Welcome back to the Pain Science Education Podcast with Orit Hickman

Dr. Orit Hickman, owner of Pain Science Physical Therapy in Seattle, discusses implementing the latest pain science into clinical practice, focusing on the three types of pain: nociceptive, peripheral neuropathic, and nociplastic pain. Dr. Hickman shares her journey in integrating pain science into patient care and the importance of trauma-informed approaches. Tune in to learn how to evaluate and treat different types of pain and how to take a holistic approach to chronic pain.

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The Integration of Pain Sciences into Physical Therapist Practice with Orit Hickman PT, DPT

Welcome to this week’s episode of the Pain Science Education Podcast. This week, we’re discussing how to implement the latest pain science into clinical practice. My guest this week is Dr. Orit Hickman. Orit is a physical therapist and owner of a clinic called Pain Science Physical Therapy, where she and her staff integrate the latest in pain science into the care of their patients with chronic and persistent pain. On this week’s episode, we will cover how, of course, to use pain science in clinical practice, as well as the three different types of pain, nociceptive, nociplastic, and peripheral neuropathic pain. We’ll review how to evaluate and treat the three types of pain in clinical practice. We’ll also discuss how to take an integrative, psychologically and trauma-informed approach to persistent and chronic pain. This episode is chock full of information, whether you are a licensed health professional or you’re someone who’s looking to alleviate their own chronic and persistent pain. So make sure to grab a pen and paper or open up a note section on your computer so you can take some notes. All right. Thank you again for joining me this week. Make sure to share this episode with your friends and family on your favorite social media platform. And without further ado, let’s begin and let’s meet Dr. Orit Hickman.

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Hey there Orit. Great to have you on the podcast this week. Welcome.

Hi, Joe. Thanks for having me.

I’m excited to talk about all things pain science, because I have the Integrative Pain Science Institute and you have Pain Science Physical Therapy.

Yep.

Two awesome names, but I love the name Pain Science Physical Therapy. And to my knowledge, it’s the only one in the country, which I think is really exciting. And I, you know, I think it just really speaks to where we are as a, as, as physical therapists, where we’re going as a profession. Um, what patient care could and should be about what our healthcare system should be focusing on when it comes to pain care. So I’m interested in a little bit about just your journey as one you’re, you’re a clinician with an expertise in chronic pain. And then two, you’re also a private practice owner with an expertise in building a practice specifically around pain science and chronic pain. So how did you arrive at this place?

Orit’s Journey: Building a Practice Specifically Focused on Pain Science and Chronic Pain

So I have been a practitioner for 23 years. I graduated with my master’s from Temple in 2000. And then pretty much the day I graduated, the program switched from a master’s to a DPT. And they said, if you guys want to come back and finish your classes and do some more online classes, then you can get your transitional degree. And so I pondered that for probably about a year, year and a half. And then I decided to go ahead and do it because that was the direction the field was going in. So I came back, I finished my DPT and started, I was practicing at the time in the acute care setting. So I started my career in a level one trauma center in DC. I was there for about a year and a half. And then when I got my DPT, I was working in a community hospital in Southern Maryland. And I remember talking to other providers about my degree, and they were like, you’re a doctor? And I would always introduce myself as Dr. Hickman, physical therapist. So I got used to that at the time, and I was comfortable with sort of pushing boundaries in our field from the clinical side. I moved to outpatient after three years in the hospital setting and was excited to kind of use what I felt was all of my clinical brain. You know, all the things that I learned in school that I didn’t get a chance to really utilize in the hospital setting, was using more and more in the outpatient setting. So practiced for four years in Maryland before we moved out here to Seattle. We moved out here to Seattle in 2007, and I went from a clinical setting where I was treating patients anywhere from two to four patients an hour to treating a patient every 30 minutes. And I thought, hey, this is pretty cool. I’m getting to spend more time with patients. And 30 minutes felt really good, but after a period of time, like about a year, 30 minutes didn’t feel long enough. And so I started having dreams of opening a clinic where I could spend one-on-one with patients for an hour at a time. And so I planned that process or that transition over the course of the year. I started practicing and I was treating these patients. And when I first opened, I had no patients on my schedule. So I had no providers referring to me. I had no patients, but it was the least stressful day of my life to just know that I had some little bit of control over what was going on in my clinical practice. But the patients started to come, the providers started to learn about me, and I got to see these patients and spend time with them. And spending time one-on-one with patients is really it’s really fascinating, especially when you get an hour, you go from 30 minutes where they’re shuttling through and they’re going to work with an aid to just spending all that time with them. And when I got to that place, I started to notice that I wasn’t as good as I thought I was as a practitioner. I’d been practicing by that point for about nine years. And I was finding that I had some patients that were doing really, really well, like they did really well with manual therapy, pastoral retraining, strengthening, you know, adjusting just their daily activities, things like that. But then I had patients who they would have flare-ups and I couldn’t explain why they were having flare-ups. And their flare-ups would be things like emotional triggers, like they’d say, oh, okay, my in-laws were in town this week and my pain levels were off the charts. Or I had, you know, I drove past this area where I’d had a trauma and my pain levels really spiked. Or there would be other things, like it was patients with either a trauma background or maybe like patients who had had a car accident. And I just could not figure out how to get their pain to stop. And all the things that I would do would maybe give them a temporary relief, like especially manual therapy, I’d find, oh, okay, that really helped. And they’d come back the next session, they’d say, oh, that was really great, do the same thing again. I would do the same thing again and I wouldn’t have the same results. And so, I was starting to think, okay, I’m, I’m missing something in my, in, in what patients are experiencing or what their pain is. And I couldn’t really, you know, I, by that point, you know, when you’re nine, 10 years out of practice, you, you’ve done a lot of continuing education. You have a lot of knowledge. So you think, Hey, I got this. And I wasn’t getting it.

