In Your Pants with Dr. Susie G - A World 🌍Of Hurt

Episode Date: April 12, 2019

How do we get pain and why do we hurt? Annie O'Connor gives us the low down in today's In Your Pants podcast episode. In today's episode, here's what you'll learn: - How we get pain and why we hurt? - How the brain is the main protector and pain is a protective mechanism - 3 different ways the brain protects us - Why chronic pain is so bad today? - Annie's most influential patient case that has changed her practice and the way she treats people in pain - Annie's advice for healthcare providers working with people in pain Hope you enjoy the show!

You're listening to In Your Pants with Dr. Susie G, the physiotherapist for your private, helping you get in the know down below. Hey guys, this is Dr. Susie Kronsky, and thank you so much for joining me on another episode of In Your Pants. Today, we have a very special guest on the show. She is a phenomenal clinician and educator. Her name is Annie O'Connor, and she's here to tell us why, things down below. hurt and the brain's role in our experience of pain not just down below but anywhere else

so without further ado let me formally introduce Annie to the show I'm going to read off her fantastic and very impressive bio and then we're just going to get to it jump right into learning about the brain and how it influences our pain experience Annie O'Connor is the chief Clinical Officer for Musculoskeletal Partnerships at the Shirley Ryan Ability Lab, which is formerly known as the Rehabilitation Institute of Chicago. Annie has co-authored, in 2018, the Pain Mechanism Classification Chapter in the Rehabilitation of the Spine, a Patient-Centered Approach. She has also co-authored, in 2017, Therapeutic Exercise Chapter in Orthopedic Knowledge, update and spine this chapter specifically is dedicated to helping medical doctors understand

pain mechanism classification and the importance in therapeutic exercise selection she has co-authored in 2015 her wonderful book a world of hurt a guide to classifying pain and in september 2016 a journal article in the journal of manual and manipulative therapy called validation of a pain mechanism classification system in physical therapy practice. Both publications offer a research-supported paradigm shift in managing musculoskeletal pain, promoting effective and efficient outcomes with significant cost savings. She is an orthopedic clinical specialist of the American Physical Therapy Association and has a certification in mechanical diagnosis and therapy in the McKenzie Method. She lectures nationally and internationally on the pain mechanism

classification system, neurodynamic evaluation and treatment, mechanical diagnosis and therapy of spine and extremities, kinetic chain evaluation, functional manual therapy, and exercise prescriptions as represented in the world of her book and training courses. She was instrumental in establishing the pain mechanism classification system at the Shirley Ryan Ability Lab, formerly known as the Rehabilitation Institute of Chicago. She is a member of the American Physical Therapy Association and the Orthopedic Section and Canine Special Interest Group, the North American Spine Society, and McKinsey Institute. She serves on the specialty panel for physical therapy for the AIM Healthcare and the Research and Advisory Board for MyAbilities, an Ontario-based software company.

She continues to treat orthopedic, neurological patients, and canines with pain and spasticity to achieve the best life possible. Hi, Annie. Thank you so much for being on the podcast today. we have some big shoes to fill. Well, thank you for having me on the podcast today. And I wear a size 11. So I think I'm going to be good shoes. Awesome, because I have a size five. So it looks like you've got it covered. I wish I was five, because you can always find shoes in a size five, you can never find good looking shoes in a size 11. So it'll be my chore today to make the size of my shoes fit into the size of your shoes, right? Awesome. Or what we were talking about earlier in my pants. You're fitting into my pants, right? Well, I'm even afraid to go there,

to be honest with you. But don't let me flip this where I'm now interviewing you. Okay. Because I know. No worries. No worries. No worries. Well, let's get started. Because this is an awesome topic. We have a great book out there, A World of Hurt, A Guide to Classifying pain. So let's jump right in and ask, you know, what is the pain science telling us as clinicians to prioritize in what we tell our patients? I'm glad we're starting off with that, because I really think that the people that we serve, the ones that are really suffering, you know, they really need to understand how we get pain and why we hurt. And we know that this has been going on for 20 years and the explanation of that and the movement of like, hey, we have to explain

