Pain Care Redefined: Non-Drug Therapies for Pain Relief with Heather Tick, MD

[01:47] Dr. Linda Bluestein: Welcome back, every bendy body. This is the Bendy Bodies Podcast, and I'm your host and founder, Dr. Linda Bluestein, the Hypermobility MD. This is going to be a great episode, so be sure to stick around until the very end so you don't miss any of our special hypermobility hacks. As always, this information is for educational purposes only and is not a substitute for personalized medical advice. Dr. Tick, I have been so, so looking forward to this conversation. Hello and welcome to Bendy Bodies.

[02:16] Heather Tick, MD: Thank you so much, Linda. I've been anticipating this because I really admire your work. It's difficult to get information on the conditions that you cover and the focus on connective tissue. So this is very important work you do.

[02:38] Dr. Linda Bluestein: Oh, thank you so much. And I have to say, I'm going to hold this up immediately to show this book of yours that I read when I was on vacation. The entire thing is full of highlights, bookmarks, and it's just such a fantastic book. Of course, we're going to dig into this more later, but if someone has not purchased this book, by the end of this conversation, I'm sure they're going to, because it is so, so valuable.

[03:10] Heather Tick, MD: Thank you.

[03:12] Dr. Linda Bluestein: Yes, of course. So let's start out by talking about what integrative medicine is, because I feel like that's a topic that is unfamiliar to a lot of people. If you could explain to us what that is and how it differs from traditional approaches.

[03:28] Heather Tick, MD: A lot of the language that we use here is problematic. We use the word "traditional" for Aboriginal medicines as well, but we also use it for the way in which Western medicine has become very high-tech and sophisticated. So I will use the word "conventional" for that one — conventional medicine.
[03:54] Integrative medicine is not just adding things to the menu that conventional medicine uses, which is what a lot of people think. It's actually a different approach. It's a different focus. It's looking at how do we achieve health? How do we help people achieve health? There have been times when I will be talking to a patient and I'll say, "How can we help you be healthier?" And they said, "How can I be healthy if I have pain?" I said, "Well, actually so much of you is healthy. You're just focused on the pain. Let's focus on the health." Because actually when you make people healthier, when you help them make themselves healthier, all conditions get better — whether it's their blood pressure or their skin conditions or their gastrointestinal stuff. Their liver disease can sometimes get better. Their kidney disease can sometimes get better when they are looking after the basic fundamentals of health, and their pain gets better. Our brain in general focuses most on what we practice, and if we're constantly thinking about pain, we actually devote a larger part of our brain to that. So in integrative medicine, what we try to do is change the conversation and find out what are the things that people eat, drink, think, feel, and do, because those things contribute more to health than anything that medicine can do when we're dealing with chronic conditions.
[05:39] Conventional medicine has been brilliant. It's siloed medicine, it's highly specialized, and what that has led to is people who are experts focused on very narrow parts of the body. They've made brilliant advances. I don't want to minimize how brilliant modern medicine has been, especially in terms of acute illnesses, but sometimes with chronic illnesses as well. But there's a difficulty when this expertise is in distinct categories and those categories aren't communicating with each other regularly. You know, the joke is, "I only treat the left shoulder" — taking it to the extreme. But sometimes it almost feels like it is that extreme. So integrative medicine tries to integrate all of that.
[06:34] Yes, it does try to integrate other strategies as well — things that have been well researched, like acupuncture, like manual therapies. Music therapy. Nutritional therapy has a ton of research showing benefit. So we try to include a lot of other things and be open-minded.
We talk about evidence-based medicine, and included under that heading is evidence-informed medicine. Because there are certain things that have money devoted to them which have the potential to make great profits for companies. And even though some of the funding comes through government, there's still a focus on pharmaceuticals and high-tech procedures. Those have had brilliant outcomes, but we've left behind a lot of strategies, techniques, and practices that don't have sufficient research on them. They have some research that indicates benefit, they're very low risk, and so they're worth trying. We call that evidence-informed — when there is some research on it, but it is not definitive because there was no entity willing to pay millions of dollars to do a very large-scale standard type research project. So that's where we come from.

[08:22] Dr. Linda Bluestein: I love that. Those are really great points of clarification and such an important strategy. And in terms of pain management, I find that some people interpret that as the treatment of persistent pain with opioids, but you and I know that pain management can and should include so much more. So how would you define pain management?

[08:43] Heather Tick, MD: Well, to start with, I would get rid of the word "management."

[08:48] Dr. Linda Bluestein: Okay.

[08:49] Heather Tick, MD: I would use "care" instead. "Management" has come to mean how do we deal with a chronic disease. We manage diabetes, we manage high blood pressure, and with pain, it has led us down this pathway of: well, we start you on a high blood pressure pill and you have to stay on it forever, because we don't see any way that it can get better without staying on the pills. And when you do that with pain, of course, it does exactly what you mentioned — it led us down this path of opioids. So that's the first word I want to get rid of in that sense.
[09:30] The second word I also want to get rid of is "pain." I really encourage people to break down what it is they're feeling. This is a strategy I developed because of things that I was feeling in my own body. "Pain" is an alarming word. And when you use it over and over and over again, we devote more time to those pathways, to that focus — pain starts to take up a bigger place in our brain, and it's alarming. It communicates with all the alarm centers, and we know what that does. That gives people more distress, which gives you more discomfort. So I prefer other words.
[10:22] I think that if people think about what it is they're feeling and where — "I have cramps in my legs, I have discomfort in this joint, I have a stabbing feeling here" — if you break it down that way, I think it's easier to tolerate, because you have a certain understanding of what it feels like and therefore what the goal is: "I'd like to get rid of that stabbing feeling. Can I move differently so that gets better? Can I massage something? Can I press on something? Can I do something with my physical body that's going to alter this physical feeling?" — rather than this amorphous thing we call pain.

[11:17] Dr. Linda Bluestein: The title of your book is Holistic Pain Relief — and I held it up, but I should hold it up again. So that is very, very interesting. Can you tell us who you think would most benefit from this kind of strategy that we're going to talk about today?

[11:34] Heather Tick, MD: I've had somebody who was a double PhD in immunology and biochemistry, a nutrition expert, say, "This isn't a pain book, this is a nutrition book." Partly that is true — it has probably a lot more holistic nutrition covered in it than many nutrition books. So I mean, anybody who has discomfort in their body, anybody who has pain, anybody who knows someone who has pain, and anybody who wants to learn how to prevent it — because that's a lot of what I talk about too. How do we keep from sliding down that slope?

