Can Pain Education Lessen Chronic Pain with Adriaan Louw, DPT?

[01:56] Dr. Linda Bluestein: Welcome back, every bendy body, to the Bendy Bodies Podcast with your host and founder, Dr. Linda Bluestein, the Hypermobility MD. I am so excited to bring this guest to you today, Dr. Adriaan Louw. When I was in so much pain and really, really struggling to get my life back, it was people like Dr. Louw who really turned the tide for me. Learning about pain neuroscience really helped me to understand why I was hurting so much and what I could do to help myself feel better. Dr. Louw is a world-renowned physical therapist and pain scientist whose groundbreaking work in pain neuroscience education has transformed how clinicians understand and treat chronic pain. He's authored over 120 peer-reviewed papers and books like Why Do I Hurt?, helping countless patients and providers rethink pain from the inside out. If you or someone you care for lives with chronic pain, this is definitely an episode you're not going to want to miss. I'm so excited about this conversation because understanding pain science has tremendous potential to reduce suffering and impact anyone affected by persistent pain. As always, this information is for educational purposes only, and it's not a substitute for personalized medical advice. Let's get started. I am so excited to be here with Dr. Adriaan Louw, and I've been wanting to talk to you for such a long time. So thank you so much for coming on the Bendy Bodies Podcast.

[03:26] Adriaan Louw, DPT: Well, thanks for having me. I appreciate being here.

[03:29] Dr. Linda Bluestein: Yes, absolutely. This podcast focuses on people who have connective tissue disorders like the Ehlers-Danlos syndromes and people who have co-occurring conditions like dysautonomia. Of course, one of those is POTS and mast cell activation syndrome. But we know that a lot of these people are impacted by persistent pain and definitely nociplastic pain. We're going to get into some of the more specifics with hypermobility in just a little bit. And we know that the listeners include both patients and healthcare professionals. But let's start out talking about pain science, because you are absolutely one of the founding fathers of pain neuroscience education. I just want to find out first, why did you get so involved in studying this in the first place? And how has your thinking evolved over the past decade or so since you published articles like "The Clinical Application of Teaching People About Pain"?

[04:23] Adriaan Louw, DPT: Yeah, it's a really good question. The easy answer is I got here because I failed. I think for healthcare providers today, it makes a lot of sense. I was not trained to treat more complicated patients. And I mean no disrespect with that. I just think it's good for our listeners to know that we get trained a lot, but we don't know everything when we graduate. We know enough to get started. How's that? And so the joke of everything is when you have a funny accent and you have relatively okay success with patients, you get more complicated patients because people start saying, "I don't know what to do with you. Go see the guy with the funny accent." The easy answer in today's world is I became burned out. I just did not know what to do with these patients. I felt absolutely inadequate. And it took me down a path that some very kind people in my life actually steered me in this direction and said, "Hey, this is cool stuff out there. You should go check it out." So I was probably at a good point in my life professionally, saying, I need help. And so I started reading and reading. Then some of the smartest pain people in the world, David Butler and Robert Mosley, took me under their wing. I started working with them very, very closely, started teaching with them. And that just started driving things. As you get into this, you get more questions. You answer one question and then you have five more. And so it just started this incredible process for me to learn more about a human being's pain experience.
[05:45] As far as the last ten years go, that's a really, really good question because I have a hundred things going in different directions. But I think we're just becoming more and more interested and aware of how complex a human being's pain experience is. They're all different. They're unique. They're 100% real. And trying to match treatments to every individual that we see on a daily basis — yeah, that's probably where I'm at professionally. I'm just trying to get a handle on this thing because, like you said, once you get an answer for something, you get ten more questions. So I'm not sure if that answers you, but yeah.

[06:22] Dr. Linda Bluestein: Well, it does make me feel better that it's not just me, because I feel like every time I learn one thing, it raises so many more questions. I feel like I used to think that I knew a lot, and now I feel like I'm actually knowing less over time in some ways. But I think we get more and more curious, and we understand that things are so incredibly complicated. Like you said, the pain experience. You've often said that pain is an output of the brain, not an input. Of course, so many of us think of it as an input only. How do you help patients actually experience that concept rather than just understanding it intellectually — because we know that pain involves every aspect of a person's life. How do you actually accomplish that?

[07:16] Adriaan Louw, DPT: For the last 350, 370 years, we've always taught pain as an input. You have an injury, you sprain your ankle — I'll use the most basic simple thing — you sprain your ankle. And we were taught that pain messages come in and we experience pain. The advances in neuroscience tell us it is kind of the opposite. We get information coming in, but the brain plays a big role. The important part is the way we transfer this to patients is through stories, metaphors, examples. If I sit with someone and tell them just the plain simple biology behind it, I think most of us will get a migraine because it's so complicated. But we've taken these incredible concepts of pain and how they work and put them in a story. And I will sit with a patient and explain to them or teach them the story, and embedded in the story there is information where they can actually get this realization.
[08:04] A great example would be where I sit with the patient, we're just having a conversation in the clinic, and I'm getting the sense that they want to learn more. I ask them, "Has anybody ever explained to you really why you hurt, or why your pain is spreading?" Most people say nobody has ever explained that. Then I might ask somebody, "If you sprain your ankle, would it hurt?" And they would say, well, yeah, of course. That's common sense. But what would happen if you cross a busy street and you sprain your ankle — in that split second, at the corner of your eye, you see a bus coming straight for you? Does that hurt? And that's when you see those gears turn. My patient will sit there and say, well, no. I say, well, why not? "There's a bus coming." Exactly. So our brain has to make a decision: do I produce pain and we grab the ankle, which puts your life at risk, or do you just run across the street on a sprained ankle? And I know this sounds silly, but it's this incredible thing to watch somebody conceptualize. I've had so many patients turn to me and say, "So what you're telling me is pain is what I think." I say, "You're actually correct. It's more complicated, but yes, our brain plays a major role." And so in that brief interaction, just a conversation, just a story, they go, "Wow, that's interesting." And then we have further conversations, deeper conversations about how pain works.

[09:20] Dr. Linda Bluestein: I love that explanation. I hear all kinds of metaphors and you use a lot of them in various books — I have to hold up my two copies of this one. Of course, you have lots of great ones, but that one is really great. Why Do I Hurt? We'll have links to all kinds of things that you've written — articles, books, and so on. That's such a simple example that people can really understand, right? The bus is coming and you better get out of the way, sprained ankle or not. What about healthcare professionals? What do you think are some of the common misconceptions that healthcare professionals still have about pain, and how do you think they can actually unlearn those concepts?

