Putting Pain Into Context

Fiona McMahon, DPT, PT

What-is-Mindfulness-Meditation

 

Pain is a common part of our lives. We experience it in both large and small doses, from stubbing your toe on a table leg to the pain of childbirth or a broken bone. As clinicians, we see pain on a daily basis and patients with some kind of pain make up the lion’s share of the cases we see at Beyond Basics Physical Therapy.

Up until 20 years ago, pain was seen as a unidimensional phenomenon, simply a stimulus sent to the brain to inform the individual of tissue damage. As our understanding of pain has broadened over the past few years, we recognize that our perception of pain is also comprised of factors like emotion, situational context, experience, and memories, as well as our beliefs and expectations. This new way of looking at pain has expanded our knowledge and has opened up new options for treating pain beyond just facilitating tissue repair. Understanding your own pain can also help you regain control over your pain. If you have pain, I sincerely hope you read on.

 

Why Pain

Pain, especially acute pain serves a very important function. Pain is the the signal to the brain that warns of tissue damage. It compels you to take action. It is the force that causes you to rapidly remove your hand from a hot surface before severe damage occurs. It keeps you from using an injured limb, which is in the process of healing. It is the protector of your body and is an integral part of staying healthy.

The problem with pain is when there is a mismatch between the actual tissue damage and the amount of discomfort it causes. Chronic pain is a pain that persists 3 months or more after an injury and does not resolve with resolution of the injury. This type of pain is much harder to treat as the causal mechanism is not easily identifiable like a cut or a broken bone would be. According to the American Academy of Pain Medicine, chronic pain affects 100 million Americans, which is more than those suffering with heart disease, diabetes, and cancer combined. Chronic pain accounts for 630 billion dollars of US health care costs.

 

What makes acute pain chronic?

Pain is very much affected by the circumstances in which it arises. Stress and anxiety are both two huge mediators of pain. We often look at stress as bad. I know I do.  But in cases of acute stress and imminent danger, it is stress that causes a release of endogenous opioids (body-produced pain-killers, which actually function to lower your threshold for pain). An example is a man who manages to escape a burning building, who realizes he is severely injured only when he makes it to safety. Stress is not the same as anxiety; it is a reaction to dangerous or harmful events already set in motion.

However, stress, as we know, is not a pure good. We all have read warnings about the long term effects of stress. The hormone most closely associated with stress is cortisol. Cortisol gets a bad rap, but it has its place. In a situation that requires it, cortisol is a veritable godsend. It causes the body to mobilize glucose and calcium to give one energy to escape, fight, or rescue. The only problem with cortisol occurs is when it is released over long periods of time. Cortisol is released with stress, both emotional and physical. Cortisol draws glucose from the muscle tissue and calcium from the bone. Over time, long term stress can cause muscle pain, weak bones, weakness, and beget a further cycle of pain. It has been proposed that the dysregulation of cortisol can be linked to chronic pain syndromes like fibromyalgia.

Anxiety is usually associated with stress and often times go hand in hand. Anxiety has an important distinction from stress. Anxiety is related to the fear of negative events happening before they have actually happened. It has the opposite effect of stress in the body and actually lowers your pain threshold, making unpleasant physical stimuli more painful. This illustrates the effect of perception on pain. Anxiety and stress that occurs from worrying that the pain will go on forever, or prevent you from functioning fully, actually perpetuate pain and may be in fact, a self fulfilling prophecy.

Further evidence that pain is not solely a response to noxious physical stimuli, is provided by the phenomenon of phantom limb syndrome. Phantom limb phenomenon occurs when an individual perceives pain in a limb that no longer is part of his or her body. Phantom limb pain sparked Ronald Melzack’s investigation into pain and his subsequent proposal of the neuromatrix of pain.

Melzack argues that because the pain associated with phantom limb feels so real, there must be an underlying neural circuit, responsible for that limb, and all limbs, that are responsible for the body’s sense or schema of that limb. Melzack goes on to explain that the circuit can be modified by incoming stimuli, such as heat, pain, vibration, et cetera, but the circuit can also exist and work entirely on its own as in the case with phantom limb phenomenon. He argues that these circuits are “built-in” but modified by experience and do not necessarily need  external stimuli to activate a given circuit.

