28. Lessons Learned: Dave Tilley, DPT and Charlie Piermarini, PA-C

Hello everyone, I'm Dr. Darsha, and I'm Dr. Altamash Raja, and welcome to Medicine Redefined. A podcast where we will explore the often overlooked but necessary components of health, what we consider to be the fundamentals. We will investigate topics and practices that can give you and your patients the best chance to optimize a healthy lifestyle. It's time to move the needle forward and put the health back in healthcare. Its story time brought to you by LocomStory.com. Today we'll be reading docs and shocks. Some docs are overworked as work works, overworked, workers weary. Some docs are overstocked stock, as pandemic tiktoks keep docs off clocks. If docs are in shock, as the pandemic clock tiktoks then locums is the token to unburn the burnt out broken. So how many clock tiktoks must talk until docs, tiktoks, and swaps to the spoken locum, tenons token to unburn the burnt out broken. Enough ticks have talked. The time is now and locums is how. Locum tenons tends to trend as a godsend men to burnt out ends. And if you do not understand that, that is okay because you can go to Locom Tenons for more information. Drpodcastnetwork.com or slash LocomStory is your final destination. Okay. Enjoy this lessons learned. All right. Hello, everyone. Welcome back to another episode of Medicine Redefined. This time a lesson is learned here with Dr. Raja, Ultimashman two and a half months into sports medicine fellowship, any updates for us. I love every second of it. It's busy, but you know what, man, it's so much more fun because you're truly getting to see the patient population that you've always wanted to work with. You know, from the lens of they want to continue being active, right, physical medicine rehab, as much as I love it, it's much broader, right? And that's why you go specialized and then you subspecialize to kind of really try to find your niche niche, whatever you want to call it. And so that's where I am. So I love it. Awesome. What about you, man? Awesome. Good, good. Good. I know. It's cool. I mean, I enjoy it, you know, I guess it's kind of where you are in the sense that we've gone general and now at least at least I'm in Piaminar, right? And then after this, we'll see what happens. But it's just nice to be in a field, like you said, where you're finally being able to do what you want to do. So it's just cool working with those patients, trying to motivate them, seeing the lifestyle aspects that we usually do, right? Had a patient the other day come in and be like, she just had a stroke, second stroke. That first thing she comes in for her admin and says, I want to cigarette. Just like, oh, man, all right, this is going to be a good one, you know, and trying to figure out how we can stop that cycle of housing those strokes. So cool, man. All right, well, let's get into it. So two guests, three episodes, Dave Tilly and Charlie Pyrmarini. So let's start with Dave Tilly first, talking about gymnastics. Where do you want to start with that? You know, I am so happy that Dave got to sit down with us and educate us on the side of gymnastics. Again, I think one of those sports, as I mentioned in our discussion with him, that doesn't really get the spotlight, except when there's a lot of negativity for something. I mean, that's the sense that I get just following it peripherally, being just, you know, your average fan and not being involved in the sport. And so obviously with the most recent Olympics, a lot of maybe a little bit positive about Pyrmarini that I would say negative attention and rightfully so Olympics is the largest stage. And so just getting educated. And I think that we kind of broke it down into two separate episodes. I think the first part was more important where we talked about the history and, you know, how we got to where we are and the culture, which is one of the areas that he enjoys talking about. And so I enjoyed learning about that and also learning about the sports, the basics of it, how different levels and athletes kind of ascend and, you know, at what level they can compete in the Olympics. And that was the most informative, I think, that I didn't have a background on. Yeah. Completely agree. I think there's so much nuance to gymnastics that I didn't really understand. Like you said, as an average fan, the only time it probably really gets the spotlight is if the U.S. wins gold and if they don't, there's going to be some sort of negativity associated with a gymnast or the team, why the coach was something, right? Yeah. And, you know, obviously this time around, it was the Simone Biles, which I rarely watch the news as it is. Like you said, like you said in the episode, I couldn't get away from the whole Simone Biles controversy. But it was interesting to see kind of what happened with the twisties, you know, nobody really talked about the media and it kind of just goes to show how much these players don't really get a say, right? In terms of talking to the media and really explaining the truth and, you know, a lot of that's probably