Welcome back to the Healing Pain Podcast with Dr. Karen Litzy.
For the past year, I have created a podcast around healing pain naturally dedicated to millions of Americans with chronic pain that are looking for healthy alternatives to healing for pain that do not involve drugs or surgery. Also, this podcast is for the professionals that support that paradigm shift. Today, I’m trying to really up level this cause by taking it to Facebook Live. I have a great guest today. Her name is Dr. Karen Litzy. She is a doctor of physical therapy who lives in New York City. She has a concierge one on one physical therapy practice with a focus on healing those who have chronic or persistent pain. She’s also the host of the Healthy Wealthy and Smart podcast where she provides up to date clinical as well as business strategy from the best and brightest physical therapists, entrepreneurs and health professionals. In addition, she’s the spokesperson for the American Physical Therapy Association Media Corps. You can find out more about her at KarenLitzy.com.
About Dr. Karen Litzy
As part of my commitment to my clients and my career, I am constantly engaging in continuing education. I have been lucky enough to learn directly from some of the best in the profession. I have received certificates from Dr. David Butler, Dr. Lorimer Moseley, Dr. Adriaan Louw, Dr. Paul Hodges, The Institute of Physical Art, The American Physical Therapy Association, Hospital for Special Surgery, and many more. I graduated from Misericordia University with my masters degree in Physical Therapy in 1997 and then graduated from the same university in 2014 with a Doctorate of Physical Therapy.
How to Assess and Interview Patients about their Pain Experience
Dr. Karen Litzy, welcome to the Healing Pain Podcast live on Facebook.
Joe, I’m happy to be here, the inaugural run of a Facebook Live setup. I hope that this goes well and people log on and ask us questions and get a good conversation going.
Tell us about your physical therapy practice. How does work? Tell us about the environment.
My physical therapy practice is here in New York City. It’s a concierge practice. I go to patients’ homes or offices for one on one treatments. Each treatment is about an hour. I really just use manual therapy, exercise, movement, patient education, a lot of pain science. A lot of my patients do have chronic pain conditions like CRPS and things like that, which is chronic regional pain syndrome. I’ve really found that people like having someone come to them and it makes one less thing for them to worry about. I also see a lot of kids. Oftentimes, these kids are very over scheduled. To have someone come to them just makes life a lot easier.
When we talk about pain, I think there’s this stereotype insignia that someone in pain is someone who’s older, they’re on along in their years, they’re joints are starting to deteriorate. Tell us about children. Are children getting chronic pain?
There are children with chronic pain. There’s no doubt about it. As a matter of fact, I was with a friend in Miami a couple of months ago and her daughter who was under the age of twelve had chronic regional pain syndrome. They thought that she had sprained her ankle. It’s the same story. They went to a whole bunch of different doctors, she was put in a cast, she was taken out of a cast, she was put in a boot, taken out of a boot, put back in a boot. All these symptoms were there. There was swelling, there was redness. It was super painful. She did have CRPS. It’s the same thing as an adult. Pain doesn’t discriminate and it doesn’t matter how old you are.
For my friend’s little girl, she ended up, finally, getting hooked up with the right practitioner to help her get back on track. A lot of it had to do with, “Let’s educate her on what’s going on. Let’s let her know not to be so fearful of movement.” She was afraid to play basketball with her friends. This is something that she loved doing. Your treatment is the same, but your approach can be completely different. I think when you’re dealing with children, and I’ve dealt with a lot of kids, I’ve had kids with chronic neck pain and things like that, your explanation of pain just has to be different. Not the explanation, your approach is a little bit different because now you’re relating to a child who might be eight or nine years old.
Instead of going with a lot of neurophysiological terms that maybe an adult might understand, I will do things like say, “There’s an alarm in your head and there’s an alarm in your brain.” Instead of saying neuro tags and all these different inputs, I might say, “When you do XY and Z or when you’re in this situation or maybe when you have a big test and you feel stressed,” a nine year old knows what being stressed is, “It may cause that alarm to go off and then you’ll have pain. It doesn’t necessarily mean that you’re doing more damage to yourself.” That they get. I find that children, I think because they are less cynical about pain and about causes of pain, that they actually do really, really well when you give them some education on it.
