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Why Do You Hurt? A Sensitive Alarm System

This article is a transcribed edited summary of a video Bob and Brad recorded in March of 2020.  For the original video go to

Bob: Today, we are joined by Dr. Adrian Louw. This is a great honor for us. I’m going to let him tell his background, but basically we refer to him as a pain expert.

Dr. Adriaan Lowe: No problem. Happy to be here, this is amazing. This is amazing to meet you guys.

Bob: You’ll find out it’s not as amazing as you think., lol. But if you could give us a brief background.

Dr. Adriaan Louw: Yeah, I’m from South Africa with a funny accent. I was trained as a physical therapist, came to America, land of opportunity. I started treating patients with traditional therapy. For some reason, I started seeing more complicated people and the stuff that worked yesterday doesn’t work anymore. And then I needed to find something else, and I found this incredible thing called pain. Well, it’s called pain neuroscience to be true, and it just took me on this incredible journey. The more I learned about pain, the more intriguing it became. And challenging patients became less challenging. It doesn’t make it easy, not even close, but here I am. And then decided I like it so much, lets study it.

Bob: Where did you get your PhD from?

Dr. Adriaan Louw: In South Africa, I did the research here but run through a university in South Africa.

Bob: Dr. Louw, he studied under some of the most famous and most intelligent physical therapists in the world. You won’t know their names but, be assured that it’s true.

Brad: And look at the literature he’s published.

Bob: Oh right, when you look at the books, it makes us think that we haven’t been doing enough with our life here. His books are listed below.

Bob: The book that is the topic of this particular segment today is, Why Do I Hurt? This is one of your more popular books.

Dr. Adriaan Louw: Yeah, it is.

Bob: So, this is all about our subscribers, so we want to make sure that we are doing them benefit here. Can you give a kind of case study of an average patient that you see and how you go about treating them basically?

Dr. Adriaan Louw: That’s fine. You know what, there’s a story we hear commonly in every clinic, you guys have heard it too, right. I mean no disrespect, but people in chronic pain when they come to us, you know, there’s a classic story, where do you hurt? And we hear, everywhere. What makes you better? Nothing. What makes you worse? Everything. Everything right? This is a challenge we face. That little song, as I call it, there’s not a county in the world that cannot sing that, it’s a global problem. And so when people come to us, they’ve been everywhere. They don’t know what to do. We don’t understand pain well enough, and so one of the fundamental things we ask patients often is, what do you think is going on with you? That’s my number one question, whenever I talk to students. I love that question, because it tells me what they’re thinking. And the patient can answer me from here to there. They can say, well, didn’t your read my report of a bulging disc? So they just told me what they are thinking. And I can talk about that intelligently because you and I and Brad, we all know what the current literature says. But then on the flip side, they can say I have no idea. That’s why I’m here, which is so neat, because it’s an open script, right?

Bob: Sure.

Dr. Adriaan Louw: And you know, after the evaluation, getting to know the patient, I’ll often ask them, has anybody explained to you why it hurts? And it still shocks me that 99% say, nobody’s ever explained it to me. So in this case, what basically works is we’ve taken the most advanced science on the planet that we know of and we put them in stories. Human beings learn through stories, metaphors.

Brad: Exactly, I agree 100%.

Dr. Adriaan Louw: Can you remember what you were taught about history in the third grade?

Bob: Wow, if it’s in story form, probably so.

Dr. Adriaan Louw: Yeah, exactly. We don’t remember facts.

Bob: Right.

Dr. Adriaan Louw: But do you remember the story, The Tortoise and the Hare.

Brad: Oh, yes

Dr. Adriaan Louw: So what we’ve done is taken the most advanced neuroscience and put it in stories. Simple easy stories. We then tell a patient the story, which I’ll tell you one in a minute, and what we have found out from some amazing research is that people’s lives are better for it. They understand what’s going on, they know what they can do. And so the most –

Bob: Purely by the education itself?

Dr. Adriaan Louw: By the education, but what’s important is we need to understand you aren’t going to explain pain out of people. Pain is complex. It’s very real. But, it makes them calm down, they have less fear. They’re more likely to move and what makes them better is movement. I think there’s a misconception these books and everything is, we don’t explain pain out of people. We just make them understand that pain, which makes them less fearful, which makes them move.

Bob: Which relates back to the point that you made when they first come in. You ask them what is causing their pain and they don’t know. And by not knowing, they’re more stressed out.

