The Beyond Pain Podcast

Episode 62: The Real Reason You’re Still in Pain: Language, Labels, and Low Expectations

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Summary

In this episode of the Beyond Pain podcast, hosts Joe Gambino and Joe LaVacca discuss the impact of medical advice on pain management and the importance of understanding how the body adapts to stress and movement. 

They share personal anecdotes about 4th of July celebrations and delve into the complexities of chronic pain, emphasizing the need for patient education and the dangers of nocebo effects. 

The conversation highlights the significance of loading joints and tissues appropriately to promote healing and function, while also addressing the psychological aspects of pain management.


Takeaways

  • Medical advice can often discourage necessary movement and loading.
  • The body adapts to stress and can strengthen with appropriate loading.
  • Fear-based thinking can hinder recovery and progress in pain management.
  • Education and communication are crucial in managing chronic pain.
  • Pain is not just a negative experience; it can be informative.
  • Flare-ups are a normal part of the healing process.
  • Understanding pain as a skill can empower patients.
  • The initial advice from healthcare providers can have lasting effect
  • Strength training and movement are essential for joint health.
  • Navigating pain requires learning and adapting strategies.

Joe Gambino (00:44)
Welcome back to the Beyond Pain podcast. I am one of your hosts, Joe Gambino, and I'm here with our other host, Joe Lavocca. can find us on Instagram at joegambino.dpt for myself and at trenthemotion.underscore.pt for Lavocca over there. This podcast is also on Instagram, Beyond Pain podcast and on YouTube cups, joegunderscore.pt. And there is an application form in our show notes. If you'd like to reach out, please do. Welcome back, Joe.

Joe LaVacca (01:08)
Good to be back. We're a week away from 4th of July. What are you doing for the 4th of July? What's the Gambino clan doing for the holidays?

Joe Gambino (01:12)
Mm-hmm.

I don't

even know what we're doing for the 4th of July. Our 4th of July's have been different since we moved. We used to host 4th of July every year. We would have 20 of our own guests that we would squeeze in our apartment and then we'd do a barbecue downstairs in our small backyard. And then my cousin and all their friends, we would have like 40 people in this like small, small space grilling and eating and everyone kind of bring some food. It was a lot of fun.

Joe LaVacca (01:26)
I remember, I think I've been there a couple of times for 4th of July.

Joe Gambino (01:45)
So that's one thing that we really miss about being home. So I don't really know what our fourth is going to look like this year as of now. Jen, I haven't really talked about it yet, so.

Joe LaVacca (01:56)
Yeah, we used to go up to the rooftop and I remember watching some of the fireworks.

Joe Gambino (01:57)
Yeah, we'll watch the Macy's fireworks.

Yeah, which is always fun. You're never going to get those views again. We were on the third floor of apartment and on our roof we had a perfect bird's eye view of the skyline and the city. And every 4th of July Macy's would put on a nice fireworks show and as long as it wasn't on the other side of the bridge we had a perfect view of it. So was a lot of fun.

Joe LaVacca (02:03)
Yeah, that was a good time.

Joe Gambino (02:21)
upstairs and a couple drinks after the barbecue and just watch the show and then head back down and go to bed.

Joe LaVacca (02:26)
It is still

to this day one of my favorite New York City memories that I had getting to hang out with you guys and then going up to the rooftop. It just felt like such a city like Queens Brooklyn thing to do. You know, I really felt embedded into the culture. So thank you for allowing me to feel that way. Long time, long time.

Joe Gambino (02:29)
So.

Mm-hmm.

Yeah, that's big. You've been in New York your whole life. So that could be a top memory

is of high regard there.

Joe LaVacca (02:47)
Yeah, no, definitely. mean, I still haven't been in the Statue of Liberty. So, I mean, you know, I...

Joe Gambino (02:52)
I have to tell you guys the

story. I tell you the story about the helicopter ride?

Joe LaVacca (02:57)
Maybe not.

Joe Gambino (02:58)
man, don't know we, let's say, should I do it on this episode? Just be the episode. So I had a opportunity to work with this guy who's a, he owns a hedge fund and ⁓ yes, got a helicopter ride out to the Hamptons and on the way back, he attached me to his shoulder and he, he's like, would you like to see that one of my moves when I have a girl on the helicopter with me? And I said, sure.

