Sciatica

YouTube video

Nick: Welcome to the Ascend Health Show. I’m Nick Angelis. I’m a Nurse Anesthetist and one of the Owners of Ascend Health Center. And I’m here with Dr. Bob from HealthSource of Fairlawn. He’s my personal chiropractor as well. So if at the end of the show, you see me get up, then you should find another chiropractor, but just kidding, he does very well, my back and neck feel great. And that’s what we’re gonna talk about today. Sciatica and back pain.

Dr. Bob: Yeah.

Nick: So how are you doing today?

Dr. Bob: I’m doing well. I actually just got done seeing a few patients before I joined you. And this is a topic I was excited when you invited me to discuss it, because it’s something that we treat frequently in our office. And so it’s something I’m very comfortable kind of talking off the cuff with you about.

Nick: For sure, and I feel this is something where you’re gonna have more expertise than I, because obviously in anesthesia school, we learned all about the dorsal horn and all the nerves of the spinal cord in great length. But sometimes it’s not as practical, because obviously I do anesthesia for back surgery and I treat sciatica at my clinic as well. But I actually, even at the get go, I should say, I’m not a first line option for back pain. I — I’m a solid third line option for back pain. Don’t come to me if you just get some back pain.

Dr. Bob: Yeah, you’re coming off the bench–

Nick: Yeah.

Dr. Bob. -for back pain.

Nick: For sure. I’m like the Lamar Odom, of–

Dr. Bob: There you go.

Nick: If it was like 20, let’s see before the cocaine days. So that would be, but after the ketamine days, but maybe like 2014-ish, Lamar, something like that.

Dr. Bob: Yeah Lamar of 2014. All right. I like it.

Nick: Or Iguodala around 2017.

Dr. Bob: There you go.

Nick: That might be a better example, which I’m sure alienated 80% of our viewers.

Dr. Bob: That’s right. Or probably they’re more like Deli or the Cavs.

Nick: Well, actually another episode we had was about men in counseling.

Dr. Bob: Yeah.

Nick: And I said, there’s no men watching this. These are all the women who want their men to go to counseling. So maybe similar for back pain.

Dr. Bob: Yeah.

Nick: These aren’t the sports fans. These are the women who live with them. They’re thinking, “You know what, I’m sick of hearing him go at half time when he has to like put the remote down and go get some more chips.”

Dr. Bob: I’ve absolutely had that, that type of interaction with a patient before just a couple of years ago, I had a patient who came in, you know, kind of a grumpy guy experiencing these type of symptoms. And I said, “You know, what, what brings you in? What’s motivating you to do something about your back.” And he goes, “Doc, I don’t even know why I’m here.” And sometimes with the right patient, it can be really good to be direct with them. And I said, “Look, I know why you’re here. Your wife’s been listening to you complain about this for five years and she’s just tired of hearing it.” So.

Nick: But I’m the same way too. Like whenever I come for an adjustment, I’m like, “Everything’s great.” And they start pushing things like, “Oh, guess, guess it’s not.”

Dr. Bob: So you’ve been going well. “Oh, oh yeah, you know, that has been bothering me.”

Nick: Right. Well, even the way I describe it in my clinic for mental health, since that’s the majority of what we do is, you don’t go to the dermatologist with your makeup on. So you shouldn’t come to me saying, “You know what, anxiety and depression, they’re great feeling good today. It’s a good day.” It’s like, this is the time when you can complain and it’s helpful. And we can figure out exactly what’s going on. You can save the brave face for, you know, your acquaintances or somebody else other than us.

Dr. Bob: Yeah. That’s, that’s really important. I like that analogy too, because I’ve, I’ve even had patients who come in and they’re afraid to complain about their pain. Right. And you’re like, “No, no, no, this is the place to do that. We’re here to, to help you with that.” Yeah. I like the analogy of taking off the–.

