The Beyond Pain Podcast

Episode 16: Taming Pain with Dr. Michael Ray

• Par Four Performance • Episode 16

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Summary
In this episode of the Beyond Pain podcast, host Joe LaVacca interviews Dr. Michael Ray, a chiropractor and clinical scientist specializing in pain. They discuss various topics related to pain, including their love for coffee, what they are currently reading, watching, and listening to, and their personal experiences with pain.

Dr. Ray shares his journey from experiencing chronic neck pain to becoming a clinician and researcher in the field of pain. He emphasizes the importance of helping individuals make sense of their pain narratives and the limitations of the biomedical model in understanding and managing chronic pain.

In this conversation, Michael Ray discusses the challenges of studying interventions for pain management and the impact of narratives on pain experiences. He also shares the findings of his study on chronic pain and mortality, highlighting the need to address social determinants of health and provide equitable access to healthcare. Michael emphasizes the importance of understanding that individuals with chronic pain are not broken and that there are ways to cope and improve responses to pain.

Takeaways:
Dr. Michael Ray shares his personal experiences with chronic neck pain and how it influenced his journey to becoming a clinician and researcher in the field of pain.

He emphasizes the importance of helping individuals make sense of their pain narratives and expanding the understanding of pain beyond the biomedical model. 

Dr. Ray discusses the limitations of the biomedical model in explaining and managing chronic pain and the need for a more comprehensive approach.

He highlights the role of open-ended questions and collaboration in understanding and addressing individuals' pain experiences. Studying interventions for pain management is challenging due to the complexity of pain experiences and the inability to isolate active ingredients like in drug trials.

Narratives and language used in healthcare can have a significant impact on pain experiences and individuals' ability to cope with and respond to pain.

A study on chronic pain and mortality found that individuals with chronic pain and high impact chronic pain had elevated mortality rates compared to the general population.

Addressing social determinants of health and providing equitable access to healthcare are crucial in improving outcomes for individuals with chronic pain.

It is important to understand that individuals with chronic pain are not broken and that there are ways to cope and improve responses to pain.

Joe LaVacca (00:02.101)
Hello everyone, welcome back to the Beyond Pain podcast with myself, Joe Lavaca, and normally Joe Gambino, although Joe Gambino is away on vacation today. You can find me at Strength in Motion underscore PT. You can find Joe Gambino at Joe Gambino DPT. And you can follow the podcast at Beyond Pain podcast. And if you are on YouTube, we also post videos of the podcast there as well.

And you can find that at cups of Joe's underscore PT on YouTube. And even though Joe is not here today, I'm joined by a very special guest, someone I've really been looking forward to chatting with, and that is Dr. Michael Ray. Michael is a chiropractor and clinical scientist, expert in all things related to pain. And we are very, very excited to have him on the show.

Michael, welcome. And if you want to introduce yourself, give us a little bit more background to the listeners. We greatly appreciate it, my

Michael Ray (01:10.389)
Thanks, Joe. I appreciate you guys having me here and I'm excited to be on a podcast and chat about all things pain. Background on me is interesting, kind of a twisty, turny road to where I'm at today. So I'll just start with current. I'm an assistant professor of health and human sciences.

at Bridgewater College, just finished my third academic year there, and then primarily focus research on chronic pain, kind of a multifaceted approach. So I'm not the way to think about this for kind of context as you have your basic science research of people who are trying to further figure out, you know, correlates to the development of chronic pain and pain in general. So this could be like, no,

Seception research genetic research animal model research and then you have kind of the so basic science built into pre -clinical and clinical research So looking at working develop directly with humans experiencing chronic pain And then you have an arm of translational and implementation research So that kind of looks at are we doing what we should be doing patient experience and chronic pain I hang out on the latter end. I'm not a basic science researcher

But I do look at translational and implementation research. So are we adapting clinical practice guidelines? And then I look at interventional research. So what should we be doing with people experiencing chronic

Joe LaVacca (02:43.467)
That's awesome. And I think that your work could solve a lot of problems I see on social media these days. So hopefully we can keep talking about that and introduce more and more people to it. Mike, I got a couple of fun questions for you before we get rolling into the other stuff. And I know you're completely unprepared for these. These are going to be real hot button topics. have a background of like coffee on this show. And a little bit of the background on that is

Michael Ray (03:05.131)
Who eats?

Michael Ray (03:10.262)
Yeah.

Joe LaVacca (03:12.747)
Joe and I used to work together at a clinic. This is maybe 10 years ago. We were pretty young at the time and we just literally started putting the camera up. It was the beginning days of all these things. We just start to riff about random topics. It's cringe worthy. Like it's cringe worthy. Uh, but we keep them up there in the, the YouTube thing. And it's sort of like this reflection of who we were and where we came from, but we always made sure that we had a cup of coffee in our hands while we were doing this. I see you are sipping some coffee there, my friend. So tell the listeners.

Michael Ray (03:27.233)
Perfect.

Michael Ray (03:39.571)
I do, yeah.

Joe LaVacca (03:42.805)
How does Dr. Michael Ray take his coffee? What is special about your cup?

Michael Ray (03:47.701)
That it depends, right? On a whole host of things. Like am I going for quantity? I just need caffeine. And so that's different than if I'm going for quality, which I prefer quality most of the time. So really a fun story to me, Father's Day was recently and I have a five year old daughter. And so my partner and her got me an AeroPress, which I've not had an AeroPress, but I've been interested in it because we do.

We do day hikes and stuff like that and travel. And so I wanted something portable. So Aeropress, if I'm traveling or need just like a single cup, pour over if I have extra time. And then if I'm needing just a lot of coffee, it's probably going to be a French press or drip. and then I'll take it a step further. My preferred like sourced region is Ethiopian coffee.

