In Your Pants with Dr. Susie G - Pain Heroes 🦸‍♂️🦸🏽‍♀️

Episode Date: September 23, 2019

Pain is a normal human experience that everyone experiences at some point in their life. For some, pain can stick around longer, sorta like a house guest who's overstayed their welcome. This unrelenting persistence can quite be challenging, testing your mental and physical resilience. Although living with pain is hard, there's hope. In today's episode, Alison Sim, author of Pain Heroes: Stories of Hope and Recovery, and I have a candid conversation about pain from both the patient and clinician perspective.

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, welcome to another In Your Pants podcast episode. I'm so glad that you're here with me today. Thank you so much for watching and being a listener and follower. So on today's episode, we're going to talk about pain, which is, as you all know, is one of my most passionate topics to learn about and to educate other people about and to help them live a life that they dream of, one that is not focused on pain. And most importantly, it's

a topic and a passion of mine to let people know that there's recovery. Recovery is on the table and there is hope. So to help me do this today, I have asked Alison Sim. Alison Sim is the author of Pain Heroes, Stories of Hope and Recovery. This is a great book. It shares stories of several people who have had chronic pain, persistent pain, and their journey to recovery. And so if you're feeling down or blue and stuck in a rut, perhaps this book can shed some light and give you some hope of that it is possible to live a life without pain. It is possible to still find meaning in life, even though things might be uncomfortable. So I really recommend Alison Sim's book, Pain Heroes.

Before we jump right in, I wanted to formally introduce Allison and give you a little bit of her background. Allison is a qualified osteopath since 2001. She has a master's in pain management from Sydney University Medical School and Royal North Shore Pain Management Research Institute. She's lectured at Australian Catholic University, Victoria University, RMIT, and George Fox University, and a variety of science and clinical subjects. She's also worked as part of the teaching team at Deakin University Medical School, and she's currently based in Melbourne, Australia. She's working in a pain clinic, helping those with persistent pain get their life back. So without further ado, let's get the show started. I really hope you enjoy

it. Allison, thank you so much for being on the In Your Pants podcast. How fitting. Pelvic pain in your pants. Thank you so much for having me, Susie. I'm excited to be chatting from across the world. Oh yes, I know. Melbourne, Australia, everyone. That's right, down under. That's right. Again, no pun intended, right? I mean. No, no. So I wanted to actually start our conversation today by reading from your book. So Alison has a book called Pain Heroes and I just thought it was really profound so I just and it is from the introduction but just so great um it states the people in these stories have generously given their time and permission to share their story

because they believe that it has value to other people who have pain and each of these individuals have had pain that has had a significant impact on their life it made them feel miserable disconnected from friends and family and might have even made them unable to work or look after their families. In some cases, they felt so despondent that they did not want to live anymore. This is what pain can do. It can pervade every bit of a person's life, taking away the good bits and leaving behind distress, medical appointments, medication side effects, and misery. How true is that? And I'm sure everyone who's watching and listening who has ever dealt with pain or is dealing with pain can attest to that? I think so and it's interesting when you

read it out I haven't read the book for quite for some time when you read it out I think oh yeah that that makes a lot of sense yeah it is pain is incredibly pervasive and it it really can take away life it really can can take a person's life and shrink it right down to to being all about surviving. Right. Absolutely. And so just starting off our conversation here about the importance of clinicians understanding modern pain science and really why that is important, but also why is that important in the context of the relationship with the person in pain and the person providing services? I think that's a really good point, Susie. And I think what it comes back to is the idea is pain science is not a thing it's not a technique and that's often what we see bandied

around on on the internet is uh you know are we going to debunk this this pain science thing it's it's um it's science it is it is what it is it's science and understanding it doesn't um it doesn't devalue off from what we've learned in pt school or um whatever whatever university the education we've had or undergraduate education, it just paves a way for understanding why pain is so tricky to treat. And so that's why I think it's important. It's not because it devalues anything that we've learned in the past, but it gives us a bit more hope and a bit more understanding. And most of that comes from what we take away from the pain science, which is there isn't going to be a quick fix tissue-based answer for this and really if that's

the crux of it and and then the other thing I think that we take out of it is that if that is the case what is the most important thing that we can understand and I think that's to look at the person in front of you and to understand them because there is so much value in that relationship between the therapist and the patient and how that drives everything from that point, that it's worth making the time to understand that. And I think it's very hard to do that when we're action-based practitioners. We build, I guess, a value of ourselves and what we do around what we do with our hands or what we do with our exercises or what we do