censored from the above and the gymnast's committee and et cetera, et cetera. And how much of a mental toll that must play, right? And I think the biggest thing I learned from Dave was how physical and mental gymnastics is, right? Because all these Olympic sports, you're really thinking about going to the Olympics as a teenager, as an early teenager is when you probably know if you have it or not. And then once you're 12 years old, in that puberty stage, where he's saying where, you know, emotions are changing, your physical body is changing, you need to figure out how to make adjustments. And, you know, as we learn psychology, when you're in your early teens, that's your whole identity crisis in a way, right? You're trying to figure out who you are and what you want to be, your passion, all those types of things. But to imagine somebody going through that physical toll and mental and emotional toll at that young age to get on the, you know, biggest and brightest spotlight is wild. Yeah. No, I want to come back to the truthies in a second because I think that that's something that, again, from the scientific person and me really getting educated on that, that thing that was super important and that's going to be a conversation that I'm going to have with anybody who I treat in gymnastics, moving forward. But again, touching back on this, what you're kind of alluding to is that, you know, part of the reason that the culture is quote unquote, off might be because of that power dynamic that he talked about. I think that's really important to address that he mentioned for those who might have listened to it. You know, since athletes started a much younger age, maybe they're starting at 6'7 and then maybe the coaches might be in their 40s or 50s, that age gap is large, right? And so a lot of times, maybe as they're developing, and again, you talk about the emotional toll and so many different things are going on. I think one of the quotes that he mentioned, I hope, on a ruin is, you know, gymnastics tries to make elite athletes when athletes are in this chaotic time of their lives and then he's referring to puberty, right? So you've got these, just children, honestly, and as they're going through adolescence and before they're even adults and they can kind of formulate their opinions and speak up for themselves, they don't know any better, right? So a lot of times, coaches are extremely influential. And if that coach doesn't have the best of intentions, that's going to be hard. And you know what's interesting about that situation is, I mean, that's kind of really where the parents have to come in, right? And they have to come in, even if they're uneducated about it, they need to empower their children, I think, to recognize and report and communicate. I think, obviously, the best coaches, and Dave talked about this, they communicate, they over-communicate, right? When I asked them about, hold up, like, you know, the main male, their type of stuff, especially with the recent hole, the last couple of years with Larry Darce's situation, I think that that's, you can never under-communicate, I think. Well, you can't over-communicate a little bit, Eric Cressick talks about this, but I think in this sense, when it's a sensitive period, it is good. You know, not being a parent, though, I will say that it's difficult, right? I can respect that it's likely easier said than done that the parents kind of really have to empower their children and say, hey, like, you know, maybe the coach isn't right on everything. I think there's a really a balance as there is with everything in life, right? But what I'll tell you is being on the other side of the coaching side, when I saw a lot of parents come in and they had five, six, or six year olds or seven year olds, and they had high aspirations, they're like, oh, yeah, you know, my kid's going to be an elite gymnast. I saw that, and I remember, and the episode I mentioned when people would bring their four year olds who were really good at climbing and stuff, but that just automatically translated into they're going to be like on the rings or something, you know? And I was just like, I'm not really sure if they were or weren't part of the problem, but I imagine like everything else in life, it's a collective effort that gets this to be better. And it all starts with the conversations that we're having now. Yeah, absolutely, man. And just to kind of relate that, you know, you brought up Larry Nasser, and I know we touched on that with Dave in terms of how he handles kind of, you know, being a male coach working with young female athletes, you know, always ensuring that the parents understand that if there is an incident where, you know, he has to put his hand, you know, right behind an athlete. And in case you're going to fall, he might touch an area where, you know, today's world it might be inappropriate, right? So he's going to report that incident, say, hey, listen, this is what happened, and he's going to over communicate that in that regard, because again, he wants his families that he's treating to be