[12:21] Dr. Linda Bluestein: Sure, that's great. I have an acronym that I use for developing comprehensive treatment plans for my patients that I published about recently in the CME journal Topics in Pain Management, and it's MENSPMMS — it stands for movement, education, nutrition, sleep, psychosocial modalities, medications, and supplements. It helps me remember the various different aspects of the plan that I want to create for my patients. You cover so many different aspects in your book. Of course, I will link that book in the show notes so people can access it for themselves. I would encourage people who don't have the ability to purchase the book — which I don't think is that expensive — to request it from their library, because all libraries should have this book.
[13:13] We're going to dive into a few of the letters of that acronym, but let's start with some of the others that I think we haven't covered as much. First I want to talk about education. You and I belong to a group where we talk about pain and how to help people better improve their quality of life. I've heard you talk a lot about pain neuroscience. What do you think patients should hear about pain neuroscience? Why is it important for them to understand how pain processing works? How do you think that can benefit them?

[13:48] Heather Tick, MD: That's a great question. It is really important for people to understand, number one, that all pain is experienced through the brain. If you don't have a connection between body and brain, you can't feel anything that's going on in your body. Pain is an interpretation that the brain makes of all the different sensations that are coming up from the body. So that's the first thing.
[14:20] What that means is that sometimes it's hard for us to figure out exactly what's going on in the body — sometimes because of the entire web of connective tissue that permeates all of our tissues, that we're only now beginning to understand and that most of conventional medicine really doesn't have a good grasp on. But people like you do, and people who are studying connective tissue and fascia extensively are really making great discoveries. The brain takes all that information, it processes it. It's a bit of an alarm signal for the brain, and so the brain really starts to trigger the alarm systems that we have, and that then modifies our experience. So anything that's alarming is somewhat uncomfortable for us, and that augments the experience of pain.
[15:22] This leads us to a very, very effective strategy to deal with this, which is pain psychology. Pain psychology has done a tremendous amount of work in coming up with strategies that help to turn around that alarm signaling system, and that dramatically modifies the experience of pain. It doesn't mean that there's nothing going on in your body, but there might be things going on in your body that we have trouble figuring out. So while we're learning and trying to explore and figure out what's going on in the body, let's take advantage of pain psychology, which has a tremendous amount to offer. And again, it doesn't mean this is a psychological problem. It is a neurological, physiological problem that involves the same biochemicals, the same naturally occurring neurotransmitters and inflammatory markers that make up all of our reactions. As I'm fond of saying, it's all the same ingredients and the same soup, and it's throughout our brain and body. Whatever we can do to modify the parts that are increasing the alarmingness of our experience, the better.
[16:57] Second, I think it's really important to understand that there are two major classes of pain that we distinguish: acute pain and chronic pain. But really, timeline isn't the difference between those two — it's mechanism. Acute pain refers to pain where we can identify an origin. You have a broken leg, that's why you have pain. Everybody understands that, you relax because you know what it is, and so the experience of it is different than if it's something that's ongoing that nobody can put a name to, that nobody can figure out. And when we're dealing with soft tissues, that's very often been the case — nobody can figure out what's really going on because they're not trained to figure out what's going on in soft tissues. And so far, our technology has not been good at detecting soft tissue abnormalities, or movement abnormalities.
[18:12] Movement plays a huge role, and in the medical profession, it's really at a very rudimentary stage in terms of how conventional medicine looks at movement. Chronic pain — there are some mechanisms within the brain that begin a process called sensitization, which means it's like turning up the volume on certain signals in the brain, and a lot of it does involve the stress system. That's part of what happens when we get chronic pain. But pain that lasts a long time can also be, especially with soft tissues and movement, ongoing acute pain — what we call nociceptive pain, meaning something that's irritating, that's bothering us, like a pin sticking in you. It can keep happening even though each episode is maybe short-term. So that does seem like chronic pain, but it isn't — it's ongoing acute pain. That's an important distinction that can sometimes be hard to make.
[19:37] And then I think we have to realize that there's a reason we get chronic pain. There's a reason our system becomes sensitized, and it's because it's built into our genetics. Evolutionary biologists have recognized this — it's a relatively recent discovery, within the last 10 to 15 years — that this is not a maladaptation. This is an adaptation. Chronic pain keeps us safe. It doesn't mean we want to keep it, it doesn't mean we like it any better, but we have to get away from the idea that we need to obliterate pain, which is the whole culture of opioids, of painkillers. We use warring imagery — war on cancer, war on drugs, war on pain. That adversarial language just raises the alarm system even more. I don't think it's productive, and certainly in opioid land, it really has not been a helpful thing.

[20:55] Dr. Linda Bluestein: That makes a lot of sense. I'm thinking back to when I was at my worst, around 2009 and 2010. Starting from then until about 2014 or so, when I came across a video by Dr. Dan Klawe, one of our colleagues, about central sensitization. I was watching this video, and I'm an anesthesiologist, so I had learned some pain management and done some pain medicine in my residency. But it was still so shocking and so informative watching this. I thought, this is what's happened to my body. The light bulbs went off because at that time I was suffering a lot — not just having a lot of pain, I was suffering. A lot of that was the catastrophization and things like that that I was doing to myself. So it was very helpful to me to understand pain psychology. I've had on the podcast Dr. Beth Darnell, who I'm sure you know from Stanford. You know, it's great to understand those things, and I think having that kind of information is very empowering to people because there are some things that we actually can control that we don't necessarily even need a physician to help us with. We can get that information and start working on those things ourselves.

[21:00] Heather Tick, MD: Absolutely.

[22:24] Dr. Linda Bluestein: Okay, so let's talk about nutrition, because your book is really rich with lots and lots of information about nutrition. In fact, on your website you have information about nutrition as well as some really great recipes, many of which I have tried out. Why is nutrition so important for those with persistent pain?

[22:43] Heather Tick, MD: When we're dealing with computers, we all know the term: garbage in, garbage out. When you look at the standard American diet, the food that is readily available, the food that is subsidized by our government, it is highly processed. It has very little of its native nutrition left in it, and it is usually full of salt, sugar, and the wrong kind of fat. The acronym is Standard American Diet — called SAD. And it is very sad.
[23:26] There are things that get sold as food in our country that would not be allowed in many other countries of the world. It's just illegal to use some of the additives and chemicals. We have thousands of substances that are added to our processed foods which have never been tested for safety.

[23:52] Dr. Linda Bluestein: Say that again — that's really important.

[23:52] Heather Tick, MD: We have thousands of food additives added to our processed foods which have never been tested for safety. So it's basically an unregulated area. And that's not counting the tens of thousands of chemicals that have been released in our environment. When I wrote the book, I think it was 70,000 or 80,000. It now has to be hundreds of thousands — maybe 150,000. And this is only things that are known — pesticides, all sorts of chemicals, our PFOSs and our plastics and all our petroleum products. These are things that become ubiquitous. They spread everywhere. There's DDT in penguins in the Antarctic, even though DDT was banned a long time ago and was never used in the Arctic. Our children are born with pesticides in them, with toxics in them.
[25:29] Now, that all sounds very dire, but we can ameliorate it. We can modify our exposures by reading labels and making sure we know what real food is. Go into a big supermarket — there are probably 20,000 to 30,000 different items in it. Most of those things are not food. The things that are food — and supermarkets may be getting smart to this and changing their arrangement — are usually around the outside of the store, not the center. You want the fruits and vegetables, you want the protein foods if you're eating animal protein, and then if you're going to be eating baked goods, things that are baked and not made in mass-processed factories. You want as much of your food to come from as close to the farm as possible and as far away from the factory as possible.

