Physical Therapy for Chronic Pain

Vicki:

Welcome to our HMC Healthworks Podcast. September is pain awareness month. And today, we’ll be speaking with Rachel Presnell, a physical therapist at Select Physical Therapy in Cromwell. Rachel has a BS in human physiology from Boston University and a doctorate of physical therapy from MGH Institute of Health Professions in Boston. Rachel also is certified in dry needling, and she also is an orthopedic clinical specialist. So, Rachel, we’re so happy to have you with us today.

Rachel:

It is so great to be here.

Vicki:

So Rachel, when we were preparing for this podcast here at HMC Healthworks, the first person that came to my mind when I was thinking about pain awareness was you. You helped me through a really difficult and painful time in my life after a car accident I had about a year ago. According to the CDC, there’s already over 116 million American adults annually that experience chronic pain. Could you talk to us a little bit about what chronic pain is?

Rachel:

Yes. Chronic pain is defined as pain that lasts longer than three months, which people usually find to be a pretty short period of time. But that’s usually when we believe you start going down that road of having to deal with pain on a chronic level.

Vicki:

It does seem short. But for the person that’s going through it, it feels even longer than the three months.

Rachel:

That is true.

Vicki:

Speaking from personal experience. Another thing I wanted to ask you about, which everyone is well aware of the national crisis in this area is about the connection between chronic pain and the opioid epidemic. I know the CDCs they’ve been on the front lines since this opioid epidemic. They estimate the cost of dealing with chronic pain in that particular opioid problem is estimated at approximately 600 billion annually.

Rachel:

I’m actually so glad that you brought this up because with everything that this country has been dealing with. The opioids, there’s a lot of research showing other methods that can be way more effective in terms of treating chronic pain. While, opioid treatment can be necessarily in certain cases like cancer treatment, hospice care, and other acute conditions. It’s not been shown as an effective treatment for chronic pain. For instance, nowadays, they’re not even really giving opioid post-op. They’re trying to manage it with things like Tylenol. So opioids have several side effects, including constipation, confusion, nausea, vomiting, dry mouth, itching, sweating, depression, addiction, and withdrawal symptoms when you stop taking them. I’ve had patients have withdrawal symptoms even after taking them a very short period of time, which is one of the things that makes them so dangerous.

Vicki:

I know just a couple of days that they had me take them after the car accident. I didn’t like them. It really didn’t make me feel better. It just made me be out of it and not care. It definitely makes sense why the CDC recommends non-drug approaches such as physical therapy for pain.

Rachel:

Physical therapy has been huge nowadays with dealing with chronic pain, particularly because of all of this research in opioids and how other ways that we can deal with this. We reduce dependence and improve quality of life by not having people take the opioids. The treatment that we evaluate the patient and then treatment is determined by clinical research and clinical experience to detail and to visualize for each patient versus a drug regimen program that is not specific to each person’s needs. We have the ability to work with all ages and ability levels to improve movement patterns, reduce pain and improve overall quality of life.

Vicki:

Rachel, I remember when I first started working with you, you said something, these aren’t the exact words, but it stuck in my mind something to the effect of while I may experience good days and bad days with my pain that with your help there’s still much that I could do to make the good days better and the bad days less frequent. I always felt like that’s where physical therapy comes in.

Rachel:

We definitely, and usually what I tell people is after you leave physical therapy if you were feeling better for 12 hours the first time. Hopefully, the next time it’s 24 hours, or at least we see a decrease in the intensity of pain or the duration of pain. So we’re always trying to make a change in those good days and bad days. What we really try to focus on is movement patterns that make you feel better so you feel safer to move. The more you can move, the better that you’re going to feel. So we strengthen muscles and joints and improve flexibility. So you can improve your normal daily activities. Then when you gain confidence in those, then you can progress all of your activities. We do that. We also try to reduce the inflammation and try to change the ways that you do things. So you don’t think so much about your chronic pain. We re-educate your nervous system to make it less sensitive to the pain signals.

