Episode 10: Dr. Hiza Mbwana, DPT on Physical Therapy for Chronic Pain

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SPEAKERS: Dr. Andrew Wong, Dr. Hiza Mbwana, DPT

Welcome to the Capital Integrative Health podcast, a podcast dedicated to transforming the consciousness around what it means to be healthy and understanding the root causes of both disease and wellness. I am Dr. Andrew Wong, co-founder of Capital Integrative Health, an integrative practice committed to expanding access to holistic root cause medicine to the global community.

Today we have our friend and colleague Dr. Hiza Mbwana. Hiza is a Doctor of Physical Therapy specializing in helping clients recover from injury, address acute or chronic pain and restore optimal function. He is passionate about helping his clients reach optimal wellness by addressing the whole body. We are lucky to have Hiza here at CIH to provide Physical Therapy to our patients. He enjoys living out health and wellness in his own life and spends his time trail running and cycling and doing other quality family activities with both his family and his friends in the DC area. Join us for a conversation today about addressing physical pain in a holistic manner and bringing back optimal function and wellness to the body mind and spirit.

Dr. Wong:

Welcome, Hiza to the podcast.

Dr. Hiza:

Thank you for having me. I appreciate it.

Dr. Wong:

And I will say this is the very first podcast we’ve ever done on a Friday. So this is very groundbreaking and pioneering here like one of your trail runs, I believe.

Dr. Hiza:

Well, I hope I don’t break the process.

Dr. Wong:

It’s always good to go a little off track, you know it. And we’ve done that a little bit before we got on the air here. But we talked about tacos and how we really enjoy you know looking at the best taco places in the area.

Dr. Hiza:

Yes. I think we have a lot of work to do. I mean.

Dr. Wong:

There’s a lot of exploring.

Dr. Hiza:

We’ve only covered a small fraction of it and I think there’s room for improvement.

Dr. Wong:

So, we’ll get back into that, as that relates to physical therapy and different health issues. Let’s talk first though, about its kind of your background and how you got, why did you pursue physical therapy as a career? And did you have any experience that led you to want to work professionally in the health and wellness field?

Dr. Hiza:

Sure. Well, I guess I kind of got to it in a very indirect, direct way. So, growing up one of our family friends. So, I moved here from Tanzania. And when we moved to the states, we had like a, we had a family or liaison person. Someone kind of it helps you integrate with American culture. And so she, I call her my aunt, my aunt Sarah. She would literally, every weekend. She would pick us up and take us to explore different things. Whether it’s horseback riding, swimming. Anything. But she also happened to be a PE instructor at, or she taught at Ithaca College. And they would, they had a performance lab. Human performance lab there. And they were looking at CO2 max variabilities and they were looking for younger population, younger samples. And so she would volunteer me. I would go. I would participate. I’d wear this giant, you know mask and get on the treadmill and they would do all these different tests. And then afterward, we would go to Ponderosa or something like that and just you know have a huge lunch but then. So, that’s how I got into it. So, my experience or my exposure with performance was pretty early on just from just being part of that environment so often and then seeing you know coaches and seeing athletes in there. Also getting rehab or athletic trainers working on athletes. So you know. So part of that she was also a big fan of gymnastics. And so on Friday nights, they would have gymnastic meets there at Ithaca College and so we would go. And for me, I wasn’t really interested in the actual performance itself. I was more interested in how do they get to that point right? How do they do the tumble? How do they do these flips? How do they do that day in and day out and why are some wearing ankle wraps and why some aren’t wearing ankle wraps? And so again. I, that’s just the way I thought of it. I never looked at it as “oh, I’m going to gymnastics. I’m going to watch the show”. So, that happened that I guess that’s kind of how it’s always been for me. It’s like I look at performance but really the behind-the-scenes stuff.

Dr. Wong:

I mean what’s, what led to that or the root cause is.

Dr. Hiza:

Yeah. And so for me, I’ve always kind of looked at it like that. And then in high school. I had a really bad ankle injury and that was my first exposure to physical therapy. So, it was a, it was pretty bad, I tore in a couple of ligaments. So, the options were physical therapy or surgery. So surgery for me wasn’t an option. Because they said I wouldn’t be able to play within the next year. So they said if I do physical therapy and everything looks good. I may be able to get back to playing in. You know, eight to ten weeks. So, I was like I’ll take eight to 10 weeks. This is fine. So, I ended up hanging out with this physical therapy group for the entire time. And then after that. I really fell in love with the profession because it was also around the same time my parents were saying, “You know, you should think about what you want to do for college. You’re not gonna let anyone decide, we’ll tell you that right now. So, think about it”. So, I realized. I was like. Well, I really like physical therapy. I had a great time in physical therapy. So, why don’t I explore that? So, I volunteered my time after school, after soccer practice. I would volunteer my time at this same physical therapy claim throughout my high school.

Dr. Wong:

Nice.

Dr. Hiza:

Yeah. So every, you know. Three or four days a week. I would be there every single day.

Dr. Wong:

Nice. So, you’ve been really been a physical therapist. And training for a long time.

Dr. Hiza:

I have been for a long time.

Dr. Wong:

Just to go back to Ithaca College, in the HPL (Human Performance Lab). What, how young were you when you started?

Dr. Hiza:

I was nine.

Dr. Wong:

Wow! So, you really have that.

Dr. Hiza:

I was nine.

Dr. Wong:

Amazing.

Dr. Hiza:

Yeah. So, I’ve always been around that environment. So, but again. I think for me. The main thing was really I enjoy the most. How things work? How people work? How the body functions and how it kind of bounces back after injuries? So, I’ve always been keen on that. But I think, you know, my Aunt Sarah really helped. Really kind of solidify that. Because I didn’t really have an idea of what I wanted to do. But I think her, exposing me to that young age. Was kind of a, in a pivotal part, a pivotal point for me.

Dr. Wong:

And then in terms of shadowing different PT practices etc. Did you learn different, like nuances to treatment and those types of things from there?

Dr. Hiza:

I don’t. I mean, you mean, after?

Dr. Wong:

Well, I guess we’re, even in high school but then afterward of course.

