Very Clinical: Pain Prevention for Dentists with Dr. Jessica Merhar

[00:00:01] This is a production of The Very Dental Podcast Network.

[00:00:16] Welcome to The Very Clinical Podcast. In about the time it takes to do an MO on three,

[00:00:21] we will entertain and amaze you with tips and tricks on regular daily dentistry.

[00:00:26] Here's Kevin and Zach. What is up, Very Clinical listeners? Welcome back to yet another episode of The Very Clinical Podcast.

[00:00:33] Yep, we're still doing this.

[00:00:35] Zach, we're just coming to you from Kansas City, Missouri with me as always my trusty co-host Dr. Kevin Hairfriar.

[00:00:42] Kevin, what is cracking in Cleveland?

[00:00:44] Cleveland is hot and muggy today. Can you believe that? In April or whatever it is? Last day of April.

[00:00:50] Our Guardians slash Indians are in first place. And what about your... You know who's in second place? Your pathetic Royals.

[00:00:57] The Kansas City Royals for now. For now.

[00:01:00] We're off to a hot start. That's very nice. Have you been to a baseball game yet this year? No.

[00:01:05] No? I gotta wait till it's summer.

[00:01:09] Okay. It's too unpredictable.

[00:01:12] I like spring baseball. I've been to one game. I'm going again on Friday, so I'm jacked.

[00:01:17] I'm loving it.

[00:01:18] Your weather is ultimately better than ours at this time of year.

[00:01:23] Probably a little. All right. We have a guest. We broke the budget and we're bringing the guest.

[00:01:27] And you have a personal connection as a guest. So Kevin, you introduce our esteemed guest this week.

[00:01:32] Yes. So I was talking to Zach prior to going on air and Zach couldn't believe I actually have friends.

[00:01:40] And so we're invited one of our friends, my friends onto our show. The lovely

[00:01:48] Jessica Murhard. Jessica, say hi.

[00:01:51] Hello.

[00:01:52] All right. So Jessica is an actual friend of mine. I know that it's hard for the listeners to

[00:01:57] believe, but Jessica has a...

[00:02:01] Wait a minute. Just pause for a second. Jessica, do you acknowledge Kevin as a friend

[00:02:05] or is this a one-way street here? We gotta clarify this for the audience here.

[00:02:10] Kevin is an actual friend.

[00:02:12] Okay. Wow. All right. Congratulations, Kevin. That's great.

[00:02:15] Yeah. So I made a goal like five years ago to make one friend and

[00:02:21] I actually got two, Jessica and her husband, Justin.

[00:02:25] Oh good. I love it.

[00:02:26] Yeah. So Jessica has some special interests and special training that we kind of alluded to

[00:02:34] in our last podcast. So we may have to bring that up to remind the listeners of what we were

[00:02:38] talking about. It was kind of mentioned in passing, but after we talked about it, Zach

[00:02:43] and I thought this would be a great thing to talk about for our health. So Jessica,

[00:02:50] can you just give us an introduction? Tell us where you went to school, what your training is

[00:02:57] and what your favorite ice cream is and all that kind of stuff.

[00:03:03] Ooh. I like this. Yes. So I graduated from Cleveland State with my bachelor's in health

[00:03:13] science and then went into their doctorate of physical therapy program. Well, I graduated

[00:03:21] in 2012 from there. And since then I really haven't left school. So I have been through

[00:03:28] a lot as far as additional education. So I completed a one-year orthopedic residency

[00:03:36] through the Cleveland Clinic in 2017. And while I was there, so when you're doing

[00:03:43] a residency just like a physician would, you spend time with different mentors.

[00:03:49] And while I was there, I had a mentor, his name was Rick Kinzer and he specialized in

[00:03:55] the McKenzie Method of mechanical diagnosis and therapy. He was a diplomat. And while I was

[00:04:01] watching him and his patient outcomes, I thought to myself, this is something different that I've

[00:04:08] ever seen. I was never really taught about it much in school. And it's not just spine-related,

[00:04:15] neck, back, but it's all mechanical, like extremities, any type of pain, like how a

[00:04:20] patient responds. And so at that point I realized, okay, I'm going to finish this residency,

[00:04:27] but I would like to do further training in the McKenzie Method. So through that, I completed,

[00:04:33] it took me, I think two years to complete all their coursework and to become, I took their