Vicki:

That makes sense. The other thing I wanted to talk to you about was some of the physical therapy treatments and the modalities that you use to help folks ease the pain.

Rachel:

The first thing we do start with is patient education. The discussion on the first day about chronic pain and what it means can be pretty expensive. There’s actually a book sometimes I’ll give out to people called Explain Your Pain. Because the way that our bodies rewire themselves when they think it has to get used to chronic pain is hugely important to understand. We try to make sure first that you understand what’s happening and then what physical therapy means. Every single person is so individual. So it’s really important that they understand what their role is along with what my role is. Part of this physical therapy is empowering the patient to take charge of their own recovery.

Vicki:

That was a big key for me. I mean, I remember one of the things that was really helpful for me was how you educated and guided me and understanding the source of the pain and the causes and those particular areas of effective from my injury and then the physical problems that manifest themselves after the injury. I also felt when you were just referring to really trying to do an extensive education with them about the whole pain starting, ending the things that you just discussed about. How personalized it is that you were really thorough, and you were very in-depth in my intake, which you were just describing. I was wondering, talk to me about the steps or the process that you use during your first consultation.

Rachel:

I always want by the end of the first consultation, have people have exercises and things, homework for them to do. But in order to get there, it really is a lot of discussion. When is your pain worse? When is it better? Are there certain things that you can do to relieve the pain? Because then some of those things we can focus on to get better movement patterns. The length of time, and then a thorough physical examination of depending on the body part. The range of motion, the strength, help peeling all the tissues in the area to see what might be feeding into some of the pain pathways.

Rachel:

So the very first session is a lot of history taking, and then from there, physical evaluation and then again, education, and then, of course, giving something on that first day to make sure that they can start controlling their own fate when it comes to chronic pain.

Vicki:

You’re right about that, that’s a big piece of it, is the involvement of us. I know with myself I had my homework and my exercises, and I was working on them, but some of them, I was not as coordinated in doing. But you were always very encouraging, saying, focus really on the ones that you can do and just make sure you’re compliant with that. The other thing I felt when I was at Select Physical Therapy, that my overall experience, or it seemed like to me, the goal of physical therapy was going to be focused on, as you described, how to best take care of myself in general, so that I have experienced less pain, like going through those times and the different patterns that you discussed.

Vicki:

One thing that I always noticed when I was in there is it seemed that all the patients that were in you’ll care no matter what it was for, whether it was a car accident or an age-related thing, or a younger person with a sports injury that I always observed, that you all were teaching them specialized techniques, just for everyday movement and activities. And I also felt that the thing that helped me and that I was thinking someone would hope to find if they do go into physical therapy is really a positive encouragement where you all focused on safely increasing our daily exercise and just helping us learn to pace ourselves and alter our movement dysfunctions. I observed and experienced some different types of therapy during my treatment time. And I wanted to ask you about them and how do you explain these to our listeners? Talk to me a bit about the role of exercise in physical therapy.

Rachel:

So there has been a lot of research, as you can imagine recently when it comes to activity and chronic pain. Basically, everything points to movement makes things better, and that actually pain is okay. For a really long time, everybody was don’t push into pain, don’t push into pain, and unfortunately, that has established a lot of fear and avoidance behaviors. So now basically all of the most current research that we should a little bit of pain is okay. So that’s what I try to explain people when I’m getting them act moving is it’s okay to feel some level of pain. You just don’t want to push past it and make yourself no longer functional.

Rachel:

So we do a lot of, and you know this based from our discussions, a lot of communication. When I did this the next day, I couldn’t move. Well, then that means we did too much. So doing that fine, I always call it a fine line of wanting to increase activity without it being punishing. Because again, the more you move, the more confident you feel in moving, the less muscle guarding, the more you move, and it ends up being a positive circle. So we do passive activities, which either the therapist or the patient themselves use for flexibility to gain mobility. And then we do a lot of active exercises, which they do under their own power that could be bike, riding, treadmill, arm bike, and then moving into strengthening, postural exercises, things like that. Because we do want to strengthen muscles, improve flexibility, increased joint mobility, and strengthen the muscles around weak joints. I always tell people, for instance, if it’s arthritis, I can’t go in there and scoop the arthritis out, but what I can give it as an optimal working environment between strength and flexibility.