[10:08] Adriaan Louw, DPT: I mean, this is pretty simple. We are so biomedically trained. We have shifted the pendulum so heavily. In the traditional medical world, we've taught that bad tissues means you hurt. And if you hurt, you must have bad tissues. We connected those two together. We now know — and it's important for all healthcare providers and our patients to know — that there are people today with very healthy tissues that hurt really bad and are in a very bad spot. But there are also people with kind of yucky tissues and life is amazing.
[10:39] For too long we've shifted the pendulum too far. All of us know today that yes, if you sprain your ankle, very likely you're going to get some pain. If you have rheumatoid arthritis in a joint, you're probably going to have some pain. Yes. But the pendulum has shifted so heavily. And if I had one wish, it would probably be to get healthcare providers to understand that a human pain experience is more complicated than just the health of your tissues. Tissue health plays a major role — yes, yes, yes, we're very good at that — but it goes way beyond that. Which brings us to the biopsychosocial model, where what you're thinking drives your pain. And going back to the ankle sprain story, it doesn't mean it's in your head. I think that's one of the biggest misnomers. You tell a patient something like that and they'll say, "Oh, I know where this guy's going — he says it's in my head," which assumes it's not true. We've done a lot of brain scan studies. I'll just be straight up: we've never scanned fake pain. All pain is real, but your brain must be part of it.
[11:33] And so my message to healthcare providers is that psychologically, we can drive pain — fear, catastrophization, depression. Those things are very real and very important, but they're as important as the health of your tissues. Your social environment, what's going on at work, what's going on with your family — pain is more complex than just tissues. And I'm a physical therapist. I was trained in tissues and that's kind of where I came from. But it doesn't matter if I speak to orthopedic residents or any other medical providers — we go heavy in that direction. And I wish we could pull that back just a little bit more and understand that people are more complex when it comes to pain.

[12:17] Dr. Linda Bluestein: I find that with the biopsychosocial model, some people are in the biologic part and some people are in the psychological part, but it's all of that, right? It's all of those factors put together that cause the pain experience. I've literally had family members ask me, "Is this person's pain real?" And I've said the exact same thing that you just said: all pain is real. I've also had family members say, "Well, is that just the placebo response? And therefore that person's pain wasn't real." It's really difficult. And for people who are suffering with pain, validation is something that's so important. So balancing that validation, but at the same time saying, look — once you recognize that the brain is so important, that actually gives you another lever to pull, another thing you can actually use to impact your pain. And we know pain and suffering are not the same thing. So I think that can especially help decrease suffering.

[13:19] Adriaan Louw, DPT: Oh, absolutely. The part that I find fascinating is why we have such a stigma when it comes to the brain. I know what it is. It comes back to old models — if it's in your tissues, it's real; if it's in your head, it's fake. It comes from the old Cartesian dualism model. But what I need patients to understand, when we talk about the brain, they need to think more about a professional Olympic athlete. The future of sports performance is the brain, period, done. We know that. No matter what big sports medicine conference we present that at, it is the future. And why are we so afraid that what's going to help athletes perform better is going to involve the brain? Well, the same thing happens in pain. For you to get better, we're pretty okay with the tissue stuff, but why don't we take this supercomputer — 86 billion neurons, so incredibly fascinating, it rewires itself every three weeks — and make it better and better so you actually perform better?
[14:15] But we have this stigma: "Oh, it's in my head." And I blame us, the healthcare providers. I blame our old models. But I want our patients to understand that your pain is very real. It doesn't make it any different, but don't be afraid to talk about the brain. Don't be afraid to learn about the brain, because it's not the same as saying, "Well, it's in your head." Your brain is part of it. If I punch you in the arm right now, it's your brain that's going to say, "Adriaan is a jerk. Call the lawyer." But your brain must be part of the equation. And so instead of running away from the brain, run towards it, because I think the future and all the ways we're looking at the brain is going to play a major role in helping us understand and help people in pain.

[14:59] Dr. Linda Bluestein: That's great. I have a couple of follow-up questions to that. One, I'm thinking about something like dementia — I feel like there's just stigma surrounding the brain in general, right? If you have dementia or depression or anxiety or other issues in your brain, I feel like there's more stigma often with that as compared to a lot of other conditions like cancer. But I also wanted to come back to the brain rewiring every three weeks. Tell me more about that.

[15:28] Adriaan Louw, DPT: A common word that's thrown out there is neuroplasticity. Neuroplasticity occurs not only in the brain but throughout the central nervous system and peripheral nervous system. Plasticity obviously means it changes — it can rework itself. About fifty years ago, we believed the brain you have today is the brain you've got. Take it or leave it. That's the hand you were dealt. But we now know that there are 125,000 miles of wiring in your brain that gets replaced every three weeks. And when I tell patients that, they sit there and go, "Wow, that's interesting." And I turn to them and say, "You know what that means? This can change." "You mean I can get better?" Absolutely. Plasticity. We now have bioplasticity, neuroplasticity, whatever — plasticity gives us hope. It means it can change.
[16:14] Our nervous system rewires itself in terms of nerve sensors and ion channels. They change every 48 hours. Their half-life is about 48 hours. So all these things associated with our pain experience are not stuck. They're not fixed. The system can rewire itself. It happens a little slower for us oldies like me, but it happens. We did a study recently in nursing homes where we trained older adults — people 80 years and above — and they got it. They got the pain stuff. By the way, they outscored the younger older adults. Plasticity happens more in kids than in older adults, but it happens all the time. And so the message I always give patients when I talk to them about this shift is that it happens, it's very real, and it means things can get different or better. What happens with most patients is they lose hope. "That's it. Life's over. Bury me now. I'll never recover." And I say, why? "I got this condition." So what? You can change. This system changes itself and we can rewire it by what we're doing. And I think that provides an enormous amount of hope for the future.

[17:23] Dr. Linda Bluestein: And didn't we used to think that neuroplasticity only happened in children? So knowing that it happens in adults as well is so huge and so important. And people that have connective tissue disorders often have recurrent dislocations and subluxations and a lot of ongoing tissue trauma. They might have a new injury before the first one even heals. So is there a way that people can tell how much of their pain is nociplastic pain — pain in the nervous system — versus tissue pain?

