#174 Become Pain Free and Take Control of Your Health with Dr Deepak Ravindran

23rd Nov 2022

My good friend Deepak is back on the podcast today speaking with Sakina. I had the most wonderful conversation with Deepak on the podcast before.

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Dr Deepak Ravindran is a boundary spanning ‘upstreamist’ with a trauma informed approach to pain practice. He has over 20 years of experience in Pain Management and is Clinical Lead in Pain Medicine at the Royal Berkshire Hospital in the UK. He is also one of the very few consultants in the UK who holds a certification in musculoskeletal, pain medicine and is board certified in lifestyle medicine. Longcovid, Pain Medicine and Trauma informed practice are subjects that Deepak is passionate about and today Sakina chats to him about:

  • DIY vs DWY medicine
  • Sleep and it’s impact on chronic pain
  • Setting the circadian rhythm, sunlight and caffeine
  • Making complementary therapy more accessible

He hosts the PainSpeak podcast and is the author of the Best Seller “The Pain Free Mindset” released in 2021 and it’s by far one of my favouroite books. It’s aimed at patients suffering with pain but it’s also immensely useful for all healthcare professionals in understanding all the recent advances around pain management in a trauma informed manner.

Episode guests

Prof. Dr Deepak Ravindran

Deepak is Honorary Professor at Teesside University, a full time NHS Consultant in Pain, MSK and Lifestyle Medicine and Author of the Amazon Bestseller “Pain Free Mindset”. He serves as the Deputy Editor of E-Pain Platform at Health Education England and The Chief Medical officer at Boutros Bear, a digital rehab platform. He is an associate with Peak Health Coaching and is working as Director of Lifestyle Medicine for a primary care network (PCN) of GP practices in Reading, UK.

Dr Deepak Ravindran adopts a trauma informed ‘upstreamist’ approach to pain practice and has helped set up award winning community pain service in Berkshire (IPASS) in 2015 and the Berkshire Longcovid Integrated Service (BLIS) in 2020. A Management Honours graduate from Henley Business School, he has been awarded the National Apprentice of the Year(2021) by Chartered Management Institute (CMI). He is part of the scientific advisory board at Curable, MyPain and PainD. His research interests include Longcovid biological mechanisms, Pain science education and behaviour change with the University of Teesside and as senior Visiting Fellow at the University of Reading.

The updated audiobook of his paperback Pain Free Mindset has been released in April 2024.

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Podcast transcript

Sakina: So just before you was talking about the takeaways from this conference we're at and people from different backgrounds sitting together and trying to find solutions. Could you tell us more about that?

Dr Deepak: It's been really transformational or very interesting for me because this is the first time I'm attending a conference like this where I'm able to see mainstream medical physicians and clinicians who are able to sit down and have a talk and have so much in common with complementary therapy practitioners, with integrative practitioners, functional medicine practitioners, and you arrive at a almost common consensus that there's so much in lifestyle medicine, the simple things that we can do, and if we learn to do them better and we can support our patients to do them better, then there is going to be the potential for reversal of chronic disease. I mean, I like this morning when Prof Ornish Dean Ornish actually said, if you want to make something sustainable, you need to make it pleasurable, you need to make it meaningful, and you need to make it reimbursable. And I think the best thing about this conference up to now I'm seeing is you've got people who are quite highly placed in the political sphere in the UK, who have been part of the food strategy or part of the mental health strategy or part of the whole health strategy. They're all talking together, they're coming on a common forum, they are discussing about what we can do as a system to change, and that's very promising. I don't think I've seen that evidence so often in mainstream medicine and I'm just glad that it is starting to happen. And from my own field of chronic pain, where we are being told that drugs like opioids are not the answer, injections don't work in everyone, we need to offer patients something valuable and something useful as an alternative which they can get benefit. And I think this kind of lifestyle integrative approaches where you can give them that understanding is a great idea.

Sakina: Yeah, it is very, very interesting to have these conversations and see how then we can apply them to the field of medicine and integrative medicine and apply them to patients.

