Latest / The Driven Athlete / Joint Pain Management, Spinal Health, & Cutting-Edge Treatments w/ Dr. James Ghattas | Ep 46

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Joint Pain Management, Spinal Health, & Cutting-Edge Treatments w/ Dr. James Ghattas | Ep 46 · The Driven Athlete

• 0:00
  Speaker 1: If you're a driven, active person who wants to reach and pursue a higher quality life with some ambition, then guess what this podcast is for you.
• 0:07
  Speaker 1: This is the Driven Athlete Podcast.
• 0:10
  Speaker 1: What's up?
• 0:12
  Speaker 1: Y'all?
• 0:13
  Speaker 1: It's your man, dr Kyle.
• 0:14
  Speaker 1: Driven Athlete Podcast.
• 0:15
  Speaker 1: Welcome back.
• 0:16
  Speaker 1: We got Dr James Gaddis with us again.
• 0:18
  Speaker 1: Thanks for coming in.
• 0:19
  Speaker 1: I know you're a busy dude, so appreciate it.
• 0:21
  Speaker 1: It's good to be back.
• 0:22
  Speaker 1: Thank you, and especially with some interesting interactions that happened today before you got here.
• 0:30
  Speaker 1: We'll leave those off the record.
• 0:31
  Speaker 1: It's awesome.
• 0:32
  Speaker 1: So I appreciate you coming in.
• 0:33
  Speaker 1: Remind everybody again where you're at your practice, name what y'all do and what you're focused on.
• 0:40
  Speaker 2: Definitely so, dr James Gaddis.
• 1:00
  Speaker 2: I run Palm Beach Regenerative Sports and Spine.
• 1:05
  Speaker 2: It's a regenerative orthopedics practice musculoskeletal issues for two and a half months now.
• 1:09
  Speaker 2: So we're on a roll, that's awesome.
• 1:12
  Speaker 1: I mean, we're getting busier, I assume.
• 1:14
  Speaker 2: Yeah, definitely getting busier, thank God.
• 1:15
  Speaker 1: Cool, that's awesome and helping people, that's the main thing.
• 1:18
  Speaker 1: Clarify everybody orthobiologics what that means.
• 1:22
  Speaker 2: Stem cells yeah everybody orthobiologics, what that means, stem cells?
• 1:25
  Speaker 2: Yeah, so orthobiologics is basically using your own tissues to treat any sort of musculoskeletal problems.
• 1:30
  Speaker 2: So uh, prp, plasma, super concentrated platelets, uh mesenchymal stem cells which comes from your bone marrow, and then a host of other things like prolotherapy and adipose and uh youuronic acid, things like that.
• 1:45
  Speaker 1: Yeah, Cool yeah.
• 1:47
  Speaker 1: Prolotherapy I've had several providers definitely recommend that and think it's a good option.
• 1:55
  Speaker 1: We'll explain more of that.
• 1:57
  Speaker 2: Yeah, I love prolotherapy because of its simplicity and how effective it is.
• 2:03
  Speaker 2: So it's literally dextrose, 12.5% dextrose.
• 2:07
  Speaker 2: You can mix it with some ropivacaine to make things more comfortable for the patient and it's injected into a variety of tissues like tendons and ligaments, in order to do two things.
• 2:19
  Speaker 2: One, it kind of acts as an osmotic gradient to sort of tighten up ligaments and tighten up tendons that are sort of lax or loose and have some instability.
• 2:27
  Speaker 2: Okay, and it is a mild irritant to the tissue.
• 2:30
  Speaker 2: So it triggers a mild inflammatory response to kind of kickstart that healing cascade again.
• 2:36
  Speaker 1: Right Okay, prolotherapy.
• 2:37
  Speaker 1: It creates a mild irritant.
• 2:38
  Speaker 2: Mm-hmm.
• 2:39
  Speaker 1: And purposefully to create an inflammatory response or, in the cascade of purposeful um regenerative process right?
• 2:47
  Speaker 2: Yeah, exactly.
• 2:48
  Speaker 2: So the whole, the whole premise is that you know, we heal and regenerate from injury because we have blood supply.
• 2:55
  Speaker 2: So, like when you cut your skin, the first thing that shows up obviously is bright red blood, and then the blood kind of slows down and you platelets start to aggregate and then the blood stops and then you get a scab and then, however many weeks later, you're left with either a scar or a minimal scar or something like that.
• 3:10
  Speaker 2: So blood kind of carries all of our healing cascade.
• 3:14
  Speaker 2: Our musculoskeletal tissue, specifically ligaments and tendons, just inherently don't have that good of a blood supply, and cartilage too I forgot to mention.
• 3:23
  Speaker 2: And so what happens is the rate of degeneration sometimes outpaces our ability to heal and so we need to encourage blood flow to go into that area.
• 3:34
  Speaker 2: So by injecting prolotherapy or this dextrose solution, you're kind of essentially injuring the tissue very mild injury and so it redirects blood there, kind of cues the body to say, hey, there's an injury here, let's divert some nutrients, divert some blood and so on to that area.
• 3:50
  Speaker 2: So it's logistically super simple because it's you don't have to take blood and process and do this, and that it's readily available.
• 3:57
  Speaker 2: So it's a great tool to have for most practitioners.
• 4:00
  Speaker 1: It's a I mean, it's makes total sense.
• 4:02
  Speaker 1: And also it sounds like a lot of the direct dry needling, right the effects that we try to pursue with purposely stimulating a healing response, a little bit of micro trauma, right?
• 4:11
  Speaker 1: Yeah, exactly, muscular tendon disjunction or at the tendon or the insertion site for something like a long-standing rotator cuff type pain or elbow tennis, elbow pain, whatever, um, for a tissue that's degenerative at this point, like a tendinosis versus like it's acutely inflammatory.
• 4:28
  Speaker 1: You know, inflammatory response but to stimulate a purposeful healing response and blood flow, mild microtrauma and then the cascade of healing and it beelines all the blood flow and all the healing factors that would accommodate with that yeah, exactly what have you I'm sure you've I with dry needling.
• 4:44
  Speaker 1: We do it very often with that.
• 4:46
  Speaker 1: Was you with prolo therapy in addition to dry needling?
• 4:49
  Speaker 1: Would that be too aggressive or do you think it's a good follow-up treatment?
• 4:52
  Speaker 2: Um, no, actually I think that's a great idea.
• 4:55
  Speaker 2: When I was on Colorado, we would frequently have our you know patients who are getting treated with either prolo or SCP uh, be immediately evaluated and seen by our therapist that we had in-house then and he was very talented at dry needling.
• 5:09
  Speaker 2: He actually trained a lot of the other PTs in the Denver area on dry needling, so we would use them hand in hand and it basically, yeah, the 30,000-foot view keeps that.
• 5:22
  Speaker 2: It keeps you in that state of healing response as opposed to it sort of you know, dying down and kind of entering into that sort of chronic phase.
• 5:31
  Speaker 1: Right, you mentioned cartilage, right, which, from our understanding, is, I mean, basically aneural and avascular.
• 5:38
  Speaker 1: Yeah, and some interesting research that I've come across and was presented with and I was like this makes total sense of like maybe this is the cure for arthritic changes, degenerative arthritis, which is like progressive and you can't reverse it.
• 5:52
  Speaker 1: But some research I mean I'm going to get your opinion on this, but what I've been exposed to and seen and I'm like yo, this makes total sense and hopefulness, right, totally.
• 6:00
  Speaker 1: And like a thought of like how do we approach this then?
• 6:03
  Speaker 1: Of repetitive, intermittent compression of the joints, which is exercise, right, oh yeah, purposeful, exactly what that is.
• 6:12
  Speaker 1: Purposeful compression?
• 6:13
  Speaker 1: It's just a matter of like not being too aggressive.
• 6:16
  Speaker 1: What they're finding in some of the research is like pre and post MRI imaging is for arthritic cartilage joints.
• 6:24
  Speaker 1: They take an image eight months prior, 12 months, like this is like a 12 month, 24 months time, um, with purposeful, non-aggressive, non-inflammatory exercise where, like, your symptoms would tell you, right, this is too much right.
• 6:39
  Speaker 1: So it's like I feel good, I feel loose, I feel warmer, I actually feel better now than I did 20 minutes ago after doing it or an hour ago, versus for doing some exercise, some movement stuff.
• 6:46
  Speaker 1: Okay, cool if we keep it at that level.
• 6:49
  Speaker 1: For 12 months at post, mri was showing more vibrant, brilliant and thicker cartilage, whereas a control group that wasn't any exercise was still thinner and more brittle, yeah, and I was like, how is that possible?
• 7:02
  Speaker 1: Though?
• 7:03
  Speaker 1: If it's avascular, neural, I well, maybe it's just growing from the subchondral bone and growing vertically from there, like, if you imagine, like from underneath, and it's feeling the compression from the subchondral bone and it's stimulating an adaptation underneath that and growing cartilage from the ground up.
• 7:18
  Speaker 1: Um, that's, I don't know.
• 7:19
  Speaker 1: That's what I was maximizing, right, like that, really explaining, maybe it's just a response.
• 7:24
  Speaker 1: And then also the argument of, like the synovium and the synovial fluid, um, for the nutrients to stimulate more of that and then imbibe through the cartilage.
• 7:34
  Speaker 1: I don't know what your thoughts on that yeah, I mean it's.
• 7:37
  Speaker 2: It's almost like poetic, right.
• 7:39
  Speaker 2: You know, if you kind of step away from the you know the deep technical science and you just sort of look at like what these cells are.
• 7:47
  Speaker 2: A cell is basically this, you know, factory.
• 7:51
  Speaker 2: It's got a purpose, it's got a function and its function begets its structure or vice versa, sorry, its structure sort of begets its function, meaning that the way it's built kind of determines what it does and it sort of you know, it doesn't have like a consciousness, it doesn't know that like, oh, I'm a cartilage cell and I know how to make it basically relies on its environment to tell it what to do.
• 8:13
  Speaker 2: It relies on its immediate environment to tell it what to do.
• 8:15
  Speaker 2: And so if you are a cell that is primarily responsible for taking blood from the matrix of bone and then putting out cartilage on the other side, at that sort of like bone cartilage interface, then you need the stimulus to tell you that, oh, it's cartilage making time.
• 8:31
  Speaker 2: It's time, yeah, and the time to make cartilage is when there's impact and friction and movement and you know dynamic forces and so on.
• 8:37
  Speaker 2: So it's just, and then you can kind of apply that principle to almost any cell type.
• 8:42
  Speaker 1: Yeah, there's a study that I came across that I was like this is mind blowing.
• 8:47
  Speaker 1: It was like I think it was in the running or in the conversation, like a Nobel prize almost, but it was a study of a group of beagles, dogs and a control group and then a group of experimental beagles and they tested their knee cartilage and did an image ahead of time, um, and then for that it was an 11 year study.
• 9:10
  Speaker 1: Oh, 11 years, the whole lifespan of the dog.
• 9:12
  Speaker 1: Yeah, exactly, and they had them wear a double weighted vest of their body weight, a double body weight vest, and they ran seven miles five days a week for 11 years.
• 9:23
  Speaker 1: Yeah, versus the control group that just played normal dog stuff.
• 9:27
  Speaker 1: And at the end of this is what gets controversial they sacrifice the dogs and they open their knees up to investigate their cartilage, and the experimental group that ran so much.