[18:01] Adriaan Louw, DPT: I think it's a really good question. For patients, it'll be tricky. I don't think I've ever really had a patient, when they have a pain experience, sit there and go, "Now, was that nociplastic or was that nociceptive?" — and I'm being silly about it. For us as healthcare providers, we've learned to put pain in different buckets, and it tells us where we need to go look based on how they present. It drives the healthcare provider's thought process in terms of examination — including how vigorous we are, how many tests we do, the results — and the treatment. But for patients, if we asked them, "What's pain?" they'll say, "I don't know, it just hurts. Hurt is hurt."
[18:40] And so I think what we need to break down more with patients is the idea of: what pains do I need immediate attention for? Because I treat patients with fibromyalgia and other conditions, and I say, "You get pain every day. You need to know that's okay and we can talk about that, but what happens when you break your leg? That's a different pain — we need to go to the emergency room right now." So it's more about the pains that need immediate care versus pains that we need to find a way to work through — cope with, use the strategies a therapist taught you. That's where a lot of the tricky teaching happens. We teach people about acute pains, pains that don't go away, pains that don't subside quickly. There are warning signs, and those are the things we say: let's pick up the phone and make a call, or let's go to the emergency room and get it checked out.
[19:31] Because if you live with pain conditions all the time, your pain will go up, will go down. You'll have a good day, you'll have a bad day, and they'll oscillate. Teaching and coaching people that that is how a lot of people in pain work — some days they're fantastic, like "This was the best day I've had in weeks." Other days are kind of rough. That's okay. And we can work through that. But when you do hurt yourself, you need to know, "Hey, this is different. I need to go get some help." So that is probably where I'm sitting, as opposed to trying to break it into categories for patients. I find it fascinating, but I don't think I've had patients ask for that breakdown yet.

[20:04] Dr. Linda Bluestein: Yeah, I think that's a good way to think about it. And you probably don't know my own personal story, but I had severe, severe pain back when I fell off a mountain bike in 2009 and tore a bunch of things in my knee, and that kind of began a cascade of things. I have a hypermobile EDS diagnosis myself, and that's kind of how I ended up leaving my OR anesthesia practice and doing this. From about 2009 to 2016 or so, I had pain with like all capital letters — big, big pain. I talked about it all the time. I think I heard you on a different podcast talking about high-impact chronic pain. That's what I had at that time. And now it's like all lowercase letters. If I hurt something, I feel it, but it's not impacting my quality of life like it was back then. Learning about things like catastrophization — I watched a lecture by Dr. Dan Clauw, and learning about fibromyalgia and central sensitization was so pivotal for me. It was like, "Oh, okay. What's happening between my ears is making a big difference. I need to start working on that." And that's really when I started to actually improve.
[21:25] I know a lot of patients with hypermobile EDS and HSD get diagnosed with fibromyalgia oftentimes before their connective tissue diagnosis. From what you know about pain neuroscience education, do you have thoughts about whether they have both? Do they have fibromyalgia and these connective tissue disorders, or is the connective tissue disorder driving the central sensitization and nociplastic pain?

[21:56] Adriaan Louw, DPT: Yeah, you're asking me the chicken and egg story today. And the answer is yes and no. Obviously I can see where patients may have been diagnosed with fibromyalgia and through their course of struggling, seeing different providers, ultimately get an EDS diagnosis — or vice versa. The reality is it probably depends where you start.
[22:20] We wrote a paper a little while back, "Treat the Patient, Not the Label," and we showed that when patients present with all these chronic conditions and we start putting them on top of each other, they're so close. If you take fibromyalgia, chronic fatigue syndrome — which has been renamed myalgic encephalomyelitis — and you put all these conditions over each other, they overlap so much. My personal physician is actually a PA and he's a phenomenal gentleman. And I always think if I went to him and gave him a list of my symptoms, he could put me in any one of a bunch of buckets. And that bucket will then tell me whether I'm going to see a rheumatologist, an endocrinologist, and so on. Nobody's doing anything sinister here. It may just take you down a certain path. A rheumatologist may have a certain set of labels that work better for their practice. That's fine because they're trying to help you. But then after a while it's not working and you go see the immunologist. What we find is our patients start getting labels attached, and that's okay. It's a way for us to try to identify and match treatments accordingly. So I would argue that if you went one way, you may start with fibro and end up with EDS later, or vice versa. And none of this is sinister — nobody's doing anything bad. It's the inherent nature of medicine trying to wrap its mind around a very complex human pain experience that's showing up in their office.

[23:47] Dr. Linda Bluestein: And I'm glad you brought up labels, because I made a comment about labels recently that some people really took offense to, which was interesting — other people didn't take offense to it at all. I had a number of different patients in my office over this past weekend, and I really noticed that for some people, they don't care about the labels at all. They're like, "I don't necessarily want that diagnosis on my record. I don't need it." They don't need it for validation, they don't need it for getting resources or accommodations. But then for other people, they really do want it for a variety of those different reasons.

[24:24] Adriaan Louw, DPT: The important part is I always teach our residents — and this is going to sound really bad and I'll probably not be invited back — whatever the patient calls it is what I'm going to call it. If you call in and say, "I'd like you to help me with my fibromyalgia," I'm going to say, "Well, tell me about your fibromyalgia." It doesn't matter in the big scheme. And if I was a patient who had been struggling for years going from doctor to doctor to therapist, and finally somebody validates me and says this is what's wrong — and by the way, EDS is probably the tip of the spear here because this is a very poorly understood condition where finally somebody gets validated — I'm not going to take that away from you. That's your diagnosis.
[25:08] Now, for me as a clinician, when you show up with the label that brings you into my office, underneath it there's hurt. There's suffering, there are problems with sleep, there are problems with goals, there's loss of self. The list goes on. So I'm not minimizing that. I'm not saying your label isn't right or correct. It's just this fits where you are today. You tell me what you call it — if you want to call it whatever you call it, that's good, because then we can identify it and say, let's treat it accordingly. But there's no need to remove a label from somebody or to try to take it away. We're still just two human beings meeting each other in the same space. I happen to be a healthcare provider; you happen to be somebody that walked into my office and said, "Help me." And in that common ground, I'll help you regardless of where the label sits.
[25:59] What frustrates me sometimes is when people spend whole sessions trying to get rid of the label. I don't care. It doesn't change anything. You hurt, you cannot sleep, you cannot pick up your grandchild, you're very nervous about a trip coming up. How do we get you past that point — with or without the label? My advice always for patients is: this is your pain. You own your pain. Make sure you find somebody that validates you, treats you with respect and dignity. If they don't, you fire them. But remember, it's a two-edged sword — if you own your pain, that means you make the best decisions for you, but you also need to help yourself. I don't own your pain, you do. So you're going to have to work at this.
[27:01] And I can only fathom what these people have to deal with. I don't have EDS. I don't have fibromyalgia. I've had my fair share of back pain as a therapist, but I cannot fathom what these people go through. I've seen tens of thousands of them, and I've never cried as much as I have in the last ten years because I feel so bad for them. But I have to make sure people understand — I do not have EDS, I do not have fibromyalgia, so I can only imagine what you're going through.