Nick: Often I say too, that I’m going learn just as much, if not more. Actually I will learn more if I find out that what I’ve been doing, isn’t adequate. If you have a complaint about how things are going, because if we’re here to stroke, my ego, like you literally just paid money to come compliment me. How about you say, “Okay, here’s what isn’t working. Here’s what you can do better.” And maybe, and honestly, I don’t really go to that many doctors, maybe it’s a thing where you kind of want them think they’re doing a good job. And so maybe if I’m nice to them, it’ll work out better. But I’d must prefer like, “Okay, here’s where, what you’re doing is not working, so we can figure out, oh, here’s what you can do instead.” Or so we’ll have to go to Dr. Bob then and both — both are perfectly fine. I mean, that’s the thing about healthcare. We have to know where our limits are and what our boundaries are, are, what can we handle? And what is like, “Well, okay,” again, like I said, maybe in this case, I’m your third line option and you haven’t exhausted the first and second approach yet.

Dr. Bob: Yeah, absolutely. And I find that those cases where we run into more of those challenging boundaries of like, “Okay, we’ve tried the things that typically work and, and now we’re gonna have to proceed with something different.” Those for me, end up being some of the most interesting cases, because when it goes, according to plan, I’m like, okay, I — we’re just gonna continue with what we expected the way that it should go and we can kind of move on, you know, versus when you have more of a challenge and you run into those boundaries. You get to bring out your thinking cap. And that’s part of why I’m in healthcare is I like to be the Sherlock Holmes of like, kind of getting to the bottom of things.

Nick: And sadly, you can’t investigate unless you do put your own ego aside. Because sometimes it’s like, “I don’t even know if that was my A game and they got so much better.” And other times like, “Well, I tried everything. I, I knew like, what’s wrong with them. It must be something that they are doing wrong.” So for sure. So what is, so what’s the first clue then for the patient that something, I mean, this is kind of a dumb question. Think of it, because the first clue with their back hurts.

Dr. Bob: Right. Yeah.

Nick: Maybe I should say–

Dr. Bob: Yeah.

Nick: But maybe I should word it. Like what’s the first clue that, “Hey, there’s a pretty simple solution to this or I should start this process,” as opposed to “Oh, just ache and pains,” or whatever.

Dr. Bob: Well, yeah, I, I, in, in talking to you about this before, one of the things that I really like that you gave me as a preface is what are some things people can do at home? So I would say anytime that this is something to consider doing something about, it would be a symptom that lasts more than three or four days, right? If you say, “Okay, it’s really starting to bug me or the intensity is getting over a three now. Okay. Let’s try some things at home. If those things at home aren’t working, then we really need to move into like the first line.” Like you, I like the language that you used, first line providers for this type of issue.

And when it comes to sciatica and back pain, I mean even Harvard Medical Center is now saying chiropractors, that is the first line defense for this type of issue. So yeah. Then in that first phase, if we’re getting into that three or four or it’s persisted for a few days, then we try some things at home. If those things at home aren’t working, that’s when, “Hey, Dr. Bob, can I get in?”

Nick: And how this maybe an awkward question as well, unlike the dumb one earlier, but the awkward question.

Dr. Bob: There’s no dumb question.

Nick: How can they know that they’re finding the right chiropractor? Because that’s a similar to a alternative medicine in your profession there’s such a wide range of like fantastic cure. Like I would not be the, this person I am today without Dr. Bob and like, oops, I guess I could’ve just had a bonfire with my money and it would’ve been like the same sort of situation. So how do people find out, like, this is a chiropractor that can help me or this is the right first step, because again, that’s a challenge with the first line.

It’s unusual to find someone who’ll be like, actually I’m not the right one for you. Like usually we try our best to see if we can help. Sometimes I’ve been an exception to that, because I’m not good at business. Where I’ve been like, well I don’t like where I can say, “I can probably help you, but I don’t know go try somebody else first.” But how can the patient have confidence? Like, oh this, because again, chiropractic care it’s not like you adjust somebody and they’re like, “Thank you, Jesus I’m healed.” It is like a process.

