The Beyond Pain Podcast

Episode 73: From Stuck to Steady: Setting Expectations & Building a Plan for Chronic Pain

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Summary

In this episode of the Beyond Pain podcast, hosts Joe Gambino and Joe LaVacca discuss the importance of setting realistic expectations in physical therapy. 

They explore how social media influences patient perceptions, the significance of long-term goals, and the need for clear communication between therapists and patients. 

The conversation emphasizes that rehabilitation is a journey that requires time, consistency, and a collaborative approach to achieve successful outcomes.


Takeaways

  • Setting realistic expectations is crucial for patient success.
  • Social media can create unrealistic expectations for quick fixes.
  • Pain management is a subjective experience that varies for each individual.
  • Long-term goals are essential for sustained progress in rehabilitation.
  • Clear communication between therapists and patients enhances the treatment process.
  • Patients should not rely solely on pain as an outcome measure.
  • Therapists need to educate patients about the rehabilitation timeline.
  • A collaborative approach fosters better patient engagement and commitment.
  • Understanding the journey of rehabilitation helps in managing expectations.
  • Therapists should guide patients through the ups and downs of recovery.

Joe Gambino (00:43)
Welcome back in to the Beyond Pain podcast. I am one of your hosts, Joe Gambino, and I'm here with our other bougie host, Joe LaVacca over there. You can find this podcast on Instagram, Beyond Pain podcast. You can find myself and Joe on Instagram as well. Joe Gambino DPT for me and strength and motion underscore PT for LaVacca and on YouTube as well, cups and Joe underscore PT. And I call you bougie Joe, because we were talking about you not wanting a middle seat.

on an airplane prior to our conversation today. So I'm with you. I'll call myself Boushee Joe as well. We're just Boushee Joe's here. The Boushee Joe podcast coming at you.

Joe LaVacca (01:14)
⁓

Yeah, I like it. I thought

you were commenting on my pink shirt today, which I've worn to the show multiple times, but it always does get a little rise out of people when I wear my pink shirt, regardless of how many times they see it. But yes, we were prior to the show talking about middle seats because I was upgraded on my flight to Colorado this week. If you can use the word upgraded from my aisle seat in row 20 to my middle seat in like row 15. And I'm sorry, that's just not an upgrade.

Joe Gambino (01:25)
Nah.

Joe LaVacca (01:48)
You know, the five rows to be slammed in the middle of two people. And really the crapshoot is what type of people are you going to be sitting next to? You know, there's some people that need two seats themselves. Sometimes they have dogs and you know, you're really kind of risking it all when you go middle seat. So I've sat next to many, I've actually had two dogs on either side of me one time and

Joe Gambino (01:49)
I agree.

you

That's actually

pretty, is it only dogs or with the owner? Okay.

Joe LaVacca (02:13)
Oh, no, with their owners, that would actually

been a more fun conversation to have the dog like just strapped in. I actually probably would have enjoyed that flight a little bit more, let alone me having an asthma attack and nonstop sneezing and coughing to go along with it. no, other than that, man, it's been a good week. Happy Halloween. This is our Halloween episode. And we should have. Are you dressing up with the kids? Let's start there.

Joe Gambino (02:17)
That's gonna say, that'd be an enjoyable flight.

Same to you, yes. We should have been dressed up for this one.

We, this year we will not be, I have an old Darth Vader costume hidden away in a closet somewhere and we've done inflatable. we were, last year we were riding a dinosaur while walking around and the year before that we were all giant unicorns. That was rough because I couldn't see anything as we were trying to walk around and it was like rainy and misty. It was terrible. So I'll never do one like that, that you only get this little plastic little thing to look at. It was hard to walk, hard to see.

hard to chase after any sort of kid. So, not fun.

Joe LaVacca (03:15)
Yeah. Yeah. very good.

But we are undecided at the moment on if we're going to be able to go out or not. lot, a lot of it now when the kids get older is dropping them off at parties and picking them up at parties or dropping them here for trick or treating and then bringing them over here to the friend's house where everyone else is going to hang out. So we have to organize that and see if we can get some child transport. However, what I told Courtney, if we do go out, I think I have the best last minute

Joe Gambino (03:20)
A urine. ⁓

I see.

