The Thinking Practitioner Podcast:
Episode 90: Turning Down the Volume on Back Pain (with Whitney Lowe & Til Luchau)

Til Luchau:

The Thinking Practitioner Podcast is supported by ABMP, Associated Bodywork and Massage Professionals. ABMP membership gives professional practitioners like you a package, including individual liability insurance, free continuing education, quick reference apps, online scheduling and payments with Pocket Suite, and much more.

Whitney Lowe:

And ABMP CE courses, podcast, and ABMP Massage & Bodywork Magazine always feature expert voices and new perspectives in the profession, including from my partner, Til, here and myself. And The Thinking Practitioner listeners can save on joining ABMP at abmp.com/thinking.

Til Luchau:

And this episode's in-house sponsor is me and Advanced Trainings, my company. We offer all kinds of learning opportunities from one hour certificate courses to ongoing study groups online and in person. I want to highlight a live online course we have coming up very soon. It's a training in our principles of advanced myofascial technique series. We've been evolving this hybrid online format, meaning you get a chance to review all the materials on your own, and then meet live with us as the faculty. We've been doing that for about 20 years. And the latest revision, the latest version we're doing for this learning process really hits the right balance, I think between learning at your own pace, getting personalized realtime interaction and support as you go through the material. You get lifetime access to the recordings of the fully updated course materials, plus your choice of a variety of live every other week meeting times, super affordable with discounts for ABMP members AT subscribers, in-person course repeaters. And lots more. Check it out in the show notes or on my site, advanced-trainings.com

Whitney Lowe:

And you won't be sorry. You'll be glad you did that.

Til Luchau:

Yeah.

Whitney Lowe:

Won't be sorry.

Til Luchau:

Nice. Well, how you been? What are we talking about today? What's up?

Whitney Lowe:

Been good. I look down at my calendar and today, or the date that we're recording, this says April 12th on the calendar, but I woke up and there was snow on the ground this morning, and I'm thinking like I'm really over this. So it's been nice that it's been a wet winter out here in Central Oregon for the need for us to get some water, but in case nobody else got the message, we're done with winter here. Okay? So, we're done.

Til Luchau:

I'm on the road. I was just down in Southern Arizona having some great family and alone time, and then I'm on my way back, and in Durango, Colorado, and they have so much snow there. We have so much snow.

Whitney Lowe:

Yeah.

Til Luchau:

There's a hot day today and the river has just swelled its banks and it's really roiling and muddy, spectacular river down there, right below me.

Whitney Lowe:

Yeah, so it's an interesting. It's one of those la something years. It's either it's a La Nino or La Nino. I can't remember. I can't ever get straight which one it is, but it's la la la something this winter here.

Til Luchau:

Here we go. Yeah. What are we going to talk about today?

Whitney Lowe:

I think today, we're talking about back pain. We're going back to it today. We're going to talk about back pain.

Til Luchau:

Back to it.

Whitney Lowe:

Yeah.

Til Luchau:

In honor of the upcoming back jam with Diane Makowski and read that kind of an in-house sponsor too. We're going to put a link to that in the show notes as well, where we can go find out about what's happening there. And then my own spine course. But you know a lot about the back, so I'm really going to.. If you're okay with it, I'm going to ask you some questions to start the conversation, and then we can just talk about working with back pain and back issues.

Whitney Lowe:

Sounds good. I'll make up some answers. Something that sounds like reasonable, like I know what I'm talking about.

Til Luchau:

Right. All right. I'll make up some questions too. Actually, we've got some great ones there in our whiteboard. First of all, how prevalent is back pain? What's the deal? We all know it's kind of common, but how common? What's that mean?

Whitney Lowe:

Yeah, certainly. I think if we base it just on purely subjective statistics of who comes into your office wanting help and what do they want help with, back pain is pretty darn common, but at least I know the prevalence statistics around back pain that I've seen hanging around for a couple of decades, it hasn't changed too much. It's somewhere around 75 to 80% of the population will experience at least one episode of back pain in their life. So let's say that's a pretty common thing, happens to a lot of folks. Yeah. I was just going to say, one of the biggest problems around that is that it's not, in many cases, a simple thing. We just can't say like, "Oh, this is your back pain. This is the answer." It's just... I was going to ask you when I was thinking about this-

Til Luchau:

Very broad term.

Whitney Lowe:

Yeah. Going through this outline, do you remember... This is when you and I would've been young. I don't see them around too much. Do you remember those commercials for Doans pills?

Til Luchau:

I don't remember much from when I was young. I remember the music I used to listen to.

Whitney Lowe:

Yeah, there was a pills, a product called Doan, I think it was D-O-A-N, Doans Pills. That was always about like, you got a bad backache, take Doans pills, and that was supposed to be the solution for your backache complaint.

Til Luchau:

It's been with us forever. It's a huge medical complaint. It's the chief musculoskeletal complaint in terms of lost productivity hours and health expense, healthcare related expenses in the world, back pain is. And it's just a big lump of various causalities or mechanisms, or a lot of it's a mystery too.

Whitney Lowe:

Yeah.

Til Luchau:

So there's tons of research that's done on this back pain question because it's so needed and so easy to find research funding, and so easy to find subjects to look into. So yeah, it's a big deal.

Whitney Lowe:

And it's interesting to note that with all that interest in it, and with all the money and everything that's been poured into it, we still don't know what's causing a lot of people's back pains.

Til Luchau:

We have some clues, but you're right, a lot of it's still non-specific, which means-

Whitney Lowe:

Yeah. Yeah. Yeah.

Til Luchau:

Why is it so common, you think?

Whitney Lowe:

Well, I think, personally, it's so common because there's a lot of stuff going on there. And we're still learning new things. I just learned some new stuff in the last couple weeks we're going to talk about here in just a little bit of things that I... I've been studying this stuff for decades. And I'm still learning new things about potential causes of back pain, and we've further developed our research capabilities to look at biomechanical models and to look at neurological models and to look at psychosocial models that all these factors play a role in it, and it's just rarely one simple thing, but there's just a lot of things that can go wrong in that area, which kind of makes sense. If you think about it being the central area of both structure, weight, transmission throughout the body, and maintenance of the upright posture and the central area of communication with the neurological system and the spinal cord there. There's just a lot of potential things that can go haywire in that area.

Til Luchau:

Okay. So you think it's common because it's just a complex mechanical and neurological situation?

Whitney Lowe:

Yeah. To me, that kind of is... That's what I see at least. What do you think?

