The Beyond Pain Podcast

Episode 45: How to Ask this Sh*t? Bringing up Outside Stressors in Physical Therapy

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Summary
In this episode of the Beyond Pain podcast, hosts Joe Gambino and Dr. Joe LaVacca discuss the impact of outside stressors on pain management. They explore how to effectively communicate with clients about their stressors, the importance of movement in pain management, and when to shift focus from movement to other factors like sleep and nutrition. The conversation emphasizes the need for open-ended questions and validation in client interactions, as well as the necessity of adapting training intensity based on life stressors.

Takeaways
Asking open-ended questions can reveal important stressors.

Validation of a client's feelings is crucial in communication.

Pain is often tied to emotional responses and stress.

Movement should always be a part of pain management.

It's important to monitor sleep and nutrition as factors in pain.

Clients often overlook familial coping strategies for pain.

Adapting training intensity based on stress levels is essential.

Communication should focus on the client's experience, not the clinician's.

Encouraging clients to share their stories can lead to better outcomes.

Being comfortable with the possibility of not being the right fit for a client is important.

Joe Gambino (00:00.844)
Welcome back into the Beyond Pain podcast. am one half of this show's host, Joe Gambino, and the other half of this show's host is sitting across from me virtually, Dr. Joe LaVacca You can find us on Instagram. I am at joegambinodpt. He's at strength and motion underscore PT. You can find this podcast on Instagram, Beyond Pain podcast and on YouTube, cups of Joe underscore PT.

Application form is in the show notes. If you do feel like you would like our help you can certainly fill that out and reach out to us And I think I nailed everything and if you probably noticed Joe I skipped all the adjectives this time. I think I'm done with it It's just too much for me to handle

Joe LaVacca (00:39.951)
it

Joe LaVacca (00:43.396)
I was gonna say that I think without the adjectives, it kept you on point. That was maybe one of the most fluid opens we've ever had. So well done, my friend. While I'm a little upset that I won't get praise at the beginning of every episode, I think it's a better listener experience with that nice cold open that you just did. So well done.

Joe Gambino (00:53.56)
Thank you.

Joe Gambino (00:59.64)
Yeah.

Joe Gambino (01:05.422)
Okay. Yeah, maybe it would have been smoother if I threw some negative adjectives at you, you know, that I think those would come off the tongue a little easier. All right. I don't know if you're looking at the pod doc, but I I labeled the title of this episode, which obviously changed how you ask this shit. And it was a question of the day from me.

Joe LaVacca (01:10.202)
Yeah

I think we get a lot more feedback on the pod too, be like, yeah, I know, Joe's such a dick.

Joe LaVacca (01:29.778)
Cool.

Joe Gambino (01:32.594)
And I'm just curious, because I think you do this very well and see, look, here comes another damn compliment. You do this poorly, no. You do this well. And something I'm hoping to potentially just kind of get some info from you to see how I can kind of change my onboarding process or the questions I ask when I'm working with somebody. But the question is, what kind of questions and how do you start to ask about outside stressors that aren't just

movement related to figure out how much impact it's having on their life. And that could be stressors, sleep, nutrition, all that stuff. How do you get that information? How are you asking it and how are you going about it?

Joe LaVacca (02:13.04)
Yeah, think that number one, thanks for bringing the compliments back. I do really appreciate that. Yeah, well, I know you do. I think that the outside stuff that you're mentioning is probably this weird dichotomy of it's either talked about too much, and I'm actually gonna share a story about that, or swept under the rug. So I really have...

Joe Gambino (02:17.806)
I do it for you, Joe.

Joe Gambino (02:39.694)
Mm-hmm.

Joe LaVacca (02:41.668)
think that, and even for myself, there's probably a harder time finding a nice, comfortable middle. But I think what is always interesting is listening to the person just sort of like just speak about their lives. And what I've realized is that there's too many phrases or comments that you and I or seemingly other professionals and people just relate to. So

For instance, we've been talking about daycare and the kids. We've been talking about my move, maybe not on the show outwardly as much, but definitely in sort of our back channel discussions. So you can blurt out something like, oh man, this week was hectic. The kids are home. Olivia didn't have school. Man, there was just a lot to do. And I can go, oh man.

