Chronic Pain Isn’t What You Think It Is

0:00 You're listening to the PT Pinecast, where smart people in healthcare come to make noise. Here's your host, Jimmy McKay. All right, kicking things off today. I do want to say before we start, thanks to Sarah Health, the remote care platform helping clinics boost revenue without having to add staff. Sarah automates daily patient check-ins like RTM that meets RTM requirements and supports better work through between visits. Find them online at sarahhealth.com. That's S-A-R-A health.com. The Sarahs of the world do get very picky. Like I'm Sarah with an A, Sarah. without an A, this is Sarah, without an A, sorry, hsarahhealth.com. Today's episode, PT clinic owner, professor, PhD candidate, entrepreneur, podcast host, surfer, mom, and somehow finds time to bake bread from scratch.

0:51 Those are a lot of things, like Swiss army knife vibes is what I get from her. Her work sits at the intersection of pain science, clinical care, and then the messy reality of humans being human-y, as I say. She believes that chronic pain is not just a louder version of acute pain. We've said this before in different contexts, like, You know, kids just aren't small adults. They're different. So is pain. It's a nervous system story shaped by lots of things, stress, sleep, beliefs, trauma, safety, connection, the world. So let's get this pain conversation, which is always fascinating for me for some reason. Let's get in today's guests, Megan Steele.

1:32 Megan, in the flesh from the West Coast, from the Westest of coasts. The Westest of West Coast. Thank you for that lovely intro. I'm happy to be here. So let's start with what I sort of like framed or highlighted or put in bold with my words. Chronic pain is not just a louder, longer version of acute pain. What do PTs or what does healthcare miss when they actually do treat it like a longer, louder version of acute pain? That's a great question. I think we miss the point. We miss the plot when we're sort of treating it as a louder, longer, stiffer version of acute pain. when we're thinking about acute pain, we're thinking about tissue damage and nociception.

2:16 And for some of us, it's been a little while since PT school and those words are kind of coming back to us. Oh yeah, nociception. And I teach a class called orthopedic pathology to the first year physical therapy students. And we talk a lot about tissue healing times, right? Six to eight weeks on average for soft tissue, eight to ten for bone. And then What happens when people are outside of that window? We're not thinking about and hopefully we're not looking for a tissue source. Excuse me. So when someone's had pain for longer and I think. One of the great questions that I like to tell people to ask a clinician before you decide whether or not I want to work with this person, if you're someone that suffers from chronic pain, is how do you treat people differently when they've had pain?

3:08 for three years versus three weeks. Because if you're telling me, well, it's a stiffer joint. I push harder. We have to do more exercises, those types of things. I'm going to say, thanks. I'll see you later. But if you're saying to me, well, someone with chronic pain, I'm thinking more about threat detection than about tissue damage. I'm all in. I'm interested. You seem to know what you're talking about. Let's continue this discussion. It's funny, before we hit record, you mentioned Rachel's softness. She's come on the show numerous times over the last couple of years, mutual friend, and she frames some things pretty well, which is. Pain or no different things in different contexts elicit different You know, she was just on Dax Shepard's podcast and I saw this great clip and she's like, you know, someone biting you in the middle of an interaction with a partner that you want and are attracted to is very different than just being bit by a random stranger or a dog.

4:10 So looking at it outside of a biopsychosocial context. uh way seems to miss the point and if we only treat things one way we're only going to get one result so when a chronic pain patient walks into a clinic what would you suggest to students clinicians anybody listening what should the person be listening for before they ever test range of motion or strength what are like the i call them eyebrow tests what are the things that sort of make you go hmm okay That's a great question. And there's a variation of options there. But I oftentimes think about, you know what normal is, right?

4:52 You've had orthopedic pathology, you've had physiology, you've had biomechanics, you know what that is. And so things that are outside of that, when people say things like, when my stress level is higher, I have a lot more pain. When I haven't eaten well, I have a lot more pain. When I know I have to go and give a presentation, I have more pain. And not everybody has that awareness, but sometimes also people will say to you, there's no rhyme or reason to it. I cannot discern a pattern to it. Sometimes I'll just be sitting still and I have this pain. that's not a normal physiological reaction, right? That's not a biomechanical, when we think about our biomedical model, someone sitting still not moving that painful joint should not have pain if we're just thinking about strictly biomedical model.