Til Luchau:

Okay. Yeah, that makes sense to me. That's makes sense to me. And honestly, I haven't really asked myself that question, why is it so common? I know some of the rote answers that... Now we're upright, maybe we evolved, our structure evolved pads and then we went upright, and that changed the vector of loading through a structure that evolved horizontally. And if you go by that theory, and then vertical, that's one. There's also the idea that we don't move enough and we spend a lot of time sitting. That's a big one.

Whitney Lowe:

Yeah.

Til Luchau:

 That's it. That makes sense to me. Maybe they're just talking to me, I don't know, but that's a good question. And we're going to get to it, I know. But when I hear these questions, what is it? What causes it? Why is it common? I'm always thinking, okay, now how can I use that? What can I do about it? So let's work toward that.

Whitney Lowe:

Yeah.

Til Luchau:

That's what I'm interested in.

Whitney Lowe:

Yeah.

Til Luchau:

Okay. In your thinking, Whitney, what are some of the potential causes of the back pain itself?

Whitney Lowe:

Yeah, so if we look at what are those things, at least that were most likely to be identifying as causes of back pain, and this is interesting because it's shifted some over the years historically with different perspectives from time to time. But at least in the world of orthopedics, which is kind of where I feel more familiar, having spent more time sort of delving into that kind of stuff, there's a lot of emphasis on potential structural issues in there. And this is a lot about disc pathologies, spinal dysfunctions, mainly around the facet joints. Again, the facet joints are the articulating surface between adjacent vertebra, keeping in mind that vertebra don't articulate with each other in the big bodies where they're bearing weight, but it's mostly in the facet joints, which are guiding movement. And those facet joints, like any other joint of the body, have a lot of sensory receptors in there and are susceptible to joint degeneration, arthritis, and all those kinds of things. Those are the main structural things with bony surfaces in there.

Til Luchau:

Let me see if I got it. You're saying weightbearing doesn't happen to the facets? And you're saying the weightbearing happens through the disc structures probably?

Whitney Lowe:

In normal spinal mechanics. I'm not going to say any weight, but the majority of weight would be going through the bodies or the vertebra. But then you take postural aberrations, let's call them, something like the exaggerated lumbar lordosis where a person has greater sway back or greater curvature in the spinal region in the lumbar spine, for example, now that center of load has shifted in a posterior direction, and more of the posterior vertebral arch structures are carrying that weight load. So it can happen, and that's the kind of thing that would lead to structural problems of... We see that with stress fractures in the pars interarticularis and facet joint irritation, that kind of thing.

Til Luchau:

Okay. All right. Keep going. There more/

Whitney Lowe:

Yeah, lots more here. So when we talk about... Again, this kind of gets into, I think, history too, looking at what is the nature of how the back pain originated? Because we have traumatic forces that may have caused injury, damage to the spine, the back, and this will include. You may have fractures in the vertebra, you may have possible dislocations or displacement that may do that, but also now you're talking soft tissue involvement, like ligament sprains, muscle strains, muscle tenderness disorders, things like that, that are associated with force overloads on the spine. And this might be repetitive overloads, or it could be sudden whiplash type sudden individual force loads that might cause those kinds of things. So those are things from traumatic force, either high velocity or very high load, unusual loads on those forces that they're having to withstand. And then there's sort of the counter to that, which is the chronic overload from... We see this a lot in the myofascial tissues, in poor postures being loaded extensively, but then so are some of the other structural mechanical elements of the spine.

The disc is exposed to greater compressive loads from low level compression over time, let's say, sitting with a poor slouched posture. There's greater compressive loads on the disc and doing that than there is in many of the lifting activities when people are doing heavy lifting things. So there's commonly been sort of a, ever since the... Oh, what was this? In Gordon Waddell's book, Back Pain Revolution, I think is the name of that book, he spoke of this time period in medicine from about the mid 1900s up through the later part of that century called the dynasty of the disc, where once it was discovered that the disc was playing a role in a lot of these things, we started blaming the disc for all kinds of things with back pain, and that led to lots of the disc surgeries and all that kind of stuff with an over-emphasis on the role of the disc in many instances, I think.

Til Luchau:

Yeah. Frank Willard was presenting in Berlin at the Fascial Congress there on back pain, and he gave a statistic that surprised me, but I've heard it in a few places since then. He said, it used to be thought that 80% of back pain was related to disc issues. Now as they dial it down and do a larger analysis, it's probably somewhere he said, around 4% of people's back pain.

Whitney Lowe:

Four? Wow.

Til Luchau:

And that's-

Whitney Lowe:

Interesting.

Til Luchau:

Again, I've seen that in a few places now, where there absolutely is, but there are times that the discs can cause back pain, but they're probably much less, one in 25 or whatever it is, than we used to think. And he said... Of course, he was at the fascial Congress, so he is talking to a soft tissue oriented audience. He said somewhere around 60% mild fascial pain, which is a pretty big bucket too. But that says in his model, more of a soft tissue, not a deceptive generator than the articular one.

Whitney Lowe:

Yeah. The thing that I find interesting about that, and this is something I'm kind of still swirling around in my head-

Til Luchau:

Yeah.

Whitney Lowe:

... is that in many of these instances where there is soft tissue pain in those areas being generated. And the nociception is primarily being generated in the soft tissues, the question often comes up, why are those soft tissues generating excessive nociceptive input? Because I think in a lot of instances, there are in fact spinal irritants that we're just not good at identifying. And what happens... I was thinking about this analogy the other day of a sound system in your house. You've got, let's say, a nice amplifier or something that's putting the music together, and then it plays through the speakers, and essentially your myofascial tissues are the speakers. So this is where you hear the action going on. So when you got a problem, you feel that or hear that in the myofascial tissues.

And what we often do as manual therapist is we can reach over to that knob that's on the speaker and turn the volume maybe of the speaker, of the music down and affect some things in there. But the reality is, if there's bad music playing from your sound system, you don't change that until you go and change what's playing on the sound system. And that oftentimes is the central nervous system that's playing the bad music that gets spread out to the myofascial system, which becomes then the symptomatic part of that process.

Til Luchau:

Wow. You just described.. Did you finish your thought because I'm about to rip on it.

Whitney Lowe:

Yeah. Yeah.

Til Luchau:

You just described it in exactly opposite direction as I think of it.

Whitney Lowe:

All right. Well, tell me about that.

Til Luchau:

I thought the brain was the speaker. In other words, the input is the pain is in the brain idea where it's actually the experience that's happening in our central nervous system and the signal is just one of the inputs in the speaker wire say, and-

Whitney Lowe:

The reason I would say it this way is because people don't come in and say, "My brain hurts." They come in and say, "My back hurts," or "My leg hurts." So that's where-

Til Luchau:

They don't come in and say, "I have a bad speaker." They say, "That record sucks too."

