Healing and Recovering from Chronic Pain

Healing and Recovering from Chronic Pain

Insurance-Driven Health Care and Chronic Pain — How Can I Heal and Recover?

In the United States, insurance companies typically dictate the quality and quantity of the health care we receive; to obtain in-network care, we are told where we can go, who we can see, and how many visits are covered.

In-network health care providers face constant pressure to limit treatment sessions to even less than the covered number of visits; it's not uncommon for a provider to be informed that they must discharge patients more quickly in order to retain their contract with an insurer. For example, while an insurance plan may allow 20 visits for treatment of low back pain, a provider may be advised that 6 visits is the maximum that will allow them to remain competitive with another clinic, where patients are discharged after only 4 visits.

This race to discharge occurs whether the problem is acute (i.e., 3 months or less since onset of symptoms), or chronic. Not every problem develops instantly after an injury; some develop over time, or may be an issue that the patient has been suffering with for years. After 4 or 6 visits, has a patient healed and recovered from a chronic problem? No, what has happened is that the insurer has saved money, the provider couldn't adequately care for the patient, and the patient didn't get the care they needed.

There exists a movement toward 'pay for performance' in the health care industry; the basic idea behind this movement is to financially reward or penalize providers based upon their ability to achieve optimal outcomes in the least amount of time. While quality improvement is obviously important, I'm concerned that this model will reward only those who care for patients with uncomplicated, localized, and acute problems, the kind that can be easily and quickly resolved. Providers may simply avoid patients likely to lower their performance scores, focusing instead on those with the type of simple problem that can be effectively treated in the 15 to 30 minutes of one-on-one care that an in-network provider is allocated.

15 to 30 minutes is an adequate amount of time to address, for example, a simple stiff joint problem, using exercise instruction and joint mobilization techniques, but it's not enough time to address soft tissue dysfunction. In a pay for performance model, what happens to those patients who deal with chronic, complicated, or widespread problems? Many of the patients who have sought me out have suffered not only from chronic back pain; they've also struggled with neck pain, headaches, or chronic pain in many areas of their body, preventing them from moving well and enjoying life.

Is a treatment plan of discharge after a handful of visits to an independent home program, without a decrease in pain or an increase in mobility, a good outcome for that person? Does it meet their goals of healing and recovering from their problem? Should they just have to learn to live with their pain, and accept an insurance-driven model of health care that tells them nothing further can be done to help their problem? NO!

I offer a different perspective and specialized treatment approaches to people struggling with chronic pain; I am able to provide this kind of care by being a highly trained out-of-network provider.

For treatment of soft tissue dysfunction, a common cause of chronic pain, I specialize in a type of manual therapy called Myofascial Release, spending a full hour one-on-one with each patient, addressing the underlying problems causing pain and lack of mobility. Home exercises are used to maintain and improve upon changes made during treatment sessions, not as a stand-alone treatment. Not until after spending the time needed to allow people to heal and recover are they discharged, either to an independent home program or to monthly follow-up health and wellness care.

My patients receive care that allows them to get their lives back and enjoy living again, no longer plagued with pain, moving freely and without fear.

Pediatric Myofascial Release

Pediatric Myofascial Release

I recently attended a pediatric myofascial release workshop in San Jose, taught by an Occupational Therapist who specializes in working with children. She has extensive training and experience in the use of myofascial release as part of her treatment program. I took the course to learn ways in which my skills could help a broader group of kids.

I love children. In addition to the children I've treated professionally, I have enjoyed volunteer work in a variety of organizations, caring for, teaching, and mentoring kids anywhere from 6 months to 18 years of age.

The majority of children I have worked with professionally saw me for an injury or for chronic pain. I've used myofascial release to treat children with scoliosis, movement dysfunction, trauma, pain, and headaches. It's a great complement to traditional pediatric therapy, as this technique can allow for increased mobility and significant improvement in structural alignment.

In addition to these areas familiar to me, the course also covered specific application to children with head injuries, birth trauma, neurological dysfunction, and cerebral palsy.

In the neurologically impaired child, there is secondary tightness due to the effects of spasticity and limited movement ability. When added to more traditional therapy, myofascial release can be of great help for these secondary problems. I would love to be part of the team that helps kids with cerebral palsy, neurological dysfunction, or even those with autism or other developmental behavioral disorders who struggle with movement dysfunction.

To parents of children dealing with chronic pain, I would like to pass on a local resource that may be of help. While at the course, I met a physical therapist who works at Lucile Packard Children's Hospital at Stanford; she's part of a multidisciplinary team at the Pediatric Pain and Symptom Management Clinic. This team works together to develop an individualized treatment plan for children and adolescents who struggle with chronic pain. We are fortunate to have this resource nearby. For more information, see their website: Pediatric Pain Management

Overall, it was a good course. I look forward to using the information taught, in combination with my previous training and experience, to treat the children and adolescents that I see.

Myofascial Release

Myofascial Release

What is Myofascial Release? How would I know that I need it? How can this form of manual therapy help me?

