Exploring Pain Science with Paul: From Massage Therapy to Scientific Writing

159 Paul Ingraham

[00:01:34] Mark Kargela: Welcome to the podcast, Paul,

[00:01:37] Paul Ingraham: Thank you. Glad to be here.

[00:01:39] Mark Kargela: you know what, this has been a long time coming. And again, as I've reached out to you, I'm like, I can't believe it's been this long that I've taken to reach out to Paul. Cause as we talked before we went on live for a recording, I've, we've kind of known each other online, you know, indirectly through just seeing each other's names and seeing each other's work online for gosh, God, it has to be well over 10 years, if not longer.

Um, and this is really the first time we've ever connected, you know, Although face to face digitally, we, you know, maybe one day we'll, we'll, we'll meet in the flesh and be able to hang out and have a, maybe a drink or a coffee or something like that. But, um, uh, Paul, you're doing some great stuff with a pain science.

com. We're going to get into a little bit of the discussions of that whole evolution of where it's, where your kind of work started online and where it's gotten to now. But a lot of folks may not know your background as much as far as where you kind of, your starts with it. with, with kind of patient care and getting into pain science.

I'd love if you can kind of, you know, maybe give folks a little bit of a primer of [00:02:34] your background and how you kind of got to where you are today.

[00:02:36] Paul Ingraham: Yeah, sure. I mean, I feel like most people who have read my stuff probably know that I was a massage therapist once upon a time. Uh, the about page is, uh, that's where most people go early in their journey on a website. Um, but. In case you don't know, I used to be a massage therapist. That was my career for 10 years. 2000 to 2010, I was an RMT in British Columbia, Canada, and loved it. Had a great time. Until I didn't. I had also somewhat infamously left the profession in a storm of Controversy. Uh, so that all came to an end in 2010. I, uh, retired from that and switched to full time science writing. And I think of myself as a journalist now.

It's been 15 years, almost 15 years. Since I last, [00:03:34] uh, was massaging therapeutically and man, it's, it's a faded memory. Now it's starting to seem like it was a really long time ago. Cause it was, um, uh, it seems, it seems less and less important to my. career now. Journalism has taken over. I, I read, I research, I write, and I've been doing that all day, every day for 15 years, uh, without massaging anyone.

So massage therapy is history for me.

[00:04:04] Mark Kargela: Yeah. And we're going to link Paul's website. We were talking about the evolution of his website and we'll maybe get into that in a little bit, but pain science. com, uh, a great URL. And we'll maybe talk to the challenges that the URL has brought to you as far as some of the, the, 

[00:04:17] Paul Ingraham: Great in some ways, 

[00:04:18] Mark Kargela: Yeah, great in some ways, not great in others, exactly, as far as some of the misconceptions and perceptions of people.

What brought you into like science writing? Was there a curiosity you saw clinically as you were doing some of your massage therapy work that kind of led you to, you know, I know for me you may have heard the existential crises, and I [00:04:34] think I've seen this with pretty much most folks I've talked to of like what the hell am I doing in clinic when you're starting to read what science is telling us around pain and then, What you're doing in clinic doesn't always align and, and, you know, am I cut for this?

Is this, should I be doing this? What, what was your kind of journey to get to where, you know, this, this scientific writing, scientific journalism became, you know, your, your primary gig?

[00:04:54] Paul Ingraham: Yeah, I was already a writer. I had been a, I'm a lifelong writer. I started writing as soon as I could press keys on a keyboard. Um, I was born a long, long time ago. So in the late seventies as a small child, I had my first type of writer and I used it, which is kind of amazing. I mean, there's not a lot of, you know, six year olds who are banging away on a keyboard.

typewriter. And so it's really, you know, I'm one of those people that is strongly identified with a profession and massage [00:05:34] therapy was a day job for me. Um, I had tried and failed to be a freelance writer. I had tried and failed to be a novelist. Um, and I needed a day job like so many artists do like so many creatives do. And, uh, I chose massage because I liked the idea of it, and it seemed like a pretty good way of earning a living while I was continuing to try to be a writer. So, uh, so the writing was already there. And then I got involved in massage and got fascinated. by the clinical puzzles. Uh, it didn't take me long to realize that I was in way over my head. Um, but you know, that probably wasn't actually what first pushed me to write the, as a lifelong habit. I, I just, I write about things that I'm puzzled by and interested in. And what was puzzling me and [00:06:34] interesting me was some of the intense flaky nonsense in massage therapy and asking questions about why are massage therapists doing that? Um, I was pretty credulous back then. I believed a lot of weird things. Um, I was a full blown, uh, crunchy flake myself up to that point, but basically I encountered stuff in massage therapy that was too weird for me. And I started asking questions about it and it started to become a mental habit. And, uh, like as an example, um, I was super sore from a workout from a day of hiking, I think it was. And I had an Epsom salts bath and I found myself wondering in the Epsom salts bath, Does this do anything? Is this really good for my muscle [00:07:34] soreness? Didn't touch it, by the way. And I wrote, you know, like a, maybe a thousand word, uh, article about it, really just exploring my own thoughts on the subject.

