Simplifying Pain Neuroscience Education in Pelvic Health

• We'd love to welcome you to Pelvic OTPs United - Lindsey's off social media community ($39 a month with no obligation!)
• 3rd annual OTs in Pelvic Health Summit tickets are on sale!!
• Grab Your FREE AOTA approved CEU pelvic health course here.

Find my guest, Carolinne Bradley here:
@Carolinne Bradley 

____________________________________________________________________________________________
Pelvic OTPs United - Lindsey's off-line interactive community for $39 a month!
Inside Pelvic OTPs United you'll find:​

• Weekly group mentoring calls with Lindsey. She's doing this exclusively inside this community. These aren't your boring old Zoom calls where she is a talking head. We interact, we coach, we learn from each other.
  ​
• Highly curated forums. The worst is when you post a question on FB just to have it drowned out with 10 other questions that follow it. So, she's got dedicated forums on different populations, different diagnosis, different topics (including business). Hop it, post your specific question, and get the expert advice you need.

More info here. Lindsey would love support you in this quiet corner off social media!

Transcript

Lindsey Vestal My guest today is Carolinne Bradley, who is from southeast Michigan but attended college in. Michigan. Ohio and Massachusetts, gathering for college degrees in the past. She's worked as a head athletic trainer at a high school, a PTA slash manual treating therapist in an outpatient setting and currently as a pelvic health O.T. in an outpatient setting under a hospital system. She currently has been doing monthly mental Fitness letters and exercises for the company she works for of over 250 employees to promote mental wellness For the last year, after seeing how health care providers in particular as clients have demonstrated, they don't manage their stress or know ways to manage their stress and how that affects their physical health, bringing them into pelvic floor rehab. I am so excited to be joined by Carolinne today as we dive. Deep into simplifying pain, neuroscience, education and Pelvic health 

Lindsey Vestal Carolinne, thank you so much for being a guest again on the OTs for Pelvic health podcast. 

Lindsey Vestal Talk about something that is an incredible passion of mine, which you know you are. You answer so many questions so beautifully on our OTs Pelvic health Facebook group. And so I was dying to get you on here just to dig out a little bit more about neuroscience and pain education. And so I'm so grateful to have you as a guest today. 

Carolinne Bradley Yeah, thank you for having me. 

Lindsey Vestal So you work in a hospital based outpatient center, and it's a pretty it's a pretty large facility. I think you guys have 21 or so clinics. And of that there's about four where you guys focus in on Pelvic health and there's about 20 or so practitioners of which two. OTs You're one of them, as well as Emily Lieberman, who has also been a guest on the podcast. So I just wanted to start that conversation off with framing that a little bit, just to give our listeners a sense of kind of like your environment and the breadth of West breadth and width of diagnoses and clients that you treat. And that being said, I just love the way that you refer to pain neuroscience education as kind of like the primer to the paint. And I just really struck me and in such a beautiful way. You've also described the paint as kind of like manual treatments. Maybe that's amfAR or a biomechanics or whatever, hands on tools that we could use with our clients. Can you tell us a little bit more about that? And I'd also love to hear how you explain this to two fellow pelvic rehab professionals, because I think we're always on a quest to make this conversation a little bit more articulate and streamlined for our clients. 

