127- Finding the Root Causes to Your Chronic Pain with Dr. Angela Cortal

Bryan Carroll: [00:00:16] Talk about pain for a minute. If you didn't have immediate trauma to an area, let's say a broken bone. Then oftentimes pain comes on as more of an annoyance, such as back pain.

You shrug it off to sleeping wrong or doing something to it and expect it to disappear after a couple of days. But then it just kind of hangs on for awhile and weeks. Go by with your back constantly hurting. Finally, you had enough and you'd go to your doctor who then prescribed you a pain reliever and physical therapy.

You do your physical therapy for a few weeks and the pain continues. And then the next steps are an MRI with possible well surgery, or you're just stuck dealing with it. But what if there was more to the pain story in movement was only a small part of the equation. What's up everyone. I'm Bryan Carroll and I'm here to help people move more, eat well and be adventurous.

And today I have dr. Angela Cortal joining me to talk about how to find the root causes to your pain. The problem with pain is that it is a very multi hi factorial, which means pain as a movement might not be enough to get you feeling great. Again. 

Before we dive into this episode, this episode is brought to you by my other company, mountainside herbals, which has products such as digestive bitters, our very popular, FluEase tea, which flies off the shelf this time of year and even raw honey that we harvested ourselves for listening to the podcast, you can use a coupon code PODCAST to receive 20% off any order, go to mountainsideherbals.com to learn more. Now let's dive into my conversation with dr.

Angela Cortal. Dr. Angela Cortal was a naturopathic physician based in Oregon. She is passionate about reversing degenerative joint disease by addressing the root causes, and she loves partnering with her patients to optimize their health, happiness, strength, and wellbeing. Thank you for coming onto the show dr.

Angela. 

Dr. Angela Cortal: [00:02:18] Well, thank you so much for having me. 

Bryan Carroll: [00:02:21] Of course then I, I always liked to learn more about, the guests that come onto the show and the, yeah, they're more about your background. So can you tell us a little bit more about you and what got you into a naturopath minus sin and what is kind of your main focus?

Dr. Angela Cortal: [00:02:35] Sure. So I guess it starts in my undergrad years and maybe even a little bit before that I've always been really passionate and interested in science fields and incidentally at the same time had my own skiing accident that, then led into a surgery and a very. A prolonged and slow recuperation through that as well.

I was going through my undergrad in micro and molecular biology. And so, so on one front I was going, going through through my, my classes and, and my, schooling. And on the other front, I was barely keeping it together physically. And, and so, as the years, Went by, I slowly got over, some of the really bad chronic pain, but I had a lot of joint instability and weakness and enter the naturopathic medical school, just interested in bringing my, my background in science to really helping people one-on-one in the moment feeling like I was having, just a, an a, a real, tangible impact in people's lives.

And through my own education through that program. And my early years in practice, I got really, really interested. Yeah. On a personal level like Kat, is there anything else that I can do to figure this out? Why am I still struggling with this now? A decade plus a old surgical issue. And sort of put, put together the pieces between myself and pub med and experimenting on myself and, and bringing of my focus in, addressing hormonal dysfunction and hormonal imbalances that I, that I was with my patients and integrating that into a chronic, chronic joint pain.

What is it? What is the overlap there? Because the more I delved into it, the more I discovered, Oh, it's not just me. There's a, there's a lot of people out there where there's something larger going on beyond just, Oh, that joint has wear and tear. No, there actually could be something to be addressed and corrected and sort of change, change the trajectory.

So that's what I did for myself in a nutshell. And what I love doing with my patients, Which 

Bryan Carroll: [00:04:42] is interesting because your original injury, we can't, came from some sort of action. Right. And a lot of times we think of these type of injuries, as you know, just from a movement standpoint, like you went skiing, you either crash or you twisted weird and you hurt something on the process.

But then as you said, the pain continued for a long time, and then you had to start looking at, okay, what else can be feeding? This type of pain in my body. And so is this pretty common for people that, they might get an injury from some sort of action and then the pain continues for, much longer than you would expect it to.

And it's due to other underlying issues in their body. 

Dr. Angela Cortal: [00:05:24] Yeah, I would say, it shouldn't ideally that should not happen. Every, everything should be healing perfectly and on a relatively quick timeframe. And when that isn't that right. That's when I think it's time to look deeper, like what is their structure wise?

That just as chronically injured and didn't heal, is there a small tear? or is it something more. A more systemic, more and more metabolic center, something it's something to do with the rest of their body and their healing processes. Like something is standing in the way, on that front. But I would say that, yeah, it's really common.

Maybe, maybe even to the extent of it's more common than healing up perfectly and quickly. Unfortunate. 

Bryan Carroll: [00:06:07] Right. And so, if, if there is pain that is lasting a long time, how do you start trying to figure out where that could be coming from and what the root cause might be? 

Dr. Angela Cortal: [00:06:17] that's a great question. And that's, that's like a hundred percent what I love to investigate.

I would say, starts first with getting all the information. So, so on first. visits patients are coming to me with some sort of a chronic pain. I want to get all the information, not just what was that thing that started it, but what is the rest of the story been like? what is someone tried?