• 9:35
  Speaker 1: Their cartilage is thicker, more vibrant, yeah, and more resilient and, like, looked healthier, whereas the control group was more brittle and thin.
• 9:42
  Speaker 1: And so, anyway, suggesting what?
• 9:45
  Speaker 1: What's like?
• 9:45
  Speaker 1: Well, maybe exercise running in this particular, you know, with dogs as an example, but just the compression that comes with exercise, resistance training or running might actually be beneficial and not detrimental for degenerative changes.
• 10:00
  Speaker 2: Yeah, I mean, it's like we're finally sort of coming to this understanding that you know that as a soft, squishy, fleshy organism, we adapt to our stimulus and so if your body is put under this demand where you need to exercise and do certain activities, it will adapt, barring any other genetic disorder or something like that, or maybe some mechanical issue that is causing a repetitive injury or something like that, or some you know.
• 10:23
  Speaker 1: You know, maybe some mechanical issue that is causing a repetitive injury exactly I feel like, yeah, that being said, like it's just a matter of trying to limit the compensation patterns as much as possible and disparities in like strength, stability and joint range of motion, where something's going to take more brunt of the impact and other things take less brunt.
• 10:43
  Speaker 1: So you would imagine the ones that take more brunt are going to get broken down faster.
• 10:46
  Speaker 1: Yeah, you can't disperse the forces distributed equally or just too much.
• 10:50
  Speaker 1: Yeah, like just overload, right, you're just training.
• 10:52
  Speaker 1: It's just too aggressive and too much past the point of like a benefit and now we're just detrimental.
• 10:57
  Speaker 2: You know like that makes total sense, that actually like that interface that you're kind of describing.
• 11:02
  Speaker 2: Right.
• 11:02
  Speaker 2: There is sort of the sweet spots for me, because you know, most often if you get somebody who's got some sort of you know kinetic chain dysfunction or a movement disorder, essentially, and you get them in with good therapy and they respond to it great, but if their tissue is like already sort of exhausted, there's like a threshold beyond which the tissue just can't keep up.
• 11:25
  Speaker 2: Uh, the demand that it's put under, and so that's where doing biologic injections tends to make the most difference at least Does it facilitate what you want.
• 11:36
  Speaker 2: Yeah, it's like okay, I'm going to give that tissue the tools it needs to sort of respond to the stimulus that we're giving.
• 11:41
  Speaker 1: Yeah, yeah, what.
• 11:42
  Speaker 1: In what situation would people find themselves where?
• 11:45
  Speaker 1: That would be a huge benefit, Like what's, what's the profile, what's the time, what's their symptoms and stuff.
• 11:52
  Speaker 2: Yeah, I mean.
• 11:53
  Speaker 2: So a common example I see is, um, people with neck pain or cervicalgia, and that is usually because at some point in their life they sort of lost that posterior curvature of the neck, they lost that cervical lordosis, and we're going to start seeing that a lot more in the coming years because of our text culture, you know.
• 12:13
  Speaker 2: I mean, I have it, my neck is straight as a board, but basically you sort of see that clue that they're going to start having micro instability and degeneration and things like this.
• 12:25
  Speaker 2: And if they don't respond to PT in the sense that they leave therapy every time and just feeling like they're not getting any better or there's so much pain to where they're kind of reflexively inhibiting muscles, yeah, then you should know by like a few weeks if that's like okay, if continued therapy is going to, you know, help or not or do they need a boost.
• 12:54
  Speaker 1: Basically, To intervene.
• 12:55
  Speaker 2: Yeah, yeah.
• 12:55
  Speaker 2: So the way I see that in clinic is, you know, I'll see somebody for an initial problem.
• 13:01
  Speaker 2: If they're, you know, in therapy or not yet in therapy, I'll get them in and we'll do a follow-up, we'll do some.
• 13:07
  Speaker 2: I'll use that time to get imaging which takes a few weeks in some cases and then also follow up and see how they're doing with their therapy.
• 13:15
  Speaker 2: And if they're like, I mean, there's an asterisk by this, but if they're really, you know, trying their best and they're actually getting good quality therapy and they're they're still not improving, then I know like, okay, we definitely need to definitely need to intervene somewhere.
• 13:31
  Speaker 1: Yeah, totally, yeah, it's interesting, is like for the right candidate, or if someone's like it's not getting better and it's been going on for a long time.
• 13:41
  Speaker 1: Um, I've said some mentors, because I I just get frustrated.
• 13:45
  Speaker 1: Be like, why aren't you?
• 13:45
  Speaker 1: We're doing this, you know, I'm like I'm intervening here.
• 13:48
  Speaker 1: Like this is, you should be getting better.
• 13:49
  Speaker 1: You're doing exercises and like well, I'm doing some of them.
• 13:52
  Speaker 1: Like okay, well, that could be better, of course, but like wait, this doesn't make sense.
• 13:55
  Speaker 1: I'm getting frustrated.
• 14:07
  Speaker 1: And they're like well, ask them other questions.
• 14:08
  Speaker 1: Like what is it?
• 14:08
  Speaker 1: What's your vision?
• 14:08
  Speaker 1: Look like, yeah, like what do you want out of this?
• 14:10
  Speaker 1: Let's say, like met with a magic wand, in like six weeks, you feel totally like you're.
• 14:14
  Speaker 1: You're what you want.
• 14:15
  Speaker 1: The outcome has been presented.
• 14:17
  Speaker 1: Ask, you know, like ask those type of questions like what do you want?
• 14:20
  Speaker 1: Like how are you feeling?
• 14:21
  Speaker 1: What do you?
• 14:21
  Speaker 1: What's like the ultimate win for you?
• 14:22
  Speaker 1: Like what do you?
• 14:22
  Speaker 1: What does this look like for you in six weeks or a year?
• 14:23
  Speaker 1: Like what do you want?
• 14:23
  Speaker 1: And like how are you feeling?
• 14:23
  Speaker 1: What do you?
• 14:24
  Speaker 1: What's like the ultimate win for you?
• 14:24
  Speaker 1: Like what do you?
• 14:24
  Speaker 1: What does this look like for you in six weeks or a year.
• 14:25
  Speaker 1: Like what do you really want?
• 14:26
  Speaker 1: You know, and like some of them sometimes would be like I just went for this insurance claim to follow through.
• 14:30
  Speaker 1: I hate that.
• 14:32
  Speaker 1: I'm like, oh, snap Duh, like not everybody wants to get better.
• 14:36
  Speaker 1: If and in addition, if there, even if there's not any insurance, involvement of like some kind of financial gain which is totally understandable, like it's just tough, right.
• 14:45
  Speaker 1: And then, as practitioners like us, we're like we want to help everybody get them all better and then be like we're, we're winning this Awesome.
• 14:51
  Speaker 1: You know, yeah, um, in addition to that, asking them questions about, oh, just getting to know them.
• 14:56
  Speaker 1: You know, like I haven't, cause we, since we spent so much time with people, we get it.
• 14:59
  Speaker 1: We have really interesting conversation.
• 15:00
  Speaker 1: I have very interesting conversations.
• 15:02
  Speaker 1: Conspiracy theory, like it's yeah, it's awesome.
• 15:05
  Speaker 1: I'm like, huh, okay, tell me more, but anyway, um, the uh at the top of their family and their, their relationships and stuff, and then they start sharing more information voluntarily, you know, and I'm like, oh, I see you've been in pain for a long time and you've been the center of attention for your family and family support, for all these doctor's visits and all these appointments.
• 15:27
  Speaker 1: Yeah, I didn't think about that and you were mentioning previously to like, but your childhood was like kind of traumatic.
• 15:33
  Speaker 1: By no means my mental health professional.
• 15:37
  Speaker 1: I'm just going off of what other professionals told me to mentors and stuff and I'm like it seemed, I'm like yo.
• 15:41
  Speaker 1: This makes sense.
• 15:42
  Speaker 1: My conversational topics, my expectations for treatment are gonna be a little bit different.
• 15:45
  Speaker 1: Imagine if this person were to get better and have no more pain.
• 15:50
  Speaker 1: Then they don't need any more doctor's visits and they don't need any more attention from their family.
• 15:54
  Speaker 1: So they feel like they're losing their social support and they feel like they're not important anymore.
• 15:59
  Speaker 1: But if they do have chronic pain and they're always an issue and they have all these appointments and they're always continually the center of attention, it's not like they're craving attention, it's more like I'm not an expert on this stuff unhealed trauma from previously that they need and a lack of support previously that they want more of that and if that's removed because of their pain gets better, then they ultimately lose.
• 16:22
  Speaker 2: Yeah, and that's the tricky part about chronic pain, because it sort of it like reinforces thought patterns, it sort of, and that's why it's hard to get out of chronic pain, because you basically have this stimulus.
• 16:34
  Speaker 2: Your brain, your conscious brain at least, is trying to process the stimulus and it, unless you like, sit and meditate on it or, you know, share your experience with someone and whatnot.
• 16:44
  Speaker 2: This is why psychotherapy is so important for chronic pain.
• 16:47
  Speaker 1: Oh my gosh.
• 16:47
  Speaker 2: Because if you're not directing like dedicated attention to why you're in pain mentally and emotionally, then your brain doesn't get the cue to sort of explore other thought patterns when it comes to dealing with the pain.
• 17:04
  Speaker 2: So you just kind of go into it.
• 17:05
  Speaker 1: I'm sure for you guys I mean, like the people that you've seen, that's chronic pain a lot.
• 17:08
  Speaker 2: Yeah, especially not so much in orthobiologics, actually, interestingly enough, I mean, we still have people, obviously, with chronic pain.
• 17:13
  Speaker 2: But what I've found is that there's a little bit of a selection bias, because by the time someone has found me or found a provider like me, they've done some research or they're in a community of people who are thinking this way and have told them.
• 17:27
  Speaker 2: So they're already in this mindset of, oh, I don't want to just magically get better, I want to heal, or like I want to repair, I want to fix the problem and to be in that mindset.
• 17:38
  Speaker 2: You're already kind of on a different mental.
• 17:41
  Speaker 2: You know, I guess page But'll.
• 17:44
  Speaker 2: I wanted to comment earlier when, when you're mentioning is that sort of uh, that train of thought where it's like, oh, I just want to get this pt out of the way, like I'm guilty, uh, because that that sort of culture starts in the doctor's office, because when you're beholden to the insurance model, what ends up happening is that physical therapy becomes an obstacle to your reimbursement.
• 18:10
  Speaker 1: Yeah, it's a gateway to like well, let's just stop messing around and let's just get this thing fixed or my settlement will come through to show that it failed Like oh great, you just belittled everything we do.
• 18:19
  Speaker 2: Yeah, exactly.
• 18:20
  Speaker 2: And like the words we'll say is like, okay, you got to get this physical therapy done so that we can do the injection.
• 18:24
  Speaker 2: And so in their mind they're like all right, let me just get this out of the way as fast as I can.
• 18:28
  Speaker 2: And so it's also that mindset starts there.
• 18:33
  Speaker 2: Unfortunately, you know, and that's again part of the reason why I left traditional sort of insurance-based pain management, because I know that in reality my treatments aren't as effective on their own and they're way more effective if the person is getting good therapy at the same time.