super comfortable. And it's a shame kind of what happened with Larry Nasser, right? Was that almost five, six years ago when that news broke out and kind of given the osteopathic positions, you know, of that name, but really all manual therapists, right? Yeah. And again, this kind of goes again, back to this, this is the world of Orthodox that we live in. It's the, it's the world of quote unquote functional medicine. I mean, call it whatever you want. You and I have talked about this offline so many times. You know, what's interesting about that situation is, again, people jumping onto, on someone dials for not performing and whatnot. So what was a two or three days ago, actually, so we're mid September now, they actually Simone Biles, Alia Riesman and two of our teammates, I forget their names, they actually sat in front of the Senate and actually testified for the whole Larry Nasser situation. Oh, really? You know, against the USOC and we'll link to kind of some of the stuff on that and there's a, there's, you can actually see the whole thing, it's a four hour long YouTube video. But, you know, it just, it's so much pressure. I mean, no, what Simone Biles is now 24 years old, Alia Riesman is a little bit older, but I think some of her other teammates are younger. So when they went through this ridiculously disgusting situation, they were in their teens. And it did speak up, right? They did speak up and they talked about it. But when you, when you do speak up and you do report and, and you don't feel protected, and you also mentioned kind of the pressure that you have of being an elite, elite gymnast where the whole world is looking at you, right? So you've got that situation in the back of your head. And, and as I mentioned before, Simone Biles said that she wanted to continue competing because had, I think she's the last person left at the Olympic stage from that team, who was part of the, that, you know, victim of that abuse, right? And so she said, part of the reason I wanted to continue going back is because if I don't step in the limelight, then, then the conversation is going to die off. Right. And then she gets the twisties, right? Which, for, for, like, it's kind of, you're basically equilibrium is completely distorted. And as you're flipping up and down, you don't know what's up, you don't know what's down. And obviously, it can be a terrifying predicament to be in. There was an awesome, two awesome articles that will link in the show notes from the Washington Post and Time magazine that kind of helped describe the situation. And there was a quote that in 1988, Olympian described it as a non-serious stroke. This goes back to your point of taking care of person as a stroke. And we know what the interesting situation about this is Simone Bail, who has this quote unquote non-serious stroke, how were you going to defy it as something that's crilly dangerous, comes back, I don't know, a week later, and wins a silver and a bronze, right? Right. So she still wins two metal. So, yeah. So now you're like the second and third best, it's just impressive, you know? It is. I mean, I can't, I'm someone who can do a backflip and a frontflip and I've done them for dance competitions and I could tell anyone out there, it is very mental. Like before you even start your run to do a fronthand spring or to do a roundoff into that backflip, you are predicting every one of your movements and you're predicting how you're going to land and when you're going to flip and it's so nuanced, it's every millisecond. And I've bailed out many times and luckily not on hardwood floor or anything, but I've bailed out just because there was a mental block in my head and I said, and mid air, I'd say, nope, and I would just fall straight on my back. Now, imagine if in that millisecond I'm going to land on my head, right? And we've both probably had patients who have spinal cord injuries just from a trampoline, things like that. So it's a real physical, you know, dire situation at that point and I think that's what people need to realize. You know, a lot of these people are saying, well, I can't, Simone Biles just try at least, right? And if she doesn't win whatever, it cares if she doesn't win, at least she tried and represented the US, but hey, you got to realize that whole mental block starts even before the routine. What's interesting, it's kind of like getting the yips right in a lot of other sports. I mean, I think a lot of us appreciate it and maybe golf or some other sport. Like, okay, a, a hitter in baseball again, it's just a, it's a much more popular sports in the States. And so, you know, we're like, oh, man, he's in his head. He's in his head. He's in his head. And that's okay. But again, as kind of Dave touched on gymnastics is 10 times more dangerous than golf, right? A hundred times more interesting golf. I'm sorry. Like nobody involved, you know, like the likelihood of getting a TBI unless the ball somehow ricochets and comes back at you and it's really hard. I like that's not happening. Before you're just in my car accident, like tiger rights, but