The PRISM Model: Revolutionizing Pain Management in Physical Therapy

Joe Tatta: 0:00

And our scope of practice with that has grown, where we're no longer just using exercise and manual therapy. We're using psychologically informed skills. We're considering someone's physical health as well as their mental health. All these things have had an impact on how we practice. But with that, models have to evolve as well, right? But it's really difficult at times to get practitioners to change when the system they're working in, because we're really talking about a system here, right? And PRISM is a systems based approach. It's really hard when professionals are working in systems that don't financially incentivize So, that's a barrier

RODECaster Pro II Chat & Cam Link 4K-2: 0:40

Pain science and bio-psycho-social practice all sound great in theory.. Application is always where the challenges lie. Frameworks and models can be very helpful in our application, as it gives us a way to organize our thinking and working with a patient. And this week's guest, Joe Tatta, along with his colleagues have developed such a model, the PRISM model. In this episode, Joe will discuss his background in private practice and what brought him to his current focus on complex pain issues. We're going to discuss concepts of salutogenesis and resilience, and how that influenced the development of this model. He's going to share the model and whole and touch on the domains and processes contained inside. You'll come out of this episode with an appreciation of all that goes into comprehensive pain management. And as always we'd love if you could like comment and share with anybody, you think would benefit from the episode. If you really want to go deep, then check out the modern pain pro community that's linked below in the show notes.

1:27

This is the Modern Pain Podcast with Mark Karchula.

Mark Kargela: 1:31

Welcome to the podcast, Joe.

Joe Tatta: 1:34

Hey, Mark. It's great to be here. Thanks for the invite.

Mark Kargela: 1:36

No, great to have you. We've met, I think it was in Boston International Association for the study of pains conference. I think it was 18. If I remember right, it's been a minute. But and obviously follow your work throughout my time knowing you and it's been on mainly digital as many of the online world we live in is where we get to know folks more digitally before we meet them in person. And really have had huge respect for your work and we're going to talk a little bit about more about that today, especially in regards to the model you've developed with some of your colleagues. But before we do that, Joe, if you don't mind introducing yourself for the audience, and I'd love to hear a little bit of your journey to where you've come to this focus on persistent pain.

Joe Tatta: 2:11

Sure. I've been a physical therapist since 1997. Back in the day, most of us had a bachelor's degree. So came right out of school with a bachelor's in PT and started practicing at a really great small community hospital in New York City and New York City's Greenwich Village. And it was inpatient multidisciplinary rehab. So I did that for about two years. When I was there, I also started moonlighting, doing a little bit of outpatient. Physical therapy and different practices in the area. And then I made this kind of big jump into a dance medicine practice where I, most of the day, my schedule was treating performing artists. Ballet dancers, Broadway dancers, musicians really fun group to work with. And when I was there working with a particular ballet dancer, I had this kind of experience with her where I She came in diagnosed with a fusion of L5 S1, which we know is called a sacralization, and it's a normal occurrence, an anomaly that happens in many people, except she was really fixated, I would say, on this diagnosis. I would work with her. She obviously was strong and flexible and agile and quite a beautiful mover we shall say. But it was really difficult for her to get beyond this idea that she has this potential fusion in her back. Which she identified as potentially limiting her range of motion. So during this time, I was like, oh, there's something else going on here besides the physical body, which I had, known on some level. I was a competitive gymnast gymnastics is a kind of a mind body sport, if you will. But it really started me thinking broader okay, what else is going on here? That particular practice had a Pilates studio attached to it. So Pilates is known as a mind body exercise. So I got certified in Pilates and started teaching that to my dance medicine patients as a form of rehab. And I also started teaching it as a form of general body conditioning for other people. So it was interesting to see how that developed. From there, I left that practice and me and another physical therapist started our own private practice. One of the first cash based practices in Manhattan, in New York City. And it did well. Thankfully, we were blessed and we grew to a second clinic, then eventually to a third clinic. And to make a short, long story short we opened up about 17 clinics over the course of about 15 years. Always had my hand in patient care avid, continuing education, avid learner. I love taking courses and reading books and reading research and treating patients. As the practice grew, I also wound up in more of a management position where I was in charge of bringing students, student physical therapists into the practice. Training new graduate physical therapists and mentoring and developing, if you will, the clinic directors who were in charge of the clinics. And this is a little bit before the day of things like residency programs and things like that. We actually created our own I'll loosely call it a residency program, if you will, because we found that, new professionals, new physical therapists needed some help and guidance and mentorship as they went from being a student to being a, a new grad physical therapist, so to speak. And then usually over the course of the first, five to 10 years, I think we're like sponges and really absorbing a lot of information. So we help them with that, professional development process as well. Somewhere in 2016, I exited from that larger multi clinic practice took about three months off, and I was like, what do I really want to do? I've done a lot of the clinical side of this, I've done a lot of practice building, and I really wanted to reach people on a bigger level. So I wrote a book. I went to a New York City publisher and got a book deal, and I wrote my first book, which is called Heal Your Pain Now, and put that out there in the world, and I said, all right, let me see what comes back from this. And some interesting things came back, both from people with pain, as well as from the various professionals out there. Of course, people were looking for care because it's really difficult for people to narrow down what is good, safe, effective quality care in our kind of healthcare diaspora, especially in the United States of America, where things can be a little conjointed in the pain management world. And then physical therapists and other professionals reached out to me and said, Hey, I read your book and I. Learn that you talked or have studied mindfulness. What did you do, basically? So from there, I started educating and training physical therapists in, what you and I might term as biopsychosocial, a whole person approaches to pain. And that's the basis of kind of what got me here today.

