want to point out about that.
One, I feel like that’s the reason that you know, I didn’t call, but I emailed. So I emailed Joe and said, gosh, you know…there’s not a book on this. We really should consider doing that.
And the reason, one of the big reasons that I felt strongly about the book, the idea of the book was to help the future clinicians out there, the PTs that come behind us, the kids that feel like, can we, can we practice integrative medicine? Is that in our scope? Can we practice lifestyle medicine? Is that in our scope? And overwhelmingly, I wanted them to know, absolutely, yes, 150%, it’s in our professional scope of practice. It may, you may not feel like it’s in your personal scope, but go, go vet the evidence, go read, go learn, go take a course, but it’s absolutely within our scope.
But there’s one issue with that and that is our PTs today face a bunch of challenges that, school is more expensive. School is longer. There’s dwindling reimbursement. There’s all of these issues. There’s salaries that aren’t commensurate with being a, having a, being doctorally prepared. So those are the things swirling around in my head. What do you think some of the biggest challenges are that face physical therapy and our future PTs out there?
29:09Dr. Brett Neilson: I’ll jump in as a PT educator.
Yeah, I mean, this is a complex issue. And Ginger, you touched, you know, highlighted on some of the big things, right? Which is the cost of education continues to rise. The PT salaries are pretty flat and constant, as is, you know, reimbursement rates and cost of living is going up. So there is going to be a tipping point at some point in time where demand and less, you know, students either want to come into PT or they exit PT really early because the financial component of it just doesn’t make sense. So I think that’s one huge issue is the money side of things.
I think the other side of things too is that, you know, what’s being taught in PT school today. They have to learn so much of the foundations, but are they really getting contemporary expertise and contemporary knowledge and tools that they’re going to be able to use? As an example, most programs have very little, if any content dedicated to lifestyle medicine type of, you know, even knowledge and understanding, let alone interventions. And as long as CAPTE, which is oftentimes thought of to be 10 years behind, and as long as programs have to continue to teach, to CAPTE standards, it doesn’t allow them the opportunity to really expand and push this profession forward. You know, I’m excited that at our program, it’s a balancing act. Yes, we’ve got to meet all these standards and make sure we’re covering, you know, what CAPTE is requiring, but then what is the high value contemporary information and skills that we can teach our students so that they are exiting our program, you know, with the best available knowledge and at least the tools to understand where they need to go next to seek out additional learning opportunities. So, but yeah, it’s a complex one. I’m excited to hear what Jessie and Adriaan have to share as well.
31:24Dr. Jessie Podolak: Well, I would say one thing that I hear from students and from learners from not in the academic arena, but are working, continuing ed type of PTs out there, is just that the daily clinic grind that changes the demand to do more with less. You know, the creative things that businesses have to do to just keep the lights on because of dwindling reimbursement. You know, one of my heroes is Anna Lembke, psychologist who wrote Dopamine Nation and some others. I love her. And she coined this term, the Toyotaization of medicine. At least I think it was her who talked about this happening in the medical sphere where healthcare kind of became health business and physicians had to churn them out, right? Productivity is looked at. And in that, there needed to be quick solutions and quick answers, and that fed into the opioid epidemic. On the PT side of it, I think there are some clinicians who still get to enjoy, that I always ask, how long do you have with patients? Do you still have your 30 minutes to 45? How long do you get for an eval? But some are just crunching down, crunching down, crunching down. And when you think about that contemporary model, like to really delve in and kind of find out how is somebody sleeping? What is their stress? What’s their social support? What’s their nutrition? Those are each, you know, sometimes really detailed conversations. And if you’re trying to wedge them into shorter and shorter and shorter visits, it’s a recipe for this kind of feeling of I just don’t have the time to do for this patient what really they need.
So I think the model is not always conducive and that can cause a lot of burnout and a lot of discouragement knowing there’s so much that we could do and we only have four visits. That’s all that’s authorized and they’re only, you know, we get 20 minutes max by the time the person is in or out or whatever. So I think that just some of the realities of health business are they’re demoralizing some of our caregivers out there.
33:41 Dr. Ginger Garner : Absolutely, and preventing us from even delivering the care that would be effective. Because 20 minutes doesn’t allow for that. There’s no magic wand that’s going to, you know, provide the kind of outcomes we need if we only get 20 minutes, or whatever the timeframe may be for patients.