That’s interesting. You bring up the word being cynical about pain. A lot about the pain you may experience, your specific experience around pain has to do with what you’ve been taught about. By getting to a child who’s maybe six or seven or eight years old and starting to work with them and explain to them what pain is, are we helping them form a better cognitive relationship with their pain experience?
I definitely think so. I think Adriaan Louw might be working on like a childhood curriculum for schools in his area. He’s in Iowa. I think that’s something that he and his team are working on. I found that children, they just get it and then they move on. Of course, I have to say that the children that I’ve seen, I’ve seen a couple of kids for neck pain, they have had diagnostic tests. All red flags were ruled out, they had MRIs and X-rays and everything was negative. I think that makes the parents even more nervous because now we don’t have something to blame. But of course, all red flags are ruled out.
Dr. Litzy, you mentioned CRPS or chronic regional pain syndrome. Can you explain to people what that is? I think a lot of people actually have it, but not properly diagnosed. They don’t really understand exactly what it is.
Chronic regional pain syndrome is a very complicated pain diagnosis. It can happen after very simple things, like an ankle sprain or a knee sprain. I have a patient with CRPS who was going through a turnstile in the subway and somebody pushed it really fast and it hit the back of her Achilles. I have to say, I don’t know why some people get CRPS and others don’t. There is some evidence to suggest that people who have had bouts of depression or anxiety within their life are more susceptible to that.
What happens with CRPS is you can get skin changes, someone’s skin can get very red, it can even look a little purple, it can get very dry. People sometimes describe it like fire. They’re being poked with a hot stick. It can be very debilitating to the point where you may have to use an assistive device to walk, if it’s in your lower extremities. Essentially, what happens is that harm alarm in your brain is always churning. When you have CRPS, your nervous system is much, much more sensitive. As a result of that sensitivity, things that maybe wouldn’t bother you or me, like walking down the street or standing for a few minutes, really bother people with CRPS because they have such a sensitized nervous system. I know that’s a very watered down definition, but just so that people understand what the symptoms are and maybe a slight reason as to why that’s happening. It really is some maladaptive behaviors in the brain.
I think it’s a great explanation actually for those who don’t know what CRPS is. Earlier in our conversation, you said that pain is an output of the brain. Other than pain, you’re saying that there are other signs or symptoms that can be an output of that warning sign.
The pain is certainly that emergent output of the brain, but with CRPS there are also those trophic changes or skin changes, then you also have some sensation changes. I think some of those sensation changes, again, may be due to this, what David Butler and Lorimer Moseley will call smudging within the brain. The way I tell my patients is, if they’re art lovers, think about a Caravaggio painting or one of those types of artists’ paintings, or even Michelangelo, where you can see every wrinkle, every nail, every expression on the face and throughout the body. It’s very, very detailed. When you’re healthy and pain free, that’s what your body sees. Your brain knows every part of your body, it knows every wrinkle, it knows every joint.
What happens in people with chronic pain conditions is this, what they call smudging. What smudging is, is it’s taking that Caravaggio painting to more of like a Cubist Picasso painting. Now, all of a sudden, this clear picture that you used to have of your body is not so clear anymore. If you know what a Picasso Cubist painting is, the hands over here, it’s no longer even a hand. It’s just a triangle or something like that. Because of that, your brain has a hard time identifying those parts of the body. I think that can be a good explanation to people for why is the pain spreading, because all of a sudden your brain doesn’t have a good sense of where your body is, where it is and all those little details that make up you.
This happens not only in CRPS, but also happens in back pain, neck pain, osteoarthritis, really almost any type of chronic pain syndrome.
No question. It happens in any chronic pain condition. It’s one of the things that, with education and with maybe graded motor imagery treatments, graded movement exposure treatments, that can be reversed. That doesn’t have to be your life for the rest of your life. I think that’s really important to know.
I think it’s a great message. You do not have to live a life of chronic pain. There are many, many treatments that you can employ in your life to help you heal from pain. How much time do you spend with your patient talking about this inflammation? Where do you start to initiate that?
