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[00:01:34] Mark Kargela: Are we getting caught up in the debate between passive and active care? What if I told you that the whole passive versus active care argument is a false dichotomy? Whether it's manual therapy, exercise, or lifestyles changes, there's no one size fits all approach to helping someone in pain. In today's episode, I want to show you why passive care isn't the enemy, how active care is more than just exercise, and why the real game changer lies in something that doesn't get nearly enough attention.
 
The tough conversations and the deep work that happens between you and your patient. Let's dive in. 

This is the Modern Pain Podcast with Mark Kargela. First, passive care is not the enemy. I made a post on social media recently and I had a few people saying, Oh, here we go. The whole passive care is the devil argument again.
 
And if that's the way it comes across, that's on me, of course. But I don't feel like passive care needs to be the enemy. Shoot, I do it on the regular. I do some soft tissue work. I'll do some manipulative, some manual therapy work from time to time. I'm not against it. I've just really begun to look at it for what I think it truly is.
 
It's [00:02:34] not a curative intervention. It's something that can modulate pain. And if the patient has enough resources and is still pursuing valued things, or maybe if it gives them the change in their pain temporarily, that gives them the boost to get back to the things in life that are meaningful, then have at it.
 
Passive care is not a problem. I think obviously our care shouldn't strictly be passive that hopefully we're getting people into more active roles and getting back into things in life that are important to them. But. There's no need to throw passive care away, which I think is sometimes when it gets threatened and I've had that stage of my career to are really holding on tightly to something I was invested in.
 
And for me, it was more time, right? And sunken costs of money I paid for courses to learn some of these things. It's hard to let that go. But I think it's also why we might need to be a little bit skeptical when somebody who teaches it. Or has significant financial interest in this passive piece of care being important because that's what they teach and they profit on and I'm not saying there's some folks who teach these things and are very open with the limitations of them, but they're also open for that.
 
This can be a valuable pain modulator [00:03:34] for the right patient. And I respect that. So I'm not against the whole passive care, you know, push or the I'm not against the whole passive care. Uh, model in certain instances and when put in perspective of a big picture approach for somebody in pain. Now, let's move to active care.
 
Active care is fine as well. I definitely think, you know, in the grand scheme, we hopefully are getting people actively off tables where we're not just sitting them on a bed and plinth and doing various things to them where eventually, They got to start getting back into things in life that are important.
 
And most often than not, I tell people, is your life going to be lived laying on your back or laying on your stomach? No. So would you agree with me that we probably need to get you doing some things off this mat that would look like the things that you told me are valuable to you? And hopefully at this point, and at day one, we understand what's meaningful for the patient, what's valued by the patient.
 
So that becomes the narrative of their. Treatment, but I will say there is some and I have friends who are doing great jobs helping physios better [00:04:34] incorporate strength and conditioning principles in the practice shoot. I love strength and conditioning. I do crossfit and really enjoy it. It's my way of kind of mental health and physical health.
 
So again, I think active care exercise is great, but I think if those of you listening, if you work in settings where there's a lot of persistent chronic pain. Do patients in chronic persistent pain want to be throwing dumbbells and barbells around? I'm not saying it's not great for the right person, but I think we have to be careful and understand the context we work in and function in.
 
Sure, there might be some patients, even in those contexts, that might take a big 180 in life and want to get into some fitness and different things, and we should. Be willing to offer that, right? But there are some patients where shoot, just getting off the couch is tough. Just being able to get out of, out of bed and function to prepare meals for their family is a major endeavor.
 
So looking at them pushing out dumbbells and barbells and things like that, probably not realistic. So you need some ways to scale your active care to the person in front of you. I do think there's a little bit with the strength and conditioning movement where some, and I know this [00:05:34] definitely happened to me is when I'd grab onto new interventions, like.
 
Every patient got it, right? Every patient I was trying to push into doing, for me, it was the functional movement systems and SFMA, which, again, has its role and can be some helpful bits of information. Of course, it's not anything that's magical or a one size fits all type thing as with most interventions.
 
We just have to be careful that we don't try to push our agenda on patients and try to find out, well, what's their agenda? What do they want? What's important to them and valuable to them in life. And let's work towards that. And let me build interventions, be they passive, be the active to start work, working you back to those things and not get so caught up in our PT brains or clinician brains, if I need to correct the biomechanics and we need to correct their lives, right?
 
And if what we do passively or actively can help correct somebody's ability to pursue value and meaning in life, Hey, I'm all for it. Now, the one thing, and I don't think this is a surprise if you've listened to this podcast at all, the, the most difficult intervention that gets the least bit of airtime is communication skills and being able to [00:06:34] really listen.
 
And that's the biggest part of communication. I think sometimes people hear communication, it's like, well, let me do more things that I can talk at the patient with. Which again is part of it, but I think the biggest part of communication that healthcare fails miserably at is the listening part. It's the ability to shut up, be present, put your phone aside, maybe lower the screen of your laptop with your EMR.
 
