95. Pain Care Redefined: Non-Drug Therapies for Pain Relief with Heather Tick, MD

Episodes have been transcribed to improve the accessibility of this information. Our best attempts have been made to ensure accuracy,  however, if you discover a possible error please notify us at info@bendybodies.org. You may notice that the timestamps are not 100% accurate, especially as it gets closer to the end of an episode. We apologize for the inconvenience; however, this is a problem with the recording software. Thank you for understanding.

***Note: Visit this link for more updated information on the risks of chiropractic neck manipulation. https://www.nytimes.com/2023/03/15/well/live/neck-manipulation-chiropractor.html

Linda Bluestein, MD (00:02.734)

Chronic or persistent pain is extremely common with connective tissue disorders like the Ehlers-Danlos syndromes, which is why we are so fortunate to have world renowned pain expert, Dr. Heather Tick with us today. Dr. Tick is a clinical professor at the University of Washington, Departments of Family Medicine, Anesthesia, and Pain Medicine. She is the first holder of the Gunn-Loke Professorship in Integrative Pain Medicine.

Her work is focused on clinical care and teaching, as well as research into comprehensive care, prioritizing effective, safe, and evidence-based non-pharmacologic options. Her goal for over 35 years has been to change how pain medicine is practiced. She chaired the Academic Consortium for Integrative Medicine and Health Pain Task Force, and served as the chair of the SIG, or Special Interest Group.

in musculoskeletal pain for the IASP, the International Association for the Study of Pain. We will also be discussing her two fabulous books and website, which is rich with information on health and integrative pain care. Dr. Tick, I have been so, so looking forward to this conversation. Hello and welcome to Bendy Bodies.

Heather (01:14.141)

Thank you so much, Linda. I am also have been anticipating this because I really admire your work. There is, there is, it's difficult to get information on the conditions that you cover and the focus on connective tissue. So this is very important work you do.

Linda Bluestein, MD (01:36.162)

Oh, thank you so much. And I have to say, I'm kind of, I'm gonna hold this up immediately to show this book of yours that I read when I was on vacation. And I have to just like, let's see, how can I do this? The entire thing is full of highlights and bookmarks, and it's just such a fantastic book. Of course, we're gonna dig into this more later, but if someone has not purchased this book by the end of this conversation, I'm sure they're going to, because

It is so, so valuable. Okay, yes, of course. So let's start out by talking about what is integrative medicine? Because I feel like that's a topic that is unfamiliar to a lot of people. And so if you could explain to us what that is and how that differs from traditional approaches.

Heather (02:08.422)

Thank you.

Heather (02:25.681)

So a lot of the language that we use here is problematic. We use the word traditional for aboriginal medicines as well, but we also use it for the way in which Western medicine has become very high-tech and sophisticated. So I will use the word conventional for that one, conventional medicine. So integrative medicine is

It's not just adding things to the menu that conventional medicine uses, which is what a lot of people think. It's actually a different approach. It's a different focus. It's looking at how do we achieve health? How do we help people achieve health? And there have been times when I will be talking to a patient and I'll say, how can we help you be healthier?

And they said, how can I be healthy if I have pain? I said, well, actually so much of you is healthy. You're just focused on the pain. Let's focus on the health. Because actually when you make people healthier, when you help them make themselves healthier, all conditions get better. Whether it's their blood pressure or their skin conditions or their stomach gastrointestinal stuff.

their liver disease can sometimes get better, their kidney disease can sometimes get better when they are looking after the basic fundamentals of health and their pain gets better. Our brain in general focuses most on what we practice. If we're constantly thinking about pain, we actually devote a larger part of our brain to that. So in integrative medicine,

what we try and do is change the conversation and find out what are the things that people eat, drink, think, feel, and do because those things contribute more to health than anything that medicine can do when we're dealing with chronic conditions. So conventional medicine has been brilliant. It's siloed medicine, it's highly specialized, and what that has led to is

Heather (04:46.545)

people who are experts and focused on very narrow parts of the body, but they've made brilliant advances. I don't wanna minimize how brilliant modern medicine has been in terms, especially of acute illnesses, but sometimes with chronic illnesses as well. But there's a difficulty when this expertise is in distinct categories, and those categories aren't communicating with each other regularly.

And so, you know, you have somebody, you know, the joke is, you know, I only treat the left shoulder. I won't treat the right shoulder, you know, taking it to the extreme. But, you know, sometimes it almost feels like it is that extreme. So integrative medicine tries to integrate all that. And yes, it does try to integrate other strategies as well, things that have been well-researched, like acupuncture.

Linda Bluestein, MD (05:20.014)

Yeah, exactly. Right.

Linda Bluestein, MD (05:27.766)

Mm-hmm.

Heather (05:41.409)

like manual therapies have a decent amount of research, music therapy, a lot of nutritional therapy has a ton of research on it that's showing benefit. So we try to include a lot of other things and be open-minded. So we talk about evidence-based medicine and included under the heading of evidence-based medicine is evidence-informed.

medicine because there are certain things that have money devoted to them which have the potential to make great profits for companies, unfortunately. And even though some of the funding comes through government, there's still a focus on pharmaceuticals and high-tech procedures.

And again, those have had brilliant outcomes, but we've left behind a lot of strategies, techniques, and practices that don't have sufficient research on them. They have some research that indicates benefit. They're very low risk. And so they're worth trying. And so we call that evidence informed when there is some research on it, but it is not definitive because there was no entity.

that was going to pay for millions of dollars in order to do a very large scale standard type research project. So that's where we come from.

Linda Bluestein, MD (07:19.118)

Okay, I love that those are really great points of clarification and such an important strategy. And in terms of pain management, I find that some people interpret that as the treatment of persistent pain with opioids. But you and I know that pain management can and should include so much more. So how would you define pain management?

Heather (07:41.413)

Well, to start with, I would get rid of the word management. And I would get rid of the word management and use care instead. Management has come to be, how do we deal with a chronic disease? Well, we manage diabetes, we manage high blood pressure. And with pain, it has led us down this pathway of, well, we start you on a high blood pressure pill and you have to stay on it forever.

Linda Bluestein, MD (07:46.089)

Okay.

Linda Bluestein, MD (07:51.31)

Mmm.

Heather (08:10.085)

because we don't see any way that it can get better without the keeping, staying on the pills. And when you do that with pain, of course it does exactly what you mentioned, which is it leads us to, it led us down this path of opioids. So that's the first word I wanna get rid of in that sense. The second word I also wanna get rid of is pain. I really encourage people

to break down what it is they're feeling. And this is, I have to say, this is a strategy I developed because of me, because of things that I was feeling in my body. And pain is an alarming word. And when you, and as I said before, when you use it over and over and over again, we devote more time to those pathways and to that focus.

pain starts to take up a bigger place in our brain and it's alarming. So it communicates with all the alarm centers and we know what that does. That gives people more distress, which gives you more discomfort. So I prefer other words. I think that if people think about what it is they're feeling and where. I have cramps in my legs. I have discomfort in this joint. I have

whatever they want to call it. And I have a stabbing feeling here. If you break it down that way, I think it's easier to tolerate because you have a certain understanding of what it feels like and therefore what the goal is, which is, hmm, I'd like to get rid of that stabbing feeling. Can I move differently so that gets better? Can I massage something? Can I press on something? Can I

do something with my physical body that's going to alter this physical feeling rather than this amorphous thing we call pain.

Linda Bluestein, MD (10:13.842)

Okay, and the title of your book is Holistic Pain Relief, and I held it up, but I should hold it up again here. So that is very, very interesting. So can you maybe just tell us who you think would most benefit from this kind of strategy that we're going to talk about today?

Heather (10:31.553)

Well, I've had somebody who was a doubled PhD in immunology and biochemistry, who was a nutrition expert say, gee, this isn't a pain book, this is a nutrition book. And partly that is true. It has probably more nutrition covered in it than more holistic nutrition covered in it than many nutrition books.

Heather (10:59.557)

So, I mean, anybody who has discomfort in their body, who has pain, and anybody who knows anyone who has pain, and anybody who wants to learn how to prevent, because that's a lot of what I talk about too, how do we keep from sliding down that slope.

