Conversations with Practitioners :: Katrina, Part One

You guys. I am here to introduce you to someone you’re going to love. Her name is Katrina and she’s my primary physical therapist. I’ve only been working with her for a month and she’s already my friend. I hit the post-op jackpot, and pretty soon you’ll understand why I feel that way.


So a little about Katrina: She graduated from Texas A&M University in 1984, and then from PT school at Texas Tech University in 1986. She’s got 21 years of PT experience, including specializations in burn and wound care, acute care and orthopedics. She’s been involved in pelvic floor work for 18 years. She is McKenzie certified and has done more continuing education in myofascial release than you could shake a stick at (okay, you could do it, but you’d shaking for a long time.) What might interest you most about Katrina is that she has SI joint issues, and she also has had a rare condition (not SI joint related) that eventually required surgery. She knows what it’s like to be passed from doctor to doctor, and how scary it is to try and advocate for yourself when you feel like the doctors aren’t getting it. She’s been at Hands on Physical Therapy for more than 20 years.


Last week Katrina and I sat down together and had a phenomenal conversation about all things chronic pain. She is wise. Intuitive. So compassionate. She’ll tell you that she’s not an authority or expert on chronic pain, but her ideas and philosophies really resonate with the part of me that’s often felt orphaned by the medical community at large. It’s so wonderful to feel heard and to be led (as opposed to ignored and pushed.)


Anyway, I recorded the conversation and I’m going post the transcription of it here, in chunks, over the next several days and maybe even weeks. Fair warning: this is a long post, but there was no good place to chop it off. We built on what we were talking about. And besides, when you’re reading a word for word conversation between two people, it goes really fast. Take it in spurts if you like, or read the whole thing. Either way, I think you’ll be enriched, or at maybe even feel a tiny bit validated or enlightened.


One thing to keep in mind: this conversation isn’t just about sacroiliac joint dysfunction. It’s more about chronic pain and how that fuels and complicates whatever dysfunction or ailment you have. But for me, since I have several comorbidities, it’s all jacked up together.


Laura: In my own experience, there seems to be two types of physical therapy. I’ve been to the kind where you walk in the door, they get out the clipboard, and they stick you on a bike and set a timer. And then when that goes off, they show you another balancing exercise and they set the timer and leave again. They might be watching you walk or do exercises, whereas when I walk in your office, I get a full hour of your undivided attention. In a tactile, hands-on way, you’re seeing how I move and what’s going on inside. Can you help me understand the difference between the two? Is it a different philosophy? A different business model?


Katrina: It’s a different business model. Most of the people that you did therapy with [in that type of setting] have the same training as the rest of us. When we go through our PT training, which is now all on a doctoral level, we’re all taught basically the same stuff. Then [students] do an internship where they choose their emphasis — do you want to specialize in wound care? Do you want to specialize in pediatrics? And so on.


L: Just like a doctor.


K: Yes, it’s the same thing. So when you go to work for PT Clinic A, the model is they have to make money, especially if they’re going to hire 10 PT’s, because it’s a numbers game. Insurance doesn’t pay anymore. So they’ll have three or four people going at the same time. I used to work in a clinic like that. I was expected to see five people in an hour, unless I had an evaluation. Then I only had to see four people an hour. And the paperwork? You do that at home.


L: So you keep the patients busy.


K: Yeah, I’m writing notes while they’re doing their 10 minutes on the bike. You’re trying to write your notes because you still have to quantify to an insurance company what you did. So the difference between that and our practice is that when Jody [Hendryx, the clinic owner] started the practice it was never going to be about the money for her. Unfortunately [in some sense] it has to be about the money because we have to pay the bills. We have to turn the lights on, we have to have a building, and we have to be able to pay new therapists to come in. But for her it was more about healing, not so much about treating. So she had to set down her model of “this is what I was taught in PT school.” It’s not that we don’t use that, but the hands-on approach comes from the training we usually receive outside of physical therapy [school.] They touch on it in PT school, but you don’t have time to really practice that because you have so much material to get through. They hope you get what you need in a clinic when you’re doing your internship. So it’s a choice and it’s a business model.


L: I guess what I’m thinking — at least in my own experience (when I went to another clinic it was for an ankle fracture) I didn’t feel like it helped me at all. I feel like if I had walked into that place after my SI joint surgery I would’ve been disappointed. And I might’ve even injured myself.


