The Beyond Pain Podcast

Episode 34: Making Life Bigger with Gino Lazzaro

• Par Four Performance • Episode 34

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Summary:
In this episode of the Beyond Pain podcast, hosts Joe Gambino and Joe LaVacca welcome Gino Lazzaro, a physiotherapist from Germany. The conversation begins with light-hearted banter about Christmas traditions and coffee preferences before diving into Gino's personal journey with pain and how it has shaped his approach to treating athletes. Gino shares his experience with a wrist injury sustained during gymnastics and discusses the differences between acute and persistent pain in athletes, emphasizing the importance of a biopsychosocial approach to care. In this conversation, Joe LaVacca and Gino discuss the bio-psycho-social model of pain management, emphasizing the importance of understanding the multifaceted nature of pain. They explore therapeutic approaches such as Acceptance and Commitment Therapy (ACT) and Cognitive Functional Therapy (CFT), and outline a five-step process for helping athletes navigate chronic pain. The discussion highlights the significance of communication between therapists and patients, and concludes with a powerful message about focusing on life beyond pain.

Takeaways:
Gino Lazzaro is a physiotherapist who works with athletes.

He had a significant wrist injury during gymnastics that impacted his career.

Pain can often be a side effect of an acute injury but can become a problem in itself when persistent.

Athletes often lose touch with the present moment due to their pain experiences.

Building rapport with patients is crucial for effective treatment.

Gino emphasizes the importance of taking time to recover properly from injuries.

His experience with pain allows him to empathize with his patients.

Biopsychosocial care is essential for managing chronic pain.

Gino's background in sports influenced his decision to pursue physical therapy.

He enjoys making cappuccinos and has taken a barista course. The bio-psycho-social model helps identify main sources of problems.

Supportive environments can sometimes hinder recovery.

Job satisfaction and nutrition significantly impact pain levels.

Acceptance is crucial for psychological flexibility in therapy.

Identifying a baseline level of activity is essential for recovery.

Progress should be incremental, not excessive.

Stabilization phases are important for emotional well-being.

Communication between therapist and patient is vital for success.

Focusing on life goals can help manage chronic pain.

Coping strategies are key to living with persistent pain.

Joe Gambino (00:00.727)
Welcome back into the Beyond Pain podcast. am one of your hosts, Joe Gambino, and I am here with our other co-host, Joe LaVacca Mr., we'll call him, aka Christmas starting in November. I remember a perfect stride, Joe, like November 1st, the Christmas music starts to play, and that's usually a little bit too early for me. So, you know, Christmas season is here in full effect, so how to bring it up? more of a, you know, Christmas starts right after Thanksgiving. That's appropriate for me.

Joe LaVacca (00:19.276)
That is correct.

Joe LaVacca (00:29.324)
Yeah, I told Avery today we're going to put up our Christmas tree. And I said, I can't wait to throw on my Elvis Presley Christmas vinyl. And that typically is the signal for me that Christmas is officially here. I've been delaying it. I've been delaying it a bit, but I have it.

Joe Gambino (00:32.393)
Joe Gambino (00:36.931)
She's like, who's that?

Gino (00:39.478)
Yeah.

Joe Gambino (00:43.733)
I see. This is really late for you. I thought the tree would be up the house be decorated.

Joe LaVacca (00:48.75)
You know, playing every other weekend game and traveling so much, it's always based on when me and Avery can kind of do it together now. So we were going to throw it up together like halfway and then she didn't want to do it halfway. So we're to do it all today and then make a whole big deal of it.

Joe Gambino (01:03.787)
I see. Very nice. Very nice. We'll have fun with that. And, and we do have a guest on the podcast today. We're here with Gino Lazzaro. He is the owner of pain physio. He works with athletes that have a persistent pain. Welcome into the show.

Gino (01:21.952)
Thank you so much for the invite guys. As I said, first international stage for me, so very cool. Sweet.

Joe Gambino (01:26.933)
Yeah, first international guest for us.

Joe LaVacca (01:32.012)
And Gina, where are you located?

Joe Gambino (01:32.086)
Amen.

Gino (01:33.918)
In Germany, near Frankfurt, many people know Frankfurt, so that's about half an hour from here.

Joe Gambino (01:37.005)
Yes.

Joe LaVacca (01:39.97)
do you partake in Oktoberfest festivities and what are those like?

Gino (01:44.374)
Probably one of the only Germans who doesn't partake in any of those things. I don't drink alcohol, so I'm really boring. Yeah, not really my jam. I hate the music and... Yeah, yeah, yeah.

Joe Gambino (01:44.515)
You

Joe LaVacca (01:48.878)
you

Joe LaVacca (01:56.014)
Okay, there was a... no, whoa, we're going deep now. There was that commercial though, I remember, was promoting people to drink more water. And I forget who made it, but it was everyone walking around with a beer stein, just cheersing water and dancing around. So you're not even there doing that, like just beer steining some water.

Gino (02:10.613)
Yeah.

Gino (02:17.273)
absolutely not. I try to stay as far away as possible from that.

Joe Gambino (02:25.123)
Is that like the tourist trap that you guys try to avoid in Germany or is that like people flocked to it? Yeah, okay.

Joe LaVacca (02:25.247)
bit of physio.

Gino (02:30.824)
No, actually most, I would say most Germans like that stuff or a lot of Germans like that stuff. It's just not my thing.

Joe Gambino (02:35.328)
I see.

