Welcome back to the Healing Pain Podcast with MAJ Timothy Benedict, PT, PhD

We have an interesting and important topic. We are discussing how to use Pain Neuroscience Education to treat PTSD and chronic pain in soldiers and veterans. My expert guest is Major Timothy Benedict. He is a physical therapist assigned to the Army Public Health Center in Aberdeen, Maryland. He’s the Deputy Chief for the Advanced Analytics and Data Stewardship Division, the Clinical Public Health and Epidemiology Directorate, and assists with field investigations for the Injury Prevention Program. As part of Major Benedict’s Ph.D. studies, he developed a military-specific Pain Neuroscience Education Intervention for soldiers and veterans. He also completed a randomized controlled trial examining Pain Neuroscience Education for soldiers with chronic low-back pain and post-traumatic stress.

On this episode, you’ll learn all about the link between post-traumatic stress and chronic pain, how to explain the link between PTSD and pain to your patients, the evidence supporting Pain Neuroscience Education for individuals with pain and PTSD, how understanding the neuroscience of pain can help you build compassion and empathy for your patients and how this research applies to civilians such as firemen and police officers. If you’ve been following along with the show, you know that I often ask our guests to provide some type of free download, a quick PDF cheat-sheet or maybe something you can use in the clinic. Major Benedict has gone above and beyond any guest, that’s ever appeared on the show. He has provided you with a complete 44-page treatment manual on how to use Pain Neuroscience Education with soldiers and veterans.

This manual is complete with full-color illustrations, metaphors, and language that is specific for this population. If you’re a practitioner and you’re someone who uses Pain Neuroscience Education with this particular population of clients or patients like soldiers, veterans, military, police or anyone in that realm, you’re going to love getting your hands on this. It’s free for you to download. All you have to do is text the word, “170 DOWNLOAD,” to the number 44222 or you can open up a new browser on your computer and you can type in the URL www.IntegrativePainScienceInstitute.com/170download and I’ll send it right to your inbox for free. Let’s begin with Major Timothy Benedict and learn about Pain Neuroscience Approach to treat PTSD and pain.

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A Pain Neuroscience Approach For PTSD And Pain In Veterans With MAJ Timothy Benedict, PT, PhD

Tim, welcome. It’s great to have you here.

Thanks, Joe. I’m honored to be here and I’m looking forward to talking with you.

I came across a study of yours which we’ll talk about here. A lot of your work centers around links and associations between post-traumatic stress and pain, specifically in soldiers, which is a super important topic nowadays. A lot of the work that’s being done both in the world of physical therapy as well as in the world of psychology is looking to help support our soldiers and help them cope with many things that have happened in the past to them or what’s happening to them. You’re a physical therapist and you also have a Ph.D. Give us a little bit of background and a little bit about your bio. Give us an idea of how you wound up where you are, where you’re working and the great things that you’re working on.

I joined the military in 2002. I was an infantry officer and I was deployed right away to Iraq for a year. I got back and spent a year in Italy where I was stationed with my wife, then immediately I went to Afghanistan for another year. It was a busy time of life. It was during that second deployment that I applied to the Physical Therapy Program through the Army-Baylor Program. When I got back from my second deployment, I went to PT school through the Army. I got stationed in beautiful Hawaii where I had another combat deployment to Afghanistan. Once I got back from that deployment, I started to apply for a Ph.D. program, which I’m fortunate. The Army sent me to the University of Kentucky. I had to study for three years and completed my Ph.D. studying Pain Neuroscience Education. We’ll talk a little bit about why I particularly wanted to study the link between pain and stress and PTSD.

Tell us where you are now, where you’re working, what your work looks like and what that centers around.

I’m at the Army Public Health Center that’s in Aberdeen Proving Grounds, Maryland. I’m working on injury prevention. I’m studying the link between soldier confidence and injury and other types of programs where we can get that construct of thought efficacy, confidence and how that impacts a soldier’s ability to do their job, to remain injury-free and to be resilient enough to remain a soldier.

I want to start and say thank you to you and your family for your time and your service. All of us, we appreciate it. It’s important that we recognize that. Moving on back to the world of PT, why post-traumatic stress? How did that start to interest you and why focus on that?