[00:04:38] credentialing exam to become a McKenzie certified clinician. And then from there,

[00:04:45] I decided I wanted more education than McKenzie and they offer

[00:04:50] like a two to three year long diploma residency program. So that was probably the most

[00:04:57] amazing career experience I could have had. I spent six months doing didactic learning,

[00:05:04] but then I spent nine weeks in Montreal with a clinician, his name was Michael Dyke. He's

[00:05:11] probably the most talented clinician I've ever had the chance to work with. But with that,

[00:05:16] we just really kind of fine tuned my clinical skillset, evaluating treating patients,

[00:05:23] utilizing this McKenzie Method. I came back literally the week of the pandemic.

[00:05:30] So they were shutting the borders and I came home on Friday right before they did.

[00:05:35] So that was interesting, but it was nice to kind of then transition to a slower clinic to learn and

[00:05:42] utilize some of the skills I just learned. And currently last year I graduated with my MBA

[00:05:51] and I'm currently doing a fellowship in manual therapy, which as a clinician,

[00:05:57] so as a physical therapist, there's a lot of different specialties you can get into.

[00:06:01] And people don't realize like after you get out of school that there's so much more that you can do.

[00:06:09] So there's residencies, there's fellowships, there's diploma training. And I've always said

[00:06:15] the trifecta that I really want is to become board certified in orthopedics, my McKenzie

[00:06:22] diploma and to be a fellow of orthopedic manual physical therapy. So I'm hoping to

[00:06:28] finish that later on this year and then I'll be set for now.

[00:06:34] So our listeners are right now saying, yeah, she's kind of a slouch.

[00:06:42] But the reason we've brought Jessica on is because as our listeners know and Zach knows

[00:06:49] and I know, do we know a dentist out there or anybody in the dental profession that has not

[00:06:55] had some sort of back pain or some sort of physical problem throughout their career? Zach,

[00:07:02] has that ever happened to you? No. 100%. I've spent the majority of my career in some

[00:07:06] sort of pain. All right. So before we get to that, we have to have a comedy bit. So

[00:07:12] what we're going to talk about, we also alluded to in our last podcast,

[00:07:17] one of the things that I guess I forget what Alan said about something cool that you're doing.

[00:07:26] And we mentioned the TRC, which is the restaurant club, that there are four members of the

[00:07:33] restaurant club here in Cleveland. That's pretty exclusive. It's very exclusive. Wow.

[00:07:38] Me and Missy, Jessica and her husband Justin. So- Do you guys have jackets?

[00:07:44] Yes, we do. We have jackets. We have a blog. We have swag. That's great. We have a chant.

[00:07:56] Secret handshake? Is there a secret handshake? All of that stuff. That's good.

[00:08:02] Because we kind of mentioned that in passing last time, we'll reiterate what the- actually,

[00:08:06] I'm going to let Jessica explain what the restaurant club is because she's our guest.

[00:08:11] What is the restaurant club? Well, it is a whole lot of fun. So it's actually one of my favorite

[00:08:18] things to do. So we take turns picking out restaurants for the other couple to be surprised

[00:08:29] to be able to go to. With it, it doesn't matter if it is super fancy or not so fancy.

[00:08:38] Sometimes it's restaurants that we have been to and sometimes it's restaurants that we haven't

[00:08:43] been to. So we surprise the other couple, we drive together and surprise them with this wonderful

[00:08:49] treat. And we enjoy a lovely experience where we share all of our food and we discuss all the

[00:08:56] deliciousness or not so deliciousness. It is quite the experience. Right. So we've been

[00:09:07] uh, we've been- we counted up last time. I can't remember what the total number was, but

[00:09:12] instead of counting up the number of restaurants, we're gonna- you and I are going to talk about

[00:09:17] our favorites and then we'll go on with the show. So I'm going to say that my favorite

[00:09:24] of all time was the first restaurant club when we went to Rude on the west side of Cleveland,

[00:09:31] um, mainly because we were walking down the street. I didn't- we had no idea where we're going. We

[00:09:37] were walking down the sidewalk and Jessica says this is it. And from the outside,

[00:09:43] didn't look like that special, but it was one of the best meals I've ever had in my life.