[26:54] Dr. Linda Bluestein: That makes a lot of sense. I've definitely heard that before about shopping in the periphery. At one point I thought I had heard about somebody or some organization trying to develop a rating system, 0 to 100 — soda would get a 0, and something like wild salmon would get somewhere in the 90s. That got abandoned, which I think would be really helpful for people, because it's hard to take the time to read all those labels. I think that would be a helpful thing if it ever did happen.

[27:41] Heather Tick, MD: It would be helpful. You can now still put the word "healthy" on your processed food without having even one food ingredient in it. The FDA has a proposal to require at least one ingredient in the processed food that sounds like food listed on the label. The food industry is fighting against that.

[28:16] Dr. Linda Bluestein: So are you saying that if they were to add this one ingredient, they could call the entire food "healthy," and this is something they're fighting against because it isn't even a regulation now?

[28:29] Heather Tick, MD: That's right. Think of the big box cereals. Most of them have a higher glycemic index than sugar does, meaning they turn into sugar in your body faster than sugar itself. Part of it is because they're so overprocessed that the grains become like sugar. So they don't have to list sugar, but they're still acting like sugar. And they get to say "this is part of a healthy breakfast." They just never tell you that the part that's healthy is what you add — whether it's your milk or your oat milk or your fruit. That's what's healthy, not the part that comes from the box, for most of the big company cereal brands.

[29:20] Dr. Linda Bluestein: And that's an aisle where you can just stand there and see — obviously they're marketing to children. And of course they list the separate sources of sugar separately, so they can list them lower down or make it look like there's less sugar. So that's all very problematic.

[29:48] Heather Tick, MD: Yeah, it is.

[29:50] Dr. Linda Bluestein: So we know that no two people are identical when it comes to nutrition, but there are some general guidelines — and you've already mentioned some of them — for reducing chronic pain and inflammation. Another thing that I know you and I have chatted about is mast cell activation. Are there other general guidelines you would like to share?

[30:22] Heather Tick, MD: Mast cell activation is a very elusive condition. It's probably playing a role in many of the chronic conditions that we're puzzled over, many of the conditions that are part of the sensitization syndromes.
[30:53] The original recognition that there was a clustering of conditions that all go together — fibromyalgia, interstitial cystitis, migraine, irritable bowel, and many others — was a paper by Mohammed Yunus, and that paper was kind of grabbed by people who were treating these chronic conditions. They said, "It's just a sensitization syndrome, there are no causes, we can think of them in a very different way and just send them to pain psychology because that's really where they seem to be getting most help anyway." And it was true, at that point we were getting most help there. That was really useful, but there was a sense of "there is no cause" that left behind curiosity.
[32:03] Curiosity is one of the things that's hardest to hold on to as we practice medicine in modern times, but it is one of the most crucial things we need to have as part of our practice. Even if you look at Yunus's paper, he says we don't know what the causes of these are, but they very well may exist — keep an open mind. People didn't pay attention to that, and they really closed their minds for a long time, until we've had some advances in genetics and in understanding connective tissue and the connection between our connective tissues and mast cells, and other aspects that are pro-inflammatory. And anything that's pro-inflammatory is sensitizing to our body and our brain.
[33:08] There's no way to have inflammation isolated in our body. If there is inflammation anywhere, it can reflect as inflammation everywhere. It doesn't mean that if you have a sore finger with a sliver and an infection that it is literally everywhere, but it goes to your brain and your brain sends out alarm signals and develops inflammation in an area reflecting that finger in the brain. And that then has the ability to sensitize the system. Some people are more prone to sensitization than others. Mast cells — I'm still in my infancy in terms of learning the extent of their impact, but it's very interesting medicine and it really does pique my curiosity.

[34:12] Dr. Linda Bluestein: I learned a lot when I was asked to give a presentation on the role of mast cells in pain at a mast cell activation syndrome conference. At first I said, "I don't think I know enough about that topic." They said, "Well, you're the only pain doctor coming to the conference, so we would like you to give this talk." I learned so much in the process of preparing for that talk and came across a fascinating paper that I'll link in the show notes called "Mast Cells as the Gatekeeper of Pain." I did not realize before I started reading all of these articles how heavily involved mast cells were in both peripheral and central sensitization. It's really fascinating. And I love what you said about curiosity, because I think that's what really makes us good physicians — when we keep that open mind and keep curious about things and are constantly learning.

[35:10] Heather Tick, MD: We're used to categorizing the things and the people that we see. We have a checklist, it's an algorithm, we go through the algorithm and say, "We've reached enough items that got checked off, so this is what they have." And that's our diagnosis. A diagnosis is a concept — like the word "tree." If I say the word "tree" to you, you have a vague idea of what I might mean, but you don't really know what I'm thinking. Is it an oak? Is it a bonsai? Is it a family tree? And it's the same with our patients.
[35:59] Instead of ignoring the items outside of the algorithm, we need to pay attention to them, especially in chronic disease. In acute disease, if you come into the emergency room with chest pain, they have to use an algorithm — is this a heart attack or heartburn? They have to know immediately, they have to treat immediately. That's really important. But in chronic disease, we learn so much if we look at the outlier points, and that's really what leads to curiosity and new discoveries in medicine.

[36:39] Dr. Linda Bluestein: That's especially important for people who have things that are considered rare, like the connective tissue disorders — whether it be the phenotype for hypermobile EDS, which we know we cannot do genetic testing for yet, but someday we probably will. It's especially important for people who are experiencing a variety of symptoms throughout the body that are seemingly unrelated, but actually can be.

[37:14] Heather Tick, MD: Yeah. And often in medicine we name things for the phenomenon. We'll say, "That's dermatitis," which just means inflammation of the skin. You haven't told me anything about the cause. There are so many things in dermatology that just get called a dermatitis. They write it off and say, "Here's an anti-inflammatory. Take that. If the topical anti-inflammatory doesn't work, maybe we'll give you one by mouth." They're not even digging deeper because they're siloed in the skin — they're not looking at other things that might be impacting the skin or the inflammatory system that could give them more information.
[38:17] I'd hate to pick on dermatologists specifically — we do this in all sorts of specialties. But resting easy once you make that generalized diagnosis, saying "It's dermatitis, I don't have to think about that anymore" — well, it's probably not going to kill the person, but there might be something else brewing there that is being missed, even if it's not your area of expertise.