Joe Gambino (02:39.395)
I was wondering if it was like the sorry Joe, I was wondering if it was like the ball drop in New York. Like I would never ever ever go to the city to attend it because of how crowded it is. Sure it might be cool to see once but I would never sit in any of that. So I was wondering if it was a similar, go ahead Joe, sorry to cut you off twice in a row.

Joe LaVacca (02:39.532)
And you mentioned you're... No, no, no, you're... But... Yeah. That's a perfect example.

you

Joe LaVacca (02:55.704)
Yeah. Yeah, no, no, no. was thinking, I was literally thinking of the same thing. I was like, yeah, there, is definitely these tourist traps that were all over New York City. And then the first one that came to mind, I was like, the ball drop. I'd never do that ever. Wouldn't be caught dead. So we were definitely on the same wavelength there. But you're from Germany, right? Do you know what part is, are you from Frankfurt?

Joe Gambino (03:10.699)
Yep.

Gino (03:12.842)
Yeah, that's a good comparison.

Joe Gambino (03:16.045)
Well...

Gino (03:17.728)
Yeah, yeah.

No, from the Black Forest actually.

Joe LaVacca (03:23.638)
What does that mean? Where is that located on the Germany map? Southern. Okay. All right. Very good. Very good.

Gino (03:27.328)
Southern, as far south as you can go basically.

Joe Gambino (03:31.927)
I like the name Black Forest, sounds straight out of like a Lord of the Rings or something. Well, it's a, you know, no alcohol for you. But our first question for all of our guests is how do you take your coffee? We have a very loose theme of coffee on this show. So we'll start there. Nice easy question for you.

Gino (03:33.717)
Yeah.

Yeah, sounds mystical,

Gino (03:52.31)
So I did a barista course about six months ago or more. So we have a machine here. And that was literally one of the best purchases I've made in my entire life. So good. The problem is, though, and you might know that you can never drink coffee anywhere else anymore. It sucks. And it's super expensive. And it tastes.

Joe Gambino (03:57.659)
Gino (04:19.88)
not even half as good as at home, so that's difficult, but I have a cappuccino always.

Joe Gambino (04:26.177)
perfect.

Joe LaVacca (04:28.054)
Yeah, Joe is very good at making the home brew coffee. I have asked for a new, the show has inspired me for Christmas to actually ask for a gift this year. And I actually asked for a new coffee machine. I need to step the game up. I need to get on the level of our guests, the level of Mr. Joe Gambino. Now, when you took this barista class, did you learn how to make some designs in your cappuccino with the milk? Are you doing like a leaf? Are you doing like a heart? What's going on with the designs?

Gino (04:39.434)
That's good.

Gino (04:44.561)
You

Gino (04:56.822)
Unfortunately not. Is it called latte art in English as well? I'm not sure. But none of that was happening there. It was really basic to be honest. I'm pretty good with a heart, even a feathered heart by now. But that's about it, where I am.

Joe LaVacca (05:01.058)
Yes.

Joe Gambino (05:10.977)
Yeah. that's what would you say was the biggest takeaway or thing that you learned from the course?

Gino (05:20.384)
From the coffee course.

Joe Gambino (05:21.717)
Yeah, from the coffee course.

Gino (05:23.606)
It was basically the discussions afterward where I spoke to the host. In the course itself, I didn't learn anything because I watched a gazillion videos on YouTube beforehand. And then I just asked him some stuff about the machine, how to set it up, et cetera. And then got some individual takeaways for my machine.

Joe Gambino (05:35.937)
Yeah.

Joe Gambino (05:41.635)
Hmm.

Joe Gambino (05:47.383)
Very nice. I was hoping that I get a little tidbit there for my own coffee making experience. Hey, you're good. Don't worry, my level is not that high too. right now I'm now that it's warmer, I'll be dabbling to more cappuccinos by the ice lattes all summer. So yeah.

Gino (05:53.622)
Sorry man, don't think my level is as high.

Gino (06:07.251)
that's good. That's good.

Joe LaVacca (06:09.846)
I actually thought you stayed ice all year round, Joe.

Joe Gambino (06:12.439)
Well, have ice right here, so I do stay ice usually year round, but you know, sometimes a little warm though is nice. I'll go a little warm.

Joe LaVacca (06:14.188)
Yeah, yeah, that's what I thought I remembered the fun fact.

Joe LaVacca (06:20.926)
changing it up. Gina, I got another fun question for you. You mentioned that you didn't like German music, maybe just in the whole scheme of the Oktoberfest. So what's your favorite American song if you're listening to any...

Joe Gambino (06:21.965)
Yeah.

Gino (06:36.992)
Favorite American song?

That's a good question. I definitely go for a track that Eminem has made. I'd probably say When I'm Gone. Yeah.

Joe LaVacca (06:47.694)
okay, wow.

Love that. I love that. I was just hoping that you weren't going to pick something like John Denver, or like Neil Diamond. I was like, no, don't do it, Gino. And I was setting you up for the trap, too. I was setting you up for the trap. And you just totally surprised us with some Eminem. All right, cool. That's my favorite artist also. So much respect to that. Yeah, for sure. didn't realize that. I guess I failed to realize sometimes that how global.

Gino (07:03.498)
Hahaha

Gino (07:09.374)
Thanks. Can't go wrong with

Joe LaVacca (07:21.664)
a of these artists are and how the world has gotten so small with social media that, you know, the minute or day I hear a song from an American artist is probably the same day you guys hear it now for the most part, if you're following along with them. So that's pretty cool. So.