Mark Kargela: 6:49

Yeah. Yeah. An interesting journey. I didn't realize, you had that big footing in private practice to start and then, done some great things. I definitely will link some of your books in the show notes. So folks can check out those. You mentioned that biopsychosocial approach. And of course, that's been, angle back in the seventies, of course, propose that. And then I think we latched onto it along with, the explain pain movement. I think Butler mostly really And Maybe the, and along with maybe Louis Gifford being, two pioneering groups that really were pushing the envelope with that. And as we've seen the bio psychosocial model kind of evolve over time I think it's been clear, Peter Stillwells work along with some of his colleagues and others and been CarMax been talking about on social media. I know yourself putting out some great content in regards to that. Why do you feel like it's time for us to evolve that model and take it steps further than maybe what you've seen? Traditionally, as it's been applied in physiotherapy and maybe in pain in general.

Joe Tatta: 7:43

Yeah, it's interesting. When you look back, the biopsychosocial model was developed, I think it was like 1977, right? So this is not new, even though people are on, social media talking about it like it is new, but it's not a new model. That model was adopted by the American Physical Therapy Association, like somewhere probably like in the, early to mid 2000. So let's just say 2005 somewhere. So really we were late, I would say, in some way to say, Hey, this is a really good model of health and we should start to teach this to physical therapists and use it in practice. And I definitely don't think we should throw the biopsychosocial model out at all. It should make, it should be in our our DPT education. And in some way we should lean back on it when we're. evaluating, managing, and treating both acute and chronic pain. However, when you look at the literature and you talk to colleagues out there physical therapists specifically have a pretty hard time embedding this model in their practice, so to speak. Lots of different reasons for that. Some of it's education around the model and how to use it. Some of it is skill. They may not have the knowledge or skill to use the whole model. Some of it is the practice setting that they're in, where they don't have enough time, or the policy of the organization, whether it's a hospital or an outpatient practice, really doesn't emphasize this type of approach. I think the biggest thing, though, is that we, as a profession, have evolved. When I went to school, there was a, primary emphasis on biomechanics and pathoanatomy, so to speak, pathokinematics. And definitely my probably first, seven to ten years heavy focus on that. But if you are a, thinking professional, and you're saying, Wow, some of my patients are doing really well, and they're fully recovered. And then I had this other group. That I'm not really sure I'm having an impact at all. So what am I missing? Or what's missing from my evaluation or my approach, basically? And that has been reflected, I think, in the physical therapy research. It's been reflected in DPT education, where we're now talking about more of a whole person approach to both health in general as well as pain. And our scope of practice with that has grown, where we're no longer just using exercise and manual therapy. We're using psychologically informed skills. We're considering someone's physical health as long as, as well as their mental health. All these things have had an impact on how we practice. But with that, models have to evolve as well, right? So I said, okay. Can we actually, or should we take a look at and maybe start to create a new model that might be beneficial not only for physical therapist practice, but other healthcare professionals as well.

Mark Kargela: 10:35

Yeah. Yeah. And the model we'll discuss the prison model, I think was what was birthed out of that thought process. I'm curious, before we get into the specifics of it you've sounds like you've laid out how the thoughts that kind of founded why you guys. And your colleagues have developed this, but I'm just wondering if you could discuss how, the coauthors and other folks that were involved with it and their background and how they've also contributed and influence that model.