Brett, you mentioned an important point too, before we get to Adriaan’s response, which is one thing just to keep on our back burner, maybe you want to answer it now is, you know, at in your program.
34:15 Dr. Ginger Garner : Pacific, the Pacific Hawaii program, is that correct?
Dr. Brett Neilson: Yeah, Hawaii Pacific University.
34:15 Dr. Ginger Garner :Hawaii Pacific University. When I first read it, I was like, HPU, that’s High Point University because we have another DPT program down the street, a different, different HPU. Where does ILM fit into the current curriculum? If it does, is there a class for it? Is there an elective?
34:39 Dr. Brett Neilson: It’s bits and pieces of it are kind of threaded through multiple different courses from, you know, from our pain science course to our advanced therapeutic interventions course, and a few others. So, but there is not a dedicated, you know, course to integrative lifestyle medicine. And I think that’s a, you know, it’s, it’s a contemporary thing that hopefully is, is coming. And I know there’s multiple different ways you don’t necessarily have to have a specific course on it right. There’s multiple different ways of delivering the content. But, you know, I think, allowing the space for those topics to occur is really really important as well, so.
35:27 Dr. Ginger Garner : Yeah, it is. Adriaan, what’s your wisdom on this?
35:32 Dr. Adriaan Louw: Oh my goodness, everything they said. Yeah, you know, for me it just comes out to one word is money. I’m sorry, but money fixes a lot of the problems we have. If students don’t have debt as much as they do, if we get better reimbursement, I mean, the list goes on. If you want to build a lifestyle medicine course for PT schools tomorrow and get Blue Cross starting Monday to reimburse $1,000 a minute for lifestyle medicine treatments, it’ll be in the schools tomorrow, it’ll be in private practice. It’s all driven by reimbursement. We were just at CSM last week and everything, the fanciest robotics in the world, the most incredible VR, whatever, none of it matters because guess what? You can’t get paid for it. The list goes on, right? And so the one that I just would add, I think you guys have all mentioned it. You jokingly said, Ginger, earlier, Adriaan’s been everywhere. I feel like I’ve been everywhere. I’ve been training tens of thousands of people all over the world. And the one thing that does concern me on the weekends, I see a lot of tired therapists. They themselves, they’re tired, they don’t sleep, they don’t exercise, they don’t hydrate enough. And again, this is the best example, but it concerns me when our best resource we have, which is the human being that sits in front of us that went through years of training, is not taking care of themself either. Because I would argue that if I showed up in the clinic and I was ready, I was energized, I’m hydrating well, I’m eating well, I’m sleeping well, I probably could handle a little bit more in the clinic than I can if I’m not. And so I just find so many tired therapists. And then, oh, heaven forbid, let’s give up our weekends for continuing education and therapy only, right? And the list goes on. I mean, it’s work-life balance, it is taking care of yourself. But man, if we found money somewhere, better reimbursement models, those kinds of things. That’s why the stuff that Jesse is doing as a standalone practice, I think is amazing. I think we need to get something better going, but we all know it, and it’s a common thing.
Yeah, it boils down to money. It really does. If we got more of it and we owed less of it, and if things have changed drastically, we all know it. So yeah.
37:42 Dr. Ginger Garner : It’s so true. You guys have brought up so many relevant issues of being in business, if you’re insurance-based, dwindling reimbursements. If you are cash-based, private pay, you still have to do everything from dusting your countertops, to mopping the floors, to making sure those yoga mats are clean, to hiring, you know, doing payroll. And I have a private practice as well that’s cash-based. And so I’m just listing all the stuff that I do in a week.
And then the problem with being burned out or the potential burnout of. And I can’t believe I were all of you guys at CSM and I just missed all of you last week. So sad about that. I saw so many people every corner I would round. I’ve seen another person and yet we didn’t run into each other next year in Boston.
38:37 Dr. Brett Neilson: Ginger, can I jump in and make one more comment on this topic before we shift gears? Yeah. Because I think I 100% agree with Adriaan that money drives everything, but I think that practice also drives. And so if we can attack this more from a practice perspective, meaning if more clinicians can integrate integrative lifestyle medicine concepts into practice and we can have evidence to support it, that then can drive money. And at the same token, that then informs CAPTE standards and education.
