On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Dr. Joe, Tatta, PT, DPT to talk about using acceptance and mindfulness-based interventions to build resilience and overcome chronic pain. Dr. Joe Tatta is a global leader in integrative pain care and an advocate for the safe and effective treatment of chronic pain. He is the Founder of the Integrative Pain Science Institute, a cutting-edge health company reinventing pain care through evidence-based treatment, research, and professional development. In this episode, we discuss: 1. Psychological variables associated with chronic pain 2. What is Acceptance and Commitment Therapy (ACT) 3. How is ACT different from traditional cognitive behavioral approaches and pain education? 4. How is ACT different from mindfulness, like the kind we encounter in popular culture? 5. How does ACT help physical therapists’ function better and prevent professional burnout? 6. Dr. Tatta's latest book “Radical Relief: A Guide to Overcome Chronic Pain Resources: Radical Relief Book ACT for Chronic Pain Professional Training Course: Mindfulness-Based Pain Relief Practitioner Certification RELIEF: and online mindfulness community for pain care. Facebook: @drjoetatta Instagram: @drjoetatta Twitter: @drjoetatta A big thank you to Net Health for sponsoring this episode! Learn more about the Redoc Patient Portal here. More about Dr. Joe Tatta: Dr. Joe Tatta is a global leader in integrative pain care and an advocate for the safe and effective treatment of chronic pain. He is the Founder of the Integrative Pain Science Institute, a cutting-edge health company reinventing pain care through evidence-based treatment, research, and professional development. For 25 years he has supported people living with pain and helped practitioners deliver more effective pain management. His research and career achievements include scalable practice models centered on lifestyle medicine, health behavior change, and digital therapeutics. He is a Doctor of Physical Therapy, a Board-Certified Nutrition Specialist, and Acceptance and Commitment Therapy trainer. Dr. Tatta is the author of two bestselling books Radical Relief: A Guide to Overcome Chronic Pain and Heal Your Pain Now: The Revolutionary Program to Reset Your Brain and Body for a Pain-Free Life and host of weekly Healing Pain Podcast. Learn more by visiting www.integrativepainscienceinstitute.com. Subscribe to Healthy, Wealthy & Smart: Website: https://podcast.healthywealthysmart.com Apple Podcasts: https://podcasts.apple.com/us/podcast/healthy-wealthy-smart/id532717264 Spotify: https://open.spotify.com/show/6ELmKwE4mSZXBB8TiQvp73 SoundCloud: https://soundcloud.com/healthywealthysmart Stitcher: https://www.stitcher.com/show/healthy-wealthy-smart iHeart Radio: https://www.iheart.com/podcast/263-healthy-wealthy-smart-27628927 Read the full transcript here: Speaker 1 (00:00:01): Hey, Joe. Welcome back to the podcast. I'm happy to have you on again. Speaker 2 (00:00:06): Hi Karen. Thanks for inviting me. I'm excited to be here. Speaker 1 (00:00:08): Yes. And today we're going to be tough. Well, let's not let's, let's roll it back for a second. So it seems like each time you've come on, we've talked about some different aspects of pain, right? We're both in that chronic pain world, we love treating people with chronic pain and talking about chronic pain or persistent pain. And we've done that quite a bit. We've talked about the psychological variables associated with persistent pain and how psychologically informed physical therapy is so important. So let's talk about which variables we should be most concerned about with regard to effectively treating pain, big question right out of the gate. Speaker 2 (00:00:52): It is, and it's a, it's a great place to start. And that's a question that all of us are asking ourselves and researchers are asking this question more and more and we're trying to figure out, okay, what is like the key variable? Is there one key variable that we should be paying attention to? And it's interesting if you look at the evolution of chronic pain and I think both you and I have been practicing for about 25 years. So we've really have seen things transitioned from this biomedical biomechanical model, right? And the core of that was let me figure out, let's try and figure out or identify what's wrong with the physical body. Right. Pretty easy. Speaker 1 (00:01:34): And then the pain goes away. Speaker 2 (00:01:36): Exactly. And we were all there at one point, then this bio-psycho-social model comes in and we're like, okay, there was there a psychological variables that we should pay attention to. And what's interesting is when I talked to physical therapists about the psychological variables, they bring in a little bit of that older biomedical model in the sense of how can I identify what's wrong. And then if I know what's wrong, then I can fix it. And it makes sense. And that even shows up in some of our mental health colleagues as well when they approach people with pain. So when we look at, you know, there's kind of like five big ones pink catastrophizing, can you see your phobia, fear, avoidance, depression, anxiety, those five persistently show up in the literature as variables that are associated with poor outcomes with regards to chronic pain. So you see them all the time and we have ways we can test for it, right? Pain, catastrophizing scale Tampa kinesiophobia scale, et cetera, et cetera, evolve are well aware of these. And we all use them. What I want people to consider for a moment is these are all what we would call vulnerability processes. So this is what makes someone vulnerable to transitioning, let's say from acute pain to chronic pain and they may be important and they are important, but I would like people to consider for a minute. If you flip the coin over, what's the opposite side of vulnerability. Speaker 2 (00:03:13): And this is really important when we think about chronic pain, because our job as professionals is not necessarily to identify here's, what's wrong. You physically, here's, what's wrong with you psychologically or emotionally. And now I'm going to fix, modify or change those variables. We want to focus on as professionals. The other side of that coin is how can I help someone be more resilient? How do I develop, build or foster a sense of resiliency. So that other side of the coin, which is really what has interested me the most, I'd say in the past 10 years is looking at those positive, psychological factors that are associated with resiliency. There's three of them. We can kind of talk about them a little bit each but there are pain, self-efficacy pain, acceptance, and then values based living. Speaker 1 (00:04:01): Okay. So let's dive into each of those. So let's start with pain. Self-Efficacy what the heck does that mean? Speaker 2 (00:04:09): Yeah. And we hear the word self-efficacy used a lot, and I want to make sure that we tag on the word pain with that because just normal quote unquote self-efficacy you can measure self efficacy, but really as a pain professional, whether you're a physical therapist or another licensed health, professional, or certified actualize professional someone's confidence or their ability and their confidence in themselves to function and figure out what the cause of their pain isn't to overcome. It is basically what we identify as pain self-efficacy. Now you can actually have good self efficacy and have poor pain self-efficacy so it's important as professionals that we look at him as, okay, how can I help someone with pain self-efficacy with regard to their rehabilitation and overcoming pain. Speaker 1 (00:05:04): And so say that one more time for me, I'm going to edit some of this out, but I just want to get that into my own brain. Speaker 2 (00:05:15): No, no problem. So paint, self efficacy is one's confidence regarding their ability to function while they experience a while they have pain. Speaker 1 (00:05:24): Okay. Got it. Got it. All right. That makes sense. And that is coming from someone, the long history of chronic pain. That's not easy. Can I say