Joe LaVacca (03:42)
costume that I've the idea that I've ever had. No, we're going to go as six, seven. I'm just going to draw number six on my shirt. Courtney is going to draw number seven on hers and we are six, seven. ⁓ So and I feel like that would go over really well by just literally thinking of it last night. I was like, well, if we go out, I'll just be the number six. You'd be the number seven.

Joe Gambino (03:43)
You're dressing up as me?

Nice. Thank you guys.

Joe LaVacca (04:06)
We all loved it. Like even as it was like, that's the best costume idea ever. And I was like, yeah, and guess what? I'm going to use your markers and just ruin a Target shirt that I bought for $8. I think I have two or three like white ones. And was like, I'm going to give mom one. And there we go. So if we go out, you'll see pictures of us being six, seven.

Joe Gambino (04:08)
Yeah. ⁓

There you go.

Nice, very nice, I like it. Olivia is gonna be Wonder Woman this year and Baby Joe is Superman, they're taking on their superhero forms this year.

Joe LaVacca (04:31)
⁓

Love that, love that.

Joe Gambino (04:35)
Yes, yes, yes. All right, man. Well, let's dive in. We're gonna be talking a little bit about expectations in and around physical therapy, what to expect, kind of spurred from a conversation you had with the patients. Maybe we can start there and.

digress, so to speak.

Joe LaVacca (04:54)
Yeah, yeah. So I think what sparked this, a few people this week, one person I met just the other day, virtual. And as we go through our process of intake and questions, the things that I always love to ask people are, what are your expectations of today? What are your goals? What do you want from me to make our time together successful? And this person responded, well,

Joe Gambino (05:16)
Oh, it's these stupid weeds we have. Oh, the weed?

Joe LaVacca (05:21)
I'm really just hoping that you can fix me today. And prior to that, we had talked about

Joe Gambino (05:21)
Yes. It's like this weed that we have. You can see that one. It's little squishy looking weed.

Joe LaVacca (05:26)
shoulder issues, back issues, foot issues, knee issues, you you name it. And I sort of said, well, I can definitely do my best to guide you on a process of getting you back to what you want to do by addressing the biggest needs first, but by no way, shape or form, can I?

fix you today. And there's a little bit of a connotation there with most of my time, my bias or what I go into every session thinking is the person in front of me is not broken. And we've talked about that on the podcast before too, just reframing how you view yourself in your rehab process is very important. So right off the bat, me saying, well, I can't do that.

can be a little bit alarming, I think, for people. Like, well, what is it that we're gonna do today? So I always say, and we've said on the podcast many times, we're going to start a process or a journey today. I can't get you stronger in 60 minutes. I can make you a little bit more knowledgeable in that time, sure. We can lay out a plan that we think is acceptable, maybe in those 60 minutes, but it's really going to take your action

and your consistency with the process, that's going to make the change. So how do we go about helping people or how have you gone about helping people set a realistic expectation of themselves or what we can offer them when you're dealing with patients in especially the virtual space.

Joe Gambino (07:04)
It's a little harder when somebody comes in and the expectation is that after the session or one or two sessions that we're going to magically make their pain go away. We're fixing it and we're a mechanic. We just have to lift the hood and tap on a couple things or replace something and they're better.

I think in those cases, right. during those sessions, I want to try to create a little bit of buying that we can make short-term changes, right? Like we can maybe reproduce their pain or make their pain feel better by doing a couple tests. and then spending time kind of education on, okay, well now that we're able to modify your pain and do this kind of stuff, this is what the kind of plan of care will look like. And then giving them what.

the I don't know, not necessarily like the step by step, but hey, you know, in order for us to, it depends on the injury, right? Like a tendinopathy conversation is gonna be very different from, you know, an acute low back injury so to speak, but trying to let them know like, hey, this is typically what we see as far as recovery at times is going to require us to do this many sessions. This is kind of the expectations for you. And then asking them how they kind of.

feel about it and then how can we almost work backwards there and kind of come up with a plan that's suitable for them and not always, I've had people who like that's just not gonna job with them and then I'm just not the person that's going to be able to help them. But I think you need to for these people to give them the expectations, hey, this is what you should expect, right? And this is where your expectations are. How do you feel about that?

