Resolving Chronic Pain with Dr. Joe Tatta: Rational Wellness Podcast 058

Dr. Joe Tatta explains how to Resolve Chronic Pain by using his Functional Medicine approach when interviewed by Dr. Ben Weitz.

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Podcast Highlights

2:03  Dr. Tatta explains his journey from being a traditional physical therapist who sees pain as a mechanical phenomenon, to seeing the role of diet and the brain in understanding what causes pain. About 15 years ago he realized that 75% of his patients were obese and he had to address their nutrition to help them reduce their chronic inflammation and exercise alone could not do that.  He studied Functional Nutrition and incorporated it into his practice. He also became aware of the neuroscience of pain and the role of the brain and of stress in chronic pain.

6:08  We discussed the role of excess bodyfat on back and joint pain, esp. chronic pain, both from a mechanical stand point and from the role it plays in inflammation.

8:45  I suggested that we approach this interview a little differently–that we go through first how Dr. Tatta’s approach to pain works for a patient with chronic back pain and then how it works from a practitioner standpoint. Dr Tatta said that he thinks of three questions. One is, what’s happening to your biology? Two is, what’s happening to your psychology? And three, what’s going on in your environment? With respect to biology, Dr. Tatta asks if they are someone who could benefit from nutrition?  One, are you overweight or obese? If you are, you can benefit from a nutritional intervention. Two, do you have some kind of metabolic factor, or some kind of metabolic test that we can look at? Things like high cholesterol, high LDL, high C-reactive protein. If there are inflammatory markers on your blood work, then nutrition’s a key.  Third, when it comes to your biochemistry, if you are diagnosed with an autoimmune disease, or one of your parents have an autoimmune disease that has caused them to have some kind of joint pain, or some type of chronic pain syndrome, you want to be really aware that that tends to run in families. And you may be predisposed to developing an autoimmune disease. Or, if you actually have one, that nutrition is definitely one of the first steps in helping heal and/or possibly reverse that autoimmune disease. 

13:42  Two is looking at our psychology, which means looking at if you are someone with high levels of stress or anxiety, then you likely have high cortisol levels and poor digestion and you likely will develop leaky gut and poor motility and constipation and this can lead to more toxicity. Anxiety can also lead to more muscle tension and sleep disturbances, all of which can over-sensitize your nervous system and can increase the likelihood of chronic pain.  Chronic pain can then lead to depression. You also have to consider their history and if they come from a family with divorce or trauma or a history of abuse or addiction.

16:28  Dr. Tatta then explained that there is the environmental or social part, which involves having nurturing relationships, stress reduction strategies, and having an outlet for joy and doing things that make you happy and give you a purpose or passion in your life. And once you find those things, pain starts to quiet down and relax.

17:28  I then asked if I am a patient who is seeing a traditional physical therapist or chiropractor who has given them a musculoskeletal diagnosis and is performing manual therapy and is giving them exercises, etc. What do I do about the nutrition part? Dr. Tatta explained that movement and manual therapy are helpful and they make you stronger and more flexible and able to function.  Movement also helps to promote relaxation, enhances your mood, and decreases your fear about moving, so movement also has some of the psychological parts in there, so continue with the movement. but then ask if there is a “Is there a place for nutrition in my rehabilitation?” And, if the answer is yes, ask them, “Hey, what’s maybe one or two strategies I can implement into my life this week that will help my nutrition?” If that practitioner does not know, then you might ask for a referral to someone to help them with the nutrition part of things.

20:00  Dr. Tatta addresses the psychoneurological aspects by looking at sleep hygiene and developing a mindfulness-based stress reduction routine. He also recommends mindful based meditation and also acceptance and commitment training.

23:50  We changed course and I asked Dr. Tatta to take things from the practitioner side and explain how the busy Physical Therapist or Chiropractor can incorporate nutrition and the psychoneurological aspects of pain into a busy musculoskeletal practice.  Dr. Tatta recommended adding a question to your intake form like, “Are you interested in learning about how nutrition can improve your health?” Or, “are you interested in learning how nutrition can improve your pain?” That way you can see if this is something that your patient is open to learning more about and is ready to change their nutrition. If they are interested, you can start by asking them about added sugar in their diet. Then you can ask them if they know where the omega 3 fats are in their diet?  Dr. Tatta mentioned the Paleo diet and that ancient man had lots of omega 3 fats in their diet and they are anti-inflammatory. Dr. Tatta mentioned that he has a Functional Nutrition course coming out in a few months to train practitioners. He mentioned that when he sees a new patient, he may spend most or all of his first visit explaining to his patient about nutrition.