Joe Tatta: 10:59

Yeah I wrote a, me and you may know Ginger Gardner, who is a physical therapist. You should have her on the, on your podcast. She's a really great physical therapist. And her and I co edited a book called Integrative Lifestyle Medicine and Physical Therapy, and we invited. 40 physical therapists contribute to chapters, basically. One day I was sitting on my couch with a cup of coffee, flipping through the book, and we asked the authors of each of those chapters to give us like a conceptual model, if you will, that would support whatever it is that they were talking about in that book. So we'd see really interesting conceptual models built that talk about things like health and wellness that talk about psychologically informed care, nutrition, mindfulness, all these different conceptual models. And I was like, this is interesting because as physical therapists, we learn about a lot of different aspects of care, but we really don't have our own model of pain management, if you will. We rely on other models like the biopsychosocial model. I Was like, why, I was like, why don't we have our own model of treating pain if we look at ourselves as really key players in treating chronic pain or managing chronic pain. I reached out to Steven George who co authored the chapter on psychologically informed practice in the textbook. And many people on this podcast know he was the, pivotal force in psychologically informed care. And I said, hey, I'm noticing we don't really have a comprehensive model for treating pain. If I developed one, would you be interested in, supporting a paper around it for publication? And he said, sure, I'm always interested in models. It's his thing that he does most. But I realized just him and I weren't going to be enough. I reached out to Janet Besner who wrote some of the earliest research on health and wellness promotion, because I really wanted to bring a strong health and wellness approach to the model and really start to shift away from a patho anatomic model. Rose Pignataro has a, is a, another DPT professor who has a background in health behavior change. That's what her PhD is in. She's also done a lot in the addiction space, and I think that's really important as we talk about chronic pain and the interconnectedness with regard to opioids and other addictive substances. And then Carrie Rothschild, who is a professor of physical therapy at the University of Central Florida. And what's interesting about Carrie is she's the first physical therapy professor to create a three credit pain science and pain education course in a DPT program. So she's been teaching This related content for a number of years, like within the program. And I wanted to make sure the model kind of spanned not only clinical practice, but also education. Because I think those two things need to reinforce each other. Some people think that the education comes first, then we change practice. Some people think that we're changing practice first, then the education follows. They're probably both happening at the same time on some level. But I wanted to make sure I brought some, really bright, intelligent people that could support a new model for pain education and physical therapy. So I'm extremely grateful to them. They really helped shape the way I view pain now. They helped, of course, shape the model and I'm just grateful for the input they had on the paper and great minds tend to produce really interesting things.

Mark Kargela: 14:13

Yeah. And you got a good, great group of them. They're definitely an impressive group of folks that worked on it. I like the health and wellness approach. I'm definitely in agreement. I think we so far, as far as especially in our health care system, we're such a illness based model of care where we wait till the wheels fall off before we intervene. And there's not a lot of wellness things. You speak in the model in the paper, and we'll link the paper into the show notes of this more salutogenic model of care. I'm wondering if you can talk to some folks here salutogenesis. And it's just like this nebulous. I hear it. I don't know, this whole salutogenic kind of resilience based approach. I'm wondering if you can speak to that a little bit and how that kind of forms a lot of the foundational thoughts with the model that you guys developed.

Joe Tatta: 14:53

Yeah, so when you create an evidence based model, you have to have some kind of theory as the bedrock foundation of the model. So I spent a lot of time looking at the physical therapy literature looking at the psychology literature, and I was familiar with both of those, I would say. And I was like what's in the kind of sociology realm? Because most of us would agree we spend, or we have the least amount of focus on the social aspect. of the biopsychosocial model. In the world of sociology, they do have their own models, and I came across a gentleman called Aaron Antonofsky who is a sociology researcher, and he created this thing called salutogenesis, which is a long funny word, but he was really interested in how do we create health, or what is the origins of disease. Of health. Instead of focusing on pathology or disease if you will. And some of his early work looked at women who survived the Holocaust and found that there were groups of women who thrived. In spite of this adversity, and there are groups of women who did not thrive or didn't thrive as well, so to speak. So we started looking at these groups of women who were thriving in the face of adversity. And he was like, okay, there's something here, basically. How come they're maintaining health, even though they were challenged with poor physical health, poor mental health poor social health in the course of their life, so to speak. So it really spoke to me because it was a model of building health. And ultimately. I want to, of course, alleviate someone's pain, but I really want to build their health. I have, left the pathoanatomic model behind, so to speak. Of course, I take that into consideration when we're evaluating someone, looking at, things like red flags. Important in that case, but there's a big health promotion aspect to what we do as physical therapists more and more. And there's a big health promotion aspect, too. Pain care. So cellulogenesis really spoke to me. Okay. How do we develop health in different people and populations?

