Ep. 50: Erica Meloe – Discovering the True Source of Your Pain

Even when the source of pain seems obvious, it might not be.

When figuring out the physical reasons for pain in the body, it’s easy to fall into the trap of viewing the affected body part separately from the rest. But sometimes, the source can be quite far away – an injured foot, ankle, or even toe can lead to issues with the hips, lower back, and all the way up to the neck and head. And that one is simpler to figure out.

In this second conversation with Erica Meloe, a board-certified physiotherapist and author of the book Why Do I Hurt?, we talk about the sources of pain, ways we can discover them, and way to treat them so they don’t return.

In this episode, you’ll discover:

  • Why the traditional approach to physical recovery is often not enough for great recovery.
  • How to find the root cause of pain – many times not what you think it is.
  • What to do to avoid compensation so that you don’t experience other physical problems after your injury.
  • How different emotions are connected to different body parts and how this affects your healing.

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Show notes & links

The show notes are written in chronological order.

  • Erica Meloe’s website: https://www.ericameloe.com/
  • Erica Meloe’s book: Why Do I Hurt? [get it here]
  • Episode 35: Erica Meloe – Solve the Pain Puzzle and Discover the True Source of Your Pain
  • David Butler, G. Lorimer Mosley: Explain Pain [get the book here]
  • Eric Franklin: Dance Imagery for Technique and Performance First Edition [get the book here]
  • Palacios-Navarro, G., Albiol-Pérez, S., & García-Magariño García, I. (2016). Effects of sensory cueing in virtual motor rehabilitation. A review. Journal of biomedical informatics60, 49–57. [read it here]
  • NOI Group Flash Cards [get them here]
  • The champion cyclist, her mysterious excruciating pain and her unconventional road to recovery [read it here]

00:00 – excerpt from the episode
00:59 – intro (listen to discover a little more about your host. Martin will tell you a new lesser-known fact about Dr. Maya)

01:36
Dr. Maya Novak:
When figuring out the physical reasons for pain in the body, it’s easy to fall into the trap of viewing the affected body part separately from the rest. But sometimes, the source can be quite far away – an injured foot, ankle, or even toe can lead to issues with the hips, lower back, and all the way up to the neck and head. And that example is sort of simpler to figure out.
If you’ve been a listener of the Mindful Injury Recovery Talks then you might remember another conversation I had with Erica Meloe in episode 35. This one that you’re listening to now was recorded a year earlier and it has more invaluable information that will help you, your loved ones, or you clients on the healing journey. Please enjoy.

02:27
Dr. Maya Novak:
In this interview, I’m joined by Erica Meloe who is a Board-certified physiotherapist and the author of the recently published book Why Do I Hurt: Discover the Surprising Connects That Cause Physical Pain and What To Do About Them. She is also a co-host of the podcast Tough To Treat: A Physiotherapists Guide to Managing Those Complex Patients. She specializes in treating patients with persistent unresolved pain and a really interesting part of her story is that she used to solve unique financial puzzles on Wall Street and now she utilizes those same strengths to help get rid of her patients’ pain so they can live their lives on their own terms. Erica, thank you so much for being here.

03:13
Erica Meloe:
Oh, it’s my pleasure, Maya. Thank you so much for having me.

03:17
Dr. Maya Novak:
So I’m very, very interested in this part of the story. How can someone go from Wall Street to treating patients? How did this happen?

03:29
Erica Meloe:
It’s so funny because I never knew about – I didn’t even know what a physical therapist was, let alone what they did back in the day. So I lived in – I graduated from College and I ended up living in Madrid for a year, in Spain for a year. When I came back I went to Business School and I said to myself I got my MBA, I said I’m never working on a trading floor. I said I don’t want to work on Wall Street, and lo and behold, that’s where I ended up. So never, say never! I ended up doing a lot of selling and trading of international bonds for 10 years and I would have occasional back pain. I would have occasional headaches, neck pain which is very common because you’re this all the time. I looked at my life because the world was changing. I left in the mid-90s, mid-late 90s, and I didn’t want to retire on a trading floor. So I went back to school at night to get a degree in exercise physiology, and in my program, there was a physical therapist. She was like you like figuring things out, you like the body, why don’t you look into PT, and so I did. I like to problem solve and the skills are very transferable. So I applied. I literally had a poster of words all over my apartment - I’m in New York City - what I needed, what schools I was applying to. And, you know, I was older at the time – I’m older, so it was not an easy thing to do but I just did not want to retire on the trading floor and I wanted to use my problem-solving skills in either helping people or just doing something different. It was really a time in my life where I needed a change.

05:13
Dr. Maya Novak:
And your approach is different. What makes your approach to physical therapy different than the regular stuff?

05:22
Erica Meloe:
Than the regular – the traditional approach – that’s what I’d say.

05:24
Dr. Maya Novak:
The traditional, yes, yes.