I remember I had one patient and this is where it kind of clicked for me. I had this one patient who had pain all up and down one side of her body. And I’m like spewing biomedical and like, I’m trying to give her an explanation as to why it is I think this is occurring from a joint standpoint or a muscle standpoint. And I was like, I’m just spewing crap. Like this doesn’t feel right. And I’m wrong, I’m wrong here. This is not right. So around that time, Adrian Lowe, who is very well known in the pain science world, actually came to Washington and gave a two-day talk that was titled, I think it was titled Explain Pain. Because I think at the time he was working with other practitioners in NOI. And so he came, for two days he spoke. And I never forget this. I drove, I drove to Tacoma. I sat for eight hours in this class. And the whole time the class is just like, like there’s light bulbs going off in my brain the whole time that he’s speaking. I’m like, oh, that explains this patient. That explains this patient. And oh my gosh, I forgot about this patient. And it’s just answering a lot of questions for me. But when I got up at the end of the day after sitting, my back was killing me. I was so, so sore. And I had to drive back home and I was like, wow, that was a really long day of sitting. And everybody in there is groaning because we’re all PTs and we hate to sit still. So on day two, went back to the class and he’s continuing to talk about pain and talk about the neuroscience behind pain. But the difference was that now he was introducing treatment. So he started taking us through things like lateralization training and explaining pain to patients specifically. So it was a little more treatment focused. And at the end of the day, same thing, sat for eight hours, didn’t move. At the end of the day, I got up and I had no pain. And I was like, okay, we’re there. I came to work on Monday. So this is Saturday, Sunday. On Monday, I come to work and I, threw everything out that I had been doing and just started educating patients on pain. I created my own sort of framework for this and I just started educating. And there were times I didn’t touch a single patient. Like I had days where all I was doing was talking, talking, talking, talking, talking. So this is like early pain neuroscience education, right? This is maybe 10, 11 years ago at this point. And I had providers calling me going, what the hell are you doing with your patients? I had some of them who were like, wow, this is amazing. This patient who has had persistent pain no longer has pain. And then I had other providers who were telling their patients, okay, don’t go back to her. Let’s send you over to this other person. And, you know, pendulums swing, right? So there’s swung one this direction of just doing education. And then as time went on, came back to understanding, first of all, I was fire hosing patients with information, you know, sort of walk that back, started being a little bit more mindful of how much information can they actually take in in a session? And then also starting to bring back some of the things that I had already been doing with patients, but incorporating other things like graded exposure to activity, a little bit more of understanding the impacts of trauma. Around this time, so by this point, right, I’ve opened my practice, and I’ve been practicing for a few years, and I’m bringing in other practitioners because I’m just too busy. But they’re not necessarily on board, right? So like the chronic pain patients would go to Orit and the other patients would go to everybody else. And I was like, this is really not sustainable. And it’s not the way we should be practicing. So I started to put in place the expectation that my providers would go through education. And so I created a framework and we basically picked out videos off of MedBridge. And at this point, I’d also done my therapeutic pain specialty certification. So I was pulling articles that were what I felt were relevant articles. At the same time, as I went through TPS, there were three articles that I read that were kind of what I feel like really finally was putting this all in a framework. And that was the articles by Keith Smart et al. And these articles introduced the concept of mechanisms-based classification. And not only did they introduce that classification to me, but it also was clearly putting symptomology so that there was some verbiage around this understanding of different types of pain. I know I’m jumping like 20 steps ahead. I think I might’ve missed some of the questions.

