Bonus Episode: Dr. Baraki on Pain

0:00Hey, it's Jordan from Barbell Medicine. Now this episode preview is from exclusive content that regularly goes out to our Barbell Medicine Plus subscribers. In addition to exclusive content, Barbell Medicine Plus subscribers get early access to episodes and products, ad-free listening, discounts on products and services, and the ability to ask Dr. Baraki and I questions, all for about the cost of a cup of coffee each month. And in case you were wondering, the first month is free. To join, head over to barbellmedicine.com slash plus and sign up to be a Barbell Medicine Plus member today. That's barbellmedicine.com slash plus.

0:32All right. Thanks for your consideration. On to the show. All right.

0:37Dr. Austin Baraki:Morning, guys. Morning. Thanks for coming and appreciate the invitation. It's good to be back here. Yeah, I didn't realize it's been almost 10 years knowing and working with Sal. Also been here a few times before to teach some of our seminars. We're going to be doing another one of those in September. And so pain and injury is a topic that I've been talking about, teaching about for a long time now. And I work in a hospital currently in El Paso, but on my way moving back to San Antonio again, where I've lived before. And so I teach medical trainees. I teach medical students. I teach residents.

1:14Dr. Austin Baraki:I teach other doctors. I teach on a lot of things. and talking about pain and injury consistently over time seems to be, I would say, one of the more popular topics, but I think it's also because it is one that maybe is a little bit more novel as far as how we think about it, how we approach it, how we manage it, compared with how people usually hear about pain and injury, right? So one of our big goals with Barbell Medicine, and now Sal's we're glad to have working with us on this, is getting more people active in general, getting more people strength training productively to promote healthier aging and things like that.

1:53Dr. Austin Baraki:And we know that fear of pain and injury represents one very common, what we'll call barrier, to getting people going in this, right? All it takes is seeing, you know, sometimes ESPN or SportsCenter will post a video of someone lifting weights. And reliably, what do you see in the comments? Everybody says, oh, just a matter of time before this goes wrong, that goes wrong, this breaks, right? Or I used to be able to do that until this happened or something, right? These are messages that are kind of pervasive in our culture, right? And they affect you whether you realize it or not. And so we're trying to actively push back against that.

2:31Dr. Austin Baraki:Now, I recognize that I have an audience of the converted here today, right? You guys have not been successfully scared away, but there might still be some little niggles in your mind, some apprehension, right? When either one Sal slaps another 45 on the bar or 25 or five, whatever the amount of weight is. Or if you see someone else lifting a certain amount of weight, you might look at that and just reflexively, that can't be good for you, right? We've all heard that type of phrase. And it doesn't just apply to strength training, although I think that's where that fear and apprehension comes out more often, but with all forms of physical activity.

3:12Dr. Austin Baraki:And so in our effort to get people more engaged in these health promoting behaviors, recognizing that this is such a common barrier and source of fear and apprehension for people, we actively try to provide people with tools and resources and skills and strategies and confidence to self-manage these sorts of things as much as possible. What I just described is a really important concept that I'm aiming to teach you today called self-efficacy. Self-efficacy describes that sense of I have the skills and knowledge and tools and resources and confidence to manage this challenge. challenge. The opposite of self-efficacy, or if you don't have self-efficacy, that concept would be something called helplessness, right?

4:03Dr. Austin Baraki:I have this challenge and I'm broken. I have no idea what to do. No one can help me. I need someone else to come fix me, right? We want to build you up into robust, confident individuals who can deal with the inevitable setbacks that will happen in life. I don't even bother going through the exercise when I give these kinds of talks of, Raise your hand if you've ever felt pain before. Because what's the point, right? I don't need to do that. I can already sense. Everybody in here has had some discomfort, some maybe a little more, some maybe a little less, right? But it's a universal experience.

4:39Dr. Austin Baraki:So this is also where we start to push back against people who promote either products or courses or just concepts in general. Like, here's how you're going to go through pain-free training. Here's how to prevent pain or how to prevent injury. It would be great if I could confidently advertise something that said this is just going to prevent pain or injury or anything unpleasant for the rest of your life, right? That's not reality, right? Instead, I want to equip you with the knowledge and the tools and the strategies to be able to manage it when it comes up, right? Now, ideally, you can self-manage it.