Gino (07:34.09)
sure.

Yeah. And Eminem is great preparation for a podcast as well for your voice. So I rep along 25 to life by him like once before I hop on a podcast and then my lips are already do that, man. good.

Joe LaVacca (07:47.948)
Ready to go. Wow. What a great idea. I love that. I know we all got the fancy bikes too. mean, Joe's even got like the booth recording mic over there, you know, and I feel like you can even flip yours upside down. You know, just look like you're in the booth. Yeah, I love it. I love it, man. I love it. Well, that's really cool, Gino. I really, I really appreciate that. Any other fun fact for the listeners that you want to share?

Gino (07:57.937)
Yeah.

Gino (08:03.986)
Yeah, let's do that.

Joe Gambino (08:05.835)
Yeah.

Gino (08:16.372)
I was a DJ for many years and I almost studied music production. So that's a little fun fact.

Joe Gambino (08:24.003)
Yeah.

Joe LaVacca (08:24.952)
I love that. All right. was the biggest show you ever put on as DJ Gino? Holy shit. That's...

Gino (08:29.632)
It was like a thousand two hundred people, so not that big.

Joe Gambino (08:33.65)
That sounds pretty big to me.

Gino (08:36.17)
haha

Joe LaVacca (08:37.998)
I'm trying to teach a course in New York City. I'm trying to get like 10 people to sign up. And DJ's spitting to a thousand people. And he's like, you know, it was just a regular party. It wasn't all that big of a deal.

Gino (08:41.619)
Hehehehehe

Joe Gambino (08:47.235)
It's a typical house party, just you know.

Gino (08:48.092)
Hahaha

Gino (08:52.742)
one of those nights, you

Joe LaVacca (08:56.104)
man, that's really cool, Gino. I like learning fun facts about people. So that might have one of the most fun ones so far.

Joe Gambino (08:59.948)
Yes.

Yeah, that's a good one. That and Grayson being a cheerleader at some point have been the two ones that popped to me so far. Loving it. Loving it. Well, let's let's dive. Yeah, that's it. We'll just cut it here and make a part two for next week and have some takeaways for people. But we'll dive in. Let's hop into it.

Joe LaVacca (09:06.902)
Yes.

Gino (09:10.678)
Awesome, glad to hear that. We should stop it right here because I don't think it's getting better than that.

Joe LaVacca (09:15.756)
Yeah, I was like, that's it. I'd rather say right and well and then tune in next week for another episode of Beyond Paid Pocket.

Gino (09:21.344)
You

Joe Gambino (09:32.127)
Our typical first question outside of the coffee is everyone almost I feel like in especially people getting into physical therapy, people have their own pain journey that kind of shapes the way that they kind of go about things and maybe even push them into this, this industry. If you wouldn't mind talking about, you know, your own pain experience and how that's maybe shaped how you you treat your athletes. We can we can start in that direction.

Gino (09:56.906)
Yeah, I had to think about this question for a while, to be honest, because I've been really, really lucky. I have thousands of thousands of hours of sports in my career and I hardly ever got injured or had any pain. But then I recalled one injury on my wrist that I had when doing gymnastics. I was doing like handstands on rings and then I fell down and I didn't let go of the rings.

because I was stupid. so I had some, I don't know if it was a tendon or ligament, I didn't get an MRI. And I treated it very, very, very poorly, even though I was in physio school at that point. It was the classical endurance coping that I did. whenever my wrist got a little bit better, like not even

No pain at all, just a little bit better. I would start doing handstands again and even one arm handstands working on those. And it always flared my wrist up like crazy. And then I thought, well, fuck that. Can I cuss here? Okay. I just, I was just like, screw this. I'll keep going. And the pain just got worse. And then.

I was doing that until I had to take a break because the pain was just, couldn't bear it anymore. So then I had to take like a month or two off, like completely even strength training. And then I got back in and did way too much, way too soon. And it was the classical boom bust cycle, literally. So in the end, took me two and a half years to get rid of something that could have been like six to nine months, maybe. And that really, really sucked. Yeah.

Joe LaVacca (11:50.03)
So you already had that injury into PT school, sounded. So what made you take the path towards physical therapy? Was there something else in your life that was pushing you into this interest in the pain world or the rehab world or you being such a kind of a sport guy, seems like. there teammates that you watched kind of go through things or what gave you that impetus to go to PT school?

Gino (12:09.824)
Very, very much.

Gino (12:16.928)
Well, both my parents were professional athletes and squash. So I grew up in a very, very active family. was doing like six sports at the same time in my childhood and even adulthood. So that was always a huge part of my daily life. And I was always really, really interested in the human body. So that was the main idea behind the physio.

education that I did. So not a a pain story behind that. I was just super interested in the human body and I didn't want to go to med school. So

Joe LaVacca (12:57.87)
Yeah, that makes sense. I get that. your parents, yeah, your parents are athletes, you've been an athlete. So I guess that it makes sense that your special interest has been working with athletes, particularly athletes in a lot of persistent pain or chronic pain.

Joe Gambino (13:02.089)
Nice little pivot there, right?

Gino (13:03.634)
Hahaha

Joe LaVacca (13:21.046)
I'm sure though, as you've mentioned with your acute injury with gymnastics and growing up around your parents and sport, sport teammates, sorry. What's the biggest difference do you think of working with an athlete and injury in a mindset with acute pain versus working with an athlete injury mindset with something persistent?