It’s a great introduction. I, I believe that some of the things you’re describing many other physical therapists have, have been through also, especially I think therapists that had graduated maybe in the early two thousands, I would say when DPT programs really were, um, deeply entrenched in impairment, musculoskeletal manual based physical therapy. Now that’s not the case anymore. We’re bringing all these other different, you know, aspects related to pain science and pain education and pain psychology and health behavior change and help us all this, all this is now, you know, in your average PT program, or it should be, if it’s not, it’s, it’s not a DPT or DPT program that’s up to date on things, but I’m just wondering, so you walk into this, um, you know, class with Adrian Lowe and Adrian is a great speaker. Most people are aware of him on this, on this podcast, very engaging, but we’ve all heard engaging speakers before and don’t necessarily, um, you know, have an aha moment, so to speak. So I’m wondering, like, was it, have you given any thought to, and the reason why I’m asking this question is I find it interesting that, you know, people like you and I are continually upgrading our education. Yeah. And are interested and curious. And then there are other, some other of our peers are like, ‘I’m going to see four patients an hour and, you know, do the proverbial hot pack ultrasound and quad sets. And I’m totally fine with doing that basically.’ And we know that that one, that is poor care for people with pain. And two, it gives our field a really bad reputation, right? Because people look at it like, well, this is what physical therapy is. So is it just that you are ready for that, or you were just so enthralled with pain education, or you were just like, I really want to help. I really want to understand and help someone when they have pain in their right arm or in their left leg, that doesn’t make any sense actually. Like there’s no good reason for why someone has pain on one complete side of their body, other than one, they’re having hemiplegia of some sort, possibly. Or two, yes, there’s some system-based problem that is happening here.

Why Orit Decided to Open Her Own Practice

I think to answer that question, there’s a lot of reasons why. First of all, it’s to know me. And I’m not good with the status quo when I think that there can be something better. I mean, anybody who decides to go off and open their own clinic, right? I think to some degree, that’s part of our personality. And so when I came out of PT school, I had this ideal in my mind as to what private practice or practice in general was going to look like. You know, before I went off to PT school, I volunteered for about three years in a hospital. And when in that process, they also hired me as an aide. Super scary because my job as an aide was to treat patients. And I mean, really treat them. Like I had patients that I was gait training. I had patients that I was doing wound care with. It was pretty scary stuff that I only realized was scary once going through PT school. So I spent a lot of time in PT school. I spent a lot of money going to PT school. I happen to think this field is pretty incredible. And I have kind of this ideal about what private practice should look like or practice in general in our field should look like. And so that combined with just my general overachieving tendencies was that when I came out and started practicing, I was disappointed. I had a hard time working in these places where I wasn’t seeing things functioning the way I think that PT should function. So a lot of my practice, my head was like, oh, it’s the environment that’s not allowing patients to really thrive and get the outcomes that they’re looking for. And so then I created what I thought was the ideal environment, right? I’m going to treat patients one-on-one. We’re going to have private treatment rooms. This is going to be awesome. No AIDS. And I was finding that even with the ideal situation, the ideal private practice environment, I was not as successful in treatment as I thought I would be. And so I think that when you’re in your head, you’re like, okay, I should be able to help this person. MRIs are negative, tests are all negative, they’ve had surgery for whatever the thing is, And yet they still have pain. It’s like, wait a minute, we should be able to lick this. We should be able to change this. And so I think it was just my all those pieces coming from the type of person that I am and continue to strive to be that it was like, all right, we need to something’s missing. So when Adrian started speaking, it was I mean, I’d never heard about the neuroscience of pain. I’d never heard of, even the term neuroscience was like, I mean, we talked about neurology and we talked about the nervous system a little bit in PT school, but what we threw at patients was the same in terms of treatment. We didn’t try to differentiate what type of pain was a patient actually experiencing so that the treatment could be the appropriate treatment. And so when he started speaking, I was like, wow, now we’re starting to get somewhere. But even at that time, the term mechanisms-based classification, or even the terms nociplastic pain, right, at the time we called it central sensitization. it seemed to have more of a, even a psychological component to it versus what’s the nervous system actually doing? And so this concept that pain could be, that there are different types of pain, that wasn’t even introduced at the time. It wasn’t until a few years later when I was going through TPS that I saw those articles and they weren’t, I mean, they were part of our learning, but they weren’t even highlighted the way that I felt like they should have been. It was like, hey, wait a minute. The way we learn about pain needs to completely change if we’re going to treat these patients properly.