Dr. Hiza:

I think in high school. I didn’t, I mean, I wasn’t at a stage where I can actually appreciate nuance. But I think, what I definitely knew that was different in this PT practice compared to another physical therapy practice that I ended up going to was the first one is, that I had a lot of fun. It was a lot of fun even though I was getting, I was doing rehab. They know, they knew, they were working with an adolescent. He’s not going to just sit still and be worked on and be told and be educated. Like okay, well, this is what’s happened to your ligaments. They just made it interactive. They made it fun and they made it unique to me. And they made it specific enough that I felt like this was the only person that can do this is me.

Dr. Wong:

And physical therapy is one of those things that it seems like you just said. The only person that could do it is you. And you kind of have more domain over that almost like you know taking charge of your own health that way. And that’s a really nice thing there.

Dr. Hiza:

Yeah. And I think that’s where that’s the first thing. I guess if I had to identify kind of the early nuance in terms of physical therapy for me was that you know. The body is capable of doing and you are a lot more in control than you think. And I think that was the main takeaway that I got from my early days is that you are, you’re definitely not limited to just your current circumstances.

Dr. Wong:

And we know that mindset has a huge role to play and the physical functioning recovery you know the body. Do you want to get into a deep dive into that a little bit later here?

Dr. Hiza:

Sure.

Dr. Wong:

But first, let’s talk about more broadly how did you come to work with us here at CIH? How did we meet? I know we should give a shout-out to Bonnie.

Dr. Hiza:

Yeah, to Bonnie. But, I think well and Mike.

Dr. Wong:

And Mike! Yeah, absolutely.

Dr. Hiza:

I think the first time I heard about you was, you worked with my colleague Mike.

Dr. Wong:

Yes.

Dr. Hiza:

Because he had some unusual thing. It started out with, I think it was. Oh! I remember he said that he’d been drinking a lot of french press coffee okay. And I think you identified something about the french press process was affecting his performance and so you had him change up and changed the kind of coffee he was drinking. And he felt amazing! And he felt great. He’s and so at the time. I was also looking for a Primary Care. And he’s like “You got to talk to this guy” and I was like, “Well, how? Where is he?” He goes, “Upstairs”.

Dr. Wong:

In the building. Yeah.

Dr. Hiza:

Yeah. I go. Same building. Right the path of least resistance.

Dr. Wong:

Convenient.

Dr. Hiza:

Right upstairs. And so that. I think that’s when we first met. And then subsequently I think we figured out that we were neighbors. We would kind of be in passing. And it’s like, “I think that was Dr. Wong”. And I was like, “I’m pretty sure that was him”. But again I was like, “Who would?” and then eventually, I was like, “Do you live in the area?”. Like, “Yeah. I live right over, you live right across the street”.

Dr. Wong:

And that’s the beautiful thing about like meeting people. Like, you know cross-pollination. And you know, I think we’re both interested in how we can take a holistic integrative approach to care. And that’s how I think we kind of bonded to.

Dr. Hiza:

Yeah. I agree. I think that was the main. I mean, when I decided to start my own practice. Primarily, because of that was that I just. I looked at physical therapy as a lot bigger than just you know knee pain or back pain or shoulder pain. I looked at it as really, this is a whole system process. And the current mechanisms weren’t allowing me to explore that process.

Dr. Wong:

Right.

Dr. Hiza:

So, instead of trying to fix the system. I just started my own process.

Dr. Wong:

You started Kimbia Physio, in which year?

Dr. Hiza:

2013.

Dr. Wong:

2013. Okay. So it’s been eight, nine years.

Dr. Hiza:

So. 2013. I remember that. I remember telling my patients, “Oh, it’s going to be very different you know. I just don’t look at this, we’re going to target all these other areas. We’re going to talk about, you know sleep habits. And we’re talking about”. Again, at that time. I had no idea how intricately related these things were. But I just knew that for most of my patients, stress was a big factor of pain. And you know, in the traditional setting. Patients come and go. But for the most part, the prescription was two to three times a week for four to six weeks.

Dr. Wong:

Yeah. And I just remember meeting you and talking with you more in-depth over a cup of coffee or whatever it’s like. You know, talking about stress and mindset and sleep and nutrition and all these things that I’ve never heard a physical therapist talk about that before. So, I was like this is something special here.

Dr. Hiza:

Well. I owe it. That a lot, to just being lucky enough to be in an opportunity to learn from different people. And I think that I learned from my patients more than they probably know. And you know you start to see a pattern with a lot of performers that you know if they’re all exhibiting similar stuff it can’t just be ignored right. It’s not just something that you have to at least try and tackle as much as you can. And I think that’s part of the reason why we connected and resonated so much is that I think we saw practice. You know medical practice is a lot more robust than just input-output. It’s a lot more complex than that and it’s individually based and it’s not just you know if you just do this you’ll be fine.

Dr. Wong:

Right. Absolutely. And I would also add that as you just mentioned that patients are the best teachers, right? And part of it’s about you know listening to them as they cultivate and develop that innate healing for them.

Dr. Hiza:

Yeah. And I think that is the hardest part for providers in general. Because that means you have to trust them.

Dr. Wong:

Right.

Dr. Hiza:

It’s no longer based on your skill set. Right.

Dr. Wong:

That’s right.

Dr. Hiza:

Your job is to be a nudge a gentle nudge. It’s up to them to do the hard work which is you know finding clever ways to get around their limitations. Finding ways to move beyond that. And I think that’s the hardest part is, as you know being on the sideline waiting.

Dr. Wong:

Yeah right.

Dr. Hiza:

Because you wanted to go. You wanted it to happen. But you know, I think what I’ve learned in this whole process is that you have to step back and you really have to let them do it. It might be a week. It might be 10 weeks. But it’s really up to them to work through that. And it’s not healthy for you to be kind of chomping out the bed and waiting. And it’s not your job to take credit for their progress. It’s your job to be a cheerleader. And I think that’s what I’ve learned the most from you know having started my own practice. Is that I stopped caring about the PT part and I cared more about the outcomes. And the outcomes are really, “Do I feel resilient? Do I feel confident? Do I feel educated? Do I feel knowledgeable in what is happening to my body? and, how do I move beyond that? And I think that’s the hardest part because it involves you trusting the patient to do for themselves.

