Pelvic Health, Outdated Pain Care & Empowering Patients | Sandy Hilton Interview

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[00:02:06] Sandy Hilton: The short version is Dr. Bailey sent me a guy, one of the loggers out in the Pacific Northwest.

And he came in and said, Dr. Bailey told me you're going to show me how to have sex without my back hurting. And I, I. Went and found the doctor and said, what? And he's it's mechanical low back pain. And I'm like, Oh, okay. Yes. I know how to help that. So I went back and helped this guy who then went to his logging camp and told everyone that this young 29 year old [00:02:34] PT showed him how to have sex without his back hurting.

[00:02:36] Mark Kargela: Pain care is evolving, but are we keeping up? In this episode, I sit down with the incredible Sandy Hilton, a trailblazing physical therapist who spent decades challenging outdated treatment methods. We dive into why treating pain with pain is a losing game, how she stumbled into pelvic health in the most unexpected way, and why the modified oswestry assessment is, in her words, an abomination.

Sandy doesn't hold back. She shares insights on breaking down barriers in pain care, empowering patients, and rethinking what it really means to help someone heal. If you're ready to challenge the status quo and rethink your approach to pain management, this is an episode you don't want to miss. Before we dive in, make sure to subscribe on your favorite podcast app or YouTube so you can never miss an episode.

And if you find this conversation valuable, drop a quick review or share it with someone who needs to hear it. Now let's get into the episode.

[00:03:24] Announcer: This is the Modern Pain Podcast with Mark Kargela.

[00:03:29] Mark Kargela: Sandy, welcome to the podcast.

[00:03:30] Sandy Hilton: Good morning.

[00:03:31] Mark Kargela: It is great to talk to you. I've been, [00:03:34] I've had the privilege of getting to know Sandy just per usual in the pain world. It's often digitally through social media means. And then we got to hang out. I think we were both at the IASP conference in Boston a couple of years back.

And I think we CSM, we might've touched base a few times. But regardless, it's good to have you here, Sandy. How is life your way?

[00:03:51] Sandy Hilton: Life is great. I just moved out to Portland in 23, back to the Pacific Northwest and I'm loving knowing where I am. I can go hiking in the mountains around here and know how to find my car, which was never a thing in Chicago. ,

[00:04:05] Mark Kargela: no Chicago. I love visiting. I don't know if I could live there, but I have a lot of good friends who love it. So it's

[00:04:11] Sandy Hilton: I have friends that adore it, and I'm very happy about that for them. I like being back in topography, where I know what direction I'm going based on what I can see in the horizon.

[00:04:20] Mark Kargela: understandable. Sandy, can you give everybody update a little bit? What's your practice situation right now? Where are you at?

[00:04:26] Sandy Hilton: I'm currently working oddly for a 36 years in the business PT for a physician owned conglomerate. [00:04:34] It's a, it's called Southwest Family Medicine. I lucked into it when I moved out here and Southwest Physical Therapy is a part of it. It is just a fun little clinic where we get to treat people.

I'm getting to see people that are have no insurance or very little insurance and we're able to help them out. And the luckily the. soul of the whole facility is that there's people that need help and we got to do what we need to do to help them so it fits my thoughts about how health care should be pretty well and probably the best office manager I've ever worked with who is I have to keep reminding myself not even 30 yet

so great career ahead for this person.

So still treating primarily pain some outpatient ortho Just by course, but mostly pelvic health for all genders and helping people out.

[00:05:26] Mark Kargela: You mentioned access and that's one of the big issues with, and it's one that I toy with as well, like having thought about practicing [00:05:34] on my own in the past. And I know you've owned your own practice for periods of time. How do you balance that? Like, how do you see that balanced as on one hand we have obviously.

Bills to pay, benefits to be, given to and salaries and all that stuff yet. There's such a huge need from an access standpoint for people that don't have the means, be it insurance, be it finances, be it both. How do you feel like that balance is best struck? I know it's probably an individual thing, but how do you look at it?

[00:06:00] Sandy Hilton: I, if I had the answer to that problem, I would be screaming it at Davos or someplace. But what I can do individually is really work with people to stay within their means. So if someone's look, I can come to therapy once a month, then we pack that visit with a progression of things they can try.

And I give them my email address and we do what we can to make it fit. That's true whether someone has good insurance or not, because sometimes life is just. It's like crazy seeing a young person that has a baby in there and trying to work and has other kids and [00:06:34] trying to find, a 45 minute block to go to an appointment is a big ask.

So they're actually on that same schedule as someone who doesn't have the means to come to therapy just because of their life commitments. I think we have to, in therapy, stay flexible. No pun intended about how we treat people and the ability to scale it for whatever reason, whether it's finance or time to what fits their life.

[00:06:58] Mark Kargela: I mean, and you bring up some good points too, because I don't think that is a necessarily just a hardship situation. It can be some people who have perfectly good insurance, just life is too chaotic. Things just don't line up. So

[00:07:10] Sandy Hilton: Yeah, it's like you have to come to therapy three times a week. It's not gonna happen. That's

not.

[00:07:16] Mark Kargela: and it's and being able to be flexible as a therapist, too, I think sometimes you come out of school with this belief that everybody needs two times a week for or three times a week for, six weeks and there's some situations I know some of our therapists, colleagues find themselves in and not just PT is others where there might be some pressures to, to see it.

And it's nice to [00:07:34] be in environments where that pressure isn't there. It's more for just the, good of the patients while still balancing.

[00:07:39] Sandy Hilton: right. But there are times when it's really important in pelvic health and in orthopedics. I seeing a guy, I love the wide range I have right now seeing a guy that just had a shoulder surgery. He has to come in fast enough to get all of those tissues moving to not make his orthopedic surgeon mad at me.

And total knee replacements, things like that where the surgery requires some really intense initial work. And then modify it out.