Dr. Bob: Right, back to a hundred percent.

Nick: It takes a lot of trust a lot of time.

Dr. Bob: Yeah and self-care too.

Nick: So how can a patient tell like, okay, and obviously you might say, well, you come to HealthSource of Fairlawn and you’ll be set. But in case they can’t, if in case they’re not local, what what’s the way to find a good chiropractor.

Dr. Bob: Yeah. So my advice is to start with the way that a lot of people find their chiropractor and that’s, you know, talking to loved ones, who’ve gotten good experiences and looking at Google reviews, but that’s really only the starting point. And I think a lot of people stop there.

Nick: Mm-hmm.

Dr. Bob: Right. They see, oh, someone had a great experience there and–

Nick: And they are not Bob’s wife.

Dr. Bob: That’s right. Yeah. It’s not my wife leaving Google review for me, “Babe, if you haven’t done that, please do.” But the, I think that there needs to be a follow up step to that and it’s almost like taking someone on a date. Right.

Nick: Mm-hmm.

Dr. Bob: Going and either looking on their website to understand more about what their practice is made up of, what are the types of conditions that they typically see. Do they even have a functioning website? That’s a good question.

Nick: Mm-hmm, right.

Dr. Bob: And then meeting them and deciding based on that initial consultation and exam, is this the right fit for me? Are they the type of person that’s really looking at the root of what’s going on? Or is it like, “Oh, okay. Hey Bob, nice to meet you. Welcome to the office. Go ahead and lay face down. I’m gonna adjust you.”

Nick: Right.

Dr. Bob: Without doing an examination and understanding what the condition really is.

Nick: Especially for back pain, because we’re talking specifically about sciatica with the sciatic nerve, being the largest nerve of the body going, you know, from the gluteus maximus all the way down to the foot, but at the same time, I mean it’s a really complex system.

Dr. Bob: Absolutely.

Nick: For most nerve injuries ketamine might not — ketamine may work very quickly, because that’s what it does. It’s–

Dr. Bob: Helps your nerves.

Nick: A neuropathic agent where it causes the neuroplasticity, but the sciatic nerve, again, being one of the largest nerves in the body, you’ve got some serious pain there. It takes a little while for anything to really work that.

Dr. Bob: Absolutely. And one of the conversations that I’ll have with patients is it’s important, not just for the nerve itself to heal, but if there’s something obstructing the function of that nerve and that’s where the mechanical side of what I do comes in, then we need to relieve whatever it is that’s causing that, maybe it’s a habitual or a tight muscle. The most common, tight muscle that’ll contribute to this type of issue is the piriformis. And it runs across where the glutes live or a herniated disc or something of that nature.

Nick: And that is important because you know, we’re both fans of functional medicine.

Dr. Bob: Yeah.

Nick: That can’t really help structural issues, ketamine can be really great for nerves, but I can tell when it’s a structural issue, because the ketamine infusion will work for maybe even weeks at a time, but the pain comes back quicker.

Dr. Bob: Yeah.

Nick: And that’s why some patients I’ll even do a test. Like we’ll start out with this infusion, then go see Dr. Bob or a physical therapist or whoever that may be, that can actually work on the structure. And head to head, we’ll find out what this is in some case — in one case, I told the patient, look, your abdominal syndrome is completely healed, but yet your back pain doesn’t go away with these infusions. Even though it’s more of a high intensity, two-hour sort of thing.

So it’s probably a herniated disc and your next step is getting x-ray and that’s what the situation was. And another case that it was similar to where it’s, okay, you actually need surgery because I’ve done what I can. And in that case it was a Spravatoso so that the ketamine nasal spray that insurance will pay for. So over time that slowly heals the nerves, it’s a really good way to treat pain without this intense one off sort of situation.

Dr. Bob: Sure.