Dr. Wong:

Yeah. And you know building up that trust probably week after week, overtime. Is one of the big you know, I think mechanisms of healing. As a physical therapist, what are your primary goals when working with the client?

Dr. Hiza:

Great question. I think for me again. It’s going to sound a little off base. But for me, my patients need to have fun. I mean. I think this is not something that a lot of clinicians think about. But having fun and being able to joke and talk about things that are serious but at the same time you know give them positive optimism is critical in this process. I mean, like I always joke. I always say “hey how’s it going?” I go, wait. I know you’re here. The only reason anyone comes to see a physical therapist is not because they’re feeling a hundred percent. Usually, there’s something going on right? So, no one really comes to hang out with you because they’re like “I feel great. I’m you know, I’m walking on sunshine”. And because so they’re already feeling some kind of way about themselves and so I think the most important part of my job is to make sure that the environment is engaging but also that you know we it’s light-hearted and it’s you know it’s educational but it’s got to be light-hearted and fun and it gives, it’s got to give them purpose and education.

Dr. Wong:

It’s positive reinforcement. We tend to do things more and you know repeat them if we enjoy them.

Dr. Hiza:

Yeah. And also, I mean most people understand you know from kind of an oversimplified version. What’s going on with their bodies. So, if you try to go into the minutia of what’s going on that’s great for your colleagues. That’s great for you know, if your patient is well-versed in the medical field that’s fine. But most people want to know, how do I get back to doing the things I enjoy doing?

Dr. Wong:

How do I feel better? How am I more functional?

Dr. Hiza:

And how do I find ways to continue to spend time with my family? How can I get back to playing with my kids? How can I get back to picking up my grandchild? How can I get back to riding and enjoying?

Dr. Wong:

So, would you say the primary goal would really be it’s very patient-centered actually? It’s like kind of what they want to do to be more functional and enjoy their life more.

Dr. Hiza:

I think it’s really centered around that. And it’s taken a lot. It’s a constant struggle because it’s my bias is always to fix right.

Dr. Wong:

But that’s how we’re all trained right and then traditionally.

Dr. Hiza:

We’ve always been trained to fix. But I think changing and learning to be an educator and creating a fun environment that’s engaging. Has been one of the best changes for me because it does it makes the medicine go down a little smoother.

Dr. Wong:

Yes. Exactly a little honey in there.

Dr. Hiza:

Yeah, a little honey in there.

Dr. Wong:

Maybe some of my herbs as well. Right? So, what are some common themes you would see arise with clients? I guess both opportunities and challenges I would say.

Dr. Hiza:

Well, one of the most common theme I see is the prevalence of chronic pain.

Dr. Wong:

Okay.

Dr. Hiza:

That’s been, that’s taken a huge rise.

Dr. Wong:

And we know about the opioid epidemic and all this stuff we’re trying to get.

Dr. Hiza:

I’ve seen that be kind of one of the primaries that contribute to a lot of ailments is the severity of chronic pain. The frequency of chronic pain and all the subsequent physiological changes and psychosocial changes that take place that’s been a huge huge shift. Because I remember a decade ago. I mean most of it was evaluating and treating knee pain. That’s it evaluate and treat this and now. I mean and I look back and I realized you know. Obviously, you can’t rewrite your past but you realize how many of those people weren’t there because of knee pain but they were there for something a lot.

Dr. Wong:

Absolutely.

Dr. Hiza:

More profound and a lot more nuanced than just kind of a plug and chug kind of response.

Dr. Wong:

Pain is a mind-body condition for sure. But let’s take a forest view, a step back if we can, and let’s just talk about pain and like the definition of pain. What is pain? Is pain always bad? Because I feel like this even the word pain connotes something that is you know negative. And one of the things that I always sort of say sometimes the patients anyway is you know sometimes symptoms are our body’s way as our friend to notify us that hey something is off-kilter out of balance so then it gives you an opportunity to notice that and then to maybe do something to bring that back to equilibrium so what is your definition of pain you know how do you say that.

Dr. Hiza:

Well. I, having experienced and worked with it, with a mixed patient population. Some who have pain from post-op, some who have chronic pain, and some with kind of something in between from other sprain or strain is that pain is unique to the person. And pain is more of an experience rather than a kind of the traditional binary thing is either is there pain or is there no pain? So I look at pain as really it’s a personal experience for that person and it’s mixed with past experiences it’s, mixed with past responses it’s mixed with. So it’s a lot bigger, it’s a personality right. So and in certain cultures, I’ve learned to appreciate certain cultures have different ways of interpreting pain. But again what’s unique is that even in those cultures individuals with pain have a unique response to that pain and it’s a relationship that they have. And some hold us as a badge and some people don’t. And I think having respect that it’s a little different.

Dr. Wong:

Yeah. I have a question. Just off tangent a little bit but you know in terms of that Tanzania and other places around the world that you’ve kind of experienced. Any difference in the sort of the way that people there you know you would say experience pain versus like people here in America?

Dr. Hiza:

Well, I think not to generalize. But I think for the most part for me in my culture. Pain isn’t really looked at as something that needs a lot of attention.

Dr. Wong:

Okay.

Dr. Hiza:

Right. Pain is really, if you get an injury you move on and I suspect that some of that is real. We don’t, growing up, or just live, you know lived experiences there. There are so many other things that are more pressing in my country that you know you don’t have time to actually pay attention to the subtle you know nuances of chronic pain.

Dr. Wong:

Are there physical therapists?

Dr. Hiza:

There are physical therapists and most of them work with fractures injuries etc. But I think that the idea of chronic pain being unique and individualized. I think that’s an emerging mindset because it’s from countless work of psychosocial therapists and just looking at different ways, that different cultures, interpret pain. And I think that’s been the biggest challenge is that I see pain as a unique experience and a lot of my colleagues and a lot of other people look at pain as this kind of input-output. And it’s just you know you just have a neural issue that needs to be resolved or you just have this injury.