Yeah, 100%, I know what you mean. And we both kind of do this like, uh-huh, yep, yeah, uh-huh. You know, like this sort of like nodding that we understand each other without actually maybe confirming or validating your experience. And I think one of the first things that I would always recommend when clinicians have these conversations with patients is don't immediately substitute in your experience to match

theirs. So if you were coming into me and we were talking about daycare this week and having it being a difficult, you know, a couple of days, you know, outside of the norm for you and Jen and the family, when you say something like, you know, Olivia's school was closed, man, this week was stressful. I don't automatically want to interject with, I know Avery was off from this week too. It was so hard. How hard was it for you? Because it was

possible for me. I instead would rather take that and ask just more of an open-ended question about it. You know, I understand that Olivia had no school. That must have been difficult. So I'm validating your concern. Tell me a little bit more about how the week was different with this disruption. And then that just kind of gives you the open floor to say, well, I wasn't able to work out.

Joe LaVacca (05:06.732)
I didn't do this, I feel bad now that I didn't get to do my workout, I didn't get to do this, I didn't get to do that. And that's typically how most of the conversations will go with clients. They end up placing guilt on top of the stress that they were feeling. So instead of trying to retroactively backtrack and say, well, you know what? There are probably lots of things you could have done this week.

I would sort of say, yeah, I know how much working out means to you, Joe. I know how much working at your job means to you with clients. I know how much the podcast means. I know how much your Instagram means. So to not be able to do those things, you know, must've felt like a little bit of a threat. Does Olivia have any other vacations coming up where we can plan ahead together to know what we can modify that week?

and then we have this plan for the future. Because there's no real sense in making a plan backwards. So instead, I think it would just be about looking forward, keeping the end in mind. So I think that would be number one. Does that make sense so far? And I think maybe just one or two other pieces of advice when it comes to, I would say, family.

Joe Gambino (06:25.036)
It does, yep.

Joe LaVacca (06:34.906)
And then I would also say, maybe this fits in the same way, but what I'm thinking of with family is I'm thinking of maybe moms and dads, because there's always a thing that pops up where I ask people about their pain and mainly what do they know about it? What do they understand about it? And again, somewhere along the lines of, you know, maybe in their background, as they're talking to me, they'll always bring up

Joe Gambino (06:53.612)
you

Joe LaVacca (07:02.09)
well, my mom had something like this. My dad had something like this. And I think that, again, that's a sort of a glance over. So for a lot of clients who are stuck or feel stuck, I kind of bring that back to the table and I'll say, you you mentioned your mom had this and I'm thinking about someone very specific and you mentioned how your mom worked out her entire life. What do you think your mom did well?

Hope, have you ever asked her about that? How she managed to do these things? Because I think we're so quick to blame our parents for all the things that go wrong. But then we never really just sort of said, hey, could you give me some advice on how you did this? And maybe that's going to be helpful for me. And the few times I've done that with the few clients I'm thinking about, a lot of them being CrossFit athletes, a lot of them looked at me and said, no, I actually never asked.

my mom or dad for coping strategies, and I'm sure they would love to give it to me. So that's something that I think not only I would appreciate, but my family would probably appreciate as well. In the event that it was reversed where, hey, how did your mom or your dad cope with these things? What did you learn from them? Sometimes it is negative. my dad stopped work. My mom never went to go run again.

She ended up having surgery after surgery after surgery. And then you can sort of see why all this fear is then developing at this moment in time because people are then projecting themselves into the future. So I always think that asking about familial response to pain growing up, just again, by extending the floor a little bit, really important. But again, it starts with the validation, right? So I think it's

really about resisting the idea to interject your story and your feeling, validating what they are going through, and then trying to ask them an open-ended question just to sort of build that out. And my favorite kind of thing to just wrap this up with the clients, husbands or spouses or wives would be, what do you think

Joe LaVacca (09:25.178)
your husband or wife would ask you to do, or what would you tell them to do if the situations were reversed? And that's called the double standard technique, where you are basically going to take the person that's most important to you in your whole life and say, would you tell them to give up hope?

Would you tell them to worry and be concerned? Would you tell them to stop doing all the things that they love? And if that was the case, well then, all right, I see why you feel this way. But almost 100 % of the time, when I ask that, people are like, well, no, I would totally take care of my husband or my wife. I would want to do everything for them. I would tell them to keep going. I would drive them to appointments. I would help them with the kids. I would do more things around the house.

And it's like, well, okay, if you would do that for them, why don't you think that they would do that for you? And again, that realization sort of usually kind of comes in. So I think that we listen there with empathy and this idea of trying to guide some more open-ended questions. And that's sort of like what the motivational interviewing process really is. It's continuing to ask open-ended questions in a guided fashion.