What is their response been to that? Cause that's really helpful. People think, Oh, that thing didn't help. So I'm not going to bring it up, but actually it's really helpful for me to know what do help us as, as much as it is. What, what has helped. along that process and sort of putting together their whole picture, getting a sense of what in their, in their daily life and their work duties in their exercise regimen.

what, what is stopping them? Because. Not not, everyone's going to have the same triggers, someone with knee pain. one person won't be able to, get down on the ground and that, and just squatting down is going to be impossible for them. versus someone else can't even go down a flight of stairs without holding onto the railing for two to life and taking it one at a time.

So, so everyone's different. And, And kind of figuring that out, involves a long conversation on that front and then, and then dive in and to the physical exam, trying, trying to really bring that information to light. And I've had a number of patients where. They've gone, to various larger medical centers or other providers where they just really weren't given much of a physical exam.

And if you've had chronic pain, we need to figure out what's going on. We need that physical exam. We need that information. so being able to then, dive into that, to figure out is it, is it really coming from inside of the joint because just because we're feeling pain in any joint, it could be coming from another location.

or is it cartilage? Is it ligaments? Is attendance. Is it nerves? that that's all really important to know because like the treatment, the treatment plan is going to look different. And then I would say that's just like that, that whole piece of it. and then going into, if this has been a longstanding injury, what, if anything is standing in their way of healing?

so then that's, when I branch into housing, are they, how are they moving? Are they moving at all? Do we need to, to build in just, an exercise program that works well for them, that's really important. nutritional deficiencies, hormonal deficiencies, different lifestyle factors. we know, we know there's quite a number of lifestyle factors that impact someone's.

Ability to, to regenerate that, that connective tissue, that joint tissue, just to get it to heal, whether that's, alcohol intake or tobacco or, or even, even things that we might think of as, Oh yeah, they're good to do for self care, but, but people don't connect it to actual joint pain. Like, are you sleeping enough hours?

And how has your stress levels? And then, and then going, going from that into. gosh, so, so many other things like hormones and your blood sugar and your thyroid, any, any of these things that are just, not often thought of as connected at all, but that IC a really, really tangible impact, on, on, on someone's ability to do improve their pain and heal.

Bryan Carroll: [00:09:36] So basically what you're saying is pain can be complicated. 

Dr. Angela Cortal: [00:09:39] Yes. That's the tagline. 

Bryan Carroll: [00:09:45] It is complicated. So I don't know what type of patients that are usually coming to you. Are they, like they've had an injury and they've seen a couple people and they come to see you after and, If they have seen other practitioners before you, are they more open to making all these different types of changes or are you getting kind of a mix of people that just got injured in they're coming in?

Cause I know, you know, there's a lot of people, like if we go into the lifestyle factors, you mentioned lifestyle. Factors. If you try to tell them, Oh, you need to change this. You need more sleep and all this stuff. And they're like, Hey, I'm just here for my shoulder. My shoulder hurts. Like, I don't need you to tell me what to do with my life.

What kind of pushback do you get from that? 

Dr. Angela Cortal: [00:10:29] That's a good question. And I guess I'll, I'll, I'll speak first to a patient population. I guess you could say. And I have a number of a number of patients who are coming to me specifically because they know I work with hormones and women's medicine and they just incidentally bring up this nagging low back pain.

That's been there for 15 years and I'm like, wait, okay, well, we're not, we're not, we're not going to glaze over that. We got to stop. And also that that's important too. That's stopping you from being able to exercise and tie your shoes. Like we, we also need to address this, And then as far as patients were coming in more specifically for pain, they may know that I know that I, that I do injection therapies, regenerative injection therapy.

So, so yeah, some, some are like, I have pain and now do the injection please right now. And part, part of my first visit is assessing. Maybe you're a candidate for it, but are you a candidate right, right now. And I'm making a case and I, you give it like this. I'm a, I don't know, lawyer presenting a case if, if it's really in their best interest right now, or if it's their best interest, if they haven't had labs done, they can't even remember.

And they say, I don't know, maybe 10 years ago or more like. How about, we just make sure you're not anemic. How about we just make sure you have enough time. How about we just make sure you're not like diabetic or prediabetic, because if you go through the route of injection therapies, any of those other things will impact your actual response to it.

We're talking about like potential benefit of, of care versus deferring the care, you know, a couple of years, weeks, or maybe a couple of months. And I would say that most patients are open to that. And I think you're right, that the, the amount of frustration and times someone has gone through this system, that system feeling like nothing is working.

I, I, I do believe that that people are more open to looking at their pain more holistically, if you will. Just because the other stuff didn't work, that they, they, they, they went through, you know, all the ibuprofen in the world. The physical therapy maybe helped a little, but then something came back. Then they were just kind of stuck in this like, well then the primary care just told them, okay, more ibuprofen and more PT.

And and they're like, I need something else. And then, yeah, they're, they're a lot more, open to me saying, okay, let's look at your, your joint pain within the whole system of your whole, whole kind of physical health. I remember a patient. It was maybe. Two years ago that I saw for some chronic shoulder pain.

And one of the first things she said to me is like, you're my seventh doctor to look at this. And I said, well, then. My only job is to make sure that that, that we ended right here, that there is no number eight. And, and yeah, we did, we figured out for, for her case, there was, there was, a ligament tear, due to her, her work, duties using her upper body and shoulders.