Dr. Wong:

It looked up mechanically, right?

Dr. Hiza:

Right. But I think looking at it from the psychosocial perspective has really changed my mind. And again, I think even looking at you know the way pain is handled in Tanzania. It’s really psychosocial right. So for a lot of people, they are dealing with so many other things that are so much more pressing.

Dr. Wong:

Urgent.

Dr. Hiza:

And urgent that I think there’s a certain level of robustness there that comes with that. So, I suspect that there’s a certain level of tolerance too in terms of the neuro response to.

Dr. Wong:

Challenges create resilience.

Dr. Hiza:

Yeah. And I suspect that’s probably one of the differences that I see. I mean. I think as a nation here. We look at pain where you know the level of resilience isn’t as much because there are a lot of fixes right. You have a slight ache there’s a med for that right. You have a slight sneeze there’s a med for that right.

Dr. Wong:

Pharmacy is open 24/7.

Dr. Hiza:

Pharmacy is open 24/7. And so there is a level of it creating a mindset that I can just turn this pain off immediately. I don’t really need to work through it. I don’t really need to experience that and the challenge is that when that happens in adolescents. It’s really tough to be resilient and have that resilience in your 40s, 50s, and 60s.

Dr. Wong:

If the brain pathways haven’t been developed.

Dr. Hiza:

Because the brain pathways have not been developed. It’s just like doing anything challenging. It’s scary at first and then you do it. You go, “oh that wasn’t so bad” but if you do that much later it’s like, “I don’t want to do it at all” because

Dr. Wong:

But it’s never too late. I remember the story that we can keep all the names all you know. All generalized. But if you know, ladies. Let’s say in their 70s, right. And then you were working with them for a long time and then after like you know 10 years. Like osteoporosis gets reversed they’re like lifting weights at home depot and things like that. I’m like wow this is so enlightening.

Dr. Hiza:

Yeah. I think that was, I mean. And I think that’s the biggest blessing that I’ve experienced in this process is that by changing my mindset about physical therapy, I’ve developed friends rather than just patients. And I mean that, that’s not to say every patient is a friend. But I mean. I think you know. If when you change your mindset about the way you’re caring about people. It does, it changes their mindset about their transaction with you. So, I am very fortunate I’ve met several people who when we first met did not think that they were resilient enough. They did not think that they could do and you know or even knew what a kettlebell or a dumbbell was. And so I think that was my first. That those two were probably the most pivotal or most amazing nudges that I needed to kind of confirm that, “Hey! you know what? I’ve read in the literature and what I’ve been applying practically is effective and it’s tough”.

Dr. Wong:

And I just want to revisit which is I feel like that’s so groundbreaking is like you know the care of the patient isn’t about the diagnosis. It’s actually about the care itself.

Dr. Hiza:

It’s about the care.

Dr. Wong:

Which is, you know what makes you so special in your practice.

Dr. Hiza:

I try, it’s the glasses I’m telling you. Anywhere next to glasses.

Dr. Wong:

What brand of glasses?

Dr. Hiza:

I don’t even remember, but yeah.

Dr. Wong:

And the other thing is about you know. It’s about personalization like you said. And that person’s experience of pain being experienced, not just a mechanical issue. There are motor and sensory fibers of course. And those go to the thalamus and that relays things to different areas of the brain but then the brain interprets this and then signals the amygdala and like different areas and emotional centers of the brain. So, we all experience may be the same potential physical input as something very different emotionally depending on neural pathways, resilience, childhood history. Like all these types of things. So what are some of the common reasons that people have pain? And then another kind of related question is if there’s a pain in one area, how does it connect to the whole body? Yeah, so they’re a bit you know, connected.

Dr. Hiza:

So, I mean. I think common pain or common areas you’ll typically see the most common is low back pain. We see that as kind of, and again the challenge with low back pain is that it may not be low back pain right. It might just be the proximity.

Dr. Wong:

To other areas a lot of organs, a lot of tissues around the area.

Dr. Hiza:

So, I think proximity is one. But also we’ve created an environment where anything that happens in the back we’ve treated the back as this kind of fragile structure. But you know it isn’t fragile. It’s probably one of the most resilient structures and most robust structures. So, my job is to try to work on reverse engineering that mindset that if you have a history of back pain that you don’t, it does not mean that your spine is fragile.

Dr. Wong:

Even with fractures.

Dr. Hiza:

But I think you know. Like you said. I mean, I think the interpretation of pain is really you know what we need to address the most with that patient.

Dr. Wong:

And I think let’s say someone has acute back pain. You know, I think the very traditional model was like take the aspirin, you know sit on the couch, watch Netflix but then is that really a good advice or not?

Dr. Hiza:

I don’t think it’s good advice. For most people doing everything you can to calm things down. You know modifying your activities change positions. But you can find positions of comfort. Just like any injury eventually, it will calm down. And again there are certain instances where yeah you may need it.

Dr. Wong:

If it’s severe.

Dr. Hiza:

If it’s severe or you’re getting other signs and symptoms and yes then you know it may be an emergency.

Dr. Wong:

Yeah, neurologic symptoms. All that stuff.

Dr. Hiza:

But it’s just different you know. And the pain can feel worse than the actual injury right. It’s very, I can (compare) it to a paper cut right. You can get a paper cut and it feels like it’s just awful.

Dr. Wong:

And it might be good for the listeners out there who you know maybe don’t have that clinical experience as a medical professional like yourself. What are the red flags to look out for? I think most pain, but I think low back pain since that’s the most common. What are the things? That’s like, “Okay, you should go see your practitioner about that. You should go urgently to go see someone”.

Dr. Hiza:

So most of the time if you have changes in bowel and bladder function. Definitely, that is not

Dr. Wong:

Something that got caught up quite nicely.

Dr. Hiza:

So if you experience you know changes in bowel and bladder function. Difficulty controlling bowel and bladder. That’s a red flag.

Dr. Wong:

That’s an ER.