that? Is it okay to say that that's not easy? Speaker 2 (00:05:41): Absolutely. And it does go back to what I mentioned a little bit earlier, where okay. If I have pain, it's this message this signal, if you will, that something's wrong. And it's perfectly normal that your mind goes to the place of, I want to stop. I want to eliminate, I want to resolve this pain with acute pain. That's fine. With chronic pain. It's something very different. And if someone gets kind of caught up in that Whirlpool, if you will, of constantly spinning and trying to figure out, okay, what is the cause of this? And they go down that biomedical route, that's where people wind up in trouble and where they don't find a solution for their pain and why pain persists. So pain self-advocacy is interesting because it's like, okay, do I have the knowledge? Do I have the tools? I have the ability in myself, right? Speaker 2 (00:06:36): Because if we're not looking at vulnerability for looking at resiliency, really what we're saying is somewhere within, inside you deep inside you actually, you have the ability to contact something that you haven't contacted yet, or maybe you've only contacted a piece of it. But if I can help you with that, if I can help you along that path, if I can help you along that journey, then we can improve your pain, self efficacy. And it's potentially the research is still kind of unclear, but it's potentially the number one factor, the number one resiliency factor with overcoming chronic pain. Speaker 1 (00:07:13): Oh gosh. As you're, you're saying that I, in my head, I'm going back, you know, 10, 15 years to when I was in pain all the time. And yes, I was searching for that fix. And what I found when my pain started to recede, I started to feel better was that I was always looking for that external fix. When in fact I had to look into myself to see how, what I can do to overcome this and, and to kind of move forward and make the best decisions I can at the time, the information that I have and be okay with it and then move forward. And that was the thing that really helped to kind of flip the switch for me. Speaker 2 (00:08:00): That's right. And there's, there's two really important things embedded in what you just said. The first is, as physical therapists were very aware of pain, avoidance painted warnings is almost when I look at pain avoidance now after studying acceptance and commitment therapy, I look at painted. William says, it's too simple. So it's like, if the, you know, if you put your hand over the flame, I pull my hand away. I avoid pain. If there's a rock in your shoe, you want to walk differently or take the rock out. What you're saying in your experience, Karen, which is common in many, people's almost every single person's experience you've had chronic pain. Is that the pain persisted for so long that not only did I avoid pain, but I started to move away from everything that was important in my life. And I moved toward only those potential areas on the, on, toward the potential causes that could alleviate my pain. Speaker 2 (00:09:00): Now in the act that's called experiential avoidance. And again, it's a little bit different than regular pain avoidance because experiential avoidance means the entire experience. The entire capsule of my life what's encased in there is only to seek out the elimination or the control of pain. And when that happens, that's when people go down sometimes sad and sometimes very scary routes of things like surgeries that don't work and one medication or multiple medications, or we see, you know, behaviors lead to passive treatments you know, leaving work and disconnected from personal relationships, all the things that we see that our patients struggle with. So it's what you say is really important. And to try to make those distinctions for therapists, I think are also important as well, because we can skim along the surface of pain, avoidance, so to speak. But I really believe if we want to be effective with pain, we need to go on this deeper level with people looking at that pain, self efficacy, looking at pain acceptance. And then the last one looking at values based living, which is what ha, which is actually the flip side of experiential avoidance. Speaker 1 (00:10:15): And something that you just said that sort of avoidance becomes all encompassing. And, and I will agree. That's exactly what would happen. Like I can remember doing things like going to an acupuncturist and having them put all these needles in my ear. And then I had to walk around the plinth counterclockwise three times. I mean, when you think about that, you're like, what? But I was so desperate. Like I was doing anything and everything for that fix. When I knew even as a physical therapist that walking counterclockwise around uplift three times doesn't really make a difference. But yet here I am doing it and doing that instead of, I don't know, meeting up with friends, right. Relaxing, going to the gym. Like I was avoiding all that other stuff because I was so laser focused on finding this cure, so to speak Speaker 2 (00:11:21): That's right. And as you're talking to me and I'm imagining what it's like for YouTube and in that experience, and you're talking about going to an acupuncturist with which, you know, I tell people, look, if you have one passive treatment that you engage in each week as a, as a means of, stress-relief totally fine by me. I have those as well. So we're not suggesting that people avoid anything that's passive, but as I listened to you, and at first you started, well, I went to the acupuncture was for my pain, but you continue to talk what you actually revealed was most important. The real pain was, yes, it was physical, but the real pain was what, it's, what it's stolen, what it Rob for my life. Right. I think you mentioned relationships. That's kind of like, all right, there's pain avoidance here, but what's the real pain underneath that. Speaker 2 (00:12:16): Cause that's what I'm curious to talk to people about. And that's what I'm curious to learn about patients when they come to me and they say they're suffering and they say, they're struggling. I want to know, okay. What about your life? Do you miss? Who do you miss in your life? What aspects of your life do you miss? Because the truth is Karen. If we look at the, the vast body of research that reaction now have with regards to chronic pain, most things, no matter what it is, if you apply just one, intervention works minimally and the outcomes are not spectacular. So they're minimal and they're not spectacular. But when you start to combine different things together, then you see more moderate improvements in clinical studies and you see a change in someone's quality of life. But ahead of all of that, some of the most important outcomes that we're looking for is to look at, okay, what's meaningful in your life. And how do I help you reconnect with that? And I really believe that the resiliency processes that are out there, they exist in all of our practices and an acceptance that can move therapy kind of has a bunch of different processes that really lend well to this. But if we can engage people with these positive psychological responses and move away from the negative sodas, because people are aware that they realize they're scared, hell of pain, there is trouble. Speaker 1 (00:13:45): Oh yeah, yeah. When I had pain, like I totally understood. Yeah, I have it. I don't want to I'll avoid anything to have it that yes, we totally, 100% get that. Speaker 2 (00:14:00): Right. They realized, they realized, they think about it a lot. They realize they're a little sad or depressed about it or anxious about it. They realized that it consumes their time, but they really want to know is how do I get my life back? There's a whole chunk of my life over here. Yes. When you sit down with somebody who has pain, the first thing they're going to talk about is physical pain and that's Norma. And we should, we should make an attempt to validate that for them. But later on, as you're working on their self-advocacy and as you're