Fear as it Relates to Pain

A very good friend of mine who is also a Physical Therapist asked that I do a post regarding fear and pain.  Sounded like a great idea as we all will experience or have experienced pain in our life.  

Pain can have a large impact on how we respond to it and cause altered behavior.  In particular, exposure to pain for a long time can cause us to become MORE sensitive to pain.  This heightened sensitivity leads to something called fear avoidance behaviors.  This is basically just a fancy way of saying that if you are afraid of something you will adopt behaviors to help you avoid it.  In the case of pain, this means we will do whatever we can to avoid pain.

As we develop a fear of reproducing the pain, we develop avoidance of the behavior or ANY behavior that may recreate the pain.  The longer the pain persists, the more "avoidant" we become.

An interesting aside -- if pain causes us to move in ways that are out of the ordinary in order to avoid the pain- that in itself can cause pain or muscle damage in the areas that are trying to compensate.

So can we do anything about it?

Fortunately, yes, but it is not easy.  The first step is finding ways to reduce the pain in the first place.  This may involve medication, physical therapy, massage, exercise, etc.  

The second step is very similar to the way we treat fear of anything -- spiders, snakes, etc.  It is a gradual and progressive introduction to the thing we are afraid of until we can be in its presence and even hold it without evoking the emotional response we had learned.  We are retraining the brain.  Teaching the brain that it doesn't have to be afraid of that activity and provoke a response.

It's the same thing with pain.  We gradually start working toward the activity that was causing us pain in the first place until we can perform that activity without pain any longer.  An example of this could be pain with walking.  Let's say your right foot hurts severely every time you take a step.  In this example, as the pain improves you want to gradually reintroduce walking.  This may mean using crutches or a walker to allow the right foot to be non-weight bearing and progressively adding more weight to the right foot as the reduction in pain allows - "finding the threshold" - the threshold of pain, that is. The critical piece to this is not crossing that threshold or else we evoke our friend Freddy Fear again and the avoidance behavior.  Crossing the threshold can also cause us to start to doubt whether or not we are improving and lead to greater fear avoidance.  Once full weight bearing with the walker or crutches you progress to a cane.  When you can walk without a "limp" with the cane you discard the cane.  When you can walk normally without a device, perhaps you start to jog, etc.

Obviously, this can be a very complex process in other scenarios.  The bottom line, however, is the same.  If we do not retrain the brain, we will not conquer the pain as simply reducing the pain may not be enough.  Why?  Because the longer the pain goes, the more hypersensitive we are.  This means that pain has to be practically 0 if we have had it long enough to even realize it has reduced!  This is one reason I think early mobilization after surgery is so critical.  In addition to reducing the deleterious effects of bedrest it helps us get moving before we become too afraid to move.  We confront the fear of what moving will feel like right away.  Once we confirm that we can move despite it or that it isn't as bad as we suspected we can move forward more rapidly as we have taken "Freddy Fear" out of the equation.

The post before this one was on Diaphragmatic Breathing.  This may be a good way to start moving again, especially in cases where ANY attempt at ANY movement is painful.  Deep, diaphragmatic breathing can be therapeutic.  If you don't believe me, give it a try :)

Diaphragmatic Breathing Part II

Do you believe in serendipity?  Seems like an odd way to start a post titled "Diaphragmatic Breathing Part II", doesn't it?  It connects.  Just give me a minute to get there.

Last night I was meditating.  Yet a new venture for 2017.  I have long known of the benefits but have just recently given it a truly full effort.  I am terrible at it.  I guess even more reason to keep doing it.  Even though I am not very good at it, it has really helped to calm my mind and give me clearer focus just in the 11 days that I have been employing this age old technique.

I use an app called "Calm".  You can download it from the app store.  It has daily meditations that are based around a theme.  Last night's theme -- "Serendipity".

So what does serendipity have to do with diaphragmatic breathing?  Well, nothing really, except for the fact that this morning while I was running I found myself employing diaphragmatic breathing and running with much greater ease and fluidity.  The serendipitous part is that I started this blog with a post on diaphragmatic breathing.  My meditation practice has been focused around breathing, especially "belly" or diaphragmatic breathing.  I realized this morning that perhaps, serendipitously, starting with diaphragmatic breathing was the best place to start as this is the basis for a lot of different applications from exercise to pain control.

