An inflexibility and inflammation root-cause approach to treatment [PODCAST]

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“In medicine, empiric therapy is treatment that is administered based on the probability of success because we don’t have all of the information. We make our ‘best guess.’ Actually, empiric decision-making exists in our everyday lives — running the garbage disposal when the sink is clogged, jiggling the key in the lock when it doesn’t turn. Mr. Thomas was in stable condition, and I estimated that his chances of finding an answer to his chest pain with another specialist, was very low. It was time to make my best guess.

I explained my theory to Mr. Thomas and suggested we try some myofascial bodywork. In the best case, he would feel a difference; and in the worst case, he would feel a little sore and looser in his body, but without pain relief. Mr. Thomas was definitely interested.

With hope and caution, we proceeded. I started with the sides of his chest … zig … then his abdominals … zag … then low back … zig … I checked with him frequently as he groaned with each maneuver, but he always nodded to continue. When the trial was over, I helped him sit up on the exam table.”

Cathy Kim is a family physician and can be reached at Dr. Cathy.

She shares her story and discusses her KevinMD article, “Fascia in primary care: When chest pain is not in your chest.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Cathy Kim. She’s a family physician, and she wrote the KevinMD article “Fascia in primary care: When chest pain is not in your chest.” Cathy, welcome to the show.

Cathy Kim: Thanks so much for having me.

Kevin Pho: So we’ll get into your article a little bit, but first off, can you share your story and your journey to where you are today?

Cathy Kim: Several years ago, I had an injury that had a lot of consequences, after a lot of pain and things that weren’t explained by my original injury, which was a fracture. So I used that as an opportunity to explore alternative ways of treating it, because after 20-plus years in primary care, I already knew all the options, and I wasn’t really excited about them, to be honest. So I sought chiropractic, sports chiropractic care, acupuncture, and including myofascial physical therapy, and I was just amazed at how fast the function could return when you targeted the correct mechanical problem.

And since I was really much more symptomatic than most patients, as I was doing my primary care, a well-woman exam, any kind of visit, people would bring up these complaints, and I would say, “Well, let’s try this, because I know it worked. I understand how it works. So how about we try this?” And it’s amazing to have this option of offering that to patients, instead of writing prescriptions and having them walk out still in as much pain as they came in with. I was always a big listener to my patients, so they might come out less burdened or more validated, but to actually have them walk out feeling better physically, that was a great gift I could give, a great reward in practice that I had never had before.

So it just grew to be more complex kinds of interactions with patients. And so this article, the chest pain article, was the beginning of my blog article series, to show how you could use this, how it applies to primary care, and that it is not always just for athletes or people with mechanical injuries like knee pain, things that you would tend to think are more in the realm of straight specialty medicine. So anyway, that’s how I came to this area.

And then, experiencing what fascia was and understanding it, it’s new; it’s like a new frontier, right? So I looked into how many books were written about fascia. From 2000 to 2010, it’s only about seven, and it’s about 30 since 2010. So it’s exploding as an area, especially since 2018, when some work was published about it possibly being an organ in and of itself, which then really affects every specialty. Because if it’s an organ of itself, in the whole body, then it could restructure how you’re thinking about any disease process.

Kevin Pho: What exactly is the type of medicine that you’re practicing as it relates to the fascia? And can you tell me in a little more detail exactly what you do?

Cathy Kim: Learning about working with people and these problems that I would find, among them that chest pain case that I wrote about. I went to a functional medicine conference, and I thought, “Oh, well, this is true, this root cause, of going to what that is.” When we give people Prilosec, is that really helping the root cause of why they have this symptom, right? That actually had always bothered me, even in medical school, that I didn’t understand how that was helping the root cause. So philosophically, I was probably much more aligned with that from the beginning.

And I was very mechanical-minded. Even when I did prenatal care, when the woman would complain about something, I would think about the mechanics of the pregnancy, where it sat and what symptoms she was having. So functional medicine was a good match for my inherent philosophy. It relies a lot on nutrition and the biochemistry aspect. What’s slightly different about what I’m doing as the root cause is I look at the root cause mechanics, the structural mechanics, of why someone would have something. So for instance, if someone’s torso is way in front of their hips, then you can have them pursue an anti-inflammatory diet and lifestyle, but there will be a limit to how much you are going to help with the impact of gravity on the off-balance that they have. So anyway, that’s how I’m slightly different, because I balance both of those.