Joe LaVacca (04:35.933)
Wow, you are the first guest to go into the region. Well done. A lot of fancy Aero, I think this is the second time AeroPress has come up too. So now I gotta, now I'm intrigued. Now I gotta kind of dive into that world myself. I normally do have coffee. I'm actually at Courtney's Clinic right now in Colorado. And the only thing we have leftover were these like little Nespresso dark roast, like espresso shots. And I didn't want to start trembling.

Michael Ray (05:02.51)
yeah.

Joe LaVacca (05:05.011)
on the podcast with you. So I opted to forgo the coffee today and just stick with water, but very good. I'm going to follow up now with region for future guests. you've just set the bar, my friend.

Michael Ray (05:16.042)
Well, it makes a difference like Ethiopian is super floral and fruity and so

Joe LaVacca (05:24.096)
That's great. All right. Second question. What are you reading, watching or listening to that you would recommend to listeners out there? And if you have one of all three, go for it. If you want to just pick one, totally cool.

Michael Ray (05:40.513)
Reading, I'm currently reading, you're gonna hear my dog click the clack into here. She'll say hi earlier. She's like, who are you talking to? Reading currently, I'm reading Tolstoy, Anna Karenina, I think that's how you say her last name. It was recommended to me by someone on Instagram and I've not read Tolstoy before, so was like, let's do

I've been reading for probably like three months and I'm only like 200 pages in of the like 1500 pages you have to read for this book. So I'm restraining buying any other books because I want to finish it like preferably by the end of 2024.

Joe LaVacca (06:21.141)
Hahaha

Michael Ray (06:22.977)
But it's it's good. It's it's really good there there is very clear lines of philosophy layered through this this book by told story and I like philosophy, especially when it's kind of intermixed into fictional stories, so to speak so that's what I'm reading and What I'm watching currently we're watching a couple of things. So We aren't big like TV people. We maybe get an hour in

not even every night, maybe every other night. And so we kind of pick and choose when new shows are coming out. So House of Dragon, we watch on Sunday nights. We're big Game of Thrones fans. And if you haven't seen this episode this past Sunday, I won't spoil it, but it was a big one. And then Presumed Innocent, which is a new show with Jake Gyllenhaal, also really, really good.

Joe LaVacca (07:15.881)
Yeah, court and I have been also watching Presumed Innocent and we're pretty caught up in that as well. We both really enjoy it. It's funny because, you know, court was comparing it to the Presumed Innocent, I think back in like the 80s or early 90s with Harrison Ford. And we were we were sort of thinking like, was it based around that? Because then Courtney's like, well, I think I already know who did it. I'm like, well, no, I've never seen that movie. So don't ruin it for me. So I was like, OK, well, even though she thinks she knows

Michael Ray (07:39.071)
I have a year.

Joe LaVacca (07:45.971)
like who did it every episode. You know, when those shows are really well done, you're like, well, maybe this guy did it. Maybe maybe she did it to herself. Maybe maybe somebody else did it, you know, so I've really, really been enjoying that. I think we only got what, like two more episodes left until the finale

Michael Ray (07:57.845)
Yeah, we just caught up last night. We got back into town yesterday. So we watched an episode last night. And yeah, that one also ended on not a great note. I'm curious. Yeah.

Joe LaVacca (08:09.791)
Yeah, not a great note. The House of Dragon, I watched House of Dragon. I'm also a big Game of Thrones fan too. I haven't started season two yet. So yeah, definitely no spoilers. But the thing I was laughing about with season one, was like, is everyone just named Aegon? Is it's Aegon, Aegon, Aegon, Aegon? So whenever I would read, I'd read these these things online because you know, obviously every Monday, there's got to be a meme, there's got to be people posted about it. And it's like, Aegon died. And I'm

Michael Ray (08:22.069)
Cool.

Michael Ray (08:26.793)
Yes. Amen.

Joe LaVacca (08:39.803)
good. I'm still, it's not spoiled for me because I have no idea which one actually died.

Michael Ray (08:43.263)
Which one? Yes, yes. Well, like we've said, it's been very political. It hasn't been the usual Game of Thrones. Like my anchor for Game of Thrones is the Red Wedding. So it's like, all right, are people going to die? Is there going to be war?

Joe LaVacca (08:58.279)
totally.

Right, right, right, right, 100%. All right, man, last one. And you can take this any way you like. Fun fact about life that you've recently learned or about your topic of pain that you've recently

Michael Ray (09:19.979)
Fun fact of something I've recently learned about life or pain. What's the tough one? Pain, can say, would be easier because it's related to my research. So like we had the recent publication in the Journal of Pain on mortality, which I'm assuming we're going to talk about. From a life standpoint,

Joe LaVacca (09:42.655)
yeah, definitely.

Michael Ray (09:45.921)
I, probably going to be related to being a dad. Cause it's just like, you're constantly learning on the fly and like developing into this concept of being a dad. It's like, don't, you don't walk out of the hospital and you're like, I know what I'm doing. Like it's just this evolution. So yeah, I think that that's been pretty neat and fun learning experience along the way is my daughter regularly teached me, just like her.

curiosity about the world and trying to make sense of it and her empathy towards other humans. And it's pretty awesome to see. So that's kind of a constant reminder to me, like what it means to be human, especially watching her develop.

Joe LaVacca (10:32.767)
I love that perfectly said. I feel the same way about my daughter. think even my mentality as a clinician and human being shifted when she came into the world. And even my viewpoints of movement, like watching her just learn to move and go through it naturally without me, my God, coaching her, cueing her, telling her what posture to stay in. know, she just figured it out. And I'm like, you then I'm working with all these clients, which I'm sure you can relate to.