I have never given birth, but have witnessed it - 4 times. Yes, I have 4 children.  For quite some time breathing techniques have been used to help manage the pain of delivery.  If breathing can help manage THAT pain, just imagine how effective it may be in helping with other pains.  There is a post coming on that very subject -- Pain.  Pain and its effects on the brain is the post, but there is discussion in that post about how breathing may be a critical step in breaking through pain.

It also hit me this morning that although I extolled the virtues of diaphragmatic breathing in my initial post and gave links to how to do it, there was not an explanation of how to do it during exercise.  So let's apply it to running as that happens to be what I was doing this morning, but realize you can apply this to any other activity, be it walking, cycling, swimming, etc.

So how do you do it?

For me, the easiest way to do it when exercising is to concentrate on pressing  or pulling the belly in as you breathe out.  Breathing out in this manner almost automatically forces you to breathe in correctly.  This helps to improve the amount of air and control the breathing rate.  The other helpful tip I can offer is to coordinate your breathing with your step rate.  So for example, every fourth step, I breathe out as my left foot hits the ground.  Depending on the pace and your lung capacity you may find that every 3rd or 5th step works for you.  It doesn't matter.  Coordinating it this way assists you in blowing off more carbon dioxide, helps you to "squeeze" the air out with your belly and thus pull it in using the diaphragm.  This leads to fewer breaths per minute, more efficient breathing and improved energy conservation.

Diaphragmatic Breathing

A patient presented the other day with a long history of back pain as well as numbness and tingling in the arms and legs while swimming.

After extensive workup by a number of providers: orthopedist, pediatrician, neurologist, rheumatologist, physical therapist (me); it was decided that she had "Hyperventilation Syndrome".  Basically she was breathing very rapidly with exertion but not getting enough oxygen to her working muscles when exercising.  The lack of oxygen was causing the feelings of numbness and tingling in her arms and legs.

Hyperventilation and improper breathing are issues we see with patients in a lot of different scenarios.  These scenarios can range from an athlete that is overusing accessory muscles of inspiration to the COPD patient that is trying to cope with reduced lung capacity and reduced lung tissue elasticity, to the desk jockey who is under considerable stress.  Let's face it, we NEED oxygen and will do whatever we can to get it.  No matter the cause, oftentimes it is failure to breathe using the diaphragm ("belly breathing") that leads to hyperventilation and shallow breathing and reduction in the amount of air that is inspired.

When we "mouth breathe" or bring air in without allowing the diaphragm to be the primary mover in inspiration, or breathing in,  we use other muscles located in the neck and thorax to do the job.  We tend to use these accessory muscles when under stress; be it from exercise, life, lung disease, heart disease, asthma, allergies, etc.

One particular set of muscles, the scalenes, which reside in the neck, are a very good contender for causing symptoms in the upper extremities like those mentioned above as the anterior and middle scalene muscles "straddle" the nerves and artery that will ultimately end in the fingers.  Below is a picture of the location of these muscles and the nerves (yellow) and artery (red) that can be affected.

The reason these muscles are typically overused in strenuous exercise or when struggling to breathe is that they are positioned to assist in elevating the rib cage which occurs when breathing air in.  Raising the rib cage helps increase the diameter of the thorax and reduce pressure within the thoracic cage to allow for the influx of air.  This air which ultimately enters the lungs is transferred to the bloodstream where it is taken to the organs and working muscles to supply them with oxygen.

If the scalenes are overused they can become tight and squeeze the artery and nerves that lie between them causing numbness and tingling in the upper extremities.  Hyperventilation can limit the amount of air that we take in with each breath as when we hyperventilate we typically take shallower breaths.  Or, as mentioned earlier, in the case of obstructive pulmonary disease, the lack of compliance of lung tissue makes it nearly impossible to bring in more than a "sip" of air with each breath.  In these scenarios we either breathe more frequently or use muscles like those described above to help force more air in.