• 18:51
  Speaker 2: And when I say therapy very broadly, I mean that could be good chiropractic care, that could be shockwave, that could be dry needling, could be just exercise, that could be meditation, honestly.
• 19:01
  Speaker 1: So it's all out there.
• 19:02
  Speaker 1: Yeah, I think the chronic, the, the chronic pain thing, like it's just a a topic that I'm super interested in.
• 19:09
  Speaker 1: It just makes a lot of sense where, uh, and just the thought of like, you were saying, like, um, well, to quote a mentor's initial initial quote to bring this topic up to some of our lectures and stuff, he's like to quote Lil, pain is pain is an opinion, yeah, and I was like what, like, okay, cool, you're so hard, you know like, or you're so tough, but ultimately he's like, pain is an output, it's not an input.
• 19:32
  Speaker 1: Like your arm doesn't tell you it hurts, it just sends signals that are assimilated and digested and approved and you know, um decided, and then the decisions made yep, that hurts because it's inanimate.
• 19:43
  Speaker 1: The only thing that's actually a conscious and aware is our brains, right, yeah, like nothing else is actually aware and inanimate, so alive.
• 19:50
  Speaker 1: So like knee pain, neck pain, back pain, preferred pain, sciatica, like everything, it's just, they're just input signals.
• 19:56
  Speaker 2: Yeah, the actual, like the definition of pain.
• 19:59
  Speaker 2: If you look up I can't remember it's like the International Society of Stuff that Hurts, something like that.
• 20:05
  Speaker 2: The actual formal definition of pain is the perception of injury.
• 20:09
  Speaker 2: It's not actual injury.
• 20:10
  Speaker 2: So that right there, just in that word perception, it just holds all that detail.
• 20:15
  Speaker 1: Yeah, I love that.
• 20:16
  Speaker 1: I'm sorry about your neuro stuff.
• 20:17
  Speaker 1: Did you guys dive into that stuff too?
• 20:19
  Speaker 2: We did, yeah, and I think the one thing that stood out to me is I remember reading this one paper no-transcript of the brain or the cortex, and then deep inside the brain, on the inner surfaces of the brain, especially on the insides of the temporal lobes.
• 21:01
  Speaker 2: So if you think of your brain as a fist like this on the insides of the temporal lobe, so if you think of your brain as like a fist like this, you have like your frontal lobe here, whereas this is where you control like motor movement, strength, abstract thought, planning, language, speaking, things like that.
• 21:14
  Speaker 2: The back of the brain is more sensory and like visual, spatial interpretation, and then the very back of the brain is like visual.
• 21:21
  Speaker 2: Now you have this thumb here called the temporal lobe, and the temporal lobe is our like dictionary.
• 21:28
  Speaker 2: This is where we process sound language and communication.
• 21:32
  Speaker 2: On the inside of that, if you like, peel that thumb back.
• 21:35
  Speaker 2: This is called the mesial temporal lobe and in there is where we have our most primitive brain functions.
• 21:40
  Speaker 2: This is like anger, rage, this is where we like have, generate new memories and this is where we learn.
• 21:47
  Speaker 2: The hippocampus is in there, which is like a very important structure, and so we process pain sort of in two different areas.
• 21:54
  Speaker 2: We process pain out here and this gives you the where and what it's like.
• 22:00
  Speaker 2: I have pain right here and it feels like burning.
• 22:04
  Speaker 2: So it's like a very objective interpretation of pain.
• 22:08
  Speaker 2: But then we also interpret pain on the inside, there where we process our emotions, and this is like the why is this pain happening and what do I do about it?
• 22:16
  Speaker 1: There's some fear associated with it Exactly, or memories of previous incidences that are similar.
• 22:23
  Speaker 2: All of it, all of it or memories of previous incidences that are similar, all of it, all of it.
• 22:25
  Speaker 2: So it's basically taking that stimulus that you're experiencing and it's comparing it to prior experiences you've had and then trying to figure out what is the best plan going forward to sort of handle this.
• 22:35
  Speaker 2: And chronic pain arises when there is no sort of definitive plan about, like, how to make this pain go away, and so your brain starts to dwell and dwell on it, so much so that the little areas in the on that inside part of the brain that are responsible for sort of processing and perceiving this emotional component to pain, they actually hypertrophy, they grow.
• 23:02
  Speaker 2: We can see this on a functional mri.
• 23:03
  Speaker 2: So you put somebody, a normal person I hate saying normal person, but you put somebody without reports of chronic pain in an MRI and you do certain painful stimuli and you can see where those parts of the brain light up.
• 23:17
  Speaker 2: And then you put someone who has chronic pain or, let's say, fibromyalgia or something like that, and you do the same stimulus.
• 23:22
  Speaker 2: Well, first of all, their pain stimulus threshold is much, much lower.
• 23:27
  Speaker 2: So doing something to them that's not painful they're actually perceiving pain and we can see that because the pain center is lighting up in their brain and that center is literally volumetrically bigger.
• 23:37
  Speaker 2: So their brain has devoted more neurons and more nutrients and more resources to try and figure out why am I hurting.
• 23:45
  Speaker 2: And that doesn't happen just in the brain, that actually happens in the spinal cord as well, and that kind of explains why things like spinal cord stimulation can help with chronic nerve pain, because the spinal cord stimulator is sort of helping the spinal cord rewire or go back to its pre-chronic pain state.
• 24:02
  Speaker 1: Interesting.
• 24:02
  Speaker 2: But going back to that sort of illustration, here you have this where and what objective interpretation of pain, and then you have this like why and how interpretation of pain, and what you might see is that in individuals who have brain injury, traumatic brain injury to the cortex of the brain, there tends to be this vague ambiguity to their pain.
• 24:22
  Speaker 2: They don't know why or they don't know what kind of pain.
• 24:25
  Speaker 2: You ask them where does it hurt?
• 24:26
  Speaker 2: It hurts all over.
• 24:27
  Speaker 2: Like what does it feel like?
• 24:29
  Speaker 2: And they have a really hard time sort of describing to you what it is.
• 24:32
  Speaker 2: And that's because those areas of their brains are as damaged, you know it's not functioning as well as it could be, and so they're left with a relatively disproportionately high emotional component to their pain.
• 24:45
  Speaker 1: Interesting yeah and then-.
• 24:48
  Speaker 1: So and imagine then if somebody's been in chronic pain for a long time and that emotional, the mesenchymal, what was it?
• 24:55
  Speaker 2: The hippocampus or the mesial temporal lobe.
• 24:57
  Speaker 1: The mesial temporal lobe is hypertrophy, it's bigger.
• 24:59
  Speaker 1: The emotional components then would be amplified.
• 25:04
  Speaker 1: Yeah, is that accurate?
• 25:06
  Speaker 1: So it's interesting.
• 25:07
  Speaker 1: Similar to like if, like a traumatic brain injury patient with a cortical brain of like the objective, what and where is gone, then all is left is the emotional.
• 25:16
  Speaker 1: That's a great comparative.
• 25:19
  Speaker 1: Yeah, it's really high design when it's awful hurt with that and um, some studies and mental health professionals say the same thing of, like the emotional pain from getting a breakup or a loss is coming from the same region of the brain.
• 25:35
  Speaker 1: Is that accurate, um?
• 25:37
  Speaker 2: yeah, I mean gosh, I'd have to go back to my neuroanatomy, but uh, you know that, like rage and sadness and suffering, these, all these all come from that kind of same thing.
• 25:47
  Speaker 1: Mesial temporal cortex yeah, so that's what we're saying, like it's so emotional reactions to loss or challenging breakups and relationships, whatever it.
• 25:54
  Speaker 1: It hurts, right, they don't know how it hurts, but it just hurts.
• 25:58
  Speaker 1: That makes total sense.
• 25:59
  Speaker 1: Like I don't know where it hurts or what, but it hurts.
• 26:01
  Speaker 1: Hurts, hurts deep down, hurts in my heart, right, like relationship trauma, like difficulty with a breakup, like loss of a family member, you know, if someone's close to you, whatever.
• 26:11
  Speaker 1: That makes total sense.
• 26:13
  Speaker 1: Yeah, because you can't define it.
• 26:14
  Speaker 1: Like my arm doesn't hurt, but I'm aching right now.
• 26:17
  Speaker 1: It doesn't make sense, but anyway.
• 26:19
  Speaker 1: So imagine if somebody with, just in general, the thought of, like the biopsychosocial model of medicine, right Of, like the biology, the psychological component and then the social structure component that contributes to health, longevity and the pain experience man.
• 26:36
  Speaker 1: This connects so many dots and makes so much sense.
• 26:39
  Speaker 1: Pain is coming from the same region that emotional, physical pain, that emotional pain also comes from.
• 26:46
  Speaker 1: Yeah, so we can't disconnect the interplay between those two.
• 26:49
  Speaker 1: And physical pain still elicits some kind of an emotional response and you can't disconnect the mind from the body and like, oh my gosh, that makes so much sense yeah, and just to add to that, so what's sitting, you know, in between those two mesial cortex.
• 27:04
  Speaker 2: So imagine if I had a thumb here.
• 27:05
  Speaker 2: You know what's.
• 27:05
  Speaker 2: What's sitting, you know, in between those two mesial cortex.
• 27:06
  Speaker 2: So imagine if I had a thumb here.
• 27:07
  Speaker 2: You know what's.
• 27:07
  Speaker 2: What's sitting on the in between these two inside regions is your hypothalamus, and the hypothalamus is basically like your well, it's the, it's the headquarters for your entire endocrine system.
• 27:18
  Speaker 2: So that's where you get all the initial signals for, like you know, growth hormones and testosterone and estrogen and all these things.
• 27:26
  Speaker 2: So it also regulates your metabolism.
• 27:28
  Speaker 2: And then it's also the seat of your sympathetic nervous system, the fight or flight nervous system.
• 27:34
  Speaker 2: So, because they are so close, there is inevitably interplay there, and that's why, when you feel anger and rage, you vasoconstrict and your pupils dilate and you know you get your heart rate goes up and your blood pressure goes up.
• 27:47
  Speaker 2: And yeah, so it's, there's definitely direct communication there.
• 27:52
  Speaker 1: That makes a lot of sense.
• 27:53
  Speaker 1: So you get, it's just interesting, you can't neglect the physical changes can manifest, especially long-term, from um, emotional and mental stress, anxiety, like physical manifestations and symptoms happen from just stress and anxiety, yeah, um, and the mental and the emotional component which is interesting, cause, like with, at least from the conversations in our fellowship program we talk about, with pain science they always talk about we, we bring up like whatever you can't separate the mind from the body, um, and if there is chronic pain present, we things still hurt, even if there's perceived danger.
• 28:35
  Speaker 1: Yeah, real or perceived.
• 28:37
  Speaker 1: It's like my pain is an 8 out of 10.
• 28:39
  Speaker 1: Well, I can't tell you, just the same way as I can say how happy are you?
• 28:42
  Speaker 1: Well, I'm a 6 out of 10.
• 28:43
  Speaker 1: Well, you look like you're a three out of 10, happy, it's like really, you act like a three.
• 28:46
  Speaker 1: Yeah, you act like a three.
• 28:47
  Speaker 1: Wow, that sucks.
• 28:50
  Speaker 1: Like you can't tell somebody like, well, I'm an eight out of 10.
• 28:52
  Speaker 1: Well, no, you're not.