And it was super amateurish by my modern standards, but it was, it was the first time that I tackled a debunking. And, uh, I got hooked. And that article still exists to this day. It's like a 20, 000 word monster. It has a ton of citations. I have thought more and written more about Epsom salts than anyone else alive, as far as I know. And, and, uh, and that was just the first topic that got me. And now there are, now there are hundreds, hundreds of topics. I can't keep up. There's a to do list of a thousand more topics that I still haven't. Touchstone.

So that is how it began.

[00:08:26] Mark Kargela: nice, nice, I, you know what, the typewriter brings back some, some fond memories, you know, the old carriage return and, and some of the different things [00:08:34] that, you know, I talked to, like, my daughter just, it's a blank stare whenever I, she's like, it doesn't make any sense whatsoever. She just has known everything to be as digital.

As it has been. But the good old fashioned typewriter with the old whiteout, I remember learning keyboarding with the old typewriters in our, in our high school. So yeah, that's, that brings back a blast from the past. With your publishing in some of these topics, and again, you're publishing in topics where there's a lot of cultural popular belief.

Epson Salts is a great, probably, example of this. I haven't peeked at that article. But I have to imagine you've had to navigate some challenging responses to some of your, some of your work. Some people don't like science if it doesn't really agree with their worldview of how they, you know, think Eps and Salts are.

Uh, one, I mean, I'd love if you could share how much of that you deal with on a regular basis and then what's been your strategy? I think, You know, if we always just engage with everybody that disagreed with us, we, you know, find ourselves a very unhappy, frustrating existence. I'm just, yeah, busy for sure.

And I think it's [00:09:34] healthy, right? I think it's, it's good to surround. I actually like keeping feeds of people I don't agree with on my social media and stuff, especially ones that I can have a respectful dialogue with. I don't mind disagreement. I think it's, it's healthy, but what's been your experience with some of the disagreement and kind of responses to some of your, you know, Again, maybe challenging popular cultural beliefs around some of the pain topics.

[00:09:55] Paul Ingraham: Yeah, I mean, I started out as a creative writer, um, which is the, you know, the hint of a, of a feeling that I should probably have a footnote. So my early efforts were, um, colorful, be a good word for it. Um, provocative. Uh, in your face and I got a lot of hate mail for a long time. Um, the, my early work was, um, uh, very controversial and attracted a lot of fan mail and hate mail. It was very polarizing. Um, [00:10:34] That got really exhausting after a few years, uh, especially when that moved to social media. And, you know, for a little while there, you know, circa 2012, um, it was just nonstop. There was just every day, all day was arguing with strangers online for a while. Didn't take me too long to decide. I didn't really want my life to be about that. Um, and there was a darker side too. There were, uh, there were legal threats and hassles and regulatory threats and hassles. That's why I left massage, because my, uh, uh, professional regulator wasn't happy with the things that I was writing. They thought I had a bad attitude. And, uh, and so, you know, it's the, it wasn't just getting poison pills in my inbox. It was, you know, there were serious reasons to try to minimize the [00:11:34] conflict and the drama. And so I started on the path that I'm still on now, which is Be classy. Don't fight with people. I don't argue online at all. If someone comments on one of my Facebook posts with something, you know, with some form of blatantly counterfactual information, I will step in and I will say what I believe to be true.

the case, the truth. Um, but I don't argue with people. I don't challenge people. There was, I took me years to edit, um, my work to revise my content so that it was still entertaining and fun and had an element of whimsy. I didn't want to edit all the color out of it. But I had to declaw it. I did a lot of declawing for a long time. And it worked. I no longer get a ton of hate mail. [00:12:34] And I think that my online persona is what I want it to be now, which is the guy who stays classy and keeps it thoughtful and not argumentative. I hope.

[00:12:48] Mark Kargela: Yeah, which I appreciate with you. I think I've always seen you as somebody who's, you know, carries themselves very well and, and, you know, kind of portrays yourself and your thoughts in a, you know, very intellectually honest manner and, uh, doesn't get really pulled into the mud a lot. I'm wondering with the social media world that we live in, where.

Sometimes the polarization in the clause out stuff is what, you know, some of our folks want to put out there. Cause if you look at any of this stuff, like if you really want to get followers and attract that stuff, it doesn't sound like that's really, I mean, you, you're more interested in developing, it sounds like a readership or folks that are not into the polarizing and which sounds like saves you a good bit of mental health, you know, bandwidth as well.

I'm just wondering, is there ever, do you feel like that was something you had to [00:13:34] sacrifice like that whole. It's not like you don't have a decent social media following. You have a solid social media following. But do you feel like the, the, the taking the teeth out of things is something that you willingly done knowing it may impact, you know, that, that social media world that we live in as far as your, your growth in that, that, that world?

[00:13:53] Paul Ingraham: I think I've really paid a price for it. Actually, uh, my social media following is pretty decent, but I've been, you know, dramatically surpassed by, um, exactly the kind of, um, characters online that you would expect people who are. If you want to put it as nicely as possible, the brave ones, the ones who are, um, loudly and constantly daring to directly challenge bullshit. Um, I can admire that, but yeah, there's by keeping a very even tone and not being sensational, [00:14:34] um, I think I've sacrificed a lot of growth, um, I could have ten times the following that I do now if I wanted to be spicier. But I don't. I really don't. And, uh, and so this is, you know, there's at least two ways in which my career has been held back, uh, by my values and by my tastes.