So people just kind of come to a realization on their own. And in some ways it's sort of like inception, right? Like I need to plant this idea into your mind so it grows and then you can make connections into your own life. And again, it's not a perfect, I'm not batting a thousand over here like Elon Musk would say, but the thing is like,

Joe Gambino (10:56.046)
Mm-hmm.

Joe Gambino (11:12.46)
Hmm

Joe LaVacca (11:16.338)
I'm trying to wait for the right pitch to swing at. And it doesn't mean it's always going to go well. And I think when you're having those conversations with people, you have to be prepared that some of them aren't going to go well, even with your best intentions, even by following simple guidelines, because this stuff is emotional. And I can probably think off the top of my head, you know, two or three really great conversations I had this week.

But the one that's plaguing me is the one that didn't go well, right? And that was just this week. And I could probably think about that every week if I really wanted to kind of sit down. again, like this stuff, pain is an emotion. I think we've definitely talked about that before. When you bring emotions into conversations, you don't really know where they're going to end up, right? So don't be surprised when things

Joe Gambino (12:02.222)
Mm-hmm.

Joe LaVacca (12:16.038)
go off the rails a little bit. But I do think that for the most part, if you can be composed, like never act surprised, if you can admit, you know, when you were feeling something or when you can admit that, okay, maybe I was misunderstanding you, let me just backtrack a couple of things or a couple of points and just let you know why I asked that or why I thought that. And it just gives again, now us a little bit of space too.

to kind of give us that ability to go back and forth. So I think those would be the simple sort of like step-by-step things I would go on how to ask that shit. But just like pain, I mean, I never really know how it's gonna go.

Joe Gambino (13:03.906)
Yeah, fair enough. like that. And you know, and I appreciate the the insights there. Not, know, as far as maybe to kind of backtrack here on the podcast, you know, I think that, you know, both of us know, I don't know how much the listeners know. Right. But outside stressors can 100 percent have an impact on underpain response. So I'm just trying to figure out more so as to add enough for me is not so much, you know, how they ask the questions. But, know, it's, you know, trying to figure out.

where in the process and I'll give you an example. had a conversation with someone on Monday. The conversation went really well. mean, a lot of emotion was brought up on our call together. And then after, know, conversation went really well. And then I think we talked, touched base yesterday again. And then she was telling me how there's like a whole lot going on in her life right now. And she feels like there's a lot of anxiety and there were definitely stuff like that that popped up on the call, but it wasn't so.

you know, in front here. then, know, as this is someone who I'm not currently working with, so it's, you know, we didn't have, you know, all the next steps that would help me kind of dive into that stuff. But it's just, know, as I'm kind of, know, if if I was going through that process, I'm trying to figure out, you know, how do I try to figure out, you know, how sleep is, how all this stuff is. And I'm thinking of just having it as kind of like an intake, you know, like an intake form or something like that. Those questions, just to get that information so that this way,

if the conversations lead that way, or I find at some point in our journeys together that we need to have the conversation because I know sleep is an issue or I know that there's major house renovations, family stuff, know, somebody's, know, parents, you know, got sick or something like that. You know, there's ways that we can start to navigate those as like as hurdles kind of pop up. And I don't necessarily know if I need to force feed them into conversations.

Just to get answers. So I appreciate your insight there. And I don't know if you have any other comments based off of that

Joe LaVacca (15:00.722)
Well, I think that maybe as a tie-in question, I don't necessarily have an intake form. It's very generic. I just want to know some quick background things about people. But I would say that at the end of the initial assessments, or I mean, I guess you could put this in anywhere. I kind of thank people for sharing their story. And then I'll say, there's so many things that can potentially help us today, know, outside of the world of exercise or movement.

Joe Gambino (15:22.84)
Mm-hmm.

Joe LaVacca (15:31.036)
So I'm just gonna ask you a couple of things on sleep, on how you eat, on your relationships, and you don't have to dive real deep into them right now, but we do know that sleep and pain have been shown to be correlated. How do you think you're sleeping day to day? And people, most of the time I would say people actually tell me, yeah, I think sleep is okay, right?

Joe Gambino (15:48.312)
Hmm.

Joe LaVacca (15:55.834)
Okay, fine. I'm not going to ask any more like, are you really sleeping six to eight hours a night? Are you going to bed at the same time and waking up? No, okay, you don't think right now sleep is a factor. Okay, great. We also know that diet can maybe contribute to some inflammatory markers in the body. Overall, do you think that you're eating a pretty balanced diet? And then again, that just kind of gives them this idea of just like a personal reflection. If...