K: For some people, that model works great. If it didn’t, those wouldn’t exist. I think we talked one time about percentages and research. When you do research on a drug or on a treatment protocol, [there is statistical data.] For example, 75% get better, and 25% don’t get better or maybe they get worse. It might even be 60/40 or 90/10. Jody and I feel like our business exists to serve the percentage of people that don’t get better by the status quo. Typically we get people who say, “I’ve had PT. I don’t want to do PT again. It didn’t work.” You know, there’s a population that we don’t serve. If you’re an athlete and just tore your rotator cuff, and you need to be trained to throw a ball again, we can help but we’re not going to be your best bet. We don’t have the equipment to practice the throwing, or a gym to do it in. We don’t serve that segment of the population.


L: You know what’s so funny though, is that most people in my shoes aren’t aware of the 75/25 percent paradigm. We have no idea. It’s just like doctors: you start out thinking they’re all created equal, that they all went to similar schools and pretty much have all the same knowledge (which we later discover isn’t true.) So how can people seek out a more personalized approach?


K: It comes down to the patient being willing to do their own homework. Patients don’t know that. You go to a doctor, you trust a doctor, and you empower a doctor to some degree to help you, and they say, “Oh, you need physical therapy. Here’s a list of six in your area, or here are the three that I prefer.” Unfortunately the three that he prefers may be the three that marketed him very heavily. It may not have a lot to do with their skill. And he doesn’t [necessarily] know if he’s not a patient. In the beginning most of our referrals came from doctors who saw us as clients. Or the patient will back to the doctor and say, “Why aren’t you sending your patients here?” [They’ll especially say that] with chronic pain. Because that traditional kind of PT you were talking about? You can’t exercise pain away. You can exercise to support healing tissue, but if you’re in chronic pain, exercise typically doesn’t change that.


L: Define exercise. Doing reps?


K: Yes. Also riding a bicycle, getting on a treadmill, getting into an aerobics class.


L: It comes down to everything else in the medical field. Self-advocacy is crucial.


K: You know, the Internet has helped. If anybody went to our website and read articles that we’ve written on our blog, there’s info there that might help you better understand where we’re coming from. All that to say, investigate the clinic you’re considering.


L: So what I’m hearing you say is that that the traditional approach can help, let’s say, 75% of the people. I guess reason I’m making this distinction is because one thing I’ve found among people who live with chronic pain, and have gone through doctor after doctor, procedure after procedure, and spent all their money and are worse off, we tend to have a bit of an adversarial point of view. We think practitioners should KNOW how to treat us properly, and when they don’t it feels like somehow being mishandled, or worse, neglected or abused. I’ll be the first to admit that I’ve taken it personally at times. I think it’s easy to get mad because we’re not in the 75%.


K: By the time you’re mad, it’s taken another year or so to find where you need to be. You think anger doesn’t feed your chronic pain? And there’s no place to express that. One of my patients came in and her first words to me were, “I’m super grumpy today and I’m a little bit mad.” So I set my computer down and said, “What are you angry about and how can I help you with that?” She went on to talk about how she’s been put through the system, and she’s so tired of these problems and nobody listens. Really what she needed was to be heard for a second. But you can’t do that in a gym. I had a patient the other day who cried for a full hour. I wasn’t sure how I was going to get her out of my room to get my next patient in. She was so undone, and my attempts in the last 10 minutes were to try to put her back together so she could walk out. You can’t do that in a standard PT office. She wouldn’t have felt the safety and freedom to go there. And all that stuff that’s inside absolutely feeds that pain. The best way to get to it is to touch it physically. I’m touching the thing that hurts. Now let the emotion with that have a place to go. You can’t separate [the emotional and the physical.]


L: How much do our emotions play into chronic pain? Jody was telling me yesterday that when you’ve had chronic pain for two months, there’s a neurological component that is hard to break.


K: That’s right. There’s tons of research that shows that.


L: Number one, is it possible to retrain those circuits somehow?


K: Absolutely.


L: How do you do it? What kind of practitioner do we go to in order to do that? And how are our emotions feeding in to that? I wonder especially about fear and how that works against us. But all the trauma of living with chronic pain, the trauma of what we’ve experienced. How do you take those things apart?