Where I start with my patient, the answer, and I’m sure people are not going to like this, is it depends. It starts with the interview, it starts with me asking them to tell me their story. It starts with motivational interviewing techniques, which might be mirroring what they’re saying, reflecting on what they’re saying. Reflecting might be, you may say to me, “I’ve had this pain for five years and now I feel like I can’t do anything with the rest of my life.” I may reflect that back and might say, “It sounds like you’re not that hopeful. Can you explain a little bit more as to why maybe that might be?” Then you get a little bit deeper into what the person is thinking and how they’re framing their pain within their life.
As I start to explain some neurophysiological or neuro immune physiological parts, what they say to me during the interview, I will pick up on and write things down. They may say, “My father had back pain so I know I’m going to have back pain.” That’s something I want to talk about. Or, “I have this herniated disc and it’s never going to get better.” That’s something I’m going to go back and refer to. I think that’s where I start. Listen, some people, on that very first visit, they’re not interested. That’s okay. If someone’s not interested on the very first visit you see them and you start bombarding them with “pain science” information, they may not get back because they’re too overwhelmed.
From Simone, “How do you get the chronic pain people to understand when they feel they are able to change, particularly if they are in a flare and believe there’s no hope?” Simone, that’s a great question. What I found is by listening and doing some of those motivational interview techniques, number one, the person, you can just see that nervous system starts to calm down a little bit. For someone like that, I may not go into right away, “There’s a glial cell attached to each synaptic connection and this is why when you feel sick or when you feel stressed, it’s because there’s hormones going in. You open up ion channels.” That person is not interested in that right now.
For someone like that, especially if they’re in a flare up, what I might do is I might go with the double peak, I don’t know if you’ve ever seen the two mountain peak metaphor. You’re showing someone without pain, their nervous system is buzzing along at a regular rate. All of our nervous systems are buzzing along at a regular rate, otherwise, we’d be dead. You want that nervous system to buzz along at a regular rate. They go up the mountain, the very top or the peak of the mountain is tissue damage. A little bit before that is pain, but you have this huge buffer zone in between. When you’re in a flare up or people who’ve had chronic pain, they might be buzzing a little closer to the peak.
Maybe their tissue damage is not right at the peak but just below, but they’re feeling pain way before any sign of tissue damage is happening. It’s because they’re a little more sensitive. I usually will go into this sensitive nervous system discussion with those people. That really seems, in my experience, to help people calm down and to say, “Oh, I’m not doing anything to myself. It’s because I’m a little more sensitive.” Then for the treatment, we’ll go in to how to not be quite as sensitive.
I also think, if you’re a practitioner, because there are lots of practitioners who work with people with chronic pain, there are physical therapists, there are chiropractors, there are medical physicians, there are the massage therapists, we can go down the list of practitioners, health coaches. I think it’s very, very important that the first session, you talk a lot with your patient about what to expect over the coming weeks and months. Because chances are people with chronic pain need a lot of support and they’re going to need you for a couple of months, usually it’s typically two to nine months, depending on how bad their chronic pain is. You start to explain to them what they can expect both during the treatment with you one on one or if they’re working in a group practice, and what it’s going to look like over the course of the two to three, six to nine months.
I think so often, patients come to those who say they can heal chronic pain. They just get started on treatment and the patient doesn’t really know. They want to want to participate in it. It’s very, very important to motivate your patient and connect with them on a level that they’re going to be an active participant with you in the therapy going forward. Because the truth is, what we know from science is that the active therapies, something where a patient can take an active role in therapy with you, works better than the passive therapies.
They had their place, passive therapies. But ultimately, if we want to change the brain and nervous system, we need more active therapies.
There’s no question. A lot of times, at least in my experience, by the time someone comes to me, they’ve gone through the, like we said about my friend’s daughter, they’ve been to a million different practitioners. By the time they come to see me or even some of the other massage or chiro or what have you, they might be six months in, a year in, two years in, three years in of chronic pain. So a lot of times, they are coming in because they want you to fix them. I agree with you, managing that expectation of, “We’re not here to fix you, but we’re here to work together, to guide you and to work with you. Not to just come in and give you a quick fix because that’s not how it works with chronic pain.”