[00:08:04] Mark Kargela: That flexibility is huge. Now, you've been huge in the pelvic health arena. I know you wouldn't say that because you're humble, but I've just been hugely respectful of your work there. I don't do a ton of it myself, you've helped me and my wife as she was dealing with some challenges postpartum and you've I've always been someone who, to refer.

Any of my P. T. colleagues to chat with you about pelvic health. How did that emerge in your practice over the years as far as, was that just a need you saw that you needed to fill or how did that kind of come about?

[00:08:32] Sandy Hilton: Dr. Bailey in Junction City, [00:08:34] Oregon. It's cool to be back here where I tell the stories my origin story. There's an old Eric Meira's podcast when he was interviewing PTs has the whole gruesome detail on it. The short version is Dr. Bailey sent me a guy, one of the loggers out in the Pacific Northwest.

And he came in and said, Dr. Bailey told me you're going to show me how to have sex without my back hurting. And I, I. Went and found the doctor and said, what? And he's it's mechanical low back pain. And I'm like, Oh, okay. Yes. I know how to help that. So I went back and helped this guy who then went to his logging camp and told everyone that this young 29 year old PT showed him how to have sex without his back hurting.

And I had a men's health following.

And so I learned. So you'll hear a lot of pelvic health therapists talk about they got into it because of a problem they had in pregnancy or someone they cared about had a problem in pregnancy. And I'm always like, yeah, so Doc Bailey got me. The, I worked with men's health probably for six years before I saw [00:09:34] any female pelvic issues.

Female pelvic issues are more complex than many male pelvic issues. Which is weird because there's a debate going on, debate conversation going on Facebook's pelvic pages right now about whether a female pelvic therapist should feel comfortable treating men. And my stance is you should treat who you're comfortable treating because the patient is going to pick up on that.

And we owe our patients more than that. Find someone who likes it. But also I started in men's health and I just think the guys are overlooked in this area and male pelvic pain is still one of the leading causes of suicide. Cause so many guys don't talk and they're like, this is my life now.

What's the point? And they don't even get to realize there's help.

[00:10:19] Mark Kargela: Do you

[00:10:19] Sandy Hilton: huge need.

[00:10:20] Mark Kargela: , do you think there's a, it sounds like there's a, just a stigma that some guys. challenge to, to do it. And I

[00:10:26] Sandy Hilton: I think it's the same with their ankles though. I don't know that it's necessarily.

[00:10:30] Mark Kargela: is very true. It's, it seems like the boomer generation, I was just having a [00:10:34] conversation with a patient whose husband is going through a heck of a time and very resistant to any help from the healthcare arena, where I just remember like uncles of mine and things like, unless there was like profuse bleeding that needed to be stopped by a professional that they weren't going to

[00:10:47] Sandy Hilton: Absolutely. All those jokes about farmers, it's yes.

[00:10:51] Mark Kargela: you

[00:10:51] Sandy Hilton: there's some cultural stuff in other cultures as well. But I think the rub some dirt on it and drive on is pretty standard.

[00:10:59] Mark Kargela: . With some of the complexity around pelvic health. Cause I remember when I was first grabbed onto the, pain science wave. Cause it was a big epiphany for most of us. Cause it really made sense for a lot of the complexity, at least somewhat. Cause there's obviously a lot of nuance to that, but

[00:11:14] Sandy Hilton: So much.

[00:11:15] Mark Kargela: it's when I was talking to clinicians, I would be able to teach.

And I remember the women's health and pelvic health therapist St. Mark, we been doing this for a while. This is, you're not really telling us super new things with that. How have you found it sounds like from a pelvic health perspective, this stuff has been. Kind of fabric part of the fabric of what y'all have been doing from pretty much [00:11:34] the get go Do you think explain pain just really made sense of what you already were seeing in pelvic health

[00:11:39] Sandy Hilton: Oh, I think it made a huge difference in the not chasing pain itself. That is how I grew up in manual therapy through the barns. I'm a far world which might be shocking to all the people who know. I'm sciencey, but yeah, I can speak crystal. The I make that joke to my friends who were in it, so it's fair.

None of them would be shocked. The. There is less down, but still a, a. subset of treating pain that thinks we need to treat pain with painful techniques. In the pelvic health world, that was a surprise to me to find out that was what was considered a standard of care was skin rolling and deep tissue work that was exquisitely painful.

So I came to the I, I was insulated from the organization stuff moving around a lot. And then when I started going to the US meetings I was somewhat shocked that there were people that were treating [00:12:34] pain with such painful techniques in a really vulnerable area. So it's been an interesting journey of saying there are other ways to do this.

So I think that's 2010. somewhere like that in CSM was in San Diego and they had brought the section of women's health had brought Laura Mosley to it. And there were people in that room that were like, this is not how we treat pain. We go after the tissues and we beat them in dissipation is my words.

And more of the respecting, The nuances of pain as something that we don't have to just beat until they submit, but maybe change the internal conversation of how pain is perceived. And take it from a more polite perspective was really helpful because that was my intuitive response to it is we don't You don't have to hurt people who hurt to help them get better.

And certainly not a part of the body that has all these reflexive protective mechanisms. It was really nice for me to have better [00:13:34] words of, I can use the words from pain science to explain why I choose not to treat with painful techniques and have it be more than, it just doesn't feel right. Which was pretty much what I had before that.

[00:13:50] Mark Kargela: , I think painful techniques I mean, it's still pretty pervasive around the treatment of pain sounds like you know in pelvic health There's been at least a little bit of a recognition that maybe that isn't the on famine

[00:13:59] Sandy Hilton: There's a lot, and there's really good work Helena Frawley down in Australia has been doing some work for ages and got the International Continent Society to take trigger points out of how they define what you do and talk about stiffness in the tissues instead of chasing these things. So it's happening.