Whitney Lowe:

Right. Yeah. And that's to me where that's the central nervous system problem with.. Yeah, that's really just a bad song. You got to change the music in there. All right. So anyway-

Til Luchau:

It's, I was looking for the analogy, but they're both analogies. But that is a factor, isn't it, that-

Whitney Lowe:

Yeah.

Til Luchau:

... there is signal? And so far in your list there, there's signal explanations. We got structural, we got disc, we got facets, we got traumatic forces, we got tissue effects. And that's pretty common way to think about that. There's a signal generating mechanism, and that that's the pain producer.

Whitney Lowe:

Yeah.

Til Luchau:

And now you're bringing the central nervous system, which is a whole different modulator.

Whitney Lowe:

So we haven't really touched on that as another big causative factor. So this is related, because when you talk about disc pathology, you're usually talking about discs are pressing on nerve roots. Or in some cases in the low back, maybe even on the spinal cord in a cauda equina syndrome or something like that. So we have mechanical compression of neural structures. But another one that I think is just not getting adequate attention, and this is something that's kind of in your ballpark, because I know you're big into looking at the issues of inflammation around various different tissues, but there's a lot of potential. And I think this would probably bump up the numbers of your colleague that was talking about 5% of the discs involved in back pain. I think those numbers would go up if we really talked about chemical irritants to the nerves as a result of disc pathology.

For example, there is a chemical, an enzyme in the nucleus pulposus of the disc called phospho lipase A2, which can leak out with just a really, even a small annular tear on the outside of the disc, and leak into the intervertebral space. And that can irritate the spinal cord or the nerve roots and cause that same kind of neural irritation. And you go get imaging, and they'll say, "No, you don't have a disc protrusion pressing on a nerve root." There's nothing there that's pressing on the nerve root because it's not a mechanical problem, it's a chemical one.

Til Luchau:

Right. So the chemical irritation of the nerves. Now, there is some really compelling and pretty common research that inflammation in one structure can evoke an inflammatory irritation in surrounding structures. Even if there's no mechanical compression or no physiological mechanism for that, just the inflammatory, cytokines and processes nearby can really make something hurt.

Whitney Lowe:

Yeah.

Til Luchau:

So the disc could be part of that. Any of the soft tissues around the spines, the bones, the plates themselves, all of those are thought to be places where inflammatory processes could be happening, either because of an injury or because of a metabolic or inflammatory immunological issue that would result in this back pain. So our classical explanations are largely mechanical and compressive, but there's probably a whole category of pain that is chemical, like you say, or inflammatory, or just irritation, independent from mechanical forces.

Whitney Lowe:

Yeah. And those are harder to see and harder to measure. So they don't get, I think, identified as often.

Til Luchau:

Yeah. Right. We don't have an inflammatory MRI. We don't have... There are assays and things, but they're pretty complex. Yep, that's right. But fortunately, the good news is coming, fortunately, that we can work with it still. Even if you can't see it on MRI, there's definitely ways to work with that pain, whether it's compressive mechanical or inflammatory irritation or sensitization.

Whitney Lowe:

Yeah. Right.

Til Luchau:

Now, you said something there interesting. You said, is back pain a psychological problem? That's a question you're throwing out for us to discuss.

Whitney Lowe:

Yeah.

Til Luchau:

What do you think?

Whitney Lowe:

Well, so often people get told oftentimes that this is just a psychological driven thing. And oftentimes, unfortunately, I hate to say this, but I think there's a lot of truth in, is that this does tend to happen in a lot of instances where a healthcare professional is unable to identify any other factor, and then this just gets lumped into the category of, this is in your head, or this is a psychological problem, you have to deal with it somehow or other.

Til Luchau:

Yes, that's right.

Whitney Lowe:

I certainly think there are psychosocial factors that can play a part in any kind of pain situation in a lot of different areas, but I do think that a larger percentage of people's back pain gets blamed on these psychological factors simply because practitioners are not thorough or comprehensive enough in finding some other solution.

Til Luchau:

So you think that if they were thorough, they could find a mechanical solution?

Whitney Lowe:

I wouldn't say necessarily mechanical, but some other kind of solution.

Til Luchau:

Maybe, go for it.

Whitney Lowe:

Yeah.

Til Luchau:

Yeah.

Whitney Lowe:

Could be mechanical, could be in a neurological, could be metabolic, but I would say some other solution that might at least be playing a significant part of that. And that's not saying that there's no psychological component to these things. I just think that for some people, unfortunately, that component gets overplayed as a part of ignorance-

Til Luchau:

That's right.

Whitney Lowe:

... on the part of the practitioners who's who are unable to find a solution.

Til Luchau:

Well, because the musculoskeletal classical world knows so little about the influence of psychological factors, it's a big black box where things get swept. And because stress, for example, is such a common factor in so much pain and so many issues that, again, it can be just a big rug to sweep things under-

Whitney Lowe:

Yeah.

Til Luchau:

And it's a definite factor, but that doesn't always leave people with places to go. And like you said, can even lead to that invalidation of feeling dismissed.

Whitney Lowe:

Yeah.

Til Luchau:

It's just something you that's doing that to yourself.

Whitney Lowe:

Yeah. Yeah. Absolutely.

Til Luchau:

Hey, can I read you a quote that really struck out-

Whitney Lowe:

Oh, let's hear it.

Til Luchau:

... stuck out about this. Yeah. Okay. This is from, a paper by Hansen, 2016. He says, "Hans Kraus MD, described as the father of sports medicine in the United States, postulated that non-specific back pain is a 'disease of civilization caused by sedentary lifestyle, stress, and suppression of the fight or flight response.' Kraus wrote in 1970..." he was very influential in back pain treatments and thinking back then, "that in our civilized cities, we lead the lives of caged animals. And he theorized that a lack of exercise and emotional stress leads to muscle weakness, stiffness, pain, and injury. 45 years later," Hansen wrote, "Dr. Mense," which I believe is how Dr. Mense pronounces it. I'm going to mention them again a couple places here. "Immobilized rats," sorry, rats "immobilized rats in narrow tubes, and discovered that this model of psychological stress induced sensitization of dorsal horn neurons."

Anyway, these poor rats he stressed out by keeping them in narrow tubes and measuring what was happening in their nervous system for the signals that related to nociceptive activity. And sure enough, the dorsal horn neurons got sensitized to receiving input from the low back, especially validating Kraus' theory in a laboratory setting. So Mensey was doing these really interesting experiments where he was saying, if we stress out an animal, does the sensitization change? Does the sensitivity to signals change? And showed pretty convincingly. And now it's pretty well accepted that stress is... It's like turning up the mic here.