Dr Deepak: Because ultimately I think it's about implementation. We can talk all this, but actually if we're not able to do and do it sustainably, then this is just talk.

Sakina: I actually had that later on, but I wanted to dive into what you think, you talk about patient empowerment a lot. And you've talked about it on the previous podcast you had with Rupy a while back. But I'm wonder, I'm wondering about the limitations maybe of patient empowerment and how far can we go as individuals to really improve the way we manage our pain or we manage our health? And what is the role of professionals? So maybe, maybe now professionals being a help for implementation rather than treatment, but how can they work together? How can patients and professionals, health professionals work together to make sure that pain is managed in the best way?

Dr Deepak: It's a very complicated question there with so many strands in there. So I'm going to probably take the what I think is the starting point on there. So when I did my sort of qualification with lifestyle medicine, the British Society of Lifestyle Medicine, I realised that actually as a healthcare professional, as a clinician, my role in chronic disease, in long-term pain management has to move from someone who gives orders or says this is what a patient must do, to actually be more of a coach and someone who can work alongside the patient and actually then work together to find something that is valuable and relevant to the patient. And I think that's a big, almost a mindset change in the healthcare professional as well, because that's not how we get taught in medicine. We get taught in medicine to make a diagnosis, to be very clear and firm in our diagnosis, and then give a drug or a treatment. Now with chronic disease, we realise that when there are so many factors and variables and contexts that are taking there, we need to step back and actually say, what does matter to the patient? And in that sense, I think supported help to the patient is so important. In the book, I talk about this and I'm not sure if I talked about with Rupy in the last podcast, is I have this thing that our healthcare system has been traditionally a done for you. You just be passive, you come here, you lie down, and we'll make the diagnosis, the treatment, and then you follow our orders and be done. And we've seen that that system is neither sustainable nor does it work because people don't stick on to their drugs, people don't follow the orders and they don't do it. Then somewhere in the 80s or 90s, we had all these pain management programmes and there, which is like done with you. You sort of do a programme, you do a little bit of doing it with them, you say what are your goals, but then you actually just tell them what to do, but you don't show them how to do it. And now we have come to the point where suddenly we are saying, do it yourself. We'll just give you a few leaflets and do it yourself. And that is a big shift for patients to over a period of 30 years to suddenly move from being very passive to just being left on their own to just get on with it and manage their condition. So I think we need to probably as healthcare professionals have a role in this DWY, done with you space, and in the DIY. So the do it yourself space, we need to actually say how to do it, we need to break it down and give them a system on how to do it easily, make it pleasurable, make it meaningful, and that would probably make it sustainable. I think that is the space I think I'm very interested in saying we need to work with the patients, we need to co-design treatments with the patient, and we need to say this is a system, these are your goals. If we want to help you rise to the level of your goals, we need to improve the systems. Otherwise, like James Clear said, people don't rise to their goals, they fall down to their systems. And if you don't set systems in place to support them, then they are not going to be able to stick to the change that they make to manage their pain or manage their long-term condition. As a lifestyle specialist now, it's not just about pain itself, because if the diabetes is not well controlled, their chronic pain will increase. If their COPD or their asthma is not well controlled, they're going to be breathless, their chest is going to be tight, then their neck pain gets worse or their back pain gets worse. If they've got Alzheimer's or Parkinsonism or some of these other long-term conditions and they are eating unhealthy diet, then the food is going to be inflammatory and make their generalized widespread pain worse. So to me, pain management not only just involves about teaching them about pain, but also to say manage their chronic disease, then all of that can be better improved.

Sakina: All falls into place. The evolution is quite interesting, the fact that before it was quite doctor-led, and then patient got a bit more involved, but we weren't telling them how to do things, and now it's all do it yourself and responsibility is all in the hands of the patient. We give a lot of tools, we share a lot of tools, but then it can get overwhelming because there's just so much out there.