And so I think this can be a multi… I don’t think we should sit around waiting for the money to happen, right? Because I think we can all agree on this call that it ain’t happening. But we can start to address it through education and through practice and through research, which then should drive the money. And I think that’s going to be really important, something to consider. Just one other example, Hawaii Pacific University has a health promotion course, which is fantastic and it starts to address some of these things, but it really talks more about the well person.
And so I think there’s that blend of also seeing the whole person from the beginning point all the way through the full end of the spectrum. So I just wanted to add in those couple of things.
39:59 Dr. Ginger Garner : Yeah, that last thing you said is so important of seeing them through from beginning to end. And that brings up another important point of what I felt was really a driver or catalyst for the book. And that is letting PTs know, existing and future PTs, that we are across the lifespan providers. We should be frontline providers.
And currently, we’re not viewed as that by the public. And it’s a very good segue into the next question, which is centered around solutions. So of course, one of the solutions is we write more books, we write more book chapters, we write more papers, we do more research. But what are the things that you have identified, because it sits heavy on our hearts, seeing the next generation of PTs saddled with debt and feeling like things could be bleak, while at the same time, they are super excited about what they’re learning, because they know that they’re going to make a difference.
What would we say? What would you say? How do you think we can overcome or navigate the challenges that we just talked about? And Brett, your last comments were a great segue into this question.
41:18 Dr. Jessie Podolak: I think one thing, just as advice for probably PT students, you don’t get into a PT program unless you are a hard worker or you’ve proven, you’ve been able to pass certain academic rigors that allow you to get into school. So I think we tend to draw a very high performing lot, which is great, but it has that shadow side of push, push, push, push, push, push through, push through, push through, and having this expectation of ourselves that we’re just gonna, we’re gonna do it, we’re gonna do it. And soit kind of comes back to that self-care. That it’s okay sometimes to hit a pause button or to ask for help or to reach out.
And I do think that the younger folks are probably better at that than I ever was. But if you push too hard, too long, you inevitably just hit this wall and it’s almost like it’s too late. And so just reaching out earlier and asking for help, making your concerns known, staying curious. So I think that as much as we can, just to keep people in his best self-care, which again is our lifestyle medicine tools.
So it’s not, I really think of lifestyle medicine, especially some of the mindfulness-based stress reduction, meditation, those. You don’t learn that book knowledge. That is experiential knowledge. You don’t know yoga because you watched a class. You experience Pilates and yoga in your body. So the embodied practice of some of the things that we’re, so as Brett is making up his next class, I know he will, because he has already in the fellowship, integrating in little practices so that we can experience them, see what fits, try on breath work. Don’t wait till you’re at the, smashing your head into a wall to integrate some of these things.
43:23Dr. Ginger Garner : Yeah, you know, I can’t remember which author, I read an article or a book, and I can’t remember which author this was, but they gave it a phrase, the phraseology they used to describe what you were talking about was the dark side of resilience. And I don’t think we often think about that because in popular media, I’ve got all kinds of books on my shelf in front of me about resilience, resilience, just have more grit, just lean in, just keep pushing, right? But there’s very much a dark side to that. And I think that, yes, us type A PTs that are driven, driven, driven. Often don’t ask for help until like, when I’m teaching yoga, I will talk about don’t put your face into the windshield where you can’t make any adjustments in a yoga pose because your face is already smashed into the windshield, you know. Back up so you can see what you’re doing and make little small adjustments. So I think that message is such a good one that we have to be aware of the dark side of resilience. Resilience isn’t all great. Really good point.
44:29 Dr. Adriaan Louw: Yeah, you know, I think a lot of things that are happening in lifestyle medicine is what we went through in pain for the last 15 to 20, 30 years. You know, I heard for the longest time there’s a pain revolution, there’s a pain revolution and yeah, maybe there was, I wasn’t invited but the last 10 years, 15 years has been insane and it’s actually very comforting going to CSM where there’s thousands of therapists and then sessions that are just going bonkers over pain science, right? And I think the same thing will happen with lifestyle medicine. Sometimes we just need to let it grow, let it water it, let it take its… Now, will there be sessions on lifestyle and medicine? Absolutely, but we’re going to start seeing sleep in this session and motivational interviewing here and little pieces will start splintering out but I think the message is definitely happening by itself.