It's happening globally, slowly, as it happens.

[00:14:19] Mark Kargela: Still wonder sometimes. I mean, we have a lot of perverse incentives. Dry needling comes to mind. I'm not I'm not against it, but I just think a little bit of a similar whack a mole of like painful spots with something that hurts a little bit, but we don't need to go there. Cause I

[00:14:31] Sandy Hilton: There's a whole other podcast. I do [00:14:34] think that if that there are a lot of different ways to help people. And when someone says, Hey, I did this thing and I feel better. I'm going to celebrate that with them. I am not going to get into a philosophical conversation of what the mechanisms of this change might have been, but rather just say that is fabulous.

How can we keep that going? So I'll yes. And that forever, but

[00:14:54] Mark Kargela: And I think that's a great approach to it. Right. I, my ego driven, early insecure clinician years would have probably had a discussion of

[00:15:02] Sandy Hilton: you might do a bit of whiteboard

drawings.

[00:15:04] Mark Kargela: a hundred percent. So yeah, I think being willing to just, Hey, you know what, I can roll my eyes internally at the narrative that got maybe spewed into that person.

But then, Hey, let's just, we got a window here to see if we can keep you moving towards something that's

[00:15:18] Sandy Hilton: Right. The only time I do get a little, a lot pedantic is when someone is scared. When someone has been told you can never sit or you will have to give up this sport that is defining to who you are then I get, that's not [00:15:34] true. Let me show you all the reasons why it's not true. How much research would you like to see?

So I will get that

when someone's

[00:15:40] Mark Kargela: when it's very apparent that the narratives coming around are holding people back from reengaging in life because of out of fear and avoidance and things that we'd all do if that was the kind of going mindset we

[00:15:51] Sandy Hilton: I had

a person come in that was like, had been told by a, I'm filtering as I speak, had been told by a medical professional, not a PT that they had to restrict their diet so much that they were literally suicidal. They're like, if this is the rest of my life, I'm not even going to do it. And I said, well, I have really good news for you.

None of that's true. And I just pulled up all this stuff for them to see. And they were like, oh yeah, so I'll pull out the data when it's appropriate, but otherwise I'm a little egalitarian.

[00:16:27] Mark Kargela: I think just kind of context dependent and as with most things as far as when it becomes something that's for the best interest of the [00:16:34] person in front of you. I think we have a duty to challenge some of those narratives for sure.

[00:16:37] Sandy Hilton: it's part of what makes the field fun.

[00:16:39] Mark Kargela: . 100%. And I can challenge, like I work in a DO setting and I have nothing, but I've enjoyed them personally.

I do differ a little bit on the narratives. There's a lot of positional diagnostics and, fear created of things moving in and out of position that sometimes can be a barrier to some folks. But, I think you can portray that in a way that's, and do you ever get in situations where it's clinically, it's obviously you're not going to just say that's Dr.

Smith is wrong. I don't know what they're saying, but maybe create a clinical scenario where the person gets to challenge that themselves and maybe make some sense of it and talk their way through it.

[00:17:12] Sandy Hilton: I do, and it's always in the, we'll have some good news for you, and Netter comes out and we look at the hip capsule and how much ligaments are there or what the anatomy is in there and say, I know. You used to use stories, so I'll use the, like, when, late stage pregnancy, when you want to put your foot on the floor, it feels like your pelvis can be moving about 750 miles apart from each [00:17:34] other.

But what's probably happening is this little shift. Both of those things are true. It's it feels like stuff's just going to separate and it can't. And so I'll have conversations like that about, it can feel like this and it feels, yeah, it totally goes out of alignment. But look, here's the good news.

This has held so well together that what's probably happening is this force transfer is not going right. And you just, it makes sense to feel like it's falling apart, but it can't. So here's some things you can do in the moment to feel better and more secure. And I just never use those words like it's gone out of alignment or things like that.

[00:18:11] Mark Kargela: I think most of us hopefully have had a little bit of a rewash of kind of our language and things, and it's still a work in progress. I know sometimes I slip up and say

[00:18:20] Sandy Hilton: And sometimes people are so strong in that belief, I just don't even go there.

[00:18:25] Mark Kargela: It's you dip your toes in the water and see, Nope, that's not ready to be challenged at this moment. Let's just move on to something that moves them hopefully in a different

[00:18:32] Sandy Hilton: cause they don't, they just need to get [00:18:34] better. They don't need to agree with me.

[00:18:35] Mark Kargela: I want to back up a little bit. Cause one of the things you mentioned with your origin story with the gentleman saying he wanted to, have improve his back pain for sex life. The Oswestry, for instance, I know I've heard you talk about this, but the Oswestry, and I already can see the passion coming, they've removed that, right?

The modified Oswestry removes the sex question from it because, and I get it, some cultures, cultural sensitivities and things like this. What are your thoughts on that? Do you think that's really been a part of why some of the folks, where we're not tapping into maybe all the values of a patient and just pretending that part of their life isn't important and exists?

[00:19:10] Sandy Hilton: Yes, and it was actually one of my screening questions when I was moving out here was the clinics to which oswestry do you use? And both of the ones that I worked at briefly, just at one place now, use the original oswestry, not the abomination, as I call it. And I've said that to the authors of the paper where it was removed and justified.

So. I don't think you should say stuff out loud in the world if you're not willing to say it [00:19:34] to the people that were involved in it. And I'm very willing. The sex question was removed because as I recall the paper in 2001, I think it was there in the clinic when I lived in Louisiana and we were using it.

And then I went to Germany and they were using it. Oh, no, it was. Oregon, Germany, back to Louisiana, and I went to pull the oswestry in Louisiana, and it was, I would like, remember standing in the office going, who took the sex question off? Where's, why is it not here? And it was removed so that the researchers wouldn't have to deal with the question.