And there was no number eight. 

Bryan Carroll: [00:13:33] That's great. Yeah. and you also in there, you brought up a very interesting point because, If people, a lot of times, if they're following just a standard, standard care process, they go to their primary care physician. They tell them, you know, like I said, ibuprofen and PT, they go to PT, PT doesn't work.

They kind of do the loop all over again. And then the next step is okay, go see a surgeon, orthopedist, whatever it is. And then now you're stuck in a loop of now we're looking at surgery. And for a lot of people, that's kind of the route they get stuck with because they don't know these other options, which is great that we're talking about this, but what would you do to be able to get more people to recognize that maybe that surgery option isn't what you need.

There's other steps other than ibuprofen and PT, that might be more important. And you need to look at that 

Dr. Angela Cortal: [00:14:24] first. Well, I mean, that's, what I'm trying to do is get the word out there that like fair that the ibuprofen, you know, is used to reduce inflammation, to reduce pain. physical therapy is great.

So I'm definitely saying like, there's, there's for sure a role for that. And I just wish that like, In, in that early conversation that, that more people, you know, from the provider and also from the patient standpoint, had the, the, the knowledge and awareness. It's like, there's a lot other things we can look at before surgery.

Like, yes, the surgery is needed for some people. I would just say that probably not the number of surgeries that happen. All these other things were looked at. but essentially people could put off their surgeries or not as many people would need the surgeries. And also for a lot of my patients, they're being told maybe they do have the surgical consultation and they're like, yeah, it's not bad enough yet.

Come back in five or 10 years when it's worse. They're given nothing out there they're given basically no hope, but to just sit there in their pain for years or a decade, and then come back for the surgery, it's like that. I think we can buy you some time. And I say that because of all, the many, many patients and all the positive outcomes I've seen, like there's more we can do.

It's just a matter of awareness. Right? 

Bryan Carroll: [00:15:47] Yup. That's exactly it too. And then, I don't think people also understand that. You know, surgery is a business too, right? If you were shut down for four months due to COVID, and you aren't performing surgeries and you have bills to pay then right now, I mean, people are going to be pushing more for surgery than they were before, which is kind of a sad reality, but it's 

Dr. Angela Cortal: [00:16:07] true.

It is. And I there's, there's been a lot of really hard or really challenging things going on. And if there's a benefit, one of the few, little glimmers of positives, it's been that some patients have seen me because they could not get into the surgeon. And they were so desperate that they just Googled like nonsurgical options for hip osteoarthritis because their, that surgical center was closed.

They couldn't even get in for the consultation. so there, there has been. a slight positive to everything else that's been going on. Is that okay? Some people are now taking this time where they're just sitting at home in pain, being told that that the, the medical center is closed. And, and this is, this is finally the time that they've had to find, find a different route for 

Bryan Carroll: [00:16:54] themselves.

That's perfect. so one of the things you have mentioned, his metabolism can impact pain and then the hormones can impact pain. Can you explain more about how both of those can impact pain? 

Dr. Angela Cortal: [00:17:08] yes. So, metabolism can and does mean many things. but within our context, I would say inflammation is a really top one.

We know there's a lot of inflammatory markers that we can check on labs that are associated with different chronic diseases, such as. Heart disease and high blood pressure and diabetes. so, so some of these we can check and some are actually coming even specifically from our, our fat cells. and so, so cytokines are our certain inflammatory markers and we know that those coming from fat cells of different kinds can be elevated in and around osteoarthritis.

And it's this sort of, Snowball effect where, where we don't really know chicken or egg, what starts, but in osteopathic w if there is also some metabolic disease, then the, the different kinds of inflammatory three markers are creating this sort of effect where they're creating more, more of the osteoarthritis process, which then in turn is upregulating as is increasing the different kinds.

And some, some really interesting research. I think I happened upon it earlier this year was looking at knee osteoarthritis and the fat pad right next to the knee. They found that's where that's where most of those different kinds were coming from. So literally the fat right next to the joints is what was kind of setting off the joint, which was in turn setting off the.

The inflammatory markers coming from the fats. and then, and then jumping into, into glucose insulin. So a lot of people are aware of the importance of checking your blood sugar and making sure that's well-regulated because of diabetes and prediabetes. but we also know that just generally having.

insulin resistance or some of the markers of insulin resistance as sort of a, a chronic, metabolic hormonal dysfunction is, is fairly common. the most recent stats I had come across as about seven and eight of the adults in the U S have one, one of the markers you need, you need three to get the diagnosis.

But, but that being said a lot of, lot of people, a lot of the adults in the U S have, have some of the markers of metabolic disease. And so, so, so we see that also have the sort of, setting off the degenerative joint processes and, and creating this effect where. After meals, there's this increase of insulin that happens in the environment of insulin resistance, which then directly irritates and inflames the joints.

We can actually see this, I don't do this, but in research they can, they can check, the fluid inside of joints and find, and find increasing insulin. So, so that's actually a really early the marker of, of insulin resistance, increased insulin within the, within the joint synovial tissue. or synovial fluid, excuse me.

and then, yes, there's so much to this. This is kind of my, this is my terrain right here. so then, other hormones, so insulin, yes. Is a hormone, but then other hormones like thyroid and our sex hormones and adrenal hormones, all of them also have an impact in, in, joint health. I would say in that balance between.