Whitney Lowe:

Yeah.

Til Luchau:

You just pick up a lot more background noise, and everything comes in louder in a way too.

Whitney Lowe:

Yeah. I heard an interesting analogy, somebody speaking about this, saying that it's just like when you bite your lip accidentally, and then that is super sensitized. So now, it takes just a little bit of irritant now further to make that be very painful again and very painful. Every time you now have this little swollen thing inside your lip because you bit it or something is going on there, every little bit of increase in that magnifies it and ramps it up even further. So yeah, I think we have to deal with that a lot.

Til Luchau:

Well, yeah. The biting lip analogy, the sunburn is another one going into the shower after a sunburn-

Whitney Lowe:

Yeah.

Til Luchau:

... those are both injuries. What he's saying, that in this case, even just stress, not being able to move, which is not an injury, it's stressful, changes the perception of pain. And that goes with a lot of research that says pain is so contextual.

Whitney Lowe:

Yeah.

Til Luchau:

That what we experience... And back pain seems to be one of those ones that emerges out of the background of everything going on, that so much of the input, these multifactorial inputs result in something like back pain. There's like TMJ, other ones that seem to be the weak length or the canaries in the cold mine, or whatever they are, that just respond to this background.

Whitney Lowe:

Yeah. Sure. Sure. And we have lots more research now too about things like the whole flight or fight response, staying activated for long periods of time and suppressing parasympathetic activity like the normal metabolic processes of digestion and tissue repair and things like that that would go on, that would allow you to be able to get back to normal function. But we keep that ramped up for so long, then it's no wonder we continue to have some pain and problems associated with that across the systemic, the whole systemic system.

Til Luchau:

Yeah. Okay. I got to go back a little bit to some of the mechanical ones. You were doing your list of mechanical ones. I forgot to put mine in. What about fascia? Because we got nerves, we've got muscles, we got bones, we have inflammatory process. But there's also, of course, in my world, a lot of emphasis, a lot of attention paid to the wrappings of those things, per se. And there's some really compelling research that says it changes in back pain, either that or it's changes produced back pain. It's not always clear which way that goes, but that it's thicker in people with low back pain. This is Angevin and Fernandez, that it slides less, especially in low back pain. Those layers of the thoracolumbar fascist A, the big fascial wrappings of most of the back structures, there's less glide between them in people with low back pain. And there's some good evidence that says when we change the thickness or we change the gliding through things like manual therapy, that the pain changes to.

Whitney Lowe:

Yeah.

Til Luchau:

Yeah. And then back to your sympathetic thing, about 40% of the nerves in the thoracolumbar fascia are sympathetic nerves. And we don't quite know what that means because... It just amazes me how much of this parasympathetic, sympathetic, fight or flight, rest and repair model is pure theory with very little empirical research or evidence or testing. But we know that about 40% of the fascial nerve fibers in the thoracolumbar fascia are sympathetic. That could be simply because they regulate vascular vascular dilation and contraction. Yeah?

Whitney Lowe:

Yeah.

Til Luchau:

But it could be too that there's a link there between the stress factors that seem to show up earlier in as low back pain than say other parts of the body. People don't come and say, "I got ankle pain," and you say it's stress.

Whitney Lowe:

Yeah.

Til Luchau:

But back pain is one where we go, "Yeah, that's definitely a stress factor."

Whitney Lowe:

Yeah. That is interesting, huh?

Til Luchau:

Let's see if I've forgotten the other of my important points. Oh, the highest risk factor for low back pain in one big study with Ehrlich, I'll put the link in the show notes, World Health Organization sponsors study of low back pain, the highest risk risk factor for low back pain, dissatisfaction at work.

Whitney Lowe:

Really? Huh? Interesting.

Til Luchau:

Not occupation, not gender, not age, nothing, dissatisfaction at work.

Whitney Lowe:

Yeah. And that would certainly point to a lot of those stress-induced things that we've been talking about as well. Yeah.

Til Luchau:

Yeah.Isn't that interesting? And gosh, do you know anything that's good for stress?

Whitney Lowe:

Donas Pills?

Til Luchau:

That's it. Taking a pill that has been advertised and has convinced you as effective is proven to help you with your back pain.

Whitney Lowe:

Yeah.

Til Luchau:

It's true. As well as some really good stuff for stress, like therapy maybe.

Whitney Lowe:

Yeah.

Til Luchau:

If you don't get the reference, there's things we do through that. And boy, I'm biting my tongue because there's so much I want to say about that when we get around to what you can do about it.

Whitney Lowe:

Yeah. Yeah. So lots of things to turn down the descending modulation from the stuff that we're doing here. But anyway, go ahead. What were you going to say?

Til Luchau:

Maybe turn it up if I want to-

Whitney Lowe:

Yeah, turn up the... Yeah, thank you. Turn up the descending modulation.

Til Luchau:

Yeah, turn down the pain experience.

Whitney Lowe:

Yeah.

Til Luchau:

And even things we can do to turn down that signal and not susceptive signal by these mechanical factors, like you mentioned, or gliding factors or thickness factors, those are probably all signal or inflammatory load. But then we can turn down the sensitivity through stress modulation, through some other things that help descending modulation, et cetera.

Whitney Lowe:

Yeah. Yeah.

Til Luchau:

Okay. How do you figure out though, what's the cause? You want to say anything about that? How do you figure out the cause of back pain?

Whitney Lowe:

Yeah. I've certainly been trying to do this for many, many years. But one of the things that I noted in here was I came across this study years ago, and I cannot remember the exact title of it, but it was something to the effect of, and it was about back pain, and it's something to the effect of what you have is who you see, meaning you've got back pain and you go to see a chiropractor and you've got a subluxation. You go to see a massage therapist and you have myofascial trigger points. You go to see an acupuncture physician and you have a chi blockage. And so everybody will have-

Til Luchau:

You have Maslow, and you have a nail because-

Whitney Lowe:

Exactly. Yes. So it's all about the lens through which that practitioner is looking at your back, oftentimes to figure out what's going on. And there's probably some element of truth in everybody's perspective there, but I think it becomes really difficult to nail that down in many situations. But the one thing that I would say about this is whoever you are and whatever your particular orientation is, the better is your history taking and your evaluation process, the more comprehensive is your evaluation and your picture and understanding of how to interpret that, the better you're going to be at nailing down a larger number of relevant factors in there. So that's, again, just putting in another plug for the important value of assessment and evaluation because I just-

Til Luchau:

Yes.