The one thing I would ask and I’m probably going to get flack for this one is I’m just asking the lifestyle medicine folks to make sure we keep doing research about it because one of the things that happened in our side of it Ginger, is pain got hijacked for a while by what I would consider people way out on the fringes that had no research, they did things that I think may have even harmed what we were trying to do and I’m not trying to point fingers at people, but we have a professional responsibility.
People listening today, they may like, not like evidence-based practice, but it is our North Star. It tells us where we are and so I was one of the most fortunate therapists in the world. David Butler was my advisor and I remember entering pain science in the 90s when neurodynamics was taught as a quackery, it was attacked in the journals but kudos to the people then that put time, money and effort into the research and so yes, some of these things were mentioned today five years ago was basically seen as on the fringes, it’s alternative or it’s weird, it’s all these terminologies and so my ask for people that are interested in the lifestyle medicine is keep driving the research because that will keep us on that straight and narrow.
The evidence is mind-boggling in sleep, in nutrition, in this because then we can stay to this path that I think will happen by itself anyway. That’s probably the big thing, I think we just need to keep an eye on that.
46:44Dr. Ginger Garner : Thank you for mentioning that. This particular question we could stay on for a while so I’m going to try and recap everything that was said and Brett please chime in again. Because it’s been a while since we circulated all the way around. So I hear, you know, staying in the research, which is important. Keep asking good research questions and seeking those out. I hear looking at a better demonstration of the value of physical therapy services. Specifically with what the public may perceive, because I don’t think they understand that we do and can practice integrative and lifestyle medicine techniques.
47:28Dr. Ginger Garner : Advocacy, that’s a big one. Movement towards what we need to do, I think, is a shift in mindset of what we see in our profession. I don’t know how you guys feel about this, but I often think that. PTs will think of themselves as clinicians and not advocates or activists, but as professionals, I think we are obligated to be both. We need to be able to advocate. We need to be able to support the people who are creating laws. Otherwise, we don’t, well, I guess as the phrase goes, if you don’t have a seat at the table, you’re on the menu kind of thing.
So I don’t know if you guys have anything else to add, you know, about particularly the advocacy piece and what messages you might have for the folks listening about how do they get involved? How do they begin to make a difference? One is set your boundaries and be aware of the dark side of resilience. Don’t push so far that you’re in burnout and your face is in the windshield. But the other part of that is, how do they get involved with creating change, even at the smallest level, so that we do have higher perceived value, people understand what we do, and we do get reimbursed at higher rates.
48:49 Dr. Brett Neilson: Yeah, Ginger, I’ll hop in here. Um, so I practice in the state of Washington and since I became licensed back in 2009, we’ve had to go through legislative battles to earn the right to perform spinal manipulation, and we’re currently going through the process to be able to practice trigger point, dry needling, or, or intramuscular needling as, as we referred it in this state. when 45 other states can practice it.
And the thing that I often hear from physical therapists is, oh, I’m not going to needle or I’m not going to manipulate, so I don’t really care. Um, but I think that’s besides the point. And I think it’s, you’ve got to look more holistically about your profession and the patients, right? So even if you don’t think you’re going to use these tools or modalities, think of your colleagues and counterparts who may use them and may help a patient and keep a patient from going down the drugs and surgery route.
So I think we’ve got to be advocates for our profession and it really just starts with being, being a member, um, and paying attention to what’s, what’s going on in your state. It takes very little time to have a voice. And in fact, they make it so easy now that they push it to you through an email. You click a couple of buttons and you can email a message to your legislator. Um, you know, if you can’t, if you can only dedicate a little bit of time, uh, find out when your state legislative day is and your mark that on your calendar and attend that one day, that can be your one day of advocacy and giving back and I guarantee that the more people that show up at the Capitol, um, the more your legislators hear from physical therapists, the deeper those relationships become. And when you want to get things done, or when somebody’s trying to, you know, maybe attack something that you’re already doing, um, you know, those, we, we can’t wait, right. We’ve got to be, have this kind of ongoing, consistent advocacy. We can’t just show up when we need something.