[00:09:48] I've been back there three or four times. Um, and the subsequent Christmas, uh, Charlie

[00:09:57] couldn't get back to Utah on time. His plane was delayed. So he was in Cleveland for an extra

[00:10:03] couple of days and we went there and Mr. Hard to please said this was the best meal

[00:10:09] he's had all year. So Rude, uh, in Lakewood, right Jessica? It's in Lakewood. Yeah. In

[00:10:15] Lakewood, if you're a Clevelander or you're visiting Cleveland, go to Rude. You'll have

[00:10:19] a great time. And at the end, there's pie. There's pie. They're known for pie. Yeah.

[00:10:26] Tell me the food genre of Rude. So, uh, it's very, I'd say it's sort of eclectic. I had,

[00:10:34] I had, I know that that time I had, uh, coffee rub filet, which doesn't seem like that's

[00:10:42] that awful. No, that's good. You're on a steak, a coffee rub steak. They had, they had elk.

[00:10:47] Um, okay. That's cool. What was the thing that Missy got that some sort of truffle or,

[00:10:53] um, did she get a butternut squash gnocchi from the next room? Um, she got that. And then I know

[00:11:03] previously on the menu, I was a little disappointed. They had pigeon, which I really wanted to try

[00:11:07] just to be a weirdo, but, uh, that was not on the menu when we actually got there. Um, so

[00:11:12] I don't that it's just really cool. And there's pie. Did I mention there's pie?

[00:11:16] There's delicious pie. There is pie. We are actually picking up pie this weekend for mothers

[00:11:23] a little early for, yes, from rude for mother's day for Justin's mom. Excellent. It's so good.

[00:11:28] All right. So what's your favorite? Well, I'm the type of person that I take pleasure out

[00:11:34] of other people having a good time. So I feel like rude was my favorite because you guys

[00:11:39] enjoyed it so much. All right. Well, if we're going to play that game, my second favorite was

[00:11:45] Zug because when we walked, I remember looking at your face when we walked it,

[00:11:51] you had this look of like what children look like on Christmas day when they come downstairs

[00:11:56] and see all their presents. And that was Zug is a Lebanese, right? It's like fancy Lebanese,

[00:12:03] um, uh, small plates, small plates, the fried chicken, which that sounds like,

[00:12:11] you know, like Kentucky fried chicken is not anything like that at all. I've not,

[00:12:15] I've never had anything like that before in my life. And then there was the hummus. What was that?

[00:12:23] Uh, God, I can't remember. Anyway, the hummus, oh, it was hummus, lamb, peach,

[00:12:30] something or other. It was really cool. So, um, that's in Cleveland Heights. Very cool.

[00:12:34] If you're also in Cleveland and, uh, I would suggest to Zach, Zach, I don't think has any

[00:12:40] friends. So this is never going to work. Not yet, but if he does, uh, make a goal to get some

[00:12:47] friends, he should start a TRC Kansas city. And then we could have a long distance TRC that

[00:12:55] we've always dreamed about. There it is the longest distance we've ever gone is, uh, Cuyahoga

[00:13:02] falls, right? The breakfast. Yes. Yeah. Yeah. So TRC can be brunch. It can be breakfast

[00:13:11] I like the concept of not knowing where I'm going. And I just end up there. I like when someone's

[00:13:15] like, this is where we're going. That's it. I like when we're driving and Justin,

[00:13:19] Jessica's husband is like, I know we're going here or this one, you know, and

[00:13:24] Oh, he's trying to predict it. He's trying to read you. Yeah. I got you. Okay.

[00:13:30] We have a secret list of where we're going to go next and the next place.

[00:13:35] Yeah. We'll see. Yeah. Well, has anyone stolen someone else's place from the list? Like,

[00:13:40] Oh, that was, that was where I was going to go. And not yet. Time. Ah, you got me. No,

[00:13:45] not yet. But we have a secret super secret surprise for two weeks from now. Um, that I,

[00:13:53] I, I hope I'm not overselling it, but that's what we're doing. All right. We've got to get

[00:13:59] on with the show. So, uh, Jessica, have you ever treated any dentists or all surgeons or

[00:14:04] any other sort of dental clinicians with their back pain? Hygienists, existence, any of those?

[00:14:11] Yes. And I will say dentists in general are, that is a hard profession because most dentists

[00:14:21] do the same repetitive movements all day long. And you're very specific on your

[00:14:27] static posture, how you're holding things, certain positions. Um, and so that can make a little bit

[00:14:33] tricky when we're trying to figure out how we need to move someone the best way to move them

[00:14:39] to help decrease their pain because they keep just doing the same thing over and over again.