• 28:53
  Speaker 1: Well, how would you know that?
• 28:54
  Speaker 1: You can't right the people perceived danger or real danger to your tissues.
• 29:06
  Speaker 1: So like if someone's been in pain for 13 years with back pain from a car accident.
• 29:11
  Speaker 1: It's like well, tissues heal in six to eight weeks and bones heal in 12 to 16 weeks, depending on how healthy they are.
• 29:18
  Speaker 1: But how are they still in pain, where, if we're touching their back, how's this feel?
• 29:23
  Speaker 1: Does this hurt?
• 29:23
  Speaker 1: Does that not hurt?
• 29:24
  Speaker 1: And they're like jumping off the table and it's like that's not a painful stimulus, but it's painful for them and it's still real for them.
• 29:30
  Speaker 1: We're not discrediting that, but it's like that's not a painful thing.
• 29:35
  Speaker 1: And, according to the images and after surgery, structurally everything's good, like we're good, structurally the tissues are fine, but you're still in pain.
• 29:45
  Speaker 1: How's that possible?
• 29:46
  Speaker 1: It's like it's not real danger, it's just perceived danger at this point.
• 29:51
  Speaker 1: We're not going to tell patients that, of course, but like it's just perceived at this point.
• 29:54
  Speaker 1: So what are those perceptions and the fear associated with that?
• 29:58
  Speaker 1: And some of the memories with the hippocampus right, because that's short-term memory, right, or long-term memory, working memory?
• 30:04
  Speaker 2: It's working memory.
• 30:04
  Speaker 1: There's memory involved there too.
• 30:06
  Speaker 1: So it's like the memories involved and the hypothalamus whatever you're describing and the temporal mesenchymal.
• 30:13
  Speaker 2: Mesial temporal.
• 30:14
  Speaker 1: Mesial temporal lobe If you say it fast enough, it will just agree.
• 30:17
  Speaker 1: I was like no, you just said mesenchymal stem cell.
• 30:19
  Speaker 1: That's what I was.
• 30:20
  Speaker 1: Yeah, Mesial, temporal lobe man.
• 30:23
  Speaker 1: All the interplay, it makes total sense.
• 30:25
  Speaker 1: Yeah, Of like, we're going to get physical manifestations.
• 30:28
  Speaker 1: The emotional pain that comes with it is coming from the same center as physical pain.
• 30:33
  Speaker 1: We can't disconnect that, and it's been going on for a long time.
• 30:37
  Speaker 1: So the memories are still there and it still hurts, even though it's not actual danger of the tissue.
• 30:43
  Speaker 1: So it's like well, so what do we do Right, even though it's not actual danger to the tissue.
• 30:45
  Speaker 1: So it's like so what do we do right?
• 30:46
  Speaker 1: Like, how do you treat?
• 30:46
  Speaker 2: that I mean, you know, a big part of it is that there are actual structural, chemical changes happening to your nervous system in response to the chronic pain.
• 30:54
  Speaker 2: So, like you know, you have all the like supporting cells, what we call like microglia, which is like the scaffold of your nervous system.
• 31:02
  Speaker 2: They start to change in ways that promote this sort of perception and transmission of pain signaling.
• 31:08
  Speaker 2: So interesting.
• 31:10
  Speaker 2: Yeah, it's like you have to have a top down and a bottom up approach to treating pain.
• 31:17
  Speaker 2: And that actually illustrates another point that I see a lot in clinic, and that is that your images images, I mean, like MRIs and x-rays don't always, they rarely, correlate with your pain or the symptoms that you're having in severity and in location.
• 31:33
  Speaker 2: Totally true, yeah.
• 31:34
  Speaker 2: So I see patients that walk in and their MRI looks like a bomb went off and they're just like hey, I walk 10 miles every day, no problems, you know.
• 31:42
  Speaker 2: And then I see the opposite.
• 31:45
  Speaker 1: That's awesome, awesome.
• 31:45
  Speaker 1: That makes sense.
• 31:46
  Speaker 1: I walk 10 miles a day.
• 31:47
  Speaker 1: Yeah, exactly, nine holes of golf, I'm good yeah, and then I see the absolute opposite.
• 31:51
  Speaker 2: I see very, you know, mild, moderate, you know pathology on on an imaging and they are.
• 31:56
  Speaker 2: Their life is very disrupted by what's going on.
• 31:59
  Speaker 2: And I'm seeing physical changes because, like you know, they have boggy tissue textures.
• 32:03
  Speaker 2: They have, you know, they might be a little bit edematous over certain muscles or they have like ropey changes in their muscles and it's like, okay, there's obviously something happening.
• 32:11
  Speaker 2: Something that I've been meaning to explore more and I have a former attending when I was in neurology residency, who's, like, really done a deep dive on this is exploring the like cellular biology behind our fascia, the cellular biology behind our fascia, because we know now that a fascia is basically it's just an extension of our nervous system, it's the interface between our nervous system and our musculoskeletal system and it penetrates everything.
• 32:37
  Speaker 2: It's like cotton candy that just is all over the place.
• 32:39
  Speaker 2: And so I feel like, even if structures look fine and your spine looks fine, your alignments look good, good and your discs look good to our caveman eyeballs, you're still in pain.
• 32:51
  Speaker 2: That's probably because something's happening on a microscopic level that we can't appreciate.
• 32:55
  Speaker 1: Through the fascia.
• 32:56
  Speaker 2: Through the fascia, and I think that holds the answer to fibromyalgia as well.
• 32:59
  Speaker 2: And I think there is a very close interplay between the health of our fascia and our neurochemistry profile, like being I don't want to say serotonin deficient, but having depressive symptoms and being chronically fatigued and so on.
• 33:19
  Speaker 2: So there's definitely an interface there that I haven't been able to tease out yet, but I need to read more.
• 33:26
  Speaker 1: That's smart enough for that.
• 33:26
  Speaker 1: That's really interesting.
• 33:29
  Speaker 1: I mean, cause we we definitely have seen a plethora of patients that have chronic recurrences of pain.
• 33:36
  Speaker 1: You know reports of being a pain for a long time, where imaging looks unremarkable.
• 33:42
  Speaker 1: It's like, oh, some mild, maybe some moderate pathology evident on these images or the reports we're getting from the radiologist.
• 33:49
  Speaker 1: You know what I mean.
• 33:50
  Speaker 1: But there's definitely a disconnect of, like the symptoms and the prognosis and the functionality to what the image and structure is showing.
• 33:56
  Speaker 1: Where it's like let's not hang our hat on just what we're finding.
• 34:00
  Speaker 1: It also doesn't dictate if we're going to get better or not.
• 34:03
  Speaker 1: It's just a bummer because we see a lot of patients that come in and they're like my doctor told me that I have the back of an 80-year-old and it's bad and we're not ready to do surgery yet, just not yet, but we need to and you're effed until that.
• 34:20
  Speaker 1: So here's some Advil.
• 34:22
  Speaker 1: So you went in the doctors with like moderate back, mild to moderate four out of ten pain.
• 34:29
  Speaker 1: You left the doctor's office and that night your pain was eight out of ten.
• 34:32
  Speaker 1: Nothing changed yeah except the image and the conversation.
• 34:36
  Speaker 1: I'm like man, that was a detriment.
• 34:39
  Speaker 1: You know like we need to rule some things out.
• 34:41
  Speaker 1: I don't hate imaging by any means, you know, and I'm like that could be said differently.
• 34:44
  Speaker 2: You know what I mean yeah, and I wonder how much of it is also like expectation management too.
• 34:48
  Speaker 1: Oh, totally, yeah, totally For sure you mentioned Advil.
• 34:52
  Speaker 1: Yeah, okay, yes, you're going to make me wince, let's talk about that Cause.
• 34:55
  Speaker 1: That's one of my main thing.
• 34:56
  Speaker 1: We talked about it last time.
• 34:57
  Speaker 1: Yeah, I still want to ask about ibuprofen.
• 35:00
  Speaker 1: That's a bash, the company.
• 35:01
  Speaker 1: You know like.
• 35:02
  Speaker 1: I don't want to get sued Well it's generic.
• 35:05
  Speaker 2: now You're good.
• 35:05
  Speaker 1: Yeah, okay, perfect, nobody holds the patent.
• 35:06
  Speaker 1: Good, well, that's good.
• 35:08
  Speaker 1: And then the functional spinal unit yeah, but anyway, all right.
• 35:10
  Speaker 1: So ibuprofen Advil.
• 35:12
  Speaker 2: Yeah, so ibuprofen is like the flagship non-steroidal anti-inflammatory drug or NSAID.
• 35:18
  Speaker 2: Yeah, and that encompasses, you know, ibuprofen, naproxen, celebrex or celecoxib, meloxicam, cotorolac.
• 35:28
  Speaker 2: Oh meloxicam is an NSAID, mm-hmm.
• 35:30
  Speaker 2: Okay, cotorolac, diclofenac, etotolac, it goes on and on, and on and on.
• 35:35
  Speaker 2: There's so many of them and they are just you know, they're everywhere.
• 35:47
  Speaker 2: Some are over-the-counter like ibuprofen and naproxen, and then a lot are prescription based.
• 35:50
  Speaker 2: So naproxen sodium is a leave.
• 35:51
  Speaker 2: Yeah, naproxen is a leave.
• 35:51
  Speaker 2: Ibuprofen is Advil.
• 35:52
  Speaker 2: Motrin, I think, is like a blend of ibuprofen and aspirin and, I think, caffeine and then Tylenol acetaminophen.
• 35:59
  Speaker 2: Tylenol is acetaminophen.
• 36:00
  Speaker 2: That is not an NSAID.
• 36:01
  Speaker 2: That is an antipyretic, which means it works on your hypothalamus to regulate your core body temperature and regulate the inflammation, but it doesn't work on some of the enzymes that NSAIDs do.
• 36:16
  Speaker 1: Okay, yeah, but Tylenol, it blocks pain receptors then, or signaling too, or is it only temperature and it, yeah, it reduces inflammation by controlling your temperature, that's it interestingly enough.
• 36:30
  Speaker 1: Yeah, okay yeah.
• 36:32
  Speaker 2: So that's why in in my practice, I recommend using tylenol for post-procedural pain.
• 36:37
  Speaker 2: Uh, because it it doesn't act on.
• 36:40
  Speaker 2: It doesn't cause platelet dysfunction, it's not an anti-platelet, it doesn't act on, you know, your cyclooxygenase or lipoxygenase enzymes which kind of modulate this inflammatory response and produce different types of like tissue precursor cells.
• 36:54
  Speaker 2: So Tylenol doesn't affect any of that.
• 36:56
  Speaker 2: So I reach to.
• 36:57
  Speaker 2: You know, I recommend Tylenol for acute pain, but I don't recommend Tylenol for, like you know, everyday pain management, because inevitably you will get, um, oh, my God, the word is escaping me right now Uh, tachyphylaxis, which is a fancy word for just getting used to it.
• 37:15
  Speaker 2: So eventually your body sort of gets accustomed to having this outside source of this, of this kind of so it starts acting like decaf.
• 37:22
  Speaker 2: Yeah, you become a little bit dependent on it.
• 37:23
  Speaker 2: Yeah.
• 37:24
  Speaker 2: So you'll start to get like rebound headaches and rebound aching and stuff like that Interesting.