working on that third week relationship, which really needs to start like the first 10 minutes of the treatments, it really does. Doesn't it doesn't start like three weeks later. What's the first five minutes. These are the questions that we should be asking ourselves. And these are the questions that we should be asking our patients to help them navigate what's happened to them. Speaker 1 (00:14:48): Okay. So let's, let's talk about that. So you're Speaker 3 (00:14:52): The physical, I'm the physical therapist, right? How do I broach these topics or these questions with the patient without offending them without coming across, as you know, you may have patients say, Oh, that's too personal. Do you know what I mean? So how as physical therapist, and this is where, you know, you had mentioned acceptance and commitment therapy, right? So how has physical therapists, can we incorporate, act into our treatment practice? How can we do this without being offensive, Speaker 2 (00:15:34): The best place to, and I'd like, I like the word offensive because I do believe as even though I'm a big fan of psychologically informed physical therapy, and I've talked about this on podcasts and everything, I've done books, et cetera. We have to realize as physical therapists, there's a cognitive dissonance there, which means when someone comes to see us, they don't expect that we're going to be talking about psychological variables. They don't expect that. And nor should they, we have a long, long, long way to go. Not only in our own profession, but in the entire healthcare system, before we get there. Speaker 2 (00:16:15): When you're talking about interviewing someone or evaluating someone or assessing someone during the evaluation, which is really where you should start to talk about values based living, there are a couple of just simple questions that you can add into your evaluation. So again, this is psychological informed care, right? We're not becoming psychologists. We're just using principles of to inform our care so that our outcomes are better. So for example, one of the most important questions, which I always get positive responses from, and people never feel taken aback by this is if you didn't have pain right now, what would you be doing with your life? Speaker 2 (00:17:00): And it's an open-ended question, right? What kind of weaving in like, you know, principles of motivational interviewing. It allows someone to think, wow, if I didn't have pain, what would I be doing? And you, and I may be able to, to kind of access that very easily or rapidly. However, someone who's had pain for a long time. It's like, there's been a smoke screen in front of their eyes. They're no longer able to see that. Okay. There's another aspect of life for me, somewhere that I can begin to kind of work on. Another really simple one kind of a nice metaphorical one is if I had a magic wand and I can wave the magic wand and make your pain go away, what would you do? What would you do tomorrow? Or who would you visit? Who would you go see and spend your time with? So a couple of just really simple open-ended questions that you include an initial valuation. And I recommend, you know, when people first start training with me, I give them lots of different handouts with regard to values, because you can spend a whole hour on this, but if you're new, just seeding this into your practice just a little bit, day by day or session by session. So to speak, it's a nice way for you to change because there's behavior change. That's involved for us as professionals as we start to use these new interventions. Speaker 1 (00:18:20): Yeah. And I think as the, the healthcare professional, the physical therapist, like you said, there is still that unconscious bias of I got to fix it. Right. So I think I would imagine you can correct me if I'm wrong, but the more patients that we see and the more that we ask these questions, the more that I think we'll be able to kind of delve into this other part of the person sitting in front of us. Because the one thing that comes to mind when you said if you didn't have the pain, what would you be doing? What if someone's like, I don't know. I can't even picture it. You just put, I don't know. I can't picture it and move on to the next question. What, what, what happens next? Speaker 2 (00:19:11): Well, there's a couple of different parts there. Karen. the first part I just want to mention, so physical therapist and other health professionals who work in rehab are excellent at goal setting. And in fact, I think physical therapists and probably OTs are the best at goal setting, probably in the profession, in the, in the healthcare professions. Historically, we've not been very good at talking about meaningful or value based activities. What if I told you as a professional, that it's more important to help clarify someone's cloudy values instead of setting really precise short-term and long-term goals like we've been trained. So what I'm really saying is we have to challenge ourselves and look at our own practice and say, okay, what am I doing? That's effective and what am I not doing? That's effective. Now, the reason why it's called acceptance and commitment therapy is because with regard to pain, acceptance, that's, one's willingness to acknowledge pain as part of their life experience. Speaker 2 (00:20:15): And with that acknowledgement, they avoid the, they avoid the attempts to control or eliminate it. Now pain acceptance is important for people living with pain, pain. Acceptance is also vitally important for practitioners who treat people with pain because of the research is clear that we don't have a really spectacular way right now to eliminate someone's pain. I'm not saying that we can't do that. I believe it does happen, but what I'm proposing. So people who are listening to this episode is that in many ways, we put the cart before the horse, and we've said, I'm going to make your pain go away first. So we have all these ways to make your pain go away. And then you'll return to life. Speaker 2 (00:21:03): When in essence, we have to say, let's talk about how we can start to clarify what was important to you in life. Take little steps toward that. And then with that, your pain will start to go away. They're very different messages and they're also very different ways to approach a patient. So if someone turns to you Karen and says, I have no idea. I've had pain for 10 years. It's affected me so badly. I lost my job. I've lost my personal relationships. Let that person talk about their loss because just like that vulnerability process, right? They're talking about how they're vulnerable. Well, on the opposite side of that, they're really saying, I want to, I want to maintain relationships. I want to get back to work. So allow people some room, actually many times when, when questions like that come up, this is going to sound strange to people. Speaker 2 (00:21:56): But I just sit there in silence. I maintain eye-contact. I maybe move a little bit closer to the person. And I just give them some space to process that and to process the, the idea that someone's asking them, someone's interested in their life beyond just pain relief. And that can be really difficult, especially for physical therapists, because we went to school. And even if you go to like DPT program websites right now, it says like, you will learn how to like resolve someone's pain. And then we get out into the world. We got out into, you know, the profession. I mean, we figure out, Hmm, maybe I'm not as good at this. As I thought, Speaker 1 (00:22:36): This is, this is really hard. Am I missing something? I must have, they didn't teach me this in school. Am I, what do I need to learn to do this? Speaker 2 (00:22:46): That's right. So the question is, you know, what, if the way to help someone contact her values is to just sit with them and allow them some space to start to think about that. Because chances are, if someone's wrapped up in experiential avoidance, they're not thinking about that on a daily basis. They're thinking about, I need to