138: Understanding the psychosocial role of your pain with Charlie Merrill

00:00:09 Chazmith: Welcome to Our Power Is Within Podcast. I'm your host, Chazmith, and my mission for this podcast is to inspire you to take your power back and to realize that you are the healer that you have been looking for all along. We are capable of healing in mind, in body, and in soul. 

00:00:29 Chazmith: Today's episode is brought to you by CFS School, founded by Jen Mann and Karden Rabin. If you are not familiar with Jen and Karden, please check out a recent episode 119 where I picked their brains, hear about their personal health and healing journeys, and discover how CFS School was birthed. CFS School is a nervous system healing program, including an integrative brain retraining approach, polyvagal therapeutics, trauma resolution techniques such as somatic experiencing tools, inner child work, and parts work. It's designed to help guide, support, and empower you on your self-healing journey to heal from a variety of mind-body disorders, some including CFS, fibromyalgia, POTS, autoimmune disorders, sensitivities, and more. What's really great is they have two wonderful options. There is a self-study option, perfect for people who want to go at their own pace, and there is also a live option. It is a live cohort program that is perfect for somebody who wants more guidance and ongoing live support. The coolest part is the next live cohorts begin at the end of June and signups are available now. The last cohorts did fill up quickly, so if you are interested, book your free discovery call today. There will be links in the show notes. 

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00:02:23 Chazmith: I had the most wonderful and fun chat with our guest today, Charlie Merrill. Charlie has a background as a clinician and physical therapist who is classically trained to approach the different parts of the body when someone was in pain. However, through his own research, studies, experience, and also learning beside and with Dr. Howard Schubiner, who was also a guest on one of the first episodes of the New Year, he has come to understand how there is an emotional aspect that plays a role in what appears as pure physical pain. Together, they actually co-host a program called Beyond Pain Education that is designed for other PTs and clinicians or even health fitness coaches who support people with physical pain to see beyond the physical body as the source of this pain. This program is going to kick off live in Boulder, Colorado this June 9th through 11th and then continue thereafter monthly on Zoom for six months. It's not too late to sign up if it sounds like something you are interested in. This might be one of those episodes that you want to grab a pen and paper and take some notes, so please enjoy. Charlie, thanks so much for being here with me today. 

00:03:40 Charlie: Thanks so much for hosting me. I'm excited to talk with you. 

00:03:43 Chazmith: Yeah, me too. I think the way we're going to start out this conversation is I know, just to give a little brief intro for everyone who's listening, that you have a really diverse background, originally classically trained as a physical therapist, correct? 

00:03:58 Charlie: Yeah. I like to say I spent the first half of my career strictly in the world of manual therapies and biomechanics and fixing bodies basically. 

00:04:07 Chazmith: Ah, okay. Yeah. And at some point during your life, obviously that shifted and you started to look at the pain that you were addressing within yourself and your clients through a completely different lens. And I'd love to start with actually just talking about that and where the transition came about and how it came about. 

00:04:28 Charlie: Sure. I spent a lot of time and money sort of getting trained in these manual therapy techniques, which was my passion early on. I was really excited because I had mentors that were so skilled at working on the body and helping people get relief that way. And it turns out if you can reduce fear and you sort of have an optimistic view of someone's prognosis, they do really well with body oriented techniques. I call them bottom up techniques, right? As good as I was at that, it became clear that I was missing something, right? And I started to realize that my secret sauce was my ability to connect with people, I call them therapeutic alliance skills, right? My connection skills. It turned out that was like a really important intervention in and of itself, right? My ability to listen alone was really important in my outcomes. And I'd had my own back pain in my 20s that I overcame that at the time was traditionally diagnosed as a herniated disc and maybe surgery and I spent time rehabbing it and doing core stability and all these things that my mentors at the time thought was the right thing to do. I read John Sarno's book at the time. And this is before I got into physical therapy school. And it was really helpful to me. Like it really gave me confidence and hope and it was an important part of my process. And so about 10 years into my career, I was like, I wonder if anybody's like taken that basic idea that our pain is connected to our emotions and developed it clinically, right? And connected with Howard Schubiner. And for me, this was like the next logical step. I could not go down this road. And at the same time, my colleagues were talking about pain neuroscience. And the neuroscience, the emergence of that, was really exciting, but coming from sort of a different direction. And so my work was about, can I synthesize these two things, right? The TMS, PPDA, John Sarno model with the emerging pain neuroscience to bring it into clinical practice. And so I've been working with Dr. Schubiner now for a number of years to make that happen.

00:06:39 Chazmith: That's awesome. You first saw him out then from a professional level, you weren't actually trying to solve your own pain problems, if you will. It was more just noticing that no matter what you did with certain clients, not everyone got better or was it really just tapping into this memory of your time reading the book with Dr. Sarno and being curious?

00:07:01 Charlie: Yeah, I mean, I'm a Sagittarius, so I'm a truth seeker by nature. And so for me, it was very much a professional interest of like, I want to know what's the next logical step for my clinical practice? How can I better support people in getting well, performing better, my athlete clients in addition to my everyday clients throughout the lifespan? And so yeah, but that said, I like all of us deal with primary pain or neuroplastic pain, whether we know it or not. And as I go back, like in the rear view mirror, and I reflect like a lot of the things that I've dealt with, my own body have a primary pain component. So it turns out that as I learned more about it, it's been really helpful to me personally, as well.

00:07:46 Chazmith: Right. So for everyone who's listening, I know that it might not be a familiar term primary pain. Can you explain for people listening what you mean by that?

00:07:55 Chazmith: Yeah, I like the term primary pain because we, as of January of this year, have a new diagnostic code in the DSM, which is the book of diagnostic codes. So it's been internationally accepted, this name, primary pain. I think it might replace neuroplastic pain and TMS and some of these other names. Primary pain is essentially pain or other symptoms that are driven primarily by the brain and nervous system in the absence of some structural medical problem. Different from secondary pain, which is pain that's secondary to a structural issue or a medical issue, like cancer or diabetes or a fracture or some type of injury. 