I appreciate all this. You’ve helped me connect some dots because I went to school before you graduated in ’97 with a bachelor’s in physical therapy, which, you know, you would think, and this is, this is what I constantly think about in my head. Now that I have a doctorate degree and went back to my transitional. And I see it’s interesting because when I went to school, we had a specific course called neuroanatomy and a specific course called, called neurophysiology. Right. So, and we also, at one point, I just had this discussion this week at a conference, actually, we also had a core, a course called psychology of the disabled.

Interesting. Yeah.

Right. And I think over time, not that I think I know, we all know this over time. Programs change. They restructure how, how educational content is delivered. And I think some of the things that, you know, we’re all talking about now, actually was in my program a long time ago, definitely not framed the way it is now. But I think the foundation was there. And then, as I said, as the 2000s came in, and there was like this manual therapy, impairment explosion, so to speak, I think it got weeded out. But I’m happy that we’re all here today, because obviously, this is a better way to practice. And I’m also, you know, it inspires me to listen to you because I think right now there’s so much talk about burnout. How do we change burnout? How do we alleviate burnout? And because there are people who are anxious and depressed and all that stuff, and all that’s true. And I’m like, the number one way to alleviate burnout in a practitioner is to give them all the tools and skills they need to treat patients. The number one, that’s the number one way. Yes, obviously there’s a time element to that, right? There’s a competency element to that that people have to learn, but what I find so often is that therapists get stuck in jobs and they don’t pivot. They’re like, okay, this is it. This is just the way life is. And I’m like, well, no, here’s what you can do. You can change jobs. You can start your own job. You can reeducate, retool yourself if that’s not what you learned. And it’s not their fault necessarily that they didn’t learn in school. But I think the complacency is something that we should all be uncomfortable with. And I think you’re a good example of kind of, you know, turning lemons into lemonade, so to speak, right? So tell us about how the name Pain Science Physical Therapy came about, because it’s such a unique name.

Orit’s Practice: Pain Science Physical Therapy

So we, back in 2019, just before COVID, I brought in a friend who at the time was, so he’s a consultant, and at the time his consulting work was for large healthcare organizations. Like he would come in and he’d basically clean them up, He would implement 5S and he would implement management tools and he was basically, basically at the time I had this sort of grand idea in my head that I wanted to have multiple clinics. And I said, I said, John, please come in, meet with me, meet with my team. I wanna pay you ahead of time to help me before we grow too big and we have too many problems. And so he came in and he’s not a provider, right? He’s truly a management person. And he spent a ton of time with me and my leadership team working on cleaning up our systems and our processes. And to this day, we still use pretty much everything that he’s given us. It’s been huge for us. In the middle of that, we were discussing rebranding, because I said, if I’m going to put multiple clinics in multiple locations, we can’t have a Lake Burien physical therapy in North Seattle, we need to have something different. So he was the one who said, you really need to have a name that’s like pain science, because that’s like your jam, that’s the thing you’re doing, And I was like, I don’t know, PTs don’t put pain in their name. I mean, I fought it for a while, but he was right. I mean, the reality is, is that we treat pain, we utilize science and we utilize pain science in the treatment of all of our patients. And as scary as it was to take the name on, we did. And we did a little bit of research. I first made sure there was nobody else with that name in the country. And then I talked to my lawyers and was like, can we trademark this? Because I knew that if my grand plan was to have multiple clinics, what if those clinics ended up crossing states? We definitely wanted to make sure that we were trademarked. So we did, we trademarked the name. trademarked the logo, and there’s a federal trademark. And so in 2021, it took that long because there was this pandemic in the middle that kind of slowed everything down. And that was actually a blessing for us as well because we took the time to step back, retool, And as soon as we made the name change, it just clarified everything for me and for us as a company. Our core values at that point were already set in stone. And then it was like, wait a minute, this is how we’re going to hire. And oh, by the way, this is how patients are going to know us. And it just it just was a snowball effect. It really worked for us. And so, and by that point, we also had a lot of providers who knew that we were doing something different. They didn’t always understand what it was we were doing because who does, right? PT seems to be this nebulous thing. No providers ever understand what we’re doing, but they got that what we were doing was different. They got that we were focused on working with patients with persistent pain. Yeah, it worked.