take my medication this morning. I need a hot bath. I need to take my magnesium. I need to take my nap. I need to do some distraction activities. So I don't think about pain. That's what their mind is preoccupied with. Speaker 1 (00:23:26): Yeah. Or yeah, a hundred percent. A hundred percent. Yeah. Everything you're saying, I'm like, yep. I can remember like, Hmm, okay. I have to figure out what pillow I'm going to use. I have to figure out how much I'm going to put my bag. So it's not that heavy. When I walk around, do I have a break during the day? Did I take Advil? Did I? Yeah. So on and so forth, but that is, that's all encompassing during your day. And, and I don't think I had, well, yeah, well, when I sat with David Butler, he's like, well, what, what would you be doing? Right. And I, my answer is, I don't know. I, I never thought about it. Right. You know, and, and, and being able to send, he did exactly what you just said. He's like, well, think about it. Speaker 2 (00:24:17): And I w I want to, you know, reinforce what you're saying is that for some people it's extremely difficult for them to think about it. Yeah. Speaker 1 (00:24:24): Yeah. It's and it's really uncomfortable and it's uncomfortable. So just think of it's in control for the patient. And you're the therapist on the other end, is it uncomfortable for you as the therapist to watch someone be uncomfortable and wiggle in their chair, so to speak? Speaker 2 (00:24:41): Yeah. I love that. And my response to that is empathy for the people we work with involves a little bit of us feeling uncomfortable and sharing that unpleasantness with the person that's in front of you. And in many ways we mirror people actually. So as they're struggling and suffering as a human, who cares about someone we're struggling and suffering too, because ultimately, ultimately every physical therapist I've ever met. And, you know, I've interviewed a lot of therapist. Karen, when I asked him, why did you want to become a physical therapist? And they would say, well, I want to, to help people. And if I always dig, dig in there more, there's always a story of, well, when I was in high school, my, you know, my grandfather had a stroke and he wound up living with us and I saw the PT come in the house, or I was an athlete and I had an ACL repair. And I saw all these people in this PT place and how I could help them. So, you know, there's a, there's an aspect of human resiliency built in with that. I lost my train of thought. Sorry. one thing you can try for people who are having a hard time connecting to their values, their personal values is to ask them, Hey, if I were to share some information with you about how we can alleviate pain, who would you share that with in your life? Speaker 1 (00:26:13): That's nice. So then Speaker 2 (00:26:15): It takes it off of, it takes a little bit of the pressure off the person or off the patient. Speaker 1 (00:26:20): Yeah. Yeah. It takes a little bit off them and puts it onto someone else. Right. Speaker 2 (00:26:25): Right. And in general, we all want to help other people. And especially people with pain, they really do care about other people. And they really have an interest in not seeing other people's struggle the way, the way they've been struggling. So it's a nice way to just kind of shift the conversation a little bit. And if you continue with that, what you'll eventually see kind of like in ourselves when we learn things right. And when we teach things, we actually wind up implementing it into our life in a way that's more effective. Speaker 1 (00:26:52): Yeah. Yeah. That reminds me of Sharon Salzberg, loving kindness, meditations. So when she does those meditations, she sort of starts with, you know, think of someone else and, you know, offer them like a life of ease, a life of love, a life of serenity or kindness. And you kind of repeat that mantra for awhile and then just say, offer it to the world and you offer it to the world. And she's like, okay, now offer it to yourself. So that you've practiced someone else you've practiced the world. And then you can turn it back onto yourself. And it's, I always felt like, Oh, this is nice. Now I don't feel bad. Wishing myself a life of ease or a life of ex you know, love or XYZ. Right. Cause I think sometimes when you, I think a lot of people feel this way. They have a hard time being kind to themselves and allowing themselves to not suffer. Speaker 1 (00:27:50): Even though with chronic pain, you are suffering and you don't want to be suffering yet. It's hard to recognize that in yourself. You'd rather put it onto someone else or wish that for someone else. But it's just so hard to wish it for ourselves because maybe if, if you've had chronic pain and I'm just, I don't know if this is true or not, but you can't, it's hard to see yourself out of it. Right? And so it's hard to even think of yourself, elevating yourself up to something that maybe you'll never get to. So then you'll, won't be disappointed. Speaker 2 (00:28:25): That's right. I, I talk about this in my book, in the, in the sense of self-compassion, which can be difficult, as you said, it's a little bit easier to be compassionate toward other people. And it can be more challenging to be compassionate toward ourselves. Where I see this show up with regard to chronic pain is people have been taught. You have to fight pain. Yes. You have to overcome pain and you see this online people even come in, I'm a pain warrior. Speaker 1 (00:28:50): Yeah. Right. You gotta be tough. Speaker 2 (00:28:52): Right. You have to be tough. You have to fight it out. You have to struggle with it. And my question really with regard to that is, okay, there's definitely some work that we have to do here. There's some effort that we have to put into this and there's some behavior change. We know that as professionals, but if you enter into a battle with pain, what kind of message is that sending your mind? Speaker 1 (00:29:17): You're always on guard. You're always on high alert. And that's kind of the opposite of really what we want when we're working with people with chronic pain. That's right. Speaker 2 (00:29:25): And even, even Karen, because I can see you on video right now, as you do that, you're stiffening your whole body up. Right. And we know that things like spasm, muscle spasm, tightness is an outcome of some of these psychological variables. We're talking about being a warrior. Imagine you see holding a gun or holding like a spear they're stiff and very contracted, right. Really what we do with act. And many of the mindfulness and acceptance based approaches is we start to soften to the idea that maybe I don't have to fight this. And that may be my fighting. This maybe the battle with this is the worst, worst, worst part of this. And if I can just let this go just a little bit and allow it to be that maybe not only will my physical body soften, but also my mind will start to release a little bit with regard to some of the things that I've been struggling with or some of the things that I've been grappling with with regards to pain. Speaker 2 (00:30:21): And we know that when that happens, people work toward more pain acceptance. Not only does the quality of their life improve, but as I mentioned before, or that kind of cart before the horse, that's also when pain relief happens, why does pain relief happen with that? And that's, I think it's an important point to talk about, well, we have a reward system in our brain, right? That produces its own opioids. When you engage in activities that are meaningful and important to you, it kind of, you know, twinges that reward system in your brain over meaning it makes you feel good. Right? So engaging in things that make you feel good or rewarding or engaging in things that are rewarding, make you feel good, they bring you pleasure. Right. They bring you joy. And with that, it alleviates pain. So yes, there are ways for us to help with pain control. And there are ways for us to help people be a little bit more willing to engage in their life, even with a little bit of pain and both