And a lot of the things they'll initially open up with is like their posture and how do they move and they should move one way. And I'm like, well, I don't know if you have any nieces, nephews or young kids. I mean, what do you do with them? And, you know, it always sparks like a little interesting conversation person to person. So I really appreciate you saying that because I can totally relate to it. So thank you, man. Thank you for sharing our three hot seat questions. The rest of the stuff I think will

probably a lot easier for you to answer. They'll all fit into your wheelhouse and I'm looking forward to hearing your answers on those too. So the podcast, obviously Michael is called Beyond Pain or Hope or Desire Here is to share stories about pain, mainly from clinicians, know, cause we're people too. And I think a lot of people are always surprised when I share that I'm in pain or I've had an injury. It's almost like, Whoa, well, aren't you the physical therapist? Like you're not allowed to have pain. You're not allowed to have an injury. Like I thought that's why

started doing all this. So the first question we always love asking guests is, know, what is your relationship with pain? You know, what's your injury history? And you know, what was the thing that maybe sparked you down this road? Because they all seem to usually blend.

Michael Ray (12:14.409)
Yeah, those are good questions. and I was working with a client a while back and she asked me a similar question. I was like, I probably should write this up at some point. Cause it's not something that at least for me, it wasn't, it's not something I've readily put out there and talk about openly.

Not because I'm fearful of doing it. It's just usually the spotlight's not on us, right? Like we're trying to help other humans who are having these experiences. And one of the fears I have when working with humans is I don't want to make it about me by talking about my experiences with pain. So that said, it was a long history. Like I've experienced chronic neck pain since undergraduate studies, so early 2000s.

Um, I grew up in a family in which, uh, my mom has had persistent recurrent pain since, uh, she was involved. We, myself, my mother and my sister were all three involved in a pretty severe car accident and. Oh goodness. I want to say this was like 93. Um, and after that, my mom went on to have chronic neck pain.

And I kind of was there for seeing a lot of, not great healthcare consultations from many, many different titles and kind of going through that experience. she subsequently was, you know, went on disability.

and hasn't worked since. so kind of seeing the, what I now will call closing off of the world to her, didn't have that language then. And how impactful when I reflect on like her trajectory, how impactful that was on her life through clinical narratives and explanations for persistent neck pain after this car accident. That also influenced me. And at the time I didn't know that my experiences with pain

Michael Ray (14:14.259)
had this social cultural influence that was rooted in my upbringing. And so I got into bodybuilding early on in life. I started getting into a late high school or early college, started at my first competition at my school and college at the age of 18. And I developed some left shoulder pain that was fairly persistent. And I was convinced that there was something structurally wrong with my left shoulder.

I saw an orthopedic physician, did physical therapy, I saw a chiropractor, did massage therapy and it wasn't getting better. And so I was a patient pushing for imaging, got an MRI. There was like a small slap tear, labral tear. And the surgeon finally, probably out of frustration of my repeated concerns, decided to do arthroscopic surgery, went in and did

label repair, a joint debridement and called it a day. And then even after that, I still had shorter pain. went to physical therapy, was still dealing with it and it remained kind of a mainstay. And then I want to say around my sophomore year of college, I was doing pull -ups and got a pretty severe muscle strain in my right trap.

And that's the start of my persistent right -sided neck pain and has sustained similar trajectory of orthopedic consult images, cortisone injections, chiropractic care, PT. And so that kind of led me into, interest in healthcare.

I went on to chiropractic school, got my DC at the end of 2015, opened a clinic. so going into that, I was thinking about modalities. Like I was very much a interventionalist mindset. Like how am going to fix pain? Can I get certified in rock tape? Can I get certified in ART and IASTM and all of these things? Cause I was going to fix pain. And then I.

Michael Ray (16:29.185)
met different clinicians along the way, was challenged to think about things differently, started working in clinical practice. I opened my own practice in January of 2016 and realized that my view, my model of pain was very narrow and I was very biomedically rooted. wasn't even like, my education didn't talk about models of pain. It was just this assumption that if you have pain, something's wrong in my job as a clinician is to fix it.

for you, need to do something to you. And so as I worked with more patients dealing with chronic pain, I realized that my model was very limited and I needed to expand it. And my own lived experiences, my own upbringing had influenced the way that I experienced pain personally, but also the model that I used to view it and how to address these issues with people. And so I've worked pretty hard at trying to move beyond a diet

medical model and that's ultimately led me into the research world. I felt as though to this day we are severely lacking an expanded model of understanding from a healthcare professional standpoint to help individuals with lived experiences of chronic and persistent pain and so that's what I mostly do these days is research on chronic pain that I do telehealth. So I was a bit of a long

long windy answer but hopefully it gives context.

Joe LaVacca (17:59.251)
No, I think it gives a ton of context and you how you originally kind of opened it up on you never as a clinician or at least one of the things I was taught when I was diving into all these things about communication and trying to help people make sense of their pain was that same idea of like, know, don't make it about you, right? Because this is their experience. It's their individualized representation of what's going on in their body.

But then the more I started just to kind of become more open as a clinician and how I learned to almost, you know, ask for permission to speak my story to some people. I think it really led to some deeper connections and you have so many things that I think so many clients can connect to and hold onto previous traumas, like a motor vehicle accident. Parents always come up, you know, in, in good ways and bad ways,

I think more of the time I hear, I don't want to be my mom. I don't want to be my dad. I don't want to be my grandfather. And then now, you you're kind of seeing some of those patterns emerge. Like you've had some neck pain. think you've mentioned to your mom, some neck pain too. So when you are thinking about helping people understand their experience and make sense of their narrative, how do you go about doing that and keeping yourself removed?

Or has that maybe evolved for you over the last few years as being a clinician and researcher?

Michael Ray (19:32.501)
Yeah, I think it depends. think certain cases it wouldn't work well that if I started opening up about me, like you do run the risk of, know, hey, I kind of think about it if you're sniffing at others talking to you about a bad day they had, and you start talking about your bad day as well, they're like, well, what the hell? you're supposed to support me.