And that's one of them. And, and the other is, you know, not being, uh, not the crass pursuit of, uh, of attention through giving people easy answers and quick fixes. You know, the, the old line skeptics are always saying this, that, you know, if only we do away with our ethics, we could be rich because it's easy to sell snake oil. So, um, but you know, the tamer version of that is not necessarily selling snake oil, but I just refuse to [00:15:34] give people what they really want, which is simple answers, and that has really. probably seriously suppressed my ability to make a living.

[00:15:46] Mark Kargela: Yeah, I mean, I admire you for your integrity and your ethics to, you know, maintain that pursuit. I think it's tough, right? I know there's some people who are very, you know, have found a way to maybe balance a little bit of that. I struggle similarly with that. The, you know, the, what you see is like the, the keys to growth in social media.

You really need to take a stand and, and really make it as simple. I'm sorry, you know, science and pain isn't simple and it's not meant to be simple. Um, if the answers were easy, you know, we wouldn't have problems with pain. We wouldn't have, you know, the issues we have. So, you know, kudos for you for, for standing up for something you believe in on that front.

I'm wondering if we could circle back, because I thought it was fascinating, you know, the, the evolution of your online writing career, especially with where you started on [00:16:34] SaveYourself. ca to what, you know, now to Pain Science, and some of the challenges still that exist, like you said, and we spoke about before we went on, but I'd love to share that with the audience as far as Kind of how it started, obviously save yourself CA, there were some obviously challenges you faced with, with that URL and drove you, gosh, and that you, you had mentioned about nine or 10 years ago, almost to change to pain science.

com. And now that's given you some, some challenges as far as from a perception, maybe marketing, branding types of perspective. I'm wondering if you can kind of share that journey with the audience.

[00:17:06] Paul Ingraham: Yeah, sure. Yeah. So save yourself. ca was my, the original website name. I actually had a couple of others. I think, uh, mindbodyguide. ca was one and, uh, I had something good for, my massage therapy practice in Vancouver. I can't remember what it is right now, but it was great. I remember, I remember people being envious of it.

It was early days, right? Hardly anybody had a website back then. Um, Save Yourself was not a, [00:17:34] I didn't think much about it. And, uh, and I regretted it almost immediately after creating it and then lived with it until 2015. Uh, kind of cringing the whole time. You know, I built a business. I had several ebooks that were selling nicely from about 2007 to 2015. Um, all on that name, Save Yourself, which has, um, I just don't care for the vibe. It, and it directly implies exactly what I just said. I don't want to do ever, which is give people easy answers. Um, I, I want. To help people, but I don't want them to think that they can save themselves just by reading an article that I've written.

I don't care for that. It over promises. And, uh, and I think that it's really hard to deliver in my business. Um, so I try not to promise much because I, I think that it's really hard for people to solve difficult pain problems. So I [00:18:34] ditched Save Yourself in 2015, which was, uh, entrepreneurial and catastrophic, uh, in a couple of ways, it was an SEO disaster for no apparent reason, um, I had consulted with an expert. I spent, I think that, you know, I think it cost me about five grand, um, to work with that expert before, during, and after the transition, which was disastrous. Uh, we. I firmly believed that there would be no problem with my Google page rank, that my, uh, my articles would continue to show up on the first page of many searches. They didn't. Um, in fact, Google practically got rid of me entirely. And it took, I never, I never recovered. The website never recovered from that transition. Um, I got back to a point, you know, where I could. do okay, but it was an [00:19:34] SEO disaster and I've never figured out why. A tremendous amount of effort I put into trying to figure that out. Still have no explanation for what the hell happened there. Now, maybe of a little more interest to your audience, other than the SEO backstory, um, the name pain science, I chose that very carefully. at the time. I put a lot of thought into it. I probably thought about it for, you know, all of 2014 before I finally made the transition.

And then almost immediately, like within a year, I realized I had made another huge mistake. Uh, naming things is hard and, uh, and I could not have anticipated that. what was going to happen. And what happened is that pretty much at exactly that point in the history of our field, um, that's when people started to think that pain science was the same thing as, [00:20:34] uh, pain neuroscience education and explain pain. Pain neuroscience education being the generic general concept for trying to treat pain by talking to people about it and how it works and explain pain being the primary branded example of PNE. I don't understand why to this day, but people think that the words pain science refer to P& E and ExplainPain. And they don't. They just don't. Unless you accept that popular usage defines words, which, ultimately, it does. Um, and that's my problem. Is that large numbers of people think that my website is about ExplainPain. That it's an ExplainPain website. That I'm like, you know, part of Laura Mosley's, uh, empire. And I'm not. I like Lorimer. I respect him. Uh, I have, um, been interested in his work for [00:21:34] many years, but I write about a lot of stuff that has nothing to do with explained pain. And increasingly I do have some concerns, some problems with P& E and explained pain. It's getting kind of awkward. So not only does the name bizarrely mislead people into thinking that I'm all about ExplainPain, uh, but increasingly, uh, you know, back in 2015, I would have been almost proud of that.