Joe Gambino (16:00.364)
Yeah, of course.

Joe LaVacca (16:23.6)
let's say exercise or lifestyle changes that we suggest early on aren't going to be feasible for them. Well, let's come back around because you said you maybe needed a little help on sleep. I know the last few weeks during this has been difficult for you. Do you think it's worthwhile for us to maybe visit ways on how to sleep better? Do you think it's worthwhile for us to maybe monitor food intake?

Do you think it's worthwhile for you to maybe have a conversation with your husband, with your parents, with your spouse, with your sibling, know, whatever, your work partner, to sort of like maybe get you back to where you want to be. And you know, maybe you or I can help more or less with those things, but I used this phrase with someone this week in one of those conversations that wasn't going well where, hey,

I don't know if I'm going to be your final destination on your journey or just a stop along the way. And I want you to know that I'm comfortable being both. If we can, you know, help you and figure out a path forward for you and we get you to achieve all your goals. Wonderful. If this is just one more stop where, Hey, you weren't ready to hear a change in narrative. You know, we weren't ready for all the things I was going to ask you to do.

engage with me and monitor yourself on True Coach and, you know, get back to communicating with your trainer. And, you know, there was a lot of responsibility that I put on you to try to make this be successful. And maybe we're just not ready for that yet. Or maybe we're just not a good fit. And I think that we have to be comfortable with that conversation to knowing like where we stop with our expertise in certain areas where we can help people.

Joe Gambino (18:04.611)
Mm-hmm.

Joe LaVacca (18:16.732)
but then also being okay with it.

Joe Gambino (18:18.424)
Mm hmm. No. Yeah. One of questions I always ask people when I'm about to work with them is like, just give them a zero to 10 scale with confidence in, do they think it can help? And if it's not a 10, then, you know, I don't think I'm the right person for you. Right. So then, you know, it's okay. Maybe you try this or that or whatever. That's what I was talking to. Who's like, you know, they wanted to work with me, but they had this conceived notion in their back, in the back of their mind that they wanted to do in person. I was like, well,

probably should do in person at this point because likely, you know, you're not going to be fully bought into this and they're definitely you need to be on board with the plan, need to like, know and trust me, right? In order for us to have some success with pain here. So maybe it's better for you to look elsewhere and I can help you find somebody if you want. But so I really I appreciate that. I have one more question for you on all of this topic here, because as I as I mentioned before, right.

Joe LaVacca (19:06.738)
Totally.

Joe Gambino (19:14.478)
other stressors can have an impact on pain. for the listeners, if someone's listening and right now all they're doing is movement related pain management. They're trying mobility, stretching, whatever it is, right? To get out of pain. At what point should they say, maybe it's not the movement that's going to get me there. Maybe I really need to look at my understanding of pain, my stressors. I need to like focus on recovery more.

Is there a point in time where you think someone should start to question that and maybe put a little more effort there as opposed to just movement?

Joe LaVacca (19:52.051)
Yeah, I think they should never stop the movement. I mean, unless, unless it is causing some sort of detrimental effect. And there's not too many conditions off the top of my head where I think exercise is going to make worse. Maybe a bone fracture or a bone stress injury. Or maybe we can make that argument that, if you keep loading this thing or pushing this thing,

Joe Gambino (20:09.068)
Hmm.

Joe LaVacca (20:21.446)
you're going to make things worse. I'm sure there's some inflammatory or systemic conditions that I'm not thinking of off the top of my head, but unless it's causing a detriment to your body or the tissues at hand, never stop. So the example I'll typically give to people is almost like a roulette board, roulette wheel, I guess it's not really a board. But we have these things that we think will give us the best chance

Joe Gambino (20:27.47)
Sure.

Joe Gambino (20:45.026)
Mm-hmm.

Joe LaVacca (20:51.292)
for winning and let's just keep moving and exercise as a big piece of the pie on this roulette wheel and it's bigger than every other spot on the board. So if I was going to keep betting, it would always make sense for me to put a couple dollars on movement because I have the best chance of that giving me a successful outcome.

Joe Gambino (21:14.382)
you

Joe LaVacca (21:18.822)
Then I think it's just worth looking at the board and saying, okay, well now the wheel has a hundred other options. Which one at this time do you think makes the most sense to you based on maybe our interactions? I like this like no trust idea. Based on what you feel capable of or maybe have the resources of. And then let's put some money on that too.