Dr. Hiza:

If you notice. If you know in some instances the pain can be severe enough that you notice some changes, you know. Essentially like numbness and tingling in the leg, weakness in the leg, if you notice an inability to lift the leg or use those muscles on that side. That again could indicate some sort of compression on those nerves and again you may need to go to the emergency room just to have it evaluated and make sure and confirm that okay it’s this nerve being compressed. Again, it will probably get better on its own with a little TLC modifier.

Dr. Wong:

And that’s where the diagnosis would,

Dr. Hiza:

That’s where the diagnosis would be helpful but for the most part. A lot of acute back pain is, feels really bad. But in terms of severity of damage is that’s the challenge is really how do you calm someone down when they’re in the middle of that? And I think that’s where the education comes in and that’s where kind of letting them lead with, “hey this is annoying this doesn’t bother me. So, if this doesn’t bother you, do that. So the idea is to try to calm everything down while you build up everything around it. So.

Dr. Wong:

Right.

Dr. Hiza:

You need to continue to increase the level of movement. Confidence.

Dr. Wong:

Yes.

Dr. Hiza:

While you’re recovering from the primary injury.

Dr. Wong:

And it’s so important to address that early. Because what I see sometimes is people may either not intentionally ignore it but it doesn’t get really addressed properly. And then what can happen is one area of pain can just kind of go global right, with that thalamic relay. So it’s kind of like you want to address that to get that pain threshold down in a way so that they can continue to be balanced.

Dr. Hiza:

Yeah. Exactly and I think that the challenge for so many is that we’ve created a boogie man out of the back right. We’ve created this mindset so it does drum up all of the, you know the excitatory parts of the fear of flight right.

Dr. Wong:

Got to take that outdoor town right away.

Dr. Hiza:

You know. And I think, I look at pain is also a protective mechanism, right? So pain is also a way to stop you from doing future or undue harm. And so listening to it is important but it shouldn’t be it. Shouldn’t be looked at as you always need to turn it off. You don’t need to always block the pain. I think it’s if you think of it as a way to protect you. It’s protecting you from doing something silly until things calm down.

Dr. Wong:

So it could be a protective message from my body.

Dr. Hiza:

I’ve always listened. I’ve always looked at pain as a protective mechanism rather than you know a noxious stimuli that needs to be squashed.

Dr. Wong:

In terms of low back pain. Just to go a little bit more into that. How would you approach that in terms of a common pain area as a physical therapist overall? Not as assuming it’s like musculoskeletal. It’s nothing severe. No cotton and stuff like that.

Dr. Hiza:

Yeah. I would say that for me. What works really best is to reassure and encourage movement. Reassuring and encouraging movement whatever that is to you. However, you know. However often you can do that reassuring and encouraging movement is critical in that process. Because in order for your brain to make those necessary pathways, it needs context. So you need the context around. Okay well, this really hurts. But I can move my arm. This really hurts, but I can move my leg.

Dr. Wong:

So, trying some things out and see what works.

Dr. Hiza:

So, trying doing other things that are not you know provocative and they’re not going to irritate those structures is key. And whatever that means, whatever that may be. That means “hey I get up every you know 20 minutes and I try to find ways to stand up taller or I work on you know my arms or I work on my shoulders or I work on my legs”. Anything to stress different areas while that primary area is calming down is a critical nudge forward rather than “Okay, I’ll wait until all my pain is at a zero and then I’ll start because that could be several weeks”.

Dr. Wong:

And there’s a degree of exercise or movement with let’s say back movements that may change over time as the body recovers you know. Someone could tolerate a certain you know, lesser frequency of the movement. And then, later on, it could be greater and they have to kind of that’s where that whole tinkering kind of corrected.

Dr. Hiza:

Yeah. I think it’s all about graded exposure when it comes to recovery, is that as long as you give just enough of a nudge, your body will make those adjustments accordingly and they will adapt to those demands accordingly. But if you give too high a dose, then weird things can happen.

Dr. Wong:

So too low a dose, sitting on the sofa versus too high, all right.

Dr. Hiza:

Too low a dose is too low, too high a dose is gonna be noxious.

Dr. Wong:

Well, you’ve given me the excuse to do the three bears in the oatmeal story, movement. Not too much little right.

Dr. Hiza:

That’s right! Yeah, just right.

Dr. Wong:

Okay great, that’s awesome. So we can talk about, and then talking about the root cause of low back pain overall. Why do so many people have low back pain? What are the common reasons? And are there any habits people are doing daily that are contributing to let’s say low back pain first?

Dr. Hiza:

Yeah. I mean, I think most people with back pain the main challenge is doing something too quickly or ramping up too quickly in terms of activity without enough preparation.

Dr. Wong:

Maybe, Weekend Warrior Syndrome?

Dr. Hiza:

Yeah. Weekend Warrior. But I think most of it if you think about you know our bodies, our musculoskeletal system is all based on capacity. Right? Do you have the capacity to tolerate that stress? And you know, for some people they have the capacity to get up and walk or pick or as high as you know deadlift 500 pounds, right? So the strength is one thing. Strength isn’t the issue, it’s really capacity. And you know, and that’s why there are some people who are sedentary but have no back pain and there are some people who are sedentary and have back pain. It’s not because you’re sitting too much. It’s just your structures either have the capacity to tolerate that level of sedentary lifestyle or not. And I, so that’s why it’s very varied. And I don’t like to use absolutes in terms of you know if you sit too much you’ll have back pain. Because the problem is that, I’m sure we all have plenty of colleagues who you know sit and you know they kind of contort themselves in these weird processes. They’re completely asymptomatic.

Dr. Wong:

And there are some genetic single nucleotide morphisms for like skeletal structure. And people have like different bone masses depending on their person, the genetics family and stuff like that.

Dr. Hiza:

Yeah. And I think that’s why it’s important to look at this as a case by case rather than you know kind of these broad brush strokes. In terms of you know, everyone who sits has back pain or everyone who does construction is back pain. Because that’s not real.

Dr. Wong:

The 90 percent of us in America that have metabolic syndrome, it doesn’t help things like that.