Dr Deepak: I'd come to think of it like, for example, IKEA. You know, we all talk about IKEA being the place for do it yourself. You know, they just, you buy the stuff and you can make it. But you'll always have people who are very good at making things, so they can just take an IKEA box and make the furniture off. But IKEA has also done the thing that where they've got lots of videos, they show how to do it. So for the people who are less confident, who know a little bit, they could still buy from IKEA, but they will then have people who show them videos that are done to show them how to do it and they can follow the instructions. And then you've got a group of people who will always be less confident. So they will probably want to buy IKEA, but then they will need someone to come and build it for them and actually show them how to build it. And I think in healthcare, it's very difficult. If you've got your average 45-year-old, 40 to 50-year-old, when they were eight or 10 years old, they were in the passive model where they've just been told this is how you just learn and listen to me. And now in their 40s when they've got a condition, they're just being told, no help, you just learn to do it yourself. That's a cognitive dissonance that people will find difficult to wrap around their head and we need to be able to support them to say you can do it, you can do it well, we can help improve your self-efficacy and give you the confidence to manage your long-term condition, your pain, and actually if you do it well, there's now the evidence to say that you can rewire your neural circuits and you can potentially reduce your pain. I mean, since we last spoke there, there's this study that came out from Boulder in Colorado for back pain. And in that study, they were able to show these were people who had some scans in the back showing some signs of aging, but there was no nerve pressure, there was no impingement, there was nothing trapped or anything like that. But they were having six or eight or nine years of low back pain, which was quite severe. And in four weeks of actually working with them, these investigators were able to reduce 80% of the pain in these people. So many people became pain-free. So actually, we can reach that stage of getting some people very pain-free if we can get them to understand that there is nothing to fear sometimes and you can rewire your neural circuits and do it differently.

Sakina: So it's all about meeting people where they are and giving them the level of support that they need and the level of inspiration. As you were saying, the IKEA comparison is quite interesting actually. Everyone will react to IKEA differently. Some people will panic faced with the manual and some people will feel very comfortable with it. Some people will need more support, videos, and some people will need more support, a person coming and guiding them through it. So you've been posting on YouTube, right? You've been starting to go through some of the approaches in your book on YouTube. So that's a way I'm guessing you're trying to provide that information, that support to people. How has that been?

Dr Deepak: I think the book was, when I wrote the book there, I got the information out. But it's the same feedback that I got back there is there are some people who love the book, and there are other people who said it's too dense, it's like lots of words and it's black and white and there are no pictures there. And I said, well, the publishers could only have black and white pictures, that's all it could be paid for. But then the need was how can I then break down that message and make it simple? And I realised that I can probably tell each patient as they come into the clinic, but that is too intensive for me. So I thought, well, if I can then talk to you like I'm doing now in podcasts, and if I go out and actually have a YouTube channel wherein I use this visuals and this graphics a little bit of audio, a little bit of video, and a little bit of messaging there, then that is the way to probably reach different adult learners. Because at the end of the day, we are trying to get people to become aware of something, to feel they can learn something with confidence, small steps, and then make it easy to absorb the content, reflect on it, and if they are ready to make change, then know where they have to go to make that change. Sometimes they could do it all by themselves, but sometimes they need a little bit of helping hands to start with. So that's what I'm hoping my YouTube channel will be able to do is talk about these concepts within the book and then take it to the next step to say, if you're interested and you're ready, then that would be the place. I think I like that's why I like that cycle of change model. A lot of us are not even aware that we can overcome our pain and make a difference. We think we are stuck with it either because of genes or because of that's my bones or that's my spine or that's my muscles or that's my neck, without realising we can make a difference. There is a lot we can do. And for those people, all we can do is raise awareness and give them information. But when they're ready to make change, the cycle of change predicts that a lot of people will be in pre-contemplation or contemplation. But when they're ready to make change, we need to show them where they can go to make that change and how can they do that change. And the important thing that I think the NHS is not yet funding properly and not thinking about it is how do you sustain the change? Once they've made the change, there's always a chance that we might slip off the wagon. It's normal. I think we need to make that normal and make it aware for our patients that it's okay to slip off, okay to have a flare up of pain. But when you do get a flare up of pain, this is the flare up plan, this is the way to support you, and it doesn't mean if you had a flare up, something's gone wrong, but this is the way to get back into the cycle of maintaining the change. That is something as well the NHS needs to actually support people in. We can't just say, oh, you've done one pain management programme or you've done one six-week programme, now you should know everything and you will remember everything for the rest of your life. That's not sustainable as well. We need to keep supporting them and find sustainable ways to support them.

