Hi Guys! I recently did an interview with Dr. Stephanie Carter Kelley who is doing some amazing things for the chronic pain community. She does an amazing job of using the biopsychosocial model to address pain and individualizing her treatment for each client. Check out this interview to learn how she uses yoga, physical therapy, and education to help her clients reduce their pain.Â
Takeaways:
- Physical therapy focuses a lot on the biomechanics of the body, but it can be a whole person approach if you would like it to be. Physical therapy is a growing field that is beginning to encompass more than just the physical aspects of healing.
- In order to heal, we need to train the nervous system to be less hypervigilant and sensitive. It has a lot to do with neuroplasticity. Yoga seems to have a better understanding of the nervous system.
- Acute pain (short term pain) and chronic pain need to be treated differently. Some of the treatments used for acute pain can be harmful to those with chronic pain. Treating chronic pain often involves taking a step back and looking at the big picture.
- Sometimes when yoga doesn’t resolve a person’s pain, it may be due to the fact that they are convinced that their body is the source of the pain, rather than the nervous system being the source.
I would love to hear about your personal journey with pain.
I went into physical therapy because I had back and neck pain, but it got worse in college. As a physical therapist, I had great pain management strategies after college and continue to exercise and do all of the things. My personal practice and studies led me to specializing in spine care because that’s where I had been experiencing pain.
At some point, I realized that what I was doing wasn’t working. All the things that I was taught and going beyond that was not working for my pain. As soon as I graduated from college, I almost immediately started into a Master’s program. I was learning more about the manual therapy that we do as physical therapists. I focused on physiology and strength training. I was really trying to understand how to help myself. I stayed very active and I was lucky to stay away from pain medications, except over-the-counter. Yet my pain kept getting worse. It started in the low back and then down into my sacroiliac joint, and then into my hip. My neck pain eventually spread to my jaw. This was all over the course of 20 years.
When I had my first child, I experienced a lot more pain during that pregnancy and afterwards it just felt like my body was wrecked. I started doing yoga and building myself back up. Yoga had been something that I had done previously over the years. I always did a lot of different types of exercise. After that pregnancy, I had an infant to take care of but it’s easy to roll out your mat and do yoga in a different room. I started feeling a lot better. At that point I was also a researcher and I was teaching in academic programs for physical therapy. With that research mindset, I started looking into yoga and asking “why is this really working?”.Â
The first thing that I ran into was this stress management piece. There are pieces of yoga that really help us manage our stress. Then there is creating physical alignment and balance within the body. Yoga poses go from right side to left side and you can feel whether or not you have equal balance, strength, and mobility on each side of your body. I developed more awareness of what was going on within my body and that was really interesting for me.
I became motivated by the power of yoga and I left traditional physical therapy and went into yoga studios. I began teaching yoga for people with chronic pain. That was about eight years ago now. I still dabble in physical therapy to keep my practice going.
Eventually I found that even the physical practice of yoga was not enough. It’s not about doing these five or six poses. There was something that was still missing. At a particularly low point in my career, I had a lot of insomnia. On those nights that I couldn’t sleep, I started meditating. Meditation took me to a different place. It allowed me to investigate what was going on in my mind. It allowed me to look at the internal sources of stress. It’s easy to see all the external sources of stress with family, work, and being a caregiver. All of those are stressful on the outside, but the meditation gave me more awareness of what was going on internally. I had some big “aha” moments as to some of the deeper sources of my stress. That led me to some trauma-informed understanding of what was going on from my past. I’m adopted, so there’s a period of time in my infancy where I didn’t really know where I was. My parents told me that I cried a lot when they first got me, so I think that first year of my life was very disruptive to my nervous system. It set me on a path to have a nervous system that was hypervigilant.Â
The meditation was necessary for me because of what it was teaching me. I started understanding and learning more about pain science. I started to understand how stress, inner rumination, and some of the negativity of my own thoughts explained a lot about what I was experiencing. Science now tells us that these things can keep us in pain. All of these little parts that I was dealing with from the body, my energy states and stress, they play into our physiological and neurological processes. From infancy to almost 50 years of age, I was in a perpetual state of chronic pain. Now it’s this process of unfolding and unfolding all of these ways that I have learned to live managing this very overactive and hypersensitive nervous system. It’s really interesting that the evolution of my pain really follows a specific framework that we use in yoga therapy.Â
I had to look beyond what my profession was telling me to do. As a physical therapist, you have to do X, Y, and Z. But that doesn’t feel right. I had to tap into what my body and my experiences were telling me and move more in the direction of that. Then the final part of the framework in yoga therapy is your spirit. The process starts to involve asking yourself “What do I want? What is my purpose? What are my values and how do I live each day?”. I’ve had to learn how to let go of all of the stressors our society tells us that we’re supposed to have, especially as women. We have to take on certain roles and be certain things.