Yeah. I mean, the minute I logged onto your website, I was like, okay, this is someone with a vision who’s doing something different, which is, which is great. And I really appreciate that. So I, so now the clinic is up, it’s humming, you’re growing, you’re hiring, um, other practitioners. And, you know, when that happens, you have varying degrees, as you mentioned of clinical skills and competency. Right. Yep. And your staff has a, I know some of your staff has a wonderful background in pain science and pain education, but even with that, you’re like, okay, we still need to kind of figure some of these things out. So you’re starting now to look at, okay, we have these three types of pain and you see this as, I guess, somewhat of a challenge. Is that right?

Yeah.

So, you know, and we should probably tell people what the three types of pain are first, because some people who want to know what they are, right.

The 3 Types of Pain: Nociceptive, Peripheral Neuropathic, and Nociplastic Pain

So let’s talk the three types of pain first. So the three types of pain are nociceptive, peripheral neuropathic, and nociplastic pain. Nociceptive pain is, you know, that type of pain that we experience in the acute episode when we’ve injured tissue. You step on a nail, that hurts, ow, that’s nociceptive, right? It’s tissue-based pain. We can usually turn it on and turn it off. We can reproduce it. It has a very clear way that it behaves. Peripheral neuropathic pain is pain that’s due to nerve injury, nerve sensitivity, kind of the term nerve sensitivity, I’m gonna back off for that, because nerve injury, direct nerve injury, right? Sharp shooting, electrical pain, a nerve has been severed or a nerve is actively being compressed. It’s also tissue pain, right? So nociceptive and that, you know, and I’m, I’m the worst one to ask, like what’s happening from an anatomy standpoint or like a biological standpoint, because I’m usually talking to the patient. So I’m explaining this to patients. So I never like go back and go, okay, yeah, what’s happening from a, from a chemical standpoint, but the inflammatory processes different in each of these different diagnoses as well. So peripheral neuropathic is really nerve pain. Nerve pain though, especially in our clinic when we’re talking about peripheral neuropathic, we also tend to use the term nerve sensitivity because we’re talking about nerves, but the nerves themselves may not be actively injured or damaged, but they can be presenting with very similar types of pain. pain or very similar types of, yeah, similar types of symptomology as somebody with a compressed and actively compressed or severed nerve. And then we’ve got nociplastic, right? This is that central nervous system pain where everybody’s scratching their head going, I don’t know what this is, right? You’re chasing the pain. The pain doesn’t necessarily follow any rhyme or reason, flares randomly. And it’s often, the word I love to use is it’s exaggerated. It’s not in line with input. So with nociceptive pain, typically, the onset of pain is related to the, it can be more related to the type of pain. So if you have a paper cut, you know what that pain experience feels like. Just like if you bang your arm, you know what that pain experience feels like. With nociplastic pain, symptomology tends to be exaggerated. The hallmarks of nociplastic pain are allodynia and hyperalgesia. So where the pain is magnified in the central nervous system, or the sensory experience is magnified in the central nervous system, or a person experiences pain when there shouldn’t be pain, right? So hyperalgesia is that magnification of sensory information. in the central nervous system and allodynia is when something that shouldn’t cause pain causes pain. Like somebody gets rubbed with a sheet against their feet and they’re like, wow, that caused a lot of pain on my legs. So I think I got it.

It’s an excellent description. I think there are a lot of people who listen to this episode or listen to this podcast who have pain that are probably wondering, oh, which one do I have? And do I fit squarely into one or the other? Or can I start out with one and then progress to another? Is that possible?

Yeah, one of the things that I always, and this is where I think education is really important because I always communicate to the patients as well as to my team members, and they’ve seen this as well themselves when treating patients, is that patients will typically present with, could be all three types of pain, right, at any time. One is more predominant than maybe the others. And the experience that I’ve had with patients is if noceplastic pain is present, Nociplastic pain is oftentimes what needs to get treated first because it tends to make it harder for you to treat pain that’s due to tissue or due to structure because that nervous system response is not going to be equal and it just exaggerates the response. So I have that conversation a lot with patients, but yes, typically these pains are overlapping. And as providers, that’s one of the things we have to figure out is, well, what’s the main pain at this time? What should we treat first?