5:43 But when you broaden your lens and you say, oh, well, there are a lot more things like context, like my psychological state, like the amount of sleep I got that affect my body and my physical experience, then your treatment targets expand as well. You said the most important question is not where is the pain coming from, but what is this person perceiving as a threat? I mean, I feel like that just summed up what you just said there. So what does that look like in practice or how do you teach people to take that from hearing me say that really cool quote? That was your quote, by the way. That's the smart thing. Want to be a good podcast host? Steal the great quotes.

6:23 Makes you sound prolific. But what does that look like in practice? That's a great tip. How does that look in practice? Yeah, and that's quite challenging. So I also teach students in the third year, pain science. And sometimes they come back and they say, oh my gosh, because they've been out on their clinicals, right? And they're like, oh, this is what I needed. Why didn't we have this in first year? And, you know, thank you so much. And I say, well, this is the gray, right? In first year, you needed it to be black and white. because there's such a volume of information. It's like a fire hose of information coming at you with anatomy, physiology, biomechanics, pathology, et cetera.

7:05 You need it to be black and white in the first year. And it's not until you've been out in the clinic and you've seen, gosh, not everything is like the textbook that you can say, oh shoot, there's actually some gray here. There's some nuance. And so the first thing that we do, one of the first things that we do in pain science is shut up shut your mouth they say it takes eight minutes for someone to tell their story wow do you know how soon we as clinicians tend to interrupt someone uh i think this has been if it's the thing i'm thinking it's like forty two seconds or something crazy less than that maybe Yeah, somewhere around thirty seconds.

7:48 Yeah. Right. And it makes sense. We want to show that we know what we're talking about. We want to show that we're the expert. We've seen this before. We understand we're going to be the one that's going to be able to help you. And I'm not opposed to that. I think that's really important after you've let someone tell their story. And so, you know, people say, you know, like you, you handle these tough cases. You see people that have seen six other practitioners. What do you do differently? I'm not magic. I don't have some kind of a special intuitive psychic skill. I know how to shut the fuck up. Sorry.

8:29 I don't know if we're allowed to say that. Um, okay. So I'd say that's probably my biggest, um, superpower, if you will. And if you've seen me on Instagram, you might be surprised that I know how to stop talking for periods of time. I used to use this as a cheat code. Back when I used to work for radio stations and I had to interview someone, it was not a healthcare thing, but I realized this might be the only time that person's ever been in a radio station. So I need to understand that. This is normal for me, not for them. Like this is their day. Like this is fun. This is weird. But also like, what is this? I don't understand this.

9:10 So I made it a point to get with my receptionist and say, hey, whenever there's an interview, never send them back. I come and get everybody. I would meet them at the front door and I would immediately start to try any way to read that person. Are they a little sheepish? Are they nervous? I'd look for their eyes darting around, look for body language. And if I sensed a little coldness, I would give them the complete tour of the entire radio station. And my goal was to get them to warm up. But hearing what you just said, I'd never heard. I've heard the second statistic that we interrupt people at thirty two seconds or something like that.

9:51 I've never heard the other one, which is it takes eight minutes to tell their story because my goal when I turned the microphone on, there they are, was to get to the good part. So maybe I needed to get, I sort of knew, and we sort of know, I need to get the first seven and a half minutes out of the way. So when I turn to you, you're warm, you're hot. And you can step, you're mid stride. So if I ever sensed that, I would do that. That's a skill, I think, in healthcare, which is shutting up. It sounds dumb, but it's not. Shutting up is a skill. It's a skill. And then I think the number two most important skill is what you just talked about is how can I connect with this person?