That’s where my evolution of pain has brought me to right now because I am very interested in breaking free of societal expectations for women. I’m almost 57 and there are a lot of expectations of how I’m supposed to be in the world. A lot of those expectations do not feel good to me anymore. I think I’m still on a path to be completely free of pain. I am not completely free of pain, but I live with so much more ease than I ever did before.
And that in itself is amazing because a lot of people living with chronic pain are not in a state of ease. They’re often in a state of panic. Being in a state of ease and being able to enjoy your life is huge. It’s super cool that you have this long story with chronic pain. You have gone from having chronic pain yourself, practicing physical therapy, practicing yoga, and being on this journey to where you are today. Throughout this journey, what are some similarities and differences that you have noticed between physical therapy and yoga?
I think that physical therapy taught me about the body. I understand biomechanics really well and I still use that to help give people relief by helping them stretch and strengthen certain areas. Physical therapy can be a whole person approach if you want it to be. You can look at lifestyle habits and help a person add more physical activity to their life. Physical therapy is mostly focused on the physical, but it is a shifting profession.Â
Physical therapists take physiology courses, but it’s very focused on systems. We learned a lot about individual systems, but there was nothing that really helped me explain how all of those systems really work together. Yet now when I interview people or I do a comprehensive assessment, I look across all of the systems because I want to see how their chronic pain affects all of their systems. People often want to partition out all of the symptoms and our healthcare system also does this for us. We treat everything like they’re separate problems, but they may actually be connected.
When a patient comes in saying that they have ringing in their ears or restless leg syndrome or dizziness and other symptoms, I help them pull it all together and say this is actually all about your nervous system. If we can focus on treating the nervous system, there are some strategies that can help you in the moment. And then there are some things we need to do for long term management of the nervous system.Â
It’s really neuroplasticity. We have to understand what we’re feeling from the nervous system and work on changing the nervous system to be less vigilant and sensitive overtime. That’s what will ultimately lead to less pain. I see physical therapy as part of a Venn diagram. There is overlap. Yoga seems to have a better understanding of nervous system regulation.
Yoga has a focus on energy states and the way yoga instructors cue clients is different than the cues used in physical therapy. Physical therapy is more prescriptive and medicalized. Yoga is more of a person centered approach that addresses how you are feeling physically and emotionally. Yoga understands the stress piece of chronic pain.
Meditation helped me deepen my understanding of my own pain and give me more tools to address it.
I relate to a lot of what you just said. I did a lot of yoga and physical therapy on my chronic pain journey. Physical therapy was very physical focused and I saw my physical therapists trying to integrate relaxation techniques, but I could tell that the training was not really there. This makes me wonder, when you’re being trained to be a physical therapist do they teach the science behind chronic pain and how to work with chronic pain patients?
I think there’s still a lot of work to do within the education programs and physical therapy. I have taught in physical therapy programs at a local college. Since I have taught in physical therapy programs, I’m always getting some inquiries. The last time I interviewed, I asked this institution, “What are you doing with the autonomic nervous system?” Because I was willing to teach it. I’ve studied it and I understand it. I’m an orthopedic physical therapist but I very clearly understand what’s going on in the autonomic nervous system. They said that they’re not doing a very good job of teaching people how to deal with orthopedic conditions. To me, the autonomic nervous system impacts all of the systems. You might take a class on the cardiovascular system, but do we talk about how stress impacts the cardiovascular system? No, we don’t because we don’t do a good job of tying it all together.