[27:33] Dr. Linda Bluestein: Yeah. And I'm so glad that you brought up owning your pain and the validation piece, because I've done this — I've gaslit myself. A lot of people with EDS do gaslight themselves. When my doctors said to me, "There's no reason you should be having pain," I took that as fact and cried and sobbed and went into a deep, dark hole. And I have patients who come in having had terrible experiences with other healthcare professionals where they have been completely disbelieved and not validated. I wish people would realize that you don't need someone else to validate your pain, because no one else can feel it. Sometimes when I've told people — and it might not even be that they have EDS — I remember one patient specifically who was in her late 60s and didn't have EDS. She had family members that did, but she didn't. She had lots of arthritic changes and lots of things going on in her body. And when I told her, "You have lots of reasons to have pain," she just exhaled and she started to cry, because she said, "Everyone has made me feel like I shouldn't be in pain." And just simply saying that lowered her pain. So getting back to the chicken and egg thing — it's so, so challenging because people want the physical therapist, the doctor, whoever to validate their pain. But that's not how it works.

[29:08] Adriaan Louw, DPT: No, unfortunately not. And as a member of the healthcare profession, I think we could do way better. I work with healthcare providers — that's my job, to train them. And I also understand they feel threatened, because if you don't know what you don't know, then you're suddenly on the defense. You asked me earlier what's the message to the healthcare providers: we just need to learn and be humble enough to say, "I don't know." I tell my residents every day, if a patient comes in with a complex case, number one, listen. Number two, give them respect, dignity, and compassion. And it's okay to say, "I don't know, but I'll go find out." Learn all the time. Pain is complex. People that are hurt, they truly hurt. They hurt really bad. And I think we can do better — way better in healthcare with this.
[29:57] There's a cool little book I read recently, I think it's called Fast Medicine or Slow Medicine — I forgot the exact name — about how we are very good in America treating fast medicine. You break your leg, we take care of you. We can do surgery today and fix it. You have a heart attack, we're very good at that. But the slow stuff — the diabetes, the hypertension, the chronic pain — we're just not doing so hot. And so I wish we could do a little bit better with that, because we need a lot more of it.

[30:27] Dr. Linda Bluestein: Yeah. And we apply the fast medicine principles to the slow medicine.

[30:28] Adriaan Louw, DPT: Yeah.

[30:32] Dr. Linda Bluestein: We're still giving people ten-minute visits when they really need more time than that. And when it comes to you teaching other physical therapists and other healthcare professionals about teaching their patients pain neuroscience education, what specific things do you tell them in terms of how they should present this information in a way that doesn't feel dismissive?

[30:56] Adriaan Louw, DPT: That's a really good question. I think the first thing is we always teach them to ask permission. I do not have the right to talk to you about pain unless you let me. So when a patient comes in — a more complex patient — and I examine them and get to know them, I will often just turn to them and say, "Has anybody ever explained to you really why you hurt, or why your pain is spreading? Or why when it's cold you feel your knee more than when it's not cold?" And right now, most people say, "Nobody's ever explained that." Then I'll say, "Would you mind if I spend a few minutes and explain that to you before I do my therapy, before I do the stretches or the exercises?" So now I've told her I'm going to do therapy — I'm a physical therapist, so she expects that — but I'll also sit and explain things to her first. And all we do is plant a little seed. I teach her about pain. I wrap it in a little bit of compassion, empathy, and respect, and then she will process. Then we go do our exercises. And then as she goes home, we give her a little bit of thinking homework. Next time she comes in, she asks another question. So we build this repertoire over time of deeper learning where she slowly develops it.
[31:59] I always tell patients, I want to make you so smart about your pain that you walk in one day and fire me. You walk in and say, "I got it. I don't think I need you anymore." And we're going to have the biggest party in the world. If I can empower you to go, "I got it, I know what to do" — am I pain-free? No, but I know what to do. When it's a bad day, I do these seven things. When it's a good day, I enjoy life. And every now and then we kind of go off the rails and you come back to see me for a couple of visits and get back on track. There are a lot of people in this world who live very, very successful lives even with these labels attached to them.
[32:38] A few years ago, my residents made me mad — I don't know what they did, they really upset me in class about something — so I gave them homework. And if you don't make your instructor mad, I give you homework. I told them, "Go make me a list of some of the most successful people on the planet in spite of pain." We ended up with a five, six, seven-page document. Morgan Freeman has fibromyalgia. Lady Gaga has fibromyalgia. Billie Eilish has EDS. The list goes on. And it was such an aha moment for my residents. They said, "Wow, here are people who have conditions we often say we can't cure, can't fix, but they live very successful lives." Exactly. Don't let this define you. Today in this world, there is somebody with EDS starting their PhD. Today there is somebody with EDS starting a business. I know it sounds arrogant, but that's my challenge for my patients: don't let your diagnosis define you. You still have to have hopes and goals and dreams, because there are people who do this. And I get it — we go through periods of time that we feel bad and we're down about what we've been experiencing, but we can still live very successful lives. And that's regardless of whether you have back pain, EDS, fibromyalgia, and so on.

[34:06] Dr. Linda Bluestein: No, not at all. I love it. This is exactly what I wanted to talk about. So this is great. We're going to take a quick break. And when we come back, one of the questions that I really want to ask you about is whether you think that some people have more of a pain switch than a pain dial. We are going to take a quick break and we will be right back.
[34:34] Thank you so much for listening to Bendy Bodies. We really appreciate your support. It really helps the podcast when you like, subscribe, and comment on YouTube, and follow, rate, and review on all audio platforms. This helps us reach so many more people and spread the information to everyone. Thank you so much again, and enjoy the rest of the episode.
[34:55] Okay, so we're going to get to the pain switch versus pain dial question in just a minute, but first I want to ask — you've already touched on this, but so many people with connective tissue disorders have experienced medical trauma, invalidation, and they might be listening to this and thinking, "Okay, pain neuroscience sounds interesting, but I'm not sure how this is going to help me, or is this going to hurt me?" They need to really rebuild trust in their body and in the medical system. Do you think that pain neuroscience can help with that?

[35:27] Adriaan Louw, DPT: Yeah, absolutely. I'm biased, obviously. But the good news is the research is overwhelming. If we teach you about pain, your fear goes down. And fear is a big part of any disorder. If you don't know what tomorrow holds — will I be able to make it to my niece's wedding? — when you're fearful, it drives your pain experience. We have shown very clearly how we can reduce fear. Catastrophization, which is just a fancy term for seeing the world as cup half empty — "That's it, life's over, I don't know what I'm going to do" — we can turn that the other way around. And when that happens, by the way, the brain actually turns on a lot of its healthy chemicals: endorphins, serotonin, that actually ease a lot of our pain. So a lot of the things associated with the pain experience we can actually turn around, including self-reported pain, function, and disability. So I strongly believe we can do it.
[36:18] But the interesting thing is it doesn't take you from — let's use silly numbers again — from a ten to a zero. If I could do that, Bill Gates would tie my shoes for the rest of my life, right? But we can take the ten and make it an eight, or an eight can become a six, and a six can become a five. We have done three-year long-term studies to show we can steadily reduce a pain experience over time in people with chronic pain. And here's the best part: when you start feeling better, you do more. You start doing more and doing more, and then you get to the coolest part in the world where you say, "Even though I hurt, I'm going to take care of my kids. Even though I hurt, I'm going to clean my house. Even though I hurt, I'm going back to work." Now we're getting to that "despite the pain" process. Doesn't mean you're pain-free. It means I still hurt, but I have more good days than bad days, and when I do have a bad day, I know what to do about it. It definitely helps, because reducing fear and catastrophization are two of the biggest things we see across all our research.