[38:43] Dr. Linda Bluestein: Okay. Well, let's move on to modalities. I think it would be great for people to hear your perspective on some of the different modalities that you talk about in your book and that you probably apply with your patients. Why do you think it's important for patients to consider trying some of these different modalities?
[39:05] When I'm working with patients, I often ask them to give things another try because — speaking of checklists — they'll say, "I tried all of these things, nothing worked," and they're kind of ready to give up. Sometimes I say, "Well, let's try some of these things again." Sometimes they weren't done in the right sequence, or you had different expectations than what the modalities could deliver. And if you get 10% relief from this and 10% relief from that, it may actually add up. Can we talk about some of those modalities?

[39:41] Heather Tick, MD: Sure. There is a paper out there on non-pharmacologic strategies for pain care that was published a few years ago — it has evidence for some of the things I speak about, if anyone listening wants to see the research.
[40:02] Let's start with acupuncture because it is an ancient practice. It has such abundant, very sound research literature behind it showing that it is effective, that it is safe, and that it is very acceptable to patients. It's also a very holistic treatment — it affects the whole body in part because it affects the connective tissue. You're putting needles into your connective tissue and stimulating them there.
[40:49] In the pain studies — the chronic pain study done in England, which was a vast study with an individual meta-analysis on many thousands of people — what it showed is that there was excellent pain relief after a course of acupuncture. That varies depending on condition: 6 to 12 sessions minimum, sometimes 12 or more, and sometimes ongoing maintenance. But in this study, there was no ongoing maintenance, and a year later, a very significant portion of the patients were still in a better state. There is a durability to acupuncture that does not happen with a dose of any kind of analgesic — that a year later you're still going to have improvement from a chronic condition.
[41:59] The risk of serious adverse events is extraordinarily rare. Whereas when you look at conventional hospital medicine, especially in the U.S., we have data going back over 50 years showing that conventional medicine is the third leading cause of death in North America. Want to hear that one again? Conventional hospital medicine — with its drugs, with its procedures — is the third leading cause of death in North America. Nobody went to medical school for that reason. And yet that is where we have found ourselves for more than 50 years. So we should be looking at things that are safer, that also have extremely good track records for improvement and much better track records for safety.
[43:08] There was one article written by someone who took on the role of what you might call a quackbuster, basically calling all integrative doctors and acupuncturists quacks. He said in Europe there had been approximately 40 to 50 deaths from acupuncture — he gave no context. So I went and looked up these stats for all of Europe. I think it was actually fewer, like 26 deaths. And when I went and looked them up, it was over 50 years. He didn't state that.

[43:55] Dr. Linda Bluestein: Right, right.

[44:01] Heather Tick, MD: Acupuncture can be excellent. Acupressure can also be very good. It's all based on the science of traditional Chinese medicine or traditional oriental medicine. There are different schools — from Japan to Korea to China to other eastern forms of medicine — with a lot of overlap between them. Acupressure can also work for people who are needle-phobic. You can use laser stimulation of points or pressure on points, so there are different strategies.
Acupuncture has also had some excellent results in acute pain and has shown to be more effective than opioids in acute pain. There's an ongoing multi-center study of acupuncture in acute pain in the emergency room. It doesn't mean that opioids don't have a place — they definitely do — but this study was very interesting. Both in acute and chronic pain, acupuncture can delay or eliminate the need for opioids.

[45:22] Dr. Linda Bluestein: Oh, I was curious — did they try to double-blind that in some way, like do sham acupuncture with the opioids, so that people wouldn't know if they were getting acupuncture or not?

[45:38] Heather Tick, MD: In the emergency room setting I think they did not do sham — they did usual care. There's also a very sticky problem with sham acupuncture, because anything that's going to touch the skin is going to stimulate the connective tissue. So when you're using sham acupuncture as a control, you are underestimating the effects and benefits of acupuncture.
[46:12] There's an article written by — I think Myung Soo Lee is the lead, it's his group — and it involved some of the people from Cochrane as well, showing that if you use sham acupuncture, no matter which type you use — whether you needle a different part of the body or use a needle that doesn't penetrate the skin — you are still having an effect. So there is no acceptable sham at this point for blinding acupuncture.

Dr. Linda Bluestein: Okay.

[46:43] Heather Tick, MD: So let's move on to manual therapies — things like massage, spinal adjustment and manipulation, deep trigger point work. Those things can be extremely helpful, and I do recommend those strategies. There is some evidence on it, but again, it's a very difficult area to get funding for a large study. There are small studies that show good benefit.
[47:34] There are studies on chiropractic that have really settled the issue of chiropractic manipulation of the neck being a risk for stroke. There was a large study done in Canada about 20 years ago that looked at neck pain treatments in chiropractic offices and in family doctor offices, and the subsequent stroke rate was higher in the family doctor offices. So that was taken to mean that chiropractic certainly didn't increase the risk. That doesn't mean chiropractic should be undertaken without really thoughtful consideration of the status of a person's spine. Personally, I tend to like the osteopathic manipulations better because they are not high-velocity, and I think they are much gentler. The principle of just trying to move bones where they belong without paying attention to and preparing the soft tissues is misguided, and I think most of the chiropractic colleges have moved away from that strategy.

[49:13] Dr. Linda Bluestein: Interesting.

[49:14] Heather Tick, MD: They recognize they have to deal with soft tissue.

[49:19] Dr. Linda Bluestein: Well, that's good, because those high-velocity chiropractic manipulations, especially in the neck, do make me nervous with patients with connective tissue disorders.

[49:28] Heather Tick, MD: Yeah, they should. Those are people who would be at higher risk, and also those who may have severe osteoarthritic issues or certain anatomical anomalies that can put you at higher risk.
[49:52] Working with someone who understands movement, I have found to be a quantum leap from working with people who don't. Some of the physical therapy schools do teach more about movement — they all teach some, but not very much, unless physical therapists go out afterwards and seek that training. WashU in St. Louis was run by Shirley Sahrmann for a long, long time. She developed systems of describing movement, normalizing movement, and recognizing abnormal movement.
[50:47] The whole principle is that our body is connected — if you have an issue with how you plant your foot, it's going to affect everything all the way up to your neck. It's going to affect the ankle, the knee. It's going to change the way your hips need to align. That's going to change the way your pelvis needs to fluctuate — because the pelvis does move. It's going to change the alignment of your spine all the way up to your neck. Recognizing that requires training. Many people who are treating bodies don't have that training. You don't learn that in physical medicine rehab residencies and fellowships unless you are really seeking it out. Some osteopaths really do a good job of that, and there are some physical therapists out there who are absolutely amazing.

[51:59] Dr. Linda Bluestein: Do you have any tips for people who just heard that and are thinking, "That's what I want — I want to find somebody who can really assess my movement"? I totally agree, especially for people with connective tissue disorders, because it's not one part of the body, it's the entire body. Finding that person, though, feels like it could be really challenging.