Fascia is the connective tissue that spreads throughout the body in a three-dimensional web, from head to toe, without interruption. Fascia surrounds all of the soft tissue and all of the bones of the body.

Fascia, unlike muscles, tendons, and ligaments, does not simply connect one bone to another or cross over joints to allow them to move and maintain static positions; rather, it's one continuous structure that connects each part of the body to every other part of the body, like the yarn in a sweater. It provides a sliding and gliding environment for muscles, transmits movement from muscles to bones, and provides a supportive and movable wrapping for nerves and blood vessels as they pass through and between muscles. Fascia also suspends organs in their proper place.

In its normal, healthy state, fascia is relaxed and wavy; it has the ability to stretch and move without restriction. When we experience injury, inflammation, or scarring, whether from a trauma, a strain, a fall, a bump to the head, whiplash, surgery, repetitive stress injuries, or even the cumulative effects of habitual poor posture, fascia becomes tight, restricted, and a source of tension to the rest of the body. Because fascia surrounds everything in the body, tightness anywhere in this structure can cause muscle pain, nerve pain, joint pain, decreased circulation, loss of mobility, and loss of function.

When fascia becomes tight, normal soft tissue treatment, such as massage, will not help it to stretch out and become mobile again. Massage, or other kinds of soft tissue mobilization, helps localized tender or tight areas in muscles relax, decreases tension and spasm, improves blood flow, and decreases pain. The kneading and deep pressure of massage can help work out knots or reduce trigger points in the muscles, and if those are the only problems with the soft tissue, resolve the pain. However, often the effects of massage are only temporary, because it does not effectively address restrictions in the fascial tissues.

Myofascial Release ("myo" is Greek for "muscle") is a type of hands-on therapy that provides gentle, sustained pressure into myofascial restrictions to relieve pain and restore mobility. In myofascial release, affected fascia is slowly stretched by the therapist's hands until a barrier or restriction is reached, and then a light pressure is maintained for typically three to five minutes, until the barrier releases. As the restriction releases, the therapist feels motion and softening of the tissue.

Common problems treated effectively with myofascial release include chronic pain, back pain, neck pain, headaches, TMJ problems, fibromyalgia, scoliosis, head trauma, movement dysfunction and neurologic dysfunction. It is gentle enough for pediatrics and fragile geriatrics, but can also be deep and effective for sports injuries.

In my experience, when dealing with more chronic, complicated, or widespread problems, the addition of myofascial release to other forms of soft tissue mobilization, joint mobilization, exercise, and education has been the difference between learning to live with a problem and recovering from the problem.

Manual Therapy

Manual Therapy

If my Physical Therapist does manual therapy, what does that mean, and how will it help me?

I am a Physical Therapist who uses manual therapy to help address the underlying causes of a person's pain or dysfunction. Not all physical therapists are manual therapists, and not all manual therapy is the same. Sound confusing? I'll try to explain.

Tight or weak muscles can make it difficult to move the way you are supposed to without having pain as a result; most physical therapists teach people how to do exercises that address areas of tightness or weakness. When a person performs exercises to become more flexible or stronger, it commonly becomes easier to function, and pain is decreased.

However, what if you are in too much pain to do the exercises, or the exercises are not enough to help get rid of the pain? What if there were a kind of hands-on therapy that could help your body heal better than just exercise alone? That's what manual therapy is; it's a generic term for hands-on therapy that helps address the underlying cause of a problem, and more quickly and completely heal that problem.

There are many different types of manual therapy. For example, some manual therapy focuses on joints, which can become stiff and tight. When tightness of the capsule around the joint is the cause of the decrease in motion, a physical therapist may use joint mobilization manual therapy techniques to help the stiff joint become more mobile; better mobility allows better function and lessens pain.

Not all joint tightness comes from tightness of the capsule around the joint; often, tightness comes from problems in the soft tissues surrounding the joint.

There are many different kinds of soft tissue in the body, including muscles, tendons, ligaments, nerves, and blood vessels, these and the organs all having one thing in common: they are surrounded by fascia, a connective tissue that spreads throughout the body in a three dimensional web, from head to toe, without interruption. Fascia has an appearance similar to a spider's web or a sweater; for those who cook chicken, the thin, glistening, membranous tissue found all over the chicken is fascia.

Tight or immobile fascia typically results in chronic pain, referred to as myofascial pain, often diagnosed by pressure on sensitive points in the muscles ("trigger points") causing referred pain in seemingly unrelated areas of the body. The pain persists or worsens, and normal soft tissue treatment, such as massage, tends to be ineffective in causing the fascia to stretch out and become mobile again.

There is a manual therapy treatment able to restore mobility to the fascia and effectively treat myofascial pain, called myofascial release. My next blog entry will describe what myofascial release is, how it is different from other forms of soft tissue treatment, and how it is effective in decreasing pain and increasing mobility and function when other forms of exercise, joint mobilization, or soft tissue work have not worked well enough.