Linda Bluestein, MD (11:19.086)

Sure, sure, that's great. And I have an acronym that I use for developing comprehensive treatment plans for my patients that I published about recently in the CME Journal, Topics in Pain Management, and it's MENDS-PMMS, and it stands for Movement, Education, Nutrition, Sleep, Psychosocial, Modalities, Medications, and Supplements. And it just helps me to remember the various different aspects of the...

plan that I want to create for my patients. And you cover so many different aspects in your book. And of course I will link that book in the show notes so people can access it for themselves. And I would encourage people if they don't, if they don't have the ability to purchase the book, which I don't think it's that expensive, for sure it's not that expensive, but they could also request it from their library because all libraries should also have this book. So, let's...

We're gonna dive into a few of the letters of that acronym because I think we have some great overlap there. And some of the other aspects like movement was covered quite a few times. Sleep, we just talked about in a recent episode, although I would love to hear your take on, of course, those things. But let's start with some of the other letters that I think we haven't covered as much. So first I wanna talk about education. And you and I belong to a group where we talk about pain and how to help people.

better improve their quality of life and things like that. And so I've heard you talk a lot about pain neuroscience. What do you think patients should hear about pain neuroscience? Why is it important for them to understand how pain processing works? How do you think that can benefit them?

Heather (12:58.329)

That's a great question. I think that it is really important for people to understand, number one, that all pain is experienced through the brain. So if you don't have a connection between body and brain, you can't feel anything that's going on in your body, but pain is an interpretation that the brain makes of all the different sensations that are coming up from the body.

And so that's the first thing. So what that means then is that, sometimes it's hard for us to figure out exactly what's going on in the body. Sometimes because of the entire web of connective tissue that permeates all of our tissues that we're only now beginning to understand and that most of conventional medicine really doesn't have a good grasp on.

But people like you do and people who are studying connective tissue in fashion now very extensively are really making great discoveries. The brain takes all that information, it processes it. It's a bit of an alarm signal for the brain. The brain really starts to trigger the alarm systems that we have in our brain. That then modifies our experience. Anything that's alarming is

is somewhat uncomfortable for us. And so that augments what the experience of pain is. And this leads us to a very, very effective strategy to deal with this, which is pain psychology. Pain psychology has really done a tremendous amount of work in coming up with strategies that help to turn around that alarm signaling system.

And that dramatically modifies the experience of pain. Doesn't mean that there's nothing going on in your body, but there might be things going on in your body that we have trouble figuring out. So while we're learning and while we're trying to explore and figure out what's going on in the body, let's at least take advantage of pain psychology, which has a tremendous amount to offer. And again, it doesn't mean this is a psychological problem.

Heather (15:21.621)

It is a neurological, physiological problem that involves the same biochemicals, the same naturally occurring neurotransmitters and inflammatory markers that make up all of our reactions. Because as I'm fond of saying, it's all the same ingredients and it's the same soup. And it's throughout our brain and body.

And so whatever we can do to modify the parts that are increasing the alarmingness of our experience, the better. So that's first off. And second, I think it's really important to understand that there are two major classes of pain that we distinguish, acute pain.

Acute pain is something, it's generally a short-term problem, but not always, and chronic pain. But really, timeline isn't really the difference between those two. It's mechanism that's the difference. Acute pain is really referring to pain where we can identify an origin. Like, oh, this is, you have a broken leg. That's why you have pain. Everybody understands that. You relax because you know what it is.

And so the experience of it is different than if it's something that's ongoing that nobody can put a name to and nobody can figure out what it is. When we're dealing with soft tissues, that's very often been the case that nobody can figure out what's really going on because they're not trained to figure out what's going on in soft tissues. And so far our technology has not been good at detecting

soft tissue abnormalities, and as we will get to, is movement abnormalities. So movement plays a huge role. And it is, in the medical profession, it is, it's really at a very rudimentary stage in terms of how conventional medicine looks at movement. So chronic pain, there are some mechanisms within the brain

Linda Bluestein, MD (17:26.145)

Mm-hmm.

Heather (17:46.913)

that begin a process called sensitization, which means it's like turning up the volume on certain signals in the brain. And a lot of it does involve the stress system. And that's part of what happens when we get chronic pain. But pain that lasts a long time can also be, especially with soft tissues and movement, it can be ongoing acute pain because

it's, we call it no-susceptive pain, which means something that's irritating, that's bothering us, that it's like, you know, I don't know, somebody poking at you, and sticking in you, you know, it can keep happening, even though each episode is maybe short-term, but it keeps happening. And so that does seem like it's chronic pain, but it isn't. It's an ongoing acute pain. So that's an important distinction that sometimes is hard to make.

Linda Bluestein, MD (18:41.389)

Hmm.

Heather (18:45.585)

for people. And then I think the other part of it is that we have to realize that there's a reason we get chronic pain. There's a reason our system becomes sensitized, and it's because it's built into our genetics. And this has been recognized by evolutionary biologists. They have looked at it. It's a relatively recent, like within the last 10 to 15 years.

recognize that this is a thing, that it isn't a maladaption. This is an adaptation. Chronic pain keeps us safe. It doesn't mean we want to keep it. It doesn't mean we like it any better. But we have to get away from the idea that we need to obliterate pain, which is the whole culture of opioids, painkillers. That doesn't make any sense.

to try and, I mean, we use warring imagery when we're talking about war on cancer, war on drugs, war on this, that, and the other thing, and war on pain. And it's that adversarial language, I think, just raises the alarm system even more. I don't think it's productive. And certainly in opioids land, that really has not been a helpful thing.

Linda Bluestein, MD (20:10.782)

That makes a lot of sense. I'm thinking back to when I was at my at my worst, which was in around 2009, 2010. And starting from then until about probably it was like 2014 or so when I came across a video by Dr. Dan Clough, one of our colleagues about central sensitization. And I was watching this video and the you know, many anesthesiologists so I had learned I had done some pain management and things like that. But I still

I had done some pain medicine in my residency, but then it just was so shocking and so informative, like watching this and I thought, this is what's happened to my body. Like the light bulbs went off because at that time I was suffering a lot. I wasn't just having a lot of pain, I was suffering. And a lot of that was, you know, the catastrophization and things like that I was doing to myself. And so...

it was very helpful to me to understand pain psychology. And I've had on the podcast, Dr. Beth Darnel, who I'm sure you know from Stanford, I'm sure you interact quite a bit. So, you know, it's great to understand those things and to have that kind of information, I think is very empowering to people because I think there's some things that we actually can control that we don't necessarily even need a physician to help us with. We can get that information and start working on those things ourselves.

Heather (21:31.376)

Absolutely.

Linda Bluestein, MD (21:33.734)

Okay, so let's talk about nutrition because I agree your book is really rich with lots and lots of information about nutrition And in fact on your website you have information about nutrition as well as some really great recipes many of which I have tried out Why is nutrition so important for those with persistent pain?

Heather (21:53.105)

Well, when we're dealing with computers, we all know the term garbage in, garbage out. And when you look at the standard American diet, the food that is readily available, the food that is subsidized by our government, it is highly processed. It has very little of its native nutrition left in it.

Linda Bluestein, MD (21:59.362)

Ha ha!

Heather (22:22.117)

and it is usually full of salt, sugar, and the wrong kind of fat. So the acronym is standard American diet, as you well know, called SAD, and it is. It's very sad. There are things that get sold as food in our country that would not be allowed in many other countries of the world. It's just illegal to use the additives and chemicals.

We have thousands of substances that are added to our processed foods, which have never been tested for safety. We have that it's shocking. We have thousands of food additives added to our processed foods, which have never been tested for safety.

Linda Bluestein, MD (23:02.03)

Could you say that again? That's really important.

That is shocking.

Heather (23:19.973)

So it's basically an unregulated area. And that's not counting the thousands, the tens of thousands of chemicals that have been released in our environment. Like, I mean, when I wrote the book, it was, I think, 70 or 80,000. It now has to be hundreds of thousands. Maybe, maybe not hundreds, maybe 150,000. But this is, and this is only the things, it's things like

pesticides and all sorts of chemicals are PFOSs and are our plastics and all our petroleum products. These are all things that the ones that are listed that are known are the ones in the developed world. The developing world may have others that we don't know about and they're still they become ubiquitous. They spread everywhere. There's DDT in penguins.

in the Antarctic. It's found now, even though DDT was banned a long time ago and was never used in the Arctic. Our children are born with pesticides in them, with toxics in them. So it's, it, now, I mean, that, that all sounds very dire, but we, we can ameliorate it. We can...