K: So the best example I can give you — simple, simple, simple example — you’re sitting in a movie, a horrifically sad movie. And you don’t want to be caught crying, because you’re “that” strong. So what happens? You build up that emotion and what do you feel? The throat gets really tight and you’re just holding it back. No one hit you in the throat; there’s no physical trauma there. But there’s physical discomfort there. It’s a physical manifestation of an emotion. You know if you would’ve just cried, that would go away eventually, right? But you didn’t. So that emotion got trapped there. And so lots of times people will say, “I know it’s tight. I’ve stretched it. I’ve pushed on it. I’ve had acupuncture to address it. I’ve had, I’ve had, I’ve had… I’ve done, I’ve done, I’ve done. And the pain is still there. Maybe the pain is not physical. Maybe it’s emotion trapped in there, and until you give that emotion space to be released [it’s going to be symptomatic.] There are two really good books I recommend for that. There’s a book called, Waking the Tiger, by Peter Levine, that describes the emotional and physical components. And then Dr. Christine Northrup has done a tremendous body of work on that. It’s a LOT [of information] but you just take it one chapter at a time. She mentions the emotional/physical connection in Women’s Bodies, Women’s Wisdom and The Wisdom of Menopause.


L: I have amassed so much grief over the last 10 years. And I’ve been so busy surviving, I know I’ve neglected it. I’ve silenced it out of necessity. I’ve ignored it either on a conscious or unconscious level. And there have been so many times where I’ve thought, “If I could just cry. If I could just release whatever it is that is making me feel deeply sad or angry inside, maybe my body wouldn’t hurt so much.” But it’s hard to access all of that when I feel like I’m ready to give it some airtime. I’m like, “I know it’s in there! Other than reaching my hand down my throat and trying to pull it up, I don’t know how to get it out of there.” I’ve done lots of therapy. I’ve done an enormous amount of “processing” my emotions with super trustworthy and qualified people. What would you say to someone who’s had so much trauma and grief and for whatever reason feels kind of stuck?


K: I don’t think it has to be that dramatic. I saw a lady yesterday and her emotional response was dramatic. She was crying and weeping so loudly that they could almost hear her in the front office.


L: About her pain or other things?


K: I don’t know. I didn’t ask! It didn’t matter. She was letting go of the emotion, and my job was to keep her safe and make her feel safe. The thing about trying to figure all that out, is the minute you get out of the feeling and start asking, “What? Why? How?” you shift from right brain to left brain. And when you’re in your left brain…


L: It can be a distraction.


K: It IS a distraction! Good example, my daughter was born with the umbilical cord wrapped around her neck. I knew this, and it’s not something I shared with her until she was much older. But she has this crazy fear of choking. Crazy. She won’t eat spaghetti. And so one day when she was eight or nine years old, she starts choking on something and I literally had to do the Heimlich on her. She was panicking. And I said, “You know, Quincy, when you were born the umbilical cord was wrapped [around your neck] so much so that I had to stop pushing. He had to reach in and clip the cord before you could be born.” If I hadn’t told her that she would’ve never known. [But she felt it nonetheless.] You don’t have know. You don’t have to label your grief. You don’t even have to make an attachment. You might. If that happens, it just validates what you’re going through. But you don’t have to. And I don’t think it has to be this crazy, dramatic crying episode. It may look like that; it may just be a deep sigh of, “You know what? I no longer feel that burden.” Stay in the feeling. Pray for guidance and peace and release. Trust that when you need it, it’s gonna come. You have to trust that, though. And you also have to start developing a belief system that you actually can heal from that. You have to believe that. If you don’t believe that, you’re never gonna get there.


L: What role does our belief (or lack thereof) play in our healing?


K: Well, placebos. Placebos work! You believe you’re taking a pill or doing something that will make you better — they work! Why do placebos work? People believe they’re gonna work. But there’s no one-size-fits-all. You can’t say, “Don’t EVER do surgery.” If there’s a disease process, you may have to have surgery to get the disease out of there. And if that’s the catalyst that gets somebody moving forward, then why is that a bad thing?


L: Okay, but let me be devil’s advocate here: why couldn’t I have just believed it before surgery and not needed surgery? This is a huge trigger for me—people telling me I just didn’t believe enough.


K: There comes a point where… I mean, the body’s a mechanical thing. Some laws of physics will apply to your body. Things wear out.


L: Like when there’s no cartilage in the knee, there’s no cartilage in the knee.


K: Yes, and you can’t regrow that to the best of my knowledge. If you’re paralyzed from the waist down, we’re pretty sure those nerves do not grow back. You know, if there’s a woman who has uterine cancer, is it such a big deal to remove it and then heal what’s left? I don’t think that’s a problem. If it is better for your health, in the long run, to get rid of the disease and then work with what’s left over and you’re happy with it, and you can survive and function, how can you judge someone for having had that surgery?