Whitney Lowe:

And this is something that Stew McGill said to us in our podcast with him a while back too. He said he just doesn't really buy that idea of non-specific low back pain. He said most of the time, it's just because somebody just wasn't thorough enough in their evaluation to really nail it down what it really was.

Til Luchau:

Well, he's maybe one of the extremes of that, because again, his method when he was given free rein just to do it how he thought it should be was a three hour initial session or something like that, but most of which was history taken and experimentation. But the point being that you're making, which I really agree with, is that the clearer we get on what reduces the pain, what possible factors might be from people's past, but especially what's happening with it now, the more... Well, maybe the fewer times we have to reach in the toolbox to find the tool that makes a difference. Again, you said it helps us nail it down. I like the comparison there, because again, there may not be a hammer. Maybe it is, but maybe there's something else that... The more we understand, the more sense we have of it, the more likely it is that our working hypothesis we start with is going to get some results. And that's how we know we got the tool at the right time for the right person, that kind of stuff.

Whitney Lowe:

Yeah. And what I also find interesting is, and this has been true a lot for us in the massage and manual therapy world over the years, is how our understanding of what we do has changed a lot-

Til Luchau:

Yes.

Whitney Lowe:

... in terms of thinking that we're doing something for... At least let me speak for me personally, my own personal belief and understanding around what I'm doing shifted a lot from more structural and mechanical oriented things about I am making this tissue softer, and I'm changing this alignment thing and I'm doing this kind of thing to something that's a lot more richly involved with the nervous system and the responses of the brain and the effects of those things on the speaker system that I talked about earlier on, how that plays out in those soft issues in the body. And I don't think we're at the end yet. I think we're still evolving that understanding, but it is interesting to watch that change significantly.

Til Luchau:

All right. Using our speaker analogy, I just thought of an interesting scenario. If you want someone to have an good experience listening to music, you could spend a lot of time picking the right record. There's something to that. But there's also something about predisposing a listener to a state of enjoyment, getting them in the mood or finding the right timing for this or helping them really receive the music in the right way so that... I'm going to say that I could... If I had the right circumstances for someone, I could play a Doris Day record and it would be radically informative aesthetic epiphany for someone, say.

Whitney Lowe:

Yeah, so here's that music and speaker analogy taken into another level there, which is you can get really good music and have really good speakers and play it in a really crappy room of acoustics and it sounds bad.

Til Luchau:

That's one of the contextual factor. Yeah.

Whitney Lowe:

That's the contextual factor right there, is that you make that room really nice, acoustically ideal, and then the good music played through the good speakers (myofascial system or body system, whatever you're talking about there), now the room sounds really good. And that's what you're talking about with the contextual.

Til Luchau:

That's good. That's right. Or if someone's working, if in the middle of composing an important text and you try to get them to listen to your music, it's like the receptivity is a contextual factor too, the timing of that. So you could be the best speaker system in the world, the best room, the best music, forget Doris Day, let's pull something really special out of the collection. If it's not the right time, forget it. Same with our manual therapy interventions too. So much of it is priming the pump and getting that preparatory phase of getting someone in that receptive state and finding the right timing, different things we do.

Whitney Lowe:

Yeah.

Til Luchau:

Well, do you want to talk about posture? Did you get to say what you wanted to there?

Whitney Lowe:

Yeah, I think we kind of touched on a number of those things. And again, that is a huge rabbit hole to get down because it certainly has been a prominent piece of a lot of models of back pain for a long time.

Til Luchau:

Yes.

Whitney Lowe:

I'm kind of that camp of I don't think... And this is mainly talking about static posture here, but again, there are postural positions that you might do. For example, in an occupation where let's say your occupation's somewhere you have to bend over for long periods of the day to work on something that's down below you, that's going to put a lot of mechanical stresses on your back, for sure. But I think when we say the word posture, we're oftentimes speaking of that kind of evaluating somebody's standing postural position. And I think there's been a lot of, in certain camps, a lot of emphasis on posture in the past. It may have changed significantly, and there's been a lot of research, I don't know if we'd see a lot of research, but certainly some research recently that has indicated some of these postural factors may not have been as important as we may have once thought they were.

And I'm kind of the camp now of saying that... I'm certainly not all the way on that end of the spectrum with those individuals say posture is not... There are people that say, posture's not of significant cause of pain or whatever. I can't go there because I know for myself, every day at the end of work when I go in the kitchen to cook dinner and I'm shopping vegetables over the counter, my back hurts after 45 minutes there, and it's about posture. So I know that's true.

Til Luchau:

Was it posture or was it lack of movement?

Whitney Lowe:

It's not lack of movement because I'm moving all around in the kitchen and doing things. But again, those two things are hard to-

Til Luchau:

Is it five minutes of the posture or is it the 45 minutes of not moving?

Whitney Lowe:

I think it's more of the slightly leaning over posture, but I do think let's say non varied movement, movement that's not varied enough absolutely plays a role in that, because my back can also get really tight after a few minutes of just sitting in a position of non-alternating movement.

Til Luchau:

Well, those are arguments in the debate, aren't they?

Whitney Lowe:

Yeah.

Til Luchau:

That there is historically an emphasis on the correct position, getting the posture right and in static mode, and it's the view that maybe that was... Sorry, pull me out of the rabbit hole if I'm spending too much time here.

Whitney Lowe:

Right. Yeah.

Til Luchau:

Maybe that was the result of the technology being photography, which is a still image. That's what we used to understand and analyze and think about things.

Whitney Lowe:

Yeah.

Til Luchau:

So that there was a lot of historical emphasis in our field on static position. And that was actually a radical contextual change from what had come before, because it was saying now, even the way someone stands could be part of their back pain. That also was a radical new thought and was a contextual factor in that way because it hadn't really been considered.

Whitney Lowe:

Yeah.

Til Luchau:

And so that really got some traction, got some mileage.

Whitney Lowe:

Yeah.

Til Luchau:

So then maybe, again, paralleling maybe the development of film or video, we started to think, okay, so maybe it's the way we're moving that does it? Maybe it's not just the way we're standing, but it's the way we're moving?

Whitney Lowe:

Yeah.

Til Luchau:

And similar debate there too, yeah, there are probably ways to move that help you feel better than others, but the argument being, well, maybe it's the amount of movement is more important than the exact way you move, or like you said, the variety or the timing or the magnitude, those kind of things being important as much as the exactly correct patterning or correct alignment movement being less of a factor.

Whitney Lowe:

Yeah.