Are you on board with this plan because otherwise if you don't really do that for them They're just not going to be set up for success regardless and they're probably not going to show up They're only going to stop showing up because you're not helping them in the one or two sessions from their expectations or they're go find somebody else who better fits Their belief system. So either you're gonna figure that out sooner than later on that call Maybe they do understand that they're like, thank you for the education I didn't realize this and now you've set them up for for better success long term

Joe LaVacca (09:06)
Yeah, I think the that conversation is so important and as much as social media has been helpful for you and I for multitudes of clients across the world with the amount of free information that they can get. I do think it's those services a bit of a detriment where you are reading these successful case studies. And let's be honest, a lot of people are only posting their successes.

It's not the difficulties in the journey. It's not the difficulties getting up to visit 27. It's, Hey, I met Joe. He was in so much pain and now look where he is like, boom. those side-by-side comparisons I think are a little bit misleading. And I understand how they are enticing for people and how people seek our services. And then with that same expectation of all.

I saw this on Instagram the other day and this person got better in a day. How come I can't get better in a day? And typically I think of these like little, let's say drastic points of improvement or even anywhere in our life. There's good things that happen to us without reason. And a lot of that time it just comes down to luck, right? I got a check in the mail the other day from a family member who I haven't heard from.

And I was like, wow, this was super nice. There was nothing I did to deserve this. This was just dumb luck. Now, when I compare those to the instant things that have happened in my life, especially over the last like year, usually instant things are not typically good. Like, I woke up in pain. there was an incident at, Addison school. there was a death in the family. like, like instant things that happen are usually never too good unless they're just dumb luck. So how much of.

our lives or the rehab process, can we just expect on luck? And I think that puts us at an unfair advantage when we're working with clients. Because to then go from this idea that I'm just going to be lucky to fix myself instantly is probably not realistic. And then you and I selling people or selling this idea that, hey, we won't even know where we are for another eight weeks or 10 weeks or 12 weeks. And I like what you said about

you know, getting buy-in or inspiring these people or our clients to think like, Hey, well, let's think about what's the most limiting factor. Like how can we like lower your pain a little bit show you that you can make changes. But what I found for a lot of people that's, that's really tough. And I'll give two examples. One, that worked out well. And this was with the client the other day. She gives me a lot of things that she was hoping that I would fix in that initial session.

And when I, when I paused her and I said, okay, if I'm hearing you correctly of all the things that you've listed, swimming sounds like it's really important to you because it's your aerobic exercise and you're trying to lose weight. And right now your shoulder is limiting you from swimming. let's forget walking for a second. Let's forget squatting. Let's forget, you know, you know, doing all these other exercises that you're trying to do at the gym. Let's just focus on this one thing. You want to swim. So.

We want to try to establish a pathway to get you to swim. That's goal number one. We do a quick assessment. We notice like it's very common. There's a little bit of internal rotation deficit on that same side. Maybe it was due to swelling. Maybe it was due to, you know, a bunch of other things. We do a couple of stretches, some isometrics, and then lo and behold, you know, her internal rotation gets really better and that sparks this excitement in her. And, you know, she looked at her shoulder and she was like, wow, it feels so much better.

Can you, you have the same thing for my hip? You have the same thing for my foot? You know, you have the same thing for my knee? And I'm like, well, hold on. mean, the only thing I know right now is that this, you know, worked for your shoulder temporarily. Now we have to think about training it, but this seemed to be a roadblock that maybe was inhibiting your swim. If we address this accordingly, hopefully swimming gets better, right? But at the same time, I had another client with hip pain who is a power lifter.