32:04  Dr. Tatta explained that when addressing the psychological aspects of pain into your practice, you need to assess and test the patient using a questionaire, like the Pain Catastrophizing Scale or the Tampa Kinesiophobia Scale.

 

 



Dr. Joe Tatta is a doctor of physical therapy, board certified nutrition specialist and functional medicine practitioner.  You can get additional information at his website, http://www.drjoetatta.com/   Dr. Tatta has a great podcast, The Healing Pain Podcast, which provides lots of information about healing pain naturally. And if you’re a practitioner, or you’re interested in getting certified, and ways to heal people naturally, from a mindfulness, cognitive-based aspect, you can go to theintegrativepainscienceinstitute.com. 

Dr. Ben Weitz is available for nutrition consultations specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also specializing in Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure as well as sports chiropractic work by calling his Santa Monica office 310-395-3111.


 

Podcast Transcripts

Dr. Weitz:            This is Dr. Ben Weitz with the Rational Wellness Podcast, bringing you the cutting edge information on health and nutrition from the latest scientific research and by interviewing the top experts in the field. Please subscribe to the Rational Wellness Podcast on iTunes and YouTube, and sign up for my free e-book on my website by going to drweitz.com. Let’s get started on your road to better health.  Hello, Rational Wellness Podcasters. This is Dr. Ben Weitz again, and for those of you who enjoy the Rational Wellness Podcast, please go to iTunes and give us a ratings and review so more people can find out about our podcast. Or, if you’d like to watch the video version, go to YouTube and become a YouTube subscriber to my Weitz Chiro, or you can look me up through Rational Wellness or Doctor Ben Weitz.

Anyway, today we are going to talk about pain. It’s the first time we’ve talked about this very, very important topic. And, we have Dr. Joe Tatta with us. And he’s a doctor of Physical Therapy, he’s also a board certified nutrition specialist and a functional medicine practitioner, like myself. And he specializes in treating persistent pain and lifestyle related musculoskeletal, metabolic, and autoimmune health issues.  He’s the host of the very successful The Healing Pain Podcast, and he has a number one best-selling book, Heal your Pain Now: A Revolutionary Program to Reset your Brain and Body for a Pain Free Life. He’s currently in private practice in New York, where I grew up, and also provides online health consulting to help people achieve a pain-free life, free from chronic disease. Joe, thank you so much for joining me today.

Dr. Tatta:             Hey Ben. It’s great to be here, thanks for having me on.

Dr. Weitz:            Great. So can you tell us about your journey from being a traditional physical therapist who typically see pain as a purely mechanical phenomenon, to seeing the role of diet and the brain in understanding what causes pain.

Dr. Tatta:             Yeah, it’s a great question to start with. And you know as a physical therapist, similar to chiropractors and other types of professionals out there, when you go to school, you get mostly a biomechanical framework of the human body as it relates to pain. So, things like range of motion strength, how joints move and glide and slide, all those types of things. And when it comes to treating pain we look at things like joint manipulation, joint mobilization, therapeutic exercise, and all those are extremely important when it comes to pain.  Somewhere within the evolution of my, I don’t know, 25 years in practice, I had kind of two epiphanies. One was, I don’t know how long ago, it may be fifteen years ago, and I looked around my clinic, and everyone was pretty obese. And, I did a little survey, sent to all the therapists. I think I had about … There were about five therapists working with me at the time. And I said, “Hey, let’s just do a quick little clinical study in our practice. Let’s see how many patients are overweight, that wind up in the overweight category, and let’s see how many patients are obese.” And it turned out something like 75 percent of our entire clinic caseload, the patients were obese.

And, that’s in line with the clinical data that we have. You start to look at people with osteoarthritis, rheumatoid arthritis, all the autoimmune diseases that, as you start to get inflamed, and you put extra weight on your body, you start to develop more types of pain syndromes. So that’s what kind of delved me … Or that’s what kind of took me to a deep dive into functional nutrition. Because exercise is only … It’s super important, don’t get me wrong. I’m a physical therapist, so of course I love exercise, but it’s only going to get you so far.  If you have someone who’s overweight, if you have someone who is obese, as a patient. If you have someone who has chronic inflammation, you’re starting to see there are certain things in their lab values that are pointing toward inflammation or inflammatory markers that, yes, exercise is going to help turn that around, but we have to look at nutrition as really one of the first steps in helping those patients.  So that’s kind of what made me get into functional nutrition, and start to study functional nutrition. Which is not common for a physical therapist.