It would, at first, it was like, oh, okay, well, it's, you know, there's a lot more to what I do than ExplainPain, but, but sure, ExplainPain, it's great. Now, it's more like, Eh, I don't really want to be known that way. I really don't. And yet, that association between the words pain science and explained pain, it is strong, and it's puzzling. So for the record, my website is about the science of pain. All science of pain. Not just [00:22:34] pain neuroscience education. Definitely not just that.

[00:22:38] Mark Kargela: It is interesting the public perception that goes on and how, like you said, just how words get kind of based on cultural popularity. They kind of get kind of pigeonholed into a certain meaning when obviously there's a lot more depth to, to your website and your work than, than P& E. And I think I share similar, you know, kind of, I don't want to say disenfranchised, maybe a little bit of like seeing where P& E has kind of, you know, made its rise and it's, again, it's been a helpful overall thing for us to kind of understand, but I think we've really understand we can't just explain away pain for people and that it takes a lot more complexity and, and, and person centered things.

to get after it. I'm wondering what your biggest influences have been for scientific writing. There's some great websites out there that are kind of debunking websites. Um, uh, God, I can't think of that. There's one Helen Hislop and a few others are on it. I can't think of the name for whatever reason. I'm sure you'll tell me, um, just some of the like, [00:23:34] uh, Steve, somebody novella or something.

I can't remember.

[00:23:38] Paul Ingraham: Steve Novello or someone. Yeah. He's probably my single biggest influence,

[00:23:42] Mark Kargela: Yeah, like, yeah, I can't remember the name, science based medicine or something like that, maybe that's the, okay, see, my brain was forever, I just had like a little brain lapse, but I'm wondering, like, sites like that, or what have, what have been the big influences that kind of push you in your scientific writing, has there been anybody you look out there that you see, like, hey, they're doing it in a way that I kind of admire and kind of can model myself after a little bit?

[00:24:03] Paul Ingraham: Yeah. There's, I mean, there's a lot of, a lot of great examples and, and, and here's where I, you know, inevitably start to, you know, forget people that I should remember, but, um, science based medicine. org was really important in my development as a science writer. Um, I lucked out and met the people responsible for SBM at a skeptical conference in 2007. Uh, just after they had started SBM and, uh, I got in on the ground floor. I invited myself. I said, Hey, do you want, you know, do you want help? [00:24:34] I can do whatever needs doing proofreading and. technical stuff and I got involved and was in close communication with that crew for a few years and, um, and it was, uh, it was an education. I learned a lot. I learned fast. I had a lot of biases challenged. When I met them, I was already enthusiastically embracing my new identity as a skeptic, but I was a, I was a baby skeptic. There was so much I didn't know, and by the time they were done with me, I was no longer a baby skeptic. I was a toddler skeptic. It's a long process. I think something people really don't understand, and I think this is actually particularly a problem in our field, that a lot of, um, card carrying skeptics in this business, um, are pretty, sorry fellow skeptics, um, beginners. They're beginners. and don't have a [00:25:34] good appreciation of just how much there is to know about skepticism itself, about critical analysis, um, about, uh, uh, the kinds of ways that we fool ourselves, even the skeptics. Um, It's pretty common for skeptics to pay lip service to the idea that we need to apply our skepticism to our own thinking, that we need to see how we fall victim to exactly the same things that we accuse quacks of. Unfortunately, it's, I think, very rare for skeptics to actually do that. It's really hard to apply these rules and this wisdom and this knowledge to our own ideas. super difficult. And, uh, and I, I see an absence of that, um, pretty regularly and it worries me and it frustrates me because simplistic [00:26:34] skepticism ultimately probably isn't much better than than the alternative. A little better. I would choose team skeptic every time over team quack, but there really are problems with knee jerk simplistic skepticism.

It can, it can do damage.

[00:26:54] Mark Kargela: With that said, I'm wondering like what you've come across in your, your journey to toddler level skepticism, um, that maybe is your biggest concepts that really have, maybe that you were exposed to that made you realize, and I'm, of course, probably this podcast that we could probably sit for 

[00:27:09] Paul Ingraham: It's not long enough. 

[00:27:11] Mark Kargela: Yeah, exactly. We, but, but maybe like, what are the concepts? And again, maybe that could spur some of, of our burgeoning skeptics out there who are listening. 'cause I definitely, probably would, I would probably be a beginner skeptic for sure. I think, I don't put it, I, I try to read science-based medicine and think, and, and look at the critical thought and analysis that goes into.

Making these skeptical arguments [00:27:34] about treatment claims and new things that come out the new shiny, you know, regenerative medicine activity which that's my current frustration as far as Science be damned as far as our jump on profit based medicine But anyway, that's another topic for maybe another podcast, but I'm wondering if you could share maybe some of the Um, concepts that you found that were very helpful in, in maybe your development of more higher level skepticism and maybe some resources out there, obviously science based medicine being one of the best ones, but maybe be it a book or a website or something that you think folks might get some benefit from.