Oftentimes, I’ll relate my own story to people. I have that ability to say, “Listen, I’ve been in your shoes. I know what you’re feeling. It took me this long to feel better.” Do I have flare ups every once in a while? Yeah, but now I know that the flare up is not the end of the world. Now, I have a flare up and I just keep doing my thing. I still go to the gym, I still treat patients, I’m not laid up in bed for weeks and weeks on end and taking medication. I may take an over the counter medication, but I’m not taking a pain killer, I’m not taking anything harsh.
I think when patients hear that, they’re a little more at ease. Sometimes you will have a flare up and that’s okay, that’s normal. It might be a stressful time in your life, it may be, if you had an accident and you have chronic pain as a result of that accident, it could be around the time you had that accident. All of these things contribute to the input going into the brain and they all have to be addressed with the patient. It’s a complicated group to work with, but a lot of fun and very rewarding, as you know.
The creation of pain in someone’s brain and body, whatever you want to call it, is a very complex phenomena. I think the methods for healing it are actually quite simple. I think a lot of practitioners miss that in our healthcare system today. I think we’re starting to push forward some of this information, which is great.
I want to talk to you a little bit more about pain. I want to ask you a couple of questions. If someone comes to you, let’s say, they’ve had back pain for five years and they’ve seen an orthopedic surgeon, they’ve seen a pain specialist, they’ve seen all sorts of different people. They say to you, “I’ve had this back pain for five years so it must mean that an old injury I had did not heal,” which is a very common thought that most people have. What do we say to patients who are coming with that thought in their head?
Absolutely. What I’ll usually say is that, for the most part, tissues will heal within three months of that original, whether this person had an accident or they were shoveling snow five years ago and hurt their back and it’s never healed. I’ll usually say, “Tissues usually heal within three to four months.” I may go with the example of a broken leg. Once you break your leg, you’re in a cast, it gets out of the cast and heals. That bone is healed. You can have an X-ray, it shows that it’s healed. That may take six to eight weeks, maybe longer depending on comorbidity and things like that. People usually say, “That’s true.” Then I’ll say, “Why do you think that your back is the exception?” Then I’ll go into, “It’s not that the tissues are still damaged, it’s the communication, it’s the changes that happened within your brain. That’s what has continued your pain.”
I will absolutely go into all the different inputs that can go into that emergent output property and that perhaps they’re a little more sensitive. I may do two point discrimination testing, which is where you start with one point and you gradually widen, you can use calipers or something like that for people who weren’t familiar with it. You go out and out and out until they feel two points. I’ll just show them and say, “Can you see? This is what it should be, X amount of millimeters or centimeters apart. This is where you are. You can see that perhaps your brain isn’t really understanding what’s going on in the back.”
We’ll go into some grading movement and things like that. Again, it depends on the person, but most people get it. Listen, sometimes, if you have someone who’s really, really entrenched in that biomedical model, it’s going to take a little more time. That being said, I may have that person focus more on maybe movement and exercise, and it works.
The contribution of talking about the brain is so key. I think the one place that this starts to become a little gray and fuzzy, and I’ve talked to probably some of the best pain scientists in the world and I’ve asked them, what about when it comes to an active inflammatory disease like rheumatoid arthritis, which is an autoimmune disease? I tell you, some of them, “Let me think about that for a minute because we have an active disease that’s causing the inflammation, that’s causing the pain.”
In my research for my book Heal Your Pain Now, which is available on Amazon. In my research, I found that even for those with autoimmune disease, rheumatoid arthritis, Lupus, there are still changes in the brain and spinal cord or the nervous system that happen in every single patient no matter what your pain is. Yes, you may need to do, let’s say, a gluten free diet to heal your gut and inflammation, but there are still aspects of the brain in pain or pain science that you need to work on to become 100% pain free. Where do emotions play a role in pain?
I think emotions play a big role when it comes to pain. I think that’s where doing things like meditation can come in very handy, working with a health coach, working with a pain psychologist. Everyone’s part of the team. I think the more complicated the pain situation is, the bigger team you need. Oftentimes, I refer patients to pain psychologists and I refer patients to registered dietitians, I refer patients to life coaches and things like that. It has been very helpful. I think when people do have large emotional ties to their pain, I think you, as the practitioner, have to know what you can handle surrounding that and when you need to refer out to a pain psychologist or psychiatrist. I think, as a physical therapist, that’s key in helping your patients get to the next phase.