Dr. Adriaan Louw: Absolutely.

Bob: It’s a part of the anxiety that goes along with it. They’re thinking, what is it? Is it something very serious? Which they usually think it is. And it may not be. It doesn’t equate with injury.

Brad: Or I think, you know, something I personally can relate to is I have a condition called spondylolisthesis. With a big name like that, a diagnosis like that, the average person really doesn’t know what it is. That’s very frightening.

Bob: Yes, it is.

Brad: They think I’m not going to be able to run again. I’m just going to have to be still. And so when I do videos on it, I let them know what I’m doing or what I’ve come from. Hopefully that helps to get that brick wall, that diagnosis out of the way. I think that happens, like just even with simple arthritis. Someone will come and say, I’ve got arthritis in my muscles. Which, you know, you can’t get arthritis in your muscles, it’s in the joint. I try to explain that so this is going to be helpful for me to hopefully better relate to those patients.

Bob: Could you mention the study that they talked about the brain scan showing the before and after?

Dr. Adriaan Louw: Yeah, yeah, we have done some studies. And they’re a little bit technical. But when you scan somebody’s brain during something painful, for example they move their back, the brain lights up, it uses more sugar, more oxygen, and that’s what those blobs are. And what we found is that as we teach you about the pain, the brain really dampens down. Very similar to, if not more than what we can do with medicine right now. Which is really powerful. And that then reduces that threat value, and the brain goes, I must be okay the guy with the funny accent explained it to me.

Bob: Yeah, that’s true.

Dr. Adrian Louw: You know Brad, you mentioned arthritis. I lived in Iowa and I asked my farmers every day, with their John Deere overalls, John Deere hat, you know, what do you think is going on with your back? I’ve got arthritis. What they basically told me is because I’m old, I must hurt.

Bob: Yes,

Dr. Adriaan Louw: They tie together, and we know it’s not true. Because, if arthritis and back pain were the same thing, then only old people should hurt. Then, why do 50% of school kids have back pain? It is not the same thing.

Brad: Sure.

Dr. Adriaan Louw: And so when we show somebody that as you get older, there’s more arthritis, or as we call it wrinkles on the inside. Right, you’ve just got more wrinkles on the inside. But back pain we know peaks at age 35, 45, 50. I show it to patients, I draw it for them. They go, wow, so just because I’m getting old doesn’t mean I have to hurt. Exactly! Let’s get on the bike. We can change movement, but we cannot change aging. But aging and pain are two different things. We have a lot of research showing that people that are older hurt because they’re not moving not because they’re old. That it is a fallacy. An example would be again, like I said, we talk to people and explain and they may turn to me and say but why do I hurt? That’s kind of what we get to right? So we use an analogy, the analogy we use is a sensitive alarm system. You two have houses right? You guys are so popular, it’s probably in a gated community.

Dr. Adrian Louw: Right. You guys are the man.

Bob: Haha…. A double wide trailer is what it is.

Dr. Adriaan Lowe: At least doubles, lol. So we tell people your house has an alarm, right. And so we use an analogy everybody’s familiar with an alarm. So, I would simply sit and ask him if you step on a nail, do you want to know about it? So, what do you guys think if you step on a nail?

Bob: Absolutely, you want to know about it.

Dr. Adriaan Louw: Why?

Bob: Because it could get infected –

Dr. Adriaan Louw: Exactly right.

Brad: What if it’s rusty?

Dr. Adriaan Louw: Exactly. A rusted nail especially so guess what? I’ve never had somebody say no, why? Because our patients are smarter than we think. Now I’ll ask him why and they’ll say, I did not get an infection. So, how do you know there is a nail in your foot? Well, you don’t have eyeballs at the bottom of your foot, right? So, we have an alarm system. Our body’s nervous system works like an alarm system. That’s the metaphor. People understand an alarm system. Step on a nail, the alarm system ramps up in the foot, fires a message to the spinal cord to the brain saying ding, ding, ding, there’s a nail in the foot. All I do is I tell the patient; does it make sense? And again, most people say that makes total sense. Now you know what the real patient says? “What does this have to do with my back?” Then you sit there and go, “Yes!” Why, you ask? Because they ask the right question. “Well, Frank, guess what? You were in the backyard raking the leaves and you felt a pop in your back. What happened? The alarm went off. How do we know it? You went to the emergency room.” Nobody goes to the emergency room saying, ‘I feel great’, so something trips your alarm. I’m not making fun, but it’s kind of that, wow, okay, this makes sense. And they say what should happen is we pull the nail out. The alarm system calms down, right? You guys have stepped on a nail or thumbtack and when you pull it out, does the alarm just go away?