As a young PT early in my career, I started to notice this subpopulation of patients that came to me who had PTSD. It seemed that no matter what I threw at their issues, no matter what I would do or what I applied from learning at PT school, I felt like I couldn’t make any type of difference in their pain. These people need more than addressing physical issues. I became frustrated because I didn’t feel that I was personally able to help them the way that I wanted to. I knew a lot of us recognized that they did need help and treatments on the mental health side of the military. With that came a lot of stigmas. There’s a lot of skepticism then when any provider tries to talk about the mental health component of their pain aspect because our patients are coming to us with real physical symptoms and real pain. They get frustrated when no one can explain why they have those symptoms. I wanted to try to bridge that gap to help them see the things that we as physical therapists can do, but then also to give them buy-in for why the treatments that address the social aspect of their whole health and body applying to help them with their problems.

As we’re talking, I’m reflecting back on my education as a physical therapist. In the traditional PT curricula, I can’t think back and remember if I received any trauma-informed education as a physical therapist. It’s interesting because mental health providers oftentimes receive trauma-informed educations. It’s either part of their schooling or they can take a continuing education course. As PTs, maybe it was different because you were trained in the military. Did you get a little bit of that in the PT program that you attended? Was it something you started to notice at work and then do research on it?

It’s completely from clinical experience, unfortunately. As you mentioned the importance of that entry-level clinical education, I had never even heard of Pain Neuroscience Education during my entry-level program. It’s certainly a gap. I imagine that as we learn more and more about the neuroscience of pain and how important that is even for entry-level PTs, that the trauma aspect of that, which is super important and relevant for chronic pain period, let alone PTSD. I think they’ll become more mainstream and in the end, we’ll get more education.

How do you explain the link between PTSD and pain to your patient or someone who has pain?

There are two important parts of this conversation. Number one is to validate the patient’s symptoms. A story I share with any patient who I’m trying to explain the link between pain and stress. It’s a fact in any history story. We observed the 78th Anniversary of the Pearl Harbor attacks. It’s an amazing story. On the morning of the Pearl Harbor attacks of December 7th, 1941, Army Private George Elliot is up on the north shore of Oahu. He’s looking at his radar screen and around 7:00 AM his screen lights up. He says, “There’s an aircraft here.” He calls up the higher headquarters, “What should we do about this?” Some Army Lieutenant up on Washington said, “I think those are just American planes coming back returning from a flight.” He essentially said, “Don’t worry about it. Forget about it.” Anyone who’s read history and seen the movie understands Pearl Harbor. It’s a major disaster to ignore that radar screen on Pearl Harbor.

What I asked my patients than was, “Do you think that this radar operator is ever going to ignore his radar screen?” Of course, not. He’s going to be extra hyper-vigilant. The small thing that moves on the screen, he’s going to call up higher headquarters. He’s not going to take no or he’s not going to ignore that radar again. From that point, we can validate the fact that when you’ve had trauma when you’ve had a major injury, your nervous system is like that radar. After those events to protect yourself, it’s not going to be easy to ignore these dangerous warnings anymore. That’s the first thing that we can do to validate these symptoms. You have real symptoms and we can explain why it makes perfect sense that your body would adapt in a way to give you some extra protection after you’ve experienced the trauma of the injury.

You give them a good metaphor that starts to tell a story. It’s a context that they can relate to directly. Some people with PTSD feel like if they were to go for treatment with a mental health provider, which we know it could be effective and I encourage people to do that, but there’s some stigma attached to that. Have you experienced that the Pain Neuroscience Approach doesn’t carry that same stigma and people have been potentially more open and interested in that approach?

You may have mentioned an article that I wrote that introduces Pain Neuroscience Education to individuals with PTSD and pain. We did have one group where we throw education at them. They can still be met with, “We need to have a deeper conversation, one-on-one, to explain the neuroscience of this.” It’s definitely not a slam dunk, but it’s a conversation starter. It gets the wheels turning and helps these patients understand the link between the two. What I tried to do is explain the neuroscience of stress because everybody understands the stress, especially soldiers and veterans, but everyone gets stressed.