[00:14:45] So, um, I think what we really want to get into is at least in this episode, let's talk

[00:14:52] about sort of, um, prevention and best practices to avoid having a total disaster with your back

[00:15:04] and missing time at work. You know what I'd also like to hear about in addition to that,

[00:15:07] I think that's a great way to start. But the second thing I'd like to get into is like,

[00:15:10] okay, I'm in pain. Yeah. What, give me some, like, give me a few troubleshooting moves,

[00:15:16] tips, ideas to get me to the next day. You know, other than, you know, ibuprofen and

[00:15:24] a heating pad or something like that. So let's, yeah, I'd love to hear, I'd love to hear both

[00:15:27] those things to start off with for sure. Let's start out with prevention.

[00:15:32] Yeah. So prevention, I feel like it's easy and tricky at the same time. In general,

[00:15:38] our bodies like to move. So the more we keep them moving, the better that they're going

[00:15:42] to feel. However, with that movement, our bodies want a state of balance. So if you're doing

[00:15:51] a lot of head forward, head down or slouch sitting or bending over, our bodies usually do

[00:15:58] well with balancing that out. So when it comes to neck or upper back, doing a little like

[00:16:05] chin tuck or head roll or some upper back stretches or doing some standing back bends

[00:16:11] can kind of balance things, reverse kind of all that forward movement.

[00:16:17] Reverse out the pain. Yeah. I love that. So one of them, well, I wouldn't say one of my goals

[00:16:24] for my patients when I see them first is to eliminate their pain. But then we also have

[00:16:30] this phase where we call it recovery of function, getting them back to doing things

[00:16:35] that they're used to doing, getting back to doing certain things that work or certain

[00:16:39] postures. But the last phase is long term management and prevention. And so our body

[00:16:46] usually gives us symptoms and signs beforehand, increased stiffness and increased soreness is your

[00:16:54] body's way of saying, hey, something's not right. Let's do something about it. However,

[00:16:59] most people don't know what to do. And that's where it could benefit. If you see someone who

[00:17:04] specializes in mechanical pain or back pain, they can help identify which movements that

[00:17:10] person needs to do to prevent another episode from coming about. So Zach, has this ever

[00:17:15] happened to you where you've had back pain and you just sort of suffer through it?

[00:17:19] Oh, 100%. What's been your strategy for when that happens?

[00:17:24] Before I kind of got religion on this stuff, it was the worst possible thing. Like she said,

[00:17:31] the body's like to move. It was bio freeze, ibuprofen, a back brace and toughening it up

[00:17:44] and basically doing nothing until it got better, which was a horrible loop in cycle that I lived

[00:17:49] in for well over a decade. That long? Oh yeah, 100%. Yes, that long for sure.

[00:17:56] Jessica, I think we talked about this. I do have to say you have one famous patient,

[00:18:00] famous to the show and that is Missy. So I kind of watched in wonder as you...

[00:18:12] This is how fun the TRC is. After TRC, you get an appointment with Jessica in her own home

[00:18:17] and she gives you physical therapy exercises to do that magically fix your back and

[00:18:24] holy smoke, now I'm really interested. You got room for one more? Not quite overnight,

[00:18:30] but almost overnight. But anyway, I think we talked about that the last time I hurt my back,

[00:18:36] I was like brushing my teeth or something silly in the morning or I sneezed or something like

[00:18:41] that. Oh, the sneeze pain. I can feel it. I can feel it right now. Every time that's

[00:18:46] happened to me in the past, because I'm a boomer or whatever, I'm still going to go to

[00:18:53] work. I'm still just going to tough it out. I'm going to try to get through the day. It's going

[00:18:58] to hurt like crazy. I'm going to pretend like it's not there. And for the most part during the

[00:19:03] day, because of all the hyperness going on doing our jobs, I can ignore it. But as soon

[00:19:08] as the last patient walks out the door, I'm in a heap of pain. Hey, Gen X does that too,

[00:19:14] boomer. Gen X plays that game too. I don't think there's a dental practitioner out there

[00:19:22] that hasn't happened to. So these preventive measures I think are really important. And

[00:19:32] just watching what you did for Missy, a very rudimentary understanding of what

[00:19:39] you were trying to do there made so much sense. So let's go to this scenario where

[00:19:45] that Zach had alluded to. You've hurt your back. What's next?