All of this goes to say, that pain is much more than the response to a physical stimulus, and cannot be treated simply by removing that stimulus. Effective treatment of pain requires both a top-down and bottom-up approach.

Treatment

So what is to be done about chronic pain? It appears clear that the first step is to remove the stimuli causing the pain. In physical therapy, an individual’s trigger points may be treated, his or her posture corrected, and muscles strengthened as well as many other techniques and strategies. All of these treatments are a step in the right direction. But in many cases of chronic pain, this is usually not enough. Physical therapists must recognize how their patient’s pain experience is modified by the context the patient is in . A therapist may encourage deep breathing and progressive relaxation to help calm the central nervous system and lessen an individual’s stress burden. He or she must also be vigilant to recognize when counselling, neurodynamic training, or cognitive behavioral therapy is necessary to break the stress, pain, and anxiety cycle.

At Beyond Basics, we realize your pain may not be unidimensional. We practice a holistic therapy designed to put our patients at ease and guide them through their recovery journey. In addition to teaching our patients stress management techniques, we also host bi-monthly meditation sessions with Ryanne Glasper ( see her current schedule in resources). We are also experts at recognizing when a patient might need a little extra help in his or her recovery. We work closely with many tri-state area therapists, psychiatrists, and psychologists and can refer when necessary to help augment our patients’ results.

Pain is an extraordinarily difficult part of the human experience. If you are in pain, today’s the day to seek help and get your life back. We invite you to start your journey with us, Beyond Basics Physical Therapy in New York City.

 

For Further Reading about Chronic Pain:

 

Heal Pelvic Pain

By: Amy Stein DPT

http://www.healpelvicpain.com/

 

Headache in The Pelvis

By: David Wise and Rodney Anderson

https://www.amazon.com/Headache-Pelvis-Revised-Expanded-Updated/dp/0972775552

 

Explain Pain

By: David Butler

https://www.amazon.com/Explain-Pain-David-Butler/dp/0987342665?ie=UTF8&hvadid=49868747328&hvdev=c&hvexid=&hvnetw=g&hvpone=&hvpos=1t1&hvptwo=&hvqmt=b&hvrand=9859257768995611935&ref=pd_sl_1tz644lwle_b&tag=googhydr-20

Meditation at Beyond Basics

Ryanne Glasper

110 East 42nd Street, Suite 1504

New York, NY 10017

  • October 13th, 2016 at 7pm :  Pelvic Pain, meditation workshop with Ryanne Glasper, DPT & Restorative Yoga
  • Register at: pelvichealth-101.eventbrite.com 
  • Keep your eye on our website/blog for more upcoming classes!

 

Sources:

Allen R, Zahn M. Understanding Pain. DermoNeuroModulating.

 

American Academy of Pain Management. AAPM facts and figures on pain management. http://www.painmed.org/patientcenter/facts_on_pain.aspx . Accessed July, 2016

 

Melzack R. Pain and the neuromatrix in the brain. J Dent Educ. 2001. Dec; 65(120: 1378-82

BBPT Health Tips: Entering Hydration Station

Fiona McMahon, DPT

water-life-crop

 

The dog days of summer are here, folks! Walking from the subway to your apartment feels akin to walking on the surface of the sun and it’s nearly impossible to avoid sweating through the back of your shirt on your way to work. It’s time to think about your water intake.

At Beyond Basics, you can often hear our therapists ask this question over and over, “are you drinking enough water?” But how much is enough? Can you over do it? And lastly, why is it important for me to be drinking so much water?