the brain's role in pain. And we all have had those moments where we've tried to accomplish that only to have come back to us that the patient thinks that we don't believe them or they think there's some psychological element to their problem. And what we've done is we've kind of miss the grassroots of explaining the brain. You know, the brain is there to protect us, and pain is a protective mechanism. And what we've come to learn through the literature is that there's actually three different ways that the brain will actually give us pain in its attempt to protect us. And so as we kind of work with patients that are, you know, suffering from pain, we need to kind of really kind of hone in on which mechanism is really

dominating their suffering and give them an analogy often we use the kind of a you know the lamp analogy like you know how your lamp works if your bulb wasn't working you'd go through a series of steps to figure out what mechanism is why it wasn't working was it the bulb was it the switch was it the cord was it the circuit breaker was it the provider you know was it the little box at the pole you know where where the house was not recognized or but in pain it's no different like where where is the breakdown is it really in the body or is it in the nerve or oh no is it somewhere in the brain the things that we can't see and then being more in tune with that in the sense that there's three different areas in the brain you know we've talked about in the book in

in chapter six, this overprotective mechanism, which we call central sensitivity. And we have to kind of explain to patients that, hey, your brain is wired to react relative to how you're analyzing. And that analysis is actually influenced by the words that you use and how you describe yourself and the thoughts that you have going on. Intuitively trying to say, well, what does this signal actually mean. So if we think the signal means danger, or we think the signal means harm or unhealed tissue, then our brain's duty is to sensitize those tissues even more, which ultimately means you're going to have more pain. And that pain can actually feel like it's spreading to other areas of your body. So that overprotective mechanism, we really have to

help patients understand and have them really understand the words that they're using, the thoughts that they're having, and then give them a different way at analyzing because their analysis is actually coming out that something dangerous is happening. Right. Versus that another mechanism that we talk about in chapter seven called the effective mechanism is such a cool mechanism that our brain can actually use our body in a diversion so that we actually get help. So this mechanism is more wrapped around diversion, meaning if my brain senses that I'm not coping with emotional things that may be going on with me or social conflict that they may be having, and I'm under stress, and I'm not coping well, or I'm not coping healthy, my brain may

actually protect me by giving me pain in important locations in my body relative to my past that tries to get my attention. My brain knows if it makes my knees hurt, I'm going to listen. And what it's trying to do is get us to seek help. What happens in the seeking of the help, we hope that we kind of seek help from a provider that understands that it may not be my knees that are actually the problem, but it may be my life needs and those needs of coping with things that are going on. And I think this is just a really cool segue, Susie, on how does the brain actually physiologically accomplish that? And it really is kind of cool that our brain can actually shut off the blood supply to any tissue in our body. And as soon as that actually occurs,

the persistence of nociception begins. So this is truly an output mechanism. Now, this has been given a lot of different terms, right? We've had these be called mind-body disorders. We've had these be called psychological symptoms. We've had these be called tension myositis syndrome. we've had this called psychosomatic pain but the real deal is is that yeah your brain is just protecting you wanting you to get help shutting blood supply off to a tissue so that you'll actually feel something this is real but the issue with the tissue is not the tissue and if we as providers can't pick that up by realizing wow we try these interventions that those tissues don't seem to work. And we're not screening them well enough with yellow flag

risk forms to try to understand depression and anxiety and how well they're coping and sleep disorders and the things that are going on in one's life. We may really miss this. And then these people kind of wallow within care and not really having a true effect. So Annie, you mentioned a really big word called nociception. And for those listeners who don't understand what that is or how it works, can you please explain that to us? Thanks, Susie, because sometimes I slip into medical jargon and I pride myself on being more simple than that. But nociception just really is a term that is describing that our body and all of its tissues and its moving segments have receptors. And those receptors are dedicated to send certain signals to the brain in hopes