More joint degeneration versus encouraging more joint regeneration because theoretically, any of our tissues should have the capacity to heal. But if someone is, and so for most of these hormones is it's a deficiency. So, so a deficiency in thyroid hypothyroidism or a deficiency and testosterone or estrogen, any of those will basically just slow the rate of the recovery of the regeneration.

Of that joint tissue of that cartilage tissue. We can see this in, quite a, quite a lot of research now is looking at this. And so we can see it in adults and just checking their hormone levels and seeing where, where are you in terms of, do you have osteoarthritis and then following people over time to see, is that stable?

Is it good? Does it get worse than we can see those with the, with the lowest hormone levels, get the earlier diagnosis of osteoarthritis and also. Then accelerate more quickly. And they also have animal studies where they literally are blocking their hormone and then adding in hormone. And when they're blocking their estrogen, they see the art, the osteoarthritis happen.

And when they add the estrogen back in, they see the joint regeneration happen. 

Bryan Carroll: [00:21:29] Interesting. Yeah. So going back to the, the pain being complicated. So, even like phyto estrogens and all that type of stuff that can influence it as well. 

Dr. Angela Cortal: [00:21:39] yes. Yeah, there there's, there's so many things that can influence.

if we're talking specifically about estrogen and estrogen receptors, there are things that are estrogen mimicking and estrogen blocking, and, and then in the middle, I'd say there's also compounds that are estrogen modulating. So some things will overall. confer a net negative estrogen, sort of circulating estrogen levels of some old be used sort of, adding, adding to the estrogen and creating an increase and then some are a little bit more balancing.

And so yeah, with phyto estrogens, gosh, sort of, I mean, it's all over the place and that, When you see that, for example, certain, certain, so it compounds can be helpful, but then for others, there's research showing that regular high soil intake is negative for, for your estrogen. And, and so w we have a couple of things going on, which is not only.

What, what, if anything, is the soil itself doing, but then in the context of, if this is not an organic food product, what has been applied to it and is that also is Zino estrogen are the, are any of the, you know, chemicals that are, that are put on these crops also affecting our estrogen levels. We know that just in environmental science, gosh, just about every, anything we don't want, in terms of plastics and pollutants and those kinds of things that can, can have a negative impact on our hormones.

It's, it's quite widespread and we just have to, gosh, to be our own advocates for, just clean eating, making sure, you know, what's in your food and knowing what's in your, Your environments in, in what you're putting on your body and in detergents, in, in kind of all of that. 

Bryan Carroll: [00:23:29] And then are you also looking at other environmental issues such as mold?

Dr. Angela Cortal: [00:23:35] I would say I am an amateur on that front and that I get the experts involved. If I do think there's, some type of like chronic mold illness. I know, I know some, I would say I have like, an introductory, a naturopathic introductory level to it and can talk, can identify some of them. some of what might be connected there can discuss some, testing with patients, but I'm, I'm usually referring to the experts so that they can put together a little bit more comprehensive, treatment specifically 

to 

Dr. Angela Cortal: [00:24:08] that.

Bryan Carroll: [00:24:09] So what are some ways to help people to start making a healthy balance of hormones and not just depleting the hormones or pushing them out of balance? 

Dr. Angela Cortal: [00:24:20] Well, that's a great question. And I, and I would start by saying that we're not all necessarily, necessarily working from a place of everything is deficient.

So, so it's a matter of what's going on with someone and what do we want to test and, and what may be, you know, then found to be high or low. but, but generally speaking for like estrogen progesterone and just asked her own what we call the sex hormones. I look at nutrition, I look at lifestyle, I look at at movement and I want to make sure that nothing is deficient in, in those realms so that they can actually be creating the right mountain sets and levels of hormones as, as much as they are, or their body will, allow for.

So, making sure that someone is eating adequate, what we've seen that the macro, macro nutrients, getting, getting enough of the proteins and healthy sources of fats and, what does their diet look like generally? Are they eating. something that's more whole foods or are there relying on a lot more processed foods that would typically be higher in simple carbohydrates and refined sugars and those kinds of things?

what is, what is their, water intake? Like? What is their digestion like digestion that, our digestive system is really important in our hormones in terms of getting out what we want to get out. Through the natural sources that our body's eliminating things. so kind of making sure that that system is online and working well with them, everything.

and then what I was mentioning earlier, just in terms of quality, sleep and amount of sleep and stress levels, and what support does someone need around that to make sure that that's that's as much as an imbalanced as we can be with sort of a crazy. It's Pressfield world out there. We've got to take really good care of her.

And, and then movement wise. I'm, I'm just kind of wanting to nudge gently encourage patients along if they are inactive, what is the first step to getting them active? We know that painful. Painful arthritic joints are not going to improve with inactivity. It just doesn't. The science doesn't work that way.

We've got to figure out what is the step one? Is it, is it a yogurt or she gong class? Is it a water aerobics? Is it, is it just doing some stretching at home? you know, often I I'm, I'm talking though with my patients about getting, getting someone to do a, more of a biomechanical analysis and figuring out what muscles are engaged in versus aren't engaging, get something a little bit more customized to them.