Nick: I was like, look, once a week, I’m going and adding intravenous infusions or intermuscular injections or supplements. That’s not normal like a nurse anesthetist should be able to treat you successfully if you’re here once a week, your only option is surgery. And she had the surgery and that was, and she was able to do so knowing that she wasn’t, it wasn’t one of those cases. But we both seen, where okay, I didn’t really need this surgery. But now what do I do?

Dr. Bob: And I think interventions like surgery, as an example, can get a bad reputation, because sometimes practitioners can blanketly use them in cases where it doesn’t make sense.

Nick: So it’s not unique to finding a good chiropractor. We’re saying this about every–

Dr. Bob: Yeah. Really about any intervention. Right.

Nick: So like, let me cut on you. And you’re like, I haven’t told you my name yet.

Dr. Bob: Right. It might not be the right intervention for you, but I’ve had a handful of cases in my career that have gone to surgery and responded well, because I felt like we exhausted the other options and that helps to weed out the patients who really can respond with other treatments that don’t need to go to that. So I’m with you on that a hundred percent.

Nick: Yeah. Earlier I, I did a show about fear and pain. My schedule guest couldn’t come. So I just thought I’d talk to the camera for a minute or two until I bored myself. Sadly for any watchers it was like solid 25 minutes of talking to myself. But there’s such an interplay between fear and pain. And that’s part of it. If you’re going to surgery thinking I’m in pain, so I’ll do this, but this could be a terrible idea. Sometimes we see that and I’m not trying to get mystical, honestly.

Dr. Bob: No, but there’s a neurochemical component to that.

Nick: Even in anesthesia, I’ll purposely tell a joke, right. As a patient is falling asleep and they so rarely wake up with some of the reactions that I see from my colleagues, just because they went to sleep happy. I turn the brain off basically. And it comes back in that same state of I’m happy as opposed to does something hurt. Did I mess this up? How’s my back?

Dr. Bob: That’s probably why I’m not in anesthesia. Cause I’m not very funny.

Nick: Right. Or they come, they wake up on Wednesday, “Like, oh, that wasn’t funny at all.”

Dr. Bob: Yeah. Right.I’m I still remember that joke. It was terrible.

Nick: Oh man. So is there any particular exercise you mentioned the piriformis earlier. Is there any particular exercise specific for sciatica?

Dr. Bob: So there is one, it would be difficult for me to demonstrate it for you, but we call it a sciatic nerve glide. And the they’re pretty easy. If you go on our YouTube page if you just go to YouTube and look up HealthSource of Fairlawn, there’s an exercise on there called the sciatic nerve glide. And it’s a pretty simple at home exercise.

Nick: Mm-hmm.

Dr. Bob: That if there’s something muscularly that’s getting caught on that nerve, think of it like, like a piece of floss that’s running down from your lower back to the bottom of your foot and there are muscles through there that can kind of entrap that nerve. It works to floss that nerve back and forth and help to free it up from any fascia or muscle tightness that could be contributing to that.

Nick: And I think too, with physical types of therapies, like massage or chiropractic care, like if it works and then it stops working, you should still go back and do it again. So I mentioned the ketamine for something like sciatica, you might need a day long infusion that lasts four hours and you’ll be set for three months and you need to come back that’s, that’s okay. Other cases, it’s more of like I’m healed. Thank the Lord. And that’s fine too, obviously.

Dr. Bob: Yeah, absolutely.

Nick: But like, I don’t like to do repetitive intravenous infusions. If the prompt comes back, I don’t feel that that’s a great solution.

Dr. Bob: Yeah.

Nick: And I know that’s how every single pharmaceutical product works, but it’s much better if you can find something that isn’t interfering with your body’s natural processes.

Dr. Bob: Right.

Nick: Like one of our Spravato patients we worked to get her off every single medication so she could try to get pregnant. And honestly, I was pretty skeptical with everything that she had. So she was only doing the Spravato. I was like, this is a helpful thing. We’ll stop this once you become pregnant. And once that happened now for nine months, I told her, you need to do everything. Physical therapy, chiropractic care, massage. Like that will be your focus for all of your issues. Both mental and physical, honestly.