[37:15] Dr. Linda Bluestein: And I often tell people that if we can just stop that spiral that often happens with people who have connective tissue disorders — if we can just start getting things going the other direction — any little bit of improvement, success usually seems to build on success. Like you said, you go from the ten to the eight to the six. If you just keep plugging away, because it doesn't happen overnight, right? It usually took you a while to get to this place, so it's going to take a while to get to a better place.

[37:50] Adriaan Louw, DPT: Yeah, absolutely. If we could find a way to take it from ten to zero, we'd both be making a lot of money. But it doesn't work that way. I need to lose some weight right now and guess what — it's not going to happen overnight. You can take a pill, but long-term it won't work. You have to spend time, effort, energy, work out, watch your sleep, watch your stress levels. Anything worthwhile takes time. And the same with pain. We can reduce pain — it can absolutely be done, it's been shown — but it doesn't go drastically or instantly.
[38:21] And as we feel better, it's like when you have the flu. When you have the flu, you feel absolutely horrible and you're on the couch feeling sorry for yourself. But as you start feeling a bit better, you do a little bit more. You feel a bit better, you do a bit more. And that slowly shifts. What pain neuroscience education really does is make you go, "I'm going to be okay." We can teach you why you hurt. Why when it's cold do you feel your knee more? Why when you're stressed do you feel this? Why when you have a fight with your husband do you have more pain? Let's talk about emotions and pain. The more you learn about pain, the less afraid you become. I've always said, pain that's understood is not to be feared. So if you have pain, you go, "I got it. The guy with the funny accent explained it — it doesn't mean the end of the world. It means I do hurt, but I can take care of it." That reduces the stress level, which actually makes you feel like, "I can take care of it and I can move on." That's the important part. But I'm sure somebody listening right now goes, "Well, that sounds so easy." No, it's not. It is hard work. But it can be done and has been done. Yes.

[39:17] Dr. Linda Bluestein: And a lot of people who have these conditions — you already mentioned ME/CFS — very common. And with fibromyalgia, you have a lot of cognitive fatigue. You might have brain fog, a lot of people have neurodivergence. Do you have any suggestions for how to explain or how to adapt PNE for people who might struggle with long explanations, might have ADHD, or struggle with abstract concepts?

[39:44] Adriaan Louw, DPT: Yeah, the cool thing about this is PNE doesn't have to be long. I think my favorite project — one day when I'm in a nursing home thinking about what I did in my life — is going to be that we built a middle school PNE program where middle school kids are learning about pain. And when I have a fifth-grade little boy sitting there, sticking his finger in his nose and scratching his rear end, and he goes, "I got it" — I kind of jokingly think, well, everybody can get it.
[40:14] We just did a study in the military with veterans with post-traumatic stress disorder and traumatic brain injuries. All we do is slow them down, repeat the stories. When we give them written stuff, we just make the font a little bit bigger. They get it. Older adults, I mentioned earlier. People can learn about pain. We've done it in a study with sign language. We've done it through interpreters. We've done it in Spanish, in different languages. It's not complex — it is very simple, easy stuff. And if somebody does have a brain that's super busy, which is common in pain, it's just a process of doing it again and again. So I would teach you in the clinic, but I'll give you something to go home and read — read it again and again so you can slowly build that knowledge. But it's not — I hope people don't think we're going to sit down and give you the textbook of pain and say, "Go read this." We're just going to tell you a silly little story and you're going to go, "Wow, that's a cool story." But in that story, there are concepts that you go, "Oh, I got it." And so they can get it. They absolutely can get it.

[41:11] Dr. Linda Bluestein: Okay. And if you could redesign PT education from scratch — I'm going to give you a magic wand for a second — what would you remove, add, or change to better prepare clinicians for managing chronic pain?

[41:26] Adriaan Louw, DPT: Nice try, Linda. I'm not going to get the academics that mad at me today. The good news is they do call us. There's not a week where I'm not somewhere in this country teaching pain science to PT students, OT students, and others. The question that always comes on the academic side is, "What do I take out?" There are fundamental things we need to know. Do we need entry-level clinicians to be at the top of their game on everything? No, they just need to be proficient and safe. But my number one message is: pain cannot be an afterthought. Pain is often the afterthought. We learn about the knee, the joint, the ankle — and pain is just kind of tacked on.
[42:01] I was invited to a PT school recently and the faculty met with me and said, "If you could redesign things, what would you do?" I said, now I'm biased, but I would put pain first in the curriculum because it talks about human pain and human suffering. If we start there, we're good. Then when you go into modalities, neuro, peds — you take pain and pull it beautifully through pediatrics, through neuro. You start applying it throughout, because ultimately a patient that comes in, be it pediatric, neuro, whatever, they have loss, they have fear, they have pain, they have disability. But typically there's this one two-hour lecture on pain on a Wednesday when the wind is from the south and it's a nice fifty-three degrees out. It's an afterthought. It happens in medicine too. We just trained 132 medical residents in Pennsylvania where, again, they just get a small lecture on pain — and by the way, it's not even mandatory. It's kind of like, "If you want to come, you can come." So we've got to do better. But if I had a magic wand, thank you, I would put pain early in the curriculum because it puts everything else into perspective a little bit better.

[43:10] Dr. Linda Bluestein: Yeah, I really wish that would happen in medical education. I feel like we don't learn enough about pain in medical school. I was asked to give a couple of lectures when I was on the faculty at this medical school, and I'm thinking to myself, I wonder how much other training besides what I'm teaching them they've had about pain, because it affects everything.

[43:37] Adriaan Louw, DPT: And that's the point. It travels all the way through, and human suffering is everywhere, no matter what they're presenting with.

[43:47] Dr. Linda Bluestein: Okay. So now I'm going to ask you the switch versus dial question. I have some family members who seem to have a pain switch instead of a pain dial. One of them that I'm thinking of in particular — I was trying to help them through a terrible, terrible pain in the hip and groin. They weren't able to really localize it. This went on for months and they were really, really struggling. We were all struggling to figure out what the cause was, and eventually it was determined that it was probably hip osteoarthritis. I've never seen this before — I'm an anesthesiologist and I've done tons of anesthetics for hip replacements.