• 37:28
  Speaker 2: I always limit those kinds of medications to no more than, like, two to three times in a week.
• 37:34
  Speaker 1: Oh, wow, yeah, when does the oh gosh, what was the word?
• 37:37
  Speaker 1: Tachyphylaxis?
• 37:37
  Speaker 1: Tachyphylaxis?
• 37:39
  Speaker 2: Yeah, it can happen as quickly as three days.
• 37:42
  Speaker 2: Yeah, if you're using it every day for three days, you can develop a tolerance very quickly.
• 37:48
  Speaker 2: Interesting, and so a lot of the times.
• 37:50
  Speaker 2: So, because of my neurology background, I see a lot of headaches and I would say, like 70% of patients I see with headache have a medication overuse component.
• 38:02
  Speaker 2: Whether they know about it or not is different, but most of the time they don't know.
• 38:07
  Speaker 2: What's the common ones Tylenol, Advil.
• 38:10
  Speaker 2: Yeah, Tylenol, Advil, Aleve, aspirin like goodies and BC powder, all those things, and then in some cases, like the migraine rescue meds, like the Triptans and the Ergots and things like that.
• 38:25
  Speaker 1: Where does coffee fall on that?
• 38:27
  Speaker 1: I love coffee.
• 38:29
  Speaker 2: I'm a coffee guy.
• 38:30
  Speaker 1: I'm not a coffee snob, like I'm cool with Dunkin' Donuts, dude, like I'm.
• 38:34
  Speaker 1: Like yo give me one, give me one pump, otherwise it's like it's overwhelming.
• 38:37
  Speaker 1: Yeah, like, oh, that just tastes gross.
• 38:41
  Speaker 2: To be honest, I've like purposefully not really looked too much into coffee because I don't want to spoil it for me.
• 38:45
  Speaker 1: But what I do, I'm just going to like leave that unturned.
• 38:49
  Speaker 1: I'm not going to like open that up.
• 38:51
  Speaker 2: What I do know is that the rebound headache you get from coffee is because your art, like caffeine, helps us vasoconstrict.
• 38:58
  Speaker 2: It basically increases our sympathetic drive and tells our stimulant.
• 39:02
  Speaker 2: Yeah, it's a stimulant, so it tells our arteries to sort of tighten down, and that's why it wakes us up when we feel really great.
• 39:08
  Speaker 2: If you're dependent on caffeine and you go a morning without your caffeine, well those arteries are sitting there waiting for this signal to be like hey, tighten up.
• 39:17
  Speaker 1: Time to go to work.
• 39:17
  Speaker 2: Yeah Well, it's usually not an issue.
• 39:20
  Speaker 2: Where it becomes an issue is where the arteries penetrate the blood brain barrier or the meninges, so like at the, at the tiny little holes in the skull, particularly in the back of the skull, you have all these little holes called foramen, and your blood vessels go in and out of these.
• 39:36
  Speaker 2: Well, at that, uh, at that entrance of those little holes is your meninges, the wrapping of your brain, and those are loaded with pain receptors.
• 39:46
  Speaker 2: And so if you have an artery going through there and that artery relies on coffee to sort of constrict, and there's no coffee there, what happens is that artery is like kind of swollen and dilated and then it's pulsing, so it's pumping against the meninges.
• 40:00
  Speaker 2: It's like hitting the meninges.
• 40:01
  Speaker 2: Yeah, where?
• 40:02
  Speaker 1: is my coffee yeah.
• 40:03
  Speaker 2: Where's my coffee?
• 40:04
  Speaker 2: And you're getting that like just back of the head headache.
• 40:07
  Speaker 1: Sometimes you get it here, so we'll have to have a whole podcast on headaches.
• 40:09
  Speaker 1: That's super interesting yeah um, yeah, that's all because not, definitely not a strong suit of mine, but anyways, um, well, that's really cool, all right, so then, so that's tylenol, and you recommend that for post post procedural, short-term reliefterm relief.
• 40:24
  Speaker 1: Yeah, I was going to ask you that.
• 40:25
  Speaker 1: Let's say, there's an athlete who's like you got a competition, I got to, we're playing today.
• 40:30
  Speaker 2: Yeah.
• 40:30
  Speaker 1: I need.
• 40:30
  Speaker 1: I got hurt.
• 40:31
  Speaker 1: I need something to feel better.
• 40:32
  Speaker 1: Yeah, I was told by a trainer back in my day I like sprained my ankle really bad and we were playing like a major school and I wanted to try like we're.
• 40:41
  Speaker 1: It was a big time thing and I was like I'm playing yeah like my ankle was jacked, I was black, it was huge, you know.
• 40:51
  Speaker 1: I couldn't walk on it for two days after I sprained or something, maybe.
• 40:53
  Speaker 1: Yeah, wrapped it up, try to get the swelling out.
• 40:54
  Speaker 1: And then I was like I'm practicing tomorrow, like I'm not not practicing because I gotta practice this week in order to travel for later this week.
• 41:00
  Speaker 1: And the trainer was like, just wrap it, take three at sorry, take four, advil, at breakfast, four lunch and four at dinner for the next three days.
• 41:07
  Speaker 1: So 12 a day for the next three days, I know Dang.
• 41:12
  Speaker 1: I was like, yes, sir, yeah, I'm getting out.
• 41:14
  Speaker 2: What are you going to?
• 41:14
  Speaker 1: say no, I'm like I want to play.
• 41:15
  Speaker 1: So I wrapped it up.
• 41:17
  Speaker 1: I practiced that day, hurt, Like it Didn't feel great, loaded up on Advil Didn't feel good, but anyway, yeah.
• 41:26
  Speaker 1: So what do you do?
• 41:26
  Speaker 1: What do you recommend?
• 41:27
  Speaker 2: Tylenol then yeah.
• 41:28
  Speaker 2: So if it's like an acute injury, like a sprained ankle, and you know there's swelling and heat and bruising, then it's probably appropriate to take an NSAID, especially if, like you, have to do something the next day, like what you just described.
• 41:43
  Speaker 2: Like sports or something have to do something the next day like what you just described?
• 41:48
  Speaker 2: Yeah, but how long to be your go-to or what would you suggest?
• 41:50
  Speaker 2: Well, it really depends on, like the uh how do I say the foundation of sort of pain relief that you have right.
• 41:54
  Speaker 2: So if you are someone who is like you know, in a pro-inflammatory state just kind of like the average pro-inflammatory state then reaching for what I would otherwise recommend, which is like Tylenol, curcumin and heat like you know, topical heat, or like a heat pad or like a CBD cream.
• 42:18
  Speaker 2: Okay, you know that's what I would recommend, but if you are not, let me how do I rephrase this?
• 42:25
  Speaker 2: It's like it might not be strong enough and you might need an NSAID in that case, which I'll also talk about the timing of NSAIDs, because that's important as well.
• 42:33
  Speaker 2: In general, what I recommend for acute pain is Tylenol.
• 42:38
  Speaker 2: You know, your max daily allowable dose of Tylenol is three grams, 3000 milligrams.
• 42:43
  Speaker 2: So if you're going to take Tylenol, take enough so that it actually makes a difference.
• 42:47
  Speaker 2: So take a thousand milligrams and then take it again in six hours if you need to, but don't exceed 3,000 milligrams.
• 42:56
  Speaker 1: For the day or for each dose.
• 42:58
  Speaker 2: For the 3,000 milligrams is the daily dose?
• 43:01
  Speaker 2: Yeah, 24 hours, yeah, but if you're going to take it, you know, take a whopping dose up front, just so you can actually make that difference.
• 43:08
  Speaker 2: Um, curcumin, uh, which is a derivative of the um, or, excuse me, turmeric, which is a extract of curcumin, um, with black pepper extract, is, you know, a good option as well.
• 43:22
  Speaker 2: That's more of like a long-term kind of solution.
• 43:24
  Speaker 2: So, because it acts on a different mechanism, it's more of like a genomic transcription thing where it like reduces your expression of inflammatory markers in general over time.
• 43:35
  Speaker 2: So it doesn't act like a quick acting, like we would expect Tylenol or Advil to, but it is a good baseline to build on.
• 43:43
  Speaker 2: Also, omega-3 fatty acids, omega-3 specifically.
• 43:47
  Speaker 2: So when you buy a supplement you got to look at the label and see how many milligrams of omega-3 is there, compared to like six and nine and other things.
• 43:55
  Speaker 2: So 3,000 milligrams of omega-3 fatty acids acts in a similar fashion as an anti-inflammatory, without the platelet dysfunction, okay.
• 44:05
  Speaker 2: So Tylenol, omega-3, curcumin, and then CBD ointments Okay, and not to shamelessly name drop or anything, but there's a CBD that I use and recommend, called CBMD, and they're basically high potency, third party verified.
• 44:25
  Speaker 2: You know all the above.
• 44:26
  Speaker 2: And it's got like menthol and camphor in it as well, so it like gives you that cooling kind of distraction effect as well.
• 44:31
  Speaker 1: Interesting.
• 44:32
  Speaker 2: Yeah, and it's a cream?
• 44:33
  Speaker 1: What are the oil?
• 44:34
  Speaker 1: What's the beauty oil?
• 44:35
  Speaker 2: Yeah, you can do Like under the tongue Tinctures.
• 44:37
  Speaker 2: Yeah, I personally think tinctures are great for more like low-grid chronic pain and uh like anxiety okay has mood stabilizing effects.
• 44:48
  Speaker 2: It also kind of helps gut health.
• 44:49
  Speaker 2: So if you want more of like a general health approach, then yeah, the tincture is probably better cool, that's really cool.
• 44:54
  Speaker 1: All right, um man, I've been taking turmeric with black pepper and I'm open to ideas for brands and stuff just from costco, because it's the biggest.
• 45:02
  Speaker 1: Yeah, qnol is the brand yeah, qnol yeah is that solid?
• 45:06
  Speaker 1: I think so how much?
• 45:07
  Speaker 1: And then, uh, stacking that with fish oil nordic natural, from when I was told and confront or tell me what your thoughts the epa and dha molecules was the most.
• 45:18
  Speaker 1: That's the thing you want to look for the most density of of his effectiveness.
• 45:22
  Speaker 1: Yeah, is that correct?
• 45:26
  Speaker 2: just to make sure it's omega-3 and not nine or six like you were saying yeah, I mean from what I know is that you want to find the omega-3, but I I should probably look into that a little bit more okay, um, and then, but taking all those simultaneously, what dose of turmeric?
• 45:40
  Speaker 2: I think it's um.
• 45:43
  Speaker 2: What I have is 300 milligram.
• 45:45
  Speaker 2: Yeah, it's a 300 milligram dose of curcumin yeah, um.
• 45:49
  Speaker 1: And then what about ginger?
• 45:50
  Speaker 1: Um, have you heard any anti-inflammatory properties with that?
• 45:54
  Speaker 2: anecdotally I haven't honestly looked into it too much.
• 45:57
  Speaker 2: Okay, I do know that.
• 45:58
  Speaker 2: Um, there's something called resveratrol.
• 46:00
  Speaker 2: Resveratrol is an extract from the skin of the grape that is very good at maintaining what's called like endothelial health.