So how can we combat these very different, yet related scenarios?  The answer typically comes down to breathing predominantly with the diaphragm, thus minimizing the use of these accessory muscles of inspiration and controlling the breathing rate.  These breathing techniques have been employed to help reduce stress, help athletes perform better, help heart and lung patients conserve energy and maximize oxygen saturation.

How do you do it?

Learning how to breathe in this way seems as though it should be easy, but actually takes quite a bit of practice.  We have to basically retrain ourselves to breathe in a different way as we have probably been breathing incorrectly from birth.  As my 6th grade band instructor said, "The only correct breath we took was our first".

So how do we do it?  Below you will find a link to a website that explains the proper way to breathe diaphragmatically.  It demonstrates breathing in this manner in a number of different positions.  Starting with the supine position or laying on your back may be the easiest way to start and then progress to sitting and standing as you gain mastery.

Go to the link listed below and enter access code:  T2LPPLH3

Diaphragmatic Breathing

Minimalist PT Explained

At the risk of repeating myself, I feel it necessary to clarify this idea of minimalist physical therapy before pushing forward with posting a bunch of stuff.

I had a bit of an epiphany when I was visiting my friend's running store today.  That running store, Charm City Run was just voted the best running store of 2016.  Part of the criteria for being named store of the year was involvement in the community and charitable contributions.  The Charm City Run slogan for those that don't know is "Live.Give.Run".

That's when it hit me -- not the live or run parts.  I already do that, I think, but the word GIVE.  It was at that moment that I realized what this is all about; why I feel so compelled to pursue this venture.  I want to be able to GIVE something of value that goes well beyond the four walls I practice in every day.  I wanted a way to reach people beyond my zip code and a way to reach people that may not have the access, time or resources to be able to commit to several sessions of traditional physical therapy.

 I have spent 20+ years in the business of GET.  GET referrals, GET visits, GET new patients, GET reimbursement, GET paid, GET patients to refer other patients, GET the word out about the practice, etc.  Honestly, this business of GET has been marginally successful.  So why not try something completely different and opposite?  How about GIVE?  How much information, help can I GIVE, regardless of what I GET out of it.

I am by no means Saint Theresa.  I have not toiled in squalor solely to help better others' lives.  I have a pretty decent middle class existence.  I like having things.  I like making money in order to buy things.  I also have found that chasing "things" has not proven to be particularly successful or satisfying.  So why not spend some time trying to give away some stuff.  That stuff being knowledge, experience, self-help tips - not mine necessarily, but those of patients, fellow providers, etc.

So what's the BHAG?  Big, Hairy, Audacious Goal?

The challenge I have made to myself and continue to make to myself is this:  Can I figure out enough in 1 visit to give someone what they need in order for them to make themselves better without having to return?  I guarantee you that won't work for everyone.  That's not the point.  The point, however, is how much can I GIVE the patient to do and take myself out of the equation.  Do they REALLY need to see me "x" times per week or is there more THEY can do?  That in a nutshell is minimalist physical therapy.

I am fully aware that motivation, learning ability, cognitive ability, education level, socioeconomic status, etc. can ALL effect the ability to give more responsibility and power to the patient.  I am also aware that this does NOT work for some and maybe never will.  Hell, this blog may never be read by anyone other than me and my wife who gets the wonderful task of editing.  But why not try?  Why not try to spare people's time and resources?  Sure, the more I see someone, the more I make.  But how cool to be able to help someone WITHOUT seeing them.  Hmmmm.  Not the model I was taught in PT school.

I guess at this stage of my career I am interested in doing things differently.  I am interested in reaching more people and providing a resource or conduit of information from which others can benefit.  An interest in providing substance and what is REAL, not marketing hype and self promotion.

That is the essence of minimalist physical therapy -- do more with less.

Because this site is geared toward providers AND patients, the content will be written such that any lay person could understand it.  The benefit of this site will be lost if the content is overly technical.  As stated my first post, Welcome/Mission Statement, this is intended to be a resource, not a scholarly publication.

Welcome/Mission Statement

New Year, New Venture

Welcome to Minimalist PT!