Adriaan Louw, DPT: Sure.

[44:22] Dr. Linda Bluestein: And this family member was literally writhing on the gurney, just floundering around — but normally has no pain. For months before the surgery they were flopping around like a fish, terrible, terrible pain. Had the surgery — it was a spinal and sedation — came out of the procedure, and the pain switch was just turned off. No pain. They had no post-op pain. Never took any opioids. Got back to activity quickly. This particular person really seemed to have either tons of pain or no pain, and it wasn't necessarily super connected to what was happening in their body. And there's more than one of them in my family, by the way. Whereas other people like me, I feel like I can feel everything. Do you have an explanation for that?

[45:16] Adriaan Louw, DPT: Well, first of all, you violated the first rule of medicine, which is we don't treat family. It's like the mechanic's car is always broken. This is a really good question. We know that everybody's pain is different, everybody's experience is different. The day and time that we meet, you are a sum of everything that's happened in your life — all the memories, all the experiences, good, bad, ugly. So in a family member's case like that, why does one person respond this way and another person that way? Welcome to Behavioral Medicine 101.

[45:56] Dr. Linda Bluestein: We don't know.

[45:58] Adriaan Louw, DPT: There are 150,000 reasons for it. I just find it extremely fascinating. I've always told my students: I never understand why one person sprains their ankle and stands up and goes, "I'm good, let's go watch the game," and another person sprains their ankle and it becomes a life of pain. There are so many things going on — their beliefs, how they were trained, their social upbringing, how they learned about pain, their belief system.
[46:24] Sometimes it could be that there is a really bad hip and we've been playing at the margins without really checking. Oh my goodness, there is a really bad hip. We take care of that nociception instantly and boom, they feel fantastic. That happens. And so it's truly a combination. My gut hunch is that people with these pain switches — everything or nothing — probably have a very strong belief in a certain direction: "I have a bad joint, and if you fix the joint, I'm better," and it just turns it off. People with the dial are probably people who live more with pain where the nervous system has a good day, a bad day, kind of oscillates — always at a heightened state but going a little up or a little down, never fully on or off.
[47:04] But you bring up a very good point, because I get attacked on social media sometimes. People say, "All that Adriaan does, he talks to people about pain." And I say, you're out of your mind. Literally, when I'm done with my examination, about ninety percent of my patients start crying. I say, "What's wrong?" They say, "That's the most thorough medical exam I've had in ten years." I have no business sitting with you and saying, "I can't tell you why it hurts more on a Monday" if I haven't checked to make sure your back is okay, your hip is okay, do you have pulses, how's your blood pressure. I've got to check everything. And when everything checks out, then we can say, "Well, let's give you another explanation for why it hurts." So we have to do our due diligence first, and then pain science really comes in. The things that don't make sense — the hip looks okay, the back looks okay, but why do I hurt? Well, let's give you another explanation for how pain actually works. "Oh, that's different." And I think that's a critical element of this.

[48:21] Dr. Linda Bluestein: And for parents that might be listening — I'm seeing more and more children with chronic pain, and I often say "persistent pain" rather than "chronic pain." I sometimes remember and sometimes forget. For children that are having persistent pain, are there particular things you would recommend to parents? And actually, let me back up — are there certain things you would recommend to parents even if their child doesn't have persistent pain, but that might help them cope with future pain in the healthiest possible way?

[48:59] Adriaan Louw, DPT: Wow, you're throwing me a lot of grenades today. The easy answer is: the best way to treat a child in pain is, in a very politically correct way, remove the parent. We have enough research to show that how parents behave drives their kids' pain. And I have kids, I love my kids to death, but there's a study that showed they took kids that went through orthopedic surgery — as an anesthesiologist, you'll appreciate this — and then tracked these kids a year out. They classified the surgery as success or not a success based on pain, disability, and so on. Then they looked at everything they measured around the time of the operation to see what could predict outcome. And the number one predictor of children hurting one year later was the parents' catastrophization around the time of the surgery.

[49:43] Dr. Linda Bluestein: Wow.

[49:44] Adriaan Louw, DPT: And so my message to parents is: chill out. Let the healthcare providers do what they do. In our clinic, we used to see a lot of kids with CRPS — a very complex condition — and for a third of them with children, we would not treat the child unless we had a session with the parent first, all about how they should behave. Because the reality is, if you freak out, the child freaks out. I'm not having a go at parents — I think they're absolutely important. But we need to think about how we act around our children when they hurt, and even when they don't hurt. If little Johnny falls off the swing set — not freaking out, making sure he's okay, rub the dirt off, make sure the elbow is moving, he's good. It's kind of like the old days: check, make sure they're okay, they're good. Parents play an incredible role when it comes to children's pain experience.
[50:34] Kids are plastic. They fall out of a tree and get back up in the tree again. They have incredible ability to shift with a lot of the therapies we do, but often it's these other things. Kids don't worry about work. They worry about social interaction: "Am I different than my peers? I look different. They can go out at recess, I cannot. I'm different." That is a big stressor for them, whereas we worry about going back to our job. So they're a little bit different in that regard, but kids are awesome. They're extremely resilient.
[51:05] The bad part of this whole conversation is, unfortunately, if trauma enters the picture, then we've got a whole different bag of issues. So if children don't shift quickly, we have to assess a little bit deeper. But my message to parents would be: just if any way possible, if everything checks out, don't freak out. Take a deep breath, downplay it a little bit, make sure they're okay. And by the way, get them away from the meds, because good Lord, I think kids eat ibuprofen like Skittles anymore. My son came home from football and it was just ibuprofen. I'm like, "Dude, I teach the classes. You're embarrassing me." Those kind of little things I think are imperative for us.

[51:48] Dr. Linda Bluestein: Yeah, definitely. I really think that educating the parents is so, so important. And oftentimes they're dealing with their own thoughts about their child — if their child does have a serious medical condition, they're dealing with their own grief. I encourage them to get counseling for themselves and deal with those kinds of things too. And what you said about trauma — it's extremely common with the patients I see that there's some trauma in their history. And of course we're living in difficult times. I don't know that anyone gets through childhood without at least some trauma, but it's certainly a spectrum. Some people have had tremendous things they've suffered through, and other people — I remember being at a different family member's funeral and listening to my husband talking to his siblings, and thinking, wow, they had a really incredibly normal childhood. My childhood wasn't like that at all, and it's nothing my parents could have done differently, but it was really eye-opening.
[53:04] And when you were saying that, it also reminded me of when I was an anesthesiologist — there were some patients that really, really wanted to be present when their child went to sleep. And it was fascinating because studies showed that the calm parents who really didn't need to be there had the most beneficial effect on the child, and the really, really nervous parents who wanted to be there had the most detrimental effect on the child. So the parents who were like, "No, I'm fine, you can go ahead and take them back" — yeah, it is interesting, as an anxious parent myself.