Dr. Bob: Yeah.

Nick: So that’s part of it too. Sometimes it’s almost like a emotional entrapment that needs to be released, not a structural. Okay, this muscle’s in the way of the nerve, and whatnot.

Dr. Bob: Yeah. But even you know, contributing to how the mechanical side can help with something like that to manage it while she can’t be on those medications. There are a lot of positive neurotransmitters that are released during exercise or manipulations that can help patients to feel better as well.

Nick: Right.That’s true. In ketamine, for example, one of the ways it works is brain derived neurotrophic factor. It’s a chain reaction and that’s a natural endorphin, so to speak. It’s missing in concussion injuries after traumatic brain injury. And so it is, it works better because it’s what the body naturally produces. So it’s not a case of, okay, the morphine replaced the Enkephalin or even in, in the case of marijuana where, okay, the endo-cannabinoids system is activated, but as soon as this comes out of your body, it’s gone.

Dr. Bob: Right. So then you go back needing more.

Nick: Right. And so it’s true that yoga, infrared saunas, a lot of those, even prayer can obviously not to the same degree that the medication will, but they’ll still have those healing, neurotransmitters, that repair brain cells that are — sort of like construction for your neural networks.

Dr. Bob: Absolutely.

Nick: Now. But I do wanna also say as a caveat, because I don’t know. I just love being the devil’s advocate for the opposite of what I say.

Dr. Bob: Challenge yourself.

Nick: Right. Because I think in wellness and health, we get so excited about, here’s this magical substance, whether it’s veratrol or this supplement or that. For example, like there’s so many studies on chocolate and wine being good for you. It’s like, obviously someone’s paying a lot of money to let you believe that something that may not be good for you in, in large quantities actually is like nobody’s funding broccoli studies.

Dr. Bob: I was gonna say there, there might be a little inherent financial bias going on there. Red wine companies are like, “Yes, please bring out more resveratrol for everyone.”

Nick: Right.Your liver likes being really, really big and working really hard. It’s like working.

Dr. Bob: That’s it. This is the cure for everything.

Nick: Right. Ladies and gentlemen don’t you want a muscular liver?

Dr. Bob: Yeah, that’s right.

Nick: That sounds better than fatty liver. Doesn’t it?

Dr. Bob: That’s right. It does.

Nick: So back off of my tangent. So brain derived neurotrophic factor is a wonderful substance. There’s plenty of research on how to get it, but you know what? Cocaine also releases brain derived neurotrophic factor. So you have to realize that there’s limits where trying to do the good thing or trying to feel better, it’s so easy to go too far. I’m sure you’ve had patients where you’re like, actually don’t come back next week for a chiropractic visit.

Dr. Bob: Yeah.

Nick: How about we let this relax for a little bit.

Dr. Bob: Absolutely.Yeah. You can do, you can do too much. And in cases like sciatica, sometimes it can be caused not from that muscle, but like I mentioned before herniated or bulging discs and there are certain situations where a patient might not be able to handle a subsequent treatment really close together, because they can be intense, so.

Nick: Because back pain is one where if you just decided, well, I’m just gonna give up golf and I’ll give up walking. You will actually get so much worse even though the pain at least temporarily gets better.

Dr. Bob: Absolutely. It goes back to what you’re talking about with fear, right? One of the things we talk about in my industry regarding fear is fear avoidance behaviors. Oh, well I don’t mow my lawn anymore, because every time I mow my lawn and my back hurts. Well, that’s not a sign that you need to eliminate mowing your lawn. And it’s a sign that you need to work on the stability of being able to perform that movement without it contributing to lower back pain because it wouldn’t be normal for you to have back pain during that.

Nick: Right. No, that makes sense. And also that’s an activity where it’s kind of structured. Here’s the motion I’m making.

Dr. Bob: Right.

Nick: You’re not like pushing truck tires at 5:00 AM or anything like that.