00:08:37 Chazmith: That's so interesting. I would just by nature think that they were opposite just from–

00:08:43 Charlie: I know.

00:08:43 Chazmith: Kind of just what you learn growing up. You would think it would be primary if it was from an injury and actually muscular, skeletal first, the way you're describing it is like flipping it.

00:08:54 Charlie: Right. And it took me a while to catch on to that too. But the other reason I like it is because it reinforces the massive paradigm shift that we've seen in the science around pain and how it works. Right. We used to think that there were pain pathways and there were pain centers and that the pain came from the tissue and then the brain registered it like ding, ding, ding, like something happened, you have pain. And now we know it's the opposite, that pain is a brain down phenomenon or pain is experienced in the brain, just like vision and hearing and other sensations. They're constructed and experienced in the brain and anything that we see in the body is an output, a result of the brain sort of being in a state of protection or danger alarm. So it sort of flipped our understanding of all pain and symptoms from being a body problem to what we call a biopsychosocial opportunity, let's say, where we're considering the body, the psychology and the social realities of any person. And that's why I always say this isn't like some exclusive, rare diagnosis. This is a very human experience. It happens to all of us whether we realize it or not. 

00:10:06 Chazmith: Right. Now, what's your take on, I don't know if you ever read the book by Dr. John Sarno, The Divided Mind. Did you read that one? 

00:10:14 Charlie: Of course. 

00:10:14 Chazmith: Yeah. Okay. And he talks about how he was of the belief that even situations where there perhaps was an actual injury that could have actually in some capacity shifted something in the muscular, skeletal symptom, he still thought there could have been and often was a kind of psychological, emotional, alternative element to it that it wasn't just like a fluke or purely coincidental. Like he mentioned how often people get a hamstring strain or sprain on one of their last training days right before the big race, things like that. What is your take on that?

00:10:59 Charlie: Yeah, for sure, I… because I treat a lot of athletes in my clinic and because I'm usually the first people they see, first person they see, I treat people in the acute phase of injury all the time or after surgery. And one of the things I work really hard to do is be preventive. Like, I don't want people to tip over into chronicity. I don't want them to sort of spiral down this road of fear that leads to what we call chronic pain, pain that's been around three months or longer. And so we have the opportunity to treat the psychological and social components of injury, of tissue injury or surgery so that people have a better outcome. Right. So I have a client right now who had a total knee replacement. He's just a few weeks out from surgery. And he has a lot of healing going on, right? Like they basically replaced his joint. So there's inflammation, there's stiffness. Those are physical, like bits of information coming into the brain that are triggering some amount of protection. But there's also the psychological component of that surgery, like things he's heard from other people that have had the surgery. And he's a younger guy. Like how does it affect his future as an athlete? What are his thoughts and feelings and behaviors around that? What are his expectations? And then of course, the social realities too, how does this affect his connection with community and his ability to get out? And he loves music, his ability to go and see live music and go dancing. Right. 

00:12:25 Charlie: These are things that I think, as clinicians, we need to be considering beyond just what's happening with the fascia or the muscle or the tendon. And if we can cover all those things, the bio psychosocial components, then the outcomes are night and day and we prevent this tipping over into chronicity. Right. Like in the chronic pain world, we're often talking about, okay, you had surgery a year ago, two years ago, five years ago, and you're still in pain. Right. So we're assuring people that the body is healed. And then any pain they have left, we need to kind of treat it differently at that point. In this case, we're talking about doing that work. We're talking about front end loading that work, doing it really early so that they recover from the surgery and they're not five years out, right? Still struggling to get back to living their lives again.

00:13:15 Chazmith: Right. Yeah. Preventative just because you're trying to make sure it just actually heals and doesn't linger into that chronic pain realm. Yeah. Do you think, though, that there's ever situations where what is a “chronic injury” could have some psychological or spiritual or metaphysical component behind it? Like why it even happened to begin with?

00:13:40 Charlie: You mean like why you crashed on your bike or why you got into a car accident?

00:13:45 Chazmith: Well, no, not like that. That's like very… no, I'm thinking like you're just running and all of a sudden you're like, oh, I pulled something. Do you think that in those situations where it seems like it could be very real and it could be tissue, that it could actually just be the onset of an emotional or social, some kind of mental pain that's kicking in? 

00:14:09 Charlie: Oh, yeah. Yeah. That's a great question. And because I see people really early, I would say most of the time, that's what happens. People aren't always aware of that, but even the athlete that comes in, that has a sudden onset of back pain or pain in their knee or a climber that gets pain in their shoulder, and I see them like the second day, right? For eight or nine out of 10 people that come to see me with acute pain, pain that just started, this is new pain. I like to define acute pain as new pain, not pain from an injury. Eight or nine out of 10 people that come to see me have no clear mechanism of injury. There was nothing that happened. There was no fall, there was no crash, there was no sprain. The pain often comes on out of nowhere, oftentimes not even during exercise. It's afterwards or it's the next day, right? And they'll quickly link it to, oh, it must have been that workout or it must have been that thing. But that turns out to be a false association most of the time. So with a lot of my clients, we actually don't start from the assumption that there was an injury unless we have evidence that there's an injury, especially during the exam, right? Which is an important part of getting clear on, okay, you feel like you hurt your hamstring yesterday, but let's evaluate it and see if the hamstring is really injured or whether it just hurts or whether it's just a little bit guarded for some reason. And if there was no obvious moment of injury, then what else is going on in your life? What else was going on yesterday that might better explain the timing and the location and the severity of this flare-up or of this pain? 