Yeah, essentially, I have a patient who I’m currently treating who has chronic low back pain and she just sprained her little pinky. which, you know, wasn’t a big injury basically, but it really made her understand the difference between, okay, this is an acute injury versus this long-term nociplastic pain that I’m, you know, having to deal with basically. So as you mentioned, this can, you know, it can be just this one type of pain or these different types of pain can exist in just one person at any time, different body parts and things like that. We have these three types of pain, where does this fit or how does this fit into your practice and, you know, training the staff, things like that?

How to Educate Practitioners About the 3 Types of Pain

So for all I meet with pain, I mean, I meet with my practitioners one on one every week. And a lot of times when we meet, there’s a lot of discussion about patient care. So I do a lot of mentoring. And what I found was that I have all this knowledge in my brain from things that I’ve learned in the more traditional, I’ve taken classes, I’ve taken courses, I’ve read articles, and then I have all this clinical knowledge. And it’s like, well, how do I give them all of this? And so, and to preface that I have, I have a lot of younger clinicians working for me so relatively new grads maybe a year out at this point. who while they’ve had some introduction, right? They knew the terms, they knew what I was talking about. The practical, how do I actually use this in my everyday practice was lacking. And they’re in really good programs that I know have classes that go through all of this. So that piece of how do we put it together was really missing. And so working with you recently, I was super excited to create a manual, a training manual. So we’re starting to, and team members are starting to go through it and give me feedback and be like, okay, what pieces do we, what pieces are missing? What pieces aren’t? But the best part of this is that I can create videos which include things like how do we assess for nociplastic pain? And then how do we treat it? And how do we do sensory testing with these patients? And how do we give the patients evidence so that we can get their buy-in that this is what’s actually going on, that it’s real, that it’s biological, that there’s real stuff happening here and it’s not psychosomatic, which for a lot of patients, obviously, when they’ve had pain for this long a period of time, at one point or another, somebody tells them this is all in your head, which equals you’re faking it or it’s psychological, it’s not real.

Yeah. I’m not a fan of the term psychosomatic. I know it’s used in other countries and it’s kind of like a normal part of the, of their healthcare system. But I think, you know, looking at pain within our kind of us based healthcare context, the psychosomatic does typically does not sit well with the people I treat. And I think that’s really just a cultural thing that we have here. Um, I know some groups have tried to bring that back, but I think it’s a little tricky, so to speak. especially in a physical therapy environment or context. So you create this manual to help other therapists understand a mechanism-based approach to pain based on the three types of pain. What’s the manual called?

Teaching Physical Therapists a Mechanism-Based Approach to Pain Care

What did I call it? I think it’s called the PSPT Practical Pain Science Manual. You should probably look. That’s too funny.

Sounds like a perfect name though, doesn’t it?

I actually think it’s called the PSPT training manual. But practical pain science makes more sense. We have that term, we’re using that for a newsletter that we’re hoping to start here that’s going to be also geared towards providers in the region. Because it’s just, again, it’s that practical piece. It’s like, how do I apply, right? And that’s the piece that I felt like was really missing. It’s like all the information was there, just not put in a format where they could just go and use it.

Yeah, that’s what I love about both you and Maria who will be on in a week or so with her project. Both of you are just, you know, have taken the science and, you know, two different applications because you’re, you’re using it to create something to train practitioners, which is so needed. And she’s using it to train or educate the patient, which is so needed and the manual and the book that Maria wrote, which we’ll get to in a, in the next podcast episode, kind of reinforce each other, right?

Yeah. And our original plan. So, so Dr. Maria Garvey Caruso, who’s going to be on your podcast next. When we sat down, so Maria and I both been through TPS and we both felt like there were things that were missing. in this process for treating patients with pain. And, you know, remembering that, you know, if a patient has persistent pain, they can be any type of patient, right? They can be a patient who comes in with, you know, from a sports medicine injury to somebody who has fibromyalgia. But there were these pieces that were strongly missing. And one of them was my original intention was, hey, I want to see you course, because I want to be able to educate all providers because we’re missing this practical application. And then Maria was like, hey, we really need something on the patient side too. And so we were hoping, and I think we achieved this, was for these two things to work together so that if the providers, in this case, we’re starting with my team members, right? If they go through the training manual, they can then take Maria’s workbook and use that with patients. And there is just this natural relationship between both of these things. because there is a lot of information out there. And even my manual, it was just, it was, there’s so much, and I’m still working on just kind of scaling it back and adding one other section in there. And it’s like, okay, this has a ton, there’s a ton here, but providers need to be able to take something and run with it and do it quickly. And so if you have a manual, like if you have the pain freedom workbook, like what Maria created, then it’s like, oh yeah, I remember that when I went through the manual, we talked about X, Y, and Z, and now it’s here in the workbook so that I can use this directly with patients.