[00:28:07] Paul Ingraham: Yeah, I'll think about that. There's no one place. Uh, uh, I think that the, uh, the Skeptic's Guide to the Universe, which Steven Novella's, that's also his project, is doing a pretty good job with that. And Steven Novella's course, um, uh, He's got a course with The Great Courses, which is, uh, focused on, um, uh, cognitive, uh, [00:28:34] uh, distortions.

There we go. Couldn't quite get the word. Cognitive distortions. That's what it's all about. How thinking goes wrong. That's an excellent basic grounding, but that's going back years now. Um, they've got a book, um, that I think is probably an excellent general guide. to skepticism about a wide range of topics. Um, so the Skeptic's Guide to the Universe book is pretty great. Um, those guys have been, you know, they've been at it for a long time and it shows. Um, now to answer the start of your question, um, I think a really common problem that we see is mistaking an absence of evidence for evidence of absence. So really, Common basic mistake that, um, uh, knee jerk skepticism makes is just because there is no evidence for something, uh, concluding that there can't be and that there isn't and never will be, um, and most, uh, most people are familiar with [00:29:34] the phrase, you know, an absence of evidence is not an, um, uh, evidence of absence. But again, we have a lip service versus reality problem. People will say that, but they don't tend to act like it. So to make this practical, to make this, uh, give you an example, um, trigger point diagnosis, um, skeptics are very skeptical about trigger points. And one of the go to arguments is that, uh, diagnosis is unreliable.

Okay. Um, the reality, as I understand it, studying subject very, very hard for a long time, is that we have a classic example here of an absence of evidence. We just don't actually know how reliable trigger point diagnosis is, how we don't know how reliable that is. Um, also [00:30:34] related problem is. Kind of absolutism. A lot of things aren't reliable in medical diagnosis of all kinds. Diagnosis is a squishy business with lots of problems and lots of diagnosis suffers from low reliability. That doesn't mean that it's fundamentally misguided or impossible. So somewhat poor reliability is to be expected, uh, for a lot of, uh, well, virtually anything you do in a physical exam. It's not, um, it's not weird that it, is hard to diagnose things by feel. Uh, we should expect that, but mostly there's just not adequate evidence on the topic, but you wouldn't know that from the way skeptics talk about it. Um, there's an, uh, it's almost automatic to just say it's not reliable. Therefore, there [00:31:34] are no trigger points. That's the conclusion. And that is, it's not necessarily wrong, but it is much too simple. There's way more to it than that. And I never see the nuance. And I, what I see is the skeptical agenda. The skeptical bias is strongly powering what is said about it. Their goal is to discredit the idea of trigger points.

And they do that by saying, you know, It's not reliable because, um, there's an absence of evidence on that. Uh, what we actually need is to study it properly and find out the truth. And that hasn't been done yet. It's just simply not clear. We cannot use the evidence one way or the other. Um, but skeptics use an absence of evidence all the time to overstate the case against certain things. And I am cool with that when it's homeopathy. Um, but there's a bunch of stuff in the gray zone in the middle in our [00:32:34] business that is, uh, a lot more complicated than the most rank snake oils.

[00:32:42] Mark Kargela: Yeah. And that's the tough thing too, when we're communicating in these like false dichotomous social media worlds where it's like you're either a pro or a con and there's no middle nuance, obviously that you really study and look at it's, it's hard. And I think we've talked about this where it just creates these areas where clinicians who are trying to get a footing in their clinical development, they're early on in their career.

Um, and then they just see these social media, you know, absolutist statements when there is probably a lot of gray and nuance versus, you know, what gets clicks and what, what gets people, you know, riled up and things with, with. Kind of the skeptical approach. I got to imagine you get the the nihilist tag thrown at you a bit because I, you know, being skeptical myself in a lot of ways, like, well, you're just saying nothing works, you know, that nothing exists.

No, we can't do anything with pain. [00:33:34] And there seems to be these kind of knee jerk reactions. And it often, when it's threatening one of maybe our pet intervention or, or, you know, maybe whatever we're big homeopathy. You know, supporters or whatever, what's been your experience with the whole nihilist rebuttal that you, that sometimes comes back when you're skeptical.

And, and where do you think that comes from, from some of the folks that are kind of maybe lobbing it our way?

[00:33:59] Paul Ingraham: Well, there's a lot of turf defending, right? That's probably the main motivation. Practically anyone, you know, who has ever, um, said, You're so negative, you don't think anything works. They're almost always defending something that they think does work. Um, something that I really want patients to understand, but Honestly, professionals need to understand it too.

I didn't get it for many years as a working clinician. You know, this probably is a post clinical insight for me, but eventually I figured out that practically everything you've ever heard of in the [00:34:34] field of manual therapy, practically every method of treating pain that you've ever heard of was essentially created by Bye. marketing. We have many gods of the gaps. We don't, it's very difficult to treat stubborn and puzzling pain. And so for decades, we've had entrepreneurs, uh, cooking up highly marketable for how to solve those difficult problems. And it's the loudest and the most emotionally appealing and the most competently and aggressively marketed ideas that have become dominant. And that's the only way that anybody has heard about any of these things. And so the field is just awash. It is almost exclusively about These, uh, ideas that have been [00:35:34] successful in the marketplace. They didn't rise to the top because they had good evidence. I can tell you that. They didn't win because they had science behind them. Uh, in fact, there's a very strong pattern in the last, you know, several decades of, of, uh, the business of ideas, treatment ideas, preceding, uh, science about them by a lot by decades. So, you know, something like say, prolotherapy was out in the wild and being practiced routinely for probably 20 years before anyone did a study on it.