Mark Kargela: 16:54

Yeah, I like that kind of social approach and we see so much, those you listening, which I know a lot of you are working with people in pain. There's such huge social aspects when we hear stories of family and workplaces and all the things that kind of can positively and negatively impact pain depending on the circumstances and the unique context of the person in front of us. The process you taught or the model you talk about. takes a process based approach, and I think it's important for folks to delineate what does a process based approach look like compared to maybe traditional models and traditional approaches in pain. Can you speak to that a little bit?

Joe Tatta: 17:29

Yeah, I can talk to a process based approach and then I'll weave that back into cellulogenesis in some way. Still to this day, we, not just physical therapists, but a lot of health professionals are very intervention oriented. Interventions fall really well into biomechanical or biochemical approaches to health and disease, including chronic pain. So with that, we expect this one to one relationship. For example if I go out today and throw a baseball around, and I haven't thrown, let's say I haven't thrown a baseball around for a long time, I might irritate my rotator cuff tendon and have a little bit of inflammation there. And I go into my medicine cabinet and I pop to Advil, a very kind of bio, biochemical agent. And I expect this almost immediate relationship to happen where the pain decreases and maybe my range of motion improves and I feel better if you will. We have spread that intervention approach, if you will, across healthcare and definitely into pain care and definitely into physical therapy where we're looking for. The best manual therapy technique, we're looking for the best exercise. I think dry needling is a pretty good approach to that. I'm not against dry needling, I think it has a benefit on some level, but still many people are using it as far as like that one to one relationship, if you will. A process based approach really is a health behavior change approach. So as physical therapists, we are health behavior change experts. And really what we do is we're taking someone, as they're coming in to see us, once a week or twice a week over the course of a to however many weeks it is, we're taking people, whether you realize it or not, we're taking them through some type of change process. And with that, they may be changing physically, They may be changing psychologically and emotionally they may even be changing spiritually and socially on, on some level. And I've become really interested in how can I help guide and facilitate this change process and how does that work? And once I started shifting my mindset on what's the best intervention to alleviate pain versus what's the best process I can bring someone through based on who they are their previous life experiences and what they're currently experiencing. What's the process I can take them through so that they can either one, become more resilient to pain or two, completely recover. And even within that recovery, is there some growth that happens? So all of that is wrapped up into a process based approach. Probably most easily identified in the psychology literature, but you can have physiologic processes that change. Many of our patients have metabolic syndrome. There are ways or processes that we have for changing someone's metabolism, so to speak. That's a process that happens over time. Sure, you can take something like metformin, which might regulate your blood sugar in a relatively fast way, but things like exercise, physical activity, nutrition. Also has the same effect, but those things happen in a more of a process over time. So ultimately, one, I want to change the way I approach someone because my approach to someone does have an impact on how they feel and how they function. And the two, I want to start to shift therapists, specifically physical therapist idea that you can take this process more health behavior change approach. Which is just as effective and many times more effective than an interventional approach.

Mark Kargela: 21:06

Yeah, definitely would agree, as trying to incorporate some process based approaches into my practice and things. It's looking a lot more comprehensively at the human in pain, of course, than just through this. I'm going to identify one. impairment or dysfunction and eradicate it with my chosen intervention, which again, I'm similar with your thought process around like dry needling. It seems to be the most popular one currently. And again, looking at this like one off, I'm just going to identify the one thing. And we don't recognize the biopsychosocial nature of that treatment in and of itself with contextual effects and all that stuff. That's for another podcast, of course, but I'm wondering if you can speak to the domains of that prism model of kind of what those are made up of and how you came up with them.