05:25
Erica Meloe:
The traditional. Well, I think the way I assess and treat patients; it’s really truly an integrative approach. It’s a holistic approach that really focuses on the whole body and the whole person, not just here down, right. The whole person and that really focuses on finding the underlying cause of the problem. Sometimes it’s not a body part. Sometimes it’s some cognitive or emotional issue. For example, I had a patient of mine who – and at the end of the day we’re trying to unlock a better movement strategy, whether that means intervening at your head, or your neck for a foot issue, or your lower back for your hip. You want to find a way into someone’s system. I can give you an example. I have a patient of mine who had chronic, chronic – or they’re using the term persistent now instead of chronic in our field, so very much of a persistent low back pain and she had been everywhere. This woman was at her wit's end. She’s had laparoscopic surgery for an abdominal issue. She’s been to multiple doctors - OB, gastro, and physical therapists, and she wasn’t getting better. The frustrating part of it, for me, is a lot of times I’m usually the last person that they come too and they’re already frustrated when they come and see me and I haven’t even met them yet. So for her, she had a problem sitting. So what I do for this assessment is a pick a movement or an activity that very much replicates sitting for her. So I looked at a squat. You need to squat to sit. Every time she squatted, her head would go to the right – I mean obvious. I went what’s up with that? So through my assessment and through the history I found out she had a prior foot issue. So every time she walked, she’d look down to her right. She developed a movement pattern to the right. So in the assessment – I’m really abbreviating this – but I ended up making a few adjustments to her head, just manually, just correcting. She squatted and she had no pain. Then she started to cry. I see that a lot because they’ve had persistent pain and even if they can do one squat with no pain, that’s something for them. Another example is I have a patient here on Broadway. She had persistent foot pain. She couldn’t do a relevé, at all. Actually, both of these patients are in my book, and she could not do a relevé and she had to carry a lot of costume on the stage. She also was out of work for a while and for a working actor to be out of work is hard emotionally. So to make a long story short, she ended up having a whole body – a lot of it’s they’re changing – it’s the change of center of mass. She had to carry a lot of weight in her hand, so every time she did a relevé, she would shift her entire thorax or trunk to the left. Once again to make a long story short, the source or the primary source was up in her ribs, her ribcage. She just wasn’t controlling her movement and it was filtering down to how she put weight on. So the same thing. I corrected her trunk and she did a relevé and she started to cry. So it’s very emotional for these patients, I think. I love to treat these types of patients because they’re fascinating to me. But after a while – the more persistent the type you have and the more persistent the nature, there’s generally more than one – we call it driver – one cause. Did I treat her foot? A little bit. Did I treat the woman’s back before? No. It just depends on the person. So that’s a long answer to your question, but we look at the whole body!

09:23
Dr. Maya Novak:
Yes, there are a few important things that you said here. First of all, of course, they are crying because these patients don’t have pain for a week, or maybe for a month. This is probably pain that is going on for months, or sometimes for years, or sometimes for decades. So when a person is there and finally there without pain, I mean I would cry, definitely.

09:51
Erica Meloe:
Yep.

09:51
Dr. Maya Novak:
Tears of joy. But also another thing that you mentioned was compensation. When you are seriously injured and you are doing your best, but you’re moving really fast you can start compensating and you’re not even aware of it.

10:12
Erica Meloe:
Correct, and I think that the more – I’m very flexible. I’m hypermobile, very loose joints. The more flexibility you have the more options you have, which is good and you can compensate for so long until you run out of options. I think that making the patient aware of a movement pattern – they’re like oh, I’m being more mindful of how they move, oh, I’m standing on my right? I didn’t know that. Then you actually center them and you let go and they’re shifted all the way over. When you – I will tell you – awareness is half the problem. If you make someone aware of something they’re doing and they’re motivated, they will try and correct it. At the end of the day, you will be treating compensations for the most part.

11:02
Dr. Maya Novak:
Yes, awareness is extremely important and I’m seeing or meeting a lot of people with ankle injuries – fractures - because this is my story.

11:12
Erica Meloe:
Yes.

11:12
Dr. Maya Novak:
I fractured and dislocated my talus bone. So many times the story is oh, but I would love to walk and then when they have the opportunity to start walking, they start really fast. But then the compensation can kick in pretty fast too.

11:34
Erica Meloe:
Correct, and you need to have – it’s all about unlocking a new movement pattern, and training the brain to move differently. That is like literally learning how to walk over again and it has to be mindful. You have to be conscious. It’s not just walk on the treadmill and read a book. You actually have to – I do a lot of visualization. So, for example, with my performer on Broadway, since she’s a performer we had different cues. So for her trunk, I had her visualize imagine having balloons in your armpits, imagine you’ve got space in between your ribcage. You need to think about those things because that changes your brain and how you move. It’s all about the brain at the end of the day and how training your brain is so important, and it has to be conscious. It literally cannot be an afterthought.

12:29
Dr. Maya Novak:
It’s true. It’s basically teaching your body and brain almost all over again.

12:36
Erica Meloe:
Yep.

12:36
Dr. Maya Novak:
It takes some time and it also takes a lot of practice and awareness.

12:41
Erica Meloe:
It does, and there’s been a lot of research out there now – most recently on cueing. So in the past, a lot of people, trainers, would say squeeze your butt, or flatten your foot, or cueing a body part. That’s more of an intrinsic cue, where you want to give someone an extrinsic cue. Like, imagine you’re walking on sand and your feet are floating. Things like that have been shown in the research to help, I guess, improve the motor pattern quicker than squeeze the glutes, do that because many people don’t know how to squeeze their glutes, or squeeze their butt, or flatten their feet. You need to imagine something different. It’s different for everybody. Like my performer, she would sing and that would be like perfect for her. She’d sing a song and everything would be great. You have patients say – I sometimes say think of something joyful. Let’s say I’m on someone’s foot, for example. Think of something joyful, and I can feel changes in their foot when they’re thinking about something joyful. You absolutely – I definitely feel that. So it’s about the whole connection.

13:57
Dr. Maya Novak:
Mm-mm. True, and as you said, we are not technical animals. It’s not like squeeze your glutes and you will know right away how things work. But if someone says to you, imagine walking on a sandy beach, you know how this feels. You know exactly what that is.

14:17
Erica Meloe:
Yep.

14:18
Dr. Maya Novak:
At the beginning you mentioned that you were, of course, treating the whole person not just the body part.

14:27
Erica Meloe:
Right.

14:28
Dr. Maya Novak:
What I love about your approach is that you are actually looking into the causes. So it’s not just doing a bit here and it might work, but really going deep into the cause. Can you talk about what the causes can be for pain, for different types of problems?