That is great. And also, I just want all my patients to get moving and, and then get, get those muscles turning on without, without any, any muscle engagement, muscle strength. There's a lot more force going through those joints that really needs to be, we need the muscles to kind of take over their share of the load of our.

Just wait walking around this world day to day. And then, so also during physical activity, so kind of getting those muscles turned on when they're supposed to be getting them strong, building up those muscle fibers that creates its own. A kind of positive feedback loop with our hormones, so that we're getting a much better balance of, of the testosterone of the estrogen when someone is developing the muscles versus in that previous state of, of note of minimal or no activity.

Bryan Carroll: [00:27:47] So when you are trying to, develop, better muscle fibers and increase muscle or lean tissues, are you, have you noticed a lot of people are consuming. Low levels of protein in their diet. and are you advising them to increase protein levels? And if so, what, what, like how much protein per pound of body weight are you looking 

Dr. Angela Cortal: [00:28:10] at?

that's a great question. So I would say that not all patients, but a decent amount, if they are actually tracking their protein intake are lower than, than what we want. And, and so just kind of generally globally, I work with a lot of women. and so I would say that, gosh, they may, some averages may be like 35 to 50 grams of protein a day.

And I know they're gonna get there. That that's, that's something that's inhibiting their healing that we need to get a little bit more protein on board, because that is one of the building blocks of regenerating this chronically injured tissue. So I'm boosting them up. I'm like, okay, next step is 65 and maybe.

I don't personally see patients with advanced kidney disease, so I'm not having to, walk a fine line between any sort of protein intake concerns, generally speaking. So, so I would say that that I'm increasing my patients, boosting them up from a deficiency to. you know, 65 is kind of a first step, more like 75 to a hundred grams.

And that, that is, we just talk about what works best for them, what they, what they like to eat, what they will eat, what they will cook and, and figure out if that's, if that's me. Eggs. if, if they're kind of maxed out on their meal wise and they're like, I can not eat any more beef eggs. And if we're adding in like a college in powder, I tend to, I tend to use, college and Potter if I'm using a protein powder, just because of its ease on the stomach.

I don't have to worry about the kinds of. dietary intolerances with like soy and whey and those kinds of things. I, I tend to, I tend to find that patients don't don't mind that they can get an unflavored or flavored one. so, so kind of incorporating it into their life seems to be pretty easy. If I'm at home something specifically a supplement.

Yeah, it 

Bryan Carroll: [00:30:10] seems like a lot of people aren't consuming as much protein as they think they are. and then once they start adding more and they do feel pretty full and it can be hard for them to get more in. 

Dr. Angela Cortal: [00:30:23] Yes. Yup. Yup. And, and so that's, and also if someone's eating like two meals a day, instead of three, you know, most of us are not going to eat six or eight eggs to them in a, in a setting.

So it's, it's, it's figuring out like what, in their current meal plans can be adjusted. And then do we need to add something else extra? I am personally not a fan of putting the college in powder, straight into my coffee aisle. I like my coffee to taste like coffee. So if I'm doing a college of powder, I'll do like one of those like mocha flavored ones and just pretend it's like a totally different thing.

It's not like coffee. It's a totally different beverage. 

Bryan Carroll: [00:31:02] So, you know, you're getting a lot of information from just a health history report with people. And then, once you start getting some ideas of different areas that you want to take a deeper look at, are there specific lab tests that you like to run to try to gather more information, or is it very dependent upon what you see in front of you?

Dr. Angela Cortal: [00:31:21] it is very good, much, individualized, but I definitely, I'm wanting to get a sense of timing of past labs. Like if nothing has been running in recent history, then, then let's talk. Maybe that's not me ordering it. Maybe they're already going to see their primary care pretty soon. Great. Okay. So we talk about like, It's it's nothing, for step one is nothing extremely in depth.

It's like, let's just get your basics first to see what, what further we need to dig into there. So like, I just want your glucose, your hemoglobin A1C, like, just get any thyroid test whatsoever. Just get your, your CVC and your metabolic panel. Like let's just get some basics run first. If that hasn't been done in a while.

If I am, concerned or wanting to work up, to, to rule out some inflammatory disorders or rheumatoid arthritis that we haven't really mentioned. So by wanting to see if they're joint diseases due to an autoimmune condition, then yeah, there would definitely be, different, different panels. I'm running there.

Uric acid is something that I, that I do check pretty commonly because, because I kinda have my, my, foot in each world of this kind of metabolic. Concerns and joint disease. And I see that your acid is sort of a direct, direct interaction there. And then the hormone panels is definitely case by case.

If someone feels like my energy is great, everything feels good. I just hurt my back. You know, doing some sort of physical activity or I have a number of patients that fall off. Ladders and horses and things. so I was like, okay, it was just, just an injury from this, but nothing else, you know, taking, taking all the rest of their, their history, everything.

Yeah, it seems pretty good. Okay. I'm not necessarily, I'm going to say we definitely need to run every hormone on you. but if a patient is coming in for lingering, sacroiliac pain, plus fatigue and, hot flashes and weight gain and, and their sex drive fizzled up. And then, okay. Like, let's, let's think about this as, you know.