Linda Bluestein, MD (24:27.882)

Oof. Wow.

Heather (24:46.573)

modify our exposures by reading labels and making sure we know what real food is. So go into a big supermarket, there are probably 20, 30,000 different items in it. It doesn't mean a thousand cans of Campbell's soup and is a thousand. No, that's just one thing.

Most of those things are not food. The things that are food, then the supermarkets may be getting smart to this and changing their arrangement, but usually it's around the outside of the store, not the center of it. And so you want the fruits and vegetables, you want the protein foods if you're eating animal protein.

and then things that are, if you're going to be eating baked goods, then things that are baked and not made in mass processed factories. You want as much of your food to come from as close to the farm as possible and as far away from the factory as possible.

Linda Bluestein, MD (26:04.254)

That makes a lot of sense. It's kind of good if you, I definitely heard that before about shopping and the periphery. And at one point in time, I thought I had heard something about somebody or some organization trying to develop a rating system, zero to 100. I don't know if you're familiar with this at all. And they started working on it. And I don't know what happened, but you know, like soda would get a zero. And I imagine something like wild salmon would get a, I don't know, somewhere in the 90s probably.

And, but that got abandoned, which I think would be really helpful for people because a lot of people, you know, they, it's hard to take the time to read all those labels or, you know, they're trying to figure out what shortcuts can they do. And so I think that would be a helpful thing if that ever did happen. I know at one point I'd read about that.

Heather (26:51.458)

It would be helpful. You can now still put the word healthy on your processed food without having even one food ingredient in it. The FDA has a proposal to require at least one ingredient in the processed food that sounds like food that's listed on the label.

the food industry is fighting against that.

Linda Bluestein, MD (27:26.442)

So are you saying that if they were to add this one ingredient, that then they could call the entire food healthy? And this is something they're fighting against because this isn't even a regulation now. Wow. So...

Heather (27:39.057)

That's right, yes, that's right, yes. Well, I mean, think of the big box cereals. Most of them have a higher glycemic index, which means they turn into sugar in your body faster than sugar does. And part of it is because they're so over-processed that the grains become like sugar. So they don't have to list sugar, but they're still acting like sugar. And...

And they get to say this is part of a healthy breakfast. They just never tell you that the part that's healthy is what you add. Whether it's your milk or your oat milk or your fruit, that's what's healthy, not the part that comes in the box. For most of the big company cereal brands, yeah.

Linda Bluestein, MD (28:10.711)

Oh, yeah.

Linda Bluestein, MD (28:15.576)

Right.

Linda Bluestein, MD (28:21.538)

Right, right, right.

Linda Bluestein, MD (28:30.402)

And that's an aisle, I feel like, where you can just stand there and take a look at, obviously, their marketing to children, and it's just crazy when you see how many different products there are and how many different things that they're putting in there. And of course, then they list the separate sources of sugar as well, right? They break them out separately, so they can list them lower down in the list or make it look like there's less sugar. So that's all very problematic.

Heather (28:57.786)

Yeah, it is.

Linda Bluestein, MD (29:00.006)

So we know that no two people are identical when it comes to nutrition, but of course there are some maybe general guidelines and you've already mentioned some of them for reducing chronic pain and inflammation. And another thing that I know you and I have chatted about a little bit is a mast cell activation. And so are there other thoughts that you have about, of course, that we just talked about the preservatives and pesticides and things like that. Any other general guidelines that you would like to share?

Heather (29:31.61)

Um, no cell activation is a very, as you know, very well. It's a very, um, I don't know, it's, it's an elusive condition, probably playing a role in many of the chronic conditions that we're puzzled over. Um, many of the, of the conditions that are part of the, uh, sensitization syndromes.

Linda Bluestein, MD (29:42.559)

Mm-hmm.

Heather (29:59.445)

So I don't know if this is a bit too much in the weeds and details. So the original idea for sensitization and the original recognition that there was a clustering of conditions that all go together, such as fibromyalgia, interstitial cystitis, what are some of the others, migraine, irritable bowel.

And there are many of them. It was a paper by Muhammad Yunus from Australia. And that paper was kind of grabbed by people who were treating people with some of these chronic conditions. And they said, it's just a sensitization syndrome and there are no causes. And we can just kind of think of them in a very different way and just send them to pain psychology.

because that's really where they seem to be getting most help anyway. And it was true at that point, we were getting most help there anyway. And so that was really useful, but there was a sense of there is no cause that left behind curiosity. And curiosity is one of the things that's hardest to hold onto as we practice medicine in modern times, but is one of the most,

crucial things that we need to have as part of our practice. So even if you look at Eunice's paper, he says, we don't know what the causes of these are, so I can't give you causes, but they very well may happen. These things, you know, have an open mind. People didn't pay attention to that and they really closed their eyes for a long time until we've had some

some advances in terms of genetics and in terms of understanding about connective tissue and the connection between our connective tissues and mast cells and other aspects that are pro-inflammatory. Anything that's pro-inflammatory is sensitizing to our body and our brain. There's no way to have...

Heather (32:21.109)

inflammation isolated in our body. If there is inflammation anywhere, it can reflect as inflammation everywhere. Now it doesn't mean that if you have a sore finger and a sliver and an inflammation and even an infection that it is literally everywhere, but it goes to your brain and your brain sends out alarm signals and it develops inflammation in that area reflecting this finger.

in the brain. And that then does have the ability to sensitize the system. So some people are more prone to the sensitization than others. And mast cells, I mean, I'm still learning. I'm still in my infancy in terms of learning the extent of their impact. But it's very interesting medicine and really does pique my curiosity.

Linda Bluestein, MD (33:21.438)

Yeah, I have to say I learned a lot when I was asked to give a presentation on the role of mast cells in pain at a pain, excuse me at a mast cell activation syndrome conference. And at first I said, I don't think I know enough about that topic. And then they said, well, you're the only pain doctor who's coming to the conference. So, so we would like you to give this talk. And I learned so much in the process of preparing for that talk.

and came across a fascinating paper that I'll link in the show notes called Masked Cells as the Gatekeeper of Pain. And I did not realize before I started reading all of these articles how heavily involved masked cells were in both peripheral and central sensitization. So yeah, it's really fascinating. And I definitely, I love what you said about curiosity because I think that's what really makes us good physicians is when we do keep that open mind and keep

curious about things and are constantly learning.

Heather (34:19.577)

Yeah, we're used to categorizing the things and the people that we see. And so we have a checklist and it's an algorithm. We go through the algorithm and we say, oh, okay, we've reached enough items that got checked off. So this is what they have. And that's our diagnosis and a diagnosis is a concept. So a concept is like the word tree.

Linda Bluestein, MD (34:24.386)

Mm-hmm.

Heather (34:49.017)

So if I say the word tree to you, you have sort of a vague idea of what I might mean, but you don't really know what I'm thinking. Is it an oak? Is it a bonsai? Is it a family tree that I'm thinking of? And it's the same with our patients. So instead of ignoring the items outside of the algorithm,

we need to pay attention to them, especially in chronic disease. In acute disease, if you come into the emergency room with chest pain, they have to use an algorithm. Is this a heart attack or is this heartburn? They have to know immediately. They have to treat immediately for one condition and they have to ignore the other, not ignore the other, but they can calm down over the other. And so that's really important. But in chronic disease,

We learn so much if we look at the outlier points. And that's really what leads to curiosity and new discoveries in medicine. Yeah.

Linda Bluestein, MD (35:56.61)

And that's especially important for people who have things that are, I think, considered rare like the connective tissue disorders, whether it be that they have the phenotype for hypermobile EDS, which we know we cannot do the genetic testing for yet, but someday we'll probably have that. But it's especially important for people who are maybe experiencing a variety of symptoms throughout the body that are seemingly unrelated but actually can be.

Heather (36:24.541)

Yeah, yeah. And often in medicine also, we name things for the phenomenon. So we'll say, oh, that's dermatitis, which just means inflammation of the skin. You haven't told me anything about the cause. And there are so many things in, certainly in dermatology, that just get called a dermatitis. They write it off and they say, here's an anti-inflammatory. Take that.

and if the topical anti-inflammatory doesn't work, maybe we'll give you one by mouth. And they're not even digging deeper because it's, again, they're siloed in the skin. They're not looking at other things that might be impacting the skin or the inflammatory system that could give them more information. And I mean, truth be told, for a lot of things, we don't have the information yet.