Yeah. In your manual, can you give us an idea of the four main modules that are in there so we have an idea of what the manual is and how that it’s kind of laid out? Because you did a really, as you said, the field of pain science is enormous, and even just those three types of pain, It’s a lot of information right there. So you did a really good job at distilling things down into the most important concepts and really interventions and tools to help the therapist obviously treat and manage the pain that the person’s experiencing.

Well, first of all I have to thank you Joe because I did this with a lot of guidance from you. When I came to you originally I said I want this continuing education course and you said well, I think we need to start with a manual and I was like, I don’t want to do manual. But you were right. That’s where we needed to start. And essentially, of course, is going to come out of this. So your feedback and your guidance has been just super crucial for me to get to this place to be able to see this come to fruition. And I pulled up the manual so that I can remember exactly, but the first section really goes through the mechanisms-based classification. So we lay out nociceptive, peripheral, neuropathic, and nociplastic pain. There’s also some education there on how do you educate a patient about these types of pain, because that’s incredibly important. And it starts to go a little bit into treatment, but really in section two, it starts to really hit treatment very, very focused. So looking at things like how do I do, how do I treat, how do I educate a patient on the different metaphors, using the different metaphors and mantras and information that we know works when we’re looking at pain education. So, you know, educating them on the alarm system, for example, and flare-ups and kinesiophobia. So that’s really section two. And it goes through graded motor imagery, which that technique in and of itself is such a huge piece of helping somebody’s you know, nervous system really change what it’s doing. So really retraining that system and then going through graded exposure or pacing activities and talking about how we, how, how do you do that with the patient? Right. So it’s really the practical components. Section three, we started to, I went into, you know, dove into lifestyle because you can’t, you know, If a patient’s not sleeping, got to address that, right? If they’re not eating well, got to talk a little bit about that. When we’re talking about things like persistent pain and that nervous system staying in a ramped up state, we’ve got to talk about stress. And so that was that third section. And that last section was, It’s funny, for all of the sections, it’s the one that I was most unfamiliar with, because I hadn’t dove into this, but it was looking at different populations. So looking at the queer community, BIPOC population, and patients with a history of trauma, and it was the most challenging for me because it was where I had the least amount of technical knowledge, even though I have patients that fit, you know, that are identified with all of those communities, all of those populations. And so, While it was the most challenging, I think out of all of them, it was probably the most important section because it was the one that I had the least amount of knowledge about. And those in themselves in and of themselves could be a whole other training. But those are the four sections. So it starts with just that overview of what the classification looks like. It dives, section two dives into how do we treat those patients based on that classification. The third section looks at lifestyle management and chronic pain. And then the fourth section is those special considerations, those special populations.

How did the trauma awareness and the overlap with chronic pain change the way you look at people and how they’re and what they’re experiencing in their life?

You know, I don’t know how to answer that question. Ask it to me again.

When I look back at school, we’re aware of trauma in the sense of physical trauma to a body. Someone gets into a car accident, it’s a high velocity accident, and whatever, the cervical spine flexes forward at a high velocity, travels back into extension, and we have an easy time imagining that there’s some tissue damage there, if you will. Overstretched ligaments and tendons muscle that tears, maybe even some some nerve that could, you know, be taught and lead to something like, you know, a nerve proxy or injury, right. And then we see things in, you know, building the literature around chronic pain, with regard to trauma. Now we live in a society where then awareness of social determinants and how it affected the trauma experience of COVID-19. And now we live in a society we’re watching, you know, war happen in certain countries, and the impact that that has on whole populations of people, and not only an individual person’s nervous system, but a collective nervous system. So when I look at your practice and the pathway you’ve taken as a practitioner, as a business owner, and I sense that you’re moving in the bigger direction to, okay, how do we impact collective nervous system, so to speak, in my community, in my practice, in my town?