work effectively and both work synchronistically together to help people. Speaker 1 (00:31:35): Yeah. I know. I always look back and think, you know, there were days where I couldn't turn my neck from side to side, like I would be crying during the week, but then on Saturdays I pitch a double header and I was a windmill pitcher. No pain felt great, really good because I loved pitching. I love being with my team win or lose. It was awesome. Even if I got like hit with a line drive or something, I just, like, I was hit with a line drive in the shoulder. Didn't bother my neck at all. Didn't even think about it, no problems doing that. Right. And people would always, that's why, when you have someone with, in my case, like chronic neck pain or chronic back pain, and you see them doing something like pitching a double header, a fast pitch softball game, well, there's no way they could have pain because they're doing this. Right. Right. And so it's, it's from what you just said for me, this was really valuable in my life was meaningful. It gave me joy. So I was able to do it with Speaker 3 (00:32:40): Very little, if any pain, but on the outside, people are thinking she's faking it. Right. So what, what, what do you do in that respect? Yeah. Speaker 2 (00:32:51): Well, I just want to what you're saying resonates well with me, it takes me back really to like the first year I was practicing, which is like 25 years ago before I studied anything about acceptance and mindfulness based approaches. And I had a, a young woman who was, she was the same age as me at the time she was 26 and she was walking down one of the beautiful tree line Brown street, brownstone streets of Brooklyn on it's on a Saturday evening and a drunk driver. Kim wants to the curb and pinned her between the car and the steps of the brownstone. And instantly she was an above knee amputee on one side and the below knee amputee on the other side. And she was a patient of mine pretty much the first, entire six months of my career, basically. And the beginning of her rehab was so smooth. Speaker 2 (00:33:44): It was wonderful. And you know, it was a physical therapist. We just feel good because we're helping someone walk again and we're fitting them for prosthetic limbs and we're making them stronger. And that went all really well until two things happen. Once you start to lose some weight because she was in the hospital and eating better and exercising. So the prosthetic didn't fit as well. So it was a constant struggle with the prosthetics every day. And then two, she developed a neuroma on her, on her. One of her legs, there was a period for about two weeks where she was so utterly depressed and unhappy. Cause she was in so much pain and suffering so badly. And all of us, the PT, the OT, the nurses, the psychologists, I mean, everyone went into her room and try to motivate her. You know, we use these like rah, rah, watch your tacky. Speaker 2 (00:34:36): Yeah. Cheer her up kind of thing. So one day I went into her room and I just sat next to her. And I said, I don't, it doesn't seem like you want to walk today because that was my job. Right. As a PTA, she said, no. And I said, okay, well, what do you, what do you want to do? Then? I said, you can't stay here. You can't stay in this bed forever. You know that, you know, eventually you they're going to send you home. And she said, there's only one thing I want to do. She said she was engaged at the time. Actually. She's like, I want someone she's like, I want to get married. And I want someone to wheel me out into the dance floor in my wheelchair. I want to stand up and I want to dance with my dad. Speaker 2 (00:35:23): And that's all she wanted to do. She didn't want to walk. She didn't want to walk 50 feet in a hallway with a Walker times two. Right? Nope. Didn't care about that. She didn't care about the prosthetic legs. Really. She didn't really actually that at that time she didn't even really care if she was in a wheelchair, the rest of her life. That's what she wanted that moment. So you know what we did together. Okay. Put your hands on my shoulders. Stand at the edge of the bed. I put some music on and all we did was weight shift. Now, could I have done something more therapeutic from like a physical therapy perspective? Of course I could. Was there something, was there anything that was more important to her in that moment? No. No. Speaker 1 (00:36:10): Yeah. And now, now given the knowledge that you now have and what we know about pain and what we know about this more value-based activities and mindfulness and act, looking back on that, what does that do for you? What does that make you think of now where you are now looking back on that as such a young therapist? Speaker 2 (00:36:36): Well, it makes me think two things. First I am eternally grateful for the skills and knowledge I have now that I try to share with people as much as I can. And then I also reflect on who didn't I help? Oh, that's a can of worms, right? Yeah. Who slipped through my fingers that I wasn't aware of. And that makes me reflect back on, okay, what are we not teaching licensed professionals, especially physical therapists in school, right? So the amount of time we spend on evaluating the structure, function, the structure and function of a joint is in my opinion, at this point in my career is kind of absurd. Speaker 1 (00:37:23): That's the word? That is. So that's the word that came into my mind too. Speaker 2 (00:37:27): The reason why it's absurd and not no offense against, you know, our colleagues in academia is that this is so much packed into a PT program now. Yeah. So we have to get better at, okay. What do we have to, obviously we have to, we have to understand how to measure strength and range of motion, function, et cetera. But it's perhaps most important that we learn how to motivate and change behavior. Speaker 1 (00:37:56): Yeah, absolutely. Because when you, when you think about pain and certainly chronic pain, but even acute pain, what does acute pain do to us as humans? And then as a result, chronic pain, it changes our behavior. It forces us to change our behavior. If we sprain our ankle, we've got a big puffy ankle. Are we going to walk and run for the next week or so? No, it's going to change our behavior. And in chronic pain, that behavior change becomes more than just a few weeks of a behavior change. It becomes an embedded behavior change into personality and into everything that we do. Speaker 2 (00:38:39): That's right. And the reason why acceptance I commend therapy is so important for physical therapists is because when we look at all the literature on cognitive behavioral therapy, traditional cognitive, behavioral therapy, and even pain science education, and both of those I'm I'm in favor of, and I support, but the outcomes actually may be a little better with act with an act approach specifically for the pain, the population of those living with chronic pain and as physical therapists, knowing that we function in practice settings, where we come face to face with people who are in acute pain. And if we can start to deliver some of this during the acute setting, right, then we can prevent the transition to chronic pain. And I think that's the most important. So if you're in acute orthopedics, if you are working in inpatient rehab, I mean home care, all the various places that we function, physical therapists are in the perfect position to take the brain and the body or the minds and the body put them together and help someone overcome their pain. Speaker 1 (00:39:50): Yeah. And, and it goes back to what you said in the beginning, it's sort of fostering that resiliency in people, and that can happen the day one, you injure yourself. You know, last summer I, I had a partial tear of my calf muscle. And the first thing that came into my mind was, well, the first thing was I felt down when it happened, I was like felt for my Achilles tendon. I'm like, okay, the Achilles tendon is there. I'm good. And isn't that amazing? Like I, anything else to me was like a nothing thing. Right. But the first