Joe Tatta: 21:47

Yeah one, a big literature search where I look through of course the physical therapy literature because it's going into a physical therapy journal ideally. But also the psychology literature the neuroscience literature sociology literature as we mentioned. Some of which are on population health because we should also be moving to more of a population health perspective in what we're doing, trying to reach all the people that have pain. It's really difficult to do that kind of on a one on one basis. So looking at the evidence as Mark, when you look at anything for chronic pain that's delivered in a single intervention, um, outcomes are maybe minimal, right? But even within that, there are still interventions or still processes, so to speak, that do start to float to the surface that have a positive impact on people's health. They are biopsychosocial in nature, but they extend beyond biopsychosocial in nature. I promised I would bring this back to salutogenesis again. And so at the core of salutogenesis is what's called a sense of coherence. And that really spoke to me the most from that cellogenic model. And a sense of coherence is broken down into three components. So it's does a person understand what their condition is and what's happening to them? Can they access resources? Aaron Antonofsky called these generalized resistance resources. So can they access resources and can we help them access resources? That helped them bounce back from this adversity. And then finally, can they find some meaning in this entire experience that they're having? For us, it's obviously the pain experience, so to speak. So I was like, okay, this sense of coherence really sounds like management in some way, right? Can we help someone understand what pain is, right? Knowing that it's not necessarily a biomechanical or biomedical phenomena, but it's a biopsychosocial phenomena. Resources, I have resources as a clinician that I can help them with, but they also have resources or strengths within themselves that I can help cultivate. And then finally, somewhere in the process is there some type of meaning coming out of this process that, and that meaningfulness is really important to keep people engaged. In the process. So linking process based approaches to solutogenesis, I think sense of coherence does that well. And the domains that we found, there are six of them and I'll go through these one by one. First domain is person context. Second domain is purpose. Third is pain literacy. Fourth is pain mindset. Fifth is physical activity and then the sixth is physiology. So those domains are not the interventions or not the things that we're doing, two people are doing in practice. Those are the areas that we're working as we're helping someone move through this process of recovery. So in the biopsychosocial model where you're working, as you're working in the biomedical domain, the psychological domain. Or the social domain. In the PRISM model, you're working in one of these six domains. And the domains actually interconnect and they have an influence on each other, if you will.

Mark Kargela: 24:58

Yeah, yeah. No, and the model's very comprehensive as far as it's touching on, the, what I definitely think considering the breadth of your literature search and As you mentioned, you weren't just peeking at physiotherapy literature, you were looking at neuroscience, psychology, literature so definitely can see how it's a very comprehensive model. Those of you who are listening or watching, definitely check out the show notes to take a gander at the article, but within those domains, you've built in some of the processes that you are working to take folks through to make some of these health related changes and, helping people. Live resiliently with pain or like you said, possibly even resolve it completely more if you can speak to some of the processes that kind of fall within some of those domains that you identified.

Joe Tatta: 25:41

Yeah, so we saw these six domains that really spoke to us. And we're like, okay, now we need processes, behavior change processes, to support those domains. When you start to look at a more comprehensive, integrative model, there's a lot to consider. I started out with five processes that support one domain. For example pain mindset, I had these five processes. And as I started putting this model together, we were like, this is too big, right? Too much going on, basically. And whenever there's too much clinicians tend to shut down. They need something that's a little more approachable. So we narrowed it down to three processes per domain, and we have a lot, we've had lots of good feedback on the number of three when you look at the model. There are processes that most physical therapists are aware of. Some of them they're things that we use all the time. Some are new to some physical therapists depending on what their background and education arm. And then there were, with that, there were some processes that we had to completely leave out. And ones that we threw around for a while and tried to figure out if they had a place. So for example, when I first submitted the paper I had prescribing as a process under physiology. And actually it was called prescribing slash deprescribing. And the reason why I had that in there is because as a licensed health professional, I realized that medication has a place in pain management, right? Sometimes that medication is used inappropriately. So there are times when we need to prescribe medication to impact someone's physiology, right? The domain of physiology, and let's say someone's on a high dose of an opioid long term, they might. develop opioid induced hyperalgesia, right? So the opioids had an impact on their physiology and that medication may need to be tapered or de prescribed. As when you submit a paper the peer reviewers take a look at it and they said we understand why prescribing and de prescribing is here in this kind of physiology domain. And we know that physical therapists do prescribe medication in the military, but in general we don't really do this as PTs. tHat kind of hit the cutting board, so to speak. And they said, what about physical activity? Squarely in our bread and butter. And I had therapeutic activity in there, so I put that one back in. Another one that people often ask me about is embodiment. And initially that one process was mindful movement. What I, again, I want to shift people's mindset to more of a process based approach. So mindful movement is really the intervention, right? So this is the instruction I give. The type of exercise I may be using as the intervention is mindful movement. But I wanted to take people on more of a process based journey, so I chose embodiment. And embodiment is interesting because it goes against the very kind of top down cognitive behavioral therapy, where thoughts influence emotions and behavior. I think traditional pain education fits into that as well, where we're working just with people's thoughts or beliefs, and that influences their behavior. But this new process of embodiment really says that our nervous system is a dynamic. Interconnected system. So it's not going top down. It's not going bottom up. Those things are happening at the same time at every moment. So embodiment is really a way to bring together the idea that my sensory experience, my cognitive experience, my emotional experience, and my physical experience all influence each other at the same exact time. In the present moment, no matter what's happening so it's just like an idea of like maybe what hit the chopping block and what was included and why, but there's 18 processes in total. Now we're not suggesting that you would use all of them. You may just use one like you may just spend the first session on focusing on pain literacy, right? So the domain of pain literacy, and you may be working on beliefs. So the process you're working on is beliefs. The domain that it impacts is pain literacy. As, uh, therapy is going on, you then may shift and say, Hey, sleep is an issue. Let's work on the circadian cycle, the process of circadian rhythm, so to speak. You may discover that someone lives more in their head, so to speak, and not, and less in their body. So you may rely on embodiment as a process. So I think most of us, as you work with patients, you were taking a more comprehensive approach. You probably wind up talking about these processes at least once, but we want to make it more intentional that you should consider most of these processes throughout the course of rehab.