[52:26] Heather Tick, MD: It really is. When I was in Seattle, I searched for about 4 years before I found somebody. What I would suggest — and I don't know if you have the ability to do this, but we could actually both do this — is have on our websites a list of people who are suggested to us by our patients who have found somebody who is really good at assessing movement. I could certainly give you a couple of recommendations to put on that. I would love that.
There's something almost gifted about these practitioners — the way in which they see three-dimensionality, watch you move, and know exactly where on your body to go to find the issue. To me it's still a little bit like magic. I can do some assessment of movement myself, but it's not top-notch compared to some of the people I've consulted.
[53:48] Speaking to whatever therapist you're considering and asking, "What's your training in movement?" is a good start. They should watch you move. They should ask you what difficulties you're having. Are you feeling stuck somewhere? They should be focused on movement rather than just structure. So many are focused on structure because it's so much easier.

[54:17] Dr. Linda Bluestein: Yeah. And this makes me think of one of my earliest patients, who also happened to work for me at that time and was going to physical therapy. We weren't making a whole lot of progress with her neck pain. She came in one day with a massive backpack over one shoulder, and I said, "That could be part of the problem." Honestly, when she changed that — I said, "Figure out how you can carry less, carry a crossbody bag or a wheeled suitcase" — that really made a big difference. So I think our movement is so impacted by some of the habits we develop that can contribute to suboptimal movement.

[55:02] Heather Tick, MD: Yeah.

[55:04] Dr. Linda Bluestein: Okay. What other modalities should we know about?

[55:07] Heather Tick, MD: Heat and cold are helpful. Epsom salt baths, I think, are brilliant. Just make sure you put enough Epsom salt in there — I put at least 2 cups in, and I add half to a full cup of baking soda because it gets absorbed much better into your body. Soak in there for a long time. That can be really helpful for your muscles. A lot of us are magnesium deficient.
[55:28] For movement practices — there's yoga, but if you've got a bendy body, you have to be careful because you can really stress your joints. Tai Chi, I've actually just started this year, and I am really impressed. I used to think of it as too slow, not getting there, not giving me the stretch I want. I had tried it a couple of times before but hadn't stuck with it. This time I decided I was going to stick with it because I was doing my yoga stretches, but I too have some hypermobility, and yoga can exacerbate that, can make it worse.
What I've found with Tai Chi is that the slow repetitions of movement — where you're told, "Don't ever go past 70% effort, and if it feels a little uncomfortable, just back off, but just keep doing it" — whether it's the rotation around the hips, the up and the down, so many different movements, they do a magical thing to your connective tissue.

[57:08] Dr. Linda Bluestein: Wow.

[57:09] Heather Tick, MD: I find that it speaks to my connective tissue in a way that — I think it's because it is so gentle and so repetitive that it convinces my brain that this is safe. They keep saying throughout it: "If this doesn't feel safe, don't do it. Don't go that far, or stop, or rest. Be kind to your body." That constant messaging, both through the movement and what you're hearing, really makes a huge difference.
I also have a bendy body but with tight areas of connective tissue, all of which are exacerbated by anything that sets off mast cells, as you well know. And it improves. I think mast cells have a major role to play in the stress response. When mast cells get triggered, that just makes your brain go, and that then in turn alarms everything else.

[58:25] Dr. Linda Bluestein: Yeah, definitely.

[58:28] Heather Tick, MD: Watching a mast cell diet — it's a difficult diet. But for me at one point it was life-changing. I can cheat a little bit now, thank goodness.

[58:44] Dr. Linda Bluestein: That's kind of how I am too. I had to be a lot stricter in the past, but now that I'm doing so much better, I can be a little more lax about it. What about things like shockwave or laser or ozone injection? Anything like that you think is helpful?

[59:01] Heather Tick, MD: I've had some experience with laser both personally and professionally, and laser can be extremely powerful. The problem with laser is that it's an uncontrolled industry. I mean, it's not totally uncontrolled — they have to get FDA approval — but a lot of lasers are developed by businesses as opposed to scientists. There are certain parameters of light that are more effective than others, so certain devices are better, and then they have better-trained practitioners. But there's a ton of them out there, so it's really hard to know how to judge them all because there's too much to police.
[59:49] There's one that was developed by two laser scientists — actually one laser scientist and one rocket scientist — who were married and working up in Canada. They developed a wonderful system. They do have them placed around the U.S. as well, and they train their people to use them. They were science-based, they collected data, and they resisted commercialization. I'm not sure what's going to happen in terms of the legacy of their work. It would be a shame if it died with them, because it's one of the systems that actually is useful.
[1:00:37] There's a lot of research that goes on in Europe and in Israel on laser — stimulating stem cells for spinal regeneration and for spinal cord injuries, for instance. The Italians have done something similar. I'm sure if they're developing lasers and looking at stem cells, there are other applications, but I haven't checked up on the literature recently to see where they're going with that.
[1:01:17] Ozone is interesting, but exactly which applications are useful is of concern. Injected into certain structures in combination with some of the regenerative therapies like prolotherapy and stem cells — that has some scientific mechanistic rationale and makes sense. But I don't know that it's ready for prime time in terms of the way it's being practiced right now. For the most part it's not going to hurt you, but you have to make sure that whoever is injecting you is trained in that science, knows their way around the body well. Any kind of needling, you need someone who understands anatomy and doesn't stick a needle into your lung when they're aiming at a particular muscle.
[1:02:52] Shockwave — they use it extensively in, well, obviously in kidney stones and things like that. They also use it in orthopedic medicine in horses. I know that's a funny reference, but they care about their horses — they're expensive, they want them to improve — and they use laser on horses too. They wouldn't do that consistently on an ongoing basis if it wasn't effective. So there must be something to it from an orthopedic standpoint. Again, it's not literature I'm totally up to date on, so I'll just quote my horses.

[1:03:47] Dr. Linda Bluestein: Okay. And I definitely want to make sure we talk about supplements and medications, because I'm sure a lot of people are very curious about that area.

Heather Tick, MD: Yeah.

[1:03:53] Dr. Linda Bluestein: Are there medications in particular that you think are overprescribed for chronic pain, and are there ones that are underutilized?

[1:04:03] Heather Tick, MD: Well, opioids are vastly overprescribed, and I don't think we need to say any more than that. If you want to look at the white paper from 2019, there's a reference to it on my website. It has a big introduction to why they're overused and what their risks are.
[1:04:28] In general, if we think back to our medical education, we learned a lot, a lot, a lot — and it's more now — in terms of what percentage of our education is devoted to starting drugs.

[1:04:48] Dr. Linda Bluestein: Hmm.

[1:04:50] Heather Tick, MD: Do you remember how you learned about stopping drugs, other than antibiotics?