[53:45] Adriaan Louw, DPT: Yes, absolutely. You know, I'll tell you this — I told you about the middle school studies we did. We did a study in California. Unfortunately, COVID stopped us. We have the data but we never published it because I need more data. We're going to bring it back again. But we trained the parents about pain, not the kids. We took a class of middle school children, but the parents had to come in for a parent-teacher meeting. So we trained the parents and then tracked the kids. And it was fascinating because the more the parents learned, the more the kids' behaviors changed — because they filter it down, right? Mom and dad basically filtered it down to the child, and then they responded. Yes, a parent's role is huge. It's absolutely fascinating, but it's critical in how a child experiences pain.

[54:28] Dr. Linda Bluestein: Yeah, I can definitely see that. Are there certain things that excite you about the future of pain neuroscience, or anything particular that you're working on right now?

[54:38] Adriaan Louw, DPT: Yeah, there's a lot. Obviously the world of plasticity — things are changing. Brain scan technology — in the early nineties we started scanning brains and saw these blobs pop up and we got all excited. Now we're getting better at those things, so we're learning more about the brain. The Connectome Project was completed around 2013, 2014, mapping how the brain connects itself. Really, really cool. And then things like artificial intelligence, virtual reality, augmented reality. I spend a lot of my time in CRPS-related research as well. What we can do with virtual reality — where we can mimic body parts in space that people can manipulate instead of their painful limbs — there's a lot of cool stuff happening there.
[55:26] But I think the one that excites me most is this: I do strongly believe there is a pain awareness coming — a bigger one. You mentioned nociplastic pain. There was a small group of us in the mid-nineties talking about all these things and getting excited. There were maybe seven of us, meeting once a year. Now it's front and center in medical journals, in physical therapy journals. It's becoming mainstream. And I've always said, if we can take a unified approach where we all speak the same language — the physician, the therapist, the psychologist — there's no way we cannot move this forward. Pain phenotyping, which is truly the buckets we put people in between nociplastic, nociceptive, peripheral neuropathic — it excites me because I think we're finally, as a community, getting here.
[56:15] And our patients are getting smarter. We've never really tapped into them as part of the answer. We've always had the answer because "I'm the provider, so I give you the answer." But there's a lot of cool things happening. Lifestyle medicine — nutrition, sleep, exercise, de-stressing — is becoming mainstream. When I was growing up, yoga was something that weird people did way out there. And you didn't care about drinking water. Those things are becoming mainstream. Lifestyle medicine and pain science go hand in hand. So there's a lot of things that excite me.

[57:04] Dr. Linda Bluestein: Yeah. And I totally agree about speaking the same language. This happens all the time where somebody says, "I went to" — and I hate to single them out, but it's often a chiropractor — "and they told me I had the worst spine they'd ever seen." And oftentimes they're young, and I'm thinking, oh my gosh. Even if you do have some problems with your spine, that type of language is so harmful. There are lots of studies looking at that. So you're right — we all need to be on the same page. We really need to think about the words we use because they have such a huge impact.

[57:44] Adriaan Louw, DPT: Oh, absolutely. Where does it harm? Where does it heal? In the late nineties, we started scanning people with no pain and found out there's a whole bunch of people walking around downtown San Francisco today with a bulging disc, and life is amazing. People with rotator cuff issues, people with hip labrum issues. So yes, we find stuff in the scans, but it's not always the end of the world. But the things we find in scans come with words that scare people: torn, ripped, ruptured, bulge, herniated. If you told me that, I'd be terrified to move again. And really, what it tells us is: you sprained something, you strained something, and tissues heal. I think one of the most incredible things on this planet is that I can literally sit at my desk right now, cut myself, it'll bleed, and it will heal. What a great thing. I always jokingly tell clinicians, "You need to put a little sign in your waiting room that flashes every ten seconds: 'Tissues heal.'"
[58:43] To a certain degree — because you sprain your ankle and a few months later you say, "Well, it's better." Now, for an EDS population, you say, "Wait a minute." Truly it is a little more challenging, but tissues do get better. We do strain them more, maybe injure them more, maybe stress them more, but they can recover from it. And that's one of the beautiful parts of our body, unless something is truly significantly prohibiting it.

[59:07] Dr. Linda Bluestein: And when I learned about mast cells and how much mast cell mediators influenced pain processing, that was another huge period of my life, thinking, wow — because so many of these people who have connective tissue disorders are somewhere on that mast cell activation spectrum. So that's probably contributing quite a bit.

[59:30] Adriaan Louw, DPT: Yeah. In the pain science world, we've always talked about the nervous system — neurons, axons, whatever. And then at some point we kind of bumped our head against the wall and said, hello, there's an immune system. And the immune system talks to the nervous system and vice versa. For the longest time we said a neuron just sends a message through. But there's an immune cell that sits next to it, and what happens in the immune system influences it. So yes, we are becoming way more aware of the interplay between these huge immune responses and the brain's plasticity. It changes the brain's processing, it changes the sensitivity of the nervous system. And that brings us full circle to lifestyle medicine — your sleep, your nutrition, the stuff that can drive your immune system very powerfully. It's fascinating. And there's so much we don't know yet, but we do know more than last year, hopefully.

[1:00:23] Dr. Linda Bluestein: Right. And it's funny that you mentioned those things because I have an acronym I use to describe the method I basically take in my clinic: MENSPMMS. It stands for Movement, Education — and the education piece is of course pain neuroscience education specifically — Nutrition, Sleep, Psychosocial modalities, Medications, and Supplements. Out of those, I have movement first and medications last, because so many people, myself included, right? I kept thinking, as soon as I find the right pill, my pain will be better. And it turned out it was obviously way more complicated than that.

[1:01:04] Adriaan Louw, DPT: No, absolutely. But it's a society thing, right? We all want the pill to lose weight, the pill for this, the pill for that. And I'm an American, so supersize it while you're at it. There is a time and a place for the right medicine at the right time. I treat a lot of people, for example, on membrane stabilizers where, without that medication or maybe a low-dose antidepressant, I can tell you straight up I probably cannot physically touch them in the clinic because they're so sensitive. So I always say skillful delivery — the right medicine at the right time. That's where my physician comes in, the pharmacist can help, and so on. But I love the idea that medicine should never be your first thought. It should be kind of towards the end.
That said, I'm sitting here as a non-pain participant in this conversation. If I were a patient, I'd say, "That's total crap — I want a medicine because I hurt like heck today." So I can only fathom where they're coming from. They want help. I get that. Totally get that.