Joe LaVacca (19:52.159)
Yeah. Yeah.

Michael Ray (19:55.081)
So if it's the right case, yeah, I share more than I used to when I got started with this. And when you were talking about kind of family influences, I was thinking about, will often hear, well, I don't want to have a bad back like my dad. My dad has a bad back. My grandfather has a bad back. And so some of like just the...

process of peeling back those layers, tend to open up with pretty broad questions of like, can you, can you tell me a bit more what you mean by bad back? Like what, does that mean? And they'll say, well, you know, they had back pain, they couldn't do X, Y, Z. And so it lets you kind of lead more into, well, you know, what did they believe low back pain meant? What were they told? What do you believe low back pain means? What have you been told? And so you, you try to ask open ended questions so people will tell their story.

and their understanding of their own experiences. And then you have to gently try to see, we collaborate on that a bit more, maybe expand our viewpoint of what pain means.

Joe LaVacca (21:02.483)
Right. When you bring up, you know, these roles that you were kind of going through, right? And this has also popped up a lot in multiple conversations with clinicians we've had on so far is, you know, this, was a bodybuilder, you know, I was strong, I was fit, but I had this sort of like background shadow of like chronic pain in my family and traumas

I'm moving through it, moving through it. Was there ever a point where, you I think you mentioned frustration of your surgeon, but was there ever a point where you started to feel frustration through this process? And it seemed like maybe you did in your story and it turned into something good for you. You sort of like dove into the research world. So where do you think that turning point was for you where you sort of said, Hey, you know what, if I have all these negative emotions, like so many

of the patients that we work with now do. How did you go about turning it, making it into a positive, and then really listening to your story, building almost like a new identity or a new avenue for yourself, maybe even personally and professionally?

Michael Ray (22:14.773)
Yeah, part of my personality, which can be good or bad, is wanting answers. I can become a bit obsessive about it, which works to my favor in research, because you maintain tenacity and curiosity.

And so that's kind of what happened is feeling as though as a patient, I wasn't getting the answers that I felt were satisfying to me. Why am I having to keep getting X, Y, or Z therapy done to fix my problems? And then from a clinician, feeling as though that was only temporary fixes for people that.

The narratives that I was giving only explained part of it or probably were false at times or were false at times. And then were temporary relief strategies for people that didn't lead to long -term help. And so that led to reading a lot. I mean, ultimately reading a lot of research. If I feel like I don't know something, I try to read as much as I can. If I feel like someone else has a particular subset of knowledge that I could learn from, I'll reach out and

connections. mean, that's how the whole research team I currently work with, like that's how I made those connections is reaching out and talking with them and kind of dedicating myself to it. I prioritized it and kept working at it. And so that helped me reframe my own personal beliefs about pain. It helped me kind of mold my narratives to others, whether it's on social media or

in telehealth these days. And so that's really influenced my understanding and approach for pain related issues.

Joe LaVacca (24:01.703)
Right. So it seems like you're almost kind of like internally motivated to kind of seek the truth or find that answer. And there are some clients that have that internal motivation and some of them are more externally motivated. You know, they need some reward system or they need something to kind of push towards. when you are trying to help someone make sense of their narrative, which, you know, when I follow you on social media, you know, that's such a recurrent message, you know, helping people make sense.

Michael Ray (24:09.365)
Yeah.

Joe LaVacca (24:30.443)
How do we go about doing that for like different styles of people? Why is that so important in the rehab process?

Michael Ray (24:37.983)
Yeah, I think it depends on the person's need for an explanation. Like from my experience of healthcare, I was on a holy grail search for a diagnosis.

I'm going to figure out what's wrong with me. We're going to do the intervention. We're going to fix me and I'm going to be fine. and sometimes that works like, right? Like the way I think about it is COVID -19 is a great example, unfortunately, but we were impacted by a novel infection in humans. hadn't seen before. didn't have, interventional management strategies that we had research on. hadn't had a vaccine. So people were presenting with symptoms, but we didn't have an explanation to address it.

Eventually, we isolated the viral infection, we figured out a vaccine, and we treated accordingly like we have done for quite some time with vaccines. The biomedical model, the silver bullet approach like that works.

quite well in scenarios of chronic pain, persistent recurrent. don't have that ability. can't link the ideology despite our best attempts, you know, and we've kind of shifted over many decades of saying, you know, if we take low back pain, well, it's, we can look at X -rays and we have bony misalignment for the chiropractic world, scoliosis. could talk about, various changes we see.

on imaging x -rays, then we've got MRI abilities. We talked about the neural correlates of persistent low back pain. So must be, know, peranormal encroachment or stenosis or disc herniations, or, and then now with fMRI, we're saying, well, pain is an option for the brain. And so we're consistently shifting the underlying etiology, which makes sense from a basic science approach, that we get better at looking for causes and explanations, and we probably get better

Michael Ray (26:32.839)
finding them, but it hasn't yet really translated meaningfully to the patient level. So telling someone that low back pain is caused by their bones in their back or the discs in their spine or the brains, constantly relating danger messages, and that's the output of pain doesn't have meaningful translation to influence management. when people see me,

My level of depth of detail is dependent on their need for explanation. Some people I could talk to who are experiencing persistent or recurrent neck pain may be satisfied with, you know, sometimes we just get stuck in these patterns and we have a persistent recurrent pain. But the good news is nothing you've said to me today. It gives me a lot of cause for concern that we need imaging. need to go find a specific problem with a specific intervention.

to get the outcomes you're looking for. And that's a really good spot to be in because now we can manage this conservatively. We can work through this. We can dose and movement to tolerance. We can progress towards the things you want to do, like play golf or go swimming or weight lift or whatever it may be. Whereas others may say, well, what do you think is the cause of it? You I was told by so -and -so that I have disc herniations in my neck at C6, C7, and that's the problem.