at getting certain things done. So for example, we have one signal or receptor that will signal when your body is getting too much of one direction and not enough of another. For example, the simple one of you may be doing too much forward bending in your lower back and not enough backward bending in your lower back. And thereby a signal now is getting sent to your brain that says, hey, you need to do more backward bending. So in your opinion, Annie, why is chronic pain so bad today? It's not just, there's not one answer on that, that's for sure. But in my opinion, I've, over the last 33 years of practice, I've seen that there's, all stakeholders have a part in this problem. And what I mean by stakeholders, the patients, the providers,

and the payers. And I have great hope that because right now the patients, providers, and payers are all a little pissed, we can actually change the problem. But we all have to recognize our parts in the problem. And what I mean by that is we've got to take a serious shift in our practice to undo this epidemic. And from a provider standpoint, from my standpoint, I'm a provider. I have to really look at how we've been prioritizing treatment interventions for pain. You know, the fact that we've, in our country especially, prioritized surgery and injections and procedures and pharmacies. We'll trial these things. Our patients will get these things prior to getting just education like you and i are talking prior to getting just good

movement care and the understanding of what that signal means or even let's talk about the foods we eat and healthy lifestyle habits because we'll prioritize those more involved procedures over the simple procedures of words and moves and foods we're delaying and causing persistence and symptoms, and even to some degree, we're actually worsening. Now, think about the payer's side to this. You know this, Susie. I mean, you're a provider. Payers will actually reimburse more for pharmacy, surgery, and procedures and tests, more than they will for chiropractic care, physical and occupational therapy, or even alternative treatments like acupuncture, an apopath. So the fact that in our insurance plans, we're reimbursed more for these

palliative passive treatments is a problem. And providers, yeah, I, you know, I'm a provider of 33 years. I have to own what mess I've caused the system. I always say, I hope people will show up to the two-day course I run where I can tell you about the things that I did wrong, because those really have enlightened me on how to do better and one of the things as a provider is the use of the words chronic and how we explain pain using anatomical and pathological language we need to get more specific and call it what it is it's a central nervous system mediated hurt more specifically get in there and talk about the protective mechanisms within the brain because we're sensitizing patients relative to the words we're using you know and then lastly

you know the patient's role in that same you know patients are very passive and they want a test or or a procedure right and how we get them out of that funk because we we know that the the brain itself remember the brain i love studying the brain because i mean we all have one too so we should be studying it that's right we don't know how to use our iPhones and our Apple computers we don't even know how to use our brain I mean you know what what do we expect out of that but realizing that your brain defaults to negativity defaults to passivity and then your body in general defaults to gravity so we have to be really take an active role in flipping negativity to positivity, passivity to activity. And then we have to realize that we are fighting gravity

every move we make. And our advertising should be relative to these active and positive kind of interventions. So I believe that there's, you know, all stakeholders have a contribution to why it's so bad. And in order for us to undo it, we have to kind of look in the mirror and say, how are we going to shift this? And that, you know, I'm happy to say that the fact that I've been in it so long and that, you know, continue to stay in it is that shift is happening. Now it may be happening one provider at a time, one payer at a time, one patient at a time, but it's happening. Right. You're doing Susie by allowing these discussions to happen and allowing people to listen and and kind of hear hear this information is is how that's that's happening

so thank you making a change yeah no thank you i mean we need we need people like yourself and myself and all the others who are really changing the way we help people and it's a paradigm shift and sometimes there's some pushback as you know you know even amongst our own colleagues and stuff There's a lot of just, you know, lack of understanding or whatever gets in the way. But it's hard and it's challenging, but it's also very rewarding in that sense that it makes sense. I mean, it's logic and it makes sense. You can't argue that.

You can't argue that. You can't argue with logic, you're right. No, you really can't. And we're fighting this battle too. remember if we discovered something good in medicine right if medicine discovered something good it takes almost 22 years to get that to be a standard there for everybody wow yeah that's a long time long time it's a career you know when you when medicine discovers something bad like our discovery recently of doing too much testing for low back pain our discovery of using anatomical

and pathology language to explain back pain when we discover something bad like we have been it's going to take us 44 years to get that out wow so this is what we're in right so as we we've recognized to this day where we're at with opioid use and too much testing and not aggressive and active enough and not explaining enough to patients it's we're in that shift but that shift it's got time that it's going to take to happen too because we already know these things with when something's bad it takes 44 years to get it out and something's good it takes 22 to get it in right this information we're talking about I mean this came out in the 90s you know and we've been practicing this way since the late 90s and now in 2016-18 it's getting