Carolinne Bradley Sure. So so even in my background, chronic pain was always something I was really fascinated with and how we treat it, how we go about it. And even my master's with our team. But typically, when I get into discussing pain with patients, I want to ask them the questions. Usually I don't start to get into pain itself till maybe the second or third visit. I want to build rapport. I want them to trust me and what we're doing. But it may come up, let's say, first visit or second visit, depending on what brought them in. But typically, I want to ask them, you know, what, what do you think is causing your pain? Just kind of build that curiosity and kind of limit that judgment. As Levine had once said, everyone has that fundamental drive for healing, which can be encouraged by curiosity and exploration. So when it comes to pain itself, and I know you probably use this term to Lindsey, is that pain is an alarm system telling us to change something. And so, you know, when I'm discussing them with that, I avoid statements like, you know, anything linked to more of that negative side of things like you're weak or this is the worst thing I've ever seen, or you probably have this and kind of making those absolute statements. So when it comes to discussing, is this the primer to the pain? You know, the idea behind this is basically we want to change their perception of pain. A lot of times, right, we see it as a negative. But when it comes to pain, you know, it's there for our survival. It's there to help us and to tell us something is wrong. And I, I even like to cite Adrian Wu on his description of pain and saying, you know, if you stepped on a nail, you would want to know about it. Right. So, you know, using stories and anecdotes like that will help build their curiosity, you know, trying to understand why they might have pain and what's going on in the body. And so when referring to the prior to the patient. So when working on changing their perception on pain and what's happening, ideally we're trying to just lower that alarm system because again, even with the nerves that are connected to how our pain is processed, we're trying to decrease some of that sensitivity. So if they're understanding that perception, it kind of lets their guard down in order to allow those manual techniques and exercises to really help them. 

Lindsey Vestal I love that. And I really appreciate you kind of sharing that. Sometimes you're not bringing this up until, you know, second or third session. And I'm curious, you know, I love the Adrian Lowe example. And, you know, I, I really appreciate sort of like the simplicity and also the validation that pain is there to help us because so many of us have such. A negative relationship with it. Understandably so. But kind of reexamining the body as an intelligent adaptation. Right. That that some of these these these techniques and tools and looking at it as a supportive mechanism is such a big frame of reference and and and changed how most of our relationships with pain especially even going back to thinking about like when I first had children, my reaction when my daughter fell down. Right? Are we kind of aggrandizing it and making it sort of like this this thing to be avoid it versus just being curious about your environment and exploring it. And sometimes as a result, we do get pain, we do get hurt. And so kind of like a lot of these early programing and reactions that we're getting from our environment, I think often really influence and kind of bring us to an understanding of our relationship with pain today. So I really love all of those examples of, of kind of how you're changing and, and encouraging the client to be curious about their understanding of it and what it could mean. Even going back to that very first question that you ask them, which is like, what do you think is causing your pain? And I'd love to hear a little bit about like some of the answers that you've gotten when you've asked that question, just to kind of help us understand the breadth and width of of of that human experience. 

Carolinne Bradley Sure. Yes. So some of the answers that I might see, you kind of, you know, all over the board, I would say, but they might cite what the doctor told them. Let's say, I have a disc herniation or it's because I have arthritis. Or they might relate it to maybe how they're moving and I don't move enough. Or some might say, I don't know. I don't know what's causing it. And so trying to get some clarification and understanding where they're at in their journey and what they see as why they might have pain is really something I might see. I think a lot of times they relate pain to damage. And so usually there is like again in their response, something they may have been told like an injury in the past. And so I use it to kind of clarify something that they did go through and how physiologically that can happen. And maybe it's years down the road that things should be healed at this point. But again, I don't want to create any kind of defensiveness but more of an understanding. So there might be some discussion of anatomy, right? And what brought them in and what they've experienced or trauma in any way as well, and how that affects our nerves and our our whole nervous system. 

Lindsey Vestal Carolinne I'd love to hear when I think a really common misconception is that pain does equal tissue damage. Would you mind sharing with us how you kind of help help a client see that in a new way? 