Gino (13:43.242)
Hmm. A good question. would say that pain is, is more of a side effect of an acute injury. So it's a, it's just a side effect, as I said, and when pain becomes persistent, it can become the problem itself. And then it branches into so many areas of life. That is another, it's like a tumor. It goes everywhere and

People always spend a lot of time in the past and in the future. So they kind of lose touch to the present moment because they always think about, yeah, three years ago I was still running marathons and how am I supposed to do X, Y and Z this weekend? I have to plan ahead if I can even do this one workout because I might have a flare up for two days. So I don't know if I can go to that birthday party of my friends, et cetera.

So they're always in the past or in the future. yeah, that kind of reminds me of, of act. So acceptance, therapy a lot where you really want to bring the person to the present moment. That's a, that's a big thing. And I also believe that biopsychosocial care or even like an activism or inactive care becomes increasingly important. The longer the pain has persisted for because like a

hamstring tear, you don't really have to be talking about how the family situation is, et cetera. If they have a support network around them, it'll just get better very quickly. But with these other things, it becomes very, very important because they might have detrimental people around them that make this pain last. Yeah.

Joe Gambino (15:29.859)
I like that. I'm a little curious. mean, it's like going back to your pain story and tying it back into what we're just talking about. You know, I feel like your journey of like even in PT school, I think it's one for listeners, right? Like, you know, PT school, like, you know, I've been a trainer my whole life. I've had a similar story with my back and stuff like that. Like it happens to us, we make the same mistakes as everybody else, right? So I think people need to give themselves grace when they have pain and they over push it and flare ups for normal and all that fun stuff. But

With what you learned over that two and a half years to kind of get over your wrist pain, how has that helped you or shifted how you approach your athletes with working through the chronic pain? Has that like, yeah, has that had any sort of like shaping to what you do now?

Gino (16:13.064)
Mm-hmm. That's a good question.

Gino (16:18.4)
Definitely. mean, for one, it really helps me build rapport with my patients because I can tell from my own experience how difficult it is not to be active when sport is such a big part of your life. And then I'm like, I get it. And I just want to save you two and a half years that I missed out on by being too fast. So the wisest thing for you to do is

take a step back right now, even if it is for a month or two months, which might seem long for you right now. And I totally get it because I was there before. If we zoom out a little bit, this is actually a very short time span because you want to be doing sports for the rest of your life. And if it takes you two months to recover properly, then I would suggest that you take that time and I can assist you with that, making it as easy as possible for you. So that is.

a big thing, building a great relationship, working relationship with my patients. And that is, as we know, one of the most important parts of our clinical encounter.

Joe LaVacca (17:30.7)
Yeah, I like that a lot. Gino, the thing you touched on too, with the bio psychosocial model and for patients listening, that's just the way of clinicians trying to identify main sources of problems or entry points for intervention.

You mentioned the hamstring strain or tear, very biological, know, very tissue focused. You can look at that on an MRI. You can see, you know, visible signs of damage and yeah, that's pretty straightforward. Like you need the six, eight, 10, 12 weeks, whatever to recover. We gradually built you back up. But then you touched on something I think that was important and you are identifying something that would be detrimental.

to your athletes and maybe make you force outwards a little bit. What would an athlete, particularly, you your patients and stuff, what should people be looking for as detrimental effects, maybe in other areas that you've seen and helped your clients work through?

Gino (18:25.526)
The first thing that comes to mind, which is of course recency bias, but the first thing that comes to mind is that if they have people around them that are too supportive, this can become a big problem because that can reinforce a belief in you that you are not capable at the moment. If everyone says, yeah, yeah, Joe, don't do that. I'll do that for you. Yeah, no, you can't do that. I will do that for you. Please just lie in bed. Don't move at all. How does that make you feel?

Do you feel like strong and empowered or do you feel like weak and fragile? That was like the one that came to my mind like immediately. But of course other things are the, the, the, the work environment that you are in. Like if you're happy with your job or not, we know that this has a huge effect on, for example, low back pain. So job dissatisfaction, is a risk factor of developing back pain.

Joe LaVacca (18:58.146)
Yeah.

Yeah, delicate for sure.

Gino (19:24.98)
That's a, that's a big thing. yeah, of course, nutrition is another factor. Sleep, a big one, like these recovery factors. yeah, I, I like the, the CFT kind of style where this third thing is about how can you as a person be healthier? And that means like relationships that could mean nutrition, that could mean sleep, whatever. What can you think of right now that would make you a healthier person?

And what are some low hanging fruits that you can work on? That's another very important distinction here. Because if you can't change your work situation that easily and you're like, yeah, your work situation sucks and that's keeping up your pain. Thanks for nothing. Yeah.

Joe LaVacca (20:09.07)
Yeah, I think that's so overlooked.

with the things that people can control. And they zoom in and they just focus on this one thing and then they lose sight of all this other stuff around them that can make them better or make them who they are. And that whole stuck in past and future I think really robs you of that identity. And one of the things I really try to push with people is, what's gonna bring you back to feeling like you right now? Is it taking care of your kids? We were talking about kids before the show.

you know, is it pouring yourself into your job? Is it doing something like a walk instead of a run? Like what, what can we do for that? So I really appreciate that. Two things that you, you also mentioned, and just more for like clarification stuff. You mentioned act therapy, which is acceptance and commitment. you mentioned CFT, which is cognitive functional therapy. Yeah. Yeah. No, no worries. No worries. No. So just for like, again, like patients listening or,

Gino (21:07.551)
sorry, I forget. Yeah.