• 46:09
  Speaker 2: So on the inside of the arteries it has this thin, one cell thick lining called endothelium and that's basically like where all your first responders are to any sort of vascular injury, and so resveratrol helps kind of like stabilize that membrane so that it's not so reactive and oxygen like oxidative so I would imagine that would help with thrombolytic type of development or atherosclerosis stroke.
• 46:35
  Speaker 1: Interesting yeah, what's it called?
• 46:37
  Speaker 2: resveratrol cool.
• 46:39
  Speaker 1: All right, that's cool, that's.
• 46:41
  Speaker 2: That's very interesting, yeah and then I think I've read that vitamin D also has some anti-inflammatory effects as well.
• 46:47
  Speaker 1: Interesting.
• 46:48
  Speaker 1: I've heard a lot of things about turmeric and black pepper.
• 46:50
  Speaker 2: Yeah.
• 46:50
  Speaker 1: The QAnon I've been taking recently.
• 46:51
  Speaker 1: I'm researching about ginger apparently some similar effects.
• 46:54
  Speaker 1: It was like turmeric, black pepper and ginger and then taking omega-3, yeah, and then coffee, and coffee.
• 47:07
  Speaker 2: But yeah, and then coffee and coffee.
• 47:07
  Speaker 2: But I like the cbd, that's good, that's a good idea.
• 47:09
  Speaker 2: So that that's one thing that, like I'll admit is, is, uh, an area that I could, I wish I could dedicate like a lot more time.
• 47:14
  Speaker 2: And reading is getting stronger with my supplements, yeah, and like supplementing diet, because I feel like there's just so much room for improvement in that arena and you can get lost in the literature.
• 47:29
  Speaker 1: Yeah, totally All right.
• 47:30
  Speaker 1: So explain, advil, why is it no bueno.
• 47:33
  Speaker 2: Yeah, so basically the non-steroidal anti-inflammatory is they act in like a bottom up fashion.
• 47:41
  Speaker 2: So they basically take, you know, your platelets which modulate the inflammatory reaction to sort of injury and they cause platelet dysfunction.
• 47:51
  Speaker 2: They inhibit molecules like cyclooxygenase and lipoxygenase and essentially what's happening is by taking these medications you are stopping inflammation by stopping the cells that start the healing cascade.
• 48:12
  Speaker 2: But if you have to take them, it's better to take them in the morning than at night, Because throughout, you know our kind of diurnal course of the day, from the moment we wake up to the moment we go to sleep, we sort of accumulate micro injuries just from being around and existing, and that's fine, just from being around and existing and that's fine.
• 48:38
  Speaker 2: But at night, when we're getting good sleep, that's when our and this is why REM sleep is so important and just having a good sleep hygiene is so important, because that is the opportunity for our body to sort of assess what has gone on that day and then damage control and then heal and repair basically.
• 48:54
  Speaker 2: So that has to happen at night.
• 48:55
  Speaker 2: That's why when you pull an all-nighter, you have a sleepless night or you're not getting good sleep or you have sleep apnea.
• 49:01
  Speaker 1: That's why your chronic pain gets worse is because you're never really getting that opportunity to enter that healing, repairing lymphatic phase of sleep yeah, and then stress and anxiety increase because you're not sleeping good and you're hurting more and you're not sleeping good because of that, and then you have more anxiety because you're not sleeping exactly, and then you have more stress and the stress affects your memory and concentration.
• 49:20
  Speaker 2: yeah, um.
• 49:22
  Speaker 2: So if you taking NSAIDs at night, you're essentially just stopping that that healing and repairing process that your body naturally goes through at night, and um so.
• 49:34
  Speaker 2: So there was a study where they it was like a mouse study where they, you know, they induced tibial fractures in the mice and then they had some mice take NSAIDs at the beginning of the day and then like an actual pain medication, like oxycodone or something like that, at night, and then vice versa for the other mice and I can't remember what time period, but basically they sacrificed the mice and then they looked at how the bones were healing and essentially the mice that were taking it at night they just had way worse nonunion and they were worse off essentially.
• 50:15
  Speaker 2: So we know that taking NSAIDs at night is probably not a good idea, interesting Okay.
• 50:22
  Speaker 2: So you have to take it.
• 50:24
  Speaker 1: Take it with food in the morning, in the morning, but you're not a fan of it just because it blocks from the ground up the natural inflammatory responses that we want to have happen.
• 50:32
  Speaker 1: That would facilitate healing otherwise.
• 50:36
  Speaker 2: And it stops things like cartilage growth.
• 50:38
  Speaker 2: Um, it's inhibits blood flow to you know very, very small capillary beds.
• 50:45
  Speaker 2: So things that are vulnerable to that are like your vertebral discs.
• 50:49
  Speaker 2: Your vertebral discs don't really get their own blood supply to begin with, so they kind of require this sort of uh diffusion of blood across, like the end plates from the bones, and so that kind of stops that blood flow.
• 51:03
  Speaker 2: So they're not getting nutrients, so now they're more susceptible to being degenerated.
• 51:09
  Speaker 2: Naproxen, for example, is the worst for cartilage because it inhibits this molecule called lipoxygenase which is responsible for making the fatty chemicals.
• 51:22
  Speaker 2: That sort of are part of a building block for cartilage.
• 51:26
  Speaker 2: What else I mean?
• 51:28
  Speaker 2: The list goes on.
• 51:29
  Speaker 2: The other big one is that, similar to what we were talking about with Tylenol earlier is there's that tachyphylaxis effect, so you become quickly dependent on it.
• 51:37
  Speaker 2: The way I see it, progress is like someone has an injury and then they take the NSAIDs in order to sort of get over that pain and be able to function for like the next day or something like that, but then it quickly transitions from that to now they need it in order to get over any sort of pain and then it transitions to now I need it every day to just kind of not have pain in general.
• 51:59
  Speaker 2: Um, and so then they become quickly dependent on it and then that you know, the degenerative issues start to sort of speed up at that point yeah, yeah, and if that's becoming decaf for them next step?
• 52:12
  Speaker 2: what do you mean?
• 52:13
  Speaker 2: Decaf?
• 52:13
  Speaker 1: like decaf, like it's not capped, like it is.
• 52:15
  Speaker 1: Oh it's, yeah it's, like it's not effective you know yeah then that would assume that they would try to pursue um prescription-based pain meds yeah, it ends up happening.
• 52:25
  Speaker 2: If the over-the-counter ones aren't effective, then you know they go to their doctor and the doctor goes okay, well, here's meloxicam or here's silicoxib, you know so what's but meloxicam from?
• 52:36
  Speaker 1: it's a muscle relaxer.
• 52:37
  Speaker 1: Is that correct or no?
• 52:38
  Speaker 2: No, that's, oh my gosh.
• 52:40
  Speaker 2: Wow, the words escaping me.
• 52:44
  Speaker 2: No, meloxicam is an anti-inflammatory, and then I can't remember.
• 52:49
  Speaker 2: I don't know why I can't remember the muscle relaxer.
• 52:52
  Speaker 2: It'll come to me.
• 52:54
  Speaker 2: There's like four common ones, yeah.
• 52:57
  Speaker 1: I'm drawing a blank too, because I've seen all the time I haven't prescribed it in so long.
• 53:00
  Speaker 1: Well, there you go for getting.
• 53:02
  Speaker 1: Well good, yeah, um so, but like meloxicam is an NSAID, it's just a prescription med instead.
• 53:07
  Speaker 2: Yeah, it's a prescription NSAID, and uh, its whole thing was, um, either it was either meloxicam or or celicoxib.
• 53:15
  Speaker 2: One of them was had a theoretically less increased risk for heart attack and stroke and then the other one theoretically had a less risk for stomach ulcers and things like that.
• 53:26
  Speaker 2: So what ends up happening is you get this medication that some trial showed like, oh, it's a little bit decreased risk of this, and then insurance companies will approve that for any person that has knee pain and has a history of peptic ulcer disease, so they're getting that met.
• 53:41
  Speaker 2: Or anyone that has back pain and has a history of coronary artery disease, they're getting that other one.
• 53:46
  Speaker 2: And so how valid is that data?
• 53:49
  Speaker 2: I don't know.
• 53:52
  Speaker 1: Yeah.
• 53:52
  Speaker 2: There's kind of an agenda behind it.
• 53:53
  Speaker 2: I don't disagree, but I'll stop there, otherwise I'll disappear at some point.
• 53:57
  Speaker 2: Yeah, no more podcasts.
• 54:00
  Speaker 1: I'm not paranoid exactly.
• 54:03
  Speaker 1: Well, that's no, I'm on the same boat, man.
• 54:04
  Speaker 1: I think, like man, insurance it makes sense to cool concept.
• 54:13
  Speaker 1: It's just a naturally human greed, I feel like it's just.
• 54:14
  Speaker 1: Which is always the problem, it seems like for everything, um, it's just becoming so convoluted and difficult that, like, health insurance runs the world pretty much, yeah, from my understanding, where big farm is still the little brother as you ever see, that there's a netflix documentary on this, um, I don't know, just chronic chronicling that.
• 54:33
  Speaker 1: It's just super interesting.
• 54:34
  Speaker 1: And oh, there's this really cool joe rogan podcast that they dive into this.
• 54:37
  Speaker 1: Yeah, and the guy he used to work for, he was an insurance sales rep, um, and, and also pharmacology, our pharmaceutical sales rep, and he was like we were still beholden to the insurance company.
• 54:47
  Speaker 1: Like big pharma is still the little brother to insurance.
• 54:49
  Speaker 1: They dictate the world right now, especially in the health care at least.
• 54:52
  Speaker 1: Yeah, but anyway.
• 54:53
  Speaker 1: And the thing about the companies that invest and own those health insurance companies, i'm'm just saying I don't know, man, like something's going on here.
• 55:01
  Speaker 2: You know it's kind of like you know, since I stepped away from that, it's like ignorance is, I guess, is kind of bliss, but I should probably stay in tune, stay in tune.
• 55:10
  Speaker 1: Yeah, interesting.
• 55:12
  Speaker 1: And then our last thing well for today, do you mention the functional spinal unit, right?
• 55:17
  Speaker 1: And then our last thing well for today, do you mention the functional spinal unit?
• 55:20
  Speaker 1: Right for just the lens and how you all perceive how the cervical spine, thoracic spine and lumbar spine work together.
• 55:23
  Speaker 1: Yeah, Explain more of that.
• 55:25
  Speaker 2: Yeah, so the functional spinal unit is kind of how we break down the spine, and so the spine, as you know, is like this Jenga tower of vertebrae and you have these three main domains.
• 55:37
  Speaker 2: You have the cervical thorac, know, is like this Jenga tower of vertebrae and you have these three main domains.
• 55:38
  Speaker 2: You have the cervical, thoracic and lumbar.
• 55:40
  Speaker 2: They're all kind of shaped a certain way because they're tasked with a certain function, and so the functional spinal unit is comprised of the interface between two adjacent segments, so the bottom half of one vertebrae and the top half of the vertebrae below it and everything in between, and so that is basically.
• 55:59
  Speaker 2: We'll take lumbar spine, for example, so like the bottom half of L1 and the top half of L2.
• 56:05
  Speaker 2: So that is the interface between that and the disc, so the intervertebral disc.
• 56:10
  Speaker 2: There is sort of the midline.
• 56:11
  Speaker 2: Then you have the facet joints, which is in the I should have brought my spine model the facet joints, which is the, the joints in the back of the spine.