[1:04:55] Dr. Linda Bluestein: Pretty much zero.

[1:04:56] Heather Tick, MD: Yeah, exactly. And so there's this fallacy that you can take a drug that has been studied scientifically in studies that go on for 3 months or 6 months and keep somebody on it forever. So you get things like proton pump inhibitors — sophisticated stomach remedies. They cause all sorts of damage. They cause malnutrition. They can cause fractures because you can't absorb your calcium. You lose your magnesium. You don't absorb your iron. And I haven't mentioned the word "microbiome" at all yet — it totally changes your microbiome. Because stomach acid is actually essential for life. That's why you get this up-regulation where the stomach says, "I have to try and make as much acid as I can to overcome this proton pump inhibitor." And then when you miss a dose, you get this ton of acid, and you think, "Oh, I really need the antacid." Well, no, you don't. You were just addicted to it. So those things get overprescribed, and I think they're a cause of pain.
[1:06:28] Antidepressants are a whole other topic. We talk about mechanisms — this one affects norepinephrine, this one affects serotonin, this one affects dopamine. It doesn't take into account that as soon as you alter one level of neurotransmitter in the brain, there's a huge cascade that goes on and we don't really know how to track that.
There's another wrinkle to this conversation, a relatively new discovery: our gut and our microbiome produce more neurotransmitters than our brain does, both in number and amount. We know we have a gut-brain — that's established science. But what does it mean when our gut produces 80% of our serotonin, not our brain? What are we changing? What are we doing? Gut and brain communicate instantaneously.
[1:07:57] I'm not saying there is no application for antidepressants. Short-term, for people in chronic pain, if they can get people to sleep, if they can modify some pain while those people are working with pain psychology and learning to modulate their own brain neurotransmitters, I think they have a use. But the idea that we can keep people on them forever, and the idea that they're easy to come off of, is another fallacy. So those things are just so much more complex than our prescribing practices reflect at this time.
[1:08:46] Now, I know something you're interested in is low-dose naltrexone.

[1:08:52] Dr. Linda Bluestein: Yes.

[1:08:53] Heather Tick, MD: Low-dose naltrexone is appealing because it's almost like a homeopathic — just a little nudge in a direction. For most people there are very few side effects, and they can get some benefit. Again, most people don't stay on it long-term because they don't find it helpful long-term. Some people do have adverse effects. For some people, it activates them and they can't sleep, even at this tiny little dose. It just goes to show you the impact of manipulating our brain chemicals — how significant that impact can be. Some people get depressed on low-dose naltrexone. I did. I tried it once and couldn't tolerate it for a week. I stopped it, tried it again, same thing. And I'm just not a depressed person — I don't do depression, fortunately.

[1:09:59] Dr. Linda Bluestein: That's really, really interesting. And you started at a low dose — a low, low dose and titrating?

[1:10:06] Heather Tick, MD: Yeah, a milligram.

[1:10:07] Dr. Linda Bluestein: Oh really? Wow.

[1:10:07] Heather Tick, MD: A low, low dose. And actually half, because I opened the capsule and took out half, so I really went low. And no, can't do it.

[1:10:21] Dr. Linda Bluestein: Interesting. Okay, what about supplements? Are there supplements that you think can be helpful?

[1:10:28] Heather Tick, MD: Well, first thing: if you can't afford good food, spend your money on as much good food as you can afford. About the only supplement that perhaps you should take if you're living in the Northwest would at that stage be vitamin D, because it's very inexpensive — you can get a big bottle at Costco or almost anywhere for a couple of dollars.
[1:10:57] So the first things I would discuss with my patients — I start them off slow and then kind of sneak up on them — are vitamin D, magnesium in a good form, and omega-3 fish oils. Those are the trio I use first. There's actually good evidence for each of them playing a role in pain. Magnesium has a huge role to play in connective tissue, but also in pain mechanisms — there are receptor sites for magnesium on some of our receptors that transmit pain.
[1:11:42] With magnesium, I recommend people take enough so that they have 1 to 2 easy-to-pass bowel movements per day. I like people to take at least 2,000 milligrams of a quality omega-3. Vitamin D3 is the best absorbed form, so that is the one that is best. If you're on certain insurances they'll only cover D2 — it's better than nothing, so take it. Omega-3s usually aren't covered. Magnesium, I've seen it covered occasionally.
The forms of magnesium you want: glycinate is a really good one, taurate is a really good one, mixed salts is a good one. Magnesium sulfate doesn't absorb through the gut, but it does absorb through the skin — that's what's in Epsom salt. You can also make your own lotion with magnesium sulfate just by dissolving Epsom salts into a lotion and spreading it on your skin. That would be a really inexpensive way of getting some magnesium into you. There are also lotions you can buy that are already prepared with magnesium in them. Citrate is probably the least expensive of the oral magnesiums that are still useful. If you buy the citrate that is a liquid in a conventional drugstore, however, you're going to be getting a prep for a colonoscopy. Don't do that — nothing's going to stay inside, including the magnesium. So you want that in pills or powders. There's a powder called Calm that's a nice bedtime lemon-flavored powder you can take, and that can be very helpful for sleep as well.
[1:13:41] If people have insurance coverage, I will check certain nutrients. I'll check their protein levels, their vitamin D level. Omega-3 testing is quite expensive. Magnesium testing is not actually useful — serum magnesium, like serum calcium, is carefully calibrated in the blood, and it's dangerous if it goes too far off. The body pulls it from other tissues. And RBC magnesium — it's hard to know if that's even representative of anything, because it's actually a cell without a nucleus, the only kind like that in the body.
[1:14:37] B vitamin supplementation can be extremely important. Some people don't convert regular B12 or B6 well to the active forms, so taking the active forms is useful, though it can get expensive. B vitamins are extremely important for mood, for pain, for a lot of the mechanisms in the body that help our mitochondria — our little energy factories inside all of our cells. Other things: if people can afford it, coenzyme Q10 is really important as well. There are other things that can help feed your mitochondria and keep them fit.

[1:15:39] Dr. Linda Bluestein: That's helpful, because a lot of people have problems with fatigue — that's a really common symptom. And I'm sure people are going to hear the part about mixing Epsom salts with lotion and want more details. Would you be willing to give us just a little bit more detail about how people can do that?

[1:15:58] Heather Tick, MD: You know what, I don't even know what the exact proportion should be. The Epsom salts have to dissolve into the lotion. I've found recipes online, but I don't remember any of them offhand. There is an MD, actually a specialist in magnesium, who has a lotion.

[1:16:27] Dr. Linda Bluestein: Okay. And I know Ancient Minerals is a brand that has some really nice products as well, if people want to buy something that's ready to go. I know for me, my migraines that had been resistant to so many different medications — I was on Topiramate for years and so many other things. I was in the hospital at one point with status migrainosus and on DHE and things like that. And finally I actually got relief with vitamins, B vitamins, and magnesium. Now I don't take anything for migraine.