L: As you’re talking it’s occurring to me that when we 25 percenters go looking for help, we assume we’re in the 75%. And I feel like a lot of the practitioners do too. So they’re telling us all these things, and we’re trying to get better, and we’re turning ourselves inside out and ultimately want to scream, “It’s not working!” And there’s this tendency to take all that on and feel “less than” because we’re not in the 75%. But you don’t know that’s why it’s not working. There’s this shame and blame that has descended on me so many times, simply because I’m not in the 75% of people who respond to conventional, non-surgical treatment. I’m not in the clinical majority.


K: That’s such a good point. You are [somehow managing to function] as though you’re in the 75%. You’re led to believe that by everyone you talk to. They say, “Studies show this works.” But you know there’s always a caveat: “Studies show this works, FOR A CERTAIN PERCENTAGE OF PEOPLE.” I mean, why do you think you have to sign that novel of a release, the one that lists all the possible side effects from general anesthesia? It goes fine for most people, but 3% of the people might have serious side effects or even die. You hope you’re not in the three percent, but everyone goes in hoping they’re in the other 97%.


L: I don’t think it’s intentional usually, I really don’t. But I can’t lie: it’s felt like abuse to me at times. It’s an oversight that is very sad and unfortunate because of what it does to our beliefs about ourselves, and our ability to get well. We bounce like pinballs from practitioner to practitioner. In my own experience, there are so few clinicians who might consider that the person in front of them isn’t in the percentage of people who are “typical” for any given affliction. So us atypical folks end up feeling abandoned. Nine times out of ten, doctors are going to stick hard to the studies and percentages. Medicine is primarily a science.


K: That’s what we were taught. It’s a very western medical model. If I take a class on something that’s sponsored by the American Physical Therapy Association, it’ll always say, “Evidence based practice format.” I like evidenced based — don’t get me wrong. Because you kind of need to know where the 75% is. And I’m guilty! You walk in to my room for the first time, and I’m looking [at your notes and saying to myself,] “Okay, she had an SI joint surgery, she has hip pain…” In my head I’m already formulating things that I think I want to look at. But I hope that I can leave enough room on either end to go, “Hmmm… that’s not what I expected!” instead of saying, “That’s not what I expected so I must’ve tested it wrong.” I think that’s what a lot of doctors do, i.e. “I didn’t see it right because that’s not what I expected. So I’m gonna force this square peg into this round hole.”


L: Do you think some of that has to do with ego?


K: Oh sure. But I don’t think that’s always the driving force.


L: This is how people fall through the cracks. I learned about a woman who had been in an accident. To use some metaphors I mentioned earlier, she was a pinball, she was a 25 percenter, she was working with clinicians that were all 75 percenters, a lot of whom had healthy egos. And she was also dealing with an insurance company that had a bottom line. And when she didn’t get better they labeled her a malingerer and sent her to a psychiatrist. This makes me want to cry, or maybe even punch somebody in the throat.


K: I see that every day. In our little office we say, “They’re so attached to the story. When are they going to be able to let go of the story?” You know, the story gives us a little bit of power, to be able to say, “well, this was four years ago and I’m still trying to do this and I still have a lawyer and I still have all these bills and insurance won’t pay for it.” You get so attached, like little tentacles, to the strength of that story, that to think about letting it go is hard. But what if you could let go of that insurance company? If money wasn’t an issue and you could let that go, how much more energy would you have to devote to the healing process rather than the blame process or the “it’s not fair” process? And that’s a tough one. We’re all humans and we want to be treated fairly. We pay our insurance premiums. It should be there for us when we need it. And when you start getting passed from person to person it’s so easy to get attached to, “I’m gonna run out of money!” It’s that fear thing you talked about. You have to be willing at some point in your healing process to put it all down, and to say “That story’s old. I’m not going to hang on to it anymore. The money? God will provide me with what I need. At the time, I’m going to get what I need as I need it. You just have to start believing those things. The need to stick to the story is so understandable, but it holds you to your injury.


L: Some of that is part and parcel of being a 25 percenter in a 75 percent world. You’re so used to NOT getting what you need, you think it’s not out there.


K: One of the keys for me (and this is a lesson I’m still learning every day) is that if I can really quiet my mind, lose all of that noise about the strength of the story and the insurance company, etc. just set it down for 15 minutes and really go inside and really feel, I think our bodies have the answers if we would just let it emerge. We may not like the answer. But I think deep down we know the answers, but we can’t seem to quiet our minds enough to sit and listen to it.


To be continued…


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