10:36 How can I recognize where they are and then connect with them? Which, you know, I have a friend that graduated from some of the top schools in the country. She went to Duke and then she went to Columbia and she said, I know all my biomechanics. I know all my neuro, I know everything, but they never taught us how to talk to people. Who knew? Shocking, right? Who knew? Shocking. And there's a great, I love, I show in my classes, there's a great pie chart. It comes from the psychological research, but they found that it translates well to physical therapy. And it's like the percentages of the things that help people to get better. These are the things that have been shown to improve outcomes.

11:18 And therapeutic alliance, thirty five percent. Wow. What people come in with, forty percent. You can't do anything about that. Right. That's their history, their beliefs, their biases, their expectations. Excuse me, not expectations. So thirty five percent is the relationship that you ideally will make with them. And so I tell my students, your goal on day one, your primary goal on day one is to get a day two. You don't need to figure it out all on day one. If somebody's had pain for twenty years, it's very unlikely that you will figure it out on day one. You need to connect with this person enough so that they will come back and then feel comfortable enough with you to share what's really going on with them.

12:12 Yeah. And I think those are skills that we don't emphasize enough in PT school. And I think that ideally needs to change. Yeah. And we've talked about that before. I've used an example and people laugh when I give it in a presentation because I also like when you give when you're talking one on one with someone, it's different than when you're talking to a room full of people. Right. We're more apt to laugh and there's group and yada yada. So I'll parallel marketing or patient relationships to an actual traditional relationship, like stereotypical. And I'll say, well, of course, the goal of the pickup line is to get married.

12:56 And everyone laughs. And they're like, of course. I'm like, oh, I'm not married. That's why I must be doing it wrong. Like the goal of pickup line is to get a laugh. The goal of a laugh is to build rapport, to get coffee. The goal of one coffee is to get dinner and then dinner is to get whatever. And it builds from there. And then I'll say, you know, I'll parallel the marketing. I go, well, the one post, the goal is to get them to buy something. And they're like, yeah. And I go, do you see how ridiculous that is? Sometimes you see how ridiculous you're making that giant leap. But this giant leap is ridiculous in the relationship context. But it's the same with with therapeutic alliance. It's like, hey, I'm your PT. Just trust me. Do you know who says just trust me? Used car salesman.

13:37 Anybody who's saying trust me, demanding your trust, right, immediate red flag. And if this person, because I've heard it before too, which you just alluded to, has probably seen multiple providers, if it's long-term chronic pain, they've tried a lot of different things. They might be exhausted from trying things because they're not just dealing with pain while they're sitting in front of you. That's their all the time or a lot of their time. This is mentally, physically, emotionally exhausting. And it's going to take a little bit. Right. Exactly. And also, you know, they've had people who have maybe dismiss them or maybe kind of like first thing. Oh, I know exactly what this is.

14:18 You got seconds in trust me. I know I've been here. I'm the expert. I'm the preacher from the pulpit. Who's going to be the person who's going to solve this problem for you because that feeds my ego. Right. Cause I'm the best. Um, and so it's really refreshing to people who have been in those situations to hear, tell me, we got all the time you need. no rush and for people to say i feel seen i feel heard i feel safe here that's just like oh the best yeah well you you mentioned instagram Do you like doing that?

15:01 So it sounds like you laughed, but it's a funny question. But I've talked to a lot of people in health care, obviously. It's sort of what I do. And people with large followings are trying to get a following, right? And some people, when I ask that simple question, do you like doing that? A lot of them, after a little while, will say, honestly, no. Or I love it. I mean, I don't mind doing it. But I got to be honest, as a guy who talks a lot, I go in waves where I might do a lot like for months and then all of a sudden I don't wanna look, I don't even wanna open the app or any of the apps and people I've gotten messages, are you okay? And I'm like doing great. But I used to tell this to broadcasters, if all you do is consume stuff here at the radio station, what are you gonna talk about?