Bob: Well, it starts to calm down.

Dr Adriaan Louw: It lingers a little bit. What happens is, Frank, they pull the nail out, the alarm just calms down; we put a bandage on. We get a tetanus shot and life is good. By the way, we learned something today. Don’t walk barefoot around nails. Pain isn’t a bad thing. Without, pain, we’d be dead right? It teaches us, sharp is bad.

Bob: People who cannot feel pain are in trouble.

Dr Adriaan Louw: They’re in serious trouble. Look, at our diabetic patients. We have to watch their feet, so here’s the crutch of the matter: All of us have an alarm system. It ramps up and says, ding, ding, ding, you stepped on a nail. Ding, ding, ding, you hurt your back, you have spondylolysis. You hurt your leg, you just broke your leg. It tells us to go get some help. We take care of the problem. We have surgery, we have therapy, we get some help. You’ve had that happen to you, all of us have. Even Mike, the guy behind the camera has had it happen to him. It happens to all of us, what a beautiful system. Here’s the problem though, in about one in four people something trips the alarm, Ding, ding, ding, “go get some help.” Then we do something but that alarm never calms down. That’s what we call a sensitive alarm system. We have fancy medical terms for it but it doesn’t matter, it’s a sensitive alarm system. In all the years we’ve done this, in all our research, in all the thousands of patients, I’ve only had three questions. How do you know this? Doctor drives a Jaguar, what do you drive? You’re only a therapist and I understand that. By the way, this story says very simply, they really want to be validated. How do you know this? Number two, they want to know why did it stay up? My neighbor had the same thing but she’s fine.

Bob: Yes, why am I different?

Dr. Adriaan Louw: Yes, and the last thing is, what do I do about it? That’s number one, by the way. If they ever ask, what do we do about it, that’s the right question. How do we dampen this system down? Very simply, how do you know it? We can see it by a test. You can barely move the arm and barely touch your back. You told me ‘you used to could’, is what we call it. Before your pain, you could run five miles, now you can barely walk a half a mile. You used to be able to sit for an hour and now you can sit for five minutes. Your tolerance is off. Many patients get that “Aha” moment. We talk about all the stresses in life. If you have pain, you see three physical therapists, two doctors, two chiropractors, a podiatrist, whatever, and it’s not getting better. Will your alarm calm down? Never have I had a patient say yes, they’re smarter than that, they say no, it’ll stay up. Exactly!

Bob: It might even go higher. Every time they meet someone that can’t help them, it goes in their mind like, I’ve really got something severe.

Dr. Adriaan Louw: Exactly. Then you get failed treatments with this. It works for a little bit and now there’s rumors about layoffs at the office and because I’ve missed a lot of time, I go see Brad and Bob, I’m going to be the first one that is going to be laid off. Then all this runs to keep this system elevated. Then finally, what do we do to turn it down? This is the coolest part. There’s so many things. We’ve now figured there’s about 22 things you and I and Brad do every day in therapy that actually turns the brain’s own medicine on. We are talking about exercise, pilates, relaxation, mindfulness, sleep hygiene, nutrition, everything. There’s so many cool things you can do non pharmacological. I think every listener and all of us in America are aware that drugs are good but some of them do very bad things for some people. So can we get the healthy side going and that’s kind of the idea. Simple story, this is our highest rank story where patients go, wow I got it. So what you’re telling me is that the reason I’m still hurting is not because the ankle is still bad. No what we are doing is we are moving people away from their tissues, but remember, all we can do is it’s only because we’ve done due diligence and examined someone very carefully.

Bob: To make sure the tissue is healed.

Dr. Adriaan Louw: A lot of people have blamed us and say, oh, all you do is talk to people about pain. 90% of our patients literally cry after the examination. I’ll ask them, what’s going on. They say that’s the most thorough medical exam I’ve had in 10 years. One of my students have figured out, the thing that makes this work, is when people feel like they’ve been listened to and validated they trust you. I think for the clinicians listening even today it’s creating that; I’m here how can I make your life better? It’s a connection. Let’s teach you a little bit or what’s going on. And we’ve just found that if you teach people their lives are better for it.