with this technique or that technique. And when we look at this idea that what if just talking and understanding your patient had more value than anything that you did with your hands, and that's kind of what pain science points to. But sometimes it's very hard for us as action people to embrace that understanding and to sit back and to sit on our hands and to stop talking and to listen because it feels

like we're doing nothing. Right. And I think that's where understanding the science can really give us the backing to say, no, actually this has value, this is worth it and even though it doesn't feel like I'm doing anything, there's probably more value in this than what I might do with, you know, with sorting out someone's, straightening someone's spine or anything like that, which is often what we're taught at university.

And I think, you know, it's easy when you live in a bit of a pain science bubble to think that things are changing and they certainly are. But, you know, I remember teaching at PT, Physical Therapy College in America, and I'd be teaching a pain science subject and then literally the students would then walk into, you know, a biomechanics class where they're learning about how, you know, this being rotated

this way can do this and this is the root of all problems. And it's really, you know, it's easy to see how people can get really confused and and a bit I guess disconnected from from all of this when you've got people you know an entrenched understanding of something and then um these newer ideas that are coming and debunking some of this stuff so yeah it's it's a bit it can be really confusing right right and also I think it's just it's easier to latch on to those kind of beliefs because well it's an answer and it seems logical right I mean you know in general it was like okay that's an answer, I know what's wrong, but then it just leads people down a rabbit hole of, well, what

happens when it stops working or doesn't work anymore? I mean, does that pervade you to be more of a broken person, you know, or that there's something seriously wrong with you or, you know, the list can go on and on, but that is a good point that you bring up that it's not just in the tissues. And in your book, you mentioned how that can be very hard for patients or the person in front of you to swallow that pill you know like to wrap their head around it's pretty much then yeah you're right it's pretty much the number one reason that I that I wrote the book because I I get it um you know as a as a practitioner and as a patient I guess I get that understanding that sometimes it's really hard to shift your focus when you've when you've held this idea

so tightly that something's wrong and needs to be fixed and that there should be an answer and it also it flicks back to our understanding as a consumer society and um you know i've had some members of my family going through health issues at the moment and i can i get it you know their understanding with the rest of life is that everything comes with money-back guarantees often things are very black and white but unfortunately the human body just hasn't read that memo it hasn't read the rules that says that you know this should equal this and when you do this this should, you know, it's just not how the human body works, but we don't understand that. And that drives our expectations. And then our expectations is, as you say, that's where we get

sent down the rabbit hole. Right. Right. And, and there's also this, um, facing uncertainty or, you know, uncomfortable with uncertainty. Uh, and that's, I mean, that is life. I mean, it's more philosophy, philosophical in nature, but it is true. There's a lot of uncertainty in life and there are no guarantees other than death and taxes for some but you know the tax is part death I think we all can agree on that happens to all of us um but yeah so you know that uncertainty of not only not knowing what's happening to to me and my body but also of when's that next flare-up gonna come you know it's very cyclical persistent pain exactly yeah I think um you're right you're embracing that uncertainty can be a really hard thing both patients and practitioners

because because it's often the lack of control that is one of the worst things and if you if you look at the common themes in what people are saying you know in the book there's there's eight stories in there and a lot of them and you know I work with pain patients every day um a lot of the stories a lot of the the guts of the suffering comes from the lack of control and it's that idea that if if i can control something then um it's less frightening and so embracing uncertainty is really tricky equally as as you were kind of hinting at before you know we're talking about the patient side of things but also for the practitioners it's hard for us to embrace uncertainty especially if what we've been taught in a you know this sort of didactic fashion is

you know this is the way you do things and if you do this well the emphasis is that if you do this people will get better and then but then what happens to the practitioners when they don't when they're doing all these things that they've been taught at school and patients don't get better and i think that's where pain science gives us a break because it means that we're not getting across with ourselves as practitioners we're not seeing ourselves as failures we're not putting the um you know equally we're not putting the blame back on the patients we're saying the science is what the science is and it tells us that stuff is really um you know it's really hard to fix and and that the changes are no longer in those tissues that they're in the nervous