thing I needed to do was I felt down, I was able to point and flex my foot. My Achilles tendon was intact. I got up, I lived up the field fine. I was like, okay, I'm good. But the next day I was like, Oh my gosh, what if this doesn't go away? Speaker 1 (00:40:41): What if this, because of my own history with chronic pain, it's what if this is chronic? What if it never goes away? But, and I, instead I went the next day, I went to see an orthopedist and he did kind of what you're saying. He was like, listen, this is what's going on. This is what's going happen. And he gave me out like a timeline of expectations and for me, and, and the way that I function, that was a great way to build up my resiliency to know, Hey, first of all, it's not my Achilles tendon. And second of all, this is what's going to happen over the next couple of weeks and over the next couple of weeks, what he said happened. And so I felt okay, I'm good. It's a little sore. It's a little painful. I'm okay. With the backdrop of that chronic pain history was really meaningful to me. Speaker 2 (00:41:30): Yeah. There are variations of informed consent, just informing someone, okay, what here's what's happening. And here's how this is potentially going to play out. Can be really, really important and powerful for someone. It can help ease someone's anxiety. It can help ease their worry and concerned about it. And as I mentioned before, these are the places where, you know, we thrive as PTs actually, especially with regard to pain. I mean, if you look at pain education in licensed health professional training, PTs have the most more than psychologists were than the other mental health professionals, more than OTs. So, you know, we're putting all these pieces together. And in fact, when you look at what are the most important factors to help someone with pain it's pain education, right? So we talked about that some type of cognitive behavioral therapy, acceptance and commitment therapy is a third wave generation, cognitive behavioral therapy. And then something related to lifestyle, probably the most important factor with regard to lifestyle is movement is exercise and physical activity. So when you put pain education together with act together with helping someone or promoting physical activity, that's probably the kind of trifecta. Those are the, that's the secret sauce, if you will, of helping someone with pain. Speaker 1 (00:42:52): Yeah. I, I agree a hundred percent and now let's dive in just quickly. If you can give the listeners kind of like, what's the difference? You, you sort of alluded to it now between acceptance and commitment therapy and cognitive behavioral therapy, and also the difference between act and mindfulness. Speaker 2 (00:43:19): Sure. All really important distinctions. Thanks for the question. So cognitive behavioral therapy is kind of the first therapy that was used with regard to people's thoughts, beliefs, and emotions around pain. Most of that work focuses on identifying or challenging problematic, problematic, or modifying thoughts. And with that, as someone modifies their thoughts, you hope that it modifies and changes their behavior. So restructuring thoughts, we've heard these words before restructuring thoughts, reframing thoughts even the reconceptualization of pain, which is a purely from like a pain education perspective. It's still a more traditional cognitive behavioral therapy model, helping someone identify their thoughts, and if their thoughts are maladaptive, how can we change those thoughts now they're important. And there's a place there for that. What I propose to people when they start to look the literature on changing thoughts, specifically with pain or the route with regard to pain, it can be quite difficult and quite sticky to do that. Speaker 2 (00:44:29): There's some pretty good research that shows that there's a small group that will reconceptualize their pain really early on. There's another smaller, equally small group that will never change. And then most people are kind of somewhere in the middle. So they understand what you're saying. They understand that, okay, the herniated disc in my back, isn't the only factor with regards to my chronic lower back pain. And they understand that, you know, thoughts about your thoughts about pain, negative thoughts about pain are not necessarily good, but they don't reconceptualize. They don't change those thoughts on a hundred percent. The difference with acceptance and commitment therapy and even mindfulness, they're both what they call third generation cognitive behavioral therapies, which instead of targeting these maladaptive thoughts and beliefs, we simply help people observe that they have thoughts about what's happening. And instead of changing that we help people understand or identify, recognize that they can have those thoughts and beliefs, but still continue on with the things that are important to them in their life. So it's a big distinction. It's especially challenging for physical therapist who spent a lot of time studying pain education. And there's a physiotherapist from Ireland that came into my act program and she studied pain education for a long time. And then she studied cognitive functional therapy, both two evidence-based wonderful ways to treat pain, but she found that there were some people, a lot of patients actually, that they understood didactically what you were saying to them, but it didn't change their behavior. Speaker 2 (00:46:10): So what's wonderful about act is that act is a behavior change model. It's really based in behavioral therapy. And there's also something nice about not having to struggle with someone to change their thoughts and beliefs all the time. It takes a little bit of pressure off the person who has pain and it takes a little bit of pressure off of the therapist, Speaker 1 (00:46:30): Right? Because sometimes when you try and change those thoughts and behaviors, and I don't know about you, but I've heard this when I first started you know, really studying more about pain science and, and understanding how, how pain affects people in so many different ways. And when I first would talk to people and I bet, you know what I'm going to say here? What, what would they say to you? So you're saying it's all in my head. That's right. Right. Speaker 2 (00:47:00): And the, you know, when that happens, people feel invalidated and it kind of takes us full circle to the beginning of our conversation is it focuses on their vulnerability. Oh, so you're saying there's something wrong with the way I'm thinking. And the truth is if someone thinks about their pain, a lot, that's 100% normal. Cause that's, that's a pain supposed to do. Pain is supposed to alert you to something that's potentially harmful or something that's dangerous. So just normalizing that everyone's mind my mind, Karen, your mind, someone who has pain, we all think all, most of our thoughts throughout the day, our thoughts about how do I avoid things that could potentially harm me, things that are potentially uncomfortable, helping people just observe that actually can be the step before even the reconceptualization of pain, because how can you, how can you expect someone? How can you help someone to target thoughts and beliefs about pain if they haven't even thought about, okay, what are my thoughts? Speaker 2 (00:48:12): What are my beliefs about pain? What am I thinking right now? The average person has somewhere between 6,000 and 12,000 thoughts per day. And the truth is most of them are negative because it's a survival instinct, right? We brought this through with survival instead. How can I observe these thoughts? How can I observe my emotions? How can I be getting to observe the physical sensations in my body, whether that be anxiety, whether that be physical pain and realize that I can have contact with that, but not let it impact my behavior. So that's really the biggest difference between an act or a mindful, acceptance based approach versus a more traditional cognitive behavioral approach. Speaker 1 (00:48:57): Yeah. Thank you for