But resting easy once you make that diagnosis, that's a generalized, and I hate to pick on dermatologists on this, it's just the first thing that came to mind, because we do it in all sorts of specialties of just saying, you know, it's dermatitis, I don't have to think about that anymore. Well, you don't in that it's probably not gonna kill the person, but there might be something else brewing there that is being missed, even if it's not your area of expertise.

Linda Bluestein, MD (37:31.738)

Sure.

Linda Bluestein, MD (37:35.019)

Right.

Linda Bluestein, MD (37:51.694)

Sure. Okay. Well, let's move on to modalities. And I think it would be great for people to hear your perspective on some of the different modalities that you talk about in your book and that you probably are applying with your patients. And why do you think it's important for patients to consider trying some of these different modalities? And I guess, especially when I'm working with patients, I often ask them to give things another try. Because they'll

speaking of checklists, they'll be like, okay, I tried all of these things, nothing worked. And therefore, they're kind of like ready to give up. And so sometimes I say, well, let's try some of these things again. Sometimes maybe they weren't done in the right sequence or you had different expectations than what the modalities could deliver. And if you get 10% relief from this and 10% for that, it may actually add up. Do you talk to your patients about some of these different modalities? Which ones?

Can we talk about that a little bit?

Heather (38:50.877)

Sure. So there is a paper out there called the Non-Pharmacologic Strategies for Pain Care that was published a few years ago. And it has evidence, if anybody's listening, who wants evidence of some of the things that I speak about. So let's start with acupuncture, because it is an ancient practice. It is.

It has such abundant, very sound literature, research literature behind it showing that it is effective, that it is safe, and that it is very, very acceptable to patients. And then it's a very holistic treatment. It doesn't, it doesn't, it affects the whole body, in part because it affects the connective tissue.

You're putting needles into your connective tissue and stimulating them there. What's been shown in the pain studies for the chronic pain study that was done in England, that was just a vast study. They did an individual meta-analysis on, I think, many, many thousands of people.

And what it showed is that there was excellent pain relief after a course of acupuncture, which is it varies depending on condition, but six minimum, 12 or more sessions and sometimes ongoing maintenance. But in this study, they looked at studies that had no ongoing maintenance. And a year later,

a very significant portion of the patients were still in a better state. So there is this durability that happens with acupuncture, you know, that does not happen with the dose of any kind of analgesic, that a year later you're still going to have improvement from a chronic condition. And the risk of adverse events

Linda Bluestein, MD (41:03.073)

Right.

Great.

Heather (41:14.173)

Serious adverse events are extraordinarily rare. Whereas when you look at conventional medicine, our type of hospital medicine, and especially in the US, we have data going back over 50 years showing that conventional medicine is the third leading cause of death in North America. Want to hear that one again?

Linda Bluestein, MD (41:37.778)

Mm-hmm. Yes.

Heather (41:38.973)

Conventional medicine, conventional hospital medicine with its drugs, with its procedures, is the third leading cause of death in North America. We didn't go to medical school for that reason. Nobody did. And yet that is where we find ourselves and where we have found ourselves for the last 50 years, more than 50 years. So we should be looking at things that are safer.

that also have extremely good track records for improvement and much better track records for safety. So there was one article that was written by somebody who was, he took on one of the roles of, you know, quack busters.

of basically calling all integrative doctors quacks and acupuncturists quacks. And he said in Europe, there have been, you know, 50, I can't remember the exact number, but it was approximately in the 40s or 50s, deaths from acupuncture. So I thought, he gave no context. So I thought, okay, let me go look up these stats for all of Europe. And I think, actually, I think it was less, it was like 26 deaths.

I went and looked them up. It was over 50 years.

except he didn't state that. So where are we? Okay, acupuncture. So acupuncture can be excellent. Acupressure can also be very good. It's all based on the science of traditional Chinese medicine or traditional Oriental medicine. There's different schools from Japan to Korea to China to other Eastern forms of medicine.

Linda Bluestein, MD (43:05.294)

Right, right.

Heather (43:32.317)

that can be very, with a lot of overlap to them. Acupressure can also work for people who are needle phobic. You can use laser stimulation of points or pressure on points. So there are different strategies for using that. It's also had some excellent work in acute pain and has shown to be more effective than opioids in acute pain. There's right now, there's an ongoing

a multi-centered study of acupuncture in acute pain in the emergency room. It doesn't mean that opioids don't have a place, they definitely do. But this study was just very, very interesting both in acute pain and chronic pain, acupuncture can delay or eliminate the need for opioids. Go ahead.

Linda Bluestein, MD (44:15.596)

Mm-hmm.

Linda Bluestein, MD (44:32.498)

Oh, I was curious to ask if they tried to double blind that in some way, like do sham acupuncture with the opioids and then do like a placebo with the acupuncture so that because otherwise people would know if they're getting acupuncture or not, right?

Heather (44:46.557)

Right, right. I think in the emergency room setting, they did not do sham, they did usual care. There's also a very sticky problem with sham acupuncture because of anything that's going to touch the skin is going to stimulate the connective tissue. So when you're using sham acupuncture as a control, you are underestimating.

the effects of acupuncture, of the benefits. So there's just an article that was written with I think Myung-Soo Lee is the, it's his group who wrote the article and it involved some of the people from Cochrane as well, showing that you if you use sham acupuncture no matter which type of sham you use.

You can needle a different part of the body. You can use a needle that doesn't penetrate the skin. You are still having an effect. So there is no acceptable sham at this point for blinding acupuncture. So let's move on to manual therapies, which would be things like massage,

Linda Bluestein, MD (45:59.359)

Okay.

Heather (46:13.213)

spinal adjustment manipulation, deep trigger point work with manual therapy. Those things can be extremely helpful, and I do recommend those strategies. There is some evidence on it, but again, it's a very-

difficult area to get funding for a large, large study. So there are small studies that show good benefit. There are studies on chiropractic which have been done, really settling the issue of chiropractic manipulation of the neck, being a risk for a stroke.

There was a study done in Canada that was quite a large study done about 20 years ago, and it looked at neck pain admission, not admissions, treatments in chiropractic offices and in family doctor offices. And the subsequent stroke rate was higher in the family doctor offices. So basically they took that to mean that...

Linda Bluestein, MD (47:28.952)

Hmm.

Heather (47:31.101)

it was that was just a statistical glitch, but that certainly chiropractic didn't increase the risk. It doesn't mean chiropractic should be undertaken without really thoughtful consideration of what is the status of this person's spine anywhere. Personally, I tend to like the osteopathic manipulations better because they are not high velocity, and I think those are much

Linda Bluestein, MD (47:58.049)

Mm-hmm.

Heather (48:01.053)

I think that the principle of just trying to move bones where they belong without paying attention and preparing the soft tissues is misguided. And I think most of the chiropractic colleges have moved away from that strategy.

Linda Bluestein, MD (48:23.406)

Interesting.

Heather (48:23.581)

they recognize they have to deal with soft tissue.

Linda Bluestein, MD (48:26.926)

Mm-hmm. Well, that's good, because those high-velocity chiropractic manipulations, especially in the neck, do make me nervous with patients with connective tissue disorders.

Heather (48:38.269)

Yeah, yeah, they should. So, I mean, those are people who would be at higher risk. And also those who may have severe osteoarthritic issues going on or some sort of, there are certain anomalies that can put you at higher risk. So, working with someone who understands movement,

I have found to be a quantum leap from working with people who don't understand movement. And so some of the physical therapy schools do teach more about movement. I mean they all teach some but not very much unless physical therapists afterwards go out and seek out that training. Wash U.

in St. Louis was run by Shirley Sarman for a long, long time. And she developed systems of describing movement and normalizing movement and recognizing abnormal movement. So abnormal movement, it, you know, the whole principle that our body is connected.

that if you have an issue with how you plant your foot, it's going to affect everything all the way up to your neck. It's going to affect the ankle, the knee, it's going to change the way your hips need to align, that's gonna change the way your pelvis needs to fluctuate because it needs to do this movement on a regular basis, the pelvis does move. It's going to change what happens to the alignment of your spine all the way up to your neck.