00:15:51 Chazmith: Yeah, yeah. That's what I was curious because, I mean, coming from an athletic background myself, I know that I've personally experienced this and also witnessed it so many times where you do like, what you just said, make that association. You justify, oh, this pain came on, oh, it must have been this, where we say, you hear it all the time and I wonder how much the brain clings to these beliefs that we hear all the time. Like, oh, it's overused. Like this is a classic one. You think you hurt your right shoulder and all of a sudden, five weeks later, your left shoulder hurts and we say, oh, it's because you're overusing your left side because your right side was injured, or over training or over this. So we have all these beliefs and then we create these associations and I wonder how often it's actually the sport or the activity that we did for something else like how you just kind of explain. 

00:16:44 Charlie: It's usually something else. 

00:16:45 Chazmith: Yeah. 

00:16:45 Charlie: Let's just say. 

00:16:46 Chazmith: Yeah. 

00:16:46 Charlie: Yeah. Which is hard to believe. 

00:16:48 Chazmith: Right. 

00:16:48 Charlie: I think we underestimate the capacity of the human being, right, of our physical capacity to do anything. 

00:16:55 Chazmith: Yeah. 

00:16:57 Charlie: That’s the first thing that we look at to say, oh, this must be wear and tear, overuse or overtraining and I live in Boulder, Colorado, right? One of the fittest towns in the world. And the fact that I'm seeing this in my practice, that the majority of my clients are not injured. It's kind of shocking. I've seen people that run ultras, they're running 100 mile races and most of the time it's not their body that's holding them back. It's their psychology. 

00:17:24 Chazmith: Right. Yeah. Which is so neat. I think that was my favorite thing about reading Dr. John Sarno is I had grown in the community so used to like being so protective of our spine because, well, you hear all the stories like, oh, if you injure your back, it's never the same or, oh, if you get back surgery, you're going to need five more back surgeries. So I became so overprotective of my spine and so worried about doing everything, so perfect so that I didn't mess something up or hurt myself. And then when I read his book and I started understanding like, oh my gosh, no, our spine is really strong. This is not real. Everything I've kind of wrapped my head around believing, is it started really making me question all of it, and I thought it was a lot more empowering to learn that we're actually incredibly physically capable and strong and durable. 

00:18:22 Charlie: Yeah, for sure. What was funny is I read John Sarno's book in parallel with rehabbing my own back, my herniated disc at L5-S1 that caused very real loss of muscle mass, loss of reflex. I had some atrophy in my leg. I had very consistent symptoms that pointed towards a structural injury to my back. And even though I read John Sarno's book, I still went through this process of sort of rehabbing my body and getting my core strong and working on mobility and flexibility. And those things were really helpful to me at the time because I believed that they were going to be helpful. I really trusted that that was going to be really important for me. And so that outcome was very real, like those things truly helped me. But then I went through this phase of like you being really protective of my back and always moving in neutral and trying not to move at deflection and extension when I did certain things. And I had to go through then later in life, this process of unlearning all of those rules that I created for myself to allow my spine to move again, to trust that it was strong. And of course, I'm a physical therapist. Like for the first half of my career, I was teaching a lot of these things to people to protect their spine because it was vulnerable, because this is what we learned in school. 

00:19:40 Chazmith: Yeah. 

00:19:41 Charlie: And so I'm spending a lot of my time helping people unlearn some of these unhelpful myths, biases, false associations, but that started with me doing that for myself.

00:19:52 Chazmith: Yeah. So you're talking about your spine and now looking back in hindsight, you do believe that there was more to what was happening in your back than just a purely physical situation, right? 

00:20:05 Charlie: Yeah, for sure. I mean, it might be too much to go into my story, but I actually injured myself freshman year of college, skiing moguls. That was when the injury happened. It was a very distinct feeling followed by a lot of symptoms for about a week. And then it went away and it went dormant for about three years. And three years later, I was in a part of my life where I was in a relationship. I was just starting, to physical therapy school. Let's just say, I was in a massive transition in my life and the symptoms came back. That's when they did the MRI. That's when they saw that there was a herniated disc and started attributing it to my symptoms to this disc. One doctor wanted to do surgery. Another doctor who is more Sarno-esque said, listen, you're young, you're already feeling better. Give us some time, be patient. And that's what I did. And six months later, I was pretty much back to normal and I really haven't had back pain since. And now I'm almost 50, right? So this is, what, over 25 years. And at the time, we didn't know that discs could heal themselves, right? We didn't know that in about six months to a year, the disc would… your immune system would eat away at that material and wall it off and then you're good. And so I always wondered, like, where did that disc go? Like, why am I pain free now? Because it looked pretty gnarly on the MRI, right? And so again, in the rearview mirror, I've had to rebuild the story for myself of, even though I had an injury to my disc and something that looked structural or secondary, right, there was still a significant psychosocial component to that injury. And luckily, I had people that even though they were doing very traditional manual therapies and core stability and manipulation and massage and movement stuff, that stuff made me feel safe. And so I got better. Would I have gotten even more better sooner if I'd addressed the psychosocial components? Probably.

00:22:02 Chazmith: Yeah. Yeah, that makes so much sense. And now you said that you did actually even experience some, like, atrophy and very actual, tangible, real muscular symptoms, if you will, around this situation, correct? 

00:22:18 Charlie: Yeah. I mean, if I had seen me as a clinician at the time and I'd examine me, I would have said, wow, you have a lot of the objective findings that we see. 

00:22:26 Chazmith: Yeah. 

00:22:26 Charlie: When someone has an L5-S1 disc herniation to the right, impeding the nerve and causing compression on the nerve, and probably would have encouraged myself to treat it both ways. Go see a physiatrist, get an injection and do the biomedical stuff. But let's also talk about these other things and stay hopeful and work, keep you moving. 

00:22:48 Chazmith: Yeah. 

00:22:48 Charlie: Reduce fear, right? 

00:22:50 Chazmith: Yeah. Well, that was something I wanted to talk to you about too, because I think that we have people, as you know, that are like all of the belief, it's always physical, right? It's physical, it's physical, we're always going to address the body. And then sometimes we learn about, like Dr. Sarno or just TMS or all this work. And then we kind of go into this mindset that it must always be not physical. But what I was going to ask you is how often and what's the possibility or potential that something that is more, as you call it, psychosocial can actually still cause physical shifts in our physiology, like how you had atrophy. So is that a very common thing that can happen? And then do we just address it the way you said, which is doing both, the work from both spectrums from the body perspective and the mind? 