Mark Kargela: 30:25

I'm wondering because you've done a lot of education and teaching physical therapists, this type of models and things. I'd be curious. I've seen some just in my teaching and getting folks to start thinking beyond just manual therapy and exercise when it comes to pain and a lot of that obviously in the musculoskeletal domain. But this thought of like mindfulness and doing maybe interventions that aren't traditionally part of the physical therapy Education that I obviously we, in the paid education model that your paper references, that was a big push to, hey, we need to start getting people's upskilled in DPT school to be able to have at least a grasp to understand the importance of embodiment in these type of concepts that you speak to. I'm wondering what you've seen as far as barriers or some of the struggles that clinicians have to start integrating this more holistic mind body medicine type approach when it comes to pain care.

Joe Tatta: 31:17

Yeah, I mean we have You know, all of us in healthcare have barriers, right? No matter whether you're a physical therapist, or a psychologist, or a a physician. Let's see, where should we start? I'll give you the barrier journey, so to speak. I think starting at the beginning, we have and we have a, they're called CAPTI, which is the accrediting body that accredits physical therapy programs. For the most part, you know this Mark, you teach in a DPT program, they give us guidelines. So they say, you need pain education in your program. You need psychosocial skills in the program. Okay, just those two things right there are huge, massive topics that really could be PhD programs in and of themselves. sO now you have well intentioned, highly educated DPT professors trying to figure out. How much of exercise do I put in the program? How much of physiology, medication management, manual therapy, how much goes in? And the guidelines are they're broad and they do cover all the areas. Except, as far as I'm concerned, they're not specific enough. And what happens then is you have certain programs teaching certain things. In one flavor, another program teaching something else in another flavor, and ultimately we're all teaching things in the programs I teach in DPT programs as well. We're all teaching things so that physical therapists can pass the boards, which is what we want. However, everything that happens in our programs is at least 10 years behind the evidence. Some people say 17 years. Doesn't necessarily have to be that way. And we all need to be a little more cognizant of putting things like PRISM, let's say, into the program. I'm lucky enough to be teaching PRISM in a couple of programs now. It feels good to get the evidence right there. So that's the education realm. Then you get to practice, right? And this is probably going to be shocking for people, but the one thing that drives clinician behavior, so what we do in the practice, in practice, is what gets reimbursed. It's not what we're taught in school. It's not the thing you love. It's not what the best evidence says. Ultimately, it's what we're getting paid for. That makes some people really nervous and uneasy, and I understand that, but in our kind of U. S. based consumer model of healthcare, so to speak the bottom line is always there, basically. So what gets reimbursed in physical therapy? Therapeutic exercise, neuromuscular education manual therapy, right? I can guarantee you, Mark, if all of a sudden insurance companies or Medicare said, we're no longer reimbursing manual therapy, that code is now, you can still use the code, but we're not paying anything for it. Or we're only going to pay 7, let's say, for manual therapy, right? But here's this new code called health behavior change. And the reimbursement code for that is 75. 34. That makes perfect sense. You would see clinician behavior change dramatically. One, that should happen because I think that's in line with best evidence. But it's really difficult at times to get practitioners to change when the system they're working in, because we're really talking about a system here, right? And PRISM is a systems based approach. It's really hard when professionals are working in systems that don't financially incentivize So, that's a barrier. Now, of course, there are professionals that don't keep their education up, right? They do the minimal amount, they're not interested in learning anything new, not interested in research. I think that We probably should help facilitate their progress a little bit because it's really good for their mental health to learn new things. Some interesting research around physical therapy burnout is physical therapists realize that, for example, there's a psychological component to pain. But when they don't have the skills to address that component, they're more likely to burnout. Not only does just things like PRISM, Psychologically Informed Care, not only does it help patient outcomes, patient satisfaction is based on best evidence, but it also improves our mental health. So there's a lot of barriers education wise, a lot of barriers systemically, there are a lot of barriers individually. We can definitely overcome them all. Certainly as you've experienced too, Mark, some people need a little bit more. Guidance and support and, a little bit of a kick, if you will, to move in that direction. Other therapists are like, I totally see this. I see that our patients are struggling with their mental health or I see that they're struggling with their health and their wellness, lifestyle related aspects and they're on board. So it's interesting to look at how the landscape is changing in not just pain management, but all throughout physical therapy.