system and that's probably why we need to take three steps back and consider this as a bigger picture right right and keep things simple and i love that you bring it back to the clinician too of there's a lot of burnout and we get into this profession with our heart and our soul and utmost compassion and empathy and we give it our all. And I can attest to this. I've gone through many classes and courses and certifications and more letters, but that the underlying theme that you just said was, you know, I suck as a therapist cause not all my patients are getting better. And you know, what I'm missing the magic bullet. I don't have great hands, you know, like there's something wrong with me. Um, but, and you're totally right. That is not,

that's not the case I mean there is we we just can't predict these things you know exactly and pain is really complex it's really really complex and I think you're absolutely right Susie we we are compassionate people and we go into it wanting to fix people and and naturally obviously most of us are quite driven because you kind of have to be there to to get into our professions if then you're not doing you know if you're not getting the outcomes that you want then it's natural to reflect and and it's quite natural I guess with a lot of those society pressures to think what am I doing wrong and like I I battle with that and I even in the in the presence of recognizing that burnouts are being and that we need support um I've had a tough

couple of weeks with some CRPS patients that I've found um really really tricky you know this this disease is kind of what we look to when we define chronic pain and when we look at what changes go on we look to see rps because it is the worst of the worst it kind of shows us what goes wrong in our pain systems um and that's you know that's the sciencey bit of it is is why this is tough to treat and why it's often quite unresponsive um but what it's wrapped up in is this person who's suffering and this person who's coming back week after week you know um who might not be getting uh might not be getting improvements and so as a practitioner i'm really lucky to be working in a team um and when I have those thoughts and feelings and when I'm thinking

about those patients at night which you know that's that's what causes the burnout really isn't it when you're taking them home and you and you're thinking why why what if I just did a bit more graded exposure what if I just did a bit more graded motor imagery or you know what why am I not nailing this when when there are some good ways forward is I'm thinking about that person and how much suffering they are and the look in their eyes when they're coming back in um and i think one of the things that i have to keep reminding myself of is to fall back on that team and to fall back on the mentoring and support of people around you um i had a really good chat with one of our doctors this week about that just a patient that we're co-treating and i was just saying

i understand the science i understand the disease i understand why this thing is progressing but how do I how do I sit and cope with the sad when when this person's just getting worse week after week and he was really good to to listen to my frustrations and and to hear all that and to say you know his advice was first of all even though things aren't changing in fact for this this young girl that I'm talking about she's actually going backwards week after week understanding that that she has this catastrophic history she has this you know this horrendous um childhood history of trauma and that that's probably what's driving a lot of her sympathetic nervous system um but also to know that if even though she's turning out week after week things are going

backwards she's got a listening ear and and that without me being there without someone to touch base with on that regular basis um she's not getting the reassurance she's not getting a listening ear she's not getting someone who understands what she's going through and those things have so much value and so sometimes it's you need that to be pointed out out to you and his advice to me was keep the faith it was just to to uh to hold steady and to know that you know maybe the tide will turn in in six or twelve months time and in that in that case um you know she's got the existing relationships and she hasn't gone um uh she hasn't I guess vanished off our books that she's still there and able to keep accessing help

even if it's not making functional progress for her right right and that's thank you so much for sharing that that is that takes a lot of courage but we're all you know we've all experienced those cases and many you know where we just want to help so much that we just it's just out of our control and really like you said in the beginning of this conversation is if that's all we can offer support and an ear to listen and validation that we're here for them um that might be just enough to know that there is someone that loves and cares for them and is rooting for them and they're not alone yeah and so I think that yeah that's right important yeah um wow well thank you oh my gosh I'm like okay so I would segue that into um all this information that we talked about

how how does this change our understanding of chronic pain conditions like pelvic pain so a lot of our my listeners are those that are experiencing and suffering pelvic pain so I would love your um your take on that well I think that's uh yeah pelvic pain is a really big issue isn't it and and because it's in your pants and it's down there and it's and it's dirty bits and there's shame and all those things associated with it we don't talk about it we just don't talk about it and um again things are changing we're we're less ashamed about talking about periods and uh but but still it's often just so normalized as being women's problems or that's just what you have to suck up or deal