How Understanding the Nervous System’s Connection to Trauma Can Inform Practitioners

So the trauma piece, I think that the trauma piece is really important. How that impacts me, so I come from a background with trauma. And have a sensitive nervous system. And I’m very upfront with that when I talk to patients. When I was initially moving into pain science education, the patients that I was most having trouble with or having most difficulty moving them forward were patients with a history of trauma. And for a lot of them, it was not recent trauma. Right? So when you talk about the car accident example, we’re used to understanding, okay, this is what just happened. But then two years, five years, 10 years, 20 years down the road, and a patient is still experiencing pain when that tissue has healed, it’s like, well, wait a minute, what’s going on here? And so learning about yellow flags, understanding that trauma, there doesn’t need to be a heck of a lot of it, right? It’s the brain and the nervous system’s perception of threat. So if the brain thinks something threatening has happened, that’s a trauma experience. And there’s this whole cascade of what occurs in the nervous system as a result of that. And so understanding the connection to trauma has allowed me to have the ability as a practitioner, to be more empathetic, to be more open, but also to be able to explain to a patient, let’s talk about the biology of what it is that’s happening in your nervous system every time you go into fight, flight, freeze, and all the different things that kind of fall into that realm. Um, when I first graduated from PT school, you talk about the, the manual component and that, that back in the 2000s, that was our focus. I, I actually remember saying, I don’t want to treat somebody’s psychology. I just want to treat their body. Like I had this sort of like, I want this separation. Um, and now I want the opposite. Because I know that you can’t get at the heart of things unless you truly understand as best as we can by not being in somebody’s shoes, what it is that they’ve been experiencing. It’s allowed us to partner more readily with clinical psychologists. It also allows me to be very comfortable when a patient tells me that they’ve had a not good experience with a provider for me to direct them towards a different provider. And I have really clear understanding of why it is they need to go to somebody else. So having the research and having that, the understanding that this, this component absolutely impacts and has been very crucial for us to change how we do things in here. From the collective, from the collective, when we look at the, you know, the population, and we think about how we’re going to grow as a company, makes me very careful with who I partner with when we make decisions about things like marketing, for example. Are they going to, are they clear about our voice? You know, I, we don’t want to use certain words, like even in my website, I have to go through and I will have to go back. And there’s a bunch of stuff that I’m like, Oh, that might be a little inflammatory that might be triggering. And so how do we continue to make this space a space that people come into and they go, I’m safe. I’m going to heal here when we can’t control all the stuff that’s happening out there? How can we make sure that the voice that we’re communicating and all the ways that we do that are in a manner that keeps people understanding that we get it and we want them to feel safe and comfortable here? That may be where we went with that.

It’s been great talking to you today about pain science and pain education and your practice, of course, which is pain science physical therapy in Seattle. Let people know how they can learn more about you and how they can follow your work.

So you can learn more about the clinic by going to our website, painsciencept.com. We also have a YouTube channel where I put out lots of videos about pain science, as well as other things related to physical therapy. We have an Instagram page, we have a Facebook page, and I’m also on LinkedIn. So if you want to reach out, you can do that as well. And in LinkedIn, you can find the clinic name, but you can also find my name, Orit Hickman, so I have my own personal LinkedIn page. And those are probably the easiest. You can also email me if you have any questions, dr.orit, so [email protected].

Right. So a point to everyone to her website, which is pain sciencept.com. You can, of course, find all the links that are mentioned on the show notes at the integrative pain science institute dot com. At the end of every episode, I ask you to share this with your friends and family on Facebook, LinkedIn, Twitter or wherever anyone is talking about pain science and pain education, physical therapy, pain, neuroscience, all the things that we spoke about today.

Important Links

• Orit Hickman
• @painsciencept – Instagram
• @drorithickman – Instagram
• PainSciencePT – Facebook
• Dr. Orit Hickman PT DPT TPS – LinkedIn

About Orit Hickman

Dr. Orit Hickman graduated in 2000 from Temple University with her MPT and then in 2001 with her tDPT.  She has practiced in the acute care setting, pediatric and outpatient settings.  She opened her practice in 2009 which was born out of a desire to treat patients 1:1. This clinic started out as a community-based clinic which focused on manual and exercise therapy.  As time went on Dr. Hickman shifted her focus to treating patients using pain science and a biopsychosocial approach.  In 2021 the clinic rebranded from Lake Burien Physical Therapy to Pain Science Physical Therapy. Dr. Hickman has shifted from primarily patient care to overseeing her clinic in its new space and mentoring her team members in the treatment of patients with persistent pain.  When she is not working she is walking her dog Murphy (who also spends lots of time in the clinic), boating with her husband or doing art.