 

Benefits of Hydration

 

  • Body Temperature Regulation: The body needs water to produce sweat to cool your body, without enough water the body cannot cool itself, which can be dangerous especially in hot weather. This is especially important in children and older adults
  • Physical Performance:  Decreases in athletic performance have been seen with as little as 2% body mass water loss. Ensuring you are hydrated ensures a better workout.Dude running
  • Brain Power: Even mild dehydration can put you in a bad mood, as well as affecting memory and alertness  study lady
  • Bowel Function: Not consuming enough water can slow down the movement of stool and lead to painful constipation  Excellent-toilet-paper-holder
  • Heart and Blood Pressure: Dehydration decreases the volume of blood in the body. With decreased blood, the heart has to work harder to circulate the smaller volume throughout the body, resulting in increased strain on the heart. This is of particular concern in those with heart conditions.  hearthealthy
  • Bladder:  Drinking enough water can reduce risk of urinary tract infection by keeping bacteria in low concentrations in the urinary tract. It can also reduce general bladder discomfort by reducing the amount of bladder irritants present in the urinary tract.

 

 

 

What should I Drink?

How much and what to drink isn’t always clear. I often get asked, what counts. Does decaf coffee count? Does juice count? My answer in the pelvic health world is no, water is the only thing that counts as water (even sparkling water doesn’t count). My aim is to reduce the amount of bladder irritants present in the bladder, in addition to adding all the other benefits outlined above.

So How Much Water Do I Really Need?

–  The advice for how much water to drink is varied. One common adage is to drink 8- 8 ounce glasses a day. This is a great starting point and doesn’t take into account an individual’s size or how much s/he perspires. We also can’t always rely on our own thirst. In both the elderly and children, the sensation of thirst does not always occur strongly enough or frequently enough to prevent dehydration. The common rule of thumb is to drink half your bodyweight in ounces. So take me, for example, your average 140 pound physical therapist:  Half my bodyweight is 70 lbs, so I should drink approximately 70 ounces or 8.75 cups. If I exercise, I should increase my water intake to match the amount of water I lose in sweat. Other reasons to increase water intake include, hot days, history of constipation or if you are breast feeding.

Another little saying I often say to my patients is, “If you are going to pollute, dilute”. What that means is, if you are going to indulge in a little caffeine or alcohol, follow it with an equal volume of water to prevent any dehydrating effects.

 

Sources:

Popkin B, D’Anci K, Rosenberg I. Water, hydration and health. Nutr Rev. 2010 Aug; 68(8): 439–458.

Cupping: Not just for Olympic Champions

Fiona McMahon, DPT , PT

Cupping

If you are like most Americans, you have probably heard a lot about “cupping” because of Olympian, Michael Phelps. Phelps has been seen tearing it up in Rio with purple hickey-like spots all over his back. Like kinesiotape in London and Beijing, cupping has become the new hot thing for top level athletes.

We, at Beyond Basics Physical therapy have been using cupping in our treatment of patients for a while now. Our aim is to improve athletic and recreational performance, and the mobility of restricted (or stuck) tissues to help the tissues function better and lessen our patients’ pain.

In our practice, we use cupping as an extension of our hands to help tissue that has been immobile secondary to injury or disuse, to regain its’ optimum mobility. By improving mobility, cupping can help to reduce painful pulling on tissue, improve blood flow, and reduce dysfunction around the adhered area.

In our practice we find that cupping can be particularly helpful in treating old surgical scars, such as cesarean section scars, to reduce painful pulling and disruption of the function of nearby organs and muscles. We also like to use cupping on notoriously tight and troublesome structures like the iliotibial band to help with conditions like runner’s knee.

Cupping is like any treatment modality, it is not a magical cure that will immediately banish all your ills. Cupping is a tool used by therapists and acupuncturists in conjunction with other treatment modalities to correct any other underlying factors that may be contributing to a patient’s condition. It may not turn you into an Olympian like Michael, put in conjunction with a skilled physical therapy program it can help you feel a whole lot better.

Welcome to Beyond Basics Physical Therapy’s monthly “Tip from your Physical Therapist!”

Fiona McMahon, DPT

We are rolling out a new tip monthly to help you increase your fitness and general health. Today we will be going over a stretch. Before we get started, let’s go over some basics.

The most common question I get asked when I give people a stretch to do is, “ should I do this stretch before or after I work out?” My answer usually is, whenever you are most likely to remember to do it. The best stretch or exercise is one you actually do”. I then go on to explain that you get a little more bang for your buck if you do it after exercise. In a Cochrane review, researchers show that stretching before exercise typically reduces delayed onset muscle soreness (DOMS) by ½ point on a 100 point scale and stretching afterwards reduced muscle soreness by 1 point on a 100 point scale.