Dr. Weitz:            Yeah.

Dr. Tatta:             Just about a year ago, I worked with the American Physical Therapy Association, actually changing our scope of practice. In saying, “Hey, as physical therapists, we should be screening and evaluating patients for challenges or problems with their nutrition. And, if it’s something that we feel like we can’t handle, then we can refer them on to the appropriate practitioner, but at least screen them and provide them with some basics.” I mean, every licensed healthcare practitioner, as well as health coaches, can do things like that.

So that was the nutrition. The other part, when we talk about the neuroscience behind pain, it is one … Again, when I went to school, I studied neuroanatomy. I studied neurophysiology. But, the field of pain science has exploded in probably the past about ten years. And, it has really started to inform all of our practice, as it relates to helping people with pain. And a lot of that relates to two things. One, it relates to an education piece, that we have a big role, as practitioners, to educate patients about what pain is, and what they can do to empower themselves. Nutrition is part of that, but the other part of it is about the brain and about stress. And how pain and stress are uniquely related, and you really can’t have one without the other, and what patients can do, and what practitioners can do to help educate their patients and to help their patients with regard to helping them cope with the chronic pain that they’re having.

Dr. Weitz:            Yeah, it’s interesting you mentioned the weight. I know that … I remember looking at the literature five, ten years after I got out of school, and it didn’t seem like there was a lot of correlation between gaining weight, unless you really gained a lot of weight, and back pain. And then I was at the gym, and I grabbed a thirty pound dumbbell, and I was using it for something, and I thought, “Oh my god, can you imagine dragging this thing around all day long? Every time I do everything?” And, it made it obvious. This has got to put a stress and an extra load on the musculoskeletal system, on your spine, on … Just doing this all day long. I don’t care what the studies show. This has got to be a big negative for back pain.

Dr. Tatta:             Yeah, we did have, I think when … I graduated in 1996. So I’ve been practicing now for a number of years, and-

Dr. Weitz:            Yeah, I’ve been practicing thirty years as well. I started in ’88.

Dr. Tatta:             Yeah, and we didn’t have the research then, we really didn’t. Like back when I went to school, there was a lot of talk about, “We need more research, we need more research.” Now, pretty much, if you go into Google, you go into PubMed, and you put things in, something’s going to come up that’s going to start to inform some of the theories that you may have. There’s a great study, I can’t remember which journal it’s in, but they actually did a phone survey of a million people. And if you know anything about clinical studies, a million people is a huge study.

Dr. Weitz:            Yeah.

Dr. Tatta:             And they asked them really two key questions. One is, what’s your BMI? So what’s your Body Mass Index? Have you had pain within the past thirty days? And have you had pain within the past year? And those two questions, pain within the past thirty days, and pain within the past year, start to point to the fact that someone has chronic pain. The definition of chronic pain is pain that persists more than three months. And as the BMI goes up, the likelihood of someone having pain, or chronic pain syndrome, goes up well.

Now, weight on your joints is a big part of that. No one wants to carry around this spare tire. But, we also look at that body fat, or that fat around the midsection, the visceral fat, is inflammatory. When you look at CRP, C-reactive protein, or high sensitivity C-reactive protein in patients with back pain, have been noted to have higher levels of CRP that have back pain. So we have to look at the mechanical, so we have to look at things like movement, exercise, what type of postures are you sustaining for longs periods of time. But also looking at, how much weight are you carrying? Where is that weight distributed around your body? And, what does your diet look like?

Dr. Weitz:            Good, interesting. So, we could do the conventional approach that I usually use, which is, we go step-by-step through some of your system, and the strategies you lay out in your book. But I was thinking it might be more interesting to approach this interview this way. Since my goal of my podcast is to help educate both the layperson and the practitioner, I thought it would be an interesting exercise to go through, first as a layperson who ends up with pain of some kind. Let’s say I’ve had back pain off and on for a number of years. How would I approach it using your concepts and strategy in terms of looking at not only the mechanical causes, but the nutritional and mind-based strategy.

So, if I’m a patient with low back pain, and just had another episode, and I come in, and I go, “You know, Dr. Tatta, I’m sure you can fix me. But, I’m sick of this back pain. It just keeps coming back. And I was hardly doing anything, I was just tying my shoes, and now I’ve got to go through this whole thing again. I’ve got to wait weeks before I can get back to my activities.” So, what else should I be looking at? And when do I want to look at nutrition as playing a role in back pain?