[1:01:59] Dr. Linda Bluestein: Yeah. And that's where I explain: if you get ten percent out of this and another ten percent out of that, and you find five things that each give you ten percent improvement, now you've got fifty percent. And fifty percent improvement actually is huge, if you think about it.

[1:02:13] Adriaan Louw, DPT: Huge. Yeah. I would take that any day.

[1:02:17] Dr. Linda Bluestein: Yeah. Yeah.

[1:02:18] Adriaan Louw, DPT: I love how you explain that. It's a great way to think about it — if you just get a little bit better in each one, then yeah.

[1:02:24] Dr. Linda Bluestein: Yeah. Like when my physical therapist first tried using TENS on me, I was like, nope, it didn't cure my pain, so I kind of discarded it. And now I realize that if it helps a little bit, then why not keep it as one of the tools in my toolbox? If I'm having a rough day, why not use it?

[1:02:51] Adriaan Louw, DPT: Wow. That's a great way to look at it. See, I learned something today. I could try it now.

[1:02:56] Dr. Linda Bluestein: The ten percent rule.

[1:02:58] Adriaan Louw, DPT: Yes.

[1:02:58] Dr. Linda Bluestein: Awesome. Awesome. So we like to end every episode with a hypermobility hack. Do you have a hack that you can give us?

[1:03:07] Adriaan Louw, DPT: That's a good question. Again, like I said, this is not specifically my area of expertise. But I think the biggest thing is I want people to know what to do when things go bad. We always talk about coping skills. There are five things I always tell people when they're having a bad day. We make a little sticker and put it in people's exercise folder.
Number one: problem solve. Why are you having a bad day today? We have to learn something. "I walked a lot yesterday." Okay, so can you see that if you walk too much, this happens?
Number two: help yourself first. Before you call me, put your ice pack on, your heat pack, your TENS unit, whatever you have found works.
Number three: prioritize. We wake up every day with all our plans, and then we're having a bad day and we don't draw a line through everything to say we'll just lay on the couch. We may move a meeting to tomorrow. We may only sweep one room instead of all the rooms. Prioritize your day.
Number four is the getaway. Sometimes we have more pain just because we're in a stressful situation. So the office worker: step away from your desk and go get a drink. The busy homemaker: just go check the mail even though you know it's not there.
And number five, we always talk about red dot exercises. I'm a physical therapist, so patients have exercises. I always give them two or three that I put a big red dot on and say, "On a bad day, you only do those two or three, not all the other ones." Because if you do too many, you're going to say you won't do it, but you cannot do nothing.
What we typically find is that on a bad day, patients work through these five steps, find ways to get through, and go, "Wow, I'm better." Or they come back and say, "I had a bad day." And I say, "How are you doing today?" "I'm okay today." See? You can do this. You can help yourself. That has always been powerful for me to teach people — coping strategies for a bad day, because when you have a bad day, you need to know what to do about it.

[1:04:54] Dr. Linda Bluestein: Definitely. And when you said that, it reminded me of one of my favorite physical therapists, Brad Bielke — I have to give him a shout out. I don't know that he's listening, but if he is, he helped me out a lot. After I had major spine surgery — I had a Tarlov cyst and had surgery for that — I remember going into one of the sessions. He was so great at helping me learn that the nervous system has to feel safe, and starting to use my hamstrings again in a super gentle way. No weights, just laying on my belly and literally moving my leg just a little bit — a small range of motion — just reteaching my brain that this is safe and it's okay.
[1:05:40] I came back to one of the sessions and told him, "Oh, I'm sorry I didn't do my exercises this past week." I was in that place of not quite my best — not in a terrible amount of fear, but some. And he said, "Well, how do you feel?" And I said, "Oh, actually I feel pretty good." And he goes, "That's great." He reframed what I was thinking. I was coming at it from a negative place, but he said, "I want you to do your exercises, obviously, but you didn't, and nothing terrible happened because you didn't do them for a few days." So I think sometimes that reframing is really helpful.

[1:06:18] Adriaan Louw, DPT: Oh, absolutely.

[1:06:21] Dr. Linda Bluestein: Before we go, first of all, I want to thank you so much for chatting with me today. Like I said, this has been on my bucket list for a long time.

[1:06:25] Adriaan Louw, DPT: Like I said, I think you need a different bucket list, but thank you for having me. I appreciate it. Thank you so much. Yes.

[1:06:35] Dr. Linda Bluestein: Yes, absolutely. So before we go, can you let us know where we can find you so that people can learn more about your amazing work?

[1:06:36] Adriaan Louw, DPT: Yeah, I work full-time at Evidence in Motion, which is an educational organization for healthcare providers. And then for patients, there's a really cool little website — it's free. It's whyyouhurt.com with a double Y, so whyyouhurt.com. There are a lot of videos on there where I actually teach people about pain so they can learn a little bit more about it. And if they're looking for providers that we have trained, there is an interactive map where they can click and find somebody in their state that we've trained accordingly, and maybe seek out care more locally.

[1:07:16] Dr. Linda Bluestein: Fantastic. Well, thank you so much, Dr. Louw, for coming on the Bendy Bodies Podcast and sharing your vast knowledge. Of course, we just hit the tip of the iceberg, but I think this is really valuable information that will be helpful for a lot of people.

[1:07:29] Adriaan Louw, DPT: Well, thank you so much for having me, and best wishes to all your listeners. I hope they have a good journey going forward.

[1:07:33] Dr. Linda Bluestein: I really enjoyed that conversation with Dr. Louw and hope that you found it really, really helpful. I do feel like the biopsychosocial model of pain is so often misunderstood, and we need to consider all of the factors, and I thought he really did a great job of explaining that. I want to thank you for listening to this week's episode of the Bendy Bodies with the Hypermobility MD Podcast. You can help us spread the word about connective tissue disorders like EDS and HSD by leaving a review and sharing the podcast. This helps raise awareness about these complex conditions. If you would like to meet with me one-on-one, please check out the available options on the services page of my website at hypermobilitymd.com. You can also find me, Dr. Linda Bluestein, on Instagram, Facebook, TikTok, Twitter, or LinkedIn at hypermobilitymd. You can find Human Content, our producing team, at human_content_pods on TikTok and Instagram. You can find full video episodes up every week on YouTube at Bendy Bodies Podcast. To learn about the Bendy Bodies Program disclaimer and ethics policy, submission verification and licensing terms, and HIPAA release terms, or to reach out with any questions, please visit bendybodiespodcast.com. Bendy Bodies Podcast is a Human Content production. Thank you for being a part of our community, and we'll catch you next time on the Bendy Bodies Podcast.