And when they did finally do it, it was a highly biased, crappy little trial. I don't actually specifically know this about prolotherapy. I'm just guessing this is the pattern, you know, there's nothing for ages. And then finally, someone decides. [00:36:34] To do a study to prove that their pet therapy works and it's usually terrible highly biased p hacked to death, uh, cruddy little trial. And so there's some truth in the accusation that I don't think anything works because almost everything that everybody's heard of is problematic. We do in fact. Swim in a, in a, a sea full of crappy ideas. And so there's, there is a lot of negativity, but what, but the answer that I've always had to, uh, to anyone who says you're so negative, you don't think anything works is, well, here's a whole bunch of examples of things that I do think are worth doing and valuable. It's not that I think that nothing works. It's that I think a lot [00:37:34] of the most popular ideas are pretty bad and have a lot of problems. And the competition is relatively difficult to explain, not as sexy, doesn't sell as well, it's more complicated, um, so it's just harder to, um, give, the simple answers aren't there to give. It's not that I don't think anything works, it's that I don't think anything simple works. Um, so that's it. That's a shot at an answer to that very difficult question. I have an entire article on my website about my negativity,

[00:38:15] Mark Kargela: Yeah, 

[00:38:15] Paul Ingraham: I wrote years ago.

[00:38:17] Mark Kargela: we'll link it in the show notes and obviously we'll link, uh, your website and your work. Cause I think it's definitely, um, we, we need to get that SEO travesty, right. It at least a little bit, hopefully this can 

[00:38:27] Paul Ingraham: Oh, there's, there's no hope. The Google, the Google situation is appalling these days.

It's just terrible. [00:38:34] 

[00:38:34] Mark Kargela: That's a bummer, man. I'm sorry. Sorry to hear that that went down, but, um, I'm wondering, like, if you have any, like, Things like the under, I mean, you don't have to give me any top secret projects or anything like that, but where, where do you think we need to be going as far as like as a profession and maybe professions around pain?

Like what, what needs to be out there from an information standpoint for clinicians? Maybe it's something clinicians need to pick up or, uh, topics that are out there that are just greatly understudied. Is there anything out there that you feel like, man, if we really want to move ourselves forward to better, understand this nebulous, complex, you know, emergent complex phenomenon that is pain.

Anything that, uh, you would point folks to or, or kind of recommend folks to?

[00:39:19] Paul Ingraham: Um, the general trend that concerns me is that we're moving from, um, the simplistic ideas of the past to brand new simplistic ideas that are not really an improvement. Um, And [00:39:34] where we actually need to go, I think, is, uh, we need to learn a lot about physiology. the the problem with pain and rehab is that it turns out, right, that it's a much harder job than anyone thought it would be. And the, the history of the field is grounded in the assumption that it's not. Uh, the assumptions of structuralism, that the body is like a complicated machine that wears out and breaks down and needs to be aligned and balanced and fixed in various ways, and, uh, the, you know, we had a few decades of that and it remains the dominant. Paradigm to an astonishing degree that is still what both patients and professionals basically think about musculoskeletal medicine, that it's a kind of, you know, fancy mechanic and, but the progressive alternatives. that have been, [00:40:34] um, you know, quite strongly pushed in the last 10 to 20 years. Um, I'm not sure that they're much better. And I don't think it's really an improvement to go from the, the simplistic bio perspective of structuralism to this, simplistic, um, psychosocial, um, the, I have not said this as well as I would like. Let me, let me do one of those interrupts. Let me, uh, let me, let me tackle that again. Hang on a

second. Bear with me.

[00:41:13] Mark Kargela: no worries, man. I like where your head's going with it.

[00:41:23] Paul Ingraham: I'm searching for something I wrote.

[00:41:26] Mark Kargela: Yeah, no, no rush, man.

[00:41:31] Paul Ingraham: I don't know if I'm going to be able to find it at high [00:41:34] speed. Hang on. You okay with this?

[00:41:39] Mark Kargela: Yeah, absolutely. I'm just, I'm just, somebody just messaged me. There's been pestering me here.

[00:42:03] Paul Ingraham: Yeah, this is too hard to do.

[00:42:07] Mark Kargela: No worries.

[00:42:09] Paul Ingraham: Now that's a hard interrupt because I don't, I lost my train of thought entirely and don't even remember where we

[00:42:14] Mark Kargela: I think you kind of had gotten into where, like the alternative of the psychosocial you are saying, like we need to kind of really study physiology more in that the initial fancy mechanic ing around, you know, bio, you know, focused pain understandings obviously is run its course, but the new alternative of like [00:42:34] psychosocial simplistic, simplistic psychosocial, uh, views obviously isn't much better.

Um, and that's kind of where you were leaving off a little bit.