Dr. Tatta:             Yeah, so, this will be good for first, anyone who suffers with pain. But, practitioners will also like this kind of quick framework also.

Dr. Weitz:            Great.

Dr. Tatta:             So, I think of three critical pieces. One is, what’s happening to your biology? Two is, what’s happening to your psychology? And three, what’s going on in your environment? So, one, what’s happening to your biology? Two, what’s happening to your psychology. And three, what’s happening in your environment.

Dr. Weitz:            Okay.

Dr. Tatta:             Now, the biology is, are you someone who could benefit from nutrition? Because nutrition affects the chemistry, the biology of your body. How do you know? One, are you overweight or obese? If you are, you can benefit from a nutritional intervention. Two, do you have some kind of metabolic factor, or some kind of metabolic test that we can look at? Things like high cholesterol, high LDL, high C-reactive protein. If there are inflammatory markers on your blood work, then nutrition’s a key.

Dr. Weitz:            Elevated blood sugar, yeah.

Dr. Tatta:             Yeah, HBA1C, the things like that. Third, when it comes to your biochemistry, is if you are diagnosed with an autoimmune disease, or one of your parents have an autoimmune disease that has caused them to have some kind of joint pain, or some type of chronic pain syndrome, you want to be really aware that that tends to run in families. And you may be predisposed to developing an autoimmune disease. Or, if you actually have one, that nutrition is definitely one of the first steps in helping heal and/or possibly reverse that autoimmune disease.

Dr. Weitz:            And, by the way, a lot of people are not even aware that they have an autoimmune disease. They just know that they have, for example, hypothyroidism, which is the most common autoimmune disease. And, the fact is is, in the United States, over ninety percent of patients with hypothyroidism is actually autoimmune in nature, known as Hashimoto’s. And so, not only patients who are aware of having an autoimmune disease, but autoimmune diseases, they may not be aware of. They may just think they have some flakiness on your skin. Or they just have psoriasis on your skin. That’s an autoimmune condition. So there’s a whole range of autoimmune conditions that people don’t realize. And when you factor those in, there’s a huge percentage of the population with autoimmune disease.  Go ahead, sorry-

Dr. Tatta:             No, that’s … They’re great points.

Dr. Weitz:            Yeah.

Dr. Tatta:             I’ll give one more caveat to that biology section, that bio part. And, it’s a diagnosis that doesn’t really fit clearly into any one category. And that would be fibromyalgia. So, we can look at fibromyalgia from the lens of a central nervous system disorder. Where the brain and central nervous system have a difficult time processing pain in the normal way. We can look at fibromyalgia from more of an endocrine perspective. We can look at fibromyalgia from more of a gut nutritional perspective. And, the real part about fibromyalgia is that it will traverse all of those things.  So, fibromyalgia is going to be in every category. But, nutrition can be a wonderful place for those with fibromyalgia to begin as well. It may not cure some with fibromyalgia, but it’s definitely going to be the first stepping stone.

Dr. Weitz:            And by the way, fibromyalgia’s often … The person comes in who says, “You know, I just hurt everywheres. I’m sore up and down my back, my arms, my legs,” right?

Dr. Tatta:             Yeah, that’s right. That’s right.

Dr. Weitz:            Yeah.

Dr. Tatta:             So that’s the bio. Two, looking at our psychology. So, if you are someone who has, or had, anxiety, those with high levels or anxiety are predisposed to developing chronic pain type syndromes. And it makes sense. If you think about general anxiety, those with anxiety get tense. Their HPA access, or the hypothalamic pituitary adrenal access, is often in overdrive. And they have very high cortisol levels. When you have high cortisol levels, a number of things happen in the body. It affects your digestion. You develop leaky gut. The motility of your digestion tends to slow, so people tend to become constipated. They don’t have a bowel movement as frequently, which leads to things like toxicity.  Having anxiety leads to muscle tension and tightness throughout the body, especially the muscles around the spine. Having anxiety often leads to sleep disturbances. So, looking at psychology, looking at things like anxiety. After that, looking at things like depression. So those with chronic pain often … Upwards of fifty percent, if you look at studies, struggle with depression. And it’s difficult to figure out whether that’s chicken or the egg. Did depression start first and then the chronic pain? Or did the chronic pain start first and then the depression?  I like to think, and this is not true for everyone, but for a lot of patients, the depression started second. Because oftentimes people have dealt with chronic pain for so long and have struggled to find an answer. Struggled to find a clinician who will work with them one-on-one, listen to them, treat them as an individual. And when you’ve been in that kind of tug-of-war with pain for a long time, it gets exhausting. And that’s why you see people with not only chronic pain, but chronic fatigue.