00:23:42 Charlie: Yeah, it's a good question. I don't think of this as a dualistic binary, right? I think both of those camps are, for lack of a better word, just wrong. It's never just one or the other. So everyone's on a continuum. And when I teach, I try to encourage clinicians to determine, where is this person on the continuum. Some people have more psychosocial factors, and the body is less important. Some people have body factors, like my guy with the total knee replacement, like I'm going to work on his body because I can change his brain, his nervous system from the bottom up, right, by treating his tissues. In my case, a lot of my symptoms, a lot of my objective findings were probably due to that disc causing some compression on that nerve. In other words, those physical findings are due to an injury or structural problem. Most of the time when people come to see me, they haven't had an injury, but they have these other life stresses that are going on. They still have physical findings. Like when I evaluate them, I'll find muscle tension, I'll find some asymmetry, I'll find some change in flexibility. Most of the time, those things were pre existing. They're just normal. They call them normative, or they are the result of a nervous system that's in a state of danger alarm, not the cause of the pain. So this is the brain's way of sort of trying to protect you, is by making your muscles tight, by taking away mobility, by taking away power. It's not always necessary and always helpful. We can treat it, but to blame that, to sort of play into this idea that there's something wrong with the body is not usually helpful. And we see a lot of those things clear up if we treat the psychosocial factors associated with whatever is going on for that person. We see the objective findings change without touching the body at all. 

00:25:31 Chazmith: Wow.

00:25:33 Charlie: It's kind of wild. And so it's really changed my perspective on sort of the importance, the relevance of those physical findings.

00:25:41 Chazmith: Yeah. And that's what I was wondering is if just doing the psychosocial work, then all of a sudden the body can just shift because it was held in tension, because of something else. And I wonder in your experience through the clients you've worked with so far, when do you feel and how do you discern when it's more important to really just focus on the psychosocial aspect versus, oh, you know what? I'm going to work on this with this person, but I actually think doing this bottom up approach will also really support this healing journey and support them along their recovery. 

00:26:17 Charlie: Yeah, it's a good question. I mean, I try to meet people where they are. So if people have a lot of… if I have a sense that the psychosocial factors are the most important things to treat and the person's really open to that, then I focus on those things because I find them to be the most effective. If I have a client that orients more towards the body or they kind of feel like they need to check that box, like they need to feel like we're doing the body stuff first, then I'll intervene first from the bottom up. And that's okay. But I'm very clear with people why I'm doing that, right? I'm very clear that I'm not fixing anything. I'm not putting the bone back into place, right? I'm not doing any of these things that we used to think were true. I'm just giving input to the body to change the brain's perception of safety versus danger, let's say. And sometimes we check that box first, and then we work on the psychosocial stuff second. And when I'm teaching clinicians, the way I help them understand conceptually where they need to go is when they're evaluating someone, do their findings make sense? Do they match a pattern that points towards a biomechanical tissue damage, right? Injury, overuse problem. 

00:27:28 Charlie: We can see this because the pattern makes a lot of sense when you're trained to evaluate the body chemically. For a lot of people where the psychosocial factors are the primary challenge, the physical findings show up in this kind of strange, illogical way that doesn't match what we were sort of trained to look at. It's like a loose association of things that probably were pre-existing, right? Like scoliotic curves and muscle tension being imbalanced one side to the other. And one ankle being more stiff or, no, I'm getting a little specific now, but as a clinician, we're looking to make sense of our findings to say, does this really seem like something that I can clear up by treating the body and improving this person's movement and their flexibility and their strength? Or does it really seem like these findings are maybe the result of whatever's going on in this person's life, right? This point where they are in their life and whatever it is that's not working for them. 

00:28:30 Chazmith: Gotcha. Yeah. And so what I feel like a theme here is that it seems like maybe a lot of the work that we go and get done that we've been taught is going to help us feel better, is creating safety. If you have the right clinician, whether it's like acupressure, acupuncture, chiropractic, PT, certain types of maybe exercise with a coach, it seems like the belief that this could work, the belief from your practitioner that it's going to help you, and then their confidence and then their ability to create safety for you around doing these services. That's really why these things are successful, isn't it?

00:29:13 Charlie: Yeah, for sure. Yeah, it's a big component. And so I never want to minimize the opportunity that exists there, especially in the short term, to help people just feel better so that they can then do the other work if they're open to that. Because it's hard to do any of this if you're in pain. I mean, pain makes everything hard. So if we can use these bottom-up interventions to get people feeling better with the right intention to help them understand why they're helpful, we can do it in a way that reinforces safety, then we can kind of get to the good stuff, as I say. 

00:29:43 Chazmith: Yeah. Maybe not everyone wants to get there and they just want to go to their chiropractor three days a week for the rest of their life. But it seems like ideally, if we could get to the true root of things, we could use this stuff to supplement or help us to create that safety and that safe space. But the idea is to not need that stuff forever.

00:30:01 Charlie: Yeah, I think there are two things that are challenging about that model. One is that you're treating the result of pain, right? You're sort of treating the wrong thing, as it were. And that can lead to dependency. And oftentimes, what happens is the pain will come back or it will show up somewhere else because we haven't really gotten to the core source of what's driving it in the first place. And so, if people come to me and they want me to treat their body and they're not open to this other piece, these other pieces, that's okay. We treat that. And then they come back again, maybe a month later, six months, a year later, treat it again. And then I just plant seeds over time and sort of encourage them in this new direction. So the idea that this can lead to dependency on another clinician I don't love, right? But the other thing that I think is more important is that people miss the opportunity when they're not connecting their symptoms to what's going on in their life, they're missing the opportunity to grow in some way. And I'm not just saying, like to be less scared of pain. I'm not just saying, like, to reduce the fear about pain. I'm saying they're missing the opportunity to grow in their relationship, in their career, right? For a lot of people, the theme is around retirement, right? At retirement age, a lot of people get pain. And we can treat the pain, but if we don't connect it to retirement, we're missing the chance to talk about meaning and purpose. We're missing the chance to help someone have a thought transition from their career to whatever's next for them. So to me, making meaning from symptoms is one of my favorite parts of the process. And I think one of the most important parts of the process that we miss if we treat the body. 