dry, yeah, which wasn't having to do golf. But, you know, and the, you know what the other wild thing about the situation is, she's not trying average moves. She has four moves named after her, right? So she's trying the most complex moves ever. And you know, it's so it's just kind of, I think that Dave said it best. I think we really need to sit back before we think about this or judging other people, particularly people who we have, we've never met. We probably will never meet and just think about like what the situation could be. Try to empathize with the human and say, Hey, like, you know, what's going on? And if you are that person who's kind of reactive and kind of jumping to the gun, maybe, maybe kind of just take a look at the mirror and say, Hey, why, you know, why are we doing this? Because I don't, I mean, now here's a situation where we know we had this. She had some family issues going on. I mean, that's too much for anybody in the world to take. And so I think that at the end of the day, it's really important for us to kind of reflect on that. Absolutely. Cool, man. I guess at the end of that first episode of Dave, he also kind of touched on some gymnastic moves that we could kind of incorporate and why we should incorporate it. And, you know, I've always been fascinated by the gymnast body just because I mean, they are hella muscular, they are super flexible, super mobile. It's almost, you know, they're jack of all traits and they're jacked. So I mean, I think working with that core, somebody else that some people out there can follow is Chris Summer. I know he's been on the Tim Ferris show and he puts out a lot of different progressions that you can master. So he might be someone, check out even Max Shank. I mean, he does a lot. Yeah. I was just going to say, yeah, yeah, I was just going to say Max is a great job of giving regressions as well and helping modify it. I mean, he's really big into that and obviously he's impressive. And so, previous guest, I think episode 2325, 24, 24, 24, 24, 25, 26, 25, 25, 25, 25, Oh, you're talking about Max, yeah, Max, Max, or I believe 2324, yeah, yeah, yeah, yeah. Anyways, you guys in search him. Yeah. So let's switch gears. So the second episode was much more rehab oriented for our healthcare medical professionals were we talked a lot about the common injuries. And you know, he described a little bit more into the different types of gymnastics, right? You have artistic, which is kind of like vault, beam, floor, that kind of stuff and understanding the sport. This is like anything else in sports medicine or rehab medicine. You have to understand what that functional issue is and then what the limitations might be and what the mechanism of action is. And so, you know, I loved that we kind of walked through the injury to performance continuum. That was awesome. Yeah, absolutely. And I think for all the new listeners out there, this is kind of the third time we really touched on this because it's so important, you know, to his colleagues, to wish. And oh, my god, damn, oh yeah, slow in mind there for a second. Came onto this show, right? We've worked a champion and we've all had this discussion about how do we communicate? How do we give the most effective and efficient care to our patients? And it's such an important topic because yet in the years of healthcare, nobody has figured it out, right? To make it really viable and sustainable. So that was just a really cool conversation in terms of how he goes about ensuring the best care in terms of how he communicates with the, you know, surgeons post op or if it sports medicine docs, pre-op and trying to see whether his patient might need surgery or not. Yeah, interdisciplinary communication and the interdisciplinary signouts that Dave, Dave Ote first talked about on our show Long Way Back when he did. It's my favorite thing, man. Look, I think that we know that collaboration is key and I know that they've talked about hey, like physicians are busy and, you know, on that note, I will say that I recently saw an athlete, maybe a high school athlete, high level and he's working with a strengthen conditioning coach and kind of at a performance facility. And they gave me, I told the mom, I was like, let me get the number, I'll talk to them. So I got the cell phone number of the coach and I also got the facilities number. And I tried about six times for the next 24 hours and I left messages and I still haven't heard back yet. To my coaches and colleagues, I'm saying if the physician is going to do that too, like first of all, I really urge us to do that and I'm sure they're busy too, but at least they can call back. I mean, I don't really know where the line is where I have to keep calling them or becomes borderline harassment. Maybe they just don't want to talk to me and that's fine too. And so yeah, so what I'm, I guess what I'm getting at is there are limitations, right? There are limitations in the system. You know this, like we have things to do, but we can either sit here and complain about them, right? Which I hope that's what