15:47 I need you out at a coffee shop or a concert or getting your oil changed to come in and comment on life which is essentially what you're doing so so so I'll ask that question do you like doing it um yes and no and I think there I do go in waves and when you talk about kind of like oh these are all the things that she does I think I should put an asterisk there and say like not all at the same time right and so it seasons right you know like I I can't tell you how long it's been since I've been out in the water, but it's because I've been trying to swing at this academic goal that I have that is really taking up a lot of my time.

16:33 You know, and I think we should also mention that I totally biffed it when you first invited me onto this podcast because you sent me a DM and I was like, yeah, sure. Send me an email or something. I can't remember. I was like really busy right now or something. And then like, I don't know. what i'm doing i don't know who the big dogs are i consider you a big dog congratulations i don't think i think most people because i talk to a lot of people in this context when they know they're recording and there's a little clock you know tell a little red light and then after and most people are more the same than they are different in a lot of ways in terms of like some of these big names are like i don't know how i got here don't know what i'm doing what am i doing next i don't know in fact the more interesting people say that the people who are like i know exactly what i'm doing everything's up and to the right here's the plan those people they're wrong most of the time it's like it's dunning kruger a little bit where like the smartest people um and the most interesting people when i ask them to talk are typically like why would you want to talk to me i don't have anything to say i'm like i don't know you just wrote three books or you do these amazing things um So I think we're all doing a little bit of that.

17:50 Oh, well, that makes me feel better. Thank you. Yeah. I think if you lined me up with, I don't know, twenty other PTs and said, who's most likely to succeed on social media? Like, I would not be in the top ten of that one. But I've had some success. And I think a big part of that I credit to someone we both know named Shantae. who i stole at cpta one year and i tried to just like pump her for free advice as one does you know um and she was like looking at my instagram which was very like buttoned up and i was like these are the facts and this is my research study that i'm showing you and she was like so what i'm seeing right here is not exactly what i'm seeing right here and i'm like I'm not gonna tell people that I skateboard on the weekends.

18:38 Why not? And that's exactly what she said. She was like, you can be a human being and people will be interested in you. And you can still give quality information. And so, yeah, that's kind of what I did ultimately. So the pain science course that I teach in third year is only part of the semester and that's funding reasons and academia reasons that are above my pay grade. I've asked many times, the students ask, can we expand this course? We want more. And it's always been a no, because otherwise we'd have to charge them more and they're already paying an arm and a leg. So I said, okay, I'm going to meet them where they are. Well, not really where they are because they're really on TikTok, but that scares me.

19:21 So I said, I'll go to social media and I'm going to make a pain science Instagram for them. And the weird thing happened is other PTs who didn't have pain science in their PT program said, Hey, we didn't get this information. And then. people who suffer from pain, who are not clinicians, said, hey, we didn't get this information. Nurse practitioners, MDs, DOs, people are like, why don't we have this information? Where was this? Right, exactly. And so, I mean, there are efforts from AOPT to integrate pain science into all of the DPT programs and the entry-level programs, but it's hard work and it's slow and it takes time and...

20:09 You know, there are a lot of moving parts in that. And so this was kind of my way to say, let's just get it done. Do you like doing it more now that you sort of feel like yourself? Does it feel less like work yet? Oh yeah, definitely. And I, you know, try to show you the sides of like my husband asking me for free PT advice and I'm like, oh yeah, why don't you work on my website? You know, so it's like, you get to be a little bit more of yourself. That brings people in. Totally. And every PT, yeah, every PT is like, same, I do not treat my family, you know?

20:50 Yeah, just kind of a universal truth of our profession, I think. Sure. They're not going to listen anyway. Exactly. They don't do their home program, and you're like, where's my cocaine? So what do health care providers get wrong when they use pain neuroscience education with chronic pain patients? So let's say that they're like, OK, great. I'm understanding what she's saying. What are a couple of the hurdles that maybe they trip over in the beginning that are common that you see? Yeah, so what I see in students who have pain science education in their PT programs is they're doing more pain explaining than treating someone differently.