It’s kind of like the friend, right. You can’t just like be the friend who only calls when you need something, right. That’s not going to get things done. You, you need to be there, create those relationships. And so while some people may think it’s a lot of time investment, it’s really, really minimal. Click a few buttons, show up one day a year, and that’s more, um, than, than we’re doing now. Um, and would make a huge difference.
51:15 Dr. Ginger Garner : Absolutely. Oh my gosh. That’s why I was doing this. I’m like, oh, you’re just speaking my language. I am our APTA North Carolina legislative chair, and you’ve just used the script that I use every day when I’m speaking to DPT programs and trying to get the students involved. It does take less than five minutes of your time. So if you’re a PT and you’re listening, we’re speaking to you, especially if you’re not an APTA member. I spent several years kind of with the notion that, oh, what is APTA doing for me? But I think that that’s a shoddy kind of poor attitude to have because if we want to create that change, it has to be from the inside out. Oftentimes, we can’t just knock on the door, like you mentioned using the stranger analogy, and ask for something when we’re not involved. So how do you create that change?
We could talk and talk and talk about that, but I just want those of you listening to realize that it doesn’t take a lot of time. And if you don’t know who your legislative chair is in your state, reach out. They will be more than happy to have a quick chat. If you’re in North Carolina, that would be me to help you get involved. It is really a minimal commitment because there will be a battle at some point that will personally affect you, and you’re going to want to have a seat at the table for that.
52:39 Dr. Jessie Podolak: And Ginger, can I just add a little bit to that? Sam, I mean, we talked about, you mentioned the opioid crisis. That has opened a door for us. Like we should be pounding on the door saying, let us in coach, we have solutions. We have such better medicine in movement, in education, in sleep. And so just being proactive and not waiting for, not waiting for the invitation on that and get to know just even your very most local representatives and establish some relationships with them before you know it, they’ll be, they’ll ask if we, get good at your craft and it’s scary, but it is so worth it to get down and share information. I’ve had some really nice conversations with our state legislature, which started at legislative day, leave your card, say, I teach pain science. It’s been really cool. Yeah, they absolutely put in the door
53:36 Dr. Ginger Garner : It does. They absolutely listen. I had a bit of a personal experience with that I ran for North Carolina State Senate in 2018 and got to know a lot of of
the State Council as well as local representatives along the way. I met a lot of good people, all doing this for the right reasons. And they are regular people doing their best, trying to balance legislative and regulatory issues with their own families, their own jobs. Lots of legislators are part-time. In North Carolina, you guys might be appalled to know that the annual salary for a, what is a full-time job, is $14,000 a year.
So they have to have a full-time job and be a full-time legislator, right? And take and field all these concerns and yet be up and aware on, oh, a spinal manipulation bill, which we got passed a few years ago. Dry needling, which we won our case for a few years ago. So if you guys are looking for some input on that, call North Carolina, we can help you out with that.
54:51 Dr. Ginger Garner : They don’t know and they can’t possibly know. They have real estate law one day and physical therapy issue the next. They don’t know. So they’re real people with real concerns and they just want to hear from you and they’ll be more than happy to talk to you, particularly if you’re a constituent so.
Alright, I don’t want to close out this interview without asking a really important question because you guys wrote a fantastic chapter and both Joe Tatta and myself felt strongly that a book on integrative and lifestyle medicine couldn’t be published without a pain chapter. So what would you say is your big takeaway? What do you want readers to know about your chapter if you could only give them a couple of points about it?
55:35 Dr. Adriaan Louw: Brett, are you going to go first, because I think we have the same one.
55:41 Dr. Brett Neilson: Sure, I’ll jump in. Yeah, as Ginger said, pain is not usually thought of as a part of lifestyle medicine. And I think, you know, Jesse’s probably responsible for this. But, you know, sometimes you have to crawl out of the abyss before you can really start focusing on your health or becoming a more healthy individual. And a lot of these individuals who really could benefit from lifestyle medicine are likely in pain, as we know, there’s a high incidence of chronic and persistent pain in this country and around the world. And so I think that’s really, really, it’s a critical component, I view, of lifestyle medicine is how do we address pain. And I think Jesse pointed this out earlier in the call too, that many of the same strategies to take an average person to a more well person are the same strategies that we can use to help somebody kind of crawl out of that abyss of pain. So there’s some gold nuggets in this chapter that I would highly recommend checking out.
56:42 Dr. Ginger Garner : Thanks, Brett.