with it and it's just not the case and we know that our understanding of pelvic pain things like endometriosis or musculoskeletal components or um you know pelvic pain is can be incredibly multiply multifactorial but just our understanding of it and even picking up young girls to be able to have these conversations with young girls and say hey you know a little bit of period pain's normal but you shouldn't be taking days off school on a regular basis um and and that if you are that we need to talk about this we need to actually try some things because again if we look back to the science if we catch this stuff earlier and we stop more of the peripheral sensitization um if we stop people suffering if we stop them sort of falling into the i guess the more

psychosocial stuff so they're they're losing days of school or work there it's having a big impact on their life they're starting to define a lot of things around pain if we can stop people going down that path by um you know maybe hormonal treatments maybe exercise therapy but but maybe talking about it um and that's not to to normalize it or talk it away but to actually start engaging in dialogue and saying um that you know rather than being reactive and going down the path of having multiple surgeries let's actually let's talk about this from the get-go and stop this thing from becoming a thing um that's something I'm I'm very passionate about and um is is this idea that we can we can catch a lot of this stuff a bit earlier but we've got to start having the

conversation with our girls oh I I'm so glad you brought that up because I say that all the time and I my I predominantly treat men who have pelvic pain and so it's very similar where I would even say that women have more outlets or available resources, whereas men, like my husband would say, I would have no idea who to talk to or which doctor to start with. What do I even look up? And as you know, the internet is a double-edged sword. It can be very helpful, but at the same time, it can be very harmful depending on what you come across. And there's a lot of misinformation. So you mentioned this rabbit hole and they struggle with that too. I mean, you know, genitals mean a lot there's a lot of real estate and and and um of course it only takes one one

spitting twice shy right it only takes one time yeah or something to disrupt the normal functioning of things down there and then there's this just really huge uh fire like it's a little one but then it can grow to a really big forest yeah a big cascade yeah and put it out and you're absolutely right with um with the men uh you know if a woman's having a bad day is there is even even though we're saying there's not a lot of society's acceptance or understanding of period pain and stuff like that it is still a bit more understandable than a bloke who's saying my testes are really sore no one wants to talk about that they're not going to the gym yeah how are your testicles my penis hurts today you know

that's exactly right it's um you know there's there's way more taboo around that so you're absolutely right it's it's um it's associated with shame it's associated with manhood there's just so much going on there and as you say um the blokes are even um worse off than us in terms of talking about this stuff yeah and not to minimize either situation obviously everyone's absolutely not it's just you know battle and struggles and and you know all genders all walks of life i mean there's enough to go around to you know so much out there culturally society in society and so yeah um you mentioned crps earlier in our conversation and just for our listeners out there and this will segue into our my next question about your case report but let's talk

about crps what it is and the relationship between pelvic pain and incontinence and crps oh that's okay so it might not be that relevant to your listeners if if most of them are patients with pelvic pain then it might not be something that that they're coming across but perhaps for practitioners who are dealing with with people with crps um as a definition chronic regional pain syndrome crps is a um i guess a a version of the nervous system where things go fairly pear-shaped and they go fairly pear-shaped in a predictable way so often it comes after immobilization of a limb so perhaps we look at a fractured wrist or a fractured ankle or something like that um they often are immobilized for a period of time it it often it is often

associated with higher levels of trauma so if someone's particularly stressed about their condition or if there is trauma associated with how that condition actually came apart came about for example accidents or um you know really traumatic things people don't go out or get in their car to expect to to have a car accident and that can be incredibly traumatic um what what tends to happen is that this instead of getting good tissue healing or sometimes even in the presence of good tissue healing the nervous system gets a little bit wound up and so if we take the example of say a fractured wrist that's been immobilized what can tend to happen is that we start to see color changes sweating changes hair changes so all these things that aren't

normally associated with something like a fracture that start to affect different parts of the body so usually it would start in the area that the damage has occurred so we tend to see these things going either pink or blue they tend to get swollen or sometimes they go white as well so hot cold what else and and often associated with incredible pain so and and pain that's of a of a particular nature so-called neuropathic pain so often people patients describe it as being sharp shooting burning electric quite um classic neuropathic descriptors um one of the things that people often present with is what we call allodynia so that it really hurts to touch the area so they get really sensitive to having things like bed sheets on on a foot or um or wind or the