it doesn't sound like I'm doing that. But I'm trying to make a point that we can either do that or we can help circumvent the barriers to help the patient because isn't that the main goal, right? Like isn't it all about the patient and whatever it's going to be, it's going to be me communicating with therapists, therapists communicating with the coach or vice versa is how do we all come together and and get the best because I think the analogy that he used or the metaphor that he used was, you know, we're all looking at giant elephant, right? And people are seeing the same problem from, from different vantage points and one person saying, Oh, it's a big fluffy ear. That's what an elephant is. It's just like a blanket. And another person is like, Oh, it's a fluffy tail, I don't know, elephant tails, a fluffier hat. But the other thing that my thought is we can all talk to each other and say, Hey, what do you see? What do you see? And, and then we can kind of, you know, or we can either take a zoom out approach. But likely zoom out approach is hard to do. So if we just communicate with each other, I think it'll be easier to put that puzzle together and solve the issue. So I think that's kind of where it is, man. Yeah, absolutely. I so I've recently just enrolled in a health system science academy course here at Penn State. So, you know, essentially going to be talking about insurance companies, just how the health system works from top to bottom, teams, communication, all those things. So it's pretty cool because I'm actually probably one of only like five residents in it and the rest are attendings. So it's really cool to get that perspective from attendings who have been in this position, whether they're educators or whether they're an administration and just kind of seeing how it works. Because again, I think I'm super passionate about this continuum of education and how pre-meds have no idea what med school is like. Med students have no idea what residency is like and as residents, I have no clue what attending life is like in terms of administration and notes and all those things, right? So trying to bridge that gap is something I'm trying to, trying to do. So it's going to be cool to see and trying to bring up these conversations and hopefully add some value now that we've had these guests on to give some sort of another vantage point for other people to see. So, yeah. I love that. That's awesome, man. You got to let me know how that turns out. Yeah, we'll do. Absolutely. Yeah. Cool, man, updated. Yeah. Awesome. So let's shift gears. Let's talk about CBD. Right. Yeah. And basically, hemp. Yeah. And for the men, I think you probably came into it with a lot more background knowledge than I did. Sure. And you talked to me. Tell me what you learned. Yeah. I learned a lot actually, man. And you're right. I did come in known a good amount just because I've really been into that kind of alternative space, a good amount in terms of pain and had a lot of conversation with attendings because here at Penn State now, we're actually allowing patients to bring in their own supply of medical marijuana or CBD or whatever in my contain as long as it provides good use for the patient's treatment plan. And even now, during the rehab side, we've had probably three or four patients now on spinal cord ask about it, ask about if they can use either THC creams, if they can get marinal, if they can use any form of cannabis. And I've had these discussion with my attendings and they're starting to learn more and more about it too. And they've actually presented at conferences in the last two years about cannabis and spasticity and spinal cord injuries. So it's becoming a more popular conversation, not just amongst physician and patient, but also physicians themselves and sharing data and sharing what they've seen. So it's been cool to kind of provide some value again in those conversations. But it was fascinating to see Charlie as a PA educate us on this because obviously, there are some regulations where he can't prescribe anything with THC in it being a physician assistant. He can only do CBD. Yet, he has courses and he's providing this education in the whole spectrum. But I think learning about the endocannabinoid system was something that I was always kind of gray on. I was little naive, I guess, in terms of that. So learning about CBD one, CBD two, and different receptors. And understanding that it's not just CBD and THC, right? There's so many different forms behind THC. There's so many different analogs of CBD and how they work on the receptor is super important. And I really urge everyone to just listen to that episode if they haven't and also just delve into this stuff because it's truly the future. I mean, this is something that we're going to see more and more in clinics. We're seeing more legalization across the country. And it's just something that we all need to keep our eyes on. Yeah. And just to kind of touch on the endocannabinoid system, I mean, so we know that I was also fascinated that first described in 1992 and over the years, we