21:35 So it feels a lot like, okay, pain neuroscience education, this is the thing that we have to do. So I'm going to do everything else that I've done the same. And then I'm going to talk at this person for fifteen minutes while they're doing their exercises or while I'm doing manual therapy. And that's not effective. And so I love that Laura Mermosley wrote, you know, in twenty fifteen pain science education, fifteen years on, where are we now? You know, Pain prevalence in the general population was at twenty percent when he wrote it. It's at twenty percent now. It's not the panacea that we all thought it was going to be. You're never, ever, ever going to talk someone out of pain.

22:16 And that's where I have a hard time with some of the psychological interventions that, you know, are hands off. or not movement related because it's very unlikely that you're gonna talk someone out of pain because when you're talking to them, you're talking to their cognitive brain, their thinking brain. And that's not where chronic pain lives. Chronic pain lives in the subconscious below conscious awareness. And so I think we as physical therapists are the perfect practitioners to be able to have an impact on people's chronic pain. Why, what sets us up uniquely? we have an understanding of the physiology we can use manual therapy which talk therapists are not allowed to do and we understand movement and so i can use my manual therapy to access someone's subconscious and i can also use certain types of movement to access someone's subconscious so that their nervous system and their brain gets the message of safety and then we can make changes i'm not going to talk you out of pain and i'm not going to force that joint into, I mean, I could probably temporarily, but you're not gonna like me very much.

23:32 And it's very unlikely that that's gonna stick long-term unless your nervous system says, I can accommodate this. I can take this in right now. Other things come into play, right? Stress, sleep, trauma, relationships, past experiences, safety. They all change how patients experience pain. Talk about, I just gave a list, and those are just things, that's more than, they all fit in biopsychosocial, but how do they actually change how a patient experiences pain? So things like, we'll just take trauma, for example.

24:12 So we'll say we're talking about like a big T trauma, like a one specific incident, for example, like a car accident. So our nervous systems are designed to protect us. And if we think also about pain as our body's protective mechanism, then we can think about it as what is my body trying to protect me from here? And so over the course of our lives, we learn about pain. We learn about pain from our caregivers, from our experiences, from observing others. There's a lot of ways that we learn about pain and most of it is not conscious. Nobody sat you down and said, So snakes, here's the thing, right?

24:56 Snakes comes to mind because I just saw a video of my daughter last week at preschool holding a snake. Did not come up in conversation once. I was like, how was school? Fine. Cut to her holding a snake. Did not mention that you held a snake today. Yeah. Nope. Didn't come up. So our nervous systems learn over time associatively, most often subconsciously. So that Pavlov, Bell, the dogs start salivating. Same for us with pain. I learn that driving in my car on a certain freeway at a certain time of day is a threat. So my nervous system says, I'm going to help protect you. I'm going to sound the alarm.

25:38 And the alarm can be pain. The alarm can be what you just demonstrated, muscle tension. The alarm can be changes in movement patterns. There are a number of different ways that our body protects us. And if we think about pain in that way with our chronic pain patients, we're really treating them very differently from people in acute pain. Yeah, I'm thinking of people, too. There are certain people when they call, just their name on my phone makes me go like I can feel my body change. Like I now have to deal with this person or do I ignore this person? So you don't have to go far. You don't have to give me too many analogies for me to picture this.

26:18 That's absolutely right. And I think about a patient that I saw very early on in my career. who had a spouse at the time who was physically abusive. And they had since divorced, but they had kids together. And so she was somebody that came in and said, my pain is so variable. There's no rhyme or reason to it. There's no pattern. And over time, by getting to know her and understanding what was really going on with her, we found out that any time that she has to interact with this person, her pain level shoots up. And so the kids were going through these life events and having to get together and have dinners and graduations and things like that.

27:03 And any time I know that this person is going to be at one of those events, pain. I was talking to a friend who's a psychologist and it was after my mom passed away. And he's like, how are you doing? And I said, I don't know. Every once in a while I get upset for no reason. And he paused because that's what psychologists are very good at, the pause. And he goes, your mom died. That's a reason. And I remember thinking like, oh, I hadn't. Yeah, that's the reason. But like, why am I on a Tuesday? He goes, I don't know. Maybe you thought about your mom. Maybe you looked at something. Maybe you saw something she gave you. He's like, I don't know, man. But he's like, the reason is she died. the trigger might have been a memory, a song. He's like, it kind of doesn't matter.