So, anxiety, depression. The third one I put under the psychological realm. Or anyone that has kind of an early life trauma. So, if you come from a family where there was divorce and trauma. If there was a parent who was abusive, if there was addiction, if you struggled with things like bullying, problems in childhood. Any type of adverse childhood experience can predispose you to having chronic pain.  And what happens with that, is it wires your nervous system. The nervous system becomes very sensitized. It becomes very sensitive to any kind of input. So, normal movement, or one night of poor sleep, can cause the nervous system to become very excited, and the nervous system creates pain as a warning sign. It’s this warning sign that there’s something wrong in your life, in your environment, and pain is ultimately something needs to be taken care of.

So that’s the bio. We did the psycho, or the psychological. And then the environmental, or what technically is called the social part, is what’s happening in your environment. Do you have nurturing relationships? Do you have a stress reduction routine that you implement? For those with chronic pain it may be daily, but most of us should be doing something at least twice a week that lowers our stress level. Do you have an outlet for joy and things that make you happy and give you purpose in life?  When you’re just going … And, we’ve all been there, Ben. Right? We’ve all been there … Times in our life where we had to work hard, we had to work extra, we had to be in school and have a job, we had to have a job and raise the kids, and put extra hours in at the office. But, there’s times where we have to sit back and say, “Hey, I’m only human. And I need to figure out how can I alleviate my stress, how can I find an outlet for purpose and passion in my life?” And once you find those things, pain starts to quiet down and relax.

Dr. Weitz:            So as a patient, what should I do? Let’s say I go to traditional physical therapists who’s says, “You strained your back,” or, “You have X diagnosis, you have,” whatever, “A bulging disk.” And, “Here, you need to do these exercises. You need to take ice.” Or you go to chiropractor and he says you need to come in twice a week for adjustments, and manipulative care, and other therapies. And then you need to do these exercises, et cetera. What do I do about the nutrition part?

Dr. Tatta:             Yeah, so, movement and manual therapy is wonderful. And it’s often a first step in the care of pain. And, movement of course, makes you stronger, it makes you more flexible, it helps you function. But, movement also helps to promote relaxation. Movement also helps enhance your mood. Movement also helps decrease your fear about moving again. So movement has the biomechanical parts, but it also has some of the psychological parts in there. So if you’re seeing a physical therapist or a chiropractor, and movement is part of your routine, awesome. Keep it in there and keep up the good work.

If you’re seeing a professional that is not up-to-date on some of the latest pain science techniques, then there’s a couple of key questions you may want to ask them. You may want to ask them, “Is there a place for nutrition in my rehabilitation?” And, if the answer is yes, ask them, “Hey, what’s maybe one or two strategies I can implement into my life this week that will help my nutrition?”  Oftentimes, like if you’re online and you’re watching a podcast, or watching a summit, there’s all sorts of biochemistry information, all sorts of supplements, all sorts of different diets. Oftentimes it could just be one or two simple things that you start to do on a weekly basis that can help you reverse your pain. So, ask your practitioner, “Does nutrition play a role in pain? Does it play a role in my type of pain? Can you help me? And if you can’t help me, can you refer me to someone who might be able to help me with nutrition?”  So that would be my recommendation to a patient if they’re talking to any kind of practitioner about their pain and what their course of treatment would include.

Dr. Weitz:            Okay. Well what about some of the mental aspects of pain? Should I be concerned about that? Does that really matter?

Dr. Tatta:             You should. Because pain, the definition-

Dr. Weitz:            What do I do about it?

Dr. Tatta:             Yeah, you definitely should. The definition of pain is that it’s both that physical experience, as well as that emotional experience. So, the first thing is to look at sleep. You don’t necessarily need to go to a practitioner if you have challenges with sleep. But if you’re not sleeping at least seven hours a night, then you’re going to be more predisposed to having things like anxiety, depression, problems with stress reduction. So, go to bed and wake up at the same time every day. So, let’s say you’re in bed by 10:30, and you’re up by, let’s say, 6:30. Make sure you have that set routine every day of the week, even on the weekends.  Big thing with all my patients, and I even notice it with my friends and family, is that phone, that television, the computer, the laptop, the iPad. We can go down the list of all these things, they really need to start to be powered down around 9:30 because that blue light keeps you wired. All of us are on computers all day long, and we don’t realize how stimulating it really can be. So, shut those down. I love to tell patients like start a nice little gentle stretch routine at night, some mindfulness meditations, five or ten minutes before you go to bed, is a wonderful thing to help you relax your nervous system. And then, start to get in bed … And, really bed is meant for two things. Sleep and sex. So that’s what the bedroom is meant for. Set it up for that. So, make time for sleep, make time for sex as well, and enjoy your bedtime.