To go further into the story of George Elliot in Pearl Harbor, we have an amazing gift of the stress response, this fight or flight response because several lives were saved. We can all appreciate the fact that these soldiers who were being attacked at Pearl Harbor needed to have the energy. They needed to get that heart rate racing, the focus, the ability to mobilize those fight or flight muscles and run for cover and return fire to save their lives. We can certainly understand the stress response and the usefulness of that during a crisis. The problem occurs though when these crises go on and on with no rest. Thinking about George Elliot there and his radar screen, he’s going to be extra focused for the remainder of his shift that day. Probably for a couple of days, he’s going to have enough adrenaline and cortisol flowing through him to stay focused.

Can you imagine if you’re on the screen 24/7 week after week, day after day? Eventually, he’s going to tap out. He’s not going to be able to maintain that vigilance. It’s the same thing when we measure stress hormones in individuals who have had PTSD, had chronic symptoms for several months, several years. What we see then is this helpful stress hormone, cortisol starts to crash. It’s like running out of ammunition. Cortisol is a hugely anti-inflammatory drug that the body produces. When it’s been going on for too long in chronic cases, it’s no longer able to provide that anti-inflammation. That’s where a lot of these problems like people not sleeping well, chronic pain, digestive issues, depression that come along with having stress for too long.

People’s problems are a lot more than just their physical issues and the solutions are much more than just the physical solutions that are needed.

I’d love for you to talk about that paper that you did. I believe it was part of your PhD, which is great information. I’d like you to walk us through what the aim of that paper was and some of the things that you created from that. We’re giving them away for free. Tim has been generous. They’re great guides on PTSD and Pain Neuroscience Education. Any practitioner should have their hands on this if you’re working with this population. First, is there some research supporting PNE, Pain Neuroscience Education for PTSD? Tell us about your work specifically.

I had this idea and it made perfect sense to me. I have a link between chronic pain and PTSD. To get a diagnosis of PTSD, there are a few clusters. Number one, after you’ve had a trauma, you start to re-experience this. Number two, you’re hyper-vigilant. Number three, you avoid things that remind you of that trauma. It’s very common that you have co-morbid negative cognition like depression, remorse, guilt. When I look at that cluster there, we see a lot of things in chronic pain as well. We know people in chronic pain, they avoid. They re-experience pain after tissues have healed. They can be hyper-vigilant and have central sensitization. To me, it seemed like there was a close conceptual link between those two issues.

I wanted first to make sure that as I talked about the neuroscience of stress and pain that veterans or individuals with PTSD would be able to comprehend it. There are lots of other studies that have looked at the same type of issue. Let’s make sure that the patient can understand Pain Neuroscience and like what Moseley and other practitioners have found, patients do a much better job than what we as clinicians typically give them credit for. The first thing was making sure that these veterans could understand it. By using the military stories like when I talk about Pearl Harbor that connects with these veterans and would help them understand what’s going on with PTSD and stress. That was the main aim, first of all, before going out and launching it in a clinical trial. Can these veterans understand it? Does it connect with them? The first pilot study with samples of several individuals both with and without PTSD found that they had good comprehension equal to a medical expert panel once we control years of education. We met our first goals in making sure that our end-user would be able to comprehend it.

It’s tremendous work and I know specifically in the field of PT, there are not too many people looking into PTSD and Pain Neuroscience Education in that population.

It’s definitely new. I’ve met a few individuals that see them in combined sections meeting who are looking into it. To my knowledge, this was the first curriculum specifically developed for PTSD. You asked about my other research. The next part was testing it in a clinical trial. We did a randomized control trial within the VA as well as with some active-duty soldiers. We use the materials that we’ve developed from this book, the PTSD and Neuroscience Education and compared that to what we call traditional education, the standard of care education. That was all pulled from the National PTSD Center. We were giving solid evidence-based recommendations as to the control education. They were receiving things like mindfulness. They were getting relaxation techniques, breathing techniques, exercise guidance, a lot of things that we would typically get.