And there's a little line in the paper with the modified oswestry, it's that they took it off because they didn't want to deal with it, which I think is the most horrible. Example of how not or horrible the best example of how not to do biopsychosocial care. Sex is an ADL. It's a really important thing.

And a lot of times with low back pain, that's because their knee hurts or their back hurts and you can help them with position. And then, they can still feel like a person [00:20:34] who is in an intimate relationship removing it. Gets rid of a beautiful screening for Cauda Equina Syndrome because That's massive and should be picked up.

Or, sex is never supposed to hurt. It's supposed to be pleasurable. It's one of those things, as Melissa Farmer, fabulous psychologist, did a presentation once, said that peeing, pooping, and sex are all supposed to be pleasurable. And if any of that is lost, you have not only a dysfunction that needs to be addressed, but some of the main relief in our lives is gone.

And so why would we do someone into thinking that's a permanent thing that has to stay

[00:21:14] Mark Kargela: It's interesting. We just had a psychology group who was presenting on, how that exact thing, where it became this kind of, almost taboo topic where it becomes this kind of thing that people aren't willing To mention, how would you recommend a clinician to just at least open a door for that discussion?

Maybe it's not in their osteostomy, maybe they're in the modified [00:21:34] osteostomy situation, but how can they like

[00:21:36] Sandy Hilton: me?

I'd be like, use the real one.

just just stop using the abomination and use the real one. It's impromptu web. P. T. never loaded it when we were there. I mean, it just paper still works.

[00:21:48] Mark Kargela: exactly.

So in that case, maybe they can't, we'll say they're in the bureaucratic can't happen too many committees it needs to go to, or at least it's going to be a while. What would you recommend as far as maybe ways to at least open a door for discussion

[00:22:01] Sandy Hilton: I honestly just ask it as a secondary screening. And say, because it should be, it really should be part of any orthopedic or spinal, certainly thoracic to lumbar, spinal issue, and we just go for all of them of, have you had any change in bowel, bladder or sexual function? Because, again, those are screenings for cauda equina and peeing.

Incontinence is never normal and pain with any of those things is also never normal and there are signs that you should be referred to someone who can help you make that [00:22:34] stop.

[00:22:34] Mark Kargela: No that's a good strategy. I think just becomes when it doesn't becomes this like awkward introductory

[00:22:39] Sandy Hilton: Yeah, include it with bowel and bladder and then it's all the awkward conversations in one little bundle you can get it over with quickly,

[00:22:46] Mark Kargela: as well just knock it

[00:22:47] Sandy Hilton: to get it out. But I don't think that you should ask a question if you're not prepared for the follow up. So if someone says yes, you just don't have any problems with this.

Yes. Okay. How's your shoulder? It's you do need to ask follow up questions. What has changed? Have you spoken to someone? Would you like some names to go talk to you about more of this? And I don't think that someone who's not comfortable talking about sex should have that conversation.

The full conversation, you should get comfortable with saying, if there's a problem, would you like me to refer you to someone?

Here's some names and just have them ready so that you can then move on and know that you've sent someone two really powerful things. There's people who can help you and it's not normal that you stay like this. Because again, I'll go back to, look, [00:23:34] this is a high risk of suicide. Fecal incontinence, people stop going out, stop having social interactions.

They'll have to quit work, but not tell anyone why they quit. Urinary incontinence is a little easier to deal with, but still stops people from doing things they love, like running or gymnastics. And as I've said, pain with intimacy is a massive problem in relationships and the willingness to stay alive.

And those are all pretty important. And

[00:24:05] Mark Kargela: people's lives and for most people's lives, I should say, where, you take that away or it becomes greatly limited. I mean, it could be a massive piece of the puzzle that if you can help that person regain.

[00:24:15] Sandy Hilton: it's changeable.

This is not,

yeah, it can change.

[00:24:20] Mark Kargela: I'm wondering if we spin it a little bit to explain pain a little bit. We've all had that initial and I'd be curious what your like major epiphany or book or resource that really shifted or really made you have an aha moment. And then as a [00:24:34] second part to that, As we've, as science has moved and we've learned things, obviously the research Traeger study showing that, the pain neuroscience didn't make the big changes we were hoping to see and stimulated the thoughts, which I think makes sense was clinically that it's not going to be a standalone intervention.

I'm wondering how your look at like pain neuroscience education has evolved from that initial aha moment you may have had.

[00:24:57] Sandy Hilton: Well, it went first from, wow, I have better words to use. That weren't just, I think this, to, oh, look, some other people think this. So that was comforting. I have, I love, I've had the luck and the opportunity to hang out with some people that, that are part of those studies. And meet them and talk to them. World Congress of Pain is the best place to walk up to Traeger and say, tell me about your study which the fabulously fun to do. One of the, my epiphanies along the course happened walking down a street in Milan, with James Macaulay, who is part of that group. He's out of [00:25:34] Sydney, who was asking me why I'm good.

James, if you're listening, I apologize. I'm going to get it wrong. But the gist of it was what is it about graded imagery, graded exposure that you think applies to pelvic health? It was said in one of those lovely questions that was also very polite saying you might be very wrong. It was, I think it was fun.

The. Because he was right in that we don't, we didn't at the time, and we still don't have good studies on does that apply in pelvic conditions. And I said, possibly with his prompting that I think. That what we're doing is getting people to pay attention to parts that they have been trying either not to pay attention to at all, or can't stop paying attention to, and neither of those things are right.

So, I think what, rather than saying, we're going to do a laterality testing on your penis, you didn't know I was going to have conversations, we're not a clitoral or penis [00:26:34] laterality really isn't a thing. I. Don't have boy parts, so I can't tell you if there is great dexterity in right and left penises, but Anatomically, I would not think so the So it's like it's not that we're not doing laterality testing we're not where would you put the mirror, there's it's not the strict sense of what was studied for it, but the conceptual model of you might be always paying attention or Won't even think about the part and neither of those are okay, we can use components of that.