Kevin Pho: So let’s transition into your KevinMD article, and I think it’s going to give my audience a fuller picture of what you do in the exam room. So you wrote this case, “Fascia in primary care: When chest pain is not in your chest.” Now, for those who haven’t read that article, can you just walk my audience through it and explain why you decided to share this particular case?

Cathy Kim: I thought this case was a good illustration of what, well, it kind of encapsulates the trepidation and the thought process of what happens when you are conventionally trained, traditionally trained, as an allopathic physician, a medical doctor, which is not very experiential. Everything is rote, through sitting in lectures, and so you don’t really do a lot of hands-on, except maybe when you do venipuncture on your classmates, like that.

So I thought that this was momentous, in terms of chest pain. With chest pain, it’s the heart, it’s the lung; we take it very seriously. So to take this approach that I had, and look at all his data: By numbers, this man should have nothing really seriously wrong with his heart and his lungs, yet he could not walk a block, or around the block. That’s basically what I go through with the different kinds of patients, because they might come to me, and then they have nowhere else to go.

And so a lot of people who are doing fascia work, a lot of these books, these people are anatomists or body workers, and not, maybe, orthopedists. But because I’ve been a primary care doctor all the way from prenatal care to the elderly population, you know how when you’re in a lecture, at a conference, and you learn something new, and then all of a sudden you think of three patients and how that matches? So imagine all the light bulbs that go off for me when I figure out something or I see it in a patient, and it reminds me of the pregnant woman and, at the same time, an adult, and all of those. So I have light bulbs like that going off all the time.

So the synthesis of all of that, while I put together the mechanics to see: If I release the right places, could this man’s chest pain be improved? Because based on my experience, I did not think that referring him once again somewhere else was going to give him a lot, especially when he had had to stop working. So there was a lot riding on that for him.

Kevin Pho: Now, what kind of modalities did you do in this particular case to help him with his fascial pain?

Cathy Kim: I didn’t know it was fascial pain, but I was trying to understand based on a careful history, because they always teach us in medicine that the details are in the history. And so if you’re skilled at listening, you can pick out the parts that make a difference. So when I listened to his story, and how that bothered him, and the details of what was happening, I thought, “OK, it seems to be really movement, and how can I help him with that?”

So I would have to say that, in kind of a scrappy engineer way, you know how someone could just make something out of things at home and use little sticks and that, I just made it up, and also used what was worked on me and how it was worked on me. Because I realized, when I was worked on, PVC pipe was used, elbows were used, and hand pressure was used. So it depended on the area, what was useful, what I could do there. So if it was around his rib cage, I used my elbow mostly. But at that time, I was just starting out, so I really didn’t use anything more than just my hands, pressure, and my elbows, in the attempt to loosen these fascial layers that had become adherent to each other. So anyway, that is what I did.

And because it was new, I didn’t want to go all in and hurt him a lot, so I did it just as a little light test everywhere, and as long as he was OK with it, we kept going, because he also knew that he couldn’t work, and he was willing to try.

I cannot tell you how meaningful that patient visit was, in a busy primary care day where you’re scheduled every 20 minutes, and you see this person, and they have so much riding on the fact that they can’t work, and they’re looking for help. And so you’re doing this on-the-spot experiment by the seat of your pants, and trying to make sure that you’re also riding the line of, really, their best interest, and you’re not hurting them, and checking in. So it’s uncharted territory, which, in this age of GPS and satellite technology, you almost never are in. But this was truly uncharted, because it’s not like I have a mentor for that or anything in this work.

And so that was amazing, to have him explain to me, when you’re just suspensefully waiting, and hearing him say that he’s crying because he’s so happy, from months of having this disability, really, with no hope. So it’s like I’m an explorer and scientist and all that at the same time, working on someone. We’re just going to try to figure it out.

Kevin Pho: And for clinicians who are interested in exploring more about what you do, is there a fellowship or a training course, or any books or online resources you can recommend?