[00:19:54] What do you do? So it's always tricky too, because your back pain and my back pain can be

[00:20:00] completely different. And so research actually shows if we did nothing that most people would

[00:20:07] get better within six to eight weeks on their own. But who wants to wait that long? And what

[00:20:12] do you do if you have to work? So I always say, again, it's about balance. And I know

[00:20:20] you said not to quote literature, but in the sense that research does show that people who

[00:20:31] have mechanical back pain do demonstrate a directional preference. And what that means is

[00:20:36] that there's movements that you could do in one specific direction that can either unlock your

[00:20:43] back, can help improve your movement or can decrease or abolish your pain. And per that

[00:20:48] research, 78% of people respond with going backward. 6% respond with going forward and 16%

[00:21:00] need either a lateral movement, whether it be a gliding or rotational movement.

[00:21:05] So if you're thinking, okay, I'm bent over in this chair all day or I feel pain, there's clues.

[00:21:12] So if you feel pain when you're getting in and out of a car, you feel pain when you go from a

[00:21:17] sit to a stand. Zach and I are both nodding our heads about the car. Because I've felt

[00:21:22] all these things. In fact, just mentioning it brings back bad thoughts. So yeah, keep going.

[00:21:28] You got it. And I hear this all day in the clinic. I feel fine when I'm sitting,

[00:21:32] but it's when I go to stand up. Or I'll ask, how about walking? Actually, walking is not so bad.

[00:21:39] That is a sign that you need to be doing some type of backbend. So you can do a standing

[00:21:44] backbend where you stand with your hips against the counter, bathroom counter, kitchen counter,

[00:21:51] or just using your hands and you're just going to go backward as far as you feel like you can

[00:21:57] to get the lower part of your low back to start to move.

[00:22:02] Now, ways that we determine if this is the right direction for someone

[00:22:07] is patient response. How do they feel? So for example, you talked about the sneezing

[00:22:14] pain. So a lot of times with sneezing, coughing, straining, those are signs of disc

[00:22:20] involvement. And so with the disc, sometimes they can compress a nerve and people can feel

[00:22:25] pain going down their leg. And we use that as a really nice, yeah. I always say if you've had

[00:22:32] nerve pain, it's one of the worst pains that you've experienced. So that was the straw that

[00:22:40] finally I was like, okay, I don't want to live like this anymore. And that's when I started

[00:22:44] doing something that wasn't ibuprofen and bio freeze and sitting around doing nothing.

[00:22:50] That's what finally pressed me into action. And more. Yeah. So Zach, I listened to that

[00:22:55] podcast you sent me today about it. And towards the very end, the guy in the podcast was mentioning,

[00:23:01] oh, I did these press ups and it helped. And in my mind, and the method, all of that was kind

[00:23:07] of left out of it. But that basically is the McKenzie method is identifying that directional

[00:23:14] preference, but then knowing how to progress and which steps to take based off of that.

[00:23:20] And so if you did a standing back bend or you did laying on your stomach, like a press up,

[00:23:26] so where you're not a pushup, but you're allowing yourself to do like this backward movement

[00:23:32] and it causes the pain in your leg to start moving up to the middle of your back.

[00:23:37] That's called centralization. And that is the number one indicator that you're moving

[00:23:42] in the right direction. And that for you is like your directional preference. And research

[00:23:46] shows that just from, if you did that about every two to three hours, whether it be one set of 10

[00:23:53] or two sets of 10, all depends on how you feel that within one week, you should at least be

[00:23:57] 50 to 60% better. So that would be matching your directional preference. So the podcast

[00:24:05] she was referencing that I, Andrew Huberman, Huber and lab literally just did a back show

[00:24:10] that released on, let's see, we're recording this on the 30th, it really released on the

[00:24:14] 29th. And so I sent that to Jessica. I just thought it would be interesting to, you know,

[00:24:19] see what I don't think it mentioned the McKenzie method, but I looked up the McKenzie method

[00:24:23] and interestingly enough, that's where I started without even knowing I was doing it.

[00:24:27] Press ups were like step one of about 10 steps I've done. They got me headed in

[00:24:33] the right direction, you know, and that reversing out the pain that's, that's helped

[00:24:37] for that's like a lot of body parts that helped with my knees that helped me with

[00:24:42] what I had a shoulder impingement. It helped me with that. All of it reversing out big believer.

