Huge thank you to BBM, and a question about a hypothetical patient

First off, I’d like to give a huge thank you to the BBM crew for everything you have put out there with regards to injury rehab and pain science. My journey with the biopsychosocial approach to injury management began a little over a year ago when I had a huge flare up of a 4+ year battle with low back pain, only this time it was accompanied by a burning sensation on the lateral side of my left ankle and extended into the top of my foot. I was about 3 hours deep into a desperate youtube video search on backpain/sciatica management when I stumbled across a video of a relatively well known powerlifter/bodybuilder/nutrition phd who was being assessed by Stuart McGill.

Reading through the comments section, some brave youtuber recommended our youtube video star ditch the “big three” and hook up with Dr. Austin Baraki. I followed the link and read Aches & Pains. I immediately disregarded it as hogwash from a new age physician. After all, who was he to provide a management strategy that conflicts with Stuart McGill? I continued the big three and continued to get worse. I reached out to Stuart McGill and tried to get an appointment, and they turned me down (in hindsight, I will remain eternally grateful for this).

I read Aches & Pains again, and thought, maybe there’s something to this, perhaps my pain is not as intractable as I believed. I discovered Greg Lehman, Lorimer Moseley, David Butler, and Peter O’Sullivan. I watched their Youtube lectures, listened to podcasts they were on, and I bought Explain Pain. I started learning about central sensitization and the effects of anxiety on pain perception.

Pain science education was my turning point. It was as if the material put out by BBM and the aforementioned twitter gurus had given me permission to move. I began deadlifting again for the first time in 4 years (I went up to 135 on my first session, and left the gym after 2 reps because of the associated fear/anxiety). I went back the next week, and did it again, and progressed very slowly until I had a resurgence of groin/testicular pain from a sports hernia I previously had (unnecessarily?) surgically repaired. I thought I sustained another tear in my rectus abdominis and external oblique that was aggravating the genital branch of my genitofemoral and ilioinguinal nerves.

I practiced meditation to calm my nervous system. I woke up three days later and… the pain in my right testicle was gone… but I now had horrific pain in my left testicle, which subsided later in the day and never came back.

This time last year I was afraid to pick up my 12lb dog. Last week I deadlifted 405x6, followed by two sets of 405x3. Will I ever deadlift 600+ at 180lbs again? I sure the hell hope so, and at this point, I don’t see any reason why I can’t.

I wasn’t instantly cured after I read Aches and Pains, but information put out by BBM on podcasts and articles started me on this path and I don’t think I ever would have come this far without it. So a big thank you to the BBM crew, and I hope this inspires someone else who may still be in the struggle with chronic pain.

Now for my hypothetical patient question.

32 year old male, high stress job with long hours, long history of anxiety (mostly health anxiety) induced physical symptoms and OCD tendencies (He’s had just about every physical anxiety symptom you can find on google, including chronic pain and IBS-D). He caught some sort of food poisoning while traveling in Central America with his wife. Both him and his wife exhibited the same exact symptoms, approximately 10 days of really gnarly diarrhea. At approximately the two and three week mark after the diarrhea had cleared up (upon return to the US), he had two separate stool cultures done for parasites/other pathogens, both were negative. There has also been no visual evidence of intestinal bleeding or blood in the stool.

The hypothetical Wife has recovered at this point but complains of fatigue (but has always complained of fatigue). Our male patients diarrhea turned into constipation that is easily treated with miralax and/or psyllium husk, although psyllium seems to cause intestinal discomfort. The constipation has been accompanied by a great deal of anxiety, a feeling of stomach/rib tightness and pain that migrates side to side top to bottom, and now insomnia (all three possibly due to excessive googling of symptoms and being scared shitless (pun intended) of what he found). The male has previously experienced this same exact stomach/rib/chest tightness and pain approximately 2 1/2 years ago for a period of 2 months, with spontaneous resolution of symptoms. Our hero previously chalked this up to anxiety related muscle tension, and often experiences symptom migration, with a new symptom coming into awareness after resolution of the previous one. The stomach/rib pain often disappears during exercise, post exercise, and post meditation.

My question… at this point would a biopsychosocial approach to management of this be warranted? By this I mean, focusing less on the pain and discomfort to allow the nervous system time to desensitize, attempting to change his beliefs about the condition of his bowels, and temporarily avoiding postures/foods that may irritate the already tense/irritated tissues and structures? The PCP for this patient is the type to keep ordering tests and providing theory after theory until the patient goes home wondering if he has both Cancer and Parkinson’s. If you have a minute, I’d appreciate your thoughts on this hypothetical patient.

Thank you again for everything you guys do.

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Thank you very much for telling your story! That sort of thing makes our day and we’re glad to hear you’ve gotten to where you are today. Remarkable story.

Regarding your friend: I’m sorry to hear about this difficult situation. It sounds like his PCP is probably not helping things by continuing to dig further and further here. I obviously can’t confidently comment on his case since I don’t have all of his clinical data nor have I evaluated him, but it sounds like you probably have the right idea here. We would argue that a biopsychosocial approach is always the right approach to take – that everything has components of all three contributing, but that the relative proportions change. IF most of the major “biological” drivers that would merit unique/specific treatment have been ruled out, it may be doing more harm than good to continue chasing more advanced diagnostics versus reframing the situation and promoting more reframing, self-efficacy, and self-management, as you have learned.

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Thanks for your thoughts on the matter. I never thought about it that way, similar to a Venn Diagram with varying degrees of overlap/different sized circles.