It’s not that they have blinders on. It’s that physical therapy is a long curricular program. Pain science is starting to get into programs, but it really depends on who is teaching it and how well they understand it.
A lot of these things are new and they’re just not yet in the curriculum. When you look at the accreditation standards of what goes into a physical therapy curriculum, it’s a lot. It’s hard to fit it all in. We’re all subject to continuing education and that’s how you keep progressing in your practice.
A lot of what you just said is very accurate for nursing schools as well. We cover a lot of information, but we miss out on chronic pain and how to effectively treat it outside of biomedical strategies.Â
You learn acute pain and chronic pain doesn’t fit into the treatment model of acute pain. Yet we’re treating chronic pain like acute pain and a lot of the strategies we use to treat acute pain can make chronic pain worse.
I completely agree with that. We take a very biomedical approach when we need to be taking a biopsychosocial approach. I don’t even think we used the word biopsychosocial within nursing school. It’s a word I have been trying to introduce my patients to and I feel like that makes them aware that they have more options for treating their pain.
Yeah, absolutely. Even the testing that we do for people who have chronic pain (labs and imaging studies) and then how we talk about those results. All of that can be somewhat unhelpful, especially when they don’t find anything of significance. The doctors will tell their patients that there’s nothing wrong and they don’t go on to educate to them about how there are some things that we can’t see or test for. They should be sending these patients to someone who has a better understanding of chronic pain conditions. It’s really frustrating.
I teach yoga in a physical therapy department in a hospital and I thought that I could stay isolated from all of the biomedical stuff. I’m in a frustrating situation trying to educate others but the whole healthcare profession has to want it.
Yeah and realistically, I know that our doctors, physical therapists, and other people want to do the absolute best they can for the patients. I almost want to blame the education that is provided to healthcare providers. We’re not trained on how to have long conversations with patients when all their tests come back negative. We need to extend the conversation to “where do we go from here?” It feels like we’re just saying, “Hey, all of your tests are negative. That’s all. Best of luck”.
I will also blame the reimbursement system too. The reimbursement system says that you only get 10-15 minutes with each patient. And it’s hard to figure out how to document and bill these conversations. They don’t fit neatly into our billing requirements. Yet because I find these conversations so valuable, I figure it out. I can take some of the biomedical tools and assessments that I use in physical therapy and use them just for the purposes of documenting within the medical system. I do vital signs before and after my yoga classes as a way to measure the state of the nervous system. When people have worked with me for a while, we begin to see decreases in their blood pressure and heart rate. I use those metrics as a way of validating the work that I’m doing. I’m teaching yoga under the umbrella of physical therapy and it seems to be working.
Many years ago, I worked with a woman who had had 20 years of chronic pain surgeries and she didn’t want to have any more surgeries. She came to me completely rigid from the top of her head down to her toes. I started her in the yoga classes and she slowly started opening up a little bit more. And then she tells me, “I find myself doing these little tiny cat cows (yoga pose) all the time. I do them when I’m driving, sitting, and if my back gets achy”. To me, that’s a win. She is starting to use different strategies for pain relief. If she keeps doing this long term, she’ll have less pain overall. It’s not a quick fix.
Right. We have talked a little about the science behind pain and the nervous system. Let’s dive into that a little bit more. How would you describe what chronic pain is, especially in comparison to acute pain?
In acute pain, we’re still using the model of injury and inflammation. While inflammation or swelling is present, the tissues send signals up to the brain communicating that a certain area needs to be protected. And that’s okay when you have an injury.Â
When people have chronic pain and they come in to an appointment saying that they are having a pain flare, I go through a different process with them. I just had a woman the other day who said that she was getting into a higher car than usual and she strained her hip when she did that. The next day she felt a lot more pain. So I asked her, “How did you feel in that moment of getting in the car?” because when we injure ourselves, we usually know when it happens. We usually know right away when we have an injury. So if you didn’t feel immediate pain in the moment, then it’s not likely that you actually had an injury with an inflammatory process starting.