And so if they're saying, I'm having neck pain and it's occurring with a ridiculous symptoms into my arm and I'm getting numbness and tingling like, yeah, that's probably correlated. Does it change what we need to do for your case? Typically not. You know, here's the things we're watching for to see, do we need to do things differently? You had sudden loss of grip strength, motor weakness, loss of range of motion. Then yeah, we're probably going to have to do something differently.

So it really just depends on case context and the needs of that individual for my explanations. And I usually err on the side of minimal information because in my mind, I'm worried about a nocebo effect. I don't want to instill fear in the individual.

Joe LaVacca (28:42.485)
Would you mind diving into just for, again, maybe like the lay listener, what the difference is between a placebo effect and a nocebo effect? Because many people have heard of placebo, but not enough I think have heard of

Michael Ray (28:56.993)
Yeah. So, um, they're, Latin terms. Placebo means I shall please. That's like the translation of it. And no, no, no, SIBO means I shall arm. And so most people are familiar with the placebo effect, right? Cause they'll say, well, it's a sugar pill is how people talk about it, but you get some outcome. You, you, let's say our outcome of interest, because I'm a pain researcher is driving down a numerical pain rating. So on a scale of zero to 10, how much pain are you in? Someone says an eight.

We do something to that person and it drops to a six. Was it what we did to them that reduced that number?

Or was it a bunch of other influential factors, maybe time ahead at last, maybe there was a positive relationship with the clinician, maybe, who knows, natural history occurred. Any number of things could influence that. So when we do studies on interventions, like vaccines I was talking about earlier, we do randomized controlled trials. So we compare whatever the actual interventional substance is to something that lacks that substance.

studies work quite well in drug trials and vaccine trials because we can isolate for a lot of the context, we can isolate the active ingredient and then compare it to something that doesn't have it. so that both bolsters our confidence to say the outcome we observed is most likely directly attributable to the interventions ingredient where it falls apart a good bit. we're slowly kind of evolving how we look at things from an interventional standpoint and the

rehab field, pain and rehab field is these non -pharmacological conservative management strategies, it's much harder to do that. When you're talking about education or physical activity

Michael Ray (30:49.857)
cognitive behavioral therapy or ACT as your intervention, we can't really isolate the active ingredient like you can in a drug trial. So we're having to evolve the ways with which we study these things. On the flip side of nocebo with it meaning I show harm, maybe we make your pain intensity go up or maybe we contribute to fear avoidance behavior because we told you your neck pain is because you have poor posture, you have tax neck, you

herniated discs, you should be cautious in how you move. And if you do move, here's specifically how you should move. And so that can be harmful language to people and that can make their ability to cope with and respond to pain experiences worse. And so we're balancing that between providing a reassurance and adequate information and education while giving a path forward and an attempt to minimize harm with our narratives.

Joe LaVacca (31:47.901)
Right. That's a great definition. Thank you for diving into that. And I think you, bring up a couple of great points there because there's easy ways to assess meaningful outcomes. Maybe when it comes to an active ingredient, did it work or did it not? You know, we have a control group. We have something very tangible that we can maybe potentially measure, but with pain being, you know, an experience, something that emerges very complexly from multiple different avenues. And you've touched

family, social, cultural already as it is, how do you measure someone's changed experience? That was always sort of what I found very challenging in the clinic. And then I think maybe the point there too with the narratives is what I've told people is, look, if you behave like you have poor posture or you have text neck, I had someone come in last week who was told that she has military neck.

I'm not even sure if I really remember what military neck was, but it was just like super, super straight as opposed to, guess, the opposite. So I was like, okay, cool. Now, now I have, I have both, right? So Tex neck is down, military neck is all the way up and you embody that experience. So if someone tells you something is fragile or broken or the cause for your pain, or maybe the sole cause for your pain, you end up behaving and moving differently. And then for us, we mentioned our, you know, our daughters, like if I thought,

I was in danger of lifting up my daughter when she was younger. She's 10 now. I don't know if she wants me to lift her up anymore. those experiences, I'm sure you can relate, of just picking up your little girl and hugging her. And that made me feel like a million bucks. And then so many parents and grandparents who come in, they're like, I don't want to lift up my grandchild. And I'm like, well, hold on. Why not? It's like, because my discs are like pillows. My spine's too unstable for that.

Michael Ray (33:25.205)
Yeah.

Joe LaVacca (33:39.579)
reframing that is so, powerful. And, you know, I think that's why I appreciate the work that you do so much to not necessarily eliminate pain, but to change someone's lived experience as they cope with pain. I think now is some of the biggest value that I try to provide for people. And it's amazing how many people say, you know, I'm still having some sensitivity in the back. I'm still maybe having my neck pain. I still occasionally get some of

know, tingling, buzzing thing, but I know I'm not in harm's way anymore. And my life bubble has grown, even though my pain bubble has kind of remained the same. I'm just doing more things and I really, really think that that's valuable. So thank you for sharing that as well. Do you mind if I pivot a little bit and ask you about your research?

Michael Ray (34:32.457)
No, I don't mind at all.

Joe LaVacca (34:34.215)
All right. Recently, and I think you mentioned it in your intro to that you did a study on chronic pain and mortality. And this really made me pause and reflect a little bit because I'm really excited to hear you talk about your findings because I think maybe when I was growing into this whole pain, neuroscience, clinical education, sort of like bit, know, one thing I would commonly say to mostly clinicians when I was teaching was

you know, pain hasn't killed anybody, right? You we need to like move off of this. And it was sort of a pretty aggressive take. Again, maybe like one of those cringe worthy things where I wish I didn't say as much as I did. And yet when I look at your study, I can see sort of like the headlines booming on TikTok or Instagram, right? Like chronic pain leads to early death. So before we, you know, listen to some animal like myself, giving misinformation like I used to do, or we read, you know, some sort of

tabloid headline on your research. What do you think that we should be taking away from the most recent trial that you published?