Carolinne Bradley Sure. I, I tend to like to use Mosley's pain quiz and I'll have them fill it out. I might have them take it home, bring it back. You know, I tell him, Don't look up the answers. Don't try to figure it out. Like, what's the right answer? I want you to to answer it honestly and then they'll bring it back in or I've had them do in the session itself and go through it and then we'll talk about it. Some of them are more specific that really get into like the cellular molecular level of pain, which I don't expect them to know necessarily, but that's where it kind of just kind of gets them to be more curious about pain and why it happens. And so I feel like that kind of gives me the opportunity to talk about, you know, nerves, right? And how they require space movement and blood flow. And I had a coworker use the analogy of putting a 20 foot giraffe in a ten foot cage. And so over time, the sensitivity changes in the body and that alarm system becomes more and more sensitive. So in that case, I might use the example of, you know, you have a house with a security system, and if someone were to break through the front door, of course the alarm system will go off. But over time with that sensitivity that those nerves go through, depending on what they've been dealing with, you know, if a leaf blows by then their alarm systems turn off and they get that pain response or that pain signal. And so it doesn't necessarily mean that there's damage there. It's more your body's trying to understand, is this a perceived threat? Is this something that we need to worry about? You know, do we need to send inflammatory mediators? So what what do we need to do? So it's to signal, you know, what's the best next step? Because at this point, we need to change something or we need to be okay with it. That again, the the limbic lobe, a lot of the body anatomy stores, some of the experiences you might have had in the past and use it to protect you and signals those body parts of your body to know and to say, hey, do we need to stop what we're doing? Can we continue what we're doing? And so I've used that with some of my patients, you know, that, let's say, experience some pain and what they're doing or if we're doing some manual techniques. And I might say that this isn't meant to scare you but protect you. And we just want to let your body know that this is not a threat. 

Lindsey Vestal I love that. That's really that's really lovely. I'm a big fan of the Central Sensitization Index or inventory as an outcome measure. I'm curious, do you use that one or what other outcome measures do you do you use? 

Carolinne Bradley So I've used the pain catastrophizing scale. I might have them do that perceived stress scale. Those are some of ones I tend to use. The only thing with some of them I don't tend to want to give right in the beginning or I more so want to get the conversation going of where they're at with their pain, how they view it and everything first. So I'm careful with some of the outcome measures only because I some people might get defensive when they see that or like the way that they answer those questions and such. And I want to build rapport first with those have been some of my to go to is or like I said the Mosley's pain quiz I've had them fill out to just to get an idea. 

Lindsey Vestal Yeah that's awesome. You know, when we started our conversation I mentioned how, you know, you work with a fair amount of physical therapists at your clinic. I'd love to hear a little bit about how. How you guys collaborate together. 

Carolinne Bradley Yeah, sure. So typically when a physical therapist is interested to collaborate with me, usually let's say they've been seeing a patient for, let's say, 2 to 3 visits or more, or they've gotten kind of an idea as far as what they're coming in for, you know, using their techniques and treatment interventions. And, you know, they might say that, you know, I think we're helping them physically, but mentally and emotionally, I think this is a barrier for them and limiting them in their progress. And so usually they might send me an email or have a conversation with me or they might transfer you. They might even transfer the patient to me to see them specifically. But I do love coach training because they've already built that rapport with the patient themselves. And then they they might say, Hey, I'm going to have Carolinne sit in with us. Do you mind? And to kind of get that idea to sit with them and then we'll plan a visit to work together. And that way they're aware of it. And again, depending on the person that they're seeing, if they have, let's say, mental illness or. Maybe they're on the autism spectrum or anything like that. You know, she wants to make them comfortable and okay with me working with them, of course. And then in some sessions, it really depends on the person and what they're comfortable with. But I might dive into more of the emotional mental aspects and paint education with the client and a patient. And then our physical therapist might, you know, do some of the more manual techniques. We kind of might split it up, so I might start the conversation with them. And then at one point, she might do some male techniques or maybe not. She might sit in on the session. And then just for, you know, reassurance and comfort level. Sometimes she's actually done a few things and then stepped out and then came back just to give us some time because, you know, some patients aren't comfortable with two 2 to 1 kind of ratio, like two people kind of sitting there and talking with them in some ways as well. But every person is different when I work with them. You know, I have had discussion about pain. I might use visuals with pain. We might dive into breathing and management. I've also done like to point discrimination for for them to kind of help understand the cortical mapping and how their bodies are processing pain for those with chronic pain. So it really depends on the person and what she finds that they need help with. We have seen clients where they were doing. They might do well, they might feel good leaving seeing the physical therapist, but then the psychosocial aspects or maybe the stressors in their life or what kind of may trigger them and their symptoms. Some are aware of that, some aren't. And so sometimes when the team might notice that and when discussing with them and how they're doing in their progress, and she might say, hey, let's have Carolinne work with us and cooperate with us. 