Given that we just rang in a new year, it seemed the appropriate time to try something new and different.  New and different for me, that is. Never in a million years would I have seen myself doing a blog.  However, at the urging of a tech-savvy friend of mine, this "minimalist" when it comes to treatment ideas and techniques, decided to give it a go.  After all, it IS 2017!

As a practicing physical therapist for almost 24 years, I have seen and done A LOT.  I would like to think that in that time I have been able to help some people get back to living their lives to the fullest and have been able to provide them with the tools necessary to manage whatever condition necessitated them seeing me in the first place.

I have worked in every setting imaginable in the PT world and through this varied experience have been exposed to people of all walks with just about every diagnosis, social situation imaginable.  Through this "exposure" and experience I have been able to not only educate my patients regarding their conditions, but have learned a ton from them as well.  In fact, I would go so far as to say that in many cases I learned much more from them than they learned from me.

This is the very reason I decided to start this blog.  By the way, the mission statement is under the heading of the blog:  "A forum for patients and providers to share information and exchange ideas with the goal of putting the power of healing in patients hands".

 My reason for starting this blog?  

Through the exchange of information and experience with numerous patients and numerous providers over the years, I have come to find that often times the simplest, most basic tips, exercises, treatment techniques can go a long way in helping people not only get better, but manage things themselves.  If the patient has the power to manage things themselves, they can greatly "minimize" the amount of direct, hands-on care that they require.  After all, isn't that the idea?  To empower people to be able to manage their condition?  From a business standpoint, I guess, this makes little sense, right?  I mean after all if they don't NEED me, they also aren't PAYING me.

Isn't life about more than profit margins and revenue, though?  At the risk of sounding like an idealist, I would like to think it is mostly about "doing the right thing no matter the cost or the reward" -- to loosely coin a phrase from my friend St. Ignatius of Loyola.

I must give credit where credit is due.  I did not come up with this "minimalist" ideology on my own.  Approximately 10 years ago, a former patient and now friend turned me on to a great website/blog.  The website is Ross Training.com.  My friend, a lifelong exerciser and amazing guy had been using some of the exercise programs written by the site's founder, Ross Enamit.  His initial program was called "Never Gymless".  The basic premise being that you can get very fit without equipment; that you can use your own body weight any time, any where and get incredible results.  He has a plethora of exercise regimens, home gym equipment ideas and training advice -- FOR FREE.  What a novel idea!  A gift to those interested in pursuing fitness.

My friend and I have had many discussions over the years about just how much sense his approach made.  It's basically the KIS principle -- Keep It Simple.  Do something enough and it can have benefit.  No need for fancy equipment, complicated regimens.  Just DO SOMETHING!

Then the light bulb came on.  Why not apply this to physical therapy?  How much can I do with less?  What can I give people to do that is simple, yet effective?  Can I put the power of healing more in THEIR hands than mine?  After all, they're living with their condition 24/7.  I'm pretty sure they are more invested in getting better than I am in getting them better.  They also have thought about their condition significantly more than I have and probably bring something to the table that can help me help them figure out how to get better.

That was the motivation for this latest "brainchild"/blog if you will.  Not a place for me to espouse how amazing I am and how many awesome things I've figured out that work for people.  No.  A place where ideas can be exchanged, topics can be explored and people can be empowered to take care of themselves.  Am I trying to say that traditional PT is useless?  Absolutely not!!  I'm just saying we may be better off approaching things from the standpoint where the patient is in control of their rehab, where they can do what they need any time, anywhere, like my inspiration "Never Gymless" instead of going to an office somewhere 3 times per week for however many weeks.

This is not to say that patients do not need or benefit from hands-on care or assessment.  To the contrary, this is the foundation for figuring out what they can do to help themselves.  Obviously, certain issues require A LOT of hands-on time.  I just happen to think that perhaps we can strive to minimize just how much time that is.

So in a nutshell - "Do more with less".  Welcome to the site!  Bring your ideas, insights, impressions, criticisms, etc.  Let's share what we can do to empower those that want to improve, get better, reduce pain, improve strength, whatever it is; myself included.

I look forward to the journey and the opportunity to provide a resource that hopefully will be of value.