And so that recognition is, it requires training. And so many people who are treating bodies don't have that training. You don't learn that when you're going to physical medicine rehab, residencies and fellowships, unless you are really seeking it out and you go work with some osteopaths, really do a good job of that.

Heather (51:02.877)

and some of the physical therapists, there are some of them out there who are absolutely amazing and do a really phenomenal job.

Linda Bluestein, MD (51:11.331)

And do you have any tips for people who just heard that and are thinking that's what I want. I want to find somebody who really can assess my movement and I totally agree with you, especially for people that have connective tissue disorders because it's not one part of the body. It's the entire body. And as you said, it's all it's all connected through fashion and everything. So finding that person though, I feel like could be really challenging.

Heather (51:35.581)

It really is. When I was in Seattle, I searched for about, I don't know, probably four years till I found somebody. And so what I would, I don't know if you have the ability to do this, we could actually both do this. We could have on our websites a list of people who are suggested to us by our

Linda Bluestein, MD (51:46.936)

Wow.

Heather (52:05.309)

who is really good at assessing movement. And I could certainly give you a couple of recommendations to put on that list if you want to do that. I mean, there's something gifted about them in that the way in which they see three-dimensionality and watch you move and know exactly where on your body to go to to find.

Linda Bluestein, MD (52:13.718)

I would love that.

Heather (52:34.525)

what the issue is. To me, it's a little bit still magic. I mean, I can do some re-evaluating assessment of people's movements, but it's not top-notch, as some of the people I've consulted have been. So yeah, I think that would be a really good recommendation. So, I mean, speaking to them about, speaking to like whatever therapists you're considering,

Linda Bluestein, MD (52:38.966)

Yeah.

Heather (53:04.029)

and saying, you know, what's your training in movement? And, you know, they should watch you move. They should ask you what difficulties you're having with your moving. Are you feeling something? Are you feeling stuck somewhere? What's going on? They should be focused on movement rather than just structure. And so many are focused on structure because it's so much easier.

Linda Bluestein, MD (53:27.606)

Yeah, yeah. And what makes me think about this too, is I'm thinking about one of my earliest patients that I had who also happened to work for me at that time and was going to physical therapy and we kind of weren't making a whole lot of progress with her neck pain. And she came in one day with this massive backpack over one shoulder and I said, that could be part of the problem. And honestly, when she changed that and I said, figure out how you can carry less things, carry a cross body bag or something.

a wheeled suitcase, whatever, and that really made a big difference. So I think getting back to the your movement also is so impacted by some of these habits that we develop that can contribute to suboptimal movement.

Linda Bluestein, MD (54:14.366)

Okay, what other modalities should we know about?

Heather (54:17.085)

Well, heat and cold are helpful. Epsom salts baths, I think are brilliant. Just make sure you put enough Epsom salt in there. I put at least two cups in there and I add a half to a cup of baking soda because it gets absorbed much better into your body. Soak in there for a long time. That can be really helpful for your muscles. A lot of us are magnesium deficient. I mean, some of the movement

Linda Bluestein, MD (54:32.663)

Okay.

Linda Bluestein, MD (54:41.27)

Mm-hmm.

Heather (54:46.621)

therapies or movement practices. Of course there's yoga but if you've got a bendy body you have to be careful of yoga because you can really stress your joints. Tai Chi I have actually just started this year and I am really impressed. Yes I used to think of Tai Chi as being it's too slow

it's not getting there, it doesn't give me the stretch that I want. I had tried it before a couple of times, but I hadn't stuck with it. And this time I decided I was going to stick with it because I was doing my yoga stretches, but again, I too have some hypermobility. And so yoga can do,

can exacerbate that, can make it worse. And what I found with the Tai Chi is that the slow repetitions of movement, where you're told, you know, make, give this as, don't, never go past 70% effort. And if it feels a little uncomfortable, just back off. And, but just keep doing it. And you do this movement, whether it's the rotation around in your hips.

or whether it's the up and the down, this movement, just so many different movements, they do a magical thing to your connective tissue. I find that it speaks to my connective tissue in a way that actually, and I think it's because it is so gentle and it's so repetitive that it convinces my brain that this is safe. And they keep...

Linda Bluestein, MD (56:17.739)

Wow.

Heather (56:34.077)

saying throughout it, if this doesn't feel safe, don't do it. Don't go that far or stop or rest. Be kind to your body. And that constant messaging, both through the movement and what you're getting in the message, it really, I think, makes a huge difference. And so I, who have also a bendy body, am able to, but I also have all these tight areas of

Linda Bluestein, MD (56:42.926)

Mm-hmm.

Linda Bluestein, MD (57:02.294)

Mm-hmm.

Heather (57:02.941)

connective tissue, all of which are exacerbated by anything that sets off mass cells, as you well know. And I may, it improves.

Linda Bluestein, MD (57:11.365)

Yep.

Heather (57:18.781)

I think mast cells have a major role to play in stress response. Like when mast cells get released, get triggered, that just makes your brain go crazy. And that then in turn alarms everything else.

Linda Bluestein, MD (57:35.868)

Yeah, definitely.

Heather (57:37.405)

And so, you know, watching a mass cell diet, it's a difficult diet. Um, yeah, but for some people it's well, for me at one point it was, it was life changing. So, yeah, I can cheat a little bit now. Thank goodness.

Linda Bluestein, MD (57:53.514)

Yeah, that's kind of how I am too. I had to be a lot stricter in the past, but now that I'm doing so much better, yeah, I can be a little more relaxed about it. What about things like shockwave or laser or ozone injections, anything like that you think is helpful?

Heather (58:01.021)

Yeah.

Heather (58:10.205)

Okay, I've had some experience with laser, both personally and professionally, and laser can be extremely powerful. The problem with laser is that it's an uncontrolled industry. I mean, it's not totally uncontrolled. They have to get FDA approval, but a lot of lasers are developed by businesses, as opposed to by scientists. And so there are certain parameters of light that are more effective than others. And there are certain devices that therefore are

Linda Bluestein, MD (58:22.573)

Mm-hmm.

Heather (58:39.485)

are better and then they have better trained practitioners. And then there's a ton of them out there so it's really hard to know how to judge all the others because there's too much to police in terms of what I would want to send my patients to. So there's one that was developed by two laser scientists, one, actually one laser scientist, one rocket scientist. They were married and up in Canada.

And they developed a wonderful system. They do have them placed around the US as well. And they train their people to use them. And they were science-based. And they collected data. They resisted commercialization, though. And so I'm not sure what's going to happen in terms of legacy of theirs. It would be a shame if it didn't.

died with them because it's one of the systems that actually is useful. There's a lot of research that goes on in Europe and in Israel on laser, and it's stimulating stem cells for spinal regeneration, for spinal cord injuries, is one of the scientists that's working in Israel.

and the Italians have done something similar. That's the literature I'm aware of from those countries, and I'm sure if they're developing lasers and looking at stem cells, there are other applications for that. But I haven't checked up on the literature recently to see where they're going with that. Ozone is interesting. But again, I think

exactly which applications are useful is of concern. So injected into certain structures in together with some of the regenerative therapies like prolotherapy and stem cells, that has some scientific

Heather (01:01:03.709)

mechanistic, it makes sense. But I don't know that it's ready for prime time in terms of the way it's being practiced right now. I mean, I'm sure there are some good people who are working on it, but I can't give you a list of, where do you find good ozone therapy? For the most part, it's not going to hurt you.

Linda Bluestein, MD (01:01:07.275)

Mm-hmm.

Heather (01:01:32.413)

But you have to make sure that whoever the person is who's injecting you knows about injections, that they're trained in that science and they know their way around the body well. Any kind of needling. You need to have somebody who understands anatomy and doesn't stick a needle into your lung when they're aiming at a particular muscle, things like that. There was a third thing there that you asked.

Linda Bluestein, MD (01:01:57.802)

Yeah.

Linda Bluestein, MD (01:02:02.065)

I think Shockwave.

Heather (01:02:03.517)

Oh, shockwave. Shockwave is, I mean, they use it in extensively in, well, obviously, in kidney stones and things like that. They also use it in orthopedic medicine in horses. And I know that's a funny reference, but they care about their horses for the most part. They're expensive. They want them to improve.

and they'll use laser on horses too, but they also use shockwave. So they wouldn't do that to horses in a consistent ongoing way if it wasn't effective. So there must be something to it from the orthopedic standpoint. It's again, it's not the literature that I'm totally up to date on, so I'll just quote my horses.