14:53
Erica Meloe:
So a common one that I do see is – for ankle injuries, for example. The foot can be a cause of many, many issues, not just a foot issue. It could be the cause of a knee, hip or lower back – I will tell you, the foot is – especially if you walk a lot like you’re in New York. The foot is very common – we’re just talking musculoskeletal for now to start with. The foot is very common. I also believe that the thorax, the trunk is a very common cause driver. A common cause because a lot of people, we have to lift and we have to do different things. When people have lower back pain, unless it’s an acute issue, in my practice the majority of the time I’ve found that it’s generally not the lower back that is the source of the problem – for the persistent issues. It’s generally more trunk. It could be up in the head, like some cranial – because I do some craniosacral – it could be up there. I’ve had many patients with back pain who have causes in their thorax, their neck, or their pelvis. Everybody’s different because it depends on what they’re doing. If they’re sitting – like for example if someone has a problem with back pain with walking, you absolutely need to look at their feet. I watch them do a step forward, and I’m looking for – I know what is “normal” in terms of that particular activity. You’re looking for something obvious. So those are common patterns. In the neck a lot of neck pain does come from the neck, to be honest. But there’s a lot of stuff in the cranium that people don’t – or aren’t aware of – visual issues as well. People can stop here with the neck. I believe that up until sort of down to ribs three – so your collar bones, your shoulders, they all contribute to neck pain. You will see someone having a foot issue and the cause is their neck. It’s not common, but you will see that. I had a patient who had hip surgery. I didn’t really make her better. She had a labral issue in her hip and she had surgery for that. She ended up having a foot issue that was driving her hip problem. So I think surgery is okay to do, but ultimately if you’re not finding the true strategy or the true cause of the problem, then it’s all for nothing. You need to figure that out beforehand. Then there are people who you can get them to a certain point, but there’s something else driving their symptom. A lot of it is expectation and cognitive. If someone believes that their hip is the source of their hip pain and you find out that it’s their foot or their trunk, they will never get better unless you break that down and try to explain to them that the hip is not the problem. Some people won’t get that, and that’s going to be their barrier to change. If you find - if they’ve had their hip treated and they’re not getting better, you would think that they would say oh well, it’s obviously not my hip, but some people are adamant that’s a certain body part when you find through your assessment it is not. So those people – I always tell patients too, when you think of it – what you focus on you get. If you’re focusing on pain all day long, there’s changes that happen in your brain that don’t downregulate your system, they upregulate your system. I always tell people it’s like the orchestra that won’t stop playing. You need to get the orchestra to stop playing and that’s why you’ve got constant pain, you’re thinking about it a lot. I do empathize because I’ve had many injuries myself, but it’s been shown what you focus on you get and you have to have people doing different things. There are emotional issues as well. Patients have certain – I have a patient now, she’s had multiple – she’s probably one of the toughest patients I’ve ever treated. She has multiple injuries. Her first injury was her in her left shoulder blade. I’m sorry, her left collarbone or clavicle, and then she’s had multiple issues since then. Her hip is her main problem. This was the first injury. So everything she does, she does this. She’s almost like she’s protecting her body part because she doesn’t want to let that go. That’s not just having someone squat. You need to take the time to talk to them and find out. Everybody’s different. I believe in the first visit you need to get all the information you possibly can. I mean some patients just want to tell their story, and telling their story is cathartic enough. Oh, I feel good, I’m good. I’ll go, you know – because they have to unburden themselves at the end of the day and sometimes that is very helpful in lowering someone’s pain level.

20:10
Dr. Maya Novak:
True. I’ve heard so many stories about what you just described. Protecting one part of the body and then something else happens because they were trying to protect it. What you described at the beginning –what you’re also doing is you’re breaking down people’s beliefs about what could be the cause, or what they believe is the cause.

20:37
Erica Meloe:
Correct. That’s correct because a lot of people feel that treating the symptom is the way to go. That works if you have an acute ankle sprain or if you’ve had an acute back injury, you don’t have time to compensate. But I will tell you, nine times out of 10, 99%, it is something else. Once again, there could be multiple issues - if someone’s hypermobile or if they’re on their feet all day. You look at the whole person and that is their story, their beliefs, their emotions. I always say what do you think the cause of the problem is? Another great question I just recently started asking is how old do you feel? Not how old are you, because I know how old they are.

21:29
Dr. Maya Novak:
Mm-mm.

21:29
Erica Meloe:
But how old do you feel? If someone who’s 30 says they’re 90 – they feel 90, there’s a problem. You get that a lot. So I like how old do you feel, and what do you think is the cause of the problem? Because that brings the patient into the whole picture and I like that. The patient’s at the center of everything. Sometimes it’s hard to convince people that not treating their hip will get their foot better, so I’ll do a little treatment. Or I’ll just say you know what, let’s just not treat the hip for four weeks and if you’re good, then it’s not your hips. You have to sort of negotiate sometimes. At the end of the day you’re dealing with human beings, everybody’s very different.

22:12
Dr. Maya Novak:
Yes. I love this new question that you have – how old do you feel? Because it actually shows how they are feeling emotionally and mentally, not physically, but really what is happening inside of them. I can so connect with this because years ago I had a feeling, like probably a decade or maybe more ago, because of all the emotional stuff that I was going through, I felt like 50 years old. It was tough. So how do you start treating a patient when you see that emotionally and mentally they are not where they should be?