00:31:39 Chazmith: Yeah, I love that. And I would love to hear if you have any insights as to in your experience across all the athletes you've worked with, do you see patterns like, for example, you commonly see people who have back pain, maybe they felt really unsupported in their life, like in a particular situation, like really unsupported at home with their significant other or at their job, or they have knee pain because they felt something else. Do you ever see patterns where it's almost to the point where now you know they come in and it's their knee, you're going to go right to this thing because it's so common? 

00:32:17 Charlie: Yeah, I mean, every day, all the time. And I think I would say that pain is the best way to get an athlete's attention. So I think this happens to athletes even more than the general population, because if the brain's trying to get your attention about something that's going on in your life, let's pull exercise and then see what happens. Right. And so–

00:32:38 Chazmith: Yeah, right. Right. Because it's a good distraction. 

00:32:41 Charlie: Yeah. And there are so many themes that come up for athletes. So there's not like, I don't like to make rules around it. If it's the knee or the back, I don't like to make assumptions about what that means for that athlete. I think it's an emergent process that really is about exploring and collaborating to sort of find what that means for them. But there are a lot of themes around not being supportive. There are a lot of themes around change. There are a lot of themes around fear of success, fear of failure, putting pressure on yourself, attachment to identity, trying to prove something or self-esteem or self-worth. Right. These are things that come up a lot for athletes. Perfectionism, right. Achievement orientation, type A personalities. And you mentioned earlier, like a lot of the athletes that I treat will have pain in the taper phase. Let's say, for those of you who don't know what a taper is, let's say you're training for a marathon, one to two weeks before the marathon, you'll usually cut your training a lot so that when race day comes, you're recovered. And so the training volume is less, but pain will show up in that last two weeks. This is acute pain, right? Again, this is new pain that wasn't there during training. People are very quick. Athletes are very quick to say, well, it must have been that last long run or it must have been because my volume is so high. But objectively, they're doing less at that point. 

00:33:59 Charlie: And what we need to be looking at is the anticipation of the upcoming race. Maybe your family's coming to watch. Maybe you have a PR that you're just a little intimidated by. Maybe you don't trust your training and don't feel like you kind of did enough. And you're also training less. You have more time and space to sort of think about these things. You're not as distracted. And you're kind of worried that like, I'm not training. Like, I feel like I should be training right up until the race day. And of course, that's not how fitness works. But those false associations will hold people back. And so the last thing I want is for someone to have their race day sabotaged because they think there's something wrong with their body. I can't tell you how many athletes I've shepherded through that last week or two before their race with a lot of pain, sometimes, like race ending, like I'm not going to be able to go, kind of pain. And they show up on race day and they're fine. And they kill it only because we've addressed the psychosocial parts. The fear and anxiety and another feelings and thoughts that are holding them back before the race. 

00:35:03 Chazmith: Yeah, it makes so much sense. So I'm going to shift gears just a little bit because we've kind of been talking about this from an athlete lens. But I want to address something that's really common in the chronic pain and illness community. We have a lot of people who have either suffered for sometimes extensive periods of times with something like CFS or exercise intolerance, however that develops, right? So they end up maybe being bedridden or having to take an extended period of time off of exercise or movement and activity. And then say as they're starting to heal and do this emotional work and they're doing neuroplastic work and they're feeling better and they start to incorporate exercise back into their life. What happens is sometimes we can go through a period where we do experience heightened soreness, muscular soreness or fatigue. And I know I've personally experienced this. It's interesting when you've had, say the inability to do it for so long and maybe you've gone through several crashes and ebbs as some people call it where you're kind of still learning what your true limits are. It can be very interesting because that fear can still show up. And we almost forget what's normal, right? Like what's normal soreness from the workout I did today versus what might be neuroplastic or something more psychosocial still showing up versus like, oh yeah, I just did a lot that my muscles aren't used to doing. Do you have any advice or insight for anyone listening who's gone through that or is going through that? How they can address these transitional periods to really build their capacity and to not be in fear around soreness or fatigue post exercise? 

00:36:51 Charlie: Yeah, it's a great question. I'm going to start with the words adaptive change and deconditioning. So a lot of the physical things that I see on my exam in these situations are just because people haven't been in their bodies, right? They haven't been using their bodies. And so things get tight, things get weak, use it or lose it, right? This is a normal phenomenon. And so it’s helpful to have a clinician that can normalize this. And at the same time, green light people back into moving their body in healthy ways and to sort of make a plan that's thoughtful, that's gradual, that's graded. And like I have people texting me all the time as they're doing this saying, is this okay? Charlie, this is what I'm noticing. What do you think? And it's nice to have someone external to sort of reinforce safety until people can do it for themselves, which is sort of the ultimate goal. It's like having a guide, right? And someone to collaborate with to figure out like, what's the right thing to do. It's probably important to say that in those situations, without exception, movement is the prescription. Like, not moving or resting is going to keep you right where you are. So absolutely without exception, getting people moving again is important. And I've seen people that have had spinal fusions revised and have been bed ridden and have not moved in years. They're worried about their fusion, right? They have real concerns about their body. Even in those situations, movement is the path forward. Like you can't get better without moving your body and getting back into your body, I would argue. 