Lindsey Vestal Yeah, I love that. It sounds like a really collaborative, harmonious relationship there. 

Carolinne Bradley Definitely. 

Lindsey Vestal Carolinne, I on the Facebook group have seen you talk about what you describe as a yellow flag activity. Can you tell us what that is? 

Carolinne Bradley Yeah, sure. Yeah. So I mean, by one of my coworkers, Carl, he. He's P.T. That works a lot with pain in the orthopedic realm. But basically, yellow flags are seen as what can also be keeping your alarm system or those nerves sensitive. And so with the yellow flag activity, basically it allows them to connect between outside factors or occurrences around the time of their injury or trauma and what they're being seen for. So on the handout itself, you know, and usually I like to explain to it to them first so that on the handout I've given, it kind of guides them along like as possible, you know, yellow flags and lights. And so I might use that same idea of, you know, your body as a house, right? And you have a security system and where, you know, if a leaf blows by and that seems to trigger your alarm system, even though it's really meant for if someone breaks through the door or the front window or anything like that. And so yellow flags are items in our life are factors that can also make our nerves sensitive. So that could be, you know, financial burdens or responsibilities or work stress or relationships or, you know, losing a loved one. There's different things in life that can, you know, add to how we're feeling and how we're dealing with pain. Because, again, it keeps our alarm system and those nerves sensitive. And so the idea behind it is usually I give them the handout. Describe a little bit about yellow flags and paint. And at this point, usually I've already had a discussion with them about pain and just, you know, asking those questions, building that curiosity. And then I have them take it home, fill it out. And I usually tell them, you don't need to bring it back. I just want you to do this for yourself. So take some time, you know, 10 or 15 minutes to yourself in peace and quiet and just reflect on that for yourself. And some individuals, they want to talk about it when they come in. They don't necessarily have to. Or I might say, you know, what did you gain from the activity? Just to see how they do as long as they did it Right. That's you know, that's really my main goal if they did it. And so just connecting those emotions with events and things in life that can really be adding to their their pain and such. 

Lindsey Vestal Yeah. Yeah, I, I think that's great. And, you know, one of the things I wanted to ask you was how to how do you build curiosity and not judgment in these conversations. And I think that all throughout this conversation you have pretty much answered that question in such a such story as such a story based format. Is there anything else that comes to mind, though, that you haven't spoken about in terms of that building curiosity aspect? 

Carolinne Bradley I would say just the biggest thing is, you know, how we're presenting to another person. So obviously asking those how what questions, but listening without interrupting, you know, empathizing with them, trying to understand where they're at. Right. I can't you know, I'm not experiencing what they're experiencing. So I want to hear their perspective and know what's going on for them. And, you know, I might use mirroring or label the feelings that they might be having and some of those counseling skills that I learned even through old school as far as just helping to build rapport and trust with them when having these discussions. And those are some of the things that I tend to do most often and, you know, be approachable, be open. And just be there for them. And a lot of times I found and probably in the last year that I've had a lot of individuals, especially with chronic pain, that feel like they haven't been heard from other health care providers. And so and these are people that are also health care providers you've been to I've seen where they're disappointed with how they've been treated, what they're dealing with. And not all of it is like kind of linked in to the pain science per se, but maybe just what they're dealing with with their symptoms and public health in general, that no one's been able to help them with their answer those questions. So that's what I feel like I'm able to help them with and try to do as much as I can to answer their questions. And so for me, it's, you know, it also works a lot of my communication skills, you know, and everybody's different and how how my body language is in relation to them and kind of being at their level. So. 