Joe LaVacca (21:13.506)
maybe clinicians who haven't heard of these things, would you mind just doing a quick explanation on how or what ACT therapy or CFT therapy is and how you bring it into your treatments with your athletes?

Gino (21:28.648)
Yes. So, so ACT is a behavioral therapy method. And the key component is that you have to accept your, you have to start with acceptance. If you cannot accept the situation you're in right now, there's no room for change. So psychological flexibility is the key part of ACT. Like there's this hexaflex of acceptance commitment therapy. So

six different components that interact with each other. like being present in the moment and what your values are and then committed action is the last step. So it really starts with first an understanding of the problem and then having the person accept the situation the way it is right now. Then not overly identifying with the thoughts that the person has. Then there's this thing with a conceptual self.

very in depth now, but we have these I am statements like I am an athlete's, I am a pain patient, whatever. We should really try to like, split up this identification that a person has with something because that is a very static thing. And the self is something that changes dynamically. And

If you're stuck in the static mode of I am an athlete and you're not able to participate in your sports, that makes it very difficult for you to cope with the situation.

So questions that I like to ask is why do you like participating in sports? What is the value behind that? And maybe it is pushing boundaries. Maybe it is social interaction. Maybe it is proving something to yourself because the only time in your life that you were praised by your parents was when you achieved something. Then that would lead us to a totally different path.

Gino (23:33.396)
really finding out why something is of importance for you right now. And that gives us a lot of opportunities to work with that. For example, if you just really like the complexity of the sport and you like pushing yourself, there are many different ways to do that in life. I mean, you could play chess. I love playing chess, by the way. That can really push yourself. And you can do that immediately.

No problem at all. And that might fit with the same value that you find in participating in sports. That's the idea behind that. Yeah.

Joe Gambino (24:14.081)
Yeah, I like that a lot. I'm kind of curious, you earlier you met, you know, you were talking about if you had, you have people who are, you know, very difficult situations when you're an athlete, like you identify as an athlete, you've done your whole life, you get injured, and then you have a hard time navigating pain because it's holding you back from doing something.

So how do you, I guess, how would you educate somebody based on everything we just talked about, if you have one of your athletes come in and they can't run again, or they can't play golf, and they're really struggling to kind of get back to it, how do you kind of help them figure out what they can start to do now, and then as you're trying to work back to getting them to the activity they want to do?

Gino (24:52.628)
Yeah. So I'll basically frame that as the five step process that we also teach people in our coaching and that I just published in my pain guide that people can just download for free. because those are the five steps that have been working really well for, for us. And it just gives the people a framework that they can work with. And that can really help like some sort of trajectory or like a thread.

that really makes sense for them. So step one will be what is your status quo? Where are you right now? That is the most important first step that we have to know about. And then the step that most athletes miss is finding a baseline level that they can tolerate. And I'm not excluding myself here. I have been there before, not talking from here to there. I have been there.

How much stress is tolerable for you? And I say stress and not training or training volume because that is one stressor, but it could be many other things that add stress to your life and that influence pain. So what is a stress level that you can easily tolerate without increasing your pain? Because if you have that, that is like a safe resort that you can always go back to when you have a flare up. It's like a safety net.

And that can really help people. That it never means or hardly ever means that you have to completely stop with everything that you're doing if you're aware of this one safety net that you can always go back to. So that's something that we try to find with our athletes immediately. And it's usually a lot lower, the stress level or the activity, if you want to say so, than what they're used to. And that's important.

They're like, Gino, can we do some more exercises? Yeah, yeah, we'll get there. Don't worry. Let's discover your baseline level first that you can always tolerate. And then step three would be progress and not in a stupid way where you feel good that day and you just do like 50 % more than the last session. Like incremental steps. There are some studies out there and it's highly individual, of course, but like 10 to 20 % increase in load maximum is where we go with.

Gino (27:16.438)
And then the fourth step is a very, very important one that most athletes miss, me included, is the stabilization phases. What we as athletes like to do because we're very ambitious is last time I was deadlifting 140, like kilograms, and so next time I'll do 145. And then if that worked well, I'll definitely go for 150 the next time.

Joe LaVacca (27:42.411)
you

Gino (27:43.968)
So we just always try to progress every single session and just breaking that mindset a bit, because when we're in pain therapy, the goal is not to increase your load tolerance in every single session. Like it's not about maximum performance, what we're doing right here. So always include stabilization phases where you just keep the stress level equal, like the stress level that you can.

that you can manage, meaning in our case, the training load, even if it worked well that week, let's stabilize that for another week. And that's extremely crucial for emotional, emotionally valuable activities. I really doubled down on that because like, for example, I have many athletes with lower limb problems and they really want to get back into the, into jogging. is very

meaningful for them. And so we start jogging like with intervals, for example, like a one-one interval is something we start with. So 30 seconds of walking, then 30 seconds of jogging and then walking again. And then for maybe even just like 10 minutes in the first session, if they haven't jogged in two years. And then they're like, Gino, this was amazing. How about we do more next time? Like, yeah, I know we'll get there.

Joe LaVacca (29:08.482)
Mm-hmm.

Gino (29:13.864)
I know I would want to do the same thing, but it could be that you had an awesome week this week. No stress at work, maybe even no work at all because you were on holiday. How about we see and test if that works as well next week? If so, awesome, then let's progress the next time, but let's stabilize this first. And then the fifth step would be reaching a goal or a milestone.