22:56
Erica Meloe:
That’s a good question. For example, I’ll have a patient now, she’s very much invested in, very analytical, and very much of a this is her, this is the person - so cocooning, you’re cocooning. What I always tell patients is I try to get their expectations, because a lot of times people expect to get better in three visits. Even though I’m like the 50th therapist they’ve seen, that just does not happen generally. So I try to manage their expectations first. So then they’re like okay, now I know the plan. Then I always tell – because a lot of times people will say oh, they say the pain is in my head and I should be better by now – I say the pain is your brain, yes, but not in the way you think it is. Okay. Pain originates in the brain and, yes, you’ve had a traumatic injury and you’ve had many – you’ve seen many physical therapists or doctors – but you need to understand that there is hope. It may be a different body part. You just need to – you need someone to think outside the box. Even if we start to move you – even if you literally lie on your back and just drop your knees side to side, that’s movement. So even if you walk one block, that’s a start. You have to walk before you can run. The biggest mistake people make is going back to sport too early. The emotional – if they need a referral out, I will refer them out to a psychologist or something, but a lot of times – there’s a great book out called Explain Pain by David Butler and Lorimer Moseley, they’re Australian physios. There’s a beautiful graphic in there about somebody is like an orchestra, like I was saying before, an orchestra in the head. And yes, your pain is real, but we need to find a strategy together, we’re a team that you can move with minimal to no pain. Or, we can try to find a strategy where you can move, even if you push through a little bit, but you will recover the next day. Because a lot of times patients who are emotional – they won’t do anything, they’re afraid. The fear does so much. It makes them rigid and you can’t really move. I have a woman I’m treating right now, she walks like this, back pain for over two years. I just basically – I said what do you love to do. She was like I love to dance, ballroom dance. I’m like that’s what you need to do. You need to dance and move. Like we need a little salsa, and then her emotions changed. So I try to make it – I try to do something fun. It’s tough managing the emotions, I will tell you. It’s tough at first because people cry, people get frustrated, they get angry. I’ve seen it all. I never give up on a patient. That’s one thing, I will just hammer home and I’ll try to find something, even if it’s doing yoga, or Pilates, or walking around the block. It has to be something they like to do.

26:05
Dr. Maya Novak:
Mm-mm.

26:06
Erica Meloe:
That’s what I try to do with the emotions. I’m not sure if that’s the answer you were looking for, but that’s really what. I try to get them involved and make something fun and supportive. They need support. They just can’t be by themselves.

26:18
Dr. Maya Novak:
This is such helpful advice in regards to making the thing fun. Because a lot of the times we think of movement as something we have to do, and we hate it. For example, going to the gym, not everybody loves the gym, but everybody goes there so I have to go there as well. So what you just described is perfect.

26:44
Erica Meloe:
Yeah.

26:45
Dr. Maya Novak:
Have you noticed maybe – because before we talked about musculoskeletal reasons, but also psychological reasons – have you noticed that some emotions might be connected to some body parts?

27:00
Erica Meloe:
Totally. Yes, like my patient with the clavicle fracture, that’s her first injury, okay. First injury and she’s very protective of that and a lot of emotion goes in there. So if I’m doing something with her I’ll feel. Actually, I’ll put my hands on her and she – if I have her do something on the table – I will feel this coming into my hand. All I’m doing just putting my hand there. So she is using that protective mechanism, pulling, she’s protecting that first injury. So there’s a lot of emotion there, absolutely. And necks – I had a patient who I literally just put my hand on her neck because I was feeling and she grabbed my hands and she took them off and she was like I’m so sorry, my husband tried to strangle me five years. I was like oh my god. I’m like where did that – why didn’t you tell me that in the interview. She didn’t even open up about it. So I’ll never forget that. So I literally like was like on her head, and I finally eased my way in. So those are highly, highly charged. I also think that there’s a lot of emotion in the trunk and the thorax. It’s the sympathetic nervous system. We have a lot of sympathetic overdrive in through there. I see patients – even though I would say I’m working on a foot or I’m working on, let’s say, their shoulder or elbow, they’re going to start to sweat because they’re on sympathetic overdrive. There could be something in their system that’s just setting them off.

28:35
Dr. Maya Novak:
Can you explain for those who don’t understand this term, what this is. What is this sympathetic drive and also how to downregulate it?

28:46
Erica Meloe:
So the sympathetic nervous system is like your fight or flight. So you want to be – like if you see a bear – you want that to kick in. You want the cortisol, that hormone, that stress hormone. You need that there to run. People who are under a lot of stress, anxious individuals, they tend to be on this sympathetic overdrive. Their heart rate goes high, breathing rate goes high. That’s the sympathetic nervous system. You sweat. That works in some people for short periods, like running from a bear. But what we want to induce in people like that is to increase their parasympathetic nervous system, which is the complete opposite. Breathing, mindful-based movement, relaxation, lower your breathing rate, lower your heart rate, visualization, breath work is the easiest and quickest way to do that with your eyes closed. Meditation – great, yoga – those are all great, Pilates. And if they make you do – once again, it’s fun, it will lower that sympathetic tone. Breathing is the easiest way to start.

29:59
Dr. Maya Novak:
We'll continue in just a moment. I wanted to quickly jump in for two things. First, thank you for tuning in. And second, I’m sure you have at least one friend, colleague, or family member who would very much appreciate this episode. So share it with them and help us spread the word. Now let’s continue…

30:21
Dr. Maya Novak:
So if someone is now wondering why is this important for my healing to work on meditation, mindfulness, breathing, visualization – how is this actually going to help my body?

30:35
Erica Meloe:
Well a lot of time it – because we have – what it does, in a nutshell, is if we have a lot of cortisol in our system because we’re afraid, we’re injured, that excess cortisol does something to a Substance P, which is a pain relieving hormone, that blocks it. So you need to get your sympathetic nervous system under control, your cortisol level down, so these pain-relieving hormones can do their work. People always say to me, oh, you know, I’m so much better when I’m on vacation. Of course, you are! You’re on vacation. You’re relaxed. Meditation, it induces slower breathing, it invokes healing mechanisms.

31:27
Dr. Maya Novak:
Mm-mm.

31:28
Erica Meloe:
A lot of it’s hormonal, for sure. You can feel reductions in muscle tone. I put my hands on someone’s body, a body part, and I have them think of something joyful or breathing. You can feel their body relax. It is a real and true thing.

31:42
Dr. Maya Novak:
What you describe, with going on vacation, that is so, so true. Even just changing your environment slightly for a day or two, you can see the changes. What would you then suggest to someone who, for example, goes for a vacation or just a weekend getaway and they feel better, and then they come back to their normal life and the pain is there again?