27:45 But he's like, I need you to understand that there was a reason because that was the thing that I said. Well, for no reason. I just break down for no reason. He goes, there's a giant reason your mom died. And the way he paused and said it made me have the connection and go, oh. I don't need to explain this. There's a reason. That's cool. And now when it happens to me, I quite, this happened two, three years ago. I still think of that conversation with my friend and I go, oh, there's a reason. I sort of don't need to know what it is or I can try to figure it out if I don't want this to happen. But also like there is a reason. So I don't have to feel because I felt bad about feeling bad. And that's not pain, but I could see like where there's a parallel. Oh, absolutely. Yeah.

28:26 And, you know, it's great that you have this friend. And I think he's a great example of knowing how to shut the F up. Right. Like we could all take a note on that. And it's the same for pain. And it's great that you have this friend and you have this experience so you could see that connection. And it's hard for some people to get there. Right. We've been told that you have a brain and a nervous system, a central nervous system, and then you have your body. Right. And these things don't really impact each other and they don't connect for years and years and years and decades. Right. We think about the Descartes model, which is kind of just like. the precursor to the biomedical model, which we've been kind of following for two hundred years.

29:11 But biopsychosocial has been around since the seventies, nineteen seventies. And so we've known about it and they've actually done studies about what makes it hard for clinicians to implement this, even though we know we should be practicing in a biopsychosocial framework. Part of it is they don't feel comfortable understanding it, talking about it. And therefore, then I'm not going to try to explain it to someone else who, you know, might be a little bit skeptical. And so I think that's an important piece of our education as physical therapists that we need to have, because when we get training on this as physical therapists, there's also research on this that we are excellent at implementing it.

29:56 And so some people say to me like, well, how do I get there with my patient? How do I, if you know, it's, it's very easy for someone, especially someone who's had a history of being told it's all in your head. This isn't real. There's nothing on the scans. Everything's coming back clean for them to hear. There's a mental emotional component to this and it's still real. It's still not in your head. And that's also a skill that we practice in pain science because you have to know how to explain it to someone. You have to know how they can get on board with it. And some people will come into me and they'll say, you know, I've tried this, that, and the other, and I'm here for whatever, right?

30:40 Like whatever you got, I'm bought in, I'm here for it. And there are other people that say, I don't understand that. I'm not interested in that. I would like physical therapy. And that's okay. I'm going to meet you where you are at some point during our relationship together. I might say to you, Hey, you know, we've gotten to this point. It seems like we've made a certain amount of progress and there might be some other components to this. Would you be open to talking about them? So I talk a lot about motivational interviewing with my students. I talk a lot about shared decision-making because there's no amount of me forcing education information on you that's going to change your mind.

31:25 Right. So here's something I always wondered, and you mentioned twenty fifteen sort of being that look back and names like Lorimer Mosley and a lot of pain researchers, a lot of PTs who sort of embrace this. I always wondered this. How do you explain to students or to clinicians in your own clinic or anybody how to ask deeper questions without feeling like, because I graduated in twenty fifteen. So I was launched into the world. Sorry, I graduated twenty sixteen. So I sort of launched into the world a year later. How do you ask people to ask or teach a team to ask deeper questions without feeling like they're pretending or trying to be a psychologist?

32:07 So that part came in where I was like, I don't want to pretend I'm doing something that I'm not trained to do, but this is important. I think Opening the door is a big piece of it and helping someone to recognize that our pain is influenced by our thoughts, feelings, emotions. All pain is processed through areas of our brain that process memory and emotion. And so every pain has a memory and emotion associated with it. And sometimes giving people that information and then shutting up is enough.