I think that was one of the most is my clarity on no, I don't just take this whole bundle and picking the pieces out of it that I think are helpful, twisting the research beyond all original intent to pull the parts out that I think I could try in the clinic. And because of that, I was never really this proves what we're doing more let's see what happens.

And I still do that, even as it continues to evolve, because it doesn't all [00:27:34] match. Like Peter O'Sullivan's work very beautifully about cognitive functional therapy, some of the terminology in that doesn't work with pelvic health either. So you just take what you need and use it.

[00:27:45] Mark Kargela: And that's a great example of clinical expertise, right? Somebody you willing to go off script and have a process to tinker with the person in front of you and a, in a very evidence-based person centered where, what are some guardrails, right? Where we're not going way off into

[00:27:58] Sandy Hilton: Sort of, unless you talk to the researcher who did the study, in which case you are so off,

but I think, and there's, how do you look at that kind of tussle that is be behind the. Tightly controlled internally valid research environment and what we see in the front lines of clinic because I Recognize I you know, I've had this kind of tussle with myself of like how you know Helpful is research sometimes when it's half of my patients if not three quarters of them are in the exclusion criteria we're like and then we're trying to ascribe all these values of averages and means to people that probably are not in that [00:28:34] group, but

does it, so who's in the studies anyway, is, a bunch of. PhD students that agreed to be in the study, how representative are they of the population in general? I say often in the clinic. So. I'm going to answer your question. To take this to urinary incontinence or fecal incontinence, we'll do bladder diaries or bowel diaries.

Tell me what goes in, what comes out when it does, what happens so we can take a look at it. There are ways to do that are more or less precise. And the way we have our bladder diary set up at the clinic, it has three methods. It's my office manager, who I think is fabulous. Designed it of people don't get what you're telling them.

We have to do this picture. I said, okay. So there's three different methods on there. Method one is measuring outputs. Put a little hat on the toilet or use a urinal. Measure the cc's that come out. Method two is small, medium, or large. Method three is counting the seconds. And I just tell them, please don't mix your [00:29:34] methods because then I can't use it.

But all of the time is, look, this first one where you're measuring, that's the right That's the best way to do it. That's going to give us the best information, but we're not doing research. So if you would like to do one of these other two because it fits in your lifestyle better, do that. Just know that we're not as precise as we would be if you did the first one.

And then please don't mix your methods. So they leave choosing what works best for them, knowing this is going to be. close ish, if they choose not to do the measuring. And that kind of sums up how I look at research in the clinic. It's this is great and I can't apply it, so I will do what works for this person in front of me, keeping in mind that I'm not really, I'm off script, like you said.

But the tension between that is what keeps work fun. I like it. A

[00:30:22] Mark Kargela: A hundred percent. I mean, that's the beauty of the clinic. That's why I've lasted 21 years. I know you've been in the clinic a bit

as well. So

[00:30:28] Sandy Hilton: years, yeah but that's what makes it fun. You're like, I have this idea. Wow, that didn't work. [00:30:34] Now I'm going to use this idea.

[00:30:35] Mark Kargela: it's just there's I know you've done improv. I've taught to one of our friends, Logan Buckley, who about improv and how helpful that is as a clinician, right. As far as cause whether you like it or not, I mean, the best clinicians are probably the best improv performers. Maybe they haven't got out there on the circuit by any means, but

you have to be

[00:30:51] Sandy Hilton: project.

[00:30:52] Mark Kargela: It would, and actually Eric Krueger, if you talk to him, he's over in New Mexico, he's actually in the process of working with someone to at least present something at CSM because he's done some improv himself and he's yet reach out to him.

He's going to be

[00:31:06] Sandy Hilton: We had so much fun doing that at San Diego Pain Summit. It was hilarious.

[00:31:11] Mark Kargela: I remember hearing about, I wasn't there for that one, but I've, I heard it was a blast

[00:31:14] Sandy Hilton: It worked better than we, any of us could have intended. It was so much fun.

[00:31:19] Mark Kargela: And it's, how do you feel like, what would you recommend a young clinician? Cause I know just speaking for myself, there's such this imposter. I don't belong. I'm not smart enough. I'm not good enough yet. And you clutch to the moors of certainty of I have this [00:31:34] research study or I have this system, be it science based or not, that's going to guide my way.

And being able to, how do you help someone maybe be willing and, Yeah. Comfortable to go off script yet. Keep it in the bounds of, what is best for the person in front of you.

[00:31:49] Sandy Hilton: Too famous. What I'll tell students too is none of us know everything. The science is constantly emerging. So what I knew about pain five years ago is not what I say now. And I hope in five years I'm saying the same thing. I have an advantage in that I don't, my arms are weird. I don't pronate or supinate, especially on the left.

So that does nothing. And. So, way back in PT school, when we were supposed to learn these very specific manual techniques to move one piece next to another, there's a fair number of them I physically can't do. And yet, people got better. So, I knew from very young, not even graduated, that these whole you've gotta do [00:32:34] PNF and your hand has to be here and you have to here, you can't facilitate that muscle group, that's not true.

Because people still got better and it is physically impossible for me to put my hand where it was supposed to be. So I changed it. So I never believed that we had to do it a particular way. I thought that's how the person who taught the class wanted to teach it. Turns out that's true. And so much is marketing so that you can sell your course and say you're different from somebody else.

Prove to an insurance company that they should pay for your particular technique Not all of that probably like a tenth of that matters Well also why I'm not going to be a millionaire sending selling classes because I couldn't

[00:33:15] Mark Kargela: I know I, I've just had this discussion, like my conscience, I can't do it. Like I can't go, I can't sell some false sense of certainty. Cause I wouldn't be a look in the mirror at night. I'd be like, I am selling a bag of goods.