Sakina: Yeah, and then definitely social media is a first step, I guess, to reach and to open those conversations and that awareness. So I was thinking maybe we can, so you shared the acronym, mindset acronym on Instagram a few weeks ago, and you were reminding people the need to shift from medication intervention towards more diet, sleep, exercise, and therapies, which is the acronym. So mindset is not only just mindset, it's actually an acronym for all these approaches. And I know you dived into a few in the previous episode, but I thought maybe we could speak about sleep a bit more. So the bidirectional relationship, potential bidirectional relationship between sleep and pain. So how lack of sleep could impact pain and how pain could impact lack of sleep, and maybe some practical tips that you may have for people who are suffering of chronic pain and struggling to find sleep.

Dr Deepak: Quite useful really. It's now, I just in fact last week I released a video on why sleep is so important. So this is one thing. We always think that people who are in pain will have less sleep. And the assumption people make is it's pain that's causing the lack of sleep. What the studies are showing now is that if you have started off having less sleep due to stress or due to work or due to watching late night television, binge watching there, and if you reduce your hours of sleep, you are actually putting your nervous system at a vulnerable state for pain to happen, for chronic pain to persist. Now that's a complete mindset shift because that is something that people haven't wrapped their heads around that if you are having a continuous days of less sleep or you're doing lots of night shifts and you don't recuperate, then you're actually placing yourself at risk of having chronic pain. So that is the bidirectional nature I allude to. The second part which I found it actually very useful information to understand is that sleep is that time of our life and our day where the MOT of the brain happens. You know, we have a lymphatic system within our brain itself, which is responsible for cleaning up all of the waste that gets accumulated during the day when we are doing cognitive process, when you're thinking, when you're working, when you're looking, when you're doing things, there is this waste that gets generated and that waste needs to get cleaned up. The housekeeping function happens when you sleep. So when you sleep less than six to eight hours, that housekeeping function gets progressively eroded, and that means we are now discovering that when you have this kind of waste accumulating, and if it accumulates in certain nodes or certain junctions, is when early Alzheimer's and dementia can happen there. So it's not just pain, it also has an impact on other places. So a lot of times, I just ask patients, as far as pain and sleep is concerned, the first thing they can do is, yes, look at technology. If you can afford it, look at these sleep trackers. Everybody's got a phone now, think about these kind of a tracker, you might have a Fitbit. So just to see what your sleep pattern is, what's getting disrupted, what's not getting disrupted. The second thing I tend to tell them is maybe if you have one of these sleep apps to start with. So now I think last month it was fantastic that for the first time the NHS has approved Sleepio, which is a digital app that they said GPs can actually recommend for their patients to improve sleep. And I think thinking of those kind of sleep apps would be a next step to say gives you a better idea there. Once you've identified and looked at a pattern and seen what parts of your sleep are missing there, the third thing I would say is can you start with simple steps? It means can you get out and get some sunlight in the first two, three hours in the morning? That is useful in terms of resetting some of the master clock and the other clocks that regulate your circadian rhythm as it were. And the fourth is the attention to diet and nutrition. Simple things, you know, can you reduce your coffee intake or make sure that your last caffeine is beyond three o'clock or something like that? Can you look at your alcohol content and actually see if you can reduce or avoid alcohol at least two to three hours before your planned bedtime? And it's important whether if you can do this as part of a group, so if your family is supportive, if your members are supportive there and can hold you to account, then I think those would be the first three, four simple things I would suggest. I think there are more tips in the book there, but I don't want to overwhelm your listeners. So probably these things, a good app to start with, a tracker to monitor, and a little bit of sunlight and reduce caffeine.