Mark Kargela: 36:26

Yeah, I think it goes back to what you mentioned earlier in the, in our discussion as far as like that, that always that 10 to 20 percent that aren't responding to that traditional intervention based way of getting at it. And I think there's been shifts I've made in my career as well, where initially it was like, I just go to my security blanket with everybody in the back office and Point fingers at the patient. There's, malingerers, symptom magnifier, all the things that, unfortunately, we take patients with mainly out of our inability to understand and help those folks. And now we have some of these models. So I think there's a bit of therapists, I think, who still want to hold on that security because it is. It requires us to get uncomfortable. It requires us to navigate into humanity, which isn't algorithmic, which isn't a PowerPoint bullet point, type list of things you can ask and question and differentially diagnose, which again, as you've mentioned, those things are important, but you, to me, it's the most rewarding care too, when you can be comfortable in that uncertainty and, a model like this gives us at least some concepts and theories, some way to more ourselves to something to where we're not just. Flailing in the wind, mindlessly, it's where we have some, domains and processes to go off of. I'm wondering when you kind of work, maybe you can speak to that too in your journey and what you see too. Have you found it where just therapists struggle with that discomfort, that uncertainty where it's not the impairment that I identify and I fix with this intervention, whatever the flavor of the month is for the therapist. I know I speak for myself, I guess I had, I think we've all had that toolbox. mindset of I just need a new tool. It's gonna be the one that fixes this 10 to 20 percent and then you keep seeing that 10 to 20 percent persist in our practice. But what do you think about that discomfort and that maybe that struggle that therapists have to make that transition from The knowing I have the answer in the fixed versus I don't know but I have some processes I think we can lead you towards to get you to the things that you value in life. What do you think on that?

Joe Tatta: 38:28

One of the things that is great about practicing for a while is patients come back to you. And oftentimes they come back to you with the same diagnosis or same complaint. And you ask them what have you been doing to manage it, basically? And they say, oh, I've been doing that exercise that you gave me, three, five, ten, in my case, twenty something years ago. And what's interesting about that is it shows you what's not working. Because if the a patient came to me a while ago correcting her pelvis, so to speak, right? Because this is what we did in the late 90s, early 2000s. We corrected people's pelvis. I knew how to mobilize the base of the sacrum in all 10 different directions. And that does feel good, actually. And there's a place for that on some level. So this patient comes back to me and she's I still have my SI joint flared up again. I have SI joint pain. I've been doing this thing, but it's not working. And I didn't say this to her, but in my mind I'm like, this is great. Now I know this is not working for this particular person, right? So what else do I have or what else should we be doing to help this person cope with their pain and obviously recover? We ask our patients to do a lot, to take on a lot at times. We asked them to trust us that, we're relying on our education. We're relying on our skills. We're relying on our therapeutic alliance, so to speak to a big extent. With that, yes, we have some difficult things to do and we have to take a look at ourselves and say, all right, this person now has been coming for eight weeks. Did some kind of measurable life impacting change happen for that person in eight weeks? If it hasn't happened, pretty good reason that you need to do a re evaluation, reassess what you've been doing, and change the treatment plan. That's what a re evaluation is for, right? To reassess. In that reassessment, you probably should change the interventions or the processes that you're working on to help people. Is it uncomfortable? It can be, right? It can be uncomfortable especially if you work, let's say you're mentoring a student and they look up to you as like the licensed doctor of physical therapies and practicing for 20 years and this person isn't getting better. It's yeah, I may have missed something in my assessment, or maybe I didn't place enough emphasis on one process in our care together. So you adjust with that. But I'll tell you, it's really interesting when you start to do that. Yeah. It's a different way to practice and again, I think insurance has caused us to have a very linear way of thinking because we're getting 12 visits. So you start, you should see like linear progress to the point where pain is gone and they're fully recovered. We know human beings aren't linear. heAlth behavior changes are linear recovery is not linear, and probably the things that we're doing in some way is not linear as well. So I think it's good that we ask ourselves to perform better, if you will. And when I, lecture at conferences, I always, one of the things I ask people is how many of you, as physical therapists, are doing a really good job at healing the chronic pain of all of your patients. Raise your hand. And ultimately, no one raises their hand, right? So we realize there are things that we have to improve upon. And part of that improving is becoming curious about where the gaps in your knowledge are filling those gaps, becoming curious about maybe the ruts that you're in. The same techniques, interventions that you've been relying on and how can you bolster them with new techniques or new processes to help people?