32:11
Erica Meloe:
So I had this happen to a patient of mine. I always tell them – recently actually – it’s something you’re doing. Are you not sitting at your desk all day? Are you wearing certain shoes? Is it just your work environment? I always have them take a look at what. Are they not carrying their children? Things like that. Patients will say yes, of course, I didn’t carry my baby at all and now I feel better, or I’m not sitting at my desk. I had a patient recently go away and it was the opposite. She was away and she put a pair of shoes on and her foot was – her leg actually, she had numbness in her leg – and her leg was worse, and she was on vacation. I said what did you do differently? She said like I wore these pair of shoes. Do you know, she came back, took the shoes off, and never had a symptom again. So it’s really – as I said at the beginning – it’s being aware and mindful of things. You almost want to be a detective, like a pain detective. So that’s what I tell patients. It could be the environment, it absolutely is. It’s generally not one thing, it’s multifactorial. It could be what you’re doing. What you do all day is a huge factor in how you present pain wise, it’s huge. Short of a trauma or surgery, it’s something you’re doing that you’re unaware of.

33:37
Dr. Maya Novak:
Yeah, and it’s like you describe that you have to be like a detective to figure out what is happening. Because so many times the old approach to injury recovery is to just focus on the body part and the physical body and forget about everything else. If we forget about everything else, the cause can be what you also explained – something else.

34:03
Erica Meloe:
Correct, and part of recovery is – I love that term – because how do you heal? How do you recover? It’s not just treating your foot for your hip pain. That’s part of it, but it’s multifactorial. It’s managing your emotions and your belief systems. Beliefs are huge. If you treat someone’s foot for their hip pain and they’re doing much better. As you start to progress them through, let’s say, an exercise or a movement program, and they’re not progressing as you believe they should, there is something else. It could be a simple movement pattern that you’ve overlooked. But the recovery really encompasses many body systems – many systems in the body. Recovery is a really great word for that because it’s not just recovering your foot. Your foot is attached to you! It’s not just dangling out there in space. Like you always say how is your foot doing? I would say how are you doing? Like how is your knee doing? The knee connects to the hip and the foot, so how are you doing?

35:02
Dr. Maya Novak:
Yes.

35:03
Erica Meloe:
They’re like, great. I’m like how are you feeling? You know.

35:17
Dr. Maya Novak:
Yes, it’s so, so important. You briefly mentioned brain training before. Training your brain when it comes to healing and recovery. Can you talk a bit about this?

35:29
Erica Meloe:
Yes. So when you have a habit, for example, I tend to lean a lot on my right. I’m a leftie. So with your typical strength programs or programs in the gym, you know, three sets of 10, two sets of 10, that type of thing. When you train your brain, you need volume. You need mindful movement with volume. It’s literally okay – I’ll just use the example of my patient who’s on Broadway – she imagined she had balloons in her armpits and at one point I had her doing just teeny little squats. So she closed her eyes, she did some imagery and some visualization, and she did like 50 to 60 teeny squats because that’s the number of reps – I don’t know if there’s a magic number, but it’s more than two sets of 10. It’s generally 40-50. You need that volume to get it to stick in your brain because you need to think as you’re doing and then you need to actually do volume over and over until it becomes a habit. In order to change a movement strategy, it’s not going to happen in a gym on a leg press for 10 reps, and you’re chatting with somebody while you are – or your headset. It’s just not going to happen. You need to be aware of what you’re doing. You can think of certain positions you want to be in, and that’s fine, but you need then to train in those positions. Not just on your right side and doing squats, you need to get yourself over and do volume. That’s training your brain. For example, like a pianist, if he comes in with a foot injury. Or say you have a soccer player and a pianist and they both have hand pain. Who’s going to have more pain?

37:33
Dr. Maya Novak:
I would say the pianist.

37:35
Erica Meloe:
Exactly, because that’s his livelihood. The soccer player is like I don’t need my hands, I can use my – and vice versa. So there will be brain changes in the person’s brain on imaging that the part of the brain that represents the hands, it’s going to be lit up. So when you’re trying to train that brain, you need to shrink that representation in the brain to a – it’s getting into neurology, but you need to de-amplify it and that’s just a lot of volume and motor control. Motor control is the new buzzword. It’s mindful movement.

38:13
Dr. Maya Novak:
I love that you are also a huge fan of visualization because I am. Without visualization, I absolutely do not believe that I would have been able to recover the way I recovered. So what do you suggest to people when you say well, visualize something? Is it just in regards to, for example, your patient with the balloons, or do you also tell them to visualize their outcome?

38:40
Erica Meloe:
That is – you know what – I don’t, but that’s a great idea. That I’m going to use. That is amazing. I don’t actually do that, and that is excellent, I will do that. Because they want to be pain-free and they want to – maybe they want to run a marathon and they can visualize. I will have them visualize doing an activity, but the outcome is different. That’s great. I do – for different people – I’ll put my hands on them and I’ll have them visualize. I go through a few of them. I need to feel a change in their body, okay. So if it’s my balloons in the armpit lady, I’ve got my thumbs on her ribcage and when she thinks of something joyful I can feel shifts. I can feel muscle tone go down. I can feel shifts in her body. I’m like that’s it. That’s her cue. In a few dance books that I have there’s a great guy, I think he’s Eric Franklin, he has a great book on dance imagery, and you need to use that. For me, as a physical therapist, I put my hands or I visually look at them. But when they’re doing their imagery, my hands need to be somewhere, but my eyes are closed. Because I need to – I won’t want to be biased with my eyes. So I’ll close my eyes and I’ll literally have them do their visualization or their cue. If I feel a change, I’m like that’s it. The ones who are pretty in tune with their bodies will get that pretty quickly. The harder ones are the ones that don’t have a good body sense and so you’re working a little bit on cueing. But those types of patients I always say – the outcome is a great cue – I’ll often say things like imagine your dancing or something they like to do. Their whole body just says oh, this is great, I can do this. If they have a problem running I’m not going to say imagine running right now, because that probably won’t be so helpful.