[00:42:43] Paul Ingraham: I still, I still have a very strong craving to find something I wrote. If you're, if you're happy waiting a little bit longer,

[00:42:48] Mark Kargela: Yeah, yeah, grab it. And, uh, I probably got about 10, 15 minutes and then, but we only got, we'll just finish this question off and then I want to kind of maybe hear any projects or anything you got going on. No worries. Yeah. We'll just kind of, usually I wind down with having you kind of let us know if there's any projects in the pipeline or anything you got going on, I want to make sure we highlight anything that could help your website out or your work.

[00:43:23] Paul Ingraham: Uh, I know where I can find this. I have a real problem with the amount that I've written. It can be surprisingly hard

[00:43:32] Mark Kargela: You get a quite the, uh, [00:43:34] collection. 

[00:43:34] Paul Ingraham: own content. 

[00:43:36] Mark Kargela: You got to, you got to have that information architecture so you can just like, you know, quickly bop into it, but no, that's, that's a challenge when you start writing enough, it becomes a, a sea of, of thoughts and, and good stuff.

[00:43:48] Paul Ingraham: Yeah. And it's, it's pretty, it's pretty easy for me to find things when I'm, uh, you know, when I'm in the zone, you know, writing, but in, in interview mode, it's a little harder to

shift gears and think about, uh,

[00:44:00] Mark Kargela: Yeah, no worries.

[00:44:02] Paul Ingraham: Come on, see this is such, this is so much what I mean, like I know I've got a draft about this and yet I am not finding it in my draft folder.

[00:44:16] Mark Kargela: Our 

[00:44:16] Paul Ingraham: it's something I've something I've spent a bunch of time on. There we go. Why is, why is care for chronic pain and stubborn injuries so crappy is the title of the post.

[00:44:28] Mark Kargela: it.[00:44:34] 

[00:44:35] Paul Ingraham: I'm getting very close to what I was looking for.

[00:44:37] Mark Kargela: Yeah, no worries.

[00:44:51] Paul Ingraham: Yeah, okay.

This is, uh, this is basically, okay, so. Let's, uh, try to merge back into it. I hope that this, I hope this isn't too jarring a transition in your edit.

[00:45:11] Mark Kargela: Uh, no worries. I I've, I'm a master at, at making it seamless to where you might notice it, but the audience will, will be good. So no worries, no worries. I love it.

[00:45:21] Paul Ingraham: My concern is that we're, we're moving out of the frying pan into the fire. that, um, that instead of the simplistic ideas of the past, we've got new [00:45:34] simplistic ideas. Uh, we've seen many laudable attempts by professionals to move beyond the structuralism of the past, but it doesn't feel like it's working out very well because now we're also seeing legions of allegedly progressive professionals. shifting the blame from visible flaws and fragility to psychology and the power of the mind, demonizing and overemphasizing stress and anxiety, uh, which they're, they're relevant, but they're rarely the root of the problem. And I think that this has resulted in a wave of ever more sophisticated ways of blaming patients for their pain. While trying not to sound like it. And getting quite clever at it. But what I hear from patients is that they still hear the subtext loud and clear. Which is blaming the mind, [00:46:34] which is all in your head. Um, and I don't think this is an upgrade and, and yet it's where I, I see it under the banner of progressiveness.

I see us hurtling towards, uh, a new simplistic thing. Uh, and what we really need is to embrace the fact that. Most pain is attributable to pathology, and a lot of it is very hard to diagnose, and rare conditions are not rare collectively. There are a lot of rare conditions, and any one of them is rare, but collectively they're kind of common. So it's, I think, amazing and disturbing how much pain is explained by subtle pathology, and Yet that is not where you see the attention. That is not where you see the energy. Instead, [00:47:34] you see people obsessed with the curable app, uh, and with pain neuroscience education, which isn't necessarily wrong, but I think that we're really missing the, what really matters.

And that basically, I think the implication is that treating pain is so hard that maybe, very, very challenging idea here. Maybe the current crop of manual therapists aren't qualified. No one's qualified. We just don't have the training. Doctors don't have it either, although they're in many ways closer. If we need to understand pathology really well to wrap our heads around difficult pain puzzles, we've got a problem. All the manual therapies have an existential crisis if that's the case.

[00:48:30] Mark Kargela: That is, that is for certain. I often think like the defined [00:48:34] professional boundaries and they're, they're, they're grouped of bits of knowledge, just really greatly limit our ability to put together neurology, immunology, all these different fields that show that there's a, quite a big complex. You know, you know, multi system dysregulatory situation where I think we need to see a blurring of some of these lines and you see it a little bit with neuroimmunology, gosh, you get psycho neuroimmunology and these different fields that are kind of burgeoning out of this need to, again, maybe the psychology.

And again, we can talk about embodiment and things, how we embody our psychological world and it creates physiologic change. I think we do, I agree, need to. not lose sight of physiology as well. Cause I do think there's definitely been, and I've mentored some newer clinicians where they've grabbed onto the explained pain bandwagon, the P and E bandwagon, and they go right to, well, this person just needs to live and deal with their pain.

I'm like, they have a very treatable condition. You've kind of just like defaulted your clinical skills and said, [00:49:34] Oh, they're in, they're, you know, something that maybe you're not feeling competent to treat. You're just going to chalk it to, oh, this is just a persistent pain issue and we need to teach them to live with it.