Joe LaVacca (03:00)
Save it. you already talked about it.

⁓ yes.

Joe Gambino (03:24)
So I hear him talk to the pilot in his headset and next thing I know we're taking a smooth ride, surfing around the Statue of Liberty and then heading off back home. It was just pretty cool. that was a very, very unique experience. Very unique way to see the Statue of Liberty. I have been there once before when I was much, much younger, but it was a very different way to see it and it was pretty cool.

Joe LaVacca (03:47)
Yeah, all right. Well, girls, beware if you're in the helicopter with a billionaire and they start circling the Statue of Liberty, you know where their intentions are. So beware. That's cool. I think I know who you're talking about, too. I think we might have actually ⁓ shared in that care. I was not escorted out on a helicopter, though. ⁓ I did have to I did have to drive onto the compound with my I think at the time my old beat up Hyundai Elantra and, you know, park it next to some Bentley's and

Joe Gambino (03:49)
Yes.

Yes.

No, you missed out.

Joe LaVacca (04:12)
Porsches and you know everything else and I was just like, yep. Yeah, I got a sunroof though. It's pretty cool You know hubcaps missing but you know, don't worry. We're working on that. I'm trying to find it still I think I know where it came off. I think I know the block so hunting for it, but Now good times. It's always nice to reflect on some New York City memories, especially During a very I feel like New York City holiday with the fireworks and stuff 4th of July So I don't know what I'm doing. I might go down and visit a buddy in Point Pleasant

him and his family have a beach house out down there. So Avery will be with her mom at a family picnic barbecue that they do every year. So I'll either be ringing it in solo or shooting down to Point Pleasant. I just don't know if I can deal with the traffic on a day like that. So to be determined when I'm ready to leave, I yeah, when I'm ready to leave, it'll be good, like very much like a wake up. I'll get a workout in.

Joe Gambino (04:44)
Bye.

Yeah. You have to go early. Yeah.

Joe LaVacca (05:08)
Check out the traffic flow pattern and if it's not looking good, it ain't looking good.

Joe Gambino (05:14)
I will tell you there's been before we dive in many times

that we wanted to do something out of Long Island. Then we'll look at the, we'll look at the, you know, Google maps and see how long it's going to take us. And if it was too long, we'd like, Nope, change of plans. Because some of that part that came out of the, quite insane. So, all right, man, we, yeah, it's very true. We both did it for half this episode and we'll give some value for the other half of this episode. And while it's freshening our brain, from last time we had some

Joe LaVacca (05:26)
Nope. Yeah.

Yeah, absolutely. There's only so much you could take. So, yeah, let's get into this topic.

Joe Gambino (05:44)
themes popped up last time about what doctors have told some of our clients and we'll just dive down that rabbit hole today. So I know we were talking right before we came on here about three different things that you've heard just very, very recently. So why don't we talk about them? can say if it, you know, we can just shoot the shit about it. So why don't you take the first one? Let me know what it is and let's talk about it and maybe you can lay the rules if you want for this one.

Joe LaVacca (06:10)
I don't have any rules. I think it's just really fascinating that you hear things so umbrella by medical doctors. You should never do this. You should always do that. I can guarantee you you'll be in the surgery room in 10 years. But one of the things that popped up yesterday and it has popped up all the time. I was working with a client with back pain. We were talking about the things that she has and has not been doing. And here's what's really interesting.

Joe Gambino (06:17)
Mm-hmm.

Joe LaVacca (06:35)
of the programs she's implemented, she's actually made gains with. She's increased strength, she's increased muscle mass, she's been able to lose weight or gain weight. So everything that she's picked has been relatively successful for the rest of her body. Here's the things that she hasn't been picking though. Any sort of loaded squat, any sort of barbell work, any sort of deadlifting.