The main different thing is that the Pain Neuroscience Education got to the why. Here’s why these things are going to work. You need to understand how these things affect your stress system, which will then affect the neuroscience or the neurobiology of the pain that you’re experiencing. That was the critical missing link. I was amazed to see how that small difference made a big difference. Our patients in the experimental group had increased pain self-efficacy. They had increased pain pressure thresholds. We found an objective improvement in their ability to tolerate pressure thresholds. They had increased control over their pain and then decrease beliefs that pain’s a sign of harm for them. We found a lot of good things. It’s a small clinical trial, fourteen in the experimental group, eighteen in the control group. I was happy to see this was a successful program with them.

You held up your book there and I have copies and I’m showing it to everyone. There are some wonderful pictures in there, stories, metaphors, instructions and help for practitioners who are working with people who have PTSD and chronic pain. We have large scale meta-analysis on explained pain and Pain Neuroscience Education. Even though it’s small, it is a randomized controlled trial that shows it specifically works in the population you’re working with. I’m wondering what you would say to a physical therapist or any other practitioner outside of the mental health realm, maybe an OT, a PT, even a massage therapist who might be saying to themselves, “This all sounds interesting, but I don’t necessarily feel that treating PTSD is in my scope. I don’t feel like I have the skills. I’m not sure if this is a place I should start to weed into.”

The cool thing about PTSD and pain is that the research shows that if you successfully treat PTSD in a mental health setting, their pain improves. Conversely, when you take individuals with co-morbid PTSD and pain and you addressed their pain, their PTSD symptoms improve. I’m definitely not encouraging anyone to go outside of their comfort or their lane of expertise. All of us have a great opportunity to affect these individuals’ mental health symptoms as well as their pain. Certainly, I don’t think you have to be an expert in Pain Neuroscience Education or an expert in PTSD. You can stay in your lane and do a great job of treating those receptive inputs, give a great exercise prescription program and a great treatment program. What our research shows is that if you apply this treatment within the context of Pain Neuroscience Education language or psychologically informed treatment, it will be more optimal than justifying a biomechanical approach to these treatments. I don’t think you have to go into a full discourse of pulling off a book and doing a walk line by line PNE approach if you’re not yet fully familiar with these types of concepts.

It’s interesting for physical therapists to think that what they’re doing can have a dramatic impact on mental health. If you go to any DPT program website and you look at what they’re listing, a lot of it is around orthopedics, sports, and physical function. Rarely do you ever see anything about what we do as physical therapists could impact mental health as much as or potentially even more so than psychotherapy for some people?

It does open up the doors. We’re talking about the whole person here. They think that you have a joint walk into your clinic or a few muscles come into your clinic. You can treat that all day. If you’re not taking that whole person and you’re not addressing the mind, spirit and their social environment, we’re not going to be as effective as if we understand how all of these things affect their brain or the way that all of these nerves are connecting and firing, ultimately affecting their pain experience and the way that they feel about themselves. We’ve got great tools and we are an incredible profession to lead this way and to help bridge that gap between the physical and what a lot of times is considered a mental health condition. We can validate these things and bring a laugh to people with PTSD.

I almost wonder if PTSD should be labeled a mental health condition and if that would maybe help people a lot. Those are big topics probably for another episode but probably on a similar page with regards to that. With regards to your study at RCT on PNE in PTSD, a lot of the PNE studies are either a 1 or 2-hour class or a 1 to 2-hour intervention with PNE. Was that how your RCT was set up as well?

Probably the total contact time was similar. We did four sessions once a week for four weeks and each session lasted about 30 minutes where we would do the education at the beginning, followed by our exercise program. It was shorter. They were able to tolerate it a little bit better in terms of an attention span so we’re not sitting there for 1 to 2 hours, but then we can reinforce it by the following week and the following week. That’s four sessions total and about 30 minutes in length for each one.

It is totally doable for the vast majority of physical therapists in private practice.

That fit was probably reasonable both in the military as well as the civilian practice of getting that patient and spending that one-on-one time with them once a week.

How does understanding Pain Neuroscience and stress help us take a more compassionate approach to our patients?