Sakina: Those are great tips and great and what I think is quite interesting is that all the tips, all the different approaches in your book, all the tips that we talk about on this podcast, they all link together and they all influence each other. So you talk about diet influencing sleep and sleep also can may influence diet. So all these things are interlinked. So efforts in one approach will have an impact on other approaches.

Dr Deepak: And I think that's the beauty. Exactly. And that's the beauty that we bring in lifestyle medicine is as Prof Ornish was saying in the talk this morning, is that all of these lifestyle approaches actually can help in reversing so many conditions. So it's not that we want to burden our patients by saying, oh, for pain you must do this, but for diabetes you must do something different, but for asthma you've got something different because the person in front of us may be someone who's got diabetes, who's got asthma, who's got weight related issues, who's got menopause related issues and other issues there. If you give them five different things, that's just going to mess with them and they won't know what to follow. So I think it's useful that at the heart of it, lifestyle medicine and the principles that we give are common and uniform across these conditions, which means if we can all sing from the same hymn sheet and give the same message, it becomes easier for the patient's cognitive abilities to take in, to practice, and the more you practice, the more you rewire your nerve circuits and build nerve circuits, and that allows for habit to be formed. Ultimately, that's what we want. We want to change some of those habits that are maladaptive in that sense, not right right now, and change it into a habit that is useful for them.

Sakina: Um yeah, the habit change is definitely very important point that we're focusing more on. Um and yeah, I wonder maybe if we could speak more about mind-body therapies then, um and their role in in sleep maybe potentially and um in pain.

Dr Deepak: So my main take on mind-body therapies, and by this I mean behavioural interventions like mainstream psychological interventions like CBT or ACT that are offered on the NHS, but also so many other therapies like EMDR or emotional freedom technique or somatic tracking or somatic experience, things for trauma, NLP, acupressure, massage, reflexology, reiki. Ultimately, if I think about it and I want to make it scientific and understand, is that we've got a sympathetic nervous system that's on fight and flight. We all always heard that there is a parasympathetic system which allows us to bring us to rest and digest. There's increasing evidence now suggesting that the endocannabinoid system, you know, the system on which medical cannabis acts, is actually present in every part of our body and that helps in balance, in equilibrium. So you've got one system that is like fight and flight to protect us, one system to keep us safe and relaxed, and then one system to kind of bring it back into equilibrium. Ultimately, if you want to calm the fight and flight system, you can use breathing techniques, but my belief is that a lot of mind-body therapies, and that's what the neuroscience evidence is now coming out, that things like yoga, things like massage or other kinds of mind-body therapies, the neuroscience is showing that they are capable of calming the nervous system down and changing the neural circuits to a state of better relaxation. So mindfulness, meditative practices, compassion, self-love, gratitude, all of these are powerful neuroscientifically proven ways to calm the nervous system down, calm the sympathetic system down to a level of equilibrium and balance. So in that sense, you can see that if pain is a state, in chronic pain is a state of hypervigilance, the system is looking out to protect you, it means that the sympathetic system is on a high alert. So using any of these mind-body therapies is a way to just bring the system down. And once you bring the system down, then it is ready to engage with everything around itself. So a lot of times I worry that if people are very traumatized, if they are anxious, if they are living in an environment where neglect and isolation and depression is paramount, then telling them like CBT, you can challenge your thoughts and change it and everything is on you, is very individual. We're assuming that the individual is capable of change and the individual has got all the abilities there and that the individual is rational and can think through this. But we know that the human being is irrational. Behaviour is so emotion driven. And so the first thing we need to do in a lot of these patients is understand their context, be compassionate to what their environments are, and find a way to first calm the system down using any of these mind-body techniques. Then is the time to give them cognitively challenging things like CBT and there, and that will move them to support point. So I think mind-body therapies play a really good role, not just for pain, but also for sleep, but generally that's why I think mind-body therapies are now getting to be more accepted for even mainstream conditions, you know, whether that's coronary heart disease, whether that's asthma management, whether that's obesity management, knowing the context, managing the trauma, reducing the fight and flight response, then you get them to engage with ways of looking after themselves.