[00:33:28] Sandy Hilton: Because really it's just the magic's in the person anyway. So if you can get them moving and you can get [00:33:34] them not afraid to move or having a part touched or thinking about a part, that's what it takes. How we do that. It should be honest and bonus points if they can reproduce it themselves. Massive.

[00:33:47] Mark Kargela: a little bit of like a clinical ego thing we have to swallow a little bit to put the patient on the pedestal not our worthiness or status as a

[00:33:57] Sandy Hilton: I took once. Um, manual therapy, Mobilization course and the instructor was saying that what you're supposed to do when the person feels better is say, well, of course, and I was thinking of looking at my. Partner at the table going, that's not my personality. I'm going to be like, yeah, nailed it and celebrate it.

And that's what I do. Because the magic is in them and I mean it when I say, if it's something that they can do themselves, which is why I choose techniques or options that people can reproduce at home over things that can only be done in the clinic. Because I don't think there's as much value in that.

Outside of saving someone's life [00:34:34] or something one off, but the rest of it really should be things they can reproduce themselves.

[00:34:39] Mark Kargela: Agreed with you. I think Often a good chunk of my career was getting excited about what happens in the four walls of the clinic, right? They're like, oh, of course, you're better I just you see how I lock that thing out from four

[00:34:48] Sandy Hilton: How good I am!

[00:34:50] Mark Kargela: Cavitated it and I feel so great about myself yet outside the four walls.

I was given no skill I mean, here's your basic self mode activity and then come back in for my ritual performance next time But yeah, it's it seems tough I know it's it, I think if students can just or your early career folks and prize some folks that might be in that existential crisis that some of us gone through if like just being willing to get in a situation where like you are Just excited to be curious of what might come out of that person in front of you and how do you tap into something that might get them moving in a better

[00:35:20] Sandy Hilton: Yeah, and be willing to de adopt, because I had a standing posture frame once upon a time, when I had my clinic in Michigan and I did it right. How we were supposed to do it then, and they had the little foot pedals, and you could put the lines at [00:35:34] exactly the right place, and I did pictures from all directions, and we did before and after.

Turns out none of that matters. But at the time I thought it did, and so I was doing the best I could with what I thought was the right way to do it, and then more evidence came out, and it was like, oh, never mind. They got better. Probably not for the reasons I thought they did, but they got better.

[00:35:55] Mark Kargela: , I mean, we could probably have an episode where we got a group of us and just go through a support

things we used to

Exactly. I'm just rehashing all the things. So if any of you out there are listening, thinking that people have just landed and been here from the get go of like perfectly and not that anybody's perfectly anything, but to our like science research based person centered care that often comes with a graveyard of things that, you know, Maybe, we cringe a little bit looking at our past selves, but at the time, like you said, it was what we thought was the best thing to do.

[00:36:21] Sandy Hilton: Different than some of those pictures from high school.

[00:36:24] Mark Kargela: that's right. My haircut back then, the bowl cut, I look back and

[00:36:28] Sandy Hilton: very unfortunate perm I got in the 80s.

[00:36:31] Mark Kargela: , I'm sure we all in the audience have those things. [00:36:34] I want to do a little rapid fire section and it doesn't have to be rapid fire. We're trying a little bit of some different formats just because, trying to keep the viewership going through a full episode and see if we can make it happen through the old YouTube algorithm.

But anyway biggest pet peeve in pain management.

[00:36:47] Sandy Hilton: Narrowing this down. That it That people are passive victims of their pain and don't have things they can do for themselves.

[00:36:55] Mark Kargela: Awesome. Awesome. Your favorite analogy metaphor with how pain works.

[00:37:01] Sandy Hilton: Like a hug that's lasted too long. It was nice in the beginning and then you start throwing elbows. And it needs to stop.

[00:37:07] Mark Kargela: Ooh, I like it. I like it. The number one mistake new grads making as they enter the profession,

[00:37:13] Sandy Hilton: That they, that they think that us old people know things.

That they don't. Achoo!

[00:37:21] Mark Kargela: many new grads feel like they don't know anything. And I think they know enough to do

[00:37:26] Sandy Hilton: They come in and they don't have all the bad habits they have to unlearn when new evidence comes out.

[00:37:31] Mark Kargela: That's very, that's a good point. Very good point. All right. [00:37:34] You can have dinner with, we'll give you one to three people in the, like your dream and they may be here or not here. So it doesn't have to be somebody you currently live in, but dinner with any historical figure in the pain world, who would they be?

[00:37:45] Sandy Hilton: Can I have three?

[00:37:46] Mark Kargela: Sure. Ooh.

[00:37:48] Sandy Hilton: Pat Wall, Lorimer Mosley, and um, David Butler.

[00:37:52] Mark Kargela: Ooh,

[00:37:52] Sandy Hilton: Oh no, I'm sorry, Dave. I'm gonna trade you out for Bronnie Thompson.

[00:37:56] Mark Kargela: , Bronnie.

Good.

Bronnie. It's all right. No, no feelings will get hurt here. I, I thought about that too. I like, man, that is tough to even narrow down to three. I'd like to see, I'd like to

[00:38:04] Sandy Hilton: Can I have a second table with Mick Thacker, Dave, and Tasha Stanton?

[00:38:09] Mark Kargela: That's a powerhouse that, that would be some I, that's half the reason I love is conferences and others is you get to even if I just get to go out to dinner and just be a fly on the wall and just listen to conversations, I feel like I learn more in those situations

[00:38:20] Sandy Hilton: Oh, man, if you ever get a chance to sit go to dinner with Paul Hodges, take it. He is hilarious and so much fun and has so many stories.