And there did seem to be a little bit more of this like joint block or joint irritation in her hip. And, we do the same things, you know, some movements, some isometrics and loading, and we're not any better at the end of the session. Right. So I've always had a hard time with like trying to get that buy-in on the first session outside of the parameters of like really like educating, communicating.

Cause I think that's where we can make the biggest shifts in perceptions and help people along the way of like, look, this is what our expectations are. Even if we had a good result, I still need you to train. Even if we had a not great result, I still need you to stick with it and realize that better times are ahead. So when you have had that happen, how have you had to navigate the ones that didn't go well with trying to get buy-in?

Joe Gambino (14:06)
Yeah, I think, mean, you know, obviously if you can, you know, I'm not going out there and say, like, oh, let me, let's see if we can modify your pain on this call. And then, you know, cause obviously if it doesn't, you know, there are a lot of cases where that doesn't happen. I think you'd be setting yourself up for failure. Um, it's, it's, it's very similar to kind of what you've said. It's, it's, know, I don't always expect that there's going to be a change like before or after, you know, like sometimes it can be worse. Sometimes it can be better. Sometimes it can be neutral and stay the same. That's all information for me to be able to determine, okay, well, what are.

How are we going to go forward with this? And then I always like to, know, someone who's very stagnant, there's really no change, it's not getting worse, anything like that. Then I'm leaving them with, you know, maybe we're able to, or whatever it is from an objective standpoint, where they wanna get back to swimming, I look at the shoulder, this internal rotation deficit, I believe, and like maybe they were limited in some shoulder flexion.

And I believe those two things is one reason why they're getting some pain when they're swimming. I'm going to say, hey, these are the things that we're tracking over our next two to four weeks. Right. And not only are we going to be tracking your symptoms and how much maybe you can tolerate swimming, but we're also going be tracking these two things. These are our kind of tests. And all of sudden, if we're starting to see all those things start to improve and then their pain is getting better, or maybe it's kind of like the frequency or intensities.

Improving a little bit, but they still have pain or they still can't swim. Well now we can say hey look Your X Y & Z that we've been tracking is actually improving right your Pain frequency and intensity is getting better even though you can't swim and you're you're still struggling here like we're on the right track, right? so we use like objective measures and other goal setting to start to You know a educate on that initial session, but then how we're tracking things session over session week over week

making sure that things are going in a way that we would expect. And if it's not, then it probably is going to be like, we need to reassess things. need to relook at things. We need to dive deeper. Is what you're doing from an exercise perspective. Sometimes we feel like if you're overly irritating it, you can find out a bunch of different factors of why someone might be stuck and you have to try to figure out what those things are. And if you can't figure that out, right, it's a refer out situation.

Joe LaVacca (16:16)
Right. I'm really glad you said about the differences in the results. Because I think that's really important for people to hear that if you and I are going to be doing tests and measures and loads and we get a good result. All right. I'm encouraged by that. Typically our clients are encouraged by that. And to me that usually says, Hey, like we're good to load this thing. Let's push a little bit. You you've been maybe backing off. You've maybe been protective, which makes sense. And maybe part of that protection process.

has actually gotten us to a point now where we can load it successfully. However, like you said, I do try to be upfront with people and saying, hey, look, well, we're going to do some tests and measures. I want you to let me know if things get more sensitive because I don't know, right? This is the first time we're meeting or, the last couple of times we meeting, it's been one good or one bad. It's like a little bit up and down. So when we get the irritability response, I also tell them, Hey,

Joe Gambino (16:56)
Mm-hmm.

Joe LaVacca (17:09)
Well, this is good because now we're understanding that this tissue actually does maybe need a little bit more rest or protection. Maybe this is that great time where, you know, if you're having foot pain or I don't know, hey, even like irritable hip pain or back pain, where that change in sneakers or the orthotic can make a really big difference. Where a compression sleeve around your knee can make a really big difference. Where

hey, like lateralizing your programming, staying away from pushing with your shoulder and just doing polls or isometrics can make a really big difference. So I think that with these results, they always give you and I information to guide people. And the only thing I tell people that I can be consistent with, you know, session to session is the education and the advice that I'm offering, you know, around someone's condition, because that's

probably, if anything, the only thing I can really control in that setting. And as much as people come in gung-ho and they want me to fix them, don't get me wrong. I know you want to help people, I want to help people, but I also want to do it in a realistic way. Because when I was a little bit too gung-ho as a clinician of like, yeah, let's fix this in like two weeks or four weeks or six weeks or eight weeks, I realized that I was kind of pigeonholing myself.