Linda Bluestein, MD (01:02:55.182)

Sure. Okay. And I definitely want to make sure we talk about supplements and medications, because this is of course an area that a lot of people I'm sure are very curious about. Are there medications in particular that you think are overprescribed for chronic pain? And are there ones that are underutilized?

Heather (01:03:13.405)

Well, opioids are vastly overprescribed and I don't think we need to say any more than that. If you want to look at the white paper from 2019, actually there's a reference to it on my website. It has a big introduction to why they're overused and what their risks are. I think that in general, in general, if we think back to our medical education.

We learned a lot, a lot, a lot. And it's more now in terms of what people are learning, in terms of what percentage of their education is devoted to starting drugs.

Do you remember how much you learned about stopping drugs other than antibiotics?

Linda Bluestein, MD (01:04:04.878)

Pretty much zero. Yeah.

Heather (01:04:06.269)

Exactly. And so there's this fantasy, this fallacy, that you can take a drug that has been studied scientifically in studies that go on for three months or six months and keep somebody on them forever. And so you get things like proton pump inhibitors, which are sophisticated stomach remedies.

And they cause all sorts of damage. They cause malnutrition. They can cause fractures because you can't absorb your calcium. You lose your magnesium. You don't absorb your iron. There's so many things. It totally changes. Oh, goodness, I haven't mentioned the word microbiome at all yet. It changes your microbiome. It is. It changes your microbiome because stomach acid is actually essential for life.

Linda Bluestein, MD (01:04:53.146)

That's shocking.

Heather (01:05:02.205)

And that's why you get this up regulation where the stomach says, I'm freaking out. I have to try and make as much acid as I can to overcome this stupid proton pump inhibitor or PPI. And then when you miss a dose, you have all this ton of acid and you think, oh my God, I really need the antacid. Well, no, you don't. You were just addicted to it.

So those things get overprescribed and I think they're a cause of pain.

Antidepressants are a whole other topic. We talk about mechanisms in antidepressants of this one affects norepinephrine, this one affects serotonin, this one affects dopamine, whatever. It doesn't take into account that as soon as you alter

one level of neurotransmitter in the brain, there's a huge cascade that goes on. And we don't really know how to track that. There's the other wrinkle to this whole conversation, which is a relatively new discovery, is that our gut and our microbiome produce more neurotransmitters than our brain does.

Heather (01:06:34.301)

both in numbers of neurotransmitters and amount of neurotransmitters. Now we know we have a gut brain, that really is established science. But what does it mean when our gut produces 80% of our serotonin, not our brain? What are we changing? What are we doing?

Linda Bluestein, MD (01:06:35.66)

Wow.

Heather (01:07:03.933)

gut and brain communicate instantaneously. So I'm not saying that there is no application for antidepressants. I think short term for people in chronic pain, if they can get people to sleep, if they can modify some of their pain while they are working with pain psychology and learning to modulate their own brain neurotransmitters.

I think they have a use, but the idea that we can keep people on them forever and the idea that they're easy to come off of is another fallacy. And so those things are just so much more complex than our prescribing practices reflect at this time. Now I know something you're interested in is, and it's a good thing to be interested in, is low-dose naltrexone.

Linda Bluestein, MD (01:07:42.756)

Mm-hmm.

Linda Bluestein, MD (01:08:02.186)

Yes.

Heather (01:08:03.165)

So low-dose naltrexone is appealing because it's almost like a homeopathic. It's just a little nudge in a direction. And so for most people there are very few side effects to it and they can get some benefit. And again most people most people don't stay on it long run because they don't find it's helpful long run. Some people do have adverse effects.

For some people, it activates them and they can't sleep, even though it's this tiny little dose. And it just goes to show you the impact of manipulation of our brain chemicals, of how significant the impact can be. Some people get depressed on low dose naltrexone. I did, I tried it once. I couldn't tolerate it for a week.

Linda Bluestein, MD (01:08:54.481)

Really?

Heather (01:08:58.012)

stopped it, tried it again, same thing. And I'm just not a depressed person. I don't do depression. It's just not in me, fortunately.

Linda Bluestein, MD (01:09:09.134)

That's really, really interesting. Wow. And you started at a low dose. It was like a low dose in titrating. Yeah. Oh really? Wow.

Heather (01:09:14.909)

Oh, a milligram. Yeah, a low, low dose. And actually half because I opened the capsule and took out half. So I really went low in it. Yeah, can't do it. Yeah.

Linda Bluestein, MD (01:09:20.65)

Right, right. Oh, interesting.

Linda Bluestein, MD (01:09:25.912)

Mm-hmm.

Right, right, interesting. Okay, what about supplements? Are there supplements that you think can be helpful? I know you talk a lot about that in some of the presentations that I've attended and I love hearing you talk about supplements.

Heather (01:09:44.733)

Yeah, well first thing is is if you can't afford good food, spend your money on as much good food as you can afford. And about the only supplement that perhaps you should take living in the northwest would at that stage be vitamin D because it's very inexpensive and you could get a big bottle at Costco or you know almost anywhere and it'll cost you a couple bucks, few dollars.

So the first things I would discuss with my patients, I start them off slow and then I sneak up on them. Vitamin D, magnesium, a good form of magnesium and omega-3 fish oils. Those are the trio that I use first. There's actually good evidence for each of them playing a role in pain.

Magnesium has a huge role to play in connective tissue, but also in pain mechanisms as well. So there's receptor sites for magnesium on some of our receptors that transmit pain. So those can be useful. With magnesium, I recommend people take enough so that they have one to two easy to pass bowel movements per day. I like people to take at least 2000 milligrams of a good quality omega-3.

and then vitamin D3 is the best absorbed one. So that is the one that is best. If you're on certain insurances, they'll only cover D2. It's better than nothing, so take it. Omega-3s usually aren't covered. Magnesium, I've seen it covered occasionally. The ones that you want,

Glycinate is a really good one. Taurate is a really good one. Mixed salts is a good one. Magnesium sulfate doesn't absorb through the gut. It does absorb through the skin and that's what's in epsom salt. You can also make your own lotion with magnesium sulfate just by dissolving epsom salts in a lotion and spread it on your skin. That would be a really inexpensive way of getting some magnesium into you.

Heather (01:12:12.573)

There are lotions that you can buy that are already prepared with magnesium in them. The citrate is probably the least expensive of the oral magnesiums that are still useful. If you buy, however, the citrate that is the liquid in a conventional drug store, you're going to be getting a prep for a colonoscopy. Don't do that.

but nothing's going to stay inside, including the magnesium. So you want that in pills or powders. There's a powder called Calm. That's a nice bedtime lemon-flavored powder that you can take, and that can be very helpful for sleep as well. So that's the place that I start. If people have insurance coverage, I will check certain nutrients. I'll check to see what their protein is like.

Linda Bluestein, MD (01:12:38.344)

Right.

Heather (01:13:07.709)

what their vitamin D level is. Omega-3 testing is quite expensive. Magnesium testing is not actually useful. So serum magnesium like serum calcium is carefully calibrated in the blood and it's dangerous if they go too far off and so the body pulls it from other tissues. So you just, it's hard to know. RBC magnesium.

don't even know if that's representative of anything because it's actually a cell without a nucleus, which is the only kind of one like that in the body. So what does that mean for everything else? And I mean, if I can get B vitamins, I would do that. B vitamin supplementation can be extremely important. And the type of B vitamin supplementation, like some people don't convert some of their...

regular, say B12, B6, they don't convert it well to the active forms. So taking the active forms is useful, but that can get expensive. But yeah, but those can be extremely important, both for mood, for pain, for a lot of the mechanisms in the body that help our mitochondria, our little

factories for energy that are inside all of our cells. B vitamins are extremely important for those. Other things for that, if people can afford it, coenzyme Q10 is really important as well. And there are other things that can help feed your mitochondria and keep them fit.

Linda Bluestein, MD (01:14:56.394)

And that's helpful because a lot of people have problems with fatigue. I feel like that's a really common symptom that people have. And I'm sure people are gonna hear the part about mixing the Epsom salts with the lotion and say, wait, I want more details on that. Would you be willing to give us just a little bit more detail about how people can do that?