40:38
Dr. Maya Novak:
True, true. Since you are working so much with people in pain and persistent chronic pain, you know that with pain we usually don’t want to move because it hurts. So how do we start moving and why is it important that we start doing something with our bodies when we are in chronic pain?

41:02
Erica Meloe:
Because at the end of the day, if we don’t move we stagnate and our body just deteriorates, and our mind as well. So there’s always something you can do. You can go what I call unloaded. Lie on the table. Even if you’ve got like a foot injury you’re not going to sit there and do heel raises or squatting yet. You can go on your back and just move your toes, move your feet back and forth. If you have a knee issue – knees are tough because you don’t want to push through a ton of knee pain – but if there’s a persistent issue you can. I do a lot of taping because a lot of patients have these compensations and I do think that you can find a movement that is relatively pain-free for the patient that they can do over and over. A lot of times it’s just sitting and just moving our legs, or just moving our feet back and forth, moving our arms. I do a lot of these funky moves like for elbow pain I’ll have them just do this. Imagine you’re carrying a plate. Imagine you’re just giving somebody – you’re getting a tip and things like that. Or we can sit and we can do slumps and sitting – anything. You can sit and you can move and dance for some of the older patients if they don’t want to move. A lot of the issues is weight bearing, obviously, but you can go unloaded on a table. No load, and have people move and sit. You can just have them stand and have them just do a teeny step forward. People walk. The more persistent the nature – I think you can push through a little bit into that pain. You need to raise your – we call it the tissue tolerance line. You need to raise that line. You need to be able to do more before that sets in. I always tell patients if you’ve done something and you’re sore for two days, you have overdone it. You’ve overdone it, okay. Then you just need to back off and do a couple of repetitions. You eventually need to build that volume up at some point. But the people who are just afraid to move have a huge fear base component to their pain. A lot of it is just managing their fear versus actually getting them to move. Because once the fear gets managed they will get better. I often have patients watch and then visualize. Watch somebody running, watch somebody walking who is pain-free. Just watch them, and watch them, and watch them. Because if you imagine doing a movement or watch somebody else do it, it activates what we call the premotor cortex in your brain. It’s the same as if you’re doing it. So I have people watch people move. If you have neck pain, look at necks. Look at people’s necks and focus on that. It’s not yours, it’s theirs. If you have a problem with a foot, look at – there are these really great flash cards that have come from the NOI group in Australia and they have a foot. Let’s say you’ve got persistent foot pain, you look at the flash cards and you try to figure out if it’s the left or right foot - it’s called left-right discrimination – in different activities. That really once again downregulates. So you’re not moving but you actually are in your brain, if that makes sense.

44:39
Dr. Maya Novak:
Yes, yes. You briefly mentioned pushing through the pain. A lot of the times people don’t think about it. They don’t think about pushing through a little, it’s more like, I have to push through the pain because no pain, no gain. What is your response to that?

44:59
Erica Meloe:
Yeah. No, I disagree. We call that like your boom or bust scenario. People are like oh, I feel good, I’m going to walk, and then they’re worse but they keep going. Then you’re down for like four days. I disagree with that because I’ve seen people push through knee pain, push through foot pain. It’s not worth it because your whole brain gets lit up. I do believe – shy of trauma and surgery – the persistent pain, you do need to push through a little, but it’s not the no pain, no gain because that does not exist. I will tell you, if you push yourself, once again, people return to sport too early and they’re pushing themselves, and pushing themselves and look what happens. They’re out again for three weeks. So that’s not – I don’t believe that’s a great scenario. I think that people need to realize that okay, pain is there for a reason at the beginning. It’s a threat. Your nervous system is threatened, that’s why you have it. So you need to de-threaten that nervous system. But the longer you have your symptoms you do need to nudge that a little, but that’s the only way you’re going to change your brain. Even if you feel good – I always tell patients – let’s say you want to walk 10 blocks, walk five blocks and come home. Oh, I feel good after five blocks. I don’t care, come home. Walk six blocks. You don’t want them to go from five to 10 because ultimately they’re going to be down for the count the next day. So I always try to minimize the expectations there, because even if you feel good, come back in.

46:36
Dr. Maya Novak:
A follow-up question to what you just said, is it doesn’t matter if an injury is really serious and big or if it’s smaller, but you mentioned a couple of times that people go back to sports too early. So how do we know? What are some steps or what should we be aware of? When do we go back and how do we go back to sports so that we don’t re-injure or delay our healing?

47:06
Erica Meloe:
I think people go back to sport too early because they haven’t been assessed properly. Shy of a professional athlete who, you know, you’ve got other issues there. Let’s say a hamstring. Let’s say someone who’s a runner pulls or tears their hamstring and they rehab the hamstring and the hamstring feels good. It’s strong, and they go back to running, and all of a sudden their hamstring hurts again even though they felt good in rehab. There’s another strategy. There’s another secondary issue that causes, or is causing the problem. It probably caused the tear in the first place. So I believe that anybody who is an athlete – or even a non-athlete – anybody - you need to look at the interrelationships of the body. Because people who will just get their hamstring rehabbed – and it will be good for a while – but then they’re injured three weeks later, four weeks later. I think the key to – at least for me – to not having that happen is a proper movement program. A proper program to load your system, depending on the type of sport or activity you want to return to. You need to put some load in the system eventually. You need to go through different phases. So, for example, I find that your foot is the cause of your knee pain, I am training your foot, not your knee. I mean your knee will get worked, obviously, but I’m working on giving you movement and exercises for your foot and incorporating them into more of a functional based program. The key ultimately is finding the cause of the problem – ultimately, and training that. If you do that correctly, the person who returns to sport won’t return early. They will be right on schedule.

49:02
Dr. Maya Novak:
Mm-mm.