The other thing I did mention along with that is, when we talk about the brain and pain, or the emotional or the cognitive psychological aspects of pain, it doesn’t necessarily mean that you have to run out and see a psychologist. It doesn’t mean that you’re crazy. It doesn’t mean there’s anything wrong with you. And in fact, developing a mindfulness-based stress reduction routine, whether it’s ten minutes in the morning, or ten minutes in the evening, has been shown to decrease pain, and the pain actually stays away almost indefinitely in a lot of the studies. So, that’s easy. You can find things online. I have downloads on my website, I talk about it in my book. They’re really easy, simple things that people can do for themselves.

Dr. Weitz:            Yeah, I noticed you talked about graded motor imagery, overcoming negative thoughts, embracing forgiveness and acceptance, acceptance and commitment therapy, which is a form of cognitive behavioral therapy, and then you also mention the mindful meditation techniques.

Dr. Tatta:             Yeah, mindful meditation is my first go-to.

Dr. Weitz:            Okay.

Dr. Tatta:             So again, you can find the downloads on that. I have some free things on my website. If that doesn’t do it, so if you develop a mindfulness-based routine, let’s say for ten to twenty minutes a day, and you don’t feel like your pain’s going to get any better. You find that you’re still kind of really attached to thoughts of like, “I feel like I’m disabled, I feel like I’m never going to get better, this pain is never going to go away.” Then, I love what’s called acceptance and commitment therapy, or acceptance and commitment training. Which I’m actually going to have a course available for practitioners in a couple months on that. so, it’s not like traditional cognitive behavioral therapy. It takes mindfulness-based principles, but it takes them kind of to a different level that lays them over your specific problems with pain.

So it takes mindfulness, but puts it over a kind of psychological framework that really helps people look at pain in a different way. Where they say, “Okay. I have pain, everyone has pain, how can I learn to approach this pain in a way that doesn’t scare me? How can I learn to approach this pain in a way where I can be willing to maybe start to move a little bit, even though I have a little bit of soreness, where I can accept the fact that I have to make some changes to my diet. I can start to work on my thought patterns and my emotions that are related to pain.” Acceptance commitment therapy is a really wonderful way for people to kind of go one step deeper into mindfulness.

Dr. Weitz:            Cool. So now, let’s reverse course here. And let’s talk to the practitioner out there. Let’s say the conventional physical therapist who’s treating patients for neck pain, and knee problems, and rehabbing them after shoulder surgery, etcetera. Or the chiropractor who’s treating patients for various musculoskeletal pain. How do they go about incorporating nutrition into their practice? Even if they believe in it, considering all the parameters related to trying to run a practice and cover your rent. How do you incorporate nutrition into a musculoskeletal practice?

Dr. Tatta:             Yeah, it’s a great question. And, I want to preface to practitioners that, nutrition is a huge field. But, the principles to help patients can be quite easy. And you can really work them into your practice with a couple of simple steps. The first one, and you can just put this on your intake form, is just a simple question that you pose to your patient. Are you interested in learning about how nutrition can improve your health? Or, are you interested in learning how nutrition can improve your pain?  That question alone can be really powerful. Because, even if you love nutrition, and you’ve tried it on yourself, and you’ve studied it for months and years and read all the books out there and followed all our great podcasts and information, if your patient’s not ready, that readiness for change, if they’re not ready, then there’s no point in really going there. So one is, see where the patient’s readiness is. If they say, “Yes, I’m interested,” then you say, “Okay, I have a couple of questions for you.”  One is, “Do you add sugar to any of your food?” That can be your coffee in the morning, that can be your sugar in the morning, that can be your cakes and desserts that maybe you’re making, things like that. Or you can ask people, “Do you know where the added sugar is in your diet?” Because sugar probably is the biggest pro-inflammatory food that we have. And obviously it leads to things like pre-diabetes, diabetes, and all the other metabolic and autoimmune diseases that we spoke about. So, just turning people on to sugar is a great way to help them with their weight reduction, and weight maintenance. It’s also a great way to help decrease the inflammation in their body.