[00:24:47] Like that's, that's a big step and that was the first step I took was along those lines

[00:24:52] without even knowing it was a McKenzie thing. So I love that you said that because that's

[00:24:56] exactly what our bodies want, right? We do so much movement in one direction. It just

[00:25:00] wants to reverse it. It wants to balance it out with the opposite movement. And so we just

[00:25:04] have to find that. And, you know, again, when we think about disc herniations, there's

[00:25:09] variability as far as like how that disc might herniate in which direction, but you know,

[00:25:14] based on the patient's response. So if I do a movement and it makes symptoms worse down

[00:25:18] the leg, I know I need to change directions, but there's a very systematic approach on which

[00:25:23] direction you choose. But I feel like for someone who woke up and was having back pain,

[00:25:28] you could do a little self check where you put your hands on your thighs and bend over.

[00:25:34] And if you feel like you're stuck, like you can't go, or if you feel like you have pain

[00:25:40] returning to standing up. So pain with returning to standing up is a sign that you most likely

[00:25:46] would benefit from doing back bends. If you, a lot of people will be like, oh,

[00:25:51] it hurts when I move back. Yeah. Cause you're stuck and you need to get movement in that.

[00:25:56] And so there's progressions on ways to build that up, but that's a sign, you know,

[00:26:00] that you kind of need to move in that direction. My other piece of advice would be

[00:26:05] a healthy spine is one that goes forward and backward, you know, side to side,

[00:26:08] rotational yoga, all that kind of stuff. But if you are having an acute episode of back pain,

[00:26:15] sitting with a lumbar roll, sitting with a towel rolled up, a pillow behind your back,

[00:26:20] just keeping a neutral spine is going to take that pressure off your back because our body

[00:26:25] likes a neutral spine. That's why people most of the time feel better with walking because

[00:26:28] you're in a more neutral position. Yep. Yep. All that. Yes to all that. I love all of that. Yes.

[00:26:36] So those are all the step one of like the acute management was like, was all along those lines

[00:26:43] for sure. So I didn't, I, I'm a subscriber to the method and I didn't even, I'd never even

[00:26:47] heard of it until you mentioned it. So I'm in. How many McKenzie trained physical therapists

[00:26:54] are there in the country? So if we have listeners and they, you know, we have listeners

[00:27:01] all over the world actually. Yeah. We're worldwide. We're an international podcast.

[00:27:06] Yeah. But if we, if someone's listening to this is like everyone listening to this has

[00:27:11] experienced this. There's no doubt in my mind. But if someone is really hurting right now

[00:27:17] or it's debilitating enough where it's, it's really a problem for them.

[00:27:24] How would they go about seeking out someone who has your level of training?

[00:27:29] So there's a little bit difference between a McKenzie diplomat and a certified McKenzie

[00:27:34] clinician. So if you went to the McKenzie Institute.org or I think in the U S it's

[00:27:42] McKenzieinstituteusa.org there is a little button that says find a clinician and it will let you know

[00:27:48] clinicians in your state or how close you are. So I send, uh, like patients in Florida.

[00:27:56] I'll recommend them look at the website and like find a clinician close to their home.

[00:28:00] Uh, but on the website, it will let people know who's a diplomat versus certified. And I

[00:28:05] still feel like a certified clinician will do a great job, but for some tough cases where

[00:28:10] some people have seen a whole bunch of other people, a diplomat is going to have just a little

[00:28:15] bit more edge up with an increased specialty as far as providing improved care.

[00:28:22] And let's say, you know, I hurt my back yesterday, let's hypothetically, and, um,

[00:28:29] I don't know about you. Sometimes when that's happened to me, my brain goes to a place that

[00:28:35] is not good. Like I, for some reason, I think I'm going to be like this the rest of my life and

[00:28:41] this is just going to be my way of life for the rest of time.

[00:28:44] That's back pain. There's a huge mental component. I think it is, it is more damaging

[00:28:51] than, like I've heard in other places, you know, and there's something about the back.