So, really appreciate your, your thoughts on that. Um, I'm wondering what your thoughts are on like some of the professional limitations when it becomes piecing together this physiology where even just physiology on its own probably isn't going to. Explain a lot of this stuff. Maybe how our mental world and physical world intersect and collide is, do you feel like that's maybe a missing piece of obviously not just tight casting?

Well, it's all in your brain or it's all in your body. It's all the things, right? It's in these systems become. I mean, that's my thought. And you can definitely disagree because I don't mind mind that at all. But yeah, I'm just curious where your thoughts are as far as like you know, maybe broadening physiology to not just the, the, the muscle and bones that there's probably more to our physiology that gets affected beyond just, you know, mechanics, I guess.

[00:50:32] Paul Ingraham: Neuroimmunology

would be the, [00:50:34] you know, the big, you know, that's, that's probably the easiest one word answer to the question. Neuroimmunology. Um, nothing's excluded. Everything that happens. But inside our skin is physiology.

Um, but I, I think that we, we have a problem with chronically underestimating what that means and just how wet and messy it is. Um, and that seemingly mechanical problems are time and time again, the tip of a physiological iceberg that we do not understand. Well, um, I'm pretty sure no, I'm, I'm really sure I, I I will go so far as to say, I know that we are missing big pieces still. Um, I take that from the fact that, you know, I don't know the number, but it's huge.

Some staggering percentage of, uh, neurologist visits, um, are inexplicable, right? People present with neurological symptoms all the time that neurologists cannot explain, cannot help because they're rightfully [00:51:34] preoccupied. Their knowledge and expertise, their training and clinical work is correctly, completely consumed with dealing with the major. known neurological disorders, but it's quite clear that there's more and there just aren't enough patients with those problems for it to become a thing. We don't even have names for some of the things that can go wrong. That's obvious. It's especially obvious in the age of long COVID. So we're missing big pieces, but I'm pretty also pretty sure that most of those big pieces are physiological, uh, and many of them neuro immunological. And, uh, and when I think about massage therapists, you know, trying to help people in pain, that they really need to learn a bunch of physiology, I despair, because it's not going to happen.

[00:52:25] Mark Kargela: Yeah. Yeah. It's a challenging, challenging situation for sure. Like you said, the manual therapists and existential crises that are inevitable with kind of [00:52:34] where our understandings of pain kind of are moving definitely. Definitely some things to think about. I'm wondering, you know, we could talk about this for hours really.

And I would, I would 

[00:52:44] Paul Ingraham: Clearly, I have to come back.

[00:52:46] Mark Kargela: exactly. Absolutely. I definitely, I would love that. And I'd love to, if you could share, we've obviously shared your website, pain science. com. Any projects you had coming down the pipeline or anything that's going on or, and then also where can people see, I know you're on X, you're on a few other platforms where, where can folks get in contact you to kind of see what you're sharing on social media when you're, when you're putting out some of your great content.

[00:53:07] Paul Ingraham: There's a steady trickle of social media, uh, uh, participation on Facebook, Threads, and X. I think that's the first time I've ever used that brand name. yeah. X Twitter is what I prefer to

call it. I'm still there. So I'm participating there and that's it. I'm technically on Instagram. Painsci is usually my handle.

Painscience on Facebook. [00:53:34] But, um, I still have, in an era when websites are dying, I still have a big one. And that is my only project. I'm not even working on a new book, particularly, although in theory, I'm always working on new books. I don't have anything like that coming. The biggest project in my life right now is slowly moving from a business model of mostly selling e books to mostly writing.

selling memberships. And, uh, and so go to pain science. com slash membership and check it out. See what I'm selling, uh, because it's hard to make a living doing this stuff. So if you appreciate what I do, I would really appreciate it. If you would help me do what I do.

[00:54:19] Mark Kargela: Yeah, definitely. Those of you listening, check out, uh, that we'll link it in the show notes for y'all to check it out. And definitely I can attest to the fact that it is hard to, to, to, to make some of this stuff work from a financially viable, not making [00:54:34] your wife want to kill you standpoint of, uh, of kind of navigating things.

And I've just want to, you know, I know I speak for our audience to thank you for the work you've put in. And I definitely for one know how much. Work well, just looking at your website, I know there was a lot of thought and work that went into it and I can't thank you enough for, for the time you spent into it.

And I hope we have content for years to come from you because you've definitely been a valuable voice in the world of pain and when we need to have stick around. So thank you for that.

[00:55:04] Paul Ingraham: Thanks. Appreciate that.

[00:55:06] Mark Kargela: Well, for those of you listening, we'd love if you could subscribe, um, on wherever you're listening to your podcast. If you're watching here on YouTube, we'd love if you could give that a like or subscribe and maybe share this episode with somebody else, maybe somebody else could use some of Paul's wisdom and kind of hear some of his, his challenges around where we are with pain, um, and some of the maybe missteps we're making as we're trying to better understand and help ourselves and most of, uh, better Most importantly, help our patients in pain.

So we're going to leave it there this [00:55:34] week. Thank you all for listening and we'll talk to you all next week.

[00:55:36] Paul Ingraham: Thanks.