Til Luchau:

Some of the reasons you mentioned, it seems like there hasn't been a study that can do it a police lineup of pain and be effective. Who in this lineup has pain? Can you spot it visually? There hasn't been a study that could do that. Even in friendly environment, academic environments where that is their model, there's a really low correlation between visual analysis and pain.

Whitney Lowe:

Yeah. Yeah. And I heard a quote from someone, and I think this was on social media like a year or two ago or something like that. And I thought, I love that quote. I'm going... That's the camp where I live in now, which is... It says something like, posture is not necessarily a cause of back pain, except when it is. And so that's just saying it's probably not a factor as much as we might have thought it is. But is it irrelevant? Absolutely not. It's going to be a factor in certain cases. But your role is then to uncover when is it relevant, and to what degree and how. And that's the trick.

Til Luchau:

And then what are the levers for shifting that? What are the ways people could work with posture, because that's a whole other question too.

Whitney Lowe:

Yeah.

Til Luchau:

So yeah, you mentioned Stu McGill. He's been accused of over-emphasizing posture and he defends his position there radically, says, "No, it's stiffness, mobility, balance." I'm probably mischaracterizing his response, for sure. But he's been an advocate for the right kind of stiffness and the right kind of adaptability balances, while Greg Layman has really been radically questioning our various explanations. He's been the spokesperson for that point of view. And at least last time I took a training from him, his position was, no posture is not so much of a factor except in maybe really specialized weightbearing situations like power lifting or something like that, that the small changes in posture probably, he says, probably don't correlate with someone's pain.

Whitney Lowe:

Yeah.

Til Luchau:

But again, I'm with you. It matters. It does matter, and it matters when it matters. But more and more in my own body, it is movement that seems that more direct correlation for me between when I'm comfortable and not comfortable with how much and how the right of movement I have less than I... Keeping the exact position.

Whitney Lowe:

Yeah. And I think we're also... Again, we're back to that issue that we talked about, which is we're isolating posture in a much bigger vase of other stuff that it's mixed around with. It's like, well, you've got a big vegetable soup there, and we're focusing on the carrots in there. And we have to remember that there's a lot of other things in the soup that are going to be playing a factor in there that might interact with the carrots and make them taste differently or act differently or something like that. So I'm into the metaphors today. It's music and amplifiers and soup.

Til Luchau:

Soup. Let's do a big mix metaphor. Let's do soup while we listen to our amplifier.

Whitney Lowe:

Yeah.

Til Luchau:

Well, thinking of that technological progression from photographs and static analysis to video and movement analysis, I wonder what's next. I wonder as we start to get artificial intelligence, how that's going to change our understanding of pain in a way. I wonder if there's a whole nother level that does include experience and does include the internal world of people, perhaps in an interesting way that expands our explanations and our thinking too.

Whitney Lowe:

Yeah. I'm looking forward to... I don't know that I'm going to be around for this, but I think it'll happen, is the intersection between visual imaging and functional evaluations. So for example, if you can blend together the imaging specialization of a moving x-ray or a moving MRI image where you can see things in motion, and at the same time, you can evaluate neural activity and say when is something getting irritated as you do this particular movement, and what kinds of signals are getting emphasized there. I think that'll be fascinating, but I don't know if I'll be around when that happens.

Til Luchau:

And I want the emotional or neural or affective map of that. When does someone get startled? When do they get upset? When do they get relaxed? When do they feel confident?

Whitney Lowe:

Yeah.

Til Luchau:

Because those also have correlations to the pain experience, at least as much as the signal, finding the signals, the mechanical signals and those correlations.

Whitney Lowe:

Yeah.

Til Luchau:

Well, Whitney, you had a couple of questions you want to talk about that I think are great ones, but I'm wondering about the order. What do you think about red flags? Rather than say that at the end, can we finish up with what we're going to do about it?

Whitney Lowe:

Yeah. Is that related into our role?

Til Luchau:

What do you want to talk about next?

Whitney Lowe:

There's just a couple of things. And I was just going to make a couple of highlights about this because I know there's... Again, we could go down these rabbit holes for days at a time here, but there are a couple of important red flags to think about. Especially in my world, I think a lot about these kinds of things with neurological sensations that indicate potential really problematic things. So for example, if we're talking low back pain and somebody has... Usually with disc or nerve root involvement, we will frequently see pain radiating down a lower extremity as a common thing, and usually that's going to be a one-sided thing to whichever side the disc or whatever is protruding out and pressing on the nerve root. But when you have something like bilateral lower extremity neurological sensations and corresponding, let's say bowel and bladder dysfunction along with that, and again, hopefully you will pick these things up in the history when you are doing a detailed evaluation, that could be indicative of a cauda equina syndrome where something is pressing on the cauda equina.

And that's a very, very serious problem that needs to be not only referred out, but possibly referred out to the emergency room because pressure on that cauda equina can interrupt blood flow to those nerves, which can cause permanent nerve damage for an individual. So those are the kind of things that we can't just sort of brush off, or let's see if we can just work on your legs and make it feel better or something like that. So those kinds of things that indicate a much more serious thing going on would be the examples of the kinds of things that I think are important to be to on the watch out for.

Til Luchau:

Okay. That was the only red flag you wanted to make sure to raise? Any others?

Whitney Lowe:

That's a big one. And then I would also say to any... When we start seeing pain sensations that are grossly out of proportion to what they should be with minor levels of movement or things like that, or things that might be indicating instability, like in a spondylolysis where there is clearly vertebral movement and translation of a vertebra, because it's really broken and translating and sliding forward, those are symptoms and signs and indicators of things that we don't want to be working on because we could aggravate them, make them worse, and they need to be referred out to some other individuals. So those are the kind of things that come especially onto my radar screen as big things to be watching for.

Til Luchau:

Yeah. And there are medical conditions that people should know about and be addressing that can be related to back pain as well too.

Whitney Lowe:

Yeah, visceral problems, things like that that might be referring pain. Yeah, absolutely. Yeah.

Til Luchau:

Yeah. Tumor, things like that too.

Whitney Lowe:

Yeah.

Til Luchau:

It's just persistent back pain without medical evaluation is probably not a good thing.

Whitney Lowe:

Yeah. Right. So yeah, all very important factors, but they play a part in us deciding what we can do, and this is kind of where we're going to go to next. What are we doing?

Til Luchau:

Let's go there.

Whitney Lowe:

What can we do? Yeah, what do you think? Yeah, what's our sort of track with this?

Til Luchau:

Oh, I get to start?

Whitney Lowe:

I know. I'm throwing it back to you this time. Yeah.