Lindsey Vestal And unfortunately, I agree with you. I think it's an all too common scenario where, you know, the pain isn't isn't validated for the client. You know, that they've been especially for the pain that just is not quantifiable by our medical, you know, system. It's like the things maybe more like fibromyalgia or some of these other things that we just can't put our finger on. And, you know, there is a lot of hand-waving and dismissal that's associated with these clients. And so is there anything that stands out in your mind that you have found to be kind of techniques that you've been able to employ to really help that client feel seen and be understood by you for potentially what could be the first time for them? 

Carolinne Bradley You know, I usually try to make them feel as comfortable as possible, you know, in the room when I'm working with them and even getting to know more about them, right? What are some things that they have going on in their life? You know, are they married to have children? Like, what is their job? What do they like to do? And so I feel like that, you know, helps to build a conversation, especially first appointment, you know, that I'm there to listen. I'm there for them. I want to help them any way I can and that they know that that's my intention, I think is really important in those cases and also to try to just make it a positive narrative and to hear what they have to say, where they're at. And and I and I, there's lots of physicians that we work with and I and they patrol the same things. And, you know, it's it's an awesome thing that we're all there to work with them on their care team and that we ultimately want them to feel better, that we want them to move towards their goals. So even goal setting is something that we might do together. Or another one is is developing strategies to help with setbacks like what can help limit them from, let's say, catastrophizing pain or, you know, let's say they're doing well, but they're worried about what if my pain starts at this point in time, you know, having strategies and even writing them out on a paper for them is really helpful. You know, we really underestimate the power of like even writing something down or journaling something or having it on a handout. We think it's so simple, but it really does. It's one last thing that they have to worry about and they can refer to back later. So I like to help with them and literally write out the strategies for them when they're feeling pain is overwhelming or they're doing well and they have a sudden they were more pain than they've been used to. So I tend to try to help them with that as well and just strategize like, how can we manage this? Or even when they're discharged, you know, maybe they're 50% better, but that's as far, far greater than they were expecting. You know, how can I help them or tools that they can use moving forward to maintain their current level of function and how they can continue to go on that upward trend? 

Lindsey Vestal I really appreciate you bringing that up because I agree with you. I think that there's a piece to the puzzle here that OTs really intuitively know in spades. And I think it's it's really worth calling out for what it is. And I think it's this idea of writing something down or spending some time even asking the question, especially in Pelvic health, especially if it's an intimate assignment, that there are an intimate home exercise aspect, an intimate aspect to their home exercise program, which is like something as simple as, you know, where do you where do you vision yourself doing this in your house? When do you see yourself doing this, especially if there's other people that live there or if they're a very busy individual, you know, giving time and space to that temporal aspect of the work that we're doing with them so they can really imagine themselves doing it, I think is, is such a it's it's removing such an obvious barrier that I think, you know, it makes all the difference in the world for the client really being intrinsically motivated to do it. And it makes me think of this statement, which is like so much of the work we do in O.T. is very simple, but simple is not insignificant. And taking that extra step to to even just helping them recognize when and where to do it, knowing right away when they walk in your your office of like any strategy or any ideas that really resonate with you today, I'm going to be writing them down for you so you can cognitively be really present. You don't have to feel like there's things you have to remember. First of all, you know, I'm aiming to send you out with three things today. You know, if that's if that's what you're doing and I'm you're going to leave with them all written down as strategies today, you know, just really making it so obvious and evident that their presence is what's the most important thing to you I think is is such an important skill. 

Carolinne Bradley Really? Yeah. I think with those that have more complex pain, need more simpler tools. Honestly, because they've been through a lot, whether it be failed treatments or people not validating their feelings that they almost need more simpler, like, okay, let's try X, Y and Z and see how you do with this. So. 

Lindsey Vestal Yeah. Yeah. Carolinne, is there any kind of like, case studies that come to mind for you or particular experiences you've had in the clinic that you think would be kind of important To wrap up our conversation today to kind of like illustrate what it is that that we've been talking about. 