[1:16:59] Heather Tick, MD: That's an awesome story. You mentioned anticonvulsants — they get used a lot in pain. My experience with them is that it's a law of diminishing returns, in that most people long-term find they lose their helpfulness. But they can be helpful for a period of time, and sometimes they're useful.

[1:17:27] Dr. Linda Bluestein: Okay. I want to shift gears and talk about interventional pain management, because patients have potentially been offered trigger point injections, epidural steroid injections — some of these are things that I used to do — radiofrequency ablation, implantable devices. When do you think those kinds of procedures are most helpful? And are there certain ones you have found to be less beneficial?

[1:17:59] Heather Tick, MD: They need strict criteria for any of those interventions, and those are published, but they are adhered to with variable consistency. There are many centers that will just say, "You have pain here, this is kind of what your x-ray looks like, I bet that's it — let's do this intervention." Anything that is irreversible, think about very carefully, because you can't go back.
[1:18:44] There have been studies that showed that injections of steroids into the spine are not any better than local anesthetic or even normal saline. It may just be that the fluid is getting rid of tiny connective tissue strands that are tethering nerves — that was a study from the University of Washington. I know some of my colleagues who do the steroid injections still like the steroids. But I've had diabetic patients whose diabetic control went out of control for months afterwards and was really difficult to get back. So I don't think it should be taken lightly. Steroids also erode tissues, both muscle and bone. What are the long-term consequences? How often can you possibly do this? It used to be said, in a muscle, no more than 2 injections per year. I know a lot of people who ignore those guidelines and do much more often. And frankly, as far as muscle is concerned, I am yet to be aware of a single study that shows there's a benefit to using injected steroids into muscle. Are you aware of one?

[1:20:21] Dr. Linda Bluestein: I'm not, but I hadn't really thought about that specifically. That's really interesting. No, I'm not aware of one.

[1:20:29] Heather Tick, MD: And when you inject into joints, you are priming the pump that's going to lead you to a joint replacement, because we know that cartilage is poisoned by steroid. Regenerative therapies are available, and if some of them are covered by your insurance, or if you can afford them, they are a much better idea.
[1:20:59] The idea that cartilage could regenerate is new. When we went to school, cartilage can't regenerate — when it's gone, it's gone. It was characterized as a chronic degenerative disease. I have some abnormal cartilage in my hips — that's all I'm willing to call it. And frankly, it is regenerating through proper movement therapies, because when you load cartilage in the proper way, it regenerates and it responds to that loading. It's slow, but I'm a patient person and I prefer it to having a hunk of metal.
[1:22:05] These interventions were developed for extreme cases — for spinal cord injuries, for very severely damaged vertebrae, either through cancers, through accidents, through congenital abnormalities. They came up with brilliant strategies that could help those people live more normal lives. That's absolutely where these procedures belong. But generalizing them simply because you know how to do them has, I think, gone too far.
[1:22:38] So there needs to be some place in the middle where, if something like that is proposed to you — before you get a radiofrequency ablation, which is killing a nerve that is going to regrow, and when it regrows it regrows more disorganized than it was before — you ask: "What are your criteria for doing this? What are the reasons you're thinking I might benefit from this? And what are the steps you're going to take?" Because there are steps they should be taking to make sure this is actually going to work — they need to do 2 trials of injections of local anesthetic into the target nerve, make sure they got the target, make sure that it worked for you, and make sure it worked long enough. Do it twice. If they have that, then you may say, "Okay, it's worth it." But ask them those questions.

[1:23:43] Dr. Linda Bluestein: Yeah, and that's definitely part of the problem. I have some young patients in their 20s, and they've had multi-level radiofrequency ablation, and that's exactly what happens — they feel like they keep having to go back every 6 months, then 4 months, then 3 months. I've even had young people who come in and they're doing a couple cervical levels, a couple thoracic, a couple lumbar. I'm thinking of one patient in particular, and I said, "Well, what are they treating? What's the working diagnosis?" — and she didn't know. I was surprised that they would keep doing those procedures.

[1:24:24] Heather Tick, MD: It's good when people trust their doctors. I'm not saying we shouldn't trust our doctors, but we have to ask questions and make sure the decisions they're thinking of making are applicable to us. I know a lot of people who get pushed into getting a procedure or a surgery because the doctor has time. "Next week we can do it right away, so let's book it." And I think that unless you were just in an accident and this is an acute problem and you're not going to be able to walk unless you get this nerve fixed right now, that's almost always a bad idea. You need to take your time. You need to ask questions. You need to read up on it. There's lots of information out there — what should be the criteria for doing X, Y, and Z procedure. It's out there.
[1:25:28] Personally, I always welcome when people come in and say, "I read on the internet about this, this, and this." I'll tell them, "Well, this one's valid and this one isn't, and here's why." Not everything — when it's not your area, you may not understand everything, and you may not be able to fish out the good information from the bad. But you should never be shamed for coming in with information from the internet. It shows interest and curiosity on your part about your own health.

[1:25:55] Dr. Linda Bluestein: I feel the same way. And you mentioned regenerative medicine. I know that this is an area, especially for people with EDS, if they have CCI or cranial cervical instability, where quite a few centers are now quite actively promoting their services for prolotherapy, PRP or platelet-rich plasma, cell-based injections, etc. What are your thoughts about regenerative medicine for people with persistent pain or tissue weakness?

[1:26:33] Heather Tick, MD: I think it can be helpful. It's one of those areas where we have to try and separate the science of medicine from the business of medicine, and when they get too enmeshed, there's a problem. I don't know exactly where we stand with that right now. I think we're learning a lot.
[1:27:06] The information we have about fascia and connective tissue is so new. Are you familiar with Carla Stecco? Her work is mind-blowing in terms of the extent of fascia. The reason we misunderstood connective tissue for so long — just associating it with those tight, tough bands of gristle on top of our muscles or attaching muscles to bones — is that we were doing our dissections on preserved corpses with a scalpel. We were cutting through 90% of the connective tissue without recognizing it was there.
[1:28:08] Carla Stecco, who is an orthopedic surgeon and an anatomist, does dissections on unpreserved bodies, and she has been able to explain so much more about what, where, and how extensive our connective tissue is. I think we'll also come up with ideas about how we regenerate it. It's tempting to think we could do that, and it would be very useful. What's been the experience of your patients? Have you seen results?

[1:28:52] Dr. Linda Bluestein: It's really mixed. And I love what you said about the business of medicine — some of these procedures require more training and are more risky, so they are really expensive, like $20,000 for some of these cervical procedures. I have selection bias, of course — people coming to see me are obviously not doing well, or else they wouldn't be making an appointment. So there are probably people out there who have had these procedures and are doing really well and never schedule an appointment with me. But I have had quite a few people who have had multiple procedures and are still struggling.
[1:29:36] I posted a question recently on social media to get feedback from people who weren't my patients, and there were some people who said they'd had prolotherapy or other procedures that were really life-changing.