56:43 Dr. Adriaan Louw: Yeah, the part that I, you know, maybe it’s the other way around. It’s everything Greg just said, you know, people in pain have lifestyle issues and vice versa. The techniques that work for lifestyle medicine works with pain. The one part I just would like the readers to understand is that teaching people about pain, pain neuroscience education by itself is utterly useless. We know that. We published papers for the last five years. You cannot explain pain out of somebody. I’ve tried. Trust me, it doesn’t work. All that pain neuroscience education does, it reduces fear. It reduces catastrophization, which gives them hope. And now that they’ve got hope and they have less fear, they move more. And what makes it better is movement. And so it just irks me when I see all the social media activity about PNE doesn’t work because they’re not because they don’t understand PNE. PNE is just a tool to set you up for success. What makes you better is the movement part. It’s the behavioral aspects. And that’s why, you know, PNE plus is basically a bit, for lack of better term, is cognitive behavioral therapy approach to a person in pain. But it’s the behavioral part, the movement, the exercise, the sleep, the nutrition, all those things that matter as well.
57:50Dr. Jessie Podolak: Yeah, and I guess the only last thing I would add on to that, and it’s probably the reason many of us love our profession is we get to work with healing humans. Humans, we’re all on that journey and so that personal connection that we make that therapeutic alliance that trust that’s part of the therapeutic experience and that’s my favorite part. And I think it’s so foundational. Adriaan always throws around that quote from Theodore Roosevelt, “People don’t care how much you know, until they know how much you care.” And so, if we just bring our caring hearts, and our knowledge, and our curiosity to the encounter. And there’s a lot of hope there’s so much hope for people who are hurting and there’s so many tools we just get to help you know guide them, let them give them the autonomy to help choose which tool is going to be the right fit for them. And there’s just a lot of hope which makes it exciting and fun.
58:43Dr. Ginger Garner : That’s such a lovely point to end on is. You know, I think it was. Dr. Elizabeth Dean said, why wouldn’t you want to be a part of the most powerful profession in the world where we can you know, use such powerful modalities that are such a low cost and low tech and exact such a profound change that overall, it goes back to what you were saying, we increase hope and we decrease fear and the overlap of PNE and ILM together are incredibly powerful things.
So I have one last question to ask, because when I, this is so inspiring to me, when I feel inspired, I start thinking about fun and play. And one of the things I love to do is music.
So a really silly question to finish up, which is what song do you think kind of represents what you do from your point of view?
59:45Dr. Jessie Podolak: I like to move it, move it. I like to move it, move it. You like to move it, move it.
59:53Dr. Ginger Garner : Oh my gosh, I love that song. It reminds me of Madagascar because they played it on Madagascar. Yeah, that was so good. My kids were little when that movie came out.
01:00:03Dr. Ginger Garner : Anybody else have a song?
01:00:05Dr. Adriaan Louw: Right, you’re the music guy.
01:00:07Dr. Brett Neilson: I said I’m not really the biggest music person, but when I think about just the current state and maybe where we can head more, the song that came to me is Big Yellow Taxi, which is Counting Crows, it’s originally written by Joni Mitchell. But really the line, they paved paradise to put up a parking lot, and really speaks to me in our current culture of wanting more and sometimes forgetting the simple and the basic, which is just health. We’re overlooking health and just throwing pills and injections and surgery at our health, trying to use those things to fix us, when in fact maybe the beauty is already there that we’re human beings, and that if we just do the right things and we use providers to maybe help coach us along that journey, we might have more long-lasting success and also find maybe more happiness in general. So that’s the song that resonated with me when you asked this question.
01:01:16 Dr. Ginger Garner : I was just bopping that on the way to the clinic last week.
As I turned right into the clinic, I got to the parking lot phrase in that song. That is so true because our system is not currently, it’s malaligned for the values of integrative and lifestyle medicine. And what we’re out there doing, what you guys are out there doing, what we are collectively doing as physical therapists is coming full circle to be able to treat those original issues, which is I think where medicine began. Not in the for-profit and the online system we have now. So I want to thank you for all being here for spending this time with me talking about everything, not just your amazing book chapter and I wish you all the best of luck in your future endeavors. Thank you.
01:02:07 ALL: Thank you, Ginger.
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