Til Luchau:

Okay, so we got all of these possible causes and factors and mechanisms. And now what do we do? I got a few key points, but again, just to ease into it a little bit, if context is a big part of it, the inflammatory low, the stress factors, the mechanical, the postural, the movement, all those things, the big questions here is, how do we influence those things? We can influence a myofascial structure under our hands. We can move a body. We can produce a sensation through our touch. Maybe there are tissue effects. Certainly, we can have autonomic effects with our work, but how about lifestyle factors? How do we influence those? Because sometimes, maybe often, maybe always, that is a big factor in back pain.

Whitney Lowe:

Yeah.

Til Luchau:

And it's an open question for me, but I think there's a lot we can do. Let's say my goal was to help someone imagine moving, help someone move more. Now, that's not classically my scope of practice as a manual therapist. That would more physical therapy, exercise, physiology, strength and conditioning, whatever. Maybe you have that background. Maybe you don't. But that's the question I hold for myself as a manual therapist. What can I do with my hands in this session, and with my words and my questions, that makes it more likely someone's going to feel their body, and so move when it's uncomfortable, that's a big one, or just be willing to try different things, try going for a walk if they haven't been walking. And there's so much we can do to help someone experience comfort and relaxation and just a sense of ease in their body.

Then the key thing is using that, taking that and using that. So just inquiring about activities and talking about someone's hikes or walks or whatever, the ones in the area, just creating possibility for people can be such an effective way to expand someone's possibilities who's experiencing back pain.

Whitney Lowe:

Yeah. And I don't think we should underemphasize the value and importance too of that amount of time that we spend with somebody that can touch on those factors, because people are so accustomed and used to the seven to 12 minute treatment time that they get with a lot of other health professionals or an abbreviated time where they're being sort of pushed through the system there. And it's hard to get to some of those things in that short period of time. And that is something that I think continues to remain a great value of the approaches of many manual therapy practitioners who can take more time and really address those contextual factors, think about biomechanics, think about neurology, think about the psychosocial domain in terms of what's happening here, not necessarily that we're going to get into or be an expert in doing all those things, but we can at least understand the ground through which those things might be displaying and playing out in the current system.

Til Luchau:

Right. And we can listen. We can understand and we can listen. We can listen. And sometimes people just don't have a chance to really think it through for themselves or to have a receptive listener who has the time to hear them out.

Whitney Lowe:

Yeah.

Til Luchau:

That kind of thing is going to be really valuable too.

Whitney Lowe:

Right.

Til Luchau:

So there's also another contextual factor I'm easing in now toward the specific from the general. The other one that we can do a lot about is sleep. Sleep and back pain are highly correlated. In fact, this is... I can't remember the reference, so maybe it's in an imaginary example of now, but it was a real one that I heard. Someone was going for back surgery. He got told by his physician that he was finally a candidate for surgery after years of back pain, and that was the last thing he had to offer them. He searched out the best back surgeon he could find who said, "Listen, from your intake conversation, you're only sleeping five to six hours a night. I'll tell you what? I'll operate on you if you can sleep eight hours a night for a month and still have pain. Otherwise, I don't want to operate on you."

So he made that his project, is to sleep eight hours a night for a month. And in the story, at the end of that month of making sleep his primary focus, he said, "Actually, the back pain isn't nearly as bad, not bad enough to have surgery. I'd rather deal with this pain than focus on sleeping."

Whitney Lowe:

Right.

Til Luchau:

Sleep effects us.

Whitney Lowe:

And I think what ends up happening for so many of these back pain patients is that would be a great thing if they could sleep. And many of them can't sleep because the pain-

Til Luchau:

That's right.

Whitney Lowe:

... and because the other factors that are present there. So it's a chicken and egg thing of how do you make that happen? Yeah.

Til Luchau:

Well, we can play a role because we can ease the intensity of someone's pain often, or we can help them feel more mobile or more relaxed, even if we don't totally erase the pain all the time, every session. That can really contribute to a better sense of restiveness and better sleep.

Whitney Lowe:

Yeah.

Til Luchau:

And in sometimes incremental ways, but sometimes in dramatic ways.

Whitney Lowe:

Yeah.

Til Luchau:

And I still think... I wish there were more night owl massage therapists. I think there's like a night shift.

Whitney Lowe:

Oh yeah.

Til Luchau:

Bedtime service, go tuck someone in, get them really calm down at home. And then would that do a lot for sleep?

Whitney Lowe:

Yeah. Well, I've seen that, yeah, personally be an absolute factor, because my wife has what's been diagnosed is fibromyalgia and chronic pain problems for years and she gets a massage every night. But right before she goes to sleep, it's not a long one, but a good 10, 15 minutes of work makes a world of difference in terms of is she going to sleep well. And if she doesn't sleep well, she's going to have a crappy day the next day and she's going to be in a lot of pain and a lot of discomfort. So I know it absolutely makes a huge difference, but that would be great. It would be a great business for the night owl massage who can come, the massage therapist can come and work on you right before you go to sleep.

Til Luchau:

Tuck in service. That's right.

Whitney Lowe:

Yeah.

Til Luchau:

Awesome.Well, that's great. No wonder she keeps you around, Whitney. That's really interesting.

Whitney Lowe:

That's probably it. It's the one thing... It's like that's irreplaceable right now, so everything else. Yeah.

Til Luchau:

All right, my other three things of what we can do, and I want to hear yours too.

Whitney Lowe:

Okay.

Til Luchau:

Well, I think of what I'm doing as... Well, let's start with the tissue. I do think about gliding of the layers, because again, there's some research basis that shows that that is correlated with feeling better in back pain. If you have more glide, you have less pain. So that's a big part of the model that I teach and I practice, I use in my practice too, is that gliding factor, less about stretching and remodeling and molding, a lot more about gliding. The other one is think big, both... Mechanical connections, it's not always just the back. You can find the effects by working with the limbs often, or the breathing or with the neck or these big probably mechanical connections that explain those. But certainly thinking big about in terms of inflammatory influences, is someone just really jacked up from stress? Is their diet out of control? Are they not exercising? All those things will increase the inflammatory reactivity of the body in a way that no matter what we do with our hands, they're going to be dealing with some of that inflammatory load.

Whitney Lowe:

Yeah.

Til Luchau:

So that's not a way we think big. We think beyond just that spot that hurts.