[00:28:58] Oh, have you? Yes. But there's something about the back that like it takes everything out and

[00:29:05] takes everything away from you just about more than anything, you know, because like I said,

[00:29:10] my knee bothered me. It was just my knee. My shoulder bothered me. Well, you know,

[00:29:14] I can still function, but there's something about your back, especially when it totally

[00:29:18] spasms out or when they, you know, though where they use the term throw out your back

[00:29:23] when it's that your back spasms like that is that is tough to deal with from a mental

[00:29:28] basis because you can't even hardly walk. Can you speak to that? Have you had that

[00:29:31] happen? Have you had that happen to you, Kevin? Were you like, yeah, I could hardly move until

[00:29:36] you I thought this was going to be the rest of my life. Yeah, yeah, exactly. I

[00:29:41] wasn't doing well mentally. No, it's a it's a bad mental thing for sure.

[00:29:46] Can you speak to that, Jessica, because I feel like part of what you did for Missy was

[00:29:50] talking her through that part of it. Yeah, so there's a huge component of

[00:29:59] where our pain comes from and the pain generates from the brain, right? And our nervous system,

[00:30:05] when it's in pain, it's sending this message of like, oh my gosh, what's going on.

[00:30:09] I like to give patients a screening tool, which is called the yellow flag risk form that helps

[00:30:15] identify all those type of things like fear avoidance, emotional anxiety, depression,

[00:30:23] nerve related irritability, all of that helps screen that and helps identify what other

[00:30:30] contributors are present for that person's pain. Because, you know, right, pain is multimodal in

[00:30:37] the fact that yes, you have this back pain, but now you might not be able to go to work.

[00:30:43] And what happens if you can't make money? You might get fired or you won't be able to

[00:30:46] take care of your kids or, you know, the list goes on of all the things you're not able

[00:30:50] to do. And that is really hard for some people. So my approach in general, you know,

[00:31:00] one is just listening to the patient and what they're wanting to get back to do.

[00:31:07] Sometimes I just give the advice like for those who are able to walk, like walking is

[00:31:11] one of the best things you can do or like back in the day, they used to say bed rest

[00:31:16] that is like not recommended. But if you're having trouble walking, you're in so much pain.

[00:31:21] I will say like laying on your stomach either propped up on your elbows or even a pillow

[00:31:27] underneath your belly for like four or five minutes and doing something every hour can

[00:31:31] usually hit that acute episode right off the bat. But if you don't tell the patient and

[00:31:38] talk with the patient and find safe movements for them, then they're going to be fearful of

[00:31:44] doing anything. So I always give my patients what I call a safety check to let them know.

[00:31:49] And that is they check their movement, they bend forward, bend back. Hey, you might feel pain

[00:31:54] during that, but if your movement is still the same, that's safe for you to do. And I think

[00:31:58] for Missy, that was the key. She had avoided things for so long that she needed that permission

[00:32:04] to move again and to move in that direction and what was considered safe pain versus we say

[00:32:10] hurt doesn't equal harm. So how do we check things? We can check strength,

[00:32:15] we can check functional baselines like stepping up or stepping down or your movement

[00:32:20] or that nerve pain to see what I'm doing is it okay for me to do.

[00:32:26] So we're kind of up against it, but I feel like Kevin, we bypassed your prevention talk

[00:32:32] and went straight into the pain management part. So we got to circle back to that.

[00:32:35] Well, yeah, I think what I know we're going to talk about next episode because

[00:32:39] we kind of talked about it behind the scenes. So Zach, why don't you do your normal wrap up

[00:32:46] and we will see Miss Jessica back in just a little bit.

[00:32:51] Yeah, that's perfect. All right. Hey, if you have not joined the Very Clinical Facebook page,

[00:32:58] what's wrong with you? Kevin, what's wrong with these people?

[00:33:00] They probably have a pain in their back. It's preventing them from pressing.

[00:33:04] They can't even type because they can't type.

[00:33:07] I understand it's the neck pain. We need to talk about the neck too.

[00:33:12] That's a big one too. We need to talk about it. It's all connected, Kevin.

[00:33:15] Yes. The knee bone is connected to the thigh bone, I believe. Something like that.

[00:33:21] I don't know how these things work.

[00:33:25] Thank you guys for listening and appreciate you trying out a new format of show that

[00:33:30] isn't talking about bonding agents or acetone or centric correlation. This is a

[00:33:36] important topic because you have to have a healthy spine to keep prepping.

[00:33:43] Just keep stropping those teeth. We appreciate you guys listening and we will see you next Tuesday.

[00:33:49] See ya!