Going back to what I said before about validating their symptoms. First of all, by being able to validate those symptoms, we can get a lot of buy-ins and help our patients understand that we get what they’re going through. We can explain it. That’s hugely rewarding for a patient to have someone who gets what they’re going through. Research shows us over and over again that adverse childhood events and childhood trauma has a number of negative health effects later on in adult’s lives. Whether you’re talking about PTSD, chronic pain, obesity, you name it. A lot of this probably had some roots in childhood. I’m a parent of four daughters. We have two biological kids and two adopted kids from China.

Those two kids have a history of trauma. It’s opened up my eyes despite what the research says. We experienced it personally. It opens up your eyes to what trauma does. We’ve almost got a case-control study of our two kids who are normally attached and wonderful biological kids, then when you have two kids who’ve had trauma. My wife and I were amazed. We’re surprised when they get an owie. It’s over and over again, “Mommy, I got an owie. I got this ow.” It’s this constant seeking for comfort. It opened up my eyes that a lot of the adults that we’re dealing with are like our kids who’ve had this trauma. They’re looking for a way to put all the pieces together. They’re looking for help.

As a clinician, we can recognize that when you have that patient who’s seeking care. A lot of times we want to minimize it and try to reassure that patient, “Your knee joint is fine. Your back, no red flags. You’re okay.” It’s like we’re saying, “Get over it.” It’s the same thing with my kids. We want to minimize it. “You don’t need a Band-Aid.” What we’ve realized is they have a real need that they’re communicating. How can we help them? How can we put a Band-Aid on them and then provide a safe context where they can grow? It’s the same thing with our patients. We can be part of their story because that’s what trauma is. These patients didn’t have control and some, a terrible life event occur to them. Now we can start to explain their symptoms as well as give them areas that they can control their body and get some influence over their stress system to eventually help them.

Thanks for that example of your children. That’s important. A lot of people will be able to relate to that. We talked about Pain Neuroscience Education. We talked about pain, PTSD, and a little bit of your research. Pain Neuroscience Education within the realm of physical therapies is a former PIPT or Psychologically Informed Physical Therapy. It’s part of a good bio-psychosocial model of care. The topic of spirituality comes up rarely on the show, but people do mention that. I would think that’s probably an important topic for some of the patients that you’re seeing. Can you talk about how that may inform your practice and your care either from a personal perspective or the perspective of your patients and clients? I did a little bit of research as I was looking at your awesome work. I was reading your dissertation. You touch on that in a subtle but effective way in your research by taking some scripture and relating it to neuroplasticity, which was interesting.

It’s fascinating to me some of the things that we identify as neuroplasticity. The Bible says, “Be transformed by the renewing of your mind.” That’s one example. Another example that’s commonly used by medical providers is meditation and mindfulness. These are practices that I have personally practiced through my faith as a Christian. For a while, I was like, “I got to make this divide.” When we’re working with bodies, we’re in a clinic, I didn’t feel that there was a role necessarily for bringing in faith discussions. As we start talking about mindfulness and other types of religious practices, you see that we can measure these practices through functional MRI.

It’s not just a mindset. We’re making real changes. From a personal as well as a holistic clinical approach, I believe that I’m approaching people through compassion and life and equipping them to be able to realize that their problems are a lot more than their physical issues. The solutions are much more than the physical solutions that we did. This has opened up my eyes and I feel it freed me as well as our profession to address deeper things than the body.

People who read this know that we’re talking about deeper things in a biopsychosocial model. Bringing that topic into our spectrum or scope of practice if you’re a practitioner or someone with pain, to think about those avenues. Tim, tell us what’s next for you? You’ve done some awesome work. You work at an amazing place helping people. What’s new for you in 2020 to 2021?

The Army’s going through a significant transformation. Every year we have to do a physical assessment test like push-ups and sit-ups. Now there is going to be the next test and it’s supposed to be much more combat-focused. They’re going to include a deadlift and throw in medicine ball to power. It’s almost like an obstacle course where you have to sprint down and back carrying a heavy load. It’s much more difficult and as you can imagine for a lot of soldiers, it’s stressful. It’s stressful as they change because people are concerned about, “How am I going to train for this? Am I going to get hurt?” That’s the main thing that we’re evaluating. Looking at my research, from what I know and what we have found through these studies, that the more anxiety you have, the more likely you’re going to get injured, the more likely that you’re going to have chronic symptoms.