Carolinne Bradley Yeah. So one case that I can say that again, that would be something that I collaborate with a p t on. But one situation I can recall was there was an individual that was doing well on, let's say the manual techniques felt good when they were ready to leave. But symptoms are come right back. Probably the moment they left the room when they get in their car headed to wherever they need to go. And so. They had been dealing with a lot. They'd also been seeing a therapist on their own. But there was a lot of environmental factors that were contributing to their pain. And I think the T had noticed that. And, you know, when I began to see this patient, I, I wanted to see how aware they were connecting the mental emotional aspects to their pain, not just the physical aspects and how, you know, pain, right. Is, is not, you know, it's emotional, it's sensory, and it could be related to actual or that potential tissue damage. And they they were already aware to know that. Okay. You know, the moment I got in the car, my pain would come right back when I started to think about, you know, these things happening in my life. And so this was one case that they had some of that awareness of what was happening and why they felt these yellow flags, as I mentioned in their life, were contributing to their pain. And they were they were coming in for levator, an eye syndrome, and they were doing all the right things. They were taking the supplements, they were doing the exercise. They were really diligent about doing what they were told. But there was just something missing and it was definitely the psychosocial aspects. And for them, it was understanding that pain is an equal damage. And they, you know, they'd had several tests done, you know, seeing colorectal surgeons, seeing GI specialists, even their primary doctor. You know, and a lot of testing pretty much reassured that there's nothing concerning. And they would always relate it to what if I have cancer? What if I have this? And they would start to catastrophize. And so an individual individual with that, it was definitely a barrier to their progress because they were gaining progress. But it was short lived because, you know, his thoughts and behaviors and things just really drove to that pain. And so they were one that I wanted to help them have reassurance when they left the room and give them tools to use when they felt like they had some racing thoughts. And what if this pain will come back and all these things are adding to my pain? And or what if this pain really means I have some damage? So we went through. Mosley's paying quiz to talk about it. And they did really well with it, kind of understanding it. And I also gave some mantras with tactile cueing. So what I used was peace begins with me. And then another one I used was with the emotional freedom technique. So tapping in. So and this would be someone that responds well to tactile input, but use tapping to help regulate his emotions. And then I also had him work on breathing techniques, specifically box breathing and to apply those, because it's hard to just kind of fix the mind with the mind. A lot of times you need to tap into the physical specifically with breathing. So they have these tools and within two visits, I would say working with them, they were saying, you know, it's actually more stressful for me to get here to the appointment any more, and I'm doing really well with these tools. And so I was kind of surprised at how quick they did well with what I gave them. And it really was just the reassurance to know that, you know, they have tools to help themselves. And then also that even if they do experience pain at any point in time, it doesn't mean that there's damage and, you know, and kind of giving them a sense of control. So that was one situation. I was really proud to see someone that did really well even just in a short amount of time. And I think as OTs, you know, it's we can do so much good and so much help in a short amount of time just by a simple sentence that you give or understanding or reassurance. So that's that was one situation that really stuck out to me, especially when I was coach treating. 

Lindsey Vestal So that's that's a fantastic example. I that's, that's wonderful. And again, it really does this phrase really does come to mind. You know, simple does not mean and significance simple is still really a profound experience for our clients. Well, Carolinne, I'm I'm so honored and just really excited by our conversation today and the incredible work that you're doing, really representing the true bio psychosocial approach that we as occupational therapy practitioners really embrace. So thank you for all the work that you're doing and just just really appreciate you today. 

Carolinne Bradley Yeah, thank you for having me. I love this conversation. So that's what that's always. So there's so much more to learn in this realm. 

Lindsey Vestal So, so it keeps us coming back for more. 

Carolinne Bradley I Beckley. 

Lindsey Vestal Thanks for listening to another episode of OTs and Pelvic health. If you haven't already, hop on to Facebook and join my group OTs for Pelvic health, where we have thousands of OTs at all stages of their Pelvic health career journey. This is such an incredibly supportive community where I go live each and every week. If you love this episode, please take a screenshot of this episode on your phone and posted to IG Facebook or wherever you post your stuff and be sure to tag me and let me know why you like this episode. This will help me to create in the future what you want to hear more of. Thanks again for listening to the OTs and Pelvic health podcast.