And the reason being is because her doctor informed her because of her degenerative disc, she should never load her spine. Here's the problem with that. A, as you age, things that we've talked about are going to change on the inside because we change on the outside. So,

I didn't wake up yesterday and see all this gray in my beard. This has been an ongoing process for the last 39 years. I have been working on developing gray hair for 39 years. Your body inside has been adapting to forces and the stresses you place on it for the time that you have been in existence. Now, the interesting thing about this person was she actually rode horses, kind of like professionally. So when you see this X-ray of her spine,

Joe Gambino (07:32)
you

Joe LaVacca (07:51)
She has arthritis of her L5S1, L4, L5. And I said to her, well, doesn't this make sense based on your programming so far? You can load your quads and your calves and your arms. And what happens? Your muscles get bigger and stronger. You have been repeatedly loading your spine with vibration on your horse. And what did your bone do? It developed more calcium. It developed extra bone.

exactly like it was supposed to. So this is not necessarily a negative finding. I think this shows us that your body can adapt to force and potentially the thing that might be keeping you in pain is the fact that now the muscles and the tissues and the tendons in and around your spine are deconditioned. So they aren't able to handle as much force as your shoulders and your knees and your, you know, insert body part here. So based on your history,

And based on how successful you've been, why wouldn't we think if we started to dose you with isometrics, with some safe movements, with great exposure to squats and deadlifts that you would not be able to adapt in the same way? You've basically shown that you can. So I always like to flip that your body is on your side. It knows what to do. It is responding. Now, different story if you were a horseback rider and

you were strength training and you were having repeated muscle tears or tendon irritations, or worse, your x-rays showed osteoporosis with repeated loading, well, then maybe we have a systemic issue. Exercise is not maybe for you at this time. We need other things. But when people have that, I usually tell them this is good.

And I think that it's so crazy to think that we should be treating tissues that have shown bits of arthritis or inflammation or this like they're some sort of special tissue that doesn't respond to the basic physiological laws that we know about of just movement and force. Do they need a break? Do they need some modification? Sure, but they don't need to be stopped forever. And that is just something so common that I know we hear.

Joe Gambino (10:02)
No, no, I think there's a couple of things in here that are worth bringing back up. first one, I mean, I, my opinion on why doctors give strong advice on to do nothing is we could, you know, it's almost a safe ass in a sense, right? Like they're trying to make sure that they're given, they don't understand loading the way that we do, right? It's not their forte, right? They're very knowledgeable in all sorts of medicine and

You know, they do get a lot of pain and their way to navigate pain is either through rest or through medication. Right. So, where we treated very differently, which is why a lot of doctors will just say, when you have something X, Y, and Z, they just say, they send you to physical therapy. And a lot of the times the scripts say just PT, you know, just evaluate and treat, right? Like they don't give you too much more on top of it unless they're very specific. And then you and I both hate when we get things on a, on a script that are prescriptive. anyway.

So that's that. But you did talk about things, you know, change as we get older. And it's not even just, you know, that things change as we get older and that we have these anatomical things that respond to the stresses of our life. But when you do get this advice to do less or to do nothing or stop doing these things that load a body part, the number one reason why you lose range of motion, we lose strength, we lose functionality at joints is because we stop putting load into them anymore.

So not only do you have this injury, this issue, and you have pain, and you're probably already fearful to move, but you have someone who you look up to and trust that says, don't do this anymore. And now you're like, oh my God, it makes you even more scared. You are even more likely to not do those things. And then I think that puts you in this kind of loop where things will just progressively get worse over time because you're not actually moving those joints. You're not actually loading those joints and you're not actually strengthening the joints. And I always go back to...

I always ask somebody is, what happens if I put your arm in a cast? What do you think is going to happen to that tissue around it six months from now? Like, my God, it's gonna be super stiff. I'm gonna have atrophy. I'm gonna have X1C. I'm like, you see the correlation here? And like, like it rings a bell to them. So.

You know, that's part of it. And the same thing, you you talked about arthritis being treated differently than other tissues. The same thing when we look around the spine is treated differently than every other tissue. Um, it was very clear, um, you know, even with, with osteoarthritis, which is, know, this is as advanced as it gets that strength training, activity, aerobic work, you know, moving that needle significantly can improve quality of life. may not get their pain to disappear and make it a little bit better, but it's going to improve their quality, your quality of life. so it.

Just that tells us that arthritis, your spine, you have pain that we need to move it, load it, do these things. We just need to figure out what that appropriate entry point is. We can't just go back to, you know, to our conversation in last episode, you can't go back to what you're doing. If you're 70 now doing exactly what you're doing when you're 40 or 30 or 20, you need to figure out, okay, what can I do today? What's my starting point? How can I start to build up from here? And I think once you start to do that,

Joe LaVacca (12:53)
Yeah.