Mark Kargela: 42:15

Yeah, I mean that resonates with me I had to say maybe I don't need to attend the next manual therapy conference again, not anything against manual therapy There's some great people who are heading up a aunt and everything but I'm like man, I've been traveling that road for like 10 to 15 years and it's like how much more do I need to hear that side of the story, which again can have its place. Again, you've mentioned some of the things, obviously we probably need to reframe it. And Steve George, one of your coauthors and other folks have done a good job helping us see a little bit bigger picture on what's happening with that. But yeah it's it is sometimes hard to expand our thinking a little bit beyond where our comfort zone is, but man, it's such an opportunity to help so many more people and at least have a better. Help people better understand and grasp their things of what's going on in their conditions versus just the traditional Biomedical way of looking at it.

Joe Tatta: 43:03

And if I could bring that back to PRISM for a minute. PRISM is a resilience based model. So it's not a model of vulnerability. So a lot of the work. That has been done in the early years of psychologically informed care was to how can we identify where people are vulnerable and most of that was how is their thinking vulnerable and how is their mood vulnerable. And a lot of that is still based on a path of psychology model if you will. Prism as a resilience model is how do we help people flourish with good health. In all the ways that we know, physically, emotionally psychologically, spiritually, and socially, so to speak. Resilience is an interesting topic, interesting construct. A lot of people look at resilience purely from a psychological perspective, and there is psychological and emotional resilience that we can build in people. But there's also physiologic resilience we can build in people, there's physical resilience that we can build in people there's social resilience that we can build in people. So when someone comes to me it's like, all right, resiliency, one helps people bounce back, right? So how can I help someone bounce back from this pain condition to the point where they were exactly how they were before the pain started? That's nice. If we can do that's wonderful. Some of it is like this person may have significant high impact chronic pain with multiple comorbidities. So how can I help them become more resilient so that we stop that process in its tracks? And once I stop that process, then can I start to reverse it? And for some people, we may not be able to reverse it all the way, right? That's where it's like. I may not be able to take your pain away 100%, but I can make you resilient enough so that this process stops and doesn't cause you any more discomfort or harm, if you will. sOmething else happens with resilience, which is really interesting and we don't talk about enough. When we help people access their own resilience and we share the skills and tools that we have to help people become more resilient. the kind of end part of resilience or what happens at the same time with resilience is they start to enjoy or benefit from some type of positive growth. So within the recovery, within the pain recovery process my focus is on resiliency. Of course I hope to get someone to full recovery where they bounce back. People also tend to enjoy once they apply these processes, something positive that comes out of the experience as well. And I really think that people come back to us because they notice that something positive is changing from their care, is changing from their interaction with us as physical therapists.

Mark Kargela: 45:56

yeah, no great points and We could probably talk about this for another hour, maybe two three hours And I know you're teaching and doing some great stuff. I want to respect your time And before we wrap it up today where can folks if they want to follow up more or get look, you know get in contact with you or getting maybe check out some of your coursework that you teach some of this with where can they find you Joe?

Joe Tatta: 46:17

Yeah, the best place to find me is on the website at theintegrativepainscienceinstitute. com There's resources and a contact there if you want to reach out to me as well.

Mark Kargela: 46:26

Yeah, you did great stuff. Highly recommend you all check it out. It's it's great content types of been able to see Joe's work and hear him speak a little bit and it's great stuff. So definitely check him out. If you're listening, we'd love to have you subscribe on your podcast wherever you're listening to your podcast. And if you're watching on YouTube, we'd love to have you subscribe there so we can get information like this out to more folks who are struggling, whether it be a clinician who's struggling to better understand and help folks in pain or a patient who might be struggling. Joe, really again, thank you so much and thank you for all the great work you're doing and keep it up.

Joe Tatta: 46:56

Likewise, Mark. Thanks for having me here.

Mark Kargela: 46:57

Absolutely. For all of you who are listening, really appreciate your listenership. Keep us in the loop. If you have anything else you'd like to have us talk about or people you'd like to have us talk to, don't hesitate to reach out via social media. But we'll leave it at that this week. We'll talk to you all next week.

47:11

This has been another episode of the Modern Pain Podcast with Dr. Mark Cargilla. Join us next time as we 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.