Yes. There's, there's something giant pain going on, but I want to see what else is going on. then, then that's where I'm doing more, more of the hormone, evaluation as well. 

Bryan Carroll: [00:33:32] Do you have kind of a basic protocol protocol or treatment that, if someone comes in and they have joint pain or do you start with, okay, let's start here and then we can start looking at labs.

but this, this is kind of the baseline level that you want to get people at first. 

Dr. Angela Cortal: [00:33:51] that's a, that's a good question. It kind of, I would say I have framework and that framework is influenced by what they are, what they are experiencing on a musculoskeletal and how that's impacting their daily life.

Plus like how much, how, how much of everything else, general symptoms, hormonal symptoms are going on for me to think about. Okay, this is quote unquote, just. Just, just pure and simple joint pain, or this is joint pain that is entirely coming from some sort of systemic hormonal inflammatory, or are we putting together?

a little bit of both. And then of course, all, all of that is then sort of matched to what, what are their priorities, what is impacting their quality of life the most? maybe. Ma, maybe the, the joint, maybe they really want to focus on something else. And they mentioned that any pain, but the knee pain is not really a concern.

It only bothers them if they bike over a certain number of miles and there, the, their priority list is low. Like I still think it's valuable, but, but I'm definitely going to focus on if it's their thyroid, that's the main concern. And then 

Bryan Carroll: [00:35:05] you also do injection therapy. Is that, PRP or what type of injection therapies are you doing?

Dr. Angela Cortal: [00:35:11] Yeah, so I do prolotherapy and I do PRP the platelet rich plasma injection. And I got into this just, mentioning earlier, just. Me me coming pub med, trying to figure out what, what else is there? What else can, can go on? Like, I'm sure a lot of people have been doing right now, sitting at home, not sometimes not able to get it in the office that they're referred to, like what, what else can, and I do, and, and having, having the medical background, I looking through Penn medicine, maybe a little bit, yeah.

More accessible to me. but regardless it's great. Free free, free the Google of all, medical papers, out there. And so I found some studies about, it was looking at PRP and it was an animal's study and it looked at, ACL tears. And it was a rat or mouse model. And so they, they, they cut one of the ACS and one of the knees and, cause it's the animal study.

And then the, and then they put PRP in there and then some, some period later they sacrifice, I used to animals and checked and saw that the ACL. Where they had put the PRP was actually stronger and thicker than the one that the rat was born with. And I thought, well, that's crazy. That sounds like science fiction.

I need to read more of this. And that was probably my first or second year in practice. And, and so yeah, that reading that paper then got me looking into like, what is this? I. I remember a grand rounds when I was in school, like about the injection therapies, but it kind of, I didn't really, I mean, I was there, but I didn't really pay super attention cause I was much more of like women's medicine and hormone focused at the time.

And, And so, yeah, I, I found out like, Oh, there's organizations that, that are all about this. And there's people that they are just focused on about this and read more research and attended their conferences, where they share all the most up to date of, you know, best practices and new research coming out.

And, and then eventually, spends a few years and traveled. All over the country and Canada and Mexico learning every, everything that I possibly could get my hands on relating to the topic of learning it, because I thought this is a whole system of medicine. This is not something just to dabble into a, so I'm going to jump in with both feet and, and yeah, I, I, I got, I got, I got training from, from all sorts of organizations and people and.

And yeah, so probably five, six years ago started bringing that into my practice and it was my acting DEMEC and personal interest in PRP that got me into it. But yeah, I actually do a huge amount of prolotherapy. That's the that's predominantly what I do just because. I guess it's what, what I, the technique of, of prolotherapy is, is pretty unique.

It's definitely a lot different than if people out there have had cortisone injections, like the whole, analyzing the joint and, and assessing ligaments and where the injections go is its own system of medicine. And, and it made a huge impact on me. And so I started bringing it into my practice and saying, Oh, this works really great.

And that, yeah, sometimes I use PRP and I like it, but. So much of the time, prolotherapy works works really, really well. 

Bryan Carroll: [00:38:19] Do you want to talk about the difference between a cortisone shot and prolotherapy? Cause I know a lot of people, they feel really good after a cortisone shot for a little tiny bit, and then it wears off as a, can you talk about what's going on there and what's the difference?

Dr. Angela Cortal: [00:38:35] Yeah. So I would say on the surface, on the surface, they might seem similar, but behind the scenes, they are entirely different. so on the surface, your knee hurts and the injection goes to your knee. This isn't like acupuncture where you're treating a different part of the body. So, so with the cortisone injections, it is a steroid medication inside of the syringe.

So that's, what's getting injected for those that don't know. so, so that goes in there and it gets inflammation just like this versus the inflammation and blocks it. Right, right out of the joint right away. So, while a lot of my patients have described that the cortisone injection can, can be a bit painful in the moment.

The pain relief is, is pretty quick. like right, right away, people are noticing like, Oh, wow, that feels great. That my joint doesn't hurt. And, and just depending on what's going on, if that really was the only thing, true source of the pain that could last a really long time, that pain relief, or it could start to wear off within a couple of weeks or a couple of months.