It’s quite fascinating to see the hormones that your body releases when you’re having high levels of stress and anxiety. What that does is it increases the signaling. There’s this big link between individuals who have that high anxiety and low confidence. Unfortunately, they’re more likely to get hurt and stay chronically injured or chronically disabled. That’s the main thing we’re looking at. How can we bridge that gap and make soldiers more confident as we transition to this new combat test?

That’s awesome work. If you get that study done and published, please come back and talk to us about it. We’d love to hear about it. This is a platform for you as well to share your work and help inform people and inform the care for both pain and PTSD and the other things you’re working on. If someone wants to contact you and learn more about you, how can they contact you?

We’ll make sure my email address is loaded into your website there. That’s the main way. I don’t have a personal website. The books that you can download, I have all the up-to-date information that I’ve put into in terms of Pain Neuroscience Education for both soldiers and veterans. A lot of it applies to civilians. The population that we’re likely seeing as clinicians is on the civilian side as well. These materials can hopefully be useful and applicable to individuals with or without military experience.

I want to thank Timothy for joining us and talking about PTSD, chronic pain and Pain Neuroscience Education. All three are important topics. When you put them together, it’s a super important topic for practitioners as well as people with chronic pain. Makes sure you take this link and you share it on your Facebook page, on Twitter, on LinkedIn. If you know populations where people are struggling with pain and/or PTSD, no matter what the cause, make sure to share with them this important information and make sure to download that free eBook. If you’re a practitioner, you’re going to love what you see in there. We’ll see you soon.

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About MAJ Timothy Benedict, PT, PhD

MAJ Timothy Benedict is a Physical Therapist assigned to the Army Public Health Center (APHC) in Aberdeen, MD. MAJ Benedict is the Deputy Chief for the Advanced Analytics and Data Stewardship Division in the Clinical Public Health and Epidemiology Directorate and assists with field investigations for the Injury Prevention Program. MAJ Benedict is assisting the Injury Prevention Program and APHC evaluate the impact of the Army Combat Fitness Test on the readiness of Soldiers.

After graduating from the United States Military Academy in 2002, MAJ Benedict commissioned as a Second Lieutenant in the U.S. Army. MAJ Benedict completed Infantry Officer Basic Training and was stationed at his first assignment in Vicenza, Italy. MAJ Benedict deployed to Northern Iraq as a platoon leader during Operation Iraqi Freedom from 2003-2004. MAJ Benedict deployed again 2005-2006, this time to Afghanistan to support Operation Enduring Freedom. MAJ Benedict applied to the U.S. Army-Baylor Physical Therapy program and got married on R&R (Rest and Recuperation) during this second deployment.

MAJ Benedict graduated from the Army-Baylor Physical Therapy program and was stationed at Schofield Barracks, Hawaii, in 2009. In 2011, MAJ Benedict deployed as the Brigade Physical Therapist for the 3rd Brigade, 25th Infantry Division to Eastern Afghanistan. On R&R from this deployment, Tim and Melissa’s first child, Lexie Grace, was born in Honolulu, Hawaii. MAJ Benedict was next stationed at Fort Hood, TX, where Tim and Melissa’s second child, Clara Faith, was born. Tim applied to the University of Kentucky Rehabilitation Sciences Ph.D. program and was accepted to study under Dr. Arthur Nitz, a graduate from the Army-Baylor program.

While at the University of Kentucky, Tim, Melissa, Lexie, and Clara traveled to China in 2016 to bring home their 3rd and 4th children: Hannah Joy and Zoe Hope. With the assistance of Dr. Adriaan Louw, MAJ Benedict developed a military-specific Pain Neuroscience Education for Soldiers and Veterans. MAJ Benedict successfully defended his dissertation and graduated from the University of Kentucky in 2018 after completing a randomized controlled trial examining Pain Neuroscience Education for Veterans and Soldiers with chronic low back pain and post-traumatic stress.