After that, I would really turn toward a brief intervention on omega-3 fatty acids. And asking people if they know where the healthy fats are in their diet. When you look at the Paleolithic Diet, the Paleo Diet, which people have heard about, and patients even read books on it, ancient man or Paleo man, probably had about ten thousand milligrams of omega-3 fatty acids in their diet, that came from a combination of plant food, and obviously, fish.  Now, so many Americans don’t eat plant foods. And, a lot of Americans don’t eat fish. When you look at the benefits of the Mediterranean diet, it’s that … One of the key benefits of the Mediterranean diet is that they consume fish two to three times a week. Steadily, every day, and they’re rich in omega-3 fatty acids. Those omega-3 fatty acids are inflammatory. They work on the same pathway in your body as Advil does. Or the non-steroid anti-inflammatories do. Except, they have no side effects. You can’t hurt someone with salmon, scallops, and some shrimp. Or, an omega-3 fatty acid.

Dr. Weitz:            And, by the way, grass fed beef would also contain omega-3s because there are omega-3s in the grass, whereas conventionally raised cattles, which are being fed cornmeal, which is high in omega-6, grass fed cows are eating a lot of grass, and that incorporates more omega-3s into their meat.

Dr. Tatta:             That’s right. And, a lot of patients … They don’t realize that they’re not consuming fish, or they’re not consuming grass fed raised beef. And, just opening them up to those things. And they’re simple because they can go to the store, they can purchase that, they can look at packages and read labels. And they feel like they’re empowering themselves with a way to help themselves.  Once you start taking out the sugar, once you start taking out the processed food, you start putting in a little bit more vegetables, some fruit, fish three times a week, people’s weight starts to drop. They start to feel better, sometimes within three to seven days, which is really a fast turnaround for a lot of patients who have had pain. And the only thing about patients who have pain is they realize it fast. They’re very in tune with their bodies. They know what they feel like on a daily basis, and once they start to get relief, they realize it, and they’re like, “Wow, I had no idea that salmon a couple times a week, as well as some scallops, really could make a difference in my life.”  As a practitioner, after that, then kind of separate. You can start to venture into some of the supplements. That takes a little bit more education. Because you need to educated about what supplements are important, what supplements to use first, what supplements are a bunch of hoo-hah. Because there’s a lot of things out there that have some claims on them that probably aren’t really substantiated. But, after that, you get into supplements, and supplements have a definite place in your practice as a practitioner.

Dr. Weitz:            What about doing a full blown, functional medicine, treatment plan for them? Having them come in on a separate day, or at a different time, or bringing in a nutritionist?

Dr. Tatta:             You can do that, of course. If you want to build an integrated practice, you can bring in a nutritionist, or a dietician, or a health coach. Or you can train yourself in functional nutrition. I have a functional nutrition course coming out in a couple months for practitioners where I train them on that. And I think for a lot of practitioners that it fits so beautifully into a musculoskeletal practice. Because you can do the manual therapy, the exercise, and work in functional nutrition, the functional medicine aspect of it as well.

Dr. Weitz:            After all, it’s a little difficult, when you’re on the floor trying to show the patient some exercise, explaining the intricacies of the Paleo Diet.

Dr. Tatta:             That’s right. I mean, what I tell … A lot of PTs ask me now, like how much nutrition do you do? And I say, “Well, show me the patient you’re talking about first. Who’s in front of me?” And a lot of times now, if I ask someone … If someone comes to me and they’re overweight, plus they have rheumatoid arthritis, and I ask them, “Are you interested in nutrition?” They say, “Yes.” Then, the first one or two visits, I may just spend on nutrition. I may not do any joint mobilization, I may not do any exercise. It may just be nutrition, and lay that groundwork first. Because the patient’s going to go home everyday and they’re going to work on their nutrition. So-

Dr. Weitz:            If we talking to practitioners right now, how does that fit into the model?  So, how do you make that work [financially]?

Dr. Tatta:             Yeah, it depends. I mean, I have a cash-based practice.

Dr. Weitz:            Oh, okay.

Dr. Tatta:             Patients come to me, they know that I’m out of the network. They know they’re going to pay cash for it. There are certain insurance companies that will reimburse for one or two … It usually falls under education. Or nutrition consultation. But, you’re right. Nutrition is not really something that gets reimbursed by a lot of insurance companies or Medicare.