5:15Dr. Austin Baraki:That would be most people's preference, I think. But it's also okay to need help. right I've had aches and pains and I've sought out help from some of our colleagues at Barbell Medicine that I hired because I thought that they were fantastic at what they do from a rehab standpoint over time periodically Sal has gotten a little too big for his britches and bit off a little more than he can chew in his training and starts to get a little bit of aches or pains and then he'll shoot me a message say I got this this backache again can you help me through and I know he even knows how to do this right but sometimes you need that outside source of objectivity or guidance or reassurance or whatever the case is.

5:49Dr. Austin Baraki:And that's fine. And to date, we have been able to work through everything that he's dealt with, essentially, right, and get him pretty strong and now pretty conditioned as well. So this can be done. So to start out with, I think it's useful to think about what types of ideas are most prevalent around pain and injury, broadly speaking, in society. Most people assume that when there is a pain, that means there is something wrong. That means you're actively causing some kind of damage to your body and that you need to immediately stop doing what you're doing, right? The classic, oh, if it hurts, just don't do it, right?

6:30Dr. Austin Baraki:There are a lot of reasons why this is problematic and often unhelpful advice and can lead to a lot of downstream harm. What we see when it comes to what we'll call musculoskeletal aches and pains, your muscles and your joints. I'm talking not like when I see patients in the ER for chest pain. That's a different type of situation. But the muscles and bones and joints, aches and pains that might come about in day-to-day life or with activity is if one were to take that advice, oh, this hurts, I'm going to stop doing that. And then later on, what might happen? Something else might start to ache.

7:05Dr. Austin Baraki:Oh, I'm going to stop doing that. Oh, something else might start to hurt. Oh, I'm going to stop doing that. I'm going stop doing that. You guys see what I'm doing, right? Literally painting myself into a corner to use that type of a metaphor, right? You run out of things that you can realistically do. Oh, I used to be able to do that, but then my elbow started hurting and then my knee started hurting and then my back started hurting, right? That's not a feasible strategy. And additionally, we also recognize that there are a lot of different influences on our experience of pain, right this starts out when you're a little kid i assume somebody in this room might have a child they might have taken that kid to the doctor and that doctor might have had to do something like give him a shot or start an iv right there is like active tissue damage happening right when you put a needle in somebody so what do you do with that kid at least when i went through training i guess i don't know finding nemo was still popular with kids it's probably some other movie or something like that now.

8:08Dr. Austin Baraki:You put an iPad on with something else and then what happens? They can get the thing done, right? Just that little observation alone tells you that there's probably a little more to the experience of pain than just what's going on in the tissues, right? Somebody in here might have been diagnosed with osteoarthritis, maybe knee arthritis or hip arthritis or hand arthritis, all very common issues, right? They might have been told you had bone on bone. I hear patients tell me that they've been told this all the time. Is it fair to say that people with that type of issue or that diagnosis have good days and bad days?

8:45Dr. Austin Baraki:Some days hurt more, some days hurt less. How is that possible? Do you have good days because your bones are better and bad days because your bones are worse or the arthritis is just there and other factors seem to be impacting good days, right? Okay. So when somebody says, or even a doctor tells a patient, I saw your x-ray, worst x-ray I've ever seen. That's kind of oversimplistic, right? Because I can't tell what the person is experiencing by just looking at an x-ray, right? I've seen some horrible, quote unquote, heavy air quote, x-rays from patients. When I look at them and they're like, Doc, I don't even know why they took that x-ray.

9:34Dr. Austin Baraki:I feel fine. This is the classic stereotype of farmers. They're just tough sons of bitches. When they come to the doctor of their own volition, something is wrong because they don't usually do that. It's usually somebody else that dragged them in. On the other hand, I've seen completely normal looking x-rays and normal CT scans and normal MRIs in people who are in excruciating pain. I just finished a round in the hospital two days ago in El Paso. I flew here Thursday night. and one of the patients that I saw that day was having this excruciating, stabbing abdominal pain, 33-year-old woman, and every type of imaging study, exam, everything like that was looking normal.

10:14Dr. Austin Baraki:Now, what do I tell her? You're crazy? Get out of here? No, pain is complicated. We got to figure out how are we going to manage this, right? I can rule out all the emergencies, all the bad stuff, all the dangerous stuff, but we got to come up with skills and tools and strategies to manage this moving forward until either a new clue emerges to show us what's going on or it goes away, which is what most of the time happens to these kind of things. Most things get better on their own with time, right? So the case I'm making here is for, I would say, a novel way of thinking about pain, even though this idea has been around for decades.