00:38:27 Charlie: So that process looks different for everybody. For some people, it's a very slow, gradual process. For some people, you give them permission and they're like, out of the gate, they have this really big, significant, fast improvement. So there are no rules, which I think makes it hard. Like there's no standard guideline for any individual. It really depends where they are in their process and how much they've shifted their belief and how many other factors, like do they have family support at home? Do they have access to nature? Right? Do they have access to some of the things that we know make people successful as movers? So I guess it's hard to give a standard guideline. But the one thing that I spend a lot of time with people on, and I'm happy to share, I made a video that talks about this process of returning to being active, despite the fact that you have pain. If you want to put it in the show notes, I'm happy to share that as a resource for people because they can hear my whole spiel about how this looks. But to summarize, it's basically the idea that you have to move into pain to get well. You can't stay at a level where you have no pain and expect it to change. You have to bump up against pain over and over and over again to show your brain and nervous system that it's safe. And sometimes it's the familiar pain that you've had, which is really scary. And sometimes it's soreness and new pain that you're not used to. Even a runner that's never had pain is going to go through six to eight weeks of on-ramp of having aches and pains in their body as they start to run again. Right? Because there's an onramp of your tissues getting used to it. And so people in pain have to go through that same onramp and navigate like this is my familiar pain. This is new pain. But it's almost impossible to navigate that process without some amount of pain. And you need permission, right? You need courage. You need a sort of a plan and a guide. 

00:40:28 Chazmith: I love that. I love how you just said you have to move into the pain. That's so valuable. Such a great insight. And I think you're right because the more we talk, the more the theme is really about being and feeling safe. And I think this is where having somebody like yourself who has this background with the body in movement and also understands the psychosocial aspect of pain, it's amazing how much you can tone the fear down when you have somebody kind of guiding you. And you say, okay, well, I'm feeling this and this and this today and I'm feeling really sore. And they're like, well, of course you are. You did all these things yesterday that I had you do. 

00:41:07 Charlie: Good job. Good job.

00:41:07 Chazmith: And it's new. Yeah. This is actually human. That in and of itself would really just help somebody go, oh, okay. Because I think sometimes if you've been really sick for a really long time or in pain for a long time, you almost forget what's normal. You might forget that, oh, I'm doing something completely new that I haven't done in so long. Of course my muscles are going to get tired.

00:41:31 Charlie: Yeah, for sure. And to add to that, as physical therapists, we're trained that you need these very specific exercises and you need to contrive them in a way that they're broken down by muscle group. And we need to do them a certain way for a certain number of reps with a certain number of rules, right? It's very descriptive. And it turns out in the research, we're not seeing that play out at all. We're seeing that there is no correct movement. There's not even a correct way to do a lot of movement. It's simply about moving in whatever way makes sense for you. And so one of my favorite parts of the process of supporting people and getting back in their body is again, collaborating with them to say, what do you want to do to move? We don't have to make up this lame series of PT exercises that you're scared you have to do for the rest of your life. Do you want to dance? Do you want to go walk around the lake? Do you want to go play with your kids? Do you want to go throw the frisbee? There are so many different opportunities at that point to get people moving in a way that is fun. It's sort of immersive. It's joyful, has some sort of awe and wonder associated with it. Rather than you need to go to the gym and you need to get strong and you need to get flexible. We know you can't strengthen your way out of pain. It's not how it works. You can't yoga flexible, stretch your way out of pain. That's not how it works. 

00:42:54 Chazmith: Yeah. I love that you bring that up too, because I think that's so important. Take this opportunity to discover what is actually fun, because that's the other thing that we get into these beliefs. We think we have to do yoga. We think we have to do certain kinds of exercise. We have to do things a certain way. And then that sounds really boring to us. And then we don't want to be a mover. Then we say, well, I don't like exercise. And I'm like, well, you're a human being. I'm not convinced you don't like moving. I just don't think you've discovered the way that feels good for you to move. And yeah, I think that heals in and of itself, because now if I'm going to do something that I look forward to, that makes me smile, that might make me laugh, that I enjoy, that's healing in and of itself.

00:43:39 Charlie: Yeah. And normalizing that the sensations that people feel in their body, as they're starting to explore movement again, that those are a part of the process. Let's celebrate that. Let's get excited about that. Your muscles are waking up. Your body's coming alive. It's starting to communicate with your brain again. One of my favorite ways to talk about this, sometimes I'll show people a picture of the homunculus, which is basically the brain's representation of the body. And it's this funny looking creature with big hands and big feet, big genitals and a big tongue, all the areas that have a lot of sensory and motor representation are really big in the brain. And so I like to show people a picture of this and describe the phenomenon of smudging, which is something that Lorimer Moseley talks about in his book, Explain Pain, this idea that those parts of the body that the brain represents get blurry. It's like they're out of focus because the brain's not getting information from the environment about where you are in space and where you end and where the world begins. And when those parts of your brain are blurry, there's fear because your brain is going to start to protect you, because it doesn't have clarity about what's happening. And so movement for me, when I describe it to my clients, is about feeding the brain information through the body to re-clarify where the body is in the world. And there's so much safety in that. Ultimately, the brain likes that so much. It likes that information. So I'll take someone from wearing foamy, hoax shoes with orthotics that has foot pain to say, hey, listen, I really want you to spend some time each day with no shoes on, on the concrete, on the grass. Like I want you to feed your brain information about what your feet are like and what they're doing. And that's terrifying at first for a lot of people. It's kind of a radical shift, but it's the same for any part of the body. We want to feed the brain information so that it has more clarity and thus less fear and better function. I mean, really, that's what it comes down to is we will see the function of anyone improve as the brain starts to understand where the body is in space better. 

00:45:53 Chazmith: Wow. Yeah, that's awesome. Is this actually a thing, this picture you talk about, this humongous that you said? 

00:45:59 Charlie: Homunculus? Yeah. No, it's a thing. Yeah, it's a–

00:46:03 Chazmith: We can Google it and see a picture.

00:46:05 Charlie: Of course. Yeah. There's actually in the British Museum, this artist created a rendering, like a physical model of the motor, which is like the output, the muscle output, like how much the brain's dedicating to movement and how much the brain's dedicating to sensory, receiving sensory information. They look a little different, but they're kind of similar. They made a model and it was in this museum. So that's the one I usually share. I can share it with you and you can put it in the show notes as well. 