49:02
Erica Meloe:
Because a lot of people who return to sport early feel good with their symptoms – they’re good, I’m good, my foot’s good. But that’s not the source of your problem, you know what I’m saying? So it really gets assessed – and this also goes to prevention. I think that if people want to start a running program and they’ve had an ankle sprain or prior foot issues, you need to get assessed by a physical therapist. Just one visit, just make sure everything’s good. That’s my view in terms of prevention and I don’t think a lot of people understand that they can do that, in America or anywhere. You can see a physical therapist without a doctor’s referral, at least the first visit in most countries and most States.

49:40
Dr. Maya Novak:
But usually you think about going to a physical therapist when something happens.

49:45
Erica Meloe:
Correct. Correct, but I think healthcare’s changing in that regard. But people still don’t think of it that way and I think they should. I think they should because – especially the longer you’ve had pain – if you’re going to start a program, you need to be assessed by somebody. You need to. Is your ankle sprain going to kick your knee pain in on your right side when you run, or are you – I mean I’ve had patients start boot camps and like two weeks later they’re in my office because they did something wrong. I mean I guarantee you it’s something that wasn’t rehabbed properly, or a muscle imbalance or a flexibility deficit. You don’t even need an injury. It’s just a muscle, or something that’s just not – running’s very straightforward. It’s run, you step, it’s very straight playing but if you go from running to tennis, that’s very different.

50:43
Dr. Maya Novak:
Yes, and what you said here with movement and fast movement or doing just too much in a really short period of time – what I am reminded of is also that ego is a really big component here. Especially if we’re talking about group programs. It can be really be like, oh, you can do it, you can do it, you can do it, and then you can do it a physical therapists office.

51:18
Erica Meloe:
Right, right. I would agree with you, and I myself, I do a lot of spinning here in New York. There are times when my left calf gets really, really tight and I’m like I’m not going to get off the bike, I’m not going to get off the bike. I’m stopping and I’m rubbing it. We’re all guilty of that and it’s a very powerful ego, I would agree with you. But then I have patients who are just like I’ll do a boot camp and I’m going to modify, and those are usually the older, more mature people who are like I’m not going to do that, and that’s it. But more of the younger ones are go, go, go, go, and they’ll just, you know. I will tell you, until you have a serious injury, if that happens in a class like that, your ego will still reign, I believe.

52:04
Dr. Maya Novak:
Well, you’d be surprised that I know many people who are injured, but their ego is still really big and it’s like no, I can do it, I still can do it, even though I have this injury.

52:15
Erica Meloe:
True, and many people push through it. I had a patient run the Boston Marathon with a pelvic fracture, no problem. The adrenalin just set in and everything and he didn’t feel a thing. So yeah, I mean sometimes the ego can work to your advantage in that regard. It’s like I’m doing this, and I’m doing this, and I’m going to shut that down, and he did.

52:37
Dr. Maya Novak:
But then?

52:39
Erica Meloe:
Well, he was quite sore after, but he wanted to do it. I said to him, did you get the go-ahead to do that? He was like yeah, like okay. So he needed a physician clearance, and the physician was like yeah, you can do it. So ultimately it depends on the discipline of the person, and if they can shut that down. Athletes – professional athletes – can shut their systems down very quickly. They can tune it out. Like a golfer, they can tune everything out and nail that putt. But an amateur golfer won’t be able to do it that much because the professional athlete, and many other people, can really quiet their brain. They can just tune everything out and nail it, and other people can’t do that, there’s other things that are coming into play.

53:33
Dr. Maya Novak:
And again, we come back to emotions and belief systems ...

53:37
Erica Meloe:
Exactly.

53:38
Dr. Maya Novak:
… and everything, not just the physical part, but the whole – holistically looking.

53:42
Erica Meloe:
Yeah, and it’s interesting. There was a study done a while ago about was a professional cyclist. It was done in Australia and she literally got back pain every time she got on the bike in a race. In race – no other times, she rehabbed, she biked, training, no problem. The minute she got on that bike during the race, she got it. So what they did is they put her on the trainer and they simulated in the clinic a live race, and they saw her body and how it moved. It was not the same as when she was training. So they trained her on this and simulated a race every single time she came in.

54:32
Dr. Maya Novak:
And again, brain training, brainwork, everything.

54:36
Erica Meloe:
Yep.

54:37
Dr. Maya Novak:
Erica, what is your number one advice that you would give someone who is injured right now and recovering?

54:43
Erica Meloe:
This is going to be very cliché! There’s a couple of things. I always tell patients to be patient, and I know they don’t want to hear that, to be honest. I would just say that you need to be open to other sources, other potential sources of your pain or of your symptom. There’s always hope, and it’s most likely something you’re doing that we just need to make you aware of and you have the power to change it. I always just tell patients to try to do something fun. If you find that you’re lonely, or you have other issues, you need to tell me or tell somebody because it will affect how you move. So that’s my multiple advice. Being patient is tough, but I do tell people that. I know it’s hard.

55:35
Dr. Maya Novak:
I know, especially with serious injuries, but how long?! Just tell me how long.

55:41
Erica Meloe:
Yep.

55:41
Dr. Maya Novak:
So you said there is always hope, but I also know that some people who are listening, they are losing hope about their healing. What would you say to someone who is losing hope?

55:54
Erica Meloe:
I would say – it depends. I would look at – I would seek another opinion. I don’t necessarily like these sort of support groups online because they’re not so – I mean some of them can be empowering but I would talk to other people who’ve had this injury, who’ve had a persistent. I would seek out somebody who looks at the whole body, who takes into account the person. I know a lot of people who have said but I’ve done that, I’ve done that, I’ve done that. But maybe not. I mean everybody’s different in how they assess the body and the person. I always say be around family, seek support, and that’s great, but the people who have lost hope – and my who came in last week, I was her last resort, literally, that’s what she told me, and she had a healthy relationship with pain. It wasn’t like woe is me, I’m not or I’m losing hope. But if you looked at her story, it was unbelievable. So she had a good attitude about it. I know that’s harder – it’s hard to do. She meditates. She does yoga. A lot of those alternative movements, yoga, doing some work with breathing, that really helps. People who have lost hope, I think, there’s always hope. I know that’s easier said than done, but would seek somebody else out that resonates with you. Because when you work a practitioner, whether it’s a yoga practitioner, or an acupuncturist, a personal trainer, a physical therapist, a doctor. You need to develop a trusting relationship with that person because you’re a team. And the relationship between you and your body, and you and your therapist is a sacred one. You need to trust that person and trust that that person will help you. So that’s important. I know a lot of people, especially in today’s environment, they don’t spend enough time with patients. You need to be heard and you need to be felt. If you haven’t found that person, you need to.