Sometimes this comes up in conversations during treatment, how someone’s anger or frustration made their pain worse a couple of days ago. At times, things that we do or the treatment that we provide has a sprinkling or smattering of some cognitive behavior therapy in there. It’s important to know, “This is outside of my training, it’s outside of my comfort zone. This patient really needs probably a pain psychologist or a psychologist who can deal with things on a much deeper, broader level.”
I think if you have a patient who says, “Oh, I’m so stressed. I’m very anxious. This is making me depressed,” or if you have someone like the example you just gave, or you have someone who says, “This pain, it makes me want to jump out the window.” There’s catastrophizing, which might be, “I’m going to lose my job, my husband is going to leave me.” Then there’s, “I feel like I can jump out a window. I can’t go on living with this pain.” As a physical therapist, I’m saying, “This is someone who I think needs a little bit more specialized care that might be beyond my scope.” Or, “Boy, I am not comfortable with this.”
You can listen and you can be there. I don’t know what the right response is to that. I had a patient like that and I then had worked with a pain psychologist with her. It was very helpful. Hearing something like that, boy, that’s a little scary. Having someone come in and say, “I have not bent over for five years because last time I did it I hurt my back.” That’s something we can probably work with. It sounds outrageous. I’ve had it happen. I don’t know if you’ve had patients like that, I’ve had patients like that. That I can work with, that I can say, “We’re going to go into some of the neuro immune system to try and help you understand this a little bit better.”
Some common comments from patients are, “I had a great Christmas, but my mother in law or father in law was there. I don’t get along with them. My pain skyrocketed on Christmas.”
That’s where maybe we go into the DIMs and SIMs. One of the newer research out through Noigroup and Body in Mind was talking about DIMs and SIMs. A DIM is a danger in me, a SIM is a safety in me. Theoretically speaking, you have more safeties in me versus dangers in me, you’ll have less pain. A SIM could be, “It’s Christmas, I love Christmas. I love the Christmas music, I love wrapping, I love baking, I love the smells. I love meeting my friends.” A DIM could be, “My in laws are coming. They make me very anxious.” Then you have to look at your day and say, “I have all these SIMs, I have this DIM. How can I make this DIM more of a SIM?” Maybe it’s changing the way you’re reacting to your in laws. That’s an example.
That’s a great example of a DIM and a SIM. “I love getting presents.” Christmas is a big SIM. “I hate traveling three hours to Pennsylvania to do it.” That could be a DIM. That’s what I say, “I hate traveling. Getting on a bus, I hated the bus.” Now, I changed that DIM to a SIM. Because now I say to myself, “I can’t wait to get on the bus because it gives me three hours to get some work done or three hours to read a book that I’m really into.” Versus, “I have to get on the bus and sit next to someone.” It’s, how would you change that DIM to a SIM? I think for patients, if you have someone coming in with that conversation, that’s a good place to insert those DIMs and SIMs.
What you’re really talking about is, when you’re working with patients one on one, their emotions or the thoughts come into the treatment session or into your conversation, it’s worthwhile talking about it and it’s worthwhile teaching them to find the signs of safety in their life, where those signs of safety exist. When you find the signs of safety both in your brain as well as in your physical body, you are on the way to living a life pain free.
You have a great podcast called the Healthy Wealthy and Smart podcast. It’s been going for probably a couple years. It’s widely successful. Tell us what your learned from that podcast.
I always say the podcast, for me, has been one of the best continuing education experiences of my professional life. Gosh, I would say, the biggest thing I’ve learned is how to speak with and get information from and interview people from all different backgrounds with different education levels. That has really carried over into my professional world when, brings us back to the beginning of our conversation, the importance of that initial evaluation and interview with your patient or your client. I feel like one of the best things the podcast has done for me is it’s made me a much better interviewer than I was. It’s helped me to think on my feet and to be able to really listen to someone, not superficially listen, but to really listen, formulate follow-up questions and thoughts in my head while they’re speaking.