I had to ask this woman, “What were you worried about?” She’s a heavy woman and doesn’t usually get in cars that high. She’s getting some surgery done on her eyes and she had been really stressed about those surgeries and she had appointments that day for the surgeries. She was mentally, emotionally, and physically tired. It was more than she was used to doing in one day and that could have been the trigger for a pain flare up.Â
We have to take a step backwards and help people take a look at the bigger picture because with chronic pain, the nervous system has changed. It’s now hypersensitive. Smaller things are going to trigger a pain flare up. It doesn’t have to be an actual injury to the tissue. When we talk in terms of stressors, it can be a physical stressor and all that means is you did more activity that day than you’re used to. You’re more physically tired, your muscles are tired, and your cardiovascular system may be tired. Being tired can be a trigger to a pain flare up. Being emotionally and mentally tired can also be triggers for pain. One of the first things I do with my process is really looking at what are the physical, emotional, and mental triggers of pain.
Which is very important because there are a lot of misconstrued beliefs about what triggers pain. There are so many different things that can lead to pain.
Yeah and from a science perspective, an acute injury is described as bottom-up signaling. The tissues of the body tell the brain that it should create pain and send the signal down. From the chronic pain perspective, it’s from the top-down. The brain is reacting to some stressor and sending pain down into the body because it still thinks that protection is needed.
My go to analogy is the alarm system where I describe acute pain as an alarm that occurs when a body part is injured and you need to pay attention to the injured part. Then with chronic pain, I saw it’s an alarm, but it’s a malfunctioning alarm because there is not an actual body part that you need to be focusing on. It’s more about addressing the stressor that is hurting your nervous system.
Is it a malfunctioning alarm or is it a valid alarm? It’s a valid alarm that is telling us to take a step back and pace what you’re doing whether it’s physical or mental. I hate to think that any part of the body is broken. There’s a reason that the alarm is going off and the next step is to identify why it’s going off.
It often results from fear. It may be that having a difficult conversation with someone was a stressor. There’s also a fear that, especially in women, that you’re not being heard and your opinion isn’t valid. I haven’t used the broken alarm analogy because I still want you to pay attention to the alarm. It’s just not signaling what you think it is. It’s not your pillow or mattress, it’s not the extra walk that you took. It’s usually not whatever you’re blaming it on. We need to do a little more investigation.
Maybe we wouldn’t say it’s a broken alarm. We could say the problem is a misinterpretation of the alarm. We often assume the alarm is signaling a physical problem and we haven’t been taught to recognize that it may be signaling a different problem.
I think that’s exactly right. It’s a misinterpretation and we now need to go a little deeper and figure out what the alarm is trying to tell you. And some people don’t want to listen to what their pain is telling them.
Yeah, people want to push it away. They don’t want to stop and think about it because pain is scary.
I’ve led some women down the path of recognizing the many stressors that are in their life and they stopped working with me because they are not willing to make changes.
I have this framework that goes over body, energy, mind, intuition, and spirit from a yoga perspective. It goes from a superficial to deep perspective and you can stop anywhere along the way. Or you could just deal with the mental aspects and not exercise, but I don’t think that true healing can happen unless you go all the way through the process. To use the alarm analogy, you’re just putting out alarms, but you’re never getting them to turn off. I think in the long run the goal is to turn that alarm either way down so it’s not affecting their daily life or to just turn it off altogether.
When you’re working with these clients, what specific strategies are you using to treat their pain? And are there any strategies that you find that are effective for most people?
Yoga is obviously my biggest one, so I offer yoga on site with my clients at the hospital and I also offer online yoga classes as part of a coaching program that I do. It’s not only the yoga that we practice. We also have discussions around what they’re feeling. It’s yoga plus education. It’s not just me lecturing them to provide education. I’m helping them educate themselves about their own experience of pain. Pain science education is a part of that, but it’s really meant to be applied. I’m an applied educator. You don’t just take the information and store it in your memory. You have to apply it.