Sakina: So a way to prepare the the body environment to then receive other therapies and be able to improve health and pain in a in a better way.

Dr Deepak: Absolutely, Sakina. I think that's that's where and I think that's why the system has to be ready to support them, expecting the individual to do everything themselves is tough. We are there and we have to be better professionals and working with patients, as we started in the beginning of this talk there, is sort of co-design with them on where they need to be and what they see as being healthy means to them.

Sakina: So those mind-body therapies, would it be more with practitioners or would it be things that people do themselves at home?

Dr Deepak: So in the in the book, I talk about the aspect that it has to be sustainable. Otherwise, if somebody is going to be paying 60 pounds a session and travelling 45 minutes to one hour out of their way to go to some place to do a mind-body therapy, then they can't sustain it for long. They'll just do it for three sessions and then something will come and they'll go up. So I guess this is a challenge that we have to do is how do we provide therapies that they could learn, some part of it they can do at home, and then how can we make it sustainable enough to provide it to them when they need it? And can it be made as part of their daily routine? You know, is there a way to ensure that it can be made? So some of these therapies lend themselves to doing it at home. So yoga, you now have wonderful YouTube videos which talk about yoga. You could probably go to a session and then you could be doing some things at home. And once in four weeks, you can still go to that session or go where somewhere to a nearby council with your friends, and that then becomes a way of community support. You do the session, but there's also things that you practice at home. But on the other hand, things like chiropractic or things like reiki or acupuncture, it's difficult to do it at home. So I guess the balance then becomes about financial sustainability and general travel sustainability in which mind-body therapy can be done by yourself and which mind-body therapy you will always have to depend on a practitioner.

Sakina: So when faced with all these different techniques, do you have any tips for finding what works for you in terms of what should I do at home myself and what sort of practitioners should I consult and try, especially with those financial barriers of maybe people want and have the means to try a session with one practitioner, but they wouldn't have the means to try different types of therapies. So do you have tips for finding what works for you?

Dr Deepak: I think I would again say that this is an example of where we want the individual to make the decision, but the system needs to first change. So my suggestion and my thoughts would be that so many councils these days are doing these kind of therapies. Maybe what the council should do or maybe what we should think about in a conference like this is to say, is there a way that councils can be incentivized to have various practitioners coming in to have free drop-in sessions, 15-minute, 30-minute sessions showcasing the various mind-body therapies that are on offer. Patients get to sample it and see what works for them. And if they feel that this is something that they feel they can do sustainably and it's all in their way, it's something that they can incorporate, they've got friends who can do it, then that becomes something that they can find for themselves. Right now, we are saying, well, you go and experiment, you know, but how will somebody go along, take a class of this and then have the willingness to say, well, tomorrow I'm going to pay 60 quid and go and do something else and the third day there. So I guess as a system, we need to change that and think about those as options. Can we have free drop-in sessions once a month or once a quarter where the council or the local organizations are able to charitably support a taster session for many patients willing to explore this. That may be an idea. But in the short term, I'd probably say simple things for pain that have definitely been shown to work, which you can do sustainably for free to start with, are yoga can be definitely try to start at home, gentle seated tai chi, and then after that, a little bit of Pilates practice, breathing techniques, progressive muscular relaxation, emotional freedom techniques, acupressure, all of these can be done with good YouTube videos at home that you can start with there. And then the next steps above that could be once you feel it's working or you want to try it, could be chiropractic or physiotherapy or acupuncture. These might be the next steps that have osteopathic techniques there to go to a practitioner to say, well, can you do one thing extra? Now, reiki, reflexology, aromatherapy are other techniques there, but these all I think will require you to probably see another practitioner first before seeing what elements can you do at home.

Sakina: I'm glad you brought up this need to change the system because we've talked a bit with other guests, we've talked about the fact that the pressure is often on the individual to make the decisions and to improve. But this idea of having a place where people can try and the council promotes trying different therapies and finding alternative ways to help support your health and manage your pain, I think is a very interesting one. And I hope that there will be interest in that in the system improving access to different types of therapies and people helping people find what works for them and try different things out.