found increasingly this to be more important in human health and well-being through maintaining homeostasis. And I think he's talked about that several times, even on our show and also in his episode in various aspects of physiology, right? And you mentioned that CB one, CB two receptors, but there are a myriad of ways that it actually works in the body to kind of regulate that homeostasis that we don't fully understand. And he touched on how complex it is. And it's not just exclusive to the CB one and CB two receptors. And we've got the trip V one receptors. We've got the GPR 555, 5 HD one alpha, A2A. And all these are together working to help with inflammation pain anxiety. Some of the, some of the most highly studied things that we have to this day. Of course, there are studies kind of supporting one thing or another, but I would say the strongest evidence we talked about is epilepsy, obviously the empty FDA approved drug. But I would say the most commonly used thing for this is pain. And that's what he's seeing in clinic, he's mentioned. Another interesting thing that he talked about is we have to continue developing a stronger understanding of it because the fact of the matter is as regulations are getting looser on this and what I mean by that is at the state level, it's being legalized with the federal level is still not. Charlie didn't mention that. You can buy it at the gas station, like you said. Every grocery store that I go to, man, just rows of it, right? And so it's easily accessible. And to us, the scientific community has to have a better understanding and we have to have conversations about it because the patient are going to reach for it. You know, there's just like I do, man. Oh, my pain, I think, is it's increasing, right? We know that anxiety, pain, poor sleep are all intertwined and that amplifies the pain syndromes, right? And so people are going to reach for things they're going to. And if they come to us and they say, hey, Doc, like what do you think about this and if we're dismissive about it or if we don't understand it, they're just going to either go to Dr. Google and maybe not have a great source or unfortunately fall in trap of the bad actors. You know, for example, I was not one of them. There's a black market out there that people need to watch out for. Yeah. Yeah. So, yeah, something important to understand, like for the one thing, we spent a lot of time talking about CBD. But of course, we touched on THC and happened and kind of teasing out the differences. And you know, some people respond really well to CBD isolate, like you mentioned, right? And then others, what we've learned when it comes to pain, medicine, when truly treating that, that the entourage effect is extremely beneficial, right? And that's for those who you'd remember that it's, you know, a single ingredient might not work together. But as a team, the whole crew can have better efficacy. Unfortunately, the problem is the whole crew can also make you high, which is not typically, well, I shouldn't say typically, sometimes it's not desired, right? And especially when you're taking other medications or if you've got work related issues or whatever might be in, you know, long-term risk of psychosis and that kind of stuff, which is equivocal in terms of the data. But you know what, if I'll pause there to see if you have any other thoughts, but I did want, like I recently, across my radar, two cool studies came into pain mechanisms that, if you're interested, I can talk about otherwise. Yeah, absolutely. I mean, what you thought. Yeah, well, just a real quick, I guess. Yeah, I completely agree with everything you said. I know I want to tell people that while more and more benefits may come out with looking at cannabis, right, through these research studies, because it's important to note that back when cannabis first was research in the 70s and 80s, you were only allowed to research it if you could find negative side effects, right? That's the only time government would actually give you grants and money to study weed. So while we're starting to see more benefits because we already knew the side effects, we're also going to see more side effects, right? I think people need to understand that. We already know that if somebody has mental health issues or schizophrenia, cannabis is almost a no-go, right? Especially THC because we can induce that schizophrenia to become even worse. And it's important to note that THC and CBD, the molecules itself in today's marijuana plant, it's like a hundred times more concentrated than it was back in the day when people were first using this and already Vedic medicine, alternative medicine, right? So the effects of the psychosis and the numbing, I guess, people want to say the stoned, I guess, would be a lot lower, right? So it was more medicinal in that sense, whereas now it's really kind of just takes over your body because it's so potent. Yeah. Yeah. No, that's right on. And that's, I think, kind of when I did a literature to just, again, look at it from the angle of pain medicine. What I was interested