Dr. Hiza:

Right, right. Correct. I think inflammatory responses. I think that’s another major factor that again, I think since I’ve become acutely aware of that having worked with CIH communities that there’s just so many things you don’t know. So I’ve learned a lot that you know some of these conditions may be inflammatory responses from areas that are way outside of my scope of practice.

Dr. Wong:

Especially, yeah. And especially if it’s like systemic inflammation. They have low back pain and neck pain and joint pain, knuckle pain.

Dr. Hiza:

And I usually, and those, are those are the types of patients that are kind of my light bulb moment patients. Because typically if you’re going to have system-wide sensitivity it’s a, it usually indicates it’s a more systemic issue rather than you know a unique “Okay, I, you know, shoveled yesterday and now”,

Dr. Wong:

Right.

Dr. Hiza:

“Everything hurts as opposed to. I’m just you know, I’ve got back pain because I shoveled last night and I’ve got to wait for it to go away”. And so, I’ve become acutely aware or I’ve started to appreciate more just how inflammation impacts a lot of my patients, especially patients with chronic pain. But also some of my non-chronic pain patients as well. Looking at inflammatory responses and getting an appreciation of those inflammatory markers has been really helpful to educate them too. Because it could be an indicator that this is a lot bigger than oh you strain your shoulder doing a lift.

Dr. Wong:

Yes. And then another big point would be, you know. Another big area, a common type of pain I guess, would be neck pain. You know, the upper back, the shoulders, the traps, SCM, all that stuff. What do you recommend in general? Knowing that it’s not a cookie-cutter approach for sure but with neck pains.

Dr. Hiza:

If it’s. if the sensitivity is it just kind of shows up out of the blue, it’s not like “Okay well, I fell on my head” or you know, I was right most of that is really the neck pain and shoulder pain. It’s, I look at it more as an endurance issue. So, it’s not necessarily pain but it’s in response to those muscles fatiguing. So, you’re holding these small little muscles that have very low tolerance in the first place. You’re holding them in these static positions for an extended period of time. They’re getting tired and what you’re feeling is really fatigue which is why it feels better when you lay down or you feel better when you take the stress away from those structures.

Dr. Wong:

And there’s a lot of bowling here. Bowling alleys in our area and actually we’re all bowling every day because our heads are 12-pound bowling balls.

Dr. Hiza:

Yeah. So, I think you know, neck and shoulder pain. A lot of it is really, it can be attributed to muscle fatigue and chronic muscle fatigue rather than something pathological in nature. And then that’s why most of the exercises are most of the interventions are really just movement. Just move more. They don’t have to be heavy-weighted movements but just moving more out of those positions that you’re holding for an extended period, a period of time. But the same adage though is that some people have

38:31

better capacity than others some people can hold that bowling ball a lot longer than others

Dr. Wong:

And there’s mitochondrial support.

Dr. Hiza:

And support. And also, I mean, I think if you have a better, if you don’t have the same stressors. So stress is also part of this too because stress will just elevate.

Dr. Wong:

Yes. Stress elevates inflammation, you know.

Dr. Hiza:

So we know that stress is coupled with muscle fatigue. In those sad entire positions is going to cause a lot of these symptoms. So my approach to neck and shoulder pain is really a little different than most. I don’t like to prescribe you know just weighted exercises right away. I usually prescribe bodyweight movements first for several weeks and because the other part is also if you’ve gotten to the point where you’re dealing with neck and shoulder pain it’s not something that just happened overnight.

Dr. Wong:

Right.

Dr. Hiza:

You’ve worked really hard to develop that. So it’s not a matter of just saying “Well if you just do this you’ll be fine.” I think you have to create an environment there that lets them identify this is, “In addition to my work I also need to incorporate this movement that gets me out of this jam”. And you don’t really have to prescribe a thousand different exercises. Sometimes, one thing is anything to move them out of that position,

Dr. Wong:

Okay.

Dr. Hiza:

Is efficient enough or sufficient enough. And they can. And once they start to feel the difference. I think that’s where the buy-in is really when they feel the difference. “Like, Oh! Well, I used to have that you know pain right in between my shoulder blades now. I do this movement and I don’t feel that or I feel it much later in the day.” and it obviously it’s not present in the middle of my meetings and I’m not noticing it because I’m doing and all. We’re doing is just changing the length-tension relationship and just increasing the endurance to a lot of those muscles that are fatiguing or fatigued easily.

Dr. Wong:

And we’re about a year and a half now. This pandemic, I think more people work from home they’re on zoom. Maybe the posture’s not quite right. I haven’t met anyone that hasn’t had neck and shoulder pain.

Dr. Hiza:

Yeah. I mean, I think that’s the true metric of all of this, is that if we get more people moving I think you’ll notice that, I mean the patients that are you know that we are working with, I think that’s what they noticed in the beginning is that “Oh my pain is not as

bad” and again it’s not that you’ve done something nuanced or something novel. You’ve just given them an opportunity to change their habit right and that’s what we were talking about earlier is that you’ve got to get out of their way too and just let them figure out what works best for them. It doesn’t matter if they do it first thing in the morning middle of the day or right before bed. They have to establish that rhythm. it’s their lifestyle, it’s their lives. And iif you try to put too many rules in, it becomes more of this kind of battle of wills.

Dr. Wong:

And I love what you see on Facebook. Sometimes about like keep moving keep active get going. That kind of thing. Because one of the things that a wise person once told me, and I can’t remember who they are but you know, but this idea that if we are moving we’re alive, if we stop moving and we’re static then that’s not telling our body that we’re alive actually. So we need to keep on moving. Whether even if we’re on zoom you know, we should keep moving and thinking.

Dr. Hiza:

And like you touched upon earlier though. You know, in terms of improving mitochondrial performance movement. That’s part of that energy transport system, right? If you’re not doing enough to create that response. Then yes, your ability to mitigate a lot of these challenges becomes harder and harder and harder. And the more sedentary it kind of it fuels that fire. So that’s why we want more people to be more active and whatever that means to you, you just have to move. It doesn’t have to be that special exercise that my PT gave me. Could just be as simple as, I’ve got to prioritize every two hours. I get up and I just do jumping jacks whatever that is. And whatever that means to you and I think the goal or the role for physical therapy in this process is being an educator, right? And just kind of nudging folks along in this path and just creating a lifestyle goal rather than you know a treatment goal.