Michael Ray (35:41.003)
Yeah. My hope is, from a research standpoint, it ushers in more funding is ultimately what I'm hoping for it because it just further highlights the need to address some issues related to pain from a basic science point all the way up and ensuring that we're

adequate helping individuals who are experiencing persistent recurrent pain that were giving equitable access to healthcare and management and long -term clinical continuity of care for these individuals. I think it will help if I talk a little bit about how we...

did the study, what our outcomes were, so on and so forth to give this context. So this was an epidemiological study. So we looked at, when you talk about epidemiology, you're talking about population level. And so you're looking at generalizations. And so I had done research with national health.

Interview survey data and H .I .S. which is in essence each year our government pays for interviewers to go out and kind of canvas the country in various geographical locations to ask all sorts of questions in person that are related to health. In essence it's getting a pulse on the health of Americans and it could be related to any number of factors and the questionnaire is adapted each cycle each year. So like now we're

in our COVID -19 questions and log COVID questions. Specific to my interest when I started working on this type of data was looking at physical activity and pain. And so we published that, I want to say a year or two ago, which is the relationship between physical activity and pain in US adults.

Michael Ray (37:37.289)
And that was showing us that those who met physical activity guidelines were much less likely to report experiencing chronic pain and vice versa. Those experiencing chronic pain were much less likely to engage physical activity.

And so subsequent of that study using an HIS data, I was expanding kind of the outcomes I was looking at. And I had read a few studies in other regions across the world that looked at mortality. And so that got me thinking, I was like, well, do we have that data in the U .S. that we looked at on a population level, the relationship between people reporting chronic pain?

mortality rates. So mortality rate being what's the expected number of people who are going to die on any given year just because as human beings we are mortal we do die.

And so we have a rate in the U S we know what our mortality rate is. know top 10 causes of death, stuff like that. Uh, but we didn't have, uh, a lot of data on looking at chronic pain and mortality. had some, and it was on smaller data sets and it was somewhat conflicting. Some were saying that they found a relationship between chronic pain and mortality. Others said they were able to attenuate the effect of chronic pain on mortality.

by adjusting for various factors related to psychosocial variables and lifestyle variables like meeting physical activity guidelines. And so I went looking to see, the NHIS have data on this? Because it's not something that's asked about directly in the NHIS.

Michael Ray (39:17.749)
Fortunately, the NCHS, which is kind of the hub for conducting the NHIS, does have this data. So they do what's called a data linkage program. So they linked NDI, the National Death Index. So a lot of people may not know this, but when you die, well, they probably do with COVID -19 because this is a bit of a debate, like cause of death during COVID -19 time.

Joe LaVacca (39:40.479)
Right, right, right.

Michael Ray (39:42.017)
But if you die, it gets recorded, it gets logged in our NDI. I think it's been ongoing since the 60s or 70s at this point. I we've maintained a registry on this for quite some time. And so the NCHS linked NHIS data, which is on the health and wellbeing of Americans, with NDI data. So now you're able to look at across time.

If people are reporting sedentary behavior, if they're reporting hypertension, hypercholesterolemia, what's their death rate, mortality rate? And that's kind of how we figure out like,

hypertension, you know, it's one of ways we figured out hypertension is a risk factor for heart disease, which is a risk factor for early mortality. Well, because the NHIS started asking about pain related topics and specifically persistent pain in 2016, we were able to link that 2016 data and 2017 data from the NHIS to 2019 NDI data. And now this let me model what is the relationship between people reporting pain and

reporting other comorbidities, psychosocial variables, physical activity levels, and what's their mortality rate. And in doing that, we found a few things. The mortality rate just for general population, I think was like 2 .82%, meaning that at any given time point during our 2016, 2017, 2018, 2019 data sets, 2 .82 % of the population were dying. And you can quantify that

We can say that equates to X number of hundreds of thousands or millions of deaths When we looked at people who were experiencing chronic pain, so pain that was persisting or recurrent for three months or greater

Michael Ray (41:27.657)
and high impact chronic pain. So pain that's persisting or recurring for three months or greater and caused the person to have an activity limitation one or more. So they weren't able to do social or extracurricular or work related activities. We saw a pretty significant increase in mortality rate. So it jumped up, I want to say it was four percent for people experiencing chronic pain.

I'll give you the exact numbers because I don't want to misquote my own research. And it runs the risk. We try to be very careful with our language on this because as you alluded to, this could be one of those things that it gets misinterpreted and taken out of context and could potentially cause a nocebo effect in and of itself.

So we found that the people with chronic pain had a 5 .55 % mortality rate. So about double from the general population. And then those experiencing high impact chronic pain had an 8 .79 % mortality rate.

Joe LaVacca (42:22.9)
Right.

Joe LaVacca (42:28.447)
Wow.

Michael Ray (42:37.729)
And this led to excess deaths. So what you can do is you can look at this and say, okay, if the mortality rate is 2 .82 % for the general population, how many people are dying each year? And then you can look at if the mortality rate for chronic pain is 5 .55%, how many people are dying? And you look at, what would be the expected number of deaths and people experiencing chronic pain based on the general population mortality rate of 2 .82?

then you can subtract those two numbers and see that it's contributing to excess deaths. And when you look at it even more, you can do some modeling. It's called hazard ratios. So hazards ratios, it's a risk factor measurement. looks to see, does the experience of chronic pain and high impact chronic pain have no effect on your risk of death, mortality?

an increased effect or a decrease effect. That's kind of the spectrum you can be at. We found that it increases the risk of mortality. And so that just means that those who are experiencing chronic pain or high impact chronic pain had a higher risk of being assumed dead at follow -up versus those who weren't experiencing these two issues. It is pretty significant. We went through the process and controlled for a lot of things. We controlled for

Joe LaVacca (43:52.661)
Yeah.