I think that’s been a huge education for me and has really helped to enhance my therapy practice as well. I can’t go into individually everything I’ve learned. Just this year alone, I think I did 50 podcasts, one a week. To say what I’ve learned from each individual is a little difficult. I think overall, I’ve become more confident as an interviewer and even more confident as a therapist. For me, it’s great motivation because you’re interviewing people who are really passionate about what they do, whether they’re a physical therapist, I have a lot of female entrepreneurs on. It’s contagious.
To wrap up Karen, where do you think pain treatment will go in the next, let’s say, ten years? I’ve been a physical therapist since 1996 and it’s changed drastically. What do you think will happen in the next ten years, let’s say?
I think that you have so much new research and information about just the body in general that’s coming out. Number one, I think hugely, the relationship of the immune system to the neurological system and how that plays into painful conditions. I think that’s a huge, huge innovation that’s come out in the past couple of years. There’s some wonderful work going on at University of Cork in Ireland through people like John Cryan. He is a neurologist that specializes in the microbiome. I think that he’s really coming out with some innovative research. I don’t think it’s quite there yet, I think it’s getting there but it’s not quite where it needs to be. I look forward to that over the next ten years.
I think I spoke to him last year, their goal is to really develop some therapeutics that can treat things like depression and pain by taking something to help regulate the microbiome, it’s not quite where it needs to be yet. I think there’s still a lot more research that needs to be done. I think they’ve done it in some rat studies, which has been very promising. I think in terms of pain, there’s some really great things on the horizon. I hope that this old, outdated biomedical approach keeps getting less and less. I think the bio-psycho-social approach is becoming a more accepted approach. My hope is that this whole biomedical that A plus B equals C when it comes to pain just goes away because it’s outdated and it doesn’t do anybody any good. The patient, the practitioner, anyone.
I love pain science, love it. It’s so fascinating to me. I’ve used it with patients. I absolutely absorb it all. I talk about it in my new book, Heal Your Pain Now. I also talk about the microbiome. I’m so glad you brought it up because having a healthy microbiome, having a healthy gut is so important when it comes to one, decreasing inflammation in your body, but two, there’s a direct connection between your gut and your brain. It’s called the vagus nerve. It’s probably one of the largest nerves we have in the body, it’s actually a two way connection. It’s information that passes both ways. A lot of the hormones and neurotransmitters in your central nervous system that are responsible for the pain response are actually produced in your gut.
I can tell you, since I became a certified nutritionist, implementing good nutrition practices, at times taking things like gluten, diary and sugar free diets to decrease inflammation has been key to help people with chronic pain, especially the fibromyalgia group I can tell you. Those with fibromyalgia are known to have, when you look at studies, they’re known to have gut problems in almost 100% of patients with fibromyalgia. Now, we can say that gut problem is caused by their diet or is caused by a central nervous system that has gone a little bit awry. In my opinion, oftentimes, it’s both. You see both of these things happening in chronic pain patients, whether it’s patients with fibromyalgia or it’s patients with chronic pain, CRPS, osteoarthritis, all of them. I loved that you brought the microbiome into the conversation. I also think it’s a place that physical therapists are going to start to venture more into. On my blog, in my podcast, I talk a lot about it.
I think it’s an emerging research area with a lot of promise.
Tell all of our viewers today, tell everyone where they can learn more about you and what you’re about.
You can learn more about me, it’s very easy, KarenLitzy.com. You can connect with me through there as well, through the contact page. If you want to listen to the podcast, there is a tab on there for the podcast. Or you can go to Podcast.HealthyWealthySmart.com.
Excellent. I want to thank Dr. Karen Litzy. She’s a doctor of physical therapy. She has a wonderful podcast and a great website. Check her out, KarenLitzy.com. In addition,
This was fun. We have to do more of this. Next time, I promise though, I’ll keep that animal in the other room right away.
We like little kitty mascots.
See, that could be a SIM. How we were talking about SIMs and DIMs. Just at that moment, he was a DIM because he’s being super annoying, but normally he’s a cute little cuddly SIM.
We hope you learned a lot about pain and how to heal pain naturally. Thank you for joining us for the first Healing Pain Podcast live. If you have any questions for us, please reach out to us on our Facebook page, ask us a question. We’re more than happy to share it next time we’re live. We’ll see you next time. Thanks, Dr. Karen Litzy. I’ll see you soon.
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