Sometimes the most important thing we can do for people is education. And there’s a lot of education that goes into a nutritional consultation. And, that first visit, if you can get a lot of education in around food, diet, what they should be eating, what their plate should look like, what they should be putting in their shopping cart, what they should be feeding their kids, how to look at a menu when they go out to eat. And say, “Okay, this is not good for me. These are better options for me.” At that first visit, may be well spent by just using that first visit and billing it as patient education, or billing as nutritional consultation. Before you get into, let’s say the lumbar stabilization exercises, or the manipulation or the manual therapy, whatever it is that’s part of your practice, it really does have its place. I also think that, let’s also be ahead of the curve. So as practitioners, let’s also say that within a couple years, insurance companies are going to have to wake up to the fact that we have a hundred million Americans with chronic pain. Probably two thirds of every American is overweight or obese. These two types of conditions or diagnoses are intimately related. And nutrition probably should be the first place we go for a lot of patients. So, we need to start to practice what we preach.

Dr. Weitz:            Certainly what you’re saying made sense, but whether insurance companies are going to start reimbursing doctors for time spent for preventing some of these issues, I’ll believe it when I see it. So, how can a practitioner work in some of these mind-reprogramming techniques? Is it enough to just say to the patient, “I want you to visualize your pain going away,” or, “I want you to have a positive mindset,” Or, do you need to sit down and go through some of these exercises with them and really explain and do you need to do psychological session with them? Or sessions?

Dr. Tatta:             Yes, you don’t need to be a psychologist, or a mental health practitioner, but you do need to assess, and you do need to test. There are two really simple things you can use to do that. One is called the Pain Catastrophizing Scale. It’s a really simple test you can give the patient. I think it’s about ten or fifteen questions. That ask them information about what their thoughts are related to their pain. And it looks at things like how they ruminate about pain how many negative thoughts they have about pain. And if they have a score that’s significant, usually above a thirty, then it tells you that they oftentimes think about their pain. They ruminate about their pain. And when they become kind of attached, or kind of stuck to those negative thoughts, it makes pain worse.  So, the pain catastrophizing scale is first.

Dr. Weitz:            Okay, would you mind emailing that to me so I can include it in the show notes?

Dr. Tatta:             I sure will, yeah.

Dr. Weitz:            Thanks.

Dr. Tatta:             The second one is what’s called the Tampa Kinesiophobia Scale. And I can email you that as well.

Dr. Weitz:            Great.

Dr. Tatta:             And what that does, that looks at someone’s fear of movement. And, when you think about patients who are not compliant, or they’re scared to begin to exercise, because they have pain, usually it’s because they fear that exercise is going to make them worse. So we know that exercise can be really powerful, but at times it can be really difficult to have the patient buy into that, so to speak. So this scale, the Tampa Kinesiophobia Scale, will tell you if that’s part of the patient’s problem. If fear is their overriding emotion that’s preventing them from moving at home, from doing their daily activities, from being compliant with the home exercise program.

So those are the two most important. A lot of it is just bringing awareness to the patient. So you can actually go through those tests with your patient and explain to them, and say, “Hey, it’s totally normal that you have some fear around pain. Just realize that, when you have that fear, it prevents you from exercise. What we’re going to do together is I’m going to start you on a nice, gentle exercise program. That’s going to build day by day, or week by week. And, it should make you feel better. You may have a little bit of soreness after doing some more exercises, but you shouldn’t have intense pain for days. If you do, just let me know. But realize that, exercise has effects on your body, it also has effects on your mood, and your psychology. It makes you feel better as you start to move. So give me a couple weeks, let’s develop the exercise program together. Find a type of exercise that works for you. And over time, the fear and the anxiety that you have will decrease.”  So those are the two things that you can … Again, you can put that into your paperwork, into your initial intake paperwork to see how someone’s doing.

Dr. Weitz:            That’s great. So I think that’s pretty good. A valuable amount of information about pain, and how we should think about it. How both patients should think about overcoming pain, and how a practitioner can think about how we can incorporate nutrition and some of these mindful-based strategies into their practice as well. So, I thank you for that. How can patients and/or practitioners get a hold of you to get more information about your programs that are available, or you’re developing, as well as about your practice?

Dr. Tatta:             Yeah, everyone can find me on my website, doctorjoetatta.com. I have a great podcast, as you mentioned before, called The Healing Pain podcast. Which has tons of free information about healing pain naturally. And if you’re a practitioner, or you’re interested in getting certified, and ways to heal people naturally, from a kind of mindfulness, cognitive-based … The biopsychosocial aspect, you can go to theintegrativepainscienceinstitute.com.

Dr. Weitz:            Cool. Great. Thank you, Joe.

Dr. Tatta:             Thanks Ben, great being here with you.

Dr. Weitz:            Thank you, I’ll talk to you soon.

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