that. That is very helpful. Cause I'm sure you get that question quite a bit. So it's nice to be able to clear that up. So now let's shift gears slightly ever so slightly and talk about your new book, right? So your new book, radical relief, a guide to overcoming chronic pain. So let's talk about it. Why the title why'd you write it? Go ahead. Speaker 2 (00:49:27): Well, after my first book came out called heal your pain. Now in that book, I had a section called the brain and pain. And at that time, the author only gave me so much space to write about the mind, so to speak. So I had to, I had to include small sections about mindfulness and about act and in general about the mind and how the mind responds to pain. And it kind of forced me to take a very didactic approach to pain. And people would reach out to me all the time. I want to learn more about mindfulness for pain. I want to learn more about this thing. You mentioned act about pain. So both professionals and people were coming to me. So I couldn't put it in that book. And I really firmly believed that deserved its own resource because there are solid mental skills, training and exercises that are in this book, radical relief that wasn't in my, in my first book. Speaker 2 (00:50:24): Second is it's a little bit tongue cheek, so to speak, it's a radical idea to think that two physical therapists want to spend their Thursday evening talking about the mind and mental skills training with regard to pain. So as we said before, like there's a little bit of a cognitive dissonance in there, but we know that physical therapists have a very important part with regard to helping people cope both physically as well as psychologically and emotionally. You know, the third aspect is just in general to give people this notion that it's not a radical idea to use your mind, to use mental skills training, to use mindfulness, to overcome pain. And that can be a part of your treatment. And in fact, as you and I are sitting here counting, I can guarantee you there's someone right now, who's being treated for pain who are not being offered these types of skills and you know, you, and I think it's absurd actually, but this is still happening. So radical relief really is a short book. It's only about a hundred pages. It's a workbook that includes over 50 cognitive and mindfulness type exercises to help people overcome their chronic pain in essence. And it's also written for practitioners to use as a guide in the manual that they can use in clinical practice. Speaker 1 (00:51:45): Yeah. And the one thing that I liked about the book aside from, as we were talking before we went on air, it's very, very pretty all of the illustrations are quite beautiful. But I like the fact that within each chapter there's like exercises and you have to literally write things down, pen, take pen to paper, and you can do it right in the book. Or you can grab the extra sheet of paper or what have you. But I like the fact that you have to write things down because there is something to that, you know, there is something to writing to the physical act of writing something down on paper versus typing it out or just thinking about it. And so that's something that I really appreciated throughout the book. Speaker 2 (00:52:30): Yeah. And I learned that from my first book as my first book was a very education based approach. As we mentioned, pain education is important, but it, it doesn't do a great job of changing behavior when you get involved with act, act as a very experiential therapy. So you're not sitting across from someone like talking to them, you're actually engaging with them in a lot of different ways. So what I really found was, and people can, you know, note this down for themselves. The average person doesn't want to flip through 300 pages of a book to learn about pain. They want something that's relatively short. They want something that's clear. They want something that's useful that they can really pick up, you know, now and start to use. And I think it's the same with practitioners, right? There's only so much theory and philosophy we can think about before we say, okay, what do I do with my patient today? What am I do with patient? I have at nine o'clock tomorrow, who's been suffering with fibromyalgia for 10 years. So that's why I tried to approach this book very differently from, from the first book. Speaker 1 (00:53:35): Yeah. And, and before we went on air, you, you asked me if I had a post-it note to which I said, I have a large sheet of white paper and you said, no, it needs to be a post-it note. And I said, well, I have a mini post-it note, will that do the trick? So please, please tell me why I needed a post-it note and not a large white sheet of paper. And perhaps the listeners, if they have a post-it note, they can go and grab one as well. Speaker 2 (00:54:05): Yeah. So if everyone has a post-it note and a pen or a pencil, please hit pause and grab that and come back. But as you mentioned, Karen, it's a workbook. And you said putting pen to paper changes things, right? Because in some ways it's it's experiential. So I was, as, as I was mentioning before, we don't have a good way to change thoughts and beliefs. So with that, we have to help people relate or respond differently to thoughts and beliefs. Right? All of us have things in life, thoughts and beliefs about ourselves that are somewhat unpleasant and painful, right? Some of them are really, really horrible things about ourselves. And some are, some of them are things like, you know, not so horrible. So if you'll kind of engage in this with me, I'd like you to just reflect on yourself and your own life experience and think about one negative, thought about yourself, not the worst thought possible, but one thought that, you know, maybe on a scale of one to 10 with like one the least impactful and like 10, the worst, maybe you're somewhere like a four or five. And then I want you to write that down on the post-it note. Speaker 3 (00:55:19): Okay. Speaker 2 (00:55:20): So we can't change this thought, right? The thought is there and just rip it off a little post-it pads, Speaker 3 (00:55:31): Still writing. Okay. Speaker 1 (00:55:42): My pen's running out of ink, but I remember what it was. It's, it's half written. It's written. I just, my pen ran out of ink, but okay. We can, we can go on. It is written. Speaker 2 (00:55:52): I'm going to do this with you actually. So it's written there and what I want you to do is pull it off the, pull off the post-it pad. Okay. And I want you to hold it up. I don't know, maybe about a foot or so away from your knees. I want you to look at it. And in your, in your mind, I just want you to repeat the word nice and slowly, and really kind of get lost in that word just for a moment. And then as you get lost in that word, just notice if you feel anything different in your body. Speaker 1 (00:56:37): Yeah. Looking at the yes. Speaker 2 (00:56:39): Right? Okay. So you see how thoughts have an impact on how we feel now, what I want you to do is I want you to take your arm and stretch it out as far as you can go. And I want you to look at that word. And what I want you to do is I want you to flip it upside down. Now, just turn it 180 degrees and now look at it and now see if it has any less of an impact on how you feel. Speaker 1 (00:57:07): I mean, maybe a little, Speaker 2 (00:57:09): A little bit right now. What I want you to do is I want you to maybe prop it up on the computer screen in front of you, and I want you to push back. So maybe you're 10 feet or so. Speaker 1 (00:57:22): Okay. Go. As far as my mic, as my ear, phones will take me Speaker 2 (00:57:28): And then maybe just stand up as you're there and now look at the word and then notice if there's any difference in how you feel or how you relate to that word. Speaker 1 (00:57:43): Yeah. Maybe a little bit, now that I'm standing and people can't see me, but I think I automatically stood up in the power pose. Speaker 2 (00:57:49): I noticed I still noticed put your hands on your hips. Right. So would you say there's less of an