Bob: I think what Dr.Louw is referring to here is what happens when someone comes in with those type of symptoms quite often and the typical clinicians going to go, you know, “this is a head case.” And you know there is nothing worse.

Dr. Adriaan Louw: (Groans) Oh, no…

Bob: Well, you know they do. And a lot of physicians, they are just like I’m trying to get this person out of my office as fast as possible. And they don’t really have an explanation for them. They just want to send them out the door.

Brad: I don’t want to interrupt here but I just had a patient here this week. A total knee replacement, you know now they want to do it in one day. So he went in, total knee replacement, overnight and they discharged him the next day. You know they gave him exercises but only two or three. He was feeling; it hurts, I don’t know what I’m doing and its swelling up. And he was very anxious. He was feeling he was pushed through the system. He didn’t know what was going on. And I did, I spent about an hour and 15 minutes with him. By the time he left I told him the exercises to do, I said this looks like a normal knee, your range of motion looks good. He was so relieved. He left and we are going to see him three times a week to get his range better then decrease as things improve. I mean just the psychological aspect of it, I didn’t do anything to his knee except move it a little bit and looked at his walk to make sure he was safe.

Dr. Adriaan Louw: You did more than you think you did. Trust me, we can prove that. I have to do this. I’m sorry, you guys have a major following but, all pain is real. We have never scanned fake pain. I would highly recommend if you’re a patient listening to this and if somebody ever accuses you of that fire that healthcare provider. They do not deserve to see you. And for the healthcare providers, just because somebody tells you something that doesn’t make sense, that doesn’t mean it isn’t real. It just means we haven’t studied it yet. Not even close.

Bob: That’s exactly right.

Dr. Adriaan Louw: I will just tell you that the longer I’ve done this, I’m getting older and older, and I really revel when somebody walks in and says I’ve been everywhere and everything, “who are you.” Who are you as a person. How can I make your life better? And there are so many things we can do. Even just listening to our patients. The most powerful words ever studied in medicine, ‘you’re going to be okay.’ How cool is that. And again, it’s so sad; I was in a class last week for Physicians Assistants and in their practice act they are not allowed to tell the patient they are going to be okay because it gives them false hope. I hope you give me false hope. I rather be that guy. Like Brad said, I’m going to be okay. Bob said, I’m going to be okay.

Bob: I want to be the optimist.

Dr. Adriaan Louw: I think this is so neat. Our words matter, our patients matter, all pain is real, we’ve never scanned fake pain. You know stuff like pain that spreads in the body, we now know why it happens. The thing that drove me nuts, when patients came in here: What makes your pain worse? When it’s cold out. I had no idea what to do with them. I didn’t know what muscle that was, which joint is that. But now I know there are some really amazing receptors in the human body that tell us ‘hey it’s getting cold in Minnesota, put on a sweater.’ And if they become a little over abundant we get sensitive to cold. Wow. And we have found out that if I tell that to Grandma, she’s going to go “I’m going to be okay.” How cool is that. You know one of the reasons I wanted to be here is, I need people in pain to understand that we are here and we’re here to help. And if someone isn’t helping you, fire them. They don’t deserve you. This is your pain. As my mentor David Butler told me years ago; tell patients you own your pain not someone else, you make the best decisions. And so I hope the healthcare providers today, if there is one thing you can do, it’s cheap, it’s free by the way, listen. Just listen, be there. I have no problem telling a patient I don’t know what to do with this today but let me think about it, but tell me your story. Get to know them. There’s so much about reassurance. Reassurance is analgesic. We’ve studied this.

Bob: Sure. I’m getting tingling up and down my spine. I want to give you a standing ovation, seriously. That is just awesome. But I think we will end this conversion here. We will have two more conversations with Dr. Louw coming up so be sure to look for those.

Brad: As for the information we’ve covered here, it can be found primarily in Dr. Louw’s book, Why Do I Hurt.

Bob: For therapist and clinicians, you might consider the book Integrating Manuel Therapy and Pain Neuroscience, but in addition there are classes that are given.

Dr. Adriaan Louw: Yes, so one of our jobs is, we want to train the next generation. We want to train the most compassionate, empathetic, well trained people on the planet. So, we teach seminars all over, teaching Evidence in Motion.

Bob: If you google Evidence in Motion, Dr. Louw’s name will come up. Thank you very much Adriaan.

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