And is really two or four weeks or six weeks or eight weeks really enough time for any one person to say you've been successful or you've, know, quote unquote failed PT. And I realized that the people I've been giving more space to like, look, this is going to be a process where I want us to commit to the 10 weeks, the 12 weeks. I want us to go through a full course unless we really see your function deteriorating in that time.

consistently or we see a red flag pop up, I want you to know I'm prepared for the good days and I'm prepared for the bad days. But when I've given that mentality to people, that like a longer runway approach, it's almost like, all right, I know that this is going to happen. I know Tuesday could be good, Wednesday could be bad. Let me see what happens next Tuesday and next Wednesday. So the big kind of like advice I try to offer people is don't think that

as wonderful as you and I are, Joe, that we can make permanent change in a single session unless it probably comes down to just dumb luck. And as clinicians, you and I, I think, can probably run with that luck and be like, oh, well, this will work for everyone. And now let me start to post this and spread this message that I can fix you one and done or three and be free and...

four and no more. And I've heard all these little catchphrases from PTs over the course of my time, over the last 15 years. And they always made me cringe a little bit. It was like, how can you say to someone four and no more or three and be free when that's giving you such this narrow window to make a change or an impact in someone is putting so much pressure on the person in front of you to be like, well, if, Joe, the magician can't get me better in three or four, well, I must be out of luck.

Like, where am I going to go now? So those expectations, I think, are really super important to give to clients for clients to understand. And I just think that they set us up for just so much more success in the long run when we know that this will be more of this journey and like teamwork mentality rather than, Hey, Natasha, Hey, Chris, you know, you have four weeks to get better.

or I'm going to refer you out. It's almost like an ultimatum. So I hope that anyone listening who's a client can understand that, work with your provider in being clear on expectations and what you expect of that person. Is that realistic? And what do they expect of you? And is that realistic for your timeline? Because I know people have kids and work and jobs.

and there's deaths in families and there's accidents and there's bad things that happen that can deter you. So if you come back in after not seeing your PT for six weeks or eight weeks and things haven't improved or gotten worse, well, that kind of makes sense. So are we putting too much pressure on you to get better with everything else going on in your life? And then how can we make that approach when you're not here with us pay off more in the long run?

Joe Gambino (21:32)
Yeah, yeah, I like that. mean, I one reason why I think a longer term, you know, I think if like, say I was working with somebody and they didn't have a lot of pain and their their goals were very small, like I just need to be able to like, I don't know, just go through a normal day like I sit most of the day, I don't really do too much. I'm not very active. Like those people don't need a long plan of care. I mean, I work with a lot of people who are parents, they're

They like to be active. play golf, they run, they work out. So when we're looking at, know, depending, obviously depends on how long they've had pain and there's a lot of factors to it, which we can certainly talk about. And they want to be able to like, Hey, I just want to like trust my body to be able to deadlift again or play around a golf or go on a golf trip with my buddies. Or I want to be able to go like I've had people talk to me about.

you know, their significant other or like their daughter's getting into running and they want to partake in that. it's like a family thing. Like, you know, when somebody has these kinds of goals, like now when we start to look, okay, Hey, like a lot of my, my timeframes when I work with people, like four, four months, six months, like it could even be be a year, right. And it's really allowing us to set the stage for like, okay, well let's get you out of this, like initial pain journey that you're in. We can get you loaded and start that process and build a confidence now. And then we can now have,

Enough of a runway and enough time to get you as close to you know, like how do we start to do the higher level loading? How do we really bridge the gap with PT? Like, you know, I've had I was talking to someone recently and she did I Don't know maybe like six weeks of PT and she's she's a golfer She goes on golf trips all the time her back hurts from you know playing golf and she's like she did six weeks of PT and feels like she's capped her you know the