Vicki:

That definitely makes sense. Another thing I wanted to ask you about is what is manual therapy? Tell me the difference with that, compared to other types of therapies that you all.

Rachel:

I usually like to take a comprehensive approach to therapy, where there is passive and active exercises and strengthening and pasture like we just discussed. But a lot of therapy will also I often have manual, which is hands-on therapy. That can include massage, which eases pain and promotes healing. It boosts circulation. It can be soft tissue mobilization, which is more of what I would do that increases mobility around a joint by breaking up scar tissue, releasing tension, treating a DEMA, and addressing myofascial adhesions, which are huge with chronic pain or direct manipulation of joints. So joint mobilizations and manipulations to restore alignment and improve function.

Vicki:

The one thing I also really wanted to ask you about is, so when you were talking about the manual therapies that would be when we would conclude our sessions, you would administer massage, which you just said one of the manual therapies. I have to say that that always really seemed to help the injured neck and shoulder areas, and it was really soothing, and it helped me with the pain a lot. So I also was thinking about there’s two other things that we did at the end of my sessions, and one was that you hooked me up to a nerve stimulation machine, which I love because I really felt it helped alleviate my pain and provided comfort at the post PT session. So talk to me a little bit about that unit.

Rachel:

What we use in the office is typically interferential current, which is a little different than the home units, but the TENS units are often what you can use, where you stimulate that painful area for relief. You put the electrodes on the skin and then turn the machine up to a comfortable dosage.

Vicki:

How does that stimulation the electrical current, how does that work to relieve pain?

Rachel:

The stimulation interrupts the pain signals from the nerves in that area. So basically, it interrupts the pain pathway to your brain. It can also boost endorphins and neurotransmitters, which will serve as natural painkillers.

Vicki:

It definitely did that for me. It was definitely something that I felt definitely reduced the pain, and I did. I always felt better afterwards. In addition to doing that electrical stimulation, the second thing you did when we were doing that is that you took big ice pads. You put them on my neck and shoulder, and I noticed that with that electrical stimulation coupled with that cold ice pad, it really seemed to give me that pushover for leaving, always feeling good and not sore. Tell me a bit about the role of hot and cold therapies for pain.

Rachel:

Stereotypically, we think of cold therapies for acute inflammation. When I have somebody that I’ve taken through a lot of exercises where I think that it might actually increase the pain. Afterwards, sometimes we’ll end with a cold pack to just reduce the inflammation that we had just increased with the very important exercising. Hot pack, I usually think of for stiffness, more of a chronic ache rather than an acute pain, and so sometimes they are used usually to warm people up before the physical therapy happens. But it’s not necessary to use the hot and the cold pack necessarily every session. It’s an individual thing.

Vicki:

That makes sense. Because I didn’t see everybody doing it, but I know that I did it, and it was always helpful. I know that you’re going to know what I’m going to ask next because I was always so fascinated when I was in physical therapy. I wanted to ask you about some of the newer and maybe less well-known therapies that are out there because I was watching you do a treatment with someone, and it looked like some type of pricking of a needle, and I was wondering what’s going on there?

Rachel:

I am certified in dry needling, and I always laugh and say it’s the closest thing we as physical therapists have to a magic wand because I will palpate for the trigger points, then muscles, and then I stick a needle in it. And when the needle goes into the trigger point, a message goes to the brain for the brain to release that trigger point. So it’s actually a pretty effective tool. So if you have a strain in your calf and you’re a runner, I can stick a needle in it and typically take that strain away.