• 56:23
  Speaker 2: Yeah, I'm such a nerd doing all this stuff with my hands.
• 56:24
  Speaker 2: Yeah, um.
• 56:24
  Speaker 2: So yeah, you have like the vertebral bodies.
• 56:25
  Speaker 2: They're interfaced with the disc.
• 56:27
  Speaker 2: Then you have, you know, the, the joints that are formed when you stack two vertebrae on top of each other, and those are the facet joints.
• 56:35
  Speaker 2: Um, then you have you have the spinal canal and the neuroframin, which is where the spinal cord and the spinal nerves sort of go through or exist, and then all the ligaments that hold them together.
• 56:48
  Speaker 2: So around the vertebral bodies you have the anterior longitudinal ligament and then behind that the PLL, posterior longitudinal, and then you have spinal cord and then behind that you have the ligamentum flavum, which is like this big, thick yellow ligament basically, and then interspinous, supraspinous, intertrans, so there's just a whole network of ligaments that sort of hold these two vertebrae together.
• 57:09
  Speaker 2: And then you have all the muscles that are what I call one-to-one deep stabilizers or deep segmental stabilizers.
• 57:17
  Speaker 2: These are muscles that start from one vertebrae and go to the immediately adjacent vertebrae, as opposed to long segment stabilizers which go from one to like three, four, maybe even more vertebrae down the road.
• 57:29
  Speaker 2: So all those structures make up the functional spinal unit and when we approach a degenerated spine or a painful spine, we have to examine all the structures in the functional spinal unit and figure out how are they.
• 57:48
  Speaker 2: We have to get away from the pain generator model, the current sort of pain management model is like find the one thing that hurts the most and stop.
• 57:56
  Speaker 2: That management model is like find the one thing that hurts the most and stop that.
• 58:01
  Speaker 2: So when you do that you inevitably end up chasing your tail because you're going to stop one thing and then another thing becomes now the main problem and then the next thing becomes the main problem.
• 58:06
  Speaker 2: But if you look at the functional spinal unit, then you can figure out where did that dysfunction arise and how, and then if you can treat those things, all of those functional units inside that model, then you can promote stability in that spine.
• 58:22
  Speaker 2: So the thing I see most commonly in the lumbar spine at least we'll use that as a common example is you have these two units, you start to have degeneration of the disc.
• 58:34
  Speaker 2: Now, disc degeneration is like wrinkles.
• 58:36
  Speaker 2: We all have it.
• 58:36
  Speaker 2: I think 30% of the population above the age of 20 has some degree of disc degeneration of the disc.
• 58:37
  Speaker 2: Now, disc degeneration is like wrinkles.
• 58:38
  Speaker 2: We all have it.
• 58:38
  Speaker 2: I think 30% of the population above the age of 20 has some degree of disc degeneration.
• 58:42
  Speaker 2: And so when a disc degenerates I think I stole that from your podcast like a couple of weeks ago actually yeah, On the imaging.
• 58:50
  Speaker 1: Yeah, it was like insane.
• 58:52
  Speaker 1: But like 45% of people over the age of 43 have some kind of it's crazy Like 73% of people at 43 years old 45 years old.
• 59:00
  Speaker 2: Yeah, it's a lot, so I love it.
• 59:01
  Speaker 2: When somebody comes in, they're like it's my slept disc.
• 59:03
  Speaker 2: I'm like join the party.
• 59:05
  Speaker 1: It's the old L5 S1.
• 59:06
  Speaker 1: It's like, okay, everybody has that.
• 59:10
  Speaker 2: So you start out with this nice plump, healthy disc and the height of that disc matters because if you have a plump disc then the ligaments that are holding those things together are taut.
• 59:20
  Speaker 2: They're under the appropriate amount of tension that they need to be under.
• 59:22
  Speaker 2: If that disc starts to degenerate which we can talk about what causes the disc to degenerate later.
• 59:28
  Speaker 2: But essentially that disc gets like little microfissures and it's wrapping and it starts to leak the contents of a disc and gradually over time even without herniations or protrusions or extrusions whatever over time that disc starts to lose its height.
• 59:43
  Speaker 2: It just kind of slowly shrinks and I can see that on an MRI, because a degenerated disc goes from this nice shiny, white-looking plump disc and it starts to turn gray and then black and then you see it sort of shrink.
• 59:55
  Speaker 2: When you lose that height, those ligaments that are stabilizing that unit in the front, back and the sides become a little bit lax right, and so now you have this just micro instability, a little bit of wobble between those units.
• 1:00:07
  Speaker 2: You also have now increased pressure and load on those facet joints that were in the back.
• 1:00:13
  Speaker 2: Those facet joints are not really supposed to bear any weight, they're supposed to dictate movement and so you get this kind of wiggly, wobbly unit, right?
• 1:00:23
  Speaker 2: Well, your brain senses this because it has a lot of position sense fibers in there and it says, hey, there's something wrong, this is moving not the way it should be, we need to stabilize this.
• 1:00:34
  Speaker 2: So it sends an order to the muscles to say work overtime, so those muscles clamp down.
• 1:00:39
  Speaker 2: Muscle guarding spasms.
• 1:00:41
  Speaker 2: Muscle guarding spasms yeah, that acute spasm is exactly that.
• 1:00:44
  Speaker 2: That like, oh, I was in bed for a week.
• 1:00:47
  Speaker 2: That's a muscle spasm because something has become unstable suddenly.
• 1:00:52
  Speaker 1: Like enough danger was perceived for everything else to take action Like oh, hang on, yeah, exactly, and those muscles clamp.
• 1:00:55
  Speaker 1: Was perceived for everything else to take action by hope.
• 1:00:57
  Speaker 2: Hang on, yeah, and those muscles clamp down and then if they don't really get a good blood supply or they're kind of weaker than they should be, then they don't get the blood and the signals that they need to relax, and so that muscle is stuck in that contracted position almost like rigor mortis, and that is painful.
• 1:01:13
  Speaker 1: Yeah, sucks.
• 1:01:15
  Speaker 2: Yeah, all right.
• 1:01:15
  Speaker 2: So you get that a little bit of instability.
• 1:01:20
  Speaker 2: Their brain senses it contracts those muscles down.
• 1:01:21
  Speaker 2: Now those muscles are working over time without getting paid over time and they start to inhibit, they start to shut off or atrophy because now they're not getting the appropriate nutrients.
• 1:01:31
  Speaker 2: You know, those deep segmental stabilizing muscles with, aka the multifidus muscles, they start to suffer first and then they start to recruit the help of their neighbors, the long segment stabilizer muscles.
• 1:01:45
  Speaker 2: And so now those things are not only are they're doing intricate long distance work, but now they also have to work overtime and stabilize their immediate segments.
• 1:01:55
  Speaker 2: So now they're getting overworked and they attach to other things, like your rib angles, they attach up a little bit higher.
• 1:02:01
  Speaker 2: So now down the road you start to get like trigger points and pain along the margins of your ribs, going back to the spinal unit itself.
• 1:02:11
  Speaker 2: That little bit of instability and that increased movement starts to wear down the ligaments and then the ligaments try to repair themselves, but they repair themselves in a disorganized fashion.
• 1:02:23
  Speaker 2: So they start to get a little bit thicker, the ligaments that are inside that spinal canal.
• 1:02:28
  Speaker 2: When you lose that height they start to buckle and they buckle in towards the spinal cord and they buckle in towards the spinal nerves.
• 1:02:37
  Speaker 1: It narrows the space for the cauda equina and the spinal cord, exactly so it's a cascade of a lot of stuff.
• 1:02:43
  Speaker 2: Yeah, and so you have to, really are the ligaments and the muscles and the facet joints that are implicated in that degenerated level.
• 1:03:03
  Speaker 2: No matter what you do, you have to treat those.
• 1:03:05
  Speaker 2: Then, outside of that, you sort of decide which structures are symptomatic and which structures are you know, like if somebody has some degenerative scoliosis structures are, you know, like if somebody has some degenerative scoliosis?
• 1:03:20
  Speaker 2: I know that at the apex of that you know that curve, there's going to be facet irritation, facet joint swelling.
• 1:03:24
  Speaker 2: So we're going to treat that facet joint.
• 1:03:25
  Speaker 2: I know that there's probably going to be some narrowing around that nerve root, so we're going to do platelet lysate injections there to wash out some of those inflammatory markers and give the nerve some nutrients.
• 1:03:35
  Speaker 2: And then in some cases, if the disc is not completely degenerated or if it's got an annular tear or if it's bulging a little bit, then you can actually put platelets into the disc itself to help sort of seal up whatever that annular fissure was, so that it stops losing its goodies.
• 1:03:54
  Speaker 2: The other thing to keep in mind is when you have a degenerated disc.
• 1:03:57
  Speaker 2: The other thing to keep in mind is when you have a degenerated disc, it's leaking out its contents and those contents are primarily what's called glycosaminoglycans.
• 1:04:05
  Speaker 2: It's like these sugary molecules, very caustic to the nerves.
• 1:04:08
  Speaker 2: And so, without even touching a nerve or having a bulging disc that's compressing a nerve, you have this inflammatory milieu that's just irritating the spinal nerve root and so the patient would start to feel increased nerve symptoms.
• 1:04:25
  Speaker 2: They would have sensitivity, they would have tingling, they'd have pain, the muscles would be twitching and fasciculating because that nerve is like firing off when it shouldn't be.
• 1:04:32
  Speaker 2: As opposed to structural compression of a nerve, the lifeline of an irritated nerve or the lifespan of an irritated nerve is healthy.
• 1:04:42
  Speaker 2: Nerve starts to get irritated because of those caustic chemicals and you have increased nerve symptoms.
• 1:04:47
  Speaker 2: Now let's say that disc continues to degenerate and it bulges and it starts to touch the nerve.
• 1:04:51
  Speaker 2: Now Well, initially you're going to get that classic lightning bolt sciatic pain because something is touching those sensory fibers on the outside of the nerve as it continues to compress that, those sensory fibers on the outside of the nerve die off.
• 1:05:04
  Speaker 2: So the pain goes away.
• 1:05:06
  Speaker 2: You might think, oh, I'm getting better.
• 1:05:09
  Speaker 2: Compression continues and now that pressure is starting to affect the motor fibers on the inside of that nerve.
• 1:05:15
  Speaker 1: You drop foot.
• 1:05:16
  Speaker 2: Yeah, and so then you start to get weakness and then, if that continues, then you get atrophy and so on.
• 1:05:22
  Speaker 2: So it's like increased nerve symptoms and then now decreased nerve symptoms.
• 1:05:26
  Speaker 1: And referred.
• 1:05:27
  Speaker 1: Yeah, yeah, interesting man, that's crazy.
• 1:05:30
  Speaker 1: I could see and imagine where it's like.
• 1:05:33
  Speaker 1: Let's help from a patho and atomical standpoint, which is orthopedic surgeons, which they deserve a ton of respect, and the insane rigorous academic directions like it's insane and they're super smart.
• 1:05:47
  Speaker 1: But I could see from their end right, they, they're very, their lens is super patho and atomical of like, okay, here's a wobbly spinal unit, let's just fuse that thing.
• 1:05:57
  Speaker 1: Yeah, problem solved.
• 1:05:59
  Speaker 1: Or there's narrowing of the foramina where the nerve root passes through, or the disc contents is compressing against the nerve and encroaching on there.