front stage appearance that's the 20 some years we're talking about wow yeah and it's not new stuff like you're saying and i tell my patients that all the time i'm like this has been decades decades you know in in in the stream but not mainstream unfortunately exactly so on on that note of you know you mentioned patients and their influence in their own health what were the most influential patient cases that you've come across that have changed the way you practice in all of this? Well, if I just talk a little bit about, you know, I opened up talking about two of those protective mechanisms, right? Central sensitivity, that overprotective mechanism, right? And what's always been astounding to me is how rapidly that mechanism can change

if you can get their thoughts and words in the right direction. In one case that really kind of blew my mind relative to that was a 14-year-old girl. She was a soccer player and she had had symptoms since she was 11. So I had seen her after a three-year journey of many different providers, right? And this young girl coming in with her knees taped in about every taping direction that you can. And her anteltic gait, like when you watched her walk, you could tell that with every step, the protection that was going on within that system. And this was in both kneecaps. And, you know, just her general concern, because she's been told that her kneecaps are dislocating.

and so she has been to provide her to provide her to provide her we're strength training her hips we're taping the knees we're we're doing all this and we're telling her all of this right so that day you know after screening her on the yellow flag and seeing her fear avoidance questions be so high and asking her what does she think is going on and what's happening and hearing that with every step, her kneecaps dislocating, and she's wearing cartilage out. And just these thoughts that were running around in this young 14 year old head, who's so smart. She's so intelligent. She's highly analytical. She's got incredible willpower, because she's just staying in it. But she's got her system stuck in an overprotective mode relative to this thinking

pattern and so that day we meet her we explain the overprotective mechanism to her and how that works and how the brain itself relative to how we think about things can actually make our tissues even more sensitive and how we have to start kind of really giving her more control on saying is this pain that you're having right now a green light safe keep going a yellow light too much too fast. Let's pace it a little bit. Or no, is this truly a red light? That signal is trying to tell you to stop. And we're going to base that not on what you feel, but the range of motion in your knees. Because if your kneecap was really dislocated, dislocated to the point of harm, you would lose a considerable amount of range of motion, at least 50%. So if your range of motion

is still intact and there is no difference in it even though your pain could be a 10 over 10 we we have to assume at this point in time that there has been no harm getting her to really understand that traffic light guide now this girl's 14 okay she's smarter than me so we give her our little traffic light guide that has the red green and yellow light what it means. I sent this girl home because she was coming from like three hours away. I sent her home with the traffic light guide and her lower extremity functional scale, the outcome measure we have them use, where basically she was pretty much, I think she was like a 20 over 80, which is pretty severely disabled, where she couldn't do much. And I said, look, all I want you to do

is I want you to take your traffic light guide. And I want you to take these 36 little tasks that you measured in your ability. And I want you to do that task. And I want you to tell me, is it behaving like a red light, a yellow light or a green light? It's what I consider a cognitive behavioral functional exercise. And I said, that's all I want you to do. I want you to learn how to analyze those things to say, is it safe for me to be doing? Should I be pacing that? Or should I really be stopping that one? And we're going to base it on your knee range of motion. That's your harm check. You're going to check to see if you've lost any motion. And we're going to see what happens to the system as we learn to analyze correctly whether this is safe or not. And she

kind of returned after two two weeks two to three weeks Susie I walk out there first off she's got no paper or anything on her leg she sits does a squat with no problem walks back intelligent gates gone everything's gone she's smiling and I was like first question did you do your homework did you learn anything from it she hands it to me she looks she goes well look at everything I said you even did the running one and she goes yep she goes they're all green she goes I wasn't doing any harm to myself that's profound pain she goes it's amazingly different she goes you were so right it was the way I was thinking about it that was causing my problem and at that moment I really knew the power of people's brains when they really understand what's happening and for her it made