Michael Ray (43:58.685)
demographics, so age, sex, race. We controlled for psychosocial variables, so related to activity limiting anxiety and depression and emotional problems. And we controlled for lifestyle factors, so BMI, physical activity levels.

and look to see, could we drive down the mortality risk that we were seeing increase for these individuals with chronic pain and I am back on thing. And we could, if we controlled for these confounding variables, if we controlled for psychosocial variables, if we controlled for lifestyle variables, we could bring it down from what it was, but it was still noticeably elevated. So just to give you an idea, let me find it real quick.

So it was still about two times to two and a half times higher for those that are experiencing chronic pain and high impact chronic pain for the hazard ratios. So even when we were controlling for all of these things, we were still having a fairly elevated, give me just a second.

Michael Ray (45:16.181)
I have a mechanical keyboard, just because I love the sound of it, which is, it's funny, right? So it really is.

Joe LaVacca (45:18.219)
It's like soothing, it's soothing. Yeah, it puts you in that hypnosis while you're typing and stuff, Hey, was just, my daughter says ASMR probably about five or six times a day. She's like, ASMR, ASMR. So that was the first thought that popped into

Michael Ray (45:28.135)
Well, what do they call this like ASMR from?

Michael Ray (45:39.445)
Yeah, exactly. So let me just pull this up real quick so I can give some accurate numbers.

Joe LaVacca (46:05.771)
I think so much of what you're saying already makes so much sense. And this data is so fascinating to me. So, and it's just opening up probably about like 10 more questions for you too. But I'll keep it, I'll keep it the next, I'll wrap it up into like the one or two for you.

Michael Ray (46:16.855)
Michael Ray (46:21.921)
No, no, you're fine. So when we adjusted for psychosocial variables, for demographics, for lifestyle variables, we still saw that those that were having chronic pain and high impact chronic pain were still having elevated mortality risks. So for an example, for chronic pain, it was still 1 .225 times higher.

And for high impact chronic pain, it was still 1 .657 times higher, meaning around 22 % to 65 % higher for experiencing these issues. So we were able to reduce it, but it's still a meaningful, both statistically and to me clinically, meaningful difference in mortality risk for these individuals. And so that ultimately what led me and my co -authors to conclude.

is there's probably social determinants of health at play here. There are external factors influencing what we're seeing. I just don't know how else we could explain it to still see a meaningful elevated mortality risk for these individuals. So thinking about things like access to health care to have continuity of care long -term, receiving the type of health care that we should be giving.

Joe LaVacca (47:20.075)
100 % right.

Michael Ray (47:39.795)
So following say clinical practice guidelines for these cases. That's kind of where I think we'll be led in future research investigations is looking at the influence of social determinants of how things that are external to the individual. And I think it's much needed. We're very often hyper -focused on looking inward into the individual. Like what's wrong with you to have these experiences? And it's much harder for us to zoom out and say, well, hold up, what's the environment like? What's the social cultural

like what is in place that is bringing forth these experiences or intensifying these experiences or making them worse for individuals? And it's interesting because my master's is in exercise science. So for a long time, I focused on looking at lifestyle factors because of that. And we saw and are seeing a similar approach with obesity issues and saying like, you know, hey, there are environments that have been set

Joe LaVacca (48:10.09)
Right.

Michael Ray (48:39.689)
that magnify the obesity issue, that this isn't someone's lack of willpower or lack of ability. We're realizing that there are external factors that are making this.

much worse at a population and individual level. And I'm kind of seeing a similar thing in our pain research that we're needing to realize that there are external factors to the individual. And I think it's important too, because the history of working with people dealing with persistent recurrent pain has been quite stigmatizing. It's a lot of patient blaming. It's a lot of you are active enough or you're too active or you're overweight or you're underweight or you're not managing your stressors or, and so we're

Joe LaVacca (49:18.421)
Sure.

Michael Ray (49:24.535)
much stuck in a pattern of like this is your fault it's kind of like shaking your finger at your kid versus saying like have I set up the environment in a way with which would help people to thrive and have either less pain and or cope better with pain

Joe LaVacca (49:25.621)
sick of it.

Joe LaVacca (49:41.779)
Right. I think that's so important, not only for patients listening, but for clinicians listening, because I think the social determinants of health kind of gets swept under the rug by a lot of us because we don't feel in control of them. And as I think a provider who is supposed to give something, right. And I think initially earlier in your days as a provider, you were trying to fix a person's pain, right.

you what I'm gathering from you and others is that pain is an experience, you know, and it's maybe a lifetime of experiences that have built up to this, you know, single point interaction that you have with a clinician. Oh, and you only have 60 minutes to sort of like figure it out, right? And that's another problem, like with that social determinant model is that, you know, I think sometimes I can talk to people for probably two, three, four, five, six hours if I had the time and they would let me.

Michael Ray (50:19.274)
Right, right.

Joe LaVacca (50:30.155)
Whereas other people come in and they get it really quickly in 20, 30 minutes. we're sort of like, you know, watching our watches as the session passes. So I think you bring up there such a, such a valuable point. And, know, for me as a clinician, it's something I've always really been intrigued by those, those social factors. And especially when it always came to longevity, because so many people would come in and, and tell me that, you they don't go out anymore with friends or family that they're staying away from parties. They're not interacting with kids. And, and my question is always like,

why are you staying away from those? And it usually comes back down to the biomedical explanations that they've been given. Well, you know, this is impinged or this is too weak and I have to hit all these prerequisites, you know, before I do all these things again. I have to, you know, hold a plank. I have to do this. I have to, you know, go through a 12 week exercise program and...