10:52Dr. Austin Baraki:It's just taken forever to kind of percolate into pain and rehab professionals, doctors, and definitely to the public, right? So instead of this traditional view, what I'm going to contrast, the traditional view of pain means something is wrong, means I have to stop, means I have to fix something, right? That very simple linear type of logic, to this more all-encompassing, broad, complex understanding that we call a biopsychosocial view of pain. That's a big, complicated word. So I'm just gonna organize it up here like this for you. Bio, referring to what are the fundamental biological issues that could be going on?

11:38Dr. Austin Baraki:Like, is there arthritis in a joint? Is there inflammation? Does this person have rheumatoid arthritis affecting their knuckles or something like that, right? psychological factors, not is this person crazy or is this pain, quote, all in their head, definitely not suggesting that, but rather what are the psychological influences on that person's experience? I already told you one of them with the little kid. Attention. How much attention are you paying to this issue? For example, somebody might've experienced some low back ache. Are you constantly ruminating, thinking about your low back all day, every day?

12:22Dr. Austin Baraki:If you manage to come to the gym and your coach is watching you squat a set, are they asking you after every single rep, how's your back feel? How's your back feel? How's your back feel? Constantly drawing attention to that area. You got to see why that might be less than helpful in this kind of situation. Beyond just attention, what are some other psychological variables that can impact how we experience pain? What about just like our interpretation of what it means? How are we thinking about what does this pain mean? I see this all the time. So contrast one scenario where somebody experiences some back pain and their interpretation is, I just herniated all my discs.

13:03Dr. Austin Baraki:I broke my back, as Mike Tyson once famously said. I'm never going to be able to move again. I'm going to be in a wheelchair by the time I'm whatever years old I'm not going to be able to pick up my kids again or my grandkids again How are you going to experience that pain and what are you going to do if that is your interpretation You're going to just get all rigid stop moving, stop engaging in life Contrast it with a different interpretation of that pain Oh, as now we have Sal well-trained. Tweaked my back. But I can feel my legs. I can move around. It hurts, maybe even pretty bad. But I know that it's probably not something serious.

13:54Dr. Austin Baraki:I know that the vast majority of these are going to get better with a bit of time and continued movement and activity. Right? And so that interpretation, you see the difference. What is the difference between those two? One is a high perception of threat. This is dangerous. This is bad, ominous, right? The other is, yeah, this is potentially really uncomfortable, but it's not a massive threat to my existence, to my function, to my future, to my life, right? That difference in interpretation changes how you experience that pain and what you do the behavior in response. One behavior might lead you to say, I need to lay in bed for six weeks, which is the worst thing that you can do for back pain, right?

14:46The other is moving around

14:49Dr. Austin Baraki:based on your tolerance, patience, time, understanding that it's going to come and go wax and wane, and that this is very likely to get better with a positive kind of optimistic prognosis. So those are just a few examples of how psychology. There's way more that I could get into there, right? Not only attention and your interpretation, things like fear, anxiety, depression, lots of other factors that can impact how we interpret pain, therefore experience pain, and therefore what we do about pain. What about social factors or environmental factors? What have you been told about pain? What did you learn about pain from maybe your parents when you were a kid.

15:32Dr. Austin Baraki:I've seen people who said, I've had some very memorable consults with patients. One patient who I quote often when I give these kind of talks, he was in his 60s and he had chronic back pain for years. And he finally was at his wit's end and wanted to talk to me about it. And he told me, Doc, I come from a long line of bad backs, which was a very striking and odd thing to say to me. A line of bad backs, not like people, but just like bad spines, right? But that was his expectation from observing his family members and seeing their experience and just assuming, well, that's my lot in life, right?

16:08Dr. Austin Baraki:It turned out it wasn't. He ended up getting better, but we needed to change a ton of things about his activity and his understanding of what was going on, right? Or the doctor who tells you, you're going to be in a wheelchair by this age. You can see how that sets certain expectations and influences how you interpret the meaning of your pain, right? Now, what about the other situation where maybe you're in the gym lifting on this rack and you see Sal in the gym lifting on that rack and you see him tweak his back, but then you see how he responds and he just recognizes a little achy, but I know what to do.