That's a very, very big thing that we do with our athletes in the beginning, that we ask them what are emotionally meaningful goals for you. And then we try to break those down into achievable milestones. If someone wants to run a marathon again and hasn't jogged in two years, that will take a long time. And that can become frustrating in time. So we say, how about a one-one interval of jogging and walking, as I just mentioned, for 10 minutes as a milestone.

That is much more achievable. Like sooner. Yeah. Those will be the five steps of helping the person understand the trajectory of therapy and getting their compliance. And yeah. Did that answer the question?

Joe Gambino (30:27.903)
Absolutely. Yeah, I love that because normally when you ask people questions, they don't have like a very systematic way of going about it. And I'm that way. I like to have like this is the process that we go through. So I really love this. And I think there's a lot of overlap to everything that Joe and I talk about in this podcast. And I really love this last one, reaching the goal or milestone. And I think even on top of just ones that people, you know, like, OK, this is what you want to get back to. Let's break it up into smaller pieces so that you can have these little wins that build up.

I also think like what I also do is I give some people here are some movement goals that we're working on like and if you're hitting these things even if your pain is still there it's really good sign of progress that that's coming. So this way they have something besides pain to look at because pain is a very bad objective measure first look at it's it's already frustrating for people so if that's the only thing they're focusing on it's not getting better they're going to feel like my god so

you give them these a couple of movements like, okay, this stuff is actually getting better, even though my pain is still kind of there. And I think it also kind of adds to that as well. So I really love what you said here.

Joe LaVacca (31:31.03)
Yeah, yeah, Gino. And I really appreciate the baseline and the stabilization. I think, you know, those are so key that I think you mentioned a lot of athletes miss, but I think a lot of therapists who are trying to help. Yeah, I was like, hey, shots fired day, you know, you know, but like, even the therapists, you know, who just want to.

Gino (31:31.114)
Yeah, that's a great point.

Joe Gambino (31:44.353)
Yeah, Joe, thought he was talking about me specifically.

Joe LaVacca (31:55.47)
run to treatment or run to progressions because they only have six weeks with someone or eight weeks with someone. I think framing this as more of a long-term commitment. You your tissues probably aren't going to just magically be better for the most part in four to six weeks, especially when you missed, you know, 70 % of the things that you said we were going to do because of life and family and everything else. And even if your pain gets better, does that mean you're

your tolerance, your baselines have improved.

at all, even marginally. And you shared that with your wrist, Hey, things are even a little bit better. Let me go practice my handstands again. And then I'm right back to square one. seemed. So I think that's a really important take home message. And so many clients, you know, will want to progress. And I had a guy this week, reach out to me on our little coaching program. And he's like, you know, Joe, had a little flare up a back pain.

you what do I do? And I just said, well, let's just look at everything you happen to do. And you've been in a really good period. You've been hitting all your workouts. But then I noticed that there were a couple of red ones are missed over the last couple of days. What's going on? Everything okay?

you know, I worked late. I didn't get good sleep. I've been kind of feeling a little bit off. so I just like forced myself to go to the gym today and I was like, well, why wouldn't you just take another day off if you needed to, you know, you just said that it's been a tough week. There's been all these other extenuating circumstances. Remember those are stresses too, as you pointed out and you just, again, he's still in back pain, but it just gave him that calm of like, you know what? You're right.

Joe LaVacca (33:34.434)
I probably push too much. This is my body just maybe protecting me or pulling me back. But these are such difficult conversations to have with athletes who always think or want to do 10 % every session rather than a week or in a month. And I'm just wondering there if there has been a lot of pushback with that and how you've handled that in the clinic.

with your maybe more higher performance athletes. And I think you touched on it a little bit with the act stuff, but I was wondering if there's any other details that might be helpful for people.

Gino (34:10.686)
You mean the stabilization phases and then convincing them that it's not the best idea of progressing every single session? Is that what you want me to get into?

Joe LaVacca (34:18.806)
Yeah, sort of. Yeah. Or is there, is there a way that with your programs, you mentioned, you know, 30 and 30, is a good starting point for a lot of people. use a lot of those intervals too. And then you also sort of mentioned, you know, with all the athletes that you have, I'm sure a lot of them is like, well, if I'm not sweating, if I'm not heart pumping, it's not a workout. Right. So how do you maybe bridge that gap of still giving people some good workouts, things to do.

while they're maybe not pushing through that stabilization phase too much.

Gino (34:52.158)
Yeah, that is indeed a difficult task. I think what's most important here is that they always have to understand that what you're doing aligns with their goals. That's the most important thing and communication is key here. So you can always ask the person, do you think what we're doing right now is working on your goals specifically, or is there anything unclear about what we're doing?

Or you might even be thinking that something that we're doing does not fit with your or not align with your goals at all. If that's the case, then please let me know because we can change things immediately. Or I can explain stuff better. It's never the person's fault. It's, I always attribute that to myself, that my explanation was not clear or lacking stuff.

That's a difficult thing for many therapists and myself included is keeping your ego out of the equation. That is a big part. usually because if you can explain to them why it is more useful in the long run, doing those stabilization phases for them and they understand that, then they are definitely willing to do that because

They want to participate in their sport long-term and that's the way to do it. And the cool thing is, mean, the people that come to us have been self-selected before. I don't have to do much convincing because we talk about what did you do beforehand? And then he's like, yeah, I progressed every single session. And I'd be like, okay, where did that get you? yeah, okay. Get it might be a good idea to change some.

something about that. So that's easier than when you're in a clinic and then you're just one of those physios that the person sees. It's more difficult in that situation, I understand.