My coaching package consists of one-on-one time with people so that we can really explore because everyone’s experience is different. We can set some goals and look at any limiting beliefs. Creating a personalized approach is really important. Not everybody can come to my yoga classes and not everybody likes yoga. They might try it and go, “This really wasn’t for me”. And that’s fine. Let’s try some other movements or other physical activity practices. The one-on-one sessions are necessary in order to create that personalized plan for turning down that alarm.
I have developed a workbook. It incorporates some assessments. It has assessments that look at stress, central sensitization, self-efficacy, negative attitudes, and attitudes and beliefs. It’s the process where we keep discovering where somebody is and what are the tools that we can use to help them. Then there’s writing. I think people have to write. I think they need to get it out of their head and get it onto a piece of paper. I have lots of writing activities. I often have to push people to do writing.
One of my favorite writing exercises is expressive writing. You sit down with a blank piece of paper and just start writing. Then 10 minutes later rip the paper out of your cheap notebook and tear it up and throw it away. Then I have some other writing activities to help them look at their pain story, not just from the physical perspective (which we’re typically pushed into), but also from a mental and emotional perspective.
Let’s say in 2010 you had a pain episode. The worst that you can imagine. I want you to look at what was going on in your life at the time. What were the social, emotional, and mental stressors? Almost everybody can point to something. They’ll say, “I was getting a divorce” or “we moved across the country”. They may say that they got married. Sometimes it’s a joyful event, but it’s still stressful.
There is also meditation which is incorporated with yoga. You can also do meditation on its own if you need to use that as a practice. There are a lot of pieces that can be used to personalize treatment for each person. There are a lot of things that will work, but we have to find the ones that are going to work for each individual person. I think that’s why it’s hard to package into our biomedical model.
Yeah, there’s nothing that works for 100% of people with chronic pain. It’s more about presenting each individual with a toolbox of strategies and helping them figure out which strategies will be most effective for their pain.
Yeah, and I think that the rise of health coaching is really going to make a difference for people with pain. I know that as a physical therapist, it’s not in my hands anymore. It’s more about being able to take a step back and hear people’s stories and look at the big picture. Sometimes they will tell you a story of things that have worked and they don’t even remember it. They have forgotten so I help them really refine what works for them. I think coaching is the model. I see it more and more and I think that’s the model that we’re moving towards as a way to help not only with chronic pain, but other chronic conditions for sure.
I have encountered a lot of people who have had really positive experiences with yoga, but I have also encountered people who have tried yoga and it didn’t do anything for them. They’re often exhausted of people telling them to try yoga. Who do you think it is that some people do not respond well to yoga and what is your advice for these people?
This might not be the story for everybody, but what I see is this attachment to the idea that the body is the source of pain. It’s fostered in every medical appointment that they have. There are many people that do have things on their images like bulging discs, degenerative joints, spine vertebra being out of alignment, and other spinal problems. So they often have this limiting belief and attachment to the body as the source of pain and it gets them stuck.
I had a woman come in yesterday. She has been with me for a while and she has come a long way. Her case is complicated because she has psoriatic arthritis and ankylosing spondylitis. She comes regularly to yoga class and she uses meditation at home. She has a new pain in her hip and the first thing she asked me when we met one-on-one yesterday is what is in there that’s causing this pain. Sometimes I go ahead and give the person the physical approach because that might be the explanation at this time. When she comes back we’ll know if this approach works for her, but in the past, it has not been the answer. She has had back surgery, she’s on medications that are not helping, and the biologics that she’s taking are not helping with her psoriatic arthritis. Yet she keeps seeking the physiology reason.
When we talk about a new pain, she immediately jumps to a diagnosis or condition that she’s been given or something else. Sometimes she’ll look to the weather and says that’s why she has pain. She talks about it as if it’s beyond her control. It’s really hard to get to a point where you can say, “I have an active role in healing myself”.