How far she's gonna get in PT and she's looking for something else on top of that this gonna help her get to where she wants to go and You know, like that's great for her, right? Like she's understanding like where I was before it was great. It got me to this point I'm realizing that I'm not seeing progress. I'm now looking for for the next step But this really gives us you know, we look at four months or six months twelve months We can make a whole lot of change We can build a whole lot of habits we can really move someone a lot closer to their goals And I think when you give yourself that kind of luxury and freedom, you're not kind of just pigeon-holed to like

We've talked about this before on the podcast and a lot of times People who've had chronic pain or have been stuck is because they're just in this like rehab loop I go see pts. I get massages shockwave therapy acupuncture stretching and it's this loop and like they maybe make some progress or they're stuck and they can't get back to accent sometimes they just need to be removed from the PT environment and be hey, okay, well we can still do the things that's gonna help bring down your pain, but

Let's like make you realize you can squat again and you can, I don't know, you know, go for a walk, run again, like, like just start that process of higher level loading, right? And all of a sudden that's what they need to move and get out of that cycle. So.

Joe LaVacca (24:27)
Yeah.

Right, exactly. I mean, look at timelines for anything. And I think this is maybe like the last point I'll make is if you've had a surgery, you probably need to give yourself at least a year, right? At least a year. I don't care what your protocol says. Even if you go back to return to sport, you know, before that, I think at least a year out is going to be like, how are you? Where are you? Was the surgery successful for you?

But then we just look at just generic pain timelines. I mean, we talk about back pain a lot. It could be weeks to months to years for some people. Shoulder pain could be months to years for some people according to the data. Plantar fasciitis, months to years for some people. Anterior knee pain, months to years for some people. So when we keep seeing these studies or this data that suggests, hey, you know what?

Maybe we're mislabeling chronic pain because the timelines for a lot of the things that we see people deal with are just longer than six to eight weeks. And I don't think doctors are doing a good enough job explaining that. I don't think the PT profession as a whole is doing a good enough job explaining that. And I think that's what rushes this idea of was this successful or was this a failure? But being upfront about timelines,

Joe Gambino (25:31)
Mm-hmm.

Joe LaVacca (25:54)
And if your clinician has not been upfront about timelines with you about your journey, your diagnosis, what to expect, I think that is going to be point number one. Get on the same page with timeline. Because when I give people this idea of, it sounds, it seems like a tendon, seems like this, it seems like that. I'll always then say, well, what we know is that even with good days, bad days mixed in between, this could be a while. You know, I'll be here with you.

until you feel confident going back on your own training or until you feel confident dealing with flares or the ups and downs. But if we're looking for that six or eight week window before you go back to the doctor or six or eight week window before your insurance lapses, I don't think you're going to be where you want to be. And even just with that ahead, okay, cool. Now I know I'm not doing anything wrong with my rehab. It's not my fault. Even when I skip a week because of something happening,

I know I didn't set myself back because again, big picture with the data is going to say, this is going to take some time.

Joe Gambino (26:56)
Well, I think we're we live in a society where we're in a rush and then no one wants to be in pain and you know, stuff like that. So it's definitely a hard battle, I think, when we're talking about this stuff. And I think that, you know, I think it's easier for people when we go back to this like goal setting, hey, look at the changes that we're able to make. you know, pain, I describe to people as just like very subjective, internal process that happens. And you can kind of get really

Stuck in it right and you need to pull out sometimes other things Hey look look at how much more you can do look at how your range of motion has changed Look at how much stronger you've gotten to help them realize that they've made more progress than they think that they have So that's the last thing I'll leave listeners with you know, don't just rely on pain as your your outcome measure because it's a very Poor one and it can fluctuate really at any time for any given reason

Joe LaVacca (27:50)
Amen, brother.

All right. Well, Joe, love you. Listeners, we love you. We hope that this has been a helpful episode and do not forget to come back next week where me and Joe will be back at it again on the Beyond Pain podcast.