Heather (01:15:14.269)

You know what? I don't even know what the proportion should be. I guess it would be whatever lotion you've got and how much of the Epsom salts actually absorbs into it, because it has to dissolve into it. I've found recipes online, but I don't remember any of them offhand. There is an MDND who is a... she specialized in magnesium. She has a lotion.

Linda Bluestein, MD (01:15:32.674)

Sure.

Heather (01:15:43.805)

I'm trying to think of what her name is. She's basically a magnesium doctor, but she has a good online presence and she has a recipe.

Linda Bluestein, MD (01:15:57.047)

Okay, I know Ancient Minerals is a brand that has some really nice products as well if people want to buy something that's ready to go. I know for me, my migraines that had been resistant to so many different medications, I mean I was on Topiramate for years and so many other things. I was in the hospital at one point with status migrainosus and on DHE and things like that and finally actually got relief with vitamins.

B vitamins and magnesium and now I don't take anything from migraine.

Heather (01:16:30.301)

That's an awesome story. You mentioned anticonvulsants. They get used a lot in pain. I mean, my experience with them is that it's a law of diminishing returns in that most people long-term find that they aren't, they lose their helpfulness, but they can be helpful for a period of time and sometimes they're useful.

Linda Bluestein, MD (01:16:36.311)

Mm-hmm.

Linda Bluestein, MD (01:16:57.874)

I want to shift gears again and talk about interventional pain management because I know that that's something that, you know, patients have potentially been offered trigger point injections, epidural steroid injections. I mean, some of these are things that I used to do, radiofrequency ablation, implantable devices. When do you think those kinds of procedures are most helpful? And are there certain ones that you have found to be less beneficial for your patients?

Heather (01:17:26.045)

I think they need strict criteria for any of those interventions. And those are published, but they are adhered to with variable consistency. So there are many centers that will just say, hmm, you have pain here. This is kind of what your x-ray looks like. I bet that's it. Let's do this test.

let's do this intervention. Anything that is irreversible, think about very carefully because you can't go back. An injection of, well, there have been studies that showed that in injections of steroids into the spine are not any better than

local anesthetic or even normal saline. It may just be that the fluid is getting rid of tiny little connective tissue strands that are tethering nerves. That may be what's going on. That was a study from University of Washington. I know some of my colleagues who do

steroid injections. They still like the steroids. But I've had diabetic patients whose diabetic control went out of control for months afterwards and was really difficult to get back. So I don't think it should be taken lightly. Steroids also erode tissues, both muscle and bone.

Linda Bluestein, MD (01:19:03.39)

Mm-hmm.

Heather (01:19:16.061)

So again, what are the long-term consequences of this? How often can you possibly do this? It used to be that they would say, you know, in a muscle no more than two injections per year. And I know a lot of people who ignore those guidelines and do much more often. And frankly, as far as muscle is concerned, I am yet to be aware of a single study.

Linda Bluestein, MD (01:19:34.658)

Right.

Heather (01:19:43.325)

that shows there's a benefit to using injected steroids into muscle. Are you aware of one?

Linda Bluestein, MD (01:19:50.962)

I'm not, but I hadn't really actually thought about that specifically. That's really interesting. No, I'm not aware of one.

Heather (01:19:57.085)

Yeah. And when you inject it into joints, you're priming the pump that's going to lead you to a joint replacement, because we know that cartilage is poisoned by steroid. And regenerative therapies are available. And if some of them are covered for your insurance, or if you can afford them,

They are a much better idea. The idea that cartilage could regenerate is new. So when we went to school, cartilage can't regenerate. Cartilage is gone. When it's gone, it's gone. And so it was characterized as a chronic degenerative disease. I have some abnormal cartilage in my hips. That's all I'm willing to call it. It's irregular cartilage.

And frankly, it is regenerated. And it is regenerated through proper movement therapies because when you load cartilage in the proper way, it regenerates. It responds to that loading. It's slow, but I'm a patient person. And I prefer it to having a hunk of metal. That's just my prejudice. But it works. So.

So what were we, what was the topic? Interventions. Yeah. So, you know, there is a role. I mean, these interventions were developed for extreme cases, for spinal cord injuries, for, you know, very severely damaged vertebrae, either through cancers, through accidents, through congenital abnormalities.

Linda Bluestein, MD (01:21:27.408)

No, you...

Heather (01:21:51.069)

and they came up with these brilliant strategies that could help these people live more normal lives. Absolutely, that's where these procedures belong, but generalizing them simply because you know how to do them has, I think, gone too far. And so there needs to be some place in the middle where you, you know, if something like that is proposed to you,

like before you get a radio frequency ablation, which is killing a nerve, which is going to regrow. And when it regrows, it regrows more disorganized than it was before. If somebody's going to propose that to you, tell them, ask them, like, what are your criteria for doing this? What are the, what are the reasons you're thinking I might benefit from this? And what are the steps you're going to take, because there are steps they should be taking, to make sure this is actually going to work?

which is they need to do two trials of injections of local anesthetic into the target nerve and make sure they got the target, make sure that it worked for you, make sure that it worked for you long enough, and do it twice. And if they have that, then you may say, well, okay, it's worth it. How long till the nerve regrows and gives me even worse trouble? But ask them those questions.

Linda Bluestein, MD (01:23:12.994)

Yeah, and that's definitely part of the problem. I have some young patients in their 20s and they've had multi-level radio frequency ablation and that's exactly what happens is then they feel like they keep having to go back every six months and then four months and then three months. And then I've even had people who, young people, and they go in and they're doing a couple cervical levels, a couple thoracic, a couple lumbar. And I'm thinking of one patient in particular and I said, well, what are they treating?

what's the working diagnosis? And she didn't know. And I was surprised that, you know, they would keep doing those procedures. Yeah.

Heather (01:23:52.733)

I mean, it's good when people trust their doctors. I'm not saying that we shouldn't trust our doctors, but we have to ask questions and we have to make sure what the decisions they're thinking of making are applicable to us. So I know a lot of people who get kind of pushed into getting a procedure or a surgery because the doctor has time. Next week, we can do it right away.

Linda Bluestein, MD (01:24:21.826)

Right. Yeah.

Heather (01:24:22.109)

So let's book it. And I think that unless you were just in an accident and this is an acute problem and you're going to not be able to walk unless you get this nerve fixed right now, that's almost always a bad idea. You need to take your time. You need to ask questions. You need to read up on it. There's lots of information out there. Read what should be the criteria for doing X, Y, and Z procedure.

there it's out there the internet is is a good resource and personally I always welcome when people come in and they said oh I read on the internet about this this and this and I'll tell them well this one's valid and this one isn't and so this is why this one isn't and you know not everything when you're not um it's not your area you may not understand everything and you may not be able to fish out the good information from the bad but um I don't think you should ever be shamed.

for coming in with information from the internet. I think it shows interest and curiosity on your part about your own health.

Linda Bluestein, MD (01:25:30.222)

I feel the same way. And you mentioned regenerative medicine and I know that this is an area, especially for people with EDS, Ehlers-Danlos syndromes, if they have CCI or cranial cervical instability, there's quite a few centers that now are quite promoting their services for prolo therapy, PRP or platelet-rich plasma, cell-based injections, et cetera. What are your thoughts about regenerative medicine for people with persistent pain or?

tissue weakness.

Heather (01:26:01.853)

I think it can be helpful. I think that, again, it's one of those areas where we have to try and separate the science of medicine from the business of medicine. When they get too enmeshed, there's a problem. I don't know where we stand with that right now.

I think we're learning a lot about it. I mean, really the information we have about fascia, about connective tissue is so new. Are you familiar with Carla Steckow? I know I've spoken about her. Yeah, so I mean, her work is mind blowing in terms of what the extent of fascia, she does...

Linda Bluestein, MD (01:26:48.006)

Oh yes. Mm-hmm.

Heather (01:26:58.845)

you know, what we, the reason we misunderstood connective tissue for so long and just associated it with those tight, tight, tough bands of, of gristle, uh, that's on top of our muscles or attaches our muscles to our bones. Um, the reason we misunderstood it is that we were doing our dissections on corpses, on preserved corpses. Um,

with knives. We were using a scalpel. We cut through 90% of the connective tissue without recognizing it was there. And Carla Steckow, who is an orthopedic surgeon and an anatomist, does dissections on unpreserved bodies. And so she has been able to explain

so much more about what and where and how extensive our connective tissue is. And I think we'll also come up with ideas about how we regenerate. I think it's tempting to think that we could do that. And it would be very useful to think that we could do that. What's been the experience of your patients? Have you seen results?