When I say healing (I use that a lot in my social media), I would consider myself healed from chronic pain because it does not consume me every single day. When I have it, I know what to do about it. It rises and falls. I now see it as a welcome and trusted support that tells me exactly what I’m supposed to be doing in any given moment. Maybe it’s telling me to move more, stress less, or do some meditation. Sometimes I need to have a difficult conversation with someone or set clear boundaries.Â
As long as my patients hold onto the idea of their body being the source of pain, they will believe that somebody else needs to fix it. And then they don’t heal.
It’s a mindset change and that’s hard. It’s really hard to do, especially when you have had pain for years and years and you’ve been sticking with the same definition and strategies. Making that shift to go to thinking about your pain as more of a nervous system problem can be very hard for people.
Yeah and it’s been interesting to watch this patient start from zero and shift her mindset and then jump backwards. Anytime she reaches for the body as the source of pain, it takes her backwards.
I’ve experienced that a little bit as well. My pain is 98% gone, but sometimes I’ll get like a random new symptom like a headache or wrist pain. Part of me always wonders if it’s a structural problem and I need to see my doctor and get some tests done. Another part of me considers that this may be my nervous system acting up again. So I usually give it a few hours to just see what happens. The vast majority of the time, it’s definitely nervous system related.
Yes, I even do that now. I’m confident enough that even some acute pain that people experience may be nervous system related. I have teenagers that both play a lot of sports and my daughter might come off the soccer team and say “my knee really hurts”. I’ll say, “let’s give it 24 hours”. After 24 hours, I usually don’t hear about it again. There have been instances where I have watched the mechanism of injury and I’m like we should make sure that’s not broken. This happened a month ago and it was bad. It was interesting after that injury. She was really in pain and we had a discussion on the way to the hospital about how stressful the busride coming home from the soccer game was. We live in a rural area and the bus ride was going up and down hills and around curves. She was a little nauseated by the time the ride was over. I think that’s why the reaction to the injury was so big. Her nervous system was already amplified and then it turned out that she didn’t have a broken bone. She did have a decent sprain and was back on the soccer pitch in ten days.
I’d like to wrap this up with one final question. When you’re working with somebody who is either newly diagnosed with chronic pain or someone who has had chronic pain for years and years, what would you say is the best starting point for either of these individuals?
Find that compassionate practitioner who will listen to your story. I can’t tell you how many times that initial session gives people so much relief. They get 60 minutes in their initial evaluations to share their story and have somebody validate their experiences, they almost immediately feel better. It’s about finding that coach, therapist, physician, or psychologist that can offer you this. I’ve seen too many people bounce around with so many different practitioners. They bounce around from different pain management doctors and it’s all interventional pain management. They find a lot of things that don’t help. People get hopeful and excited each time they start working with a new practitioner and then they try things that don’t work and they are back to square one.
It’s such a rollercoaster for patients. You’re constantly getting your hopes up each time you try a new provider, new medication, or new procedure. Then it doesn’t work and your hopes crash again.
I wish that we had more pain psychologists and more of a team approach. We need the nurse who understands the medications, the physical therapist who understands the physical aspects, the psychologist who understands the psychology, and everyone else who is needed. We need a team helping these people.
I do have some hopes that those groups are growing with the Veterans Administration. They’re growing within some hospital systems. I work in a tiny little rural hospital. There are more people online now.Â
When looking for providers, read their bio and the approach that they use. Do they use stress management or pain neuroscience education? If they’re using these types of approaches then they’re on the right track.
Huge thanks to Dr. Stephanie Carter Kelley for doing this interview. I learned so much from her and I hope that you did too. Check out her website to see if her services may be a good fit for you: https://stephaniecarterkelley.com/.
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This is great, thank you! I wrote about a similar thing with my chronic pain – yoga didn’t work because me mind was trash talking the whole way through -once I turned the volume down on that things started to get better – it really IS the big picture like you say, Linda xx