Joe Gambino (13:03)
A lot of success can be had and lot of progress can be made and we can really kind of move the needle A on pain, on function and then quality of life.

Joe LaVacca (13:11)
Right, right, exactly. The other thing that I hear all the time is this prediction of what will happen to you in the future. And not only should you stop loading something because it's painful or it shows up a certain way on your x-ray, but if you decided to ignore my wisdom, my advice, my authority,

Joe Gambino (13:30)
Mm-hmm.

Joe LaVacca (13:34)
you will surely be in line for a knee replacement. You will surely be in line for a spinal fusion, a rotator cuff repair, you name it. And then the funny thing is with a lot of these procedures, the more we study them, the more they're not really outperforming sham therapies, placebo treatments. So really what is the benefit of surgery for a lot of people? Is it just

the ritual, is it just now the fact that you actually do have to wake up and de-load it purposely for three to six months, like you have no choice? Whereas we could have treated you like you had a virtual surgery and been like, okay, you can't run right now because of your knee arthritis and it's becoming a little bit painful. Well, yeah, those flares can last maybe eight weeks, maybe a little bit longer. But in the meantime, can we build you up on the bike? Can we just have you do a walking program? Can we?

Joe Gambino (14:11)
and

Joe LaVacca (14:32)
restore just some of your day-to-day function and then see how we go. So I always think it's really fascinating in this world that we're in, with all the complexities of pain, with all the complexities of working with individual people, that doctors still have told so many of my clients, with a guarantee, you are going to need a replacement, you are going to need a surgery. And I do think that's actually probably really, really tough to overcome.

Joe Gambino (14:44)
Yeah.

Joe LaVacca (15:02)
because this authority figure who you went to go see before us has now put a nocebo or like this like really detrimental thought virus into your mind and that thing is gonna spread and it's gonna take over everything you do. And it really is unfortunate because I think by the time even we try to convince people otherwise, you know, the damage is done and then they have that flare and then it.

Joe Gambino (15:04)
Mm-hmm.

Joe LaVacca (15:29)
reconfirms what the doctor was saying. So even though we can say, we know this is normal, we have data on it, it's going to be okay, we can keep being your guide, we're going to be here for you, the minute that pain comes back, the minute the swelling comes back, the minute they get another x-ray or MRI, 10 years later and it shows more change, as it should by the way, it just goes back to reconfirming the original thought.

Unfortunately, I don't think anything more damaging than an original negative thought and that takes a lot of time and sometimes we just don't have that time with people.

Joe Gambino (16:02)
Yeah, I mean, you know, I think we could probably do a whole, we probably should do a whole episode on nocephic language and how that can affect somebody is very, what somebody may think is something helpful information for somebody is that can be, you know, goes into your head and then leads to a very poor outcome because it creates fear. can create a lot of other things that really prevent you from, from seeing your, potential as far as progress can go.

So I think that, know, and this is one big thing and I think this is where a lot of the pain signs and the biopsychosocial model really kind of try to push. And I think it over pushed it and to some degree, but I definitely do believe that the way that we talk to our patients, our clients can really, really, really set the tone for our progress. How far they, or what they can really achieve. And I had somebody who I was working with only for a short period of time. We started our journey. He was very fearful of his back. He's been told a whole lot of things by a whole lot of people.

You know that I was frail and I should do X Y and Z and we started our process and after the first two weeks He was doing much better, you know, he was starting to move more His pain was coming down and he had to go on a trip had a long drive after his long drive He had a flare-up. He wasn't doing our things after he got there and then two weeks later after he got back He was like no I need to go back to my doctor and then all of a sudden the fear came back right and that's exactly one example of you know when somebody gets all these

Negative things that are told to them and there's all this fear gets built up can be very hard for them to overcome because the second their pain comes back or the second a flare comes back which we both know is going to happen in the journey no matter how much you can set that expectation for somebody when it does happen if those emotions are going to be too strong where they can't really process it then we're gonna have this completely fear-based thinking that's going to set them back and make them change the course and I think this happens to a lot of people in chronic pain and

What keeps people from sticking to a program for long term is if you're doing something and you're feeling good and then you have that flare up and like, maybe I'm not fixed. I'm not healed. My pain's back. And now I need to change what I was doing. You were probably, you could have been on the right track and you just needed to get over this little bump in the road. And then you, if you would've kept going, you might've made it to where you wanted to get. But because now you change in approach that was actually seeing your benefit and you try something different now and you keep doing this over and over again, this is why some people will feel better.