And, and my, my thinking about that is that yeah, the inflammation was perhaps part of it, but there's obviously something else going on that made that wear off and made it just not, not a longterm treatment versus what the prolotherapy and the PRP. So those are under an umbrella, we'd call a regenerative injection therapies.

And so the whole, how the whole, why? Like what. How it works is, the injection is creating this, I guess I explained to patients like it's communication. I need to figure out where the injections go. And then the, the injections, them separate providers in communications, your body in essence sort of tracking it or just telling it.

That, that no, this isn't a chronic injury. This is a new, fresh injury. You've just got injured right here. So bring in the immune system, bring in just the, the healing processes that we all have within us. And, and reheal that tissue reveal that, partly it was ligament, tendon, joint, just generally speaking.

And so, they, they all of numbing agents in them by and large. So, so there can be a, a brief, numb, a pain relieving effect from that, but their intent isn't just, okay. We just get the pain, just suppress the pain. suppress the inflammation. And, and our job has done here is there's really a deeper goal to it and that's to get the joint, to heal, to get it to kind of a new and better place.

And, and so that's where they, it can be a little bit less of an instant credit, to be honest with the injections there. Yeah. Because the effect is often building. So while some people will notice like, Oh, wow, that was a really, really great response within, you know, a day or a couple of days. What's more typical is Brett to just be slowly building over weeks.

And with the prolotherapy, I would say about three to four weeks out is pretty typical. And with the PRP, it can be as much as six or eight weeks. So for more than a month, just slowly, slowly, slowly, it's it's getting better. It's healing. 

Bryan Carroll: [00:41:39] Is it true? If you get multiple cortisone shots in the same location, then I can start to degenerate the joint.

Dr. Angela Cortal: [00:41:45] yes. What I will say is that research shows that with three or more within a year, it will increase and accelerate a degenerative joint disease or osteoarthritis, same thing. what, what I would say is that we don't know one or two is a hundred percent harmless. It's common. It's done. There's millions of people out there getting it.

But we can't say that one or two is perfectly fine. And then suddenly three is terrible. my, my take on it is that we just don't have enough research comparing, saying, okay, we know three in a year is bad. Let's compare that to two let's come here. Let's have one. And see if we really do have a true, like dose dependent response, for example.

So we see two thirds of the damage with two in a year, as opposed to three and one third of the damage of one we don't, we don't have that, that. Fine detail of information. so I think they should be considered cautiously. There, there can be, there have been of course be a benefit, but there can also be a risk as well.

Bryan Carroll: [00:42:46] Well, do you have any final things that you want to touch on for chronic pain and just joint disease in general? 

Dr. Angela Cortal: [00:42:53] I would say, I just want to encourage you all to just keep going. If you feel stuck, just keep going. If you're not getting the answers, just keep going. If you feel like your doctor, is that listening to you or that you're like.

Crap. My joints really do hurt and I don't think I have gotten a decent physical exam of the procedures had just came out and, and their, their hands never contacted that joint. That hurts. Just find more options. There's more out there. If you feel like you're stuck in a waiting game or just plain stuck, keep, keep investigating, keep going.

That's that's how I, that's how I figured out my path. And, and that that's, that's what I help with my patients as well. 

Bryan Carroll: [00:43:35] And then what do you do each day to improve your own health? 

Dr. Angela Cortal: [00:43:40] I am a super good sleeper. I have never been someone who scrims on their hours going through my nine years of undergrad and medical school.

Never an all nighter. I'm I definitely believe in the restorative powers of sleep. And if I get under eight, I'm like. I feel like I'm losing something like losing a game. It's like game of five. I'm like definitely over eight hours every night. 

Bryan Carroll: [00:44:08] And then, well, people can find you at dr. Cortal.com and you also have a new book that's just been released.

Do you want to talk about that book? 

Dr. Angela Cortal: [00:44:17] Yes. So my book, a younger joints today just came out a couple of weeks ago. And it's more on this topic, if you are curious about thinking, like, yeah. I feel like there probably is something more going on with my joints. What could it possibly be? This is laying out my whole thought process organized into a seven step approach where you're going through all of these topics.

And I, and I talk about. What do we know as far as all these other things that are really never, never connected with joint pain, the actually do have a real, a appreciable impact. And it's up on, it was on if you're an ebook reader it's in Kindle. And if you're, a paper book, a paperback reader like me, then, then it's also up there as well.

Bryan Carroll: [00:45:02] Perfect. and you also see patients both virtually telehealth and in person. So people want to reach out to you, that then they can, well, thank you so much, dr. Angela for coming on and talking about, just chronic pain and different ways that we can start to reduce it and how complicated pain is. I think that's going to be the title is pain as complicated.

So thank you so much. 

Dr. Angela Cortal: [00:45:25] Thank you for having me. 

Bryan Carroll: [00:45:27] As I said in the beginning, pain is a multifactorial condition and there are a lot of other steps you can go through before having to succumb to surgery while no one really 

Dr. Angela Cortal: [00:45:38] wants to go under the knife. 

Sometimes 

Bryan Carroll: [00:45:40] it seems like the easy way out, if it will relieve your pain, but any additional trauma to the body and tissues can cause more issues later down the road.