Dr. Bob: That’s right.We have patients that do that too. CrossFit. It keeps us in business.

Nick: Right, right. I think a few years ago it was Zumba, that probably like had you like, probably like started–

Dr. Bob: Yeah. Getting the hips going and everything. Yeah. That’ll definitely, it started my career off.

Nick: You are chiropractor today because of Zumba.

Dr. Bob: Yeah. I, I think that I was finishing, clinical rotations in school as Zumba was like kind of starting to slow down a little bit. So you’re probably right.

Nick: Well, I mean it works out, because my career started with like pain is a sixth vital sign. We have to treat pain no matter what. And then it took a decade for doctors and nurses to realize like, this is a terrible idea. Like this whole, “Oh, you won’t get addicted if you take this right. Isn’t really a thing.”

Dr. Bob: It turned out not to be true.

Nick: Because some of the papers say like that’s for serious back pain. That’s first line is opioids. Second line is opioids with nonsteroidal anti-inflammatories, you know, Toradol, Motrin, Aspirin. And then some of the Gabapentinoids like Lyrica and Neurontin, which worked really well for some people, but others it’s like, well, this was a terrible idea.

Dr. Bob: Yeah. Yeah. Yeah. Unfortunately, when I was first — it was probably my first or second year in practice had a patient that it was the right circumstance for this patient to have surgery. Unfortunately there was a complication in the surgery that wasn’t you know, kind of expected, not anticipated. And it was the complications afterward were treated with Lyrica and she wasn’t the right patient for Lyrica and it led to a lot of other of problems.

Nick: Because a lot of those medications, they’re meant to deaden the nerves, they’re meant to — let’s make everything, not feel quite as intense. Obviously ketamine’s the opposite where it’s forming new nerve connections and that takes a little bit of, it can be challenging for patients that, “Wait, what do I do with these new sensations, even new emotions,” or one of your patients that we share, she actually could hear different after a ketamine infusion.

And she was unaware that she had any hearing problems, but because it sort of indiscriminately in her case rebuilt her nervous system, which was my hope. I was like, you’re gonna need an intense, almost like a chemical rebuilding of every single neuron in your body, which is what happened. But that’s also the challenge of back pain and sciatica we don’t know what normal is, because we sort of, it’s kinda like when your brakes give out in your car, like I’m like, “No, I think it’s always taken a hundred feet to stop this car.”

Dr. Bob: Yeah, exactly.

Nick: Like it’s gradual or when I’m sitting waiting for my laptop to load, I’m like, “Oh this, this takes long, because it’s such a slow process.”

Dr. Bob: Yeah. For us sometimes that’s one of the hard parts about initially communicating with a patient is showing them, you know, even though this is what you’ve been experiencing, this is not normal. You know, if it hurts for you to just do a simple range of motion and, or, you know, you have major asymmetries in the way that you’re moving that’s not normal. You know one that comes to mind, that’s a common contributor to this type of issue is severe internal rotation restriction in the hips.

We see that a lot with patients and patients are like, “Oh yeah, you know, I was just born that way with stiff hips.” And I’m like, “No, you weren’t born that way. Look at a picture of you when you were three years old, you could squat like a champion, you just lost it because you sat for so long.” Right. And so sometimes a part of the process is working through making changes, not just to where it hurts, but to the surrounding areas that are putting stress on that tissue in the first place.

Nick: Right. No, that makes sense. Like you come out the birth canal, your father holds you up like easy, easy the hips, the hips.

Dr. Bob: That’s right, exactly we don’t come out like that broken. I mean, I don’t, I don’t wanna underestimate how important it is when people have congenital abnormalities, but that really represents a small percentage of the population.

Nick: Yeah, absolutely. So if, if someone listening or like we said earlier, more likely someone who loves them, who is realizing they’re not normal, they don’t realize that they’ve got these issues yet. What’s the first step to contacting you or uh, more generally too, of what can they do for this situation?