to find out about that, you know, we've got several RCTs and there's a recently published meta-analysis 2019 showing that cannabinoids can have a medium to large effect on self-reported pain, right? But interestingly, what they found in that paper was that the placebo effect had also a small to medium effect on self-reported pain. So what we're trying to figure out, okay, what's the real key here? Now, I think that the data supports a 30% of the time the placebo is beneficial. I would always question at the end, does it really matter at the end of the day if we're in the business of helping people or not. Now there's a separate discussion to be had about doing no harm. And I remember we've talked about this at length, financial harm is one of the things in these things are not free. They cost money. Yeah. So it is, again, very complex in that nature. But we also have evidence showing that, as I mentioned, and you also mentioned, as you know, TAC alone isn't enough, right? And TAC and CBD combined seem to work better. And so it might not just be the psychoactive components that you've touched on. But then we don't really truly understand CBD's mechanism of action. And some people will argue in those previous studies that alluded to that, hey, it might be the placebo effect. So that kind of sets the stage a bit. So this study that was published by David Adal in April of this year, actually, discussing some of these and trying to tease out, hey, is it the placebo effect or is it the actual CBD that's affecting? So what they did in this paper is it was a crossover double line randomized control trial studying young, healthy adults. So they had 15 individuals without any pain medications. They kind of, that was part of the exclusion criteria. And they basically gave all of the healthy adults the intervention was to induce pain with heating pads, right? Okay. Like really high high thermal heat. Yeah. It's a comfortable heating pads that put you in a like a sparse, I'm talking about stone massage here. But they put them in a nice four buckets, right? So bucket one was they told the individuals, hey, you're getting CBD, but they got placebo. Okay. Bucket two was they got placebo. They were told they were going to get placebo and they actually got placebo. Okay. Bucket three is they told they were told they were going to get placebo, but they got CBD. Do you know how much CBD they were getting? How many milligrams? So yeah, CBD product was a CBD isolate of 0.3 ml, 0.3 ml, okay, I wonder how many milligrams they were. I don't know. We could do a quick conversion. I'm sure. Yeah. Google search. But that's what and then they also in the last group was they told they were told CBD and they're got CBD, right? So it's again, they're trying to tease out they like, is it the actual medication, the pharmacological effect, or is it the anticipation that's really into and so and they also had like a one week wash out when they wanted to assess the effects. So what they found was the CBT had a pharmacological effect on pain, but so did the expectation of receiving CBD, which suggests that the actual medication and the expectation of the medication helps, which again comes back to the placebo effect. Now it's important to note that this wasn't the first and only study to investigate similar parameters. Ultimately, I think we have yet to tease out what the pain relieving effects of CBD are. But at this point though, like everything else, it appears that they're multifaceted and it's and they don't CBD isolate at least don't tend to carry the cannabis related side effects kind of the stone and things that people want to stay away from it and are scared about. What might take away from this and it has been forever is pain is an extremely difficult phenomenon to unpack, right, and understand and let alone measure, it has complex biological, sociological interactions that influence each individual's experience. And I think that's why research at the level of one study isn't good enough and we have to continue doing it, doing it, doing it again. This comes back to the problem with research too as well though, is you have to isolate variables, right? It's hard. And that's where the meta analyses and systematic reviews that look at different things are kind of helpful. I thought that was interesting because it's so well contemporary, it was published a couple months ago. There was another paper I think that you and I talked about looking at burnout and anxiety and JAMA published in August of 2021 and they basically really quickly on this one. This was randomized trial for health care workers on the front line dealing with COVID and they wanted to measure burnout versus just standard of care. I'm not really sure what the standard of care was, but ultimately they gave the two arms, just standard of care versus CBD and standard of care. And people in the CBD group showed decreased scores for emotional exhaustion anxiety. So I think again, it goes back to pain is multifaceted and that's probably why it seems to work for these pathologies in isolation, but also