32:51 I recently started a podcast with a friend who is a twenty six year pain survivor. She's had nine shoulder surgeries on the same shoulder, and it was a result of a traumatic accident that she had and Her doctor looked at everything. I think it was her maybe fourth surgeon who said, is there anything else you'd like to tell me about this? And just that, you know, when you see somebody start to kind of well up, tears you start to see the chin quiver those are kind of your cues to say is there anything else about that that you think might be relevant here or you think might be important you know there's some really great research or a growing body of evidence that shows us that we're not just our physical bodies and things that have happened in the past tend to have a big impact on our perception of physical sensations so you know do you think there's anything else that might be relevant here.

34:03 You don't have to be a psychologist. And I don't train people to try to be a fake psychologist. That's not in anyone's best interest. But when physical therapists use psychological techniques, they have success. And if you think about it, you probably have used many of these in your treatments already. You know, cognitive behavioral therapy, you get people to reframe something. Acceptance commitment therapy, you get them to understand this is your reality right now. This is where we're starting from. This is going to be a little bit uncomfortable. This is going to be challenging. There are a lot of different ways. Some of the things that I teach have some EMDR basis where we're doing bilateral movements or bilateral manual treatments.

34:53 So we can use these psychologically informed practices without being psychologists and be very effective. What would you suggest someone read? I like to ask people who read and speak a lot, like where they go for the well and who sort of said it really well that really impacted you. So specifically about pain, what lands with you or what do you like a lot? Yeah, I like, of course, The Body Keeps the Score. Vander Kolk, Peter Levine is certainly a great resource there. There's also a great book called What Happened to You? That is by Bruce.

35:35 I'll think of it. And he is a psychologist who's worked with a lot of children with trauma. And he talks a lot about the associative learning that happens there. So he had a kid that was in foster care and there was one particular caregiver or teacher that this kid really had a problem with and he got really aggressive with him and they couldn't understand why. And the reason he was in foster care was because of an abusive parent. And when they brought this parent in, they had a conversation with the teacher, they talked about strategies and things like that.

36:16 And it wasn't until they brought this parent in and they realized they both wore Old Spice cologne. And that was this kid's trigger to say, you are not a safe person to me. And if you think about smell, you know, it's so subconscious, you don't even need your conscious processing. It happens almost immediately. Yeah. Um, also one of the, one of the strongest senses tied to memory. I learned that from a sitcom in the nineties. That's exactly right. That's exactly right. And Bruce Perry is his name. What happened to you? He's written a couple other books as well that are great.

36:59 Yeah, and really pain is a memory. Chronic pain is a memory. And so again, when we think about it as a threat detection, we think about it as a memory. Then we're thinking about treatment in a very different way than within traditional physical therapy where I just, you've got to get stronger. You've got to get more mobile. You've got to get X, Y, Z. All right, we have a tradition on the show. It is called the parting shot. This is the parting shot. One last mic drop moment. No pressure. Just your legacy on the line. I want to thank Empower EMR for supporting the show.

37:42 If your clinic is stuck on an EMR that slows you down, Empower gives you cleaner workflows, faster documentation and support that actually shows up. Find them online at EmpowerEMR.com. And U.S. Physical Therapy. A nationwide network of clinics focused on developing clinicians, supporting career growth, and helping PTs build sustainable futures in the profession. Find them online at usph.com. So here's your parting shot question, Megan. If healthcare providers could change one belief about chronic pain over the next five years, what belief would you make the biggest difference for patients? What would your priority for a belief change be?

38:24 my priority for a belief change would be that patients are not just their physical bodies physical therapy is personal and when we provide whole person care and create a connection with our patients we can really make change with chronic pain connect with Megan on Instagram. I'll put the link in the bio, as they always say, or the show notes will do that. But thanks for doing this. I appreciate it. Yeah. Thank you so much for having me. That's it for this one, but we're just getting warmed up. Smash follow, send it to a friend, or crank up the next episode.

39:08 Want to go deeper? Hit us at pgpinecast.com or find us on YouTube and socials at pgpinecast. And legally, none of this was advice. It's for entertainment purposes only. Bulls**t! See, Keith? We read the script. Happy now?