00:46:32 Chazmith: Yeah. Yeah. I would love to do that. I'm sure I want to see it. I'm sure other people want to also see it because it sounds fun. That's cool. Okay. So I have another question. I know that you've talked about doing a clinical evaluation and I'm curious, you have your clinical evaluation that you do when a client comes to see you, but are there any types of evaluations that people can do on themselves if they're not in a, say a financial position to go to a clinician and they are listening to this and they're like, okay, well, I want to know if my pain might actually be not as real, AKA, not as in the muscular, skeletal system as I thought it was. Is there a test they can do or like any kind of thing they can take themselves through? 

00:47:17 Charlie: This is real art. And as a clinician, there's a certain amount of liability involved, right? And taking what we do professionally and automating it. I see on Instagram all the time, these apps that analyze movement and break down biomechanics. Most of them are focused on finding the things that are wrong with you, right? Where you're stiff, where you're weak, where your movement flaws are. And this is based in old science that doesn't correlate with pain at all. Maybe we can say it's tied to performance as an athlete. And if you clean those things up, you perform better, but those things are not the drivers of pain. Most of the time. I still have on my to-do list, making some sort of physical self exam to help people feel safe in their body. And I do this with people virtually when I evaluate them from a distance, I ask them to go through a series of movements and tests so I can get a sense. But I'm correlating this with my subjective history, right? With my question and answer part of my exam, I'm correlating it with things like, was there an injury when your pain started? How long has your pain been going on? Are you a first time offender or is this like the third time you've had pain in this area? Symptom behavior, as you probably know, is really important. So we have a list of 15 symptom behaviors that point towards primary pain, not a structural problem. Personality traits are really important as an indicator of how much someone might be prone to having more primary pain. And the exam, of course, is like for me, the last part to confirm where we are in the continuum. So it's not like a standalone thing, right? 

00:48:56 Charlie: And of course, I miss saying, if there was an injury, what's going on in your life when the pain started? What's going on in your life now? Those psychosocial factors are the most important part of the history when we're trying to figure out what we need to do. So for instance, if someone's pain started kind of out of nowhere or after a workout, and they happen to have just lost their job or someone important in their life passed away, or their kid is struggling at school, or they're moving, right? Sometimes the change is even kind of a good change in people's lives, but it's stressful, right? Because it's change. If we see that paralleling the onset of symptoms, and/or we see that ongoing, right? When I'm evaluating the person. These stresses that are above and beyond our normal [remorative] stress become a really important factor. So I'd almost say that after the subjective history, I have a really good sense for where someone is on that continuum before I even evaluate their body. So I would like to say that the objective exam, in some ways, has limited value. If you think you have elbow tendonitis, this is a really common one. Someone comes in, they had elbow pain, it's been going on for a long time, and I'm poking on their elbow, and it doesn't hurt. That tells me something, right? Like how weird that you have elbow pain, but when I poke on the tissue, it doesn't actually hurt. When you imagine doing something like a pull up or rock climbing, your elbow hurts, right? That's kind of weird. But when I touch it, when I touch it, it doesn't hurt. Someone that has back pain, they have very real pain in their back. Again, there's no difference between primary and secondary pain. All of this pain is real. It's the same pain. It's caused by the same phenomenon, which is the brain. But if I have someone with back pain and I go through my tests and I'm not seeing a positive straight leg raise, slump test, the reflexes are normal, their strength in their legs or arms is normal, I feel confident, right, that I can move on. If this isn't a primary body problem, this is an injury problem or a herniated disc or whatever. Does that make sense? 

00:51:08 Chazmith: Oh, yeah. Yeah, completely. And those are just like some of the little cues that I wanted to have you share for people so they could begin to ask themselves those types of questions to distinguish the difference in their own bodies. What would you say to somebody who's listening, who as they listen to this hour, they're thinking, oh my gosh, this definitely is what I'm going through. This is neuroplastic or, as Charlie says, psychosocial, like, okay, what's next? What do I do about this? Like, what would be their next logical step from your perspective if they're kind of out there navigating this on their own? 

00:51:46 Charlie: It's a great question. I think a lot of people get what we call the book cure, right, where they understand how this works and they can see their pain for what it is. The fear reduces and then the pain goes away. This happens for me all the time. Again, to go back to where we started this conversation, this is a normal human phenomenon. This affects all of us, whether you know it or not. This is just how we work. It's how we're wired. And so just starting to pay attention is really helpful. I had some soreness in my back the other day. I made an Instagram post about it. And I knew my back wasn't injured, but it was tight. And it was really sore when I woke up. And when I went and exercised, it actually felt a lot better. And I knew it was tied to some anxiety and pressure I was putting on myself around work on that particular day. Like, I knew what it was from. And so I could see it for what it was. I could move anyway and just trust that it would take care of itself. And 24 hours later, it felt fine. So that said, not everybody gets the book cure, right? Not everybody sort of people need support. Sometimes they need someone that will bear witness. I've had people write down their story before I see them. They'll write me a two page history. And they've never written down their own story before. And they're like, that was so helpful for me to just share my story with you, whether it's written or verbal, because they feel seen and heard. Right. 

00:53:11 Charlie: And so at the most basic level, having an empathic and compassionate clinician that can really support you in this can be a really important starting point. Sometimes I see people once and that's all they need. And sometimes it's more of a long term relationship where we start by talking about pain or other chronic symptoms. And then it turns into working on performance as an athlete, or it turns into almost like coaching, where now we're talking about their relationship, or we're talking about their career, or we're talking about the decisions they're trying to make in their life around whatever it is. And again, as you attach symptoms to meaning, that's one of my favorite things, is to see that relationship transition from pain to like, what's really going on here? What is your brain trying to tell you? What's the message? Where's the growth, right? So anyway, I kind of skipped around your question there a little bit, but where do people start? I think it always starts with education, understanding the new science of pain, the paradigm shift that's happening, and that this is a normal human experience. This is not just some small group of people that are dealing with this. I think it's the cure for a lot of things in our society. I think it's that big of a deal. This point in history. 