Joe Gambino (21:37.966)
Hmm.

Joe LaVacca (21:45.33)
So I want you to keep doing your exercise. We're seeing improvements in your range of motion, your strength, your whatever, walking speed, right? Objectively, the data is there to say this is working, even if it's not helping you with your pain. So let's keep movement and now let's add in some tactics for sleep. Spin the wheel, right? And let the wheel go, in our case, probably four, six, eight weeks, right?

And then when the wheel stops, what happened? you know what? I'm sleeping a little bit better. This was helpful. But again, it didn't really give me the results I was looking for as far as pain. Okay, cool. Well, now we know that we can still do movement. You have better sleep habits. So now I'm just distributing my funds out a little bit more. What's the next one? And then we kind of just, I think, go from there. That process, though, is really difficult.

Joe Gambino (22:33.112)
Mm-hmm.

Joe LaVacca (22:43.474)
I mean, and that's a process that I'm then asking someone to commit. I mean, probably for 24 weeks, maybe longer. I mean, do people have that amount of time and patience, financial flexibility to do? I'm not sure. And when I can't guarantee an outcome either way, I can just say, hey, these are all things that are gonna make Joe Gambino better. You're gonna get a stronger knee. You're gonna have.

Joe Gambino (22:53.666)
Mm-hmm.

Joe LaVacca (23:11.814)
better restorative sleep, you might live another five years on the planet. Well, what does that all mean if those additional five years, you're gonna be in just as much pain as you are in now? I don't know, are people gonna sign up for that? That's a difficult conversation, I think.

Joe Gambino (23:17.166)
Hmm.

Joe Gambino (23:24.94)
Right. Now that's fair. I think you really from where my mind goes with all this is, know, looking for trends. mean, there's, there's plenty of stories that I've, I've come across over time where when shit hits the fan, so to speak, right. Increased stress in their life. movement patterns refer back to old ways, pain increases, things like that. And I think it's just in those times.

I think it's really more important for people to just adapt their stressors as far as physical goes. So if you're all of sudden have a whole ton of stress and maybe it's relationship, maybe it's work, whatever it is, and all of a sudden you feel more pain and you feel more sluggish, then you're probably not going to want to push as hard in the gym as you typically would, right? Because then you're just going to be really overflowing that bucket. Now, right now for me, I mean, my sleep is absolute garbage because of the baby not always sleeping through the night.

you know, and sometimes I feel like I'm heavier, my recovery is surely not there. So when I'm in the gym, right, I'm not going to be trying to kill myself because then it's just going to make, I think everything just a little bit worse, right? So I think people should react to specifically in those events when they know this happens when I'm stressed, my pain gets worse, I'm more tired, I'm more frustrated, right? Signs of like,

You're being pushed a little bit too much. Then I would just back off the intensity of your training. Maybe do some things a little bit more gentle. And then as things start to, I would never stop, like you said, because you can still make progress. I'm still getting stronger, even though I'm not sleeping well, right? I'm still feeling really good, even though I'm not sleeping that well, but I have to manage and monitor that a little bit more and just kind of really listen to how I'm feeling. I mean, I think if people can do that, I think there's a lot of success that can happen because it's the same thing with training. You want to go run a race.

Right. Um, and maybe you want to go run a marathon. You've never done it before. Volume for running is taking up. We're not going to increase your volume of strength training too. Right. That doesn't make sense. We would hit a wall at some point because everything is just going up too high. We would drop your training volume as your running volume went up. I think it's the same thing with life stress, right? If life stress is kicking you in the face, then your training intensity should come down a little bit so that you can manage that.

Joe Gambino (25:41.986)
and then as stress comes down from all that stuff, you just pick back up your intensity.

Joe LaVacca (25:46.086)
Right, yeah, no, I totally agree with you. I think that's a really good way to put it as well.

Joe Gambino (25:52.27)
All right, my friend, any other thoughts that you have on the topic?

Joe LaVacca (25:56.314)
No, I appreciate your questions as always. I hope that the people listening took some value from our thoughts today. And if you have nothing else, Joe, I love you. Listeners, we love you. And if you made it this far, we extra, extra love you. And don't forget to come back for another exciting episode next week of the Beyond Pain podcast.

Joe Gambino (26:06.446)
Take us home, baby.