And I know people are going to get uncomfortable because man, I got to keep up with my documentation. Um, but again, try to find strategies and systems that allow you to keep up, but still remain present and purposely curious and present with the patient. And you need to work on that ability to listen, to be able to get the patient's story, to be able to ask them leading questions and, um, you know, open ended questions to start getting their story front and center, because those are the bits of information that oftentimes can be the huge unlocks for people to really.
 
Understand what are the barriers in your life. Why do these symptoms that I can change short term in a pain modulating procedure, be it active exercise, be it um, you know, passive treatment. Why doesn't it last outside the four walls of my clinic? [00:07:34] Well, you need to have an explicit understanding of what happens outside those four walls that can help you maybe have a better understanding of why it isn't holding true between sessions.
 
Um, the other thing I would just is trying to really get a patient's mindset front and center, right? Being able to. Understand where's the patient's head. What do they think's going on? What do they think they need to get better? I think really deeply understanding where the patient's thought processes around everything you're asking them to do, what they think they need to do to get better, what they think's going on in their body can really open up some significant, maybe maladaptive beliefs and behaviors around their condition that will help you maybe target them through behavioral experiments, through exposure with control and various things to kind of see if we can be again, a little bit more big picture with them.
 
Tough conversations are hard, tough conversations aren't easy. I know for me, clinically, when I'd have patients who'd come into my clinic and start crying or get angry or, you know, have all these raging emotions and understandably, based on the stories and the lives [00:08:34] they've lived around their pain situation.
 
But for me, I was so uncomfortable with it that I'd either like, if it was anger, I'd kind of really reflect some of that back to them and get, you know, maybe a little bit angry and bitter with the patient myself. But if it was like tears or emotions, I just didn't have the skill set to deal with that.
 
I've talked to my wife. She was always used to say whenever she'd cry, I'd get just very uncomfortable, but I've had to learn To be instead of leaning away and backing up from emotions, try to lean in and try to lean in and see, Hey, this looks like it's really got you emotional. Can you tell me what's going on?
 
What's behind some of this that you're, you're dealing with right now? Um, it can be uncomfortable and it will be, and it's never going to be comfortable when you see somebody crying. At least I hope not. But I think it's our duty to see, well, what's behind that they're expressing something, some significant emotions, even if it's anger to like, Hey, I can see you're really mad.
 
And it looks like you're frankly pissed off and it sounds like you have every right and reason to be pissed off based on what you just told me you've been through. But can we tell, can you talk to me a little bit about what's behind that? What are the things that's gone [00:09:34] on with this that it really have gotten you so frustrated?
 
It sounds like it's been a tough road for you. I can't stress enough how big those type of conversations can make one, your therapeutic alliance with people be significantly better to where patients finally, Hear a clinician who's sitting down with them, looking with them in the eye, not just looking to type in their computer and check off boxes in their EMR, but actually understand what's behind some of these situations and the emotions that they're displaying in clinic.
 
That, to me, is what's going to open the door for the patient to really say, this guy gets me. He's actually going to be somebody different than the last 15, 16 clinicians who, Brush them off, cut them off, didn't let them have their story told. You know, we've all had the stories of patients. Unfortunately said you're the first person who's actually listened to me.
 
And I still think that's a travesty and it guts me to hear people. Let's say you're the first person after decades for some people that's actually listened to what I've been dealing with. That's actually given me an opportunity to express how I feel, which again is And I, and I don't think it's based [00:10:34] on healthcare professionals not wanting to help people, but I think we've been put in systems and modes of care and biomedical models that don't prioritize the person's story, that don't prioritize these things that are anything but soft skills, but I'll tell you, they are the absolute game changers if you put in some deliberate practice.
 
So it's not going to be, I'm going to lean in on emotions one day and it's going to all go smooth. There are going to be times, and I still have times where emotions enter the room. Things enter the room and I don't always handle it perfectly. And sometimes it doesn't go well at all. Sometimes it goes less than well to say the least, but I do feel like in those situations, I've been able to really have the person more often, more often able to kind of open up and let me know what's been going on behind some of those emotions.
 
And it's opened up some really powerful ways. We've been able to kind of align with each other, me validate what they've gone through. And really help become that guide by the side that that patient needs. So hopefully that was valuable to you. This episode is a little bit different than our weekly. I just wanted to get on, it's a little bit of a maybe ranty way of getting at it, but hopefully it's something that's valuable for you.
 
[00:11:34] And if it's something that you feel you resonate with, I'd love to hear in the comments. Where do you find this whole passive versus active care dichotomy that's on there and and on in the end? Do you really feel like those two things matter If the person's not getting back to life and maybe. We need to get into some of these tough discussions and get in the mud with people and see if we can help them navigate back to the life that's meaningful and valuable to them.
 
So let me know in the comments of what you think and I'll jump into the comments and we'll have some discussions. Thanks for listening to the episode. We'll talk to you next week.