air conditioner they can't cope with the air conditioner being on the skin of their affected limb um and and as well as that they often find it hard to weight bear if it's a leg or to use the hand so it often gets a little bit atrophied um and then sometimes in the worst case scenarios it can spread so it can go from a particular limb to other limbs or to other areas of the body so it's a um it's a pretty ugly condition that often carries with it an awful lot of suffering and pain and in your case report does it include is it a combination of crps pelvic pain and incontinence because i everything that you've described i can tell you that i've seen in like happening in the genitals and because it is this nervous system response so men will often

report changes in blood flow to genital area burning stinging sensitivity to clothes or underwear or anything light touching the penis um and then there seems to be this like this embodiment that happens too with this with their genitals too like feeling weird and not them, you know, not, not part of their body. And so that probably has to do with the cortical changes. Exactly. Exactly. Um, and, and, um, so I don't know if this is what your case report goes through, so I don't want to take the thunder away. No, no, no. So, um, yeah, but you're absolutely right. And, um, the cortical changes that you're referring to in the limb, what we tend to see is, is a bit of a neglect. Um, often people will either, uh, describe their limb as

being not their own or enormous or ugly or hideous or or if you ask them to perhaps draw a picture of their body they'll draw it as either incredibly small or incredibly large so they lose the context of what that limb is and that's because they're not using it and so they don't get that reassuring normative feedback into their into their cortical areas of their brain there's absolutely no reason why exactly the same thing can't happen with the genitals and i think um you know vulvodynia is a is a great example of where we see a lot of these very similar changes so we can see the the aledinia where people are so sensitized that they can't wear underwear or they can't wear pants um that that light touch sends them um screaming um and often you'll see a lot of mucosal changes and

things like that as well so those systems are being involved for crps uh diagnostically there's a set of criteria that are called the Budapest criteria and they involve having the affected limb having a certain number of those criteria. So the swelling changes, the temperature, the colour, all of those types of things to be technically classified. But obviously it's a spectrum and really CRPS is just the worst of the worst when we look at neuropathic pains. It's kind of how it expresses itself in its worst beast. For the case study that you're talking about the case report um we're in the process of of writing up and and um sending in a case report that we've treated um on a patient as a team who and and the young girl involved

started off as a minor sprain strain of her knee and then spread to her um upper limb on the same side so she started with crps in the knee and then spread to the the upper limb um as this progressed as this disease progressed for her uh she started to notice that she was getting some incontinence events and these uh were happening without her noticing so she actually couldn't feel the sensory changes of actually having had um you know having wet herself um but she would smell it or she would notice it so she couldn't feel the warmth um she couldn't feel the the wetness because the sensory changes in her limb and her obviously her pelvis were so um were so bad that she wasn't feeling it but what she would notice was that she would actually see the color

changes or she would smell the urine so um that for her was just devastating she was a young girl and she's at university so it was quite frightening um and and obviously um for her pain specialist it's not something that they would tend to talk about they're quite focused on the limb they're quite focused on what's going on in the area and um and it was not something that we we'd seen or dealt with very very often or or yeah it was just not something that i had thought about much um but then we we did an mri to make sure there wasn't ms or or other um sort of more um central nervous system or central processing issues going on um and that was all clear and then it just made sense to say well well if we get changes in either skeletal or

autonomic muscle tone in other crps cases why wouldn't it affect the bladder um that that makes total sense um and so um this young girl because she had so many practitioners and had seen so many people um she was quite relieved that we were able to do that in-house that we were able to do an examination and treat that in-house so she didn't have to start with any practitioner and go through all of her story again right um and we very quickly identified that she didn't have a lot of, she didn't have any voluntary muscle control over her bladder and over her pelvic floor that we were able to rectify pretty quickly with just some biofeedback

and some training. And she then went on to do a bit of home-based training with a biofeedback device. And within two weeks, the incontinence events had reversed. so um she was getting to a point where it was happening almost daily and and she was it had happened twice at university so she was pretty ready to pull the pin um and not go to uni which you can understand i think that's that's um that's quite a frightening thing um and so for her to be able to come back and and it and it happened within two weeks so it was for her to be able

to come back and say actually um you know this is reversed and and i can feel when i need when i need the urge um so it was essentially um both skeletal and autonomic components that we just rehabbed um with a bit of biofeedback and and so people who work with stress incontinence wouldn't be surprised by those results at all i think i think the stats are somewhere in the vicinity of 8 to 12 weeks of uh of pelvic floor training reverses about 80 percent of stress incontinence so it's pretty high yeah you know pelvic pelvic physical therapists are kind of going, yeah, yeah, that's normal. I guess for us from a more neurological or pain background, the case itself makes sense, but it's not something I'd come across or that we'd talked