16:48Dr. Austin Baraki:He starts moving around, loosening it up and modifying his plan. You're seeing a different response, a different approach. So responses from others, learned experiences, and expectations are huge factors for how we experience pain and what we do in response to pain, right? So all of this, again, I give a much more extended version of this talk at the seminar, and there's a lot more detail I could get into on these, but these are just a few examples that hopefully get you thinking beyond just like my meniscus or my disc, right? A very specific structure that now must be wrong if it's something hurts that I need to go and get fixed or I need to stop doing what I'm doing.

17:36Dr. Austin Baraki:There's a lot of influences on this, right? So now let's move on to what can we do? What are some of these skills and strategies and things like that to manage when this inevitably happens. Some ache or some pain arises either in the gym or more often out of the gym. I've had more weird, annoying, random neck tweaks outside of the gym than I ever have in the gym. I've had things that come up in the gym too, but this stuff just happens, right? So we can use this similar organizational framework to talk about what are some of the things that we can do. And my argument here is that it is a good thing that pain is this complex because that means that there's a lot of different variables that we can play with.

18:26Dr. Austin Baraki:Imagine if all there was to pain was just what's in your joint. What would your only option be to treat it? Oh, just, I guess you need a new knee, right or you had back pain the only option is just i guess we got to fuse your spine right that would be deeply unfortunate fortunately that is not the case we have lots of things that can impact our pain which means we have lots of things that we can play with along with time for things to improve so from a biological quote-unquote standpoint point. This is, I would say, an oversimplified model, but it helps our limited human brains organize this complicated topic.

19:13Dr. Austin Baraki:That's why I do it this way. What are some of the things that can be relevant here? There are fundamental realities about our tissues that must be respected. So, for example, say somebody ruptures their ACL and does go and get an ACL reconstruction. There are certain expected healing timeframes that we have to respect after that type of a procedure, for example, right? I'm not going to say, oh, the pain is, you know, all in your head, so why don't you go, you know, three-rep max squat post-op day one. Now, we know that there's a certain amount of time that needs to happen for the tissues to heal and recover, right, after something like that.

19:53Or if somebody has a muscle tear, it can be a pretty significant injury, potentially, right?

20:00Dr. Austin Baraki:that's going to need a certain amount of time to heal. That doesn't mean that you have to be completely immobile during that time, but we have to respect the biology of that there, right? Or if someone has, like I mentioned earlier, rheumatoid arthritis, that's an autoimmune condition. Your body's immune system is attacking your joints and contributing to, not the exclusive cause of your pain, but contributing meaningfully to that pain. And so if I just try to do some psychotherapy on you, that's not going to work if I'm not treating the inflammation that's in your joint. So there's some biological factors that we have to address, right?

20:36Dr. Austin Baraki:Or at least assess and pay attention to. What are some other things there? And sometimes where I put these are going to be a little arbitrary, but again, for the sake of organization. What about the amount of overall stress that the person is under? Could be some degree of psychological stress, could be some degree of what I'll call physiologic or biological stress, what's their training load like, for example? Right? How much are they training compared with what's their recovery capacity like? So that's why usually one of my first questions when I'm talking with people about their pain and injury issues is, tell me about your recent training.

21:15Dr. Austin Baraki:And so if they tell me that, yeah, I just started this new program about four weeks ago, and it has me maxing out every day on all my lifts and then adding more weight. And if I fail reps, that's a good thing because I'm like really pushing my body to the limits. And that's how you adapt and get stronger, right? Doesn't take a genius to recognize that might be maybe a little more than they're ready to tolerate. Not shocking. You might develop some aches and pains doing something like that, right? So I'm going to put, abbreviate here, training load, because that's going to be a major variable that I'll come back to when it comes to managing aches and pains in training.

21:54Dr. Austin Baraki:Other things. Tell me about your sleep.

22:01Dr. Austin Baraki:Plenty of research evidence, as well as I'm sure anecdotal experience that you can probably attest to of aches, pains, all sorts of other bad things when you're not sleeping. Worse. More pain intensity, more pain duration, right? And so that's another basic question. If I'm trying to help somebody through a rehab process and they're telling me I'm sleeping two hours a night, I've got the deck is kind of stacked against me a little bit here, right? Maybe prioritizing whether you do three reps or four reps in the gym is not the best, most important thing for us to be focusing on if you're not sleeping.

22:40All right, that is a wrap on this free sample of our bonus content that regularly goes out to our Barbell Medicine Plus subscribers. Again, to join, head over to barbellmedicine.com slash plus and sign up to be a Barbell Medicine Plus member today. That's barbellmedicine.com slash plus. Thank you so much for listening. We'll catch you guys next time.