sense because that's why none of the interventions worked on the kneecaps or the hips or anything because it wasn't that it was the way she was interpreting what was safe or not safe that was a very impactful case for me in the sense of central sensitivity and how quickly it can change if we can get the education right and give them the right cognitive behavioral functional exercise that gives that gets them going right and absolutely the intelligence that these people have and the analytical ability that they have and let them teach themselves they're more likely and she would you know and after each activity I said after you do the activity and you say that the activity is green you need to confess that with your mouth so your brain hears you

say it right right yeah me listening to you you need to say brain you don't need to protect these needs anymore that life is green i had no change in my range of motion air means this is safe for me to do and i can do it again tomorrow and she said the power of confession so that central sensitivity we always say hey you got to catch it you got to correct it you got to confess it and then you got to celebrate it nice yeah beautifully said and that girl she's so courageous for being willing to do that with you I know a lot of my patients you know a lot of them are on different spectrums and different journeys they're you know where they're at but some are even really just challenged just to explore that with curiosity and compassion for themselves

because there's so much fear you know oh it is and we don't i i think it you know we're we're given such education right and relative to that we can't appreciate where they're coming from from it and probably some of the things that my patients have really taught me through the years you know is that you just got to really step back and appreciate where they're coming from And if we're unable to do that, it's going to be very difficult for us to get them in the right path. Right. It's very true. Very true. So I know that was one of your biggest influences in your practice. Are there any other big influences that have kind of shifted your mindset and your paradigm of helping people? From patient cases?

or anything really kind of what made you kind of oh I see the light now well the light bulb went off I like to tell a quick story about when I first started as a therapist I was so eager I was you were going to cure this pain thing now you know we're talking you know 85 so a long time ago and how I came out and I was like oh my god nothing's working so I you know shoot I got to go back I got to get I got to get an advanced degree and at that time you know it's the master's and you know I got to specialize in orthopedics and I get a master's in orthopedics I got to go to a residency program you know and I knew after that I was like oh yeah this is it I'm ready now manual therapy you know I'm trained by the best and come out and I'm extremely frustrated that's not

working you know and so then I'm now I'm like okay you know what I gotta it's John Barnes things you know I think it's moving cranial bones I've gotta you know dive into this dived into all that course work dived into osteopathic I was going to become an osteopath because I wasn't using muscle energy and went through that whole training program, went through the Paris training program. And every time I embarked on a new program, I had more frustration in how it wasn't working. And I was blessed that I could do all this. I mean, my organization was sending me to all these courses and helping me afford all these things, but only with more and more frustration.

And I come out, and then I'm in combined sections in 1995, and I see David Butler speak about pain mechanisms. And it was the hugest aha moment that I had because I was like, oh, that's why that works for that. That's why that works for that. Oh, no wonder that works for that. And for the first time in clinical practice, I was psyched about being in clinical practice because I finally knew how to use all these tools. And it was such a simplistic way at organizing all the literature that I read, all the people that I saw speak, all the great clinicians that followed, the Loramers, the Robin McKenzie's, the Geraci's, the Joel Press, the Craig Liebenson's, all these people that awarded me the time to work with them. I finally could figure out their expertise where it fit into the continuum so that I could serve that person better. and that's where the passion came to do this within our institute and to implement this method

of pain mechanism classification and then we like i said three training manuals later we're with the published book really trying to get it to the consumer level and close the gap on the clinician and the consumer get them that's amazing and your story sounds very familiar sounds very familiar going down many paths many training certifications right and sometimes you have to do that like you know you have to do that in order to be humbled enough I mean the Lord humbles us often doesn't he and a lot of it is through that I mean he's got a calling on my life and I know that in order for me to do what he wants me to do I've got to be humbled through these experiences and part of that was all this training and all these certifications and

only to come to realize that it is going to be about how we explain things the relationships we have and the fact that we're there to walk with them to their betterment teamwork I love it that's really great so for somebody who's listening you know someone who is struggling with pain what would be some of your you know I think main pieces of advice that you would give them to help them work through this difficult time in their life that's a great question I mean I think the most influential piece of education anyone who has pain is is the pain safe to move or not no exercise is pretty much the truth about everything isn't it now I mean and people believe in it. And whether you call it just movement or exercise or whatever, but is it safe