Joe LaVacca (18:13)
Yeah.

Joe Gambino (18:24)
Pain comes back, feel better, pain comes back. And every time they take two steps forward, they take two or three steps backwards. Right? And they're not doing that, you know, two steps forward, one step back, two steps forward, one step back where they can continue making progress over a long period of time. So that's hard. I've had pain for a long period of time and sometimes it's very hard to kind of see your way out of it because pain is such a internal process. And when it's there, it's hard to know what's going on or see yourself out or, you know, see how you can get around this.

And that's why I always like to use function as a measure of progress because there are other things that are better trackers than your pain alone. So I don't know, that's the whole tangent there from what you were saying, but I'll leave it at that.

Joe LaVacca (19:06)
Yeah,

no, yeah, and I sort of agree with you though. I mean, the idea of education or communication and the reason why it's so valuable is because it changes you in an instant. The strength stuff, the mobility stuff, the lifestyle stuff, your return to run, walk, whatever, is going to change you over the course of months and years. But.

that initial advice that you get from a doctor, from someone you trust, the initial advice you get from us, the initial understanding you have about your experience and your condition, it won't make it cured or immediately better in the sense of your pain goes away. And I think that's where a lot of people started misinterpreting the pain science stuff is, I explained pain to people, but they still have pain. Yeah, that wasn't the point of the education.

Joe Gambino (19:54)
Good night.

This is the best thing I've ever

Joe LaVacca (19:59)
The point of the education was for you to be on the same page with someone so you have the opportunity to work with them for the next six months, a year or beyond. And if you don't take that one second or you're filling someone's head with some fear or nocebic language as you mentioned, well, then that's going to affect every other thing you do with them. So that's why I think it's so valuable.

That's why I push it so hard in my message with education and on social media and the reason why I spend so much time working on it within the first couple sessions with people, because I don't think there are any special exercises or magical programs. However, if I can understand what you think about your experience, if I can understand what's holding you back, if I can answer your questions, and then we both agree that this is not going to be a

two session fix or one exercise fix, we go into it with the understanding that, every eight weeks we're checking in, are we a little bit closer to our goals? If so, yes, let's continue. If not, hmm, what did we miss? What else can I offer you? Or who else can I offer you on your journey? And let's keep you moving in the right direction.

Joe Gambino (21:13)
Yeah, I agree with that. think the biggest thing that someone can get is what happens when should his defend those flare ups happen, right? And does it derail you and how do you appropriately modify and change and understand pain and what it really means because pain, as we've talked about, isn't this broken, this very, very negative thing. It's information. It's really a request for change from your body, right? If you break your arm, your body wants you to not move it and not do anything because it doesn't want to make things worse.

and it needs to go through its healing process at the end of the day, right? So understanding that, understanding how to navigate pain, how to do all that stuff is a skill that people need to learn going back to, we had way back in the day when we Tyler on the podcast talking about pain as a skill and kind of navigating that stuff. That stuff is very, very important to the process. I think it's very undervalued and people just expect I'm gonna get these movements and this is of course gonna make me better.

And sometimes, especially if you've been dealing with pain for a long time, you need to learn the skill of how do I navigate pain? How do I manage pain? How do I live with pain? All of those things, because like we said last episode, you know, it may not be realistic for me to say, I can get you from where you are today to never having pain or another issue again. We're going to be navigating these things, but you need to learn these tools so that you can feel empowered to take care of yourself and understand it and proceed when it does happen.

Joe LaVacca (22:33)
Right, Totally agree, my friend. Anything else you want to add in this episode? All right.

Joe Gambino (22:37)
Well, no, this is

a short but powerful episode. So take us home.

Joe LaVacca (22:41)
Powerful.

like that. Yeah, I like that too. All right, cool, man Well, Joe, love you. Thank you listeners. We love you Thank you for joining us for another episode and don't forget to come back next week for even more power on the Beyond Pain podcast

Joe Gambino (22:55)
HOO-

Ha