Dr Deepak: I think it's a very complex response. Pain is a very complex response. It's an interaction between various systems. And I think we need to be aware therefore that each person is unique, their context is unique. And so we can never be sure that one kind of mind-body therapy will work predictably in everyone. Each person will change differently. So I think we need to be able to provide a menu from which then people can be helped to then tailor down towards there. The biggest thing is we need to be able to address health inequalities. There are people who cannot access digital technologies, there are people who will never be able to interact in a group setting. So how can we provide things then that are individualistic, that are personalized as well? And I think that is always going to be a challenge, but that's where I think the system needs to step in to make the first step. You know, it's like one of those similar behavioural economics. If you have a loyalty card, if you get the first two coffee things punched and given to you, you feel incentivized. So I think that's where the system needs to actually step up and say, here it is, come along, try it, see what it does for you, then take it from there.

Sakina: I'm excited to see where it will go and if, if it will, those approaches will be...

Dr Deepak: It does. Like for example, I lead the long COVID service in our Berkshire area there, and we I managed to secure funding from NHS charities, so we got about 30,000 pounds, and we were able to actually tell our patients, yes, we want to calm the nervous system down with COVID and long COVID. We know that the immune system and the nervous system is hyperactive. Let's try these things. So we spoke to a couple of at a online tai chi group, and they are offering a free set of six, subsidized, but six sessions that are being given to all the long COVID patients that come to the clinic. We spoke to a nearby spa and they said they would be able to give three sessions of a flotation pool therapy. We spoke to another centre there who said we will offer gentle physio and breathing techniques about 20 sessions. So all of these are subsidized and in a way for the long COVID patients who come to our service, we're able to tell them, these are the first steps. These are near to you, these are close by, these are completely free. Do you want to trial them? Maybe if they work for you, then you can discuss that you continue with them. But these are the first steps. So it can be done and we are seeing the take up and we are seeing the response there. So I think if the system can help, we've got proof of concept that it can make a difference. We just need to be more people invested in this.

Sakina: And those sorts of approaches also improve the community building aspect of it, because it's quite interesting you reached to local, local, online as well, but a mix of local and online tools and people and communities and groups that could help and contribute, give their skills to help. So it's also building relationships and a team of people that can work and together.

Dr Deepak: Absolutely. One of the partners is actually an organization called Community United, and they know a lot of ethnic groups and faith leaders and people who other communities and disadvantaged populations who may not even want to come to health care. And actually by reaching these community united groups and saying this is what we know about long COVID, these are the ways you can calm the system down, do a few podcasts and do some videos with them, get the patients to come on to their forums and talk about it. It just builds that wealth of, as you exactly said, a community spirit, because conditions like long COVID, for example, is another new long-term condition. We can't expect the healthcare system to be managing everyone, and there are certainly elements of that condition which can be supported in the community. We've listened to all our COVID related issues, how COVID is much more common and long COVID is much more common when there are multiple comorbidities in a person, which are usually long-term conditions and chronic disease. So it's so important that we encourage and empower the community and empower the people to actually say you can make the change. These are the first steps. We'll help you make those first steps, and then we'll support you as you get more confident in looking after your chronic disease.

Sakina: Great. Thank you so much. That was a perfect way to end the conversation today as well. And I'm excited to see how we can help people implement those approaches better and how we can find what works for individuals and not just throw a bunch of advice and expect people to do it themselves. So I'm excited to see what comes next.

Dr Deepak: Absolutely. Wonderful. I thank you so much Sakina for having me on there.

Sakina: Amazing.

Dr Rupy: Thank you so much for listening to this week's episode of the podcast. Remember, you can check it out on YouTube, subscribe whilst you're there. Make sure you subscribe to the Eat, Listen, Read newsletter. It's free, guys, and it's recipes, mindfully curated content. It's very short, it doesn't clutter your inbox. And check out the app. You can download on the App Store, The Doctor's Kitchen. It's hundreds of recipes that you can filter according to your health goals. I will see you here next time.

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