Dr. Wong:

Yes. And just a quick point about that from a functional perspective. Exercise and movement will basically create mitochondrial biogenesis. The mitochondria, being the batteries in your cell producing energy biogenesis. Meaning, going to create more mitochondria. So literally you’re going to have more capacity for load as you go towards that graded exposure to movement over time if you do that on a regular basis. And you don’t do it too little or too much that you know someone can really make a great recovery there.

Dr. Hiza:

Yeah. And that’s the beauty. And I think for me at least, that’s why it’s so important that you do give them that time. Because those processes take time. They take several weeks to build up to take several weeks to ramp up.

Dr. Wong:

And so, I think just to summarize that in terms of the, we’re talking about pain here now. Still, is there anything people can do at home to address pain in general? You know, what are the things they’re not necessarily seeing a physical therapist? Maybe they are ideally. They are, but if they’re not. What are they doing is it keeping moving or what are the kind of things that you’d recommend?

Dr. Hiza:

Yeah. I would, I mean again movement. My bias is movement. So most of the time, I will definitely encourage people to stay active. And just you know, the hard thing is the psychosocial component, right? So when you have that much pain or you are limited by pain it also changes the brain chemistry as well right. So your ability to feel resilient and your ability to feel robust are also challenged at the same time. So if you have pain and you don’t feel very resilient it just kind of feeds into each other and then again can create a lot of unusual responses. And some of those things we’re still learning and still appreciating. You know, how they interfere or how they impact individuals? So I think if you’re having pain and you’re experiencing intractable pain then definitely get medical attention but if it’s chronic pain in nature or you find that sometimes it’s there and sometimes it’s not, those are usually good indicators that you’re either experiencing a tremendous amount of stress coupled with being more sedentary. So just something as simple as getting out for a walk and then just working on you know breathing. Just getting out, just do something completely off the beaten path. Go for that hike go for that one you know, “Okay, i haven’t been to great falls in two years maybe it’s time to go to great falls.” And you know take it all in and go.

Dr. Wong:

It’s just a great time to go, it’s still there. The waterfall’s still there.

Dr. Hiza:

But I think a lot of us tend to try to be insular about our pain and say, “Well, if I just wait it out it’ll get better. If I just not do, it’ll get better.” But there are a lot of things that you can do proactively to nudge that process along.

Dr. Wong:

Yeah, so well thank you so much for seeing all these you know patients here at CIH and you’ve been such a wonderful you know, boost to the clinic in terms of just like really helping people. Just talking with some people recently about that. And I’m kind of curious how you see physical therapy integrating with healthcare overall? Whether it’s medicine or nutrition or acupuncture etc.

Dr. Hiza:

Well, I see, I mean, I see physical therapy as just an extension of overall health care. I think it’s one component. But I think, what I’ve appreciated about working at CIH is seeing how all these different legs play a role in terms of boosting and balance and holding people up. So looking at health, looking at you know, gut health, looking at inflammatory markers, looking at hormonal changes, looking at bone density and how all of these things affect an individual. Coupled with how movement can play a role in. That for me has been instrumental. And I, I’m forever changed in terms of the way I look at things. I’m forever changed in terms of the way I appreciate the body. Because for a long time, my bias was just movement, right exercise. You know, stay active you’ll be fine. But now I have a better appreciation that there are a lot more moving parts and they’re all happening simultaneously. And so you know, an environment like CIH is a perfect environment for a lot of people. Because this is one place where that’s appreciated across the board that there are multiple systems being affected and they’re all happening simultaneously. They’re not happening independent of each other. They’re dependent on each other and that tie-in has really, has been a really eye-opening experience for me. Because it does help me have better conversations with patients. I can have better more in-depth conversations about, “Hey in addition to this bone density work, we also know that based on your last lab results this and this and this is present. Which means that we need to be mindful that maybe you don’t wrap things up too quickly. Maybe we gradually, maybe slower than what we’re doing now.” So, having that additional information has been really instrumental for them but it’s been even more important for me.

Dr. Wong:

Well, integratively too. You know, supporting all the legs at the table, set the table stands up, right? If you had like a five-legged table and then only three of them were there. The table would be tilted a bit. So like looking at it from all angles but also from, you know, person’s perspective. In terms of lifestyle, we really believe here, we all kind of believe here that you know movement and nutrition and sleep and mindset, cultivating healthy relationships, getting out in nature these are first-line medicine.

Dr. Hiza:

Yeah. I agree. I couldn’t agree more with you. And I think that in terms of a lifestyle practice. I think that’s I’ve kind of had people have asked me, What kind of physical therapist are you? And I used to try to come up with a novel thing, “I’m, you know orthopedist based or performance-based. But for the most part, I’m a lifestyle physical therapist. And most of my patients have very specific lifestyle goals and my job is to identify how we can disrupt what they’re experiencing to start to create a positive response so that they can get back to doing this thing.”

Dr. Wong:

That makes sense. Most people don’t go to the healthcare practitioner to go to them on its own.

Dr. Hiza:

Right.

Dr. Wong:

Suppose there are some people there “I want to see Hiza’s face every week.”

Dr. Hiza:

There’s some people that want to come hang out with me.

Dr. Wong:

That’s true! They can have some tacos with you.

Dr. Hiza:

Yeah, exactly!

Dr. Wong:

But you know a lot of times people were like, you know, how can I become more functional? How’s my quality of life? Can I play with my kids grandkids hobbies you know?

Dr. Hiza:

And I think that’s been the best part about this mindset or the difference in mindset is appreciating that most people have very specific lifestyle goals. And, but they don’t know how to start that process or that they’ve had negative experiences in the past in terms of starting that process. And I think what’s different, I guess. What differentiates my style is really I try to listen to the patient and figure out or identify what’s the best nudge forward and sometimes it’s do nothing, sometimes it’s due a little bit and sometimes, it’s do a lot. So it’s all depending on where they’re coming and how they’re you know interpreting all of this.