Whitney Lowe:

Yeah. And I think just taking your analogy too about the sliding gliding and the enhancing pliability of those tissues, and there goes a long way into other things like if I can do that and it feels better for me now to bend over and pick up that pencil that fell on the floor like, "Oh, that didn't hurt," when it usually would hurt before. Just being able to do some of those kinds of movements leads to more movements. And we know oftentimes that movement is really the best antidote for a lot of those back pain complaints. So absolutely any of those things that we can do to make an intervention to change the neurological sensation of what movement is and what's going to hurt and what's not going to hurt, I think are extremely valuable.

Til Luchau:

Huge. Mense, this guy that I mentioned who immobilized the rats in the tube, he did another study where he had sensitized rats swimming. He called it short term swimming. And he did a control group that didn't swim and he measured their sensitization over days. And in five days the rats that were swimming had a much lower level of sensitization than the control group.

Whitney Lowe:

Yeah.

Til Luchau:

So his takeaway was that, yeah, just movement, just exercising helps lower that sensitivity of the neurons. Nevermind signal, nevermind context, nevermind any of that self, just the amount of gain you got turned up in your amplifier changes just with exercise.

Whitney Lowe:

Yeah. Yeah. Definitely. Yeah.

Til Luchau:

Okay.I got one more.

Whitney Lowe:

Yeah, let's hear it.

Til Luchau:

And it's related to that example I just gave. We can think of our touch as changing tissue, gliding, et cetera, we can think about the context, but we can also think about our touches normalizing sensation or turning down the sensitivity through the touch itself. So it's like if I imagine that what I'm doing is helping adjust that amps output, or adjust the microphones reactivity, there's lots I can do anywhere in the body. Any level of pressure that can help lower that sensitivity of that system, and that helps a lot with pain, just that our touch has that power as well.

Whitney Lowe:

Right. And I think for me, just... And I'm just going to say I'm in agreement with all of those things that you said. Those will all be sort of in the ballpark of the things that I would emphasize doing. But also, I would take the approach of thinking that... A lot of my whole orientation towards this kind of thing has changed a lot from thinking about a very cause effect relationship between what I do and what is wrong. Do this for that particular thing because you're going to get this result. I'm a lot less in that camp now than I used to be, and a lot more in the camp of, we can do a wide variety of things in the context and nature of the way in which we touch people. And the other thing is that you take something like a really specific technique. Let's say somebody's got low back pain that seems to be myofascial in its at least origin or presentation to a large extent.

And you go in, and when you work really specifically on those multifidus that are the most painful ones, and it's: "oh, that's it right there. That's it. You nailed it."

Til Luchau:

Yeah, absolutely. Yeah.

Whitney Lowe:

That, in and of itself, the sort of sensation that the client is now going to have about you are an expert at finding those spots in me, and that whole thing gets back into the sensation of a confidence in you and your ability, which plays a big role in the outcome factors that are happening there too. So I think a lot of times the specificity of that type of work's a good point, in terms of really getting those results, plays a lot into context, again, that we've talked about of why that kind of thing can get to be really effective, not so much because I'm really doing something to those individual multifidi fibers that I thought I was doing in there, but the specificity with which I'm treating them and making those kinds of results, maybe really getting bigger pieces.

Til Luchau:

Really great super point. And my eyebrows raising around the way we say, really. I'm not really doing something. I'm just increasing your confidence. What is reality? What is reality here anyway?

Whitney Lowe:

Yeah.

Til Luchau:

It has its own reality. It's just... And that confidence, like you said, or the sense that it can change. If he can press on something and then it feels better, gosh, my pain is changeable, that gives me a lot of hope. That's a real experience, as much as a real congestion in the ischemic function of the tissue, say.

Whitney Lowe:

Yeah. So I do believe that I'm putting pressure on the multifidus and giving a tangential force to it. So I am really doing something to that tissue, but the effect of what happens when I do that is I think where the question marks are for me a lot more so.

Til Luchau:

Nice. Nice.

Whitney Lowe:

Yeah.

Til Luchau:

Yeah. Multifidus deserve honorable mention, thoracolumbar fascia, iliolumbar ligaments, arcuate ligament. There's some favorite little, like you said, places that really can give some of that experience of like, wow, my back pain, it's changeable.

Whitney Lowe:

Yeah.

Til Luchau:

But they're great ones to remember too.

Whitney Lowe:

Yeah.

Til Luchau:

All right. Anything else?

Whitney Lowe:

Again, I think we could go talk for a couple of days on all these kinds of things, but that's probably a good place for us to wrap for the day here.

Til Luchau:

Okay.

Whitney Lowe:

So that's where we'll take it back to.

Til Luchau:

Great. Nice talking to you. I'll do our closing sponsor spot.

Whitney Lowe:

Yeah.

Til Luchau:

And that's for Handspring. Because when I was looking for a publisher for a book I wanted to write, I was lucky enough to have ended up with two offers, one from a huge international media conglomerate, lucky me, and the other from Handspring Publishing, which of the times just four people in Scotland with a love of great books and a love of our field. I'm glad I chose to go with Handspring, as not only did they help me make the books I wanted to write, The Advanced Myofascial Technique series, but their catalog has emerged as one of the leading collections of professional level books written especially for body workers, movement teachers, and all professionals who use movement or touch to help patients achieve wellness.

Whitney Lowe:

And Handspring has recently joined with Jessica Kingsley Publisher's Integrative Health Singing Dragon Imprint. So head on over to their website at handspringpublishing.com to check out the long list of great titles they have, and be sure to use the code TTP at checkout for a discount. And thanks again, Handspring. We thank you to all of our sponsors, and especially thank you to you, the listeners who are hanging out with us. Hope you got some interesting insights on back stuff today. You can stop by our sites for videos, show notes, transcripts, and any extras. You can find that over on my site at academyofclinicalmassage.com. And Til, where can they find that for you?

Til Luchau:

advanced-trainings.com.

Whitney Lowe:

And if you have any questions or things that you'd like to hear us talk about, email us at info@thethinkingpractitioner.com or look for us on social media under our names. My name today, I'll take Whitney Lowe. And how about for you, sir?

Til Luchau:

Till Luchau is my name. Rate us on Apple Podcasts. We really do read the reviews that rate us. Just click a star, or just write a little thing. It's so great to hear how this is landing for you. And that's a wonderful way to let us know, but also to let other people know because that's how people find it. Apple Podcast has a huge influence on podcast ranking on all platforms, so when you rate us there or comment there, it really helps people find the show. You can also hear us on Spotify, Stitch, or Google Podcasts, or wherever else you listen. Please do share the word and tell a friend.

Whitney Lowe:

Sounds great. Well, thank again for the great discussion. I thoroughly enjoyed it. And we'll pick it up again on the next go round.

Til Luchau:

You too, Whit. See you later.

Whitney Lowe:

Okay. See ya.