Joe LaVacca (36:59.246)
Yeah, absolutely. I wanted to shift gears a little bit because you have a podcast and I think it's an awesome resource. You've had really wonderful guests on there. So if people are listening and they haven't checked out your podcast, strongly recommend that. We'll drop a link for you in the notes when the episode comes out.

Gino (37:06.08)
Yeah.

Joe LaVacca (37:22.114)
But with all the people you've had on particularly, or at least published recently, right? Cause I know you maybe have talked to them throughout different periods, going back, re-listening to your interviews, what was the biggest takeaway over the last six to 12 months that's helped you with your process, with your rehab? It could be maybe even personal or professional. What's that biggest takeaway?

Gino (37:46.166)
I think it's something that was reinforced that has been there before and that I keep being reminded of and that's humility. So it's fair to say that I had the opportunity and I'm extremely grateful for that to speak with some of the most well-known people in our industry. By the way, you guys are absolutely invited to the podcast, just to say that publicly because you guys are doing amazing work.

Joe LaVacca (38:11.448)
We're in.

Gino (38:16.148)
What I've come to realize again and again is that the people that I have interviewed are extremely careful about what they say and what claims they make. And they're usually, they usually add a shitload of nuance to their statement. And that's a sign for me that they are experts in what they do.

That is something that has been underlined in the last six or 12 months, a lot. that has shaped my content greatly. Whenever I'm like, yeah, I should do like a punchy headline or like, I have to change that statement a bit because then people will like it more and whatever. No, not doing that. Not doing that for the sake of growth, ever.

Joe Gambino (38:47.107)
Now

No, good.

Joe Gambino (38:57.377)
Hehehehehe

Joe Gambino (39:05.891)
Yeah, no, get you, man. That's a I don't think I think I don't think people like general public and I don't even think a lot of practitioners get understand that like the things that we say to people like how much they they take that in and they can take it out of the positively or negatively. And I have actually a client who I'm working with now. He's been having long term issues. I worked with him at Perfect Stride and now we've been kind of

going through this journey now and he got an MRI on his back and he was seeing a doctor for his hip and they just saw like some contrasting like the MRI actually had an MRI on his hip and the doctor as they were looking at it, I just saw like some contrasting up in like the lower back which wasn't even part of the imaging like probably didn't have a good look and she was like, you should go get this looked at I think you might have cancer and yeah and the dude got like freaked out.

Joe LaVacca (39:56.723)
I'm

Gino (39:57.458)
That's messed up,

Joe Gambino (39:59.201)
Yeah, like how it like as a medical provider, can you can you say something like that to somebody and have no real merit? Like, I don't know, even like just like the way like even if you were concerned, like, I think the other way that you go about having that conversation with someone has to be so different. Like you can't just like, by the way, you know, this looks like this might be, you know, go, just go get a look at like, like that is, know, now you're like, all of sudden, like now he's super nervous.

And now he's just like trying to figure it out. And it's like, wow, like that's, that's a day, like almost a dangerous thing for a medical provider to say. Right. Yeah.

Gino (40:33.908)
Yeah, that's messed up. How is it in the States? How long does it usually take? Like I'm imagining this person leaving with this thought that he or she might have cancer. How long does it take for him to get that checked by another professional?

Joe Gambino (40:47.971)
Yeah, well, he didn't have a back doctor. So I had to help him find one. And then I feel like he like maybe it almost took him like a month or something like that to get it. So. Yeah, yeah. Yeah, luckily we talked about it. Yeah.

Gino (41:01.406)
Whoa, that's messed up, That would have been the most terrible month of my life.

Joe LaVacca (41:07.75)
Absolutely. Is that similar in Germany? Would they be immediately referred like across the street next door or is that similar constraints?

Gino (41:17.974)
If it's very severe, you can always just go to the hospital and then get it checked immediately. I don't know if that's the case in the States, but you can definitely do that. If it's not as severe or sinister, need to go the normal way and then it might take like three months for you to get an appointment with a doctor if you're not privately insured.

Joe Gambino (41:48.259)
Yeah, it's crazy. Well, let's, let's get off the bad topics here. do have crazy things that I hear crazy things I hear doctors say. Yeah, They got uppers and downers, right? We got to take you through the emotional roller coaster. But I actually curious here, because I have like one specific story in my mind that actually way before PT school, like I don't I don't know.

Gino (41:52.054)
Let's all cry now and then just let's end it.

Joe LaVacca (41:55.03)
Yeah, was a nice downer, Joe, nice downer. had DJ Gino leading it off and now it's like...

Gino (41:59.069)
Hahaha!

Gino (42:05.406)
Yeah, it's a roller coaster here,

Joe Gambino (42:17.923)
like general public, feel like sometimes when we say, you know, like stress and stuff like that can cause pain. Like people almost like thing is like, you're telling me like I'm making it up or it's in my head or something like that. you know, I, when I was first learning about, pain science and stuff like that, and, and as I was going through that process, I had one client when I was a trainer years before that all of a sudden, I didn't really understand it then, but it made like a whole lot of sense to me. And like what I think really like,

made me more interested in pain. Like I was like, wow, I really saw this pattern of when this person was stressed, movement patterns got worse and pain increased. And it was like, like I was predictable. Do you have a story like that? Like currently or in the past that like you've seen with somebody that like really highlights, okay, you know, like I really see when someone's more stressed out or something happens in their personal life that it bleeds over to flare ups and pain and poor movement with your with your athletes.