[00:38:28] Mark Kargela: I got to reach out to Paul and see if I can get him on the podcast. I think I might've reached out once and I bet like [00:38:34] maybe 500 if I'm doing, if I'm having a good stretch on, I know people are busy. Apparently they don't just spend Persistence is podcast.

[00:38:39] Sandy Hilton: because it's about timing.

[00:38:41] Mark Kargela: I try to be politely persistent just to let them know that, Hey, I still am interested in things.

But yeah, no, that's, that is always the challenge. Speaking of this, I hear rumors that the pain science and sensibility situation, is there any rumors that I hear about this? That might

[00:38:56] Sandy Hilton: We have two or three recorded. It's just a technical error of the person who's supposed to take over posting those is not getting her job done of figuring out how to do that. It will go live as soon as I figure out how to do it.

[00:39:11] Mark Kargela: And after this recording, if you want to sit, if I can lend any support to you in that, because I miss your and Corey's voice. That was one of my favorite podcasts because it obviously tickled all my biases.

[00:39:21] Sandy Hilton: We are so close. He's in Vancouver. I'm in Portland. It's just we were blessed with having Eric Mira manage all that for us. And then when he stepped back from that, then neither Corey or I have made it happen [00:39:34] to take over the posting of things.

[00:39:36] Mark Kargela: It's, as somebody who's trying to keep a regular clip going with podcasts, I think this will be episode number like 178 or something like that. It's a lot of work and it's a lot of behind the stuff. So if I could just chat with people, my goal is to do some things where I have community and different things where I could just pay somebody to do all that stuff that Eric did for you.

Just a lot of tedious stuff that isn't I don't hate it, but it's not probably my heart of my

[00:40:00] Sandy Hilton: I'm trying really hard to get into a good workout. Good aerobics and good weightlifting every day, and then that takes, and then you gotta sleep for seven to eight hours, and I gotta wear, yeah,

[00:40:10] Mark Kargela: yeah There's not enough hours in a day. I can relate to that fully so I'm trying to make sure I've had a point where I was not as present with family and things to where I had to you know have a Reckoning of like I need to change some things. So, you know if podcasts don't go out

[00:40:25] Sandy Hilton: See, so new grads, we don't have it all together.

[00:40:28] Mark Kargela: 100%.

I think that is probably one of the more refreshing things to get to know people in all the space is [00:40:34] like in, in talking to brownie and others and folks, especially with Ron acts where we deal with our own inner dictators. And we all have it. We all have our stuff. And it's just some of, if you talk to people, you'd be surprised that, everybody's going through, has gone through deals with things, deals with challenges and all that stuff.

I think there's this false sense of like invincibility of some of these authority figure. I bet if you talk to Lorimer Mosley and folks like that,

[00:40:56] Sandy Hilton: Yeah, and he's not like that at all. Tosh, who is amazing, Tosha Stanton is brilliant, she's not like that at all. Who's one of my other favorite people, research clinicians Uchenna Osai, absolutely Her brain is awesome and one of the most fun people to talk to you could ever be around. The, it's, the list goes on.

There's so many great people out there and they're just people.

[00:41:22] Mark Kargela: Yeah, great people to pick their brains and are often extremely kind with their time to to share their knowledge with you because they probably been there to where they've been chomping to

[00:41:31] Sandy Hilton: Yeah, they,

you

Fighting the good fight in the clinic [00:41:34] or in the lab. Research is hard.

[00:41:36] Mark Kargela: Oh, yeah, 100%. So final question, because I want to respect your time.

But if you could have the ability to wave a magic wand and change the course of pain management as far as what would you like to see some of the biggest changes to really bring us to? Because obviously, there's been some great developments explain pain and pain, neuroscience, education, and all these different things that have been great parts of it.

But where do you see the future like an ideal? Future, which I know is always a utopian view, but what would that look like if you could just wave that one and have pain care be like practice?

[00:42:10] Sandy Hilton: From a clinician perspective, things I'd like to see in research or Yeah,

[00:42:14] Mark Kargela: well, maybe

management

of patients. Well, you, if you can connect them, you roll with it. I'm fine with that too.

[00:42:20] Sandy Hilton: Okay first, when someone says they hurt, believe them. Don't make them prove it. The insult of that is just insane, and you can't prove that you hurt. Two, organizationally, an understanding that it [00:42:34] takes time. And it is more time than the number of visits. So if you're going to give me eight visits, I want eight over however long it takes.

Not eight within a month. Because it's not the number of visits. It's the time to be able to help them as it progresses across the future. Third, the continued push to have clinicians and researchers talk to each other so that the questions that are being developed are answerable. One thing I learned from talking to my research friends when they asked me what I wanted to know is that I don't ask very answerable questions. Tell me what to do is not an answerable question. Does this work? Also not an answerable question because there's so many things that have to be answered before that. But clinicians can really be a look. This is the problem we see in real people. How do I take where you are and apply it to this person?

Those conversations need to continue.

[00:43:26] Mark Kargela: Totally agree. I think, clinicians, I think being a little bit in, having some strategies or some resources for them to start publishing some of their case studies, I think case [00:43:34] studies are undervalued and underestimated as their ability to help guide maybe researchers to start posing some of these questions that can move, move

[00:43:41] Sandy Hilton: Right. And my fourth one, get rid of the abomination of the modified asbestos.

[00:43:45] Mark Kargela: I, I figured that was coming in.

I like it. You should, yeah, you should make up a t shirt on that because I think, and it's it is huge. I think again, talking to our psychology colleagues at our university and things, I think it, it definitely has been a huge issue with really not being able to understand the whole human

[00:44:02] Sandy Hilton: You And we just put more and more barriers in front of patients and it was bad before when I first was distressed by the revision, it is worse. Now, there are more barriers for people to get care. There are more barriers for things that aren't considered. That just the belt's getting tightened so much that people are basically being told, I don't care, deal with it, buy their insurance companies, but it's things that rob a person of what makes their life meaningful.