I highly recommend testing out some of these methods. If you can, before having to get surgery. 

Dr. Angela Cortal: [00:45:57] As a reminder 

Bryan Carroll: [00:45:58] for listening, you get a 20% discount at mountainside herbals by using the code podcast. Go to mountainside, herbals.com to learn more. Next week, I have 

Dr. Angela Cortal: [00:46:08] dr. Roger Murphree on 

Bryan Carroll: [00:46:10] the show. Let's go learn who he is.

I am here with dr. Roger Murphree. Hey, Roger. What is one unique thing about you that most people don't? 

Rodger: [00:46:19] I'm a gourmet chef. 

Bryan Carroll: [00:46:22] Tell me more. 

Rodger: [00:46:23] It's interesting. So let me tell you about this, Ryan. I grew up in a household where my dad cooked, but he traveled a lot. He did a lot of traveling, but my mom couldn't boil water.

So we grew up and none of the kids could really cook. And, but it, it, interestingly, my younger brother, 10 years, my junior turned, he went. To culinary school became a, a well known chef. He worked with a lot of James, worked with two James Beard award winners, which is the, you know, Academy award of chefs.

And, yo about, 10, I guess about eight and years ago. I just, I, you know, I was grilling out some chicken where we're on a vacation, no condiments, no, usually smeller them whispers or sauce or whatever. And you think I've got that gourmet, but I picked some, some herbs out of a garden and put them on there and realize, wow, that, that was really, that was good.

That was good. And, so I've just over the last eight or nine years, I've just turned into a passionate. 

you know, 

gourmet cook, you know, I just, I get it. I just have, you know, all these cookbooks I cook out out. And so it's been a real, it's been a real blast. 

Bryan Carroll: [00:47:25] It's so satisfying when you make something that's just absolutely amazing and you're proud of it.

Rodger: [00:47:33] Absolutely. 

Bryan Carroll: [00:47:34] Yeah. Well, what will we be learning about in our interview together? 

Rodger: [00:47:39] Well, I tell you what we're going to be learning about as a, as a TA, as something that I'm so passionate about and it's fibromyalgia. Which is a group of symptoms, which include a few Seki, sometimes disabling pain, low energy, restless leg syndrome, marital bough, anxiety, depression, brain fog.

Those symptoms alone would put me off people down and out for the count. Right. But for fibromyalgia, they have all those things. And, you know, one of the great things about. Bout that if there is for me, why it's made me such a better doctor, because I've had to treat so many different types of conditions.

So I think people are gonna listen to the, to the podcast. They're going to find when they have fibromyalgia or not. They're going to find some golden nuggets in there that I think will be helpful for them. If they're 

just looking to get healthier. 

Bryan Carroll: [00:48:26] And what are your favorite foods or nutrients that you think everyone should get more of in their diet?

Rodger: [00:48:32] Well, I think that, you know, you really, you're doing your body a disservice. If you're not eating enough vegetables, I just think that it's not, it's, it's an easy thing to do. You know, the easiest thing for me to do is, is just, I use a salad promise every day. I mean, it's just the easy thing and all that sound you've got, you know, you got tomatoes and you got carrots and you got, maybe pull up raw cauliflower or broccoli.

I mean, it doesn't sound doesn't sound real appetizing, but. You know, once you start getting into that healthy habit of eating a lot of planning, a more of a plant based diet, I'm a mediator as well, a good steak. And you know, and, but I think your body really needs those, those phytochemicals, those flavonoids that you get from plants, the fruits are okay.

You know, but I think sometimes people eat too much fruit, but plants, gosh, if you just eat, 

if you just do 

one thing a day and that is just eat more, more plants. 

Bryan Carroll: [00:49:28] Yup too much fruit, not enough vegetables. That sounds like the ratio. Most people follow in. What are your top three health tips for anyone who wants to improve their overall wellness?

Rodger: [00:49:41] I think number one is, you know, I really believe that everybody needs an hour of power. And then maybe, you know, ma'am, they may start off as a quarter of an hour 

power, but 

if you find time to watch TV or you find time to be on Facebook or whatever it is, you can find an hour car ride an hour and you can divide that hour up in different ways.

But for me, It's a part of that time as meditating, or it could be prayer, whatever you feel more comfortable with, but it's quiet time where you're feeding your soul with positive material reading material, whether that's Joyce Meyers, Wayne Dyer, Deepak Chopra, Joel Olsteen doesn't matter, but just something that feeds your soul healthy.

We've got so much negativity in our. In our environment right now. And then I believe that any, you know, stretching really stretching, and then affirmation and goal setting, I think are important to review those every day. And then my number one is exercise. If you can have a population, I work with a fibro.

That's not something they can do immediately, but I do think that exercise is the great panacea. If you exercise consistently, you can get away with, with, with, some, some less than stellar eating habits periodically. It's not an excuse to not eat. Healthy, but you can get away periodically with a glass of red wine or a beer with your buddies out.

Or if you're, you know, if you just had to have that macaroni and cheese that is at your favorite restaurant once a month, you know, you can get away with doing that 

Bryan Carroll: [00:51:10] again, it is another episode on pain conditions and diving deeper into the root causes. So until then keep climbing to the peak of your health.