Rachel:

It’s a little uncomfortable while I’m doing, but the benefits outweigh the amount of time that you feel uncomfortable. The thing is kind of brings us back to our earlier conversation is the important part is following it up with neuromuscular re-education. I can take the trigger point away, but say it’s in your upper trap for postural reasons. If we don’t correct the postural difficulties, then the trigger points just going to return.

Vicki:

It’s not a single approach. You’re saying it’s just an extra tool in your toolbox to get the person really healthy?

Rachel:

Exactly.

Vicki:

The other thing that I know definitely affected me, and I’m sure people have read about it. But I really wanted to get your thoughts about something I feel, which is one aspect of pain that often gets overlooked is that we’re always focusing on the physical side, and there’s a real mental side of pain. I know that when I was in your care, I was not in a good place mentally when I was in pain. I was having physical challenges. I feel my mindset wasn’t very good. I just wanted to know what’s the role with physical therapists with that? If you could just address depression, anxiety, and your experience and overview of it.

Rachel:

So actually, that is a great question because we have physical therapists now. There’s a huge part of our education that addresses the bio-psycho-social approach to physical therapy, we call it. So clearly, we’re focused on the biology and what the pathology is, what’s happened. But we have to be considering the psychological and social issues that are associated with chronic pain or other injuries. So we really do try to help address the depression and anxiety. And like I said, I’ll even give people the Explain Pain book to read, which really addresses what actually happens in your brain when you’re experiencing pain, particularly chronic pain and how it actually changes the shape of your body part on your homunculus, we call it is you have a picture of your body on your brain and everybody part is supposed to take up a specific amount of your brain.

Rachel:

But when you have chronic pain, that body part grows and takes up more space and pushes other aspects of your body away, and then it becomes your whole focus. So even having these conversations and having people understand that we understand that and how we need to address it is hugely important.

Vicki:

It’s interesting because it just triggered a memory I had, and it was always very sincere. I think that connecting with a physical therapist really is also part of the journey, and I always was appreciative and felt that with you. I think what you were talking about not having the focus on just the pain. I remember you would have discussions about goals. If I was trying to go to an event that I was nervous about because I was still having a lot of pain and just that interaction of saying, okay, what are you nervous about? What are you going to do? Those kinds of things. And then, doing the check back when I came back. I also felt like that was really part of the recovery too. Thank you so much for that. And in anybody listening, I would definitely recommend when you’re finding a physical therapist, find someone you connect with and that is interested in you more than physically. Before we close today, there’s something I always ask all of our guests. I mean, if there was one thing you could tell someone about pain, what would it be?

Rachel:

I would say that we all have it. We all experience it. You’re not alone. To definitely get help, I always say when I see people. They’ve had pain for longer than I think they should. I always say, why didn’t you call me early and get help. There’s people out there that can help support you and help get you moving. Because again, the more you move, the better you feel, and even though sometimes that seems like a daunting task when you have a lot of pain, that’s why it’s important to go to an expert that can help work you through it.

Vicki:

You’re right, Rachel baby steps.

Rachel:

Exactly.

Vicki:

So thanks so much for… I know, I did it. So I’m really a big advocate of getting over that fear and just baby steps and keep pushing. It was really great. Thank you so much for speaking with us today.

Rachel:

It was excellent being here. And again, anybody can reach out to me with any more questions if they have any. I work in the Cromwell office. You can call here, get my email or contact you for my email. Because again, I’m a firm believer people shouldn’t have to have a lot of pain and that they should be doing all the things that they want to be doing. So I’m always here to help.

Vicki:

Thank you so much. And for our listeners, two things I wanted to tell you, Rachel’s with Select Physical Therapy. She’s at the Cromwell office. You could look them up online. If you need to be in some capable hands, Rachel and her colleagues are the people that can help you. I also wanted to thank all the folks that tuned in today and remind you to stay tuned for future HMC Healthworks Podcast. And also, just go to agencyhealthworks.com for more information on physical, mental wellness. And well, everyone stay healthy, happy, and safe.