And then I always just kind of keep swirling in my mind. This is not something I directly say to patients, but I'm like, why, why is that? Why are all these clinicians kind of really kind of stuck in that mindset or that mentality? I think that will kind of bring us into this question of you individually with your practice. It seems like it's mostly virtual, if not all virtual, you do a lot of education there. So what makes you and your practice that tame pain, which I absolutely love?

Right? Not eliminate pain, not crush it, not kill it, tame it. What makes that different than other models that are out there that you've

Michael Ray (51:59.637)
Yeah, this is a good question. And to your point, the branding was quite purposeful. I don't.

When I work with humans, I don't typically set the expectation like, we're going to eliminate this. You're never going to have this experience. Instead, say pain is a part of human existence. And more importantly, usually the question we're asking is what are our responses to those experiences? And so I think that's what we do quite well. I like the setup because yes, we do a consultation. We allocate the 60 minutes to it.

And kind of an aside to say, some of my research is taking me into the emergency department. And a lot of my future investigations will be coming out of that. And it's because the truncation of time, a lot of times you're talking seven minutes or less on these consults. And so that's just not, it's not enough time. And then there's no continuity of care. There's no follow -up. There's no, you know, here's a list of referrals that you can go follow up with and whether they do or don't, we don't know.

And so we are able, you know, virtually to give that 60 minutes, but then also we have a lot of people, not almost the majority sign up for long -term programming with us, which is a monthly subscription, uh, reasonably priced and we can maintain, you know, they, a lot of times like the individualized activities and exercises. My bias is the individualized communication. like, I don't think we're programming anything magical. It's just individualized to you, but I like that

can keep talking to you and communicate and you can send me videos and I can send you videos. And so I look at it as being a guide. We're able to come alongside you, walk with you through this process, learning how to respond to pain, gaining new understanding. And I think about it having now taught in higher ed for a number of years.

Michael Ray (53:54.707)
is it's like taking a class because you don't go in and learn everything you need to learn about a particular topic in one day, one week, one month, and typically not even one class. Education is this ongoing evolutionary process. And so I kind of looked at the rehabilitative process being very similar.

Joe LaVacca (54:18.571)
Yeah. Oh man. Absolutely love it. Reminds me a lot of the model that we've sort of slowly built at Strength in Motion too. And I think you hit the nail on the head just as our previous guest Tyler Kallasay did and Mike Stella did. It's like, you can get programming on ChatGPT now. You hey, how do I build a program for strength in two days and 20 minutes and ChatGPT is going to spit something out. You know, don't think. Yeah, it's probably it's probably not bad, right? You know, and I'm like,

Michael Ray (54:40.393)
Yeah, it is probably pretty good.

Joe LaVacca (54:47.887)
And that's what I tell people. like, you you're not, that's not really the fee you're paying for it. It's, being able to reach out to me at any moment in time. It's being able to ask questions. It's being able to, you know, modify your programming on the fly. And, know, something that I've always took from Craig Liebenson was, you know, let's fail as fast as possible, but you and me working together in that guide sort of position allows us to fail as fast as possible and then know what, you know, can work for you in a sense to help you achieve your goals.

So I absolutely love that. think that's a really big piece that's missing or maybe lost upon a lot of clients when they look at numbers and finances and all the sort of money they put in going back to social determinants to try to solve their problem and not having maybe access to a clinician like yourself. So thank you for doing that. Can I throw one last question at you? All right. This is another one that we've sort of been closing out with with a lot of guests.

Michael Ray (55:35.969)
Yeah, of course,

Joe LaVacca (55:45.725)
What do you think is your biggest piece of advice for those with chronic pain listening

Michael Ray (55:54.471)
that's a good question. The first thing that comes to mind is know that you're not broken, right? I think it's, there are, there are a lot of feelings that get wrapped up in experiencing chronic pain, you know, self doubt, shame, guilt.

in ultimately isolation a lot of times. And so I think the first step is knowing like you're not broken and that there are ways with which we can typically cope better with our experience that oftentimes does coincide with noticing less pain as time goes on and as we improve our responses. And so there are people out there like you all that are here to help and willing to help and are trying very

are to change the way we do things in healthcare. And so having that understanding you're not broken, finding things that you can do, even if it's with some pain is pretty huge. If you say, I wanna go do whatever, if it's walk to my mailbox and check my mail, can we walk halfway with some pain? And then next time can we walk a little bit farther and a little bit farther and before you know it, you're walking past your mailbox.

It doesn't have to be pain free and it's okay to have some pain. think that would be best advice I could give.

Joe LaVacca (57:15.539)
All right. Amen. And I wish we could put that on some sort of like, solid piece of stone and just hang it up. It in my clinic. Yeah, you're not broken. That's a great, great, amazing takeaway. Michael, how do people find you? How do people work with you? What's the best

Michael Ray (57:22.109)
I didn't know that.

Michael Ray (57:33.854)
Yeah, the easiest way is just go to our website tame pain t -a -e -p -a -i -n .com And you can find all of our social media links there and take all that good stuff You can if you want to follow my research this research date that has all of my up -to -date publications on it just search my excuse me, Michael Ray, and that'll bring me up and Yeah, if you need

reach out via email it can just be michael at taintain .com and you'll be able to get me there as well. I'm pretty responsive typically.

Joe LaVacca (58:10.464)
Thank you very much. Michael, appreciate your time. Much love to you. As Joe Gambino would say to our listeners, much love to everybody out there. And if you've made it this far into the episode, extra, extra love to you. We will see you again next week. Michael, thank you again so much. Really appreciate it.

Michael Ray (58:27.103)
Thanks Joe.