for me to move or not? It's probably the most impactful piece of information for anyone who hurts. Because if they can understand that the signal that's being sent ultimately is safe for me to move, they're going to get back to doing things that they need to do. And just by doing things that they need to do, they're going to feel better. And the biggest way for you to know is something safe is relative to, is your range of motion the same? So like in the example we used with the girl with the knee, she would check her range of motion in her knee millions of times a day. And every time that knee moved exactly the same as it did the previous check, she knew everything she did was safe. And that she needs to think about how safe it is. She needs to confess

how safe it is. And she needs to keep doing it. It's like a green light driving, keep going, proceed forward. And the only time that we would say that that light is red, where it says stop, no, this is, hey, danger, stop. This is not good. You need, your action plan should be notifying your team or seeking help is when that range of motion changes by 50% or greater and you lose 50% or greater your motion. At that point in time, we're going to give you the nod, you know what, something happened. And now you should worry about it. Now you should think something happened and you should seek to understand what happened. But if that range of motion doesn't change, that's your hallmark sign that whatever you're doing is safe and that you should keep going

if it's a little too much too fast pace yourself but if you're back to baseline keep going so a traffic you know we use the traffic light guide to movement safe pain it's one of the most powerful pieces of education that we've come to learn with any mechanism that we're treating and we've got that in the in the show notes you shared it shared that with us so i'll definitely make sure to attach it for everyone who's listening. It's a great handout. It is a great handout. And we've sent more people home with that and come back and they're like, I got it. Okay, good to know. That's awesome. Yeah, I know. That's really, really great. Now, in this, you may or may not, you know, maybe you'll shed some light, I won't make assumptions. But let's say, you know, I treat

patients who have pelvic pain. And oftentimes there isn't much range of motion to measure down below if you get my drift. How would you go about, I mean, I'm not sure how to put the pieces together on that. Like, okay, you know, how would they, how would someone who doesn't have a range of motion check use something like this similarly? Thanks for bringing that up. This is probably one of the number one questions that comes from our courses. Just as important as range of motion is function. So if your associated impairment or pain doesn't have a range to check, like your pelvic floor, we have functions, whether that function be bowel activity, bladder activity, sexual activity we would look at functions and if that function really hasn't changed

we haven't lost ability in that function then we would give you that same analogy on this is safe for you to be doing the thing that we've got to do is we got to get it off of the pain and into the function ability or movement as their analytical structure in order to determine whether it's safe or not. So we would look at functions and we would work very hard with that patient on what function could we use every day that you would do, no matter how bad it hurts, that if that function is still intact, the same, no different, that we could now discern this situation as safe, move forward. And sometimes it's a collaborative work. I had a young lady had a course in a live demo in Buffalo when we were giving her the traffic light guide she was

you know somebody who we believed had was dominated by central sensitivity the function changed you know she she didn't want to do movement her function changed she goes if I know if I can sit on that floor every day and pet my cat and get up then I know I'm fine I said well there we go that's the one we're going to use then because the confidence is partly what you need to impart right so you know within your delicate area of practice that's where we would have to focus on confidence in the function right exactly yeah I mean I feel like the pelvis just adds a whole nother layer of just so much uncertainty because there isn't you know much that does show up on scans or tests or anything like that much like other types of pain as well

but it's just you know it's a taboo subject in our cultural in our culture and society and so that's also another just another barrier to go through i suppose in our pelvic health team that you know we work really closely with here at our the shirley ryan ability lab they i mean they're using the same principles right so you know they're they're not losing sight of what's the dominating mechanism. You're right. The pelvic area is a very important area to a lot of people. And it's, it makes sense that it would be an area routinely used by the brain in a protective way when life may be not going as well. And we have to make sure that we're, you know, with our intricate skills of being able to be inside the pelvis, we have to make sure that we're