together, right? So yeah, I mean, I think that the evidence is moderate to strong, I would say. In terms of out there, I don't know if it's compelling enough to support taking it versus not taking it, but I think at the individual level is kind of where we have the teaser out. It's crazy you mentioned that, man. I'm reading Jay Shethy's book Think Like a Monk right now and he talks about Shaolin Monks and they did a research study on them with nonmeditators and they used thermal heat to induce pain on the wrist. And what they found was nonmeditators obviously had a lower threshold for the physical and sensory component of feeling that pain whereas the Shaolin Monks, when they looked at their brain and the MRIs and stuff, what would light up is the physical, but their sensation to it would not light up at all. So you could almost burn them and they wouldn't feel it, right? Which kind of explains how inducing fire on these Buddhist monks and things like that is a lot like it just goes to show that placebo effect and training your mind and there's a lot more nuance than we actually even know, right? It might not just be the CBD receptors, which again, I think people need to understand endocannabinoid systems is inherent in our body. It's not something we kind of just develop. It's that runner's high. When you run for two miles and all of a sudden you get this urine flow, those are your, you know, endogenous opioids, we say, filling up those receptors and making you feel like that. So this is something that's inherent in our body, but yeah, man, I don't know. It's super interesting stuff. I mean, right on, man, again, I think that what I'd like to kind of close with is one takeaway from one of the many takeaways, but a powerful takeaway from Charlie that I got is when you asked him about, what's the conversation that he has with his patients when they're coming to pain? And what I got from here is that again, because he's influenced with Dr. Timothy Patel, who's awesome. She's been a previous guest of ours. You know, it's all about empowering the patients to take control of their lives. Pain can be so incredibly debilitating, anxiety can be debilitating, lack of, or insomnia, and all these things to any cancer can be, everything can be, right? And to each, every single person, whatever pathology they're struggling with, that's impairing their quality of life where Pima and R, that's what we do, which I'd improve quality of life. And so his whole mission and our mission is to empower patients to take control of their lives. And it really all starts with education. So that's what it's all about. And hopefully people continue to educate themselves and learn. And yeah, that's all I got, man. Love you, man. Yeah, that's exactly what I said at the end of that episode with Charlie when I was talking to the listeners. I mean, if we can just all educate each other, and again, these are conversations that people are having on the daily with their parents who are in pain, you know, with other friends talking about, hey, you guys heard a CBD. I got legalized. What do you think about it? You know, I have this pain, but I want to get off opioids and these are real conversations and these are conversations that people want to bring up to other physicians. So whether you're a physician, you're a healthcare provider, you're a patient, let's kind of educate each other, share that episode out to the people that you're having that conversation with. And let's continue to learn. He mentioned, I believe it's called medical marijuana 411.com. If providers want to get more educated on cannabis. And then again, you can check out restorative CBD, which is Charlie's company, where he also has some courses too for patients as well as healthcare providers. Right. Cool. Yeah, it definitely is a medical marijuana 411. Yeah, we'll link that in the show notes, brain, brain, having that coffee yet. But yeah, we'll link all that and we will also put the studies in there that we touched on. And guys, as always, any feedback that you have for us, if you're enjoying it, let us know. Let us know what you are not enjoying and what you'd like us to improve on. If you have any recommendations for guests and stuff, we're always ears and we want to continue making this better for you guys and make it more informative. Absolutely. All right. Sounds good. Take it back, man. Thank you so much for taking time out of your day to listen to our lessons, but we really enjoyed doing these episodes as it gives. Ultimately, I chance to really share what we are experiencing, how we are taking what our guests talk about and implementing them in our own lives. But then again, providing education to all of you. So if you are a new listener, welcome to Medicine Redefined. We encourage you to reach out to us for feedback. If you have any guest recommendations, you can find us on Instagram at medredefined. My personal Instagram is at doctor.darsh, as doctors spelled out. And then ultimately, it's at doctor.org, but the doctor is DR in that case. 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