[1:29:48] Heather Tick, MD: That's good. The early adopters pave the way for change, as long as the business side doesn't overwhelm it with bad data because they're going after business rather than results. Because if these procedures can ultimately get good literature behind them, they could get approved and perhaps be covered by insurance for people.

[1:30:21] Dr. Linda Bluestein: Right. And what you're saying about the business of medicine — it's the patient selection. If you're less discriminate and you do procedures on people who are not as appropriate, you're going to do better from a financial standpoint. I've seen patients get really upset if they went to a surgeon and were actually declined surgery. But that's actually a really good thing if they told you that you did not need surgery.
[1:30:46] And in the interest of time, I want to refer people to page 230 of your book — "Questions to Ask When Consulting a Surgeon." So I want everyone to look at page 230 and make sure to look at those questions if you're contemplating surgery. People who have EDS especially, or other connective tissue disorders, often have suboptimal surgical outcomes, and we need to be much more thoughtful before we undergo procedures, especially ones that are, as you said, not reversible.
[1:31:21] All right, so this has been so much information. We had some really great questions that were submitted online, and I want to just hit a couple of those if we could.
[1:31:35] The first one is: if a person has chronic pain and they experience either new symptoms or a flare, sometimes they have a hard time telling when they should seek medical attention and when they should try to use the tools they have at their own disposal. Do you have any tips for determining if something is a flare or an exacerbation of an existing problem versus a new problem?

[1:32:09] Heather Tick, MD: That's a tough one because there are just so many variables at play. Which part of the body is it, where is it — if it's crushing chest pain and it's similar to the type of pain you may have had in your chest that was myofascial before, still go get it checked out. And then go through the strategies that have worked for you before.
[1:32:39] You may want to have a certain timeline in mind, like: "I'm going to try my pain psychology exercises, and I'm going to go see my physical therapist," or "I haven't been doing Tai Chi lately, let me go do some of my exercises." There are supplements that can help — turmeric is a really good painkiller and a healthy one. It's also good for your brain and your heart at the same time. Omega-3s are also analgesic. Magnesium is also analgesic. Look at the stress in your life, make sure you're sleeping, analyze the context of it. And don't ignore it if there is some major sign, like crushing chest pain or suddenly not being able to lift your leg.

[1:33:41] Dr. Linda Bluestein: Okay, and we touched on this a little bit, but before we wrap up, I just want to see if you have any thoughts about the business of medicine — or not even strictly within medicine, but it's kind of become the Wild West. People can now go into a space and sign up for an IV infusion and pick from a menu like they were ordering at McDonald's. How can people best determine if someone has the knowledge, training, and expertise to help them with their particular problem? Do you have any tips for avoiding charlatans?

[1:34:35] Heather Tick, MD: With IV medicine, I really do think you want it prescribed by somebody you trust, whose references you have checked, or who has treated people that you know and care about who have done well with them. MDs are not trained to do nutritional intravenous unless they have gone for special training, and you want to know what that special training is. Naturopaths do have training in nutritional intravenous supplementation. But you really do want to investigate and check, because there are life-threatening mistakes that can be made through intravenous — it's not like popping a pill and saying, "That had a bad reaction, I better not take another one." You've just injected it into yourself. There's a far greater risk.
[1:35:52] I'm not saying it's never useful. It can be extremely useful, but unless you're trained yourself, you don't have the ability to make the decision of what you need. Some sort of testing needs to be done to assess your need, and then you need a really well-trained professional to administer it.

[1:36:19] Dr. Linda Bluestein: Okay, that's excellent. And Dr. Tick, can you share with us your favorite hypermobility hack?

[1:36:26] Heather Tick, MD: I think I spilled the beans early on. It's Tai Chi. I think it speaks to connective tissue in a way that utterly surprised me, and it reaches the deepest levels. It goes right down into your bones just because of the slow pace of it — the gentleness of it, but the repetition, the incessant repetition. If you're having an impatient day, as I did during my Tai Chi class last night, and you just can't get through it all, they let you — they say, "If you need to speed up, speed up. Do what your body needs right now." But for the most part, it's just this slow, rhythmic inner massage of your entire body. I think it has tremendous potential, and I'm really glad I found it.

[1:37:31] Dr. Linda Bluestein: "Inner massage of the entire body" — I love that. And where can people find you online?

[1:37:37] Heather Tick, MD: I'm at www.heathertickmd.com. I haven't posted to social media in a long time, but I probably will be getting back to that shortly.

[1:37:50] Dr. Linda Bluestein: Okay, great. Well, I'll definitely link that in the show notes. And I just want to remind everyone that you've been listening to Bendy Bodies with the Hypermobility MD podcast, and your guest today was Dr. Heather Tick, world-renowned pain medicine physician. Dr. Tick, I cannot tell you how grateful I am to you for taking so much time to chat with me today. Your wealth of knowledge is just incredible, and I'm so, so grateful to you for sharing this information with my listeners.

[1:38:20] Heather Tick, MD: Thank you so much for having me, Linda. I think the work you do is so, so important. There are so few people who know and understand what you know and take the time to pay attention to this very special, but not all that uncommon condition. I think we should all be grateful to you for doing this. Thank you.

[1:38:47] Dr. Linda Bluestein: Oh, thank you for the kind words. I really appreciate it. All right. We'll see y'all next time on the Bendy Bodies podcast.
[1:38:57] Thank you for listening to this week's episode of the Bendy Bodies with the Hypermobility MD podcast. Visit our new website at bendybodyspodcast.com where you can now view guest profiles and show notes with links to products and journal articles. Leave me a comment, sign up for updates, leave a review or a voicemail, and access the podcast on your favorite player, all directly from our website. You may hear your voicemail in a future episode where we answer your question or dive into your gracious feedback. Follow us on Instagram at bendy_bodies. We love seeing your posts and stories, so be a buddy and engage our community by using the hashtag BendyBuddy — that's hashtag B-E-N-D-Y-B-U-D-D-Y. You can also find me, Dr. Linda Bluestein, on Instagram, Facebook, Twitter, or LinkedIn at HypermobilityMD. Visit hypermobilitymd.com for information about medical services and one-on-one coaching. This podcast is for general informational purposes only and does not constitute the practice of medicine or other professional healthcare services, including the giving of medical advice. No doctor-patient relationship is formed. Do not disregard or delay obtaining medical advice for any medical condition you have. Opinions shared are that of the guest and do not necessarily represent the views of the host or any particular organization. Sponsorship of the podcast does not necessarily mean an endorsement. Thank you for being a part of our community, and we'll catch you next time on the Bendy Bodies Podcast.