Gino (43:17.84)
yeah, absolutely. I mean, just recency bias again, but people are very sick at the moment here because it's getting colder outside. And we know how big the influence of the immune system is on the sensitivity of the body, like in general. And then people have more pain and they're like, why do I have more pain? And I'm like, you have an infection right now, right? Yes. And what does that have to do with my pain? A lot.

And then I go on explaining some stuff. Yeah. So that would be a recent example, but other times as well, have many, our coaching is quite quote unquote expensive for, for many people, because it's very intensive, like one-on-one work that we do with them. And so we have lots of entrepreneurs as well. so they're there many times they are in very stressful environments, like when they reach a deadline or something.

They have loads of responsibility and then usually their pain gets worse. They sleep less and they're in lot of stress and pressure.

Joe Gambino (44:22.145)
Yeah, yeah, I was just was just curious. Yeah, good job.

Joe LaVacca (44:24.11)
I think the, I think the, one of the things I shared with a few clients recently is that I think the complexity of pain is also its gift because it doesn't allow us to look at it in one lens that it's, you know, just this tissue. It's just inflammation. It's just a tendon. It's just a muscle. And in many of the conversations I've had with people about illnesses or stress, they never made that connection before.

And then to go back to the whole placebo response of like, you have cancer. Well, it's a lot more empowering for a person to look at their life. Maybe like the client I was speaking about before and saying, yeah, I haven't run down this week. I've had a lot of stress this week. Work's been busy. I've been working later. Haven't been sleeping as long. I traveled.

That's a way better thing to cope with than I think your disc went out again. I herniated another level. I tore something worse because I think when those nocebo responses take hold of people,

I think that's what people feel like they lose progress in. I've been building and building. I've been working with Gina. I've been working with Joe. I've been doing my mobility. I've been doing my intervals and now I have pain again. So it just must be this tissue and now I must need to go get injected surgery or maybe I have to give up running altogether rather than saying, you know what?

I have so many other strategies, whether it's breath work, meditation, working on sleep, working on relationships, like you said, and maybe those don't take the pain down to a zero. And I don't think in many cases they actually do, but to alleviate suffering and avoid that big behavior change of maybe resistance or avoidance, I think that's really where

Joe LaVacca (46:16.236)
We look at pain complexity as something that's bad, but I really think that it's truly a gift for clinicians and patients alike.

Gino (46:23.51)
100 % couldn't agree more.

Joe LaVacca (46:27.374)
So, all right. Joe, do you have any other questions before I let Gino go with our final one here? All right, Gino, you're now international, right? This is official, right? So if you could reach everyone in the world, which this podcast surely will take you, it's gonna take you global, brother, right?

Joe Gambino (46:35.408)
I do not know.

Gino (46:41.034)
Let's go. Big stage.

Gino (46:53.078)
Yeah, man.

Joe LaVacca (46:54.51)
What would be the one piece of advice you have for athletes in chronic pain that you hope they take from your message or this podcast or just the work that you do with them?

Gino (47:07.382)
I would actually put athletes in brackets here because what I'm about to say would apply to everyone with persistent pain. And a big shout out to Ben here, my buddy Ben Cormack. He's doing amazing work as well. Go check him out. Core Kinetic, if you haven't. This is not sponsored, of course. Try making your life bigger instead of making your pain smaller. That is a big part.

Joe LaVacca (47:25.863)
Hahaha

Gino (47:37.376)
How can you focus more on doing the things that you love and the process of that and not the outcome and the pain? And we're living in, at least here in Germany, that's the case, in a time and place where people are constantly reminded of their pain. Like after every exercise or every time they see the patient, how's your pain now? Yeah, how's your pain now? How do you feel now?

And we know that focus increases neural activity. And if you always focus on your pain, this will reinforce pain. So try to focus more on the things that you want to achieve, the small steps that take you there. And this can and will, in many cases, even reduce the pain. But this can be a

very frustrating if your main goal with persistent pain is to get out of pain, because there are conditions where you will not get out of pain. And if that's your only goal, then your life will suck a lot. And there are perfect examples. For example, Dr. Bronnie Thompson, who I've interviewed as well, she lives with with persistent pain, and she does well. It's the coping that's really crucial how you

how you manage the pain, pain self-efficacy. This is the key word here. So that will be it. So make your life bigger instead of focusing on making your pain smaller. Amen.

Joe LaVacca (49:14.796)
I love that. absolutely love that. I draw those bubbles for people quite frequently and that's also a very eye-opening experience for them. All right. Joe, any other closing remarks or thoughts?

Joe Gambino (49:27.455)
I don't think so man, take us home.

Joe LaVacca (49:29.262)
All right, Gino, we have absolutely loved having you here on the podcast. We will most assuredly invite you back. We look forward to hopefully being on yours as well in the future. Joe, I love you. Gino, love you. Listeners, we love you. And please, balloons for Joe Gambino today. All right. And please. wait. can I do this one? yeah, I know. I know I shut off my my things because I kept

Gino (49:39.807)
Absolutely.

Gino (49:48.788)
And fireworks wait. no, not coming. Usually that does fireworks. I know what's happening.

Joe LaVacca (49:58.296)
doing thumbs up and they were popped up and all this other stuff. anyway, if you made it this far, thank you and please come back next week for another episode of the Beyond Pain podcast.

Gino (50:00.114)
You

Gino (50:08.394)
Peace.