about very often. So that's why I thought it was a really interesting case. And I've been lucky enough to get Dr. Jane Chalmers from University of Western Sydney on board as a supervisor in getting this case um written up and and jane's incredibly experienced with pelvic pain that's that's her her bag but she's also done a lot of research in crps prior to her phd so um i was lucky to have her there for advice and support in in getting that up and and written oh that is so awesome and thank you for sharing that you know the treatment and how things can change you know things are optimistic things can change and um yeah adaptable and it may not be easy but some cases are some cases are harder as you said yeah that's exactly right and the interesting thing

with that case which causes a lot of reflection for me is well why can we rehab her her bladder and her pelvis but but she's not getting good rehab with great exposure in her limb um yeah which is which is really interesting and and also the rehab changes to her pelvis didn't change any of the aledinia or the hyperalgesia that she was getting around her perineum which you know you'd hope in an ideal world would translate through but I guess the shining beacon you know the the ray of hope in her bleak skies that at least she's not um incontinent and she can go to university without having to as a young girl without having to be concerned about embarrassing herself in that situation absolutely which would only make things worse in terms of a

heightened sense of awareness and threat you know being able to go to university and have a really you know not be embarrassed as you say so try and be normal try and live a normal life right that's that's our intention of keeping her at uni is is to you know to keep things as normal as we possibly can while the rest of her life's kind of falling apart right exactly I love it and that's again that's what your book is really you know about and I think you did mention in here about you know to to get better but to focus on function and not on pain and and that's kind of what we're alluding to is like be getting back to normal despite you know adversity or a challenge of how can we still make life meaningful um in the face yeah even in the presence of pain you're

right Susie that's right yeah we don't we don't necessarily have to take the pain away um well for those neuropathic pains the longer I work in that I really understand where the patients are coming from when they say you know I just I just don't want it there I just want it to be gone and for us as practitioners to say oh well you know you can you can focus on on function and and we don't have to take the pain away that it is a bit of a second best so I get that I understand that coming from the patient's point of view absolutely and from my own personal experience I know that that's you know someone telling me that I would my reaction back in the day I would would be like I'm going to slap you right now what are you talking to me about like get back like you try

dealing with this you know and getting back to normal like you know I probably said that in a few little words and not appropriate but you know no I but I think that's exactly and that's where the understanding comes in is is that if you're sitting up in your high and mighty tower and you're, you're asking lots of closed questions and you're telling the patient what they should and shouldn't be doing. Um, they are, of course, they're going to be sitting there looking at you and thinking, how would you know? How would you know if you, if you haven't really understood their story and if you haven't demonstrated that you've understood their story and that you've listened, um, of course the thoughts that are going to be going through their mind is what

would you know? Or how would you know? And you haven't lived in my shoes. That's right. That's right it's empathy compassion listen and be a human with that person in front of you you're here too we all have struggles that we're dealing with so oh my gosh Allison thank you so much for this very enlightening and wonderful conversation all this wisdom you shed upon us thank you oh thank you for having me having me to chat Susie it's been lovely well thank you and you know I know everyone's going to be seeing my um troubled child in the background so I apologize for the barking and the um whining but how can listeners get in touch with you if they wanted to well obviously I'm going to link your book in the show notes but is there any other contact information

or social media thank you you've been very kind um very kind with your support of the book thanks Susie. Um, I am on Twitter. I am beyond M pain on Facebook. I am beyond mechanical pain and, uh, everywhere else. I'm just Alison Sim. People can, uh, my, my website as well is, um, beyond mechanical pain.com. So there's contact details there for email and everything. Um, yeah. great and when's your case report coming out you think you guys are writing it we are we're very close to having it uh ready to submit so um hopefully in the next little while great great i know it's a process it's a long a long process but thank you for the efforts for all of you and i just certainly can't wait to read it and share it with the rest of the world so thank you very

much again for all the work that you do um for us clinicians and for everyone that you you're touching their lives as patients and people who need help so thank you again allison for being on the show and having this chat with me wonderful thanks suzy 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 your feedback. Thanks again. I apologize for the barking and the whining.