00:54:34 Chazmith: Yeah, definitely. Okay, I have, well, let me, I'm gonna… have one more question I want to ask you. But before I ask that question, speaking of just everything we're talking about, what are the services like that you're offering? And how do you, you know, do you do Zoom? Or do you do in-person only in Colorado? Just talk a little bit about what you offer and how people can connect with you.

00:54:58 Charlie: Yeah, so my clinical website is mperformance.com. I'm on Instagram @CharlieMerrill. That's actually the handle for most of my social media stuff. I have a lot of actually more exercise based stuff. I'd say my old school stuff. Like, what do you call that? Like my retro content about movement and exercise is on YouTube. I forget the name of my YouTube channel. Maybe you can put that in the show notes. It's just kind of good solid movement-based information on there. My newer stuff is on Instagram. My clinical practice here in Colorado, where I practice as a physical therapist is in Boulder. I also do more of a coaching based part of my practice that I can do on Zoom virtually. I don't do that as a physical therapist. That's sort of in a coaching role. So it's a little bit different because I can't get my hands on people and evaluate them in the same way. So that said, people can reach out if they want guidance, sort of more of a coaching based guidance. I also work with a startup called Lin Health, which is a digital health platform that is really trying to scale this and make this affordable. We're working on insurance coverage right now. And that's also a coaching centered platform where people can communicate asynchronously and through live video chat with a coach and really work through the process. So I'm really excited about that. And I'm behind that sort of as a consultant with a bunch of other really smart clinicians and scientists like guiding the growth of this digital health platform and the content that's inside of it. So Lin.health is where people can access that.

00:56:35 Chazmith: Okay. That's awesome. That's awesome that you're doing that. Thank you. All right. Final question. I ask everybody, one message for the world. If you were told you could only share one message for the rest of your life, what message would you want to share with the world? 

00:56:49 Charlie: Oh my gosh, that's a big question. 

00:56:52 Chazmith: I know. 

00:56:54 Charlie: Well, I'm almost 50 now and I've been an athlete my whole life. And what I'm learning as I get older as a mover is the value of novelty, the value of play, the value of being in nature and variety is the spice of life. So I've become more sort of explorative in my movement. I'll just answer this from a movement perspective because I'm a physical therapist, right? I've been thinking a lot about the difference between exploitative and explorative movement. This is something I took from the Noigroup, my colleagues in Australia. Exploitative movement is the type that you kind of know what's going to happen. You've done it a bunch of times. It's satisfying. You get a hit of dopamine, but it's kind of predictable. You kind of do it on repeat, right? It's like the mouse pushing the lever and getting the cheese or whatever. I've been seeking out more explorative experiences where I don't know the outcome. I haven't been there before. It's a little less familiar. It's novel. There's a sense of wonder and awe again, which I think is really valuable for us as human beings. And it's really exciting. But a lot of people shy away from that because it's a little scary. And so I want people to seek out a balance of those two things so they can get a sense for the beauty and the gift of both. And this is just what I'm leaning into as I'm going into the second half of my life. Yeah.

00:58:27 Chazmith: I love that. I love that so much. And I can so relate because, yeah, for a long time, I would see these other kinds of movement and things, but it was unfamiliar and unknown. And I know I was going to make mistakes and I wouldn't do it perfectly. And I was so scared to just go into it. It was so much easier to go into what I already knew I could do really well. And that's something that I'm also playing with is, no, I want to go try these things that I might… it might look messy and it might be messy and it might not work and I might make a mistake. And that's all okay because there's joy and liberation in that and so much that can come through it in a good way. So that's awesome. Thank you. 

00:59:08 Charlie: Yeah. Let me give you one more add on to that. This idea that there's a right way to do movement. Right? Early in my career, I was taught like this is the way you do it, it has to be perfect. Clearly, as time's going on, most of the learning that we all do in anything comes from making mistakes. It comes from doing it wrong or doing it in an imperfect way. And so I encourage people to move in explorative ways where they get it wrong. The skill acquisition part of any learning… any skill is my favorite, like how quickly you get better at things by making mistakes is my favorite part. When I get to the point where I kind of know it and I mastered it, I kind of move on. I seek out that like what's the next thing. So I like to encourage people to not get hung up on, you know, there is no perfect movement. There is no perfect posture. There is no right way to do things. Every runner I see in my practice has a different gate, has a different way of running. And that's okay. Again, that's just part of us being unique. So. 

01:00:10 Chazmith: Yeah. No, that's good. And I think it keeps you youthful, right? To always be learning new skills and challenging yourself in that way, especially when it's like hand-eye coordination, body stuff, movement. It's just so positive and so powerful and productive for us to constantly be challenging ourselves to learn that next thing. 

01:00:29 Charlie: The brain loves it. The homunculus loves it. 

01:00:31 Chazmith: Yeah. Homunculus, homunculus. Yes, this is fun. I'm going to Google it right when we're done talking. Charlie, thank you so much for joining me today. I had a really lovely time talking to you. I feel like we got to dig into some really juicy, good, valuable content to share with everyone who's going to be tuned in. So I really just want to say thank you and that I appreciate you. 

01:00:50 Charlie: Thank you so much. I appreciate you as well. Thanks for making time. It's a lovely conversation. 

01:00:56 Chazmith: All right. How fun was that episode? And Charlie, I just love this guy. I also happen to be such a dork about fitness and movement and the magnificence of our bodies. And I just found everything that Charlie shared with us today so inspiring. He really shows us how strong, capable and resilient our bodies are when we're willing to do the deeper work. I hope you found value in today's episode. Be sure to tune into next Tuesday's episode for another wonderful guest story. And until next time, make this week great.