• 1:06:06
  Speaker 1: Let's just debride that out, clean it up, create more freedom of movement for the nerve and then get the disc contents that are contributing to issues.
• 1:06:14
  Speaker 1: Get that out of there too, clean it up, make it look structurally more sound.
• 1:06:18
  Speaker 1: Yeah, yeah, um, which can have good effects and then also cannot.
• 1:06:22
  Speaker 1: Yeah, and for at least for what I've been exposed to, the um outcomes after surgery for disectomy and for aminotomy, laminectomy, debridement, whatever all that stuff, but definitely not a fusion, um, it's.
• 1:06:38
  Speaker 1: It's not enough consistent outcomes of the positive for me to be like, oh yeah, problem solved.
• 1:06:45
  Speaker 1: Like dude, just get a dissect to me.
• 1:06:47
  Speaker 1: Probably like, just do that Totally.
• 1:06:48
  Speaker 2: Yeah.
• 1:06:49
  Speaker 1: I would.
• 1:06:49
  Speaker 1: I don't think I would go that route.
• 1:06:51
  Speaker 2: Yeah, it's like, but what are your thoughts on that?
• 1:06:53
  Speaker 2: I used to think, like all, I used to just put this kind of like ban on all, like, ah, surgery is bad, you don't, you don't need surgery.
• 1:07:00
  Speaker 2: Well, I've learned that that's not the case.
• 1:07:03
  Speaker 2: I think surgery, what surgery does really really well, especially nowadays, with a lot of advancements and how they do the surgery.
• 1:07:11
  Speaker 2: We have a little bit of a selection bias because we see patients that have chronic pain from surgeries.
• 1:07:19
  Speaker 2: They may have gotten years and years ago and the surgery technology was different back then.
• 1:07:22
  Speaker 2: And now what they're doing, you know, using augmented reality to directly place these pedicle screws and things like that.
• 1:07:29
  Speaker 2: It's come a long way and then they can do this and minimally disrupt fascia.
• 1:07:34
  Speaker 2: So I'm very hopeful in that regard.
• 1:07:36
  Speaker 2: Yeah, that's cool, minimally disrupt the fascia.
• 1:07:41
  Speaker 2: So I'm very hopeful in that regard.
• 1:07:42
  Speaker 2: So, where surgery is, um, great is that it is.
• 1:07:42
  Speaker 2: It's great for sort of restoring that proper structure right, especially in the cervical spine, where, where all the problems in the cervical spine arise from that loss of curve, you know, doing cervical fusion restores that curve and there are definitely good outcomes from that because you're kind of preserving nerve and spinal root when I personally think surgery falls short is that it's probably not addressing all the components of this person's pain.
• 1:08:09
  Speaker 2: And not because they don't want to or oversight, but it's just like.
• 1:08:12
  Speaker 2: Surgery is there to do one thing it's restore function, preserve nerves and preserve that sort of mechanism.
• 1:08:19
  Speaker 2: But it's not going to address fascial dysfunction, it's not going to address, uh like, muscle atrophy.
• 1:08:26
  Speaker 2: If anything, it could potentially make muscle atrophy worse.
• 1:08:29
  Speaker 2: And then you still have the adjacent segment disease problem that sort of shows up down the road.
• 1:08:34
  Speaker 1: Yeah.
• 1:08:35
  Speaker 2: And I'm kind of I'm I'm lumping surgery into fusion.
• 1:08:39
  Speaker 2: I'm talking about fusion primarily.
• 1:08:40
  Speaker 2: So when I think fusion is indicated, how are we on time?
• 1:08:44
  Speaker 2: We're good, Okay.
• 1:08:45
  Speaker 2: So when I think, when I think fusion is indicated, it's, it's definitely indicated, Meaning like if there's nerve root, severe nerve root compression, if there's spinal cord compression, if there's so much instability that you're getting like bone fractures and then you know this snipping site or like that.
• 1:09:01
  Speaker 2: You know the site where they excise disc that is probably prone to re-injury.
• 1:09:23
  Speaker 2: Or if you go in and do like a foraminotomy yeah okay, you cleaned up that joint, but we didn't address the instability that led to an arthritic joint in the first place.
• 1:09:31
  Speaker 2: Or, my favorite, these like minimally invasive spine things.
• 1:09:36
  Speaker 2: That has kind of taken pain management by storm, which is where they just oh, there's one problem here, let's shove a device in it and see if we can open up that problem.
• 1:09:45
  Speaker 2: And they just completely disregard the overall spinal mechanics.
• 1:09:50
  Speaker 2: There's something called an interspinous fusion device.
• 1:09:52
  Speaker 2: It's basically like a car jack that you wedge in between the spinous processes.
• 1:09:58
  Speaker 2: So if you have two vertebrae that are degenerated and kind of compressed and buckled down on itself, you have swollen facet joints and buckled ligaments and all that and it's causing stenosis around the nerves and spinal cord.
• 1:10:10
  Speaker 2: Well, this magic solution is you take this little jack and you completely obliterate the posterior ligaments, wedge this thing in between the spinous processes and then you just prop it open like that.
• 1:10:21
  Speaker 2: So now not only are you putting a tremendous amount of tensile force on those spinous processes that may fracture at some point, but you've also destroyed the posterior ligaments that maintain this crucial stability of the spine and you're in inducing kyph, you're getting rid of that natural curve.
• 1:10:40
  Speaker 2: Yeah, so it's just like you know these people are going to have problems down the road.
• 1:10:43
  Speaker 1: you know, I've never heard of that.
• 1:10:44
  Speaker 1: That's interesting yeah.
• 1:10:46
  Speaker 2: I mean, yeah, it's kind of crazy.
• 1:10:47
  Speaker 2: So there's definitely, you know, I think the most useful type of surgery there are these, the fusion type surgeries that are coming out now For cervical spine, for cervical spine, even now for some lumbar spine things.
• 1:10:58
  Speaker 2: But again, it's like when it's done well and it's done for the right indication, they have great outcomes.
• 1:11:04
  Speaker 2: But the problem is that, like, it ends up being the only option for a lot of people because they haven't been able to explore other options, they haven't found good therapy, they've exhausted corticosteroids or they don't know about orthobiologics or they can't afford it, something like that and so they end up getting surgery, because it's the only other option and you may not have good outcomes.
• 1:11:24
  Speaker 1: Yeah, I mean I definitely want to clear like I don't hate surgery by any means.
• 1:11:26
  Speaker 1: I think, oh yes, there's a time for it.
• 1:11:28
  Speaker 1: You know I want people to understand like I'm not anti-surgery.
• 1:11:31
  Speaker 1: There's definitely.
• 1:11:32
  Speaker 1: It could be life-saving, it could be great outcomes for people.
• 1:11:35
  Speaker 1: And I'd have to admit too, like I need to be mindful and conscious that we usually see people where they're still in pain and it hasn't been great for them.
• 1:11:44
  Speaker 1: But we don't see the people that are running around and feel great that had surgery and we don't even know that because we haven't seen them, because they're not having pain.
• 1:11:50
  Speaker 1: You know what I mean, so I can appreciate that.
• 1:11:58
  Speaker 2: I think it comes down to not really even the surgeon, but it comes down to the diagnosis.
• 1:12:00
  Speaker 2: It's like did they get the diagnosis correct?
• 1:12:01
  Speaker 2: You know if the person is in there with back pain because they have, you know, myofascial pain and you know iliolumbar ligament strain and all this stuff, and then you do a fusion like they're not going to have good outcomes, right.
• 1:12:12
  Speaker 2: But if they're having pain because they're having nerve root compression, okay, yeah, great Fusion is going to help.
• 1:12:16
  Speaker 1: Yeah, yeah, that makes total sense.
• 1:12:18
  Speaker 1: Awesome, man.
• 1:12:19
  Speaker 1: Well, I got two more ideas of podcast episodes with headaches.
• 1:12:25
  Speaker 1: Okay, yeah, and then just degenerative discs in general, more just diving into that.
• 1:12:30
  Speaker 1: I'll bring some models.
• 1:12:31
  Speaker 1: Yeah, totally, I have a spine model in my office.
• 1:12:35
  Speaker 1: I should have brought it with me too.
• 1:12:36
  Speaker 1: Like, oh, office, I should have brought it to you.
• 1:12:37
  Speaker 1: Like, oh, I should have brought my disc model.
• 1:12:38
  Speaker 1: It's like pulling out like ron burgundy, like I'm totally unprepared.
• 1:12:40
  Speaker 1: Here's a disc model.
• 1:12:42
  Speaker 1: Actually, let's talk about this.
• 1:12:43
  Speaker 1: It's like you're red dinner, everybody relax.
• 1:12:45
  Speaker 1: Yeah, that's awesome.
• 1:12:47
  Speaker 1: Oh yeah, man.
• 1:12:48
  Speaker 1: Well, dude, thank you, I appreciate.
• 1:12:49
  Speaker 1: That's really cool information and insightful stuff, especially about inseds and yeah yeah all that stuff.
• 1:12:57
  Speaker 1: That's cool, um, but if anybody wants to reach out to you, what's the best way they can hit you up?
• 1:13:01
  Speaker 2: Yeah, so you can go to my website, palm beach regen R E G E Ncom Um.
• 1:13:07
  Speaker 2: Our phone number's on there as well.
• 1:13:09
  Speaker 2: Or you can find me on Instagram.
• 1:13:10
  Speaker 2: It's doc.
• 1:13:11
  Speaker 2: Regen D O C R E G E N.
• 1:13:13
  Speaker 2: Uh, I think that's the same for my YouTube as well.
• 1:13:22
  Speaker 1: So, yeah, you can reach out.
• 1:13:22
  Speaker 1: Cool, perfect.
• 1:13:23
  Speaker 1: Yeah, we, we copied you on that car.
• 1:13:24
  Speaker 1: I love it.
• 1:13:25
  Speaker 1: I hurt my back that way.
• 1:13:25
  Speaker 2: That took three takes and my second one I was like that didn't feel good.
• 1:13:28
  Speaker 2: It was a funny angle Cause you had to go feet first, so you're kind of doing this like.
• 1:13:31
  Speaker 1: I did it backward, I don't know.
• 1:13:32
  Speaker 1: I was just like I'm just going to roll over this ball and then pretend and it looked somewhat cool.
• 1:13:36
  Speaker 1: I was like hopefully it will look as cool as Dr Dadis, awesome.
• 1:13:40
  Speaker 1: Well, thanks for coming in, man.
• 1:13:41
  Speaker 1: We'll definitely have round two.
• 1:13:42
  Speaker 1: I mean round three and round four with other things we can talk about.
• 1:13:45
  Speaker 1: We can talk about stuff all day and if you have any questions, we're always open to suggestions, comments, questions, concerns, podcast ideas and stuff.
• 1:13:52
  Speaker 1: And if any questions, we're always open to chatting with patients and maybe the best next direction you guys can go um and dr gaddis is definitely a great option for that um.
• 1:14:05
  Speaker 1: But if you have any questions, definitely reach out to us.
• 1:14:05
  Speaker 1: Our email is probably the best way team at athlete, rccom, or our phone number, 561-899-8725.
• 1:14:10
  Speaker 1: We're looking forward to chat with you guys and helping everybody in the community and we'll catch y'all next time right on.