58:14
Dr. Maya Novak:
True, very true. So physical therapists like yourself, you are so extremely important on this healing journey. However, the person is not going to come to your office every single week for 10 years, for example. How do you help your patients to self-manage their symptoms? What can they do on their own?

58:41
Erica Meloe:
I use a system – well not a system, it’s really basically we have them do like a self-check, for example. So, for example, I’ll use my Broadway person. Actually no, I have a patient of mine, he was getting injured every time he worked with his personal trainer and we didn’t know what was causing it. So his main issue – I called him a self-check – so give them a movement to do before and after the exercise. So with him, I had him stand on one leg because his issue was his back and his pelvis. Before he worked out, he would stand on one leg. Sometimes he generally has a hard time with that. So if that was not so good, I would give him what we call a re-set exercise. For him, and it’s different for everybody, it was a full squat to the floor that re-set his system, that opened up his pelvis. He stood on one leg. He was fine. He would do his work with the trainer. I said after every exercise, you do your self-check. He stood on one leg after one exercise it was good. I said then keep going. After every exercise, he did that and he found that two exercises caused him to lose control in his system. So he literally did his squat to the floor to reset his system, and they basically trained around those two exercises. He took them out for a while. That was very empowering for him because he figured out what the cause of his problem was, or what exercise was bothering him. My person on Broadway, her issue is her trunk. So something that I have her do is just rotate because that’s pretty sensitive to the trunk. So when she goes on stage, I have her turn to the right. If she’s restricted, we know there’s something in her system. With her, her sort of re-set is child’s pose, down dog. It elongates. It decompresses her system. She gets up. She turns. She’s good. She goes on stage. So that’s very empowering for people because at the end of the day, they figure oh my god, that’s what’s causing my problem. Is it sitting? If it’s issues sitting, get up every hour and do your self-check. It could be squat – it would be different for everybody, but do something that you have a problem with and see if it’s worse or better with the activity. That’s very empowering for people, it really is.

01:01:14
Dr. Maya Novak:
I love this advice because especially if we are talking about movements like, for example, going to the gym and doing multiple exercises, you will not know what actually caused it. So checking after every exercise how you are doing, that’s a really, really powerful thing to do so that you know what actually is not working for you.

01:01:37
Erica Meloe:
Exactly, and like for someone who has a foot problem, I would do probably a heel raise. If they couldn’t do that I would do maybe a squat or something. But that’s very empowering and extremely, because you realize oh, I have the power to change that. I can actually change that. And they get into it, trust me. And I will tell you, the success of the movement programs that I have done, it hinges on being able to do those correctly and then progressing. So the more you add – like with the athletes, you need to train under load, under a lot of weight and a lot of them don’t. They’re like oh, the hamstring feels good, I’m going, but they need to train that. So then they would do their sort of self-check and then their sort of reset we call it. That helps them get back in a better way.

01:02:34
Dr. Maya Novak:
Beautiful. I do have one last question for you, even though I could be talking with you for hours, definitely.

01:02:41
Erica Meloe:
Me too, I love it.

01:02:42
Dr. Maya Novak:
My last question is a bit more fun. If you were stuck on a desert island with an injury and you could bring only one thing with you that would help you heal amazingly well, what would that be?

01:02:58
Erica Meloe:
So I know – when I saw that I was like oh god, ah. I will tell you, the first thing that came to my mind, was my Bible, a Bible. I’m very spiritual. For me, that would work. So I asked a few patients what they would use, and oh my gosh, the people – I had a patient of mine and she was like oh I would bring antibiotics. Like antibiotics, what? Then I had another patient tell me she’d bring her cell phone. I’m like, but? And then somebody else would bring an icepack. I’m like, okay, and I’m bringing my Bible. So that’s what I would bring. It just goes to show you how people – everybody is very different.

01:03:36
Dr. Maya Novak:
Absolutely, and there is no wrong answer here because it’s really – when it comes to healing – it’s more important what makes you feel good and this is going to also help you. This is how I see it, the healing.

01:03:53
Erica Meloe:
I agree. Like if someone – if I had antibiotics, I’d be like well I don’t need antibiotics. I need the Bible, or prayer cards. Or ice – I don’t need ice. I can just – so it’s very interesting, yeah. That’s a great question.

01:04:09
Dr. Maya Novak:
Erica, where can people find more about you?

01:04:12
Erica Meloe:
Well, if anybody’s in New York I work at Velocity Physiotherapy on East 58th Street. My website is ericameloe.com. It has a link to the podcast and link to the book as well. I’m on social media with my – ericameloe is my handle for everything. I’m a big Instagram person.

01:04:35
Dr. Maya Novak:
Perfect. Erica, I so enjoyed this conversation and I know that it’s helping so many people around the world, so thank you so much for being here.

01:04:43
Erica Meloe:
Thank you so much for having me. I loved it.

01:04:47
Dr. Maya Novak:
Thank you for tuning into today’s episode with Erica Meloe. If you haven’t done it yet, subscribe to the podcast Mindful Injury Recovery Talks on whatever platform you’re using to tune in. Of course, also remember to share this episode with your loved ones and help them out. To access show notes, links, and transcript, of today’s talk go to mayanovak.com/podcast. To learn more about The Mindful Injury Recovery Method visit my website mayanovak.com and find my book Heal Beyond Expectations on Amazon. Until next time – keep evolving, blooming, and healing.

Love and gratitude xx
Dr. Maya

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