Dr. Bob: Yeah. So as I mentioned, if it’s sciatica related, there’s a very simple exercise that they can try at home. When we’re working with patients, we nickname it, the nose and toes exercise, because the nose and the toes go in the same direction at the same time during that sciatic nerve glide. If they find that, that doesn’t really give them any relief after having performed it 15 to 20 times then it’s a good time to pick up the phone and give us a call. So most of our patients reach out to us through our website or by phone, right, because it’s the easiest way to schedule.

Nick: Same with us, it’s Ascend Health Center or 330-754-4844. And for new sciatica patients, we actually won’t treat you without medical records. We want to see what else has been tried, because it’s, it doesn’t help patients when we try what somebody else tried. It’s like just because my name is Nick and that’s a different name than the last guy who treated you. Doesn’t mean we should try the same thing and because my personality’s a little bit different, it’s gonna work.

Dr. Bob: Oh absolutely.

Nick: Let’s not go the same direction rather let’s and I feel what I do is diagnostic, let’s find out how much of this is structural? How much of this is neuro-inflammation? What are the limits of what I can do? And then what can you add on to it? Because once, once a patient sees some relief, then they’re willing to go to additional specialists or do what they need to do. Again, as we said, without going too far, because the goal here, isn’t a hundred percent, it’s just let me function and live my life, which is much healthier way to look at it anyways.

Dr. Bob: Yeah. And everyone has us to decide what, what goal or function they have. Right. And, but I, I really liked what you said there, because you know, it’s important to us to ask in that initial assessment, what have you tried before and what worked and what didn’t, because oftentimes for me, I would say my practice is probably 50% people who’ve never seen a chiropractor until they came to us and 50% people who have. And obviously those people who have either their chiropractor retired or something wasn’t working. Right. And so I want to know what worked and what didn’t work. And, and I think that’s so crucial what you shared, because we can miss pieces and go on treating something for a lengthy period of time without really seeing, you know, what we need to do to help that patient get better.

Nick: Right. And the challenge is sometimes a patient almost did what they needed, but it wasn’t quite enough so we can try what didn’t work before. So there’s only a few ketamine clinics in Ohio and we’re all very collaborative, but sometimes it’s okay, well let’s try a higher dose or let’s add this to it or subtract this. Or sometimes we’ll, if I decrease the sedation, we have a room that it’s basically, it’s like a living room, but it’s, it’s got the cameras, the vital signs, everything else. So it’s, if I can decrease your nervousness about this, maybe we’ll have a different result.

As long as I also tweak the medications I give and the dosages and the timing. So it is that challenge of — is this completely like, okay, this isn’t gonna work at all or can we still work with this? And for example, often I’ll do like a lidocaine magnesium infusion first just to see how someone handles intravenous drugs and how well that helps the pain. In some cases, I realize, this — a lot of this is mental because you just felt great. And then your mom came in and said, “Oh, are you okay honey?” And you’re like, “Oh, the pain.” And it’s like, “Nope, you need to talk to our counselor for quite some time, and then we’ll readdress this pain issue.”

Dr. Bob: Yeah, absolutely. And I think the bio psychosocial factor that you’re talking about, there is something that it’s interesting earlier, you mentioned this, that it’s, it’s like we treated pain as a vital sign for such a long period of time that we were going after just the symptom and not maybe the reasoning behind it. And so addressing the psychological piece is huge in treating people with chronic pain better.

Nick: Otherwise you’ll adjust their neck and then the pain will go down to the lumbar and then–

Dr. Bob: Yeah, it’ll move around. Absolutely. And I’ve seen that with patients before, it’s like you have pain all over the place and you start to wonder, one of two things goes off in my mind when we start seeing that, either this is an inflammatory issue. And then we would look at like our nerdiness about functional medicine. Or we need to look at a psychological component to this and sometime both.

Nick: Absolutely.Well, great. Well, thanks for coming on the show today.

Dr. Bob: Absolutely man, I always enjoy being here.

Nick: Absolutely. And we’ll see you all later as well.

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