impact as you move away from the words so to speak? Yeah. Great. Okay. Come back forward. So what I just did is what they call cognitive distancing. So it was a way to distance yourself, literally as well as figuratively. So now what I want you to do cameras, I want you to take that same post in them. I want you to fold it up into a little square And I want you to put it in your back pocket. Speaker 1 (00:58:24): Okay. I don't have one. So I'll pretend I do. Speaker 2 (00:58:28): Yeah. Just stick it up your sleeve there. Okay. So now you have this unpleasant unwanted thought about yourself. It's not going away cause it's in your back pocket or it's in your front pocket or wherever it is, wherever you placed it. And my question for you is would you be willing to be with that thought and to be with those uncomfortable sensations you feel on your body, if it meant you could be a more effective physical therapist or be a more loving daughter sure. Or a more supportive wife or a girlfriend, or a more effective member of your community or a leader of your profession. Speaker 1 (00:59:14): Yeah. I can do that. Right. Speaker 2 (00:59:16): So it just shows you that we can change how people relate to thoughts. We didn't change the actual thought. Still there. We can change how people relate to them, to it. And we can also show people how, okay, this thought can be present with us and I can still experience it and not feel good about it, but I can still go about my life. And what I do with patients is I have them take these thoughts. Like I have a big herniated disc at L five S one. Okay. Write that on a piece of paper, put it in your back pocket in your briefcase and carry it around with you today and notice how at times that thought wasn't even present and didn't talk to you at all. And other times maybe it was present a little bit, you thought about it, but it didn't stop you. And other times it was like a big barrier. Right. And within those three, they're really important teaching moments that we can help patients with. Speaker 1 (01:00:09): Yeah. Oh, that's great. Great, great. Is that in the book? So Speaker 2 (01:00:14): The book is full of Speaker 1 (01:00:17): Nice. Nice. Yeah, no, I think that's great. And, and for, you know, physical therapists or other healthcare professionals that might be listening, that my hope is that this podcast will plant a seed in them to say, you know, maybe, maybe I'm I need to do a little bit more, you know, and what can I do to do more Speaker 2 (01:00:43): The biggest ask the biggest, one of the great gifts that I have come across in teaching physical therapists about act is yes, it helps your patients, but physical therapists notice a change in themselves from it. Because look, we struggle with not being able to help people. We get burnt out because of it. Absolutely. We have our own personal challenges that cause us pain and suffering. So to speak that we struggle with outside of our clinical work, that this type of work becomes really important to you. And the truth is, as you know, Karen pain will show up in life. Yes, it will show up when you least expect it. And these are effective skills that I really believe all of us need to learn and adopt not only for our patients, but for us to be effective clinicians and effective professionals for us to embody them in ourselves, then we can help people with these types of aspects and these, this type of care. Speaker 1 (01:01:44): Yeah. I don't disagree with that. I think that's great. And you know, I was just going to ask you to sort of put a bow on this conversation, if you will, and what would you like people to take away from it? I think you gave a little bit of it just now, but is there anything you'd want to add on to that? Speaker 2 (01:02:06): What I want people to take away from a mindfulness and acceptance based approach to care is that there's hope in it. And that hope really resides in helping helping, giving you the skills that help someone reconnect with their life. And that resilience that we spoke about in the beginning, the hope is really what people are looking for because they feel helpless. They feel hopeless. And this work is really about, okay, maybe there's some things in your physical body we have to work on. Maybe there are some thoughts and feelings and emotions that are difficult for you. Let's yeah. Let's kind of work on those, but know that you're whole, as you are, as a human being and everything that's required to overcome this already exists in you, I'm just going, gonna help you contact that in a way that's more efficient that moves you along this path in a way that's faster. So the whole part is really important and that's really what people are coming to us for. Speaker 1 (01:03:07): Yeah. Yeah. That's great. And then last question or no, well, last question before we get to, how do we contact you and all that other fun stuff, but, and you know what this question is, I think I've already asked it to you like three times, however many times you've been on the podcast, but let's say knowing where you are now as a therapist and as a person and in your life and your career, what advice would you give to your younger self? Maybe not right out of college, but let's say 10 years ago, before you really started delving into working with information surrounding chronic pain, Speaker 2 (01:03:48): I would say, give yourself space to fail and just allow that stuff, exploration of exploring different things and realizing, Hey, I didn't do that so well, or I wasn't so great today and allow yourself, there's a lot of pressure on us as professionals to be this, you know, master healer, so to speak. And I really think it's damaging to us as professionals. Speaker 1 (01:04:20): And I think that can lead to burnout, all that pressure on you to be the person, the one person in someone else's life. That's going to take away all their pain or take or add this, or take away that boy, that's a lot of pressure. Speaker 2 (01:04:37): That's right. I, I actually, I asked therapists now, who are you to take away someone's pain. Cause really think about what that really means. Speaker 1 (01:04:46): Like the wizard of Oz, Speaker 2 (01:04:48): Right? Like, is there some like magic fairy dust that you have that the rest of us don't have? And again, it doesn't mean that we can't help people with their pain. I mean, we can alleviate some of that pain, but that's not what, that's not what we're there for. We're there to be a witness to someone on their journey to overcome whatever it is that they're struggling with. And the kind of take that into a mindfulness realm, allow yourself to be your own witness as you move through the profession and you navigate and negotiate. Okay. Here's what I'm really good at and why I want to kind of cultivate and things that I don't have to necessarily engage with that. Speaker 1 (01:05:29): Yeah. Well said now, where can people find you? Where can they find the book, social media websites? What do you got for us? Speaker 2 (01:05:39): Easy. People can go to my website. The website is integrative pain, science institute.com or one very long word, integrated pain science institute.com. The book is called radical relief, a guide to overcome chronic pain, which you can find on Amazon in most countries. If you go to either one of those two places, you'll find the book and all the information about me. I also want to plug another book Karen, in which you're involved in. Speaker 1 (01:06:03): Oh yeah, yeah, yeah. That's right. It's a couple of months out still. Yeah, Speaker 2 (01:06:08): I'm working. I'm the chief editor on a book that involves about 45 different physical therapists, some from academia, some from private practice and it's with regard to how physical therapists can use lifestyle interventions and practice that book will come out probably in the fall of 2021. And I want to plug it because it's an awesome book with, you know, as I mentioned, Speaker 1 (01:06:32): Amazed some amazing people involved, Speaker 2 (01:06:34): Amazing people. And Karen is one of those amazing people. Who's