seeing the results of what we think we should see you know because often our pelvic health team they you know they recognize often that a lot of people with health pain are dominated by the effect mechanism and they're dominated by the motor autonomic mechanism and imagery and you know gradual graded motor imagery and localization work within the pelvis are more appropriate treatments than our peripheral based massage or Kegel strength training programs, you know, and that a lot of times we're working on coping and what's going on in the social conflicts that may be going on within relationships that are affecting their ability. So we really need to just keep that part as no other body part, right? Recognize its importance to that person and make

sure that we're getting the right dominating mechanism. Right. Absolutely. Thanks for clarifying with that, or at least having a discussion. No problem. About the undercarriage. Yeah, I'm not like, you know, I wouldn't say you're, you know, I'm the therapist that you're going to see for internal pelvic work. But I also am the therapist that manages a lot of pelvic health pain. Right. And, but I'm the one that's, you know, the central sensitivity and effective As soon as they're really kind of keying in that this is the area that's involved, it seems like they're off the pelvic health team and they're on any schedule. You know, and so now I'm all of a sudden I'm a pelvic health therapist, you know, but, but I, you know, I just say to people, look, I, I really don't tag myself to any body part. I treat pain and I treat function.

and so no matter what type of body part you come in with i know that we can you know classify it appropriately and there's an intervention that can lessen your suffering but you know we got to start with it from a good relationship understanding expectations and really screening through things in order to do that and really the sound board of education i love it i love it so where is the focus of your future research and teaching going thanks for asking because we've we've got a lot of things on the marker here we'll have a couple published papers out this this next year especially validation of the yellow flag risk form which we're very excited about nice congrats to finally give this form that's been in clinical practice over the last 25 years statistical merit and then

We're really, because of the robustness of the form and the ability to classify different pain mechanisms on top of the correlation we've seen in some of our preliminary studies with the physiological changes within the brain, we really want to start putting that form up against other forms. We've got people running it through GI. We've got people running it through pelvic health. So we're really kind of, our future goal is to keep comparing it to other strong outcome measures to strengthen, right, its statistical merit and its clinical practice usage. In addition to that, we're moving very robustly forward with validation of the three central nervous system subgroups and looking to work with a grant in matched and unmatched treatment interventions. So really trying to validate the central nervous system like we did in our 2016 article with validation of the peripheral nervous system. So building off of that, and I think one of my loves that's coming up within the research is really tagging certain patient education tools and the effects on brain physiology. Because we pretty much know the centers of the brain now, and we know what's working.

So now what we want to do through FMI work is really kind of be able to show that pre and post through good education centers and just the power of words, you know, and how we're changing suffering. So that's kind of three things that moving forward, we're kind of working. That's awesome. Yeah, I'm glad you have big shoes. Big shoes. yes yes that is great and thank you for all that that you guys are doing and that you're doing to help you know make this change a reality and one patient at a time i mean you're really changing lives with the information that you're sharing and so thank you so much for that how can listeners connect with you they can connect with me the most easiest way is through the world of hurt

gmail so it's the world of hurt all small case world of hurt no spaces to at gmail.com and like you know you and i've been communicating through twitter that's another great way is uh world of hurt too with the little at symbol in front if they want to follow us on twitter where we're trying to really get the word out a little bit more on the power of words moves and foods I love it oh it's great cool awesome well Annie thank you so so much again what a great podcast filled with wisdom so much knowledge and I'm sure our listeners will definitely benefit so much from from hearing this message and hopefully they can apply it immediately to their life and reap the benefits so any show notes anything that we have talked about they

will be linked to the podcast show notes so that everyone can have access to them. So thank you for sharing that as well. And yeah, it was really great to have you on the show. It was really great to be on the show, Susie. I want to thank you too. I've really enjoyed our recent communications through social media and stuff, and you're doing a really great job. So dittos and kudos. Well, thank you so much. And thank you to all our listeners out there. we appreciate you listening and as always and loving wellness for your pelvis this is dr suzy g until next time my friends thanks for listening to today's episode be sure to head on over to drsuzyg.com where you can get more information show notes and related articles on today's topic

also if you like what you're hearing head on over to itunes subscribe to the podcast and leave us a rating and review we'd love to hear feedback thanks again Thank you.