Cathy Kim: I have read a lot of books; you could see the stack I have read to look for the understanding of it more. And it’s done at such a mechanical level, directly in terms of anatomy. I’m interested in the clinical application of it for a primary care problem that you would not really, maybe, think is straightforward. So I’m working on developing that. That’s why I have blog articles in my series. When I first wrote this, it was the first one to introduce how it came into my using it for primary care. It doesn’t say it’s for pain and injury. It’s for things that you do encounter that are unsolvable in primary care. So I would say I’m interested in that. There are other workshops; I have found them more geared towards, it seems to me, body workers, people who are in sports, who are going to help people with hip pain and those kinds of things.

My root cause approach in functional medicine: It’s not just that I guide about an anti-inflammatory diet and an anti-inflammatory lifestyle. My perspective is that the two biggest problems that we are having in our modern society are that we’re having inflammation from the chronic exposure to all these newer pesticides and a non-diverse diet, and we’re having inflexibility, because in our modern lifestyle, we move less. And so I’m looking at what are the key things that we are losing in this modern way of living. No squat toilets, all modern chairs; you see how that restricts the hip so much, and that’s like a perpetual motion engine that’s driving the rest of the stiffness. So I’d say that’s how I do both, structural inflexibility and lifestyle inflammation, in that way. And so I offer that, and I’m developing that for helping other interested primary care people who think that way to work on these things.

Kevin Pho: We’re talking to Cathy Kim. She’s a family physician, and she wrote the KevinMD article “Fascia in primary care: When chest pain is not in your chest.” Cathy, you mentioned several times an anti-inflammatory lifestyle. Can you explain what that is, and what are some changes patients can do to reduce inflammation?

Cathy Kim: Sure. So I’ve given some lectures on this, and actually, I was prepared to give one at the beginning of the pandemic, which we had to cancel. I explained inflammation is basically an event that disrupts the body’s normal routine of doing things. And if you want to understand it analogously to the world, it’d be like a hurricane coming through. So a hurricane comes through, disrupts everything, floods everything, and we go into kind of a survival mode until we can get everything back.

What people misunderstand about when they get exposed to these kinds of things that make us inflamed, like pesticides, for instance, which are on everything, or even this glyphosate, which is Roundup, used on a lot of grain crops. That’s all being fed to the animals, and then we ingest that through there, right? So there are all these sources, through the processing and industrialization of agriculture and the preparation of our food, never mind in our medicines, because they add the colors, and those are artificial, petroleum-based often, right? So all of these things disrupt us.

And even if they’re natural, for instance, in my lecture, I mentioned how you can have a seaweed extract added. That’s natural, except if you ate the seaweed like we would eat it, you’re getting a tiny smidgen of that. But when you extract it and then add it for texture, then you’re getting an amount that’s inflammatory, so that’s disruptive to your body.

So my point to people is to try to help them understand inflammation. Stress causes inflammation, all these kinds of imbalance, all these chemicals, foreign things, are causing inflammation, and these are so disruptive that you need time to recover, so you can get more of your regular routine restored. And inflammation is like mud. If you looked at the inflammatory things that you take into your body as creating this hurricane, and then mud, which needs to dry out, then you would really understand how you need to tilt everything way towards having a lot more sunshine and less often the hurricane thing. So that’s how I help people understand what they need to do.

And so that ties into diversity of eating, because when you diversify your food, then the diversity of your microbiome and your gut is better, your gut, your immune system in your gut. And then, when that’s more stable and healthy, the rest of your body will follow, as long as I can help you also be more structurally sound, so that you are not trying to hoist your head up, the direction that it’s actually pitching. So that’s how that matters.

Kevin Pho: And my final question, Cathy: What is your take-home message that you want to leave with the KevinMD audience?

Cathy Kim: Diversity is probably the key word that ties the problem of inflammation and inflexibility. We’re losing diversity in our food intake, for the natural healing powers of all the diversity of what we could have taken in, so that contributes to inflammation. And we’re losing diversity in our movements as we specialize in these jobs. And we’re not even looking up, for instance, for the weather anymore, because people look down at their phone or their Apple Watch instead of up at the sky. So we are losing this diversity of diet and movement, and this results in inflammation and inflexibility, which is, I feel, the root cause for many of the illnesses and ailments that we’re taking care of. So if you can improve that, then, in a meaningful way, a lasting way, you improve your well-being.

Kevin Pho: Cathy, thank you so much for sharing your time and insight, and thanks again for being on the show.

Cathy Kim: Hey, thank you.

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