[00:44:30] Mark Kargela: I lied. It said that was my last question because your response just [00:44:34] drummed another one up like clinicians who are dealing with that same thing. I got eight visits and maybe they have the ability to spread those out where, and you mentioned earlier in the show, like how you might really load up that visit one.

How would you spread that out? Well, I mean, obviously it's nuance to the unique individual, but what kind of things are you thinking of to Okay. Spread care out when you know your resources are limited as far as number of visits, what are you, how are you going to approach that to help load somebody up with things they can do away from the clinic?

And what's your approach?

[00:45:01] Sandy Hilton: So it is it borrows from the graded exposure with always, that has to come with a little asterisk nowadays with. Graded exposure doesn't work for everyone. And if people have post exertional malaise, stop it and adjust what you're doing. The. In public health or. Well, no, just in general they'll have what is appropriate for them right now, based on the evaluation.

Like, where are you? What are the things that you can do 2 or 3 things you can do right now? And then. If I'm not going to see him within two weeks, which is usually the trial period is one to two weeks of how did [00:45:34] that go then I'm going to give them options. Say I gave him three things starts to look like we're playing a video game.

You have this tract, you have that tract and you have that tract and they get information on one or two levels of progression on each of those pathways. That they can pursue until they come back to see me again. Based on what happens in that time. So, some of it will be movement, some of it will be coordination and control.

Some of it will be if it's pain, tolerance to touch and normal pressures. And ways to progress along those three different tracks, roughly.

[00:46:12] Mark Kargela: So you got like a progression where they can self progress themselves. And it sounds as a clinician, you have I got plan A, B or C waiting, depending on how you present next time around.

[00:46:22] Sandy Hilton: Right.

[00:46:22] Mark Kargela: Well, Sandy, I could talk for another two hours and hopefully we'll get a chance to catch up

[00:46:26] Sandy Hilton: If you want to do that podcast with all of us talking about the oh, yeah, I used to do this. And now I don't that would be [00:46:34] hilarious.

[00:46:34] Mark Kargela: that should be a good episode. I'll have to see if I can throw an email thread out there to some folks and see if we can make it happen. It's all, as it's just a logistics of getting everybody together

[00:46:41] Sandy Hilton: Maxi and I did a thing for next on D adopting and it was along those lines. So, yeah.

[00:46:49] Mark Kargela: Yeah, it should be like one of those things where let's everybody come to the table. Hi, I'm Mark. I'm a recovering hardcore manual therapist. I used to do X, Y, and Z.

[00:46:57] Sandy Hilton: I used to get total needs to the total. Yeah, the doc could say, hey, I 120 by the time they see me again. I

[00:47:05] Mark Kargela: I used to

[00:47:06] Sandy Hilton: was good at that.

[00:47:07] Mark Kargela: I used to unentrap facet meniscoids with my hands. So I've had a few things and I could, that's just one of, that's just scraping the surface of things I used to do for

sure.

[00:47:15] Sandy Hilton: so much fun.

[00:47:17] Mark Kargela: Yeah, no, no doubt about it.

[00:47:18] Sandy Hilton: And we could make every new grad watch it with popcorn and say, Oh, these old farts,

they were so wrong. I want to say with all my heart that some of them won't say I'm getting taught that right now. But again, I think for the most part, there's not many bad [00:47:34] examples. I think we have, and I have huge being a academic, I'm more of a clinical academic, so I see patients and then rely on my academic colleagues across campus to do the challenging work of balancing all the stuff they have to balance with

Right.

[00:47:46] Mark Kargela: But

All right, Sandy. Well, yes, we I actually know that, if you're listening, throw a comment in there. Let us know if that would be something to you because I will. It's interesting to me. It's more of a it's usually a good support group effort so we can all feel better that we've all been through some bumpy patches of our

careers.

And

[00:48:03] Sandy Hilton: look at me not doing postural screens anymore.

[00:48:05] Mark Kargela: that's right. That's right. Sandy, thank you so much for your time. Thank you for your contributions to the profession. I've always enjoyed it. All the stuff you're putting out there. Folks are looking to get in touch with you or man, Sandy, I want to talk to her. I got a patient in pelvic

[00:48:20] Sandy Hilton: Please. I'm at Southwest Physical Therapy and so I put, I think I did my it's S Hilton at Southwest. Yeah, it's really long. Anyway, just Google it. The I now hang out on blue sky, I'm not trying to de adopt a bit [00:48:34] on social media and get outside more because I'm back in the Northwest, but yeah, you can always email me.

My regular email easier to remember is Sandy Hilton at Gmail. Please, if I don't answer you, just. bump it up because it gets buried in all of the emails I send myself with papers to read.

[00:48:49] Mark Kargela: , that's another episode for how people have managed the two read pile in their lives. That would be a good one for us all. Well, thank you again for your time, Sandy. And for those of you listening, if you could drop a comment or a that would be helpful. If you could throw a review on your podcast listening service, that would be huge.

Or if you're on YouTube, subscribe so we can help more folks get this information. If you know somebody who's challenged with a pelvic health career and trying to figure out some Maybe new ways of looking at it or needs, maybe some support that they can see that us, everyone has probably gone through their graveyard of things.

They cringe that they did in the past and, share this episode with them, but we'll leave it there that this week, we'll talk to you all next week.

[00:49:26] Announcer: This has been another episode of the Modern Pain Podcast with Dr. Mark Kargela. Join us next time as we [00:49:34] continue our journey to help change the story around pain. For more information on the show, visit modernpaincare. com. This podcast is for educational and informational purposes only. It is not a substitute for medical advice or treatment.

Please consult a licensed professional for your specific medical needs. Changing the story around pain. This is the Modern Pain Podcast.