Dr. Wong:

I love that word nudge. Lifestyle physical therapy that nudges patients to activate their own healing responses themselves. Well, thank you so much for being on the podcast today. But before we conclude this episode here. We have some fun closing questions that we’d love to kind of ask you about. First of all do you have a morning routine? and if so, What is that? If you don’t mind sharing that.

Dr. Hiza:

Well, my morning routine. I guess the best way to describe is yes I do have a morning routine but it’s varied. But I have a three and a half-year-old who is a very proactive early bird so we’re usually up pretty early.

Dr. Wong:

She’s your morning routine.

Dr. Hiza:

She is my morning routine. But yeah, we spent a lot of time together and you know since the pandemic It’s had, it’s given me a lot of time to reflect of you know just how important my family is and how important spending time with them is because we just don’t know how much time we have. This is a good reminder.

Dr. Wong:

Family’s everything.

Dr. Hiza:

So, I spend a lot of time with her and you know. I would like to believe I’m entertaining her but I don’t know.

Dr. Wong:

She’s a budding physical therapist. She’s an athlete.

Dr. Hiza:

She’s definitely. She’s about, she has a garden that she lets me tend to. Sometimes, I only carry the water I’m not allowed to touch the plants but I can carry the water (because)

Dr. Wong:

What kind of things is she growing in that garden?

Dr. Hiza:

She’s growing carrots and she grew bush beans, she grew kale, she grew peppers, red peppers. Everything herbs.

Dr. Wong:

Lots of earth organic of course.

Dr. Hiza:

I hope so! I don’t know. Fingers crossed! I don’t know.

Dr. Wong:

Yes. All right. So getting up early kind of doing some movement with her. And what book or podcasts are you enjoying the most right now would you say?

Dr. Hiza:

You know, I think the book that I’m constantly reading which was published in 2015 is The Pain Handbook. It’s The Protectometer. But basically, it looks at how pain is (really), it’s more of an emotional experience rather than this kind of you know binary thing.

Dr. Wong:

Yeah, absolutely.

Dr. Hiza:

And so, it’s given me a lot. Because like I said, based on the previous question with a three-and-a-half-year-old. It’s very hard to dedicate too much time to reading so most of my readings are journals and you know research articles.

Dr. Wong:

You said, the pain?

Dr. Hiza:

The pain handbook.

Dr. Wong:

Yeah okay, thanks.

Dr. Hiza:

Underneath is called The Protectometer.

Dr. Wong:

The Protectometer. Yeah, okay thank you.

Dr. Hiza:

But yeah, so that’s I read that from time to time. It’s just a kind of reference and it’s been a really good reminder for me that I don’t need to look at pain as this kind of binary like, “is there an injury or no injury?” Because most of the time you can have pain and not have an injury and still experience pain.

Dr. Wong:

Got it. And then, thank you. What do you do every day to cultivate joy? Heading to the garden?

Dr. Hiza:

That’s not joy for me, that’s labor.

Dr. Wong:

All right. So after the moment.

Dr. Hiza:

After the work is done, right. So, I do try to prioritize exercising and just finding time to do you know an hour or two just to myself. And sometimes that’s late night and sometimes it’s early. But I also you know watching, seeing my daughter do the things that I enjoy doing and having as much fun as (I’m) brings me joy. So it’s been great to see that, you know my wife and I are passing on, are passing out at least the mindset that exercises and being active is, it doesn’t have to be forced. It’s just a lifestyle. It’s just part of just like you brush your teeth.

Dr. Wong:

It can be fun.

Dr. Hiza:

It can be fun. So that’s for me. My family brings me joy and doing and being a part and annoying them with you know all my PT jokes and now that I’m a dad I can crack dad jokes. So I’ve been very, I feel very blessed now that I can finally crack corny jokes.

Dr. Wong:

Yeah and then do you have any PT or dad jokes in the cupboard that you want to share on air or is that? Maybe? yeah.

Dr. Hiza:

No, not yet, off air. Definitely off air.

Dr. Wong:

Right. All right.

Dr. Hiza:

Listen. These people have to have some respect for me not just, yeah.

Dr. Wong:

We’ll do this after the podcast, yes. All right. Well, thank you so much for being here today on the podcast. Awesome episode here. And thank you so much. And how can listeners learn more about you and work with you?

Dr. Hiza:

The best way is either through CIH. My information is there, or you can go to Kimbia Physio (k-i-m-b-i-a-p-h-y-s-i-o dot com) and you can find me there as well. You can connect me through that. So either CIH or through my website.

Dr. Wong:

And Kimbia, I will ask you this because I wasn’t going to ask you to remind me Kimbia. How did you get the name of your clinic?

Dr. Hiza:

So Kimbia is Swahili for running.

Dr. Wong:

Running, okay.

Dr. Hiza:

So, when I first started. I worked. I was working primarily with endurance athletes. So, I started working with like runners and cyclists started to come in, and then they would say, “Hey I’ve got, you know, a swimmer friend of mine.” So then it just kind of grew and then it went to well, “I’ve got a postpartum athlete who wants to.” So then, it kind of just grew into a bigger thing. So the initial mindset was, I was just going to work with runners and runners alone. And then it grew and it grew and it grew. And I’ve had to expand it. But I like the idea of running because it’s a constant struggle to just stay active. And I think we all have that struggle. And I think we all have the ups and downs and the side steps and progress is never always linear this nice lovely linear curve line that we all think about it’s squiggles.

Dr. Wong:

Lots of squiggles yeah. And yeah keep him, keeping moving you know yeah for sure.

Dr. Hiza:

Yeah, keep moving.

Dr. Wong:

Well, thank you so much again.

Dr. Hiza:

I appreciate it. Thank you for having me on a Friday.

Dr. Wong:

Yes the first Friday.

Dr. Hiza:

The First friday. Oh man! Good luck everybody.

Dr. Wong:

But thank you so much for taking the time to listen to us today if you enjoyed this conversation please take a moment to leave us a review rate us like us it helps our podcast to reach more listeners. Don’t forget to subscribe so you don’t miss out our next conversations and thank you so much for being with us today as well.