Reading that last paragraph, you probably thought, “small potatoes, Fiona, 1 point is not worth disrupting my routine for”. But stretching has many other benefits. The Mayo Clinic Reports that regular stretching has been shown to improve athletic performance, improve blood flow to the muscle, and reduce risk of injuries. Do I have your attention yet?

Let’s introduce July’s stretch:

Adductor Stretch

Adductor Stretch- melissa Stendahl

Staff Physical Therapist, Melissa Stendahl demonstrates

Muscles involved: The adductors, or inner thigh muscles. These muscles primarily serve the function to bring your legs together and are commonly involved in “groin tears”

Stretch Type: Static: Best if performed after workouts on warm muscles. Exercise caution if stretching cold ( unwarmed up) muscle.

As always: No stretch should ever be painful. If a stretch is painful, stop and consult your physical therapist for modification.

Directions: Hold this pose for 30 seconds to a minute; repeat. You may increase the intensity of this stretch, by hinging at the hips and bringing your torso forward over your legs. Remember, to keep your back straight and that this should be a gentle stretch and should not be painful.

Learn more about Melissa Stendahl here!

Sources:

 

Herbert R, de Noronha M, Kamper S. Stretching to prevent or reduce muscle soreness after exercise. Cochrane Review.  2011.
Mayo Clinic Staff. Stretching: Focus on Flexibility. Mayo Clinic. 2014. http://www.mayoclinic.org/healthy-lifestyle/fitness/in-depth/stretching/art-20047931?pg=1. [Accessed: July 23,2016} 

Interview with Ryanne Glasper, Physical Therapist at Beyond Basics PT

Fiona McMahon, DPT
At Beyond Basics, we are lucky to have a great crew of Physical Therapists, who come from ryanne2015diverse training backgrounds and experiences. It is some of these different experiences that betters our practice and allows us to grow as clinicians. We took some time out from our wonderful patients, to sit down with physical therapist, Ryanne Glasper, to find out what sets her apart as a physical therapist.

What sets your orthopedic approach apart from approaches seen in other orthopedic clinics?

I can tell you that I love biomechanics. I’m obsessed with how the body moves. I’d consider myself a movement scientist. Moving is such a joy to me that I not only want to facilitate my patients recovery, but also help them better understand their bodies and efficient movements. I want them to leave my office and feel empowered. Like most therapists, I create individualized programs for my patients, but I make it a point to individualize every aspect, including the manual techniques I choose, even the language I use. I try to figure out what works for them, meet them there, and then challenge them to expand, whether that be in knowledge, strength, flexibility, clarity of mind, et cetera. I

Tell us about your background and what type of conditions you saw before coming to BBPT

Before BBPT I worked at PhysioArts Physical Therapy for nearly 10 years. I worked first as a physical therapy aide while in school, and then as a therapist. I worked with a remarkable group of therapists. When I started, I was the youngest and least experienced. I worked with therapists that had ten-plus years of experience and I was incredibly lucky to be mentored by them, especially my boss Jen Green.
At PhysioArts we worked with the performing arts community, professional dancers, actors, singers …. all of Broadway basically. I think I’ve worked on every joint in the body, from the foot to the cranium! From the usual ACL reconstructions, hip replacements, rotator cuff tears to the lesser known cuboid sprains and rib torsions.

How do you integrate that experience into your role as a PT at BBPT?

While at PhysioArts I actually coordinated care with a [former] therapist at BBPT Dustienne Miller (now in Boston Area, Mass). We shared a few patients. I loved the team effort. You don’t learn much about the internal aspect of the pelvis in PT school, so her work was always kind of a mystery to me. But she helped people in a way that I couldn’t! Working with Dustienne gave me even more of an appreciation for the body. Joining BBPT just expanded my tool box! I’m not sure that I integrated my past experiences into BBPT, I’m the same therapist. I just know what’s going on inside [the pelvic floor] now!