Linda Bluestein, MD (01:28:21.962)

It's really mixed. I feel like I have had some patients that I love what you said about the business of medicine where you know, some of these places, of course, some of the procedures are require more training and are more risky. So they, you know, they are really expensive, like $20,000 for some of these, you know, cervical procedures. And, you know, it's hard, I have selection bias, people that are coming to see me are obviously not doing well, or else they wouldn't.

be making an appointment to see me. So there are people out there probably who have had these procedures and are doing really well and never schedule an appointment. But I have had quite a few people that have had, you know, multiple procedures and are still struggling. I posted a question recently on social media because I wanted to get feedback from people that weren't my patients. And there were some people who said, I've had prolotherapy or other procedures that were really life-changing. So.

Heather (01:29:18.077)

Mm-hmm. Good. I mean, it's good because that really could mean the early adopters pave the way for change, as long as the business side of it doesn't overwhelm it with bad data, because they're not careful enough. They're going after the business rather than the results, because if these procedures ultimately can get good

literature behind them they could get approved and perhaps be covered by insurance for people.

Linda Bluestein, MD (01:29:50.762)

Right, right. And I think what you're saying about the business of medicine too, it's the patient selection, that if you're less discriminant and you do procedures on people that are not as appropriate, you're going to do better from a financial standpoint. So I've seen patients get really upset if they went to a surgeon and they were actually declined surgery. And it's like, no, that's actually a really good thing if they told you that you did not need surgery. And in the interest of time, I want to-

Heather (01:30:14.237)

Yes.

Linda Bluestein, MD (01:30:18.762)

refer people to page 230. I don't know if I have, oh, I do have it flagged in here. Questions to ask when consulting a surgeon. So I want everyone to look at page 230 and make sure to look at those questions if you're contemplating surgery. I've been guilty of exactly what you said. I have a slot next week, a modification next week, let's see, and kind of rushing into things when I think you're absolutely right. People who have EDS especially or other connective tissue disorders.

We often have suboptimal surgical outcomes and I think we need to be much more thoughtful before we undergo procedures, especially ones that are, like you said, not reversible.

Heather (01:30:58.877)

Mm-hmm.

Linda Bluestein, MD (01:31:01.194)

All right, so this has been so much information. We had some really great questions that were submitted online, and I want to just, if we could, can we take time to just hit a couple of those, do you think? Okay, okay, I'll just hit a couple of them. Okay, so the first one is, if a person has chronic pain and they experience either some, either new symptoms or a flare, which of course now I'm kind of giving away a little bit of the answer probably, but.

But sometimes I think they have a hard time being able to tell when they should seek medical attention and when they should try to do some of the tools and things that they have at their own disposal. Do you have any tips for people determining if something is a flare or an exacerbation of an existing problem versus a new problem?

Heather (01:31:46.493)

I mean that's a tough one because there's just so many variables that that could be at play. You know which part of the body is it, where is it, you know if it's if it's crushing chest pain and it's similar to the type of pain that you may have had in your chest that was myofascial before still go go get it checked out. And then go through

go through the strategies that have worked for you before. You may want to have a certain timeline in mind. Like, okay, I'm going to try my pain psychology exercises and I'm going to go see my physical therapist or I'm going to go, I haven't been doing Tai Chi lately, let me go do some of my exercises. Let me take...

I mean, turmeric is a really good painkiller and a healthy one. It's also good for your brain and your heart all at the same time. Omega-3s are also analgesic, magnesium is also analgesic. So there are certain things like that you could do. Look at the stress in your life, make sure you're sleeping, sort of analyze the context of it, and don't ignore it if there is some major.

Linda Bluestein, MD (01:32:52.13)

Hmm.

Heather (01:33:12.093)

sign like, as I said, crushing chest pain or suddenly not able to lift your leg or something

Linda Bluestein, MD (01:33:19.522)

Sure, sure. Okay, and we touched on this a little bit, but before we wrap up, I just want to see if you have any thoughts when we're talking about the business of medicine and or I should say not even strictly within medicine, but I feel like it's kind of become the Wild West. People can now go into a, I don't even wanna call it a clinic, but they can go into a space and sign up for an IV infusion and they can pick from a menu like they were ordering at McDonald's. And...

There are so many.

Heather (01:33:49.245)

I'm going to interrupt you for a second because you cut out for about 30 seconds at the very beginning.

Linda Bluestein, MD (01:33:56.658)

Okay, so I'm going to say the word mistake and I'm going to ask the question again.

So I feel like it's become a bit of the Wild West. People can go into a center and order like they were ordering off of a McDonald's menu. They can order an IV infusion and they can pick what things that they want. How can people best determine if someone has the knowledge that they are expecting them to have the training, the expertise to help them with their particular problem? Do you have any?

tips for avoiding charlatans, I guess.

Heather (01:34:32.381)

Yeah, and that is really a difficult question. With IV medicine, I really do think you want it prescribed by somebody. You want to discuss it with somebody you trust, whose references you have checked or who've treated people that you love and care about and who have done well with them.

And then just actually know that in general, MDs are not trained to do nutritional intravenous unless they have gone for special training. And you want to know what that special training is. Naturopaths do have training in nutritional

supplementation intravenous. But you really do want to investigate and check because there are life-threatening mistakes that can be made through intravenous. It's not like popping a pill and saying, oh, gee, that had a bad reaction. I better not take another one. You've just injected it into yourself. There's a far greater risk with that. I'm not saying that it's not

ever useful. It can be extremely useful, but you have to, you have to, unless you're trained yourself, you don't have the ability to make the decision of what you need. Usually some sort of testing needs to be done in order to assess your need and then you need a really well-trained professional who's going to do it.

Linda Bluestein, MD (01:36:26.102)

Okay, that's excellent. And before I ask for your favorite hypermobility hack, I just want to ask people that are watching this on YouTube to hit the thumbs up button if they're finding this video helpful so other people can find it because I want everyone to hear this incredible information from Dr. Tick. And so Dr. Tick, can you share with us your favorite hypermobility hack?

Heather (01:36:47.773)

I think I spilled the beans early on. It's actually Tai Chi. I think Tai Chi is, it speaks to connective tissue in a way that utterly surprised me. And it reaches the deepest levels. It goes right down into your bones. Just because of the slow pace of it, the gentleness of it.

Linda Bluestein, MD (01:36:52.475)

Okay, great.

Heather (01:37:15.741)

but the repetition, the incessant repetition. If you're having an impatient day, which I did during the chai chi class last night, and I just couldn't get through it all, I just needed to speed up. And they let you, they say if you need to speed up, speed up, you do what your body needs right now. But for the most part, it's just this slow, rhythmic

in inner massage of your entire body and it's it i think it has tremendous potential and i'm really glad i found it.

Linda Bluestein, MD (01:37:53.106)

inner massage of the entire body. I love that. And where can people find you online?

Heather (01:37:58.877)

I'm at www. I do have social media as well. I haven't posted to social media in a long time, but I probably will be getting back to that shortly.

Linda Bluestein, MD (01:38:04.839)

Okay, and I will...

Linda Bluestein, MD (01:38:12.838)

Okay, great. Well, I'll definitely link that in the show notes. And I just want to remind everyone that you've been listening to Bendy Bodies with a Hypermobility MD podcast and your guest today was Dr. Heather Tick, world renowned pain medicine physician. Dr. Tick, I cannot tell you how grateful I am to you for taking so much time to chat with me today. Your wealth of knowledge is just incredible. And I'm so, so grateful for you for sharing this information with my listeners.

Heather (01:38:41.917)

Thank you so much for having me, Linda. I think the work you do is so important. I think there are so few people who know and understand what you know and take the time to pay attention to this very special, but not all that uncommon condition. And so I think we should all be grateful to you for doing this, thank you.

Linda Bluestein, MD (01:39:08.982)

Oh, thank you for the kind words. I really appreciate it. All right, well, we'll see you all next time on the bendy bodies podcast.